Identification of violence in the conjugal relationship based on the Family Halth Strategy

Abstracts

Estudo qualitativo cujo objetivo foi analisar o processo de identificação da violência conjugal por profissionais da Estratégia Saúde da Família de São Francisco do Conde/Salvador-BA. Entrevistaram-se 22 profissionais (médicos, enfermeiros, assistentes sociais e cirurgiões-dentistas) e após análise dos dados emergiram as categorias: (Não)identificação da violência conjugal na Equipe de saúde da Família; Percepção da violência restrita à agressão física; Magnitude e complexidade da violência conjugal; e Quebrando o silêncio na Equipe de Saúde da Família. O estudo mostrou que a identificação da violência conjugal se dá durante o atendimento profissional. A não identificação do fenômeno guarda relação com os currículos que ainda não contemplam a violência doméstica como objeto da saúde. Pontua-se para a importância da relação de confiança e da escuta no processo de identificação do agravo. Torna-se necessário melhor preparo profissional, o que possibilitará maior visibilidade da problemática e a adoção de estratégias de enfrentamento.

Violência contra a mulher; Saúde da mulher; Saúde da família; Enfermagem

ORIGINAL ARTICLE

Identification of violence in the conjugal relationship based on the family health strategy¹

Identificación de la violencia conyugal a partir de la Estrategia de Salud Familiar

Nadirlene Pereira Gomes^I; Yasminie Mota Silveira^II; Normélia Maria Freire Diniz^III; Gilvânia Patrícia do Nascimento Paixão^IV; Climene Laura Camargo^V; Nadjane Rebouças Gomes^VI

^IPh.D. in Nursing. Adjunct professor at the School of Nursing (EE) of the Federal University of Bahia (UFBA). Salvador, Bahia, Brazil. E-mail: [e-mail]

^IINurse. Bahia, Brazil. E-mail: [e-mail]

^IIIPh.D. in Nursing. Adjunct professor of the EE/UFBA. Salvador, Bahia, Brazil. E-mail: [e-mail]

^IVMaster's in Nursing. Assistant professor of Bahia State University. Fellow of the Coordination for the Improvement of Higher Education Personnel (CAPES). Salvador, Bahia, Brazil. E-mail: [e-mail]

^VPh.D. in Nursing. Associate professor level III of the EE/UFBA. Coordinator of the FAPESB/UNEB Project. Salvador, Bahia, Brazil. E-mail: [e-mail]

^VISocial worker. FAPESB Fellow. Salvador, Bahia, Brazil. E-mail: [e-mail]

Correspondence

ABSTRACT

This qualitative study's objective was to analyze the process of identification of conjugal violence by professionals from the Family Health Strategy in São Francisco do Conde/Salvador, Bahia. Interviews were held with 22 professionals (doctors, nurses, social workers and dentists) and, after analysis of the data, the following categories emerged: (Non)identification of conjugal violence in the Family Health Team; Perception of the violence being restricted to physical aggression; The scale and complexity of the conjugal violence; and Breaking the silence in the Family Health Team. The study showed that identification of conjugal violence occurs during professional assistance. Failure to identify the phenomenon is related to the curriculums which do not cover domestic violence as a health object. This points to the importance of a listening and trusting relationship in the process of identifying this threat to health. It is necessary to adopt strategies for confronting the problem, along with better preparation of professionals, which would give greater visibility to the issue.

Descriptors: Violence against women. Women's health. Family health. Nursing.

RESUMEN

Investigacion cualitativa con el objetivo de analizar el proceso de identificacion de la violencia conyugal por los profesionales que trabajan en la Estrategia de la Salud Familiar. Se entrevistaron 22 profesionales (doctores, enfermeros, trabajadores sociales y dentistas) de São Francisco do Conde/Salvador, Bahia. A partir del análisis de datos surgieron las siguientes categorías: (No)identificación de la violencia conyugal en la Estrategia de la Salud Familiar, Percepción de violencia se limita a la agresión física, Magnitud y complejidad de la violencia conyugal; y Rompiendo el silencio em Estrategia de la Salud Familiar. El estudio mostró que la identificación de la violencia conyugal se da durante la atención profesional. La no identificación del problema guarda relación con los currículos que aún no contemplan las violencia familiar como objeto de salud. Se resalta la importancia de la relación de confianza y de escucha en el proceso de identificación del agravio. Se hace necesario un mejor preparo profesional, lo que permitirá una mayor visibilidad del problema y la adopción de estrategias de afrontamiento.

Descriptores: Violencia contra la mujer. Salud de la mujer. Salud de la familia. Enfermería.

INTRODUCTION

Domestic violence is a complex process, which triggers a series of complications for the health of women and all who are affected by it, leading to demands on widely varying sectors of society, in particular on the health sector.

As it is mainly manifested in the space of the home, domestic violence compromises the interaction between father-mother-child, triggering physical and psychological damage, and for this reason is a risk factor for the health of the entire family - and, consequently, is a serious public health problem.^1-2

Based on data from the World Bank and the Inter-American Development Bank, the costs from domestic violence against women vary from 1.6% to 2% of a country's GDP; and one in every five days of non-attendance at work in the world is caused by this problem.³

At all phases of her life, whether in childhood, adolescence, adulthood or old age, a woman suffers domestic violence to a greater degree than a man.⁴ In the North-East region of Brazil, 47% of the episodes of aggression suffered by women have the domestic environment as the locus, while the percentage of men in a situation of domestic violence corresponds to 12.9%.⁵ This data points to the domestic environment as the central locus for the occurrence of violence against women.

In relation to the main author of violence practiced against women, studies show that it is principally the one with whom the victim has or has had a romantic relationship,^4-5 which configures conjugal violence, defined as any act of violence existing in a romantic relationship, whether the relationship is legalized or not. Around the world, this is the most frequent form of inter-personal violence.⁶

The following are understood as domestic violence against women: acts or omissions based on gender inequalities which cause the woman physical, sexual, emotional and moral harm, as well as harm to her assets.⁷ Irrespective of the form in which it is expressed in the relationship, the experience of the violence triggers physical and psychological problems, and can even lead to death.

Throughout their lives, women who experience violence in their conjugal relationship present more health problems, of differing dimensions and complexity, varying from physical lesions such as bruises to those related to psycho-emotional aspects such as depression and suicide, leading them to increasingly seek the health services - especially those of primary care.⁸ As a result, the health sector is a privileged locus for identifying these situations.

The continuous work, the service users' frequent return to the health center and the bond that they form with the health professionals make the Family Health Strategy (ESF) the ideal strategy to work on domestic violence,⁹ including that which permeates the conjugal relationship. It is, therefore, important for professionals to be prepared and, principally, attent to identify the phenomenon, which does not always present visible marks. Regarding nursing in particular, the care for the women in situations of violence must take into account the social, relational, economic, cultural and historical aspects - rather than limiting itself to the physical harm.¹⁰

Considering that the experience of conjugal violence triggers health problems, and that the health sector is increasingly revealed to be a strategic space for the recognition of this health risk, one should raise the questions: Are the health professionals identifying violence in conjugal relationships during their activities? How does this recognition occur?

Starting from the hypothesis that the ESF favors the identification of conjugal violence as harmful to women's health, this research aimed to analyze the process of identification of conjugal violence by health professionals who work in the ESF.

METHODOLOGICAL PATHS

This is exploratory research with a qualitative approach. The exploratory character aims to provide greater familiarity with the issue of "conjugal violence", so as to make it clearer.¹¹ The qualitative approach, on the other hand, is due to the impossibility of reducing the research object to single variables, it being understood in its complexity, such that the fields of study are not artificial situations in a laboratory, but are, rather, the practices and interactions of the subjects in their everyday lives.¹²

The study was undertaken in the municipality of São Francisco do Conde. Approximately 70 km from the capital of Bahia, the city has a population of 33,183 inhabitants, according to the most recent census from the Brazilian Institute for Geography and Statistics.¹³ At the time of the data collection, the city had 11 Family Health Centers (USFs), which is equivalent to coverage of approximately 62% of the population.

It is emphasized that the city incorporated the social worker as a professional integral to the ESF's basic team in spite of it not being necessary to link this person with this team.¹⁴ The specificity of the social services is important, above all for the development of educational activities with individuals and families, considering the context in which they live, as it favors the strengthening of participative actions for the promotion and integral protection of life.¹⁵

The subjects of the research were 22 degree-level professionals placed in eight health centers, with five in the urban zone and three in the rural zone. Thus, professionals were interviewed from all the centers in the urban zones and, because of the distances involved, professionals from half of the centers in the rural zone. Five doctors, four nurses, five social workers and eight dentists were interviewed.

The criteria for the eligibility of the subjects were: to be employed by, or to carry out professional activities within the ambit of, the Family Health Strategy (ESF) in the locus municipality and to have functioned in the ESF in the locus municipality for at least six months.

As the data collection instrument, the researchers used an interview accompanied by a questionnaire with the following guiding question: "tell me about conjugal violence in the routine of your work". The data was collected between September and December 2011.

Following the subjects' permission, the interviews were recorded with a portable recorder so as to allow the literal transcription of the statements, and to maximize the reliability in the presentation of the discourses. The data was organized based on content analysis, as this allows the objective and systematic description of the content manifested in the interviews, so as to transform the raw material into a possible representation, identifying and grouping the elements which have some degree of relationship to each other, that is, a homogeneity in the accounts.

Within the set of techniques for analysis of communications proposed, thematic analysis was chosen. This guides the systematic and objective procedures of description of the messages' contents. This technique permits one to find, through its presence in the accounts, the nucleus of meaning which is shown in the text, that is, the categories.¹⁶ Thus, the operationalization of the thematic analysis occurs in three stages. Firstly, the pre-analysis was undertaken, based on the exhaustive reading of the material, with the aim of finding the nuclei of meaning. The second stage - the exploration of the material, or codification - is to do with the construction of the categories around which the discourses are organized. Finally, there is the treatment of the data, which, once analyzed, was compared with the results of other texts which include this issue.

Regarding ethical aspects, it is worth emphasizing that the objectives were explained to the subjects, along with the importance and the right to opt to participate in the research through signing the Terms of Free and Informed Consent. Anonymity and privacy were guaranteed, in accordance with Resolution 196/96 of the National Health Council, which guides practice in research involving human beings, with the subjects of the study being identified by colors, followed by their profession.

This research project received financial support from the Bahia State Research Support Foundation (FAPESB), Bid n. 026/2009 - Pró-Saúde São Francisco do Conde, and was approved by the Research Ethics Committee of the Federal University of Bahia's School of Nursing (EE-UFBA), under protocol n. 04.2010.

RESULTS AND DISCUSSION

The study showed that violence in conjugal relationships has been identified within the ambit of the ESF, although there are difficulties in recognizing it on the part of the health professionals, above all when their ability to recognize it is restricted to physical aggression. Also indicated is the scale and complexity of the phenomenon, which points to the repercussions on the health of the women and children and to the silence which permeates the space of the private environment of the household, which requires strategies which favor its identification by the health sector. The data was organized in four categories: (Non-) identification of conjugal violence in the ESF; Perception of the violence restricted to physical aggression; The scale and complexity of conjugal violence; and Breaking the silence in the ESF.

(Non)identification of conjugal violence in the ESF

Professionals who work in the municipality of São Francisco do Conde-BA assert that they have never identified domestic violence against women, especially that which occurs between spouses, in the ambit of primary care:

[...] I've never come across it here in this city. I've never suspected it and never had anybody who reported it (Red - Dentist).

[...] I've no experience in relation to this, and I've never experienced it either [...] (White - Doctor).

In accordance with the accounts, it is possible to perceive that the professionals do not identify cases of conjugal violence, which does not mean that this health problem is not a reality in the municipality's health services.

The wide coverage and home attendance called for by the ESF allows the identification of health problems in the community, the health centers being extremely relevant for detecting domestic violence.^9,17 This being the case, the family health centers are a strategic setting for the identification of this phenomenon, although the demand for the service is not clearly related to the experience of violence.

In spite of the phenomenon's scale and relevance, health professionals still lack preparation to identify people in violent situations, even though the health sector is a gateway for these cases.¹⁸ It is therefore necessary for professionals to be trained regarding the issue of violence, such that they may be able to identify, and act effectively in the struggle against, this health problem.¹⁹

The failure to recognize this violence as a health problem responsible for demands on the health service is a problem linked to professional training, as the curriculums of the health training courses little address domestic violence as a health object.²⁰

Research undertaken with doctors has shown that these professionals do not perceive gender violence as a health problem. They also mention that this topic is not covered in the medical schools' curriculums, as a result of which it is not addressed. The failure to incorporate domestic violence in health courses' curriculums may be associated with the fact that only since 1998 has this been recognized as a health problem by the WHO.²⁰ Hence the difficulty in perceiving violence as a health object.⁹

However, although this is not a reality for all the professionals, it is important to bear in mind that, irrespective of whether the care is given by doctors, social workers, nurses or dentists, violence in conjugal relationships is being identified in the municipality's health centers:

[...] we've already had one case, she came to me, I saw it wasn't a tooth [...] her husband had hit her [...]. She arrived with her face swollen, edema. When I saw that her eye was bruised, and so was her arm, I asked: do you want to tell me what this is about? Because this doesn't look like a tooth. And she told me [...] (Sky blue - Dentist).

there was a time that a mother came here to talk with us because her daughter was being kept in false imprisonment. [...] she has hearing problems because of the blows on the head she gets from the husband (Blue - Social Worker).

The study reveals that in spite of the professionals not recognizing it, conjugal violence is a health problem which is revealed in the primary care spaces in the municipality of São Francisco do Conde, also showing that the experience has implications for the women's health.

Perception of the violence restricted to physical aggression

The difficulty of identifying women in situations of violence in the conjugal relationship may be related to the linking of this health problem only with physical aggression, which allows one to understand something of the invisibility of the violence in the health services:

[...] nobody arrives here hurt physically for me to attend them (Green - Dentist).

In addition to the physical sequelae, the violence can trigger psychological and social problems.²¹ However, the professionals were not attent to the various configurations which domestic violence can take on. Indeed, because it leaves physical marks on the body, physical violence is most commonly recognized in the health spaces. In this context, the other expressions of violence, which are not necessarily manifested physically, were not identified.

The failure to value "invisible" complaints, which compromises the professionals' ability to see beyond the physical marks, is related to the technicism which permeates the training given by the health courses.²² To this one can add the valorization of treatment, to the detriment of the prevention of health problems and the promotion of health. As a result, even if the violence is identified, the professionals' conduct is limited to treating the physical harm.²³

In this way, attendance based on physical-biological incidents does not cover the integrality of health care for women, as the demands of a social, cultural, legal and psychological nature are not met.²⁰ It can be seen that this perspective - limited to the physical lesions - compromises care for women, defined as that which occurs based on the intentions, interaction, availability and trust between professional and patient.¹⁹

Because this is an important health problem, it becomes essential to identify conjugal violence in the ambit of the health sector, in all its forms of expression, so as to reduce the rates of complications and sequelae for women's physical and mental health and, consequently, the impacts on all of society.

The scale and complexity of conjugal violence

Attention is drawn to the perception, on the part of the professionals interviewed, of how the violence in the conjugal relationship impacts on the health of the women and also of their children:

[...] I remember one patient who had already suffered domestic violence, and that the husband came home drunk and threw cold water on her and the child. [...] he had already broken her arm and had hurt her leg with knives. Today, this patient says that the child is thoroughly traumatized. (Orange - Nurse).

[...] there was a case I attended [...] the school brought a report so that the ESF would interview this family, because the seven-year-old child wasn't able to improve in her learning. [...] so, in the interview with the mother various things came up, including the father's alcoholism and his aggression in the home (Indigo - Social Worker).

Sons and daughters of women in situations of violence have three times the chance of falling ill, normally presenting more psychological problems than other children.²⁴ In addition to this, it is already known that violence can be transmitted inter-generationally, that is, children who experience violence between their parents have a higher probability of reproducing this phenomenon in their adult life.²⁵

In addition to indicating the scale of conjugal violence, as it affects the entire family's health and quality of life, the interviewees' accounts also indicate the phenomenon's complexity, which is related to gender inequalities responsible for the social belief of the man's power over the woman, and the socially-shared female characteristics of obedience, passivity and submission. These gender attributes allow one to understand the woman's silence when she experiences violence in the private space.

The women are ashamed of coming to the health center, of coming to the doctors, any assistant or nurse, and saying that they were hurt by their husband or partner. This taboo really needs to be broken. We are here to do our part (Yellow - Doctor).

We don't have many experiences [...] maybe because of the fear of reprisals from the husband, fear of being exposed in society, because of shame (Beige - Dentist).

It can be perceived that often the women do not come to the health service revealing the situation of violence, which requires an investigation on the part of the professional. There are many factors which lead the victim not to talk about her history, including misinformation, the shame of being exposed in society and the fear of reprisals, bearing in mind that the spouse is the main aggressor, with whom the woman tends to return to live.²⁶

Breaking the silence in the ESF

The study points to the importance of educational activities in health with the community and to the importance of listening to the woman as strategies for unveiling violence in the conjugal relationship.

One strategy which viabilizes the breaking of the silence is in regard to health education actions. The study shows that based on one educational activity carried out in the ESF, the women revealed their histories:

[...] we did an activity on family planning. There were more or less 16 women there. We spoke about reproductive rights, and other issues came up directed at the women themselves. After it finished, 10 stayed behind to talk with me, and all were the same case of domestic violence (Blue - Social Worker).

Attention is called to the fact that in the study, professionals from all the categories referred to the identification of women in situations of domestic violence. However, only the social workers mentioned this recognition during educational activities. Although this type of activity was not mentioned by the professionals from the other categories, it is extremely important to carry it out, above all when it is undertaken in an integrated way. In any event, it is important to reflect on the relevance of the social worker in the family health team in the locus municipality, given that, based in the Primary Care Policy,²⁷ the integration of this professional category in the minimum ESF team is not obligatory.

According to some authors,³ the social worker can be an active agent, acting in the prevention and also in the elimination of this violence in all the fields of work, being able to undertake work - with the women, the men, the children and the adolescents - which can clarify, guide and make possible reflection on this issue, such as acting so as to produce more egalitarian and harmonious values between people, irrespective of their sexes.

Irrespective of the professional who provides the attention and how they work, it is important that the professional should be prepared to establish a relationship of care which goes beyond the automatism of technical care and which thus gains the service user's trust.¹⁹ It is important for the woman to be able to feel that it is safe to describe what seems to be significant to her.

The discourses below show the importance of listening, of becoming close to these women, and of receptiveness to the revealing of the experience of domestic violence:

[...] she arrived here wanting to see the dentist, saying that her tooth was swollen, but she had lots of bruises on her face [...] I talked with her and she told me that she had suffered this violence from her husband [...]. He had beaten her because he was jealous (Lime - Social Worker).

[...] nobody confesses it to me. They don't come up to us and say, 'oh, my husband hit me'. But you see, because they turn up with their faces all swollen, scratched, sometimes [...]. You know from the conversation (Sky blue - Dentist).

[...] I think it's really important to put the patient at her ease so she can talk, and that's when it'll happen, we'll detect the problem, the heart of the problem (Orange - Nurse).

The women's opinions and values must always be valued during their use of the health services and listening must occur, for preference, in environments which guarantee their privacy.¹⁷ The study points precisely to listening as the element which viabilizes the recognition by the professionals of the situation of conjugal violence experienced by the woman as a health problem which compromises her health - as well as favoring the woman's breaking her silence, based on her revealing of her history. Thus, one can say that the ESF favors trust in the professional, which is essential for addressing the problem.²²

It is worth noting that the frequent use of the health services by the women in the health spaces makes possible not just the recognition of the experience of violence, but also of the necessary referrals, given that the identification encourages measures to overcome the problem.^8,22

In this way, early identification of the experience of violence by the woman makes it possible to intervene before the problem takes on grandiose proportions. Let us take as an example the situation in which it is not identified that a woman, attended in the ambit of primary care with signs of bruising or symptoms of depression, is experiencing violence; later, she may require more complex care, such as is provided in Emergency Room, due to more serious health problems such as lesions from fire-arms or suicide attempts. Thus, the first step for transforming this reality in the locus municipality is already being taken: the recognition of domestic violence as a health problem.

FINAL CONSIDERATIONS

The study showed that conjugal violence has been identified as a health problem present in the municipality of São Francisco do Conde-BA and that the ESF is constituted as a strategic setting for the phenomenon's recognition. This process of identification occurs during the professional attendance, whether it is by doctors, nurses, dentists or social workers, and also as a result of the undertaking of educational activities in health.

The sensitization of the ESF professional in relation to the repercussions on women's health, and the impacts for the children's lives, is revealed as an element associated with the identification of the woman who experiences violence in the conjugal relationship. One can perceive the understanding of the complexity of the phenomenon, above all in relation to the difficulty the women have in revealing their histories. The study also points to the importance of relationships of trust and listening as strategies which viabilize the identification of the health problem.

There are, nevertheless, professionals who state that they have never identified this phenomenon, which may be related to the curriculums of the health courses which still do not cover domestic violence as a health object and to the view of violence as being limited only to physical aggression.

The findings lead us to reflections on the curriculums of the health courses which, in general, do not cover domestic violence as a health object, and on the view of violence which is limited to physical aggression, failing to take into account its other expressions, which favors the masking of the problem. Hence, the curriculums in the area of health, which are still fairly rooted in the hospital-centric model, fail to make it possible for the professional view to go beyond the physical aspects, making it difficult to recognize health problems such as conjugal violence.

In addition to transforming the model of academic training, investment is necessary on the part of primary care managers and coordinators so as to better prepare the professionals to identify this health problem, thus increasing the possibility of the issue's visibility and, consequently, the adoption of strategies for confronting it, which will contribute to improving the entire population's quality of life and health.

Although the specific characteristics of the subjects interviewed do not allow the findings to be generalized, which represents a limitation of the study, attention is called to the importance of the professionals who work in the ESF in recognizing the community's health problems - such as conjugal violence. It is worth highlighting that this study offers support for professional training with the aim of identifying situations of conjugal violence at an early stage.

REFERENCES

• 1. Mozzambani AC, Ribeiro RL, Fuso SF, Fiks JP, Mello MF. Gravidade psicopatológica em mulheres vítimas de violência doméstica. Rev Psiquiatr Rio Gd Sul 2011 Abr; 33(1):32-7.
• 2. Santi LN, Nakano MAS, Lettiere A. Percepção de mulheres em situação de violência sobre o suporte e apoio recebido em seu contexto social. Texto Contexto Enferm 2010 Jul-Set; 19(3):417-24.
• 3. Almeida EOS, Nozawa TN, Romera VM. Violência intrafamiliar contra a mulher: intervenções do assistente social. ETIC [online]. 2008 [acesso 2011 Nov 10]; 4(4). Disponível em: http://intertemas.unitoledo.br/revista/index.php/ETIC/issue/view/34
• 4. Silva M. Violência: um problema de saúde pública. Conferência Nacional de Saúde Mental [intenet]. Brasília (DF): Ministério da Saúde; 2010 Jun [acesso 2011 Jun 04]. Disponível em: http://portal.saude.gov.br/portal/arquivos/pdf/violenciamartasilva.pdf
• 5. Departamento Intersindical de Estatísticas e Estudos Socioeconômicos. Anuário de mulheres brasileiras. São Paulo (SP): Secretaria de Políticas para Mulheres; 2011.
• 6. Almeida I, Soeiro C. Avaliação de risco conjugal: versão para polícias. Aná Psicológica [online]. 2010 Jan [acesso 2011 Mai 23]; 28(1). Disponível em: http://www.scielo.oces.mctes.pt/scielo.php?script=sci_arttext&pid=S0870-82312010000100013&lang=pt
• 7. Brasil. Lei n. 11.340, de 7 de agosto de 2006: Dispõe sobre a violência doméstica contra a mulher. Diário Oficial da República Federativa do Brasil [online] [acesso 2011 Mar 04]. Disponível em: http://www.planalto.gov.br/ccivil_03/_ato2004-2006/2006/lei/l11340.htm
• 8. Miranda MPM, Paula CS, Bordin IA. Violência conjugal física contra a mulher na vida: prevalência e impacto imediato na saúde, trabalho e família. Rev Panam. Salud Publica 2010 Out; 27(4):44-52.
• 9. Borsoi TS, Brandão ER, Cavalcanti MLT. Ações para o enfrentamento da violência contra a mulher em duas unidades de atenção primária à saúde no município do Rio de Janeiro. Interface Comunic Saúde Educ. 2008 Dez; 12(30):409-24.
• 10. Vieira EM, Perdona GSC, Santos MA. Fatores associados a violência física por parceiro íntimo em usuárias de serviço de saúde. Rev Saúde Pública 2011 Dez; 45(4):730-7.
• 11. Gil AC. Como elaborar projetos de pesquisa. 5Ş ed. São Paulo (SP): Atlas; 2010.
• 12. Flick U. Uma introdução à pesquisa qualitativa. 3Ş ed. Porto Alegre (RS): Artmed; 2009.
• 13. Instituto Brasileiro de Geografia e Estatística. Censo 2010 [online]. [acesso 2011 Mai 05]. Disponível em: http://www.ibge.gov.br/home/estatistica/populacao/censo2010/default_sinopse.shtm
• 14. Secretaria Especial de Políticas para as Mulheres (BR). Programa de prevenção, assistência e combate à violência contra a mulher. Brasília (DF): Secretaria Especial de Políticas para as Mulheres; 2006.
• 15. Santos HCE, Biasoli DA. Contribuições reflexivas sobre a inserção do assistente social na equipe mínima do Programa Saúde da Família. Investigação. 2008 Jan-Mar; 8(1):41-50.
• 16. Bardin L. Análise do conteúdo. 6Ş Ed. Lisboa (PT): Edição 70; 2009.
• 17. D'oliveira PL, Schraiber AFB, Hanada H, Durand J. Atenção integral à saúde de mulheres em situação de violência de gênero - uma alternativa para a atenção primária em saúde. Ciênc Saúde Coletiva. 2009 Fev; 14(2):39-47.
• 18. Gomes NP, Diniz NMF, Silva Filho CC, Santos JNB. Enfrentamento da violência doméstica contra a mulher a partir da interdisciplinaridade e intersetorialidade. Rev Enferm UERJ. 2009 Jan-Mar; 17(1):14-7.
• 19. Ferraz MIR, Lacerda MR, Labronici LM, Maftum MA, Raimondo ML. O cuidado de enfermagem a vítimas de violência doméstica. Cogitare Enferm. 2009 Set-Dez; 14(4):5-17.
• 20. Vieira EM, Perdona GCS, Almeida AM, Nakano MAS, Santos MA, Daltoso M, et al. Conhecimento e atitudes dos profissionais de saúde em relação à violência de gênero. Rev Bras Epidemiol. 2009 Set-Dez; 12(4):566-77.
• 21. Moreira SNT, Galvão LLLF, Melo COM, Azevedo GD. Violência física contra a mulher na perspectiva de profissionais de saúde. Rev Saúde Pública. 2008 Dez; 42(6):1053-9.
• 22. Bonfim EG, Lopes MJM, Peretto M. Os registros profissionais do atendimento pré-natal e a (in)visibilidade da violência doméstica contra a mulher. Esc Anna Nery Rev Enferm. 2010 Jan-Mar; 14(1):97-104.
• 23. Guedes RN, Silva ATMC, Fonseca RMGS. A Violência de gênero e o processo saúde-doença das mulheres. Esc Anna Nery Rev Enferm. 2009 Set-Dez; 13(3):625-31.
• 24. Ludermir AB, Lewis G, Valongueiro SA, Araujo TV, Araya R. Violence against women by their intimate partner during pregnancy and postnatal depression: a prospective cohort study. Lancet. 2010 Jan-Mar; 37(1):903-10.
• 25. Cruz DMC, Silva JT, Alves HC. Evidências sobre violência e deficiência: implicações para futuras pesquisas. Rev Bras Educ Espec. 2007 Jan-Abr; 13(1):29-37.
• 26. Bedone AJ, Faúndes A. Atendimento integral às mulheres vítimas de violência sexual. Cad Saúde Pública. 2007 Abr-Jun; 23(2):465-7.
• ²⁷
  Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. 4ª ed. Brasília (DF): MS; 2007.

^*

Of the 11 USFs, six are in the rural zone and five in the urban zone. Each USF corresponds to a team made up of a doctor, a nurse, a dentist and a social worker, in addition to nursing technicians and Community Health Workers (ACSs).

Publication Dates

• Publication in this collection
  01 Oct 2013
• Date of issue
  Sept 2013

History

• Received
  12 Apr 2012
• Accepted
  25 Feb 2013