Critical path of women in situations of intimate partner violence 1

ABSTRACT Objective: To know and analyze the critical path followed by women subjected to intimate partner violence until reaching a Reference Center of a Brazilian city, from the perspective of these women. Method: Qualitative research, based on the concept of critical path. Participant observations of the support group of the Reference Center and interviews with ten women in situations of violence who were followed up in this service. Results: the motivating factors for women to seek help were the increase in the severity of the aggressions, the impact of the violence on their children and support from their family. They go to several sectors and services before reaching the Reference Center, such as the police and legal counsel, health and social services. They find little effective responses from the services, and care is indicated as the most relevant response factor to face the situation. Conclusion: the assistance is fragmented and dependent on the posture of the professional. The Reference Center is recognized as an important place of support for women. In addition to governmental efforts to maintain the network structured, the permanent education of the working professionals is also fundamental.


Introduction
Violence against women is a violation of human rights and a serious public health problem in the contemporary world. Approximately one third (30%) of women who have been in a relationship experienced physical and/or sexual violence perpetrated by the intimate partner, and in some regions this rate reaches 38% (1) . A systematic review conducted with studies from 1990 to 2011 to estimate the global and regional prevalence of intimate partner homicide found that intimate partner was six times higher than the proportion of male homicides (2) .
Women who experience domestic violence have lower quality of life (3) . According to the literature, there are physiological mechanisms that associate exposure to violence with different health effects; therefore, there may be implications for mental health and cognitive functioning. In addition, the immune system may become weakened, increasing the risk of cancer and viral infections (4)(5) .
The construction of care for this population must include the identification of opportunities to provide support and connect women with other services they need. To this end, it is important to know the itinerary of these women in order to identify the possible gaps and weaknesses in the services and in their connections, the potential of the care offered by the various services and sectors, and the challenges of this area, which is essential to the tertiary prevention of violence against women. The sequence of decisions and actions taken by an affected woman to address the violence she experienced and the responses found in her search for assistance is called a "critical path", which describes the steps prior to arrival at the Reference Centers (6) .

This concept proposed by the Pan American Health
Organization (PAHO) is associated in other countries with the term "help-seeking behavior".
The critical path is an interactive process comprising the factors that motivate or inhibit affected women and their actions and the social responses they find, which in turn have an impact on their path. These women's decisions are influenced by their information, their knowledge, their perceptions and attitudes, the resources available, their previous experience, the importance given to the situation and support or obstacles encountered (6) .
The present study was based on the above and its main contribution is to give voice to women in situations of violence, seeking to understand the path they follow to obtain support to cope with this situation. This knowledge is well developed in international studies, but still incipient in the Brazilian context and in South American countries. More in-depth theoretical discussions are necessary to understand this phenomenon and expose possible cultural differences and less severe intimate partner violence (7)(8) . Thus, the objective of this study was to know and analyze the critical path followed by women subjected to intimate partner violence until reaching a Reference Center of a Brazilian city, from the perspective of these women.
Considering the complexity of the problem, health services must provide a network of services to women in situations of violence, with the joint action of areas such as education, public security, social assistance and culture. Health care professionals must understand this in order to expand and qualify the care provided to these women and to address the difficulties in the management of domestic violence (9) .

Method
Qualitative, descriptive and exploratory research, based on the concept of critical path proposed by PAHO (6) . It was conducted in the Reference Center for Women in Situation of Violence located in Campinas, São Paulo, Brazil.
The Reference Center offers individual assistance with a psychologist, a social worker and a lawyer, allows women to participate in workshops to learn activities such as hairdressing, and provides an appropriate place with a social educator to leave the children during care and a support group with weekly meetings, in addition to tours, and other activities. The main researcher participated in 15 different groups, totaling 30 hours of observation. After the meetings the notes were recorded in the field diary: the people present that day, which subjects were covered, which techniques were used, the main sentences said, the places they went for help, and impressions regarding the environment and possible complications.
The interviews used as guide the instrument developed by PAHO to investigate the critical path of women in situations of violence, which was translated and validated by Brazilian researchers (6)(7)(8) . The script of the semi-structured interviews had the objective of identifying the path they followed when they decided to seek help, their perception of care and the aspects that facilitated or hindered the process of seeking help (8) .
The interviews were individual and occurred in closed rooms in the premises of the Reference Center. the women reported they had sought help, they were asked: "Who served you? How was the process? What did they say? How were you treated? Did they refer you to another service?".
The number of women interviewed was not previously established. During the interviews, as the content was repeated, that is, when the critical path followed by them was established by their speeches, the interviews were closed, totaling ten women. The number of interviews is also justified by data that was corroborated during the observations of the support group, in which the interviewees and other participants described their stories and, consequently, the critical path followed until reaching the support service. In qualitative research, the emphasis is on the experiences and understandings of people about particular phenomena, which can be understood even with a smaller number of participants (10) .
All interviews were recorded using a voice recording application for mobile phones and were later manually transcribed. The longest interview lasted one hour, 57 minutes and 15 seconds, while the shortest interview lasted 26 minutes and 41 seconds.
The data from the interviews and from the participant observations were analyzed using the inductive thematic analysis technique, a method used to identify and analyze patterns of qualitative data mainly related to the language used by the participants (10) . The following steps were followed:

The beginning of the critical path: motivating factors
The women decided to seek for help when the aggressions became more severe; when the situation became unsustainable or when there was some extreme situation, such as a daughter trying to commit suicide due to violence suffered by the mother: (

Services on the critical path: actions taken and response factors
Among the actions taken by these women, the main ones were filing a Police Report (PR); seeking Women's Police Stations (DDMs) or conventional police stations; and seeking health and social care services. Throughout this process, they obtained different answers. The path of women in situations of violence is not linear. The services that composed the critical path of each woman and the service that referred them to the Reference Center are shown below, in Table 1.  DDMs are closed. However, according to the speeches of these women, the police report did not do any good.
One reason for not filing a report is because they did not

Discussion
The motivating factors, the actions taken and the response factors present in the critical path of the women participating in the study are represented in Figure 1: -Increase in the seventy of the aggressions; -Feeling that the situation was unsustainable; -New severe situations in the family; -Support from children; -Support from the family

Motivating factors:
-Filing of a police report without sucess; -Searching the DDM or conventional police station; -Searching health services and social assistance

Action taken:
-Few positive responses from the services; -Orientation to face the situation; -Assistance offered to the partner; -Welcoming; -Referral to the Reference Center.
Response factors: Figure 1 -The critical path: schematic representation.
conducted in Canada showed that even services such as shelters and victim assistance programs were sought by these women, indicating the increased risk of these situations (11) . The main reason women did not think about seeking formal support was because they did not consider the violence they suffered so serious and/or they thought that they would be able to deal with it alone (12) . The continued availability of a range of services that ensure the safety of these women and their families is necessary to meet their long-term health and economic needs (11) .

As in this research, studies conducted in Mexico,
Africa and in the United States, found that the main support received by women in situations of violence was from their family (14)(15)(16) . Another Brazilian research also corroborates the importance of the family as a motivating factor, since most of the women did not seek formal support and only told their family about the situation of violence experienced (7) . The impact of violence on children has been an important trigger for women to seek help, corroborating a study in Serbia (12) ; this aspect is relevant not only for women, but also for children and adolescents who witness violence.
There were times when the family was not perceived as a source of support by the women interviewed. This was also found in a study with women in situations of violence in Turkey (13) . Given the importance that this non-formal support has for the management of this situation, this aspect is as a relevant obstacle in coping with the violence suffered and it can also increase the guilt felt by these women (13) .
The beginning of the critical path is when women decide to break the silence by revealing their situation to a person outside their immediate family and friends. The critical path describes the responses found by women throughout this process (6) . The DDMs are an important resource for women in situations of violence, and Brazil was a pioneer in the creation of this type of service. The professionals that work in the DDMs should be trained to provide better care and welcoming for women in situations of violence, mainly because it is the service that is closer to these women and which has the greater potential for this assistance; in addition, it is recognized and legitimized by the population. The results regarding the DDM in this study are similar to those found in southern Brazil, where most of the women sought this service and evaluated it negatively (8) .
The only positive evaluation was of a conventional police station, not specialized in women, with the assistance conducted by a man. Considering the findings of this study and taking into account that in the DDM only women provide assistance, because this profile is expected to be better for other women, we question if what makes a difference are the attendants being women or professionals that were trained and participated in discussions on the problem, regardless of gender.
As in this research, studies in Brazil, Turkey, Mexico and the United States found that the majority of women in situations of violence who sought formal help called the police (7,13,(17)(18) . In the southern region of Brazil, a study conducted to assess the critical path of women in situations of violence found that the police are unable to ensure the current protective measures (8) .
The findings related to the judiciary are corroborated in the literature, which brings reports that workers in the legal sector pressure women to remain in the situation of violence (8) . This aspect also reinforces the gender stereotypes present in daily life.
All interviewees contacted health services for violence-related issues, a result similar to a research conducted in Canada, where 81.8% of women in situations of violence had contact with health services in the last year (19) .
Still regarding the search for help in health services, studies emphasize that health professionals are the first ones to have contact with women in situations of violence, since they generally seek health care due to aggression injuries, even if they do not state the real reason for their bruises (4,11) . In this sense, the potential of these services, in particular the PHC, for the detection, reception and referral of cases of violence can be highlighted, since they are services that are close and available to the community.
Studies indicate that women seek health care without reporting the situation of violence (4,11) . However, in this study, the findings showed that they directly reported the situation, including psychological violence, in the primary care services. Emergency services were also sought for complaints of physical violence. Finally, the specialty service was sought by a woman because she frequently went there since her husband was being followed up, which demonstrates the importance of the bond of trust.
Another interesting finding is that health professionals offered assistance to the partner. The resolution of a situation of violence includes not only the follow-up and strengthening of women, but also the reception and treatment of male perpetrators. This discussion has been emphasized in recent literature (20) .
The negative evaluations of the health services in this research can be explained by the fact that health professionals have difficulties to deal with problems such as violence, because they do not consider this situation as part of their field of activity. This is also supported by other studies, including one conducted in the same city of the current research, which revealed that some professionals have difficulties to identify violence as an aspect associated with the search for the health service and demonstrate lack of preparation for care and referral of these cases (21)(22) .
Social services, such as the CRAS, were sought by the women interviewed. Again, the evaluation of the service is related to the way they were treated by the professional who attended them, and it is positive when they feel welcome and are referred to another service. According to a study carried out in the same city, assistance to violence is person-dependent (22) . In a Canadian study on delayed help-seeking in situations of violence, the authors described characteristics considered important in the professionals for women to reveal their situation, such as high level of trust, nonjudgmental attitude, friendly listening posture and crosscultural listening (19) .
In the participant observations of the Support stereotypes; these strategies are triggers for cultural, social and political changes in broader contexts (23) .
All the interviewees evaluated the Reference Center positively, perhaps because the subjects of this research were women who received assistance in this service, which is one of the limitations of this study. Another limitation is the lack of interviews with professionals who assist women in situations of violence, which could broaden the discussions.