Understanding marital violence: a study in grounded theory*

Objective: to understand the phenomenon of marital violence based on the experience of women in judicial process and network professionals. Method: a qualitative study, with theoretical-methodological support in grounded theory. Data collection took place in two regional Courts for Peace in the Home in a municipality of the Brazilian Northeast. Interviews were conducted with 38 participants, who composed two sample groups: women in situations of violence and network professionals. Results: the understanding of marital violence emerged for the phenomenon “Experiencing marital violence as a progressive and cyclical process, with repercussions for health and implications for social relations”. Conclusion: in recognizing marital violence as a recurring problem in the life of women, with implications for their own health and that of their children, the study points to the relevance of coping strategies based on institutional and social support.


Introduction
With roots in gender inequality, marital violence has been experienced for many years, constituting itself as a public health problem. The challenge to intervene in this problem requires a better understanding of the interactional processes that pervade this phenomenon.
Women's vulnerability to experiencing violence is anchored in the socially constructed view of man as domineering, strong, virile and insensitive, and of women as delicate, faithful and submissive (1) . The different attributes, taken as inherent in men or women, derive from the social-historical construction that determines gender inequality, legitimating female inferiority and male social and sexual superiority (2) . These asymmetries favor abusive intimate relationships, leaving women prone to violence in conjugality (3) , as well as to remaining for years in this relationship (4) .
The prolonged nature of this experience, as well as the high prevalence of the harm, makes it an important public health problem. In Rwanda, a survey of 1,821 women revealed that 68% of these women were victims of intimate partner violence (5) . This reality was also evidenced in our country, as a study that investigated the distribution of conjugal violence across Brazilian states found that reported cases almost tripled between 2009 and 2014, with a significant increase in cases in the Southeast, South and Midwest (6) .
The problem is further compounded by the expenses related to health demands generated by the repercussions of this harm. In 2004 alone, Brazilian health services spent 90.2 billion reais on prevention, treatment and rehabilitation of women victims of marital violence (7) . This cost, coupled with the expenses with social and legal-police services, end up compromising the economic productivity of nations. In this regard, the United Nations estimates that partner violence-related costs in the US are nearly six billion dollars and in England and Wales approximately $33billion (8) .
Despite these burdens, many cases of marital violence have not been identified in the health services.
A national survey carried out with professionals who work in family health teams in Florianópolis, Santa Catarina, Brazil, draws attention to the difficulty of recognizing the problem in the Family Health Strategy (ESF) scenario, which is a fundamental preparation, especially for the nursing professional who, besides integrating the minimum team, has been in charge of the management of services (9) . It is worth emphasizing that the performance of health professionals is a key element in the detection of cases of violence and in the promotion of women's health and well-being, where the referral to the coping network is an essential step for prevention of the damage resulting from this experience (10) .  (11) . In this sense,  How does the service to women in situation of marital violence occur in the Network? Other issues were implemented along the conversation to achieve depth of data.
From the repetition of information and absence of new relevant data to be explored to deepen the research objective and understand the phenomenon, theoretical saturation of the data was reached (11) .
During the process of constant comparative analysis of data and concept emergence, memos and diagrams were produced concerning the researcher's reflections on data, which contribute to illustrate ideas and codes that aid theory development. The NVIVO ® 10 software was used to organize the data during the period of comparative analysis and coding.

Data coding occurred in three interdependent
stages: open, axial and selective coding (11) . In open coding, concepts were identified and grouped into strategies -refer to the actions developed to achieve the phenomenon; and consequences -results of actionsinteractions concerning a given phenomenon (11) . Finally, in the selective coding stage, the relations, associations and interactions between these five categories were interconnected around a central category, giving rise to the study phenomenon.

Results
The theoretical sample of the study comprised 38 participants, divided into two sample groups.

Discussion
As a method that aims to understand how social beings deal with their experiences (11) , grounded theory allowed us to point out that women experience a daily cycle of conjugal violence in a cyclical way. It is important to mention that this reality, present in all spheres of society, affects women in situation of social vulnerability (12) , represented in our study fro being black, low income and living in peripheral locations, these last two characteristics also make women vulnerable in developed countries such as Canada and Spain (13)(14) . The repetitive context, initially part of more veiled expressions of violence, such as swearing, deprecation, humiliation, defamation, which represent the phase of accumulation of tension.
Such events progressively evolve to culminate in an episode of greater gravity, which is usually revealed in physical form. A study in Iran also points to the cyclical and progressive character of conjugal violence, which begins in a milder way, commonly expressed in psychological form (15) . This event gradually intensifies throughout the relationship, culminating in an episode of greater severity, which usually manifests itself in physical form (15) .
Even after experiencing an acute event of violence, it is common for women to resume their relationship, as the data show. This condition expresses the "honeymoon" phase, in which the man shows repentance and the woman grants the pardon, action that is linked to the expectation of a behavioral change in the former (16) . In this respect, research carried out in Iran and Portugal also showed women's permanence in the conjugal relationship, whose estimated time is over ten years, as she believes in spouse change (17) . The belief in spouse change is often tied to convictions about inseparability of marriage, overvaluation of the father figure in child rearing, and the social stigma of divorce (17) .
Regardless of the reasons for staying in a violenceridden marital relationship, the study reveals that experiencing the harm eventually affects women's physical and emotional health. As an example, we can mention research that emphasizes different repercussions of conjugal violence on the physical integrity of women, such as cuts, lacerations, bruises, fractures, traumatic brain injury and polytrauma (4) .
Regarding mental impairment, the study points to marital violence predisposing to such mental illnesses as depression, acute stress, anxiety, and even bipolar disorder and schizophrenia (18) . care (14) , who become increasingly dependent on their partners and the marital relationship.
The damage resulting from conjugal violence is not restricted to the consequences in women's health, since speeches point to implications on children, in the form of social isolation, low school performance and aggressive behavior. National and international studies have also indicated the extent of these repercussions for children (20)(21) . In addition, witnessing harm between parents and/or being a victim in childhood and adolescence is significantly related to all types of violence suffered by women and manifested by men (22-23) .
It reveals the transgenerational character of the offense, pointed out in our study as a causal condition for experiencing violence in conjugality, since it leads to the development of the phenomenon.
As a condition that interferes with the phenomenon, the study pointed to the lack of family support as an event that weakens the woman in deciding to end the conjugal relationship. An international study of married women in Afghanistan has revealed that, because women believe that it is their job to maintain harmony at home, the family tends to hold her accountable for the violence suffered by supporting the man, who uses aggressive means to demand behaviors and standards understood as normal (24) . As in our study, other studies show the maintenance of female submission in romantic relationships anchored in the belief of women's inferiority to men, a cultural value communicated within family relationships, which hinders family support to break up with the relationship (24)(25)(26) . This construct favors women's acceptance of violent attitudes by the spouse from the understanding that they should and/or deserve to be subjected to violent acts in an intimate relationship, according to a study carried out in Cape Town, South Africa (27) .

However, women's experience of marital violence
shows that family support, if any, has proven to be a powerful support strategy that is central to women's strengthening so as to be able to nullify the experienced violence (28) . It can be inferred, therefore, that a cozy family space offers enough security to reach an internal transformation in the woman, removing her from a state of inertia and submission, which favors a break with the scene of violence (24) .
In addition to emotional support, the data point to the importance of financial support from family members in the decision to break with the abusive relationship. Although most of the interviewees reported earning less than two minimum wages, this condition does not guarantee them a favorable financial structure.
This question can be justified by the fact that, in a context of conjugal violence, men tend to subtract/ control women's money (29) . Another circumstance arises from marital separation, where the ex-spouse does not provide for the family and the woman has to take alone all the financial responsibilities, both of the home and the children. A study carried out with women in three provinces of Ecuador showed that it is common, after separation, that fathers stop providing for their children financially (30) , leaving all expenses to women.
In addition to family support, the study outlines other strategies for encouraging women to leave the violent setting, such as support from friends, religious institutions and discussion groups. These have already been considered crucial in the creation of mechanisms for decision through complaint and, mainly, by contributing with the necessary emotional support for establishing their psychological health (28) . Research conducted in the USA showed that the network of neighbors, family and friends acts in a protective way against mental illness and suicidal behavior (31) , indicating that such support has a positive influence in preventing social isolation. Another study carried out in six European capitals showed that higher levels of social support were associated with lower frequency of victimization by domestic violence (32) .
Concerning these women's participation in discussion groups, our study portrays them as a possibility of social support, since these spaces can to make decisions (28) .
This model of collective group action can still be incorporated by institutions, such as police stations and regional Courts, which were also flagged as a strategy that favors female empowerment and perhaps a break in the cycle of violence. Such scope ranges from instructing these women about the progress of the legal-police process to doing the necessary referrals, which include police, legal, psychosocial and health support. Therefore, these services should be integrated into a network in order to provide women in situations of violence with the necessary protection according to their demands and, therefore, they must act in an articulated manner (20) . These scenarios, which make up the network of assistance to women in situations of violence, are important because they encourage women to leave the situation of vulnerability involving domestic violence (33) , by paying attention to their needs in an effective way (34) .
Although the findings corroborate the complexity of domestic violence, according to production of the national and international knowledge, the discovery of an explanatory conceptual model of the phenomenon investigated by the relationship and interaction of conceptual categories and between the components of the paradigmatic model (35) (36) .

For nursing in particular, studies in Canada and
Australia have highlighted the salience of this qualification, based on a comprehensive curricular training on the subject, favoring the recognition of cases, welcoming and accompanying women during the decision process to break the violent cycle and also afterwards (37)(38) , in order to prevent women from resuming the relationship in the same disrespectful patterns.

Conclusion
Through the experiences of women in lawsuits because of marital violence, the study allowed the Considering that the study draws attention to conjugal violence as a recurrent problem in the life of women, making them and their children prone to illness, we must pay attention to these repercussions in the different spaces of care, whether legal, police or social or health-related, with a view to encouraging interventions for both groups. With regard to health environments, it is necessary to bring professionals closer to the issue of violence, especially to nursing professionals, due to their proximity to the community and their role in the management of care of FHS teams.
It is important to emphasize that, by providing care closer to this population, professionals working in PHC can provide care to women and children in situations of violence and direct them to different places in the care network, as well as being able to offer spaces for empowerment in the perspective of discussion groups. As for these spaces, it is worth mentioning that in addition to contributing to women's emancipation concerning violence, its relevance is also due to the creation of new perspectives for a future free from this experience. In addition to this possibility of support, the contribution of family and friends as a social support for women experiencing violence is noteworthy. Therefore, women should also be encouraged to seek help such as this in order to achieve a break in the violent cycle.
In addition, understanding that the cycle of violence is not limited to the experiences of women, since children involved in this environment tend to reproduce such experiences in adulthood, educational spaces with this public are also urged. These spaces can also be articulated by ESF nurses, more specifically through the School Health Program, aiming to demystify the unequal relationship of gender involved in the violent process. It is important to note the limitation of the study regarding the transgenerationality of conjugal violence, given the need to deepen this theme in order to better understand how perpetuation of violence occurs throughout generations.