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Filling out the compulsory notification in health services that care for women who suffer from sexual violence

Abstracts

OBJECTIVE:

To evaluate the proportion of health services that fill out the compulsory notification and what the main difficulties to fill it out are.

METHODS:

A study was carried out with two different approaches. For the quantitative approach, a cross sectional study was performed, with telephone data collection. In the state of São Paulo, 291 health services that had reported providing care to women who suffer from sexual violence were identified. The sample was composed of 172 services that reported providing emergency care to women. In the qualitative approach, case studies were conducted. Six cities were chosen by intention and convenience. For each of them, professionals from two health services were invited to participate. Forty-five semi-structured interviews were conducted. For quantitative data, a descriptive analysis was carried out. For qualitative data, a thematic analysis of content was performed.

RESULTS:

The proportion of health services which reported always filling out the notification in cases of sexual violence was 79.1%. More than half (53.5%) reported difficulties concerning the assisted women, one third reported reasons related to the form, and 29.7%, to the professionals. In the qualitative approach, the main difficulties were the size of the form, the problems to obtain the information about the woman and the difficulty for the professional to obtain this information.

CONCLUSION:

Although most health services claimed to fill out the compulsory notification, they also mentioned several difficulties to do so, especially with regard to the workload of professionals and the misunderstanding about the importance of the notification in the context of comprehensive care to women who suffer from sexual violence.

Sexual Violence; Women; Health services; Emergency care; Disease notification; Violence against women


OBJETIVO:

Avaliar a proporção de serviços de saúde (SSs) que preenchem a notificação compulsória e quais os principais obstáculos para o preenchimento de tal documento.

MÉTODOS:

Realizou-se um estudo com abordagem mista. Para a abordagem quantitativa, foi realizado um estudo de corte transversal, com coleta de dados por telefone. Foram identificados 291 SSs no Estado de São Paulo que referiam dar atendimento a mulheres que sofrem violência sexual. A amostra foi composta por 172 serviços que referiram prestar atendimento de emergência às mulheres. Na abordagem qualitativa realizaram-se estudos de casos, com amostra intencional e de conveniência. Foram escolhidos seis municípios, nos quais foram entrevistados profissionais de dois SSs. Realizaram-se 45 entrevistas semiestruturadas. Para os dados quantitativos, realizou-se uma análise descritiva simples. Para os dados qualitativos, realizou-se análise temática do conteúdo das entrevistas.

RESULTADOS:

A proporção de serviços que referiram sempre preencher a ficha de notificação em casos de violência sexual foi de 79,1%. Mais da metade (53,5%) referiu dificuldades relativas às mulheres atendidas, um terço referiu motivos referentes à ficha e 29,7% reportaram dificuldades relacionadas aos profissionais. Na etapa qualitativa, as dificuldades mais referidas foram o tamanho da ficha, os problemas para se obter as informações da mulher e a dificuldade do profissional em obter essas informações.

CONCLUSÃO:

Embora a maior parte dos SSs tenha referido preencher a ficha de notificação compulsória, mencionou também várias dificuldades para fazê-lo, especialmente relacionadas à sobrecarga de trabalho dos profissionais e à incompreensão acerca da importância dessa notificação no contexto da atenção integral às mulheres que sofrem violência sexual.

Violência sexual; Mulheres; Serviços de saúde; Atendimento de emergência; Notificação de doenças; Violência contra a mulher


OBJECTIVE:

To evaluate the proportion of health services that fill out the compulsory notification and what the main difficulties to fill it out are.

METHODS:

A study was carried out with two different approaches. For the quantitative approach, a cross sectional study was performed, with telephone data collection. In the state of São Paulo, 291 health services that had reported providing care to women who suffer from sexual violence were identified. The sample was composed of 172 services that reported providing emergency care to women. In the qualitative approach, case studies were conducted. Six cities were chosen by intention and convenience. For each of them, professionals from two health services were invited to participate. Forty-five semi-structured interviews were conducted. For quantitative data, a descriptive analysis was carried out. For qualitative data, a thematic analysis of content was performed.

RESULTS:

The proportion of health services which reported always filling out the notification in cases of sexual violence was 79.1%. More than half (53.5%) reported difficulties concerning the assisted women, one third reported reasons related to the form, and 29.7%, to the professionals. In the qualitative approach, the main difficulties were the size of the form, the problems to obtain the information about the woman and the difficulty for the professional to obtain this information.

CONCLUSION:

Although most health services claimed to fill out the compulsory notification, they also mentioned several difficulties to do so, especially with regard to the workload of professionals and the misunderstanding about the importance of the notification in the context of comprehensive care to women who suffer from sexual violence.

Sexual Violence; Women; Health services; Emergency care; Disease notification; Violence against women


INTRODUCTION

Violence against women is currently one of the most relevant subjects in the Public Health and human rights scope, since it causes serious damage to health and to the psychosocial development of these women11. Heise L. Gender-based abuse: The global epidemic. Cad Saúde Pública 1994; 10 (Suppl 1): 135-45.

2. Heise L, Pitanguy J, German A. Violence against women: the hidden health burden. Washington: The International Bank for Reconstruction and Development/The World Bank; 1994.
-33. Garcia-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts CH; WHO Multi-country Study on Women's Health and Domestic Violence against Women Study Team. Prevalence of intimate partner violence: findings from the WHO multi-country study on women's health and domestic violence. Lancet 2006; 368(9543): 1260-9.. Among the types of violence against women, sexual violence may not be the most prevalent one, however, it is considered to be the one to cause consequences that are as shocking as - or more shocking than - other types44. Basile KC, Smith SG. Sexual violence victimization of women: prevalence, characteristics, and the role of public health. A J Lifestyle Med 2011; 5: 407-17..

Sexual violence against women is practiced both by intimate partners and by other men, who may or may not be familiar to the women55. Guedes A, García-Moreno C, Bott S. Violencia contra las mujeres en Latinoamérica y el Caribe. Foreign Affairs Latinoamérica 2014; 14 (1): 41-8. Disponível em: www.fal.itam.mx3. (Acessado em 27 de maio de 2014).
www.fal.itam.mx3...
,66. Facuri CO, Fernandes AMS, Oliveira KD, Andrade TS, Azevedo RCS. Violência sexual: estudo descritivo sobre as vítimas e o atendimento em um serviço universitário de referência no Estado de São Paulo, Brasil. Cad Saúde Pública 2013; 29(5): 889-98..

In the past few years, in Brazil, several studies have pointed out to the high frequency with which women are attacked, especially in the household environment and in the scope of intimate relationships77. Faúndes A, Hardy E, Osis MJD, Duarte GA. Risco para queixas ginecológicas e disfunções sexuais segundo história de violência sexual. Rev Bras Ginecol Obstet 2000; 22(3): 153-7.

8. Reichenheim ME, Moraes CL, Szklo A, Hasselmann MH, Souza ER, Lozana JA, et al. The magnitude of intimate partner violence in Brazil: portraits from 15 capital cities and the Federal District. Cad Saúde Pública 2006; 22(2): 425-37.
-99. Schraiber LB, d'Oliveira AFPL, França-Júnior I, Diniz S, Portella AP, Ludermir AB, et al. Prevalência da violência contra a mulher por parceiro íntimo em regiões do Brasil. Rev Saúde Pública 2007; 41(5): 797-807.. In a recent systematic review about the prevalence of sexual violence perpetrated by "non-partners", a global estimation was calculated, in 2010, in 7.2%, and, in Brazil, in 7.6%1010. Abrahams N, Devries K, Watts C, Pallitto C, Petzold M, Shamu S, et al. Worldwide prevalence of non-partner sexual violence: a systematic review. Lancet 2014; 383(9929): 1648-54.. At the same time, many difficulties to promote whole care to women who suffer from violence have been demonstrated, especially when it comes to sexual violence1111. Oliveira EM, Barbosa RM, Moura AAVM, Kossel K, Morelli K, Botelho LFF, et al. Atendimento às mulheres vítimas de violência sexual: um estudo qualitativo. Rev Saúde Pública 2005; 39(3): 376-82.

12. Bruschi A, Paula CS, Bordin IAS. Prevalência e procura de ajuda na violência conjugal física ao longo da vida. Rev Saúde Pública 2006; 40(2): 256-64.

13. Faúndes A, Hardy E, Osis MJD, Makuch MY, Duarte GA, Andalaft Neto J. Perfil do atendimento à violência sexual no Brasil. Relatório técnico apresentado ao Ministério da Saúde. Campinas: CEMICAMP; 2006.

14. Villela W, Lago T. Conquistas e desafios no atendimento às mulheres que sofreram violência sexual. Cad Saúde Pública 2007; 23(2): 471-5.
-1515. Osis MJD, Duarte GA, Faúndes A. Violência entre usuárias de unidades de saúde: prevalência, perspectiva e conduta de gestores e profissionais. Rev Saúde Pública 2012; 46(2): 351-8..

In terms of health actions, measures have been proposed to provide effective care to women who suffer from sexual violence1616. Ministério da Saúde. Guia Prático do Programa da Saúde da Família. Brasília: Ministério da Saúde; 2001.

17. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Área Técnica de saúde da Mulher. Política Nacional de Atenção Integral à Saúde da Mulher. Brasília: Ministério da Saúde; 2004.

18. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de análise de Situação de Saúde. Instrutivo Notificação de violência doméstica, sexual e outras violências. Série G - Estatística e Informação em Saúde. Brasília: Ministério da Saúde. Disponível em: http://portal.saude.gov.br/portal/arquivos/pdf/viva_instrutivo_not_viol_domestica_sexual_e_out.pdf. (Acessado em 24 de janeiro de 2013).
http://portal.saude.gov.br/portal/arquiv...
-1919. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Área Técnica de Saúde da Mulher. Atenção integral para mulheres e adolescentes em situação de violência doméstica e sexual - Matriz pedagógica para formação de redes. Série B - Textos Básicos de Saúde. Brasília: Ministério da Saúde; 2011.. Since 1999, the Ministry of Health established the Technical Regulation "Prevention and treatment of conditions resulting from sexual violence against women and adolescents", which defines a protocol to care for women who suffer from sexual violence. In spite of that, not all emergency services treat these cases according to the regulation. A study conducted in a representative sample of Brazilian cities identified 1,395 health services (HSs) that reported caring for women and children who suffer from sexual violence; however, only 8% used the protocol to care for them in accordance with the aforementioned regulation from the Ministry of Health2020. Andalaft Neto J, Faúndes A, Osis MJD, Pádua KS. Perfil do atendimento à violência sexual no Brasil. Femina 2012; 40(6): 301-6..

Another matter of concern expressed by public policies regarding violence against women is the lack of records of the cases in the HSs, which could help the planning and the execution of measures to prevent violent events, as well as to provide faster care to the victims. In order to fill that gap and establish preventive strategies, the Federal Government defined compulsory notification in cases of violence against women. According to Law n. 10,778, from November 24, 2003a, all cases of violence against women - physical, sexual and psychological violence - assisted by public or private HSs must be notified by filling out a form. This law was regulated by the Ministry of Health on June 3, 2004, by the decree n. 5,099b. In 2011, an ordinance from the Ministry of Health included domestic, sexual and/or other types of violence in the Compulsory Notification List (LNC)c.

However, up until now, especially with regard to sexual violence, it is not possible to know up to which point the compulsory notification of violence is put in practice, nor how this procedure is seen by health professionals. Facing the exposed, this study aimed at verifying which proportion of HSs that provides emergency care for women who suffer from sexual violence fills out the compulsory notification, and which the main obstacles to fill out such a document are.

METHODS

A study with mixed, quantitative and qualitative approach was conducted with HSs from the State of São Paulo that reported providing emergency care for women who suffer from sexual violence. For the quantitative approach, a descriptive and cross-sectional study was carried out; for the qualitative approach, case studies were conducted2424. Gomm R, Hammersley M, Foster P, eds. Case study methods. Thousand Oaks: Sage Publications; 2000.,2525. Patton MQ. Qualitative evaluation and research methods. 2nd ed. London: Sage; 1990..

For the quantitative stage, a proportion of HSs who fill out the compulsory notification estimated in 50% was considered, with 5% probability of type I error and acceptable absolute difference between the sample and the population proportion of 7.6%, by establishing a minimum number of 166 HSs2626. Kish L. Survey sampling. New York: John Wiley and Sons; 1965..

The quantitative stage included 172 HSs that reported providing emergency care in cases of sexual violence. These services were identified and selected as follows: from all of the 240 HSs in the State of São Paulo that were part of the research "Profile of care to sexual violence in Brazil"1313. Faúndes A, Hardy E, Osis MJD, Makuch MY, Duarte GA, Andalaft Neto J. Perfil do atendimento à violência sexual no Brasil. Relatório técnico apresentado ao Ministério da Saúde. Campinas: CEMICAMP; 2006., the coordinator or the person in charge of caring for women who suffer from sexual violence was invited to participate in the study. Besides, other services indicated by these people were contacted; when more than one service was indicated, only one of them was raffled. A total of 291 HSs was initially approached; 40 immediately refused to participate in the study, and 5 were considered as "lost" due to several failed attempts of contact. Twenty-five other services claimed not to provide emergency care to women who suffer from violence in general, 16 stated not providing emergency care to women who suffer from sexual violence, 32 did not notify cases of violence in general (any type) and one service could not inform it.

By telephone, a structured and pre-tested questionnaire was applied to the coordinator or person in charge of caring for women who suffer from sexual violence in each service. Interviews were recorded after authorization.

The compulsory notification form is part of the National Disease Notification System (SINAN) and has several blanks to be filled out; among them, personal data of the patient, complementary data about the assisted person, information about the event, type of violence and some specific blanks for cases of sexual violence. There are also data concerning the probable author of the aggression, and information about evolution and referral.

The independent variables considered in this study were: type of HS (hospital, Women's Health reference center; emergency room / emergency unit (UPA); Family Health Program (PSF); Basic Health Unit (UBS); outpatient clinics; Specialized Care (SAE)); and position of the respondent (social worker; nurse; physician; psychologists; another position).

Dependent variables were:

1) How often the notification form is filled out in cases of sexual violence:

  1. Always;

  2. Most of the time;

  3. Sometimes;

  4. Never;

2) Awareness about the compulsoriness of the notification:

  1. Yes;

  2. No;

  3. Does not know;

3) Party to which notification of violence cases are sent:

  1. Police (Police Station/ Women's Police Station/Military Police);

  2. Specific services (child protective services/Child and Youth Courts; Women's and elderly protective services);

  3. Health administrators (Ministry of Health; Municipal Secretariat of Health; State Secretariat of Health);

  4. Surveillance/Information Systems (Epidemiological Surveillance/ Information Systems from the Ministry of Health);

  5. Institutions that provide care to women and adolescents in the city;

  6. Others;

  7. Does not know;

4) Reasons reported by HSs to fill or to not fill out the compulsory notification form in cases of sexual violence:

a. Reasons to fill it out:

  1. Compulsoriness (Because it is mandatory/ Ministry of Health and/or city demands it/ Protocol or routine of the unit);

  2. Information or statistics (Helps to identify the number of cases/obtain statistical data; Health of the woman who suffers from the violence/ So the woman can follow the protocol/be tested/take medicines);

  3. Public Health Programs (Helps to define strategies to implement prevention programs addressed to sexual violence/public policies);

  4. To refer the patient to another institution;

b. Reasons to not fill it out:

  1. Reasons that reveal the lack of information of the respondent (Never received information/ The woman does not always want to accuse/ The woman needs to decide whether or not to file an incident report/ She is not referred to the internal sector that conducts the notification);

  2. Reasons related to the lack of preparation of the professionals (Not all of the professionals know how to fill out the form/ Some of them think it is not necessary / Lack of sensitization);

  3. Reasons for the service functioning (It is not always possible to get all the data/ Lack of time / Lack of professional);

  4. Other reasons;

  5. Does not know/Not informed.

With regard to the characteristics of HSs that filled out the notification form, the following dependent variables were analyzed:

1) Professional who fills out the notification form:

a. Physician; nurse; social worker; psychologist; nursing technician or assistant; others;

2) Main difficulties faced while filling out the compulsory notification form:

  1. Reasons referring to the women (Difficulties to obtain information from the patient/ Resistance and/or fear from the women);

  2. Reasons referring to the form's characteristics (The form is difficult/complicated to fill out; The form is too long; It takes time to fill it out; Work flow concerning the notification is flawed/lack of systematization);

  3. Reasons of the professionals (Lack of time/ Forgetfulness/ Unwillingness from professionals);

  4. Reasons referring to the characteristics of the place (Lack of a more private place for assistance and questions);

  5. Another reason;

3) Opinion about whether or not the notification form brings any benefits to the women:

  1. Yes;

  2. No;

  3. Does not know;

4) Opinion about which benefits women can get:

  1. Information or statistics (Helps to identify the number of sexual violence cases/ obtaining statistical data);

  2. Public Health Programs (Helps to establish strategies to implement programs of violence prevention);

  3. Health of the Woman who suffers from the violence (Helps posterior follow-up/ proper treatment);

  4. Women can talk about it;

  5. Police/judicial process (Documents to work on/ Provide the proper follow-up; Way of repressing this type of violence/ scaring the aggressor);

  6. Another opinion;

  7. Does not know;

5) Measures adopted to ensure the secrecy of information in the notification form:

  1. Being careful to file the information (Form filed in a specific location/file room; Form filed in the patient's medical history; Stored in a filing cabinet/closed cabinet; Filed in a closed/locked room);

  2. Limited access (Employees of the service can access the file/ Only one employee has access to the file/ Accessed only by authorized personnel, with a written judicial consent or from the director);

  3. Referral to other institutions/parties (Referred to Epidemiological Surveillance; Referred to other institutions/parties; Referred to another service/ party in a sealed envelope);

  4. Form filed in the patient's medical history;

  5. The service does not keep a copy of the form;

  6. Filed in the reception/in the service.

A simple descriptive analysis was conducted2727. Altman DG. Practical statistics for medical research. Boca Raton: Champman & Hall/CRC; 1999. with the statistical package SPSS for Windows.

For the qualitative component, based on data obtained in the quantitative stage, an intentional sample was determined2525. Patton MQ. Qualitative evaluation and research methods. 2nd ed. London: Sage; 1990. from six cities, whose selection was defined according to: geographic distribution in the State of São Paulo of the cities participating in the first stage; their sizes (< 100,000 residents and ≥ 100,000 residents); the existence of at least one HS that always filled out the compulsory notification form in cases of sexual violence, and at least one HS that filled it out with another frequency (most of the time, sometimes or never). Four large cities were selected (≥ 100,000 residents) and 2 small ones, with 2 HSs each.

Two researchers visited each selected HS to conduct semi-structured interviews with the coordinator or the person in charge of caring for women who suffer from sexual violence, as well as other professionals involved in this process. In total, 45 interviews were conducted. Most interviewees were female and had worked for years in the visited services; 31 were professionals who directly cared for the women (16 from the nursing field, 8 physicians, 4 social workers and 3 psychologists); 14 were administrators.

For the interviews, a script based on the results of the first stage of the study was used, aiming at further analyzing some aspects, especially those related to the difficulties to fill out the notification form. This script was composed of eight questions about the following topics: aspects of the process of emergency care addressed to women who suffer from sexual violence, awareness about the compulsory notification form for cases of sexual violence, how the form was filled out, difficulties found while filling the form out, and which process was adopted after the form was filled out. Institutions that reported not filling out the form or filling it out only sometimes were asked about the reasons for that reality.

Interviews lasted 20 minutes, in average; they were recorded and transcribed. The thematic analysis of the content was performed with the software NVivo. Researchers read2828. Minayo MCS. O desafio do conhecimento: Pesquisa qualitativa em saúde. 5ª ed. São Paulo: Hucitec-Abrasco; 1998. the transcribed texts to identify the significance units related to the objectives of the study and to the quantitative results. These units were grouped and classified in categories of analysis; after being articulated, they could respond to the proposed objectives2929. Ziebland S, McPherson A. Making sense of qualitative data analysis: an introduction with illustrations from DIPEx (personal experiences of health and illness). Med Educ 2006; 40(5): 405-14.. This article presents results related to the following categories of analysis: awareness about the compulsory notification form for cases of sexual violence, the process of filling it out, the difficulties found to fill it out, which procedure is used for the filled out forms and suggestions to improve the filling out conditions.

The protocol of this study was approved without restrictions by the Research Ethics Committee of the School of Medical Sciences at Universidade Estadual de Campinas, protocol n. 144/2009. The valid guidelines of Resolution n. 196/96 from the National Health Council (about studies involving human beings3030. Ministério da Saúde. Conselho Nacional de Saúde. Resolução nº 196/96 sobre pesquisa envolvendo seres humanos. Bioética 1996; 4: 15-25.) were respected in this study. The participation of subjects was voluntary and their identities were kept in secrecy. For the quantitative component, the first version of the informed consent form was read for each one of the possible interviews, and they were questioned about the decision regarding whether or not they would participate in the study; when the person decided to participate, this decision was recorded by telephone. For the qualitative stage, before the interview another informed consent form was provided so that the professional could read and sign it, in case of participating in the study.

RESULTS

Out of the 172 HSs that reported providing emergency care to women who suffered from sexual violence, 46.5% were hospitals, 23.3% were emergency rooms or UPAs, 16.9% were UBSs, 10.5% were outpatient clinics/SAEs, 1.7% were PSFs, and 1.2% were Women's Health reference centers. More than half (58.1%) of the participants in charge of caring for women who suffer from sexual violence were nurses, 19.2% were physicians, 10.5% were social workers, 4.7% were psychologists, and 7.6% reported having another job. Most (79.1%) of these 172 services claimed to always fill out the notification form, 12.8% mentioned filling it out most of the time, 5.2% reported filling it out sometimes, 1.2% claimed to never fill it out, and 1.7% did not inform it.

From the 167 HSs that notified cases of sexual violence, 95.2% reported being aware of the compulsoriness of the notification, except for one HS that did not respond.

Most of these 167 services that filled out the compulsory notification form with some frequency (except for one HS that did not answer) claimed that the sexual violence was notified to surveillance or information services from the Ministry of Health (65.7%), and 20.5% mentioned health administration parties.

Spontaneously, the most mentioned reasons for filling out the compulsory notification form in cases of sexual violence were compulsoriness (60.9%), and the acquisition of information or statistics (27.8%). Among the reasons for not filling out the form, the ones that were mostly mentioned reveal the lack of information from the respondent (8.3%) and the lack of preparation from professionals (6.5%) (data not shown in the table). In the HSs that filled out the notification form with some frequency in cases of sexual violence (n= 167), professionals who mostly did so were nurses (78.4%), followed by physicians (46.1%) and social workers (24.0%) (Table 1). The action of filling out the form being performed exclusively by nurses was reported by 51 HSs (30.5%), while this attitude from the physicians was registered in 14 HSs (8.4%). With regard to the difficulties faced while filling out the form, 57 HSs (34.1%) answered there were not any (data not shown in the table); among the 101 that indicated some difficulty, 53.5% claimed this difficulty was related to the women; 33.7% mentioned reasons related to the characteristics of the form, and 29.7% talked about reasons from the professionals who should fill it out (Table 1). Most respondents (86.2%) said that the notification form could bring some benefit to the women (data not shown in the table); out of these, almost half (48.6%) mentioned that the form can contain information or statistics, thus contributing with the implementation of Public Health programs (38.2%) (Table 1).

Table 1.
Characteristics of health services that filled out the notification form in cases of sexual violence always, most of the time or sometimes.

The following measures were cited as the most frequently used ones to guarantee the secrecy of the information in the notification form inside the HSs: care for the filing of information (67.1%); limited access to the form (65.2%); referral to other institutions/parties (60.9%).

In the qualitative stage, in all of the cities (four large and two small ones), at least one of the HSs reported always filling out the compulsory notification form. In a HS located in a small city, it was reported that whenever there was a case of sexual violence, the Epidemiological Surveillance of the city (which was inside another studied service) was activated to go to the HS and fill out the form, thus taking the necessary action to care for that case.

Most professionals who filled out the form were nurses. Some physicians who accepted to participate in the study were not aware of the existence of the compulsory notification form, nor about which professionals were in charge of filling it out.

With regard to the difficulties found to fill out the compulsory notification form, the most mentioned one referred to the size of the form ("long"; "extensive"; "too many details"; "too much information"). Another difficulty was the problem of obtaining information from the woman ("weakened"; "vulnerable"; "sometimes the woman does not declare she went through this type of violence"; "apprehension"; "fear"; "shame"). There was also the difficulty of the professional to obtain the information ("embarrassment"; "finding it hard to talk to the woman in such a delicate moment"; among others). The two last difficulties were sometimes related to the fact that there was not a room or a place in the HS where the woman and the professional could talk in private.

Almost all HSs that filled out the form stated they kept a copy of the notification in the institution, however, only a few employees, besides the person who filled it out, were aware of that. With regard to the procedures adopted for the filled out form, there was no consensus among the participants. Many of them reported sending it to Epidemiological Surveillance, but some sent it to other institutions, including police stations; many of them did not know what happened to the notification form.

The interviewed people gave suggestions to improve the conditions regarding the process of filling out the form in the services, such as: training for the professionals, raising awareness about the importance of the form, involving the professionals, reducing the amount of information in the form, improving women care, so that she would not have to repeat the same information. However, the most frequent suggestion was to perform periodical trainings for professionals in each HS, especially due to employee turnover.

DISCUSSION

The results presented here indicate that the action of filling out the compulsory notification form of sexual violence is still not totally incorporated to the routines of the HSs that care for these cases in the State of São Paulo. This becomes a matter of concern when we consider that the State of São Paulo was pioneer in Brazil with the establishment of services that provide care for women who suffer from sexual violence. Besides, it is important to consider that most services that participated in the study were hospitals or emergency rooms, which one could assume would be more familiar with the matter of notification.

Even though most interviewed people have manifested the opinion that filling out the form can bring benefits to women, only more than one quarter of the services reported the possibility of obtaining statistical data/information about the occurrences as a reason to do so. This reinforces the hypothesis that not all professionals are aware about the importance of notification as a management instrument to provide subsidies to public policies. With the notifications, it would be possible to map the occurrences and the characteristics of violence, which would lead to more effective interventions to prevent and fight such an aggression3131. Saliba O, Garbin CAS, Garbin AJI, Dossi AP. Responsabilidade do profissional de saúde sobre a notificação de casos de violência doméstica. Rev Saúde Pública 2007; 41(3): 472-7..

This situation may be related both to the education of health professionals and their ability to do their jobs in public health services. A study conducted with professors from medical and nursing schools3232. Souza ER, Ribeiro AP, Penna LHG, Ferreira AL, Santos NC, Tavares CMM. O tema violência intrafamiliar na concepção dos formadores dos profissionais de saúde. Ciênc Saúde Coletiva 2009; 14(5): 1709-19. showed that even though professors recognized violence as a health problem, they had difficulties including the theme in their classes. By analyzing the curriculum of these schools, it was possible to observe that the violence subject was demonstrated or shown by a correlative term in 23% of the medical disciplines, and in 16.3 of nursing classes. On the other hand, some studies with professionals from public health services have shown that they do not feel skilled enough to provide whole care to women who suffer from violence1515. Osis MJD, Duarte GA, Faúndes A. Violência entre usuárias de unidades de saúde: prevalência, perspectiva e conduta de gestores e profissionais. Rev Saúde Pública 2012; 46(2): 351-8.,3333. d'Oliveira AFPL, Schraiber LB, Hanada H, Durand J. Atenção integral à saúde de mulheres em situação de violência de gênero - uma alternativa para a atenção primária em saúde. Cienc Saúde Coletiva 2009; 14(4): 1037-50.,3434. Vieira EM, Perdona GCS, Almeida AM, Nakano MAS, Santos MA, Daltoso D, et al. Conhecimento e atitude dos profissionais de saúde em relação à violência de gênero. Rev Bras Epidemiol 2009; 12(4): 566-77., which can certainly compromise their understanding about the need for notification, including with regard to violence against children and adolescents3535. Gonçalves HS, Ferreira, AL. A notificação da violência intrafamiliar contra crianças e adolescentes por profissionais de saúde. Cad Saúde Pública 2002; 18(1): 315-9.. It is worth to remember that the need for periodical courses for this type of assistance is emphasized by the Ministry of Health3636. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Área Técnica de Saúde da Mulher. Prevenção e tratamento dos agravos resultantes da violência sexual contra mulheres e adolescentes. Série A - Normas e Manuais Técnicos, Série Direitos Sexuais e Direitos Reprodutivos, Caderno n° 6. 3ª ed. Brasília: Ministério da Saúde; 2011., which was strongly suggested by the participants in this study. However, it is also important to consider that this difficulty to fill out the notification of violence cases can imply certain resistance from professionals to treat this matter as a Public Health issue, instead of a police problem.

It is also important to consider that the organization of work in the HSs may present workload issues for some professionals, and the requirement of filling out one more form can be considered to be excessive, especially when the importance and the reason of this requirement is not understood. Both stages of this study showed that, in most cases, nursing professionals were in charge of filling out the notification form. This is in accordance with the work model that is usually observed in the services, in which nursing professionals are usually in charge of filling out several forms; therefore, they add this chore to the work of care per se . Especially in emergency services, this can represent a major difficulty to be overcome, and an attitude that can even result in the act of not filling out the form, or filling it out incompletely. Besides being clearly indicated in the quantitative approach, this behavior was more explicit in the qualitative approach, when people referred to the length of the form and the time used to fill it out.

Another aspect that was shown in both stages of this study was the reference of interviewees about the difficulty to obtain the necessary information for the notification of women who suffered from sexual violence. This fact has been observed in other studies, not only with regard to sexual violence, but also to other types of violence suffered by women1515. Osis MJD, Duarte GA, Faúndes A. Violência entre usuárias de unidades de saúde: prevalência, perspectiva e conduta de gestores e profissionais. Rev Saúde Pública 2012; 46(2): 351-8.,3737. Schraiber LB, d'Oliveira AFPL. Violence against women and Brazilian health care policies: a proposal for integrated care in primary care services. Int J Gynecol Obstet 2002; 78(Suppl. 1): S21-5.,3838. Schraiber LB, d'Oliveira AFPL, França-Júnior I, Pinho AA. Violência contra a mulher: estudo em uma unidade de atenção primária à saúde. Rev Saúde Pública 2002; 36(4): 470-7.. It is important to consider that the woman who suffers from sexual violence arrives in the HS in shock, and often wishing to hide and talk as little as possible. Therefore, health professionals must know how to take in the woman who has been assaulted, giving her space to complain and obtain all of the necessary information accurately, so as to avoid the need for her to repeat the story, which is certainly painful1919. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Área Técnica de Saúde da Mulher. Atenção integral para mulheres e adolescentes em situação de violência doméstica e sexual - Matriz pedagógica para formação de redes. Série B - Textos Básicos de Saúde. Brasília: Ministério da Saúde; 2011.. It is worth to mention that the notification form does not need to be filled out immediately, as soon as the woman arrives, which is when she is emotionally more fragile. If the information in the medical record is properly filled out by all of the health professionals who care for the woman, it will be an important complementary source to fill out the form afterwards.

It is also important to mention that the act of taking in women who suffer from violence, from some of the professionals in emergency services, also depends on the perspective of these professionals regarding the meaning of violence against women and the impact that such violence can have on themselves, who may as well have experienced or be experiencing similar situations1111. Oliveira EM, Barbosa RM, Moura AAVM, Kossel K, Morelli K, Botelho LFF, et al. Atendimento às mulheres vítimas de violência sexual: um estudo qualitativo. Rev Saúde Pública 2005; 39(3): 376-82.,3939. Reis MJ, Lopes MHBM, Higa R, Turato ER, Chvatal VLS, Bedone AJ. Vivências de enfermeiros na assistência à mulher que sofre violência sexual. Rev Saúde Pública 2010; 44(2): 325-31..

The main limitations of this study involve the fact that this is not a probability sample, initially based on a previous study conducted between 2005-2006 in HSs that reported providing emergency care for women who suffered from sexual violence1313. Faúndes A, Hardy E, Osis MJD, Makuch MY, Duarte GA, Andalaft Neto J. Perfil do atendimento à violência sexual no Brasil. Relatório técnico apresentado ao Ministério da Saúde. Campinas: CEMICAMP; 2006., including other services indicated by the former. Therefore, the results cannot be generalized for the State of São Paulo. Besides, another limitation refers to the fact that it is not possible to verify how well the services fill out the form. So, it is not possible to state if the HSs that reported always filling out the notification form did so completely and properly. It is worth to remember that, in the qualitative stage, the interviewed people emphasized that the extension of the form and the need to include many details about the violence suffered by the woman were seen as difficulties.

Despite the aforementioned limitations, the results make it clear that the compulsory act of filling out the notification form for cases of sexual violence against women still needs to be elaborated with the HSs, both so that professionals know how to do it and so they can understand its importance as part of the effort that the whole society should keep making in order to reduce violence against women. Therefore, it is important to consider that, in order for such an understanding to occur, professionals need to realize the utility of the collected information in terms of their daily practice; otherwise, the notification form tends to be progressively seen as a useless requirement in terms of improving the care provided to women who suffer from sexual violence.

CONCLUSION

Even though most HSs reported filling out the compulsory notification form, they also mentioned having several difficulties to do so, especially with regard to the workload of professionals and to the lack of understanding about the importance of this notification in the context of whole care to women who suffer from sexual violence. It is possible to see the need for strategies that improve the education of professionals, so that they can incorporate the notification form as part of care provided to women, as well as the due valorization of this care among the several attributions of the HSs.

ACKNOWLEDGEMENTS

The authors would like to thank the São Paulo Research Foundation (FAPESP), for completely financing this study (process n. 2010/50345-6).

REFERÊNCIAS

  • 1
    Heise L. Gender-based abuse: The global epidemic. Cad Saúde Pública 1994; 10 (Suppl 1): 135-45.
  • 2
    Heise L, Pitanguy J, German A. Violence against women: the hidden health burden. Washington: The International Bank for Reconstruction and Development/The World Bank; 1994.
  • 3
    Garcia-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts CH; WHO Multi-country Study on Women's Health and Domestic Violence against Women Study Team. Prevalence of intimate partner violence: findings from the WHO multi-country study on women's health and domestic violence. Lancet 2006; 368(9543): 1260-9.
  • 4
    Basile KC, Smith SG. Sexual violence victimization of women: prevalence, characteristics, and the role of public health. A J Lifestyle Med 2011; 5: 407-17.
  • 5
    Guedes A, García-Moreno C, Bott S. Violencia contra las mujeres en Latinoamérica y el Caribe. Foreign Affairs Latinoamérica 2014; 14 (1): 41-8. Disponível em: www.fal.itam.mx3. (Acessado em 27 de maio de 2014).
    » www.fal.itam.mx3
  • 6
    Facuri CO, Fernandes AMS, Oliveira KD, Andrade TS, Azevedo RCS. Violência sexual: estudo descritivo sobre as vítimas e o atendimento em um serviço universitário de referência no Estado de São Paulo, Brasil. Cad Saúde Pública 2013; 29(5): 889-98.
  • 7
    Faúndes A, Hardy E, Osis MJD, Duarte GA. Risco para queixas ginecológicas e disfunções sexuais segundo história de violência sexual. Rev Bras Ginecol Obstet 2000; 22(3): 153-7.
  • 8
    Reichenheim ME, Moraes CL, Szklo A, Hasselmann MH, Souza ER, Lozana JA, et al. The magnitude of intimate partner violence in Brazil: portraits from 15 capital cities and the Federal District. Cad Saúde Pública 2006; 22(2): 425-37.
  • 9
    Schraiber LB, d'Oliveira AFPL, França-Júnior I, Diniz S, Portella AP, Ludermir AB, et al. Prevalência da violência contra a mulher por parceiro íntimo em regiões do Brasil. Rev Saúde Pública 2007; 41(5): 797-807.
  • 10
    Abrahams N, Devries K, Watts C, Pallitto C, Petzold M, Shamu S, et al. Worldwide prevalence of non-partner sexual violence: a systematic review. Lancet 2014; 383(9929): 1648-54.
  • 11
    Oliveira EM, Barbosa RM, Moura AAVM, Kossel K, Morelli K, Botelho LFF, et al. Atendimento às mulheres vítimas de violência sexual: um estudo qualitativo. Rev Saúde Pública 2005; 39(3): 376-82.
  • 12
    Bruschi A, Paula CS, Bordin IAS. Prevalência e procura de ajuda na violência conjugal física ao longo da vida. Rev Saúde Pública 2006; 40(2): 256-64.
  • 13
    Faúndes A, Hardy E, Osis MJD, Makuch MY, Duarte GA, Andalaft Neto J. Perfil do atendimento à violência sexual no Brasil. Relatório técnico apresentado ao Ministério da Saúde. Campinas: CEMICAMP; 2006.
  • 14
    Villela W, Lago T. Conquistas e desafios no atendimento às mulheres que sofreram violência sexual. Cad Saúde Pública 2007; 23(2): 471-5.
  • 15
    Osis MJD, Duarte GA, Faúndes A. Violência entre usuárias de unidades de saúde: prevalência, perspectiva e conduta de gestores e profissionais. Rev Saúde Pública 2012; 46(2): 351-8.
  • 16
    Ministério da Saúde. Guia Prático do Programa da Saúde da Família. Brasília: Ministério da Saúde; 2001.
  • 17
    Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Área Técnica de saúde da Mulher. Política Nacional de Atenção Integral à Saúde da Mulher. Brasília: Ministério da Saúde; 2004.
  • 18
    Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de análise de Situação de Saúde. Instrutivo Notificação de violência doméstica, sexual e outras violências. Série G - Estatística e Informação em Saúde. Brasília: Ministério da Saúde. Disponível em: http://portal.saude.gov.br/portal/arquivos/pdf/viva_instrutivo_not_viol_domestica_sexual_e_out.pdf. (Acessado em 24 de janeiro de 2013).
    » http://portal.saude.gov.br/portal/arquivos/pdf/viva_instrutivo_not_viol_domestica_sexual_e_out.pdf
  • 19
    Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Área Técnica de Saúde da Mulher. Atenção integral para mulheres e adolescentes em situação de violência doméstica e sexual - Matriz pedagógica para formação de redes. Série B - Textos Básicos de Saúde. Brasília: Ministério da Saúde; 2011.
  • 20
    Andalaft Neto J, Faúndes A, Osis MJD, Pádua KS. Perfil do atendimento à violência sexual no Brasil. Femina 2012; 40(6): 301-6.
  • 21
    Brasil. Lei no 10.778, de 24 de novembro de 2003. Estabelece a notificação compulsória, no território nacional, de caso de violência contra a mulher que for atendida em serviços de saúde públicos ou privados. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/2003/l10.778.htm. (Acessado em 28 de agosto de 2008).
    » http://www.planalto.gov.br/ccivil_03/leis/2003/l10.778.htm
  • 22
    Brasil. Decreto no 5.099, de 3 de junho de 2004. Regulamenta a Lei no. 10.778, de 24 de novembro de 2003, e institui os serviços de referência sentinela. Disponível em: http://www.planalto.gov.br/ccivil_03/_ato2004-2006/2004/decreto/d5099.htm. (Acessado em 28 de agosto de 2008).
    » http://www.planalto.gov.br/ccivil_03/_ato2004-2006/2004/decreto/d5099.htm
  • 23
    Brasil. Portaria no 104, de 25 de janeiro de 2011. Define as terminologias adotadas em legislação nacional, conforme o disposto no Regulamento Sanitário Internacional 2005 (RSI 2005), a relação de doenças, agravos e eventos em saúde pública de notificação compulsória em todo o território nacional e estabelece fluxo, critérios, responsabilidades e atribuições aos profissionais e serviços de saúde. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt0104_25_01_2011.html. (Acessado em 8 de maio de 2014).
    » http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt0104_25_01_2011.html
  • 24
    Gomm R, Hammersley M, Foster P, eds. Case study methods. Thousand Oaks: Sage Publications; 2000.
  • 25
    Patton MQ. Qualitative evaluation and research methods. 2nd ed. London: Sage; 1990.
  • 26
    Kish L. Survey sampling. New York: John Wiley and Sons; 1965.
  • 27
    Altman DG. Practical statistics for medical research. Boca Raton: Champman & Hall/CRC; 1999.
  • 28
    Minayo MCS. O desafio do conhecimento: Pesquisa qualitativa em saúde. 5ª ed. São Paulo: Hucitec-Abrasco; 1998.
  • 29
    Ziebland S, McPherson A. Making sense of qualitative data analysis: an introduction with illustrations from DIPEx (personal experiences of health and illness). Med Educ 2006; 40(5): 405-14.
  • 30
    Ministério da Saúde. Conselho Nacional de Saúde. Resolução nº 196/96 sobre pesquisa envolvendo seres humanos. Bioética 1996; 4: 15-25.
  • 31
    Saliba O, Garbin CAS, Garbin AJI, Dossi AP. Responsabilidade do profissional de saúde sobre a notificação de casos de violência doméstica. Rev Saúde Pública 2007; 41(3): 472-7.
  • 32
    Souza ER, Ribeiro AP, Penna LHG, Ferreira AL, Santos NC, Tavares CMM. O tema violência intrafamiliar na concepção dos formadores dos profissionais de saúde. Ciênc Saúde Coletiva 2009; 14(5): 1709-19.
  • 33
    d'Oliveira AFPL, Schraiber LB, Hanada H, Durand J. Atenção integral à saúde de mulheres em situação de violência de gênero - uma alternativa para a atenção primária em saúde. Cienc Saúde Coletiva 2009; 14(4): 1037-50.
  • 34
    Vieira EM, Perdona GCS, Almeida AM, Nakano MAS, Santos MA, Daltoso D, et al. Conhecimento e atitude dos profissionais de saúde em relação à violência de gênero. Rev Bras Epidemiol 2009; 12(4): 566-77.
  • 35
    Gonçalves HS, Ferreira, AL. A notificação da violência intrafamiliar contra crianças e adolescentes por profissionais de saúde. Cad Saúde Pública 2002; 18(1): 315-9.
  • 36
    Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Área Técnica de Saúde da Mulher. Prevenção e tratamento dos agravos resultantes da violência sexual contra mulheres e adolescentes. Série A - Normas e Manuais Técnicos, Série Direitos Sexuais e Direitos Reprodutivos, Caderno n° 6. 3ª ed. Brasília: Ministério da Saúde; 2011.
  • 37
    Schraiber LB, d'Oliveira AFPL. Violence against women and Brazilian health care policies: a proposal for integrated care in primary care services. Int J Gynecol Obstet 2002; 78(Suppl. 1): S21-5.
  • 38
    Schraiber LB, d'Oliveira AFPL, França-Júnior I, Pinho AA. Violência contra a mulher: estudo em uma unidade de atenção primária à saúde. Rev Saúde Pública 2002; 36(4): 470-7.
  • 39
    Reis MJ, Lopes MHBM, Higa R, Turato ER, Chvatal VLS, Bedone AJ. Vivências de enfermeiros na assistência à mulher que sofre violência sexual. Rev Saúde Pública 2010; 44(2): 325-31.
  • Financing source: São Paulo Research Foundation (FAPESP) (process n. 2010/50345-6).
  • a
    Establishes a compulsory reporting, in the national territory, of the cases of violence against women that are attended in the public or private health services21.
  • b
    Regulates the Law 10,778, of November 24, 2003, and establish referral services sentinel22.
  • c
    Defines the terminology adopted in national legislation, according to International Health Regulations 2005 (RSI 2005), the list of diseases, injuries and events in public health, of compulsory notification throughout the national territory and establish flow, criteria, responsibilities and duties to professionals and health services23.

Publication Dates

  • Publication in this collection
    Mar 2015

History

  • Received
    16 Sept 2013
  • Reviewed
    03 June 2014
  • Accepted
    08 Aug 2014
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