Background: Violence against women (VAW) is highly prevalent in Brazil, around 30% of women report sexual and/or physical violence from an intimate partner during their lifetime. Among the users of primary health care (PHC) centres, the prevalence reaches 50%. In São Paulo there has been a public health policy for all types of violence since 2001 and since 2015 all healthcare facilities are required to have a ‘violence prevention group’. However, the implementation of these policies has been fragmented and inconsistent.

Prior work: Our research in Brazil builds on an MRC funded study in which we designed and implemented an intervention for domestic violence (DV) in two PHC settings. Our formative evaluation led to the development of an intervention which included training for healthcare providers and the establishment of a pathway for all DV cases to be referred to the ‘violence prevention group’. Our intervention increased the identification and referral of survivors of violence within the clinic.

Research outline: For our ongoing NIHR Global Health Group work, we will expand into sexual and reproductive health care services. Antenatal care, family planning, STI prevention and treatment, breast and cervical cancer screening occur mostly within PHC settings in Brazil.

The aim of this study is to develop, implement and evaluate culturally appropriate interventions aligned with local health policies, to improve the disclosure, first-line support and referral of women who have or are experiencing DV, in sexual and reproductive care in PHC facilities. Mixed-methods evaluation will be conducted.

General objectives: to develop and implement an intervention in six PHC facilities. To evaluate: changes in the identification of DV, first-line support and referral of such cases by health care providers; and changes in sexual and reproductive health and occurrence of violence experienced by women who disclosed VAW at those facilities.

Specific objectives:

1. Evaluate the health system readiness assessment of the PHC facilities to adopt the intervention
2. Conduct qualitative interviews with managers and providers to inform the development of an intervention previously tested during our MRC funded study
3. Pilot the intervention in six primary health care facilities (western and central regions of São Paulo city)
4. Conduct a longitudinal qualitative study of women who disclose domestic violence to understand their experience of changes in sexual and reproductive health and further experience of violence.
5. Conduct a longitudinal qualitative study to understand the changes in beliefs and actions of health care providers who receive training on violence against women regarding identification, appropriate response and referral of cases.
6. Conduct a cost-effectiveness economic evaluation of the intervention.

Research progress:

• The team has accessed the readiness of 9 intervention sites, adapting the data collection during the Covid-19 pandemic. The research team evaluated the readiness for action through in depth interviews with healthcare providers and managers, and by direct observation and applying a specific questionnaire with the service manager and administrative staff. The data from the questionnaire has been organized in a spreadsheet to be analyzed with the broader HERA database.
• We conducted 61 semi-structured interviews with local managers (clinics directors) and healthcare providers from 10 different intervention sites in three regions of the city. The interviewanalysis helped us to expand our previous findings, shape the intervention and gain knowledge of the similarities and specificities of the different regions in which we were working.
• We expanded the intervention to ten primary healthcare facilities, rather than doing only six as initially planned. One of the PHC clinics gave up participating in the research prior to the intervention implementation due to change in management and other competing priorities. After conducting the intervention in four facilities in the west region and one in the central region we established a partnership in the south region where we worked with four additional services. This expansion of the field work aimed to study the different managing arrangements and how this might impact the intervention implementations and sustainability, based on findings of the formative research.
• This particular objective was severely impacted by the restrictions brought by the Covid-19 pandemic. Being DV a sensitive and delicate topic, the recruitment of women and the conduction of interviews needed cautious adaptations in order to cause no harm to participants. Our research team developed and pilot tested an ethical and safety protocol for remote qualitative research with domestic violence survivors. We were able to recruit 4 women who disclosed domestic violence to the healthcare providers to participate in our research with regular interviews across time. We are currently working with the healthcare providers to be able to recruit more participants, but the qualitative aspect of this objective will allow us to work with a relatively small sample.
• For our longitudinal qualitative study we conducted 29 post-intervention interviews with managers and healthcare providers from nine intervention sites. We also took field notes of the training sessions of the healthcare providers and of the 38 supervision sessions that were conducted after the training, as part of the intervention model. The supervision sessions will be offered as a support to the healthcare providers until February/2022. This material provides rich insight into the process of cementing what was learnt in our training sessions and what was incorporated to their routine and should be really useful in understanding the strengths and challenges of the intervention. We concluded the evaluation phase fieldwork and we are now analyzing the data and writing papers to be submitted to national and international journals.
• The research team gathered existing national data on the burden of domestic violence. In addition, we kept a detailed spreadsheet with all the costs related to the intervention. As initially planned, we are collecting data from the domestic violence survivors identified by the participant clinics using the Euro-Qol EQ-5D-5L questionnaire. However, so far we could not recruit a significant number of women in order to conclude the economic evaluation. All the work done so far will place our research team in a much better position to conduct the economic evaluation in the future, when pandemic restrictions are suspended and we can talk to HCP and women directly.

Other important developments

• Cost extension: while conducting the formative phase we realized that understanding the managers’ role and views was central to understanding the feasibility of our model and the possibilities of scaling it up. In our cost extension study we adapted the topic guides of the PHC facilities managers to include new questions that helped us to understand their challenges, demands and perspectives. We interviewed 4 managers from the west region post-intervention (4 interviews) and 4 managers from the south region both in the formative phase and evaluation phase (8 interviews). We also thought it was important to understand the people that they answer to in the hierarquy of health system. To do this, we interviewed 5 municipal managers involved in the implementation of the policy to tackle violence. In addition, we interviewed 2 managers from the private non-profit  organization that administers the PHC facilities and that are responsible for overseeing the implementation of the policy, one in the south and one in the west region.The interviews helped us to understand what the different levels of management prioritizes and how demands are communicated between them and the HCP. We are now analyzing those findings in light of what they mean for the delivery of care for women experiencing domestic violence. The interviews with the managers also had the effect of helping us to foster a closer relationship with them, which has been beneficial to the research.
• Expansion: We were recently asked by our partners in the south region to scale-up our intervention to their local network, training two more primary health clinics, two emergency services, one mental health service and a NGO. We understand this invitation as a validation of our model and a sign that we are seen by our partners in the field as offering useful resources. We also see it as a possibility to expand our partnership in the future.
• Throughout our research we found that a very effective way of engaging with stakeholders is being an active part of their network. We have been invited to speak in different forums organized by the municipality in which we had the chance to discuss with healthcare professionals and managers about the challenges they face when dealing with domestic violence. We have also received requests from our partners to use the educational material produced by the research since they found it useful. During the pandemic our educational material has been disseminated in PDF. format in different regions of the city, a cheap and very effective way of reaching many healthcare professionals.