New lives, new challenges: access to intimate partner violence services for portuguese-speaking immigrant women

Intimate partner violence is a global health issue and the most common form of violence experienced by women. This study explored barriers to accessing help to Intimate partner violence related health services among Portuguese-speaking immigrant women in Toronto, Canada. Exploratory study conducted by a survey and focus group discussions with 12 Portuguese-speaking immigrant women. Results clarify the struggles faced by Portuguese-speaking immigrant women and their pathways to care and help-seeking. Participants reported that the fear of being deported, obtaining evidence of abuse, and lack of language-specific services were the key barriers to seeking help. When available, language-specific community-based services, along with faith and religion, were noted as key factors that supported women’s resilience. Nurses who provide care and services to women who are dealing with Intimate partner violence should rethink the scope of their advocacy actions toward addressing these structural barriers by building alliances with organizations to better serve and protect women in such vulnerable situations. Descriptors: Canada; Immigrant; Intimate Partner Violence.


INTRODUCTION
Recognized as a serious public health and human rights issue (1) , intimate partner violence (IPV) is the most common form of violence experienced by women worldwide (1) . IPV is defined as any behaviour within an intimate relationship that causes physical, psychological, or sexual harm to those in the relationship (2) . Women of all backgrounds are vulnerable to IPV, regardless of their age, ethnicity, sexual orientation, racialized status, or socioeconomic status (1) . A multi-country study (1) reported that approximately 30% of ever-partnered women experience physical and/or sexual IPV in their lifetime. The actual number is likely significantly higher, given that IPV is known to be universally underreported (1) . How disclosure of, and help-seeking for, IPV unfolds in the post-immigration context is poorly understood in many immigrant-receiving societies. Researchers are beginning to document these issues in the Canadian context.
IPV accounts for 25% of all crimes reported to police in Canada (3) . In 2013, police reports revealed that 80% of people experiencing IPV were women. Women's responses to IPV are partly determined by the supports and social services available to them. Compared with their Canadianborn counterparts, immigrant women face additional barriers that prevent them from seeking and accessing help for IPV (4) . Barriers include concerns about immigration status, racism and discrimination, lack of information about the available health, social, and legal services, as well as a lack of linguistically appropriate responses and culturally responsive resources (4)(5)(6) . Some research has explored IPV within specific ethnic groups in Canada (7)(8)(9)(10) . A search of relevant literature yielded three refereed articles that included Portuguesespeaking immigrant women in Canada. First, Barata et al. (11) , explored beliefs about "wife abuse" and "appropriate" actions. They found that Portuguese-speaking immigrant women were more likely than Canadian-born women of Portuguese background to believe that they should be a better wife, pray for the abuse to stop, and to remain in the abusive relationship. Second, Barata et al. (12) , explored (using the same set of data) definitions of wife abuse and women's beliefs about appropriate responses among research participants, and found that women were likely to stay in abusive relationships because of learned tolerance to abuse. Third, Souto et al. (10) , examined the experiences of psychological IPV among 10 older (60+ years) Portuguese-speaking immigrant women; the findings revealed that participants did not want to leave their abusive husbands, and tended to seek help in learning ways to improve their relationships.
To add to the Canadian body of knowledge about IPV in immigrant communities, this paper presents the findings of a completed study that explored the experiences of IPV and helpseeking behaviours among Portuguese-speaking immigrant women in the Greater Toronto Area (GTA) -one of the top destinations in the world for immigrants and refugees. Among the 140 languages spoken in Toronto, Portuguese is the sixth most common language (13,14) . This study explored barriers to accessing help to IPV-related health, social, and settlement services among Portuguese-speaking immigrant women in Toronto, Canada.

METHODS
This exploratory study used a case approach to examine the interrelated issues of IPV and access to services among Portuguese-speaking immigrant women in the GTA. This design helps researchers engage in an in-depth analysis of a given phenomenon when they are unable to undertake a large study across groups (15) . Following approval by the Research Ethics Board at Ryerson University, participants were recruited through flyers posted at community agencies that provide social and settlement services to Portuguesespeaking women in the GTA. The flyers were printed in Portuguese and included information about the study's focus and the eligibility criteria: born outside of Canada; mother tongue is Portuguese; 18 years or older; have current or past experience of IPV; and, willing to take part in a focus group discussion.
Twelve Portuguese-speaking women participated in the study and data was collected with a survey and focus group discussions. The survey consisted of 21 questions spread across three sections (demographics, types of IPV, and helpseeking behaviours). The first section included questions related to age, country of origin, marital status, household size, education, language spoken at home, and employment status. The second section included questions related to physical abuse, emotional abuse, harassment, threat and control, financial abuse, spiritual abuse, and sexual abuse. These questions were developed based on the questions used in the Canadian Community Health Survey (CCHS), the General Social Survey (GSS), and WHO questionnaires. The last section included questions about reasons for and strategies used in seeking help. The survey also included space for participants to write any additional relevant information. This information was collected to further understand participants help-seeking experiences.
Participants were asked to participate in a focus group to discuss their help-seeking experiences. The group discussion was conducted in Portuguese and was audiorecorded. The discussion lasted for 80 minutes. The RA later translated and transcribed the audio-recording into English. Each participant was given a small honorarium (CAD $ 20) to help cover expenses related to participation (such as childcare, transportation, and time). The consent forms, completed surveys, and audio-record files were stored in the principal investigator's office in a locked cabinet.
New lives, new challenges: access to intimate partner violence services for portuguese-speaking immigrant women The data analysis employed a Foucauldian "incitement to discourse" as suggested by Creswell (15) as a way to verify the qualitative findings, with a particular focus on: culture; ideology (by criticizing the power imbalance among women, abuser, and the medical, social, and legal systems); gender; textual language (analyzing their narratives and accounts of IPV valuing words and corporal expressions); relevance (by illuminating women's resilience and professional stakeholders' decision-making); advocacy (by adopting a socially engaged discourse); and, methodological rigour in fieldwork.
The data collected in the study utilized Laurence Bardin's categorical thematic content analysis (16) which includes three phases: pre-analysis, material exploration, and inference and interpretation of results (16) . This allowed for the identification of categories to understand the barriers to accessing help to IPV-related health, social, and settlement services which were: fear of deportation, struggle to obtain evidence of abuse, lack of language-specific services and supportive factors.

RESULTS
Twelve Portuguese-speaking women participated: Eight were from Brazil, three from Portugal, and one participant did not disclose her country of origin. The age of the participants varied, six reported being between the ages of 26-35 years, four participants were between 36-45, and two participants were between 46-55 years of age (Charts 1, 2 and 3).

Fear of deportation
Five Brazilian participants reported fear of deportation as a key barrier to seeking help; many reported feeling unprotected without appropriate immigration documentation status. One woman commented extensively on her own experiences, which revealed several challenges related to not having proper documentation. Other Brazilian women seemed to agree with her accounts, as evidenced by their facial expressions and nods.
There should be more support in helping [undocumented] women get their documents. If a woman knows that there is [even] a three percent risk of having immigration involved, she will not go out there knowing she is at risk of having her child taken away. (W8) The fear that police involvement would lead to deportation caused a great deal of insecurity among women who were already in a vulnerable and fearful state: If you do not have the proper documents in Canada, the chances of immigration finding you is 95 percent… You are totally unprotected. (W6) Fearing repercussions from immigration and police officers if they reported the abuse made undocumented women feel vulnerable, which in turn affected their emotional stability and undermined their intention to seek medical help or even contact social services: If you do not have a good [immigration] status and you call the police, you run the risk of immigration catching you. Therefore, you try to do other things like calling a friend. (W12) Participants who were waiting for more permanent status expressed fear of deportation. They believed that any action against their husbands could interrupt their immigration application and destroy the hope of a better future for their children in Canada. As a result, they felt hopeless and suffered in silence.

Struggle to obtain evidence of abuse
The same Brazilian woman expressed concerns about having her claim of abuse believed in court. Other women agreed felt that if they did not provide physical evidence, the court would not believe that they had been abused.
A picture of a woman's face completely bruised and destroyed is not enough proof in court. If you have a broken arm, they want proof of an X-ray of your broken arm. (W6) Obtaining this kind of proof would be particularly difficult for those who do not have an Ontario Health Insurance (OHIP) card and must therefore pay out-of-pocket: Overall, Brazilian and Portuguese women were worried about the importance of providing evidence and felt that they were placed in a difficult situation by being required to provide evidence. Some said that access to social services constituted a If a woman does not have money, she will not be able to do a medical examination and will not be able to provide proof of her abuse and suffering in court. (W4) Unfortunately, this was the case for many immigrant women due to their immigration status. Other physical health problems resulting from the abuse = 3 Treatment of physical injuries = 2 Dental care = 1 New lives, new challenges: access to intimate partner violence services for portuguese-speaking immigrant women pathway to achieve some political literacy: they learned with social services providers about the legal requirements, legal technical language, and challenges to assemble evidence to a court hearing, as well as possible legal system pitfalls. They noted that by accessing services (including health, legal, and social services) they could create a strong case by engaging in the intense work of gathering evidence of abuse. Accessing services is more difficult for undocumented individuals, again illustrating that immigration status in a host society is an important social determinant of health among socially vulnerable individuals.

Lack of language-specific services
Language was clearly a barrier to services. Of the 12 participants, five stated they were unable to have a conversation in English, which they identified as a serious barrier to navigating services. W6 referred to this communication barrier: I called the police and I got charged because he [abusive partner] spoke more English than I did. I ended up in immigration because the police contacted immigration. (W6) She continued that while she was in police custody, she was not given an interpreter, so she was unable to communicate her side of the story to the police officers: At the police station, I asked for an interpreter and the officer did not give me one. My entire face was swollen… I was put in prison for three and a half hours without knowing why I was in prison. (W6) This woman disclosed another lack of support regarding legal protection as a foreign citizen:

Expectations of proof of IPV by immigration and legal services
Immigration services here want a statement from someone saying "I will rip your head off," or it has to say "I will kill you," for them to take it seriously. Lack of English language proficiency can also complicate access to and utilization of legal services: I stayed almost two years in court trying to explain my situation because I could not speak English properly… if you do not know how to speak the language, you are totally screwed for the rest of your life. (W3) The above excerpts illustrate how the women's actions were constrained, and also how they were further marginalized and made even more vulnerable by service providers in the immigration, police, and court systems. As a result, they felt unsafe. Even the youngest participant reported having limited proficiency in spoken English and said this affected her ability to advocate for herself. Without greater fluency in oral English, it is difficult to understand the legal jargon used by police officers and the court.
Negative responses from diplomatic personnel also led to frustration among some participants. One woman (W11) said she had expected "more legal aid and protection" from her country's Consulate because she thought that diplomatic personnel would be interested in defending their nationals and providing compassion for them in a foreign country. She discovered that the UN considered IPV a condition for a refugee claim. Because of the lack of help from her Consulate, she reached out to a UN office in New York and had a UN advocate represent her by phone in a court hearing.

Supportive factors
With regard to Portuguese-language support services, participants identified three organizations in the GTA that provide social services and counselling services in Portuguese for women experiencing IPV: I just want to say thanks for the services we have. I only knew about [xxx] and my counsellor there helped and accompanied me throughout my whole process… I am free and separated for more than six years. (W8) Others said they felt supported in accessing services and consequently felt safe. However, not all participants were aware of resources available in Portuguese. Many said they had relied on information about resources from family, friends, or people they had met. One said: I do not know Canada well. I do not know a Portuguese support group that helps. (W5) One Brazilian woman reflected positively about the societal differences she experienced in how IPV is perceived: This is the first time I see this in Canada and contrary to Brazil. There, if your partner beats you no one pays attention. While, here there is more protection and more support. I feel more safe and secure here than in Brazil. (W2) While some participants had positive experiences accessing community-based help, others felt completely isolated. Some participants said it was difficult to find existing social networks of other Portuguese-speaking women in the GTA, leading them to question the very existence of community agencies delivering IPV-related services in Portuguese. They referred to the need to speak to others like themselves: I also think that our community needs help with mental health/psychiatric treatment because wanting it or not, I think it is good for women to talk to other women who went through the same problem as you in a room… that helps you. (W3) One of the group's recommendations related to this theme was to improve access to health, social service, and settlement support in the community, and ideally within their own neighbourhood to help women receive quick access to such supports.

Sub heading re: faith
Many participants discussed how they relied on faith and religion as a source of strength in the face of IPV, but only one noted in the questionnaire that she used a religious institution as a place to seek help. One woman said: Most participants made comments with explicit or implicit references to religion. For example, in reference to having to deal with a particularly difficult situation involving police officers, one woman said: "God made me like David in the cage of lions" (W6). Others made comments such as "God, please have mercy on me" (W9) and "thank God" (W8) as they recounted their stories. One said: I always told God, everything else can happen to me except going to jail. I told the officers if you want me to leave the country tomorrow, I will. I was also fighting at court to have legal custody of my son. (W6) Undoubtedly, faith and religion had a synergetic effect with psychological capital for those women who decided to fight IPV, even when contacting police officers in emotionally challenging situations.

DISCUSSION
Participants' accounts revealed five major conceptual themes: fear of being deported, struggle to obtain evidence of abuse, dealing with language barrier to services, accessing community-based services, and relying on faith and religion. The participants were vulnerable to IPV within the context of certain social determinants of health including age, access to services, coping skills, immigration status, income, spoken language, social exclusion, social safety nets, social support, and unemployment.
The barriers to seeking help that affected participants' decisions to seek help included embarrassment, current immigration status, fear of losing custody of children, and threats of more violence. These findings are consistent with those of other studies involving immigrant women with other languages and ethnic backgrounds (17)(18)(19) . The most significant barrier to disclosing abuse and seeking help was the uncertainty associated with their immigration status and potentially being deported or losing custody of their children. Immigrant women are most commonly accepted into Canada as a dependent of their spouse, even when both spouses have equal job skills and education qualifications. This means that an abusive husband has a significant degree of control over whether his wife can leave him (20,21) . Our study participants also identified language barriers to accessing care services; previous research has also revealed the need for services to address linguistic barriers (22) .
Participants identified religion and faith as playing an important role when they experienced IPV, stating that faith helped them continue fighting; some accessed social support from religious institutions. This finding is also consistent with previous research indicating that religion and spirituality can provide women with the strength to survive IPV (6,23) . Although other studies with various populations have reported similar results, the present study focused on immigrant Portuguese-speaking women living in the GTA, a population that has received little attention from researchers. The results reveal the importance of increasing services in Portuguese to help members of this community access services for IPV. The results also reveal the need to strengthen policy and engage stakeholders to give voice to women who feel powerless and hopeless when experiencing IPV.
At a societal level, these social determinants of health could be improved through prospective comprehensive action strategies (7) . Specifically, inter-sectorial collaboration is needed to create supportive environments to increase service availability for linguistic minority women experiencing IPV. It is important to note that the paradox embedded in the fact that seeking help for IPV experienced in Canada can result in detention and deportation for undocumented women remains unsolved. This is especially troubling given the fact that as a violation of human rights, IPV can support a refugee claim, but not a safety net for those experiencing abuse in Canada.

CONCLUSIONS
The survey and focus group discussions with the 12 Portuguese-speaking immigrant women experiencing IPV helped provide a nuanced understanding into their pathways to care and services. The barriers to accessing health, legal, protective, and social services were compounded by fear of deportation and other structural issues and made it nearly impossible for the women to escape the abuse. Their resilience was supported by their spirituality and religion, and by support from language-specific community agencies.
The small number of study participants from each country, prevented inter-and intra-group comparisons. Also, data collection and translations were carried out by the first author, the second author (from Brazil), and an RA fluent in Portuguese (born in Canada); as such, it is possible that some of the linguistic and cultural nuances may have been lost during this process. Nevertheless, a case approach can help examine the interrelated issues of IPV and access to services among women from one immigrant community in the GTA.
Future research may include a larger sample that will allow for inter-and intra-group comparisons. In terms of practice, we suggest that nurses rethink the scope of their advocacy when encountering immigrant women experiencing IPV. Nurses need to move beyond the organizational level and bridge several levels of decision-makers to implement more socially inclusive policies. Nurses must also rethink and redesign their approaches to build alliances with organizations and key individuals from various immigrant communities. They may serve as interlocutors with diplomatic representatives to create channels of communication with MPs, Consulate members, religious leaders, police, and court representatives to integrate community advocates to better serve and protect women in such vulnerable situations. Additionally, policies targeting newcomers' access to health services must be re-examined.