INTERPERSONAL VIOLENCE AGAINST ADOLESCENTS: AN ANALYSIS OF THE CASES NOTIFIED IN THE STATE OF ESPÍRITO SANTO

ABSTRACT

Objective:

to identify the notification frequency of interpersonal violence against adolescents in Espírito Santo, Brazil, and its associated factors.

Method:

a cross-sectional study conducted with data from the Information System on Notifiable Health Problems from 2011 to 2018. The associations were tested by means of Pearson’s chi-square test and Poisson regression.

Results:

the frequency of interpersonal violence was 72.2%. The outcome was associated with male adolescents, aged from 10 to 12 years old, of black/brown race/skin color, with no disabilities/disorders, occurrence on public roads, and male aggressors who were suspected of alcohol consumption (p<0.05).

Conclusion:

interpersonal violence is a problem with severe implications throughout life. This study helps to reveal the importance of surveilling violence in order to know the magnitude of the problem, as well as its characteristics for health promotion, prevention of the events and due intervention.

DESCRIPTORS:
Violence; Adolescent; Notification; Health Information Systems; Cross-Sectional Studies

RESUMO

Objetivo:

identificar a frequência de notificação de violência interpessoal contra adolescentes no Espírito Santo - Brasil, e os fatores associados.

Método:

estudo transversal com dados do Sistema de Informação de Agravos e Notificação de 2011 a 2018. As associações foram testadas pelo teste qui-quadrado de Pearson e regressão de Poisson.

Resultados:

a frequência de violência interpessoal foi de 72,2%. O desfecho esteve associado a adolescentes do sexo masculino; com idade de 10 a 12 anos; da raça/cor preta/parda; que não apresentavam deficiências/transtornos; à ocorrência em via pública; aos agressores do sexo masculino e que estavam sob suspeita de consumo de álcool (p< 0,05).

Conclusão:

a violência interpessoal é um agravo de sérias implicações ao longo da vida. Esse estudo contribui para revelar a importância da vigilância de violência, a fim de conhecer a magnitude do agravo, bem como suas características para promoção da saúde, prevenção do evento e intervenção.

DESCRITORES:
Violência; Adolescente; Notificação; Sistemas de Informação em Saúde; Estudos transversais

RESUMEN

Objetivo:

identificar la frecuencia de notificación de casos de violencia interpersonal contra adolescentes en Espírito Santo, Brasil, y los factores asociados.

Método:

estudio transversal realizado entre 2011 y 2018 con datos del Sistema de Información sobre Problemas de Salud de Notificación Obligatoria. Las asociaciones se sometieron a las pruebas chi-cuadrado de Pearson y regresión de Poisson.

Resultados:

la frecuencia de violencia interpersonal fue del 72,2%. El desenlace se asoció con adolescentes varones, de 10 a 12 años de edad, de raza negra/morena y sin discapacidades/trastornos; al igual que con incidentes en la vía pública y agresores del sexo masculino bajo sospecha de consumo de alcohol (p < 0,05).

Conclusión:

la violencia interpersonal es un problema con graves repercusiones a lo largo de la vida. Este estudio contribuye a revelar la importancia de supervisar la violencia con el fin de conocer la magnitud del daño, como también sus características para la promoción de la salud, prevención de los eventos y debida intervención.

DESCRIPTORES:
Violencia; Adolescente; Notificación; Sistemas de Información en Salud; Estudios Transversales

HIGHLIGHTS

Higher prevalence of interpersonal violence against male adolescents.

Higher prevalence of interpersonal violence against adolescents belonging to the black race.

It is essential to survey violence to interrupt its cycle.

INTRODUCTION

Adolescence is a period marked by rapid physical, cognitive, social, emotional and sexual development. Many risk behaviors are consolidated during this phase, requiring special attention in the policies and programs targeted at this population group¹.

Violence is among the major risks affecting this age group. Interpersonal violence is one of the leading causes of death in adolescents and young individuals at the global level, causing almost one-third of all male adolescent deaths in low- and middle-income countries in the Americas Region².

In relation to mortality due to violence in Brazil, according to a document produced by the United Nations Children’s Fund (UNICEF) and the Brazilian Public Security Forum (Fórum Brasileiro de Segurança Pública, FBSP) using records of Police incidents and public security authorities, there were 34,918 intentional violent deaths of children and adolescents between 2016 and 2020, where most of the victims were adolescents aged from 15 to 19 years old³.

This phenomenon has led to a significant increase in morbidity and mortality, contributing to a decrease in life expectancy and quality of life, mainly among young people and adolescents, increasing care and costs in health and social security, absenteeism at work and school, and family and personal breakdown⁴. The violence suffered in this period can result in severe physical and psychosocial consequences for people, exerting a direct influence on the quality of life of this group⁵.

From the enactment of Law No. 8,069, the Child and Adolescent Statute (Estatuto da Criança e do Adolescente, ECA), the Brazilian legislation started to recognize childhood and adolescence as peculiar developmental phases, establishing the need for comprehensive protection of children and adolescents in order to guarantee their development in conditions of freedom and dignity. As the notification of suspected or confirmed violence is defined as compulsory, those cases should be reported to the Children’s Protection Council, as established in Article No. 13 from the ECA⁶.

In the health sector, in 2001, the Ministry of Health published Ordinance No. 1,968, which established notification, to the competent authorities, of suspected or confirmed cases of maltreatment against children and adolescents assisted in SUS entities⁴. Therefore, the purpose of compulsory notification of interpersonal violence against children and adolescents is to trigger the social protection network, in order to stop the forms of abuse and restore the victims’ rights⁷, with the possibility of being carried out along with other institutions that must act articulated with it, such as the Police Stations for the Protection of Children and Adolescents and the Prosecutor’s Office.

In view of the responsibilities already established by law, it is indispensable that health professionals have broad knowledge of the problem of violence, in order to fulfill their ethical and legal commitment. They must officially communicate suspected or confirmed cases of violence against adolescents to the relevant bodies, with a view to preventing the problem, as well as monitoring and protecting the victims⁷.

Given the above, the objective of this study is to identify the notification frequency of interpersonal violence against adolescents in Espírito Santo, Brazil, and its associated factors.

METHOD

An epidemiological, analytical and cross-sectional study using data from the notifications of interpersonal violence cases recorded from 2011 to 2018 in the Information System on Notifiable Health Problems (Sistema de Informação de Agravos e Notificação, SINAN) in the state of Espírito Santo, Brazil. The study period of choice is justified because it was only from 2011, through Ordinance No. 104 of January 25^th, 2011, that all types of violence became part of the national list of diseases and health problems of compulsory notification⁸.

The Ministry of Health considers individuals belonging to the age group from 10 to 19 years old as adolescents, in line with the World Health Organization definition⁴. For notification purposes, the definition of an interpersonal violence case against adolescents corresponds to a suspected or confirmed case of all forms of domestic/intrafamily, extrafamily/community or sexual violence, human trafficking, slave labor, child labor, torture, legal intervention and homophobic violence⁴.

In order to study interpersonal violence as an outcome, field number 54 (“Was it a self-provoked Injury?”) from the violence notification form was used. Fields answered as “No” were considered interpersonal violence cases. The independent variables were grouped into characteristics of the victims, the aggressors and the events.

In relation to the characteristics of the victims, the following variables were analyzed: gender (male; female); age group (in years old: 10-12; 13-17; 18-19), race/skin color (white; black/brown); disabilities/disorders (no; yes); and area of residence (urban; peri-urban). Regarding the aggressors, age group (in years old: 0-24; 25+), gender (male; female; both); and suspected alcohol consumption (no; yes) were considered. As for the events, the following variables were observed: occurrence locus (home; public roads; others); recurrent violence (no; yes); and referral (no; yes).

The data were previously qualified according to guidelines included in the tutorial for the notification of interpersonal and self-provoked violence⁴. Subsequently, they were analyzed in the Stata statistical program, version 14.1. The results were presented through absolute and relative frequencies, as well as 95% confidence intervals (95%CIs). Pearson’s chi-square test was employed for the bivariate analysis. In the multivariate analysis, to obtain the association between the cases of interpersonal violence against adolescents and the exposure variables, the unadjusted and adjusted prevalence ratios (PRs) and their 95%CIs were calculated, according to the Poisson regression model with robust variance. The variables that presented p<0.20 in the bivariate analysis were included in this last analysis. As it is a situation that takes place after the outcome analyzed, the “referral” independent variable was not included in the multivariate analysis.

This study is part of the project entitled “Violence during the different life cycles in the state of Espírito Santo: An epidemiological analysis”, approved by the Research Ethics Committee of the Federal University of Espírito Santo and identified by registration of opinion number 2,819,597.

RESULTS

Between 2011 and 2018, of the notified cases of violence against adolescents, 6,348 (72.1%; 95%CI: 71.1-73.0) notifications corresponded to interpersonal violence. Most of the victims belonged to the female gender (N: 4,070; 64.1%), to the age group from 13 to 17 years old (N: 3,902; 61.5%) and to the black/brown race/skin color (N: 4,229; 76.8%); in addition, they had no disabilities/disorders (N: 4,895; 91.6%) and lived in urban/peri-urban areas (N: 5,775; 91.3%).

Regarding characterization of the aggressors, most of them were aged 24 years old at the most (N: 1,582; 51.7%), belonged to the male gender (N: 4,273: 83.6%) and were not suspected of alcohol consumption (N: 2,287; 69.6%). In relation to the events, more than half took place in the homes (N: 2,878; 53%) and were not recurrent (N: 2,697; 56.4%). There were referrals in approximately 5,448 (87%) of the cases (Table 1).

Table 1
Characteristics of the notified cases of interpersonal violence against adolescents. Espírito Santo, 2011-2018 (N=6,348)

Variables	N	%	95%CI
Gender
Male	2,278	35.9	34.7-37.1
Female	4,070	64.1	62.9-65.3
Age group
10-12 years old	1,220	19.2	18.3-20.2
13-17 years old	3,902	61.5	60.3-62.7
18-19 years old	1,226	19.3	18.4-20.3
Race/Skin color
White	1,275	23.2	22.1-24.3
Black/Brown	4,229	76.8	75.7-77.9
Disabilities/Disorders
No	4,895	91.6	90.8-92.3
Yes	448	8.4	7.7-9.2
Area of residence
Urban/Peri-urban	5,775	91.3	90.5-91.9
Rural	554	8.7	8.1-9.5
Age group of the aggressor
Up to 24 years old	1,582	51.7	49.9-53.5
25+ years old	1,478	48.3	46.5-50.1
Gender of the aggressor
Male	4,273	83.6	82.6-84.6
Female	839	16.4	15.4-17.5
Suspected alcohol consumption
No	2,287	69.6	68.0-71.1
Yes	999	30.4	28.9-32.0
Occurrence locus
Home	2,878	53.0	51.7-54.3
Public roads	1,779	32.8	31.5-34.0
Others	772	14.2	13.3-15.2
Recurrent violence
No	2,697	56.4	54.9-57.8
Yes	2,089	43.6	42.2-45.1
Referral
No	794	12.7	11.9-13.6
Yes	5,448	87.3	86.4-88.1

• 95%CI: 95% Confidence Interval
• Source: Information System on Notifiable Health Problems (SINAN), from 2011 to 2018.

Table 2 presents the bivariate analysis results corresponding to interpersonal violence against adolescents and the independent variables, where a relationship with all the variables under study is noticed (p<0.05).

Table 2
Distribution of the characteristics corresponding to the notified cases of interpersonal violence against adolescents (N=6,348). Espírito Santo, 2011-2018.

Variables	N	%	95%CI	p-value
Gender
Male	2,278	82.5	81.0-83.9	0.001
Female	4,070	67.3	66.1-68.5
Age group
10-12 years old	1,220	86.0	84.1-87.8	0.001
13-17 years old	3,902	69.9	68.7-71.1
18-19 years old	1,226	67.7	65.5-69.8
Race/Skin color
White	1,275	66.2	64.1-68.3	0.001
Black/Brown	4,229	75.1	74.0-76.2
Disabilities/Disorders
No	4,895	78.0	77.0-79.0	0.001
Yes	448	48.2	45.0-51.4
Area of residence
Urban/Peri-urban	5,775	71.7	70.7-72.7	0.011
Rural	554	76.1	72.9-79.1
Gender of the aggressor
Male	4,273	89.9	89.0-90.7	0.001
Female	839	30.1	28.4-31.8
Suspected alcohol consumption
No	2,287	60.1	58.5-61.6	0.001
Yes	999	85.0	82.9-87.0
Occurrence locus
Home	2,878	59.6	58.2-61.0	0.001
Public roads	1,779	96.7	95.8-97.5
Others	772	81.7	79.1-84.0
Recurrent violence
No	2,697	75.5	74.0-76.9	0.001
Yes	2,089	67.5	65.9-69.2
Referral
No	794	67.2	64.4-69.8	0.001
Yes	5,448	73.0	72.0-74.0

• Source: Information System on Notifiable Health Problems (SINAN), from 2011 to 2018.

In the multivariate analysis (Table 3), after controlling for the confounding variables, it was verified that the notification of interpersonal violence against adolescents was 17% higher among male victims (PR = 1.17; 95%CI: 1.14-1.21); just as there is a higher frequency among those belonging to the age group between 10 and 12 years old (PR = 1.17; 95%CI: 1.13-1.22) and to the black/brown race/skin color (PR = 1.10; 95%CI: 1.06-1.13), as well as among those with no disabilities/disorders (PR = 1.59; 95%CI: 1.48-1.70).

Another finding was the higher prevalence of male aggressors (PR = 2.49; 95%CI: 2.32-2.68) and with suspected alcohol consumption (PR = 1.15; 95%CI: 1.11-1-19). The most common occurrence locus for the cases of interpersonal violence against adolescents were public roads (PR = 1.45; 95%CI: 1.39-1.51) when compared to homes (Table 3).

Table 3
Bivariate analysis with the unadjusted prevalence ratios and multivariate model with the adjusted prevalence ratios corresponding to the variables associated with the cases of interpersonal violence against adolescents (N=6,348). Espírito Santo, 2011-2018.

Variables	PR	95%CI	p-value	PR	95%CI	p-value
Gender
Male	1.23	1.20-1.26	0.001	1.17	1.14-1.21	0.001
Female	1.0			1.0
Age group
10-12 years old	1.27	1.22-1.32	0.001	1.17	1.13-1.22	0.001
13-17 years old	1.03	0.99-1.07		0.98	0.94-1.02
18-19 years old	1.0			1.0
Race/Skin color
White	1.0		0.001	1.0		0.001
Black/Brown	1.13	1.10-1.18		1.10	1.06-1.13
Disabilities/Disorders
No	1.62	1.51-1.73	0.001	1.59	1.48-1.70	0.001
Yes	1.0			1.0
Area of residence
Urban/Peri-urban	1.0		0.006	1.0		0.172
Rural	1.06	1.02-1.11		1.03	0.99-1.08
Gender of the aggressor
Male	2.99	2.82-3.16	0.001	2.49	2.32-2.68	0.001
Female	1.0			1.0
Suspected alcohol consumption
No	1.0		0.001	1.0		0.001
Yes	1.42	1.37-1.47		1.15	1.11-1.19
Occurrence locus
Home	1.0		0.001	1.0		0.001
Public roads	1.62	1.58-1.66		1.45	1.39-1.51
Others	1.37	1.32-1.42		1.30	1.24-1.37
Recurrent violence
No	1.0		0.001	1.0		0.124
Yes	0.90	0.87-0.92		1.03	0.99-1.07

• *PR: Prevalence Ratio.
• **95%CI: 95% Confidence Interval.
• Source: Information System on Notifiable Health Problems (SINAN), from 2011 to 2018.

DISCUSSION

In Espírito Santo, between 2011 and 2018, 72.1% prevalence of notifications of interpersonal violence against adolescents was identified, with the highest value recorded for male adolescents aged from 10 to 12 years old, of the brown/black race/skin color and with no disabilities and/or disorders, public roads as occurrence locus, and male aggressors suspected of alcohol conducted at the time of the incident.

The current study verified that the notification of interpersonal violence against adolescents was 17% higher among those belonging to the male gender. According to other studies, boys are more frequently involved in violent events than girls, either as victims or as aggressors^9-10. It is also worth noting that the fatal outcome of interpersonal violence, that is, homicide, represents the first and second cause of death, respectively, among male and female adolescents in Brazil, being higher in the male gender when compared to the female one¹¹.

In this context, it is important to consider that gender is internalized through socialization, a cultural process of incorporating ways of representing the Self and assigning value and behavior in the world. In this way, masculinity is constructed from social expectations about what it means to be a man, anticipating that men will engage in risky behaviors, have difficulties showing or discussing their emotions and seeking help. This profile is associated with higher rates of interpersonal violence, homicide, suicide and traffic accidents in men, among other events¹².

In this study, violence was more prevalent in the age group from 10 to 12 years old, for both genders. Although the death outcome occurs in older adolescents, the literature points out that the younger the victim, the higher the occurrence of violence, especially in its domestic variant¹³. It is worth noting that aggressors impose a domination situation on those who are weaker. In turn, and due to emotional immaturity, these latter oftentimes have difficulties recognizing the situations of violence¹⁴.

Therefore, it can be understood that the younger the age, the greater the vulnerability and the higher the risk of violence, as performance of basic activities depends on the caregiver¹⁵. Associated with physical, emotional and financial dependence, these factors lead people in a situation of violence to depend on a support network to report it.

In relation to the higher proportion of victims belonging to the black race/skin color observed in this study, this finding corroborates other studies in the literature. According to a Brazilian survey that analyzed the factors associated with intrafamily violence against adolescents, the chance of a black-skinned adolescent suffering violence was higher when compared to white-skinned ones¹⁶. As is the case with another study, where black-skinned adolescents presented higher prevalence of interpersonal violence, such as bullying and domestic violence. It is worth noting that the research indicators related to violence were less frequent among white-skinned adolescents¹⁷.

As a result of racism, there is perpetuation of the stereotypes about black-skinned people in society, associating them with dangerous or criminal individuals, which can increase their victimization probability, in addition to perpetuating certain existing stigmas¹⁸. These stereotypes manifest themselves through the lethality of violence against adolescents in Brazil. According to the data presented by the Brazilian Public Security Forum in partnership with UNICEF, 80.0% of the homicides during adolescence were among those self-declared as black-skinned³.

It is necessary to emphasize that social inequalities among individuals belonging to the black race lead to countless vulnerabilities, mainly in terms of health; therefore, race/skin color should be understood as a social variable that bears the burden of historical and cultural constructions¹⁹.

Lower prevalence of violence against adolescents with some disability and/or disorder was detected. This finding contradicts a cross-sectional study that reports higher prevalence of violence in victims with disabilities and/or disorders²⁰. According to a systematic review with meta-analysis, the chances for children and adolescents with disabilities to be victims of violence were 3.7% higher when compared to those with no disabilities²¹. People with disabilities experience embarrassing and excluding situations, in addition to humiliating ones, and they have been a use and abuse instrument by people without disabilities, whether physical, moral or psychosocial abuse²². Divergence of the result presented in this study with the literature can be due to the fact that adolescents with disabilities depend more on others to be taken to health services, leading to greater underreporting in this group. It is necessary to conduct more studies in Brazil to reveal the extension of this problem.

Public roads stood out as the occurrence locus of violence, diverging from a study conducted in Salvador, which points to homes as the most incident locus for the phenomenon. The fact that public roads were the main occurrence locus in the current study can be justified by adolescents beginning to have greater contact with extrafamily violence, changing life habits, starting to go out more frequently, attending parties and clubs, and exposing themselves to more risks in public spaces⁵. Thus, older adolescents, aged from 15 to 19 years old, are more susceptible to violence on public roads, while younger adolescents and children are more susceptible to domestic violence⁵.

When compared to the female gender, the current research shows higher prevalence of male aggressors. This finding was also detected in a study, also on SINAN data, carried out in Salvador from 2009 to 2015, which showed that most of the aggressors in cases of physical and sexual violence were male: 78.4% and 96.2% respectively²³.

In social conceptions, being a man is a synonym to having virile and aggressive masculinity, constituted from meanings that associate males with power. This reinforces the stereotype that men should not be afraid, cannot cry or evidence feelings, and that they should always show courage. Therefore, the need to assert this stereotype is manifested through aggressive behaviors, which turns these men both into perpetrators and victims of violence²⁴.

It is important to consider that intergenerational transmission of violence is an important factor in the construction of men as perpetrators. According to the literature, people with a history of violence during childhood or who witnessed domestic violence are more prone to reproducing acts of violence in adulthood^25-26.

In relation to suspected alcohol consumption by the aggressors and its association with higher prevalence of interpersonal violence against adolescents, this finding was also common in other studies, which identified a significant association between the occurrence of violence and consumption of alcoholic beverages^23,27. Several models have been proposed to explain the complex relationships between violence or aggressions and alcohol. Multiple factors should be considered regarding the effects of alcohol on the occurrence of violence, such as: amount ingested; cultural norms related to the use of violence, including gender norms; aspects of the environment in which alcohol is consumed, such as strong cultural associations between drinking and violence; alcohol consumption in contexts where violence is more likely; and greater tolerance to violence when people are drinking¹².

According to the literature, substance abuse apparently reduces inhibitions around violence, reducing fear of risk situations and feelings of guilt that would arise without this consumption²⁸, thus suggesting that alcohol can ease aggressive behaviors.

It should be emphasized that, in Brazil, alcohol abuse is partly encouraged by the country’s culture. In addition, it also represents a public health problem because it generates family, social, physical and psychological disorders, with the possibility of leading to violence²⁷.

Finally, in the context presented in this study of adolescents as victims of violence, it is important to emphasize that the literature points out that a history of violence during childhood is related to greater problems with alcohol in adult life^29-30. Therefore, the importance of interrupting the cycle of violence at the earliest life stages is once more reinforced, such as in childhood and adolescence.

Regarding the limitations of the current research, as it is a cross-sectional study it is not possible to have certainty about causality of the associations. In addition, the use of secondary data influences the quality of the information obtained, as there is still underreporting in the services, with causes ranging from lack of training of the professionals to identifying and notifying episodes of violence to inadequate filling-in of the notification forms, or to unsatisfactory performance of the competent bodies in complying with security measures and with the victims’ rights.

CONCLUSION

Given the social and epidemiological severity of violence against adolescents, studies on such aggressions reported to the Information System on Notifiable Health Problems (SINAN) may contribute to expanding the knowledge related to the types of violence against this group and guide the elaboration of public policies for its prevention.

From the results presented, it is concluded that the frequency of interpersonal violence against adolescents is high, being associated with greater occurrence in the following situations: when the victims are male, individuals aged from 10 to 12 years old, of black and/or brown race/skin color, not presenting any type of disability or disorder, with recurrence, and residents of rural areas; when the aggressor is male and suspected of alcohol consumption; and when the case of violence occurs on public roads.

In view of the above, for the coping actions against violence to be effective, it is of the utmost importance that services and institutions act in an articulated and integrated manner within the assistance scope, making it necessary to increasingly qualify the information to know the magnitude and characteristics of the problem to surveil it, promote health and prevent the occurrence of violence.

The need to expand visibility and discussion of violence against adolescents is then perceived, so that society is more moved about this topic and for health professionals to be duly trained and able to identify, notify and face this problem, in order to provide better care quality.

Given the epidemiological and social severity presented, it is hoped that the current study may contribute to expanding and delineating public policies aimed at this phenomenon in accordance with the current legislation, ensuring the protection and rights of these individuals, not allowing the victimization and suffering cycle to perpetuate itself.

ACKNOWLEDGMENTS

The authors would like to thank the Espírito Santo Research Support Foundation for funding the project through FAPES/CNPq/Decit-SCTIE-MS/SESA Edict No. 03/2018 - PPSUS.

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• ¹
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Edited by

Associate editor:

Dra. Claudia Palombo

Publication Dates

• Publication in this collection
  25 Sept 2023
• Date of issue
  2023

History

• Received
  26 Sept 2022
• Accepted
  01 May 2023