Intimate Partner Violence: Barriers to Action and Opportunities for Intervention Among Health Care Providers in São Paulo, Brazil.

Health care providers (HCPs) who directly interact with women play a critical role in intimate partner violence (IPV) prevention and response. The aim of this study was to identify the structural and interpersonal barriers to IPV response among HCPs working in public health clinics in Santo André, Brazil. Eligible participants included all HCPs providing direct care to individuals at three public health clinics. Participants self-administered an adapted Knowledge, Attitudes, and Practices survey on IPV. Data were analyzed using Epi Info 7 and SAS 9.4. 114 HCPs completed surveys. Less than half of HCPs (41%, n = 34) reported ever having asked a woman about abuse in the past year. HCPs who perceived fewer barriers were more likely to report asking about IPV. The top three reported barriers to asking women about IPV included the following: few opportunities for one-on-one interaction (77%, n = 65), a lack of privacy (71%, n = 60), and fear of offending women (71%, n = 60). Fewer providers who perceived the barriers of lack of privacy asked about IPV (50.8%, n = 33 compared with 84.2%, n = 16; p < .05); less providers who perceived few opportunities for private patient interactions asked about IPV (48.3%, n = 29 compared with 75.0%, n = 18; p < .05). Our results support the need for a systems approach of institution-wide reforms altering the health care environment and avoiding missed opportunities in IPV screening and referring women to appropriate resources or care. Two of the most frequently reported barriers to asking IPV were structural in nature, pointing to the need for policies that protect privacy and confidentiality. Within the Brazilian context, our research highlights the role of HCPs in the design and implementation of IPV interventions that both strengthen health systems and enable providers to address IPV.

"Women fear the law more than abusers": a study of public trust in health and legal response to violence against women in Santo André, São Paulo State, Brazil.

Little is known about how perceptions of government affects women's views of violence against women. This qualitative study examines women's perceptions of violence against women laws and trust in the health and legal sector response in São Paulo State, Brazil. Thirty interviews with female residents of Santo André, 18 years and older, were audio recorded, transcribed, coded, and analyzed for themes using MAXQDA12 software. All women were familiar with at least one federal violence against women law. They expressed widespread lack of trust in the government. They viewed the legal sector as ineffective and felt violence against women laws have little impact, or exacerbate violence. Disdain for the health sector was less prominent than for the legal sector. A generalized lack of trust in government manifests as a lack of confidence in these laws for women seeking support through legal and health sectors. Adoption of legal protections for women is a significant accomplishment. However, health and legal sector violence against women response needs to consider perceptions of government, how violence against women laws are operationalized, and the role of each sector in ensuring women's safety. Violence against women response efforts should include standardized intersectoral procedures including referral to accessible resources and means of screening women who may be at high risk for femicide.

Women fear the law more than abusers: a study of public trust in health and legal response to violence against women in Santo André, São Paulo State, Brazil / As mulheres têm mais medo da lei que dos agressores: um estudo sobre a confiança pública na saúde e a reposta jurídica à violência contra mulheres em Santo André, São Paulo, Brasil / Las mujeres temen más la ley que a los agresores: un estudio de la confianza pública en la salud y respuesta legal ante la violencia contra mujeres en Santo André, estado de São Paulo, Brasil

Abstract: Little is known about how perceptions of government affects women's views of violence against women. This qualitative study examines women's perceptions of violence against women laws and trust in the health and legal sector response in São Paulo State, Brazil. Thirty interviews with female residents of Santo André, 18 years and older, were audio recorded, transcribed, coded, and analyzed for themes using MAXQDA12 software. All women were familiar with at least one federal violence against women law. They expressed widespread lack of trust in the government. They viewed the legal sector as ineffective and felt violence against women laws have little impact, or exacerbate violence. Disdain for the health sector was less prominent than for the legal sector. A generalized lack of trust in government manifests as a lack of confidence in these laws for women seeking support through legal and health sectors. Adoption of legal protections for women is a significant accomplishment. However, health and legal sector violence against women response needs to consider perceptions of government, how violence against women laws are operationalized, and the role of each sector in ensuring women's safety. Violence against women response efforts should include standardized intersectoral procedures including referral to accessible resources and means of screening women who may be at high risk for femicide.

Resumo: Há poucos estudos sobre a maneira pela qual o governo é percebido e como isso afeta as opiniões das próprias mulheres sobre a violência contra mulheres. Este estudo qualitativo examina as percepções das mulheres em relação as leis sobre violência contra mulheres e a confiança delas na resposta dos setores de saúde e direito no Estado de São Paulo, Brasil. Foram realizadas 30 entrevistas com mulheres acima de 18 anos de idade, residentes em Santo André. As entrevistas foram gravadas, transcritas, codificadas e analisadas tematicamente com o uso do software MAXQDA12. Todas as mulheres conheciam pelo menos uma lei federal sobre violência contra mulheres. Elas manifestavam uma desconfiança generalizada em relação ao governo. Consideravam ineficazes as respostas do setor jurídico. Achavam que as leis sobre violência contra mulheres tinham pouco impacto, e que eventualmente exacerbavam a violência. Havia menos desconsideração em relação ao setor de saúde, comparado ao setor jurídico. A desconfiança generalizada em relação ao governo se manifesta enquanto falta de confiança nas leis para mulheres que buscam apoio através dos setores jurídico e sanitário. A adoção de salvaguardas formais para as mulheres representa um avanço significativo. Entretanto, a resposta à violência contra mulheres pelos setores jurídico e sanitário deve levar em conta as percepções em relação ao governo, e de como as leis sobre a violência contra mulheres são operacionalizadas, além do papel de cada setor na garantia da segurança das mulheres. As respostas à violência contra mulheres devem incluir procedimentos intersetoriais padronizados, incluindo o encaminhamento para triagem de mulheres expostas a risco elevado de feminicídio.

Resumen: Se sabe poco acerca de cómo las percepciones sobre el gobierno afectan los puntos de vista de las mujeres sobre la violencia que se ejerce sobre ellas. Este es un estudio cualitativo que examina las percepciones de las mujeres sobre las leyes relativas a la violencia contra mujeres y su confianza en la salud y en la respuesta del sector legal en el estado de São Paulo, Brasil. Se realizaron 30 entrevistas con mujeres residentes de Santo André, de 18 años y edad superior, se grabaron en audio, transcribieron, codificaron y analizaron para los temas usando el software MAXQDA12. Todas las mujeres estuvieron familiarizadas con al menos una ley federal sobre violencia contra mujeres. Ellas expresaron una falta generalizada de confianza en el gobierno. Consideraban al sector legal como ineficiente. Sentían que las leyes sobre la violencia contra mujeres tenían un escaso impacto ante la exacerbada violencia. El desdeño por el sector de salud fue menos prominente que por el sector legal. Una falta generalizada de confianza en el gobierno se manifiesta en una falta de confianza en estas leyes para las mujeres que buscan apoyo legal a través del mencionado sector y el de salud. La adopción de medidas legales para las mujeres es un logro significativo. No obstante, la respuesta sobre los sectores de salud y legal, en cuanto la violencia contra mujeres, necesita considerar las percepciones acerca del gobierno, de qué forma se aplican las leyes, así como el rol de cada sector para asegurar la seguridad de las mujeres. Los esfuerzos para atajar la violencia contra mujeres deberían incluir procedimientos estandarizados intersectoriales que proporcionen recursos accesibles y medios de supervisión a las mujeres que tal vez estén en alto riesgo de feminicidio.

Parents' decisions about HPV vaccine for sons: the importance of protecting sons' future female partners.

Parents' decisions about human papillomavirus (HPV) vaccine for sons may be influenced by potentially protecting sons' future female partners from HPV. We sought to identify characteristics of parents likely to consider future partner protection in vaccine decisions, and to determine if parents likely to consider future partners in vaccine decisions had greater intention to vaccinate. We performed a cross-sectional survey of parents with sons in a pediatric clinic in 2010. We used Fisher's exact tests to identify demographics associated with consideration of future female partners in vaccine decisions. We used adjusted logistic regression to determine if parents likely to consider future partner protection in vaccine decisions had greater intention to vaccinate sons. Most parents (76 %, 187/246) reported vaccine decisions for sons were likely to be influenced by preventing HPV transmission from sons to their female partners. Parents 40 years and older, White and Black parents (vs other race), non-Hispanic, and college-educated parents were significantly more likely to indicate female partner protection may influence vaccine decisions (p < 0.05). Parents likely to be influenced by female partner protection in vaccine decisions had greater intention to vaccinate sons than their counterparts (adjusted odds ratio 2.54, 95 % CI 1.22, 5.28). Overall, many parents were likely to consider sons' female partners in vaccine decisions. Because parents likely to consider female partners had increased intention to vaccinate sons, future efforts to improve vaccine uptake in boys should explore the benefits of highlighting potential female partner protection, as this concept may resonate with many parents.

Barriers and facilitators to testing, treatment entry, and engagement in care by HIV-positive women of color.

Women of color (WOC) are at increased risk of dying from HIV/AIDS, a disparity that may be partially explained by the care barriers they face. Based in a health care disparity model and the socio-ecological framework, the objective of this study was to identify the barriers and facilitators to HIV care at three points along the HIV continuum: HIV testing, entry/early care, and engagement. Two focus groups (n=11 women) and 19 semi-structured interviews were conducted with HIV-positive WOC in an academic medical setting in North Carolina. Content was analyzed and interpreted. We found barriers and facilitators to be present at multiple levels of the ecological framework, including personal-, provider-, clinic-, and community-levels. The barriers reported by women were aligned with the racial health care disparity model constructs and varied by stage of HIV. Identifying the salient barriers and facilitators at multiple ecological levels along the HIV care continuum may inform intervention development.

MSM in HIV-prevention trials are sexual partners with each other: An ancillary study to the EXPLORE intervention.

The EXPLORE study evaluated a behavioral intervention to prevent HIV seroconversion among men who have sex with men (MSM). The present ancillary study enrolled 345 EXPLORE participants at one study site (Boston) and assessed high-risk sexual behavior with other EXPLORE participants. It also assessed sexual intentions across other EXPLORE participants, HIV-negative individuals, and unknown HIV serostatus partners. Thirty-one percent reported having sex with another EXPLORE participant: 27% unprotected receptive oral sex with ejaculation (UO), 30% unprotected insertive anal sex (UIA), and 34% reported unprotected receptive anal sex (URA). Significant relationships between intentions to engage in UO, UIA, and URA, and type of partner emerged with intentions to engage in UO, UIA, and URA higher in HIV-negative partners, other EXPLORE participants, and unknown-HIV serostatus partners. Future HIV-prevention studies recruiting MSM at increased sexual risk of HIV infection should address participants potentially becoming sexual partners with each other.