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. 2025 May 8:47:101114.
doi: 10.1016/j.lana.2025.101114. eCollection 2025 Jul.

Healthcare responding to violence and abuse in Brazil: a quasi-experimental difference-in-differences analysis

Estela Capelas Barbosa  1 , Stephanie Pereira  2 , Loraine J Bacchus  3 , Manuela Colombini  3 , Gene Feder  1 , Lilia Blima Schraiber  2 , Ana Flávia Pires Lucas d'Oliveira  2
Affiliations

Healthcare responding to violence and abuse in Brazil: a quasi-experimental difference-in-differences analysis

Estela Capelas Barbosa et al. Lancet Reg Health Am. .

Abstract

Background: Domestic violence against women (DVAW) is a public health issue and a breach of human rights, yet evidence on effective interventions remains limited, particularly in low-income and middle-income countries. This study aimed to evaluate changes in identification and referral to specialist support associated with system-level strategies implemented within Brazilian primary healthcare (PHC) to strengthen the response to DVAW. The strategies comprised an intervention called Healthcare Responding to Violence and Abuse (HERA).

Methods: Using a quasi-experimental design, HERA was implemented in eight PHC clinics, while 33 served as controls. Data on DVAW identification and referral were obtained from the national Epidemiological Surveillance System. Difference-in-differences analysis, using negative binomial regression, assessed HERA's impact, controlling for patient inflow, clinical supervision, COVID-19 lockdown, region, and clinic. Results are reported as marginal effects with 95% confidence intervals (CI).

Findings: There was an increase in the probability of DVAW identification (0.47; 95% CI 0.18-0.77) and referral to support services (0.38; 95% CI 0.03-0.73), when adjusting for panel effects and time. The results were even larger when further controlling for additional variables (0.82 for identification [95% CI 0.44-1.21] and 0.87 for referrals [95% CI 0.47-1.29]).

Interpretation: HERA strategies increased DVAW identification and referral in PHC settings. Clinics implementing HERA were already more likely to identify and refer cases before the implementation, suggesting that HERA's strategies may be more effective in clinics that find DVAW interventions more acceptable, at least in Brazil.

Funding: NIHR Global Health Research Group Award.

Keywords: Domestic violence; Intervention; Low and middle income countries; Primary healthcare; Violence against women.

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Conflict of interest statement

Estela Capelas Barbosa and Gene Feder reports salary support from the UK Prevention Research Partnership (Violence, Health and Society; MR-VO49879/1) for the present manuscript. This partnership is funded by the British Heart Foundation, Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Health and Social Care Research and Development Division (Welsh Government), Medical Research Council, National Institute for Health and Care Research, Natural Environment Research Council, Public Health Agency (Northern Ireland), The Health Foundation, and Wellcome. Gene Feder reports honoraria for clinician teaching events and institutional support from the NIHR for the present manuscript. He also declares travel support from the Global Burden of Disease programme and serves as an unpaid trustee for IRISi. All other authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Monthly trends in identification and referral rates by region and intervention status. Note: These plots were used to visually assess the parallel trends assumption underlying the difference-in-differences analysis. While some natural fluctuation is expected, trends appear approximately parallel in the pre-intervention period, particularly in the West region.
Fig. 2
Fig. 2
Observed means and linear trends in identification.
Fig. 3
Fig. 3
Observed means and linear trends in referral.
See this image and copyright information in PMC

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