Family violence against children and adolescents in context: How the territories of care are imbricated in the picture 1

ABSTRACT Objective: to understand the context of care addressed to the families involved in family violence against children and adolescents (IVCA), as produced in the context of the Primary Health Care (PHC), from the vantage point of the practitioners of a municipality in the State of Sao Paulo. Methods: qualitative research of the social-strategic type, based on the Complexity Paradigm. The participants were 41 health practitioners in five health units of the municipality under study, pertaining to the five districts of the municipality. Data collection was done through 5 focus groups and 10 semi-structured interviews from April 24th 2013 to December 12th 2013. Data analysis was oriented by the comprehension and contextualization mindset and based on the dialogic, recursive and hologramatic principles. Results: two main issues regarding the care provided by the Health of the Family team were identified: the context of this violence (the domestic space) and the power relations that prevail in the territory where this violence surfaces. The community health workers are the targets of specific attention because they experience the live/work dialogic in this same area. Conclusion: paying attention to the territory, and considering the complexity of contexts and dimensions is inherently linked to the design of care to families involved in IVCA in the PHC environment.


Introduction
Violence is responsible for more than 1 million deaths per year, a 2,5% of total world mortality.
Notwithstanding this fact, these numbers only represent the top of a pyramid that better represents the size of this issue. Thousands of individuals worldwide are nonfatal victims of violence every day, representing the bottom of this pyramid. Children and adolescents are a large part of this silent victims (1) . This phenomenon is still more complex due to the fact that its main scene -the family space -and the repeated occurrence, hampers the care of the practitioners that give services to these families (2)(3) .
The Ministry of Health has the proposal of integration of resources and services for caring for these families involved in family violence against children and adolescents (IVCA) within a network of care, in an inter-institutional and inter-sectorial rationale, guides by Primary Health Care (PHC) (2)(3) . PHC is the first level of care and the preferred gateway of the Brazilian National Health System (SUS). It is understood that, due to geographic proximity to populations, it has the best conditions to identify, welcome and build therapeutic projects addressed to families involved in IVCA, along with the rest of the service network (2) .
Recent studies approaching the subject of violence experienced by children and adolescents, remark the importance of the contextual factors of these stakeholders in coping with violence, and cite as the main factors, the family, peers and community; showing the alienation of the structures of child and adolescence protection, using comprehensiveness as a working instrument (4)(5)(6)(7) . For this purpose and trying to overcome the challenges in the healthcare area, specifically for From the standpoint of these interrogations, the object of this study was the context of caring for the families involved in IVCA, within PHC. The Complexity Paradigm, using Edgar Morin's concepts, one of its main authors, as a reference was used as foundation for comprehension of this object. Complex thinking is proposed as an approach for objects that are "weaved together", trying to consider distinct, sometimes contradictory parts, as imbricated in the full picture of a phenomenon, as inserted in a context and not in isolation, in a dialogic perspective. For this purpose, it is needed a multi-view look into this phenomenon, trying to perceive and link local, global and the multiple relations among the parts, the whole and the context, allowing for a multi-dimensional approach, that may be contextual, dynamic and trans-disciplinary, including the contradictions (8) . To look at IVCA in a multi-dimensional way and to comprehend care in the context where that care really happens, may guide the potentialities and the impediments that the PHC practitioners face in this situation.
For these reasons, the objective of this study was to understand the context of care that is delivered to the families involved in IVCA, as produced in PHC, from the point of view of the professionals of the Health Basic Units (HBU) of a municipality in the State of Sao Paulo

Methodology
Qualitative approach study, using strategic social research, with foundations in the Complexity Paradigm, as already stated. The methodological pathway was oriented by the mindset related to comprehension and conceptualization, present in the Complexity Paradigm.
Contextualization means to recur to strategies that aim to understand a certain phenomenon as linked and not in isolation. Comprehension tries to apprehend the meaning of an object or event and its relations with other objects or events (9) .
Other than these notions, we used the principles of complexity, such as: dialogic, recursive and hologramatic. The first implies the joining and association of contradictory factors in the analysis of a certain phenomenon. The second principle is related to the recursive action in the organization, as in a whirlwind, remarking that "the recursive process is a process in which products and effects are at the same time causes and producers of the same factor that produced them" (8) .
The third principle is represented by an hologram image, in which each point contains almost all the information on the represented object, in a way in which not only the part is in the whole, but the whole is inserted in some way, in the part (8)(9) .
The field of study was a large municipality in the In this fashion, the municipality is divided in five Health Districts, North, South, East, Northwest and Southwest.
The municipality under study has 62 HBU's organized through the Health of the Family Strategy (HFS). There is a HBU for approx. each 20.000 pop. with multiprofessional teams including physicians of the basic specialties (clinicians, pediatricians, ObGyn), nurses, dentists, nursing auxiliaries and dental assistants. A few HBU's also have mental health staff (psychiatry, psychology and occupational therapy).
The participants in this study were the workers of the HBU's with the following inclusion criteria: (i) one unit from each district was included, according to availability and authorization from the district and local coordinator; (ii) only the workers with at least one year working in the Unit were considered and also they needed to be involved in actions related to families involved in IVCA; (iii) to include enough number of participants to find reincidence and theoretical saturation of the information.

Results and discussion
The IVCA phenomenon is complex and interferes that do not have a priori higher diplomas, is not done or done through initial approaches (12)(13) .
The topic so far analyzed should be expanded beyond the understanding of the territory as a geographic definition, of a political-administrative nature, that give boundaries to the action of a certain health service. In Social Sciences, the concept of territory assumes three suppositions. Firstly, there is a difference between geographic space and territory, Secondly; there is a historical construction of the territory, in the social field, linked to power relations. And thirdly, the more relevant for this study, is the subjective dimension of the territory, identification and domination of a certain space and in the objective dimension, related to political and economical action. Following this view, territories are defined by the power as effective in that space, not only political but also de symbolic appropriation (14)(15) (16)(17) .
A study stresses the fact that emancipatory practices as the house visits, allow for apprehending the health conditions as a result of the social relations, empowering other therapeutic devices such as team work and community participation (18) . In spite of being a kind of care that all the practitioners may perform, the house visits are mainly done by CHW's: The investigation is only of the CHWs… I think that if I win I would look like the CSI… (Gp1). Other aspect that the study proved about the CHW was a certain isolation of them in the healthcare, leading to propose a integration of them to the teams to overcome this trend (19) .
On the last quoted speech, the house visits in the network of care for IVCA have the role of "investigation", control and surveillance in a police fashion. Dialogically, the topic presents itself as key in the approach to IVCA, allowing to find situations that would hardly been evidenced in Unit visits, along with the perception of violent family dynamics. This approach is difficult and threatening, specially for the CHW: There is a lot of fear of accusation, and even when we have a charge, there is fear of dealing with something deeply hidden, there is a lot of fear, even the CHW's are frightened, I live here and I may be threatened (E4).
In the family context, power is directed towards the household responsible person and the entry or intervention of a health practitioner, or of who is dialogically his/her neighbor, may provoke the surfacing of a asymmetric relation. This question relates to the issue of multiplicity and plurality of territories where the Unit has to act upon. It is understood as multiplicity the relations imbricated in this care, while plurality may be understood as the set of contexts that need to be incorporated as inherent for this care (14)(15) . The health practitioners need to approach to this debate and develop their practices around these concepts,  (20) .
In the sites of this study, drug traffic appears to drugs, weapons and violence constitute a large portion of the economic and political infrastructure (21) . It is an important appropriation and domination of the territories, resulting in power relationships that are legitimated by the community, even being informal (21) .
Other than these considerations, the interviewees  (23) . A study in the United States warns for the considerable rise in depression in the involvement with gangs and infection by sexually transmitted diseases by teenagers that break the law and live in deprived social milieus (For example a weakened social network, precarious housing, exposure to violent communities, limited schooling opportunities) (24) .
Interactions with drug traffic in all the circumstances, in which they may happen, can be considered dialogic with dynamic movements of order and disorder, surrounded by antagonisms and contradictions. The recursivity in this phenomenon shows the complexity around it, meaning that there is not a perceived a causeeffect rationale, but are seen simultaneously as products and producers of the violence that produced it at the first time and retroact on it (8-9) . Integrative and intersectoral programs and actions focused in prevention, as mentioned before, are imperatives for creating "incubators" for growth and knowledge in cities in the industrialized and developing world, going against the present production of cycles of violence and misery (21) .
The community is seen as a partner and with  (25) .
The complex thinking tries to re-link the dimensions individual/species/society that give foundations to the ethics of solidarity. This issue is key for the debate about health promotion in the collective sphere, where is sought a better interaction among individuals of the community, giving rise to healthy experiences and relationships (3)(4)(5)(6)(7)(8)(9) . These aspects are reinforced by the literature, showing the importance of the empowerment of the community through programs focused in the prevention of harm, and improving the population's participation, and specifically teenagers' in the formulation of specific public policies (5)(6)(7)(8)(9)(10)(11) .

Conclusion
According with the present study, it was understood that there was a need of building a way to look to the territory beyond the specific geographic boundaries, to allocate population to services. The study opened a discussion about the multiplicity and plurality of territories that are in focus when designing the system of care for IVCA through PHC. In this environment, the CHW's were the essential elements for discussion; even though they were considered the key point for PHC, the dialogic as www.eerp.usp.br/rlae