INTRODUCTION

Violence is a social phenomenon, present in all places and social classes¹. Gender-based violence arises from the imposed superiority of men over women and affects the entire social organization, in which women suffer attacks simply because they are women. It arises from the unequal power relationship between men and women, the result of a sexist and patriarchal society².

Historically and culturally, the influence of the patriarchal system on social organizations and gender relations is observed in all modern societies, to a lesser or greater degree, which, consequently, were established through men’s domination and control over women. women and that promote male violence against women³.

Therefore, domestic violence against women (VDCM) cannot be understood without considering the issue of gender. Violence against women constitutes one of the main obstacles to overcoming gender inequalities, a fact that is heightened by issues of race/ethnicity, class, sexual orientation and sexual identity, in an intersectional way².

According to data from the Violence Atlas (2019), 4,936 women were murdered in Brazil in 2017, around 13 women per day, the highest number since 2007. This alarming fact corresponds to a rate of 4.7 deaths for every 100,000 women. In the decade (2007-2017) there was a significant increase of 30.7% in the number of homicides of women in the country, as well as in the last year of the series, 2017, which registered an increase of 6.3% compared to the previous year⁴.

The COVID-19 pandemic period ended up contributing to the increase in some indicators related to VAW, due to the need for social isolation⁵. According to the National Human Rights Ombudsman (ONDH), in March 2020, in Brazil there was an 18% increase in the number of complaints made through Dial 100 and Ligue 180⁶.

The concept of domestic violence against women is quite broad and encompasses different types of violence, which can be psychological, sexual, physical, moral and property-related². This violence causes high social and economic costs for women, families and society, in addition to serious physical, sexual and reproductive health problems in the short and long term⁷.

In the marital relationship, the cycle of perpetuating domestic violence against women is initially permeated by insults, humiliation, intimidation, mutual provocations, generating conflicts and tension. Over time, violence intensifies, whether physical, psychological, moral, sexual or property, with the woman being blamed for the act suffered. Then, the partner seeks to obtain the partner’s forgiveness by proposing that he will change and that the relationship will be transformed based on mutual promises of change, but the cycle is renewed, after the so-called “honeymoon”, making the phenomenon of VDCM recurrent, which could result in, if not stopped, femicide⁸.

Source: Lucena et al., (2016)⁸.

Figure 1 : Cycles of domestic violence against women 

From this perspective, health services are essential for confronting and addressing VAW. In this aspect, Basic Health Care stands out as a privileged level of care for combating violence against women. The reorganization of the care model, through the Family Health Strategy (ESF), enables the development of links between users and professionals, which enhances the identification and intervention on different forms of violence⁹.

The ESF, acting in isolation, is unable to meet all the needs of women in situations of violence. This occurrence requires the need to promote coordination between primary, secondary and tertiary care services, Social Assistance Reference Center or Specialized Police Station for Women’s Care, establishing the logic of co-responsibility permeated by matrix support, maintaining constant communication between sectors¹⁰.

Due to its complexity, domestic violence against women requires a joint confrontation with the support of the entire society. In this scenario, work like this makes it possible to identify factors related to this problem, as well as to deepen discussions about the impact of this phenomenon, making it essential for the generation of indicators capable of guiding the planning of government actions.

Given this problem, it is considered extremely important that health professionals are equipped to identify and provide assistance to women in situations of violence. Therefore, the interest in building and validating a specific instrument that enables data collection in a systematic way that guarantees the quality and safety of women’s care in primary care is justified.

Thus, the proposed instrument was created with the aim of helping primary care health professionals, as they are closer to women, to identify the chance of a woman having suffered or being exposed to some type of domestic violence, at the time she is attended to. in a health unit. This instrument can also be used by women’s groups, social assistance services and other social facilities that deal with the topic, as well as researchers in the area. Therefore, through the unique analysis of each situation, it will be possible to make decisions based on evidence. Thus, the objective was to describe the construction and content validation of an instrument aiming to identify domestic violence against women from the perspective of the applicability of a decision model.

METHODS

This is a methodological study developed from September 2021 to November 2022. Methodological research is defined as that which aims to investigate the methods of obtaining, organizing and analyzing data, dealing with the elaboration, validation and evaluation of a reliable, accurate instrument that can be used by other researchers¹¹.

Content validation consists of delimiting the representativeness and dimension with which each element of the measurement, appropriately, corroborates the domain of interest and the extent of each item within what it proposes to measure of a given event investigated, based on the evaluation of specialists in a specific area¹².

The study was segmented into two stages: 1) development of the data collection instrument to identify domestic violence against women; 2) validation and reformulation of the instrument. This instrument was based on the results of the integrative literature review , as well as internet searches in repositories of Brazilian public universities. The searches were based on monographs, dissertations and theses that addressed domestic violence against women in primary studies.

The review was carried out through the Virtual Health Library (VHL) and Scientific Electronic Library Online (SCIELO), the following databases being selected from the VHL: Latin American and Caribbean Literature in Health Sciences (LILACS) and Medical Literature Analysis and Retrieval System Online (MEDLINE). The following descriptors were used: “violence against women” and “domestic violence”, associated with the Boolean operator AND. Articles were selected that met the inclusion criteria: complete articles related to the research object, in Portuguese, English and Spanish, indexed in the aforementioned databases in the period between 2011 and 2021, and answered the guiding question: “What is the trend of primary research studies on the profile of VDCM in Brazil, in the period between 2011 and 2021”. The final sample consisted of 12 articles.

From this perspective, version 1 of the data collection instrument was prepared, consisting of 23 objective questions, 13 questions about women’s sociodemographic and economic data and 10 questions addressing the theme of domestic violence.

To validate the instrument, contact was made via email with thirteen experts, and the invitation letter was attached with the respective research information and their responsibilities in the study. After acceptance, the Free and Informed Consent Form and two data collection instruments were sent: 1) questionnaire characterizing the expert judges (sociodemographic and academic characterization) and 2) first version of the data collection measurement instrument, to content validation. In the end, ten expert judges responded and analyzed the validity of the instrument, taking into account what Pasquali recommends, when he recommends a number of experts between 6 and 20 experts¹².

In this way, the validation of the content of the data collection instrument was carried out by ten expert judges, these being professors/researchers in the area, professionals who work in the assistance network supporting women in situations of violence and members of the women’s movement of Paraíba. To carry out this validation, the Content Validity Index - CVI was used. This index determines the percentage of experts who are in agreement on some aspects of the instrument and its items, initially analyzing each item individually and then the instrument as a whole. An agreement rate of 80% (0.80) among experts was considered as the CVI cutoff point¹².

The IVC was evaluated by the number of judges who judged the item positively, that is, “Adequate” and “Totally Adequate”. The data generated were compiled into Microsoft Excel spreadsheets, in order to be grouped, organized into absolute numbers and percentages, allowing their interpretation and descriptive quantitative explanation.

Therefore, this research is part of the first phase of the main author’s doctoral thesis, where after validation of the content, the decision model will be constructed to identify domestic violence during care for women in Basic Health Units (UBS) in municipality of João Pessoa.

It is noteworthy that the research complied with ethical principles, obtaining approval from the Research Ethics Committee (CEP) of the Center for Medical Sciences/CCM, of the Federal University of Paraíba – UFPB under Certificate of Presentation for Ethical Appreciation (CAAE) nº 61355522.0 .0000.8069 and opinion number: 5,672,371.

RESULTS

Of the thirteen judges who received the documents for evaluation, ten returned with the information duly completed within the specified deadline. In table 1, the characterization of the expert judges, who participated in the validation of the instrument, as it follows.

As shown in table 1, 100% of all participants (n = 10) are female, 10% (n = 1) are between 30 and 34 years old, 20% (n = 2) are between 35 and 39 years old, 20 % (n = 2) between 40 and 44 years old, 30% (n = 3) between 45 and 49 years old, 10% (n = 1) between 55 and 59 years old and 10% (n = 1) over 60 years.

Regarding the academic training of the judges, 40% (n = 4) stated that they had a degree in Nursing, 20% (n = 2) had a degree in Social Work, 20% (n = 2) had a degree in Law, 10% (n = 1) have a degree in Psychology and 10% (n = 1) have a degree in Social Sciences. Furthermore, all have postgraduate degrees, 20% (n = 2) at the Specialization/Residency level, 10% (n = 1) with a Master’s degree and 50% (n = 5) at the Doctorate level.

In relation to professional performance and current role, all specialists carry out their work activities in different spaces, whether in the care, teaching or management area, where 30% (n = 3) have between 6 and 10 years of professional experience, 20% ( n = 2) are between 11 and 15 years old, 20% (n = 2) are between 16 and 20 years old and 30% (n = 3) said they have more than 20 years of professional experience. The length of time working in the area of combating domestic violence against women was also investigated, where it was observed that 100% (n = 10) of the collaborators worked in the area, with the years of experience divided as follows: 10% (n = 1) from 1 to 5 years, 30% (n = 3) with 6 to 10 years of experience, 20% (n = 2) from 11 to 15 years, 20% (n = 2) between 16 to 20 years and 20 % (n = 2) reported having over 20 years of experience in that area.

Of the 23 items submitted for validation, 65.2% (n = 15) achieved a CVI equal to or greater than (0.80) and 34.8% (n = 8) achieved a CVI less than (0.80). Of these 15 that presented validation in version 1, 77% (n = 9) are questions related to Section I - sociodemographic and economic data and 23% (n = 6) are related to Section II - data about VDCM.

In Section I – sociodemographic and economic data, there was a consensus among the judges regarding the items described. Some suggestions were made, such as gender identity, where the addition of other terms was recommended: non-binary and queers. Regarding sexual orientation, there was agreement among the judges regarding the replacement of the term homosexual by lesbian, since the research is focused on women. Regarding monthly family income, the need to include a salary range of less than 1 minimum wage was indicated. In relation to the property where the woman lives, it was recommended that the question be broken down into whether it is owned or rented, in this case indicating who is responsible for the payment. Furthermore, the judges indicated the importance of adding whether the woman receives any assistance or financial benefits offered by government assistance programs.

In Section II – data on domestic violence, suggestions were also given to include and remove possible perpetrators of domestic and family violence and, regarding the type of violence perpetrated, provide a description of each type with everyday examples. Regarding sexual violence, the experts highlighted the importance of including not only the partner, but also another family member or person close to the woman.

Furthermore, the expert judges suggested the inclusion of four questions in Section II: whether the woman has ever needed medical attention after an attack; if the aggressor abuses alcohol, drugs or medication; whether the aggressor has easy access to a firearm; and if you know or have used the Maria da Penha Law (protective measure). The suggestion to address questions adapted from the Violentometer , a type of violence scale designed to help women at risk, was also accepted.

Therefore, it is noteworthy that the specialist judges’ suggestions for additions or changes to the content of the instrument (version 1) were accepted. The suggestions were made in a place designated for this purpose in the evaluation document. Therefore, after making the changes suggested by the experts, a second version of the instrument was created and sent back to the 10 participating judges, adjusting the proposed items. In this second round of evaluation, which took place between October and November 2022, the adjusted and added items reached a CVI equal to or greater than 0.90. Thus, the final version of the instrument included 23 validated items, 14 items in Section I and 9 in Section II. Considering that the instrument in its entirety presented an agreement level greater than 0.90 it was not necessary to resubmit it for a new round of evaluation. Thus, the final version of the data collection instrument was constructed to identify domestic violence against women, according to the items presented in table 2 , with the respective value corresponding to their CVI.

According to the CVI results presented in table I, the instrument is validated in its content, which will be applied later. Thus, the results obtained will support the applicability of an appropriate decision model to identify domestic violence against women.

DISCUSSION

For Santiago and Moreira¹³, when expert judges present professional experience combined with an academic career, they are more critical in the evaluation, contributing to the construction of a higher quality instrument.

Therefore, it is worth highlighting that all study participants, as specialist judges, had experience in combating domestic violence against women, working in the areas of policy and service management, care and teaching, a factor considered relevant, as it adds theoretical knowledge and experience of professional practice.

VDCM requires services to be organized with an interdisciplinary team and articulated in a network¹⁴. This aspect of interdisciplinarity is a challenge, because although there is a multidisciplinary team, the work of professionals presents fragmentation in care due to the difficulties encountered in carrying out integrated work¹⁵.

Thus, public policies recommend that care for women in situations of violence must be carried out through intersectoral networks, made up of different services and professionals, because although violence against women has a strong impact on their health, it is a problem of a social nature. which, in addition to resources in the area of health, requires several others, such as, for example, public security and social assistance¹⁶.

Due to its complexity, VDCM still represents a challenge for the health sector. Among the main difficulties in overcoming this challenge are obstacles to adequate identification, such as cultural factors, lack of guidance from both users and health professionals, showing that both social groups are afraid in dealing with the consequences of the phenomenon¹⁷.

Therefore, professionals who work directly in the area of VDCM need to be properly involved in the process of welcoming this woman, in addition to being qualified and able to develop protective measures recommended by technical protocols, promoting a humanized service, without any moral judgment and of personal beliefs¹⁸.

The process of validating and adapting the material by experts is important, as it guarantees the verification of the coherence of the information, contributing to the development of information technology with greater scientific rigor. Health professionals and researchers need to know the procedures for validating materials, as these favor the appropriate use of reliable and appropriate instruments in their professional practice^11,19.

Thus, the expert judges pointed out the importance of using the questions addressed in the Violentometer, a type of violence scale designed to help women at risk, originating from the Institutional Management Program with a Gender Perspective in Mexico, with a view to helping victims to recognize the signs of domestic violence that they may be suffering²⁰. It should also be noted that most of the time the woman herself is not able to realize that she is experiencing a situation of violence and it is precisely in these situations that the victim most needs professional support²¹.

Furthermore, the World Health Organization states that among the factors associated with an increased risk of perpetrating violence against women are low education, harmful use of alcohol and gender inequality. In addition to these factors, there are others that can also influence the occurrence of these cases, such as the victim’s age group, color/race, marital status, employment status and the existence of children in common with the person who committed the aggression²².

Regarding education, this is an important study variable for the outcome of violence, considering that research shows that low education is associated with the types of abuse²³. Furthermore, domestic violence is directly linked to female financial dependence, when most of the time these women are deprived of employment, justifying male superiority and domination so that victims are unable to support themselves²⁴.

An investigation carried out in the interior of Rio Grande do Sul, pointed out the spouse as the main responsible for the attacks, especially when they are under the influence of alcohol and/or other drugs²⁵. It is important to highlight that according to the Institute of Economic and Applied Research (IPEA), a woman with children is more likely to experience domestic violence, especially when the abuser is not their biological father²⁶.

In Brazil, the preponderant age group for MCVD is 20 to 40 years old, that is, the highest rate of women who experience this situation are of reproductive age²⁷. From a gender perspective, an important and often neglected factor stands out: colonial sexual violence, reinforcing that racial segregation and issues related to gender are far from being aseptically separated²⁸. Corroborating these data, a study carried out in São Paulo showed that VAW is normally practiced by an intimate partner, including during pregnancy, where the age range of pregnant women who suffered sexual violence ranged between 19 and 41 years²⁹.

In this way, the need to offer qualified assistance to women living in situations of domestic violence is emphasized, through a service network that includes several entry points: urgent and emergency health services, social assistance services and Women’s Defense Police Stations (DDM), in addition to community resources. Added to this, it is crucial that there is coordination between urgent and emergency services and primary care, enabling effective action for the integrality of these women³⁰.

Furthermore, the importance of collecting, analyzing and monitoring information on any type of violence perpetrated against women must be highlighted. Therefore, the surveillance process must also be carried out in the health sector to help managers make decisions and guide strategic actions and policies to promote comprehensive care for women in situations of violence³¹.

CONCLUSION

The research promoted the content validation of an instrument, by expert judges, aiming to identify domestic violence against women, where all items obtained a CVI equal to or greater than 0.90. Thus, the instrument was considered valid and adequate to identify VAW and will be applied in the next stage of the research among women who seek care in Basic Health Units in the city of João Pessoa-PB , from the perspective of the applicability of a decision model. It is believed that the development of a decision model could be an important step towards improving interventions to combat VAW, evaluating the factors that involve this phenomenon, in different contexts of violence.

In short, considering its complexity, domestic violence against women has negative repercussions and harm to the quality of life of victimized women⁸. In this sense, it is essential to promote actions and new studies that aim to eliminate women’s exposure to situations of violence, considering economic, cultural, social, ethnic/racial and sexual orientation diversities.