Marital violence precipitating / intensifying elements during the Covid-19 pandemic

The study aims to identify marital violence precipitating/intensifying elements during the COVID-19 pandemic. This is a narrative review of the literature, and the search was carried out in May 2020. We employed the PubCovid-19 platform, which is indexed in the United States National Library of Medicine (PubMed) and the Excerpta Medica (EMBASE) database. English descriptors “Domestic violence”, “COVID-19”, and “Intimate Partner Violence” were used in the search, and nine papers were selected for full-text reading. Three empirical categories were elaborated from the exploration of the selected material: Economic instability, Alcohol and other drugs use/ abuse, and Weaker women’s support network. Support networks for women in situations of marital violence should be expanded in this pandemic context, with emphasis on the use of digital technologies as possible tools for screening pandemic-related violence cases.

introduction Due to the COVID-19 pandemic, social distancing has harmed women's lives, which is expressed through the increasing marital violence rates. Given the worldwide concern with this female exposure, which generates illnesses and deaths, and the need for intervention at this point, it is imperative to grasp an understanding of the precipitating/intensifying factors of this phenomenon.
Contextualizing the coronavirus pandemic (SARS-CoV-2), which caused COVID-19, this virus has become a global public health challenge after its rapid dissemination worldwide, following the first official case reported in Wuhan, China 1 . After a dramatic case elevation, on January 30, the disease was declared a Public Health Emergency of international importance (ES-PII) 2 , and was responsible, until May 11, 2020, for more than 4 million cases and 278 thousand deaths distributed worldwide 1 . The situation is extremely worrying in Brazil, since the number of confirmed cases exceeded 202,000 as of May 14, with more than 13,000 deaths from the disease, ranking 6 th among the world's nations with more COVID-19 cases 3,4 .
Given the international and national context, it was necessary to adopt protective measures to reduce the morbimortality of the disease. Several actions have been developed to control the epidemic curve 5 as the disease reaches the stage of community transmission in several Brazilian cities. Because it is a disease with a high transmissibility level, control requires measures of restricted contact, social distancing, and quarantine useful for prevention, based on international experiences 6 . This context, in which the domestic environment has become the safest place to contain the transmissibility of COVID-19, has been bringing developments in all spheres of society, including for many women, since it is precisely in the private space where they are domestic violence victims. Therefore, staying home does not translate into protection 7 .
Considering marital violence, news published in the media, and reports from international organizations signal significant elevation in cases in this pandemic period worldwide. Domestic violence police records tripled and doubled during the epidemic in China and Italy, respectively, compared to the same period in 2019 8,9 . In France, which already has one of the highest rates of violence in Europe, an increase of more than 30% was reported after the imple-mentation of home quarantine 10 . In Brazil, this increase was 18% in complaints to the Dial 100 and Dial 180 toll-free services, as per the National Ombudsman for Human Rights (ONDH), of the Ministry of Women, Family and Human Rights (MMFDH), in the March 1-25 period 11 . The United Nations Population Fund states that the six-month permanence of isolation can be responsible for about 31 million extra cases of marital violence worldwide 12 .
In the face of this increase in violence situations, especially in isolation or social distancing, it is necessary to understand the reasons that precipitate or intensify the event in order to consider problem prevention and coping measures to prevent COVID-19 transmission. Considering this scenario regarding marital violence, this study aims to identify marital violence precipitating/ intensifying elements during the COVID-19 pandemic.

Methods
This is a narrative review to achieve and update knowledge on a specific and barely explored theme 13 , allowing the identification of new ideas and expanding knowledge, as is the case with marital violence in the context of COVID-19. The study started with the following guiding question: what elements precipitate/intensify marital violence during the COVID-19 pandemic?
The literature search was performed in May on the PubCovid-19 platform, which is indexed in the United States National Library of Medicine (PubMed) and the Excerpta Medica database (EMBASE). This platform was created to compile COVID19-related publications and organize works by thematic areas to facilitate access and direct the researcher. The following English descriptors were employed in the search: "Domestic violence", "COVID-19", and "Intimate Partner Violence". We included scientific papers that addressed COVID-19 and had an interface with the themes of violence against women, marital violence, and intimate partner violence. Works that were not freely available in their entirety were excluded.
Thirteen scientific papers were initially selected. Four were excluded as they did not address the topic of study after reading titles and abstracts, leaving nine papers to be read in full. An instrument was created to gather information from publications for better systematization.
The studies were thoroughly read, categorized, and analyzed in order to search for the elements that precipitated the violence in the COVID-19 pandemic period. Three empirical categories were elaborated from the exploration of the selected material, as follows: Economic instability, Alcohol and other drugs use/abuse, and Weakening of the women support network.

results
We developed a table from the nine publications selected for this study (Chart 1), presenting the characteristics of these publications, by title, authorship, year of publication, country, journal, methods adopted in the study, and violence precipitating/intensifying elements.

Discussion
The selected scientific literature evidenced that one of the precipitating or intensifying elements of marital violence during the COVID-19 pandemic concerns economic instability, expressed by declining wages, unemployment, lack of resources, and female economic dependence, which predisposes to disagreements and consequently marital violence. The United Nations Population Fund (UNFPA) published the document entitled "COVID-19: A Gender Lens -Protecting sexual and reproductive health and rights, and promoting Gender Equality", which points to increased family tensions and the economic impact during a pandemic as a potential factor for higher vulnerability to domestic violence, and given that protection systems may be weakened or disrupted during this period, due to the overload of care in addressing COVID-19 victims 14 .
The rising number of marital violence cases has always been observed during major catastrophes and economic crises, which ends up being a concern in the current situation, mainly because of the uncertain end of this pandemic 15 . This context was perceived in the United States, where nine months into Hurricane Katrina, the third deadliest in the world, with far-reaching economic effects, the number of intimate partner violence tripled, and rape increased sixteenfold 16 .
This case elevation may be associated with the lack of economic resources and the consequent economic recession 17 . The International Labor Organization predicts that, with the COVID-19 pandemic, some 25 million people will lose their jobs, resulting in a severe world economic recession, leading the state to pay emergency benefits to the disadvantaged population 18 . The loss of employment during the pandemic and the consequent drop in household income makes the domestic space stressful, potentiating violent behavior 19 . Even with the measures adopted for the payment of financial aid, access to these resources is cumbersome due to bureaucracy and analysis of information, which can lead to family quarrels due to the lack of resources to purchase food.
As in most cases, the provision of financial resources is the responsibility of men, in the absence of these resources, their wives and children tend to make demands from those men concerning family subsistence, and this attitude can catalyze conflicts. This situation is corroborated by the selected literature when they mention limited access to food and hygiene products due to the lack of financial resources caused by unemployment, so women's demands lead many men to attack their partners [20][21][22][23][24] .
Another element pointed out as a precipitator/intensifier of marital violence is related to the higher consumption of alcohol and other drugs. These factors have knowingly always been correlated, regardless of the COVID-19 pandemic. However, increasing use of these substances is observed in the domestic environment due to the pandemic and social distancing, with an ensuing hike of marital violence cases in the domestic context 12,15,22,24,25 .
The production of knowledge has already shown that being under the effect of alcohol and other drugs enhances behaviors such as euphoria, self-confidence, and emotional disinhibition, which can lead to aggressive impulses and loss of behavioral control 12,15 . Alcohol and other drugs use/abuse in the context of social distancing is related to pre-pandemic habits associated with disease-related anxiety and, in some cases, by the lack of support from face-to-face support group meetings, such as Alcoholics Anonymous 22,24,25 .
Given the situations above associated with the lack of support groups, the use/abuse of alcohol and other substances can be understood as a social distancing coping mechanism. However, this, in turn, favors emotional dysregulation and tends to trigger violent behaviors 22,25,26 . In Australia, social distancing measures were implemented with the closure of restaurants and bars, leading the population to domestic alcohol consumption, an increase of more than 36% in the sale of alcoholic beverages in the delivery modality, which favored a significant increase in reported violence 19 . As a result, some countries, such as Greenland, imposed a ban on the sale of alcohol to contain violence cases during quarantine 27 .
The lack of financial resources associated with substance use/abuse during the pandemic that reverberates in marital violence makes men limit access to women's support networks, whether informal, such as friends and family or formal ones, such legal-police and health services, as a way of retaining their sovereign domestic power. Thus, in the context of quarantine, women who are raped tend to feel even more unassisted, unable to vent with anyone, and receive visits 15,22,23,25,26 . One way to intensify the coercion mechanism and weaken the women's support networks in the pandemic is through media control to avoid complaints or help requests 21 Another situation that emerged from the studies refers to untrue information provided by spouses to women in order to mitigate the search for help. This reality was evidenced in Australia, where charities to people who suffer domestic violence received complaints from women whose partners used incorrect information about the extent of quarantine measures 22 . Furthermore, victims of marital violence may be afraid to go to the hospital for fear of non-compliance with the quarantine and infection 24 .
Another challenge refers to failures in supporting women who experience violence in a pandemic, which is because health professionals face the need to join efforts to provide care related to the severe manifestations of COVID-19, and this has disrupted other services that are unrelated to the disease 12,15,21,26 . Thus, as health services focus on caring for people infected with the disease, women experiencing violence lose out even more space for care in health services.
Given the context presented by the scientific literature, there is an urgent need to expand support networks for women victims of marital violence in the context of the COVID-19 pandemic. Successful strategies were created in Italy and Canada with the development of applications that allow women in a dangerous situation to ask for help without having to make a call, and a Signal for Help campaign, in which health professionals were informed of the risk violence through a manual signal during the videoconference of the telemedicine platform 12,28 . Such strategies are essential to think about the management for the prevention and confrontation of marital violence in times of pandemic.

Final considerations
The study reveals that the precipitating/intensifying elements of marital violence during the COVID-19 pandemic are related to the socioeconomic aspects associated with lower wages, unemployment, lack of resources, female economic dependence, and increased use/abuse of substances by partners/spouses. Moreover, another element pointed out by the literature is related to the weakening of institutional and social support for women, where they include the support of institutions and relatives.
In this context, the support networks for women in situations of conjugal violence should be expanded, with emphasis on the use of digital technologies as possible tools for screening cases of violence during the pandemic. We believe, therefore, such means would prevent and face the event and consequently reduce the alarming number of cases, and mitigate the repercussions of violence on the life of the whole family, especially women.