Factors associated to the imposition of types of violence against women informed in sentry services

1 PhD, Full Professor, Universidade de Fortaleza, Fortaleza, CE, Brazil. 2 MSc, Professor, Faculdade de Ensino Superior do Ceará, Fortaleza, CE, Brazil. 3 Doctoral student, Universidade Estadual do Ceará, Fortaleza, CE, Brazil. 4 PhD, Adjunct Professor, Centro de Ciências da Saúde, Universidade Federal do Ceará, Fortaleza, CE, Brazil. 5 PhD, Full Professor, Centro de Ciências da Saúde, Universidade Federal do Ceará, Fortaleza, CE, Brazil. Objective: to identify the prevalence and the factors associated to the imposition of the different


Introduction
The violence against women is a phenomenon that reflects the inequalities of the genders in society (1) , establishing itself as public health problem for the magnitude of its prevalence (2) , seriousness and recurrence, as well as for the negative consequences in the life quality of the victims.
World-wide studies disclose high prevalence and variability (15% to 71%) of the problem (3)(4) .In Brazil, the mortality statistics show that every two hours there is a homicide of a woman (5) , representing the last degree of an aggression scale that many times begins with the psychological violence.The literature even presents the close partners or former partners as the main perpetrators of this violence (6)(7) .
Among the definitions what violence against women is, the study is guided by the definition from the Belém de Pará Convention, adopted by the American States Organization in 1994, which defines it as any action or conduct based on gender, which causes death, damage or physical, sexual or psychological suffering to the woman, both in the public and in the private scope (8) .
According to Law nº 11,340/2006, the types of violence against women appear in physical, psychological, sexual, patrimonial and moral forms (9) .However, studies warn about the interrelation of the different types of violence, configuring those cases into complex events where these forms interlace, reverberating in the gravity of the situations (6)(7) .
Understanding the phenomenon, the authors defend the influence of social factors in the occurrence of those violence cases (10) .Low schooling, poverty, lower income of the women or unemployment, as well as the use of alcohol and illicit drugs between the partners seems to exacerbate the magnitude of the problem.
The violence against women has been a frequent issue in the routine of the health services, which play a basic role in diagnosis, registration, notification and treatment of the cases (11) , beyond presenting themselves as propitious places for the effectuation of necessary strategies in the light of this problem.
The reference services for sentry violence were instituted with the intention to contribute to the visibility of the phenomenon through the potential that those present in order to generate qualitatively high information.This produced knowledge is essential for the implementation of prevention strategies and control of the problem, for the evaluation of the implemented actions and for the planning of the resources and services (11) .
The sentry services are responsible for the notification of cases of violence against specific groups according to Law Nº 10,778 that makes the notification of violence against women in the public and private health services obligatory (12) .It is important to add that Decree nº 104 of 25 January 2011 orders the domestic violence, sexual and/or other types of violence as 45º event of obligatory notification throughout the national territory (13) .
The increasing publication on the subject is recognized, however the prevalence, the typological diversity that enters the health services reflects the complexity of the problem and demands further investigation.While the international organizations alert the governments about the value of the human rights and the reduction of the social inequalities, the integral health of women still remains threatened by the force, power and disrespect of the condition as citizen (8)(9) .
Considering that the professional nurse passes the hierarchic levels of attention regarding the health of women, the study contributes to the social practice of this category, as the understanding of the phenomenon favors the delineation of strategies and specific actions, aiming at the prevention and the confrontation of the violence against this group, as well as fomenting the health promotion.
The study adopts as constructive analytical theories the legal requirements that rule the subject, considering the specifications of the violence against women (8)(9)(12)(13) .
In this meaning, to understand the factors that can contribute to the imposition of the types of violence against women, as well as sociodemographic and behavioral characteristics of women in violent situations, characteristics of the aggressions and the aggressors, may well contribute to qualify the assistance, beyond providing a contextual care on the part of the nurses.Furthermore, facing violence is complex and is associated to the lack of visibility of the problem for different entities, especially for the health services.
In this context, the study has as objective to identify the prevalence and the related factors to the imposition of the different types of violence against the woman informed in sentry services.

Methods
Transversal study that used as data source the notification forms of women who were violence victims in Fortaleza, Ceará, referring to the period 2006 to 2008.Fortaleza, capital of the state Ceará, similar to other Brazilian metropolises (2) , concentrates a significant number of registrations of violence against women (14) .
Putting the reader in the picture, at the time of the study, the administration of violence against women in Fortaleza was offered by four sentry services.The study reached three of these services, enclosing 75% of the notifications in the selected three years, which means, 960 cases.
For the accomplishment of the analysis, the study took as base the notifications regarding women of equal or superior age to 12 years who were residents in Fortaleza.From the 960 present cases, 21 were excluded: 16 for aggression against women younger than 12 years and five for not identifying the type of violence, resulting in 939 analyzed forms.For the accomplishment of the data collection, one of the authors entered previously in contact with the managers of these services, presented the objectives of the research and scheduled appointment dates and times to carry it out.This stage was accomplished manually, form by form, in the period from July to October 2009.Important is to state that the collection of these data was made in a reserved room, under surveillance of employees of the respective services, considering the secrecy that involves attendances of this nature.
The typologies of violence adopted in the study followed the ones mentioned in the notification form (15) .In this form, the occurrence data was considered that are related to physical and psychological/moral violence, recklessness/abandonment, sexual violence, torture and patrimonial violence.It is worth to point out that the form as well includes the human trafficking and the child labor, that for demanding other epistemological concepts were not targets of this investigation.
The dependent 0 variable was the registration of two or more types of violence against women and as independent variables, sociodemographic data (conjugal situation, age group, schooling, skin color, occupation, sexual orientation, pregnancy, any kind of deficiency); aggression data (place of occurrence, if it occurred other times, number of involved people); aggressor data (gender, type of relation with the victim, suspicion of alcohol use).
The variables were described in accordance with the nomenclature referred to in the notification form (15) .

Results
Among the 939 analyzed forms, the frequency of violence imposition against women was 73.9% (694).
The average age of the analyzed women who were violence victims was 33.26 years (DP=11.05).The average age among the women who were victims of two or more types of violence was 33.32 years (DP=10.57)and in the group of one single type of violence it was 33.08 years (DP=12.30).
Married women of 30 or more years of age; who have a schooling from illiterate to basic education; dark skin; unemployed; having sexual relations only with men; not pregnant and with no deficiency were the most frequent victims (Table 1).
In Table 1 is to observe that the variable schooling presented statistic significance (p=0.029) with the fact of these women being victims of two or more types of violence, whereas conjugal situation, age group, skin color, occupation, sexual relations, pregnancy and any type of deficiency did not present any significance (p>0.05).
In the group of women who suffered two or more types of violence, the frequency of the place of the aggression was highest in the residence (89.9%); the violence was recurrent (91.4%); with the involvement of one aggressor (88.2%); of masculine gender (97.5%); close partner of the victim (73.8%); with suspicion of alcohol consumption (66.5%).Among the women who suffered a single type of violence, also the residence predominated (81.6%); the aggression occurred several times (80.5%); with one involved aggressor (89.5%); of masculine gender (96.6%); close partner of the victim (65.8%); with suspicion of alcohol use (57.7%) (Table 2  The non-adjusted analysis showed a positive association between women who suffer two or more types of violence with the schooling (OR=1.39;IC95%=1.01-  3).
In the multiple logistic regression model is to observe that there were positive associations of women who suffer two or more types of violence, the schooling varying from illiterate to basic education (OR = 1.43;IC95% = 1.05-1.96)and recurrent aggression (OR=2.41;IC95%=1.57-3.71)(Table 3).

Discussion
This study presents as differentiation the identification of the factors associated to the imposition of types of violence against women, investigations that had chosen this specific topic as research object being scarce in Brazilian literature.
The findings showed a greater prevalence of women being victims of two or more types of violence, indicating that these overlap and hardly occur isolated.
Other inquiries had found similar results, emphasizing the interlacement of the physical, sexual and psychological aggressions, stating that the imposition of several types of violence seems to be associated to the higher seriousness of the cases and the demand for specialized services (6)(7)16) .
The residence constitutes a privileged place for the occurrence of these cases, reaffirming what is disclosed in literature (17)(18) -that more than 90% of the aggressions against women happen in the domestic environment.The home is the most frequently chosen place due to the fact that the aggressions are facilitated through occurring in privacy, protected from the interference of other people (18) .In this form, the private ambit that circumscribes the phenomenon restrains the disruption and the visibility of the casuistry.
The biggest occurrence of the violence perpetrated by the close partner of the victim, as found in this research, expresses subordination and domination, in which exist unequal distribution of privileges, rights and duties, establishing asymmetries of power based on the gender differences (19) .The aggressions perpetrated by the partner or former partner are recognized as one of the most frequent forms of violence against women (7,17,20) .A study accomplished in the eastern region of India with 1,718 women certified a higher risk of violence on the part of the husband than any another person (3) .
Another relevant finding of this research that reiterates literature (4,7) shows the association of the alcohol use by the aggressor with the situations of violence against women.Inquiries recognize the ingestion of alcohol as an important factor of domestic violence, which may be explained by the disinhibiting effect on the behavior of the aggressors, as a way of minimizing the responsibility for the violent behavior, or even, the combination of the alcohol use with the practice of violence may act as a denouncing factor of the impulsive personality (21) .
The authors (22) also demonstrated, in a research of qualitative approach, the deriving upheavals of the alcohol consumption in the families, emphasizing the high levels of interpersonal conflicts which emerge in several forms of domestic violence.However, the alcohol is not mainly responsible for the aggressions, acting as facilitator of previously determined situations (17) .
The unadjusted bivariate analysis showed an association between women being victim of two or more types of violence with the variables: schooling, place of occurrence, recurrent aggression, relation of the aggressor with the victim and suspicion of alcohol use by the aggressor.After the adjustment of the variables The chi-squared (χ 2 ) test was used to analyze the fact of women suffering two or more types of violence in relation to the independent variables.P<0.05 was established for statistic significance.The choice of the variables for the construction of the multivariate logistic regression model was based on the method of automatic selection (Stepwise).The relation strength between the independent and the dependent variables was expressed in esteemed values of Odds ratio (OR) gross and adjusted, with Reliability Interval (IC) of 95%.The data were organized in the SPSS program (SPSS Incorporation, Chicago, United States), version 16.0; and analyzed through the STATA software (Stata Corp LP, College Station, TX 77845, USA), version 11.0.The research obeyed the norms of Resolution nº 196/96, of the National Health Authority that regulates research with human beings and was approved by the Committee for Ethics in Research of the University of Fortaleza under concurring opinion nº 123/2009.

Table 1 -
Sociodemographic characteristics in relation to the imposition of types of violence against women.Fortaleza,CE, Brazil, 2006 to 2008

Table 2 -
Characteristics of the aggression and the aggressor in relation to the imposition of different types of violence against women.Fortaleza, CE, Brazil, 2006 to 2008 Rev. Latino-Am.Enfermagem 2013 July-Aug.;21(4):920-7.
* Pearson chi-squared test; significant when p<0.05In table 2, the majority of the variables showed statistical significance (p<0,05) in the Univariate analysis, with exception of the number of involved people and the gender of the aggressor.(continue...) www.eerp.usp.br/rlae