Violence against women during the COVID-19 pandemic: An integrative review.

BACKGROUND: During the COVID-19 pandemic, incipient data have revealed an increase in violence against women (VAW).
OBJECTIVE: To analyze the existing scientific literature on strategies and recommendations to respond to VAW during the implementation of social distancing measures in response to the COVID-19 pandemic. SEARCH STRATEGY: An integrative review was conducted based on articles published between December 2019 and June 2020. Suitable articles were identified from the PubMed, SciELO, and LILACS databases, using relevant terms. SELECTION CRITERIA: Eligible studies included opinion and primary research articles describing the dynamics of VAW during quarantine and in the context of the restrictive measures taken during the COVID-19 pandemic and proposing recommendations to respond to this issue. DATA COLLECTION AND ANALYSIS: Data were extracted from eligible publications and qualitative synthesis was used. MAIN
RESULTS: The 38 articles included in the study showed that some factors increasing women's vulnerabilities to violence were exacerbated during the social distancing and lockdown period. Health professionals are essential for screening and responding to VAW during the pandemic.
CONCLUSIONS: Strategies must include integrated actions aiming to prevent and respond to violence during and after the COVID-19 pandemic. These must be designed based on lessons learned from previous public health emergencies.

INTRODUCTION

After the statement of WHO characterizing the COVID‐19 outbreak as a pandemic on March 11, 2020, governments and authorities around the world have introduced or intensified restrictive social distancing measures to reduce the spread of the infection. These measures have impacted family dynamics through their effects on family income, interpersonal bonds, well‐being, and mental health.

Violence against women has also been recognized by the United Nations General Secretary as a “global pandemic”. The complexity entailed by the coexistence of the two pandemics exacerbates the risks of negative outcomes in the health and well‐being of those who were already living in vulnerable situations before the emergence of COVID‐19. Hazards affect women and men in different ways. In particular, “pandemics make existing gender inequalities for women and girls worse, and can impact how they receive treatment and care”.

The increase in reports of domestic violence against women during the pandemic has alerted several organizations, researchers, and civil society representatives. By using formal and informal networks, they expressed their concern and affirmed the need to establish effective interventions to prevent and combat the phenomenon. The urgency of the situation calls for analyzing the existing scientific literature on strategies and recommendations for facing domestic violence against women in the context of the social distancing measures adopted as a response to the COVID‐19 pandemic.

MATERIALS AND METHODS

The present study is an integrative literature review designed to summarize the existing empirical and/or theoretical literature in order to obtain a comprehensive understanding of the issue of interest. Based on the proposal and concepts of Whittemore and Knafl, five stages were designed and performed.

First stage: Identification of the problem

The following research question was formulated: What have been the strategies and recommendations for addressing violence against women during the implementation of social distancing measures in response to the COVID‐19 pandemic?

Second stage: Literature search

The following databases were searched: PubMed, Scientific Electronic Library Online (SciELO), and Latin American and Caribbean Center on Health Sciences Information (LILACS). The Medical Subject Headings (MeSH) descriptors used were “COVID‐19” AND “domestic violence” OR “intimate partner violence” OR “gender‐based violence,” in English, Portuguese, and Spanish.

Primary research articles, editorials, perspective pieces, and commentaries (among others) published between December 2019 and June 2020 were considered. To be included, the material had to meet the following criteria: describe the phenomenon of violence against women during the implementation of social distancing measures due to the COVID‐19 pandemic; address the dynamics of this phenomenon; and/or suggest recommendations for action. Guidelines and recommendations provided by international and national organizations or committees to combat violence in the context of the pandemic were excluded.

Third stage: Evaluation of data

Titles, keywords, and abstracts were first examined by two independent researchers for the pre‐selection of articles that would be read in full. When divergences arose, a third researcher evaluated the pertinence of inclusion or exclusion. The bibliographic references of the selected articles were perused to scout for potential studies meeting the inclusion criteria that had not been uncovered previously. A total of 85 articles were identified, of which 38 were read in full and selected for data extraction to create the synthesis matrix (Fig. 1).

Figure 1

PRISMA 2009 flowchart showing the inclusion of papers on integrative review about violence against women during the COVID‐19 pandemic.

Fourth stage: Analysis of data

The collected data were organized in a synthesis matrix. This tool was useful in grouping and comparing data, resulting in the identification of thematic categories as well as the elaboration of considerations on the topic under study.

Fifth stage: Presentation

The syntheses of the knowledge produced were made public, along with a description of the implications and limitations of the review.

RESULTS

A total of 38 articles were selected. A common perception among them is the key role of health workers, public security, and social services in screening, identifying, and addressing cases of violence. The articles use several terms referring to violence, such as intimate partner, domestic, family, and gender‐based violence. The first two terms prevail in the papers analyzed (Fig. 2).

Figure 2

Word cloud based on NVivo analysis of word frequency. NVivo 11 (QSR International MA, USA).

After the reading and critical analysis of the articles, categories were elaborated, revealing the occurrence of domestic, family, and intimate partner violence behaviors during the pandemic. Facilitating factors of violence from the perspective of individual, relational, community, and social dimensions were also identified. The strategies suggested and implemented for prevention, screening, and interventions in cases of violence were also addressed (Fig. 3). The categories analyzed are displayed in Box 1.

Figure 3

Relationship between authors and categories. NVivo 11 (QSR International MA, USA).

The course of domestic and family violence during the COVID‐19 pandemic are described by the authors. Assertions regarding the increase in violence are based on anecdotal evidence, police reports, increased demand for emergency services, shelters, and calls or contacts with help services. , , , , , , , , , , Although the review’s target population consisted of women in the domestic and family environment, the impact of violence on other family members (children, adolescents, and the elderly) is reported, which reveals the growing need for an intergenerational approach. , The articles show that the increase in violence has been observed not only in low‐ and middle‐income countries, but in several regions where social distancing measures were adopted (Table S1).

The evidence showed an increase in calls to helplines and contacts with services and organizations intended for survivors, although many articles considered underreporting was possible. , The literature observes that some issues can affect the mode of complaint as well as demand for and access to help. Barriers in reporting include the aggressive and controlling behavior of the aggressor, , low privacy, fear of contamination by COVID‐19, , decreased social support and protection during the pandemic, and scarce availability of facilities (due to reduced work hours, funds, and personnel). , , , , , , , Additionally, survivors face difficulties in implementing security plans with friends and family due to fear of contagion. ,

The link between violence against women and sexual and reproductive rights is another topic discussed by several authors, whose works reinforce the understanding of violence against women as a violation of human rights. Moreover, these studies highlight the need to maintain services that guarantee women's right to sexual and reproductive health care during the pandemic. , ,

The health sector and its professionals are recognized as the cornerstone of the screening and identification of cases. , , , , , , Because the health sector is an essential service, contact with the population may encourage survivors to seek help. Several barriers limit the performance of the health sector, including insufficient technical training for health workers and fear of breaking patient confidentiality, , , the priorities for care associated with the spread of COVID‐19, and the perception that this topic is not their responsibility.

The dynamics of domestic and family violence against women have been addressed from different perspectives as individual, interpersonal, communal, and social in nature. For this analysis, the ecological model of WHO is a valuable resource for understanding the complexity of the phenomenon, which is compounded by the experience of living through a global emergency. Using this model as a reference, one of the articles describes elements of both women and their aggressors that can put them at greater vulnerability during the current pandemic (Fig. 4).

Figure 4

Ecological model for understanding violence during the COVID‐19 pandemic. Source: Adapted from Krug et al.

The home itself has been recognized as an unsafe space for women. , , , , The presence of firearms and the increase in consumption of alcohol are also seen as catalysts for violence. , , An interesting aspect addressed in the dynamics of violence is the use of fear of contagion as a tool to practice control over the victim, in addition to the typical coercive behavior of the aggressor. , In this sense, fear of exposure has been used as a resource to keep women isolated at home and away from social contact. ,

The vulnerability of those who were already experiencing situations of violence before the pandemic has increased. Based on the articles analyzed, it is possible to assert that the pandemic has revealed several situations of rights violations in the life stories of women veterans, migrants, pregnant women, , puerperal women, and adolescents and young people. , , , , The pandemic and the measures taken to combat it did not create all observed inequality gaps in the societies. , , , Given this reality, it is necessary to transcend fragmented views of the link between violence and the pandemic to analyze the complexity of relationships within a patriarchal system. , ,

Authors formulate recommendations and strategies for the prevention and confrontation of domestic and family violence against women. Telemedicine has been used to maintain contact with patients while reducing the risk of exposure to COVID‐19. , , , , , , Its use can be recommended for screening and for the provision of support resources to survivors of violence, taking into account the need to ensure the women’s privacy and security. The recommended resources include the verification of privacy, the use of closed questions to verify security, , , , the use of specific colors or codes in case of danger, and flexibility to take advantage of the aggressor’s absences. ,

Health professionals are recognized as essential actors in the identification and management of cases of violence, with the authors highlighting the importance of their training, , , , , , , , , , , in addition to the need for support to deal with experiences during the pandemic and prioritize the well‐being of the health professionals. , Specific recommendations have been launched for psychiatrists, radiologists, and dentists and maxillofacial surgery teams.

The use of “traditional” paths, such as reaching out to shelters, victim support centers, police departments and helplines, and preparing a security plan, has been combined with the use of virtual channels, such as websites and messaging applications. Security precautions such as clearing history of use, calls, and messages should be taken when using them. , , , , ,

Public campaigns to raise awareness and informative leaflets and handouts are identified as necessary for education on the topic and should be given on available services and facilities. , , , , , , , , These materials send the message to survivors that they are not “alone” and contribute to deconstructing the idea of the aggressor’s impunity.

In public spaces like pharmacies, the use of confidentiality codes has been established , , in addition to the distribution of informative handouts in facilities considered essential services. This initiative improves access for women who are prevented from using virtual channels. Maintaining and ensuring basic services for survivors in public spaces of health, safety, and justice are also indicated as relevant strategies, in addition to operating specialized centers and volunteer initiatives. , , , , , , , , , , , ,

Several authors emphasize the need for validated and culturally adapted screening instruments. , , , Collaborative and integrated work between organizations for the collection of data, indicator selection, impact assessment, and the design of actions against violence are also highlighted. , , , , The multidisciplinary and intersectoral approach is presented as key in the analyzed articles. , , , , , In addition, many formulate questions regarding the role of local and national governments. , , , ,

Personal and community support networks and their role in denouncing and protecting survivors are another important topic in the literature. , , , , , , It is crucial to think critically about the idealized representations of family and the home, to offer survivors the possibility of talking about the subject and creating actions to combat abuse and control within the family.

The authors recommend conducting clinical, epidemiological, and psychosocial research related to COVID‐19 and sexual and reproductive health. , , They also underline the need to implement public policies for the prevention, protection, investigation, and punishment of violence, and to create opportunities for the economic independence of vulnerable women. The integration of a gender perspective in statistics, impact assessments, and actions in crises are recommended, , , , as well as maintaining and ensuring access to services focused on women’s sexual and reproductive health. , , The long‐term nature of the impact of the pandemic highlights the importance of implementing actions to prevent and confront domestic and family violence against women. , , ,

DISCUSSION

Violence and its exacerbation during the COVID‐19 pandemic have been identified as a global and public health issue that requires an urgent response. The literature analyzed consists predominantly of primary research, comments, editorials, and letters to editors raising red flags to the scientific community and advocating for the elaboration of prevention strategies and integrated responses to violence in the domestic and family space.

The existence of publications on violence in the domestic context and within family ties denotes emerging concerns about the possible impacts of social distancing measures on the well‐being and physical and mental health of vulnerable populations. These concerns are supported by the evidence of violations of the rights of girls and women during previous emergencies and disasters. The use of words such as “paradox,” “hidden,” or “tip of the iceberg” by the authors in reference to the topic reveals the complexity of the phenomenon.

Violence against women was already a global and public health issue before the COVID‐19 pandemic. Evidence shows that one in three women has experienced physical and/or sexual violence from an intimate partner in her life. The high prevalence of violence experienced by women throughout their lives in situations of “supposed normality” is an alert. In the current crisis, the coexistence of factors of a different nature intensifies the vulnerability in women.

The multiplicity of roles assigned to women in society increases their exposure to situations that deteriorate their physical and mental health. In the current pandemic, women represent 70% of health professionals, many of whom are working on the frontline. These women usually assume the roles of both caregiver and family provider, facing situations of rights violation not only at work but also at home.

Some authors have promoted certain aspects over others in their analysis of the dynamics of violence in times of pandemic, especially by focusing on individual and relational factors. This trend was observed when analyzing risk and protection factors associated with violence. In general, the literature reveals that the elements identified as factors increasing vulnerability to violence have been exacerbated as a result of the impact of the pandemic and the social distancing measures on social, economic, and personal relationships. Nevertheless, the fact that this phenomenon is being analyzed and empirical data are collected as it unfolds brings to light the need to develop epidemiological studies.

The challenges posed to governments and healthcare systems by the COVID‐19 pandemic have also impacted how violence against women is addressed. New protocols and approaches have been recommended to tackle violence, taking into account the complexity of the phenomenon. There is a concern, in several areas of healthcare, to adopt best practices when screening and assisting survivors of violence. In this sense, training and education for health professionals are key. They should include information on warning signs and technical knowledge as well as challenge the representations of health workers around violence against women.

A topic that should be discussed is the process of collecting and systematizing data on the course and dynamics of violence during the pandemic and on the extent to which health and safety systems are prepared to track cases of violence and to step in. In this sense, there is an urgent need to reinforce the joint work between public security and the health and social assistance sectors, in addition to civil society, in the prevention, identification, and confrontation of violence.

Intersectionality in prevention, screening, and intervention are essential to address domestic, family, and intimate partner violence, alongside the implementation of public policies and strategies focusing on gender and rights. Women should be included in the “decision‐making and planning of interventions, security surveillance, detection and prevention mechanisms”.

The confinement situation forces women to spend most of their time at home with their aggressor, a reality that complicates both screening by professionals and the seeking of help by the women. During the pandemic, social media has seen an increase in complaints from third parties about situations of violence. In Brazil, the Brazilian Forum of Public Security observed a 431% increase in reports of fights among neighbors on social media between February and April 2020. This reveals the role of community networks, friends, and family in identifying and taking action in cases of violence.

The strategies and recommendations presented by the authors expose the need to think about strategies before, during, and after the pandemic, given the probability that the vulnerable conditions of women will continue.

CONCLUSIONS

The use of different terms to describe the violence experienced by women reveals the multiplicity of scenarios where their rights can be violated. The already evident consequences of the COVID‐19 pandemic on the physical and mental health of populations highlights the necessity of planning actions based on the experiences of previous crises and emergencies.

The health sector has a key role to play in identifying cases, providing support, and validating the experiences of survivors during this crisis. The scientific community should perform original studies to produce evidence on the dynamics of violence at this stage and to design strategies for preventing and confronting violence against women during and after the pandemic.

AUTHOR CONTRIBUTIONS

ORS and FGS conceived the idea. ORS and FGS wrote the draft version. FGS, DV, LR, and ORS revised the manuscript. All authors provided feedback on the manuscript and approved the final version.

CONFLICTS OF INTEREST

The authors have no conflicts of interest.

Click here for additional data file.

The course

The tendencies in reports of domestic and family violence during social distancing measures

The dynamics

Factors or elements addressing the higher vulnerability experienced by women in situations of violence in the home, family, or linked with the intimate partner

Recommendations and strategies for prevention and confrontation

Strategies for prevention or intervention in situations of violence, as well as suggestions for those measures that need to be strengthened during and after the pandemic