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Revista Gaúcha de Enfermagem

versão impressa ISSN 0102-6933versão On-line ISSN 1983-1447

Rev. Gaúcha Enferm. vol.41  Porto Alegre  2020  Epub 12-Jun-2020

http://dx.doi.org/10.1590/1983-1447.2020.20190286 

Original Article

Social representations of Primary Health Care users about violence: a gender study

Representaciones sociales de usuarios de Atención Primaria de Salud sobre violencia: un estudio de género

Victoria Leslyê Rocha Gutmanna 
http://orcid.org/0000-0002-3457-7620

Camila Daiane Silvab 
http://orcid.org/0000-0002-0739-4984

Daniele Ferreira Acostaa 
http://orcid.org/0000-0001-5690-1076

Marina Soares Motac 
http://orcid.org/0000-0002-5717-9406

César Francisco Silva da Costaa 
http://orcid.org/0000-0001-6933-9705

Carolina Costa Coutinho Vallejosb 
http://orcid.org/0000-0002-1093-5366

aUniversidade Federal do Rio Grande (FURG), Escola de Enfermagem. Rio Grande, Rio Grande do Sul, Brazil.

bUniversidade Federal do Rio Grande (FURG), Escola de Enfermagem, Programa de Pós-Graduação em Enfermagem. Rio Grande, Rio Grande do Sul, Brazil.

cUniversidade Federal de Pelotas (UFPel), Faculdade de Enfermagem. Pelotas, Rio Grande do Sul, Brazil


ABSTRACT

Objective:

To analyze the structure and content of social representations about violence by primary health care users.

Method:

Qualitative study based on the Theory of Social Representations, carried out in Rio Grande health units with 150 people between January and April 2019 by applying free evocations and interviews, which were treated by using software and contextual analysis, respectively.

Results:

Violence against people, violence, physical violence, substance dependence, and robbery made up the representation in the central core. People represented violence as interpersonal, including intrafamily and urban. Women were related to domestic violence and the exercise of verbal violence, while men were more closely related to urban violence and the use of physical violence.

Final considerations:

Obtaining the social representation of violence makes it possible to reflect on the subject in the primary health care scenario, contributing to the development of strategies and targeted actions.

Keywords: Violence; Primary health care; Family health strategy; Gender and health; Nursing

RESUMEN

Objetivo:

Analizar la estructura y el contenido de las representaciones sociales de las personas que utilizan la atención primaria de salud sobre la violencia.

Método:

Estudio cualitativo basado en la Teoría de las Representaciones Sociales, realizado en las unidades de salud de Rio Grande con 150 personas entre enero y abril de 2019 por medio de evocaciones libres y entrevistas, tratadas por software y análisis contextual, respectivamente.

Resultados:

La violencia contra las personas, la violencia, la violencia física, la dependencia de substancias y el asalto formaron la representación en el núcleo central. Las personas representaban la violencia como interpersonal, incluida intrafamiliar y urbana. Las mujeres estaban relacionadas con la violencia doméstica y el ejercicio de la violencia verbal, mientras que los hombres estaban más estrechamente relacionados con la violencia urbana y el uso de la violencia física.

Consideraciones finales:

A través de la representación social de la violencia, se hace posible reflexionar sobre el tema en el escenario de atención primaria de salud, contribuyendo al desarrollo de estrategias y acciones específicas.

Palabras clave: Violencia; Atención primaria de salud; Estrategia de salud familiar; Género y salud; Enfermería

RESUMO

Objetivo:

Analisar a estrutura e os conteúdos das representações sociais das pessoas usuárias da atenção primária à saúde sobre violência.

Método:

Estudo qualitativo fundamentado na Teoria das Representações Sociais, realizado nas unidades de saúde de Rio Grande com 150 pessoas entre janeiro e abril de 2019 por meio de evocações livres e entrevistas, tratadas por software e análise contextual, respectivamente.

Resultados:

Violência contra pessoas, violência, violência física, dependência de substâncias e assalto formaram a representação no núcleo central. As pessoas representaram a violência como a interpessoal, incluindo intrafamiliar e urbana. Às mulheres foi relacionada a violência doméstica e o exercício da violência verbal, enquanto nos homens houve maior relação com a violência urbana e uso da violência física.

Considerações finais:

Por meio da representação social da violência, torna-se possível a reflexão sobre a temática no cenário da atenção primária à saúde, contribuindo para a elaboração de estratégias e ações direcionadas.

Palavras-chave: Violência; Atenção primária à saúde; Estratégia saúde da família; Gênero e saúde; Enfermagem

INTRODUCTION

Violence etiology involves multiple causes. It is an interaction of biological, environmental, historical, psychological, and social conditions that function as sources of risk or protection for the occurrence of the phenomenon. Gender issues also play a fundamental role in producing health harm. Gender is understood as the social construction of male and female, made up of symbols, norms, and institutions that legitimate masculinity and femininity models and behavior standards that are considered acceptable or not for men and women1. The traditionalist movement founded in the Brazilian state of Rio Grande do Sul, developed from patriarchal values, is an example of this established and accepted behavior model, because it associates men with the concept of strength and women with the idea of fineness or care2.

The consequences of violence, when it is not fatal, include injuries, depression, anxiety, post-traumatic stress, social isolation, sleep alterations, inadequate eating patterns, and abusive use of drugs and medications. Consequently, violence originates an overload in the health and criminal justice systems and, thus, a negative impact on the economy, as illustrated by absenteeism and the loss in productivity and human capital3-4. Additionally, violence does not strike victims only, but also people who live around them. It is calculated that seven to ten relatives are deeply affected by the traumatic loss caused by one homicide approximately, an estimate that does not take into account friends and neighbors5.

Considering violence’s complexity, it is necessary to coordinate the several sectors and services that exist in society. In the health sphere, primary health care, more specifically the family health strategy (FHS), is an important tool to detect and prevent violence situations because of the privileged access it offers to the users, by means of a set of actions that encompass promoting health and protection and preventing complications, developing a comprehensive care that positively impacts communities’ determining and conditioning health factors6.

Despite the verification that violence is of part of how the male model is built in society, one should remove men from the condition of aggressor and violent agent and women from the role of fragile and passive icon rather than sticking to stereotypes. Consequently, it becomes fundamental to understand how people represent violence to change the way it is made natural. The Theory of Social Representations allows to understand consensual knowledge, that is, the notions learned and shared at home, on the streets, at school, or by the media, which are responsible for the production of social representations, as well as make it possible to give new meaning to it, in an attempt to understand the reasoning, the logic used to formulate a certain representation7.

It is believed that knowing the social representation of violence of FHS users will contribute to understanding risk and protection determining factors involved in the phenomenon, as well as the existing gender relationships. It is also considered that, from this representation, it will be possible to think about and propose feasible strategies to denaturalize and prevent violence, taking into account the reality of FHS users. The guiding question of the present study was: What are the structure and contents of the social representations of violence of users of primary health care? The objective was to analyze the structure and contents of the social representation of violence of these users.

METHODS

Descriptive study, with a qualitative approach, grounded on the Theory of Social Representations, which has enough strength to support the existing cultural practices, perpetuating or changing them7. There are currently 25 health units linked to the FHS in the municipality of Rio Grande, state of Rio Grande do Sul, Brazil, entitled Family Health Basic Units (FHBU).

All the 25 FHBU participated in the study, which applied two techniques, free evocations and interviews. The free evocations technique consisted of asking the participants to mention the first five words that came to their mind when they were exposed to the inducing term “violence”. The interviews were supported by a semi-structured script designed specifically for the present study, with open-ended guiding questions, which included: In your opinion, what is the meaning of violence? What factors lead to its occurrence? Have you ever faced or witnessed a violence situation? How does violence affect men and women? How can the health unit contribute to preventing it?

Data collection occurred from January to April 2019. Six users who spontaneously sought care at each unit were invited to execute the evocations technique, with the balance of three men and three women kept, totaling 150 people. For the interviews, eight units that had a higher demand were purposefully selected. Four units were urban, two were rural, and two were coastal. Thirty-two people from the group of 150 who were already part of the first step of the study were invited, with the balance of two men and two women from each unit kept. It must be stressed that the users were invited to participate in the study at the waiting room, after having their needs fulfilled at the FHBU, with no impact or losses to the access to the services offered by the units.

The inclusion criteria were being an FHS user, being at least 18 years old, and not having cognitive, speaking, understanding, and hearing limitations. The exclusion criteria were being an FHS user who was not Brazilian and sought care at the health unit in an emergency situation. After the invitation, the participants expressed their acceptance to be part of the study sample by signing free and informed consent forms. The evocations step lasted from five to ten minutes on average, and the mean duration of the interviews was 30 minutes.

A room was requested in each FHBU for the researchers to carry out data collections in both steps in a place free from noise and interferences. The interview was recorded (as audio) after the participants agreed to it. The people in the sample were identified by the initial “P” (for “person”) followed by a number that indicated the order of the interview in the series (P1, P2, P3, …), to guarantee the participants’ anonymity and the confidentiality of the obtained information. Additionally, the gender of the person was identified as female (F) or male (M).

A standardization dictionary was designed for the evoked words and expressions to analyze the evocations, and the software Ensemble de Programmes Permettant L´Analyse des Evocations 2005 (EVOC) was used subsequently. It allows to organize words according to the frequency and order of evocation for the development of the four-box chart, made up of a central core, contrast, first periphery, and second periphery. The contextual analysis proposed by Bardin was carried out having the words allocated in the quadrants as a starting point. This analysis is based on searching for the context of the words present in the four-box chart in the interviews, working on the words to produce inferences and interpretations of the communication content8. The proposal was approved by the research ethics committee as per report no. 264/2018.

RESULTS

The 150 participants of the present study were between 18 and 79 years old. The prevailing self-reported skin color/race was white (56.6%), followed by black (40.6%). Regarding sexual orientation, 97.3% of the participants declared that they were heterosexual. Most had completed elementary school (50.6%) and 50% had a job. Also, most of the participants had a partner and lived with him/her (67.3%). The percentages of participants who had one and two children were 24.6% and 28.6%, respectively, which was the average.

The corpus made up of the evocations of FHS users when these were confronted to the inducing term “violence” had 668 words, with 73 distinct words. On a scale from 1 to 5, the average evocation order (known as RANG) was 2.8. The minimum frequency was 11, the average frequency was 24, and the corpus use was 71.6%. Analysis of this data set resulted in the four-box chart (Chart 1).

Chart 1 - Four-box chart, whose design was based on the evocations of FHBU users when faced with the inducing term “violence”. Rio Grande, RS, Brazil, 2019  

CC Freq. ≥ 24 Rang < 2.8 1st periphery Freq. ≥ 24 Rang ≥ 2.8
Freq. Rang Freq. Rang
Violence against people 86 2.779 Impunity 25 3.360
Violence 54 2.037
Physical violence 39 2.436
Substance dependence 27 2.630
Robbery 25 2.280
Contrast Freq. < 24 Rang < 2.8 2nd periphery Freq. < 24 Rang ≥ 2.8
Freq. Rang Freq. Rang
Homicide 21 2.619 Urban violence 18 3.333
Verbal violence 19 2.211 Moral violence 18 3.778
Domestic violence 16 2.125 Sadness 17 3.118
Hatred 15 2.533 Mistreating animals 17 3.412
Lack of respect 13 2.154 Sexual violence 16 2.813
Negative 12 2.000 Fear 16 3.000
Character 13 3.000
Prejudice 11 3.364

Source: Authors.

The most frequent and most readily evoked (lower Rang) expressions make up the central core, characterized as more stable and resistant to changes. Located in the upper left quadrant, the representation core contained the terms “violence against people”, “violence”, “physical violence”, “substance dependence”, and “robbery”.

The expression “violence against people” stood out, because it was evoked 86 times, being the most frequent. However, it was the last in the evocation order (Rang 2.779). It encompassed violence against children, women, homosexuals, and elderly people. The term “violence” was the most readily evoked (Rang 2.037) and the second most frequent (54), covering situations of abuse, aggression, arguments, and maltreatment. The expression “physical violence” was the third most frequent and the third most readily evoked (39; 2.436, respectively), standing out in the set including the other types of violence that were included in the other quadrants. The expression encompassed pushing, slapping, kicking, punching, and spanking.

Unnecessary, if people could talk […] it would not be necessary to grab a woman, beat a child, mistreat an elderly person, it is unacceptable. (P28-F).

A couple […] at the place where I worked […] that took a long time to get out of my mind. He beat her very strongly. I never thought he would come and punch her the face […] threw her in the street and kicked her […]. (P10-F).

The first thing that comes to my mind is the homosexual issue, men suffering violence […] we see the issue of homophobia a lot these days, the violence against LGBT people. (P17-M).

Still in the central core, the expression “substance dependence”, evoked 27 times, was associated with the use of substances such as alcohol and with drug trafficking. Last, the word “robbery”, although less frequent, was the second most readily evoked (2.280).

There are drugs, which are one of the main forms of violence, there is drinking… (P25-F).

These days, violence occurs basically because of drugs, intoxicating substances […] trafficking is what originates everything […] corruption and trafficking is what originates violence these days. (P11-M).

Another thing is robbery. I think there is no justification for robbery, something that cannot be justified. For feminicide, you can see that the criminal has a reason to commit the crime, which, actually, is not really a reason. But when it comes to robbery, what are you going to say? That the person is doing it just because he or she is poor? That is not a justification. (P14-M).

The contrast zone, located in the lower left quadrant, contains words that are little evoked, less often than the average, but that occupy the first positions in Rang, encompassing elements that express variations of the representation. The expressions “homicide”, “verbal violence”, “domestic violence”, “hatred”, “lack of respect”, and “negative” made up this quadrant. The item “homicide” was the most frequent and the less readily evoked (21; 2.619), covering words such as “murder” and “death”. The expression “hatred”, in turn, encompassed feelings such as indignation, anger, and outrage. The expression “lack of respect” came up as the third most evoked (2.154) and was characterized as the absence of consideration for other people. Last, the word “negative” was the least frequent, but more readily evoked (2.000), and summarized negative perceptions regarding violence, including the expressions “absurd” and “bad”.

My brother’s death. Horrible. That was a violence […] I confess to you that, if I come across him, any of them, I do not know what I… I tell you, it is not even a matter of outrage, it is a matter of justice […]. (P22-M).

Violence means… I think that it means intolerance, the hatred that people have for one another, sometimes for banal reasons […] right now, feminicide is what we see more often, against women. The guys still have that way of thinking that women have to be submissive. If they get divorced, the guys disagree, and beat women up. (P14-M).

I think it is this matter of always wanting to impose my opinion, impose my desire, not giving up, not making room for other people, wanting to be right about everything. It turns out that people are already stressed, annoyed, and from this starting point a violence act originates, many times including an argument, as we commonly see in traffic… (P23-F).

Still in the contrast zone, the expression “verbal violence” was the second more frequently evoked (19). The third expression in frequency and the second more readily evoked was “domestic violence” (16; 2.125).

I think that sometimes women take advantage of their fragility and the law, and develop a relationship with a man with little patience, and then bad things happen. But, except for that, it is a form of violence from both [parts] because women do not beat up, but they offend, and that is violence. (P4-M).

They want to scream and speak out loud, they abuse, it is easier for a woman to abuse a man with words than with [physical] aggression. So maybe she hurts his feelings more than anything, uses crueler words […]. There are many people who accept what is happening to them, so I do not see them as being so innocent. For instance, the husband that beats up his wife, she is being spanked and accepting it because she wants it. My opinion is that only people who accept to be abused are abused. (P20-F).

Sometimes, women are stubborn. Sometimes, they tease (laughters). And sometimes the problem is men, because they do not accept something. (P5-F).

I have never experienced physical violence, but violence, that psychological, verbal pressure, I am familiar with. I have been through psychological counselling for quite some time, medication, and he is there, handsome and wonderful, thinking that he has never done anything […]. (P9-F).

Violence is destruction, I have been through that before, violence at home, I was abused by my ex-husband, it is not nice, it is a bad thing, it ends up affecting you and everybody around you. (P32-F).

The peripheral system is more flexible than the central core and is characterized by being sensitive to the immediate context. The first periphery is made up of important elements (because of their high frequencies) and may indicate a reinforcement of the central core. This quadrant showed the word “impunity”, a present feeling, according to the opinion of some participants, which covers the absence of laws and/or the need for stricter laws and punishments.

There [at the penitentiary] they have got a TV, a minibar, […] steaks, onions, potatoes, I do not think this is a way of “[…] I am being punished”. They are drug dealers and eat better food than me at home […]. I think that the law has to be changed, get stricter. (P11-M).

I think that the first step to achieve that is the law, impunity, changing that, if it is necessary to implement the death penalty, let it be done, it think it will decrease, minimize, but not end violence. […] There is the matter of education, I think it begins at school, but it also has to do with the legislation because, if you are taught, at school and at home, that you must not fight and if there are laws that punish you rigorously… (P14-M).

The second periphery, located in the lower right quadrant, addresses the contradictions and manifestations of the group’s heterogeneity and, consequently, the possible changes in social representation. This quadrant shows the least frequent and least readily evoked expressions. In the present study, the included items were urban violence, moral violence, sadness, mistreating animals, sexual violence, fear, character, and prejudice. “Urban violence” was evoked 18 times, coming up in contexts of traffic violence, in parties, at school, in soccer matches, and at work, understood as non-domestic environments. The word “sadness” was the third most evoked (3.118) and the second most frequent (17). “Mistreating animals” was evoked 17 times. “Sexual violence” was the most readily evoked expression (2.813) and frequently referred to rape.

Violence means a type of aggression, something against what the person accepts as correct […] against a person or animal, whatever. (P1-F).

[…] I despise any type of violence, whether it is in the traffic, in parties, at home, or against women, as we have seen several [cases] these days […] I think there should be more dialogue […]. I believe that, unfortunately, women experience more violence, I am not justifying it, but I think it has to do with the fact that they are women. I think that men experience violence more often in parties, they will rarely go through it at home or at work. It is different with women, they suffer a lot of violence, sexual violence, by the boss, at home, by the partner, by the children […]. (P19-F).

[…] The most serious types of violence, a party right here in the neighborhood, a lad shot another one in the head, he fell on my feet […]. (P11-M).

Cruelty, it is sad, when you use violence, verbal or physical, it is unacceptable, it is tragic. (P28-F).

I have already witnessed sexual violence, I experienced that during my childhood, I lived with my grandmother and even… [gets emotional] only my wife knows. I suffered a lot because of that because, being a man, it is difficult to bring the subject up, sorry. I experienced this violence when I was younger and, because of that, I have become a more aggressive person and now I want [crying], I want to focus on my reality, forget the past […]. I have become an aggressive person and I was beaten up by my grandmother, her son, my uncle, because my parents were not around […]. I deeply regret it, every day I remember the violence I carried out, the violence I experienced. (P30-M).

“Moral violence”, evoked 18 times, involved situations such as bullying and humiliation. Reinforcing this form of violence, the word “prejudice” was the fifth most frequent and the fifth more readily evoked (11; 3.364), encompassing discrimination, racism, and homophobia situations. The expression “fear” was the second more readily evoked (3.000), understood also as panic and silence, showing omission of violence as a consequence of this feeling. The item “character” was also in second place in number of evocations (3.000) and was related to the personality of a person who perpetrates some type of violence.

Both during my childhood, because of physical violence, of aggression, because I had an aggressive dad, because he was a serviceman, and during the bullying violence, which I experienced at school. And nowadays I experience it from people in my environment, because my husband is thin and black and I am chubby and white, so I experience this prejudice. (P1-F).

I have already experienced prejudice, homophobia, no physical aggression though […], but I have already experienced the verbal one and unfortunately we end up getting used to it, so to speak, because we end up ignoring this type of violence […]. Usually we have to stay quiet for fearing suffering something more serious, an argument turning into a fight. (P17-M).

Violence is something that has already happened to me, so I think it is a jealousy feeling, everything I mentioned, jealousy, possessiveness, insecurity […]. Jealousy has a positive side, but when the partner is obsessed […]. Women must not be so afraid […] if we are afraid of them, we will never achieve anything. We could talk more, encourage other women to say more […]. I have already been very ashamed of saying that I was beaten up, he would say that he was going to change and in the end he did not, and the same thing would happen over and over. I have already got a black eye, my mouth has already bled a lot […]. It is embarrassing to tell, to expose, but we cannot be afraid because, if we keep covering their basenesses, we may not be alive the next day… (P31-F).

[...] you become afraid of going out, leaving your kid alone to go to school and, if you want to go out, have some fun, you are taking chances all the time because of violence. (P11-M).

My upbringing was really difficult, I was abandoned by my parents, I have become an aggressive person, if I got beaten up on the street, I got beaten up at home, if I beat up someone on the street, I would be beaten up just once. So I have become a very aggressive person […]. Because I have seen my aunt being beaten up by my uncle many times, I said that when I got married I would never be a violent man […]. I punch the wall, the fridge, I kick everything, but not my wife […]. (P30-M).

DISCUSSION

Family Health Strategy users represented violence as that perpetrated against someone else, either children, women, elderly people, homosexuals, or even animals, groups considered more vulnerable, reinforcing the identification of fragility in the victims. Abuse, aggression, fight, and mistreatment situations pervaded the violence representation, with its physical form standing out, contextualized by pushing, slapping, kicking, punching, and spanking. The participants also associated robbery and use of substances such as alcohol and other drugs with the occurrence and intensification of violence.

The representation indicated a prevalence of interpersonal violence. It encompasses both intrafamily violence, the one that occurs among family members or intimate partners, and community violence, that is, the non-domestic one, which usually happens among people who do not have a personal relationship3. Violence against women, present mostly in couples, is an example of intrafamily violence, whereas robbery is categorized as community violence. The latter was especially emphasized by a male participant as a more serious act than feminicide, because there is no reason, no justification for it to occur.

Drug use and trafficking are construed as situations that can originate and intensify violence, especially the urban one, resulting in frequent robbery and shootings9-10. Studies have associated the use of psychoactive substances and men’s mental distress with the occurrence of violence10-13. Alcoholism, considered one of the triggering factors of violent acts, is used as a subterfuge by health teams to attract male aggressors or men who have the potential to develop this type of behavior to appointments14.

In addition to the mentioned association, regarding the use of substances and the male public, physical violence was often associated with the masculinity model. Men embody the speech, when developing their identity, based on power, aggressiveness, and uncontrolled sexuality15. The participants of the present study recognized the public space, rather than the domestic one, as the environment in which violence involving men occurs more often. In that space, the aggressors usually are colleagues, friends, or strangers, demonstrating a tendency to reaffirm masculinity.

While the public space and the use of physical violence were associated with men, women were linked to verbal violence and the domestic environment, which was considered the place where most of the violence episodes perpetrated against them occur. In contrast to what happens to male victims, the aggressors in acts of violence against women are, most of the times, partners, ex-partners, or relatives16. Men, during the socialization process, in their attempt to get distant from characteristics related to the female sphere, predispose themselves to behaviors such as aggressiveness and competitiveness, which many times result in diseases, injuries, and deaths, in men themselves and the people who surround them15.

The implications of violence were cited by women who experienced it, showing consequences of not only physical violence, but also the verbal and psychological ones, which makes it possible to state that physical violence affects women psychologically, morally, and socially. Results of some studies12,16-17 have shown worse health indicators for women experiencing a violence situation, with a two times higher probability of suffering psychic distress, a higher occurrence of somatic complaints, use of psychotropic or analgesic medications or drugs, low self-esteem, sleep, tiredness, pain, bodyweight alterations, constipation, nervousness, post-traumatic stress, insecurity, shame, and social isolation. It is known that these consequences, especially shame, fear, social isolation, and, very frequently, emotional and financial dependence, make it difficult for women to end the relationship and, consequently, the violence situation.

In the present study, sexual violence, specifically rape, was more associated with women. However, a man reported the situation he experienced, indicating a conflict for having been through this type of violence and being a man. The occurrence of rape having men as victims is not satisfactorily explored by the literature yet, mainly because of several taboos that impair the verbalization of this type of violence by male victims. Additionally, there is a strong correlation between this category of violence and abusive alcohol consumption and psychological complaints/diagnosis such as depression, anxiety, insomnia, and irritability when violence occurs11-12. A study demonstrated that these psychological symptoms are likely to happen not only in men who suffer violence, but also in those who carry it out, and showed that violent men have a tendency to have anxiety and depression five times higher in comparison with the rest of the male population13.

Still in the interpersonal violence category, homicides and feminicides stood out. For the death to be classified as a homicide, signs indicating that the injuries were caused by someone else, to hurt or kill, must prevail4. The word feminicide, a relatively new concept, refers to the murder of women motivated by the fact that they have this gender18. These situations are an expression of the maximum form of violence. Although the word “homicide” was evoked more often, most of the situations reported by the participants were examples and citations of feminicides.

The justification for feminicide found in the present study was a masculinity standard characterized by jealousy, distrust, and lack of acceptance of the end of a relationship. It was shown that people of both genders blame women for the experienced violence, because of their submission, acceptance, or even teasing, attributing the responsibility for the violence episodes to them and questioning the accuracy or importance of the violence situation. Consequently, it was possible to notice the occurrence and perpetuation of a sexist culture internalized in both men and women.

The word “hatred”, related as feelings such as anger, outrage, and revenge, can be linked to the definition of feminicide, also considered the hate crime committed against the female gender, reinforcing the presence of a toxic masculinity, that is, one socially developed under stereotyped premises, harmful to men and the whole society, characterized by the repression of their emotions and the channeling of their personal expression as aggression and violence15.

The word “impunity” was present exclusively in accounts of male participants, strengthening the idea of indignation/outrage toward men, emphasizing the importance of education at home and at school regarding non-violent attitudes, as well as stricter laws, which can lead to a stronger punishment. The participants expressed their perception regarding the prison system, characterized by the common opinion that this environment offers several privileges and perks. It was clear, according to the participants’ opinion, that the State should reciprocate the violence carried out by society as a way to achieve justice. Without ignoring some characteristics of the participants of the present study, including the fact that they had an elementary level of education and that half the group had a job, this finding shows that a potential aggressor lives inside each oppressed person and, when they find themselves in an oppression situation, most of them become oppressors instead of seeking for liberation19.

Analysis of the first and second periphery indicated the reproduction, across generations, of male behaviors taught and encouraged by families, both by verbally inciting men and by exposing them to violence episodes during childhood and adolescence. It was possible to identify the social interaction in a violent environment in the participants’ reports, which helps shape an aggressive and explosive personality in the adult phase. Children that witness the occurrence of violence go through a greater impairment of their mental health and tend to perceive the violent behavior as natural and reproduce it in their social relationships, including a future marital one11.

The social interaction in a violent environment conditions people to repeat the practices during adulthood, either as victims or aggressors. Consequently, violence impacts all the people who experience it, which leads to its intergenerational propagation11. A comprehensive reaction to violence must not only protect and support people under this condition, but also promote nonviolence, transforming the circumstances that favor the onset of violence episodes3.

Family Health Strategy users also mentioned moral violence, bullying, and humiliation as part of the representation, in addition to situations involving prejudice, discrimination, racism, homophobia, and sexism, drawing attention to a group that is not compatible with the standards imposed by society and that, for this reason, becomes more vulnerable to the cited types of violence. Some participants mentioned the word “fear”, which can refer to both the fear of violence itself and the act of not reporting it, omitting violence situations for fear of retaliation. The fear of revenge, shame, and financial or emotional dependence have been understood in many studies as barriers to overcome violence9,17,20, given that one of the ways to inhibit violence is by making victims speak, which breaks the violence cycle18.

It is considered that basic health units, especially those that belong to the FHS program, play an important role in the fight against any type of violence, which may impact or originate diseases, resulting in the need to design actions oriented toward preventing and repairing the harm caused by these episodes by implementing public policies, with the punishment responsibility on the account of the justice system. Considering that the social representations brought up significant personal experiences regarding violence, it is fundamental that healthcare professionals detect, prevent, provide services, and welcome users. This is especially pertinent to nurses, who are in charge of service delivery in primary care, working even as FHS coordinators and being responsible for health education actions and care.

FINAL CONSIDERATIONS

The structure and content of the social representation provided by FHS users showed violence as interpersonal, including the intrafamily and the urban categories. It was verified that the representation of violence can be influenced by everyday reality, strongly marked by substance dependence and trafficking. The female figure was described in the representations as the person under a condition of domestic or sexual violence and, when it causes violence, uses the verbal form only. The male icon, in turn, was represented as a victim of urban violence and the cause of physical violence. Men also emerged as victims of homophobia and violence experienced during childhood, which possibly led them to reproduce violence acts as adults.

The authors of the present study understand that it contributes to the area by giving a voice to FHS users, highlighting the determining factors of the phenomenon, which will possibly facilitate the design of more targeted strategies and actions by professionals, for instance carrying out meetings with conversation circles about the subject, including its identification and prevention, as well as spreading care services to people experiencing violence situations. Although the present study did not emphasize violence against women, it contributed to showing that this type of violence is present and relevant to the participants, stressing important gender issues by relating the masculinity pattern in force to the occurrence of several forms of violence, especially those oriented toward women, in the experiences described in many reports.

The present study has some limitations. The authors believe that it is necessary to know the representation of users of units that are not part of the FHS system and that have services available 24 hours a day, because they meet a different type of demand, that of a population which seeks this type of service especially at night. The study offered an opportunity for people to open up. Although the addressed subject was difficult to talk about, stirring up different memories and feelings, it was observed that the participants had the need to talk about it openly, which brought about the initiative of implementing an extension project about the theme, developing interventions oriented toward and with FHS users.

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Received: September 24, 2019; Accepted: December 18, 2019

Corresponding author: Victoria Leslyê Rocha Gutmann E-mail: victorialeslye@gmail.com

Associate editor:

Cíntia Nasi

Editor-in-chief:

Maria da Graça Oliveira Crossetti

Creative Commons License This is an open-access article distributed under the terms of the Creative Commons Attribution License