Ethical challenges in global research on health system responses to violence against women: a qualitative study of policy and professional perspectives.

BACKGROUND: Studying global health problems requires international multidisciplinary teams. Such multidisciplinarity and multiculturalism create challenges in adhering to a set of ethical principles across different country contexts. Our group on health system responses to violence against women (VAW) included two universities in a European high-income country (HIC) and four universities in low-and middle-income countries (LMICs). This study aimed to investigate professional and policy perspectives on the types, causes of, and solutions to ethical challenges specific to the ethics approval stage of the global research projects on health system responses to VAW. METHODS: We used the Network of Ethical Relationships model, framework method, and READ approach to analyse qualitative semi-structured interviews (n = 18) and policy documents (n = 27). In March-July 2021, we recruited a purposive sample of researchers and members of Research Ethics Committees (RECs) from the five partner countries. Interviewees signposted policies and guidelines on research ethics, including VAW. RESULTS: We developed three themes with eight subthemes summarising ethical challenges across three contextual factors. The global nature of the group contributed towards power and resource imbalance between HIC and LMICs and differing RECs' rules. Location of the primary studies within health services highlighted differing rules between university RECs and health authorities. There were diverse conceptualisations of VAW and vulnerability of research participants between countries and limited methodological and topic expertise in some LMIC RECs. These factors threatened the timely delivery of studies and had a negative impact on researchers and their relationships with RECs and HIC funders. Most researchers felt frustrated and demotivated by the bureaucratised, uncoordinated, and lengthy approval process. Participants suggested redistributing power and resources between HICs and LMICs, involving LMIC representatives in developing funding agendas, better coordination between RECs and health authorities and capacity strengthening on ethics in VAW research. CONCLUSIONS: The process of ethics approval for global research on health system responses to VAW should be more coordinated across partners, with equal power distribution between HICs and LMICs, researchers and RECs. While some of these objectives can be achieved through education for RECs and researchers, the power imbalance and differing rules should be addressed at the institutional, national, and international levels. Three of the authors were also research participants, which had potential to introduce bias into the findings. However, rigorous reflexivity practices mitigated against this. This insider perspective was also a strength, as it allowed us to access and contribute to more nuanced understandings to enhance the credibility of the findings. It also helped to mitigate against unequal power dynamics.

An evidence-based primary health care intervention to address domestic violence against women in Brazil: a mixed method evaluation.

BACKGROUND: Health systems have a critical role in a multi-sectoral response to domestic violence against women (DVAW). However, the evidence on interventions is skewed towards high income countries, and evidence based interventions are not easily transferred to low-and middle-income countries (LMIC) where significant social, cultural and economic differences exist. We evaluated feasibility and acceptability of implementation of an intervention (HERA-Healthcare Responding to Violence and Abuse) to improve the response to DVAW in two primary health care clinics (PHC) in Brazil. METHODS: The study design is a mixed method process and outcome evaluation, based on training attendance records, semi-structured interviews (with 13 Primary Health Care (PHC) providers, two clinic directors and two women who disclosed domestic violence), and identification and referral data from the Brazilian Epidemiological Surveillance System (SINAN). RESULTS: HERA was feasible and acceptable to women and PHC providers, increased providers' readiness to identify DVAW and diversified referrals outside the health system. The training enhanced the confidence and skills of PHC providers to ask directly about violence and respond to women's disclosures using a women centred, gender and human rights perspective. PHC providers felt safe and supported when dealing with DVAW because HERA emphasised clear roles and collective action within the clinical team. A number of challenges affected implementation including: differential managerial support for the Núcleo de Prevenção da Violência (Violence Prevention Nucleus-NPV) relating to the allocation of resources, monitoring progress and giving feedback; a lack of higher level institutional endorsement prioritising DVAW work; staff turnover; a lack of feedback from external support services to PHC clinics regarding DVAW cases; and inconsistent practices regarding documentation of DVAW. CONCLUSION: Training should be accompanied by system-wide institutional change including active (as opposed to passive) management support, allocation of resources to support roles within the NPV, locally adapted protocols and guidelines, monitoring progress and feedback. Communication and coordination with external support services and documentation systems are crucial and need improvement. DVAW should be prioritised within leadership and governance structures, for example, by including DVAW work as a specific commissioning goal.

Engaging early career researchers in a global health research capacity-strengthening programme: a qualitative study.

BACKGROUND: Research capacity-strengthening is recognized as an important component of global health partnership working, and as such merits monitoring and evaluation. Early career researchers are often the recipients of research capacity-strengthening programmes, but there is limited literature regarding their experience. METHODS: We conducted a qualitative study as part of an internal evaluation of the capacity-strengthening programme of the international HERA (HEalthcare Responding to violence and Abuse) research group. Semi-structured interviews were conducted with group members, and thematic analysis was undertaken. RESULTS: Eighteen group members participated; nine of these were early career researchers, and nine were other research team members, including mid-career and senior researchers. Key themes were identified which related to their engagement with and experience of a research capacity-strengthening programme. We explored formal/planned elements of our programme: mentoring and supervision; training and other opportunities; funding and resources. Participants also discussed informal/unplanned elements which acted as important facilitators and/or barriers to engaging with research capacity-strengthening: English language; open relationships and communication; connection and disconnection; and diversity. The sustainability of the programme was also discussed. CONCLUSIONS: Our study gives voice to the early career researcher experience of engaging with a research capacity-strengthening programme in a global health group. We highlight some important elements that have informed adaptations to our programme and may be relevant for consideration by other global health research capacity-strengthening programmes. Our findings contribute to the growing literature and important discussions around research capacity-strengthening and how this relates to the future directions of global health partnership working.

Análise das trajetórias assistenciais ofertadas às mulheres em situação de violência doméstica de gênero na Atenção Primária à Saúde

Objetivo: analisar a assistência prestada às mulheres em situação de violência doméstica de gênero em serviços de Atenção Primária à Saúde, no município de São Paulo, no Sistema Único de Saúde. Método: A análise se deu a partir de quatro fluxogramas analisadores construídos com base nas informações coletadas em prontuários, como das entrevistadas realizadas com quatro mulheres em situação de violência, e dos 13 profissionais de saúde envolvidos na assistência dessas mulheres, analisados sob a metodologia Análise de Conteúdo. Resultados: As narrativas mostram que as mulheres "desabafam" para os trabalhadores, principalmente para os Agentes Comunitárias de Saúde. A violência é frequente e reconhecida, mas se torna um problema para a equipe de saúde quando há o envolvimento de crianças, ou um pedido de ajuda direto das mulheres. A assistência ofertada se mostra como tentativa dos profissionais de saúde em "consertarem" o problema da violência, com tendência às práticas prescritivas, ofertas genéricas, sem agregar as escolhas e os caminhos considerados possíveis pelas mulheres. Conclusão: Apesar das barreiras, percebe-se a inclusão da rede de enfrentamento e a compreensão da violência como uma barreira para se viver a vida.

Improving health system readiness to address violence against women and girls: a conceptual framework.

BACKGROUND: There is an increasing focus on readiness of health systems to respond to survivors of violence against women (VAW), a global human rights violation damaging women's health. Health system readiness focuses on how prepared healthcare systems and institutions, including providers and potential users, are to adopt changes brought about by the integration of VAW care into services. In VAW research, such assessment is often limited to individual provider readiness or facility-level factors that need to be strengthened, with less attention to health system dimensions. The paper presents a framework for health system readiness assessment to improve quality of care for intimate partner violence (IPV), which was tested in Brazil and Palestinian territories (oPT). METHODS: Data synthesis of primary data from 43 qualitative interviews with healthcare providers and health managers in Brazil and oPT to explore readiness in health systems. RESULTS: The application of the framework showed that it had significant added value in capturing system capabilities - beyond the availability of material and technical capacity - to encompass stakeholder values, confidence, motivation and connection with clients and communities. Our analysis highlighted two missing elements within the initial framework: client and community engagement and gender equality issues. Subsequently, the framework was finalised and organised around three levels of analysis: macro, meso and micro. The micro level highlighted the need to also consider how the system can sustainably involve and interact with clients (women) and communities to ensure and promote readiness for integrating (and participating in) change. Addressing cultural and gender norms around IPV and enhancing support and commitment from health managers was also shown to be necessary for a health system environment that enables the integration of IPV care. CONCLUSION: The proposed framework helps identify a) system capabilities and pre-conditions for system readiness; b) system changes required for delivering quality care for IPV; and c) connections between and across system levels and capabilities.

Remote methods for research on violence against women and children: lessons and challenges from research during the COVID-19 pandemic.

Collecting data to understand violence against women and children during and after the COVID-19 pandemic is essential to inform violence prevention and response efforts. Although researchers across fields have pivoted to remote rather than in-person data collection, remote research on violence against women, children and young people poses particular challenges. As a group of violence researchers, we reflect on our experiences across eight studies in six countries that we redesigned to include remote data collection methods. We found the following areas were crucial in fulfilling our commitments to participants, researchers, violence prevention and research ethics: (1) designing remote data collection in the context of strong research partnerships; (2) adapting data collection approaches; (3) developing additional safeguarding processes in the context of remote data collection during the pandemic; and (4) providing remote support for researchers. We discuss lessons learnt in each of these areas and across the research design and implementation process, and summarise key considerations for other researchers considering remote data collection on violence.

[Reasons and mechanisms for admission of children and adolescents to a psychiatric hospital: the control circuit]. / Motivos e mecanismos de internação de crianças e adolescentes em hospital psiquiátrico: o circuito do controle.

Important strides in psychiatric reform include the implementation of mental health services that replace the traditional psychiatric logic. However, admissions to psychiatric hospitals continue to occur, including children and adolescents. This study analyzed the reasons for admission to a psychiatric hospital from the institution's perspective and that of the hospitalized children and adolescents. This was a qualitative study with a hermeneutic-dialectic approach, based on a reading of the institutional documents, open interviews with eight adolescents, and participant observation. The results showed that the main alleged reason for admission reported by the psychiatric hospital was "aggressiveness", justified by the idea of "risk to self and others", while the children reported multiple reasons for their hospitalization, including drug use, minor scuffles, and misdemeanors. The analysis showed that the mechanism for admission to the psychiatric hospital involve, during anamnesis, defining an individual as deviating from social norms and, subsequently, assignment of a diagnosis to back the psychiatric institutionalization. It also showed that the backing and continuity of psychiatric hospitalizations occur in a circuit of control that is operated between different institutions for the deviants' custody. The study demonstrates that to avoid psychiatric hospitalizations, besides closing psychiatric hospitals, it is necessary to overcome the psychiatric paradigm, which in turn requires deinstitutionalization of practices and psychosocial care in open, community and substitutive mental health services.

Os avanços da reforma psiquiátrica incluem a implantação de serviços de saúde mental substitutivos à lógica asilar. Porém, internações em hospitais psiquiátricos, inclusive de crianças e adolescentes, continuam ocorrendo. Esse estudo buscou compreender os motivos de internação em um hospital psiquiátrico a partir da perspectiva da instituição e das crianças e adolescentes internados. Trata-se de pesquisa qualitativa, de abordagem hermenêutico-dialética, tendo sido feita a leitura de documentos institucionais, entrevistas abertas com oito adolescentes e observação participante. Os resultados indicaram que o motivo principal alegado pelo hospital psiquiátrico para internação foi nomeado como "agressividade", justificada pelo "risco para si e para outros", enquanto, para as crianças e os adolescentes, os motivos de internação eram múltiplos, incluindo uso de drogas, pequenas brigas e infrações. A análise indicou que os mecanismos para a internação pelo hospital psiquiátrico envolvem, durante a anamnese, uma leitura sobre o outro que o define como desviante de normas sociais e a posterior atribuição de um diagnóstico, avalizando a internação psiquiátrica. Também indicou que a sustentação e continuidade de internações psiquiátricas ocorrem em um circuito do controle operado entre diferentes instituições para tutela dos desviantes. Este estudo evidencia que, para evitar internações em hospitais psiquiátricos, além do fechamento destes, é preciso superar o paradigma psiquiátrico, sendo, para isso, necessárias as práticas de desinstitucionalização e na perspectiva da atenção psicossocial nos serviços de saúde mental abertos, territoriais e substitutivos.

Los avances de la reforma psiquiátrica incluyen la implantación de servicios de salud mental substitutivos a la lógica de los asilos, no obstante, los internamientos en hospitales psiquiátricos, incluidos los de niños y adolescentes, continúan ocurriendo. Este estudio buscó comprender los motivos de internamiento en un hospital psiquiátrico, a partir de la perspectiva de la institución, y de los niños y adolescentes internados. Se trata de una investigación cualitativa, de abordaje hermenéutico-dialéctico, habiéndose realizado la lectura de documentos institucionales, entrevistas abiertas con ocho adolescentes y observación participante. Los resultados indicaron que el motivo principal alegado por el hospital psiquiátrico para el internamiento fue denominado "agresividad", justificada por el "riesgo para sí mismos y para otros", mientras que para los niños y adolescentes los motivos de internamiento eran múltiples, incluyendo el uso de drogas, pequeñas peleas e infracciones. El análisis indicó que los mecanismos para el internamiento por el hospital psiquiátrico implican, durante la anamnesis, una lectura sobre lo que lo define como una conducta desviada respecto a normas sociales, y la posterior atribución de un diagnóstico, avalando el internamiento psiquiátrico. También indicó que el mantenimiento y continuidad de los internamientos psiquiátricos se producen en un circuito del control operado entre diferentes instituciones para la tutela de los que desvían de las normas sociales. Este estudio evidencia que, para evitar internamientos en hospitales psiquiátricos, además del cierre de los hospitales psiquiátricos, es necesaria la superación del paradigma psiquiátrico, siendo para eso necesarias prácticas de desinstitucionalización y desde la perspectiva de la atención psicosocial contar con servicios de salud mental abiertos, territoriales y substitutivos.

'Dizem que é o perigo' consequências psicossociais de rotular pessas com hipertensão leve ­ um estudo qualitativo / 'People say it is dangerous': Psychosocial consequences of Labelling People with Mild Hypertension ­ A Qualitative Study / "Dicen que es el peligro": consecuencias psicosociales de etiquetar a las personas con hipertensión leve ­ un estudio cualitativo

Hipertensão arterial leve é uma condição assintomática caracterizada por pressão arterial entre 14/9 e 16/10 mmHG e baixo risco de problemas cardiovasculares. É a condição de aproximadamente dois terços das pessoas diagnosticadas com alguma forma de hipertensão. A melhor evidência disponível não apoia o tratamento farmacológico desse grupo para a redução de mortalidade cardiovascular. Além disso, a sobredetecção de hipertensão ocorre e essa prática é apoiada por campanhas de conscientização ao público, rastreamento, acesso fácil ao teste e má prática clínica, que aumentam potencialmente o sobrediagnóstico. Poucas pesquisas qualitativas orientadas para os pacientes mostram que diagnosticar hipertensão pode ter também consequências negativas. Diante disso, são necessárias evidências sobre o potencial de efeitos psicossociais não esperados no diagnóstico de hipertensão. Objetivo: Investigar se o diagnóstico de pessoas de baixo risco com hipertensão leve tem consequências psicossociais indesejadas. Métodos: Onze entrevistas semiestruturadas e quatro grupos focais foram conduzidos em São Paulo, Brasil, com pessoas que relataram hipertensão arterial leve, sem comorbidades, com ou sem uso de medicação. Informantes foram selecionados da população geral por meio de lista de pacientes de unidades de atenção primária e também recrutados por redes sociais. Os participantes tiveram variedade em termos de sexo, idade, nível educacional, cor de pele e tempo de diagnóstico. Os dados foram submetidos à análise qualitativa de conteúdo temático por três dos autores independentemente, o que foi seguido de discussões para gerar categorias e temas. Resultados: os informantes confirmaram que o diagnóstico de hipertensão foi tomado como um rótulo para reações psicossomáticas ao estresse, medicalizou situações difíceis e causadoras de estresse, nomeando-as como doença, e foi um marco biográfico. Nós observamos consequências não intencionais do diagnóstico em uma ampla gama de dimensões psicossociais, por exemplo, medo de morte, doença e envelhecimento; pressão e controle por parte de pessoas próximas; e culpa, vergonha e ansiedade em relação ao trabalho e ao lazer. Apesar das diferentes características dos informantes, todos compartilharam histórias e sentimentos semelhantes relacionados ao rótulo. Conclusão: O diagnóstico de hipertensão é um evento significativo que afeta o dia a dia. A maior parte do impacto é considerada como consequências psicossocias negativas; porém, às vezes, o impacto pode ser ambíguo ou mesmo positivo. Os modelos explanatórios das pessoas são elementos-chave para entender e abordar as consequências psicossociais do diagnóstico, e profissionais de saúde e formuladores de políticas públicas devem estar atentos a esses potenciais consequências negativas na avaliação de risco/benefício das estratégias de diagnóstico desses casos.

Introduction: Mild hypertension is a common asymptomatic condition present in people at low risk of future cardiovascular events. These people represent approximately two-thirds of those diagnosed with hypertension. The best available evidence does not support pharmacological treatment for mild hypertension to reduce cardiovascular mortality. Additionally, overdetection of hypertension also occurs, and this practice is supported by public awareness campaigns, screening, easy access to testing, and poor clinical practice, enhancing the overdiagnosis potential. Moreover, sparse qualitative patient-oriented evidence that diagnosing hypertension has harmful consequences is observed. Therefore, evidence regarding the potential for unintended psychosocial effects of diagnosing mild hypertension is required. Objective: The aim of this study was to investigate if diagnosing low-risk people with mild hypertension has unintended psychosocial consequences. Methods: Eleven semi-structured single interviews and four focus groups were conducted in São Paulo, Brazil, among people diagnosed with mild hypertension without comorbidities. Informants were selected among the general population from a list of patients, a primary healthcare clinic, or a social network. The informants had a broad range of characteristics, including sex, age, education level, race/skin colour, and time from diagnosis. Data were subjected to qualitative thematic content analysis by three of the authors independently, followed by discussions, to generate categories and themes. Results: The informants confirmed that the hypertension diagnosis was a label for psychosomatic reactions to stress, medicalised illness experiences, and set a biographical milestone. We observed unintended consequences of the diagnosis in a broad range of psychosocial dimensions, for example, fear of death, disabilities, or ageing; pressure and control from significant others; and guilt, shame, and anxiety regarding work and leisure. Although informants had a broad range of characteristics, they shared similar stories, understandings, and labelling effects of the diagnosis. Conclusion: The diagnosis of hypertension is a significant event and affects daily life. Most of the impact is regarded as negative psychosocial consequences or harm; however, sometimes the impact might be ambiguous. Patients' explanatory models are key elements in understanding and changing the psychosocial consequences of the diagnosis, and healthcare providers must be aware of explanatory models and psychosocial consequences when evaluating blood pressure elevations.

Introducción: La hipertensión leve es una condición asintomática común presente en personas con bajo riesgo de eventos cardiovasculares futuros. Estas personas representan aproximadamente dos tercios de las personas diagnosticadas con hipertensión. La mejor evidencia disponible no respalda el tratamiento farmacológico de la hipertensión leve para reducir la mortalidad cardiovascular. Además, también se produce la sobre detección de hipertensión, y esta práctica está respaldada por campañas de concienciación pública, cribados, fácil acceso a las pruebas y mala práctica clínica, lo que aumenta el potencial de sobrediagnóstico. Además, se observa escasa evidencia cualitativa orientada al paciente de que el diagnóstico de hipertensión tiene consecuencias nocivas. Por lo tanto, se requiere evidencia con respecto al potencial de efectos psicosociales no deseados del diagnóstico de hipertensión leve. Objetivo: investigar si el diagnóstico de personas de bajo riesgo con hipertensión leve tiene consecuencias psicosociales no deseadas. Métodos: Se realizaron once entrevistas semiestructuradas y cuatro grupos focales en São Paulo, Brasil, entre personas diagnosticadas con hipertensión leve sin comorbilidades. Los informantes fueron seleccionados entre la población general de una lista de pacientes, de una clínica de atención primaria o de una red social. Los informantes tenían una amplia gama de características que incluían sexo, edad, nivel de educación, origen étnico, color de piel y tiempo desde el diagnóstico. Los datos fueron sometidos a un análisis de contenido temático cualitativo por tres de los autores de forma independiente, seguido de discusiones, para generar categorías y temas. Resultados: Los informantes confirmaron que el diagnóstico de hipertensión era una etiqueta para reacciones psicosomáticas al estrés, experiencias de enfermedad medicalizadas y marcaba un hito biográfico. Observamos consecuencias no deseadas del diagnóstico en una amplia gama de dimensiones psicosociales, por ejemplo, miedo a la muerte, discapacidades o envejecimiento; presión y control de otras personas significativas y culpa, vergüenza y ansiedad en relación con el trabajo y el ocio. Aunque los informantes tenían una amplia gama de características, compartían histórias, entendimientos y efectos de etiquetado similares del diagnóstico. Conclusión: el diagnóstico de hipertensión es un evento significativo y afecta la vida diaria. La mayor parte del impacto se considera como consecuencias o daños psicosociales negativos; sin embargo, a veces el impacto puede ser ambiguo. Los modelos explicativos de los pacientes son elementos clave para comprender y cambiar las consecuencias psicosociales del diagnóstico, y los proveedores de atención médica deben conocer los modelos explicativos y las consecuencias psicosociales al evaluar las elevaciones de la presión arterial, comunicarse y tratar.

Are We Asking Too Much of the Health Sector? Exploring the Readiness of Brazilian Primary Healthcare to Respond to Domestic Violence Against Women.

BACKGROUND: There is growing recognition of the health sector's potential role in addressing domestic violence (DV) against women. Although Brazil has a comprehensive policy framework on violence against women (VAW), implementation has been slow and incomplete in primary healthcare (PHC), and little is known about the implementation challenges. This paper aims to assess the readiness of two PHC clinics in urban Brazil to integrate an intervention to strengthen their DV response. METHODS: We conducted 20 semi-structured interviews with health managers and health providers; a document analysis of VAW and DV policies from São Paulo and Brazil; and 2 structured facility observations. Data were analysed using thematic analysis. RESULTS: Findings from our readiness assessment revealed gaps in both current policy and practice needing to be addressed, particularly with regards to governance and leadership, health service organisation and health workforce. DV received less political recognition, being perceived as a lower priority compared to other health issues. Lack of clear guidance from the central and municipal levels emerged as a crucial factor that weakened DV policy implementation both by providers and managers. Furthermore, responses to DV lost visibility, as they were diluted within generic violence responses. The organizational structure of the PHC system in São Paulo, which prioritised the number of consultations and household visits as the main performance indicators, was an additional difficulty in legitimising healthcare providers' time to address DV. Individual-level challenges reported by providers included lack of time and knowledge of how to respond, as well as fears of dealing with DV. CONCLUSION: Assessing readiness is critical because it helps to evaluate what services and infrastructure are already in place, also identifying obstacles that may hinder adaptation and integration of an intervention to strengthen the response to DV before implementation.

Psychometric properties of a condition-specific PROM for the psychosocial consequences of Labelling hypertension by using Rasch analysis.

BACKGROUND: A previous qualitative assessment of the psychosocial consequences of labelling hypertension describes the diagnosis of hypertension as a labelling event with potential unintended negative long-term psychosocial consequences (labelling effects). Until now, the benefits of diagnosing hypertension have been far more reported than the harms. To obtain the net result of the preventive interventions for cardiovascular disease, such as diagnosing and treating mild hypertension, assessing benefits and harms in the most comprehensive way possible is necessary, including the psychosocial consequences of labelling. When measuring psychosocial consequences of labelling hypertension, a questionnaire with high content validity and adequate psychometric properties is needed. OBJECTIVES: The aim of this study was to describe the psychometric parameters of face and content-validated pool of items. Other objectives were also to screen the item pool by using Rasch model analysis and confirmatory factor analysis (CFA) for identifying such items with sufficient fit to the hypothesised models. METHODS: We surveyed the pool of items as a draft questionnaire to Brazilians recruited via social networks, sending e-mails, WhatsApp® messages and posting on Facebook®. The inclusion criteria were to be older than 18 years old, to be healthy and to have only hypertension. We used Rasch model analysis to screen the item pool, discarding items that did not fit the hypothesised domain. We searched for local dependence and differential item functioning. We used CFA to confirm the derived measurement models and complementarily assessed reliability using Cronbach's coefficient alpha. RESULTS: The validation sample consisted of 798 respondents. All 798 respondents completed Part I, whereas 285 (35.7%)-those with hypertension-completed Part II. A condition-specific questionnaire with high content validity and adequate psychometric properties was developed for people labelled with hypertension. This measure is called 'Consequences of Labelling Hypertension Questionnaire' and covers the psychosocial consequences of labelling hypertension in two parts, encompassing a total of 71 items in 15 subscales and 11 single items. CONCLUSION: We developed a tool that can be used in future research involving hypertension, especially in scenarios of screening, prevention, population strategies and in intervention studies. Future use and testing of the questionnaire may still be required.

Obstáculos e facilitadores para o cuidado de mulheres em situação de violência doméstica na atenção primária em saúde: uma revisão sistemática / Obstáculos y facilitadores para el cuidado de mujeres en situación de violencia doméstica en la atención primaria de la salud: una revisión sistemática / Obstacles and facilitators to primary health care offered to women experiencing domestic violence: a systematic review

Trata-se de uma revisão sistemática da produção bibliográfica sobre obstáculos e facilitadores para o cuidado de mulheres em situação de violência doméstica na atenção primária à saúde (APS) no Brasil. O levantamento bibliográfico encontrou 1.048 referências. Analisamos 39 artigos, conforme critérios de inclusão e exclusão. A produção centrou-se em representações e crenças dos profissionais. Os principais obstáculos foram a constituição da violência doméstica contra a mulher (VDM) como questão do escopo da saúde, traduzida em dificuldades na identificação do problema e manejo no encontro assistencial, ausência de treinamento, trabalho em equipe, rede intersetorial, medo e falta de tempo. Os facilitadores focaram-se na introdução da perspectiva de gênero e direitos humanos, vínculo, acolhimento e trabalho em equipe e multisetorial. Apesar da potencialidade da APS para trabalhar com VDM, houve raros estudos que consideraram a perspectiva da gestão e financiamento, fundamental para a superação dos problemas apontados.(AU)

Revisión sistemática de la producción bibliográfica sobre obstáculos y facilitadores para el cuidado de mujeres en situación de violencia doméstica (VDM) en la atención primaria de la salud (APS) en Brasil. La revisión bibliográfica encontró 1.048 referencias. Analizamos 39 artículos, conforme criterios de inclusión y exclusión. La producción se concentró en representaciones y creencias de los profesionales. Los principales artículos fueron la constitución de la VDM como cuestión del alcance de la salud, traducida en dificultades en la identificación del problema y el manejo en el encuentro asistencial, ausencia de capacitación, trabajo en equipo, red intersectorial, miedo y falta de tiempo. Los facilitadores se enfocaron en la introducción de la perspectiva de género y derechos humanos, vínculo y acogida, trabajo en equipo y multisectorial. A pesar de la potencialidad de la APS para trabajar con VDM, fueron raros los estudios que consideraron la perspectiva de la gestión y financiación, fundamental para la superación de los problemas señalados.(AU)

Systematic review of the literature addressing obstacles and facilitators for the care of women, in situations of domestic violence (DV) in primary health care (PHC) in Brazil. The bibliographic review found 1,048 references. The analysis encompassed 39 articles complying with the inclusion and exclusion criteria. The material was centered on representations and beliefs of practitioners. The main obstacles were related to: conceptualizing DV as a health issue, resulting into difficulties to identify the problem and managing care encounters; lack of training and teamwork; scarce intersectoral network, fear and lack of time. The facilitators were mainly: introducing a gender and human rights perspective, bonding and embracement, teamwork and multisectoral work. Despite the potential of PHC to address the issue, few studies considered perspectives of management and financing, considered as key to overcome the problems pointed out.(AU)

Mudanças históricas na rede intersetorial de serviços voltados à violência contra a mulher - São Paulo, Brasil / Historical changes in the intersectoral network of services targeted at violence against women - São Paulo, Brazil / Cambios históricos en la red intersectorial de servicios enfocados en la violencia contra la mujer - São Paulo, Brasil

A violência contra a mulher ganhou espaço impulsionado, na agenda política, pelo movimento de mulheres com diversas políticas públicas voltadas para a assistência às mulheres. Analisam-se resultados de uma pesquisa no município de São Paulo, Brasil, com profissionais da rede de serviços intersetoriais especializados em relação às mudanças ocorridas com a Lei Maria da Penha. Os dados mostram que, apesar da ampliação dos serviços de assistência, defesa e proteção da mulher, há dificuldades para um trabalho integrado nas ações e na interação dos profissionais a fim de buscarem um projeto assistencial comum, fundamento considerado principal para atuação em rede. Conclui-se que a superação dessas dificuldades é um desafio no contexto político atual de sucateamento dos serviços e enfraquecimento das políticas públicas voltadas para os direitos das mulheres.(AU)

Violence against women has gained space in the political agenda, driven by the women's movement, with the making of public policies targeted at assistance for women. We analyze the results of a study carried out in the city of São Paulo, Brazil, with professionals from the specialized intersectoral services network, focusing on the changes that have occurred due to the Maria da Penha Law. Data show that, in spite of the expansion of the services that provide assistance, defense and protection for women, there are difficulties concerning integrated work in professionals' actions and interaction, which hinders the outline of a common assistance project - the most important principle for a networked action. The conclusion is that overcoming these difficulties is a challenge in the current political context of degeneration of the services and weakening of public policies targeted at women's rights.(AU)

La violencia contra la mujer ganó espacio impulsado, en la agenda política, por el movimiento de mujeres con diversas políticas públicas enfocadas en la asistencia a las mujeres. Se analizan resultados de una investigación en el municipio de São Paulo, Brasil, con profesionales de la red de servicios intersectoriales especializados en relación con los cambios habidos en función de la Ley Maria da Penha. Los datos muestran que, a pesar de la ampliación de los servicios de asistencia, defensa y protección de la mujer, hay dificultades para un trabajo integrado en las acciones y en la interacción de los profesionales para que busquen un proyecto asistencial común, fundamento considerado principal para la actuación en red. Se concluyó que la superación de estas dificultades constituye un desafío en el contexto político actual de desmantelamiento de los servicios y debilitación de las políticas públicas enfocadas en los derechos de las mujeres.(AU)

Child and adolescent mental health policy: history and paths to participation. / Políticas públicas na atenção à saúde mental de crianças e adolescentes: percurso histórico e caminhos de participação.

People with mental disorders play an important role in the mental health reform process, which involves the creation of new public policies, practices, knowledge, and ways of relating to this experience. Using a guiding question addressing the history of child and adolescent mental health in Brazil and the participation of child and adolescent mental health service users in the policy construction process, a narrative literature review was undertaken framing the main policy developments and advances in this area within the overall context of the Brazilian mental health reform. A search of technical, institutional, and legal documents in the thematic area Mental Health was conducted using a national database. The material analyzed addressed milestones in child and adolescent mental healthcare, highlighting the paths taken in building this field. The article also discusses the participation of child and adolescent mental health service usersin this process in the form of a commentary. Finally, the article highlights the need to guarantee the participation of this group to enable them to play a leading role in the struggle for the construction and realization of rights.

Na reforma psiquiátrica brasileira, é importante a participação de pessoas com experiência de sofrimento psíquico enquanto atores sociais na construção desse processo, que envolve a criação de novas políticas públicas, práticas, saberes e modos de relação com essa experiência. A partir do questionamento acerca do percurso histórico específico da saúde mental infantojuvenil e da participação de crianças e adolescentes nesse processo, foi feita uma revisão narrativa da literatura que busca evidenciar os momentos principais dessa trajetória, no que concerne à produção de políticas públicas e legislações. A revisão consistiu na busca de documentos técnicos e institucionais da área temática da Saúde Mental em base de dados nacionais, além de documentos legais. O material analisado versou sobre um conjunto de marcos da atenção à saúde mental de crianças e adolescentes e a análise assinalou os caminhos trilhados na construção desse campo. Ainda, na perspectiva de um comentário, foi discutida a participação de crianças e adolescentes com sofrimento psíquico nesse processo. Este artigo destaca a necessidade de construir garantias concretas de participação dessa população, possibilitando que assumam o papel de protagonista na luta pela construção e garantia de direitos.

Políticas públicas na atenção à saúde mental de crianças e adolescentes: percurso histórico e caminhos de participação / Child and adolescent mental health policy: history and paths to participation

Resumo Na reforma psiquiátrica brasileira, é importante a participação de pessoas com experiência de sofrimento psíquico enquanto atores sociais na construção desse processo, que envolve a criação de novas políticas públicas, práticas, saberes e modos de relação com essa experiência. A partir do questionamento acerca do percurso histórico específico da saúde mental infantojuvenil e da participação de crianças e adolescentes nesse processo, foi feita uma revisão narrativa da literatura que busca evidenciar os momentos principais dessa trajetória, no que concerne à produção de políticas públicas e legislações. A revisão consistiu na busca de documentos técnicos e institucionais da área temática da Saúde Mental em base de dados nacionais, além de documentos legais. O material analisado versou sobre um conjunto de marcos da atenção à saúde mental de crianças e adolescentes e a análise assinalou os caminhos trilhados na construção desse campo. Ainda, na perspectiva de um comentário, foi discutida a participação de crianças e adolescentes com sofrimento psíquico nesse processo. Este artigo destaca a necessidade de construir garantias concretas de participação dessa população, possibilitando que assumam o papel de protagonista na luta pela construção e garantia de direitos.

Abstract People with mental disorders play an important role in the mental health reform process, which involves the creation of new public policies, practices, knowledge, and ways of relating to this experience. Using a guiding question addressing the history of child and adolescent mental health in Brazil and the participation of child and adolescent mental health service users in the policy construction process, a narrative literature review was undertaken framing the main policy developments and advances in this area within the overall context of the Brazilian mental health reform. A search of technical, institutional, and legal documents in the thematic area Mental Health was conducted using a national database. The material analyzed addressed milestones in child and adolescent mental healthcare, highlighting the paths taken in building this field. The article also discusses the participation of child and adolescent mental health service usersin this process in the form of a commentary. Finally, the article highlights the need to guarantee the participation of this group to enable them to play a leading role in the struggle for the construction and realization of rights.

Development of an item pool for a questionnaire on the psychosocial consequences of hypertension labelling.

BACKGROUND: Hypertension is the most prevalent risk factor for cardiovascular disease globally. Roughly one-third of the adult population has hypertension. However, most people diagnosed with hypertension do not benefit from blood pressure control with pharmacologic interventions: they are overdiagnosed and overtreated and might experience negative psychosocial consequences of being labelled. These consequences are relevant outcomes that need to be assessed and validly measured to identify all benefits and harms related to interventions designed to prevent cardiovascular disease. OBJECTIVES: To develop a pool of items with high content validity for a draft version of a condition-specific questionnaire to measure the psychosocial consequences of being labelled with mild hypertension. METHODS: We selected relevant items from existing Consequences of Screening (COS) questionnaires. These items belonged to two groups: COS core items and potential condition-specific items. All items were originally in Danish and were translated into Brazilian Portuguese using the dual-panel method. Individual and group interviews were conducted with people with mild hypertension and low risk for cardiovascular disease, and were designed to test the translated items for face and content validity and were also used to generate new relevant items. Structured individual interviews were conducted to categorise all the items into domains. RESULTS: The Brazilian Portuguese dual-panel translation of both groups of items was found to be relevant for adults diagnosed with hypertension. We generated 52 new items to achieve high content validity. The result was a set of 132 items divided into 22 domains in 2 parts. Part I was directed at the general population, whereas part II was directed only at people diagnosed with hypertension and it consisted of 38 items in 8 domains. Twelve items remained as single items. High content validity was achieved with the pool of 132 items divided into 22 domains in 2 parts. DISCUSSION: High content validity was achieved for a condition-specific questionnaire measuring the psychosocial consequences of being labelled with mild hypertension. This instrument encompassed 132 items divided into 22 domains in 2 parts. Thereby, a draft of the Consequneces of Hypertension questionnaire (COH) was developed. The psychometric properties of this questionnaire will be discussed in a diferent paper.

Disrespect and abuse in childbirth in Brazil: social activism, public policies and providers' training.

Brazil is a middle-income country with universal maternity care, mostly by doctors. The experience of normal birth often includes rigid routines, aggressive interventions, and abusive, disrespectful treatment. In Brazil, this has been referred to as dehumanised care and, more recently, as obstetric violence. Since the early 1990s, social movements (SM) have struggled to change practices, public policies and provider training. The aim of this paper is to describe and analyse the role of SM in promoting change in maternity care, and in provider training. In this integrative review using a gender-oriented approach, we searched the Scielo database and the Ministry of Health's (MofH) publications and edicts for institutional and research papers on SM initiatives addressing disrespect and abuse in the last 25 years (1993-2018) in Brazil, and their impact on public policies and training programmes. We analyse these groups of interrelated initiatives: (1) political actions of SM resulting in changes in public policies and legislation; (2) events organised by SM for diffusion of information to the public; (3) MofH policies to humanise childbirth with participation of SM; and (4) initiatives to change providers' training, including legal actions based on obstetric violence reports. To promote real change in maternity care, the progression of policies and enabling environment of laws, regulations, and broad dissemination of information, need to go hand in hand with changes in all health providers' training - including a solid base in ethics, gender and human rights.

[Health administrators and public policies to deal with gender violence against women in São Paulo, Brazil]. / Gestores de saúde e o enfrentamento da violência de gênero contra as mulheres: as políticas públicas e sua implementação em São Paulo, Brasil.

The study focuses on policies to deal with violence against women in the city of São Paulo, Brazil. The objectives were to map the public policies and the proposals for institutional organization of a network of comprehensive care, in addition to analyzing the implementation of these policies, highlighting the health sector, with reports by administrators and policymakers. The study addresses the relationship between management practice and the public policy provisions, the weight of administrators' personal values and perspectives, and the weight of the socially dominant discourse in decision-making for implementation of these policies. Data were produced through semi-structured interviews with 32 administrators working at different levels in the institutional organization of the Municipal Health Department, including some policymakers in the state and national scenarios. The body of data were submitted to thematic content analysis, examining each of the interviews and relating them to the literature and conceptual framework. The study concludes that health administrators, as agents of practices, are influenced by the prevailing structures and beliefs and reference to their social and historical context for decision-making. However, when they relate to such structures, they are also capable of intervening in the ways care is produced and provided for women in situations of violence, especially by addressing the training and awareness-raising processes and new references concerning recognition of women's rights as human rights.

Estudam-se as políticas de enfrentamento da violência contra as mulheres no Município de São Paulo, Brasil. Os objetivos foram mapear as políticas públicas e as propostas de organização institucional de uma rede de atenção integral, assim como conhecer suas implementações nos serviços, com destaque ao setor de saúde, pelos relatos de gestores e formuladores da política, trabalhando-se a relação da prática da gestão com o enunciado nas políticas públicas, o peso dos valores e da perspectiva pessoal dos gestores e o peso do discurso socialmente dominante nas tomadas de decisão para a implementação destas políticas. A produção dos dados foi realizada por intermédio de entrevistas semiestruturadas com 32 gestores operando em diferentes níveis da organização institucional da Secretaria Municipal da Saúde, dentre eles alguns formuladores das políticas nos cenários estadual e nacional. A análise desse córpus de dados foi temática de conteúdo, examinando-se cada uma das entrevistas e relacionando-as com a literatura e referencial conceitual utilizado. Conclui-se que os gestores, como agentes de práticas, são influenciados pelas estruturas e crenças vigentes, pela referência ao contexto sociohistórico a que estão inseridos para tomadas de decisão de gestão. Porém, são também capazes de, ao relacionar-se com tais estruturas, interferir nas formas de produzir e ofertar cuidado às mulheres em situação de violência, em especial ao aproximarem-se de processos de formação e sensibilização e de novos referenciais acerca do reconhecimento dos direitos das mulheres como direitos humanos.

En este trabajo se estudian las políticas de lucha frente la violencia contra las mujeres en el municipio de São Paulo, Brasil. Los objetivos fueron mapear las políticas públicas y las propuestas de organización institucional de una red de atención integral, así como conocer sus implementaciones en los servicios, destacando el sector de salud, por los relatos de gestores y formuladores de políticas, trabajando la relación de la práctica de gestión con el enunciado en las políticas públicas, el peso de valores y la perspectiva personal de los gestores, así como el peso del discurso socialmente dominante en las tomas de decisión para la implementación de estas políticas. La producción de datos se realizó mediante entrevistas semiestructuradas con 32 gestores operando en diferentes niveles de la organización institucional dentro de la Secretaría Municipal de Salud, entre ellos, algunos formuladores de las políticas en los escenarios estatal y nacional. El análisis de ese corpus de datos fue la temática de contenido, examinando cada una de las entrevistas y relacionándolas con la literatura y marco de referencia conceptual utilizado. Se concluye que los gestores, como agentes de prácticas, son influenciados por las estructuras y creencias vigentes, por la referencia al contexto sociohistórico en el que están insertados para las tomas de decisión en la gestión. No obstante, son también capaces de, al relacionarse con tales estructuras, interferir en las formas de producir y ofertar cuidado a las mujeres en situación de violencia, en especial al aproximarse a procesos de formación y sensibilización, así como nuevos marcos de referencia acerca del reconocimiento de los derechos de las mujeres como parte de los derechos humanos.