Coping strategies for domestic violence against pregnant female adolescents : integrative review

Objective: To investigate and analyze in the scientifi c literature coping strategies for domestic violence against pregnant female adolescents. Method: This is an integrative literature review, conducted from July to August 2017 on LILACS, SciELO and PubMed, using the descriptors and the MeSH terms: confrontation, violence, adolescent, pregnant women, prenatal care. Result: The sample comprised 9 articles that were organized and characterized according to year, country of study and coping strategy used. The main forms of coping involved the active search for cases and the primary care approach with all family members. Conclusion: Individualized prenatal care, the change in professional training and networking activities were pointed out as important components of the strategies for coping with violence against pregnant adolescents. Descriptors: Strategies; Domestic Violence; Adolescent; Pregnancy; Public health. RESUMO Objetivo: Investigar e analisar, na literatura científi ca, as estratégias de enfrentamento da violência doméstica contra adolescentes grávidas. Método: Trata-se de uma revisão integrativa de literatura, realizada de julho a agosto de 2017 nas bases de dados SciELO, LILACS e PubMed, com as palavras-chave, Mesh terms: enfrentamento, violência, adolescente, grávidas, pré-natal. Resultado: A amostra foi composta por 9 artigos, que foram organizados e caracterizados de acordo com o ano, país do estudo e estratégia de enfrentamento utilizada. As principais formas de enfrentamento envolviam a busca ativa de casos e a abordagem em atenção primária com todos os membros da família. Conclusão: Um pré-natal individualizado, a mudança na formação profi ssional e a atuação em rede foram apontados como importantes componentes das estratégias de enfrentamento da violência contra adolescentes grávidas. Descritores: Estratégias; Violência Doméstica; Adolescente; Gravidez; Saúde Coletiva. RESUMEN Objetivo: Investigar y analizar, en la literatura científi ca, las estrategias de enfrentamiento de la violencia doméstica contra adolescentes embarazadas. Método: Se trata de una revisión integrativa de literatura, realizada de julio a agosto de 2017 en las bases de datos SciELO, LILACS y PubMed, con las palabras clave, Mesh terms: enfrentamiento, violencia, adolescente, embarazadas, prenatal. Resultado: La muestra fue compuesta por 9 artículos, que fueron organizados y caracterizados de acuerdo con el año, el país del estudio y la estrategia de enfrentamiento utilizada. Las principales maneras de enfrentamiento involucran la búsqueda activa de los casos y el abordaje en atención primaria con todos los miembros de la familia. Conclusión: Coping strategies for domestic violence against pregnant female adolescents: integrative review Estratégias de enfrentamento da violência doméstica contra adolescentes grávidas: revisão integrativa Estrategias de enfrentamiento de la violencia doméstica contra adolescentes embarazadas: revisión integrativa REVIEW


INTRODUCTION
According to the World Health Organization (WHO), adolescence corresponds to the age group between 10 and 19 years (1) .The Brazilian Statute of Children and Adolescents (Estatuto da Criança e do Adolescente) establishes the age group as 12 to 18 years (2) .For this study we chose the age group established by WHO.
Although there are disagreements about when the adolescence starts and ends, from an idealistic view, this period is considered a transition to adulthood, marked by great changes and new responsibilities.However, some authors argue that the idea of understanding adolescence as a "transitional period" tends to disregard the needs of this group.According to Adamo (1985), adolescence cannot be considered just a period of transition; it is characterized as part of a gradual, slow and careful process of maturation (3) .For public health nursing, adolescence is a social phenomenon, i.e., the historicity of the society where the phenomenon occurs is a part of it.Therefore, chronological analyses do not comprise the complexity of this social group, which is one of the landmarks of the category "generation" (4) .
The category "gender" seeks to explain the social relations between the sexes beyond the biological aspects, breaking with the idea of male supremacy (4) ; these two categories are part of the understanding of the phenomenon of domestic violence against adolescents.Ideological and idealistic norms that permeate the social relations between men and women influence what being a female or a male adolescent means (4) .Thus, pregnancy in adolescence causes different experiences and consequences for men and women due to historically built social conceptions.Some authors argue that pregnancy during this stage of life is considered a social risk that can lead to various problems, like leaving school and the health risks during pregnancy (5) .Western culture considers pregnancy in adolescence as an early insertion in the adult world, causing concerns about life projects, education, autonomy and economic rise, leading to a stress that can trigger and/or exacerbate family disputes and result in physical and spoken conflicts.Thus, pregnancy itself can be a gateway to perpetuate situations of domestic violence and its repercussions (6) .Studies show that when the pregnancy is unwanted the woman has greater chance of suffering violence, and that there is strong association between gender violence and pregnancy in adolescence (7)(8) .
When domestic violence happens during the gestation period, it can directly and/or indirectly affect the maternal and fetal wellbeing.Some studies suggest women victims of violence during this period have higher risk of spontaneous abortion, they start prenatal monitoring late (especially if they are younger than 16 years and it is their first pregnancy), they have higher risks during birth and of premature birth, fetal injuries, low birth weight, perinatal and neonatal mortality and in extreme cases, maternal mortality (9)(10) .Other studies show that female victims of violence have more chances to have a prenatal care of poor quality due to low adhesion and late start of the follow-up treatment (11) .An integrative review with adolescents and their relationship with intimate partners showed the complexity that the phenomenon of domestic violence acquires when it happens during adolescence (12) .Another study showed that the psychosocial vulnerability of female adolescents increases when pregnancy in adolescence and domestic violence happen at the same time (13)(14) .This reveals the need for tracking actions and combating the phenomenon of violence, especially regarding pregnant adolescents.

OBJECTIVE
To investigate and analyze, based on the national and international literature, coping strategies of domestic violence against pregnant adolescents.

METHOD
This study used the method of integrative review that: Provides health professionals with relevant data of a given subject in different places and times, keeping them updated and making changes in clinical practice as a result of the research (15) .The authors recommend six steps for the design of the review: 1) definition of the research question, 2) search of the studies and definition of inclusion and exclusion criteria, 3) extraction of the information and categorization of the studies, 4) evaluation of the studies of the sample, 5) analysis of the results and 6) presentation of the review with a summary of the studies (15) .
For the search on the databases, the research question was: Which coping strategies for domestic violence against pregnant adolescents are used by professionals?The online databases used in the study were: SciELO (Scientific Electronic Library Online), PubMed and LILACS (Latin American and Caribbean Center on Health Sciences Information).The keywords used were: violence AND adolescent AND pregnancy, in English, Spanish and Portuguese on SciELO and LILACS.In PubMed, the MeSH (Medical Subject Heading) terms used were: violence AND adolescent AND pregnancy AND coping.Primary studies published from 2007 to 2017 were included.
The inclusion criteria were: the article had to describe the coping strategies for violence against pregnant adolescents performed in primary health care, in schools and in other institutions for young people or experiences resulting from programs and projects developed for monitoring adolescents and their families in hospitals, emergency, or NGOs.The articles excluded were Cibele Monteiro Macedo E-mail: cibele.macedo@usp.brCORRESPONDING AUTHOR un prenatal individualizado, el cambio en la formación profesional y la actuación en red fueron indicados como importantes componentes de las estrategias de enfrentamiento de la violencia contra adolescentes embarazadas.Descriptores: Estrategias; Violencia Doméstica; Adolescente; Embarazo; Salud Colectiva.
those that discussed the policies for combating violence against pregnant adolescents that referred to violence against them in war zones, armed conflicts and because of unforeseeable circumstances or natural events; and studies that only described the epidemiological profile of them in situations of violence.
The collection took place from July to August 2017; then, the reading of the titles and abstracts and, finally, the articles were fully read to identify the used coping strategy.
For the analysis of the articles from the databases we used the data collection instrument validated by Ursi (2005).The instrument includes: identification of the publication, the institution where the study was written, publication type, methodological characteristics of the study and evaluation methodological rigor (16) .The search resulted in nine studies: four from the PubMed; five from LILACS; and no studies from SciELO.The nine articles were fully analyzed, seeking to answer the guiding question of this study.The qualitative analysis of the data was performed with the support of the WebQDA® tool (17) , creating thematic groups according to the results presented in the articles.Thus, we explored the results presented in the studies searching for similarities, differences, gaps, new approaches, coping strategies, among other things.

RESULTS
We analyzed nine studies, and the quantitative approach was predominant (n = 5).The others used a qualitative approach (n = 4) and none of them used both approaches.
Of all kinds of violence described in the literature, we observe in the articles incorporated to the review the prevalence of: psychological violence (n = 9), physical violence (n = 9), sexual violence (n = 9), intimate partner violence (n = 7).Some studies presented more than one kind of violence.
Five studies were performed in Brazil, two studies in the United States of America and one in Nepal and Uganda, respectively.Regarding the journals, seven studies were published in health journals (nursing, collective health, medicine, public health) and two studies in Humanities (psychology, sociology and education).After reading the studies, we organized them in Chart 1.   Reasons: The studies were not primary, describing only the epidemiological profile and not addressing violence against pregnant adolescents.
Reasons: The studies were not primary, they described coping strategies performed in war zones and did not included adolescents among pregnant women.This group contributed to the female adolescents, so they could restore part of their self-confidence and hope to face the transformations of their everyday life, even if it was necessary to go through periods of suffering and darkness for that.
Complicações obstétricas, eventos estressantes, violência e depressão durante a gravidez em adolescentes atendidas em unidade básica de saúde 2010 -Brazil Cross-sectional _ The results strengthen the idea that the investigation of risk factors, diagnosis and treatment of depression must be an integral part of prenatal care to pregnant female adolescents.

-Brazil
Qualitative -Exploratory _ The study points to the need of considering the woman as the protagonist of the nursing care model in breastfeeding by building listening spaces that include attention to marital violence, as well as different means of support.

DISCUSSION
The objective of one of the studies was to understand the professional experience in health units participating in the Brazil's Family Health Strategy (FHS) showed that this Strategy assists on the approximation to the phenomenon of violence (18) .The actions to cope with the problem in this context were based on the identification and notification of the cases, referrals and the use of the support network with multidisciplinary teams.Institutional and bureaucratic barriers were cited as the biggest challenges.
The prenatal consultation was presented as a moment that stimulated coping actions, since the female adolescent attends health services more frequently.Prevention, tracking and treatment actions are suggested by a study as an integral part of the prenatal care of pregnant adolescents (19) .
Interventions involving the FSH and prenatal care were based on tracking cases of violence on primary care, on the dialogue between the friends and family of the victim, on prenatal care individualized and focused on the needs of the victims, on the participation in multidisciplinary groups for debate on gender-related issues and on the relationship of the adolescent with her baby (19)(20) .These studies also cited the need for a present and permanent education and for the specific training of professionals to provide an individualized prenatal care focused on the needs of the victims.
Financial independence was addressed in two studies.The female adolescents participated in groups and educational workshops focused on exchanging experiences with other victims and learning new skills to break the dependence on the abuser.The study pointed out that the priority of these groups is to restore the self-confidence of the female adolescent (20)(21)(22) .
The construction of spaces that focus on caring for female adolescent in situations of violence, allowing the exchange, resilience, reflection and the woman to be the protagonist of the nursing care model were strategies used in four studies developed in different contexts (23)(24)(25)(26) -this highlights the potential of this kind of strategy and confirms previous studies (27) .
Generally, the strategies used with pregnant adolescents sought to structure the coping of violence on the active search for cases of violence, on the approach during primary care involving all family members and support networks, more extensive scientific production on the subject and discussions regarding changes in professional training and care to women victims of violence, especially during the prenatal period.

Study limitations
The scarce number of studies found in the literature and the fact that no review studies of this study are pointed out as a limitation.For future investigations, we recommend expanding the databases and the inclusion of gray literature.
Contributions to the field of nursing, health, or public policies This article deals with complex phenomena, namely violence, adolescence and pregnancy, which affect the healthdisease process of individuals and, therefore, is an important health issue.This review has gathered some coping practices and strategies for domestic violence against pregnant adolescents, and these tools were developed and used in different countries and institutions, involving several areas of knowledge.This demonstrates the power of these strategies and highlights the contribution of this study, especially on the science of health care for female adolescents, who are often neglected on the everyday life of health services.

FINAL CONSIDERATIONS
The low number of eligible studies for this study shows that violence during the gestation period, especially against adolescents, still needs to be studied and explored beyond the description of the epidemiological profiles of victims.By analyzing the studies, we could realize that there is a big gap when it comes to building logics of care for pregnant adolescents facing violence and on the professional training.
The studies pointed out that actions focusing on changes of the professional training are needed, especially on the health area.These practices must include theoretical references to contribute with the development of knowledge and critical and reflective skills aimed at coping with violence.Rethinking how the services are structured, articulated and organized is also necessary to identify the demands and effectively respond to the health needs of this population, by strengthening support networks and multidisciplinary teams.
The importance of acting through intersectoral, multidisciplinary and interdisciplinary networks, was also apparent as a powerful coping tool.Studies involving the sectors of education debating gender issues, of social assistance with the encouragement of financial independence, of primary health care and of the family and the community were proven to be efficient to cope with the violence against these adolescents.They contributed to develop and strengthen the link between the adolescent and her baby and to change the relationship with her family.
The strategies presented intended to strengthen and extend the knowledge of health professionals on the violence experienced by pregnant adolescents, improving care through the identification of situations of violence, resilience, incentives to financial independence and the follow-up of victims in the medium and long term.Additionally, the need for the creation of laws and care protocols with the objective of resolving the coping of violence against pregnant adolescents.

Chart 1 -
Articles incorporated to the integrative review, published from 2007 to 2017, São Paulo, Brazil, 2017

Figure 1 -
Figure 1 -Flowchart of the systematic search on the databases PubMed, LILACS and SciELO, São Paulo, Brazil, 2017