Domestic violence: from the visible to the invisible

Abstracts

Este estudio tuvo por finalidad identificar y analizar las notificaciones realizadas en las sedes de salud del municipio de Guarulhos, los límites en las acciones realizados por los profesionales y el significado de la violencia domestica en su cotidiano de trabajo. Fue descrito el escenario de las notificaciones realizadas en 2001 y 2002 con el objetivo de obtener una mejor comprensión de la realidad y apoyar el diálogo con las informaciones recolectadas a través de la investigación cualitativa. De los casos notificados constatamos un predominio de casos de negligencia en 45% de las notificaciones, así mismo, 26% fueron notificaciones de violencia física y 14% de las notificaciones fueron sospecha de violencia sexual. Quién más realizó las notificaciones fue el asistente social, siendo responsable por 46% de las mismas. A partir de las discusiones con los agentes sociales, identificamos dos categorías empíricas: "interfases de la violencia" y "miedo".

salud; violencia doméstica; niño; notificación obligatoria

Este estudo objetivou identificar e analisar as notificações de violência doméstica contra crianças, realizadas junto às Regionais de Saúde Guarulhos, os limites da atuação dos profissionais da saúde e o significado da violência doméstica contra a criança no cotidiano do seu trabalho. Caracteriza-se o cenário das notificações realizadas nos anos 2001 e 2002, no município, com o intuito de melhor compreender a realidade e subsidiar o diálogo com os dados colhidos através da abordagem qualitativa. Constatou-se predominância dos casos de negligência 45% das notificações, 26% de violência física e 14% de suspeita de violência sexual. Quem mais notificou foram os assistentes sociais, sendo responsáveis por 46% das notificações. Por meio das falas dos atores sociais, identificou-se duas categorias empíricas: "interfaces da violência" e "medo".

saúde; violência doméstica; criança; notificação de abuso

ORIGINAL ARTICLE

Domestic violence: from the visible to the invisible

Marta Angélica Iossi Silva^I; Maria das Graças Carvalho Ferriani^II

^IPhD Professor, e-mail: [e-mail]

^IIFull Professor, e-mail: [e-mail]. University of São Paulo at Ribeirão Preto College of Nursing WHO Collaborating Center for Nursing Research Development

ABSTRACT

This study aimed to identify and analyze notifications of domestic violence against children registered at the Regional Health Services in Guarulhos, São Paulo, Brazil; the limitations imposed to health professionals' actions and the meaning of domestic violence against children in the health professionals' routine. The notifications registered between 2001 and 2002 were characterized in order to better understand this reality and also to support the collected data through the qualitative approach. There is a predominance of negligence cases 45%, while 26% of the notifications related to physical violence and 14% to suspected sexual violence. Social workers registered the highest number of notifications, 46%. Based on the social agents' discourse, we identified two empirical categories: "interfaces of the violence" and "fear".

Descriptors: health; domestic violence; child; mandatory reporting

INTRODUCTION

Across humanity, talking about violence against children has been a complex issue, to the extent that it imposes appointing alternatives and expectations to fight against the social vulnerability of childhood, both globally and locally. It also implies addressing family conflicts, a chore that had been considered a place of protection against the child.

Although violence has existed since Antiquity, it is only from the 1960's onwards that health researchers have widely studied and discussed the theme⁽¹⁾.

Many problems have turned the dimensioning of domestic violence against children in Brazil more difficult, such as the different definitions of the problem, the range of information sources and the inexistence of national population inquiries. However, the results of some national studies indicate that intra-family violence in Brazil is expressive and should be considered a priority on the social policy agenda⁽²⁾.

This study looked at the violence phenomenon, especially its forms and expressions, considering its complexity, polysemy and subjectivity, besides acknowledging the multifaceted and multidimensional nature of this problem. Different types of violence tend to be expressed in combination, constituting a network in which those expressing conflicts in the social system articulate at interpersonal levels⁽³⁾.

Despite the legal change brought about by the issuing of the Child and Adolescent Statute (CAS) in 1990⁽⁴⁾ and the acknowledgment of this population's social rights, the problem of children and adolescents in social and personal risk situations was potentialized in urban centers and inside their homes.

Among the public policies for managing this problem^(5-7), those aimed at reducing morbidity and mortality caused by violence stand out, as well as those directed at guiding and improving the quality of notifications, at structuring a national violence prevention and health promotion network, at implanting and implementing violence prevention centers in states and cities and at establishing the Epidemiological Surveillance System for Accidents and Violence (SEVIV), specifically in São Paulo State⁽⁸⁾.

In the city of Guarulhos, in the last decade, important projects, programs and actions have been implanted and implemented in the specific area of child and adolescent victim protection, which emphasize notification and health care delivery to the population living in violence situations, as well as a municipal committee for dealing with domestic and sexual violence against children and adolescents^(9-10).

Based on our professional experience and supported by the objectives of this research, we attempted to answer questions like: What difficulties and facilities have health professionals faced to welcome and deliver care to child victims or suspected victims of domestic violence? What are the limits and barriers felt by health professionals that make them adopt attitudes of minimization or omission towards violence? What sector and integrated policies and actions have been adopted with respect to this problem?

In view of these considerations, this research aimed to identify and analyze notifications of domestic violence against children at the Guarulhos Regional Health Divisions, the limits and gaps in health professionals' actions and the meaning of domestic violence against children in their daily work.

METHODS

We carried out a descriptive and exploratory research with a qualitative approach. This methodological alternative helped us to understand the reality expressed by health professionals about their perspective on domestic violence against children.

The project was analyzed and approved by the Research Ethics Committee of the Ribeirão Preto College of Nursing USP and by the Guarulhos Municipal Health Secretary. After the research subjects had given their consent by signing the Free and Informed Consent Term, data were collected through semi-structured interviews and the analysis of documents and records, between August 2003 and April 2004.

In order to better understand the study object, enlarge our awareness of the problem and describe its magnitude, this research aimed to quantitatively identify the scenario of notifications of domestic violence against children at the Guarulhos Regional Health Divisions in 2001 and 2002.

Therefore, we consulted 35 notification forms of confirmed and/or suspected cases, which Basic and Emergency Health Units sent to the four Regional Health Divisions in Guarulhos, with a view to a first critical look on the study problem.

Based on this preliminary analysis of the notifications, we established Regional Health Division III as the study area and reality for understanding and investigation, through the Family Health Unit (FHU) Jd. Fortaleza and the Basic Health Unit (BHU) Carmela, which presented relevant notification indices according to the surveyed data. Next, we consulted the files of the children related to the notifications at Regional III, in order to characterize the situations that indicated the confirmation and/or suspicion that domestic violence had occurred.

The research subjects were professionals active in care delivery to children who were potential victims of domestic violence and/or their families in their daily work. We interviewed two psychologists, two nurses, two community health agents, two nursing aids and two pediatricians.

The interview script consisted of three open guiding questions: What is your experience in care delivery to cases of domestic violence against children? What have you done about the possible cases? What is your opinion on the work, the resources made available in the city for care to these children?

Based on the collected material and the theoretical framework, we analyzed data according to Minayo's⁽¹¹⁾ proposal, using the dialectic hermeneutical method, which makes it possible to confront different positions in data interpretation and, according to the author, is "the most capable of giving an approximate interpretation of reality. It places the discourse in its context in order to understand it on the basis of its interior and in the field of the historical and totalizing specificity it is produced in".

The qualitative analysis of the interviews led to data ordering and classification by registry units, referenced by themes and refined in synthetic expressions, i.e. the empirical categories that expressed reality according to the interviewees.

RESULTS

Figure 1 shows that the highest notification ratio of violence against children in 2001 and 2002 corresponds to the region of Regional Health Division III, responsible for 40% of notified cases.

As to the types of violence the victims were submitted to, Figure 2 shows a predominance of negligence cases, corresponding to 45% of notifications, 26% physical violence and 14% suspected sexual violence.

Figure 3 shows the distribution according to the professional category responsible for the notification and revealed that social assistants were responsible for 46% of notifications, followed by psychologists (12%). Nurses were responsible for only 3% of notifications. A significant part (21%) did not inform the professional category that notified the case.

According to Figure 4, 31% of the cases were only sent to the Tutelary Council, 28% to the Tutelary Council and other social programs at the same time and 23% for outpatient treatment only.

EMPIRICAL CATEGORIES

After organizing the material collected through the interviews, different readings of this material and its qualitative analysis, we apprehended two empirical categories from the professionals' statements: "interfaces of violence" and "fear".

Interfaces of violence

This category evidenced the absence of political policies to manage the phenomenon of domestic violence against children and the subjects' difficulty to identify and deliver care to cases in their daily activity. The professionals also appointed other aspects related to the problem's lack of visibility and professionals' lack of preparation to deal with this issue. They highlight the need to integrate actions with different areas and services.

Yes, a care network, it would be very good if we could work, or even have a space to discuss if not all, at least the main cases in a more integrated way. (E8)

I would really like the Secretary to implement and create a space inside the care program, where we could be trained and advised to work with this problem, as well as to allow for a more official integration with other services and secretaries. (E9)

The perception of domestic violence as a multifaceted phenomenon with complex macro-structural roots is significantly present in the statements, as follows:

[...] I'd say that the violence I detect is strongly related to living conditions... (E1)

I have several cases of alcoholic mothers who go out at night and leave their children alone, I have several cases like that. (E8)

We know about the importance of notifying and registering the cases we receive, but sometimes it becomes difficult to define if it really is or not, as many cases are social ... So who are the main victims? The children. (E10)

Another question the subjects appoint is health professionals' lack of education and training to act on this problem.

Many professionals are not prepared to assess and perceive violence situations... I think it's the professionals' lack of training and supervision, accompaniment. (E6)

I think it would have to be disseminated more among professionals, what to do and how to do it, many of them do not know how to act or do not feel supported... (E8)

Just like me, many colleagues face difficulties to identify what violence is, and what other reference have we got besides the Council. (E9)

Fear

This empirical category evidenced the fear that emerges in social actors' imaginary, daily reality and action towards domestic violence cases. It is one of the factors determining the subjects' action, influencing what they do or what they think they can or cannot do.

Because I have cases like that. There were cases in which the family tells me what happens, everybody knows, then it goes through an emergency unit and nobody perceives or does something, they often do not perceive it out of fear". (E4)

I myself, I had just put down the phone and I got scared. I said: oh dear what have I done? I got concerned, I couldn't sleep well. (E5)

The professionals' statements highlight their fear of being chased by the relatives of the notified victims.

Because other people have done this for me, you see, it didn't have to be people from here, because afterwards we're badly considered by the neighborhood. Have you imagined, denouncing a family and being obliged to go there one month later! (E5)

Yes... distrustful, I found out that she had already been called and that, very angry, she said she would find out who had filed the complaint... I was happy to see that they didn't say where the complaint had come from. (E4)

DISCUSSION

Considering the data registered at the Regional Health Divisions, cases of domestic violence against children in the city of Guarulhos are still significantly undernotified. This has made it difficult to establish new and integrated policies and actions, as "the act of notifying is a crucial element in punctual action against violence, in global political action and in the understanding of the phenomenon"⁽¹²⁾.

Undernotification is frequently related with health professionals' lack of knowledge about the importance of and procedures needed for the notification; lack of adherence to notification; their concern with the breach of information secrecy and, finally, their lack of perception about the relevance of this team for public health⁽¹³⁾.

The study showed that the region of Regional Health Division III displayed the highest notification index. This area corresponds to countless neighborhoods with a high concentration of poverty and miserable situations, territorial invasion areas and slums, heterogeneity, high population overturn overpopulated houses, besides a lack of social capital. These factors have been maintaining the levels of economic, cultural and social inequality in the region.

In this region, 06 Basic Health Units are installed, with 12 Family Health Teams, 03 Emergency Care Units and 01 Dental Care Central.

According to data by the Municipal Health Secretary⁽¹⁴⁾, based on data from the Basic Care Information System (SIAB), the estimated population of this region is 287,902 inhabitants, corresponding to 20.97% of the city's total population. Of this group, 71,198 (24.73%) are between 0 and 09 years old.

The Map of Social Exclusion and Inclusion of Guarulhos⁽¹⁵⁾ shows that different neighborhoods that are part of Regional Health Division III display significant levels of social exclusion, unemployment, low quality of life and human development.

Another relevant aspect observed in the result analysis refers to the high percentage of notified cases of negligence and the care health professionals take in the identification of negligence cases in their daily work. This identification is complex and demands a critical look from professionals, so as to distinguish the existence of intentionality in not attending to the child's needs, in the privations and lacks deriving from poverty situations.

It was also observed that the low notification levels by nurses seem to evidence the need for greater involvement by this category, which is peculiar not only due to its specific knowledge, but also due to its capacity to act, listen and relate, as an agent with the power to act and transform.

Moreover, nursing, considered as a social practice and committed to emancipation and human development, cannot be performed outside the perspective of the complexity of transformations in the contemporary social context, which includes the integral and multidisciplinary approach of domestic violence against children.

Despite knowing that notification forms have to be filled out correctly, 21% of the notifications did not inform the notifying professional category, which confirms the fact that professionals minimize the completion and importance of this form. In view of this aspect, another fact that should be addressed is the possibility that not filling out the function and the consequent signature indicate that many professionals are afraid of legal and relational problems deriving from the notification.

In our study, although the most significant results show that cases are sent to the Tutelary Councils, as determined by the CAS, it was remarkable that 23% of the notifications only resulted in the victims' outpatient treatment, without proper notification to the Tutelary Council, despite its obligatoriness.

The interviewees revealed the subjects' difficulty to identify cases exactly and professionals' lack of preparation to deal with this issue as great difficulties in care delivery to child victims of domestic violence.

The statements demonstrated the technical difficulty of the notification process. Despite the obligatory nature of notifications, professionals experience difficulties to adopt them as standard behavior, a behavior that is still loaded with many uncertainties and doubts.

This difficulty may be related to the fact that the question of domestic violence against children has not been treated in a systematic and integrated way in professional training, that is, in undergraduate curricula, and is absent from the permanent education programs health services offer. Hence, many professionals do not have basic information needed to diagnose violence exactly⁽¹²⁾.

In their statements, the professionals demonstrated that they clearly perceive the importance of integrated and articulated public policies for care delivery to child victims of domestic violence. This articulation is necessary to reorder more visible and sustainable public policies.

In this sense, public health "needs to turn towards the development of joint actions with other sectors, not remaining limited to the spaces it traditionally occupies"⁽¹⁶⁾.

As to determinant factors of domestic violence against children, it was perceived from the professionals' discourse that they articulate these factors with the structural and social violence the children, their families and the society they live in are exposed to.

The statements and theoretical production presented here make us reflect on the violence that occurs in the structural sphere, which ends up outlining violence in the private space of families. The violence pattern many families impose on their children cannot be seen isolatedly from broader issues of power, frustration, reduced social rights and privation caused by unemployment, social injustice, inefficient economic policies and the absence of the State from playing its role as a creator and manager of social policies.

The economic aspect is not the only point to be taken into account in the historical determination of violence. Educational, cultural, social and political factors need to be considered, which interrelate dialectically in the dispute for power, for the possession of the other, for authority.

Children's and adolescents' quality of life will become real when the fight against violence between social classes (structural violence, of which childhood marked by poverty, prostitution and exploration at work are some fruits) and the fight against violence inside social classes (of which childhood victimized at home is one consequence) are fought simultaneously⁽¹⁷⁾.

With respect to the empirical category "fear", it was observed that, when expressing the situation of fear, the professionals emphasize it as something real, deriving from threatening experiences they live with in their daily life, feeling threatened in their physical integrity and in the performance of their work, characterizing one of the resistances against realizing the notification, because they feel chased by the relatives of the notified victims⁽¹²⁾.

In order to understand the dynamics and manifestation of the fear the subjects report, it needs to be apprehended as a complex social phenomenon that involves the relations among social, cultural and political forces in society. Therefore, it cannot be studied outside the society that produces it, as it feeds on social facts, such as urban violence for example, as well as imaginary and cultural facts that are translated in daily relations⁽¹⁸⁾.

FINAL CONSIDERATIONS

Through this research, it can be reaffirmed that domestic violence against children and its nuances impose themselves as an exercise to understand the current dynamics of the family and society. The theme is complex and, given its complexity, knowledge about it is still under construction.

In order to impede the (re) production of the intra-family violence cycle, sociopolitical initiatives in the area should attempt to answer the challenges of withdrawing domestic violence against children from secrecy; get a better understanding of the production process of this phenomenon, train competent professionals who are socially committed to fighting this violence mode.

However, it is emphasized that this visibility process does not occur homogeneously. There are advances and backlashes, successes and obstacles, requiring perseverance and commitment.

Getting to know the meaning and interfaces of domestic violence against children according to health professionals allowed us to verify that these professionals lack education and support and that the work process needs to be reconsidered with a view to a better articulation of the social policies that need to be established among different areas.

This study is considered a contribution to the health and nursing area, through a deeper understanding of the study object, indicating that the nurses' role, as elements in the health team, implies a more active attitude, appropriating themselves of new knowledge and practices.

In conclusion, we hope that the presented results instrumentalize transformations in care practice and stimulate further research, as this study does not close off the understanding about the meaning of domestic violence against children.

Studies aimed at assessing information systems to accompany the magnitude of the problem, that attempt to improve a theoretical-analytic reference framework that is capable of permitting an understanding of the specific nature of this phenomenon today, the vulnerability and protection factors which different cultures and societies have in common, or the extent to which the theme is inserted into the school curricula at different training levels, can lead towards new knowledge and courses that make it possible to promote the rights, protection and citizenship of this population.

Recebido em: 23.3.2005

Aprovado em: 10.11.2006

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Publication Dates

• Publication in this collection
  29 May 2007
• Date of issue
  Apr 2007

History

• Accepted
  10 Nov 2006
• Received
  23 Mar 2005