Method

Results

Women were aged between 19 and 59 years old (M = 34.42 years, SD = 10.64) at the time of notification. A significant difference was observed in the age group of the victims. The results showed a greater number of reports among victims from 19 to 29 years old, while in the age group 50 to 59 fewer reports on violence were observed (see Table 1).

Regarding the race of women, 80.1% identified themselves as white. Regarding the educational level, 33.5% reported incomplete elementary education. Reports on violence were more frequent among those who were literate and had incomplete elementary education. In all the reports analyzed, 49.9% of the women were married or were in a stable union. According to marital status, married women had the highest number of reports (see Table 1).

Table 2 describes the types of violence, as well as the area and place of occurrence. Physical violence was the most frequent (69.9%). In 50.3% of the situations there was use of corporal force or beating. The types of sexual violence included mostly rape. In the urban area, a greater number of cases (88%) were identified, and the victim's residence was identified as the main place of occurrence (76.4%).

In most situations of violence, the aggressions were committed by a single aggressor (82.1%) and male (67.5%). Partners or intimate ex-partners (e.g. spouses, ex-spouses, boyfriends and ex-boyfriends) were responsible for 52.2% of reported cases of violence. In 39.8% of the cases, it was identified that the aggressor used alcohol. Significant differences in frequency of reporting were observed considering their characteristics (e.g., number of aggressors, gender of the aggressors and alcohol use) (see Table 3).

Regarding the consequences of violence, in 19.9% of cases, PTSD was identified. Regarding the care, most of the women received outpatient care (60.7%), and in 2.4%, prophylaxis for HIV and other Sexually Transmitted Diseases (STDs). The police stations were the main points of referral of the protection network (31.9%), followed by the Women's Police Stations (Delegacias Especializadas no Atendimento à Mulher - DEAM) (21.5%). In 80.5% of the situations of violence, women were discharged (see Table 4).

Discussion

This study aimed to characterize the situations of violence against women reported by health professionals through the SINAN Individual Notification Form (FIN-SINAN) in Rio Grande do Sul. The analyzes have identified the severity of aggressions suffered by women in the state and the importance of notification by health professionals who care the cases. The investigation of situations of violence is important since it contributes to decrease the invisibility of this reality experienced by countless women in Brazil. Although considered a public health problem, confront this type of violence demand more effective action and include different sectors of society (^{Delziovo, Bolsoni, Nazário, & Coelho, 2017}).

Regarding the characteristics of the victims, the number of reports on violence differed according to age group of women. This result agrees with previous studies that identified that the highest incidence of aggressions against women occurs in the age groups between 18 and 29 years old (^{Deslandes, Gomes, & Silva, 2000}; ^{Saffioti, 1997}). The data can also be interpreted from the assumption that women with more advanced ages report less the situations of violence experienced. For a long time, the importance of being a good wife and mother was strongly linked to values that made women more vulnerable to violence. Even today, many victims do not report aggressions due to fear, shame, family pressures and difficulty in understanding such acts as a crime (^{Kumar et al., 2013}). This also occurs due to the institutional inefficiency that includes the negative attitudes of the justice system, bureaucracy, lack of orientation and revictimization (^{Meneghel et al., 2011}).

Most reports made by health professionals included white women. This result, which differs from the data released from Ligue 180 (^{Secretaria Especial de Políticas para as Mulheres, 2016}) may be related to the demographic profile of Rio Grande do Sul. In the last population census, 83.22% of the population was declared white (^{Instituto Brasileiro de Geografia e Estatística [IBGE], 2010}).

Reports on violence were more frequent among women with incomplete elementary school. This data agrees with a study that aimed to verify the prevalence and the types of violence committed against 251 women who consulted a Basic Health Unit of Porto Alegre (RS). Women with fewer years of schooling presented higher prevalence of violence (^{Kronbauer & Meneghel, 2005}). In addition to the educational level, these results may also reflect differences in socioeconomic and related to the health service accessed. Women with higher schooling and purchasing power tend to search for health services and may request that the situation of violence will not be notified (^{Oliveira, Cardoso, Almeida, Cardoso, & Gutfilen, 2014}), despite the obligation for all health services in the country. Even though it was identified a higher frequency of notifications involving young women, white, with incomplete elementary school, who were married or were in a stable union, it should be noticed that violence is a democratic phenomenon that can affect women regardless of their personal and social characteristics (^{Meneghel et al., 2011}; ^{Saffioti, 2001}).

Among the type of violence, the most frequent was physics. However, as identified in other studies, violence against women may involve multiple aggressions. In many cases, physical violence is followed by psychological and sexual abuse (^{Deslandes et al., 2000}; ^{Fonseca, Ribeiro, & Leal, 2012}; ^{Kronbauer & Meneghel, 2005}). The results found in this study differed from that observed by ^{Schreiber et al. (2007}), in which psychological violence was identified as more frequent. This difference may be related to the fact that, in general, health services are accessed when violence leaves physical marks. In addition, many women and even health professionals have difficulty to identifying situations of psychological violence. Similarly, many women are forced to have sex with their partners and do not identify such situations as violence (^{White & Satyen, 2015}).

The highest number of reported violence occurred in urban areas and in the residence of the victim. The domestic context has been identified in the literature as the main place of occurrence of violence against women (^{Bruschi, Paula, & Bordin, 2006}; ^{Deslandes et al., 2000}; ^{D’Oliveira et al., 2009}; ^{Schraiber et al., 2007}; ^{Silva, Lima, & Ludermir, 2017}; ^{White & Satyen, 2015}; ^{WHO, 2016}). The privacy of home often hides the abuses committed (^{Deslandes et al., 2000}). Individuals with whom women have or had intimacy and affective bonds, such as spouses and ex-spouses, are identified as the main aggressors (^{Baugher & Gazmararian, 2015}; ^{Gallagher & Parrott, 2011}; ^{Miranda et al., 2010}; ^{Schraiber et al., 2007}; ^{White & Satyen, 2015}; ^{WHO, 2016}). Beliefs about the social roles that must be played by men include violence and the devaluation of what is considered feminine (^{Baugher & Gazmararian, 2015}; ^{Gallagher & Parrott, 2011}). Men who manifest defensive feelings and insecurity in their relationships may use violence as a way to regain a sense of power and control (^{Baugher & Gazmararian, 2015}; ^{Gallagher & Parrott, 2011}; ^{Reidy, Berke, Gentile, & Zeichner, 2014}). It is essential that interventions for violence prevention are based on the deconstruction of gender stereotypes that contribute to unequal power relations between men and women. In addition, it is important to consider the frequency of cases in which the perpetrator used alcohol. This is a risk factor that should also be considered in violence prevention policies.

Regarding the consequences of violence attributed by health professionals, PTSD was more frequently identified. This data should be interpreted with caution since the diagnosis of PTSD requires a minimum period of one month of maintenance of the symptoms after the traumatic episode (^{American Psychiatric Association [APA], 2013}). Thus, this may make it impossible to identify the disorder at the time of the service that generated the notification of violence. In order to complete the field related to the consequences, a clinical diagnosis issued by a qualified professional is required (^{Ministério da Saúde, 2008}). Difficulties in identifying the consequences have produced a considerable amount of missing information in the database. In the version of FIN-SINAN which entered into force in 2015, the consequences fields were excluded (^{Ministério da Saúde, 2015b}).

Regarding health care received by women victims of violence, most were attending in clinics and discharged after the completion of health procedures. It should be noted that, despite the high frequency of cases of sexual violence that included rape, prophylaxis for HIV and other STIs were performed in only 2.4%. This result may indicate the lack of knowledge or training of professionals on referrals recommended by the Ministry of Health (^2015a) for cases of sexual violence. In addition, the practice of some health professionals may be permeated by cultural values that minimize the seriousness of sexual violence against women. Due to the serious repercussions, the victim of sexual violence requires a service that promotes the reduction of injuries and damages to health. For this purpose, should be included measures to protect pregnancy and contamination by STIs (^{Faúndes, Rosas, Bedone, & Orozco, 2006}).

Regarding the referrals to the safety net, women were more frequently referred to police stations. This result may be related to the fact that most of the cities of Rio Grande do Sul do not have Women's Police Stations or Women's Assistance (DEAMs). The DEAMs are specialized units of the Civil Police that performs actions of prevention, protection and investigation crimes of domestic and sexual violence against women. In this place, police reports, request to the judge of protective measures and investigation of the crimes are performed (^{Secretaria de Políticas para as Mulheres da Presidência da República, 2016}). In addition to the police stations, it was identified that many cases were referred to other services (e.g., Women's Resource Center, Guardianship Council, etc). The diversity of referrals may represent a lack of organization between the health network and protection since police stations should be the gateway to cases of violence against women. According to ^{Meneghel et al. (2011}), who evaluated the journey in Porto Alegre (RS) by women search for breaking the violence, it was not possible to identify a precise and efficient flow between services, and the way is different for each woman.

Conclusions

This study made it possible to understand the characteristics of situations of violence against women reported in Rio Grande do Sul by health professionals. The main limitations of this study included the lack of control over the data collection and the export to the virtual platform of the variables that compose FIN-SINAN 2008. In addition, the analysis of the data indicated the presence of a large number of information that was reported as "ignored" by health professionals or that appeared as "absent" in the database. The absence of such information may be related to the complexity involved in the dynamics of violence and the reluctance of some victims and health professionals to report on all aspects involved in the situation. On the other hand, it can also represent the care of the professionals respondents with the information since it may not have been identified. In any case, health professionals should receive training in order to sensitize the importance of reporting and complete filling of the data. In any case, health professionals should be trained to sensitize them about the importance of reporting and completing accurate and complete data.

Violence against women is not a recent phenomenon. What is recent is the concern with confrontation, criminalization and the understanding that it is a public health problem. Abuses occur in relational and social levels, which requires cultural and educational changes for their confrontation that go beyond the criminalization of aggressors. Understanding the characteristics of aggressions and the dynamics of violence against women provide the appropriate assistance of victims and planning prevention strategies. It is increasingly important that health professionals understand the importance of reporting and making appropriate referrals for each case. The main contribution of this study is to provide subsidies that may assist in the qualification of the policy of epidemiological surveillance and the care of women victims of violence. Assessing the strengths and weaknesses of these initiatives can contribute to the more effective use of public resources to coping violence against women.