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Ciência & Saúde Coletiva

Print version ISSN 1413-8123On-line version ISSN 1678-4561

Ciênc. saúde coletiva vol.21 no.6 Rio de Janeiro June 2016

https://doi.org/10.1590/1413-81232015216.07822016 

ARTICLE

The Enlighten Campinas Program: the construction of an intersectoral and interinstitutional policy to confront violence as a social problem

Claudia Mara Pedrosa1 

Carmen Simone Grilo Diniz2 

Verônica Gomes Alencar de Lima e Moura3 

1Departamento de Saúde Coletiva, Faculdade de Ciências da Saúde, Universidade de Brasília. Campus Universitário Darcy Ribeiro, Asa Norte. 70910-900 Brasília DF Brasil. pedrosaclaudia@gmail.com

2Faculdade de Saúde Pública, Universidade de São Paulo. São Paulo SP Brasil.

3Secretaria Municipal de Saúde de Campinas. Campinas SP Brasil.


Abstract

Including the issue of violence in the health promotion agenda requires restructuring health services to incorporate violence into the front lines of care and consolidate individual and collective measures from an intersectoral, multidisciplinary and integrated standpoint, within networks that reorganize practices and embrace this issue as a key determinant of health. The aim of this article is to share the experience of implementing the Enlighten Campinas Program – a local endeavor to promote health in a large city – which amalgamated the health sector into a wide intersectoral and interinstitutional network to provide care to victims of violence. The theoretical approaches used were Social Constructionism and the Actor-Network Theory (ANT) and the methodology involved analyzing documents, a field diary, interviews and observations of Enlighten Program events.

Key words: Health promotion; Public health; Violence; Integrality in health; Health policies

Resumo

A inclusão da temática violência na agenda da promoção da saúde demanda a reorientação nas linhas de cuidado do sistema de serviços e a consolidação de ações voltadas para indivíduos e coletividades, em uma perspectiva de trabalho intersetorial, multidisciplinar, integrado e em redes que contemple a reorganização das práticas para acolher esta questão como um determinante de saúde. O objetivo deste artigo é compartilhar a experiência da implementação do Programa Iluminar Campinas – uma política local de promoção da saúde de um município de grande porte –que articulou o setor saúde em uma ampla rede intersetorial e interinstitucional para ofertar cuidados às pessoas que sofreram violência. As perspectivas teóricas do estudo foram o Construcionismo Social e a Teoria Ator Rede (TAR) e a metodologia envolveu a análise de documentos, entrevistas e observações de eventos do Programa Iluminar.

Palavras-Chave: Promoção da saúde; Saúde pública; Violência; Integralidade em saúde

Introduction

Violence and the challenges for health promotion

The Ministry of Health published the decree that instituted the National Policy to Reduce Morbidity/Mortality from Accidents and Violence, recognizing violence as a major public health and citizens’ rights issue. However, numerous studies highlight the health care obstacles to organizing and providing humanized, welcoming and effective care for victims of violence. The factors identified include the lack of professional training and difficulties developing relevant and specific measures for certain population groups and cultural contexts, among other aspects1-5. Added to these difficulties is the marked violence present in health services, impacting the health of users, the routine and quality of life of professionals, and investments in the National Health System.

Despite significant political and methodological efforts in the 1960s and 70s to understand health as a wider issue, especially due to the complex epidemiological transition, author Maria Cecília Minayo6 underscores the fact that no other topic has ever caused and continues to cause such resistance in terms of its inclusion in health guidelines as violence and accidents. According to the author, violence has become a public health problem because it affects individual and collective health and requires specific public policies, as well as the organization of specific practices and services to prevent and address it.

This article describes the experience of constructing a municipal health promotion policy – The Enlighten Campinas Program, in the state of São Paulo, which involved uniting a large network of intersectoral equipment and services to tackle violence, considering it one of the key determinants of health.

Methodological theoretical framework

In order to understand how the Enlighten Campinas Program was structured, 15 interviews were conducted with administrators, professionals and users of the health system, selected based on their intersectorality. In addition to the interviews, public municipal health documents for the period from 2001 to 2015 were analyzed, as well as the field diary of a researcher7. The study was approved by the Public Health Ethics Committee of São Paulo University and the Campinas Department of Health. The guiding question of the open interview was the process of constructing the Enlighten Campinas Program, its difficulties, potentials and challenges.

Data banks from the Campinas municipal government were searched for document analysis purposes. These documents contained technical information, instructions for the community and published news. Bulletins prepared by Enlighten Program coordinators, as well as texts and support materials used in training meetings were also analyzed. These documents were freely available on the internet and were also printed and distributed at community events and services and to professionals from different sectors. The material was analyzed to determine the official position regarding implementing the victims of violence care network in Campinas7.

To analyze the interviews, we performed sequential transcription8 to summarize the statements of each subject and “understand the dynamics of discursive exchanges (who speaks, when they speak, what they speak about) and, above all, have an insight on the set of issues under discussion”, as presented by Spink & Cordeiro8. Sequential transcription provides an overview and helps us choose a number of issues for more detailed analysis. However, it is important to underscore that the context of speech is situated, since from a constructionist viewpoint and in research with discursive practices, it is essential to refer to the whole8. Dialogic maps were subsequently prepared for each interview, document and part of the field diary analyzed. The maps are organized according to the objectives of the study and help define the issues and categories identified in sequential transcription, as well as issues that we seek to highlight in the analysis8.

Our analysis uses was based on the theoretical dialogue of Bruno Latour9 and his notion of network. The author questions the concept of network advanced by modern science and emphasizes that it views reality as a homogeneous entity outside of us, capable of being captured in models that do not represent the social practices that sustain them. In this respect, studies by Sherrer-Warren10 underscore that when considering the network, we should seek the forms of “linkage between the local and global, the particular and universal, one and the many, in the interconnections between the actors and pluralism”. Our interactions with others are mediated by objects, which contain meanings and thus produce actions. Therefore, the development of technologies created new relationships between machines and humans, redimensioning the variation between global and local10.Thus, there is a tendency to transform ample phenomena into global and systematic totalities, losing heterogeneity and particularity. In this regard, the author Bruno Latoururges us to question an early definition of connections between local and global phenomena and underscores the intermediation between people and things:

There is a thread of Ariadne that enables us to pass continuously from the local to the global, from human to non-human. It is a network of practices and instruments and of documents and translations; a tangle of networks materialized in invoices, organograms, local procedures and private agreements, which actually make it possible for this network to extend over a continent, provided it does not cover the continent9.

Results

Structuring the victims of violence care network

Structuring the care of victims of violence in Campinas, up to 2011, did not involve a specific protocol or identify the local resources for referencing. When compared to previous published data from studies in this area, the number of individuals who seek the services was underestimated and troubled health coordinators, primarily in the field of women’s health. This area identified and cared for victims of sexual violence with important health consequences, such as post-rape pregnancies, sexually transmitted diseases and AIDS.

Thus, given the need for an intersectoral approach, societal participation and sharing of responsibilities in the creation of municipal health promotion policies, in April 2001 the Municipal Department for Women’s Health held a local seminar with administrators from different municipal and state government departments in the fields of health, education, public safety and civil organizations involved in confronting sexual violence in the city of Campinas. This initial meeting focused on the care of victims of sexual violence, given the urgent need to minimize the risks of contamination and the severity of the impacts on victim health. The encounter sought to identify existing services and assess the main obstacles and potentials of each one. After the event, a letter of intent was drawn up for the creation of the Enlighten Program and delivered to the municipal authorities.

In mid May 2011, a federal grant of BRL 100,000.00 from the Ministry of Health’s Program for the Prevention of STD/AIDS led to the creation of the network to organize the flow of care, initially focusing on sexual violence and therefore forming the official itinerary of the care network for sexual assault victims. This flow restructured the health service system, interlinking services and sectors and facilitating humanized care and case referrals.

Care strategies were based on the idea of integrality. In addition, the need for professional training to provide effective care prompted coordinators, in partnership with the local women’s social movement, to hold training and sensitivity meetings for professionals from different sectors for 18 months following implementation of the program. In the opinion of those involved in structuring the Enlighten Program, guiding principles and concepts were defined in order to consolidate the network and generate substantial changes in all the areas involved, as explained by the doctor from the Center for Comprehensive Women’s Health Care (CAISM) of the University of Campinas (UNICAMP):

The concepts that guided structuring (of the network)were: sexual violence is a public health problem and not a police matter; effective prevention is achieved with urgent care of up to 72hrs; promote protection and prevent the revictimization of people at the services; care for women, children, adolescents and men; intervene in the sexual violence network; create a data bank and care for the perpetrators of violence in a non-police setting.

These and other principles consistent with the city’s health administration guided the training of the 800 professionals from different services committed to transmitting the content to colleagues in their units. The fundamental concepts used in training were: care, resilience, and solidarity.

Flow-itinerary organization

Organizing the flow of care required dividing the intersectoral network into two areas: the indirect care network: consisting of day care centers; municipal child education schools; municipal Social Assistance Services; the Municipal Guard; Human Rights Councils for Children, Adolescents, Women, the Elderly and Disabled, as well as Guardianship Councils; non-governmental organizations–such as SOS/Women and Family Action-which have worked with issues related to women, children and adolescents; the Medico legal Institute; Women’s Precincts and Police Stations; Women’s Support and Reference Center – CEAMO; Legal Aid and Psychological Assistance Services of the Pontifical Catholic University (PUC) Campinas, Paulistana University (UNIP) and the Women’s Shelter.

The direct care network was composed of Health Centers, Municipal First-Aid Posts, Center for Comprehensive Women’s Health Care (CAISM) of UNICAMP; Children’s First-Aid Center of Hospital das Clínicas of UNICAMP; CRAISA-Reference Center and Comprehensive Adolescent Health Care; CRAMI-Regional Center for the Care of Mistreated Children; Municipal Emergency Care (SAMU), Center for Psychosocial Support (CAPS), SDT/AIDS Reference Center and the Orientation and Serological Support Center (COAS)

The responsibilities of the indirect care network were wide-ranging, since they initial contact with victims of violence; specific care was provided and the Municipal Guard was summoned to take people to the Fist-Aid facility, as defined by network flows. The indirect network also notifies cases and when the occurrence involves children and adolescents, the Guardianship Council is also notified. After passing through this network, the flow is channeled to the direct care network.

This direct care network involves specific emergency care, such as that provided by multiprofissional teams of doctors, nurses, social assistants, and psychologists who are guided by the Health Ministry’s Technical Guideline “Prevention and treatment of injuries caused by sexual violence against women and adolescents11. This stage involves preventing rape-related pregnancy, STDs and hepatitis; conducting the necessary serologies; semen collection; encouraging the victim to file a Police Report and undergo a Forensic Medical Examination. Referral to the STD/AIDS Reference Center for antirretroviral medication and vaccination against hepatitis is also carried out, and the patient is then referred to the Indirect Network Services to address social and legal issues. As we will see further on, the presence of the Municipal Guard in this flow increases the speed of healthcare and provides security and protection to victims of violence, primarily the sexual variety, since the Municipal Guard patrol cars are driven by trained professionals who transport individuals to the established services and then to their homes following treatment.

In the case of sexual violence, more specific services, such as the Center for Comprehensive Women’s Health Care (CAISM),are responsible for emergency treatment and a four-week follow-up period, and then for six months until seroconversion rates are assessed. Treatment is provided by a team consisting of gynecologists, psychiatrists, psychologists, nurses and social assistants. This service is part of professional training at the University of Campinas, in the Gynecology, Obstetrics and Family Health residency programs. CAISM also performs legal abortions guaranteed by the penal code to women who become pregnant after being raped, following all Ministry of Health Guidelines12.

Formulation of the local violence notification system

The implementation of the care for victims of violence network in 2001 led to the need to create a local tool to notify cases, set the care network in motion, interact with the Guardianship Council, and organize a data bank. A specific Project was also developed in the Municipal Informatics Department that created a local notification software program, followed by the Violence Notification System (SISNOV) in 2005.

SISNOV is an integrated, intersectoral and intrainstitutional electronic notification system for cases of domestic violence against children and adolescents, sexual violence against either sex at any age, and the commercial sexual exploitation of children and adolescents in Campinas. The data contained in the system help guide specific local policies to reduce the risks and harm associated with these types of violence, as well as generate information and indicators. SISNOV was created through a city ordinance drawn up by the Municipal Council of Child and Adolescent Rights, which guarantees the creation of an Intersectoral and Interinstitutional Committee to manage SISNOV data bank information.

In 2008, when the Ministry of Health implanted the Notification and Investigation Records of Violence in SINAN (Reportable Diseases Information System),which was mandatory for health units and contained a more comprehensive list of violent offenses than in SISNOV, the administrators of this system who were planning to widen the list of violent acts adapted SINAN to SISNOV. This occurred because SINAN is a system for the exclusive use of health units and was not originally intended to record intersectoral notifications consolidated in SISNOV. With the support of the Ministry of Health and maintaining local peculiarities, SISNOV was adapted to generate notifications in SINAN. The result was SISNOV/SINAN, which can currently register 14 different types of predefined violent acts.

The system in Campinas can be accessed on the city hall’s webpage, but in order to be eligible as a notifying service, both services and professionals must register with the SISNOV Administrative Council, which analyzes the application and decides whether they are qualified to enter the care network and be part of the system.

The Intersectoral and Interinstitutional Committee of the System (CII –SISNOV) presents and discusses notification data in periodic meetings and an annual report (the SISNOV Bulletin) is published containing all the described data. The data allow committee members to monitor the functioning of the network and, when necessary, indicate adjustments or alterations to the flow, improvement in the dissemination of actions or services or the creation of training modules for professionals. In the last bulletin published, containing the notification data from 2014 to the first semester of 2015, the committee highlighted the decline in reports of violence against women aged between 20 and 29 years, in 2014.The decline was correlated to a number of factors, such as a change in address that year of the Women’s Support and Reference Center (CEAMO/SMCAIS) – an important support center within the healthcare network for women of that age group. In 2014, treatment at the service was restricted by renovations at the new site and disclosure of the new address. In 2015, however, with care provision reestablished and the new central location of CEAMO, which facilitated access, a significant rise in demand and notifications was observed.

Final Considerations

In light of the existing gaps in the care network, the Enlighten Program sought to overcome the borders surrounding each territory, which limited and defined each sectoral space. Network monitoring meetings analyzed the cases and difficulties encountered and identified the need to include new actors. Introducing the Municipal Guard into healthcare networks was an example of a new element that produced significant results.

The Municipal Guard contributed by providing protection and rapid transport to health services for victims of sexual violence. Following training, Municipal Guard professionals began to identify incidents of violence and the most suitable services to deal with them. Thus, they rapidly identified cases that needed immediate treatment, according to the Ministry of Health protocol for cases of sexual violence, and provided safe transportation between one service and another in the network.

The Municipal Guard incorporated the notion of integral care, respect and privacy into their services, recognizing healthcare as a priority and therefore playing an important role in the protection and recovery of individuals after a violent event. As such, health services began to identify and include Municipal Guard professionals in the care network. The Municipal Guard began using unmarked vehicles specifically for this service, thereby protecting citizens from the exposure and risks that a marked vehicle could entail.

The Municipal Guard contributed to reducing “time to treatment” after the occurrence of sexual violence, which is crucial for prophylaxis and quality of life, by transporting victims to the treatment center and thus prioritizing their health. Shorter time to treatment reduces the risk of pregnancy after rape, since administering the morning-after pill within 72 hours increases the likelihood of preventing pregnancy and protecting the woman from more invasive and painful surgical procedures. In the year 2000, the time to receive first care after sexual assault was 72 hours in 80%of cases. By 2007, this time had fallen to 12 hours in 88% of cases, thereby increasing the effectiveness of prophylaxis and the quality of rehabilitation for these victims.

Another important advance was overcoming the hierarchies between municipal and state agencies. The entry of the Medico legal Institute (IML) into the care network is an example of this search to overcome barriers. The IML is a division of the Department of Public Security that was included in municipal priorities at the onset of the care network, receiving part of the funds aimed at implementing the Enlighten Program. The resources were used to renovate the IML facilities and purchase gynecological equipment and materials.

By officially belonging to the care network, the IML transformed its healthcare model, which historically focused on the legal aspect. In addition to treatment, in line with a humanized health model and the needs of users, the IML currently ensures that all procedures conducted by the healthcare network are valid as an indirect report for use by the IML, thus sparing the victim from undergoing a forensic medical examination during this traumatic period.

The IML also opened its doors to internships for undergraduate Nursing students from a University belonging to the Care Network, offering access to teaching in a little explored area of health education and preparing victims for the gynecological examination. This policy enactment contributed to changing the training scenario for the Public Health System.

The Medico legal Institute used the knowledge gained from integrating the care network in physical materials by adapting the space for humanized and dignified care;and in technical skills by transforming the care model. When knowledge is embodied in several types of materials, it is the result of considerable work in which heterogeneous elements13, such as the gynecological table, vaginal speculum, physician’s white coat, disposable gloves, test tubes, reagents, skillful hands, and professional and medical protocols, are juxtaposed in a network that overcomes resistances.

The transformation that the network is providing invites reflection on the composition and connection between the actors, since all of these linked elements make up the different networks that take part in the social structure, which is not something separate and independent, ´but a place of struggle, a relational effect that is recursively generated and self-produced´14-16.

Thus, constructing a care network for victims of violence in Campinas produced fundamental differences by combining conceptual elements, such as the wider concept of care and rights; physical elements, such as Municipal Guard vehicles, and textual elements such as protocols defined in the lines of care, generating new meanings and old social challenges17-22.

Future challenges and outcomes

The Enlighten Program advanced by consolidating practices faced by administrators and services, such as difficult-to-plan and execute measures, and innovated by creating new partnerships and agreements. However, a number of obstacles and difficulties were present and continue to challenge the development and maintenance of the care network.

The frequent turnover of health professionals hinders consolidation of a common language against violence and generates inadequate or erroneous notifications, which are detected by SISNOV when incoherent data are received. Erroneous categorization of the types of violence may compromise the patient’s case and preclude the use of the system as a legitimate data bank in terms of the local reality. Each change requires services to integrate professionals to the network’s proposals and sensitize them to the work, a task not always fulfilled in a timely fashion. These organizational designs are specific for the services and are therefore challenges to consolidating the network, since it depends on the priority that administrators give to the question and their outcomes, such as maintaining care and active notifications.

Since the implementation of the care network, systematic intersectoral meetings have been held to discuss difficult-to-resolve cases, considered sentinel cases. However, these encounters do not always take place in quiet settings because the nature of some services means meetings involve large numbers of administrators and bosses. Despite these obstacles, these gathering are indispensable for conducting cases, as well as assessing and monitoring network services that the Enlighten Program spends considerable effort to maintain active.

The greatest difficulty for the program has been to offer systematic support to professionals involved in providing care to victims of violence. This care is vital due to all the feelings that can accompany violence, including impotence, fear, anguish, and repulsion, among others. The caregiver needs a space of exchange, protection, and affective support as well as the presence of a competent technician, but structuring a specific service for this demand still poses a challenge23.

The collective action proposed by the Enlighten Program to construct care for victims of violence sought to promote awareness by redefining new conceptual axes for a reality that was previously not considered as such. From the constructionist standpoint, we consider that awareness of reality is not given to someone, nor does it belong to anyone, but rather is built together through joint action.

The context of the sanitary movement in Campinas seems to have favored the ´invitation´ to this change in focus, since the concepts that guided training linked the care model to the individual’s complete understanding and expanded the participation and dialogue of professionals, reflecting the historical care management model24.

The continuity of the Enlighten Program after successive changes in municipal administration seems to indicate a consolidation of proposals that supersedes party lines and is justified by the impact on the population’s health and on society as a whole. After the care network was implemented, other programs and services focused on the question of violence were implemented (Recreated Routes and Breaking the Silence), increasing the resources offered to the population and further legitimizing the network among professionals, the local community and other municipalities.

It is important to underscore that, after receiving initial financing to implement the STD/AIDS program, the Enlighten Program began to administer the network with Municipal funds, remaining self-managed for a long time in the municipal health system. The financial planning of local management suggests there is a perception of relevance with regard to the measures proposed for the population in terms of citizen’s rights and health, as well as a decline in costs, given that the planning of actions and prevention initiatives reduced expenditure related to the causes of violence in the health sector.

The Enlighten Program has disseminated its practices through Technical Visits offered to municipalities or entities that wish to learn about the care network, in addition to providing advice to cities on structuring and implementing the care network for victims of violence, helping create a local model that complies with Ministry of Health guidelines. The program was recognized as a successful municipal administration experience, and received a cash award from the Getúlio Vargas Foundation’s (FGV/SP) Public Administration and Citizenship Program that was used to purchase computers for notification units.

The Program became part of the National Plan to Combat Violence Against Women promoted by the Federal Government’s Department of Special Public Policies for Women, the Ministry of Health’s National Policy for the Reduction of Morbidity and Mortality from Accidents and Violence, and the Ministry of Justice and National Department of Human Rights’ National Plan for Addressing the Sexual Exploitation of Children and Adolescents. In the federal sphere, the Area of Women’s Technical Health and Health Surveillance included the Enlighten Program in their training activities for the different states and municipalities still structuring their course of action, characterizing the Campinas experience as situated knowledge based on ethical and political principles.

This study helped us reflect on the need for networks to structure their actions based on existing realities, considering the reorganization of spaces and institutions, construction of appropriate language and problems found in collective settings.It is known that the data reported are still unable to map all the occurrences, but the information available is shedding light on the problem, prompting new actions and policies.

The structured work model was another important point of reflection in this study, since by constructing work possibilities in collective spaces, problematizing and considering the limitations and range of the actors involved, the Enlighten Program innovated and broke with traditional models, where a predefined action proposal is presented and an attempt is made to adjust the participants to this structure. Thus, the model proposes problematization and inclusive methodology for professionals, aimed at consolidating active subjects in empowering healthcare.

Thus, we hope to contribute to reflection on the construction of practices aimed at tackling violence, illustrating the need to establish, from the structuring stage, an amplified, intersectoral and collaborative view that enables partnerships, pacts, agreements and accountability at all moments of caregiving. The multiple ramifications of the network contribute to eradicating the immobilization of sectors and disseminating new discourses that shed light on violence from a perspective that allows it to be included in the health agenda.

Acknowledgements

To CNPq and CAPES for financially supporting part of the study that formed part of the Doctorate in Public Health, Cycles of Life and Society of the Public Health Faculty, FSP-USP.

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Received: February 06, 2016; Revised: March 03, 2016; Accepted: March 05, 2016

Collaborations

CM Pedrosa participated in the preparation, analysis, data interpretation and writing of the article. CSG Diniz and VGAL Moura contributed to the critical review.

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