SciELO - Scientific Electronic Library Online

 
vol.21 número12Quedas acidentais nos atendimentos de urgência e emergência: resultados do VIVA Inquérito de 2014Acidentes envolvendo indígenas brasileiros atendidos em serviços de urgência e emergência do Sistema Único de Saúde índice de autoresíndice de assuntospesquisa de artigos
Home Pagelista alfabética de periódicos  

Serviços Personalizados

Journal

Artigo

  • texto em Português
  • nova página do texto(beta)
  • Inglês (pdf) | Português (pdf)
  • Artigo em XML
  • Como citar este artigo
  • SciELO Analytics
  • Curriculum ScienTI
  • Tradução automática

Indicadores

Links relacionados

Compartilhar


Ciência & Saúde Coletiva

versão impressa ISSN 1413-8123versão On-line ISSN 1678-4561

Ciênc. saúde coletiva vol.21 no.12 Rio de Janeiro dez. 2016

http://dx.doi.org/10.1590/1413-812320152112.17532016 

Article

The occurrence of external causes in childhood in emergency care: epidemiological aspects, Brazil, 2014

Deborah Carvalho Malta1 

Márcio Dênis Medeiros Mascarenhas2 

Marta Maria Alves da Silva3 

Mércia Gomes Oliveira de Carvalho4 

Laura Augusta Barufaldi4 

Joviana Quintes Avanci5 

Regina Tomie Ivata Bernal6 

1Departamento de Enfermagem Materno-Infantil e Saúde Pública, Escola de Enfermagem, Universidade Federal de Minas Gerais. Av. Alfredo Balena 190/Escola de Enfermagem/5º, Santa Efigênia. 30130-100 Belo Horizonte MG Brasil. dcmalta@uol.com.br

2Programa de Pós-Graduação em Saúde e Comunidade, Universidade Federal do Piauí. Teresina PI Brasil

3Universidade Federal de Goiás. Goiânia GO Brasil

4Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e Promoção da Saúde, Ministério da Saúde. Brasília DF Brasil

5Departamento de Estudos sobre Violência e Saúde Jorge Carelli, Escola Nacional de Saúde Pública, Fiocruz. Rio de Janeiro RJ Brasil

6Faculdade de Saúde Pública, USP. São Paulo SP Brasil

Abstract

Objective:

To describe emergency care for external causes in childhood, age group 0-9 years, in Brazilian capitals, collected from the Violence and Accident Surveillance System (VIVA) Survey in 2014.

Methods:

To review data from the VIVA survey conducted in public emergency services in 24 Brazilian capitals. Variables analyzed were gender, age group (0-1 years, 2-5 years and 6-9 years), race/skin color, type of events and injuries, aggressors and other.

Results:

Eight thousand five hundred eighty-eight children received care, of which 8,164 (95%) were victims of accidents and 424 (5%) of violence. Boys suffered more accidents, most events occurred at home (65%) and discharge was the most frequent outcome. Falls were the most frequent accidents, followed by other accidents, road injury and burns. Neglect prevailed among the types of violence, followed by physical violence. The perpetrator was a child's relative in 72% of the cases, and women were the most frequent aggressors for children under 1 year, and men for children aged 6 to 9 years.

Conclusion:

Childhood accidents occurred mainly at home, and falls were the most frequent events. Family members and acquaintances perpetrated violence against children. Data point to the implementation of public prevention and child protection policies.

Key words Childhood; Injuries; External causes; Emergency care; Violence

Introduction

External causes in childhood are a public health problem worldwide and the leading cause of death in children, accounting for about 40% of all deaths in this group. Some 950,000 children and adolescents’ deaths by accidents or violence are reported in the world each year, in addition to millions of sequels arising from non-fatal injuries1,2.

The main causes of disability-adjusted life years (DALYs) arise from external causes in children aged 0-14 years, including road injury1. These events are distributed unequally and focus low-income countries and low socio-economic level populations1,2.

Violence against children occurs in various forms, whether physical violence, neglect, sexual and others, with serious consequences to their growth and development3,4. Violence against children is recognized by the World Health Organization as a global issue, affecting millions of children, family members and communities every year2.

In 2015, the UN noted overall progress in child health in the Millennium Development Goals (MDGs) Report, however, there are still gaps, which justifies maintaining these indicators in the Sustainable Development agenda, indicating the much that remains to be done in the prevention of violence against children and women5,6.

In the world and in Brazil, the large sub-notification of these events, the lack of uniformity and integration of records is still widely recognized and it is still difficult to grasp the full extent of the problem, which affects victim protection actions79.

No violence against children is justifiable and all forms can be prevented and addressed1,2. According to the Children and Adolescents Statute, no child or adolescent should be subjected to any form of neglect, discrimination, exploitation, violence, cruelty and oppression, and the right to life and health protection should be ensured10. In 2013, Brazil recorded 3,745 deaths of children aged 0-9 years by external causes, which was the 3rd cause of death after perinatal causes and malformations11. About a third of these deaths are related to road injury, drownings, breathing other risks, aggressions and falls11,12.

Accidents and violence in childhood can result in irreparable emotional, physical and social damage; they definitely mark the lives of children, families and society. The preventability of these events is clear and should involve families, schools, society and governments. All sectors of society share the responsibility of condemning and preventing accidents and violence against children1,2,5.

The Ministry of Health established in 2006 the Violence and Accident Surveillance System (VIVA), which has a component held by periodic surveys in urgent and emergency care services of the healthcare network of the Unified Health System (SUS), which are external causes’ sentinels. External causes (accidents and violence) are monitored, allowing for continued surveillance of distribution, size and trend of these diseases and their risk and protection factors, including information on vulnerable populations such as children and the elderly. VIVA has supported the planning at the three management levels of the SUS and the definition of appropriate prevention and health promotion interventions13.

This paper will describe emergency care relating to external causes in childhood, in the 0-9 years age group, in the Brazilian capitals, collected from the Violence and Accident Surveillance System (VIVA) in 2014.

Methods

This is a cross-sectional study conducted in 2014 in 86 urgent and emergency care services sentinels of the SUS located in the Federal District and 24 Brazilian capitals. State capitals Florianópolis/SC and Cuiabá/MT failed to run the survey due to local issues related to management and technical and operational aspects. The criteria of inclusion of establishments in the sample used emergency care references included in the National Register of Health Facilities (CNES). Emergency services were analyzed for the external causes-related care demand informed in the Hospital Information System of the Unified Health System (SIH/SUS) and the VIVA Survey (for services participating in one or more previous study editions: 2006, 2007, 2009 and 2011)13. The inclusion of selected services was validated by coordinators of the Noncommunicable Diseases and Illnesses Surveillance Department (DANT) of state and municipal health secretariats participating in the research.

These services are external causes’ sentinels, since they are the main gateways to violence and accidents in the municipalities. The original survey included the care provided in urgent and emergency care services located in the Federal District, in 24 state capitals and in 11 selected municipalities. This study only analyzed occurrences of the federal capitals. A 30-day collection period from September to November 2014, divided into 12-hour shifts, totaling 60 possible collection shifts was considered. The shift was the primary sampling unit (PSU). Considering the cluster sampling, a single-stage random drawing of shifts, stratified by urgent health services establishments was carried out. All care services provided due to external causes in the drawn shift were sampled and interviewed. A standardized form was used in all of the 86 Urgent / Emergency care services selected for study in the 24 state capitals.

The Health Surveillance Secretariat held a centralized training in Brasilia prior to the study to standardize collection, define and standardize records and procedures. The qualified teams have replicated training in their own municipalities, ensuring standardization of procedures. Municipalities received financial resources for logistical support in the collection, training, records, typing and other operating procedures.

All external causes’ victims seeking care in selected urgent and emergency care services and who agreed to participate were eligible for interview. Sample size was at least 2,000 attendances for external causes’ care in each capital and the Federal District, assuming a coefficient of variation of less than 30% and standard error below 3.

Data were collected through a standardized form used in previous VIVA studies and adapted for this VIVA edition14. All users receiving care due to external causes were interviewed by trained data collectors. With regard to those who were unable to respond due to injuries sustained, the accompanying person was interviewed and medical records data were collected. The current study examined the 2014 VIVA Survey 2014 data, and this investigation was approved by the National Research Ethics Commission (CONEP), the Ministry of Health. Data collection was performed following consent of victims or their legal guardians or accompanying persons, when under 18 or if they wereunconscious victims.

Care was classified into two groups: violence and accidents. Violence was defined as “the use of force against a group or community that results or has any chance of resulting in injury, death, psychological harm, developmental disability or deprivation”2. Accident was defined as “unintentional and avoidable event causing physical and emotional injuries, at home or any social context such as work, school, sports and leisure.”We considered the definitions of the 10th revision of the International Classification of Diseases and Related Health Problems (ICD-10) related to Chapter XX-External causes of morbidity and mortality. Among the events of accidental causes included are Transport Accidents (V01-V99), Falls (W00-W19), Burns (W85-W99, X00-X19) and other accidental events, such as cuts with sharp piercing objects, falling objects, accidental poisoning, suffocation, drowning and others. Violent events were classified as Assault (X85-Y09), Abuse (Y05-Y07),Legal Intervention (Y35), Self-Harm / Suicide Attempt (X60-X84).

For this study, we considered individual features, occurrence outcome and accident and violence characteristics. The following variables were analyzed: age group (0-1 years, 2-5 years and 6-9 years), race/skin color, means of transportation used to get to emergency care services, place of occurrence, type of injury, injured body part, shift and day of care, development in emergency.

Regarding accidents, type of accident was described according to age (transportation, falls, burns, other), type of victim (passenger, driver, pedestrian), victim's means of transportation (walking, car, motorcycle, bicycle), fall type (same level, bed, furniture, tree, hole, other), type of burn (fire, flame, hot substance, hot object, other) and other accidents. As for violence, the type of violence suffered was described by age group (self-inflicted injury, aggression), nature of violence/aggression (physical, sexual, psychological, neglect, other), means of aggression (physical force, firearm, blunt object, sharp object, other), whether the aggressor was a family member (yes or no), gender of aggressor.

All children under 10 years treated in urgent and emergency referral services of the 24 state capitals and the Federal District were analyzed, comparing the characteristics of accidents and violence victims, stratified by age group (0-1 year, 2-5 years and 6-9 years). The methodological option to compare events by age group was chosen based on evidence that distribution is differentiated according to the age group, both regarding accidents and violence14, making it important to understand this distribution to support public policies.

The null hypothesis of independence between qualitative variables was assessed using the chi-square test, with 5% significance level. We also used logistic regression and calculated crude OR and adjusted for age, sex and skin color to compare the associated factors of violence and accidents. We used Stata's “SVY” module, version 11 to obtain unbiased estimates when data derived from complex sample designs.

Results

From a total of 55,950 in the VIVA survey, there were 8,588 emergency care attendances among children in the age group 0-9 years, and 8,164 (95%) were victims of accidents and 424 (5%) of violence. Among children, 21.4% were younger than 1 year of age, 42% fell in the 2-5 years age group and 36.6% in the 6-9 years age group; worth highlighting is the occurrence of accidents in children aged 2 to 5 years and violence in children aged 0 to 5 years (p <0.001). As for race/skin color, 62.8% were black (black/brown), 35.0% white; most cases occurred at home (65%) and were predominantly domestic violence (72.4%) (p<0.001). Bruises were the most frequent injuries (31.5%), followed by cuts (29.7%). Head and neck (45.6%) were the most affected body parts, especially in cases of violence (p <0.001). Private car transportation to the hospital was the most common means of transport (59.5%). As to the time and period, attendances during daytime and during the week prevailed, with no statistical difference between accidents and violence. Discharge was the most common outcome of care provided (81.7%) (Table 1).

Table 1 Emergency care for accidents and violence among children, by type of event – 24 capitals* and the Federal District, Brazil, from September to October, 2014. 

Characteristics Type of eventa
Accidents (n = 8,164) % Violence (n = 424) % Total (n = 8,588) % P valueb
Sociodemographic
Gender 0.941
Male 60.3 60.6 60.4
Female 39.7 39.4 39.7
Age group (years) 0.000
0 to 1 20.3 37.5 21.4
2 to 5 42.4 37.2 42.0
6 to 9 37.4 25.3 36.6
Race/skin color 0.000
White 34.2 47.4 35.0
Black/brown 63.6 50.5 62.8
Yellow / indigenous 2.2 2.1 2.2
Has some kind of disabilityc **
Yes 1.4 1.0 1.3
No 98.6 99.0 98.7
Population in vulnerable situationd **
Yes 0.9 0.5 0.9
No 99.1 99.5 99.1
Has health plan 0.163
Yes 7.5 5.2 7.3
No 92.5 94.8 92.7
Of the event
Location of the event 0.001
Homee 64.4 72.4 65.0
Public road 15.9 9.4 15.5
School 11.9 14.3 12.0
Leisure area 4.6 1.8 4.4
Otherf 3.2 2.2 3.2
Location of the event 0.004
Home 64.4 72.4 65.0
Away fromhome 35.6 27.6 35.1
Nature of injury 0.000
No injury 12.5 16.9 12.8
Contusion / sprain / dislocation 32.2 22.6 31.5
Cut/laceration 29.8 29.1 29.7
Fracture / amputation / traumag 18.1 16.5 18.0
Otherh 7.4 14.9 7.9
Body part affected 0.000
Head / neck 45.2 52.3 45.6
Chest / abdomen / pelvis 3.9 9.0 4.2
Upper limbs 24.5 21.3 24.2
Lower limbs 20.7 8.6 19.9
Multiple organs / parts 5.8 8.9 6.0
Of care
Transport to hospital 0.609
Walking / bus / minibus 24.6 27.4 24.8
Private car 59.5 59.0 59.5
SAMU / ambulance / rescue 12.7 11.2 12.6
Otheri 3.2 2.3 3.1
Period of care 0.555
Daytime 58.3 56.1 58.2
Nighttime 41.7 43.9 41.8
Day of care 0.884
Saturday and Sunday 26.6 26.2 26.6
Monday through Friday 73.4 73.8 73.4
Previous care in another facility 0.217
Yes 35.9 31.7 35.6
No 64.1 68.3 64.4
Development **
Discharge 81.7 81.7 81.7
Hospitalizationj 12.3 14.0 12.4
Outpatient referral 5.1 3.1 4.9
Otherk 1.0 1.3 1.0

Source: Ministry of Health, Secretariat of Health Surveillance, Violence and Accident Surveillance System -VIVA, 2014 Survey.

*Except Florianópolis/SC and Cuiabá/MT, which have not performed the survey.

**The chi-square test and p value have not been calculated due to the existence of cell with value less than five.

aThe number of attendances for some variables diverged due to missing data (unknown / blank).

bChi-square test.

cIncludes physical, mental, visual, hearing impairments and other disabilities / syndromes.

dIncludes gypsy, Quilombola, villager, people living in the streets and other.

eIncludes residence and collective housing.

fIncludes bar or similar, trade / services, industry / construction and other.

gIncludes head trauma, dental trauma and polytrauma.

hIncludes poisoning, burns and other.

iIncludes police car and other.

jIncludes hospitalization and referral to other service.

kIncludes evasion / escape, death and other.

In the analysis by age group, boys suffered more injuries in all age groups (60.3%), predominantly between the age of 6 and 9 (p <0.006). In the cases of violence, boys were also more frequent victims. Children of black race/skin color (black/brown) prevailed among those involved in accidents, especially those between the age of 6 and 9 (66.8%; p < 0.001). P value was not calculated for violence due the small number of observations. Events were more frequent at home, both in accidents (64.4%) and violence (72.4%), with higher incidence of accidents among children aged 0 to 1 (p < 0.001). Among accidents, bruises were the most common injuries in children aged 6 to 9. Cuts were the most common attendances for injuries due to violence. Head was the most affected body part in accidents and violence, particularly in children aged 0 to 1 year (62.7% and 59.8%, respectively). Discharge was the most common outcome in emergency care development during the first 24 hours, with no significant differences by age group (Table 2).

Table 2 Emergency care for accidents among children by age group – 24 capitals* and the Federal District, Brazil, from September to October, 2014. 

Characteristics Accidents - Age group (years)a
0 to 1 (n = 1,742) % 2 to 5 (n = 3,494) % 6 to 9 (n = 2,928) % Total (n = 8,164) % P valueb
Sociodemographic
Gender 0.006
Male 58.2 58.8 63.3 60.3
Female 41.8 41.2 36.7 39.7
Race/skin color 0.000
White 40.6 33.8 31.1 34.2
Black/brown 57.6 63.8 66.8 63.6
Yellow / indigenous 1.9 2.5 2.1 2.2
Has some kind of disabilityc 0.000
Yes 0.6 1.0 2.2 1.4
No 99.4 99.0 97.8 98.6
Population in vulnerable situationd 0.938
Yes 0.9 0.8 0.9 0.9
No 99.1 99.2 99.1 99.1
Has health plan 0.097
Yes 9.1 6.8 7.4 7.5
No 90.9 93.2 92.6 92.5
Of the event
Location of the event 0.000
Homee 85.4 69.5 47.3 64.4
Public road 7.9 14.7 21.6 15.9
School 2.4 9.6 19.5 11.9
Leisure area 1.3 3.3 7.9 4.6
Otherf 2.9 2.9 3.7 3.2
Nature of injury 0.000
No injury 16.7 14.1 8.6 12.5
Contusion / sprain / dislocation 33.9 28.6 35.4 32.2
Cut/laceration 21.9 33.4 29.9 29.8
Fracture / amputation / traumag 17.9 16.2 20.5 18.1
Otherh 9.7 7.7 5.7 7.4
Body part affected 0.000
Head / neck 62.7 50.7 30.4 45.2
Chest / abdomen / pelvis 3.7 3.8 4.1 3.9
Upper limbs 16.3 21.7 31.5 24.5
Lower limbs 9.4 18.7 28.5 20.7
Multiple organs / parts 7.8 5.2 5.5 5.8
Of care
Transport to hospital 0.229
Walking / bus / minibus 22.3 25.5 25.0 24.6
Private car 60.6 59.1 59.4 59.5
SAMU / ambulance / rescue 14.5 12.4 12.1 12.7
Otheri 2.6 3.1 3.6 3.2
Period of care 0.133
Daytime 55.7 58.3 59.7 58.3
Nighttime 44.3 41.7 40.3 41.7
Day of care 0.167
Saturday and Sunday 26.1 28.0 25.3 26.6
Monday through Friday 73.9 72.0 74.7 73.4
Previous care in another facility 0.106
Yes 37.8 36.5 34.2 35.9
No 62.2 63.6 65.8 64.1
Development 0.076
Discharge 79.3 83.1 81.4 81.7
Hospitalizationj 14.7 11.5 11.8 12.3
Outpatient referral 4.9 4.5 5.8 5.1
Otherk 1.1 1.0 0.9 1.0
Sociodemographic
Gender 0.106
Male 57.2 56.3 71.9 60.6
Female 42.8 43.7 28.1 39.4
Race/skin color **
White 57.4 44.9 37.2 47.4
Black/brown 41.1 53.1 60.0 50.5
Yellow / indigenous 1.5 2.1 2.9 2.1
Has some kind of disabilityc **
Yes 0.0 1.5 1.9 1.0
No 100.0 98.5 98.1 99.0
Population in vulnerable situationd **
Yes 0.9 0.5 0.0 0.5
No 99.1 99.5 100.0 99.5
Has health plan 0.836
Yes 4.6 4.9 6.5 5.2
No 95.4 95.1 93.5 94.8
Of the event
Location of the event **
Homee 92.7 75.1 38.2 72.4
Public road 3.8 9.5 17.4 9.4
School 1.6 11.2 37.8 14.3
Leisure area 1.4 0.2 4.5 1.8
Otherf 0.4 4.0 2.1 2.2
Nature of injury 0.020
No injury 20.5 18.4 9.5 16.9
Contusion / sprain / dislocation 23.4 13.6 34.2 22.6
Cut/laceration 20.7 35.8 31.8 29.1
Fracture / amputation / traumag 21.8 14.1 12.1 16.5
Otherh 13.6 18.1 12.4 14.9
Body part affected 0.006
Head / neck 59.8 47.9 47.9 52.3
Chest / abdomen / pelvis 3.8 15.3 8.0 9.0
Upper limbs 25.8 13.3 25.3 21.3
Lower limbs 3.1 10.1 13.9 8.6
Multiple organs / parts 7.6 13.4 4.8 8.9
Of care
Transport to hospital **
Walking / bus / minibus 27.5 21.9 35.4 27.4
Private car 64.0 63.8 44.8 59.0
SAMU / ambulance / rescue 6.6 13.0 15.4 11.2
Otheri 2.0 1.3 4.4 2.3
Period of care 0.462
Daytime 52.0 60.6 55.6 56.1
Nighttime 48.0 39.4 44.4 43.9
Day of care 0.302
Saturday and Sunday 22.9 31.2 23.6 26.2
Monday through Friday 77.1 68.8 76.4 73.8
Previous care in another facility 0.591
Yes 29.9 35.7 28.5 31.7
No 70.1 64.4 71.6 68.3
Development 0.058
Discharge 79.1 82.3 84.5 81.7
Hospitalizationj 19.0 11.7 9.9 14.0
Outpatient referral 1.9 2.6 5.6 3.1
Otherk 0.0 3.4 0.0 1.3

Source: Ministry of Health, Secretariat of Health Surveillance, Violence and Accident Surveillance System -VIVA, 2014 Survey.

*Except Florianópolis/SC and Cuiabá/MT, which have not performed the survey.

**The chi-square test and p value have not been calculated due to the existence of cell with value less than five.

aThe number of attendances for some variables diverged due to missing data (unknown / blank).

bChi-square test.

cIncludes physical, mental, visual, hearing impairments and other disabilities / syndromes.

dIncludes gypsy, Quilombola, villager, people living in the streets and other.

eIncludes residence and collective housing.

fIncludes bar or similar, trade / services, industry / construction and other.

gIncludes head trauma, dental trauma and polytrauma.

hIncludes poisoning, burns and other.

iIncludes police car and other.

jIncludes hospitalization and referral to other service.

kIncludes evasion / escape, death and other.

In the comparative analysis of emergency attendances among children victims of violence/accidents and associated factors, calculating the adjusted OR, there were differences according to age: children aged 6 to 9 years suffered more accidents than violence (OR at 1.71 – CI 95 % 1.34-2.20); black or mulatto children suffered more accidents violence (OR at 1.27 – CI 95% 1.13-1.44), and yellow and brown (OR at 1.05 – CI 95% 1.02 to 1.08), with odds lower for white children. As for the place of occurrence, more accidents occurred on public roads than violence (OR at 1.54 – CI 95% 1.04 to 2.27). The nature of the most frequent injury in accidents compared to violence was concussion (OR to 1.60 – CI 95% 1.17 to 2.21), and the injured body part, the lower limbs (Table 3).

Table 3 Comparative analysis of emergency attendances among children victims of violence/ accidents and associated factors, according to age. Crude OR and adjusted for age, gender and skin color – 24 capitals and Federal District, Brazil, 2014. 

Characteristics Type of event(a)
Violence (n = 424) % OR Accidents (n = 8,164) % crude OR adjusted OR CI(95%) Total (n = 8,588) % p value(b)
Sociodemographic
Gender 0.941
Male 60.6 1 60.3 0.99 0.93(a) 0.73 – 1.20 60.4
Female 39.4 1 39.7 1.01 1.07(a) 0.84 – 1.37 39.7
Age group (years) 0.000
0 to 1 37.5 1 20.3 0.42 0.44(b) 0.35 – 0.57 21.4
2 to 5 37.2 1 42.4 1.24 1.23(b) 0.95 – 1.60 42
6 to 9 25.3 1 37.4 1.77 1.71(b) 1.34 – 2.20 36.6
Race/skin color 0.000
White 47.4 1 34.2 0.61 0.65(c) 0.52 – 0.82 35
Black/brown 50.5 1 63.6 1.31 1.27(c) 1.13 – 1.44 62.8
Yellow / indigenous 2.1 1 2.2 1.06 1.05(c) 1.02 – 1.08 2.2
Has some kind of disabilityc **
Yes 1 1 1.4 1.31 1,15 0.43 – 3.10 1.3
No 99 1 98.6 0.77 0.87 0.32 – 2.35 98.7
Population in vulnerable situation **
Yes 0.5 1 0.9 1.66 1.84 0.62 – 5.46 0.9
No 99.5 1 99.1 0.60 0.54 0.18 – 1.61 99.1
Has health plan 0.163
Yes 5.2 1 7.5 1.48 1.60 0.91 – 2.80 7.3
No 94.8 1 92.5 0.68 0.63 0.36 – 1.10 92.7
Of the event
Location of the event 0.001
Home 72.4 1 64.4 0.71 0.90 0.69 – 1.17 65
Public road 9.4 1 15.9 1.85 1.54 1.04 – 2.27 15.5
School 14.3 1 11.9 0.81 0.62 0.44 – 0.87 12
Leisure area 1.8 1 4.6 2.70 2.19 0.91 – 5.28 4.4
Other 2.2 1 3.2 1.52 1.46 0.70 – 3.04 3.2
Location of the event 0.004
Home 72.4 1 64.4 0.71 0.90 0.69 – 1.17 65
Away fromhome 27.6 1 35.6 1.40 1.11 0.85 −1.44 35.1
Nature of injury 0.000
No injury 16.9 1 12.5 0.70 0.79 0.57 – 1.08 12.8
Contusion / sprain / dislocation 22.6 1 32.2 1.63 1.60 1.17 – 2.21 31.5
Cut/laceration 29.1 1 29.8 1.04 0.98 0.75 – 1.26 29.7
Fracture / amputation / traumag 16.5 1 18.1 1.11 1.09 0.74 – 1.61 18
Other 14.9 1 7.4 0.45 0.49 0.34 – 0.71 7.9
Body part affected 0.000
Head / neck 52.3 1 45.2 0.87 1.01 0.77 – 1.33 45.6
Chest / abdomen / pelvis 9 1 3.9 0.69 0.65 0.36 – 1.18 4.2
Upper limbs 21.3 1 24.5 0.14 0.14 0.07 – 0.27 24.2
Lower limbs 8.6 1 20.7 2.03 1.72 1.27 – 2.35 19.9
Multiple organs / parts 8.9 1 5.8 0.68 0.70 0.43 – 1.15 6
Of care
Transport to hospital 0.609
Walking / bus / minibus 27.4 1 24.6 0.86 0.83 0.62 – 1.11 24.8
Private car 59 1 59.5 1.02 1.08 0.83 – 1.39 59.5
SAMU / ambulance / rescue 11.2 1 12.7 1.15 1.13 0.78 – 1.63 12.6
Other 2.3 1 3.2 0.86 0.83 0.62 – 1.11 3.1
Period of care 0.555
Daytime 56.1 1 58.3 1.09 1.05 0.78 – 1.42 58.2
Nighttime 43.9 1 41.7 0.92 0.95 0.71 – 1.28 41.8
Day of care 0.884
Saturday and Sunday 26.2 1 26.6 1.02 1.02 0.74 – 1.41 26.6
Monday through Friday 73.8 1 73.4 0.98 0.98 0.71 – 1.35 73.4
Previous care in another facility 0.217
Yes 31.7 1 35.9 1.02 1.02 0.74 – 1.41 35.6
No 68.3 1 64.1 0.98 0.98 0.71 – 1.35 64.4
Development **
Discharge 81.7 1 81.7 1.00 1.00 0.71 – 1.40 81.7
Hospitalization 14 1 12.3 0.86 0.87 0.61 – 1.24 12.4
Outpatient referral 3.1 1 5.1 1.67 1.60 0.82 – 3.13 4.9
Other 1.3 1 1 0.77 0.86 0.24 – 3.04 1.0

Adjusted OR for age, gender and skin color.

(a)Adjusted OR for age and skin color.

(b)Adjusted OR for gender and skin color.

(c)Adjusted OR for age and gender.

Falls (52.4%) were the most frequent accidents, followed by other accidents (36%), road injury (9.4%) and burns (2.2%). Falls predominated in children under 1 year of age (63.1%; p < 0.001), among which from bed / furniture (42.5%) and same-level (31.7%). However, the latter was more common in children aged 6-9 years (60.2%) (p< 0.001).

The second most frequent events were other accidents, highlighting collision with object/person in children aged 6-9 years (32.1%) and 2-5 years (18.9%) (p<0.001), as well as the sprain/crushing (15%) and accidents with animals (13%). Transport accidents predominated in children aged 6-9 years (12.1%); passengers were the most frequent type of victims (40.6%), especially among children aged 0-1 years (66%). The victim's predominant means of transportation was bicycle (41.5%). The bicycle – non-motorized bicycles, tricycles and similar (41.5%) – was the victim's most frequent means among children aged 6-9 years (45.8%) (p < 0.001). Burns (2.2%) were more common in the 0-1 year group (4.8%), and those caused by hot substances were the most frequent in all age groups (72.8%) (Table 4).

Table 4 Emergency care for violence among children by age group – 24 capitals* and the Federal District, Brazil, from September to October, 2014. 

Characteristics Age group (years)a
0 to 1 (n) % 2 to 5 (n) % 6 to 9 (n) % Total (n) % P valueb
Type of accident (1,742) (3,494) (2,928) (8,164) 0.000
Road injury 5.1 9.1 12.1 9.4
Fall 63.1 50.8 48.3 52.4
Burn 4.8 1.7 1.4 2.2
Other accidents 27.0 38.4 38.3 36.0
Road injury: type of victim (112) (361) (392) (865) 0.000
Pedestrian 20.2 29.2 32.5 29.8
Driver 13.8 21.8 40.0 29.6
Passenger 66.0 49.0 27.5 40.6
Road injury: means of victim's transport (112) (361) (392) (865) 0.000
Walking 20.2 29.2 32.5 29.8
Car 33.6 10.9 6.1 11.1
Motorbike 17.9 11.8 9.2 11.2
Bicycle 24.9 40.9 45.8 41.5
Bus/minibus/other 3.4 7.1 6.3 6.3
Type of fall (1,092) (1,793) (1,376) (4,261) 0.000
Same level 31.7 49.6 60.2 48.9
Bed/furniture 42.5 22.6 9.8 23.0
Ladder/step 10.7 13.2 9.7 11.4
Tree/roof/scaffold/slab 0.9 1.9 6.7 3.3
Hole/other levels 14.2 12.8 13.6 13.4
Type of burn (73) (62) (41) (176) **
Fire/flame 1.8 10.3 19.5 8.7
Hot substance 72.8 48.4 69.0 64.0
Hot object 21.6 29.2 5.7 20.3
Otherc 3.8 12.2 5.9 7.0
Other accidents (450) (1,255) (1,102) (2,807) 0.000
Cutting injury 4,5 8,5 14,5 10,3
Accidents with animals 12.4 12.7 13.5 13.0
Object falling on person 12.8 12.7 7.3 10.6
Collision with object/person 15.7 18.9 32.1 23.7
Sprain/crushing 19.7 13.2 15.2 15.0
Otherd 34.9 34.0 17.4 27.5

Source: Ministry of Health, Secretariat of Health Surveillance, Violence and Accident Surveillance System -VIVA, 2014 Survey.

*Except Florianópolis/SC and Cuiabá/MT, which have not performed the survey.

**The chi-square test and p value have not been calculated due to the existence of cell with value less than five.

aThe number of attendances for some variables diverged due to missing data (unknown / blank).

bChi-square test.

cIncludes electrical shock and chemical substances.

dIncludes choking / suffocation, foreign body, drowning, poisoning / intoxication, injury by firearms, others.

As for violence, neglect was more frequent (63.2%), followed by physical abuse (33.4%). Sexual violence occurred in 3.1% of children. A child's family member was the likely violence perpetrator in 72% of cases; women were the most common perpetrators for children under 1 year, and man for children aged 6 to 9 years (p = 0.040), as shown in Table 5.

Table 5 Emergency care for violence among children by age group – 24 capitals* and the Federal District, Brazil, from September to October, 2014. 

Characteristics Age group (years)a
0 to 1 (n) % 2 to 5 (n) % 6 to 9 (n) % Total (n) % P valueb
Type of violence (140) (162) (122) (424) **
Self-inflicted injury 0.8 4.4 2.3 2.5
Aggressionc 99.2 95.6 97.7 97.5
Nature of violence/aggression (135) (146) (112) (393) **
Physical 14.6 25.4 75.2 33.4
Sexual 0.8 4.8 4.3 3.1
Psychological 0.0 0.5 0.0 0.2
Neglect 84.1 69.4 20.6 63.2
Other 0.4 0.0 0.0 0.2
Means of aggression (132) (147) (113) (392) **
Body strength / beating 10.9 21.4 50.7 24.8
Firearm 0.8 2.4 1.9 1.7
Sharp objects 1.1 3.7 7.5 3.7
Pointed objects 0.8 2.3 15.2 5.0
Other 86.4 70.3 24.9 65.0
Family member as aggressor (135) (146) (111) (392) **
Yesd 92.4 75.5 35.5 72.0
No 7.6 24.5 64.5 28.0
Gender of likely aggression perpetrator (114) (122) (92) (328) 0.0406
Male 17.0 38.5 62.7 36.4
Female 83.0 61.6 37.3 63.7

Source: Ministry of Health, Secretariat of Health Surveillance, Violence and Accident Surveillance System -VIVA. 2014 Survey.

*Except Florianópolis/SC and Cuiabá/MT, which have not performed the survey.

**The chi-square test and p value have not been calculated due to the existence of cell with value less than five.

aThe number of attendances for some variables diverged due to missing data (unknown / blank).

bChi-square test.

cIncludes abuse and intervention by legal public officer.

dIncludes father/ mother and other family members.

Discussion

Accidents and violence in childhood entail social, economic and emotional costs and are responsible not only for the majority of deaths, but also non-fatal injuries that have major long-term impact, affecting children, adolescents, families and society1,2 who have to deal with temporary disabilities, sequels, emotional trauma and suffering resulting from injuries. The consequences of external causes in children, adolescents, families and society must be considered a major public health problem amenable to prevention and protection and dependent on affirmative public policies10.

VIVA survey has been useful to trace the epidemiological profile of emergency services, identifying characteristics of the victims and likely perpetrators12,1416, as well as to provide supplementary information from other information systems, such as SIH and SIM, supporting prevention and health promotion measures.

The current study showed the service profile for external causes in children in urgent and emergency care services, which are mostly cases that evolve toward discharge, evidencing less severe events, which is consistent with other studies. Hospitalizations occurred most often in children under 1 year, possibly due to their higher vulnerability13,15.

Accidents and violence in childhood include peculiarities in relation to gender, age, place of occurrence and characteristics or circumstances in which they develop13,17. Studies have shown that males are more affected by external causes, as was also found in this work. Authors argue that this is due to the fact that education is provided differently according to gender; boys gain freedom earlier and generally engage in more dynamic activities than girls, like playing soccer, ball games, running and using bikes, bicycles, skates, among others17,18. In addition, the occurrence of violence was more common among boys. This finding is in accordance with a review on violence and health studies, reiterating a higher occurrence of violence among boys19. Social inequalities and gender issues are, therefore, implicated in violence against children and adolescents. Early introduction of male universe symbols that encourage violence, such as toy guns and swords, fight and violence movies and games can naturalize these behaviors18.

The age group with the largest occurrence of accidents was 2-5 years, compatible with previous editions of the VIVA Survey13,14. However, other studies show different results, with higher frequency of accidents in older children (7-12 years)20, among those aged 1-3 years21 or 1-9 years16, depending on the stratification of study or profile of services. Home is the most frequent place of occurrence of these injuries, as described in other studies12,17,26, it is where children spend most of their time22,23.

The finding on falls as the most common type of accident in childhood is consistent in the literature2022. The greater autonomy and exposure to games such as racing and games can also be reasons for the higher occurrence of other accidents (collision with objects/people, sprains/crushes and falling objects), especially among the 2 to 9 years olds21,20.

In this context, preventive measures should be taken by parents and guardians, such as care with wet floors, adopting safety measures for furniture sharp angles, glass objects, cribs, windows and stairs, care with throw rugs, scattered toys, small parts which can be introduced in body orifices, care with kitchens, hot pots, irons, storage of medicines and products, electrical outlets, domestic animals, plants and others21,23. In addition, the most important thing is constant adult supervision, seeking protection against environmental risks and educational attitudes23.

The fact that road injury are the third most frequent external cause of care to children in urgent and emergency care services goes against the relevant information that this type of occurrence is the first cause of mortality among children aged 1-9 years in Brazil and worldwide1,12. SIM data show that the most frequent causes of children traffic deaths are pedestrian trampling, followed by vehicle occupants, and bikes comes in fifth place12. Deaths by trampling show the importance of adult supervision when crossing streets with children and moving them on roads. A positive highlight in Brazil has been reduced traffic deaths due to the use of car seats and safety equipment24,25.

The same recommendation goes for burns, most frequent in children aged 0 to 1 year and caused by hot substances and objects, also requiring adult supervision26.

With regard to findings on violence, examining the prevalence of neglect in children under 1 year and physical violence in older children, these are in line with findings from other countries, where both types of violence stand out. Physical violence is relevant in the Philippines and the United States, with 75% and 47%, respectively19. Other studies highlight neglect as the main occurrence of violence in this age group27. Social and cultural factors, as well as those from notification of health care systems in different contexts can support this discussion. Furthermore, findings on sexual violence are consistent with other studies that show its higher prevalence in children above 10 years, while sexual exploitation higher prevalence is noted as from the age of 1428.

External causes are very common in the world and in Brazil2 and are a serious public health problem that is still underreported. Because of childhood vulnerability, violence remains mostly silent, underestimated and brings negative consequences to children's physical and mental health13,29. VIVA breaks this silence, allowing health services to grasp this reality and take protective measures to break the vicious circle of suffering13,14.

The likely perpetrators of violence are mostly female and family members, consistent with what has been reported in other studies, which have identified attackers as the victim's mother or father or the mother's boyfriend or partner19,30,31. Accident- and violence-related injuries affect more often the head and may increase the risk of serious injury, such as head trauma23. This finding is consistent with the study by Cavalcanti32, which showed that 69.1% of children injuries are located in head and face, followed by the upper and lower limbs.

Among the limitations of this study, we quote the use of the strategy of CNES-accredited public urgent and emergency care services, excluding emergency facilities of private hospitals. We chose to use sentinel services, which brings advantages, because they deal with external causes involving children and have already participated in previous editions of VIVA. The drawback is that they are not population estimates, although public hospitals focus most attendances on external causes and can be a universe proxy. Moreover, due to the difficult topic analyzed, data on violence against children may be omitted due to underreporting and the difficult identification and assessment of cases of neglect, physical, sexual and psychological violence on children, especially when committed by family members.

The issue of violence against children is gaining visibility and importance in the international and national agendas1,2,33. In Brazil, the Statute of Children and Adolescents (Law no. 8069/1990) established a legal framework for the protection of children's rights10, and the use of VIVA's information has promoted coordination between health and intersectoral services to protect victims of violence, integrating healthcare, health promotion and violence prevention and control actions13,14,33.

Much global progress has been achieved in preventing violence against children, but there is still much to be done, and several factors limit the impact of preventive measures, among which are, as quoted by the WHO, social inequalities, which affect differently rich and poor kids1,2. No violence against children is justifiable and all can be prevented. Governments should commit to protect children from all forms of violence. All sectors of society share the responsibility of condemning and preventing violence against children and dealing with child victims1,2. The SDGs renew commitments to children's health, seeking to ensure a better future for our children12.

Conclusion

The main results of the 2014 VIVA Survey relating to events in children under 10 years in public urgent care gateways show that accidents were more frequent (95%) than violence. In general, events consisted of mild cases that led to discharge. The 2-5 years age group suffered most accidents. Among accidents, the predominant causes were falls from own height in older children (6-9 years) and from the crib/bed up to 1 year of age, followed by other accidents, and third were road injury. Road injury predominated in children aged 6-9 years and non-motorized bikes/bicycles, tricycles and similar were the most frequent victims’ means of transport among children aged 6-9 years. Burns occurred in about 2% and were more frequent in the 0-1 year group. The events were more frequent at home, in male children and those in the 2-5 years group. Hospitalizations were predominant in children under 1 year.

Neglect was the most frequent violence, accounting for about two-thirds, and predominated in children under 1 year, and physical violence prevailed in older children. The probable perpetrator of violence was a family member of children in two-thirds of the events. Women were most frequent likely aggressor for children under 1 year, and men in children aged 6 to 9 years.

The preventability of these events is clear, and it is necessary to involve families, schools, society and governments. Children are exposed to hazards and risks in their daily lives and are vulnerable everywhere to various types of injury; however, society should ensure them a protective environment1,2 that can guarantee their physical, social, cultural development.

REFERENCES

1. World Health Organization (WHO). World report on child injury prevention. Geneva: WHO; 2008. [ Links ]

2. World Health Organization (WHO). World report on violence and health. Geneva: WHO; 2002. [acessado 2013 mar 13]. Disponível em: http://whqlibdoc.who.int/publications/2002/Links ]

3. Oliveira BRG, Thomazine AM, Bittar DB, Santos FL, Silva LMP, Santos RL. A violência intrafamiliar contra a criança e o adolescente: o que nos mostra a literatura nacional. REME Rev Min Enferm 2008; 12(4):547-556. [ Links ]

4. Assis SG, Avanci JQ, Pesce RP, Pires TO, Gomes DL. Notificações de violência doméstica, sexual e outras violências contra crianças no Brasil. Cien Saude Colet 2012; 17(9):2305-2317. [ Links ]

5. World Health Organization (WHO). World Health Statistics 2015. [Internet]. 2015 [citado 2016 jan 05]. Disponível em: http://www.who.int/gho/publications/world_health_statistics/en/C:/Users/Owner/Documents/carga%20de%20doen%C3%A7as%202016/Reportes%20Global%20statictcs%20OMS%202015_eng.pdfLinks ]

6. Organização das Nações Unidas (ONU-BR). Objetivos de Desenvolvimento Sustentável (ODS): Brasil [Internet]. 2015 [citado 2016 jan 05]. Disponível em: https://nacoesunidas.org/pos2015/ods3/Links ]

7. Finkelhor D, Ormrod R, Turner H, Holt M. Pathways to poly-victimization. Child Maltreat 2009; 14(4):316-329. [ Links ]

8. Dahlberg LL, Krug EG. Violência: um problema global de saúde pública. Cien Saude Colet 2006; 11(Supl.):1163-1178. [ Links ]

9. Scherer EA, Sherer ZAP. A criança maltratada: uma revisão da literatura. Rev Lato-am Enfermagem 2000; 8(5):22-29. [ Links ]

10. Brasil. Lei nº 8.069 de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente, e dá outras providências. Diário Oficial da União 1990; 16 jul. [ Links ]

11. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e Promoção da Saúde. Sistema de Informação sobre Mortalidade (SIM). Brasília: MS; 2013. [ Links ]

12. Brasil. Ministério da Saúde (MS). Saúde Brasil 2014: Uma análise da situação de saúde e das causas externas. Brasília: MS; 2015. [ Links ]

13. Iossi SMA, Pan RML, Bortoli PS, Nascimento LC. Perfil dos atendimentos a crianças e adolescentes vítimas de causas externas de morbimortalidade, 2000-2006. Rev. Gaúcha Enferm 2010; 31(2):351-358. [ Links ]

14. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Viva: vigilância de violências e acidentes, 2009, 2010 e 2011. Brasília: MS; 2013. [ Links ]

15. Malta DC, Mascarenhas MDM, Bernal RT, Viegas APB, Sá NNB, Silva Júnior JB. Acidentes e violência na infância: evidências do inquérito sobre atendimentos de emergência por causas externas – Brasil, 2009. Cien Saude Colet 2012; 17(9):2247-2258. [ Links ]

16. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Viva: vigilância de violências e acidentes, 2008 e 2009. Brasília: MS; 2010. (Série G. Estatísticas e Informação em Saúde) [ Links ]

17. Harada MJCS, Pedreira MLG, Andreotti JT. Segurança com brinquedos de parque infantil: uma introdução ao problema. Rev Latino-Am Enfermagem 2003; 11(3):383-386. [ Links ]

18. Fonseca SS, Victora CG, Halpern R, Barros AJD, Lima RC, Monteiro LA, Barros F. Fatores de risco para injúrias acidentais em pré-escolares. J Pediatr (Rio J) 2002; 78(2):97-104. [ Links ]

19. Schraiber LB, D’Oliveira AFPL, Couto MT. Violência e saúde: estudos científicos recentes. Rev Saude Publica 2006; 40(N Esp):112-120 [ Links ]

20. Filócomo FRF, Harada MJS, Silva CV, Pedreira MLG. Estudo dos acidentes na infância em um pronto-socorro pediátrico. Rev Latino-am Enfermagem 2002; 10(1):41-47. [ Links ]

21. Martins CBG. Acidentes na infância e adolescência: uma revisão bibliográfica. Rev Bras Enferm 2006; 59(3):344-348. [ Links ]

22. Assis SG, Avanci JQ, Pesce RP, Pires TO, Gomes DL. Notificações de violência doméstica, sexual e outras violências contra crianças no Brasil. Cien Saude Colet 2012; 17(9):2305-2317. [ Links ]

23. Paes CEN, Gaspar VLV. As injúrias não intencionais no ambiente domiciliar: a casa segura. J Pediatr (Rio J) 2005; 81(5):146-154. [ Links ]

24. Oliveira SRL, Leone C, Carvalho MDB, Santana RG, Lüders LE, Oliveira FC. Erros de utilização de assentos de segurança infantil por menores de 4 anos. J Pediatr (Rio J) 2012; 88(4):297-302. [ Links ]

25. Garcia LP, Freitas LRS, Duarte EC. Avaliação preliminar do impacto da Lei da Cadeirinha sobre os óbitos por acidentes de automóveis em menores de dez anos de idade, no Brasil: estudo de series temporais no periodo de 2005 a 2011. Epidemiol Serv Saúde 2012; 21(3):367-374. [ Links ]

26. Martins CBG, Andrade SM. Queimaduras em crianças e adolescentes: análise da morbidade hospitalar e mortalidade. Acta Paul Enferm 2007; 20(4):464-469. [ Links ]

27. Faleiros JM, Matias ASA, Bazon MR. Violência contra crianças na cidade de Ribeirão Preto, São Paulo, Brasil: a prevalência dos maus-tratos calculada com base em informações do setor educacional. Cad Saude Publica 2009; 25(2):337-348. [ Links ]

28. Costa MCO, Carvalho RC, Bárbara JFRS, Santos CAST, Gomes WA, Sousa HL. O perfil da violência contra crianças e adolescentes, segundo registros de Conselhos Tutelares: vítimas, agressores e manifestações de violência. Cien Saude Colet 2007; 12(5):1129-1141. [ Links ]

29. Oliveira RG, Marcon SS. Exploração sexual infanto juvenil: causas, consequências e aspectos relevantes para o profissional de saúde. Rev Gaúcha Enferm 2005; 26(3):345-357. [ Links ]

30. Rimsza ME, Schackner RA, Bowen KA, Marshall W. Can child deaths be prevented? The Arizona child fatality review program experience. Pediatrics 2002; 110(1 Pt 1):e11. [ Links ]

31. Hamilton LHA, Jaffe PG, Campbell M. Assessing children's risk for homicide in the context of domestic violence. J Fam Violence 2013; 28:179-89. [ Links ]

32. Cavalcanti AL. Lesões no complexo maxilofacial em vítimas de violência no ambiente escolar. Cien Saude Colet 2009; 14(5):1835-1842. [ Links ]

33. Malta DC, Silva MA, Mascarenhas MDM, Souza MFM, Morais Neto OL, Costa VC, Magalhães M, Lima CM. A vigilância de violências e acidentes no Sistema Único de Saúde: uma política em construção. Divulg Saúde Debate 2007; (39):82-92. [ Links ]

Erratum

p. 3729

where it reads:

Jovina Quintes Avanci

It should read:

Joviana Quintes Avanci

Received: March 16, 2016; Revised: July 01, 2016; Accepted: July 03, 2016

Collaborations

DC Malta worked on the design of the study, on the analysis and interpretation of the data and on the critical review, also approved the version to be published. MDM Mascarenhas and RTI Bernal performed the analysis and interpretation of the data and the final revision of the text. MMA Silva, MGO Carvalho, LA Barufaldi and JQ Avanci contributed with critical analysis, final revision of the text. All authors approved their final version.

Creative Commons License This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.