Trends in public health policies addressing violence against women.

OBJECTIVE: To analyze the content of policies and action plans within the public healthcare system that addresses the issue of violence against women.
METHODS: A descriptive and comparative study was conducted on the health policies and plans in Catalonia and Costa Rica from 2005 to 2011. It uses a qualitative methodology with documentary analysis. It is classified by topics that describe and interpret the contents. We considered dimensions, such as principles, strategies, concepts concerning violence against women, health trends, and evaluations.
RESULTS: Thirteen public policy documents were analyzed. In both countries' contexts, we have provided an overview of violence against women as a problem whose roots are in gender inequality. The strategies of gender policies that address violence against women are cultural exchange and institutional action within the public healthcare system. The actions of the healthcare sector are expanded into specific plans. The priorities and specificity of actions in healthcare plans were the distinguishing features between the two countries.
CONCLUSIONS: The common features of the healthcare plans in both the counties include violence against women, use of protocols, detection tasks, care and recovery for women, and professional self-care. Catalonia does not consider healthcare actions with aggressors. Costa Rica has a lower specificity in conceptualization and protocol patterns, as well as a lack of updates concerning health standards in Catalonia.

INTRODUCTION

Violence against women reduces their participation in social life, instills fear, inhibits their abilities, deteriorates their trust in themselves, wears out their physical and psychological self-esteem, destroys their health, and denies them their rights. In Costa Rica, 58.0% of women have been victims of violence, while at least one in four has suffered some type of serious aggression throughout the course of her life in Catalonia.

Women who suffer from aggression are resorting more to health services as a consequence of the violence to which they are subjected, without specifying the form of violence they have been subjected to. , The main health problems include behavioral and psychological symptoms; sexual, reproductive, and gynecological difficulties; physical lesions; trauma; and death. Health professionals are in a privileged position to detect, treat, and further guide these women.

Violence against women is addressed by the media because of the vision and priorities of state institutions, which can be revealed by their public policies. Analysis of these policies allows us to consider the complexity of the problems and their biases. There are studies that compare the legislation , - , , regarding the subject. According to Ortiz-Barreda & Vives-Cases, one quarter of the 115 international laws have incorporated participation of the health sector. Comprehensive solutions for victims that do not report their victimization are lacking, and there is a high rate of legal and police intervention as opposed to health actions. We propose the analysis of public health policies that have more specific directives.

Detection and care at a primary level, the obligation to report to the authorities, the use of regulations and protocols, and the training of health professionals are some of the health-sector actions in Costa Rica. The health-sector actions in Catalonia are concentrated on the creating protocols at the various levels of health and social care and inter-sector coordination.

The purpose of this study was to analyze the health proposals of public policies and the health plans that deal with the subject of violence against women.

METHODS

Descriptive and comparative study of health policies, plans, and protocols that proposes health actions addressing violence against women in Catalonia and Costa Rica from 2005 to 2011 has been conducted. Public policies are a set of actions and omissions that manifest a specific format of intervention by the State. Their direction and orientation affect the future of the social process. Protocols and regulations are the common principles and guidelines that manage health services at the various levels of care, which is undertaken from the policy framework developed with the participation of the people who implement these services.

This study is part of an empirical research conducted in Costa Rica and Catalonia. Both countries have laws, policies, and plans based on finding equality for women as a way of eradicating violence against them. Furthermore, their health systems have an important role within the interagency network.

The criterion for selection of the cases was intentional violence. The strategy for searching and selecting documents is as follows:

The search for documents was aimed at unpublished documents and scientific literature between October 2011 and January 2012.

The following bibliography review databases were analyzed: official ministry and state institution pages, Academic Google databases, PsycoInfo, Medline, ISOC-Humanities Social Sciences (CSIC). The identifiers used were as follows: policies and plans/gender violence/national plans/attention protocols/laws/shadow reports/violence against women.

Thirteen documents were analyzed (Table 1). The common plan and protocol were revised at a state level in Spain, which affects the Autonomous Community of Catalonia. The document for the Organic Law 1/2004 of December 28th for Comprehensive Protection Measures against Violence was discarded, since it is integrated in the action plans for Catalonia. The Planovi in Costa Rica was used, since it was the single published document at the time of this study and the Planovi Mujer was discarded since it was yet to be published. We used the protocols and/or regulations published in each context.

Table 1

Policies, plans and protocols analyzed. Costa Rica and Catalonia, October of 2011 to January of 2012.

Type of document	Costa Rica	Catalonia	Spain
Policies	Policy for Equality and Equity of Gender (PIEG) 2007.	Women Policy Plan of the Government of the Majority of Catalonia, 2008.
Plans	Action Plan 2008-2012: National Policy for Equality and Equity of Gender 2007-2017. National Care Plan and the Prevention of Intrafamily Violence. Operational Plan 1996-1998 (Planovi). National Health Plan 2010-2021, Costa Rica.	Catalonia health plan in the horizon of 2010. Health Report for Catalonia, I and II.	National Awareness and Prevention Plan for Gender Violence, 2009.
Protocols	Governance Actions in Intrafamily Violence, 2001. Health Care Regulations for persons affected by Intrafamily Violence, 2000. Care protocol for persons victimized by intrafamily violence and/or extrafamily sexual abuse in the health areas of the Comprehensive Health Care Program, 2008. Interagency Protocol for Comprehensive Care of Sexual Rape Victims in the first 72 hours after the event, 2011.	Protocol for approach to Male Violence in terms of health in Catalonia, 2009.	Common protocol for health action before gender violence, 2007.

We performed manual analysis of the documents, systematically classifying, describing, and interpreting the contents via two paths: seeking signals from public policy and determining the actions that answer those policies in the health plans and protocols and/or regulations in health actions of each country’s context. The goals and references, concepts of violence, health tendencies, and evaluation procedures were considered. We compared the principles and references of policies, action strategies, concepts of violence, health tendencies, and evaluation (Table 2).

Table 2

Definition of categories and subcategories of the analysis of the content of policies and plans. Costa Rica and Catalonia, October of 2011 to January of 2012.

Category	Definition
Origins	Governing ideas that are the base for their insertion in the health scope within the subject of gender violence.
Strategies	Ways to reach the goals in terms of inequality between men and women and the scopes of action outlined from the specific requirements of each context.
Concept of violence against women	Terms used to refer to the situation of violence that targets women.
Health trends	Actions stipulated in terms of health in order to contribute to the eradication of gender violence towards women.
Evaluation	Strategies towards obtaining information regarding procedures and results of actions.

To ensure data quality, three analysts participated. The contents were analyzed in each document by an expert in the subject of violence against women.

RESULTS

Health actions addressing violence against women were defined in gender equality policies and plans in a general fashion. Health plans and protocols define the specific actions that respond to these policies, showing consistency or inconsistency.

Principles and references of gender policies

An important reference in Catalonia and Costa Rica was the existence of women’s movements and feminism as social generators of policies for women. There is a similarity in the subscribed international commitments. One reference in Costa Rica was the Inter-American Convention towards prevention, sanction, and eradication of violence against women (Belém do Pará Convention) while in Catalonia we referred to the European Community Treaties. The Mujer, Salud y Desarrollo Program from the Pan-American Health Organization represented an important role in financing as well as offering initial technical support for the construction of a health care model that addresses violence against women in Costa Rica. In both contexts, laws allowing the pursuit of strategic plans were the internal references. The policies analyzed have the principles of human development, equality, and rights in common.

As principles, the health plans maintain the existence of health inequalities between women and men in both countries’ contexts.

Action strategies

Costa Rica and Catalonia coincided on the following points in terms of the acting on the policies: violence, political participation, and labor aspects that favor economic autonomy. The strategies for intervention were the cultural change of values and androcentric habits, as well as comprehensive and intersectoral response. Other actions recorded in operational plans in the policy were the awareness and training, investigation, and education of service providers.

We propose a comprehensive care system that detects, supports, detains and intervenes in intrafamily violence and allows for the recreation of a new life project for Costa Rican victims. As goals, it establishes actions that affect and change sociocultural patterns.

In the Planovi Mujer, it is established that adequate, comprehensive, and quality care must be provided to women in situations ranging from violence inflicted by partners and/or family to sexual harassment, as well as rape, with articulated simultaneous responses that have an inter-agency focus.

The sixth axis, which describes women policies, in Catalonia details both general and specific goals, indicators, and institutions responsible for developing prevention and awareness strategies for all forms and scopes of violence against women. Coordination and cooperation structures are sought, which will allow comprehensive intervention and facilitate access to rights and services.

Concept of violence

Violence against women is specific and constitutes the scope of the first axis actions for intervention in the policies of Catalonia. It is determined that the weakening of human rights has multiple causes and a multidimensional nature; therefore, it must be addressed globally and with actions that encompass all systems. Violence against women is rendered specific due to their condition of social subordination in Costa Rican policies.

The term used for violence against women is differentiated in the health plans of Costa Rica and Catalonia. Violence is treated in the broader sense as a risk factor and social determinant in premature deaths in Costa Rica. In Catalonia, the term for violence suffered by women is specifically distinguished from the violence suffered by other included populations, i.e., adults and children.

In protocols and regulations, the concept of violence signals violence of psychological, physical, and sexual types. The Catalan protocol introduces economic violence, while Costa Rican regulations introduce concepts such as patrimonial violence and violence by negligence. The difference is found in the term specified for physical violence against women, since it is conceived within intrafamily violence, which includes women, the elderly, and children (Table 3). It introduces the concept of gender sensitivity to identify the factors that would render it more vulnerable to unequal and discriminatory treatment in these populations. The term used in the Action Protocol of Catalonia, is male violence and it does not follow the term, gender violence as used in the Spanish common protocol.

Table 3

Terms and definition of violence and population integrated in protocols and regulations in the health context. Costa Rica, the Spanish State and the Autonomous Community of Catalonia, October of 2011 to January of 2012.

Location	Term	Definition	Population included
Costa Rica	Intrafamily violencea	Violence prevails in relationships where there is a difference of power and within the family it is caused by imbalances of age and gender	Boys, girls and teenagers, adults and women
Spanish Government	Gender violence	The origin of violence can be found in unequal relationships between men and women and the culture of violence as a way to solve conflicts It is structural and instrumental The aggressor learns violence as a method for control and dominance of women	Women
Catalonia	Male violence	Is the expression of power by men over women, it is manifested in subtle ways and with social tolerance It is structural and has multiple causes It is an instrument to ensure dominance and submission	Women that suffer violence within the family, labor, partner relationship, social and community

a Information collected from health-related protocols and regulations from Catalonia, Costa Rica and Spain.

The Health Department SLT in Catalonia is involved in the following: training actions in care services related to male violence; groups and associations of women that work in this subject; implementation and evaluation of health protocols; training for treatment of sexual assaults; care and prevention of female genital mutilation; and production of materials for community work (Table 4).

Table 4

Health trends to address Violence against women. Catalonia and Spain, October 2011 to January 2012.

Documents	Trends
Women Policy Plan for the Majority of Catalonia	Implementation and follow-up of the protocol Special protocol in the event of sexual aggressions Training for processing of sexual aggressions Training in care and prevention of female genital mutilation Criteria for follow-up of women Materials for community work Community mediation concerning female mutilation Follow-up of inclusion of prophylaxis Minimizing burnout syndrome
Awareness and Prevention Plan for GV of the Spanish Government	Epidemiological and health indicators in the SNS Coordination and follow-up Consultancy, intervention and coordination of health services Training, common criteria Health Services Coordination
Catalonia Health Plan in the Horizon of 2010 I	Territorial implementation of protocols Evaluation of protocols Implementation of an action circuit
Catalonia Health Plan in the Horizon of 2010 II	Fast and coordinated response
Common protocol for health action before gender violence	Standardized and homogeneous action guidelines Guidelines in comprehensive care for health personnel Awareness of health personnel of the SNS To promote training of women Awareness of general population
Protocol for the approach of Male Violence in terms of health in Catalonia	To facilitate the intervention of professionals Action guidelines for sons and daughters or witnesses Circuits for correct action To unify criteria from the health scopes involved

SNS: Health National System; GV: Gender Violence

The policy in Costa Rica demonstrates different actions for the health system, such as the use of protocols, specialized care for the aggressor, communal care, and prevention training regarding the stereotypes concerning child rearing (Table 5). The health system Caja Costarricense de Seguro Social (CCSS), in the axle Vida sin Violencia, is present in limited activities as the institution responsible for actions in the creation of care services for juvenile sexual offenders and as the Care and Prevention National System for Intrafamily Violence. The policies for women in Catalonia address the issue of burnout syndrome; however, it is not specified in the protocol. This item was not mentioned in the plans available in Costa Rican policies, and was included only as a requirement for training and education in the subject.

Table 5

Health trends to address Gender Violence. Costa Rica, October of 2011 to January of 2012.

Documents	Trends
National Policy for Gender Equality and Equity (PIEG)	Specialized care for the aggressor Care and prevention in the community Use of care protocols in institutions Training in children stereotypes training concerning stereotypes in child rearing
National Operational Plan for Care and Prevention of Intrafamily Violence Operational Care and Prevention Plan (Planovi)	Communal Prevention and Awareness Detection and Record Reference and Coordination Personnel Self-care and Reflection
PIEG Action Plan	Creation of care services for juvenile sexual offenders Participate in the National System for Care and Prevention of Intrafamily Violence
National Health Plan 2010-2021	Promotion of healthy practices in subjects such as intrafamily and sexual violence To integrate in public education plans content that favor equality and equity of gender and life free of violence to develop skills within the human resources sector of health services regarding equality and gender
Governing Actions of the Ministry of Health in terms of Intrafamily Violence	Promotion and prevention Detection and registration Containment Specialized orientation Follow-up Care for offenders
Care Regulations in Health for persons affected by intrafamily violence	Central, local and regional strategic development Promotion of Health Epidemiological Vigilance Health Services
Care protocol for persons victimized by intrafamily violence and/or extra family sexual abuse in the country’s healthcare services	Instruments for primary care of victims To promote team work To award tools to health professionals
Interagency Protocol for Comprehensive Care of Sexual Rape Victims in the first 72 hours after the event (minors and adults)	Interdisciplinary, comprehensive and timely care Action within the first 72 hours To decrease the probability of HIV and/or STD infections To avoid recurring victimization To obtain legal evidence Intervention during a crisis First aid

VIF: intrafamily violence; HIV: human immunodeficiency virus: ITS: sexually transmitted infections

Violence is addressed from two strategic goals regarding promotion and prevention within Costa Rican health plans. Fifteen aspects are presented in the situation analysis of health, where there is no specific mention of the differences between men and women in terms of health. The health situation analysis reveals nine results in Catalonia. The second last aspect specifies the differences, on the basis of gender from various angles. Axis 1 of Intersectorial Commitments in health demonstrates actions addressing violence against women, adults, and children. The performance protocols have a primordial role as well as the answers in interagency circuits.

Actions are formulated in protocols and care regulations within the three levels of support in both countries’ contexts (Table 5). Referring victims within care networks and coordination of the various health and social services are a part of those directives. The protocols of Catalonia and Spain specify guidelines on the basis of the woman’s state, her condition of consciousness, and the degree to which she is threatened. Costa Rican regulations have general guidelines for health personnel to detect intrafamily violence in the various population groups. In addition, in areas where the primary care centers are located, preventive and defensive strategies are planned to protect physical integrity from violence. The governing actions of the Ministry of Health of Costa Rica include feedback and individual and group containment for people responsible for violence. An institutional proposal for self-care can be found in the rules and protocols for primary care.

Catalonia does not specify any actions towards offenders. The reference (the Common Spanish Protocol) indicates that the Ministry of the internal affairs and the organizations and resources of the autonomous communities govern the intervention and reinsertion of these people. Costa Rica mentions legal intervention and specific governing guidelines provided to process victims within the public health system. It is recommended to avoid simultaneous approach toward both the offender and the person affected and that the same professional should not see both people.

Evaluation formats for policies and plans

In Costa Rica, to formulate the Planovi Mujer, which had not been published at the time of this article, as mentioned above, we performed a previous assessment that underlined the following weaknesses: lack of conceptual clarity and ability to work with a set of rights, in addition to the absence of a strategic vision without prioritization of actions. To evaluate the Planovi Mujer, we searched for inputs and outputs of information from annual statements, national forums, and conferences held during the mid-2012 and the end of the study period. In addition, we worked with result and process indicators and depended on the Modified Statistical Measurement System of Gender Violence towards women and the monitoring system of public institution responses. The proposals for evaluation and follow-up in Catalonia establish compliance with the Plan’s follow-up council. Indicators and annual reports are defined in order to identify obstacles and proposals for action. The training, meetings, clinical sessions, and investigations produced in the period of 2008 by the operation and organization of health regions in Catalonia are described. Weaknesses are demonstrated in terms of the absence of services, as evident from forms and scopes, where it is possible that male violence may occur and there is a lack of penal and judicial measures followed by preventive educational and social intervention measures. Statistics are collected for gender violence at the state and autonomous community level. As for the proposals for evaluation and follow-up, the compliance of the Plan follow-up council is established, and indicators and an annual report are defined to identify obstacles and proposals for action.

DISCUSSION

The public agendas of both contexts have as external and internal references the movement of women and feminism with ascending logic and are constructed from a gender paradigm. The strategies for approaching violence against women have common proposals in terms of cultural change and comprehensive and intersectoral response. We respond with an ecological approach model to violence and not from classical epidemiology. One way to increase the efficiency of this model is through the participation of health personnel in protocols in order to provide training, and establish a consensus between concepts and resources. The use of care protocols and regulations is a common item in both contexts as tendencies for the health scope. Protocols were being created in Costa Rica from 2000 onwards that, at the date of this study, had no published updates. In Catalonia, the macro protocol was validated by health professionals with qualitative methodology and it is up to date at this time. The update and follow-up of these procedures characterizes the consistency of these policies and the level of priority of the subject within the scope of health.

Differences were identified in the health plans of Costa Rica and Catalonia in terms of priority level of violence against women in health. The emphasis in Costa Rica is in the Justice Administration system and the requirement for rights, which renders the role of the health system diffused, with negative consequences concerning the comprehensive and interagency response. Costa Rican public policy design is limited in order to address mistreatment of women from a comprehensive health approach, as identified in other international laws. , The health scope performs a key role as activity venue in Catalonia. In Costa Rica and in Catalonia, it was possible to establish violence against women as that which is exercised against them in a specific fashion and not as diffused subjects among a range of forms of violence in policies. However, the same term is not consistent with the one used in the healthcare system in Costa Rica. The Planovi Mujer, which specifies violence directed towards women above 15 years of age and specific violence suffered due to gender, has not been published yet and this concept has neither been transferred to the health plan nor to the regulations in effect thus demonstrating inconsistency. In Catalonia, that subject is the woman both in policies as well as in the health plan and action protocols. It uses with greater precision the term male violence in policies and health protocols, partner violence and other types of violence against women are incorporated as well as scopes beyond the family. Studies , signal the importance of conceptual clarity of what is understood as violence against women and of the paradigms from which one intervenes professionally. Public policies, as social recognition of a problem, require critical analysis. They can contribute stereotypes or remain in paradigms that do not contemplate theoretical and critical advancements, or rather, lose the strength of progressive collective actions and their historical effect.

In both contexts, the importance of professional self-care is contemplated such as is mentioned in various studies , when we are working with violence, however, the specification of actions is lacking. Work with aggressors is barely discussed in the public policies and health plans of both contexts. There is a reference to the health system in order to cover them in Costa Rica. However, more specific practices are absent in order to detect and intervene in other prevention areas and the system responds to a dichotomous model of violence.

Evaluation of the Planovi Mujer would have to be completed in Costa Rica by mid-2012, however it had still not been fully presented nor published at the time of this article. In order to formulate the Planovi Mujer, we proceeded to a previous evaluation which underlined weaknesses in the Planovi. The weaknesses demonstrated were: the lack of conceptual clarity and the ability to work with a focus on rights and the absence of a strategic vision with no prioritization of actions. In Catalonia, weaknesses were demonstrated in terms of services and evidence of formats and scopes, where male violence may exist, and the absence of penal and judicial measures followed by preventive educational and social intervention measures. We have systematized the information addressing male violence in Catalonia. This information is descriptive and it lacks reflections concerning weaknesses and the questioning of models.

Lack of integration between the analysis of non-official information and the civil organizations which can generate a different perspective is a limitation of this study. This article is an approximation to a contextual component. We did not include the experience of those who implement it. It is necessary to provide a timeline that allows insight regarding the historical process, the transformation of policies and plans through time in each context.

There are common items in the principles and strategies of public policies in order to address violence against women in both contexts. The differences can be found in the health plans and their specific health actions. Health actions in Costa Rica need to update the concepts of public policies with the health plans and their regulations, in order to have an impact on health practices. In Catalonia, it is necessary to develop health actions for those who work with women who have been victims of violence and emphasize the tasks of promotion and healthcare precautions.