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Print version ISSN 0104-0707
Texto contexto - enferm. vol.21 no.3 Florianópolis July/Sept. 2012
Ana Cláudia Carvalho Mello-SilvaI; Virginia Visconde BrasilII; Ruth MinamisavaIII; Lizete Malagoni de Almeida Cavalcante OliveiraIV; Jacqueline Andrea Bernardes Leão CordeiroV; Maria Alves BarbosaVI
IMaster in Nursing. RN at Goiás State Health Department. Goiás, Brazil. Email: email@example.com
IIPh.D. in Nursing. Faculty at the College of Nursing, Federal University of Goiás (UFG). Goiás, Brazil. Email: firstname.lastname@example.org
IIIPh.D. in Epidemiology. Faculty at the College of Nursing, UFG. Goiás, Brazil. E-mail: email@example.com
IVPh.D. in Nursing. Faculty at the College of Nursing, UFG. Goiás, Brazil. Email: firstname.lastname@example.org
VMaster in Nursing. Faculty at the College of Nursing, UFG. Goiás, Brazil. E-mail: email@example.com
VIPh.D. in Nursing. Faculty at the College of Nursing, UFG. Goiás, Brazil. Email: firstname.lastname@example.org
Firearms violence can induce post-traumatic stress and reduce quality of life. This descriptive study aimed to analyze quality of life and Posttraumatic Stress Disorder symptoms of young adult inpatients, victims of interpersonal firearm violence. WHOQOL-Bref and PCL-C instruments were used to interview 95 victims during 2007 in the main hospital of Goiânia, Brazil. The Environment and Physical Health domains presented the lower mean scores of quality of life (44.71 and 48.26, respectively). Symptoms of Posttraumatic Stress Disorder were identified in 60% of victims, but no difference was detected in the quality of life domain scores between those with and without Posttraumatic Stress Disorder symptoms. The traumas due to interpersonal firearm violence may result in low quality of life scores and high prevalence of Posttraumatic Stress Disorder symptoms.
Descriptors: Quality of life. Violence. Firearms. Emergency service, hospital.
Violence has become a major concern worldwide, because it is a threat to the primary right to life, affects health, and reduces quality of life. Firearm violence presents high morbidity and mortality in less developed countries, and affects mostly the male youth, as victims and as aggressors.1-3
Taking into consideration the magnitude of the violence problem in Brazil, the Ministry of Health proposed, in the last decade, interventions for improving surveillance, welcoming, and health assistance to victims, health promotion and quality of life.4
Violence victims experience the threat to their own and others' physical integrity, intense fear, helplessness or horror.5 In regions with high rates of violence, the occurrence of repeated events may predict Post-Traumatic Stress Disorder, and reduce the quality of life of the victims.6
In Brazil, because of the lack of accurate information in emergency departments regarding victims of violence, it is difficult to understand the effects of interpersonal violence on quality of life. Studies on the victims' perception on quality of life and post-traumatic stress may help to design strategies of professional interventions in the follow up of outcomes.
The objectives of this study were to evaluate the Quality of Life (QL) of young adult firearm violence victims, hospitalized in a main emergency service in Goiânia-GO, identify the presence of symptoms suggestive of Post-Traumatic Stress Disorder (PTSD), and analyze the QL of victims with and without PTSD symptoms.
This descriptive study was performed at the main reference public emergency service in Goiânia - Goiânia Emergency Hospital (HUGO). A total of 717 firearm violence victims were hospitalized between November of 2007 and September of 2008. Survivors hospitalized for over 24 hours, aged between 18 and 39 years, and with cognitive capacity and/or level of comprehension were eligible. The study was approved by the Research Ethics Committee at HUGO, under protocol number 046/07.
Three data collection instruments were used. The first included sociodemographic data and the circumstances of the aggression. The second was the WHOQOL-BREF quality of life assessment,7 that was translated and validated in Brazil.8 The WHOQOL-Bref instrument comprises 26 items that are organized in a four Domain structure: Social Relationships (sexual activity, social support and personal relationships), Physical Health (pain and discomfort, dependence on medicinal substances and medical aids, energy and fatigue, mobility, sleep and rest, work capacity and activities of daily living), Psychological (positive and negative feelings, thinking, learning, memory and concentration, self-esteem, bodily image and appearance, spirituality/religion/personal beliefs) and, Environment (freedom, physical safety and security, home environment, financial resources, health and social care - accessibility and quality, opportunities for acquiring new information and skills, participation in and opportunities for recreation/leisure activities, physical environment (pollution/noise/traffic/climate), transportat). The third instrument, the Posttraumatic Stress Disorder Checklist - Civilian Version (PCL-C),9 Portuguese version,10 was used to screen for symptoms suggestive of PTSD.
The victims were interviewed at the hospital, 60 days after discharge. The QL questionnaire and the PCL-C were self-administered by the subjects in a private room. When subjects requested help, the questions were read out to them slowly, but with no explanations, interpretations or use of synonyms.The data were input and analyzed in the SPSS software, version 15.0. The minimum monthly salary at the time of the data collection was R$ 415.00. The recommendations for the WHOQOL-Bref standardized syntax scoring were followed, with final scores ranging from zero to100.7 The answers were coded to show the same meaning (the smaller the number, the worse situation). Because questions Q3, Q4 and Q26 presented values in the opposite direction (the higher the score is the worst situation), these values were inverted to comprise the score (1=5; 2=4; 3=3; 4=2; 5=1). The mean score of items within each domain is used to calculate the Domain score. The scores were transformed on a scale from zero to 100 to allow for a comparison with studies that used the WHOQOL-100 questionnaire.7 The internal consistency of the WHOQOL-Bref was analyzed using the Cronbach reliability coefficient for all Domains.
The overall QL score was not calculated because it is a multidimensional construct, thus each Domain has an independent score. The Domain scores were treated as continuous variables and all the exposure variables were dichotomous. We performed descriptive analysis, and the Student t test was used for independent samples in the analysis of the differences between the QL Domain means. Statistical significance was established at 5%.
In order to screen for PTSD the symptoms were divided into groups B, C and D.9
- Group B symptoms repeated, disturbing memories, thoughts, or images of a stressful experience from the past; repeated, disturbing dreams of a stressful experience from the past; suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it); feeling very upset when something reminded you of a stressful experience from the past; having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of a stressful experience from the past.
- Group C symptoms: avoid thinking about or talking about a stressful experience from the past or avoid having feelings related to it; avoid activities or situations because they remind you of a stressful experience from the past; trouble remembering important parts of a stressful experience from the past; loss of interest in things that you used to enjoy; feeling distant or cut off from other people; feeling emotionally numb or being unable to have loving feelings for those close to you; feeling as if your future will somehow be cut short.
- Group D symptoms: trouble falling or staying asleep; feeling irritable or having angry outbursts; having difficulty concentrating; being "super alert" or watchful on guard; feeling jumpy or easily startled.
Questions in Group B are related to flashbacks, re-experiencing symptoms. Group C symptoms include a avoidance/numbing symptoms (avoiding people, thoughts, activities or places that remind the traumatic event, memory blanks, detachment, loss of interest). Group D, arousal symptoms, comprises insomnia and startled response. The victims measured the extent to which they were bothered by that problem in the last month, assigning a value on the severity scale that ranges between 1 and 5 (from "not at all" to "extremely"). A symptom is considered to be clinically significant when scored 3 or more.9 PTSD was considered positive when the individual referred, in addition to symptoms A (violent event per se), one clinically significant symptom from Group B, three from C, and two from D.
The interviews with 95 firearm violence victims took place between 60 and 194 days (mean 133.60 ± 37.62 days) following their discharge, and had a mean duration of 30 minutes. Among 136 illegible individuals, 41 refused to participate in the study. The sociodemographic characteristics of the victims are shown in Table 1.
Most victims were male, the mean age was 24.6 ± 5.5 years, and the majority of cases were low income. Most occurrences took place at night and among close ones and/or acquaintances (Table 2).
More than half the subjects considered their overall QL was not good (21.1% neither poor nor good and 35.8% poor and very poor). Regarding their satisfaction with their health, 44.2% of the subjects reported being dissatisfied or very dissatisfied, 28.4% stated being neither satisfied nor dissatisfied, and 27.4% satisfied and very satisfied.
The mean scores on the WHOQOL-Bref Domains were low, ranging between 44.71 and 52.84 (Figure 1). The mean score on the Environment Domain was lower than that of the Social Relationships and Psychological Domains.
Table 3 shows that the mean in the Psychological Domain was higher for those who reported having a religion. Subjects who reported drugs as the reason for the aggression had a significantly lower mean score on the Environment Domain. The Cronbach Alpha of the 26 questions was 0.675.
Among all analyzed cases, 57 (60%; CI95% 49.9-69.5) reported symptoms of vulnerability to the development of PTSD. There was no statistically significant difference between the mean scores on the WHOQOL-Bref Domains of the positive PTSD and negative PTSD groups (Table 4).
In this study we showed that the QL of firearm violence victims is generally low. Nearly 2/3 of the victims presented symptoms suggestive of PTSD, but no significant differences were found for the means QL score between individuals with and without theses symptoms.
The smallest scores were obtained on the Physical Health and Environment Domains, similar to the results of a study performed in Brasília (Federal District, Brazil) with spinal cord injury victims, including injuries by firearm violence.11
A lower score in the Environment Domain among those who reported drugs as the reason for the aggression suggests a poorer quality of life among drug users and dealers. Drug users and dealers are frequently involved in crimes (homicide, aggressions, robbery and stealing)12-13 and studies suggest that most of them live in areas with poor social cohesion,14 high social density and with culture of masculine privileges.15 On the other hand, one's perception of violence in their home environment may trigger fear and social isolation.5 In Thailand, other social harms were reported by drug users, such as disturbed personal and work relationships.16 Although no statistical differences were observed in the mean scores of the Environment Domain between positive and negative PTSD individuals, it is possible that the victims show an avoiding behavior towards places, persons, friends and relatives.
One reason that could explain the lower scores in the Psychological Domain of quality of life for those who did not have any religion, would be that, at least for the study participants, religions did not affect the codes of conduct,17 on the regulation of social organization, rules and attitudes.
Other point of interest is the high number of individuals with low education level. A deprived physical and socioeconomic environment may have a stronger impact on individuals with a low education level, relating the violence to poverty and social exclusion.18-19
The prevalence of probable PTSD in the present study was higher that other studies in developed country with victims of non-domestic violence,20 victims of many crimes,21 victims of aggression in emergency services22 and in victims of crimes reported at police offices.23 Nevertheless, one study performed in São Paulo, Brazil, identified PTSD in nearly 100% of kidnapping victims.24 It is possible that the support provided to the victims of violence in more developed regions may have reduced the prevalence of probable PTSD. In Goiânia, Brazil, where the present study was conducted, vulnerable groups (women and children) are priorities for the follow up programs of the violence victims.
Despite the clinical diagnosis for PTSD and the controversy about the reliable diagnosis criteria,25 the PCL-C is a good instrument to screen PTSD which was adapted for the Brazilian population use.10 In our study, most of the interviewed victims presented symptoms to screen PTSD, which may trigger family problems, frequent mood changes, relationship troubles, in addition to negatively affecting the individuals' quality of life.26-28 Experiencing violence can reduce the victim's responsiveness to the world, with a loss of interest in activities, and dismay. The association between violence and mental disorders, such as PTSD remains unclear, because most of the studies performed are cross-sectional,29 which does not allow for causal inferences.
Among the limitations of the study, we recognize that it is possible that the individuals who refused to participate were engaged in illegal activity or were involved with the police. Nevertheless, we believe that these factors may have contributed with the higher QL scores and smaller number of PTSD symptoms, making more conservative results. The cut-off point for the evaluation of internal consistency of the WHOQOL-Bref questions is variable, as long as there is no ideal cut-off point to be weighed due to the complexiy to measure the phenomenon.30
Violence is one of the major problems in developing countries, such as Brazil. Further studies, particularly longitudinal, and with a larger sample size, can clarify the causal effect between firearm violence and QL/PTSD. Also, new prospective Brazilian studies could investigate the protective factors against firearm violence for quality of life and PTSD. Our results reinforce that firearms violence may reduce quality of life and increase PTSD symptoms. Comprehensive interventions to reduce violence and drug use can positively affect mental health and quality of life of the young and poor people, promoting healthy relationships and environments.
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Correspondence: Received: January 31, 2011
Virginia Visconde Brasil
Faculdade de Enfermagem da Universidade Federal de Goiás
Rua 227 s/n Quadra 68 Setor Leste Universitário
74605-080, Goiânia, GO, Brasil
Approved: April 20, 2012
Received: January 31, 2011