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Rev. Latino-Am. Enfermagem vol.16 no.1 Ribeirão Preto Jan./Feb. 2008
Conceptions held by health professionals on violence against children and adolescents within the family1
Cristina Brandt NunesI; Cynthia Andersen SartiII; Conceição Vieira da Silva OharaIII
IRN, Ph.D. in Sciences, Adjunct Professor, Mato Grosso do Sul Federal University, Brazil, e-mail: firstname.lastname@example.org
IIAnthropologist, Advisor, Free Lecturer, Faculty, e-mail: email@example.com
IIIRN, Co-Advisor, Ph.D. in Nursing, Adjunct Professor, e-mail: firstname.lastname@example.org. São Paulo Federal University, Brasil
The present study sought to understand the conceptions held by health professionals with regards to violence within the family against children and adolescents. Qualitative case-study methodology and techniques of participant observation, interviewing, and search in documents were used. Participants were staffed in a government-run Family Health Basic Unit in Brazil. Health professionals were found to associate violence with the economic, social, and political juncture and with cultural aspects; for some, violent acts are part of the intergenerational cycle and family dynamics. Physical punishment, considered as violence by some, is advocated as an educational measure by others. Participants also base their definition of violence on an a priori construction of subjects as either victims or aggressors, thus missing the relational dimension of the phenomenon. Health professionals were found to have difficulty in understanding violence in the context that gives it a meaning and to recognize it as consequence of a complex relational dynamics.
Descriptors: violence; delivery of health care; child health; adolescent health; family health; pediatric nursing
Violence, especially as of the 80's, became a major concern in all social levels demanding attention and support from inter institutional and inter sector networks, and the health sector must also be involved. The domestic and family environment has been the predominant setting of violence against children and adolescents. Violence occurring in this setting presents an extreme level of abuse in the family relationship and is not an isolated case, but rather violent relations that occur among close people who are related(1). Children and adolescents subject to intentional and repeated violence learn these patterns as "true" and tend to reproduce this experience in their social relations. This phenomenon may follow the family for generations leading to intergeneration violence(2). Health professionals must be aware of this problem. Furthermore, the possibility of making violence within the family against children and adolescents visible through physical examination, demands a care approach taking into account the relational aspects of this phenomenon, and the context in which it occurs and has meaning.
In this sense, we have considered as relevant in the present study, to understand the conceptions that health professionals have on violence against children and adolescents within the family since they guide their care practice.
Due to the interpretative feature of the problem of the present study, we have chosen the qualitative methodology for its performance, especially for case study, as developed in Social Science(3). We use an approach of social life as a reality that can be interpreted, since the social world is made with a meaning given by individuals, as of the references of the collectivity(4-5). Knowledge is a process and the research path is more relevant than the results(3,6-7). Thus, scientificity of qualitative research is not established a priori, by strict and finished rules, but rather a posteriori, as a result of this process.
The name "case study" comes from the medical and psychological research and refers to a detailed analysis of an individual case that explains the dynamics and pathology of a specific disease. When adapted to Social Science, the case study becomes one of the main research modalities in this field, encompassing not only one individual but also an organization or community(3).
The research* was conducted in a Unit with four teams of professionals working at the Family Health Program (PSF). The main criterion for choosing subjects was to have experience with children, adolescents and families involved in violent issues. The starting point was to locate cases considered and recorded as violence against children and adolescents within the family. It is considered as violence within the family: "all actions or omissions that hinder the well being, physical integrity, psychology or freedom, and the full right to development of another member of the family. It can occur inside or outside the house by any family member, including people who take the role of parents, even without blood ties, and with a relationship of power on the other person"(8).
This concept refers to the relations where a violent act is built and made effective, not only in the physical space in which violence occurs(8-9). Although the cases approached have occurred mainly at home, the notion of violence within the family seem more suitable for the present study, because it deals with the relational nature of the problem, without focusing on the places where events have occurred.
Nineteen community health agents took part in this initial moment of the field work. During the research, other professionals from the four teams were incorporated: five health community agents, two social assistants and managers of the Unit, one dentist assistant, one nursing assistant, two dentists, three nurses and two doctors. The research instruments used were participative observations, interview and checking documents.
Observation focused on knowing the dynamics of professionals in dealing with children, adolescents and their families, in the interactions among them, in activities in the reception area, in pharmacy, room for wound dressing, and in the dental room, in collecting laboratory examinations, the activities performed in the post appointment room, inhalation, vaccine, medical and nursing appointments, home visits, Friday meetings, in which professionals of all teams of the Unit took part. The interviews with a previous script were performed after meeting with professionals for about one month. The strategies used for the interview, as well as designing the questions, were gradually built and depended on the way situations were presented during the research. Document information was searched for in the Family Health Care Unit researched, in the Conselho Tutelar Sul (South Tutelary Council) and in the Municipal Public Health Secretariat (Information Technology and Epidemiology Sectors) to complement data of the participative observation and of the interview.
For data analysis, exhaustive reading of the report was performed, together with field diaries and documents. Recurrence of questions enabled to group data from corresponding issues and, later, to change them into thematic categories, which was the axis of the analysis.
OUTCOMES AND DISCUSSION: CONCEPTIONS OF HEALTH PROFESSIONALS
Crossing data regarding conceptions that interviewed professionals have from family violence against children and adolescents resulted in six theme issues that will be presented: Consequence of social conditions, Lack of family care, preconceived ideas of victim and aggressor, Consequence of personal problems, Violence and intergenerational cycle and Corrective measure: violence as discipline.
Consequence of social conditions
Most interviewees consider violence as a consequence of cultural and social conditions, there are several causes for it, and it is linked with government policies. In this conception, that gives priority to the collective dimension, violence is a consequence of conflicts triggered by unemployment, low salaries, lack of housing, poor health conditions, and education. According to this point of view, such context favors family destruction.
Perception increases association between violence, social, and cultural problems and may be related to the fact that most families cared for by the interviewees are in extreme poverty. For professionals, parents that live in poor life situation lose the idea of dignity and self identity, and are more prone to beat their children, because they do not have values that can inhibit violence.
It is important to keep in mind, however, that making only poverty responsible to the increase in violence in the country, especially in the last decade, is a way to maintain prejudice and discrimination against the poor. This misdiagnose may make public policies based on them ineffective, with disastrous effects(10), leading to a vicious cycle because it reinforces permanently an association (between violence and poverty) which is built by a representation of poverty.
Lack of family care
Interviewees see violence against children and adolescents within the family as strongly connected with omission of family care, or "negligence", in which abandonment and disregard to basic needs such as feeding, hygiene, and vaccine prevail. The fact that the parents did not meet some basic procedures to prevent diseases predicted by health actions annoys some professionals who want to take punishing actions.
The case of L., one year old, is seen by professionals as a case of omission of basic care by parents. According to the community health agent, the mother rejected the children from the moment she was pregnant and did not attend any of the prenatal appointments scheduled. To some professionals, the mother "seems to dislike" the daughter since she was born, this opinion is based on the fact that the child does not receive the necessary care for her proper growth and development, which is made evident, according to professionals, by "lack of affection", poor body care (diet and hygiene), and not attending medical, nursing and dental appointments.
Assessing situations such as these is complex, because the threshold between negligence of parents with children, and the moral judgment of professionals of family is based on a model of care that is not part of the sociocultural world of the families. Assessing everything as negligence is a way of looking down at any other form of care, especially when it comes from a cultural universe defined by poverty. Therefore, the view of professionals is what defines negligence.
This mismatch between professionals' point of view and family is acknowledged by some of the people researched. The way some parents behave with their children regarding basic care may be considered as a normal behavior for these parents, and not as an omission. This perception is made clear in the following report:
Something very interesting is to assess to what extent negligence is really felt and understood by mothers as such. Is the treatment she gives to that child normal to her? (Physician)
Preconceived ideas of victims and aggressors
Another aspect to be considered is the way the possible violence cases against children and adolescents are seen by professionals and the position where victims and aggressors are. In most cases, the assumption comes initially from neighbors, who tell the community health agents, who, in turn, usually talk to the nurse or social assistant from the team. An example of this situation is given in the following statement.
The community agent said the father lived with two children one was two, and the other four. The neighbor told her the children screamed a lot in the evening and she though the father was abusing them. Then, I went there with the nurse, he had lost his wife recently, we arrived there and talked. As far as we could see, there was nothing different. I think because they had lost their mother, they cried a lot. (Social Assistant and manager of the Unit)
Because the girls cried in the evening and are taken care of by their father rather than their mother it was assumed they could have been suffering some kind of sexual abuse. It is implicit, both the maternal figure as the only one responsible for care, and another preconceived idea regarding gender issues, where men are identified as abusers, as of the association between masculinity and violence, preventing to see events on another perspective, different from the representation professionals have. In this perspective, men are identified as aggressors, because they received this attribute beforehand(11). Assumptions are created this way, making it difficult to assess what is really going on. Cases such as this demonstrate the difficulty of professionals to understand the context of family ties.
Violence is a relational problem encompassing different cultural subjects, such as victims, aggressors and professionals. As of this involvement, violence and its care are defined. In this relationship, previous construction of subjects as victims or aggressors may predispose the idea of violence, anticipating happenings themselves(11-12), and conditioning their assessment.
In some occasions, mothers' behavior may lead to identify evil in the mother figure that would explain violence or complicity to someone who is violent. In these cases, there is an idealized role of mothers: if they do not meet the role preconceived by professionals, it is because they are "bad". This point of view puts maternal love as an instinct embedded in women. With maternity, it is assumed that women are naturally skilled to deal with all situations regarding motherhood, with no failures.
History of maternal behavior however, shows that there is a great diversity of attitudes and qualities in the relationship between mothers and children and that love is a human feeling, with uncertainty, fragilities and imperfection(13).
In the point of view of interviewed professionals, those who love their children do not harm them, and those who harm them are morally reprehended.
Oh, it is mean, lack of affective ties, lack of heart! I don't know what makes a mother not protecting her child, or beat the child! I think it is lack of everything; it is also ignorance! There is nothing that can justify beating one's child! It is absurd! Children are helpless! They have children and then they are not patient enough to take care of them! (Nurse)
Sometimes, professionals interviewed do not see any possibility of recovery for aggressors. This conception is stronger when complications from the children are clear. An example of that is the case of G. On the second day of his life, his biological mother (18 years old) left him on the hospital. The maternal grandmother asked her to pick him up. On his fifth day of life, G. was seen in a regional health care center with traumatic brain injury and he was transferred to hospital. According to information given by professionals and the grandmother, the baby was thrown against the wall by his mother. According to the information collected, the mother had postpartum depression. This case involved professionals in several ways due to how it occurred, the aggressive act, and the severity of sequels. G. has problems swallowing pureed food; presents Nystagmus and Macrocephaly (due to hydrocephaly); cannot control his head; cannot hold objects; cannot seat alone or crawl; he is frequently admitted to hospital with pneumonia. He was recently referred to hospital with tracheotomy and gastrostomy. The fact occurred three years ago and the mother is referred to as someone who is sick and needs to be far from the child.
Consequence of personal problems
To some researchers, especially for community health agents, violence against children and adolescents is a consequence of personal problems faced by parents and that influence the way they deal with their children. This may be assessed in one of the reports. The agent conducted home visits to a mother for five months, and she saw that the mother had been left by her family when she got pregnant, and had recently divorced from her husband. Over the time, she also noticed that the mother frequently beat her 2-year-old son, especially if he could not control his bowel movements, directing at him aggressive words of despise. In the community health agent's opinion, the mother "blames the child for her suffering", and because of that she punishes him physically, this shows a greater closeness of this professional with the cultural and social world of the families cared for:
I think she beats the child because of what she experienced in her past. She thinks the child was born only to make her suffer! Because she put the evilness that happened in her life in the life of the child! (Community health agent)
Violence and intergenerational cycle
Among other professionals researched, there are some who understand violent acts as part of an intergenerational cycle and due to aggressive experience that parents experienced in the past in their family environment, making this behavior as natural and repeating it unconsciously. They consider that certain situations are complex to approach and are taken aback by what happened. However, for the social assistant and Unit manager, despite the complexity of the phenomenon, there is, behind a case of violence against children and adolescents, a context that needs to be assessed and taken care of, pointing out to a care that focus not only the victim but all the situation and agents involved in the violent act:
When I met the 45-year-old grandfather that abused the grandson I thought: how can human beings get to such an atrocity level! I felt the need for more suitable punishment, also because the victim is there and he cannot get away with it. But I don't think: 'Oh! This guy has to be killed' and so. I think he is a victim of all the problems that surrounded him since childhood. (Social assistant and Unit manager)
Corrective measure: physical punishment as discipline
The use of physical punishment with children is an issue frequently approached both by families cared for by the teams, as well as by professionals. In one of the meetings performed in the children education center, that receives children from 4 months to 6 years old and 11 months, some issues were discussed especially regarding the behavior of some aggressive children in this school. Twenty five mothers, 3 fathers, 4 teachers, the principal, the psychologist, the pedagogue and the community health agent took part in the discussion. Initially, the principal invited us to speak on the main characteristics of children development.
After explanation, the most discussed topic by parents was the use of spanking for education purposes. Several manifestations showed that this is a practice used by most of them in their every day life. One of the mothers answered, when talking about the way she educates her children:
I have three children, and I have raised them equally, but my third son, who is five, I don't know what to do! So I beat him. I do that to see if he gets better. I have even put him down on his knees to see if he learns.
Another one said:
My three-year-old is very naughty and I don't know what to do. Sometimes, beating is the only way!
These reports demonstrate the difficulty of parents to set limits to some behaviors of their children and that resort to physical punishment as an education measure, in an attempt to make them change their behavior.
It is observed that in the approach of raising children, physical punishment is seen as a way to set limits for an unsuitable behavior of their children. Implied in this action is the educational reason: parents really believe that this type of punishment serves to a purpose geared to the well being of children(14). This view is related to a cultural acceptance, present in all social classes, where the use of physical punishment is seen as a way to adjust the behavior of children(15). For most parents, the use of physical punishment is not followed by guilty, because they feel they are entitled to it. Children may react passively or aggressively. Both reactions may increase aggressiveness in adults. The risk of this situation is that violent acts become incorporated in the relationship as a way of dialoging between aggressor and victim(16).
Among professionals researched, there are some who defend the use of physical strength of parents on children in some situations. For them there is a difference between spanking and beating. They consider that spanking, when used lightly, has education purposes, but they see beating as a kind of violence, because of its aggressive feature that leaves marks on the body of children and adolescents.
Some of the people interviewed question the fact that some agencies, such as the Tutelary Council, do not advocate the use of physical power as an education resource. They consider that this type of punishment, in some situations, has an education role, and is a kind of punishment that makes children or adolescents present a better behavior - the "correction of path":
The policy of the Tutelary Council in itself has a way to act that I consider wrong, when it made clear that path correction is practically banned. I believe that sometimes you have to spank children. Not beating, but warning them! Otherwise, children won't learn! (Physician)
Such aspects demonstrate the fact that both for families and for some professionals the use of education spanking is accepted and defended as a kind of benefit, not seen as violence.
The attitude of professionals regarding family violence are related to their conception of the issue, which is not always the similar to that of the family and other sectors connected with family care, such as the case of Tutelary Council. These mismatches show the need to put the phenomenon of violence into a context, to understand the meaning given to it by the several actors involved so that a suitable care can be designed.
Health professionals think about violence with preconceived views, not only regarding the poverty of families cared for by the Unit of the PSF researched, but also regarding the social individuals that are usually identified as aggressors, as in the case of men. This leads to a pre-disposition of associating violence to certain contexts and individuals, regardless of an assessment of the happening in itself.
Here is also the difficulty in understanding violence in their context, that is, as of the point of view of someone experiencing it, and in acknowledging it as a consequence of a complex relational dynamic.
The possibility of making violence against children and adolescents within the family viable demands a "new look" from health professionals. Violence must be thought in the level of relations, within a context, and this phenomenon may not be seen as a disease of the aggressor or the victim but a consequence of a complex relational dynamic, becoming an important social problem with consequences that lead to health problems.
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Recebido em: 30.5.2007
Aprovado em: 5.12.2007
1 Paper extracted from Doctoral Dissertation
* Field research started after it was approved and authorized by the Ethical Research Committee at UNIFESP, authorization 1587/03. Before each interview, the Free Agreement Consent was read, explained and discussed, and a copy of the document was given to the Professional interviewed.