INTRODUCTION

The theme of Domestic Violence Against Women (DVAW) has been discussed worldwide, presenting high prevalence and impact in the health services. In this study, DVAW is defined as any gender-based action or omission that results in their death, injuries, mental, sexual or psychological distress, and moral or patrimonial harms, both in the public and private scopes¹.

DVAW is built from the relationships between men and women that are permeated by social and hierarchization inequalities between them². Thus, violence translates the gender social construction that attributes men power in the relationship and the Figure of a virile provider, while women remain as submission objects³.

It is estimated that 35% of the women are victims of physical or sexual violence in the world⁴. A study developed in Spain indicated that low-schooled and unemployed women are at a higher risk of being victims of intimate partner violence, with 24.8% prevalence of women who suffer the problem⁵.

In Brazil, a research study conducted by the Brazilian Public Security Forum revealed that, out of 10 women, three are victims of violence; this is synonymous to saying that 16 million Brazilian women suffer some type of violence, with most of them experiencing it in their homes (42%) and the boyfriends/spouses/partners being indicated as the main perpetrators, with 23.8%⁶.

DVAW requires dialog between several sectors of society for its confrontation and prevention, with investments in political, social and economic actions by the governments, the institutions that assist women and the entire society⁷. In the health sector, the Family Health Strategy (FHS) presents itself as a field for communication, organization and flow of users, as well as it enables initial care for women in situations of violence. Consequently, it stands out for playing a fundamental role in the Care Network for Women in Situations of Violence (Rede de Atenção à Mulher em Situação de Violência, RAMSV)⁸.

In this way, FHS health professionals are involved in the process to cope with DVAW, where this activity requires professionals to have a view of the world and of care practices that contemplates gender issues^9,10. Community Health Agents (CHAs) stand out among the FHS health professionals, as they enjoy the possibility of knowing the family dynamics for living in the same area and of establishing dialog and trust with the women and family members, in many cases with the opportunity to identify the DVAW situations from their very observations and act as a link between the family and the FHS team⁹.

In this context, the research topic chosen was “The practical dimensions of the CHAs' social representations about DVAW”, which implies recognizing the social representations (SRs) as a joint guide and definition regarding the different aspects of everyday reality, in order to ease interpretation, decision-making and a defensive stance before them¹¹. Consequently, the objective is to work on the health professionals' SRs and acknowledge the existence of knowledge that relates common sense wisdom and its links for the constitution of specific technical-professional knowledge, aimed at objects arising from the everyday professional practice of the work process itself¹².

It is believed that unveiling the CHAs' care practices for women in situations of violence based on their SRs about DVAW raises reflections about the development of actions that contemplate these women's needs in the FHS, as well as devising strategies that improve articulation between this health service and the other sectors of the RAMSV.

Consequently, the objective of this study is to understand the practical dimension of the CHA's social representations about domestic violence against women.

METHODOLOGY

A research study grounded on the Theory of the Social Representations (TSR), through which it can be understood how speeches, communication instances, images and messages show the other's opinion on a given topic, representing what each individual experienced in relation to the subject matter in the social environment in which they are immersed¹³.

The research was developed in 11 Family Health Strategy (FHS) units from the municipality of Jequié, Bahia, Brazil, based on the following inclusion criteria: urban area units with double or single teams and full teams according to the Ministry of Health's protocol during the data collection period.

The research participants were the CHAs working in the FHUs, selected for convenience. Based on the contact established with the supervising nurse, the researcher requested a meeting with all the CHAs working in the FHU team so that she could invite them to participate in the study and schedule a day and time for data collection. As an inclusion criterion, the CHAs had to be active in their functions and having worked for more than six months in the FHU; the exclusion criterion consisted in CHAs who were on holiday, leave-bonus, or undergoing health treatments during the data collection period. Thus, 107 CHAs attended the first meeting with the researcher and, of these, 48 provided their telephone number for subsequent contacts.

Data collection took place from May to August 2019, by means of in-depth interviews guided by a form that contained sociodemographic aspects and a script with three blocks of questions about the theme (DVAW, types and precipitating factors of DVAW, and the CHAs' practices for women in situations of domestic violence). The interviews were conducted individually by the researcher herself in a room made available at the FHUs where the CHAs worked, using an audio recorded and lasting a mean of 50 minutes. Theoretical saturation of the interviews occurred from the 26^th interview, when noticing repetition of contents and absence of new occurrences; however, another four interviews were conducted in order to reinforce the perception. Consequently, the study participants were 30 CHAs from the 11 FHUs.

All 30 interviews were transcribed and organized in the Open Office 4.0.0 software, assembling the corpus for lexical analysis that was processed in the IRAMUTEQ (Interface de R pourles Analyses Multidimensionneles de Textes et de Questionnaires) software, version 0.7 alpha2, in the interface from the Descending Hierarchical Classification (DHC) or Reinert's methods. From the original corpus, DHC allows identifying and organizing the Text Segments (TSs) into groups of statistically significant words from each interview. The chi-square test is used to verify the association of the TSs with a given class; the higher the value, the greater the association¹⁴. Thus, the analysis corpus consisted of 30 lines corresponding to the interviews, processed and analyzed in the software in 39 seconds.

All the participants were informed about the study objectives, reason, risks and benefits and signed the Free and Informed Consent Form. The research project was approved by the Research Ethics Committee of the State University of Southwestern Bahia, complying with Resolutions No. 466/2012 and No. 510/2016 of the National Health Council. Seeking anonymity, the participants' speeches were identified with the word Participant, followed by an Arabic number corresponding to the order in which the interviews were conducted.

RESULTS

Only one of the 30 CHAs participating in the study was male, their age varied from 32 to 57 years old with predominance of the age group between 32 and 45 years old, with 17 participants; 19 self-declared as brown-skinned, 15 were married, 14 had complete Higher Education and 24 indicated mean family incomes from 1 to 3 minimum wages.

Lexical analysis of the interviews in the IRAMUTEQ software yielded 3,058 TSs, of which 2,790 were analyzed, representing 91.24% leverage. The corpus presented 5,531 forms, with 106,739 occurrences, and word lemmatization obtained a total of 3,207, with 3,020 active word forms and 12 supplementary forms. After sizing and classification in DHC, the text segments were defined as belonging to five classes distributed into two axes, according to Figure 1.

Source: Adapted from ^{IRAMUTEQ (2019)}

Figure 1: Distribution of the thematic classes into axes according to DHC, Jequié, BA, Brazil, 2019. 

Figure 1 shows the classes organized based on the DHC dendrogram, which must be read from left to right. The corpus was divided into two subgroups (axis 1 and axis 2); axis 1 was further subdivided into subaxis 1.1 giving rise to classes 5 and 2 and to class 1: this division indicates that classes 5, 2 and 1 are content related, whereas classes 5 and 2 are even closer to each other for being structured in the same subaxis. Axis 2 generated classes 3 and 4, which, even sharing the same axis, have contents that differentiate them and justify their separation into different classes.

This study will deal with the presentation and discussion of axis 2: “Between the CHAs' practices and conceptions about the assistance provided to women in situations of violence” comprised by class 4: “The CHAs' care practices for women in situations of domestic violence” and by class 3: “Services and professionals in the context of the Care Network for Women in Situations of Violence”.

The general content of axis 2 allowed understanding the practical dimension of the CHAs' SRs about DVAW, as it mainly shed light on these professionals' care process for women in situations of violence and on the convictions about the RAMSV services and professionals.

DISCUSSION

In the CHAs' social imaginary, it is revealed that the assistance provided to women in situations of violence includes a technical dimension, a relational dimension and a guidance dimension, although there is also a managerial dimension that assumes an interaction practice and sharing of actions among the professionals, in an attempt to favor comprehensive care for these women.

Home visits are an opportunity for the health professionals to observe the women's living conditions, such as injuries in the body, the home environment, the relationship with the family members and diverse complementary information in the identification of situations of domestic violence¹⁵. While conducting the home visits, health professionals develop practices such as communication and active listening, which enhance the bond and facilitate the guidelines that can contribute to alleviating and calming down women in situations of violence¹⁶.

In this sense, based on their work process, the CHAs develop identification and intervention strategies in relation to DVAW. Home visits strengthen the CHAs' presence in the home environment, the space where they can establish a boding and trusting relationship with the women by assuming the role of social articulators and mediators⁹. The guidelines are aimed at helping to awake in the women the knowledge about their rights, protection, appreciation as human beings and empowerment so that they can enjoy a violence-free life¹⁶.

In the context of DVAW, the home space is an example of patriarchal domination; gender inequality is not something natural, it is imposed by the cultural tradition, by the power structures and by the agents involved in the social relations weave, and this will only be overcome by empowering these women, which means attributing power to them, improving their self-esteem, for example².

In the SRs, it is noticed that the CHAs presented a critical attitude and tried to minimize the women's anguish and doubts through the guidance they provided. Consequently, they assume the position of main actors in identifying and coping with DMAW⁷. However, a research study conducted about the CHAs' care practices for rural women in situations of violence showed that these health professionals feel powerless in solving the DVAW cases; therefore, they need a professional nurse to guide them in their actions⁹.

Proximity between the health services and the community becomes an important instrument that allows for more effective care to be provided, which is strengthened by establishing links comprising a network which allows for a more targeted perspective in the face of DVAW situations¹⁷. Consequently, the CHA's everyday care practice favors the construction of a bond-based relationship, most of the times being the first professional to whom the women report the violence experienced and ending up representing one of the main contacts of these women with the health field and the other care services^9,17.

Nurses play a singular role in the assistance provided to women in situations of violence; in the FHU, they are the professionals responsible for offering support to the nursing technicians and CHAs, in order to solve the cases, in addition to integrating the team, preparing training activities to identify and refer users who are victims of violence, among others¹⁸.

In addition to that, a study developed in the United Kingdom/England with women in situations of domestic violence showed that they acknowledge the importance of the role of those nurses working in Primary Health Care (PHC) in the support provided, planning of the referrals to the ancillary services and guidance about the safety of these women¹⁹.

Thus, it is fundamental for the CHAs to devise strategies aimed at modifying the DVAW situations with the purpose of overcoming fragmentation of the work process, of strengthening the bond with the nurses, and of achieving common goals.

In the meantime, the data generated by the notifications support actions and foster public policies for coping with violence and, by notifying the DVAW cases, health professionals show their commitment and understanding of the magnitude of the problem. Many health professionals acknowledge notifications as a tool to ensure the rights and protection of women in situations of violence; however, they find difficulties notifying the cases due to unpreparedness, fear of retaliation and insecurity resulting from lack of skills in dealing with the diversity of consequences inherent to this context²⁰.

The FHU health professionals notice that the interventions in the Primary Health Network not always contribute results, and that it becomes necessary to refer the cases to other services for continuity of the care provided to the women¹⁶. it is noted that, in 2014, in the Unified Health System (Sistema Único de Saúde, SUS) scope, half of the appointments with women who were victims of violence had some type of referral, with the general police stations, DEAMs, the Public Prosecutor's Office and the Specialized Social Assistance Center (Centro Especializado de Assistência Social, CREAS) standing out²¹.

Articulation between the care services for women in situations of violence needs to be permeated by collective dialog and contact with the professionals, involving the institutional definitions about the roles that each one of them can perform in the network²². Disarticulation of the RAMSV results in the professionals' dissatisfaction and impairs care continuity, as DVAW can present care demands in several sectors for the actions to be effective²³.

The CHAs' representational content about the work-related difficulties in the RAMSV is correlated to the different pieces of knowledge built by the group, both based on reified knowledge about how to cope with DVAW and on the technical-professional knowledge that governs the theoretical and experiential proposals that come into action when developing the everyday professional practices¹².

The health professionals' sensitivity in working based on the biopsychosocial perspective of the health-disease process is fundamental, considering the complexity of DVAW¹⁰. The health professional's commitment in referring the necessary cases to other professionals from the network services reflects that they expect assistance, support and care continuity so that women may build a violence-free life perspective¹⁶.

The CHAs' representational contents encourage articulation of actions between the teams, in an attempt to allow for the integration of diverse professional knowledge in the face of the needs related to the assistance provided to women in situations of violence. Thus, multiprofessional performance needs to rest upon a practice in which professionals from various services work together.

Considering the need for psychological and/or social support, most of the women victims of violence that are treated in the FHS should have the support of a psychologist and/or social worker from the Family Health Support Center (Núcleo de Apoio à Saúde da Família, NASF). Based on the interdisciplinary approach and on matrix support actions, the NASF professionals strengthen the health care practices in the FHS through planning, continuing education and health promotion²⁴, even in relation to coping with DVAW.

Thus, the care provided to women in situations of violence is permeated by collective reconstruction through the diverse knowledge represented by the different services; however, one of the obstacles for articulation of the services in the care network is the professionals' lack of knowledge about functioning of the services. The interaction process between several sectors that comprise the network will only be consolidated by means of mutual knowledge, which involves diverse information about their duties, location, referrals and counter-referrals²².

Corroborating the current study, a survey conducted with CHAs in the city of Palmas/TO showed that there is lack of knowledge in these professionals regarding the adequate course of action in the face of DVAW, as well of appropriate targeting in the RAMSV for the assistance to be provided to women in situations of violence, with the need for update courses on the theme²⁵.

In the international scenario, insufficient training of the health professionals in relation to DVAW is also cited; in a research study conducted in Turkey with family physicians and nurses, it was identified that these professionals mention lack of knowledge to deal with intimate partner violence situations, showing deficiencies in notification and referral of the cases²⁶.

Unpreparedness to deal with DVAW generates difficulties identifying the cases and how to intervene in the situations; unawareness about networking can isolate the women and hinder the critical route, that is, women can be referred to services where they will not find answers to their needs. Consequently, it is necessary to adopt practices to update knowledge about the problem, discuss the cases and understand the flowchart of the services that comprise the RAMSV for the promotion of effective changes in the assistance provided to women in situations of domestic violence²⁷.

FINAL CONSIDERATIONS

This study allowed understanding the practical dimension of the CHAs' SRs about DVAW, appropriating what is stated in reified knowledge, common sense and technical-professional knowledge ancillary to the guidance on actions in the face of the problem.

In their social imaginary, the CHAs brought up that home visits are both a care practice and a strategy to approach DVAW, appropriating the technical dimension. In this sense, during the home visits, the CHAs resort to the relational dimension supported on active listening and bonding as essential tools that favor good quality of their assistance, and the guidance dimension is used a way to exchange information about DVAW and autonomy development with the women. They also reflected on the importance of notifying the DVAW cases and of the referrals to the services that comprise the RAMSV, when they included the managerial dimension of the care practices for women in situations of domestic violence in their thinking.

In general, the CHAs' care practices in the face of DVAW are supported by the FHU nurses for the various knowledge and experience exchanges about the problem, indicating these professionals as responsible for the targeting of their actions.

By revealing the weakness found in networking, the CHAs also presented their conceptions about the services and professionals that comprise the RAMSV. The results pointed to certain disarticulation between the health services and other specialized services that comprise the RAMSV, difficulties that the Family Health team encounters when developing some care practices due to the absence of psychologists and social workers who offer support to the women's psychosocial aspects and to the lack of professional training on the theme of DVAW and networking. It is also emphasized that the municipality where the study was conducted does not have any Family Health Support Center (NASF) that might minimize this gap.

Consequently, it is understood that the CHAs are important professionals in DVAW prevention, identification and coping and need multiprofessional and intersectoral support to meet the demands of women in situations of violence. It is understood that the study contributes benefits for the RAMSV professionals, as well as for teaching and research in Health and Nursing, as it consists in providing diverse evidence about the CHAs' care practices and conceptions for women in situations of violence and the weaknesses found in the professional behaviors in the care network context. Thus, there is an evident need to appropriate the theme of DVAW through reflection spaces for the CHAs, professionals from the different areas, managers and universities, in an attempt to attribute new meanings to the professional practices in the FHS and RAMSV context.