Violência contra crianças e adolescentes: intervenções multiprofissionais da Atenção Primária à Saúde na escola Violence against children and adolescents: multidisciplinary PHC interventions in schools

This excerpt of a master’s thesis aims to describe the construction of proposals for the prevention, combat, and attention to intrafamily and school violence against child and adolescent students in a suburban district of a municipality in the inland region of Bahia, Brazil. A qualitative, descriptive, exploratory study was conducted through action research. The social stakeholders of the research were the school community, the family, and health professionals. Data were collected by systematic observation, conversation circles, and seminars adopted for situational diagnosis and the development of interventions. Data was interpreted through content analysis. The activities revealed the relevance of the work developed in intersectoral and multidisciplinary qualified network, resulting in behavioral changes of adolescents at school and in the family, their leadership in educational workshops for a peace culture, the implementation of a conflict mediation space at school, the establishment of a physical activity project, drawing parents closer to the school, and raising the awareness toward better possibilities of non-violent domestic education. We conclude that the interventions initiated a movement of change of practices and dialogue of the several district services, resulting in a gradual construction of peace territories in the school and the community.


Introduction
The articulation between the family and the school is an undeniable and challenging need.Family and school contexts interact and mediate, deserving special attention, as they constitute the two main socializing agents at the beginning of the child's social life and human development environments in contemporary western societies, and it is essential that the partnership exists and favors the development of the child/adolescent 1, 2 .
The family is of fundamental importance in the construction of human beings, considered a system that determines their ability to function effectively and benefit from experiences in the different scenarios in which they live and grow.Each family has a peculiarity and a way of functioning, and this stems from the organization process that it has established over time, having as references its beliefs, its values and the understanding of what a family could be 3 .This reverberates conceptual discussions about the family, as a systemic group of people, of encounters between different generations, of affective, material and coexistence exchanges that give meaning to the lives of those who are part of it, in situations of cooperation and conflicts, as well as influenced by the social determinants in their surroundings.However, this system governs itself from rules through which it balances and stabilizes 4-6 .It is important to highlight that, in circumstances in which solidarity and cooperation are valued and promoted, families take care of the education of the new generations, the care of their unemployed members or those in special conditions 6 .
Therefore, studying the family in the life cycle requires analysis of the individual's procedural development environment, while considering it as the primary nucleus of relationships for human learning.In general, it starts with living as a person of relationships, going through the various rituals inherent to life and culture, health and illness, being launched, each in their own time, into the world of discoveries, which involve losses and gains and, notably, learning.In this direction, family and school are points of support and support for the human being, they are existential references 7 .
Similarly, school has a fundamental meaning for children and adolescents, especially for the socialization of these individuals, as it is in the school space that they are introduced to different cultures and ethnicities.In the context of human development, the school enables continuous and complex interactions, depending on the student's stages of development, the multicultural environment that encompasses the construction of affective bonds and preparation for insertion in society.It must also be thought of in its social function of re-elaboration of socially produced knowledge, with the aim of promoting learning and effecting the development of the psychological functions of selective memory, creativity, association of ideas, organization of formal and informal knowledge of the person's interaction with the social environment 8 .
The history of violence against children and adolescents goes through the trajectory of human evolution.It can be configured as a relationship of power/duty to protect adults and society, in which actors with unequal strengths, experiences, maturity, knowledge and feelings are present and confronted.It consists of any act or omission committed by parents, relatives, other people and institutions, causing physical, sexual and/or psychological damage to the victim, resulting in a reification of childhood, depriving them of the right to be considered subjects and persons in special conditions of growth and development 9 .
Among the different types and natures, interpersonal violence is perpetrated in relationships with others.It can occur between people in the family or not, so it is divided into: intrafamily, being that which occurs in hierarchical and intergenerational relationships, between parents, siblings, children, among others, consisting of aggressive family relationships, in which violence is seen as a tool to resolve conflicts and even as an educational strategy, including the lack of basic care for children and adolescents, taking place in a space socially recognized as one of protection and love; and community, conceptualized as that practiced by individuals without kinship ties, who may or may not be the victim's conviviality, being committed in gratuitous acts, in several places, public or private, such as schools, health services, community, condominiums, among others 10 .
Living in environments in which parental violence occurs can be a factor in perpetuating aggressive behavior in children, making them victims and/or possible perpetrators, due to the naturalization of acts of violation of the rights to the protection of children and adolescents in the presence of everyday violence, a dysfunctional form of affective bonds, based on repression and oppression 11, 12 .
From a mental health perspective, these victims tend to develop low self-esteem behavior, with deficient psychosocial autonomy, which can lead to an increase in suicide numbers, applicability of recurrent violent reactions in their social interactions, especially at school, and, consequently, inadequacy to society.
The presence of violence in the inclusive school environment requires that basic rights be ensured for the necessary promotion of autonomy, work, health in the perspective of the expanded concept and the promotion of egalitarian social relations 13 .
It is understood that the occurrence of school violence is a consequence of social inequalities and all their vulnerabilities, cultural differences in the way of acting and thinking, of assimilating the world, proceeding with the violation of the rights of these individuals and having repercussions on cognitive, psychosocial development and mental health of adolescents 14 .
These violent events, whether physical, symbolic or verbal, have been configuring themselves as a complex worldwide phenomenon that is difficult to grasp.Due to the unprecedented proportions it has assumed and the repercussions it causes on its victims, school violence promotes concern and increases the insecurity of principals, students, teachers, parents and society 15, 16 .
Due to its magnitude, school violence has mobilized different areas of knowledge to form partnerships that seek to develop and implement different strategies for the prevention, care and confrontation of this problem in Brazil.
To this end, it is necessary to form networks, made up of actors and institutions, governmental and non-governmental, interdisciplinary and intersectoral, that work together, being resolute, with really effective interventions, in order to obtain promising results in the reduction of violence against childs and teenagers.
Aiming to prevent diseases and promoting the health of children and adolescents at school, a space for coexistence, learning and training for this population, the School Health Program (PSE) was created as an intersectoral initiative of the Ministries of Health and Education, by Presidential Decree No. 6,286, of December 5, 2007 17 , redefined by Interministerial Ordinance No. 1,055, of April 25, 2017, regarding the rules and criteria for joining the PSE, and provides for the financial incentive to fund the actions 18 .
With the implementation of the PSE, the importance of working in partnership between the actors of health and education in the territory is ratified, in favor of maintaining the health of children and adolescents, providing this scenario of meeting for these individuals, of protagonism, production of citizenship, empowerment and change of the determinants of ways of living 19 .
The importance of the health sector is highlighted as the protagonist of the network of prevention, confrontation and attention to situations of violence against children, adolescents and their families, through the actions of the PSE, in which Primary Health Care is inserted in the school community with disease prevention practices, health promotion and student care, including the issue of violence and the culture of peace at school 20 .
This study was motivated by the researcher's experiences as a nurse, Local Technical Reference of the PSE and researcher at the Interdisciplinary Nucleus of Studies on Vulnerability and Health (NIEVS), at the State University of Feira de Santana (UEFS), from which it is understood that the school constitutes a privileged space for articulation between the school community and primary care health teams.
In this article, the following guiding question is discussed: how do the professionals of the primary care team in a peripheral neighborhood and the school community of a municipal school in that territory intervene in situations of intrafamily and school violence?
Therefore, the study outlined the objective of describing the process of construction of proposals for prevention, confrontation and attention to intrafamily and school violence against children and adolescents students in a peripheral neighborhood of a municipality in the interior of Bahia.

Methodology
This is an excerpt from a master's dissertation in which a study was carried out with a qualitative, descriptive and exploratory approach, using action research as a design, which allowed the analysis of the problem from the perception and actions of the actors in the study, with regard to actions for the prevention, coping and attention to violence at school, developed by primary care, comprised of the Family Health teams and the Expanded Family Health Center (NASF), school community, with the researcher's engagement.
The study site was a municipality in the interior of Bahia, considered the second largest city in the state.The empirical field was a municipal school in a peripheral neighborhood.
The choice of this school was due to its location and the information obtained in contact with the school community, the Family Health Strategy (ESF) and NASF, which revealed the need for joint action, with a view to changing the context.This neighborhood was classified in 4th place, in the decreasing scale of evaluation of the level of violence in the municipality, configuring an important scenario of vulnerability for the residents of that region 16 .
The social actors in this study were professionals from the ESF, NASF and the school community, who were working or studying in the aforementioned health teams and municipal school in that neighborhood, and who developed or participated in PSE actions, for prevention, coping and attention to the violence against children and adolescents.
The inclusion criteria established were: being a health and education professional, of both sexes, of any age, working in the Family Health teams, NASF and school community, in the years 2013 to 2017, who agreed to participate voluntarily.
As strategies to approach the field, initially, a meeting was scheduled with the school's director and pedagogical coordinator, and then with professionals from the ESF and NASF in the neighborhood, to present the action research proposal.
Subsequently, the classes were visited for presentation to the students, when the first conversation circle was scheduled.To get closer to parents and guardians, it was made possible to participate in an event promoted by the school.Subsequently, we sought to strengthen relations with the school community and ESF/NASF, at all times, through effective participation in their routines.
The data collected were of two types: primary and secondary.In this article, we used the database collected in 2017, from field diary records obtained through systematic observation at the Family Health Unit and at school, conversation circles and the seminar with the social actors of the research.
For a better understanding, the stages of data collection in the field were divided into two moments: the situational diagnosis phase or exploratory phase and the planning and implementation phase of interventional actions, which will be discussed below.
According to Thiollent 21 , the exploratory phase consists of discovering the field of research, the interested parties and their expectations, and, from this point, establishing a first survey of the situation, the priority problems and possible actions.Therefore, initially, a recognition was made of the field of research, the social actors involved and the survey of problems or situations that generate discomfort, which characterized violence at school, as well as health and education practices aimed at prevention, coping and attention to this problem.For this, we used the technique of systematic observation 22 .
The observation transversalized all the phases of the methodological path, since, during the data collection, planning and execution of the interventions, the researcher behaved as an observer of the environment and the behaviors of the social actors involved in the daily events, recording in the field diary, through audio, video and photo recording, with the consent of the actors.
Using the conversation circles, the participants approached the research object, with the construction of the situational diagnosis of the school and the Local Planning and Programming (PPL) aimed at the prevention, attention and confrontation of violence in the school environment.
Initially, conversation circles were held to elaborate the situational diagnosis of violence in the studied school, being a moment restricted to the principal, pedagogical coordination and some teachers; it was discussed about the forms of violence that most occurred in the school environment and the main problems that they chose as possible triggers of situations of violence in that context.
From the selection of adolescents, after consent of parents/guardians and assent, the classes were visited to present the research proposal to the students.Then, the first round of thematic conversation was scheduled, outlining the possible activities that would be developed with the adolescents.
After surveying the problems, for the planning and implementation of actions, a new round of conversation was held with professionals from the ESF and NASF, in which the results of the initial diagnosis and listening to their experiences in the space of that school were presented.Thus, the strategies and themes that would be worked on in the interventional activities that would be carried out with the adolescents were delimited, aiming at minimizing or solving the problems encountered.Before implementation, suggestions from the school board and coordination were included.The strategies, actions and results of the interventions can be summarized in figure 1. -Adolescents were involved in the proposed workshops, producing allusive materials such as: drawings, stories, comics, raps about respect and peace, among others; -Adolescents' reflection on the themes worked, with gradual behavioral changes; -Less involvement of some students in episodes of school violence; -Improved behavior in the classroom, according to information from teachers.
Mediation of conflicts and acts of violence happening between students in the school space and its surroundings -Invite the students involved to reflect on the situation that occurred; -Invite parents of students with continuous and recurring episodes to understand the context of families and guide parents on new home education strategies and bring them closer to the school space; -Forward the student and family to follow-up by the NASF at the USF of their reference, with a guaranteed appointment; -Coordinate with ESF, CRAS, Guardianship Council, when there is a need for support to resolve external conflicts -Decreased involvement of some students in conflicts or situations of violence; -Implementation of a reflective questionnaire on the practice of violence at school, for students who perpetrate violence and subsequent discussion with mediators (principal, researcher, parents) -Improved coordination between the services that make up the network, especially between the school and the health team.
-Raise awareness of parents regarding the most appropriate forms of domestic education, without violence.As well as valuing their participation in school, to motivate them to accompany their children -Parents' reports about the change in the ways of disciplining their children Intervention and referral to psychosocial care of a 9 years old child that attempted suicide in the classroom -Immediate care of this student by the researcher, psychologist and social worker of the NASF -Immediate epidemiological notification -Invitation to the student's parents to understand the family context and provide care guidelines for that child -Referral of the student and family to follow-up by the NASF psychologist at the USF and coordination with CAPSI, CREAS, Guardianship Council to monitor the case -Multiprofessional home visit to sensitize the mother to take him to the CAPSI consultation -After some attempts to raise awareness of the parents, the mother, with the help of a neighbor and the guardianship counselor, was able to take the child to start monitoring at CAPSI -Monitoring of the child and family by the ESF and the NASF; -Monitoring of the child and family by the Guardianship Council and CREAS -Monitoring of the child and family through the school Implementation of the Physical Activity at School Project -Select students to participate in volleyball and soccer classes, biweekly, at school -Work with students on notions of discipline, respect, conflict resolution, competition, culture of peace at school and other health issues -Students were selected from stories and drawings that told why they wanted to participate in the project -Weekly sports activities were started with an approach to educational issues
The generated data were analyzed using the content analysis method, which consisted of discovering the nuclei of meaning that make up a communication which presence or frequency means something for the intended analytical objective.To carry out the analysis, it was divided into three stages: Pre-analysis; Exploration of the material; and Treatment of results, inference and interpretation 23 .
To carry out this research, the ethical procedures of Resolution No. 466/2012, of the National Health Council (CNS), the national regulatory body of these aspects, were followed for consent to research activities involving human beings 24

Results and discussion
In this item, all the results and discussion of the intervention activities carried out with the actors involved in the research are presented.
Five meetings were held with the adolescents, in class shifts, based on the diagnosed needs, with a maximum duration of two hours, in which the following themes were addressed: what is school violence for you?Peaceful ways to resolve conflicts; Bullying vs Respect; Prejudice and Racism at School; Exposition of the learning and final discussion.It is noteworthy that, in the intervention groups with adolescents, strategies and actions were used that valued playfulness and their protagonism, with dynamics, short videos, among others, in which they actively participated, expressed themselves and reproduced knowledge through drawings, comics, texts and song lyrics.
Throughout the development of these activities, it was found, with the observations and reports of teachers and other school professionals, the behavioral changes of the students, with the reduction of episodes of school violence and improvement of the postures in the classroom and during the recess.
During the diagnostic phase, a weakness in intersectoral relationships and difficulties faced by health and education professionals were identified due to the lack of knowledge of how to deal with school violence, how to prevent it, face it and assist it; and what are the responsibilities and potential of the services that make up the network.
In the reviewed studies 26-29 , it was observed that most of the approaches of health professionals in these cases reflects the lack of integration between them and the different sectors that should deal with these issues, revealing an incipient qualification, both in prevention and in care and in accompanying the victims of this phenomenon.
As a qualification strategy for the local network to work on prevention, coping and attention to situations of school violence against children and adolescents, with the aim of strengthening relations between services and improving their articulation, a seminar was organized, entitled 'School Violence vs Culture of Peace at School', in which were discussed the concepts of school violence, the strategies developed by this study, together with the education teams, ESF and NASF.In addition to the participation of the school community and health teams, representatives of the social facilities of the neighborhood and the municipality were invited: the Social Assistance Center (CRAS); the Specialized Reference and Social Assistance Center (CREAS); the Violence Prevention Secretariat (SEPREV); the Municipal Health Department (Division of Primary Care and Center for Surveillance of Violence and Accidents); the Municipal Council for Children and Adolescents (CMDCA); and from NIEVS/UEFS.
The diversity of the members that make up the network, combined with the correct use of information and social equipment, led to greater cooperation between the actors.The meetings were important, as these spaces served for professionals and the school community to exchange experiences, add more knowledge on the issue and generate more approximation and articulation between the network components 30 .
From this perspective, the comprehensive care network for children and adolescents in situations of violence, in its agenda of activities, must link technical knowledge, as well as the knowledge of social actors, valuing community protagonism in the elaboration of public policies 30 .
However, in this research, the multidisciplinary team (ESF, NASF and Education) was trained to confront and transcend the biological dimension of care, which considers violence against children and adolescents a process in which not only victims, but also aggressors and family members are parts, since they constitute spaces of affection and conflicts permeated by social determinants in their surroundings 6,31 .Thus, professionals were able to re-signify their practices, finding new ways to act at school in the face of this problem.
It was also revealed the need for a social, inter-institutional and intersectoral support network that is not limited to the health sector and that favors partnership with the community, so that actions are more effective and efficient to break the cycle of violence.
It is important to clarify that a relevant point for the positive working of the network is the recognition of municipal, state and federal managers regarding the magnitude of the problem of school violence against children and adolescents and regarding the importance of prevention, protection, confrontation and care networks, assuming and supporting the proposed actions, including the availability of resources for: activities and campaigns of local awareness and mobilization; elaboration of municipal plans for the prevention, confrontation and attention of the different forms of violence, according to the local reality; training and qualification of health professionals and other services that make up the network; and to expand and strengthen primary and intermediate care and specialized health services 30 .
Based on the understanding of the importance of dialogue and interventions with an emphasis on families, a commemorative event for Father's Day was promoted, during which two conversation circles were held addressing the research project and the issue of violence against children and adolescents, with a focus on ways to provide home education without the use of violence, whether psychological or physical.Educational videos and discussion dynamics were used, achieving the objectives of the activity, in view of the self-reflexive reports of the participants at the end of the circles, such as: commitments to changes in educational practices at home, better monitoring of the children's studies and approximation of the families to school.
In addition to being characterized as spaces for the discussion of themes focused on the phenomenon studied and for the planning and execution of interventional actions, the wheels were also used to apply the conflict mediation strategy that routinely took place at school, in which students involved in situations of school violence were invited, with their parents/guardians and school members (directors, coordinators, teachers) to discuss the incident and mediate the amicable resolution of the situation, guided by the culture of peace, good coexistence and non-violence.
In some cases of violence among students, the participation of the family was not necessary, but the student was sent to the principal's room, where he answered a reflective questionnaire about his acts of violence, which was prepared with the principal.After a few minutes, the student would sit down and discuss his answers with the principal, creating possibilities for resolving conflicts without using violence, rescuing the discussions from the thematic conversation circles in which they had participated.
In these moments, the students agreed with the conflict mediators to change their behavior in a situation of violence, to use dialogue as a tool for resolving disagreements between colleagues and that, if they were a victim, they should go to the teachers so that they take the necessary measures to resolve the situation, and not act violently to retaliate against the aggressions.The mediation circles, with the participation of parents/guardians, served to guide on new ways to educate their children, based on dialogue, and not on oppressive and stigmatizing violence, which have an impact on the behavior of adolescents at school.
These new ways of coping with situations of school and domestic violence resonated in the decrease in the recurrence of cases of violence perpetrated by the same actors, favoring a culture of peace and good interpersonal relationships in the daily life of the school.
Co-responsibility and the partnership between health, education and social action were improved when a 9-year-old child's suicide attempt was detected and prevented in the classroom.Interventions focused on this case provided workers with an understanding of their important role in the network of coping and attention to violence against children and their families.Therefore, an expanded care was developed, combining protection with care for students and their families, who began to be monitored by the following services: health (ESF, NASF, Psychosocial Care Center -CAPS -children, CAPS alcohol and drugs); social development (CRAS, CREAS and Guardianship Council); and education, with the school monitoring and providing psychopedagogical support.
With the progress of the intervention actions and strengthening of the links between health and education professionals, it was identified that the school had new and still unused sports materials, as they did not have a physical education professional or a multisport court.
Given this context, the NASF physical education professional offered to develop volleyball and soccer classes twice a week, in order to motivate adolescents to practice physical activities and promote the appreciation of good disciplinary conduct.To select the students who would take these sports classes, a story and drawing contest was held, in which they had to tell a story about why they deserved to be chosen and draw about the sport they wanted.This activity enabled students to take a leading role, as well as their creativity, commitment to better interpersonal behaviors and to studies, discussion and practices of healthy living habits, among others.
In addition to the research scenario, the researchers were involved in the school community and ESF/NASF through effective participation in the planning and daily actions of these scenarios, focused on the theme of prevention, coping and attention to school violence.As examples, the PSE actions were planned and executed; dialogue was carried out with services of the Health Care Network for multidisciplinary care; as well as home visits for intervention and referral of cases of school violence; between others.
Based on the actions of the PSE, the school space has assumed an increasing importance in health promotion, disease prevention and prevention and intervention in situations of violence and accidents among children and adolescents, strengthening its fundamental objective for the preservation of health and education and extending its educational potential in terms of quality of life 19 .
Furthermore, there was the participation in the organization of educational and commemorative activities at the school: Father's Day; Folklore Walk; Spring Parade; ornamentation for monthly events, among other actions.
As explained in figure 1, it is emphasized that multidisciplinary interventions were relevant to promote the reduction of situations of violence at school.Furthermore, they had repercussions on prevention, coping and attention to violence in the family space.

Final considerations
The development of this research revealed that the integrated work for interventions in situations of violence against children and adolescents goes beyond school walls, as it is a multicausal phenomenon that involves intersectoral actions.
It is necessary, therefore, that the conception of a network involves support, solidarity and inter-relational commitment, which are fundamental elements for the prevention, confrontation and attention to situations of violence, towards the construction of a culture of peace, based on the respect for life, diversity, empathy, balance in gender and ethnic relations, strengthening dialogue and ensuring human rights.Thus, institutions must leave their zones of isolation, specific and disciplinary work and agree on joint, multi-professional actions, in favor of more effective results in the face of violence.
As contributions of this study, we can list: the strengthening of the PSE and the multiprofessional work involving adolescents and families; the strengthening of the bond between the professionals who worked in the network of local services and envisaged facing the problem of violence against children and adolescents; the qualification of health and education professionals regarding the use of workshops and recreational activities to intervene in situations of violence; the implementation of the physical activity project in the school; the proposition of a new model of conflict mediation in the school environment; and improvements in bringing the family closer to the school.
It is hoped that the results of this study will awaken professionals, managers and communities to the existence of violence against children and adolescents in spaces that should be protective, both at school and within the family, and position themselves as important actors for the consolidation of intervention networks.
Among the limitations of this study, it was noticed the difficulties of health and education professionals in working with the theme of violence against children and adolescents, both in the school space and in its surroundings, in view of the complexity of the theme and the context of risk in that all those actors are involved.In addition, the precariousness of employment relationships of health professionals was configured as a factor that could result in the discontinuity of the activities implemented.
Therefore, it is understood that this study was important to intervene in the situations of violence existing in the school space and started a movement to change practices and dialogue between the various services existing in the neighborhood and in the municipality, revealing its potential to compose the network for prevention, confrontation and attention to situations of violence against children and adolescents, as well as effective involvement of families; enabling the gradual construction of territories of peace in the school community.

Collaborators
Anunciação LL (0000-0003-1567-7025)* contributed to the conception and design of the work; acquisition, analysis and interpretation of data for work; writing the work and critically reviewing the intellectual content; final approval of the version to be published.Carvalho RC (0000-0002-1060-2780)*, Santos JEF (0000-0003-2949-6022)* and Souza SL (0000-0001-8003-2093)* contributed to the conception and design of the work; writing the work and critically reviewing the intellectual content; final approval of the version to be published.Morais AC (0000-0001-9547-6914)* and Almeida VRS (0000-0002-0482-8433)* contributed to the writing of the work and critical review of the intellectual content; final approval of the version to be published.s

Figure 1 .
Figure 1.Intervention plan and results in the face of situations of violence against children and adolescents in the school environment, with repercussions for the intra-family space