Factors associated with reporting of abuse against children and adolescents by nurses within Primary Health Care1

OBJECTIVE: to analyze the factors associated with the underreporting on the part of nurses within Primary Health Care of abuse against children and adolescents. METHOD: cross-sectional study with 616 nurses. A questionnaire addressed socio-demographic data, profession, instrumentation and knowledge on the topic, identification and reporting of abuse cases. Bivariate and multivariate logistic regression was used. RESULTS: female nurses, aged between 21 and 32 years old, not married, with five or more years since graduation, with graduate studies, and working for five or more years in PHC predominated. The final regression model showed that factors such as working for five or more years, having a reporting form within the PHC unit, and believing that reporting within Primary Health Care is an advantage, facilitate reporting. CONCLUSION: the study's results may, in addition to sensitizing nurses, support management professionals in establishing strategies intended to produce compliance with reporting as a legal device that ensures the rights of children and adolescents.


Introduction
Acknowledged worldwide as a social and public health problem due to its impact on the morbidity and mortality of the population and also on the routine of human experiences (1) , violence is deeply rooted in social, economic and political structures, as well as in individual consciousness and cultural dynamics. Violence against children and adolescents entails a breach of the duty on the part of adults and society, in general, to protect these individuals, as well as a trivialization of the rights of children and adolescents to be treated as subjects and people under special conditions of growth and development.
The magnitude of this problem can be found in studies that show violence against children and adolescents to be the main causes of death and disease among these populations in many countries (2)(3)(4) , including Brazil (5) . The magnitude of this problem in the international scenario concerns governments, researchers and civil society, because its repercussions for the future lives of this members of these groups are significant (2,6) .
In the Brazilian context, as part of the strategy used to cope with this problem, the Child and Adolescent Statute (ECA) has established that healthcare workers and those in the field of education are supposed to report maltreatment against children and adolescents (7) . In the health field, this practice is supported by Decree No.
1.968/2001, which institutionalized mandatory reporting of abuse against children and adolescents who receive care from the Unified Health System (SUS) (8) and also by Decree No. 104/2011, which establishes that domestic violence, sexual and/or other types of violence is the 45 th event in a list of mandatory reporting (9) .
As part of the Brazilian healthcare model, Primary Health Care (PHC) presents a privileged opportunity to identify and manage situations of abuse perpetrated against children and adolescents. The reason is that this model is intended to prevent disease and harm and is grounded on health promotion to encourage coping with violence against this population.
In this field of collective health, nurses stand out because they have academic background that qualify them to perform actions that promote health as well as family care (10) . This profession has incorporated new practices that transcend the technical-healing model due to the complex demands presented within PHC (11) . In this context, maltreatment of children and adolescents and its consequences reverberate in the routines of family strategy health teams and demand from nurses and other healthcare workers an ethical and legal response in accordance with the precepts that govern this topic.
Nonetheless, studies indicate that PHC-unitoriginating reports of violence are a challenge for many reasons including lack of preparation and poor management of cases, in addition to a fear of personal or professional retaliation (11)(12) . From this perspective, this study is relevant because it lists the factors that facilitate reporting of abuse against children and adolescents in regard to the professional and citizenship roles of nurses working in PHC, an aspect seldom addressed in the literature.
We expect that these results will support the planning of actions to facilitate the reorientation of practices involving management and care provided by PHC units so that reporting becomes effective. Hence, the objective was to analyze the factors associated with juvenile abuse reporting by nurses working in PHC.

Method
A cohort cross-sectional analysis was performed using the database of a larger study titled "Violence involving children and adolescents: conditioning factors, reporting processes and coping mechanisms", the objective of which was to analyze the reporting, on the part of healthcare workers (physicians, nurses, and dentists) from the Health Family team, of abuse
In regard to the identification of abuse against children and adolescents in their professional practice,      This weakness regarding reporting of abuse in the practice of nurses is also verified in other Brazilian regions (11,13) and in countries from other socio-cultural contexts (14)(15)(16) . One study conducted in Israel with 143 nurses and 42 physicians revealed that 60.0% of the professionals did not report abuse (16) . Even though more advanced systems have been established in the USA for the reporting of child abuse for a longer period of time, there still are barriers that hinder nurses from filing abuse reports (15) .
One potential explanation for underreporting is the misinterpretation of the term "reporting", because, in Brazil, it is culturally and historically associated with denouncement (17) . In this sense, considering the role importance of having greater experience in the service is shown in a study (18) reporting that "daily contact with violence perpetrated against children awakens in the professional a state of alertness, which mobilizes him/ her to identify signs indicating violence." Another hypothesis is that nurses may have improved the way they deal with situations of child abuse,  (19) .
Therefore, management should at least ensure One study (11) shows reports of PHC nurses who believe that child and adolescent abuse is within the sphere of other professionals (e.g., social workers or psychologists).
The fact that nurses do not fear becoming legally involved also encouraged the reporting of abuse. This information confirms that having a protection and support network for those suffering violence, as well as professionals who become responsible for the reporting, Another investigation reveals that PHC workers face a real dilemma concerning the decision to report abuse, even when they are aware of their legal obligations, and may opt for a "friendly neighbor policy" in order to ensure their own safety within the work environment when exposed to situations that put their physical or moral integrity at risk (11) .
Another relevant aspect is that nurses who believe that reporting within PHC is an advantage are more inclined to filing reports. Perhaps, in accordance with the socio-sanitary considerations, these workers acknowledge the importance of ties established with the living territory and regard the nuclear family as the driving force in the recovery of values. They also perceive violence as a problem in the health sector, acknowledging the concept of multidimensional health addressed in the Brazilian Constitution (22) . Another relevant aspect is that nurses who believe that implementing reporting within PHC are more inclined to file reports.
After presenting these interpretations and arguing for their validity, it is important to note the study's limitations. A total of 60.7% of the nurses consented to participate in the study, which may imply that the ones who adhered to the study are more committed to health actions, more familiar with the topic, and/or received

Conclusion
This study clarified aspects related to reporting of abuse against children and adolescents by nurses within PHC. The regression logistic model showed that factors such as working within PHC for five or more years, having a reporting form within the PHC unit, knowing where to refer cases, not being afraid of legal involvement, and believing that reporting within PHC is advantageous, favor complying with this legal device that ensures the rights of this population.
We believe these results will sensitize nurses and also be used by management professionals to guide strategies for effective reporting. This study reveals the need to include continuous education processes within the PHC services to encourage, both professionals delivering care and those in management functions, to reflect upon this issue and identify intervenient factors that perpetuate underreporting of violence perpetrated against children and adolescents and, at the same time, weaken the system that ensure the rights of this population.