Intimate Partner Violence: Barriers to Action and Opportunities for Intervention Among Health Care Providers in São Paulo,Brazil

Abstract

Health care providers (HCPs) who directly interact with women play a critical role in intimate partner violence (IPV) prevention and response. The aim of this study was to identify the structural and interpersonal barriers to IPV response among HCPs working in public health clinics in Santo André, Brazil. Eligible participants included all HCPs providing direct care to individuals at three public health clinics. Participants self-administered an adapted Knowledge, Attitudes, and Practices survey on IPV. Data were analyzed using Epi Info 7 and SAS 9.4. 114 HCPs completed surveys. Less than half of HCPs (41%, n = 34) reported ever having asked a woman about abuse in the past year. HCPs who perceived fewer barriers were more likely to report asking about IPV. The top three reported barriers to asking women about IPV included the following: few opportunities for one-on-one interaction (77%, n = 65), a lack of privacy (71%, n = 60), and fear of offending women (71%, n = 60). Fewer providers who perceived the barriers of lack of privacy asked about IPV (50.8%, n = 33 compared with 84.2%, n = 16; p < .05); less providers who perceived few opportunities for private patient interactions asked about IPV (48.3%, n = 29 compared with 75.0%, n = 18; p < .05). Our results support the need for a systems approach of institution-wide reforms altering the health care environment and avoiding missed opportunities in IPV screening and referring women to appropriate resources or care. Two of the most frequently reported barriers to asking IPV were structural in nature, pointing to the need for policies that protect privacy and confidentiality. Within the Brazilian context, our research highlights the role of HCPs in the design and implementation of IPV interventions that both strengthen health systems and enable providers to address IPV.

Keywords

assessment domestic violence disclosure of domestic violence cultural contexts perceptions of domestic violence

Introduction

Intimate partner violence (IPV) is a social epidemic affecting one in three women globally (García-Moreno et al., 2013). IPV includes physical, psychological, and sexual violence and has considerable impacts on the mental and physical health of women (Ashford & Feldman-Jacobs, 2010; Campbell, 2002; Kiss et al., 2012). Some countries have begun to implement strategies to prevent and respond to IPV including several promising interventions (Ellsberg et al., 2015). There is an emerging evidence base for interventions that address gender norms and those that create systems for IPV surveillance—and where appropriate, screening and referral; however, there is still a need for comprehensive, multi-sectoral, long-term approaches at all levels of the ecological framework (Heise, 2011).

The country of Brazil is no exception in this global epidemic. Between 2015 and 2017, estimates of Brazilian women who experienced domestic or family violence increased from 18% to 29%; the Brazilian femicide rate is the fifth highest in the world (Pesquisa DataSenado, 2017; Waiselfisz, 2015). To address these concerns, Brazil has adopted progressive laws including the 2006 Maria da Penha law—Brazil’s first federal law criminalizing violence against women (VAW)—and the 2015 anti-femicide law, which established stronger penalties against VAW and created guidelines on reporting (Presidência da República, 2006, 2015). Although these laws both increased attention and resources for IPV prevention and response, their effect on IPV-related homicides is mixed. There have been periods of both decrease and increase in reported femicide rates in the years since the implementation of the laws (Waiselfisz, 2015). Furthermore, their impact on the health sector, and its response to IPV, remains unmeasured (Gattegno, Wilkins, & Evans, 2016).

The country’s unified health system (Sistema Único de Saúde—SUS) makes up an important part of the Brazilian multi-sectoral response to IPV since it is often where women receive care for not only violence-related injuries but also other negative health consequences of IPV (Campbell, 2002; García-Moreno et al., 2013; Kiss et al., 2012). Thus, health care providers (HCPs) who directly interact with women have the potential to play a critical role in violence prevention and response (García-Moreno et al., 2013). Although global guidelines articulating this role exist, their implementation has been slow to progress (Ellsberg, Heise, & World Health Organization [WHO], 2005; García-Moreno et al., 2013; WHO, 2010, 2016, 2017). This is particularly true in low- and middle-income countries (LMICs) where substantial barriers exist, such as widespread cultural norms that underscore gender inequity, and a lack of infrastructure designed to reinforce violence reporting and referral services (Bott, Guedes, Goodwin, & Mendoza, 2012). Moreover, training for personnel—including health professionals—has been shown to be ineffective as a stand-alone VAW prevention strategy (Basile & Saltzman, 2002; Ellsberg et al., 2015; Ellsberg, Jansen, Heise, Watts, & García-Moreno, 2008).

Thus, there is a need to identify potential improvements in the implementation of IPV prevention and response strategies within the health system. A previous qualitative study showed that if HCPs were perceived as disrespectful, women’s perception of health system IPV response was negative (Evans et al., 2018). Other structural barriers, such as lack of privacy and time with patients, may also influence whether HCPs ask about IPV, as well as how they react. As important change agents, HCPs are crucial to effective IPV intervention. The aim of this study was to identify the structural and interpersonal barriers to IPV response among HCPs working in public health clinics in Santo André, Brazil.

Method

Setting

Santo André, Brazil, is a low-income community of 700,000 in metropolitan São Paulo where suspected and confirmed cases of VAW increased by over 100% between 2009 and 2013 (Prefeitura de Santo André, 2015, n.d.). The municipality recognizes violence as a problem and was a partner in this research. The Secretariat for Women’s Policies (SPM) selected three SUS public health clinics in geographically and economically diverse communities in the municipality for inclusion.

Participants

Eligible participants included all HCPs providing direct care to individuals. We collected demographic information from respondents including gender, age, occupation, time at organization, and number of female patients aged 12 and older seen each week. Occupations included community health workers (CHWs), physicians, and nurses. Other professions include dentists, counselors/psychologists, social workers, and administrators. In addition, a category for nurse assistants was created because of the large number of write-in responses. The data presented here are delimited to participants who indicated providing clinical services as well as CHWs providing community-based health education; administrators without clinical responsibilities were excluded from the analyses.

Measures

The survey instrument was adapted from the International Planned Parenthood Federation (IPPF), Western Hemisphere Region’s Survey of Provider Knowledge, Attitudes, and Practices (KAP) on gender-based violence (GBV; Bott, Guedes, Claramunt, & Guezmes, 2010; Guedes, Bott, & Cuca, 2002). Three GBV categories were included on the original instrument: domestic violence (physical, sexual, or psychological); sexual abuse or rape; and childhood sexual abuse. We adapted the survey instruments to focus exclusively on IPV; three types of IPV were defined in harmony with the WHO categories: physical, sexual, and psychological (Ellsberg et al., 2008). In addition to questions about knowledge of and attitudes about IPV, we also collected an assessment of HCP readiness to support IPV screening and response within health care settings. Our primary outcome of interest was whether HCPs asked their patients about IPV. Using a four-point Likert-type scale (strongly agree, agree, disagree, strongly disagree), we asked about the circumstances under which HCPs asked about IPV as well as their comfort asking women about specific types of violence (physical harm, psychological harm, sexual harm, and childhood sexual abuse). We assessed perceived barriers by asking whether HCPs disagreed, partially agreed, or agreed with 11 items which included structural (e.g., time, privacy, access to resources) and social barriers (e.g., embarrassment, cultural norms). Items were categorized as barriers if HCPs indicated any degree of agreement. In addition, we measured a perceived responsibility of HCPs to ask about violence based on an affirmative response to the question: “Do you think health professionals should ask women clients routinely about violence?” The adapted modified version of the IPPF instrument was translated into Brazilian Portuguese by a member of the research team and back translated by a native speaker.

Study ethics

The study protocol was reviewed and approved by the Institutional Review Boards of Emory University, the Santo André municipal government, and Plataforma Brasil, the Brazilian National Institutional Review Board (CAAE 57344616.0.0000.5484). In keeping with ethical standards for research, steps were taken to protect the rights of participants and ensure confidentiality throughout data collection, management, and analysis. Verbal informed consent was acquired from all participants, and participants were informed that they could withdraw from participation at any time. Providers were asked only about their general practices and attitudes, and no patient information was obtained. There was minimal risk to the participants, as their participation and the information collected from them were kept confidential. WHO guidance for conducting research on VAW was used throughout the project to minimize potential risk to women, HCPs, and the researchers (Ellsberg et al., 2005).

Data collection and analysis

After consenting to participate, HCPs self-administered a paper version of the survey. Data were double data entered and cleaned using Epi Info 7. Statistical analysis was conducted in Epi Info 7 and SAS 9.4. We used basic descriptive analysis and chi-square tests with Fisher’s exact test to account for small cell size. Our a-priori significance level was p < .05.

Results

Across the three clinic sites, 114 HCPs completed surveys. The median age of participants was 40 and the respondents were 75% female. Nearly 40% of respondents had been at their organization for more than 7 years and half (50%) saw more than 21 patients per week (Table 1). The majority of individuals provided direct care to women (78%, n = 88); 18% (n = 20) of individuals indicated an administrative or managerial role in addition to their direct care role.

Table 1.

Demographic Characteristics of Health Care Professionals Surveyed in Santo André.

Characteristics	Total^a (N = 114)
Characteristics	n (%)
Gender
Female	85 (74.6)
Male	26 (22.8)
Age (years)
Younger than 40	61 (53.5)
40 or older	53 (46.5)
Occupation^b
Community health worker	29 (25.4)
Manager	20 (17.5)
Physician	17 (14.9)
Nurse assistant	17 (14.9)
Nurse	16 (14.0)
Other occupation^c	15 (13.2)
Time at the organization
Less than 1 year	4 (3.5)
Between 1 and 3 years	26 (22.8)
Between 4 and 6 years	38 (33.3)
7 years or more	45 (39.5)
Patients seen each week
None^d	22 (19.3)
1-10 women	16 (14.0)
11-20 Women	17 (14.9)
21-30 Women	57 (50.0)

N may vary by variable due to missing values.

Results add up to more than 100% because individuals could select multiple occupations.

Other occupations include dentists, counselors/psychologists, social workers, and unspecified.

Managers have an important role in decision-making and information-sharing due to their leadership role; they were included in our analysis for this reason. Managers typically split their time between clinical and administrative duties.

Participants demonstrated moderate-to-high (41%-93%, n = 45) knowledge on a range of questions about IPV including 87% knew violence in a relationship tends to increase over time. Non-stigmatizing attitudes were observed in most participants; three quarters (76%, n = 80) rejected victim blaming, and 70% (n = 74) disagreed that IPV was a result of poverty or low education. However, very few HCPs (13%, n = 14) felt that it was a man’s responsibility to control his sexual behavior.

Attitudes toward IPV screening were positive overall. Although the majority (70%, n = 55) felt it was the HCPs’ role to ask about IPV, only 57% (n = 47) felt that they themselves would feel comfortable asking women about IPV. In actual practice, around half of HCPs (58%, n = 52) said that in the past year, they ever asked a woman about abuse or mistreatment. Neither belief in HCP responsibility nor reported comfort in asking about IPV was associated with actually asking about IPV (Table 2). Of those who asked (n = 52), 56% asked as a matter of routine practice. A larger percentage (86%, n = 37) asked whether the patient said something that made them suspect violence, and 68% (n = 34) asked whether they saw physical indications of violence (e.g., bruises).

Table 2.

The Association Between Health Care Providers’ Perceived Responsibility and Comfort Asking About Intimate Partner Violence With Actual Provider Behavior.

Provider Behavior	Perceived Responsibility(N = 78)			Provider Comfort Asking About IPV(N = 82)
Provider Behavior	Yesn (%)	Non (%)	p-value	Yesn (%)	Non (%)	p-value
Asked about IPV	36 (65.4)	12 (52.2)	.31	31 (66.0)	17 (48.6)	.17
Did not ask about IPV	19 (34.6)	11 (47.8)		16 (34.0)	18 (51.4)

Note. IPV = Intimate Partner Violence.

Despite feeling strong about asking about IPV, providers expressed several barriers when asking women about IPV. The top three barriers to asking women about IPV included the following: few opportunities for one-on-one interaction (78%, n = 67), a lack of privacy (72%, n = 61), and fear of offending women (71%, n = 62). Notably, 25% (n = 28) of respondents did not respond to the section of the survey about barriers.

We further examined the relationship between provider behavior (actually asking about IPV) and attitudes (comfort about IPV/perceived barriers). In bivariate associations, individuals who perceived barriers in terms of lack of privacy (50.8%, n = 33 compared with 84.2%, n = 16; p < .05) and few one-on-one interactions (48.3%, n = 29 compared with 75.0%, n = 18; p < .05) were less likely to have asked about violence (Table 3). Although neither relationship was statistically significant, HCPs who perceived fewer barriers were more likely to report asking patients about IPV (data not shown).

Table 3.

The Association Between Provider Behavior and Perceived Barriers to Asking About IPV.

Provider Behavior	Limited One-on-One Interaction(n = 84)			No Privacy(n = 84)			Fear of Offending(n = 86)
Provider Behavior	Agreen (%)	Disagreen (%)	p-value	Agreen (%)	Disagreen (%)	p-value	AgreeN (%)	DisagreeN (%)	p-value
Asked about IPV	33 (50.8)	16 (84.2)	.016	29 (48.3)	18 (75.0)	.031	31 (51.7)	19 (73.1)	.095
Did not ask about IPV	32 (49.2)	3 (15.8)		31 (51.7)	6 (25.0)		29 (48.3)	7 (26.9)

Note. IPV = Intimate Partner Violence.

Discussion

This study provides a number of important observations regarding HCPs’ perceived responsibilities and barriers to asking about IPV, with important implications for IPV intervention strategies within health systems. Nearly all providers indicated that violence is unacceptable and did not endorse cultural norms that promote gender inequity. Moreover, there was very little variability in provider’s perception of norms around violence being negative, and 70% felt that it was the HCP’s role to ask about IPV. These positive findings suggest that not only do HCPs not blame victims of violence, but there is a considerable amount of buy-in by HCPs regarding their role in IPV detection among female patients; they see themselves as playing a crucial role in addressing IPV. Although social desirability bias and self-selection may have played some role in these results, the findings are nevertheless encouraging.

Although there is a relatively high perception of responsibility among HCPs to address IPV (nearly three out of four providers), there is a relatively low level of comfort to do so (44%, n = 38). Fear of offending patients was the third most frequently mentioned barrier to asking women about IPV which indicates that there may be a need for institutional support to increase HCP comfort discussing IPV with patients. Personnel training, however, is not an effective stand-alone or system-wide intervention—nor was training in particular demand among our participants (Ellsberg et al., 2015). Instead, promising population-based prevention interventions, such as participatory community mobilization projects and empowerment training, including health care professionals, may be considered (Ellsberg et al., 2015). The formation of partnerships with external advocates, service providers, and community organizations can be mutually beneficial and are among the most successful program in reviews of the literature (Ellsberg et al., 2015; Hamberger, Rhodes, & Brown, 2015; White & Sienkiewicz, 2018). Such a “systems approach” has the potential to improve the services accessed by women who enter the health care system and may make implementation of programmatic components, such as referrals and coordination with local coordinators of social services, more effective.

Two of the most frequently reported barriers to asking patients about IPV were structural in nature. They included a lack of one-on-one interaction with patients and a lack of privacy. These are not individual provider-level barriers, but rather point to the need for policies that protect privacy and confidentiality, as well as ongoing support for staff to ensure effective service provision (Interagency Gender Working Group of U.S. Agency for International Development, 2006). This is similar to observations in other middle-income countries where providers report being motivated to address IPV in patients, but see structural and contextual barriers (Sprague, Hatcher, Woollett, & Black, 2017). Interventions that integrate health care systems should include policies and systematic approaches in addition to individual-level support for HCPs. An effective, comprehensive systems approach to prevent IPV takes a multitude of prevention strategies (Kulkarni, 2019; Nation et al., 2003). For example, the barriers noted by our participants can be intervened on through structural changes to health care procedures (i.e., scheduling) and facilities (i.e., more private rooms). Our results further support the need for a systems approach of institution-wide reforms altering the health care environment and avoiding missed opportunities in IPV screening and referring women to appropriate resources or care (Bott, Morrison, & Ellsberg, 2005).

Less than half of HCPs reported ever asking their patients whether they had experienced IPV. Although the WHO (2013) does not recommend universal screening for IPV, consideration for how to identify and support women experiencing violence is part and parcel of essential health care provision; women at risk of femicide as well as those presenting with acute injuries merit special consideration (García-Moreno et al., 2015). To ensure consistent and appropriate IPV screening and to ensure confidence among HCPs that they will not offend patients there needs to be standardized validated screening instruments and procedures. One systematic review of 11 studies found that adopting a standardized screening procedure in health care settings more than doubles the detection of IPV (O’Doherty et al., 2014). Because screening itself does not necessarily lead to IPV referral uptake, screening procedures must be reinforced by policy and integrated with data-collection systems to ensure adequate IPV surveillance, monitoring, and evaluation of service provision, and the benefits and risks to patients (Gattegno et al., 2016; Hamberger et al., 2015; O’Doherty et al., 2014). Quick access to a violence advocate increases the likelihood that a woman will access additional resources (Feder et al., 2011). Therefore, health care systems need to develop standardized referral procedures and internal IPV staffing expertise to ensure that HCPs have specific actionable steps after screening patients and to ensure that patients are referred to appropriate services when violence is disclosed. The provision of referral procedures squarely situates the health sector response to IPV within the network of social and legal services necessary to comprehensively address women’s needs.

Women who experience IPV have complex needs and may require services from many different sectors, including health care, social services, legal entities, and law enforcement (Ellsberg et al., 2015; Hamberger et al., 2015; Heise, Ellsberg, & Gottemoeller, 1999; Kulkarni, 2019; White & Sienkiewicz, 2018; WHO, 2012). Therefore, multi-sectoral collaboration is essential for ensuring survivors’ access to comprehensive services (Ellsberg et al., 2015; Hamberger et al., 2015; Heise et al., 1999; Kulkarni, 2019; White & Sienkiewicz, 2018). In addition, national and local strategies to address IPV need to reach informal networks and the wider community to be successful in supporting women and decreasing the incidence of violence (Kiss et al., 2012; White & Sienkiewicz, 2018). Entire health systems need to respond to support women survivors of violence, with linkages to legal and social services. Additional research is needed on one-stop crisis centers, and case management services within the health sector, as well as mass education efforts (Ellsberg et al., 2015). HCP perception of responsibility and comfort with screening are among the strongest predictors of IPV screening implementation (O’Campo, Kirst, Tsamis, Chambers, & Ahmad, 2011). By engaging HCPs, health sector initiatives can capitalize on the responsibility that HCPs see themselves having in addressing the serious issue of IPV against women in Brazil.

Our data are limited by a small sample size and missing data from select item responses. Most participants were females, limiting our ability to disaggregate our data or perform an analysis of gender differences. Although not a representative sample, our field sites were purposively selected by local partners to ensure geographic and socio-economic diversity. Social desirability bias may also have influenced participant responses. Despite these limitations, the study provides insights into provider attitudes on the often-stigmatized issue of IPV and the role of HCPs in IPV screening within health care settings.

Conclusion

This analysis highlights that staff in public health clinics are ideally positioned to work from a preventive framework and address women at risk for or experiencing IPV (Cronholm, Fogarty, Ambuel, & Harrison, 2011). Abused women are twice as likely as non-abused women to report poor health and physical and mental health problems even if the violence occurred years before (Golding, 1999). The participants in this study perceived themselves as being responsible for screening women for experiences of IPV; they also listed concrete perceived barriers such as discomfort approaching the subject, a lack of privacy, one-on-one time with patients, and concerns around confidentiality. These identified barriers largely represent structural challenges within the health care system rather than individual-level concerns among HCPs’ attitudes or knowledge. However, this analysis in the context of the literature also highlights that prevention efforts need more than HCP buy-in to implement effective IPV screening and services. Although the need to address the identified barrier is of immediate relevance to the health sector, a comprehensive systems approach to IPV must move beyond the health system alone. Strategies with demonstrated promise or effectiveness include the following: reform of civil and criminal legal frameworks; media and advocacy campaigns to raise awareness about existing legislation; strengthened civil rights for women; coalition-building between government and civil society; development of the evidence base for advocacy and awareness; and behavior change communication to achieve social change (Basile & Saltzman, 2002; Ellsberg et al., 2005). Within the context of Brazil, our research highlights the role of health care professionals in designing successful and sustainable IPV interventions by strengthening health systems and enabling providers to address VAW, including protocols, capacity building, effective coordination between agencies, and referral networks (García-Moreno, Jansen, Ellsberg, Heise, & Watts, 2005). Future research should examine current screening practices, explore standardized approaches to screening and referral, and test systems approaches for addressing IPV in the health care setting and beyond.

Footnotes

Acknowledgements

The authors are grateful to Danielle Matias Dantas for her assistance with data collection and Maryclaire Regan for her editorial support. The authors would like to express their thanks to the health care professionals who participated in this research as well as the Santo André Ministry of Health who facilitated access to our data-collection locations.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded by the Emory University Global Health Institute and the Emory University Research Committee.

ORCID iDs

Dabney P. Evans

Casey D. Hall

Author Biographies

Dabney P. Evans, PhD, MPH, is an Associate Professor in the Hubert Department of Global Health at Emory University. Her research focuses on gender-based violence, and sexual and reproductive health and rights. Dr. Evans is the author of over 40 peer-reviewed manuscripts. Her public scholarship has appeared in the Pacific Standard, Ms. Magazine, and The Hill.

Danielle Z. Shojaie, MPH, is a senior research coordinator at the University of Texas MD Anderson Cancer Center within the Department of Surgical Oncology. Her current research focuses on medullary thyroid cancer and multiple endocrine neoplasia type 2. Her prior research focused on mental health and flourishing, intimate partner violence, and bleeding disorders.

Kashika M. Sahay, PhD, MPH, was a Royster fellow at the University of North Carolina at Chapel Hill at the time of this publication. Her multidisciplinary research interests involve using real-world data and evidence to improve the health and well-being of vulnerable populations. She has published in a variety of fields including social work, population studies, and social determinants of health.

Nancy Williams DeSousa, PhD, MPH, is a behavioral scientist and independent consultant with nearly 20 years of research experience primarily in the field of HIV prevention. Her research interests align with her commitment to social justice and include exploring using the theory of intersectionality to explore how gender role expectations affect sexual risk behaviors in heterosexual populations.

Casey D. Hall, PhD, MPH, is a postdoctoral scholar at the Institute for Sexual and Gender Minority Health and Wellbeing at Northwestern University. His work focuses on mixed-methods, intersectional approaches to sexual health disparity and violence research.

Maria A. F. Vertamatti, MD, PhD, is a Gynecologist and Associate Professor in the Faculdade de Medicina do ABC, in Metropolitan São Paulo, Brazil. Since 2000, she has coordinated the Program for Integrated Care for Survivors of Sexual Violence—the main focus for her research and publications.

References

Ashford

Feldman-Jacobs

(2010). The crucial role of health services in responding to gender-based violence. Retrieved from https://assets.prb.org/igwg_media/crucial-role-hlth-srvices.pdf

Basile

K. C.

Saltzman

L. E.

(2002). Sexual violence surveillance; uniform definitions and recommended data elements. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

Bott

Guedes

Claramunt

M. C.

Guezmes

(2010). Improving the health sector response to gender based violence: A resource manual for healthcare professionals in developing countries. Retrieved from ippfwhr.org/wp-content/uploads/2018/08/GBV_cdbookletANDmanual_FA_FINAL__1_.pdf

Bott

Guedes

Goodwin

M. M.

Mendoza

J. A.

(2012). Violence against women in Latin America and the Caribbean: A comparative analysis of population-based data from 12 countries. Washington, DC: Pan American Health Organization.

Bott

Morrison

Ellsberg

(2005). Preventing and responding to gender-based violence in middle and low-income countries: A global review and analysis. Washington, DC: The World Bank.

Campbell

J. C.

(2002). Health consequences of intimate partner violence. The Lancet, 359, 1331-1336.

Cronholm

P. F.

Fogarty

C. T.

Ambuel

Harrison

S. L.

(2011). Intimate partner violence. American Family Physician, 83, 1165-1172.

Ellsberg

M. C.

Arango

D. J.

Morton

Gennari

Kiplesund

Contreras

Watts

(2015). Prevention of violence against women and girls: What does the evidence say? The Lancet, 385, 1555-1566.

Ellsberg

M. C.

Heise

L., &

World Health Organization. (2005). Researching violence against women: Practical guidelines for researchers and activists. Geneva, Switzerland: World Health Organization.

10.

Ellsberg

M. C.

Jansen

H. A.

Heise

Watts

C. H.

García-Moreno

(2008). Intimate partner violence and women’s physical and mental health in the WHO multi-country study on women’s health and domestic violence: An observational study. The Lancet, 371, 1165-1172.

11.

Evans

D. P.

DeSousa Williams

Wilkins

J. D.

Chiang

E. D.

Manders

Vertamatti

M. A. F.

(2018). ‘He said he was going to kill me’: Case studies of attempted intimate femicide in São Paulo, Brazil. Journal of Comparative Social Work, 13, 57-80.

12.

Feder

Davies

R. A.

Baird

Dunne

Eldridge

Griffiths

Rutterford

(2011). Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: A cluster randomised controlled trial. The Lancet, 378, 1788-1795.

13.

García-Moreno

Hegarty

d’Oliveira

A. F. L.

Koziol-McLain

Colombini

Feder

(2015). The health-systems response to violence against women. The Lancet, 385, 1567-1579.

14.

García-Moreno

Jansen

H. A.

Ellsberg

Heise

Watts

(2005). WHO multi-country study on women’s health and domestic violence against women. Geneva, Switzerland: World Health Organization.

15.

García-Moreno

Pallitto

Devries

Stöckl

Watts

Abrahams

(2013). Global and regional estimates of violence against women: Prevalence and health effects of intimate partner violence and non-partner sexual violence. Retrieved from http://apps.who.int/iris/bitstream/handle/10665/85239/9789241564625_eng.pdf; jsessionid=AB22460484733A6745281C829E536E1F?sequence=1

16.

Gattegno

M. V.

Wilkins

J. D.

Evans

D. P.

(2016). The relationship between the Maria da Penha Law and intimate partner violence in two Brazilian states. International Journal for Equity in Health, 15(1), Article 138.

17.

Golding

J. M.

(1999). Intimate partner violence as a risk factor for mental disorders: A meta-analysis. Journal of Family Violence, 14, 99-132.

18.

Guedes

Bott

Cuca

(2002). Integrating systematic screening for gender-based violence into sexual and reproductive health services: Results of a baseline study by the International Planned Parenthood Federation, Western Hemisphere Region. International Journal of Gynecology & Obstetrics, 78, S57-S63.

19.

Hamberger

L. K.

Rhodes

Brown

(2015). Screening and intervention for intimate partner violence in healthcare settings: Creating sustainable system-level programs. Journal of Women’s Health, 24, 86-91.

20.

Heise

(2011, December). What works to prevent partner violence? An evidence overview. Retrieved from https://www.oecd.org/derec/49872444.pdf

21.

Heise

Ellsberg

Gottemoeller

(1999). Ending violence against women. Population Reports, 27(4), Article 1.

22.

Interagency Gender Working Group of U.S. Agency for International Development. (2006). Addressing gender-based violence through USAID’S health programs: A guide for health sector program officers. Washington, DC: Author.

23.

Kiss

d’Oliveira

A. F.

Zimmerman

Heise

Schraiber

L. B.

Watts

(2012). Brazilian policy responses to violence against women: Government strategy and the help-seeking behaviors of women who experience violence. Health and Human Rights, 14, E64-E77.

24.

Kulkarni

(2019). Intersectional trauma-informed intimate partner violence (IPV) services: Narrowing the gap between IPV service delivery and survivor needs. Journal of Family Violence, 34, 55-64.

25.

Nation

Crusto

Wandersman

Kumpfer

K. L.

Seybolt

Morrissey-Kane

Davino

(2003). What works in prevention: Principles of effective prevention programs. American Psychologist, 58, 449-456.

26.

O’Campo

Kirst

Tsamis

Chambers

Ahmad

(2011). Implementing successful intimate partner violence screening programs in health care settings: Evidence generated from a realist-informed systematic review. Social Science & Medicine, 72, 855-866.

27.

O’Doherty

L. J.

Taft

Hegarty

Ramsay

Davidson

L. L.

Feder

(2014). Screening women for intimate partner violence in healthcare settings: Abridged Cochrane systematic review and meta-analysis. British Medical Journal, 348, g2913.

28.

Pesquisa DataSenado [Senate Data Research]. (2017). Violência doméstica e familiar contra a mulher [Domestic and family violence against women]. Retrieved from https://www12.senado.leg.br/institucional/datasenado/arquivos/aumenta-numero-de-mulheres-que-declaram-ter-sofrido-violencia

29.

Prefeitura de Santo André [City of Santo André]. (2015, March). Mulheres de Santo André em Pauta: Perfil Socioeconômico e Mapa de Violência [Women of Santo André on the Agenda: Socio-economic profile and Map of Violence]. Retrieved from http://www.santoandre.sp.gov.br/pesquisa/ebooks/370220.PDF

30.

Prefeitura de Santo André [City of Santo André]. (n.d.). Em Santo André, o mapa da violência doméstica e sexual tem sexo [In Santo André, the map of domestic and family violence includes sex]. Retrieved from https://www2.santoandre.sp.gov.br/index.php/noticias/item/9485-em-santo-andre-o-mapa-da-violencia-domestica-e-sexual-tem-sexo

31.

Presidência da República. (2006, August 7). LEI No. 11.340. Retrieved from http://www.planalto.gov.br/ccivil_03/_Ato2004-2006/2006/Lei/L11340.htm

32.

Presidência da República. (2015, March 9). LEI No. 13.104. Retrieved from http://www.planalto.gov.br/ccivil_03/_Ato2015-2018/2015/Lei/L13104.htm

33.

Sprague

Hatcher

A. M.

Woollett

Black

(2017). How nurses in Johannesburg address intimate partner violence in female patients: Understanding IPV responses in low- and middle-income country health systems. Journal of Interpersonal Violence, 32, 1591-1619.

34.

Waiselfisz

J. J.

(2015). Mapa da violência 2015: homicídio de mulheres no Brasil [Map of violence 2015: female homicides in Brail]. Sao Paulo, Brasil: Flacso. Retrieved from https://www.mapadaviolencia.org.br/pdf2015/MapaViolencia_2015_mulheres.pdf

35.

White

J. W.

Sienkiewicz

H. C.

(2018). Victim empowerment, safety, and perpetrator accountability through collaboration: A crisis to transformation conceptual model. Violence against Women, 24, 1678-1696.

36.

World Health Organization. (2010). Preventing intimate partner and sexual violence against women: Taking action and generating evidence. Geneva, Switzerland: Author.

37.

World Health Organization. (2012). Understanding and addressing violence against women: Intimate partner violence (No. WHO/RHR/12.36). Geneva, Switzerland: Author.

38.

World Health Organization. (2013). Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva, Switzerland: Author.

39.

World Health Organization. (2016). Ethical and safety recommendations for intervention research on violence against women: Building on lessons from the WHO publication (Putting Women First: Ethical and Safety Recommendations for Research on Domestic Violence against Women). Geneva, Switzerland: Author.

40.

World Health Organization. (2017). Strengthening health systems to respond to women subjected to intimate partner violence or sexual violence: A manual for health managers. Geneva, Switzerland: Author.