Nicole Geovana Dias Carneiro
Social Support and Intimate Partner
Violence in Europe:
Looking at individual and community
influences
Porto | 2019
Tese de Doutoramento em Saúde Pública apresentada à Faculdade de Medicina da Universidade do Porto
ii
Art.º 48º, § 3º - “A Faculdade não responde pelas doutrinas expendidas na dissertação.” (Regulamento da Faculdade de Medicina da Universidade do Porto – Decreto-Lei nº 19337 de 29 de Janeiro de 1931).
iii
Corpo Catedrático da Faculdade de Medicina do Porto
Professores Catedráticos Efetivos
Doutora Maria Amélia Duarte Ferreira Doutor José Agostinho Marques Lopes
Doutor Patrício Manuel Vieira Araújo Soares Silva Doutor Alberto Manuel Barros da Silva
Doutor José Henrique Dias Pinto de Barros
Doutora Maria Fátima Machado Henriques Carneiro Doutora Maria Dulce Cordeiro Madeira
Doutor Altamiro Manuel Rodrigues Costa Pereira Doutor Manuel Jesus Falcão Pestana Vasconcelos
Doutor João Francisco Montenegro Andrade Lima Bernardes Doutora Maria Leonor Martins Soares David
Doutor Rui Manuel Lopes Nunes
Doutor José Eduardo Torres Eckenroth Guimarães Doutor Francisco Fernando Rocha Gonçalves Doutor José Manuel Pereira Dias de Castro Lopes
Doutor António Albino Coelho Marques Abrantes Teixeira Doutor Joaquim Adelino Correia Ferreira Leite Moreira Doutora Raquel Ângela Silva Soares Lino Doutor Rui Manuel Bento de Almeida Coelho
iv Professores Jubilados ou Aposentados
Doutor Alexandre Alberto Guerra Sousa Pinto Doutor Álvaro Jerónimo Leal Machado de Aguiar Doutor António Augusto Lopes Vaz
Doutor António Carlos de Freitas Ribeiro Saraiva Doutor António Carvalho Almeida Coimbra
Doutor António Fernandes Oliveira Barbosa Ribeiro Braga Doutor António José Pacheco Palha
Doutor António Manuel Sampaio de Araújo Teixeira Doutor Belmiro dos Santos Patrício
Doutor Cândido Alves Hipólito Reis
Doutor Carlos Rodrigo Magalhães Ramalhão Doutor Cassiano Pena de Abreu e Lima
Doutor Deolinda Maria Valente Alves Lima Teixeira Doutor Eduardo Jorge Cunha Rodrigues Pereira Doutor Fernando Tavarela Veloso
Doutor Henrique José Ferreira Gonçalves Lecour de Menezes Doutor Jorge Manuel Mergulhão Castro Tavares
Doutor José Carlos Neves da Cunha Areias Doutor José Carvalho de Oliveira
Doutor José Fernando Barros Castro Correia Doutor José Luís Medina Vieira
Doutor José Manuel Costa Mesquita Guimarães Doutor Levi Eugénio Ribeiro Guerra
Doutor Luís Alberto Martins Gomes de Almeida Doutor Manuel Alberto Coimbra Sobrinho Simões Doutor Manuel António Caldeira Pais Clemente Doutor Manuel Augusto Cardoso de Oliveira Doutor Manuel Machado Rodrigues Gomes Doutor Manuel Maria Paula Barbosa
Doutora Maria da Conceição Fernandes Marques Magalhães Doutora Maria Isabel Amorim de Azevedo
v Doutor Ovídio António Pereira da Costa Doutor Rui Manuel Almeida Mota Cardoso Doutor Serafim Correia Pinto Guimarães
Doutor Valdemar Miguel Botelho dos Santos Cardoso Doutor Walter Friedrich Alfred Osswald
vi
Ao abrigo do Art.º 8º do Decreto-Lei n.º 388/70, fazem parte desta dissertação as seguintes publicações:
Dias NG, Fraga S, Soares J, Hatzidimitriadou E, Ioannidi-Kapolou E, Lindert J, Sundin Ö, Toth O, Barros H, Ribeiro AI. Contextual determinants of Intimate Partner Violence: a multi-level analysis in six European cities. [Under review]
Dias NG, Costa D, Soares J, Hatzidimitriadou E, Ioannidi-Kapolou E, Lindert J, Sundin Ö, Toth O, Barros H, Fraga S. Social support and the intimate partner violence victimization among adults from six European countries. Family Practice 2019; 36(2): 117-124. doi.org/10.1093/fampra/cmy042
Dias NG, Ribeiro AI, Henriques A, Soares J, Hatzidimitriadou E, Ioannidi-Kapolou E, Lindert J, Sundin Ö, Toth O, Barros H, Fraga S. Intimate partner violence and primary care and emergency use: the role of informal social support. Health & Social Work. [Accepted 2 June 2019]
Em todos os artigos colaborei na definição e operacionalização das hipóteses em estudo e dos objetivos a responder em cada um deles, bem como na análise e interpretação dos dados que reportam. Fui responsável pela redação da versão inicial de todos os manuscritos de que sou primeira autora e colaborei ativamente na preparação das suas versões finais.
vii
Esta tese foi realizada no Departamento de Ciências da Saúde Pública e Forenses, e Educação Médica da Faculdade de Medicina da Universidade do Porto e no Instituto de Saúde Pública da Universidade do Porto, sob orientação da Doutora Silvia Fraga e da Doutora Ana Isabel Ribeiro.
Enquanto pesquisadora não recebi nenhum tipo de financiamento específico como bolsa e afins para realização desse doutoramento. No entanto, essa tese foi desenvolvida na Unidade de Investigação em Epidemiologia—Instituto de Saúde Pública da Universidade do Porto (EPIUnit) (POCI-01-0145-FEDER-006862; Ref. UID/DTP/04750/2013), além disso, o estudo Domestic violence against women/men in Europe: Prevalence, determinants, effects and policies/practices (DOVE) foi financiado pela Comissão Europeia com o número de contrato 20081310.
viii
Júri da prova de doutoramento
Doutor José Henrique Dias Pinto de Barros Faculdade de Medicina da Universidade do Porto Instituto de Saúde Pública da Universidade do Porto
Doutora Carmen Vives-Cases
Instituto Universitario de Investigación de Estudios de Género (IUIEG) Universidad de Alicante – España
Doutora Dália Costa
Centro Interdisciplinar de Estudos de Género (CIEG) Instituto Superior de Ciências Sociais e Políticas - Lisboa
Doutora Carla Maria de Moura Lopes Faculdade de Medicina da Universidade do Porto Instituto de Saúde Pública da Universidade do Porto
Doutora Maria Isabel Correia Dias Faculdade de Letras da Universidade do Porto
Doutora Susana Silva
Faculdade de Medicina da Universidade do Porto Instituto de Saúde Pública da Universidade do Porto
Doutora Silvia Jesus Silva Fraga
Faculdade de Medicina da Universidade do Porto Instituto de Saúde Pública da Universidade do Porto
ix
Agradecimentos
Nessa trajetória de motivação para realizar o Doutoramento, vários fatores e acontecimentos colaboraram com minha decisão em seguir esse caminho e selecionar tal temática. Durante diversos momentos de vida prévios à universidade me deparei com injustiças sociais que me motivaram a escolher um lado de luta nessa sociedade: estar junto das pessoas oprimidas. Ter uma mãe que trabalha com saúde na comunidade e que pratica os ensinamentos do mestre Paulo Freire sem dúvida foi uma grande motivação para abrir meus olhos e ativar minhas escolhas. Desde o início da vida universitária (na Faculdade de Medicina da Universidade Federal de Uberlândia – UFU) pude participar do movimento estudantil, debates, fóruns sociais e projetos de extensão que me permitiram entender a importância da inserção comunitária nas práticas universitárias. Quando no início dos meus atendimentos enquanto médica residente de Medicina de Família e Comunidade na Universidade Federal de Pernambuco - UFPE, pude perceber que muitas mulheres não relatavam sobre suas situações de violência que vivenciavam no ambiente de suas casas. Sofriam em silêncio e muitas vezes procuravam os serviços de saúde em busca de um momento de atenção e ajuda. Aos poucos, fui também percebendo que certas queixas ocultas na verdade estavam carregadas de uma longa história de violência na intimidade. Identificar a importância de uma escuta não julgadora e pró-ativa me permitiu adentrar em vidas de sofrimento e aprender diante muitas adversidades. A busca de um aprofundamento acadêmico que pudesse ofertar ao mundo científico mais elementos para a compreensão de um fenômeno transversal me fez caminhar até a finalização dessa Tese.
Diante de todo esse percurso, agradeço singelamente às pessoas marcantes para a concretização do presente trabalho.
À Silvia Fraga pela oferta e oportunidade em trabalhar com o estudo DOVE e pelo aceite em ser minha orientadora.
À Ana Isabel Ribeiro pelas opiniões sensatas, pelo incentivo cotidiano na reta final e pelo otimismo motivador. Sua perspicácia enquanto cientista e investigadora em saúde pública é uma enorme motivação.
Ao Professor Doutor Henrique Barros por me acolher no ISPUP e pela orientação no primeiro ano de doutoramento. Sua inteligência, visão ampliada de saúde pública, atitude em acolher investigadores estrangeiros e habilidade em se relacionar construindo redes internacionais foi e continua
x sendo um grande incentivo para mim.
A todos os coautores dos artigos que integram esta tese, pelos contributos construtivos.
A todos os participantes do estudo DOVE que se predispuseram a ofertar informações sobre suas vidas.
À Ana Henriques e à Professora Doutora Maria Isabel Dias pela gentileza em opinarem no meu trabalho na altura da reunião entrevista e em ofertarem valiosas contribuições para a melhoria do mesmo.
Aos funcionários do ISPUP, em especial ao seu Luciano que nos presenteia com o seu sorriso no rosto ao entrarmos no instituto e com seu bom humor ao sairmos. À Joana Ferreira e Inês Cipriano por serem sempre prestativas e atenciosas, acolhendo com atenção minhas demandas.
Às minhas amigas de doutoramento, obrigada por compartilharem comigo as angústias e desafios principalmente (e não só) do primeiro ano do doutoramento. Olena, muito obrigada pelo incentivo em seguir em frente e superar os muitos obstáculos da vida de doutoranda. Obrigada por me acalmar e me ensinar muitos passos estatísticos em momentos de desespero. À Adriana, obrigada pelos momentos de pausas, cafés e almoços no ISPUP, o que me permitiu uma sanidade mental mínima para suportar um ambiente por vezes hostil e não acolhedor. À Emília agradeço os aprendizados na trajetória que percorremos como estudantes e migrantes.
À Elisa, obrigada por me permitir aventurar nas desaventuras internas do meu ser e possibilitar descobertas e reestruturações possíveis e capazes de me fortalecer e chegar ao término dessa etapa de vida.
À Sara Leão, pela cumplicidade na partilha dos sonhos, dos pesadelos, dos planos de vida, das interpretações astrológicas e por ser companheira permanente de marcha. Obrigada pela acolhida e pela partilha na construção do movimento feminista do Porto. Seguiremos em marcha até que todas sejamos livres!
À Conceição pelo acolhimento no seio de sua casa, pela partilha dos momentos prazerosos e divertidos nos preparos da nossa alimentação.
xi
À Anita e Inês que compartilharam momentos de alegria, angústias, insatisfações e comemorações. Obrigada por me acolherem em sua família e por segurarem minhas mãos como irmãs. Os passeios pelo Porto regados a valiosas e inquietantes conversas tornaram minha vida por aqui muito mais agradável.
À Aida pelos mimos, partilhas de revoltas, raivas, esperanças e motivações. Por radiar ao mundo a potencialidade de uma mulher incrível capaz de alterar a trajetória de outras mulheres e, por que não, de uma cidade/país/mundo. Obrigada por concretizar na cidade do Porto a Confraria Vermelha, um espaço de trocas, encontros, reencontros e propulsão da revolução feminista. Pela sua animosidade e por ser a concretização em si do significado de sororidade.
Às muitas outras mulheres que partilharam do meu percurso durante a minha vivência feminista no Porto: Ana Afonso, Margarida, Isabeli, Helena Ferreira, Diana Fontão, Diana Costa, Alícia, Aline, Mar, Patrícia Martins. Obrigada por me permitir criar uma rede de amigas lutadoras feministas.
À Paizinha e Jaque (3 Lucías) pela amizade nascida em nossa revolucionária Cuba e pelos ensinamentos carinhosos que precisamos para viver a vida sin perder la ternura jamás! Hasta siempre compañeras!
À Natalia pelo partilhar das escolhas de vida e profissão e por sempre mostrar-se companheira mesmo diante das nossas divergentes frequências emocionais.
À Alba pelo carinho de sempre, pelo colo amigo e pela presença na minha vida. Obrigada pelos ensinamentos de bondade e serenidade.
À Universidade Federal de Uberlândia – UFU por me permitir aventurar na nova profissão de docente. Lutar pela garantia da universidade pública, gratuita e de qualidade segue sendo uma responsabilidade árdua e desafiante em tempos de intensos desmontes e ameaças.
À Maria Cristina por compartilhar a vida comigo em todas suas interfaces: derrotas, conquistas, desafios, angústias, tristezas, decepções, comemorações, alegrias, descobertas e superações (e todas as outras facetas que não cabem em palavras deixo para os sentimentos que vivemos juntas). Por praticar a amizade presente e permanente e por me ensinar que a longevidade de uma relação de amizade é garantida com a permanência cotidiana na vida da pessoa, superando os desafios da distância e
xii
marcando presença sempre que possível na vida uma da outra. Obrigada por fazer confiar em mim mesma, por sempre me apoiar e por me impulsionar nas diversas trajetórias da minha vida.
A todas as mulheres da minha família que como as outras sustentam em suas vidas o peso amargo desse sistema patriarcal, machista e racista com muita garra, sabedoria e ancestralidade.
À minha avó Maria Júlia (in memoriam) que me presenteou com o seu cuidado em muitos momentos da minha vida.
À minha mãe Renilda por ter me dado a vida e ter me permitido enfrentar as cruezas desse mundo. Obrigada por sempre me apoiar em todas as minhas escolhas, por sempre me amar e por sempre estar presente. Toda a gratidão desse mundo não seria suficiente para retribuir a imensidão desse amor. Te amo muito!
À Laura Geovanna, irmã que me ensina desde sempre a importância do respeito e o significado do amor incondicional. Obrigada por me oferecer carinho, aconchego e por me motivar na luta por um mundo melhor.
Ao Félix, companheiro cotidiano dessa jornada e que compartilhou seu amor para que meus dias fossem mais ensolarados e felizes. Obrigada pelos desafios que aceitamos juntos compartilhar e pelas batalhas em concretizar uma rotina prazerosa de combate permanente aos avanços da cultura machista.
A todas as mulheres que sobrevivem e vivem nesse sistema patriarcal, capitalista e injusto marcado pela submissão e pela opressão machista. Que tenhamos a inteligência suficiente para subverter o sistema e revolucionar a forma de viver um bem comum.
xiii
Companheira me ajude Eu não quero andar só Eu sozinha eu ando bem Mas com você Ando melhor
xiv
Table of contents
1. INTRODUCTION ... 9
1.1 PUBLIC HEALTH APPROACH TO VIOLENCE ... 12
1.2 INTIMATE PARTNER VIOLENCE ... 16
1.2.1 Definition and prevalence ... 16
1.2.2 Health consequences of intimate partner violence ... 18
1.2.3 Intimate Partner Violence and Healthcare ... 20
1.2.4 Determinants of intimate partner violence ... 21
1.3 SOCIAL SUPPORT ... 26
1.3.1 Social Support, Intimate Partner Violence and Healthcare ... 28
2. OBJECTIVES ... 31
3. METHODS ... 35
3.1 THE DOVE STUDY ... 38
3.1.1 Sampling Procedures ... 38
3.1.2 Participants and data collection ... 41
3.1.3 DOVE questionnaire ... 42
3.1.4 Ecological variables ... 43
3.1.5 Ethics ... 45
4. RESULTS... 47
4.1 PAPER I. CONTEXTUAL DETERMINANTS OF INTIMATE PARTNER VIOLENCE: A MULTI-LEVEL ANALYSIS IN SIX EUROPEAN CITIES. ... 49
4.2 PAPER II. SOCIAL SUPPORT AND THE INTIMATE PARTNER VIOLENCE VICTIMIZATION AMONG ADULTS FROM SIX EUROPEAN COUNTRIES ... 72
4.3 PAPER III. INTIMATE PARTNER VIOLENCE AND PRIMARY CARE AND EMERGENCY USE: THE ROLE OF INFORMAL SOCIAL SUPPORT ... 82
5. GENERAL DISCUSSION ... 104
6. CONCLUSION ... 119
7. REFERENCES ... 125
xv
List of Figures
Figure 1. Global and Regional Estimates of Intimate Partner Violence. World Health Organization, 2013 (31)... 17 Figure 2. Percentage of physical and/or sexual partner violence since the age of 15, European Union - 28. Fundamental Rights Agency, 2014 (32). ... 18 Figure 3. Adverse Health Outcomes of Intimate Partner Violence. Global and Regional estimates of Intimate Partner Violence. World Health Organization, 2013 (31)... 19 Figure 4. The Socio-ecological Model (adapted from Our Watch et al, 2015) (75). ... 22 Figure 5. Samplig strategies and sample size – DOVE study. ... 39
List of Table
xvi
Abbreviations
BMI Body Mass Index
CI Confidence Interval
CTS2 Revised Conflict Tactics Scales DALY Disability-Adjusted Life Year
DOVE Domestic Violence against women/men in Europe – prevalence, determinants, effects and policies/practices
EIGE European Institute for Gender Equality
EU European Union
EU 28 European Union (28 countries) EUROSTAT European Statistical Office
ESS European Social Survey
GINI Coefficient of the income distribution
GDP Gross Domestic Product
HIV/AIDS Human Immuno-Deficiency Virus/Acquired Immuno-Deficiency Syndrome IPV Intimate Partner Violence
MOR Median Odds Ratio
MSPSS Multidimensional Scale of Perceived Social Support
SF-36 Medical-Outcomes-Study 36 Items Short-Form Health Survey
SS Social Support
STI Sexually Transmitted Infection
Abstract | 1
Abstract
Social Support and Intimate Partner Violence in Europe: looking at individual and community influences
Intimate Partner Violence is a pervasive social issue that involves a multifaceted system of behaviours by a current or former intimate partner. It includes psychological aggression, physical assault, sexual coercion, controlling behaviours and/or financial abuse. Intimate partner violence crosses all socio-economic groups, ages and cultures.
Globally, approximately 30 percent of women aged 15 and over have experienced physical or sexual violence from an intimate partner during their lifetime. In the European Union - 28, prevalence rates ranged from 13 to 32 percent. Health consequences of intimate partner violence are notable by their direct effects but also by their indirect and long-term impacts that can persist long after the abusive relationship has ended.
Social support, from friends and family, seems to play a relevant role in mitigating the impact of intimate partner violence on the physical and mental health of victims. Social support has been shown to prompt people to make a firm decision to leave an abusive relationship and to break through the isolation and dependency on the perpetrators. Feeling the support from friends, family and others may improve self-efficacy, enhancing the ability to comprehend the environment of violence and to seek adequate help.
Following a public health perspective we performed three studies aiming to investigate the community and individual influence of social support in the context of intimate partner violence. We hypothesize that macro and individual measures social support should influence the disclosure of intimate partner violence victimization, and it should also influence healthcare seeking among the victims.
To accomplish this objective, we used data gathered in the scope of an European study. The DOVE study targeted women and men from the general population aged
18-64 years living in Athens-Greece, Budapest-Hungary, Stuttgart-Germany, Östersund-Sweden, London-United Kingdom and Porto-Portugal. The assessment tool covered information on socio-demographics, lifestyle factors, presence of chronic conditions, past year healthcare use, health-related quality of life, social support and intimate partner violence. Standardized scales included available nationally validated versions of the Multidimensional Scale of Perceived Social Support and the Revised Conflict Tactics Scales. Data collection was carried out between September 2010 and May 2011 after ethical approval in each country.
In the following paragraphs, we present a brief description of the objectives and results of each study performed.
Study I
We aimed to assess whether country- and city-level characteristics, namely socioeconomic circumstances, gender and income inequality, as well as levels of social support, influence the victimization accross six European cities. We looked at contextual determinants that could offer clues about the influence of social support at societal level. Several contextual variables were included: Gini coefficient, gender equality index, an index of social support, unemployment rate and proportion of residents with tertiary education. Multilevel models were fitted to estimate the associations (Odds ratio, 95% Confidence Intervals) between each type of victimization and contextual and individual-level variables. Results showed that 62.3% of the participants reported being a victim of intimate partner violence during the previous year, with large between-city differences (53.9%-72.4%). Contextual variables accounted for a substantial amount of this heterogeneity. Unemployment rates were associated with psychological (1.05, 1.01-1.08) and physical intimate partner violence (1.07, 1.01-1.13). Gini coefficient showed a positive association with any form of intimate partner violence (1.06, 1.01-1.11) and sexual coercion (1.13, 1.01-1.25). We found no association between contextual-level social support, calculated at a country-level, and intimate partner violence victimization.
Abstract | 3 Study II
We explore the association between social support and intimate partner violence victimization among adults from six European countries. We looked at each individual’s factors that could explain the association between social support and intimate partner violence. Results showed that higher levels of social support were associated with lower intimate partner violence victimization. Differences in social support were detected regarding the city of residence, and also higher levels of social support were detected among those who were women, younger, married/cohabiting, had high educational attainment, those who were never unemployed and nor had financial strain. Participants reporting physical assault victimization experienced lower social support than their counterparts. Similar results were found regarding sexual coercion victimization.
Study III
We aimed to assess the role of informal social support in the use of primary care and emergency services according to the type of intimate partner violence. Results suggested that victims of intimate partner violence with low social support from family, friends and/or significant others, had higher healthcare utilization. Victims of sexual coercion and physical abuse sought emergency care more frequently than primary care services. Victims of physical abuse receiving low social support visited emergency services more frequently than those with high social support; while victims of sexual coercion with higher levels of social support sought emergency services more often compared to those victims with lower levels of social support.
The main conclusion of these studies can be summarized as follows:
Social support has an important role in the intimate partner violence victims’ lives and in the broader society. Looking beyond individual-level drivers of violence and adopting a socio-ecological approach that acknowledges the influence of
personal, situational and macro-level factors are essential to understand social support´s influence on intimate partner violence victimization.
Lower levels of informal social support were associated with higher levels of intimate partner violence victimization. Additionally, informal social support has a significant role on the decision to use healthcare services among victims of intimate partner violence, particularly among sexual coercion victims.
Contextual determinants have an important influence on intimate partner violence victimization. Changing individual aspects may not be enough to prevent intimate partner violence, especially if individuals remain in environments characterized by disadvantaged socioeconomic conditions such as unemployment and income inequality.
Keywords: Intimate Partner Violence; Social Support; Inequalities; Europe; Healthcare utilization.
Resumo | 5
Resumo
Suporte Social e Violência por Parceito Íntimo na Europa: analisando influências comunitárias e individuais
Violência por parceiro íntimo é um problema social disseminado que envolve um sistema multifacetado de comportamentos exercidos por um atual ou ex-parceiro íntimo. Ela inclui agressão psicológica, agressão física, coerção sexual, comportamentos controladores e/ou abuso financeiro. A violência por parceiro íntimo atinge todos os grupos socioeconômicos, idades e culturas.
Globalmente, 30 por cento das mulheres com idade acima dos 15 anos já experenciaram violência física e/ou sexual por parceiro íntimo ao longo da vida. Na União Europeia – 28, essa prevalência varia entre 13 e 32 por cento. As consequências da violência por parceiro íntimo para a saúde são notadas não apenas pelos seus efeitos diretos mas pelos impactos indiretos e a longo prazo que podem persistir mesmo depois do término de uma relação abusiva. O suporte social da família e dos amigos apresenta um papel importante na atenuação desses impactos da violência por parceiro íntimo. Esse suporte social tem sido elencado como propulsor na decisão de deixar uma relação abusiva e romper com o isolamento e dependência do perpetrador. Perceber o suporte de amigos, família e outras pessoas significantes pode melhorar a auto-eficácia, reforçar a habilidade de compreensão do ambiente de violência e incentivar a procura de ajuda.
A partir da perspectiva da saúde pública, nós desenhamos três estudos com objetivo de investigar a influência comunitária e individual do suporte social no contexto da violência por parceiro íntimo. Nós hipotetizamos que o suporte social medido ao nível macro e individual pudesse influenciar no relato da vitimização da violência por parceiro íntimo e, também influenciar na procura dos serviços de saúde pelas vítimas. Para cumprir esse objetivo, nós utilizamos dados de um estudo multicêntrico europeu. O estudo DOVE abrangeu mulheres e homens com idade entre
18 e 64 anos da população geral de seis cidades: Atenas-Grécia, Budapeste-Hungria, Stuttgart-Alemanha, Östersund-Suécia, Londres-Reino Unido e Porto-Portugal. O instrumento de avaliação continha informações sobre características sociodemográficas, fatores comportamentais, presença de condições crônicas, uso dos serviços de saúde no último ano, qualidade de vida relacionada à saúde, suporte social e violência por parceiro íntimo. Foram usadas as escalas padronizadas disponíveis na versão validada em cada país, a saber, a Escala Multidimensional de Percepção do Suporte Social e a Escala Revisada de Conflitos Táticos. Os dados foram coletados entre setembro de 2010 e maio de 2011 após a aprovação do comitê de ética de cada país.
Nas próximas secções, apresentaremos uma breve descrição dos objetivos e resultados de cada estudo realizado.
Estudo I
Pretendemos avaliar se as características nacionais e em nível de cidade, nomeadamente as circunstâncias socioeconômicas, gênero e desigualdade de renda, bem como níveis de suporte social, influenciam na vitimização nas seis cidades europeias. Nós focamos nos determinantes contextuais que poderiam indicar algo sobre a influência do suporte social em nível social. Diversas variáveis contextuais foram incluídas: o coeficiente de Gini, o index de equidade de gênero, um index de suporte social, a taxa de desemprego e a proporção de residentes com educação terciária. Modelos multiníveis foram ajustados para estimar a associação (Odds ratio, Intervalo de Confiança de 95%) entre cada tipo de vitimização e as variáveis contextuais e individuais. Resultados mostraram que 62.3% dos participantes relataram terem sido vítimas de violência por parceiro íntimo no último ano, com uma ampla diferença entre cidades (53.9% - 72.4%). As variáveis contextuais explicaram uma quanitdade substancial dessa heterogeneidade. As taxas de desemprego foram associadas à violência psicológica (1.07, 1.01-1.13). O coeficiente de Gini apresentou uma associação positiva com a violência física (1.06, 1.01-1.11) e com a violência sexual por parceiro
Resumo | 7 íntimo (1.13, 1.01-1.25). Nenhuma associação foi encontrada entre o suporte social contextual, medido ao nível do país, e a vitimização da violência por parceiro íntimo.
Estudo II
Pretendemos avaliar a associação entre o suporte social e a vitimização da violência por parceiro íntimo entre adultos de seis países europeus. Para isso, detemo-nos aos fatores individuais que pudessem explicar a associação entre suporte social e violência por parceiro íntimo. Os resultados mostram associação entre altos níveis de suporte social e baixos níveis de vitimização da violência por parceiro íntimo. Diferenças entre os níveis de suporte social foram detectadas com a cidade de residência. Além disso, altos níveis de suporte social foram observados entre mulheres, jovens, casados ou em coabitação, pessoas com baixos níveis de escolaridade, pessoas que nunca estiveram desempregadas nem que apresentaram algum tipo de restrição financeira. Os participantes que relataram vitimização por violência física apresentaram menores níveis de suporte social comparativamente aos participantes que não relataram vitimização por esse tipo de violência. Resultados semelhantes foram encontrados com relação à vitimização por violência sexual.
Estudo III
Pretendemos avaliar o papel do suporte social informal no uso dos cuidados primários e serviços de emergência de acordo com o tipo de violência por parceiro íntimo. Resultados mostraram que as vítimas de violência por parceiro íntimo com baixo suporte social da família, amigos e outras pessoas significantes apresentaram maior utilização dos serviços de saúde. Entre as vítimas de coerção sexual e abuso físico, a procura pelos serviços de emergências foi maior que a procura pelos cuidados primários. Vítimas de abuso físico com baixos níveis de suporte social visitaram os serviços de emergência mais frequentemente do que aquelas com altos níveis de suporte social. Por outro lado, as vítimas de coerção sexual com altos níveis de suporte social procuraram os serviços de emergência mais frequentemente comparado com as
vítimas com baixos níveis de suporte social.
As principais conclusões desse trabalho podem ser resumidas como:
O suporte social tem um importante papel na vida das vítimas de violência por parceiro íntimo e na sociedade em geral. Atentarmo-nos aos mecanismos da violência para além dos individuais e adotar uma abordagem socio-ecologica que abranga as influências pessoais, situacionais e macro-estruturais são medidas essenciais na compreensão da influência do suporte social na vitimização da violência por parceiro íntimo.
Baixos níveis de suporte social informal foram associados a altos níveis de vitimização da violência por parceiro íntimo. Além disso, o suporte social informal possui um papel importante na decisão do uso dos serviços de saúde entre vítimas de violência por parceiro íntimo, particularmente entre as vítimas de coerção sexual.
Determinantes contextuais possuem uma influência importante na vitimização da violência por parceiro íntimo. Mudanças nos aspectos individuais podem não ser suficientes para prevenir a violência por parceiro íntimo, especialmente quando os indivíduos permanecem em ambientes caracterizados por desvantagens socioeconômicas tais como desemprego e desigualdade na distribuição renda.
Palavras-chave: Violência por Parceiro Íntimo; Suporte Social; Desigualdades; Europa; Utilização dos Serviços de Saúde.
Introduction | 9
Resumo | 9
Introduction | 11
Resumo | 11
The introductory chapter of this thesis aims to provide a comprehensive overview of intimate partner violence as a public health concern and a violation of human rights.
The first section briefly summarizes the public health approach to face the problem of violence and specifically intimate partner violence.
In the second section, we describe the definition of intimate partner violence and its relevance worldwide. Additionaly, we emphasize the harmful consequences of intimate partner violence. Following that, we focus on the role of the healthcare sector on intimate partner violence. Finally, we explain how socio-ecological models can explain intimate partner violence through a framework that considers individuals and their broader context.
The third section presents the social support concept and its relevance to the topic of intimate partner violence. We discuss the importance of family, friends and others in dealing with intimate partner violence. Furthermore, we explain the need of an intersectoral response to tackle violence. Finally, we explore the help-seeking behaviour and some barriers faced by victims of intimate partner violence to obtaining help. In this last section, we draw attention to the special role healthcare professionals can play and how they can take advantage of their position to detect, prevent and intervene in intimate partner violence. Finally, we explore the contribution of social support as a mediator mechanism to prompt healthcare utilization by victims of intimate partner violence.
1.1 Public Health Approach to Violence
Violence is a global problem that affects all communities around the world. Violence is among the leading causes of death for people aged 15-44 years worldwide (1), accounting for about 14% of deaths among men and 7% of deaths among women (2). The myriad types of violence (self-inflicted, collective and interpersonal) are expressed in multiple ways, yet they share common root causes. The cost of violence is seen both in the impact on victims' health and the economic burden it places on the healthcare system (3). Consequently, the effort to characterize different types of violence, define their magnitude and mitigate their effects should be considered as a priority for the community health.
Several global attempts are underway to promote the health of communities and individuals and to hold healthcare systems accountable for improving services and implementing new policies. For instance, the 67th World Health Assembly’s resolution strengthened the role of the health system in addressing violence (4). Similarly, the International Conference on Population and Development (Cairo, 1994) (5) and the Fourth World Conference on Women (Beijing, 1995) (6) were other important conventions that made recommendations to tackle the problem of violence against women and girls and to understand its health consequences. These and other conventions (7, 8), such as the Istanbul Convention (9), raised the awareness about the problem, recognizing violence as a preventable issue, which constitutes the first step in addressing the response to it.
Violence is a serious human rights violation that should be viewed from a public health perspective. This approach complements existing multisectoral efforts of the criminal justice and human rights responses to violence and offers incremental tools and resources. In this thesis, we will focus on violence against an intimate partner. Recognizing the status of intimate partner violence as a public health concern may transfer violence from the private into the public sphere and motivate societal commitment to eliminate this critical, cross-cultural and international problem.
Introduction | 13
Rather than focusing on individuals only, the public health approach to intimate partner violence aims to provide a population-based, evidence-driven, intersectoral, interdisciplinary approach based on the ecological model and centered in primary prevention (10). The public health perspective of intimate partner violence takes into account violence as an outcome of multiple causes and risk factors - individual, interpersonal, family, community and the broader society - that interact with each other.
An individual’s health reflects the interaction between their own biological/genetic background and family relationships and their experiences with others and society (11). Intimate partner violence needs to be addressed in a more comprehensive and holistic way, taking into account health behaviours, stressful events, individual and neighborhood characteristics, work situation, cultural social norms, the economic development of their countries, and the healthcare system (12).
As a significant cause of morbidity and mortality, intimate partner violence represents a hidden burden to the social and economic development of healthy societies (5). To prevent intimate partner violence and create societies free of violence it is important to employ all four types of prevention – preventing violence before it occurs; treating the consequences of an act of violence; facilitating long-term rehabilitation of victims; eliminating iatrogenic damage by employing only the necessary interventions. Currently, the health sector's response to intimate partner violence is mainly therapeutic and reactive. It is relevant to propose a new, additional focus on prevention.
Primary prevention of intimate partner violence aims to prevent violence from happening in the first place (13). It includes community education groups to discuss social norms surrounding intimate partner violence and to increase awareness and promote shifts in attitudes; public education campaigns using the media to target entire communities; or educational campaigns for specific institutions such as schools, workplaces, police and healthcare. Besides the incorporation of modules on violence prevention into the curricula for health students, broad policies to reduce income
inequality, poverty and improve the economic development might be relevant to prevent intimate partner violence (14, 15).
Secondary prevention approaches are focused on the detection of intimate partner violence at an early stage and thus facilitate its reduction and long-term effects (2). It may represent the immediate response to intimate partner violence, such as emergency care; recognition of signs of violent incidents or ongoing violent situations; treatment for sexually transmitted infections and for avoidance of unwanted pregnancy and referral of victims to appropriate resources for follow-up and support if it is necessary. It encompasses training for health, police, and education professionals to make them better able to identify and respond to intimate partner violence (16). It also includes implementing programmes with appropriate protocols and guidelines to better provide care to victims of intimate partner violence. This type of prevention may suggest avoiding a renewed victimization of earlier victims and mandatory reporting laws for intimate partner violence.
The tertiary prevention approach emphasizes long-term care of the effects of intimate partner violence, such as reintegration and rehabilitation trying to lessen trauma or reducing the long-term disability associated with violence (17). It may include improvements to primary care and emergency response systems and the ability of the healthcare sector to treat and rehabilitate victims; strengthening social support, prevention programmes and other services to protect families and communities at risk of intimate partner violence. Counselling for victims and support groups and psychological support might be desired in therapeutic programmes. Another way to face the problem may be to focus on counselling programmes for perpetrators to discuss gender issues and raise skills such as anger management and taking responsibility for one’s actions. It aims to change attitudes and behaviour in individuals who have already become violent or are at risk of harming themselves. In particular, it seeks to ensure that people can resolve differences and conflicts without resorting to violence.
Introduction | 15
excessive and unnecessary or harmful medical interventions, preventing and avoiding iatrogenic damages and proposing ethically acceptable measures (18-20). The renewal of the motto “primum non nocere” (first, do no harm) may include health professionals attitudes to respect victim autonomy of disclosure of intimate partner violence; the non-judgmental response in the face of willingness of victims to stay in the abusive relationship; the emphasis for patients to participate in clinical decision-making; and the promotion of a patient-centered health policy (21, 22).
Reducing the harmful consequences of an act of violence after it has occurred, and preventing re-incidence of victimization once violence has been detected are both essential actions to be put in place. But also, recognizing underlying risk factors for violence, and acting promptly to intervene before any violence happens are both crucial actions that a comprehensive public health response should undertake (23). Therefore, all types of prevention (primary, secondary, tertiary and quaternary) must be activated to tackle intimate partner violence and to address deeply rooted precursors to violence.
1.2 Intimate Partner Violence
1.2.1 Definition and prevalence
Intimate Partner Violence (IPV) is a pervasive social issue that involves a multifaceted system of behaviours by a current or former intimate partner. It includes psychological, physical, financial and/or sexual abuse, and crosses all socio-economic groups, ages and cultures (24-27).
The terminology of violence in this field has been changed all over the time (28). The feminist movement raised the importance of discussing the range of forms of violence, and emphasized the issues of power and control that characterize violence against women. At the beginning of investigation in the field, terms such as battered woman and spouse abuse were used. Over time, some researchers argued that battered woman was a term that indicated passive acceptance of violence, and also that the term spouse abuse excluded violence in other type of relationship than marriage, such as common-law union, dating violence or even violence occurring after the end of the relationship. The term gender-based violence was proposed and it still is used to identify violence directed at a person because of their gender. Both women and men experience gender-based violence but it affects women and girls disproportionately. In the seventies, as investigation of violence against women developed, researchers adopted the term domestic violence to specify the violence occurring in the domestic sphere. However, domestic violence also includes violence against children and elderly people. Currently, intimate partner violence has become the favored term to describe violence committed in the context of intimacy relationships.
Intimate partner violence includes physical assault (i.e., hurting/trying to hurt another person by physical force), sexual coercion (i.e., forcing a partner to participate in a sex act without her or his consent), psychological aggression (i.e., threatening a partner, his or her possessions or loved ones, or harming a partner’s sense of
self-Introduction | 17
worth) and controlling behaviours (i.e., isolating a person from family and friends or restricting their access to information)(2).
Globally, approximately 30 percent of women aged 15 and over have experienced physical or sexual violence from an intimate partner during their lifetime (29). Lifetime prevalence of intimate partner violence varies across regions (Figure 1) with the highest prevalence rates reported in the Western Pacific (68.0%), Africa (36.6%) and South East Asia (37.7%) regions compared to the Americas (29.8%) and Europe (25.4%) regions (30, 31). Results of the Fundamental Rights Agency – Violence Against Women - (FRA-VAW) Survey indicated that one in five ever-partnered women (22%) in the European Union have suffered lifetime physical and/or sexual intimate partner violence, and prevalence rates ranged from 13 to 32% (Figure 2) (32).
Figure 1. Global and Regional Estimates of Intimate Partner Violence. World Health Organization, 2013 (31).
Underreporting occurs worldwide (33), and some factors that could affect it are raised later on, in the third chapter of the introduction. Therefore, it is possible that the worldwide prevalence of intimate partner violence is substantially higher than that
reported and represent, in fact, the tip of the iceberg of a more widespread phenomenon (34).
Violence prevention reappeared to governments as a core responsibility for ensuring sustainability and development in the 2030 Agenda for Sustainable Development adopted by United Nations members (35). Embracing this goal, elimination of intimate partner violence should be fully achievable with an alignment of political, societal, legal and cultural structures (36).
Figure 2. Percentage of physical and/or sexual partner violence since the age of 15, European Union - 28. Fundamental Rights Agency, 2014 (32).
1.2.2 Health consequences of intimate partner violence
Health consequences of intimate partner violence (IPV) are largely established in the literature (37). Those consequences are notable by their direct effects but also by their indirect and long-term impacts that can persist long after the abusive relationship has ended (Figure 3) (38-40).
Introduction | 19
Physical harm may include hematomas, burns, lacerations, concussions, miscarriages, fractures, bruises, etc (41, 42). Psychological outcomes may comprise posttraumatic stress disorder (PTSD), anxiety, depression, sleep disorders, drug and alcohol abuse, and suicide attempts (43-46). Likewise, low self-esteem, somatization and other chronic conditions resulting from violence (47) may trigger learned helplessness that hinders victims from leaving abusive relationships (48).
Figure 3. Adverse Health Outcomes of Intimate Partner Violence. Global and Regional estimates of Intimate Partner Violence. World Health Organization, 2013 (31).
Besides that, indirect consequences may unleash chronic conditions and induce permanent stress (49). Some long-term effects include hypertension, diabetes, chronic pain, fatigue, constipation, irritable bowel syndrome, chronic disability, migraines,
weight loss, eating disorders, difficulty concentrating, urinary tract infections, stomach ulcers, memory loss, HIV/AIDS and other sexually transmitted infections (STIs) (50-53). Adding to the physical and mental health distress, people exposed to intimate partner violence have significantly reduced quality of life compared to those in the general population (54, 55). Also, their general health status is disrupted to an extent such that it disturbs their daily activities (56). The relationship between intimate partner violence and quality of life highlights the fact that violence destroys all dimensions of the victims’ lives (54).
The social and health impacts of intimate partner violence lead to considerable economic costs (57, 58). Victims may suffer isolation, inability to work, increased medical expenses, loss of productivity, lack of participation in regular activities and limited ability to care for themselves and their children (59, 60). These costs were found to be, in general, greatest during the period of intimate partner violence, but they persist for more than 5 years after intimate partner violence had ended (57).
These deleterious health consequences of intimate partner violence, deteriorated quality of life and economic costs may indicate that recovery from intimate partner violence requires more time and continuous intervention than just treating victims' immediate physical injuries. This highlights the need for actions from healthcare systems to alleviate the long-term harmful impacts of intimate partner violence.
1.2.3 Intimate Partner Violence and Healthcare
Healthcare constitutes a frontline for intervention on intimate partner violence (61). Victims of intimate partner violence are more likely to use healthcare across different types of services (62). Thus, healthcare providers should embrace the elevated frequency visits as an opportunity to raise the topic of violence during consultations.
Introduction | 21
adversities without necessarily drawing attention to the violence (63). Health professionals should optimize consultations to obtain the psychosocial history, to ask about patients’ safety and their living arrangements (64). In that way, healthcare providers may use the contact with the person as an opportunity to identify violence and the underlying etiology of the patients’ medical condition. In fact, the visits may act to prevent harm and to address one of the most severe threats to life and victims’ wellbeing.
Although some efforts were taken to integrate intimate partner violence into the curriculum, training healthcare professionals at medical and health schools is still insufficient to develop skills to approach violence (65). It is recommended that healthcare professionals develop competence and confidence to talk about sensitive questions such as intimate partner violence with their patients (66, 67). This appropriate training may improve the self-confidence of the professionals ensuring their ability to offer privacy, confidentiality and the respectful environment which patients feel comfortable to disclose intimate partner violence (68). Developing a trusting rapport with the patients should be the first step to provide person-centered care for victims of intimate partner violence (24).
Healthcare staff does not have enough training or proper guidelines to recognize and treat victims of intimate partner violence. Besides, the attitudes amongst professionals need to be adjusted for better treatment outcomes. Further research should be conducted to show the multidimensional nature of the effect that intimate partner violence has on women’s overall wellbeing.
Healthcare professionals often do not have the knowledge to recognize the victims and help prevent domestic abuse and therefore the aim is to create data for healthcare professionals, students, and other officials who encounter these victims.
1.2.4 Determinants of intimate partner violence
researchers have characterized intimate partner violence using a broad perspective including influences performing at multiple levels (12, 69-72). The socio-ecological framework conceptualizes the phenomenon as the interplay of direct and interacting influences of individual, situational, family, community, and socio-cultural factors (73, 74) (Figure 4). The framework takes into account the different levels of societal organization and their role in influencing attitudes towards intimate partner violence.
Figure 4. The Socio-ecological Model (adapted from Our Watch et al, 2015) (75).
The socio-ecological model was established as a framework for understanding some of the key factors that contribute to the risk of intimate partner violence, but it has been adapted to examine other types of violence and also additional public health problems. The socio-ecological model is still being improved and optimized as a conceptual tool. It identifies five areas that influence behaviours that could increase the risk of being a victim or perpetrator of intimate partner violence. The model is organized in five levels of determinants: individual, interpersonal, organizational, community, and societal (73).
Introduction | 23
increase their likelihood to become a victim or a perpetrator of intimate partner violence. These include demographic characteristics such as age, gender, racial/ethnic identity, marital status, educational level, employment status, financial resources, substance abuse, a history of child abuse, psychological disorders, and health conditions. For example, employed people are less likely to report intimate partner violence compared to other employment status groups such as retired people, the unemployed, and part-time workers (76, 77). Employment may raise people’s income, increase their confidence to face violence and consequently increase their ability to leave the abusive relationship (78). Low level of education was also significantly associated with adverse life events such as intimate partner violence (79).
The interpersonal factors category includes relationships between friends, families, peers, co-workers and intimate partners. The influence of this social support affects the risk of being a victim or perpetrator of intimate partner violence. Several studies recognize the impact of peer behaviour in shaping attitudes towards intimate partner violence (80). Using the homophily principle (81) , people are likely to select peer groups with similar characteristics. A peer context characterized by norms accepting of intimate partner violence may influence peers to internalize and adopt similar attitudes of being violent with their partners (82-84). On the other hand, higher levels of social support are linked to reduced intimate partner violence (85).
The organizational level covers workplace, schools, social institutions, and healthcare organizations and tries to characterize how these settings may affect the risk of intimate partner violence. More recently, some studies have evaluated the influence of the housing crisis on behaviours known to affect intimate partner violence in some neighborhood (86). Experiencing housing insecurity is significantly likely to increase intimate partner violence (87). Co-workers are a vital source of support for employed people, and the availability of social support at a workplace may act as a protective factor preventing intimate partner violence (88).
Community determinants encompass physical and social environments. Among the factors that might influence health is the social environment where people live.
Several studies have assessed the effect of the place of living on intimate partner violence (89), which includes the positive and negative health impact of social conditions and resources that allow or restrict individuals to live their lives. Living in a region with higher unemployment rates and higher levels of income inequality (measured, for example, with the Gini index) can increase the likelihood of being a victim of intimate partner violence (90, 91). Social environment (measured by socioeconomic composition, cohesion and related attributes) is likely to influence health through chronic stress, social support and coping strategies. Collective efficacy affects neighborhood social organization and may mediate concentrated structural disadvantage and intimate partner violence (92, 93). Moreover, living in a neighborhood of concentrated disadvantage might be an obstacle to access protection systems, and it might determine the sources of support victims can draw on to address intimate partner violence (94-96).
Last, the societal factors are the broad social, policy, economic and legal context that encompasses individuals, their social support, organizations, and communities. These determinants include the health, educational, economic and social policies that establish gender income equality, health insurance coverage, national and international laws.
Practices, social norms and structures connect all of these five levels of the model. Social norms allude to the perceived standards of acceptable beliefs and attitudes within a social group. These are nuanced expressions adhered to in a person’s family or peer group and not necessarily written rules. Individuals may engage in certain behaviors as a result of their perceptions about what is acceptable as violence, how others in their social support are behaving or believed and how their peers believed or think they should be doing.
The socio-ecological model underscores the fact that in order to develop strategies for reducing and/or eliminating risk through broad-based approaches to prevention programming, it is critical to develop an understanding of the complex interplay of biological, psychological, social, cultural, economic and political factors that
Introduction | 25
increase the likelihood for experiencing violence as well as the likelihood for perpetrating violence.
At the same time that it is crucial to reduce risk factors, overall, it is also critical to recognize and support protective factors. One of the protective factors for intimate partner violence - identified through WHO’s multi-country research on health and intimate partner violence - that can inform prevention efforts is social support that will be emphasized in this thesis.
Social support has been recognized as a critical determinant of health (97). Social support affects health by shaping health-related norms and attitudes; and by providing opportunities for social productivity (98). When social links are not present, their absence acts as a psychosocial stressor. Moreover, social support provides instrumental or emotional help to buffer stressful situations and their adverse health effects (46, 99). A deep understanding of the socio-ecological determinants of health can be gleaned using findings from international comparisons, from within-country differences, from individuals and biological traits.
1.3 Social Support
Social support is measured and conceptualized in many different ways. Different types of social resources can play different support purposes. Social support may be defined as the belief that one is cared for, loved, esteemed, and valued by others in a network of common and mutual obligation (100).
Several studies have reported the protective effect of social relationships. Social support may reduce mortality by lowering deaths from cardiovascular disease (101, 102). Besides, social support may provide financial assistance and material goods in deprivation contexts, and advice and information that might prompt seeking healthcare services (103). Social ties affect survival following the diagnosis of cancer and the onset of coronary heart disease by providing assistance during recovery from illness, buffering the effects of stressful events, and encouraging patients to seek medical care promptly (104-110).
Social support regarding relationships with people such as relatives, friends, coworkers, and neighbors can be described as informal social support. In contrast, formal social support refers to the levels of encouragement or assistance from individuals, or from institutions that victims may contact (or which contact them), where their relationship is based on professional responsibilities to victims.
Informal social support from family, friends, and colleagues for dealing with intimate partner violence includes helping someone emotionally by listening with empathy, the offering of shelters, financial assistance, providing information and advice, and accompanying them to professional services (88, 111, 112).
Because intimate partner violence is a multi-faceted issue, the public health approach requires an intersectorial response (113). The World Health Organization (WHO) recommends effective networks as an essential step for implementing intimate partner violence prevention programmes (113). International conventions affirm the importance of synergistic services regarding education, health sector, public security, social assistance, justice, and culture to improve the quality of assistance provided to
Introduction | 27 victims of intimate partner violence (7).
Multi-sector responses to intimate partner violence are diverse and so, the concepts of network and social support in the literature are multiple. In an integrative literature review (Appendix 2), we summarize three types of approach: social support, intersectorial networks and protective networks. Social support included family, friends and others; protective networks to all services from civil society, and intersectorial networks as governmental and non-governmental services to victims of intimate partner violence. For further details, see the paper at Appendix 2.
Only a small percentage of people who experience intimate partner violence seek help from formal sources (114). Disclosure to a friend or family member may act as a precursor to formal help-seeking (115). Therefore, informal social support plays a critical role in providing assistance and linking victims to formal services (103, 116). The help-seeking process is varied across different populations, depending on individual needs, characteristics of the victims of intimate partner violence, and the availability of resources (117). All of these factors are permeated by internal conditions such as the recognition of the problem as undesirable; the definition of intimate partner violence by the victim; the understanding of the need for help from others to leave the situation; the decision to seek help; and the selection of a help provider. Although these steps are distinct stages, the process of help-seeking is not always linear (118).
Despite the many benefits of social support, seeking support can be frightening for many victims (119). Barriers to seeking care from formal sources or to reporting violence include shame and stigma; cultural norms and beliefs; fear of retaliation; belief that violence is not an important issue or it is not a problem to discuss with health professionals; lack of money for transportation; financial and other economic barriers; and lack of awareness of available services (49, 120). Overcoming some of these barriers is a challenge to health sector services (121).
Healthcare providers may play an essential role in understanding the social milieu of their patients and in identifying unmentioned complaints to create trust and adequate referrals to other services if necessary. Therefore, as they have a unique
relationship with patients, family medicine providers can be the entry point for healthcare services in matters of intimate partner violence detection, prevention and intervention (121).
1.3.1 Social Support, Intimate Partner Violence and Healthcare
Social support seems to play a relevant role in mitigating the impact of intimate partner violence on the physical and mental health of victims (122, 123). Feeling the support from friends, family and others may improve self-efficacy, enhancing the ability to comprehend the environment of violence and to seek adequate help (124). Additionally, social support has been shown to prompt people to make a firm decision to leave an abusive relationship (125, 126) and to break through the isolation and dependency on the perpetrators (127).
People experiencing abusive relationships may have disrupted social ties and sometimes are socially isolated as a result of the abuse (100). Consequently, high levels of victimization were found to be associated with lower levels of social support (128). Such a limited support is likely to increase barriers for victims who desire change or need to seek healthcare services (129).
Victims with higher social support may feel able to seek and obtain resources that help protect them from the violence (112, 130-132), including assistance to safely leave abusive relationships (127, 133). In general, social support is a protective factor against intimate partner violence (134) and it is associated with decreased risk of mental and physical distress (46, 99). Social support reduces risk for depression, suicide attempts and anxiety (46, 135). In addition, social support has been shown to improve mental health (136, 137).
Evidence suggests that most people experiencing intimate partner violence are not passive victims; they often embrace strategies to maximize their safety and look for help (113, 138) . The help-seeking process varies depending on individual needs, characteristics of the victim, the type of abuse and availability of resources (139-141).
Introduction | 29
Getting information about the definition of intimate partner violence and its consequences helped victims to identify that what was happening to them was violence, that it was not their fault and that it was possible to live in a safety space free of violence (129).
Social support may encourage victims to disclose their experiences of violence, and to seek the appropriate help and care through social and health services (115). Consequently, healthcare providers are in a unique position to create a safe and confidential environment for facilitating disclosure of violence, while offering appropriate support and referral to other resources and services (142). Healthcare settings are able to develop liaisons with the range of network resources including crisis services, shelters, legal services, treatment programs for perpetrators and counseling.
While the empirical evidence linking lower levels of social support to a higher likelihood of being a victim of intimate partner violence is generally well established, the influence of social support on the utilization of healthcare remains relatively understudied. This thesis attempts to fulfill this literature gap, and provides research evidence of the relationship between the three factors: intimate partner violence, social support and healthcare utilization.
Objectives | 31
2. Objectives
Objectives | 33 This thesis aims to investigate the community and individual influence of social support in the context of intimate partner violence. We hypothesize that macro and individual measures social support might influence the disclosure of intimate partner violence victimization, and it might also influence healthcare seeking among the victims. In the scope of the DOVE study that comprises a sample of adults from six European countries, this thesis attempts to produce evidence on the topic by addressing the following specific objectives:
1) To assess whether country- and city-level characteristics, namely socioeconomic circumstances, gender and income inequality, as well as levels of social support, influence the victimization accross six European cities.
2) To estimate the association between social support and intimate partner violence victimization among adults from six European countries.
3) To assess the role of informal social support in the use of primary care and emergency services according to the type of intimate partner violence.
Methods | 35
Methods | 37 A description of the methods employed in this thesis is provided in this section. We describe the European multicenter study that forms the basis of the empirical work performed. We explain the DOVE project that was designed to measure intimate partner violence and health-related outcomes in six European cities. Its description includes the sampling procedures taken at each site, how participants were selected and data collection details. Later, we describe some ecological variables used in one of the studies (Paper I). Finally, we present the different ethical recommendations that were applied and that influenced practical decisions taken during fieldwork.
