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Conteúdo (article):

Fatores associados à violência contra a População em Situação de Rua em Belo Horizonte
Factors associated with violence against persons experiencing homelessness in Belo Horizonte
Giselle Lima de Freitas (Escola de Enfermagem Universidade Federal de Minas Gerais; gisellelf18@gmail.com; https://orcid.org/0000-0002-8118-8054)

Giovanna Martins e Soares (Escola de Enfermagem, Universidade Federal de Minas Gerais; giovannamartinses@hotmail.com; https://orcid.org/0000-0002-9102-1514)

Larissa Solari Spelta (Escola de Enfermagem, Universidade Federal de Minas Gerais; solarilarissa@gmail.com; https://orcid.org/0000-0003-0041-4337)

Thiago Gomes Gontijo (Escola de Enfermagem, Universidade Federal de Minas Gerais; thiago.gontijo15@gmail.com; https://orcid.org/0000-0002-7582-275X)

Deborah Carvalho Malta (Escola de Enfermagem, Universidade Federal de Minas Gerais; dcmalta@uol.com.br; https://orcid.org/0000-0002-8214-5734)

Ricardo Alexandre Arcêncio (Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo; ricardo@eerp.usp.br; https://orcid.org/0000-0003-4792-8714)


Abstract
The daily lives of people living on the streets are marred by numerous forms of violence, due to the conditions of social, economic and housing vulnerability to which they are subject. A cross-sectional, quantitative study of 356 homeless people in Belo Horizonte (Minas Gerais) was conducted between August 2021 and March 2022 to identify the types of violence suffered by homeless people and to examine associated factors. Data analysis was by Poisson regression with robust variance. Having a partner (PR = 1.748) and no income (PR = 1.441) were associated, respectively, with increases in the prevalence of structural and overall violence, while being male (PR = 0.547) contributed to less structural violence. Use of shelters was associated with higher levels of interpersonal (PR = 1.528), collective (PR = 1.487), structural (PR = 1.695) and self-inflicted (PR = 2.2) violence. The results expose the violence at shelters and demonstrate that inequalities are a determinant in the process creating vulnerability to violence.
Keywords: violence, exposure to violence, social vulnerability, socioeconomic factors, people living on the streets.

Introduction
In 1996, the 49th Assembly of the World Health Organisation recognised violence as a public health problem because of its extensive impacts on physical and mental health, as well as the health service overload resulting from high rates of morbimortality from external causes1. Currently, violence is understood on more than a biomedical rationale2 and is no longer viewed exclusively in terms of individual behaviour, but as framed by the social, historical and territorial relations that reproduce it3. Accordingly, violence is considered to be the outcome of complex interactions among individual, relational, social, cultural and environmental factors that violate fundamental rights and personal dignity4.
The intimate relationship between inequality and violence, which exposes people in situations of vulnerability, such as those living on the streets, to problems of this kind5,6. The Covid-19 pandemic resulted in a world health and socioeconomic crisis with disproportional effects on population groups in situations of vulnerability7. Prominent among the social disparities highlighted by this period in Brazil was the substantial nationwide increase in the numbers of the population living on the streets8.
When Decree No. 7.053, of 2009, instituted the National Policy for People Living on the Streets (Política Nacional da População em Situação de Rua, PNPSR), the rights of the housing deprived came to constitute a significant agenda for public administrations9,10. The decree characterises the population living on the street by the absence of housing, poverty and weak family ties. It rests on the principles of respect for human dignity, the right to a family and community life, due value and respect for life and citizenship, humanised, universal care and respect for social position and difference of origin. However, it hardly touches on the issue of violence and how it is to be treated11.
Non-compliance with these principles, plus the common experiences of discrimination and housing and economic vulnerability that constitute life on the streets, leave this public exposed to violence12,13. Also, as this population group is heterogeneous, the different life histories involved are reflected in victimhood by the many manifestations of violence: interpersonal, self-inflicted, collective or structural14.
By exploring violence in a group that has been left vulnerable, it is possible to identify the phenomenon and its distribution in the population. This is necessary in order to redirect corrective action, adopt social protection measures and structure public policies to assure human rights and quality of life effectively. Given the scarcity of research addressing the specifics of the phenomenon of violence in the population living on the streets, this study aims to identify the types of violence suffered by people on the streets and to analyse associated factors.
Methods
This analytical, qualitative, cross-sectional study forms part of the umbrella project ‘Social thermometer – Covid-19’ (Termômetro social - Covid-19). That multicentre study examined factors associated with perceived risk, behaviour patterns and protective measures for populations during the Covid-19 pandemic. In Brazil, the project was conducted by the Sergio Arouca National School of Public Health (Fiocruz) and the Universidade de São Paulo.
In Belo Horizonte, Minas Gerais State, the study focus was given by the participation of people living on the streets. The 356-participant sample was determined by finite sample calculation from official municipal data on the number of persons living on the streets. Those included were persons over 18 years of age, who had been living on the streets for more than one month and who lived in the Centre-South administrative region of Belo Horizonte, given that that is the municipal region with the highest concentration of people living on the streets15. The exclusion criterion was emotional or behavioural disorders that would compromise the responses of potential participants at interview.
Data were collected by trained students applying a questionnaire at referral centres for people living on the streets of the city’s centre-south and east administrative regions, between August 2021 and March 2022. Catchment was facilitated by the population’s bond with the centres, which had been frequented previously by the group of students in extension activities. The questionnaire addressed 15 situations which were categorised for study purposes into four types of violence.
The typing of violence was designed to assist the analysis and understanding of violence in its many forms1. In 2002, the World Health Organisation (WHO) classified violence into three broad categories: interpersonal violence, comprising family and community violence, represented in this study by violence against older persons, children, adolescents and people with disabilities, as well as intimate partner violence, sexual exploitation and homicides or attempted homicides; self-inflicted violence, represented by suicide or attempted suicide; and collective violence, represented by drug trafficking, conflicts between armed groups, such as vigilantes, and police violence.
Given the invisibility and stigma experienced by people living on the streets, this study took Minayo’s typology as its theoretical frame of reference. To the WHO classification, she added the concept of structural violence, which permeates both social relations and institutions, rendering individuals socially excluded and vulnerable16. The study instrument contemplated the following forms of this type of violence: racism, LGBTphobia, labour analogous to slavery and lack of access to basic services and rights, such as healthcare, drinking water, food and public transport.
The exposure variables considered were sociodemographic: sex (female; male), age group (18-39 years; ≥ 40 years), self-reported race/colour (white; black), marital status (with partner; no partner), schooling (high: more than 8 years; low: 8 years or less), occupation (Yes; No) and monthly income (Yes; No). Also considered were use of health care and social assistance services, government assistance benefit (Yes; No), use of hostels and shelters (Yes; No) and use of the national health system (Sistema Único de Saúde, SUS) (Yes; No). For purposes of analysis, it was decided to dichotomise variables, such as age group and schooling, where categories returned similar distribution patterns17. Also for analytical purposes and given the low frequency of self-reported yellow and indigenous individuals, the race variable was dichotomised into only white and black (the latter, a synthesis of black and mixed race).
Data were processed using the Statistical Package for Social Science (IBM SPSS 22). Descriptive statistical analysis of the exposure variables was conducted using absolute and relative frequencies, by the categories analysed. Pearson’s chi-square test was used to ascertain statistically significant differences in prevalence of the outcome, by category of exposure variable. All predictors returning p-value < 0.2 were retained for multiple analysis. The various different types of violence were tested for associations with the exposure variables using Poisson regression with robust variance. Statistical modelling for the adjusted analysis used the enter method to estimate prevalence ratios (PR) and 95% confidence intervals. Prevalence ratios with p-value < 0.05 in the Wald chi-square test and confidence intervals ≤ 1 were considered significant.
The study was approved by the research ethics committee of the Universidade Federal de Minas Gerais (COEP-UFMG) in opinion No. 4.553.211, in compliance with national health council resolution 466/2012 and the guidelines and regulatory standards for research involving human subjects.
Results
The sample (n = 356) comprised individuals who were predominantly male (89.04%), black (84%), over 40 years old (53.1%), who had no partner (93.26%), low schooling (63.2%), no occupation (72.8%) and no income (64.9%). Also, only 40.16% reported using hostels, shelters or other social assistance services, while 85.67% used the SUS.
Overall prevalence of violence was 59.60%, but higher among women, black persons, those from 18 to 39 years old, those who had a partner, no income and who frequented hostels and shelters. By type, the most prevalent violence was collective (43.5%), followed by structural (37.6%), interpersonal (37.1%) and lastly self-inflicted (10.1%). The factors associated with overall and different types of violence are shown in the tables below:
Table 1
Having no income contributed 44% (95%CI:1.054-1.96) to greater overall violence.
Table 2
Frequenting hostels, shelters and care services contributed 53% (95%CI:1.071-2.182) to greater interpersonal violence.
Table 3
Frequenting hostels, shelters and care services contributed 49% (95%CI:1.07-2.065) to greater collective violence. Being black, meanwhile, returned a 1.2 times increase (95%CI:1.053-5.054) in the prevalence of this type of violence.
Table 4
Frequenting hostels, shelters and care services contributed 69% (95%CI:1.175-2.446) to greater structural violence, while having a partner contributed 75% (95%CI: 1.01-3.023). Note that being male contributed 45% (95%CI:0.335-0.894) to lesser violence of this type.
Table 5
Frequenting hostels, shelters and care services contributed a 1.2 times increase (95%CI:1.119-4.327) in the prevalence of self-inflicted violence, as compared with those who did not frequent these services.
Discussion
The study found a high prevalence of violence among people living on the streets, most often in the form of collective violence, followed by structural, interpersonal and self-inflicted violence. In all its forms or dimensions, black persons and those with no income suffered more violence. Also, women, persons from 18 to 39 years old, those with a partner or who frequented hostels and shelters, although minorities in the sample, suffered more overall violence.
Sociodemographic, economic and health and social care service use characteristics were not distributed homogeneously among the different forms of violence. For example, having a partner and having no income were associated, respectively, with higher levels of structural and overall violence, while being male contributed to suffering fewer occurrences of structural violence. Use of hostels, shelters and other care services was associated with higher levels of all types of violence.
Interpersonal violence is understood here to be a form of communication and interpersonal relation, which can be expressed by means of physical, verbal or sexual aggression in family or community settings16. Social and economic inequalities are reproduced spatially, thus creating less-valued areas within the urban fabric where public security is characteristically lacking18. One of the more extreme examples of this dynamic is to be found among people living on the streets, who, for lack of regular conventional housing, use public space as their place of residence and livelihood, resulting in over-exposure to urban violence19.
In the municipality studied here, people living on the streets are provided with a network of public services as required by the national policy. This includes referral centres for people living on the streets, a state centre for the human rights of people living on the streets and waste pickers and temporary care services11. These are designed to foster autonomy and the opportunity to leave the streets, by steering people towards social and health care services, personal and social development activities and documentation processes20. However, the prevalence of violence found in shelter and protection facilities is determinant to keeping people away from support networks, and thus contributes to making them more vulnerable21.
In this study, when asked about their use of overnight care services, participants considered shelters and hostels less safe than sleeping on the street, and most (59.84%) opted to overnight on pavements, in squares and under viaducts. The association between use of social care services and higher prevalence of all types of violence is corroborated by an international study that reports accounts of physical aggression, criminality and drug use within these institutions22.
Collective violence is understood here to be the instrumental use of violence that serves to establish the supremacy of one group over another and/or of the State over its population. This category includes crimes by organised groups, genocides and wars16. Public power, then, acts directly to perpetuate collective violence against people living on the streets, by criminalising and sanitising this population on the pretext of maintaining public order23,24. In this way, a state of exception is imposed on people living on the streets: although their rights are assured positively in law, they are rendered invisible, neglected and at times exterminated25.
Moreover, black and mixed-race persons suffered significantly more collective violence than their white counterparts. Blackness, when associated with living on the street, mobilises processes of social and cultural marginalisation within the very situation of life on the streets itself26,27. The stigmatisation and exclusion are worsened in the context of existence as a black body, thus worsening the conditions of symbolic and material relegation experienced by black persons living on the street28, who return higher prevalences of all types of violence.
Structural violence is defined by cultural, social, political and economic processes that produce and reproduce dynamics of domination and subordination perpetuated by social, class, gender and race inequalities16. This form of violence is also termed “structuring”, because it is deeply rooted in history and has become established as the basis for most types of violence29. The situation of extreme vulnerability experienced by people living on the streets is reflected in the high prevalence of this type of violence, expressed primarily in discrimination, social exclusion and abuse of fundamental rights. Omission by the State in its social protection role is thus responsible for maintaining the cycles in which vulnerabilities are produced30.
The higher prevalence of interpersonal and structural violence against women demonstrates the everyday kinds of violence by which women are maintained in a subordinate condition with respect to men31. Also, these women’s difficulty in accessing basic rights and services increases their vulnerability and intensifies patterns of patriarchal relations that perpetuate the cycle of violence32.
Often, women living on the streets, when faced by imminent threat of aggression by other men, enter into a paradoxical dynamic of abuse and security in which their partner claims the traditional, male protective role in exchange for physical and sexual submission33. The projection of dominant masculinities and fragile femininities, particularly in the context of heterosexual relationships34, is also demonstrated by fact that, statistically, women and persons with partners were victims of structural violence, while men suffered more from collective and self-inflicted violence.
Self-inflicted violence, although less prevalent than the other types, was particularly prevalent among men and young people. The data dialogue with the literature, which has established that living on the street is a risk factor for suicidal behaviour35,36. The lack of emotional and social support, as well as the abusive use of alcohol and other drugs, are risk factors for the psychological stress to which people living on the streets are constantly exposed, which increases their vulnerability to self-directed violence37,38.
Studies of violence among people living on the streets are incipient; in fact, only one such study was found, which offered estimates of the odds of violence against people living on the streets of Uberlândia. The article found that being female and non-white was associated with greater risk of suffering violence39. Also, not having a self-reported disease and living on the streets for less than 5 years were found to be protective factors. The study reported here is thus considered innovative as it analyses prevalence in a metropolis.
Acknowledged limitations of this study include the territorial scope of data collection, which was restricted to the centre and south of the city. Although it is the region with the highest concentration of people living on the streets in Belo Horizonte15, this does mask the possibly different experiences of people living on the streets of peripheral areas of the city. The cross-cutting timeframe precludes establishing a causal relation between exposure (living on the streets) and outcome (violence). The quantitative methodology, although it does enable the data to be explored and extrapolated, has limitations as regards expressing these people’s subjective experiences.
Violence is present in the daily lives of a significant portion of the people who live their lives on the streets, particularly those who find themselves at the intersection of different kinds of vulnerability, such as black persons, women and persons with no income34. The street situation can itself be considered a form of violence resulting from negligence by the State, given that housing is a social right40.
The findings expose violence within social care services, such as shelters and hostels, which drives away vulnerable population groups. Also, the high prevalence of self-reported structural violence demonstrates an understanding of violence that goes beyond physical aggression and casts a critical eye to the structuring processes that perpetuate violence. Accordingly, this study contributes towards a more in-depth understanding of the manners in which violence is expressed in the daily lives of people living on the streets, and thus makes it possible to examine this social issue and to evaluate current public policies.

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