Artigos

Conteúdo (article):

Subnotificação de violência contra as mulheres: uma análise de duas fontes de dados
Underreporting of Violence Against Women: an analysis of two data sources

Autores
Nádia Machado de Vasconcelos. Programa de pós-graduação em Saúde Pública. Faculdade de Medicina, Universidade Federal de Minas Gerais. Belo Horizonte (MG), Brasil. Email: nadiamv87@yahoo.com.br. ORCID: 0000-0002-2323-3064

Regina Tomie Ivata Bernal. Programa de Pós-Graduação em Enfermagem, Escola de Enfermagem, Universidade Federal de Minas Gerais. Belo Horizonte (MG), Brasil. E-mail: reginabernal@terra.com.br. ORCID: 0000-0002-7917-3857

Juliana Bottoni de Souza. Programa de Pós-Graduação em Enfermagem, Escola de Enfermagem, Universidade Federal de Minas Gerais. Belo Horizonte (MG), Brasil. Email: juliana_bottoni@yahoo.com.br. ORCID: 0000-0002-9308-7445

Polyanna Helena Coelho Bordoni. Policia Civil de Minas Gerais. Belo Horizonte (MG), Brasil. Email: polyannabordoni@gmail.com ORCID: 0000-0002-1562-0558

Caroline Stein. University of Washington, Institute for Health Metrics and Evaluation. Seattle (WA) Estados Unidos. Email: cstein87@uw.edu ORCID: 0000-0003-4777-1630


Carolina de Vargas Nunes Coll. Centro de Desenvolvimento Humano e Violência, Universidade Feral de Pelotas. Pelotas (RS), Brasil. Email: ccoll@equidade.org ORCID: 0000-0003-0808-8230

Joseph Murray. Departamento de Medicina Social, Universidade Federal de Pelotas. Peltoas (RS), Brasil. Email: j.murray@doveresearch.org ORCID: 0000-0002-5511-3454

Deborah Carvalho Malta. Departamento de Enfermagem Materno Infantil e Saúde Pública, Escola de Enfermagem, Universidade Federal de Minas Gerais. Belo Horizonte, Minas Gerais, Brasil. Email: dcmalta@uol.com.br. ORCID: 0000-0002-8214-4734

Resumo
Objetivo: Estimar a subnotificação da violência contra as mulheres (VCM) no Sistema de Informação de Agravos de Notificação (SINAN) a partir de dados da Pesquisa Nacional de Saúde (PNS), para o Brasil e as unidades federadas (STATES). Metodologia: Estudo ecológico utilizando o SINAN e a PNS, ambos do ano de 2019. No SINAN, foram selecionadas as notificações de casos de violências sexual, física e psicológica contra mulheres com idade igual ou superior a 18 anos. Na PNS, foram selecionadas as mulheres da mesma faixa etária com relato de violência psicológica, física ou sexual que tenham procurado atendimento em saúde em razão de consequência relacionada à violência vivida. Calculou-se a subnotificação do SINAN a partir da estimativa da população da PNS para o Brasil e cada UF. Resultados: A subnotificação de VCM no Brasil foi de 98,5%, 75,9% e 89,4% para as violências psicológica, física e sexual, respectivamente. Os estados do Norte e Nordeste apresentaram os menores índices de notificação dentre as UFs. Conclusão: A VCM no Brasil apresenta grande subnotificação no setor Saúde, demonstrando a necessidade de capacitação dos profissionais de saúde para o reconhecimento de situações de violência e conscientização da importância da notificação.
Palavras-chave: Violência de Gênero, Violência Contra a Mulher, Vigilância Epidemiológica, Notificação Compulsória, Brasil

Abstract
Objective: To estimate the underreporting of violence against women (VAW) in the Notifiable Diseases Information System (SINAN), based on data from the National Survey of Health (NSH), in Brazil and subnational units (SU). Methodology: This work was an ecological study using SINAN and NSH, both from 2019. In SINAN, reports of sexual, physical, and psychological VAW, aged 18 years or older, were selected. In the NSH, women of the same age groups who reported psychological, physical, or sexual violence, and who had sought health care due to consequences of the violence were selected. SINAN underreporting was calculated in reference to the NSH’s estimated population, for Brazil and each SU. Results: Underreporting of VAW in Brazil was 98.5%, 75.9%, and 89.4% for psychological, physical, and sexual violence, respectively. The North and Northeast states presented the lowest reporting rates among the states. Conclusion: VAW in Brazil is highly underreported by the health sector, showing the need for adequate training of health professionals to recognize situations of violence and raise awareness of the importance of reporting.
Keywords: Gender-based violence; Violence against women; Epidemiological Monitoring; Disease Notification; Brazil

Introduction
Violence against women (VAW) is defined by the World Health Organization (WHO) as “any action or conduct, based on gender, which causes death; harm; or physical, sexual or psychological suffering to women, in both public and private realms”1. It constitutes a global Public Health problem, due to its high prevalence and the great burden it generates for society, health systems, and especially its victims2. In Brazil, the estimated prevalence of domestic or family VAW can reach up to 29%3.
VAW can have several consequences for women, with harm to their mental, physical, and sexual health. A previous study showed, for example, that more than half of all women who suffered some type of violence reported either depression or anxiety after the event, while 36% of those who suffered physical violence reported some form of bodily injury4. Furthermore, VAW has a high fatality, and in 2021, a third of all female homicides were the result of feminicide5.
Due to its relevance, since 2011, violence has been included in the mandatory reporting list of the Notifiable Diseases Information System (SINAN)6. Mandatory reporting is a compulsory strategy, and it’s responsibility of all health professionals7. It seeks to shed light on the magnitude and seriousness of this problem, as well as provide a better understanding of the profile of violence in Brazil. Epidemiological Surveillance can support actions to coping the conditions and determinants of different types of violence6. Therefore, the use of epidemiological information is essential in the planning, implementation, and evaluation of Public Policies geared toward changing the country\'s reality.
Since it became mandatory in 2011, there has been great progress in the reporting of violence in Brazil. One study8 showed that the number of reports of interpersonal violence rose from 107,530 cases in 2011 to 242,347 in 2015. In relation to VAW, the increase was from 56,800 notifications of interpersonal violence in 2011 to 185,868 in 20199. Furthermore, there was an increase in the number of reporting municipalities, from 2,047 in 2011 to 3,194 in 201410.
However, even after a decade of being mandatory, reporting still presents as a major challenge for government agencies. The Brazilian Public Security Yearbook, which publishes data from the State Departments of Public Security and/or Social Defense, points out that in 2020 and 2021 there were 35,644 and 37,872 rapes of girls under 14 years of age, respectively5. However, SINAN recorded only 20,170 and 14,344 cases of sexual violence for this same population9. Furthermore, previous studies11,12 have showed that approximately 2/3 of all professionals who identify a case of violence do not file proper report.
There is still a serious lack of studies that quantify the underreporting of VAW in SINAN, and the National Survey of Health (NSH)13, the largest household health survey in the country, can help with this challenge. In its 2019 edition, the NSH expanded the questionnaire on violence, making it possible to estimate the prevalence of certain subtypes of VAW, such as psychological, physical, and sexual violence13. Furthermore, the questionnaire asked questions regarding the aggressors, the place where the violence occurred, and the demand for health services, which helps the NSH to better meet the requirements necessary to fill out the Individual Notification Form (INF) that feeds SINAN.
Therefore, the present study aimed to estimate the underreporting of VAW in SINAN based on data from the NSH, for both Brazil and its subnational units.

Materials and Methods
This work was an ecological study with data from SINAN and NSH, both from 2019. The study population was made up of women, aged 18 years or over, residing in Brazilian municipalities.
SINAN is made up of reports that appear on the national list of notifiable diseases (Consolidation Ordinance no. 4 of September 28, 2017). This report is carried out by health professionals or those responsible for health establishments, whether public or private, by completing the INF, and forwarded to the Municipal Health Departments. There, the data is digitalized and consolidated, which is then forwarded, in an ascending order, to the Regional Health Departments and State Health Departments, and is finally filed in the Ministry of Health, which feeds the system with data made publicly available on the DataSUS6 website.
The NSH 2019 was a population-based cross-sectional survey, in which a cluster sample was used in three selection stages: census tracts or set of census tracts (primary units); households (secondary units), and residents (tertiary units). In this edition, interviews were carried out in 90,846 households, with a response rate of 96.5% of the initially planned sample. Among those interviewed, 46,869 were women over 18 years of age, who make up the sample used in this study4.
In 2019, the NSH questionnaire presented a module dedicated to questions about the experience of violence (module V), applied to respondents aged 18 years or over. Data were collected on psychological, physical, and sexual violence experienced in the last 12 months, in addition to data on the aggressor, the place where the violence took place, the search for healthcare at a health establishment, and the place where medical care was provided. It is important to highlight that for those interviewed who reported more than one episode of violence, the data on health care referred to the most serious episode in the last 12 months.
The 2019 NSH database was used to estimate the underreporting of VAW from SINAN 2019. The variables that make up each subtype of violence according to the data source are described in Table 1.
Table 1

In the SINAN database, reports of cases of sexual, physical, and/or psychological violence against women, aged 18 years or over, were selected, excluding cases of self-harm. Reports containing more than one form of violence were classified in the following order: sexual, physical, and psychological (Figure 1a).
In the NSH database, women of the same age group were selected, with reports of the same subtypes of violence and who had sought care due to health consequences related to the experience of violence in a reporting unit (question V038). Women with more than one report of violence were classified using the same SINAN criteria (Figure 1b).
The proportion of SINAN and NSH violence per state was calculated by:

〖Proportion〗_ijk=〖Frequency〗_ijk/〖NSH Population〗_j ,

Given that:
Frequency = number of cases of i-th, data sources, of j-th, states, and k-ésima, violence
NSH Population = estimate of population in j-th states
i = 1.2 (data source)
j = 1, 2, ..., 27 (states)
k= 1, 2, 3 (type of violence)
The underreporting of SINAN was calculated by
〖〖underreporting SINAN〗_jl〗_ =〖Proportion SINAN〗_jl/〖Proportion NSH〗_jl
j = 1, 2, ..., 27 (states)
l = 1, 2, 3 (type of violence)

The NSH population estimate for each state was calculated in the STATA Survey module. Database analyses were carried out using the Rstudio program.
This study used data from secondary databases in the public domain that do not allow identification of individuals, and therefore did not require approval from the Research Ethics Committee. The NSH project was approved by the National Research Ethics Commission (CONEP) under Opinion No. 3,529,376, issued on August 23, 2019.

Results
In 2019 NSH, the prevalence of women, aged 18 or over, who reported some type of violence in the last 12 months was 19.38%. Among the women who reported any subtype of violence, only 16.86% of them sought health care, which makes a population total of 1,398,465 reports of VAW seeking health care in 2019. The majority of participants (94%) reported a single type of violence (data not shown).
In the 2019 SINAN, 129,924 cases of violence against women, aged 18 or over, were reported and the majority of VAW notifications (67%) presented a single type of violence (data not shown).
Psychological violence represented the subtype of violence with the lowest notification rate in Brazil as a whole, at a mere 1.5%, and in all states. Paraná (4.3%), Pará (4.0%), and Ceará (3.7%) are the states with the highest reporting percentage. Acre, Sergipe, and Rio Grande do Norte showed the lowest reporting percentages, with 0.1% each (Figure 2).
Physical violence had the highest reporting rate, with 75.9% in Brazil, with Rondônia being the state with the highest reporting percentage (46.1%), followed by São Paulo (43.0%) and Minas Gerais (40.1%). At the other end of the spectrum, Pará, Sergipe, and Ceará had the lowest reporting percentages, with 6.6%, 7.1%, and 7.4%, respectively (Figure 3).
Finally, sexual violence was reported at 10.6% in Brazil, with a large discrepancy in reporting between states. While the Federal District (FD) presented a reporting percentage of 84.0%, the second most reporting state, Paraíba, had 38.9% of reports, followed by Pará, with 35.1%. By contrast, Sergipe presented only 0.9% of reports, while Piauí presented 1.9% and Amapá, 2.2% of reports. It is important to highlight that it was not possible to calculate the reporting percentage for Rio Grande do Sul and Mato Grosso, since there were no reports of sexual violence by women interviewed in the 2019 NSH for these two states (Figure 4).

Discussion
This study estimated the underreporting of VAW in SINAN based on data from the 2019 NSH. A high percentage of underreporting was found in the country, with the number of women who suffered violence and who sought health care being ten times higher than the number of VAW reports. Psychological violence was the most underreported, while physical violence presented the highest percentage of reports. Furthermore, the states in the North and Northeast of Brazil showed the highest percentage of underreporting.
The results of this study showed that psychological violence was the most underreported in all Brazilian states, with the best reporting rate, in Paraná, not reaching 5% of the cases and, in some states, reporting was approximately zero. By contrast, psychological violence is the most prevalent subtype of violence in the 2019 NSH, in addition to the psychological consequences being the most reported by women due to any subtype of violence4. These findings show, on one hand, the magnitude of the violation of Mental Health that the experience of violence imposes upon women and, on the other hand, how much psychological violence appears to be marginalized in the health sector. The biomedical model still persists in Brazil, with health practices centered on medical-hospital logic14. In this model, psychological suffering is seen only as a disorder that requires physiological resolution and its association with other social determinants, such as violence, is ignored or considered of lesser relevance15. Thus, the massive underreporting of psychological violence may be related to the non-recognition of psychologically abusive situations as violence, as well as to the lack of training in health services to effectively support these women16.
Physical violence showed the lowest underreporting in Brazilian states, at less than 70% in a third of the states. Physical injuries are generally those that demand the most health attention, as they directly threaten life and often leave their victims at risk of death17. Furthermore, the physical consequences tend to be more visible, which can increase the recognition of violence and engage more professionals in reporting these cases18.
The underreporting of sexual violence found in this study showed a large discrepancy between states, but the high reporting percentage found for FD is noteworthy, with 84% of reports for this subtype of violence. It is worth mentioning that the FD has a population similar to that of medium-sized capitals in Brazil. Therefore, the organization of surveillance in this district may be more advanced than in other states with countryside and rural populations. More studies are needed to understand the standardized underreporting by size and urbanization of the places studied, thus enabling a fairer comparison.
Another finding of this study was that the states in the North and Northeast regions had the highest rates of underreporting for all VAW subtypes analyzed in this study. Previous studies19,20 have shown that these two regions have the highest national rates of VAW. However, underreporting is related to the precarious implementation of the surveillance system, as these are regions with less public investment, care gaps, and less access to information technology and training21,22.
Since 1996, violence has been considered a priority public health issue by the WHO23; however, this problem continues to be stigmatized. There is a lack of training and awareness among health professionals to recognize the indirect signs of violence and to understand the importance of reporting it11.
Women who live with violence are more inclined to seek health services with indirect demands, making it necessary for health professionals to be attentive and prepared to correctly conduct themselves in these cases24. Violence should be suspected when a woman presents non-specific health symptoms, such as headache, abdominal and lower back pain, sleep disorders, fibromyalgia and irritable bowel syndrome25. Furthermore, women who live with violence are more prone to unhealthy lifestyle habits, such as physical inactivity, smoking, and alcohol abuse2.
Furthermore, health professionals need to be guided regarding the obligation and scope of reports of suspected and confirmed situations of violence. Previous studies18,26,27 have shown that the main barriers to reporting violence are: difficulty in recognizing violence, not understanding the importance of reporting, the lack of familiarity with the reporting form, as well as the fear of reprisal from the aggressor. Therefore, mandatory reporting is still a challenge, requiring awareness and training of professionals working at the local level, as well as intersectoral dialogue to consolidate flows and protocols28.
Taking into account the scenario mentioned above, as well as the need of constant updating of health professionals, the Ministry of Health, in partnership with the Federal University of Minas Gerais, developed an application to qualify the reporting of violence, known as NotiVIVA29. This application aims to guide health professionals in identifying types of violence, improve the completion of the FNI, and support the referral of suspected or confirmed cases of violence to the health care and social protection network. The application was launched in November 2022, and it is expected that its disclosure and dissemination can increase professionals\' knowledge, thus contributing to improving the violence reporting rate in the country.
In addition to underreporting, it is necessary to understand the low demand for women who live with violence in the health sector. Despite the high rate of health consequences secondary to violence, a previous study4 showed that only a fifth of all women sought care at any health facility. These women often seek other sectors, such as the Police Force or the Court System, to report cases of violence that they have suffered, as they perceive these spaces to be more appropriate or resolute30,31. At the same time, the Health Sector is understood as a place only for resolving cases of injuries and physical consequences16. Therefore, many women may not report their situation to health professionals due to the stigma of violence32,33, but also because they do not recognize health as a gateway to the Care Network for women who live with violence16,34. Therefore, better coordination between the different sectors involved in combating VAW is necessary, such as Health, Public Security, Economy, Education, and Social Assistance, in order to achieve a greater effectiveness of Public Policies and a greater outreach to women who need help to leave the cycle of violence in which they are inserted1.
It is important to remind that this study was carried out with data prior to the COVID-19 pandemic. Studies have shown that social isolation increased the rate of domestic violence, at the same time that reporting decreased35. This reality may have been influenced by the closure of health establishments, women\'s fear of becoming ill when seeking a health service, and the overload of work upon health professionals36. Therefore, it is essential to continue population-based surveys so that the true impacts of the pandemic on VAW can be measured.
Among the limitations of this study, its ecological design stands out, which hinders a causal inference. Furthermore, violence is self-reported, making it possible for there to be an underestimation of the prevalence of VAW due to recall and information bias. It is also worth mentioning that the NSH excludes populations with low household income and those living in Quilombo settlements and indigenous groups from its sample. However, as it is a household-based survey, it is considered a survey with a representative sample of the Brazilian population. Finally, when considering cases reported in SINAN, it is impossible to exclude the fact that the same woman may have generated more than one report in the system.
In conclusion, this study showed that there is a high percentage of underreporting of VAW in Brazil. It is important to note that this study is representative of underreporting in the health sector. Other types of underreporting, such as in police stations, and a general underreporting of cases, which includes all women, as in the case of those who do not have access to the women\'s care networks, must also be investigated and estimated, in order to be able to calculate the real number of women who live with violence in Brazil. Since Public Policies are built based on evidence and data from the information systems available in the country, there is an urgent need to improve the reporting rate so that women\'s rights are guaranteed and are placed on the agenda of debates among the referent governmental powers.

Acknowledgements
This research was completed as part of broader work by the Lancet Commission on Gender-Based Violence and the Maltreatment of Young People. This Commission received support from the Oak Foundation Children’s First Fund, a fund of the Tides Foundation, the Botnar Foundation, the Finker-Frenkel Foundation, Wellcome Trust, Mena Catering, and EMD Serono, a Merck KgaA company. The views expressed are those of the authors and do not necessarily represent those of The Lancet, the Commission\'s funding sources, or their affiliates.

Funding: Bill & Melinda Gates Foundation

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