COPING STRATEGIES FOR VIOLENCE AGAINST CHILDREN, ADOLESCENTS AND WOMEN IN THE CONTEXT OF SOCIAL ISOLATION DUE TO COVID-19: SCOPING REVIEW

ESTRATEGIAS PARA HACER FRENTE A LA VIOLENCIA CONTRA NIÑOS, ADOLESCENTES Y MUJERES EN EL CONTEXTO DEL AISLAMIENTO SOCIAL DEBIDO AL COVID-19: REVISIÓN DE ALCANCE

ABSTRACT

Objective:   to map the recommendations of the coping strategies for violence against children, adolescents and women in the context of social isolation due to Covid-19.

Method:  a scoping review according to the Joanna Briggs Institute, through a research strategy carried out in the gray literature by the CAPES Portal and in the following databases: SCIELO, LILACS, PubMed, CINAHL, Web of Science, and Institutional Repository for Information Exchange of the Pan American Health Organization. The analysis of the identified material was carried out by three independent reviewers. The extracted data were analyzed and synthesized in narrative form.

Results:  of the 526 studies found, 59 were kept for review and their content was summarized in six categories: 1) prevention; 2) identification and intervention; 3) continued care; 4) care for the safety and mental health of the professionals; 5) intersectoriality/interdisciplinarity; and 6) special care for vulnerable populations.

Conclusion:  the services must guarantee continuous, intersectoral and safe care, especially in the context of mental health, as well as community awareness must be promoted. Health professionals must be sensitive and alert to signs of violence, intervening immediately and connected to the safety network.

DESCRIPTORS: Exposure to violence; Domestic violence; Coronavirus infections; Social isolation; Intimate partner violence; Child maltreatment; Review

RESUMEN

Objetivo:   mapear las recomendaciones de las estrategias para hacer frente a la violencia contra niños, adolescentes y mujeres en el contexto del aislamiento social debido al Covid-19.

Método:  revisión de alcance de conformidad con el Joanna Briggs Institute, por medio de una estrategia de investigación realizada en la literatura gris en el Portal CAPES y en las siguientes bases de datos: SCIELO, LILACS, PubMed, CINAHL, Web of Science, Repositorio Institucional para Intercambio de Información de la Organización Panamericana de la Salud. El análisis del material identificado estuvo a cargo de tres revisores independientes. Los datos extraídos fueron analizados y sintetizados de forma narrativa.

Resultados:  de los 526 estudios encontrados, 59 se mantuvieron para la revisión y su contenido se sintetizó en seis categorías: 1) prevención; 2) identificación e intervención; 3) atención continua; 4) atención a la seguridad y la salud mental de los profesionales; 5) intersectorialidad/interdisciplinaridad; y 6) atención especial a poblaciones vulnerables.

Conclusión:  los servicios de salud deben garantizar atención continua, intersectorial y segura, en especial en el ámbito de la salud mental, al igual que debe promoverse la concientización comunitaria. Los profesionales de la salud deben permanecer sensibles y alerta a señales de violencia, interviniendo de forma inmediata y conectados a la red de protección.

DESCRIPTORES: Exposición a la violencia; Violencia doméstica; Infecciones por coronavirus; Aislamiento social; Violencia de pareja; Maltrato infantil; Revisión

RESUMO

Objetivo:   mapear as recomendações das estratégias de enfrentamento à violência contra crianças, adolescentes e mulheres no contexto do isolamento social devido à Covid-19. Método: revisão de escopo conforme Instituto Joanna Briggs, por meio de uma estratégia de pesquisa realizada na literatura cinzenta pelo Portal CAPES e nos bancos de dados SCIELO, LILACS, PubMed, CINAHL, Web of Science, Repositório Institucional para Intercambio de Información da Organização Pan-Americana da Saúde. A análise do material identificado foi realizada por três revisores independentes. Os dados extraídos foram analisados e sintetizados de forma narrativa.

Resultados:  dos 526 estudos encontrados, 59 foram mantidos para revisão e seu conteúdo foi resumido em seis categorias: 1) prevenção; 2) identificação e intervenção; 3) cuidado continuado; 4) cuidado à segurança e saúde mental dos profissionais; 5) intersetorialidade/interdisciplinaridade; e 6) cuidado especial a populações vulneráveis.

Conclusão:  os serviços devem garantir um cuidado contínuo, intersetorial e seguro, em especial, no âmbito da saúde mental, bem como, deve-se promover a conscientização comunitária. Os profissionais da saúde devem estar sensíveis e alertas a sinais de violência, intervindo de forma imediata e conectada à rede de proteção.

DESCRITORES: Exposição à violência; Violência doméstica; Infecções por coronavirus; Isolamento social; Violência por parceiro íntimo; Maus-tratos infantis; Revisão

INTRODUCTION

Currently, the Coronavirus Disease 2019 (Covid-19) is considered the greatest worldwide threat to public health, being characterized as a pandemic by the World Health Organization on March 11^th, 2020. Until August 23^th, 2020, 23,057,288 cases and 800,906 deaths were confirmed worldwide, and in Brazil there are 3,532,330 cases, with 113,358 deaths.

One of the main recommendations and strategies of the international health agencies to prevent or reduce viral circulation and consequent disease, is social isolation and lockdown.² Such a strategy, legitimized by the scientific evidence, exposes a paradox: the greatest risk of people suffering domestic violence (DV). International^3-27 and national^28-31 studies ratify the rise in violence against children, adolescents,^{3,11,13,31-35} women^14,36-38 and most vulnerable populations, in the context of the Covid-19 pandemic, due to vulnerability,^{6-7,15,17,24,34,36,38-45} stress,^{4,14-15,30,39,41} economic shock^8,24,46 and the situation of social isolation to contain the spread of the SARS-CoV-2 virus.^{3-5,8-24,26,28,29-31,46-47}

At the same time that there is an increase in cases of DV, a number of studies^4,36,41,48 highlight a reduction or temporary closure of government services related to health, education, social assistance, of the third sector and community that welcome, identify, notify and assist children, adolescents and women in coping with DV, a fact that amplifies the vulnerability of this population. Therefore, in order to make visible the impacts that the closure of these services causes, a number of studies^{3,6,11,31-33,35,43} pointed to the need for the journalistic and scientific media to emphasize the intensification and worsening of DV. A reflective American study, carried out during the current pandemic, added in its results that the figures regarding the perpetuation of DV can be outdated, since many women still remain without access or possibility to report their cases.³⁸

In this sense, the health professionals faced an important challenge to cope with two public health problems, the pandemic and DV against children, adolescents and women.^28,48 In view of the above, this scoping review aims to contribute to the services and professionals working on these public health problems by gathering the available recommendations from the production of knowledge generated by the Covid-19 pandemic. The novelty and originality of this study is reiterated by bringing this discussion in an articulated manner among the populations mentioned, as well as contextualized to the Brazilian scenario, which is still incipient with regard to productions in the area. These elements can contribute to the qualification of intersectoral health care for children, adolescents and women. Therefore, the objective of this study was to map the recommendations of coping strategies for violence against children, adolescents and women in the context of social isolation due to Covid-19.

METHOD

In this study, the proposal of a Scoping Review was adopted, according to the Joanna Briggs Institute(JBI) method.⁴⁹ This is a study search method to map scientific evidence related to key concepts in a particular area of interest. The categories used include effectiveness, suitability, meaning and applicability of health practices and scientific methods.^49-50

The Population, Concept and Context (PCC) strategy was used to construct the research question. The following were defined: for Population (P), women, children and adolescents from 0 to 19 years old, considering the WHO age criterion;⁵¹ for Concept (C), domestic violence, the description of the Mesh descriptor “Deliberate, often repetitive physical, verbal, and/or other types of abuse by one or more members against others of a household”. Regarding Context (C), social isolation at home during the SARS-CoV-2 and Covid-19 period. Based on these definitions, the guiding question was established: what is the production of knowledge about coping strategies for violence against children, adolescents and women in the context of social isolation due to Covid-19?

In this sense, an initial search of the studies was carried out in the period of July 2020, with the following keywords: domestic violence and Covid-19, in the Scientific Electronic Library database (SCIELO) and with the keyword domestic violence on the Pubcovid-19 platform, which features articles published on Covid-19 and indexed in the National Library of Medicine (Pubmed) and EMBASE platforms. First, titles, abstracts and descriptors were read. The selected studies that answered the guiding question of this review were read in full and their references were analyzed in search of additional studies.

The terms used for each selected database were specified and defined after the first search. Descriptors and keywords were established for the effective search in other databases and data platforms. The descriptors and their respective synonyms defined in Portuguese, Spanish and English, according to DeCS and Mesh, were the following: criança/niño/child*, Adolescente/Adolescente/Adolescent, Mulheres/Mujeres/Women, Violência Doméstica/Violencia Doméstica/Domestic Violence, Maus-Tratos Infantis/Maltrato a los Niños/Child Abuse, Maus-Tratos Conjugais/Maltrato Conyugal/Spouse Abuse, Violência por Parceiro Íntimo/Violencia de Pareja/Intimate Partner Violence, Covid-19. Along with the descriptors, the following Boolean terms were used: AND, OR and NOT, so as to compose the search formulas to be used for searches in the databases.⁵²

In this sense, searches were carried out in the databases of Latin American and Caribbean Literature in Health Sciences (Literatura Latino-Americana e do Caribe em Ciências da Saúde, LILACS), National Library of Medicine (PubMed), The Cochrane Library, The Cumulative Index to Nursing and Allied Health Literature (CINAHL) (via the EBSCO platform), and on the Web of Science and Institutional Repository for Information Exchange (IRIS) of the Pan American Health Organization. As for the gray literature, the search was carried out by the Coordination for the Improvement of Higher-Level Personnel Portal (CAPES Portal). The references listed in the studies found were also searched, in order to identify additional documents for potential inclusion in this review.

The inclusion criteria for the selected studies were primary studies with a quantitative approach (randomized or non-randomized clinical studies, quasi-experimental studies and observational studies), qualitative, quanti-qualitative and mixed. Experience reports were included, as well as literature reviews (integrative, scoping, systematic, meta-analysis and/or meta-synthesis), and guidelines. The languages of the studies were English, Spanish and Portuguese, without limitation regarding year of publication, as recommended by the JBI, published or made available until July 2020. Regarding the exclusion criteria, books and abstracts of scientific events were excluded, as well as and other studies that did not answer the research question.

The search and selection process for the studies in this review is shown in Figure 1, following the JBI recommendations, according to a checklist adapted from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).⁵³

Figure 1 -
Search strategy used for the scoping review, adapted from PRISMA.

The studies included in this review must answer the study question and inclusion criteria. Of the 526 studies found, the titles and abstracts were read by two reviewers and a third, as recommended by the JBI. A study was added by the authors by the area of expertise and to answer the review question. Of these, 372 were selected for meeting the inclusion criteria established in this review. Among those selected, 74 studies were chosen for full reading, 15 of which were excluded for not answering the review question related to the Concept and Context strategy. The final sample totaled 59 studies analyzed and included in this review.

The study data were extracted using an instrument structured by the researchers, according to JBI guidelines, which included: study title, journal, year of publication, database, country of origin, language, methodological design, type of publication, objective, introduction, guidelines or reflections on the theme. The main recommendations for the care of children, adolescents and women in situations of violence during the period of social isolation due to SARS-CoV-2 and Covid-19 were also classified. These recommendations were grouped into conceptual categories.

RESULTS

Of the 59 studies selected, the majority (53%-89%) was in the English language and was carried out by multicenter studies, among them by the World Health Organization (13%-22%). The other studies focused on different continents such as America (USA, Brazil, Peru), Asia (India, Philippines), Europe (Italy, France, England), Oceania (Australia) and Africa (South Africa). Regarding the type of publication selected, in this review, in the databases, the types of studies varied largely as reflections and opinions of experts (37%-63%), literature reviews (7%-12%), guideline (6%-10.2%), scientific article (5%-8%). In the gray literature, field notes (2%-3.4%), and documentaries and reports (2%-3.4%) were identified.

In relation to the recommendations, it was decided to present and discuss the results through conceptual categories, formulated from reading the material mapped in this review, called as follows: prevention; identification and intervention; continued care; care for the safety and mental health of the professionals; intersectoriality/interdisciplinarity; and special care for vulnerable populations. These categories worked on the logic of the comprehensive care line for children, adolescents and women and are shown in Table 1.

Table 1 -
Conceptual categories of recommendations for children, adolescents and women. Created by the authors. Ribeirão Preto, SP, Brazil, 2020.

Conceptual categories of recommendations	Studies
Prevention
To improve the mental health services, promoting psychosocial care to parents, caregivers and intimate partners, remotely or in person;	4 , 13 , 29 , 32 , 37 , 39
To increase the teams that work in the prevention of violence;	28
To provide support and guidance to parents and caregivers on: positive parenting (responsive care, family dialog, reading, positive coping strategies, early education, stimulation and protection against taboos and violence, not using force and cohesion), social support and self-care (stress management, physical exercise, relaxation, sleep and eating routine, and the prevention of useless coping strategies, such as the use of tobacco, alcohol or drugs);	4 , 9 - 11 , 14 - 15 , 30 , 40 - 41
To stay alert in relation to parents using beverages or psychoactive substances and on the increase of intra-family stress, providing treatment by telemedicine or in person;	4 , 29 , 37
To conduct state campaigns to reduce the consumption of alcohol and other drugs during the period of social isolation;	4
To guide women to keep in touch with friends and family through text messages, video and voice calls so that there is a support network;	14 , 28 , 33
To inform and guide older adult women who have caregivers to recognize situations of violence and seek help via phone, messages and e-mail in a safe manner;	39
To disclose to the population, through radio, television, notices in supermarkets, pharmacies, social networks and urgency and emergency services, information about the increase in violence, signs for its identification; reproductive health; support to the victims and locally available services (helplines/hotlines, shelters, counseling services). To produce accessible materials in Braille and Libras;	4 , 8 , 14 , 16 - 18 , 33 , 48 , 54 - 58
To create and implement laws against domestic violence and policies that guarantee employment and autonomy for women.	16
Identification and intervention
To keep professionals, especially in health and education, alert and sensitive, enabling them to identify warning signs;	5 , 19 - 21 , 36 , 54 , 59 - 60
To review protocols for the identification and support of situations of violence, considering the peculiarities of each region of the country;	20 , 28 , 48 , 61
To provide care with respect, sympathy and confidentiality, and care with a person-centered approach, validating experiences and feelings;	10 , 14 , 22
To provide standard admission forms for the evaluation of women subjected to IPV or sexual assault in units, clinics and community screenings devoted to responding to Covid-19, with individual approaches for those who are unable to respond privately;	23 , 29 , 54 , 42
To immediately refer children with suspected injuries derived from violence, if necessary hospitalization to clarify and ensure the child's protection;	15 , 62
To connect people in situations of violence to protection and continuous care services, facilitating safe access.	14 , 32 , 36
Continued care
Not to neglect care related to health and violence against children, adolescents and women;	3 , 11 , 13 , 31 - 35
To classify violence assistance, protection and prevention services as essential;	4 , 48 , 14 , 33 , 41 , 43 - 44 , 58 , 61 , 63
To adopt strategies that ensure the continued care and safety of children, adolescents and women, whether in person or remotely (development of new digital platforms that enable contact and health care; friendly and accessible platforms; leveraging existing platforms; training and support for the health professionals to work on digital platforms);	4 - 5 , 8 - 10 , 15 - 16 , 24 , 30 , 38 , 41 , 44 , 46 , 55 , 58 , 61 , 64 - 65
To promote medical and social assistance services in the nature of telemedicine and virtual counseling 7 days a week, 24 hours a day;	46
To implement legal support in a virtual manner;	8 , 46
To provide free telephone lines and hotlines for reporting violence;	10 , 14 , 22 , 38 , 41
To identify ways online or over the phone to maintain services for perpetrators of violence;	4
To enable access to reproductive and sexual health services (special attention to prenatal care, reproductive planning, abortion medications if legalized, and actions against rape) in person or remotely;	4 , 43 - 44 , 55 - 56 , 61
To ensure safety and reduce exposure in remote care (standardize the question form; explain that these questions are asked to everyone; ask questions that can be answered with "yes" or "no"; evaluate non-verbal expressions; provide a field to which the woman can access, at a time that the aggressor is not close, and which, after filling in, the health server is warned/alerted of the situation of violence; providing services with safety mechanisms for quickly exiting the page and history of navigation that make aggressor control unfeasible);	8 , 42 , 54 , 58 , 66
To provide updated information on the paths and places that are available to promote assistance, safe ways to seek help and collaborate in identifying family members, friends or neighbors who may be a source of support and contact for the victims. To include opening hours, contact details and whether the services can be offered remotely;	4 , 9 , 14 , 22 , 29 , 54
To keep service providers and community leaders informed about changes in the reference routes of care for violence;	10
Governments must finance assistance, protection and violence prevention services so that they are accessible, free, without time restrictions and that new services are created where they are not available;	14 , 26 , 44 , 54 , 61 , 64 , 67
Governments must promote the funding of hotels, inns, housings, as well as using drug abuse treatment sites to become places of emergency shelter and distancing from the aggressor;	15 , 41 , 46 , 68
To keep frequent contact with the woman and the family after the end of social isolation by protection services.	38
Care for the safety and mental health of the professionals
To assess physically and mentally, and ensure care and emotional support to the health professionals and the community involved in the care and coping with violence during the pandemic, with the care of pregnancy and motherhood, and respondents on the front lines;	10 , 41 , 54 , 69
To prioritize long-term care for these professionals;	39
To promote self-care plans and encourage professionals to meet in regular support groups;	41
To increase support for family caregivers. To increase surveillance and monitoring of these families and health professionals in the long term;	39
To reduce professional stress - rotation between functions; association of experienced and non-experienced workers; implement flexible hours, in particular, for workers directly affected or who have a family member affected by a stressful event;	4 , 41
To promote and continuously train professionals;	10 , 28 , 48 , 61
To ensure personal protective equipment for the health professionals, the community, lawyers and specialists in violence;	41
The managers must implement plans to deal with the safety and health of the workers;	14
The managers must show appreciation to the team for their commitment and ability to continue to provide the required level of service.	8
Intersectoriality/Interdisciplinarity
To carry out actions aimed at the care and prevention of violence in interdisciplinary teams. To think about intersectoral care, uniting sectors such as health, education, justice, media and non-governmental organizations;	4 , 13 , 46 , 70
Special care for vulnerable populations
To keep special attention and care for children and adolescents with disabilities, chronic problems and in situations of poverty, discrimination or conflict, marginalized during and after the pandemic;	45
To minimize risks with policies that guarantee employment, health care and economic support for disadvantaged families;	4 , 15 - 16 , 40 , 54
To waive service fees for those disadvantaged women and provide high-speed Internet access.	4 - 5 , 16 , 39 , 44 , 58 , 61 , 64 , 71

DISCUSSION

The studies selected for the present review provided important care recommendations for children, adolescents and women in situations of DV. Some of these recommendations can help to cope with violence and guarantee access to services of the care network for people in situations of violence in the Brazilian context. However, it is important to emphasize that, based on the diversity of states and cities, such recommendations must be adapted to the organizations of the local and regional networks.

Thus, examples of planning and implementing actions for the professional practice and guidance to the population and community were raised, in view of the increase in interpersonal violence previously observed in natural disasters, health emergencies and infectious epidemics, such as the Zika virus and Ebola.^{14,21,37,43,69,71}

Some studies have brought preventive recommendations, which permeate sensitized views on violence, especially on the part of the community and society, in addition to the recommendation to increase the number of teams and new forms of assistance and care for violence.²⁸ Some countries have developed preventive and informational actions linked to continuous and intersectoral care; for example, in Spain⁶⁶ awareness campaigns about the increase in DV during the pandemic were promoted and services to combat these types of violence were considered as essential for them to work 24 hours a day. In addition, new access lines and “panic” buttons were made available in applications to request help, an action also carried out in India.^59,66 The American College of Surgeons has created recommendations to reduce injuries due to firearms and sought to work on ways to safely store these weapons in the domestic environment.⁷²

Also in the preventive aspect, actions to promote accessibility are recommended, such as the production of reports on violence in Braille and Libras,⁴ in addition to providing the population with information regarding reproductive and sexual health, the signs of violence and the possibilities of help and protection services.^{4,8,14,16-18,48,33,16,54,17,55-58} Maintaining safe contact with the support network was also a preventive action with protective potential.^39,14,33,39 Sensitizing and raising the community's awareness of such issues instrumentalizes both the subjects who are inserted in a violent context and their support networks.

Furthermore, it is also important to sensitize the aggressors, removing the logic of blaming the person who suffers violence and assuming an immutable, aggressive and dominating character for men, and submissive for women. Awareness coupled with the construction of coping strategies for the perpetrators of violence, enable joint solutions to this problem. Such a strategy is advocated in Law No. 11,340 of 2006 - the Maria da Penha Law - which provides, in addition to punishing the aggressor, awareness and resocialization measures.⁷³ Even with the Maria da Pena Law, it is necessary to increase services that raise awareness and discuss machismo with the male population.

It is worth mentioning that, in April 2020, a technical note from the Prosecutor's Office was published in Brazil for the adoption of preventive measures and a contingency plan for the prevention and repression of cases of violence in the context of the pandemic.⁷⁴ However, it is important to reflect on how it is operationalized. As an example, there are prevention measures through campaigns, where actions were carried out and disseminated on YouTube and on television nationwide, highlighting the forms of violence and the hotline for reporting cases. However, such disclosure did not include interpretation of Libras with audio description, which prevents access to information to people with hearing and visual impairments. In addition, there was no disclosure in the regional locus of the availability of services for children, adolescents and women, which limits the visibility of access to the services of the care network. It is important to note that the adoption of strategies in addition to online dissemination is extremely necessary, especially in the Brazilian context, where nearly 46 million people do not have Internet access.⁷⁵

In general, the fact was also highlighted that the changes brought about by the pandemic are generating tension and intrafamily stress, by intensifying coexistence and feelings of fear, overexposure of the media,¹³ economic and social crisis,³⁷ work overload and increased use of alcohol and other psychoactive substances.³⁹ In view of this, most of the recommendations regarding the prevention of violence against children, adolescents and women presented mental health promotion measures, guidance and stress reduction focused on parents, caregivers and intimate partners, possible perpetrators of violence.^{4,11,14-15,30,39-40}

The recommendations related to “Identification and intervention” reinforced the importance of the professionals, especially in health, to remain sensitive to situations of violence and to the review of care protocols to guarantee immediate, safe and continuous care for children, adolescents and women. The studies brought the relevance of expanding human resources so that they also have a broader look at health situations, in addition to commitments related to Covid-19.^15,29 These populations must be asked at all times if they are feeling safe at their homes, with privacy and respect for the choice of the adult woman.^19,54

It is relevant to reflect that health professionals have difficulties in assisting people in situations of DV, either due to discomfort, low training or ignorance of the care protocols, which generates the referral of the person to another professional or service.⁷⁶ In the pandemic scenario, this can intensify, since the centrality of care is directed at people with signs and symptoms of Covid-19, accentuating the difficulty in identifying cases of DV by the professionals who already presented them.

In parallel, schools must promote training for teachers to identify and refer children and adolescents with signs of violence to protection services in remote education.²¹ Radiologists must pay attention to the characteristics of the injuries, reviewing medical records to verify if discrepancies occur between the report and the radiological findings.²⁹ Police officers must provide safe and effective responses;¹⁹ the professionals who manage prenatal and puerperium must be sensitive to greater incidences of depression and DV.¹⁰ In addition, in the case of children and adolescents with suspected injuries derived from violence, hospitalization or immediate referral to protective services must be carried out, given the period of peculiar development of this population and distancing from the main protective institutions.^15,62

A national qualitative study, carried out before the new coronavirus pandemic, sought to understand how the professional practices silence intrafamily violence against children and adolescents. It was emphasized that reductionist actions by the professionals compromised the reception, notification and monitoring of these cases, contributing to the invisibility of this violence.⁷⁷ Such practices can be accentuated in the context of the pandemic and hinder proper reception and notification of violence since children, as they are not the main risk group, may not reach the health services. In addition, with home visits suspended, knowledge about the health needs of this population can be made invisible.

Recommendations were presented for the articulation of services and professionals in the safety network, guaranteeing that they act in person, online, over telephone lines or other means, without interrupting the functioning of the services and the necessary care for children, adolescents and women.^{4-5,8-10,15-16,24,30,38,41,44-46,55,61,64} In the Italian context, for example, empty hotels and inns were transformed into shelters for victims of DV, providing new spaces for the care of this population.⁴⁶

In order to enable the assistance and monitoring of these services to maintain quality, it is essential that the professionals are trained and receive the necessary support to work remotely.^10,28,48,61 In this type of service, inclusion care measures to maintain the safety of children, adolescents and women are necessary, thinking that the perpetrator of violence may be in the same environment.^8,42,54,58 Once again, great challenge is faced to provide this continued care also to people without Internet access.

Primary Health Care (PHC) is one of the gateways for people in situations of violence; however, it is important to contextualize that remote and non-remote care, in the context of the pandemic, can be compromised. The pandemic exposed difficulties in the Brazilian public health system such as underfunding and, in the current government, defunding, as well as the freezing of public spending by Constitutional Amendment EC95 and the changes imposed by the new National Primary Care Policy.^78-79 Such difficulties, in addition to actions to restrict care in PHC, have hampered strategies for monitoring health situations and problems treated in the PHC network. However, we believe that the strategies presented in this review, such as networking and the sensitization of the professionals, can be applied to the Brazilian reality.

Even with the attempt of continuous care and maintenance of the intersectoriality between the protection services for DV, national data show a decrease in the number of police reports at the beginning of the pandemic, as the victim should be in person at the police station.⁸⁰ From the moment the pandemic intensified in the national territory, there was a 431% increase of publications on Twitter with complaints about aggression through the telephone service of the military police and an increasing number of femicides, while the urgent protective measures, which should be granted by the Courts of Justice, have not changed and are falling.⁸⁰ Reflections are also made on the care for children, adolescents and women in situations of violence during Covid-19 in Brazil, given the national political crisis that has generated polarization of understandings and behaviors;⁸¹ it is reiterated that, before the pandemic, DV was already outlined as a complex phenomenon and almost inaccessible by the professionals.⁷⁷

At the national level, only in July 2020, Law 14,222 was enacted, which provides for measures to cope with domestic and family violence against children, adolescents and women during the Covid-19 pandemic. Among other aspects, the law guarantees the following: that there will be continuity in the processes and public security with the implementation of an electronic police report or by telephone; and that virtual assistance does not exclude the obligation of the government to maintain in person assistance.⁸² Thus, given the complexity of violence, it is important to understand the uniqueness of each case, which will require different ways of coping and caring, such as the need for care as close to the person as possible.

Another important aspect brought by the studies in this review was the need for greater attention and care for the professionals, especially health professionals, who have faced a scenario of great stress, stigmatization and isolation.¹⁴ The fact that a large contingent of women work in the health area makes them also vulnerable to situations of violence in the workplace.¹⁴ For these reasons, it is important to guarantee the professionals care and emotional support;^10,41,54,69 reduction of work stress through job rotation; implementation of flexible schedules^4,41 and stimulating the search for support groups.¹⁵ In addition, the managers must promote continuing education^10,28,48,61 and safety plans,¹⁴ as well as provide personal protective equipment.⁴¹ It must be considered that there is a need for long-term plans to monitor these professionals and their families.³⁹ An integrative review sought to discuss the occupational and psychological impacts of pandemics on health professionals and the studies have shown that such situations are related to stress, anxiety and depressive symptoms. The importance is reinforced of new institutional processes to face these moments, as endorsed by the studies in this review.⁸³

Finally, the recommendations of this review brought the importance of the theme of DV against children, adolescents and women to be treated as an intersectoral issue and that requires interprofessional action,^4,13,46 corroborating studies in the area.^84-85 The importance of looking at vulnerable populations was also reinforced, namely: people with disabilities, chronic problems and in situations of poverty, discrimination or conflicts,^{4-5,15-16,40-41,44,54,58,61,64} as these are more likely to be marginalized during or after the pandemic.⁴⁵

The limitations of this study were mainly related to the types of studies included; the lack of primary articles can compromise the construction of relevant recommendations. The scarce number of Brazilian articles also compromises the construction of contextualized recommendations for this scenario. The practical implications of the study are summarized in the results table and can be adapted to those already existing in the line of care for children, adolescents and women in situations of violence.

CONCLUSION

This study brought recommendations for coping strategies for DV against children, adolescents and women, considering the current pandemic scenario by Covid-19. Preventive strategies must be expanded, especially in the context of mental health, articulating care for children, adolescents and women, as well as for possible perpetrators of violence against this population, in addition to community awareness. The professionals, especially health professionals, must be sensitive and alert to signs of violence, intervening immediately and connected to the safety network. The services must guarantee continuous, intersectoral and safe care, especially in the new remote modalities, and must be characterized as essential in times of a pandemic. In this context, the professionals must be physically and emotionally cared for, and already marginalized populations must be seen in these even more adverse moments.

In light of the above, this study brings important recommendations that can be adapted to the Brazilian context, based on greater dissemination of preventive content to the community, which must be understood as a strategic agent in the support network; the review of care protocols; the perspectives for new service configurations of these services by managers and ensuring greater articulation between the different points of care for this population.

It is necessary to conduct empirical studies, which analyze and evaluate the identification of situations of violence in times of a pandemic and the access of children, adolescents and women to the services of the safety net.

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NOTES

• FUNDING INFORMATION
  This study was financed by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brazil (CAPES) - Finance Code 001

Publication Dates

• Publication in this collection
  26 Apr 2021
• Date of issue
  2021

History

• Received
  01 Sept 2020
• Accepted
  03 Nov 2020