Perceptions and Practices of Angolan Health Care Professionals Concerning Intimate Partner Violence Against Women

ARTIGO ARTICLE 1229

Perceptions and practices of Angolan health care professionals concerning intimate partner violence against women

Percepções e práticas de profissionais de saúde de Angola sobre a violência contra a mulher na relação conjugal

Percepciones y prácticas de los profesionales de salud de Angola sobre la violencia contra la mujer en la relación marital Edna de Fátima Gonçalves Alves do Nascimento 1 Adalgisa Peixoto Ribeiro 1 Edinilsa Ramos de Souza 1

Abstract Resumo

1 Escola Nacional de Saúde This was a qualitative exploratory study with the Trata-se de um estudo qualitativo explorató- Pública Sergio Arouca, Fundação Oswaldo Cruz, objective of identifying perceptions and practices rio com o objetivo de identificar as percepções e Rio de Janeiro, Brasil. among health professionals in Angola concern- práticas de profissionais de saúde de Angola em ing intimate partner violence against women. relação à violência contra a mulher na relação Correspondence A. P. Ribeiro Semi-structured interviews were held with a se- conjugal. Entrevistas semiestruturadas foram Centro Latino-Americano de nior health administrator, head nurses, medical realizadas com macrogestor da saúde, enfermei- Estudos de Violência e Saúde directors, psychologists, and nurse technicians ros diretores de enfermagem, médicos diretores Jorge Careli, Escola Nacional de Saúde Pública Sergio in three national hospitals in the capital city of clínicos, psicólogos e técnicos de enfermagem Arouca, Fundação Oswaldo Luanda. The perceptions of Angolan health pro- em três hospitais nacionais de Luanda. As perce- Cruz. fessionals towards violence against women are pções dos profissionais de saúde angolanos sobre Av. Brasil 4036, sala 700, Rio de Janeiro, RJ 21040-361, Brasil. marked by the cultural construction of woman’s a violência contra a mulher são marcadas pela [email protected] social role in the family and the belief in male construção cultural do papel social da mulher superiority and female weakness. Despite their na família, pela crença na superioridade mas- familiarity with the types of violence and the culina e fragilidade feminina. Apesar de conhe- consequences for physical and mental health, cerem os tipos de violência e suas consequências the health professionals’ practices in providing para a saúde física e mental, suas práticas na care for women in situations of violence focus on atenção às mulheres em situação de violência the treatment of physical injuries, overlooking priorizam o tratamento das lesões físicas, sem the subjectivity and complexity of these situa- contemplar a subjetividade e a complexidade tions. Recent inclusion of the issue in public pol- dessas situações. A recente inclusão do tema nas icies is reflected in health professionals’ practices políticas públicas se reflete nas práticas dos pro- and raises challenges for the health sector in car- fissionais e determina os desafios para o setor na ing for women in situations of violence. atenção à saúde das mulheres em situação de violência. Violence Against Women; Domestic Violence; Health Personnel Violência Contra a Mulher; Violência Doméstica; Pessoal de Saúde

http://dx.doi.org/10.1590/0102-311X00103613 Cad. Saúde Pública, Rio de Janeiro, 30(6):1229-1238, jun, 2014 1230 Nascimento EFGA et al.

Introduction ing that these services can be an important portal of entry to support and protect women exposed Violence against women, the object of this study, to intimate partner violence and that seek help, refers to gender-based acts of violence that result public policies recommend offering expanded in physical, sexual, and emotional harm or su- healthcare to these women, which incorporates ffering for women, including threats, coercion, comprehension and change of attitudes, beliefs, or constraints on freedom in public or private li- and practices, with a scope that extrapolates sim- fe 1. Some authors discuss how such violence is ple diagnosis and care for physical injuries and taken for granted and justified by the patriarchal emotional trauma. order, in which men have the right to command Given these elements and the magnitude of and control women, resorting to violence for this violence against women, the aim of this study purpose 2. is to identify the perceptions and practices of The various manifestations of violence health professionals in Angola concerning inti- against women can cause physical and mental mate partner violence against women. health problems and increased use of health services. Population studies show that 10% to 69% of women 15 to 49 years of age have been victims of Methodology physical violence perpetrated by intimate partners at least once in their lives 3. A multi-country A qualitative exploratory study was conducted study on domestic violence found that 6% to 59% in three national hospitals in the capital city of of the women interviewed had suffered sexual Luanda: Josina Machel Hospital, Lucrécia Paim violence perpetrated by their partners sometime Maternity Hospital, and Neves Bendinha Hospi- in life 4. tal. Josina Machel is a general hospital with 480 Gender studies on violence against women, beds, treating approximately 200 emergency cas- also identified as gender-based violence, in- es per day. In 2009 it treated 55,440 emergency volves aggressions based on power relations and cases. The Lucrécia Paim Maternity Hospital has cultural differences attributed to the sexes. Gen- an emergency ward and outpatient and inpatient der-based violence can include violence by men services. It has 400 beds and treats approximately against women, by women against men, and also 200 women per day. In 2009, the emergency ward between women and between men, but women treated nearly 43,000 women. The Neves Ben- have been the most frequent victims in relations dinha Hospital is a referral center for burn pa- with men 2,5,6. tients with 60 beds. In the specificity of intimate partner rela- These healthcare facilities were selected be- tions, intimate partner violence 7,8,9 occurs re- cause they are national references for treating gardless of social class, race, ethnicity, age, or emergency cases and victims of intimate part- sexual orientation 10 and is expressed as physi- ner violence, but none of them systematically re- cal, sexual, emotional, or psychological and so- cords the latter cases. Emergency care is a pow- cial aggression 5. erful indicator of violence in Luanda, since it is Medium and low-income countries, with where victims turn in cases of trauma or immi- Angola as an example of the latter, suffer from a nent death. For many victims of violence, it is the lack of data on violence against women, which only time they will be face-to-face with a health contributes to the issue’s invisibility. Data on professional (a representative of public author- intimate partner violence from the Ministry of ity) and one of the only moments in which the the Family and Women’s Protection (MINFAMU), violence will be reported 12. recorded in the first quarter of 2006 at the Fam- Thirteen semi-structured interviews were ily Counseling Center, showed that of the 2,260 conducted with: a senior health administrator, cases of violence in Luanda, 92.6% of the vic- three head nurses, three clinical medical direc- tims were women and 90.5% of the aggressors tors (identified in the text as administrators), were men. At this institution, economic violence three psychologists, and three nurse technicians (denial of paternity, failure to pay child support, (identified as technicians), of both sexes. All had abandonment of the family, eviction of the wom- relatively extensive experience in their areas. an, and expropriation of the woman’s assets) is They were referred to the study by the Division the most common complaint (70.9%), followed of Hospital Administration and the Ministry of by physical violence (10.5%) and psychological Health. The health services authorized the study, violence (8.9%) 11. and the subjects signed a free and informed con- Health services in Angola rarely identify or sent form to participate in the interviews. deal with violence in conjugal relations, a situa- The interview script included questions on tion that hinders preventive measures. Consider- the professionals’ perceptions towards the inti-

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mate partner violence suffered by women, their not want [to have sex] or is unable for medical approach to these cases, and the role of health reasons, and even so the husband refuses to accept services in dealing with violence. The interviews that she refuse to have sex” (technician; female). were taped, transcribed, and analyzed according In such conditions, women sometimes resist but to the thematic analysis technique adapted from end up giving in, in order to protect themselves Bardin by Minayo 13. The material was organized from physical aggression as a result of their re- in a databank according to professional category fusal, to guarantee their financial support, and and the themes discussed in the interviews. The to avoid being accused of infidelity, apparently a material was later read exhaustively to identify common reaction in Angolan culture. core meanings that emerged in the previously The reasons cited for violence include situa- defined themes. The analyses were presented tions that spark jealousy. When a woman is seen according to these broader themes: perceptions talking to someone else, “There’s no other way towards intimate partner violence, care offered to solve the problem except throwing something to women in situations of intimate partner vio- at her” (technician; female). This excerpt from lence, and challenges in providing care for these an interview with a female health professional women. shows that physical aggression is commonplace, The study was approved by the Ethics Re- even taken for granted, in resolving intimate search Committee of the Sergio Arouca National partner conflicts. School of Public Health, Oswaldo Cruz Founda- According to the literature, other reasons fre- tion (case review n. 167/10). quently cited for aggression between intimate partners include the woman’s refusal to have sexual relations, disobeying the husband, infi- Results and discussion delity, failure to properly care for the children, challenging the husband on financial issues or “Women aren’t prepared for married life”: extramarital relations 15, stress, and use of alco- the perceptions of Angolan health hol and other drugs 16,17. professionals towards violence Alcoholism did not appear in the health pro- against women fessionals’ discourse as a factor associated with intimate partner violence. However, Nascimento 18 The health professionals interviewed in this found that in Kilamba Kiaxi, Angola, 18% of in- study defined violence against women as any- terviewees pointed to alcohol use as a factor for thing that jeopardizes their dignity, expressed by physical violence against women. discrimination and denial of their rights: “In my Interviewees perceived that the aggressions opinion, intimate partner violence is violence at negatively affect the woman’s health and that of all levels. Whatever undermines the woman’s dig- her family, and represent a public health prob- nity is violence” (administrator; female). lem. The most frequently cited physical conse- This kind of violence occurs between boy- quences were: injuries, hypertension, burns, friends and girlfriends, cohabiting couples, and and death. Psychological trauma included de- in common law and official marriages. Some in- pression, neglecting to seek medical services, terviewees highlighted that women are the most phobias, suicide attempts and tendency, alco- frequent victims in relationships, but that they hol abuse, and post-traumatic stress disorder. can also be the aggressors. Just as “many men kill They also cited psychological disorders during women”, “ many women kill the men, hit them, as- pregnancy, threats to the infant, miscarriage, sault them” (technician; male). According to this premature childbirth, and even the woman’s view, corroborating other studies 10,14, men can murder. be victims of women, but the cruelty and severity Other studies list as consequences of vio- suffered by men are normally less than the ag- lence against women: muscle tension, gastro- gressions perpetrated by them. intestinal irritation, genital problems, sexually The interviews showed that violence against transmitted diseases, sexual dysfunction, un- women in intimate partner relations is mani- wanted pregnancy 19, emotional anxiety, and fested as different forms of physical aggression, suicidal behavior 15. like beatings, burns, firearm and knife wounds, Some factors mentioned as associated with sexual abuse, and psychological, economic, and intimate partner violence appear to justify it and even spiritual violence. According to these health reinforce male domination. The historical male professionals, sexual violence between spouses domination over women is considered a social occurs as a form of coercion by the man against problem that subjects women to sexual violence the woman, claiming that sexual intercourse is by the partner 20. In African cultures, as in Mo- the wife’s obligation, “even when the woman does zambique for example, violence is a structural

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component of conjugal relations, reinforced by According to studies in more traditional so- women themselves, who appear to grant the man cieties, as in some African countries, violence this right 21. against women is justified culturally, and women Administrators and technicians highlighted are assigned the role of keeping the home and women’s submission, their socioeconomic de- family and the duty of obedience to (and respect pendency on men, and unemployment as issues for) the man’s wishes 15. The interviews with tech- closely related to violence and that assign wom- nicians clearly showed that a breach of roles cul- en the responsibility for the violence they suf- turally identified with the female gender, such as fer. This perception is marked by male chauvin- the woman “who doesn’t make lunch, doesn’t iron ist prejudices and values, even among women, her husband’s clothes” (technician; female) are still very strong in Angolan culture: “A woman cited as a woman’s lack of preparedness for mar- who suffers violence is one who can’t get by on her riage and for fulfilling family duties, potentially own, so she can’t say no to her partner, and that’s triggering male violence. Thus, they believe that where violence comes in. (...) it’s for lack of salt or one has “to talk to women about their comport- sugar that a beating can happen when the man ment in the home, prevent troubles by lecturing of the house is a chauvinist and raises his hand to her, explaining women’s duties within the family” strike her” (administrator; female). “...As long as (technician; female). she depends on him, she can’t say a word. What- ever she says will lead to violence” (administrator; “If there are physical injuries, we can treat female). them”: care offered to women in situations Some say that breaking with this violent rela- of intimate partner violence in Angola tionship can threaten her survival and that of the children, but overcoming this condition means The literature recommends that healthcare in achieving an equal footing with the man, allow- suspected or confirmed cases of violence should ing her to raise her self-esteem, freeing her from include investigation, protection, and qualified economic dependency and refusing to accept listening, treatment of physical injuries and psy- violence. chological trauma, and referral within and be- Contrary to this view, one of the interviewees tween sectors. Attention to this characteristic of mentioned that in some cases it is easier for the care requires a trained multidisciplinary team woman to find work and thus support the family. with a broad, comprehensive view of women’s But this also generates intimate partner violence, health 23. since “...the man isn’t used to the woman going In these three Angolan hospitals, women out to work and coming home to find him doing have a case history recorded in the emergency nothing” (technician; male). ward. If there is any suspicion of violence, identi- Following the civil war in Angola, the reinte- fied mainly by physical injuries (uterine bleeding gration of former combatants into society was in pregnant women, burns, fractures), the nurse a complex process, since they returned to their technicians question them about the circum- communities without work and with the women stances in order to confirm the violence. heading, protecting, and supporting the family The analysis showed that a major share of economically 21. The fact that the man failed to the interviewees only provide traditional treat- meet expectations as family provider and that the ment, caring only for the victims’ physical inju- woman earned better money can pose the risk of ries and encouraging the victims to report to the violence, leading the man to impose his authority police, but without referring them for psycho- by physical force, since this situation is a threat logical or social follow-up, partly because there to his male identity and represents a break in the are few psychologists or social workers in Angola, rules and beliefs that the man should not be sup- and few health services have them in their staff. ported by the woman 21,22,23. They also feel that psychological violence is not a The administrators emphasized gender in- problem for hospital and claim that “the person equalities, the biological, social, economic, and doesn’t come to the doctor to complain about psy- cultural factors that define men and women’s chological abuse” (administrator; male). roles in family and society. Male health profes- It became clear that the interviewees did sionals thus especially view women as weak, not see possibilities for their own intervention submissive, and helpless and thus more vulner- and did not feel responsible for providing com- able to violence, which in turn helps perpetuate prehensive care (beyond clinical procedures for these inequalities: “...in a way this violence af- treating physical injuries) or including a broader fects women because they’re weaker, and the men approach to the situations of violence suffered sometimes use physical force and cause harm and by women: “...we are a hospital, and our focus is injury to women” (administrator; female). more treatment-based, especially when there are

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physical injuries that we can treat” (administra- interrupt the cycle of violence, as recommended tor; female). in the country’s Law against Domestic Violence The literature has reiterated the frequent (LVD) 26. The most common approach by techni- search for healthcare by victims and a response cians towards the perpetrator of the violence is limited to the treatment of symptoms and le- to call the police, “who take the appropriate steps sions, neglecting the cause of the problem and with the aggressor” (technician; female). perpetuating physical, psychological, and social These healthcare facilities do not have any harm 24. specific recording system for cases of violence With this biologically-centered vision of care against women, and the daily care is only record- for victims of violence, the interviewees claimed ed in a general log book. Pregnant women keep a that there was no difficulty in acting in such cas- prenatal card which includes the following ques- es, as shown in these interviews: tion on violence: “Have you ever suffered any kind “I don’t think there’s any major difficulty in of violence?”, with only two possible answers: dealing with these patients because our work here physical violence and moral violence. Since focuses more on the issue of medical treatment it- women normally deny having suffered violence, self” (administrator; male). this item on the card is never filled out. Women’s “We don’t experience major difficulties in denial is likely due to the bureaucratic way the treating people, because the hospital services are question is addressed and the limited options fully equipped and prepared to treat the patients for answering. Only one technician stated that that come to our emergency ward” (technician; the hospital where he works has a form to record female). cases of violence, which are referred to the police Importantly, there have been times in health and the agency for women’s defense. services in Angola when patients had to purchase and bring the supplies used for their treatment in Major challenges for providing care to the hospitals. Angolan women in situations of intimate According to the interviews, when the woman partner violence spontaneously reports the violence it facilitates treatment and referrals. However this does not All the interviewees acknowledged that the ser- guarantee follow-up on the case, which would re- vices are not organized to offer specialized care quire a referral and counter-referral system with for female rape victims. They emphasized dif- well-defined flows and procedures, and such a ficulties in identifying and acting in these cas- system does not exist in Angola. es, highlighting women’s silence. The fact that Psychologists and social workers act as fa- they fail to disclose the abuse calls for closer cilitators in managing such cases, reinforcing attention in evaluating injuries and confirming the idea that victims should receive multidisci- suspicions. plinary care, but they only exist in one of these “The woman never admits that it was abuse. three healthcare facilities. Their reports suggest- The physician suspects it for some reason, some ed a careful and respectful encounter with these injury in an unusual site, and in the course of the patients, establishing trust between the woman conversation she confirms that she was abused” and the healthcare professional to talk about the (administrator; female). violence, prioritizing the woman’s self-esteem According to one administrator, failure to and decision-making capacity in dealing with speak about the violence can lead to repeated intimate partner violence. Even without having abuse. According to the technicians, this silence received specific training on the subject, these is due to cultural issues such as the tradition of professionals have endeavored to offer a more woman’s submission to her man or partner, dis- sensitive therapeutic approach, with orienta- couragement from the family for complaints, tion and counseling on the impact of violence on counseling the couple to make amends, and fear victims’ health, as well as on their place in soci- over losing her home and social status or suffer- ety. However, according to one study 24, they do ing further abuse. The technicians contend that not identify such interventions as professional women do not “want” to leave the situation of or scientific. On the contrary, they view them as violence because they are not willing to radically outside the realm of their professional role and change their living conditions. Ferrante et al. 27 consider them personal advice or solidarity. found similar perceptions to those of the Ango- Although experts recommend treatment for lan health professionals concerning women per- the aggressor 25, the nurse technicians reported sisting in violent relationships. that such contact is rare, but when they do suc- In addition to the reasons identified by the ceed in establishing it, they counsel the aggressor interviewees, the following are common: the by encouraging dialogue in the couple, aiming to perception that violence is normal in intimate

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partner relations 28, that there is still hope and Brazil has what is known as the Maria da love for the partner 19, that the woman cannot Penha Law 33, which criminalizes violence against find the words to express her problem, and dif- a woman by her current or former intimate part- ficult interpersonal relations between patients ner. The law protects the woman, preventing her and health professionals, full of fears, prejudices, from withdrawing the complaint. Angola has shame, and discredit 29. the LVD 26, the aim of which is to protect and as- For women to speak about their experience sist victims and prevent such violence. It covers with violence is a complex issue. Violence ap- specific issues related to victims and aggressors, pears to be equated with crimes committed by while aiming to promote gender equality. strangers and more dire situations. Domestic In practice, the care provided by Angolan violence, even with serious consequences, is not health professionals focuses more on medical normally viewed as such 29. specialties, which tends to overshadow their per- The senior administrator identified the perception, involvement, and action and thus over- ception that this is a private problem between looking the biopsychosocial dynamics entailed the couple in which health professionals should in intimate partner violence. Like these profes- not get involved, since they would be invad- sionals, some authors have highlighted the im- ing privacy, and highlighted this perception portance of a multidisciplinary team that would as an obstacle to identifying intimate partner allow comprehensive care 10,12,15,34. violence. This view indicates resistance and The reasons cited for this fragmented care embarrassment among the health profession- are the limited number of health professionals in asking women about violence when they als, lack of a trained multidisciplinary team, suspect it has occurred. Meanwhile, research- and studies to orient management in case of ers indicate that health professionals should violence. Other reasons that have been cited in- ask women clearly and objectively about their clude the lack of healthcare referral services for experience with violent situations, encouraging treating victims, in the mistaken view that such and allowing them to talk openly about the sub- care should be provided by a specialized service ject 23. Treating women in situations of violence rather than by the entire healthcare system, as a involves values, decisions, and trust to provide crosscutting issue. care and knowledge about the actions in care Angola’s National Health Policy (PNS) ac- and their consequences 30. knowledge the quantitative and qualitative insuf- A female administrator showed a discrimina- ficiency of human resources and recommends tory and judgmental attitude, ignoring women’s hiring foreign healthcare workers to fill these reasons for omitting the violence and claiming gaps until consistent training of Angolan to work that “they aren’t capable of being sincere” in re- according to the new health technologies 35. porting the cause of their injuries, adding, “We Some interviewees acknowledged the impor- want to treat them, but the women won’t let us” tance of support from the inter-sector network, (administrator; female). in agreement with the literature 36,37. But the ma- The interviews show the need for the health jority reported that the lack of linkage between professional to establish a relationship of trust, health services and social structures for support with respect and receptiveness. They contend and protection (MINFAMU, the Organization of that if a woman has been raped by her partner Angolan Women, Ministry of Social Assistance and persists in the relationship, it is because “she and Reintegration) results in inadequate care enjoys a beating”, or that she “is not ashamed of that often perpetuates violent episodes. After herself” because she fails to leave the man, with- clinical treatment, women victims of intimate draws her complaint, and makes up with her ag- partner violence are referred to support services gressor. Such beliefs ignore the typical dynam- where they receive follow-up on such issues as ics of intimate partner violence, in which a cycle abandonment, denial of paternity, failure to pay of tension precedes the aggression, followed by child support, criminal prosecution of the ag- a period of regret by the aggressor and a truce, gressor for physical assault, or violation of legal followed by a new cycle of tension. They often rulings by one of the spouses. However, there is blame the woman or overlook her complaint due no counter-referral to the health services, which to the services’ disorganization or unprepared- hinders the linkage with the network from wom- ness, leading to negative practices in care for the en’s protection in situations of violence, as pro- women 31. One of the health professionals’ dif- vided by the PNS. ficulties in supporting victims of violence, espe- The interviewees were unanimous about the cially sexual violence, is to overcome prejudices lack of professional training as the main difficulty related to cultural and moral values in order to for dealing with situations of violence. One ad- offer supportive and humanized care 32. ministrator highlighted the need for awareness

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and skills to maintain control, self-command, are also heavily laden with prejudices grounded and the capacity to orient victims of violence. in purported male superiority, attributing the This unpreparedness has been identified by ma- dominant role to men and identifying women as ny studies in the health field 16,20,38. Brazil has weak and helpless. These professionals were able public health policies to orient such care, but to list types of violence and their consequences there are still gaps in training for health profes- for physical and mental health, but their views sionals to provide this care 39. In Angola, health expressed the hierarchical and asymmetric gen- policies include the issue of violence, although der relations that foster violence, placing the re- with a limited scope, and there is an urgent need sponsibility on women for the aggression they for training, as recommended by the PNS 35 and suffer in this relationship. the LVD 26. According to the administrators, Given this view of violence against women, awareness-raising and training for health profes- the practices of these professionals in caring for sionals are essential to avoid women’s repeated victims take an essentially clinical focus, priori- victimization. Their interviews reveal a form of tizing the treatment of physical injuries while institutional violence against woman, by failing overlooking or failing to sufficiently contem- to value their complaints and by offering treat- plate the subjectivity and complexity of these ment limited to clinical procedures, failing to situations. They do not always approach or are take an expanded approach to the question. oriented to act with the individuals involved in Other issues that hinder and limit care are these situations: the woman, the children, and the lack of institutional support, absence of pro- much less the aggressor. Aggressors are rarely tocols with technical guidelines for care in such approached, and even then with a police view, cases, women’s lack of knowledge on psycho- taking a punitive approach to the case, showing logical and social care (which are new special- that the health professionals mainly associate ties in the country), lack of implementation of domestic violence with law enforcement in the the health policies orienting this care, the limited belief that the police and courts should solve the physical space of services (failing to guarantee issue. In short, in the view of the interviewees, patients’ privacy), and the health professionals’ intimate partner violence is only a matter for the work dynamics. social worker and psychologist, as well as the po- One administrator emphasized that the lice and courts. In fact, the study showed that the heavy work overload hinders in-depth investiga- psychologists were more sensitized than their tion of violence, since many cases go unnoticed colleagues from other health specialties to take and the technicians “are not capable of that kind a more appropriate approach to women in situa- of expertise, suspecting and probing a little fur- tions of intimate partner violence. ther” (administrator; male). The PNS recently enacted in Angola acknowl- As strategies to overcome these challenges, edges that women and children are the main vic- the interviewees emphasized: organization of the tims of domestic violence. In its analysis of the health services at the various levels of care to im- health situation, the policy refers to physical and plement measures for the prevention of violence psychological violence as “an unhealthy lifestyle”. against women, mobilization of human, mate- However, it fails to provide specific guidelines to rial, and financial resources in health and other provide care for victims and prioritizes the pre- sectors, such as public security, justice, and work, vention and treatment of infectious diseases, the in order to act jointly to care for women in situa- predominant problem in health services in Ango- tions of violence. la. This timid and incipient inclusion of the issue One administrator also called attention to in public policies is mirrored in the practices by the media’s shared responsibility for educating health professionals and in the difficulties they people to prevent violence against women: “The experience, and determines the major challenges mass media have the fundamental duty to com- for the healthcare system in caring for women in municate all this information and educate the situations of violence. population” (administrator; male). These challenges include: (1) administrator awareness-raising and staff training on the subject; (2) organization of healthcare services Final remarks to provide care through interdisciplinary teams, with protocols, technical guidelines, referral and The perceptions of Angolan health profession- counter-referral flows; support for professionals concerning violence against women in inti- als involved in this care; recording and report- mate partner relations appeared heavily marked ing of cases of violence to the health authorities; by the cultural construction of women’s role in (3) establishment of an intra- and inter-sector the family as mother and spouse. Their views network to support and care for victims; (4)

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approval and enforcement of measures to pre- is necessary to give greater visibility to women’s vent violence against women as a responsibility importance in society, their rights, their partici- of health professionals and services at all levels pation in the labor market, and even more ur- of care; (5) inclusion of aggressors and the guar- gently, to no longer take for granted the violence antee of trained, sufficient staff to counsel and women suffer in their social relations, especially assist couples in resolving their conflicts within intimate partner relations. out resorting to violence; and (6) promotion of It is hoped that this study will help increase changes in health professionals’ concepts and the visibility of the need to combat gender-based practices in order to no longer take for granted violence, so present in Angolan culture and so- the cultural values pertaining to women and vio- ciety. Further developments of this process in- lence, promoting healthcare in which users can dicate the need for more in-depth knowledge, receive skilled and humanized care. hearing the women and men involved in violent As in Brazil and other countries with health relations to learn how they perceive the work by policies recommending the prevention of vio- health services and the possibilities for the health lence and organization of services to care for system to offer help in such cases. victims, Angola also needs to take these steps. It

Resumen Contributors

Se trata de un estudio cualitativo exploratorio, con el E. F. G. A. Nascimento participated in the data collec- objetivo de identificar las percepciones y prácticas de tion, processing, and analysis and writing of the article. los profesionales de salud de Angola sobre la violencia A. P. Ribeiro and E. R. Souza participated in the data pro- contra la mujer en la relación marital. Se realizaron cessing and analysis, writing of the article, and approval entrevistas semi-estructuradas con los administrado- of the final version. res de salud, enfermeras jefa, médicos clínicos, psicó- logos y personal de enfermería de tres hospitales de Luanda. Las percepciones de los profesionales de salud Acknowledgments sobre la violencia contra las mujeres se caracterizan por la construcción cultural de la función social de The authors wish to thank the health professionals who la mujer en la familia, la creencia en la superioridad kindly granted interviews. masculina y la fragilidad femenina. A pesar de cono- cer la violencia y sus consecuencias para la salud física y mental, sus prácticas de atención para mujeres en situación de violencia priorizan el tratamiento de las lesiones físicas, sin tener en cuenta la subjetividad y complejidad de estas situaciones. La reciente inclusión del tema en la política pública se refleja en las prácti- cas y determina los problemas del sector en el cuidado de la salud de las mujeres en situaciones de violencia.

Violencia Contra la Mujer; Violencia Doméstica; Personal de Salud

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