Domestic violence against women during the Covid-19 pandemic: A scoping review

Objectives This scoping review aims to assess the situation of violence against women during the COVID-19 pandemic in Latin America, mainly in Brazil. Methods This study consists of a Scoping Review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. To conduct this review, we mapped scientific evidence on domestic violence during the COVID-19 pandemic. The inclusion criteria were: journal articles on domestic violence set in Latin American countries, particularly Brazil, in the context of social isolation during the COVID-19 pandemic, published between March 2020 and June of 2021. Articles that were not published in journals, studies focusing on child violence or the elderly population, suicide-related approaches, editorials and letters to readers were excluded. The databases used were: National Library of Medicine (PubMed), Embase, COVID-19 Global literature on coronavirus disease, Scopus Preview, Web of Science, LILAC's, Database of the best Evidence-Based Health (Epistemonikos) with the following strategic keywords: "domestic violence" "female'/exp OR female" "domestic violence AND women" "SARS-CoV-19") AND ("domestic violence") SARS-CoV-2" OR "2020-nCoV". The databases above were accessed in July 2021. The articles selected from the databases were synthetized following the double-check procedure and the topics that were most relevant to the subject discussed were separated. The articles used were in English, Portuguese, and Spanish. Results We discussed domestic violence against women in the context of social isolation, showing a significant increase and highlighting aggravating factors - financial instability, exacerbation of the female workload, increase in drug and alcohol consumption, lack of access to care services - and statistics that demonstrate the significant increase in countries such as Argentina, Ecuador, Paraguay and Brazil, especially in São Paulo, Rio de Janeiro, Paraná, among other states. Despite the meaningful increase in the number of cases and the aggravating factors for domestic violence against women in Latin America and Brazil during the COVID-19 pandemic, the reality of underreporting, resulting, among others, from limited legal, social and economic support and the lack of well-prepared intersectoral services may be a limitation in this scenario, since the situation can be even more acute. We presented measures adopted in Brazil and alternatives to confront the critical situation of domestic violence against women, aggravated by social isolation during the COVID-19 pandemic. The 18 most relevant articles were read twice by each author, following the “Double-Check” protocol. The articles used addressed important questions around the established goals: (a) characteristics of the current scenarios in Latin America and, specifically, in Brazil, with regard to violence against women; (b) factors that intensify this type of violence; (c) numbers that demonstrate an increase in cases; and finally (e) strategies to combat domestic violence against women. A total of 595 articles were found, then, based on the abstracts presented, 18 articles were used to write this scoping review.


Introduction
In March 2020, COVID-19, a disease caused by the novel coronavirus (SARS-CoV-2), was declared a global pandemic [1,2]. Faced with the pandemic, several countries, including Brazil, adopted social isolation measures as a way to control the spread of the disease [3][4][5][6]. This measure had repercussions on the socioeconomic dynamics of countless families, raising concerns about an increase in domestic violence, mainly against women [1,4].
Early data indicate that the social and economic consequences of the pandemic are particularly devastating for women and girls and may even reverse the progress that has been made on gender equality and women's rights [7,8]. Although social isolation is not the cause of domestic violence, its role as an aggravating factor is relevant during the pandemic, given that one of its characteristics is the exacerbation of historically constructed and naturalized inequalities between men and women [8].
In the current context, the introduction of lockdown measures affected service offers, reducing work activities. The fear of being exposed to the virus and the constant presence of the abuser at home have also become part of the daily life of women victims of violence, affecting both the offer and demand for help, respectively [9,10].
Current Brazilian legislation states that: "any action or omission based on gender that causes injury, physical, psychological or sexual suffering, moral or property damage, or death" (Article 5 law 11.340/ 06) [11] constitutes family or domestic violence against women [9,12].
Studies indicate that one in every three women have been subjected to acts of physical or sexual violence by intimate partners in their lifetimes [10,13]. This type of violence is named Intimate Partner Violence (IPV) and had already been recognized as a public health and human rights violation issue before the start of the COVID-19 pandemic [9,14].
According to data provided by The Civil/Social Defense and Public Security Secretariats, there is still a relationship between violence against women, femicide and race, showing that black women are the most affected. Regarding this profile, it was also found that most victims have low levels of education and are aged around 30 [9,15].
Despite the lack of actual data on the topic, the media suggests an increase in various types of violence against women during stay-at-home recommendations. 14 The social and economic impact of this scenario on the life of victims may have long-term consequences for society, resulting in damage to the physical, mental, sexual, and reproductive health of women [9].
The importance of discussing and fully addressing the domestic violence epidemic beneath the pandemic is unequivocal, since it isolates and disables women throughout Brazil, making it hard for them to resume social and economic activities. Therefore, we intend to gather data from scientific papers published in 2020 and 2021, with the aim to map and synthesize information related to domestic violence against women during the COVID-19 pandemic.

Methods
This study consists of a Scoping Review, conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [16]. To conduct this review, we mapped scientific evidence on domestic violence during the COVID-19 pandemic. Based on the conditions set out, the following research question was developed: "What is the situation of domestic violence against women during the COVID-19 pandemic in Brazil?".
The review included journal articles on domestic violence taking place in Latin American countries, particularly Brazil, in the context of social isolation during the COVID-19 pandemic, published between March 2020 and June 2021.
Exclusion criteria were: articles that were not published in journals, studies focusing on child violence or the elderly population, suiciderelated approaches, editorials, and letters to readers.

Latin America overview
Violence against women is rooted in a system based on the prevalence of male dominance, which guides practices, behaviors, institutions, and norms, and compounds the "female experience" [1,17,18]. Despite pervading every culture, ethnic group, religion, class and level of education, this type of violence varies due to the unequal access to justice and health services, which explains the higher prevalence of young, black victims facing unfavorable economic conditions [19,20]. Furthermore, women with easier access to specialized services are more likely to report domestic violence and remain engaged with the prosecution [21].
This violence is transgenerational, being transmitted from one generation to the next. It has been present in the private or domestic sphere for a long time, as this is a place of power relations and patriarchal domination [19,20]. In this context, Latin America has one the highest violence rates in the world, the most violent countries being Mexico, Peru, Brazil, Argentina, El Salvador, and Bolivia, which, together, account for 81% of femicide cases on the continent. Violence against women has increased considerably in Latin America during the COVID-19 pandemic when compared to North America and Europe, as shown by data that indicate an increase of about 25% in calls to the police in Argentina, and of 130% in Colombia during the first days of social isolation [21].
In Paraguay, domestic violence cases rose from 1842 to 1940, when comparing March 2019 to March 2020. The same increasing trend was observed in its capital, Asunción, which, when comparing 2019-2020, registered an increase of 102 cases in January, 97 cases in February, and 130 cases in March. The country has adopted helplines and emails as reporting measures. However, few women are aware of the numbers they should call, and only two of the helplines are free of charge, 137 and 911. Also, because of being confined to their homes with the abuser, many are unable to safely make these calls [22].
In Argentina, the situation is similar to that of other countries, as mentioned above. A study examined the evolution of calls to the domestic violence hotline -137 -in Buenos Aires and identified a 32% increase in the number of calls, taking seasonal variations into account. In contrast, when disregarding this criterion, an increase of 20% was found. As for the type of call made, those related to psychological violence increased by 76% [23]. Furthermore, a substitution of reporting channels used by victims was observed, with a decrease of about 62% in calls made by the police and an increase of 127% in calls made directly by the victims. This was due to changes caused by the lockdown, as before its mandate, victims would file their complaints at the police station, from where police officers would make the call, which was not maintained with the advent of social isolation. Among the factors that exacerbate the risk of violence against women are: changes in the unemployment rate, gender income gap, and access to finance and employment opportunities [23][24][25][26] that alter the domestic balance. In the meantime, social isolation has aggravated risk factors for this type of violence due to an increase in unemployment rates and the time spent at home. The latter being responsible for exacerbating the exposure to domestic violence, once the number of hours that couples spend together when both are in quarantine increased by about 3.8 h a day [23,27].
Regarding IPV (Intimate Partner Violence), a study carried out in Argentina observed an increased risk for the incidence of the three levels of IPVphysical, sexual, and emotional -, when both the women and her partner were in quarantine. The study was conducted in May 2020 and revealed an increase of 12% in emotional violence, 35% in sexual violence and 23% in physical violence rates [23]. IPV can be affected by three primary factors: the inability to escape the abuser during lockdown; social isolationwhich contributes to both mental health disorders and increased alcohol consumption -; as well as increased economic uncertainty and stress related to sudden poverty [1,23,28].
In Ecuador, some measures were implemented to reduce the high incidence of domestic violence, with the creation of a protocol named "Communication and Care Protocol for Cases of Domestic and Gender Violence during the Coronavirus (COVID-19) Health Emergency", which faced issues such as lack of coordination between protection services and lack of funding [29,30]. Another obstacle to the establishment of effective help in the country was the use of hotlines that were not intended exclusively for domestic violence: ECU 911 (also used for suspected cases of COVID-19) and 1800-DELITO. In addition, both are used to request the removal of the deceased from home, among other services, which overloaded these hotlines, limiting the opportunity for victims or other people to file complaints [29].

Brazil overview
In Brazil, violence against women only reached the political agenda during the re-democratization period, in the 1980s, when the first support services for women victims of violence were created, such as the first Women's Police Station (DDM), the National Council on Women's Rights and the innovative public legal abortion program in São Paulo [17,31]. However, it was only in 2002 that the Word Health Organization (WHO) recognized violence against women as a major public health issue and a violation of human rights, supporting the enactment of Maria da Penha Law (law 11.340/06), passed on August 7, 2006 [11,17]. Law 11.340/06 provides a legal and normative framework that consolidates appropriate means and tools to combat this type of violence, including restraining orders that can be issued based exclusively on the victim's word, without the need for further evidence. It also applies to transgender women regardless of whether they have changed their name designation or had transsexual surgery [9,11].
According to the Brazilian Public Security Forum (FBSP), alarming data were presented during the early days of the pandemic regarding calls made to the Police, via 190, to request help and assistance due to violence, mainly committed by intimate partners. Consequently, there has been an increase in flagrante delicto arrests. Thus, in order to have appropriate risk management in place, some states have enacted new laws intended to reduce underreporting, many of which aimed at community agents and integrative family medicine professionals, who, through periodic visits, identify and notify potential cases of violence [12].
For Maria da Penha Law to be effective, it is necessary to consider the demand for public policies integrated into the justice systems available in each Brazilian state, including healthcare and education, in addition to the joint action of the family support network [12].

Factors that intensify violence against women
Although social distancing measures are necessary to mitigate the spread of COVID-19, UN Women warned of the increased risk of domestic and family violence against women due to the intensification of family relationships, and economic restrictions and impacts that make it hard to end relationships in a healthy way [32]. In this context, the affection network and horizontal community protection are weakened and abusers gain more control over the victimsespecially when women face financial difficulties, the abuser being, customarily, the primary income earner in the household. In addition, victims are a lot more monitored, and there are more obstacles for them to seek help in cases where the abuser is working from home. This situation also leads to an increase in the consumption of alcohol and illicit drugs, and the use of medicines without a prescription, which are alarming risk factors for criminal conduct in this period [1,4,[33][34][35][36][37]. This is confirmed by some studies that indicate a four-fold increase in the risk for violence when there is harmful use of alcohol and drugs [12].
Among the factors that intensify this type of violence, we can also mention the stress experienced by the abuser due to unemployment and a fall in income, and uncertainty around COVID-19 and the future [1,12]. In addition, women's workload increased, since household chores, children, and other relatives were added to their paid jobsoften remote during the pandemic -, which overwhelmed women, and consequently, reduced their ability to escape the abuser. Lastly, the reduced access to support services is also conducive to the perpetration of violence against women [4,9,38].

Increase in the number of cases in Brazil
Before the onset of the COVID-19 pandemic, human and material resources allocated to support services for victims of violence against women were already an issue in Brazil, with cuts in funding, Women's Police Stations (DDMs) in precarious conditions, lack of interest in professional training, and disregard in the three levelslocal, state, and federal [17]. When COVID-19 was declared a pandemic, the access of victims to social welfare, healthcare, public security and legal services was reduced, posing a big obstacle to the combat of violence against women, seeing that healthcare and police services are usually the first point of contact victims of domestic violence have with the support network [10]. In general, women who have access to specialized healthcare services are more likely to talk about it openly and file a complaint [21].
In this context, it is also important to emphasize the chronic underreporting of domestic violence before COVID-19, when less than 40% of women victims of violence sought any kind of help or reported the crime, and, of these, less than 10% sought police help [8].
According to data from Ligue 180 (Call 180), the lockdown policies established since the onset of COVID-19 resulted in an increase of approximately 9% in the number of calls made to the helpline to report violence against women. According to the National Human Rights Ombudsman of the Ministry of Women, Family and Human Rights, between March 1st and March 16th 2020, 3045 calls were received and 829 complaints were filed, whereas between the 17th and the 25th of the same month, these numbers rose to 3303 and 978, respectively [8,39].
In Rio de Janeiro, data from the State Prosecution Office showed a 50% increase in domestic violence cases during the first week after the implementation of social isolation measures, with most cases being related to violence against women. Whereas, in Paraná, a 15% increase was observed in domestic violence complaints received by the Police during the first week of social distancing. In the states of Ceará, Pernambuco and São Paulo, the situation is similar [32].
Data from São Paulo's Public Security Secretariat, released on April 15, 2020 confirm the country's alarming situation regarding this issue, based on data from the biggest city in Brazil, which shows that the murders of women have doubled in the capital of the state of São Paulo. Similarly, a survey conducted by São Paulo's Prosecution Office revealed a 29% increase in applications for restraining orders made by women in March when compared to the previous month. The number of arrests in flagrante delicto due to violence against women also increased by 91 cases in the same period. In view of the above, an increase in the number of police investigations and prosecutions would be expected. However, the suspension of legal deadlines established until the end of April 2020 resulted in the opposite of what was expected, with a decrease in both police investigations and prosecutions [8,40].
Interviews conducted in May 2020 with professionals working at the frontline of the Network to Combat Violence in the capital of the state of São Paulo -in services of medium complexity provided for women feeling the social impact of the pandemic, as well as women victims of violence -revealed an intensification of vulnerabilities, which, in turn, leads to an increase in the number of victims of the aforementioned violence. Among the changes undergone by the services, the interviewees mentioned: in-person services were maintained only for recent cases, that is, those occurred in the same day or in previous days; remote monitoring of cases that were previously followed up by the service, via telephone or WhatsApp; reduced number of individuals allowed in care centers due to social distancing measures. Among the issues pointed out by the interviewees was the lack of access to devices, internet services, and pre-paid mobile credit, which ends up restricting the access of economically disadvantaged individuals to domestic violence services [27]. In addition, the use of the employees' personal devices and networks to provide services poses risks for both users and professionals. Many times, women who get access to virtual services fear that confidentiality will be broken, their reports will be recorded, their names revealed, or their messages deleted. Finally, there is also the fact that many women have limited access to communication due to the constant presence of their abuser [1,17].

Coping measures
In this context, coping measures are necessary, despite the obstacles to leaving abusive relationships. It is extremely important to create accessible organizations, well-structured care and psychological support services, and university extensions that will develop clear educational material for the population. UN Women recommends the production of educational material with information on relevant phone numbers, police stations, and websites offering 24/7 services, and the follow up from the Directorate of Defense via telephone and WhatsApp. In addition, it recommends the use of telematic systems or applications for legal remedies, the collection of data in places frequented by women, such as neighborhood drugstores and supermarkets, and restrictions on the marketing of alcohol and drugs, which are intensifiers of violence [22].
Advertising campaigns should also be reinforced, with autonomy to inform about the importance of making your home a safe place. Furthermore, it is imperative to foster personal support initiatives, encouraging neighbors and acquaintances to seek help from social and legal assistance services [32]. Complementarily, the search for help in the virtual environment has proven to be advantageous in all Latin American countries, contributing to the collection of actual data on the underreporting of cases, where police reports are not filed. Online platforms have been accessed by women of all ages, including women with disabilities, consisting, therefore, of comprehensive mechanisms that can be useful to different approaches [38,41].
At the national level, there are several support channels for women victims of violence, such as: the helplines -Disque 180, 100, 181, 197, 129, 190 e 192 -; the application "SOS Mulher'' that gives access to restraining orders, emergency services, localization, and help; the website "Ouvidoria do Ministério da Mulher, Família e dos Direitos Humanos" (Ombudsman of the Ministry of Women, Family and Human Rights); the artificial intelligence "IsaBot" for information and care; and the service mapping channels "TôComElas" e "NósEstamosJuntas" (Table 1). On both the application "Direitos Humanos BR'' and the websites ouvidoria.mdh.gov.br, disque100.mdh.gov.br, and ligue180.mdh. gov.br, it is possible to upload pictures, videos, audio files, and other evidentiary documents that prove the complaint of domestic violence and other Human Rights violations [9,42].
In order to mitigate the problem, the Municipal Secretariat of Human Rights and Citizenship of São Paulo announced a package of measures, which include accommodation assistance of BRL 400.00 for those applying for restraining orders or living in extremely vulnerable situations, hotel rooms for victims of domestic violence, qualification and optimization of the 156 helpline, quicker access to Women's Police Stations or other protection services, and expansion of house visits from Health Agents focused on domestic violence [17,43]. The measures are also aimed at male perpetrators of violence against women, with the main goal to raise their awareness, as proposed by Projeto Á gora, a project of the Psychology Department of the Federal University of Santa Catarina (UFSC) in partnership with Instituto Noos-SP, which consists of reflective groups for men who abuse women [17].
As a way to fight domestic violence, some bills were drafted, such as 1.798/2020, intended to allow domestic and family violence complaints to be filed online or via emergency telephone numbers [9].
Police and legal services have been expanded during the pandemic with remote support and the issuance of restraining orders. However, it is worth mentioning that there are some obstacles to the full effectiveness of such services, including the safety of support workers and victims filing the complaints, provided that, as mentioned earlier in this article, support workers often use their personal devices and internet services, and victims fear their data will be leaked. Thus, it would be important to adopt security measures, such as registering pseudonyms, using cryptography, and providing the necessary infrastructure for support workers in their homes. Another issue is the limited access of some victims to communication services, whether due to the lack of access to electronic devices, SIM cards or internet connection [17,42].
One of the greatest needs nowadays is the training and qualification of healthcare professionals in all undergraduate courses, seeing that currently they do not receive any specific training on how to respond to domestic violence occurrences, and the use of the Notifiable Diseases Information System (SINAN) is still restricted to a few trained professionals [17]. This approach is also justified by the fact that regional Primary Health Care (PHC) serviceswhich entail preventive measures, health promotion and family and community longitudinal careare a passport to Brazil's Unified Health System (SUS) and an important tool in the fight against this type of violence [17,44,45]. In addition to training healthcare professionals across different fields, it is also necessary to build a network with a common care project that promotes the interaction between professionals and shared care models and activities aimed at providing comprehensive care, according to the demands of each case [17,31]. In short, there needs to be an efficient management of services, ongoing professional training, financing of policies that are proven to be effective against this type of violence and the implementation of an intersectoral network [17,44]. It is also important to guarantee that women are not victimized at every service they are referred to and that the professionals, amidst the pandemic, are able to assess situations, so as to not reaffirm the need for isolation in these cases [10].
The ways to address the issue of domestic violence against women in Brazil include: creating new shelters or increasing the capacity of existing shelters; expanding substance abuse and mental health services and the delivery of food parcels and basic supplies; and developing ethical guidelines on the confidentiality of remote services [17]. It is also important to take actions to prevent violence against women by Adapted from Fornari et al. [42].
promoting state campaigns aimed at reducing the consumption of alcohol and drugs during the social isolation period; increasing the number of public officers dealing with those cases; encouraging women to keep in touch with their family and friends, via text message, video chat, etc.; and implementing employment policies to guarantee the economic autonomy of women [46]. Subsequent to this review and discussion, one of the alternatives found by the authors was to develop a university extension program to produce accessible educational materials for the population: SOS let's reveal it-attention to victims of sexual assault (SOS vamos revelar? Atenção às vítimas de agressão sexual). The interaction, combined with the interdisciplinarity in the Brazilian context and the inseparability of teaching, learning, research and extension, will help address a complex issue that still faces deep prejudice. The project focuses on the importance of a campaign to provide education on health and safety, with students as protagonists of their own learning and the population of their self-care. Finally, the project is justified by a high-quality scientific production, less focused on itself, connected to more practical issues, involving universities, civil society and integrated Health and Public Safety systems. The material produced will be organized and disseminated, and also used in scientific publications, generating data for public policies. Social media platforms, such as Instagram, Facebook, YouTube [47,48], institutional websites, interviews (podcasts) can be used as means of communication and dissemination.

Discussion
A total of 595 articles were found, of which 377 remained after duplicates were removed. Of these, 20 articles were selected to be read in their entirety. Throughout this process, two articles that did not address domestic violence against women and one article that did not take place in Latin America were removed. Lastly, 18 articles were included in this study, each of which was read twice, following the "Double-Check" procedure.
After reading the articles, it was possible to divide the information into four aspects: current situation in Latin America and Brazil, factors that exacerbate violence against women, relevant numbers regarding the increase in cases, and improvements and strategies that studies suggest could combat this violence.

Conclusion
Based on a database survey focused on different articles on violence against women in Latin America, it was possible to conclude that, specifically in Brazil, there was a significant increase in this type of violence, as indicated by the data. Be it due to financial instability, increased contact between victim and abuserin cases of IPV -, women being overload with responsibilities, increased consumption of alcohol and drugs, reduction in care services and their switch to online formatswhich are not accessible to all women -, among many other factors, most of which addressed in this article, the violence against women is an alarming situation in Brazil and Latin America and was overly aggravated during the COVID-19 pandemic. In short, the main objective of this article, to discuss the causes of increase in domestic violence against women during the COVID-19 pandemic, was achieved. The search for help in the virtual environment has proven to be advantageous in all Latin American countries. Breaking abusive relationships, structuring accessible organizations with shelter programs and psychological and legal assistance were seen as necessary.
Given the above, it is essential that appropriate measures are taken, preceded by careful analyses and the provision of adequate infrastructure to meet the needs of each location. Thus, the measures identified in Latin American countries were grouped, with emphasis on those that are consistent with the situation in Brazil, in order to expand the social, and mainly governmental, perspectives on both the possibilities for coping with domestic violence and the measures that were not very effective.

Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Submission declaration and verification The paper has not been published previously, it is not under consideration for publication elsewhere, and if accepted, it will not be published elsewhere. All authors have read and agreed to the version of the manuscript.