Artigos

Conteúdo (article):

Processos formativos para o enfrentamento das violências contra as mulheres no setor saúde: uma revisão integrativa
Educational processes to combat violence against women in the health sector: an integrative review

Julia Costa de Oliveira – Oliveira, Julia Costa de
Universidade Federal de Minas Gerais
co.julia@hotmail.com
https://orcid.org/0000-0003-3899-1092

Kênia Araújo Pires – Pires, Kênia Araújo
Instituto René Rachou - Fiocruz Minas
kenia.arj@gmail.com
https://orcid.org/0009-0008-3232-1470

Janete Gonçalves Evangelista – Evangelista, Janete Gonçalves
Instituto René Rachou - Fiocruz Minas
janete.evangelista@fiocruz.br
https://orcid.org/0000-\0002-8610-5350

Ana Pereira dos Santos – Santos, Ana Pereira dos
Instituto René Rachou - Fiocruz Minas
ana-pereira.santos@fiocruz.br
https://orcid.org/0000-0003-2758-845X

Paula Dias Bevilacqua – Bevilacqua, Paula Dias
Instituto René Rachou - Fiocruz Minas
paula.bevilacqua@fiocruz.br
https://orcid.org/0000-0003-0015-2154


Resumo
O setor saúde compõe a rede de enfrentamento das violências contra as mulheres, sendo necessário que os seus serviços ofertem atenção qualificada, o que se depara com o desafio de uma exígua formação dos seus profissionais sobre a temática, mesmo que esteja prevista na Política Nacional de Enfrentamento à Violência Contra as Mulheres. Este estudo busca analisar como profissionais da saúde têm se qualificado para atuar no enfrentamento da violência contra as mulheres no Brasil. A partir de uma revisão integrativa da literatura, 16 artigos foram analisados, abordando tanto trajetórias formativas quanto experiências de formação no contexto acadêmico e em serviço. A formação sobre violências contra as mulheres se mostrou insuficiente, o que pode ocasionar oportunidades perdidas de detecção, atendimento e encaminhamento dos casos no setor saúde ou para outros serviços da rede de atendimento. Foram identificados processos formativos ocorridos em graduações e em serviço, todos no âmbito da Atenção Primária à Saúde, os quais podem impulsionar futuras formações, necessidade reafirmada em todos os artigos. Sugerem-se parcerias entre universidades e Sistema Único de Saúde, bem como processos formativos reflexivos e participativos que considerem a complexidade social das violências contra as mulheres.
Palavras-chave: Violência contra as Mulheres; Formação Profissional em Saúde; Ensino.

Abstract
The health sector can contribute to the combat of violence against women, if its services offer qualified care, but there are challenges such as the lack of health professional qualification, even though it is provided in the National Policy to Combat Violence Against Women. This study aims to analyze how health workers have been qualified to act in the prevention and confrontation of violence against women in Brazil. An integrative literature review was made and sixteen articles were analyzed, addressing training trajectories and experience reports, both in the academic and the health service context. The training on this theme proved to be insufficient, which could lead to missed opportunities for detection, care and referral of these cases to the health sector or others related to the care network. Reports on educational experiences were identified in degree courses and in Primary Health Care services, which could boost future educational processes, a need reaffirmed in all the articles. The university, in collaboration with the Unified Health System (SUS), can contribute with reflective, participatory educational processes that consider the social complexity of violence against women.
Key words: Violence against Women; Professional Training in Health; Teaching.
INTRODUCTION
Violence against women (VAW) is a multifactorial problem that can manifest itself in various ways, resulting in or may result in physical, sexual, psychological, patrimonial harm to women, configured as an affront to human rights1,2. In Brazil, between 2020 and 2021, VAW reached its extreme point, accounting for 2,695 cases of femicide, black women being 62% of the victims3. These and so many other data illustrate that the category, “women” has no universalizing character, that is, VAW is crossed by markers beyond gender, such as race, ethnicity, class and generation4.
For a full confrontation of VAW, an “intersectoral, multiprofessional and interdisciplinary approach”5 (p. 23) is required. Among the various sectors that make up the VAW combat network is that of health, as pointed out by the National Policy to Combat Violence Against Women2. Thus, the health services should offer qualified support to women in situations of violence5.
However, VAW is often “invisible to the eyes of health professionals”, given the difficulties in detection, care and referral6 of such cases (p. 316). The loss of identification opportunities and proper care of VAW in the health sector is a theme that has been addressed by several researches in recent years7,8,9. Mendonça et al.10 indicated that, despite efforts to include violence as a public health issue, many health professionals do not share this understanding. Even when there is recognition of violence committed by these professionals, not always is this translated into routine actions and practices, there being difficulty working from an integral, emancipatory and intersectoral perspective with regard to care for women in situations of violence11.
One of the factors that contribute to the understanding of this context is the fragility of the training of health professionals on the theme of violence and VAW, both academic and in service, there being a need for education processes to qualify for such health care, as Brazilian studies point out5,6,10,11.
Beyond the national recommendations about the training of health professionals for the confrontation of VAW, this need has also been presented by the World Health Organization in several publications12,13,14,15. In 201712, a manual was created aimed at health administrators, the result of the World Health Assembly that had occurred in 2016, when a global action plan was endorsed by representatives of 194 member states to address interpersonal violence. It included guidelines regarding the training of health professionals to act by providing care in VAW cases, more specifically violence from an intimate partner and sexual aggression. In 201913, a curriculum was introduced for health professionals and, in 202114, it underwent a revision in which guidelines for administrators were also inserted. In 202315, complementary text was produced, containing guidelines for pre-service training, that is, in educational environments, such as universities.
Given the above, this study sought to analyze how health professionals have become qualified to act in the confrontation and prevention of VAW in Brazil. The unprecedented systematization of publications about educational processes regarding VAW in the academic and service context might contribute to advancement of the health sector as a strategic device to prevent and face VAW.
METHOD
From the perspective of qualitative research16, we conducted an integrative review of the literature17,18 in steps as follows: 1) Definition of the theme; 2) Formulation of the guiding question; 3) Definition of descriptors and databases; 4) Definition of study inclusion criteria and study selection; 5) Categorization and data analysis; 6) Discussion of the results and synthesis of the knowledge.
We started from the theme, “training about VAW for health professionals ” in order to devise the guiding question for the review: “How is the theme of VAW addressed in the training of health professionals?” As a search strategy, the following descriptors were utilized: (“educação” OR “formação” OR “treinamento” OR “capacitação” OR “qualificação”) AND “violence against women” AND “health” in the SciELO - Scientific Electronic Library Online and the regional portal of the BVS Virtual Health Library. The articles were selected in pairs in two steps: reading of the title and abstract; and complete reading.
Indexed articles in periodicals, published in Portuguese, English and Spanish, were included when they addressed educational processes about VAW for health professionals in Brazil. The base year for these articles was 2011, due to the publication of the Política Nacional de Enfrentamento à Violência Contra as Mulheres [National Policy to Confront Violence against Women], which made provision for training care2. Duplicates and articles not available in full were excluded.
The data were systematized with the aid of an instrument built by the authors and tested in pairs to describe the articles according to axes: basic information; methodological aspects; results and discussion (composed of fields as notes about gaps in academic and/or service training; description of the training process carried out and its possible effects; training process proposals). From this, we built four categories of analysis that: 1) addressed the academic trajectory of training about VAW for health students; 2) reported the experience of educational processes about VAW for health students; 3) addressed the educational trajectory about VAW for health professionals in service; 4) reported experience concerning the process of training about VAW for health professionals in service. Thus, result presentation would follow such categorization, followed by discussion involving the literature, supported by intersectionality4, understood as “an analytical lens on structural interaction in its political and legal effects” (p.37).
RESULTS
The search identified 350 articles. After selection in steps (Figure 1), 16 articles were included in the review11,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33 (Charts 1 and 2 ).
Figure 1. Article Selection Flowchart
Source: Devised by the authors.
Chart 1. Articles included in the review referring to academic educational processes
Source: devised by the authors.
Chart 2. Articles included in the review referring to educational processes in service
Source: devised by the authors.
Since 2011, only 2017 and 2021 did not have any publication on the theme. The year with the most publications was 2016, although it was not possible to identify a trend of greater interest in the theme over the years. All the articles presented a qualitative approach, most of which conducted interviews11,19,20,21,22,23,27,28,29,31 and content analysis29,11,20,21,22,31. Six articles consisted of reports on experience of educational processes24,25,26,31,32,33. Regarding location, six studies were carried out in the Southeast20,24,25,26,27,30; three in the Northeast23,29.30; one addressing municipalities in both the Northeast and the Southeast11; five in the South19,22,28,31,33; and one in the North21.
Of the articles included, eight addressed VAW in a general manner24,29,33,25,25,21,22,20, two specifically addressed marital violence19,28, two focused on sexual violence11,23; besides those focused on obstetric violence26 and physical violence30. One article utilized the term, “gender violence”32, and another a combination of domestic, sexual and institutional violence27.
Next, the data extracted from the articles were described, first in relation to the training of students at academic level (undergraduate and postgraduate); and afterwards by presentation of the results on the training of workers in service.
Academic training about VAW
Training trajectories
Five articles addressed the training trajectories of undergraduate health students19,20,21,22,23. All the articles addressed nursing training, one also addressed the training of doctors19, and another also addressed the training of doctors, as well as dentists and social workers20.
Among the five articles, four reported that undergraduate training on the theme of VAW was insufficient19,20,21,23. Silva et al.21 conducted a study about knowledge of VAW involving final-year students of the Faculty of Nursing at Pará Federal University. Although the theme appeared in two disciplines (“Integral Care for Women and Children’s Health” and “Nursing in Obstetrics, Gynecology and Neonatal”), most interviewees replied that the approach to the theme in the undergraduate course was insufficient, and many did not feel prepared to deal with cases.
As interlocutors, Aguiar et al.23 questioned students, professors and administrators of the nursing courses in two further education institutions, one being an educational foundation in Fortaleza, and the other a private institution in a municipality in Ceará State’s northern region. In the students\' perception, the theme of VAW appeared in the degree course in a superficial, fragmented way, diluted in terms of disciplines. However, students and professors recognized the approach to the theme in research and extension activities. On the other hand, in the view of the administrators, the theme was approached transversely, more focused on Women\'s Health disciplines.
Silva et al.20 conducted research involving students from nursing, medicine, dentistry and social work courses, scholars of the extension project, “Diagnosis and analysis of WAW in Montes Claros/MG”, from Montes Claros University, MG State . The authors found that the majority of the undergraduate students, who were already at the end of the course, had had no contact with the VAW theme, and saw in the extension project an opportunity to learn about it. Gomes et al.19 addressed the training trajectory of health professionals (nursing technicians, nurses and doctors) engaged in primary health care (PHC) in a municipality of Santa Catarina State, aiming to analyze the preparation of these professionals to aid women in situations of marital violence. Some interviewees reported that the VAW theme was not addressed during the undergraduate course, and those who reported having contact with the subject said it was rare and superficial. Therefore, this corroborated the professional unpreparedness to act in the cases of VAW and the deficiency of the training trajectory.
One article claimed that the VAW training was adequate. Sobrinho et al.22 conducted a study with students from the last semester of the nursing course at a private university in Porto Alegre. Unlike the aforementioned articles, many of the students interviewed reported having had satisfactory contact with the theme of VAW during the course, especially through the discipline, “Health and Gender”, but also through internships and other modalities, for example, artistic events. The authors affirmed the importance of approaching the theme in a degree course, and considered curriculum changes as strategies to confront VAW in health services.
All articles affirmed the need for restructuring academic curriculums and the importance of covering the theme transversally in degree courses. Furthermore, all the articles presented the idea that curriculum changes should foster humanized care by health professionals to address cases of violence, further favoring identification and treatment of these cases. Aguiar et al.23 advocated insertion of the theme of gender violence as the minimum in a curriculum in order to improve the professional performance of nurses, preparing them for an integral approach, as they tended to address sexual violence only from the biomedical perspective, and witnessed this violence only through injuries. Silva et al.21 pointed out the urgency of addressing the theme of VAW as a public, multidisciplinary health issue. Students interviewed by Silva et al.20 corroborated the relevance of multidisciplinary training and indicated the need to restructure academic curriculums with the creation of a discipline for discussion of gender and violence, as well as a transverse approach to the theme in other disciplines. Gomes et al.19 also highlighted the interdisciplinary character of the theme, emphasizing not only the importance of rethinking the curriculum structure of health courses, but also continuing the training in service.
Reports on educational experiences
Three articles reported experiences of educational processes about VAW conducted at universities24,25,26, all of them in undergraduate disciplines, two of them mandatory and one optional; one at the Faculty of Nursing, another at the Faculty of Medicine and a third at the Faculty of Public Health.
The article by Baragatti et al.24 reported the experience of the discipline, “Violence, Health and Gender”, introduced for seventh semester students in the mandatory modality in the undergraduate nursing course at the Jaguariúna Faculty, São Paulo. The purpose of inserting this discipline into the curriculum was to prepare future nurses to deal with the theme of violence in their professional practice, this being one of the axes of the approach to gender violence. Active methodologies were utilized during the process, such as the facilitation of experience reports, instigation of discussions and raising matters regarding health needs.
The article by Machado et al.25 described an experiment carried out at the Botucatu Faculty of Medicine - Paulista State University. In the experiment in question, the theme of violence against women was inserted in Module I (“Planning of interventions in Public Health problems”) of the “Collective Health III” discipline. The duration was for four months with 12 third-year medical students. The problem-based learning method was utilized, and students were invited to reflect on the theme through case reading, literature discussion, field visits, data systematization and construction of explanations about the problem, as well as creation of strategies to solve it.
The article by Diniz et al.26 reported the experience of the seminar, “The Vagina-school: seminar on violence against women in the teaching of health professionals”, which took place at the Faculty of Public Health of São Paulo University . The event was held within an optional undergraduate discipline, called “Gender, race/ethnicity, sexuality and public health”, and discussed the theme of obstetric violence in a context where students of medicine and other courses performed surgical procedures on SUS patients without consent or knowledge.
Two articles24,25 pointed out possible effects of training experiences for student professional practice. Baragatti et al.24 reported that many students began to reflect on the theme of violence from their own personal experiences. The authors believed that “experience as a student will make it possible to reflect on an action as a nursing professional with a view to transforming a situation of violence” (p. 475). On the other hand, Machado et al.25 stated that the experience with the theme in the discipline “Collective Health III” enabled the development of various skills and competences in students, such as the perception of VAW as a sociocultural phenomenon, and as a public health problem that directly impacted health-disease processes. According to the authors25, “the students manifested their sensitization and improved skills to identify, assess, monitor and refer cases of violence against women” (p. 518).
Training about VAW in service
Training trajectories
Five articles addressed the training trajectories in service on the theme of VAW of health professionals11,27,28,29,20. The articles addressed Primary Health Care professionals (PHC), among doctors, nurses and dentists28,29, engaged in secondary and tertiary care, among nurses, doctors, psychologists and social workers11, and only tertiary in conversations with doctors27,30.
All the articles referred to unpreparedness of professionals, regardless of care level, to assist women in these situations. In the study by Silva et al.30, all the interviewees stated they had never participated in training on the theme. Cordeiro et al.29 indicated that, in relation to education in service, of the 39 professionals interviewed, 23 declared that the theme was not the focus of discussions during training and meetings. Gomes et al.28 and Pedrosa and Spink27 corroborated the absence of training for professionals to deal with marital violence, whether in the degree course or in service. Moreira et al.11 also affirmed the gaps in training in the curriculums and in service, because the theme continued to be hidden in Permanent Health Education actions. Thus, they pointed out that the first contact with the issue often happened when already practicing professionals. Those interviewed stated that they sought various forms of training on their own, in addition to the existence of occasional actions on the part of the Ministry of Health, and, to a lesser extent, by municipalities, characterized as “isolated initiatives, not linked to an institutional culture in which permanent education is valued as policy”11 (p. 1,048), favoring content based on biomedical logic, without addressing historical and cultural aspects.
Of these five, three also discussed, albeit briefly, the training of these workers at the university11,29,30. These articles pointed out the lack of content matter provided in the curriculum matrixes of the undergraduate courses on VAW-related themes. By identifying these gaps, the articles approximated this fragility in academic education to the performance of health professionals in action regarding VAW cases. These professionals ended up developing informal strategies in clinical conduct, as well as distancing themselves from cases because they did not know how to act.
Health professionals, both in PHC and at other levels, felt incompetent to address this issue due to a lack of professional training at university and in service. As a result, workers\' conduct was committed to identification, care and different possibilities for referrals of users who were in situations of violence28,30. Given this, they pointed out the need to create spaces within health facilities to debate the VAW theme, as well as offer resources such as interdisciplinary, intersectoral supervision, and discussions, socially and politically contextualized27,29. All five articles expressed the need for continuous education on the theme11.27.28.29.30.
Reports of educational experiences
Three articles reported experiences of educational processes about VAW carried out in service, all in the PHC area, and two worked only with Community Health Agents (CHA)31.32, and one with nurses and nursing technicians33.
All the reported experiences originated from participatory research33, such as research-action32, whose methods were considered as training devices and as objects of analysis. Thus, while producing data for research, they promoted am educational space for health professionals in service.
The study by Berger et al.32 realized thematic workshops as educational interventions on gender, violence and health. These sessions were planned in a participatory manner, from the review of the research results, incorporating the demands of the CHA, technicians and administrators. The first educational movement consisted of exchange visits to various services of the network, such as the Police Station exclusively for Women, followed by a meeting to debate the reality of the potentialities and deficiencies of each institution visited. Afterwards, two workshops were held. In the first, five subgroups discussed the concept of gender and gender violence in society, as well as their approach to health services, sharing reflections on the whole through posters, collages and other languages. In the second workshop, the CHA, created a dramatization from a real case of marital violence in order to provide receptivity and listening training to approach the care.
The study by Silva et al.31 conducted eight educational workshops with 30 Family Health Strategy professionals. This series was based on the Problematizing Pedagogy and on the Arco de Charles Maguerez. Heisler et al.33 also held eight pedagogical workshops, conducted based on the problematizing framework, employing the Arco de Charles Maguerez, and Paulo Freire. Arco de Charles Maguerez, which constituted the basis for the two training proposals, consisted of five steps: observation of reality with identification of the problem of the practice; preparation of key points or themes; theorization; hypotheses and solutions; application to the reality.
All the articles presented effects of educational processes for the qualification of the strategies of reception, care and referral of women subjected to violence in PHC. Berger et al.32 indicated that the workshops instigated a critical reflection movement on the part of the CHA, a better understanding of how to identify and refer VAW cases, and greater security to perform such actions. In the assessment of Silva et al.31, the workshops contributed to redirecting the practice of professionals towards more sensitive, less prejudiced approaches, producing new ways of thinking and acting based on solidarity and intersectoral perspectives. Similarly, Heisler et al, 33 mentioned that the workshops made it possible for professionals to reflect on their practices of listening, bonding and home visits to female victims of violence, thus fulfilling the aim to qualify the care. With this, workers managed to identify and intervene in VAW situations.
DISCUSSION
The articles included in this review demonstrated the existence of a relationship between insufficient university training regarding the theme, and the unpreparedness of professionals in the face of these cases, combined with the absence of permanent educational processes to act in service. Although the National Policy to Confront Violence against Women has as one of its guidelines “encouragement for training professionals to address violence against women, especially regarding the provision of care”2 (p. 33), studies on the theme published between 2011 and 2022 showed a gap in this guideline.
This scenario is not limited to Brazil. An International Integrative Review34 found curriculum limitations of institutions that train health students to address gender violence committed by an intimate partner, as much in Brazil as in the United States, Canada, Spain, Australia and Mozambique. The following challenges were indicated: lack of legitimation of the subject as relevant to professional practice; and absence of financial resources and professionals to provide adequate content, and teaching and learning strategies. Such gaps reflect the complexity of the confrontation of VAW, a problem that occurs at the relational and societal levels, and demands not only educational but cultural and social changes, involving the battle against gender, class and race2 inequalities. One of the Brazilian historical milestones in this confrontation is Law No. 11.340/2006, known as the Maria da Penha Law, which conformed to such an understanding and established not only the need to curb and punish aggressors, but also to prevent domestic violence against women through educational measures. Among its proposals is the highlight, in school curriculums, on content related to equity in terms of gender, race and ethnicity; and the promotion of educational campaigns, focused on society in general, to prevent VAW.
Specifically in relation to academic training, we identify that VAW is treated in undergraduate courses about health in a superficial, fragmented, isolated way, and students are generally trained to have a strictly biomedical view of health-disease processes, where full, humanized care has no place. Although it cannot be attributed exclusively to educational processes the responsibility for structural changes in gender rules that hierarchize social relations, the inclusion in the curriculums of content that address social and cultural factors - treated in a way that fosters critical reflections on power relations - can contribute to the training of professionals sensitive to the detection, care and proper referral of VAW cases.
Such failures in the detection, care and referral processes constitute “lost opportunities”, a term utilized to refer to non-continuity of treatments after violence is detected and the obstacles that arise during treatment35. Sharps et al.36 utilized the concept to refer, for example, to situations when women suffer violence, and, when seeking help from the health services, are not treated or guided by health professionals in such a way that they become fully aware of the violence experienced, and also avoid subsequent lethal action. Thus, regarding VAW, we consider that inadequate training and the unpreparedness of professionals can be considered factors generating opportunities missed by the health sector, since a woman suffering violence may not be identified or fail to receive qualified attention that could assist her in overcoming this predicament.
Given this context, studies consensually advocate the need for restructuring the academic curriculums so that they encompass the theme. The academic community itself reaffirms this recommendation, as students do not feel prepared to handle such situations. There is also consensus regarding the importance of covering the theme transversely during the degree course, considering its complexity, the need to utilize problematizing pedagogical strategies and induce critical reflections, aligned with the ethical commitment to social transformation. In agreement with this perspective, an international systematic review37, which sought to understand which educational strategies are effective to qualify health students regarding gender violence, found that they are those with interactive approaches, practical interventions and longer duration.
In the reports of experience analyzed, there was speculation that participatory methodologies, such as Paulo Freire’s Problematizing Pedagogy, Arco de Charles Maguerez 31,33, and dramatization32, could lead students and workers to reflect on their own practice. In addition to these, we draw attention to the fact that educational games have been utilized to contribute to creative educational processes about VAW. These can be accessed by computer and/or mobile applications, as described by Almeida et al.38 when they devised Serious Games aimed at health professionals in Integrated Health Units, and Montenegro et al.39, who launched the game, “Pandora’s Box”, intended for nursing students, stating that it fostered reflection on the theme.
Such methodologies are not restricted to academic training. This review confirms that there needs to be educational processes for professionals working in services, so that training does not come to an end in the academic sphere, but is permanent and assumed by the different levels of health sector organization, as well as set forth in the National Policy for Permanent Health Education40. This policy advocates teaching-learning programs that enable critical analysis of the practices themselves to transform them, which can be enhanced by interprofessional education. The National Program for Gender Equity, Race, Ethnicity, and Appreciation of SUS Workers41, instituted in 2023, is also aligned with this perspective, and reaffirms the commitment to permanent education in health as strategy to combat the various forms of gender violence, demarcating the need to consider collaborative networks and intersectionalities.
The educational experiences reported, both at undergraduate level and in service, demonstrated how much these programs help sensitize professionals, as they receive a closer look at VAW, improving their performance in the detection, care and referral of cases. This was corroborated in other studies. For Baraldi et al.6, knowledge about violence can contribute to the care provided to these victims, as well as recognition of cases for referral. Similarly, Moreira et al.11 (p. 1,049) understood that “the visibility of sexual violence against women, the increased incidence of such cases within health services, and the strong impact of the phenomenon on administrators and professionals in charge of organizing this care, requires continuous, diversified investment in permanent education”. Moreover, they also indicate that it is necessary to constantly analyze how training actions are conducted, considering that educational processes should not be merely technical and conceptual. In other words, proper care presupposes qualified listening and bond construction33, often based on subjective aspects, ignored in the traditional biomedical model.
At this point, we emphasize it is essential that educational processes consider the multiplicity of ways in which violence can manifest itself2. Among the articles included in the review, most dealt with the “VAW” theme in a general manner, and some specifically dealt with marital violence, sexual violence, obstetric violence and physical violence. Regarding this discussion, we point out that signs of physical violence, for example, may be more visible, whereas some violence, such as psychological, moral and patrimonial, is not evident and so requires qualified listening to be perceived. There are also dynamics of violence that can be naturalized, as in the case of sexual violence that occurs within a marital relationship, which is often not perceived as violence. Therefore, the diversity of VAW with its particularities and complexities must be incorporated into the training.
Beyond the understanding that the types of VAW vary, it is essential to take into account markers like gender, race, class and territory that may be combined in the violent experiences. One of the articles included in the review reported a educational process that started from this assumption, incorporating in the introduction a reflection of how the relationships among such markers are structured, for example, abuse in the field of reproductive health26. The concept of intersectionality, developed within the scope of black feminism, can contribute to the health program training involved in VAW to consider the plurality of women\'s experiences, not corroborating the idea of a “universal woman”, so commonly found in public policies, as pointed out by Akotirene4. In consonance, Gonzaga42, discussing the training of psychologists in the field of sexual and reproductive health - which can be expanded to other categories of health professionals – was in favor of training and performance that utilize intersectionality “as a theoretical-methodological tool that helps understanding each subject in its complex formation, not from a perspective that individualizes affectations experienced via social inequalities and systematic oppression ”(p. 4).
Another aspect refers to the focus on PHC, the level of health care most addressed in the articles related to in-service training. Mendonça et al.10 mentioned the importance of PHC in combating violence, because their services are located in the territory and enable more horizontal and longitudinal interaction with users, value the autonomy and co-responsibility of the care, as well as have a central role in articulation with the intersectoral network. However, such potentialities encounter challenges, such as the absence of training for professionals, which can reproduce isolated care, not guided by integrality. Thus, they argue that PHC professionals are strategic for prevention, identification and assistance in situations of violence, requiring continuous education that includes sociocultural debates about VAW10,43. In addition, we reaffirm that, despite the potentialities of PHC, the care and VAW confrontation network is composed of several health devices and other sectors, and that the qualification of its professionals is planned for all of them2.
Finally, in the articles analyzed, the university appears as an important device for enabling the creation of reflective educational spaces, such as disciplines, extension projects, seminars and research involving the theme of VAW. Therefore, we speculate that the tripod, “research, teaching and extension”44 can be strong allies for VAW educational processes, due to the proximity between university and SUS. Here, we argue that multiprofessional residential courses can be potent spaces for critical training about gender and VAW training, as reported in the Assucena and Colonese45 experience. In addition, considering that most articles included in the review conducted research with students and health professionals in the southern and southeastern regions of Brazil, we suggest that more participatory research on VAW-related educational processes in the health sector could cover greater territorial diversity.
FINAL CONSIDERATIONS
This study sought to analyze how health professionals have qualified to work in the prevention and confrontation of VAW in Brazil, considering that the training of such professionals is one of the guidelines of the National Policy to Combat Violence against Women2. Through an integrative literature review, 16 articles were analyzed. They indicated that the training to deal with VAW in both undergraduate education and in service is insufficient. This context weakens the health sector as an active device in VAW combat, causing missed opportunities to detect cases, provide care and referrals to other services in this network.
At the same time, reports were identified describing educational experiences in undergraduate courses and in service, which could instigate promotion of future educational processes, a need reaffirmed in all the articles analyzed. In line with such findings, we suggest partnerships between educational institutions and SUS for the establishment of creative, participatory educational processes that consider the social complexity of the VAW phenomenon, based on reflective, intersectional and critical lenses. In addition, we corroborate the focus in the PHC, due to the power this level of care has to identify and forward cases, thus suggesting educational processes with CHA.
Finally, we argue that debate about violence is not an eventual appendage in undergraduate courses and isolated training in service, but the various actors that make up the health sector should commit themselves ethically and politically to the continuous confrontation of this problem.
Contributions
JCO, KAP and JGE contributed to the conception, design, analysis and interpretation of the data, and the writing of the article. PHC and PDB contributed to the critical review of the article, and approved the version to be published.
Funding
The project, “Oportunidades perdidas na resposta à violência contra mulheres e meninas no setor saúde” (Missed Opportunities in Response to Violence Against Women and Girls in the Health Sector), which served as the basis for this report, was financially supported by the Fiocruz Program of Innovation Promotion (Inova Fiocruz), Edital Geração de Conhecimento - 2ª Rodada 2021, and the Swiss Network for International Studies (SNIS) - Call for Projects 2021.
REFERENCES
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