Association between domestic violence and women's quality of life

ABSTRACT Objective: to analyze the association between domestic violence against women and quality of life. Method: a cross-sectional population-based household survey conducted with women 18 years and older, using a stratified sample by neighborhoods. For analysis, prevalence of domestic violence and quality of life index was verified and logistic regression was used to determine associations, with a significance level of 5%. Results: 424 women who had a prevalence of domestic violence of 54.4% and a quality of life index of 61.59 participated in this study. It was verified, through logistic regression, that domestic violence is associated with women's quality of life (p=0,017). The observed variables that influence the occurrence of domestic violence were in the social relations domain (p=0,000), provision of medical treatment for women (p=0,019) and safety (p=0,006). Conclusion: the study confirmed the evidence of an association between domestic violence against women and quality of life, a situation that reaffirms the importance of constructing public policies focused on gender emancipation.

In spite of its high prevalence and risk of violence, health care offered to women in situations of gender violence is still unsatisfactory (7) . This situation stems from the invisibility of the phenomenon in some sectors, such as emergency hospitals, most of which do not yet have ways to identify the problem, evidencing the predominance of the biologic model of health care, whose object of intervention is the physical damage (8) .
Data on VDCM in the state of Paraiba and in the municipality of Joao Pessoa are not organized in a database that facilitates the work of researchers and guides the authorities to make decisions in order to prevent or minimize the effects of violence against women. Additionally the data in the Public Security Secretariat of the state of Paraiba do not coincide with the existing data in the Department of Health of the Municipality of Joao Pessoa (9) .

The concept of QoL defined by the World Health
Organization (WHO) as a right of citizenship, referring to the sum of the economic, environmental, scientificcultural and political conditions collectively constructed and put at the disposition of the individuals so that they can realize their potentialities (10) .
As the concept of QoL is dynamic, broad and subjective and resulting from the sum of factors arising from the interaction between society and the environment, it is important to understand how domestic violence affects the QoL of victimized women.
Thus, the lack of knowledge about the association between domestic violence against women and quality of life is a research problem.
In view of the above, the present study aimed to analyze the association between domestic violence against women and quality of life given the existing opportunity to design and experiment with decision models that can give visibility to the VDCM phenomenon.
It try as well to assist managers in the decision-making process in the construction and implementation of new effective public policies in addressing the problem, promoting a better quality of life for them through the evidence of the influence of explanatory variables on the occurrence of the phenomenon, considering for this the adjustment of a logistic regression model. For the data collection, the following validated instruments were used: WHO VAW STUDY (11) to estimate gender-based violence against women and WHOQOL BREF for quality of life assessment (12) , as well

Statistical analysis
Statistical analysis and information were obtained with the aid of statistical software R (version 2.14.1 Finally, the Hosmer-Lemeshow test was used. (valor p = 0,095), which in this case, accepted the null hypothesis that this model is compatible with the data, i.e. there is enough evidence to say that the predictions obtained with it are statistically equal to those observed in reality (13) .

Discussion
It can be observed in this study that domestic violence is a reality, and highly prevalent in the daily life of women affecting their health and quality of life.

This result corroborates data released by the World
Health Organization (WHO) (2) which evidenced the absence of a country or city immune to violence. In a pioneering research that gathered data from 35 studies in 24 countries (14) , the high incidence of violence of men against women was shown to be the most endemic form the sexual and physical violence of intimate partners against their women, which reiterates the phenomenon as a serious public health problem.
It should be pointed out that the higher rates integrity (8) .
A study on quality of life and the presence of diseases such as depression in women suffering from violence revealed that most of the victims of aggression (72.0%) developed a significant degree of clinical depression.
The majority of women experiencing violence (78.0%) also present symptoms such as anxiety and insomnia and those who suffered aggression (24.0%) began to use anxiolytic medication after the onset of episodes (16) .

An important finding observed in the same research
is the fact that 39.0% of women who suffer violence have already considered suicide, which shows that VDCM causes effects such as poor quality of life and damages to their mental health (16) .
In this study it was observed that the variable "safety and protection" is involved with VDCM and influences QoL. It is known that despite the existence of the "Maria da Penha" Brazilian Law, many women  Rev. Latino-Am. Enfermagem 2017;25:e2901.
do not feel safe and protected in order to denounce the aggressor. This insecurity relates to the difficulty of reacting and verbalizing violence, fear for their own safety and for their children, lack of control over their lives, the hope that the aggressor will change or the willingness to protect the partner for economic or affective reasons (8) .
A study that analyzed the trajectory of coping with the violence carried out by some women showed that denouncing or deciding to end their silence in the face of the situation of violence presents both facilitating and troublesome aspects. Among the facilitating aspects are personal attitudes, such as feelings of exhaustion and revolt, and awareness of potential life risks. Among the troublesome factors, fear, guilt and shame, as well as family, material and institutional obstacles (17) .
It is important to emphasize that institutional obstacles refer to the inefficiency of the system in guaranteeing the protection of women against their aggressor, the lack of preparation and bureaucracy of the legal system, the lack of preparation of health professionals to deal with situations of violence and lack of monitoring and accountability (18) .
The instrumental knowledge that guides the professional practices is geared towards treating above all, the physical damages, thus excluding feelings and subjectivity. This inadequacy of instrumental knowledge constitutes an obstacle to the development of a health work process that changes this reality.
Research studies in health services (18) about VDCM, identified that the expectation of women when seeking the health service is to be heard and welcomed, a situation that is hardly effective. The justifications are focused on barriers created in the service, either for lack of time and resources, fear of offending women, lack of qualification or even frustration for not having the response of many users to the advice they receive. Unfortunately, only gender equality is not enough to match women socially, but it can be a starting point for their emancipation. These women make up the majority of the demand for public health services and it is in these places that they seek to be welcomed and cared for their health needs.