The challenges of the protection network and coping with violence against older people in Manaus, Amazonas, Brazil

Abstract

Objective

To know the protection network, its challenges and elements that interfere in the protection, coping and care of the older person, victim of violence in the city of Manaus, AM, Brazil.

Method

This is a descriptive study structured from a qualitative research using field research. Sixteen professionals were interviewed who are in charge of the main institutions that are part of the Protection Network in Confronting Violence against Older People in the city of Manaus from 07/29 to 11/21/2020.

Results

despite being extensive and active, the network does not have the necessary articulation to meet and monitor the demands of older people in a satisfactory way. There is also no established service flow, nor is there any monitoring of cases of violence against older people in the city.

Conclusion

Integration and articulation between the different institutions is necessary, since the multidisciplinary approach and work from an intersectoral and articulated perspective can result in potentiality in confronting violence against older people in the city of Manaus.

Keywords
Health Policy; Elderly abuse; Social Protection in Health

Resumo

Objetivo

Conhecer a rede de proteção, seus desafios e elementos que interferem na proteção, enfrentamento e atendimento à pessoa idosa, vítima de violência a cidade de Manaus, AM, Brasil.

Método

Trata-se de um estudo descritivo estruturado a partir de uma pesquisa qualitativa com utilização de pesquisa de campo. Foram entrevistados 16 profissionais que estão à frente das principais instituições que integram a Rede de Proteção no Enfrentamento à Violência contra a Pessoa Idosa na cidade de Manaus no período de 29/07 a 21/11/2020.

Resultados

apesar de extensa e atuante, a rede não possui a articulação necessária para atender e acompanhar as demandas dos idosos de modo satisfatório. Também não existe um fluxo de atendimento estabelecido assim como não há acompanhamento dos casos de violência contra a pessoa idosa no município.

Conclusão

É necessária a integração e a articulação entre as diferentes instituições uma vez que a abordagem multidisciplinar e o trabalho na perspectiva intersetorial e articulado podem resultar em potencialidade no enfrentamento da violência contra a pessoa idosa na cidade de Manaus.

Palavras-Chave:
Política de Saúde; Abuso do idoso; Proteção Social em Saúde

INTRODUCTION

In 2005, the National Council for the Rights of the Older Person convened the 1st National Conference on the Rights of the Older Person, with the theme Building the National Network for the Protection and Defense of the Older Person (RENADI). This Conference had as its central objective to define the strategies for the implementation of RENADI¹. Thus the Network for the Protection and Confrontation of Violence against the Older Person was born, which, little by little, was consolidated and strengthened in all Brazilian states and municipalities. In the city of Manaus it was no different and the city has numerous institutions dedicated to the protection and promotion of the rights of the older person, and that seek to put into practice the legal statutes and implement public policies in this segment.

In 2011, the network took on another important role: according to Law No. 12.461/11, which reformulated Article No. 19 of the Statute of the Older Person - EI (Law No. 10.741/03)², it became mandatory that the protection network was notified in cases of suspected or confirmed violence against older people. However, despite the performance of this network, the numbers of reports of violations against older people continue at high levels.

According to the reports of the Department of Intelligence of the State Secretariat for Public Security of Amazonas, in the historical series from 2012 to 2019, there was a substantial increase in the number of reports of violations against older people made in police stations in the city of Manaus. In 2012, this amount was 6,840 occurrences, increasing in 2019 to 16,697, which corresponded to an increase of more than 140% for the period³. When comparing the number of complaints made on the Human Rights Hotline - Dial 100 - with the number of older people in each Brazilian state, it appears that Amazonas and the Federal District took turns, over the last eight years between the first and second in the ranking of the most violent states against older people in the country. While the national average is 166.09 complaints per 100,000 inhabitants for the period, the Federal District has an average of 418.87 and the state of Amazonas of 418.48³,⁴.

Given these findings, it is questioned whether there is a link between the network so that the demands of older people in situations of violence receive adequate treatment and prompt responses; if there is a flow of care for the older person in case of violence to be followed by the network and how is the monitoring of these demands in the city of Manaus.

The objective of the article is to know the protection network in coping with violence, its challenges and elements that interfere in the protection, coping and care of older people, victims of violence in the city of Manaus, AM, Brazil.

METHOD

It is a descriptive study structured from a qualitative research, according to the guidelines of Richardson⁵ and Minayo⁶. It started with the guiding question: what are the challenges and elements that interfere in the protection, confrontation and care of the older person, victim of violence in the city of Manaus/Am, in the view of the protection network managers? The method used was a field research, with the use of semi-structured interviews with sixteen managers of the main institutions that are part of the protection network in combating violence against older people in the city of Manaus. Such institutions were mapped and indicated by the State Council for the Older Person (CEI), based on their roles and purposes established in the institutional discourse. All managers or immediate substitutes who had been working for at least two years in front of the institutions took part in the study.

Data collection took place through semi-structured interviews, with open and closed questions about the investigated topic. Such interviews were conducted in face-to-face meetings and remotely, using the tools “Google Meet” and “Zoom”, in the period from July 29 to November 21, 2020. For data analysis, the technique called content analysis was used, following the guidelines of Bardin⁷.

As this research involves human beings, the project was submitted to the Research Ethics Council of the State University of Amazonas (CEP/UEA), and approved according to CAAE 29766320.0.0000.5016 and Opinion 4.016.698/2020.

RESULTS AND DISCUSSION

Initially, 25 institutions were selected, of which 16 agreed to participate in the interviews. Respondents were between 31 and 59 years of age; nine of them were female and seven were male, working in institutions for periods ranging from two to nine years. In the following sections, results of interviews with 16 network managers are presented, in an attempt to understand the challenges and elements that interfere in the protection, coping and care of older people, victims of violence.

Characterization of the main institutions that make up the formal protection network in the city of Manaus, Amazonas

The managing institution of the Older Person Policy in the state of Amazonas is the State Secretariat for Justice, Human Rights and Citizenship (SEJUSC), which has a reference center called the Integrated Center for the Protection and Defense of the Rights of the Older Person (CIPDI), whose proposal is to work prevention and awareness policies on the different types of violence against older people. Psychosocial assistance is provided, as well as the reception of complaints, home visits and referrals for measures to protect and guarantee rights.

The municipal older people policy manager is the Dr. Thomas Older People Support Foundation (FDT). With over 100 years of existence, the FDT has the mission of coordinating and evaluating the implementation of the Municipal Policy for the Older Person through various programs. The Longa Permanência Program provides assistance on an asylum basis to older people at social risk, noting that the FDT is the only long-stay institution for older people in the three levels of dependency in the state of Amazonas. The Conviver Program, which runs on the premises of Parque Municipal do Idoso (PMI), and benefits older people with physical, labor, recreational, cultural and education activities for citizenship. The Foundation also conducts home visits through the Home Care Program for the Older Person (PADI) when requested through Disque Idoso 165.

The Open University for the Older Person Foundation (FUNATI) is also part of the protection network for the older person, in Manaus. It has legal personality under public law, management autonomy and, as axes of action, teaching, research, extension and assistance activities. Among its attributions are those of producing and socializing knowledge and technologies through its axes of action.

Another institution with extremely relevant services for the older person in Manaus, especially when dealing with cases of violence, is the State Secretariat for Public Security (SSP/AM). The population has 30 Integrated Civil Police Districts (DIPs), located in various neighborhoods, to register police reports, file complaints or even receive guidance on specific cases and violence. In addition to the DIPs, the older person can count on the Specialized Police in Crimes against Older People (DECCI), located in the Parque Dez de Novembro neighborhood, in the central-south zone of Manaus.

The state and municipal health secretariats are also part of the protection network, through their entire service network: hospitals, Basic Health Units (UBS), Emergency Care Unit (UPA) and Centers for Comprehensive Care for the Older Person (CAIMI), located in the north, west and south zones and which function as medium-complexity polyclinics, with multi-professional teams. In Manaus, there are currently three centers that are located in the north, west and central-south zone.

The Social Assistance Reference Centers (CRAS), the Specialized Reference Centers for Social Assistance (CREAS), the State Older People Coexistence Center (CECI) and the State Family Coexistence Centers (CECF) are also part of the network and are under the management of the Municipal and State Secretariats for Social Assistance. CRAS and CREAS are the main units of the National Social Assistance Policy (PNAS), but each has its own competencies and specificities. The CRAS are intended for Basic Social Protection, aimed at preventing the occurrence of situations of social vulnerability and risk, while the CREAS are intended for Special Social Protection of Medium Complexity and aim at social work with families and individuals at personal and social risk for violation of rights.

The State Family Coexistence Centers (CECF) and the Older People Coexistence Center (CECI) are also part of the protection network in combating violence against older people. There are seven spaces that offer basic social protection for families, with a range of activities aimed at promoting health, well-being, as well as contact with various artistic and cultural manifestations.

The Older People Rights Councils (CDIs) are also part of the protection network in combating violence against the segment. They are formed by a collegiate of representatives of the public power and civil society. It is a space created especially to deliberate and define guidelines for social policies aimed at the older people segment, overseeing services and assistance provided by public and private entities. The Municipal Council for Older People (CMI) acts within the city of Manaus, and the State Council for Older People of Amazonas (CEI/AM) in the State.

The older person’s awareness of their role as citizens makes them fight for their rights and seek effective access to justice. In this sense, two more institutions for the protection of the older person come into play: the Public Defender’s Office and the Public Ministry. For Ribeiro⁸, Brazil has a justice system for the defense of the older person that is still deficient. There are few or even non-existent courts, prosecutors, defenders and police stations specializing in older people in the various Federation Units. The city of Manaus has DECCI, in addition to the State Public Defender (DPE/AM) and the Public Ministry of Amazonas (MPAM).

Within the scope of the DPE, there is the Specialized Nucleus for the Defense of the Older Person, with a team of professionals focused on legal assistance to needy people in matters related to the condition of the older person, especially the rights guaranteed in the Older People Statute (EI)². In a complaint for abuse or abandonment, the hearing is held, the legal status of the older person is explained to the aggressor, that is, about the rights provided for in the Older People Statute, and, finally, an agreement is sought between the parties involved.

The MPAM, on the other hand, is an independent institution equipped with constitutional guarantees, essential to the jurisdictional function of the State, responsible for defending the legal order, the democratic regime and social, individual and collective interests. When any entity commits an infraction that jeopardizes the rights guaranteed by the National Policy for the Older Person - PNI (Law 8.842/94)⁹, It is responsible for taking the appropriate measures as well as promoting, without the need for legal proceedings, the suspension of activities or the dissolution of the entity, with the prohibition of serving older people in the public interest. Another important intervention available to the PM, but still little used, according to Couto¹⁰, is the civil liability of the State for non-compliance with the law. In the state of Amazonas, we currently have two Public Prosecutors for older people, the 42nd and 56th Public Prosecutors for the Defense of Human Rights of the Older Person.

Both the DPE and the MPAM are instruments of citizenship available to the older population in the state of Amazonas, considering that access to justice involves much more than the mere judicialization of demands. It involves, above all, the empowerment of older people about their rights and their co-responsibility for the peaceful search for the solution of their private, public and social disputes.

To summarize the main institutions in combating and confronting violence against older people in the city of Manaus, they are listed in the chart below.

Chart 1
Main institutions that are part of the Protection Network against Violence against Older People in Manaus and Amazonas.

Seq	Institution Name	Qty	Participant of this study
1	State Department of Justice, Human Rights and Citizenship	1
2	Integrated Center for the Protection and Defense of the Rights of the Older Person	1	X
3	Dr. Thomas Older People Support Foundation	1	X
4	Home Care Program for the Older Person	1	X
5	Municipal Park for the Older Person - (PMI)	1	X
6	Open University for the Older Person Foundation	1
7	State Secretariat for Public Security	1	X
8	Special Police of Crimes against Older People	1	X
9	Hospitals	7	X*
10	Basic Health Units	12	X*
11	Emergency Care Units	6	X*
12	Centers for Comprehensive Care for Older People	1
13	Social Assistance Reference Center	11
14	Specialized Social Assistance Reference Centers	1
15	State Coexistence Centers for Older People	2
16	State Family Coexistence Centers	5
17	State Council for the Older Person	1	X
18	Municipal Council for the Older Person	1	X
19	State Public Defender's Office	1	X
20	State Public Ministry	1	X

• *Two managers from different institutions participated; Source: Prepared by the author based on research carried out.

Although there is no consolidated information on the quantity of the network in other Brazilian capitals, it is noted that in Manaus, there are several institutions that make up the protection network, not only in the fight against violence, but that seek in various ways to protect the rights of the older person in the most diverse areas. In this research we characterize only the deemed as main, selected by the CEI, based on their roles and purposes established in the institutional discourse.

The lack of articulation in the protection network

All 16 managers interviewed were unanimous in stating that the protection network in combating violence against olde people in Manaus does not have the necessary articulation so that the demands of the older person receive adequate treatment and prompt responses. For them, the demands are streamlined through personal contacts and that the articulation needs to be strengthened, as we see below:

“[...] this interaction, that is, I know my mission and the role of the other. So I need the other’s function to complement mine. This is not happening”. (Public Ministry).

“I believe that there is no articulation in the network. We need interconnection to be able to function. There is no interconnection even in the sectors of a single network. In health, I don’t see interconnection between BHU/CAIMI/Social Centers, for example”. (State Health Network).

“We have a network with several bodies, to fight violence, but it does need an articulation in which the role of each body within this protection network is actually established”. (Municipal Health Network).

“When you establish personal contact, then the situation of that older person, it flows faster [...] but the articulation needs to be strengthened because violence can require different types of service”. (State Council for the Older Person).

The National Policy for the Older Person (PNI) establishes as a competence of the public power to develop forms of cooperation between institutions, since, despite the personal and primary network of the older person being fundamental for care, it needs to be articulated with the secondary services network, which, incidentally, need to function as a shared network of responsibilities. In this sense, the efficient articulation of the protection network and its actors is imperative. Isolated, disconnected and discontinuous actions get lost in the universe of bureaucracies of public bodies, most of the time¹¹.

Ribeiro and Silva¹² argue that violence, as a multifactorial phenomenon, requires multidisciplinary and interdisciplinary approaches, “one or two professional categories are not expected to deal with such complex situations”. For Vasconcelos¹³, hardly a single professional would handle all the aspects of such a complex reality. Cezar and Arpini14 point out that technical manuals, ordinances and laws are necessary for the care, protection and prevention of violence. However, for them to be really effective, they need to be operationalized in the daily action of the protection network services, where everyone has the duty to care for and protect the older person, especially in a context of violence.

The flow of care for older people in situations of violence, carried out by the protection network

For the 16 managers interviewed, there is no service flow outlined and followed by the network in Manaus. Their knowledge is restricted to the service flow of the institution to which they are linked.

“There is no defined flow, and worse: there is not much information for the older person and for the family where they can look in case they are a victim of violence [...] we have already tried to work the flow of care, this is a struggle, we’ve already tried to put it into law, but so far we haven’t. ” (State Council for the Older Person).

“We don’t have [a flow] and it’s absurdly confusing [...] absolutely confusing, it doesn’t make sense and this I’ve noticed since I came here [...] so it’s from scratch. We have to start from scratch [...]”. (Public Ministry).

“[...] There is no delimited flow. First they go to a health unit. Then another... and another.... There is no such design [...] I am not aware if there is any flow [...] none of the institutions I work in have this flow. In the last five years I was the coordinator of the ICU at Platão Araújo [...] I’m completely unaware of it; I was never informed about it [...]”. (State Health Network).

“I can only talk about FDT’s own flow”. (Doctor Thomas Foundation).

It is clear to the network that there is no flow of care for older people in the city of Manaus. The flowchart is one of the tools used in organizational analysis that graphically represents the sequence of an activity. Its importance is noticed, especially when used to analyze organizational processes with a view to their improvement. Through it, the processes that involve a service are mapped, allowing a precise and clear description of the sequencing of the entire service. For Peinado and Graemil¹⁵, the tool can make an impactful contribution to the management of any process and/or project, involving any area of expertise. According to Baltzan¹⁶, the flowchart is a fundamental tool for both planning and improving any process, enabling critical analysis and pointing to possible changes and adjustments. A well-designed flow can help identify unnecessary steps, bottlenecks and other inefficiencies¹⁷.

Therefore, it is relevant that the protection network in the fight against violence against older people in Manaus has well-defined activity flows, free from shadowing, rework and attribution conflicts. Whenever possible, it should also be simplified and absolutely clear for everyone involved, but especially for the older people in situations of violence, who, in many circumstances, do not know who to turn to. It should be noted, however, the challenges that the network has in the development of this flowchart of care, since there are several institutions that make it up, from various spheres of government, with different structures, with disparate organizational cultures and often opposing interests.

However, coping with violence is an extremely complex task and requires fruitful designed and elaborated actions, with the need for managers to use the most diverse management tools available and thus adopt appropriate protocols and care flows¹⁸. Isolated and disjointed actions, even if very well intentioned, are unfortunately not able to mitigate such an enigmatic and sometimes abstruse problem, which is violence against older people.

Monitoring cases of violence involving older people in Manaus

The survey showed that the network managers were also unanimous in stating that they do not know or that there is no follow-up of cases of violence against older people in the city, as shown in the fragments below:

“I couldn’t tell. I think not. I’ve never heard of follow-up”. (State Council for Older People).

“The Public Defender Assistant to Older People would not be able to say about this follow-up. He believes there is none”. (Public Defender’s Office).

“I can’t tell you.” (Public Ministry)

“Honey, it doesn’t exist. For example, psychological intervention. In Platão Araújo, we don’t have a psychologist [...] so, there isn’t. In relation to abusers, these things, there’s not, either, do you understand? I don’t know of any follow-up”. (State Health Network).

“[...] after that [the service] I think there is no more follow-up. Also in relation to the abusers, only the police station can tell you”. (Municipal Health Network).

Carrying out follow-up on cases of violence against older people is a necessary and complex mission at the same time, especially due to the place where they usually occur and the actors involved. However, in Manaus, according to the results of the present study, this does not occur. In addition to high demand, there are not enough professionals or a unified information system that can gather data, generate reports with information that has visibility to network managers.

According to Brito¹⁹, the family is the locus in which the largest number of violence against older people is concentrated and this is practiced by the older person’s own family. This is an extremely delicate situation, requiring even more in-depth studies.

For Abath et al.²⁰, it is the weakened relationships and previous family history of violence that favored the emergence of aggression. The authors conclude that “families unprepared to understand, manage and tolerate their own conflicts tend to be violent”, and add “the quality of the relationship between them and the older person depends on beliefs, values and conceptions about old age and care”.

On the other hand, Brazilian culture, supported by the Older People Statute, imposes an obligation on the family to be responsible for the care of older members². Thus, it is predictable that neglect and abandonment are attributed to relatives. In most families with problems of violence, members do not have a pro-social interpersonal repertoire to deal with difficulties and even the reduced physical space of the houses can generate strain and conflicts. As a result of the lack of skills to live with these difficulties, situations of neglect, abandonment or physical and psychological aggression occur⁶.

Studies show that many of the abusers, in addition to having a history of violence in the family, have loose affective family ties, were victims of abandonment, neglect and sexual abuse in childhood. Sometimes the aggressor can unload feelings of ambivalence, hurt and anger on the older person, placing the older person in a situation where he once was and perhaps still is²¹-²³. Allied to this fact, Neri²⁴ points out that the older person can also contribute to the occurrence of violence, due to the demands they make, impatience and even a possible process of dementia or mental illness that is not understood by family members. In this sense, what is sought is to draw attention to the complex sphere and nuances of family relationships, its multifaceted character, its dynamics and, therefore, its possible consequences in cases of intrafamily violence. Such questions lead us to a reflection on the need to change the way society fosters the aggressor. There must be a broader vision, devoid of prejudices and stereotypes, a more empathetic and welcoming society.

Hence the rapid demand for follow-up and interventions, both in relation to the older person and possible aggressors. Its effects could certainly result in a reduction in the number of recurrences of violence against older people in the city of Manaus.

It should be noted that the COVID-19 pandemic was considered an obstacle to conducting the interviews, which constituted a research limitation. Some institutions were not active due to social isolation and others claimed to be primarily focused on care related to the pandemic. Another limitation was having encountered resistance from managers, since some of them held commissioned public positions and did not feel comfortable addressing issues that could denote some gap or weakness in their professional practice.

FINAL CONSIDERATIONS

Despite not having the necessary articulation to meet and monitor the demands of older people, with no follow-up, nor defined service flows, the protection network in combating violence against the older person in the city of Manaus is extensive and active. It is up to the public authorities to develop forms of cooperation between institutions, since the older person’s personal and primary network is fundamental for care, but it needs to be articulated with the secondary network of services and function as a shared network of responsibilities.

Therefore, there is a need for integration and articulation between the different institutions: an active, intersectoral, welcoming network that dialogues, supports and knows the importance of both its work and the other components of the protection network. The multidisciplinary approach and work from an intersectorial and articulated perspective can result in potentiality in confronting violence against older people in the city of Manaus. Therefore, professionals, institutions and managers need to understand the importance of this networking based on their performance as a multidisciplinary and interdisciplinary team, that is, different areas dialoguing with their common knowledge and objectives.

• No funding was received in relation to the present study.

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Edited by

Edited by: Tamires Carneiro de Oliveira Mendes

Publication Dates

• Publication in this collection
  29 Oct 2021
• Date of issue
  2021

History

• Received
  19 July 2021
• Accepted
  13 Sept 2021