Intrafamily violence and actions strategies of the Family Health team1 1 Research financed with resources from the Dean of Research of the Universidade Estadual do Sudoeste da Bahia (2010-2012) and also by an Iniciação Científica grant with resources from the Fundação de Amparo à Pesquisa do Estado da Bahia (FAPESB) (2009-2010) and an Iniciação Científica Jr. grant with resources from the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) (2010-2011).

Juliana Costa Machado Vanda Palmarella Rodrigues Alba Benemérita Alves Vilela Aline Vieira Simões Roberta Laíse Gomes Leite Morais Elisama Nascimento Rocha About the authors

Abstracts

O estudo objetivou conhecer os tipos de violência intrafamiliar identificados pelos profissionais das equipes da Estratégia Saúde da Família e descrever as estratégias de intervenção implementadas pelos profissionais das equipes de saúde da família (ESF) nas situações de violência. Pesquisa-ação realizada em três unidades de saúde da família do município de Jequié/BA, com 25 profissionais das ESF. Os dados foram coletados por meio de entrevistas semiestruturadas, analisadas com base na técnica de análise de discurso proposta por Fiorin. Os resultados evidenciaram a identificação pelos profissionais das ESF da negligência e violência física e psicológica contra crianças; violência física e psicológica contra a mulher; e violência contra idoso provocada pelos familiares cuidadores. Os profissionais das ESF apóiam as famílias no reconhecimento da violência, propiciando a escuta, orientações e encaminhamento aos órgãos competentes; apesar de encontrarem algumas dificuldades nesse processo, como a falta de articulação mais efetiva com os órgãos de proteção e assistência às vítimas. Para a prevenção e combate à violência intrafamiliar as ESF devem agregar a rede de serviços especializados das áreas da saúde, social, de segurança e justiça e da comunidade para uma atuação integral.

Violência; Violência Doméstica; Saúde da Família


The study aimed to know the types of intrafamily violence identified by the teams of the Family Health Teams (FHT) and describe the intervention strategies implemented by the teams FHT in situations of violence. Action research conducted in three Family Health Units from the city of Jequié/BA with 25 professionals from the ESF. Data were collected through semi-structured interviews, after approval by the Ethics and Research Committee of the State University of Bahia’s southwest, under protocol nº 055/2009 and analyzed based on the technique of discourse analysis proposed by Fiorin. The results show the identification by the FHT professionals of negligence and physical and psychological violence against children, physical and psychological violence against women and violence against elderly caused by the family caregivers. The FHT professionals support families in recognition of violence, providing listening, orientations and forwarding to the competent authorities; despite finding some difficulties such as lack of a more articulation effective with the protection organs and assistance to victims. For prevention and combating intrafamily violence the FHT shall aggregate the network of specialized services in the areas of health, social, security and justice and the community to a full performance.

Violence; Domestic Violence; Family Health


Introduction

Violence is an intrinsic part of social life and, as a social product, is linked to the results of power relationships and conflicts. Although violence is not in itself viewed as a topic within the area of health, its affects this area as it causes injuries, physical and emotional trauma and death. Thus, in order to understand the impact of violence on health, it is necessary to discuss it together with problems relating to health, conditions, situations and lifestyle (Minayo, 2006MINAYO, M. C. S. Violência e saúde. Rio de Janeiro: Fiocruz, 2006.).

The way violence manifests itself is a complex phenomenon, revealing the exacerbation of social conflicts and constituting an emerging topic, relevant to the country’s health needs, representing, as it does, the third most common cause of death in the general population and the main cause of death in Brazilian men aged 1 to 39 years old (Minayo and Souza, 2003MINAYO, M. C. S.; SOUZA, E. R. (Org.). Violência sob o olhar da saúde: a infrapolítica da contemporaneidade brasileira. Rio de Janeiro: Fiocruz, 2003.; Brasil, 2008BRASIL. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Monitoramento e Avaliação da Gestão do SUS. Temático prevenção de violência e cultura de paz III. Brasília, DF: Organização Pan-Americana de Saúde, 2008. (Painel de indicadores do SUS, 5).).

From an operational point of view, the health sector classifies and categorizes violence based on its empirical manifestations: violence directed at the individuals themselves (self-inflicted), interpersonal violence (intrafamily and community violence) and collective violence (WHO, 2002).

This study focuses on intrafamily violence, which can manifest itself in a variety of forms of interpersonal violence, such as physical aggression, sexual abuse, psychological abuse, neglect, abandonment and maltreatment, among others. The violence may have one or more authors with familial, spousal or parental relationships or with emotional ties in power relationships, both real and threatened. This power may be physical or psychological or based on age, hierarchy or gender (Brasil, 2001BRASIL. Ministério da Saúde. Secretaria de Políticas de Saúde. Violência intrafamiliar: orientações para prática em serviço. Brasília, DF, 2001. (Cadernos de Atenção Básica, n. 8).; Brasil, 2008BRASIL. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Monitoramento e Avaliação da Gestão do SUS. Temático prevenção de violência e cultura de paz III. Brasília, DF: Organização Pan-Americana de Saúde, 2008. (Painel de indicadores do SUS, 5).).

Interest in conducting this study on intrafamily violence arose from experiences in work placements which are part of the Estágio Curricular Supervisionado I (Supervised Curricular Training I - ECS I), offered by the Universidade Estadual do Sudoeste da Bahia graduate course in nursing in the eighth semester, in the environment of family health care units (FHU) in the municipality of Jequié, Bahia. During these work placements, we encountered countless situations of vulnerability and intrafamily violence, involving children and adolescents, women, adults and the elderly, in the families registered in the FHUs in which the placements take place.

Intrafamily violence affects a large part of the population and has significant repercussions on the health of those affected. Thus, it is a relevant public health problems and a challenge for the Brazilian Unified Health System administrators. It is a broad and complex issue, requiring the involvement of professionals from different fields and the effective mobilization of diverse government and civil society sectors to deal with it.

It is, therefore, according to article 226, paragraph 8 of the Federal Constitution (Brasil, 1988BRASIL. Senado Federal. Constituição da República Federativa do Brasil. Brasília, DF, 1988.) the State’s role to create mechanisms to curb violence within families. However, the State is not meeting this obligation, as the existing public policies aimed at preventing and treating intrafamily violence are ineffective (Tavares, 2000TAVARES, D. M. C. Violência doméstica: uma questão de saúde pública. 2000. Dissertação (Mestrado em Saúde Pública) - Faculdade de Saúde Pública da Universidade de São Paulo, São Paulo, 2000.).

This situation shows the families’ need for the support of health care professionals through developing relationships of trust, as well as access to information, to institutions and to empowerment to make decisions (Walsh, 2007WALSH, F. Os desafios da resiliência familiar. IHU on-line, São Leopoldo, v. 7, n. 241, p. 11-12, 2007. Disponível em: <http://www.ihuonline.unisinos.br/media/pdf/IHUOnlineEdicao241.pdf>. Acesso em: 4 abr. 2013.
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). Moreover, the issue also requires social, health, education and security public policies, from the perspective of changing the panorama of violence at a local, regional and national level.

In this context, health care professionals find themselves in a strategic position from which to identify individuals in situations of intrafamily violence, and they are often the first to be informed of episodes of violence, requiring them to promote integrated care and to listen with sensitivity to these issues (Brasil, 2001BRASIL. Ministério da Saúde. Secretaria de Políticas de Saúde. Violência intrafamiliar: orientações para prática em serviço. Brasília, DF, 2001. (Cadernos de Atenção Básica, n. 8).).

Thus, it is the responsibility of Family Health Strategy (FHS) teams to discover, discuss and identify individuals vulnerable to intrafamily violence in the population covered, facilitating the definition of actions to be developed, aiming to intervene preventatively or to confirm diagnosis and make adequate measures for facing diverse situations of intrafamily violence viable.

The FHS teams should, then, be trained to provide guidance and support to those in situations of violence, aiding them to understand, analyze and make decisions pertaining to the problem. This support should be linked to a network of specialized services in the areas of health, social care, safety and justice and to the community, involving residents’ associations and women’s and religious groups, among others.

From our point of view, it is only through such initiatives that it will be possible to create spaces capable of dealing with joint action, allowing the flow of information and supporting the professional performance of FHS teams, considering that everyone is responsible for tackling this phenomenon.

In this study, we aim to contribute to promoting reflection practice of FHU health care professionals’ practice in identifying situations of intrafamily violence and developing strategies to intervene, as well as raising teams’ awareness and equipping them to develop actions to prevent and control intrafamily violence, with a new attitude. We also aim to raise awareness of the need to (re)direct public policies which contribute to curbing or preventing violence, so as to support the work of health care professionals and minimize suffering in the face of daily violence experienced, based on actions promoting equality and the exercise of human rights in policy administrators in the areas of health, safety, justice, education, defense of human rights and social movements.

Thus, the aim of this study was to discover the types of intrafamily violence identified by FHS health care professionals and to describe the intervention strategies they implement in situations of violence.

Methods

This was a piece of action-research, uniting various social research techniques which established a structure that was collective, participative and active at the level of collecting data; it required, therefore, the participation of those involved in the problem under investigation (Gonçalves et al., 2004GONÇALVES, V. L. M.; LEITE, M. M. J.; CIAMPONE, M. H. T. A pesquisa-ação como método para reconstrução de um processo de avaliação de desempenho. Cogitare Enfermagem, Curitiba, v. 9, n. 1, p. 50-59, 2004.).

The research was conducted in three FHUs in the municipality of Jequié, BA, where the ECS I work placements took place, as this allowed the inherent context of intrafamily violence, emerging through the violent situations identified during the work placements, to be uncovered in the families registered in these units.

The informants were 25 health care professionals in the above mentioned FHUs: nurses, nursing technicians and community health agents. We would like to point out that all of the professionals who make up the FHS teams were invited to participate in the research, but the doctors showed no interest.

The data were collected using a semi-structured interview, which took place and was recorded after participants had signed an informed consent form. The research project was analyzed and approved by the Research Ethics Committee of the Universidade Estadual do Sudoeste da Bahia, protocol nº 055/2009.

We used Fiorin’s discourse analysis method, as this enabled the process through which the discourse was produced to be understood and allowed us to reflect on the conditions under which it was produced. The discourse analysis studies the subjects’ world view as contained in their statements, this being socially determined. Discourse is a social position, the ideological representations of which materialize in language (Fiorin, 2003FIORIN, J. L. Linguagem e ideologia. 6. ed. São Paulo: Ática, 2003.). It can be defined as critical theory dealing with historical determination and the processes of meaning, considering the necessary relationship between language and the context in which it is produced as essential, based on discussing evidence and making its ideological character explicit, proving that, without subject, there can be no discourse, nor subject without ideology (Minayo, 2010MINAYO, M. C. S. O desafio do conhecimento: pesquisa qualitativa em saúde. 12. ed. São Paulo: Hucitec, 2010.).

Text is structured on increasingly abstract levels. To reach the deep structure, the most abstract level, it is necessary to group together meanings. That which we perceive immediately lies on the superficial level, it does not reveal the ideology which may underlie the statement (Fiorin, 2003FIORIN, J. L. Linguagem e ideologia. 6. ed. São Paulo: Ática, 2003.).

In this data analysis process, we sought to identify the most abstract level of the text. To do this, the text was first analyzed from the point of view of finding the concrete and abstract elements. Next, the data were grouped together according to elements of meaning. Finally, the central themes were drawn out. The themes emerging from this process gave rise to the categories of analysis.

The interpretation and discussion stage established critical relationships between the subjects’ implicit and explicit statements and the scientific context, based on theories focusing on the topic. The discourse analysis allowed us to conduct an in-depth evaluation of each specific expression, the context in which it was created and to observe motives for satisfaction, dissatisfaction or implied opinions through observing the various ways in which the informants communicated.

In the text, the informants are identified using the word “informant” followed by a number, representing the order in which the interviews were conducted, and the respective professional category.

Results and discussion

Intrafamily violence can take on various forms and has different levels of severity. In our study, in the FHS environment, we identified many different types of violence in the family and the groups most vulnerable to this phenomenon: children, women and the elderly. We also verified that FHS team professionals sought to develop strategies to deal with violence in the family environment.

Neglect and physical and psychological violence against children

In this category, the interviewees gave evidence of neglect and physical and psychological violence committed against children by their own parents. On the topic of intrafamily violence against children, Ramos and Silva (2011)RAMOS, M. L. C. O.; SILVA, A. L. Estudo sobre a violência doméstica contra a criança em unidades básicas de saúde do município de São Paulo – Brasil. Saúde e Sociedade, São Paulo, v. 20, n. 1, p. 136-146, 2011. emphasize how this is a painful reality, revealing mistreatment occurring in the home; it causes potentially devastating short, medium and long term damage, both physical and psychological, as childhood experiences are reflected in adult life.

Social, emotional and psychological problems are among the main consequences of this violence for the children, often leading to the adoption of certain behavior, such as alcohol or drug abuse, prostitution, teenage pregnancy and mental health problems, such as anxiety, depression, aggressive behavior and even attempted suicide (Brasil, 2008BRASIL. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Monitoramento e Avaliação da Gestão do SUS. Temático prevenção de violência e cultura de paz III. Brasília, DF: Organização Pan-Americana de Saúde, 2008. (Painel de indicadores do SUS, 5).).

Given the complexity of the topic, more in-depth analysis is needed on the social construction inherent to the context in which the violence occurs, as well as on guaranteeing human rights.

The FHS professionals’ statements portray neglect of children, mainly involving lack of care and monitoring.

[...] it’s also neglect when, there is a mother in my area who [...] doesn’t want to have her child vaccinated [...] under no circumstances (Informant 2, community health agent).

[...] it’s also a form of neglect to resist vaccination, it’s difficult for us to raise awareness with some families, to convince them to bring their children to have their growth and development monitored and of the importance of vaccination (Informant 7, community health agent).

Intrafamily neglect of children means that their temporary or permanent physical and basic cognitive needs are not met by the adults with whom they live (Suder and Crepaldi, 2008SUDER, C. F.; CREPALDI, M. A. Terapia familiar breve em programas que atendem famílias vitimadas pela violência: uma proposta de intervenção. Florianópolis: Familiare Instituto Sistêmico, 2008.). Thus, we found evidence that the neglect mentioned in the statements was related to the parents and relatives not providing the necessary conditions for the child’s development from the aspect of health, education, emotional development, nutrition, shelter or safe living conditions. It is worth noting that the more contact with the family and understanding of the family dynamic, the greater the chances of detecting cases of neglect.

The FHS teams can facilitate access to the service and meet the users’ health care needs. However, the cultural, social and economic aspects of each family or social group need to be taken into account. Thus, it is possible that the cases found were not determined solely by precarious social conditions (Apostólico et al., 2012APOSTÓLICO, M. R. et al. Características da violência contra a criança em uma capital brasileira. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 20, n. 2, p. 266-273, 2012.; Rocha and Moraes, 2011ROCHA, P. C. X.; MORAES, C. L. Violência familiar contra a criança e perspectivas de intervenção do Programa Saúde da Família: a experiência do PMF/Niterói (RJ, Brasil). Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, v. 7, p. 3285-3296, 2011.).

Another form of violence affecting children is physical violence, which can be in the form of slaps, pushes, punches, bites, kicks, burns, cuts, strangulation or injury caused by weapons or objects (Brasil, 2001BRASIL. Ministério da Saúde. Secretaria de Políticas de Saúde. Violência intrafamiliar: orientações para prática em serviço. Brasília, DF, 2001. (Cadernos de Atenção Básica, n. 8).). According to Andrade et al. (2011)ANDRADE, E. M. et al. A visão dos profissionais de saúde em relação à violência doméstica contra crianças e adolescentes: um estudo qualitativo. Saúde e Sociedade, São Paulo, v. 20, n. 1, p. 147-155, 2011., of all the types of intrafamily violence, physical violence is the most commonly found form. It is a cause for concern in various sectors of society, as it is common practice among parents and guardians as a form of disciplining their children.

The discourse of the health care professionals showed awareness of some types of physical and psychological violence against children, such as beatings and threats. In general, experiencing these types of situations leave physical, social, emotional, psychological and cognitive marks, which may also be expressed through aggressive behavior in inter-personal relationships, repeating the treatment received from their families (Rocha et al., 2010ROCHA, E. N. et al. Violência intrafamiliar contra crianças e adolescentes: entendimento dos agentes comunitários de saúde. Revista Saúde.Com, Jequié, v. 6, n. 1, p. 50-64, 2010. Disponível em: <http://www.uesb.br/revista/rsc/v6/v6n1a06.pdf>. Acesso em: 11 abr. 2013.
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).

[...] Just because the man works, she is submissive to her husband, she accepts that her husband beats the child. Just the other day he took hold of the girl, he hit her so much, he was hitting her for more than half an hour. The next day the child was covered in marks, covered in bruises (Informant 3, community health agent).

[...] the mother, at the moment of most distress or loss of emotional control shouted: if you don’t come here boy I’ll kill you” [...] (Informant 21, community health agent).

Verbal aggression [...] psychological pressure, indifference [...] towards the child (Informant 8, nurse).

Informant 3, a community health agent, reported that the mother did not move to protect the child from the physical violence to which it was subject, perhaps because of the context of her relationship with her partner, a situation which may have been influenced by being financially dependent on her partner, the aggressor. The woman’s submission to the man, in turn, reveals unequal and hierarchical gender relations, allowing the man to exercise power within the domestic environment, including attacking the child.

We observed that, in addition to physical violence, the health care professionals also came across psychological violence towards children in the intrafamily context, highlighting the mother’s loss of emotional control and verbal aggression. This type of violence consists of verbal hostility in the form of insults, contempt, criticism or threats of abandonment and constantly blocking attempts at interaction, practiced by adult member of the family system against this group (Suder and Crepaldi, 2008SUDER, C. F.; CREPALDI, M. A. Terapia familiar breve em programas que atendem famílias vitimadas pela violência: uma proposta de intervenção. Florianópolis: Familiare Instituto Sistêmico, 2008.).

In their study, Melo et al. (2005)MELO, Z. M. et al. Família, álcool e violência em uma comunidade da cidade do Recife. Psicologia em Estudo, Maringá, v. 10, n. 2, p. 201-208, 2005. state that the more intense the violence against the child, the deeper the relative harm to their self-esteem, leading to anxiety, depression, anti-social behavior, conjugal disharmony and other inadequate manners of resolving problems in adult life.

It should be stressed that Brazilian child protection legislation has evolved greatly in recent decades. However, this evolution in itself does not appear to be sufficient to prevent violence against children. Although it is an undeniable advance and has benefitted Brazilian families and children, the complexity of the phenomenon requires actions and interventions that the legislation alone is not enough to ensure (Godinho and Ramires, 2011GODINHO, L. B. R.; RAMIRES, V. R. R. Violência contra a criança. Psicologia Argumento, Curitiba, v. 29, n. 66, p. 315-326, 2011.).

We should also emphasize the need for the State to develop public policies guaranteeing structural and socio-economic conditions in order to increase the autonomy of individuals and ensure human rights.

Physical and psychological violence against women

This category portrays woman as a family member vulnerable to psychical and psychological violence. The interviewees gave evidence of a situation of submission and male dominance over the woman, as can be seen in the following statements.

Physical violence [...] in the area I cover, I know of one case [...] where the husband, [...] was accustomed to always be hitting her, to be beating her; and on this occasion he went so far as to cut her hair, she had very long hair, and from jealousy he cut half of it off, and I don’t know how, but she broke free and ran away, left home and hid in another person’s house, [...] she reported him (Informant 17, nursing technician).

The violence is related, like that, to husband and wife [...] And there was another case, a couple she was covered in marks, you know? He hit her with a brick, but she didn’t want to come here to the health care unit, and she didn’t even want to blame him. She even said to me that it was her fault, that she started it (Informant 12, community health agent).

In these two statements we can see two situations of violence against women. According to the nursing technician, Informant 17, the woman was attacked physically and psychologically, facing up to the violence and reporting her attacker. On the other hand, the community health agent, Informant 12, reported that the woman tried to play down her husband’s attack on her, taking responsibility for her partner’s violent acts as she had perpetrated the first violent act, a fact which shows the woman’s oppression or even fear at recognizing the reality of what she had experienced.

According to the Brazilian Ministry of Health, intimate partner violence against women typically involves repeated acts, which increase in both frequency and intensity and include coercion, placing restrictions, humiliation, contempt, threats and a variety of physical and sexual violence. In addition to living in permanent fear, this type of violence can also result in lasting physical and psychological damage (Brasil, 2005BRASIL. Presidência da República. Secretaria Especial de Políticas para as Mulheres. Enfrentando a violência contra a mulher. Brasília, DF, 2005.).

Sagot (2008)SAGOT, M. Estrategias para enfrentar la violencia contra las mujeres: reflexiones feministas desde América Latina. Athenea Digital, Barcelona, n. 14, p. 215-28, 2008. Disponível em:<http://www.redalyc.org/articulo.oa?id=53701413>. Acesso em: 10 abr. 2013.
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reports that violence against women is the product of a combination of personal, situational, relationship and macro-structural factors which interact to create a system of domination. Based on the discourses, we identified these factors due to social norms justifying men’s feeling of possession and control over women, as well as cultural concepts of masculinity associated with domination.

Sagot’s (2000)SAGOT. M. Ruta crítica de las mujeres afectadas por la violencia intrafamiliar en América Latina: estudios de caso de diez países. Washington, DC: OPAS, Programa Mujer, Salud y Desarrollo, 2000. Disponível em: <http://www1.paho.org/spanish/hdp/hdw/rutacritica.pdf>. Acesso em: 4 abr. 2013.
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research in Central and South American countries, named “La ruta crítica de lãs mujeres afectadas por la violência intrafamiliar” -The critical path of women affected by intrafamily violence - indicates that the critical path is a sequence of decisions and actions taken by women affected by violence and the responses they find in their search for solutions. The author also reports how, when a woman decides to speak out about her situation of violence to another person or people in her family or acquaintance, she has taken the first step on the critical path, aiming to improve her situation. In the interviewees’ discourses, we observed that, in order to seek help, the women need information and knowledge concerning available resources and public policies supporting them in overcoming the obstacles they face.

In Brazil, the study “Rota Críticas: o caminho das mulheres no enfrentamento da violência” - The critical path of women affected by intrafamily violence - (Meneghel et al., 2011MENEGHEL, S. N. et al. Rotas críticas de mulheres em situação de violência: depoimentos de mulheres e operadores em Porto Alegre, Rio Grande do Sul, Brasil. Cadernos de Saúde Pública, Rio de Janeiro, v. 27, n. 4, p. 743-752, 2011.) observed that the path of women who decide to break away from violence is a long one, marked by advances and setbacks, frequently deprived of support and often re-victimized by the very services which should be taking care of them.

The Maria da Penha law is a framework to protect women’s human rights as it recognizes that violence against women is a violation of human rights; it establishes measures to protect and care for them and to punish and re-educate aggressors (Brasil, 2010BRASIL. Secretaria de Políticas para as Mulheres. Secretaria Nacional de Segurança Pública. Ministério da Justiça. Norma técnica de padronização das Delegacias Especializadas de Atendimento às Mulheres – DEAMs Edição atualizada. Brasília: UNODC, DEAMs, 2010. Disponível em: < http://www.spm.gov.br/subsecretaria-de-enfrentamento-a-violencia-contra-as-mulheres/lei-maria-da-penha/norma-tecnica-de-padronizacao-das-deams-.pdf> Acesso em: 3 nov. 2011.
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).

However, a study conducted by Meneghel et al. (2013)MENEGHEL, S. N. et al. Repercussões da Lei Maria da Penha no enfrentamento da violência de gênero. Ciência & Saúde Coletiva, Rio de Janeiro, v. 18, n. 3, p. 691-700, 2013. highlights how women in violent situations report weakness and limitations in the application of the Maria da Penha law, highlighting how protective measures for the victims are not fulfilled and the difficulties public safety services encountered in trying to protect them. Thus, although the law outlines the possibility of protection and justice, this is still not the situation in Brazil.

In the discourses, we also observed the presence of physical and psychological violence by the women’s partners due to jealousy and abuse of power, situations which portray domestic violence with explicit unequal relationships between men and women naturalized as part of society.

Deeke et al. (2009)DEEKE, L. P. et al. A dinâmica da violência doméstica: uma análise a partir dos discursos da mulher agredida e de seu parceiro. Saúde e Sociedade, São Paulo, v. 18, n. 2, p. 248-258, 2009. conducted a study on the discourse of abused women, and reported that the majority of women they interviewed referred to their partners’ jealousy as an agent which increased tension between the couple. Intimate partner violence, traditionally present in romantic relationships, is understood to be domestic violence and is present in women’s domestic and conjugal, defined by their female role in society (Alves and Diniz, 2005ALVES, S. L. B.; DINIZ, N. M. F. Eu digo não, ela diz sim: a violência conjugal no discurso masculino. Revista Brasileira de Enfermagem, Brasília, DF, v. 58, n. 4, p. 387-392, 2005.).

Historically, it was acceptable to mistreat women, and was even viewed as a practice to correct behavior and errors. In colonial Brazil, husbands were allowed to use a whip to correct their wives. Physical and psychological aggression against women was presented as part of our cultural roots, and women were defined by their servile function towards their husbands and children, dedicating themselves exclusively to domestic tasks through which they could express their motherly gifts (Alves and Diniz, 2005ALVES, S. L. B.; DINIZ, N. M. F. Eu digo não, ela diz sim: a violência conjugal no discurso masculino. Revista Brasileira de Enfermagem, Brasília, DF, v. 58, n. 4, p. 387-392, 2005.).

Thus, many women were socialized to accept the use of violence as a natural way to resolve conflict in conjugal relationships. The women reported violence experienced by other close to them, relatives, friends or workmates, although they did not always feel solidarity, especially when gender and family concepts are very traditional (Meneghel et al., 2011MENEGHEL, S. N. et al. Rotas críticas de mulheres em situação de violência: depoimentos de mulheres e operadores em Porto Alegre, Rio Grande do Sul, Brasil. Cadernos de Saúde Pública, Rio de Janeiro, v. 27, n. 4, p. 743-752, 2011.).

Given these situations, violence occurs independently of economic or educational conditions. This violence may even take on different characteristics depending on level of education, ethnicity, geographical region and social class, no woman is safe in a patriarchal and misogynistic society (Sagot, 2000SAGOT. M. Ruta crítica de las mujeres afectadas por la violencia intrafamiliar en América Latina: estudios de caso de diez países. Washington, DC: OPAS, Programa Mujer, Salud y Desarrollo, 2000. Disponível em: <http://www1.paho.org/spanish/hdp/hdw/rutacritica.pdf>. Acesso em: 4 abr. 2013.
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). Thus, violence against women may not be viewed as a purely private matter, but rather as a public problem for which the State should take responsibility.

Violence against the elderly by family members

In this category, through the informants’ discourses, we found evidence of intrafamily violence against the elderly in the context of the FHU.

There is a case of an elderly gentleman; he looks after two brothers, they are both special needs, one of them attacked the father, and he’s not in any state, [...] physically or mentally, to look after them (Informant 5, community health agent).

[...] there’s a 14-year old; he’s a drug user and lives with his grandmother and two other brothers [...] poor thing, she’s sick, the grandmother is [...] and she always tells me how he hits her [...] because he wants money to buy drugs and the grandmother didn’t have money. So he began to attack the grandmother [...] he hit her, pushed her downstairs and she almost broke her femur (Informant 24, community health agent)

The type of violence we most often see in my area is neglect [...] mainly of older adults (Informant 13, community health agent).

Based on the informants’ reports, we can observe situations in which the elderly are subjected to physical violence from family members, especially children and grandchildren, due to metal problems or drug use. In the discourse, we found evidence that financial abuse against the elderly exists in a significant form in the context in which the FHS teams in this study work. Neglect and psychological violence are also noteworthy, as the older adult often feels impotent in the face of the situation, triggering an avalanche of frequently irreversible loss in financial, psychological and physical terms (Sanches et al., 2008SANCHES, A. P. R. A.; LEBRÃO, M. L.; DUARTE, Y. A. O. Violência contra idosos: uma questão nova? Saúde e Sociedade, São Paulo, v. 17, n. 3, p. 90-100, 2008.).

Along with children and women, the elderly often become vulnerable to violence through their dependence, due to physical, emotional and cognitive limitations inherent to the process of growing old. Stressful family life and poorly prepared or overworked carers tend to aggravate this situation.

Physical abuse and mistreatment and actions or omissions, including aggressive body language and ways of speaking and damaging or trying to damage the older adult’s self-esteem, identity or development are interpersonal manifestations of physical or psychological violence used to compel the older adult to do something they do not wish to, to injure them, cause them pain, incapacity or death (Brasil, 2006BRASIL. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Envelhecimento e saúde da pessoa idosa. Brasília, DF, 2006. (Cadernos da Atenção Básica, n. 19).).

The financial abuse demonstrated in the discourses portrays children and grandchildren as the main agents of this type of abuse, especially when it results from drug use, thus denying the older adult’s autonomy in relation to caring for themselves. Financial abuse against an elderly adult is a form of violence which manifests itself in improper or illegal exploitation of the elderly, or in using their financial resources or property without their consent (Brasil, 2006BRASIL. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Envelhecimento e saúde da pessoa idosa. Brasília, DF, 2006. (Cadernos da Atenção Básica, n. 19).).

We emphasize that, in this study, drug use by the older adults’ relatives led to de-structured family environments culminating in violent acts against the older adult and uncovering a wide-reaching and complex social problem requiring intervention by health care professionals and by the State.

The discourses portray neglect on the part of some family members in their care of older adults living with them, neglecting their health needs, with serious consequences. Such infractions are included in article 230 of the Federal Constitution, which recommends that the family, society and State’s care for the elderly go beyond ensuring their participation in the community, defending their dignity and well-being and guaranteeing the right to life (Brasil, 1988BRASIL. Senado Federal. Constituição da República Federativa do Brasil. Brasília, DF, 1988.).

It is, then, the duty of the State and of the family to collaborate to achieve a dignified old age, preferably within a family environment, in which the family’s awareness should be raised of their role in terms of legal responsibility and caring for the elderly as this is beyond the means of the State alone (Sanches et al., 2008SANCHES, A. P. R. A.; LEBRÃO, M. L.; DUARTE, Y. A. O. Violência contra idosos: uma questão nova? Saúde e Sociedade, São Paulo, v. 17, n. 3, p. 90-100, 2008.).

How FHS health care professionals dealt with intrafamily violence

In this category, we verified how professionals from FHS teams sought to develop actions to monitor and deal with cases of intrafamily violence. We identified that, when the informants came across situations of intrafamily violence, they turned to the FHS team of which they formed a part and together drew up measures to deal with the problem.

[...] I told [...] the coordinator. From then on, we exchanged strategies to be able to resolve, or help that person resolve, the problem (Informant 2, community health agent).

[...] what we seek to do is to calm the situation, converse, invite her to come somewhere we can converse privately and talk there [...] and, in the case of children whose mothers refuse to vaccinate them, we try to convince them, presenting the risks that child is running, the serious illnesses it may contract, even die, if not vaccinated, and they end up accepting it (Informant 4, nursing technician).

We usually communicate with the coordinator, you know? Unfortunately, there are many cases which are not always resolved because what she is able to do is not always enough to resolve it, because it is out of our hands, you know? In many cases of aggression, violence against women, we see that there is no support, it is not as… as… effective, you know? Not as effective as it should be (Informant 25, community health agent).

The statements show how the FHS teams recognize that intrafamily violence brings health consequences with it and seek to intervene. A study conducted by Kiss and Schraiber (2011)KISS, L. B.; SCHRAIBER, L. B. Temas médico-sociais e a intervenção em saúde: a violência contra mulheres no discurso dos profissionais. Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 3. p. 1943-1952, 2011. highlights that some professionals, especially those in the FHS, know about violent situations in their communities, but there is still a great distance between knowing about them and recognizing them as inherent to care interventions. The authors report that even in situations where violence is recognized, it is not the object of health intervention; and in cases in which the professional decides to intervene, the action is developed in a personal, rather than a professional way, out of place and ineffective.

From the discourses, we verified that the FHS professionals sought to discuss cases, outline strategies, support, listen and guide families involved in violent contexts. However, as informant 25 says, in some situations the FHS team feel they are not in a position to provide continuity of support to the family as the violence is a phenomenon with a multiplicity of causes.

In this context, we perceive it to be of the utmost importance that FHS teams, when they identify situations of intrafamily violence, do not act alone in developing strategies to deal with the problem, but rather continue to seek the support of their team. When a situation of intrafamily violence is identified, the informants report that they offer support to the family, encouraging changes in behavior.

In the discourse analysis, we also observed that the informants feel freer to advise or guide the family group involved when there is a good relationship between the FHS professionals and the family. By giving the professional the opportunity to act in the family context, the families receive guidance on changing the violent behavior. Active listening is neither guidance nor therapy. It is a way of managing the dialogue with solidarity so as to help the individual being listened to restore ties of trust, to feel understood and respected (Brasil, 2005BRASIL. Presidência da República. Secretaria Especial de Políticas para as Mulheres. Enfrentando a violência contra a mulher. Brasília, DF, 2005.).

We understand that encouraging changes in behavior alone does not include the wider issues permeating violence. Thus, it is necessary that this take place together with a detailed analysis of the families’ conditions, situations and lifestyle, as well as human rights being guaranteed by public administration so as not to reduce the complexity which permeates violence to restricted and limited technical actions.

Professionals dealing with violence in the context of the family need to be committed, to make referrals when necessary from the perspective of breaking the cycle of violence, as inappropriate action may seriously affect the life of those living in the violent situation who, in the majority of cases, are not able to defend themselves against the violence they are subjected to (Rosas and Cionek, 2006ROSAS, F. K.; CIONEK, M. I. G. D. O impacto da violência doméstica contra crianças e adolescentes na vida e na aprendizagem. Conhecimento Interativo, São José dos Pinhais, v. 2, n. 1, p. 10-15, 2006.).

FHS professionals reported they sought to listen to and guide families in situations of violence and refer them to the appropriate bodies.

[...] I accompany the family in the following way before making any decision: if we are not able to do anything, then we take a more serious approach such as, for example, filing a formal complaint to the appropriate legal body (Informant 15, nurse).

Identify, guide and refer to the appropriate body (Informant 8, nurse 8).

Talk to them and encourage them to seek help from the women’s police station or, in the case of a child, from the juvenile court (Informant 11, nursing technician).

For the Ministry of Health, it is only after a complaint has been filed with the appropriate body to investigate cases of violence that protective measures can be taken. As the causes of the phenomenon are multiple, overcoming intrafamily violence requires mutli-sectorial action involving different sectors of government, civil society, the community and non-governmental organizations acting together (Brasil, 2002BRASIL. Ministério da Justiça. Secretaria de Estado de Direitos Humanos. Plano Nacional de Enfrentamento da Violência Sexual Infanto-Juvenil. 3. ed. Brasília, DF: SEDH, DCA, 2002.).

However, some FHS professionals reported difficulties stemming from lack of effective coordination with the bodies which protect and help individuals in situations of violence, as we can observe in the statements below.

The difficulties are in omission and lack of response, you know? We do our work and then we don’t get any response, that is the difficulty and it is discouraging (Informant 3, community health agent).

[...] the difficulties are the apropriate bodies themselves (Informant 6, community health agent).

I see it like this: the difficulty is because we don’t get what we are looking for [...] in the case of the Health Secretariat, that is social care. And we don’t find any support (Informant 9, nurse).

[...] the difficulty is in the assistance because, often, we don’t find anyone who will support us, [...] who will give us the assistance to finish with this problem (Informant 10, community health agent).

The informants also highlighted the lack of support and problem solving from the appropriate bodies, such as difficulties developing strategies to deal with intrafamily violence, which would at least enable the consequences of violent acts to be reduced.

Another problem identified in the statements concerns the lack of response from the relevant bodies in developments in resolving the cases. This is evident in the reports of informants who referred cases of violence to the bodies providing assistance and did not even receive a positive response, much less a solution to the problem. A study of community health agents dealing with intrafamily violence involving children and adolescents revealed the lack of support given to these professionals (Rocha et al., 2011ROCHA, E. N. et al. Desvelando a violência intrafamiliar contra crianças e adolescentes: enfrentamentos dos agentes comunitários de saúde. Saúde em Debate, Rio de Janeiro, v. 35, n. 88, p. 63-72, 2011.). The Ministry of Health recognizes the lack of services and inadequate social response, such as intervention which is merely timely, as obstacles or delaying factors in the resolution of intrafamily violence (Brasil, 2002BRASIL. Ministério da Justiça. Secretaria de Estado de Direitos Humanos. Plano Nacional de Enfrentamento da Violência Sexual Infanto-Juvenil. 3. ed. Brasília, DF: SEDH, DCA, 2002.).

This lack of coordination hampers the integrated care necessary for a good outcome and for actions encouraging the protection of individuals in situations of violence. Thus, we observe that, in order to prevent and combat intrafamily violence the FHS teams need to work with the network of specialized services from the areas of health, social care, security and justice, as well as with the community, to ensure integrated action. Moreover, it is important that a process is adopted which continuously evaluates public policies so that public administrators establish and maintain a real commitment to improving the population’s living conditions and change the relationship between the State and the citizen for the better (Tavares, 2000TAVARES, D. M. C. Violência doméstica: uma questão de saúde pública. 2000. Dissertação (Mestrado em Saúde Pública) - Faculdade de Saúde Pública da Universidade de São Paulo, São Paulo, 2000.).

Final considerations

This research identified how Family Health Strategy professionals in a municipality in the interior of Bahia view cases of intrafamily violence and the strategies they adopted to deal with this phenomenon.

Conducting this study gave us the opportunity to develop a broader understanding of the problem, considering the complex context which permeates violence, especially in the most vulnerable groups, such as children, women and the elderly.

Based on the results found, we can state that FHS team professionals identify intrafamily violence as that which occurs in the family environment, shielded by the four walls of the home and due to male domination of women and neglect or mistreatment of children and the elderly. They view violence as a health problem, but generally focus on the phenomenon within the private sphere, without a more in-depth analysis of the social determinants inherent to the socio-cultural and economic context of those involved.

When these professionals suspect or confirm a situation of intrafamily violence, they converse with those in the violent situation and communicate with the health care team, as well as guiding the family, demonstrating that they seek to act, approaching Ministry of Health and Ministry of Justice definitions in cases of intrafamily violence. However, they still limit themselves to changing behavior.

The professionals interviewed also reported difficulties in coordinating and referring those in situations of intrafamily violence to the appropriate bodies. It is essential that intervention in these cases is multi-professional, inter-disciplinary and inter-institutional. The FHS teams should work together with the organizations and services available in the community, such as the Women’s Police Station, social care services, the Juvenile Court or the Public Ministry, as well as institutions such as refuges, women’s groups and crèches, among others, on interventions to prevent and combat violence.

We understand that it is through these initiatives that we will be able to create spaces capable of strengthening joint actions, allowing the flow of information and reinforcing the activity of professionals who protect and assist those in situations of intrafamily violence, considering that they will all take responsibility for this phenomenon.

This means the need for FHS teams to be trained to deal more effectively with situations of intrafamily violence is vital, as is the support of public administrators and the bodies responsible for protection and social care, the way of subsidizing and strengthening initiatives preventing and tackling violence and the bringing together and structuring of intersectorial services. These services are often unavailable due to structural problems, as was the case in the municipality studied where, among other problems, refuges were not provided and there were delays in registering cases as there were insufficient judges.

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  • 1
    Research financed with resources from the Dean of Research of the Universidade Estadual do Sudoeste da Bahia (2010-2012) and also by an Iniciação Científica grant with resources from the Fundação de Amparo à Pesquisa do Estado da Bahia (FAPESB) (2009-2010) and an Iniciação Científica Jr. grant with resources from the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) (2010-2011).

Publication Dates

  • Publication in this collection
    Jul-Sep 2014

History

  • Received
    10 Apr 2012
  • Received
    15 Apr 2013
  • Accepted
    25 Apr 2013
Faculdade de Saúde Pública, Universidade de São Paulo. Associação Paulista de Saúde Pública. Av. dr. Arnaldo, 715, Prédio da Biblioteca, 2º andar sala 2, 01246-904 São Paulo - SP - Brasil, Tel./Fax: +55 11 3061-7880 - São Paulo - SP - Brazil
E-mail: saudesoc@usp.br