Introducción

La violencia que tiene lugar en el hogar presenta características muy especiales ya que se da fundamentalmente entre individuos que comparten relaciones de afecto mutuo en un espacio privado. En este sentido, los grupos más afectados son aquéllos con mayor vulnerabilidad física. Los estudios realizados en México no han dado cuenta sobre las características de las mujeres que, debido a la violencia por parte de su pareja, acuden a los servicios de salud en las instituciones públicas para recibir atención. El objetivo del presente artículo es analizar los factores asociados al uso que de dichos servicios hicieron las mujeres lesionadas, víctimas de su pareja, incluidas en la Encuesta Nacional de Violencia contra las Mujeres en México (ENVIM).

Metodología

Estudio transversal realizado en mujeres de 15 años o más, que acudieron a los servicios de salud en instituciones públicas de México durante 2003. Se realizó un muestreo probabilístico bietápico. Primero se seleccionaron las instituciones de salud, y posteriormente las mujeres mayores de 14 años que emplearon los servicios de salud durante el periodo de estudio. Las consideraciones éticas incluyeron el dar información amplia a las mujeres seleccionadas sobre los objetivos del estudio y en pedirles que dieran su consentimiento por escrito. La tasa de respuesta fue de 98%.

Las variables analizadas fueron: sociodemográficas, de la pareja, la lesión física, el índice de severidad de violencia de pareja y la búsqueda de apoyo en el personal de salud. La variable dependiente se refirió a la utilización de servicios de salud para atender las lesiones resultantes del hecho violento. Se emplearon pruebas de chi², regresión logística con intervalos de confianza al 95%.

Resultados

De 24,958 usuarias entrevistadas, una de cada cinco refirió haber sufrido violencia de pareja. De éstas, 23% informó haber recibido lesiones y sólo una tercera parte acudió a los servicios de salud por este motivo. Las variables asociadas con la utilización de servicios de salud fueron: ser mayor de 24 años, tener acceso a la seguridad social (RM_A 1.36, IC 1.14-1.61), severidad de la violencia (RM_A 2, IC 1.89-2.12), pertenecer al estrato socioeconómico alto (RMa 1.36, IC 1.07-1.76), frecuencia del consumo de alcohol en la mujer (RMa 1.66 IC 1.57-1.75) y el que la mujer pudiera decidir sobre el gasto del hogar (RM_A 1.37, IC 1.09-1.66).

Discusión y conclusiones

El uso de los servicios de salud por mujeres que han sido lesionadas a consecuencia de la violencia de pareja es bajo y, en la mayoría de los casos, está supeditado a la gravedad de las lesiones físicas sufridas. A lo anterior se agrega que el personal de salud únicamente atiende la causa que motivó la demanda, y por su parte la usuaria no confía en éste. Todo lo anterior dificulta la detección y notificación de este problema, por lo que la aplicación de la Norma Oficial para la Atención Médica de la Violencia Familiar enfrenta serias limitaciones que obligan a buscar nuevas estrategias que rebasen el ámbito de los servicios de salud.

Introduction

Violence is recognized as a Public Health problem around the world. In the specific case of Intímate Partner Abuse, which occurs at home, women are particularly vulnerable to be abused by their partners. In Mexico, as in other countries in Latin America, the systematic study of violence towards women is incipient. However, it is a highly predominant problem, which has a big impact on women's health, and represents a significant challenge to the Health System demanding health care due to intentional injuries.

This paper analyzed information generated by the first National Survey of violence against women in 2003 (ENVIM, by his name in Spanish).

Objective

The main objective is to identify the factors associated with the health services utilization by women, because of partner abuse.

Methodology

A cross-sectional design was used, including women users of health care services on public institutions all over the country in 2003.

Intimate partner abuse was defined as "the repetitive event of abuse from the male partner side towards the woman, that is characterized by coercive conducts that could include physical, emotional or sexual violence". It was measure in a scale of 27 items, using the Index of Spouse Abuse (ISA) and the Severity of Violence against Women Scale (SVAWS). Both indexes were vali-dated previously in Mexican population. A factorial analysis was used and the factors that explain the variability were obtained.

The selection of women to be interviewed was done using a probabilistic stratify biethapic sample. For the first one, medical unites were selected, and for the second, women over 14 years old who went to those medical unities to demand any kind of health care services. The ethic considerations were resolved using the next procedures: participants received information about the research objectives and signed an informant consent letter endorsed by the ethical committee of the Institution. They also received a brochure with information about the local institutions where they can go in case of abuse. Interviewers trained in technical areas as well as abuse management using a questionnaire on private spaces did the data collection. The answer rate was of 98%.

The analyzed variables were Socio demographic, search of support on the health staff or reasons for not doing this. An index of socio-economic level categorized as very low, medium and high. Type of institution and services used. The dependent variable was utilization of the health services to attend the injuries due to a partner abuse event, during the last 12 months.

The analysis used was simple and bivariate using chi square, and binary logistic regression model. The final model included the variables that in the binary showed a value of p<0.25. We ad-justed the model using the Goodness of Fit Test of Pearson.

Results

From 24,958 women that utilized public health services 21% reported to have had a partner abuse event in the last year. From these, only 7.3% utilized health services.

The more important variables were: age between 25 to 34 years old, elementary schooling and women having a job. Of the sample 94% belong to the very low and medium socio-economic levels; almost half of them (47%) do not have health insurance. More than 80% have a partner at present; 7.6% reported severe violence. From those who had injuries, 72% declared to have had just one minor injury (bruises, body aches), 25.5% reported more than one type of injuries, from which 10.8% were severe and required surgery or hospitalization. The type of injuries that demand more utilization of health services were those subsequent to sexual abuse as genital infection and genital bleeding.

Only 45% of the women users' report to have medical insurance. Less than 6% of abused women talked with the health staff about their abuse situation and the main reason was the lack of trust.

The factors associated to the utilization of health services were ages over 24 years(OR_A 1.57, CI 95% 1.9 - 2.06) alcohol intake by the women (OR_A =1.66 CI 95% 1.57-1.75) High Socio economic status (OR_A =1.29 CI95% 1.07-1.54). The model was adjusted by severity index and to having medical insurance. There were not significative interactions (p>0.15) and the global adjusted model was p= 0.23.

Discussion and conclusions

There is a low percentage of abused women injured that utilize formal medical care. This is a very important result for the identification of prevention and control strategies of the partner abuse problem in the health services. The study shows the existence of different types of injuries or medical problems such as genital infections and bleedings, fainting spells, body aches that provoked on one hand that women did not seek medical attention immediately and on the other that the health staff could not identify this kind of health problems with intimate partner abuse. There is a group of more vulnerable women who do not use health services to take care of the consequences of abuse, because they are uninsured. This inequality reveals that it is urgent to provide support services to poor women in the country.

The finding about the difficulty for battered women to report their injuries to the health staff because of their lack of trust, agrees with different studies that report the different obstacles found by abused women in facing the health services. The last situation reveals the obstacles to be solved for the NOM implementation too.

It is important to mention the study limitations related with the design utilized, and the selection bias due to the inclusion only of users of services. This situation leaves at one side women with less resources, who confront big obstacles for the utilization of health services, and at the other, women from high socio-economic levels, who utilize private health services; therefore there is no accuracy the point out differences. The way in which the question about the utilization of health services was made, makes it difficult to know the number of times these were used. This variable must be explored in future studies.

The information generated by the ENVIM allows the Health Sector to define identification-attention strategies of battered women and provides information about the importance of training the health staff to generate trust among in partner-abused women.