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Conteúdo (article):

Socio-demographic, family context and behavioral variables associated with intrafamily physical violence in National School Health Survey (PeNSE)

1. Authors
Paulla Hermann do Amaral - Programa de Pós-Graduação em Psicologia da Universidade
Federal do Rio Grande - paulla.hdoamaral@gmail.com - https://orcid.org/0000-0002-6150-3862

Roberta Hirschmann - Programa de Pós-Graduação em Psicologia da Universidade Federal do
Rio Grande - robertah.epidemio@gmail.com - https://orcid.org/0000-0002-3775-0310

Tiago N Munhoz - Curso de Psicologia, Universidade Federal de Pelotas e Programa de Pós-
Graduação em Psicologia da Universidade Federal do Rio Grande - tiago.munhoz@ufpel.edu.br - https://orcid.org/0000-0003-1281-9542

2. Abstract
Abstract The aim was to evaluate the magnitude of population groups at greater risk of intrafamily physical violence (IPV) among 9th grade students. Data from the Pesquisa Nacional de Saúde do Escolar (PeNSE) [National School Health Survey] was used in a cross-sectional school-based study, whose sampling took place in three stages: selection and analysis of municipalities, schools and school classes. Univariate, bivariate and multivariate analyses were conducted, considering the sample weights. Information referring to 60,905, 108,793 and 102,072 students were examined. This identified IPV prevalences of 9.5%, 10.9% and 14.5% for each year analyzed, respectively. After adjustment, it was found that IPV victimization was higher among female students who self-declared black, brown, yellow or indigenous, were aged 15 and 16, and whose mothers had a lower level of education. It was observed that the occurrence of IPV increased in the study period, signaling the need for specialized policies, programs and services to turn attention toward the most vulnerable population segments. The implementation of preventive strategies in the school context, with emphasis on family dynamics, may be a vector for reducing the number of IPV episodes, consolidating the family as a social system contributing to breaking the cycle of violence.
3. Complete body of the article
Introduction
Violence is a universal social problem that affects the health and well-being of different populations1. It is defined by the World Health Organization as an intentional use of force against oneself, another person, group or community, resulting in suffering, death, psychological harm, impaired development or deprivation2. The nature of violent acts can be physical, sexual, psychological or related to deprivation or abandonment3. Physical violence, also denominated physical abuse, is characterized as violent, intentional acts in which physical force is used to harm, injure, cause pain and suffering, whether leaving obvious marks on the victim’s body or not4.
This type of violence is presented in different contexts, which, among them, that of the family5. Intrafamily Physical Violence (IPV) can be committed in the home or outside, by any family member in a relation of power over the victim. World estimates indicate that one in two children and/or adolescents (aged 2 - 17) suffers some kind of violence (physical, sexual and/or emotional) each year7. In Brazil, violent abuse (physical, sexual and/or emotional) is the type of crime against children and adolescents with the highest number of records in police reports. Almost 20,000 cases were reported in 2021. Of this total, 81% occurred in the victim\'s home, generally practiced by someone close to the family8.
It is the role of the parent/guardian to carry out practices aligned with the child\'s needs, so as to fulfill the goal of educating him/her in the best way possible, free from any form of violence and exploitation. However, intrafamily violence has a highly complex nature, making it impossible to attribute it to a single cause9. Contexts of social, economic and symbolic vulnerability play crucial roles in the emergence of violent relations. Social vulnerability can be understood as the exclusion of children, adolescents and their families from participation in recognized institutional and community spaces, such as day care centers, schools, leisure and cultural activities, among others. As for economic vulnerability, it is essential to highlight that the practice of violence cannot be belittled or justified by poverty. However, it cannot be ignored that precarious living conditions permeate affective ties, strengthening, in some cases, feelings of solidarity, and, in others, weakening these ties due to the low self-esteem of parents and children, generating intolerance and violent reactions in the face of helplessness and/or lack of some vital need. Symbolic vulnerability reveals the fragilization of the authority and reference of parents and others responsible for children and adolescents due to individual, family and collective conditions. Intrafamily violence, therefore, occurs in a context of binding relationships, where aggressors and victims maintain affective, albeit ambivalent ties. This violence is shaped by asymmetrical relations of power between generations and genders9.
The occurrence of IPV against children and adolescents can negatively affect physical, cognitive, emotional and social growth, or even contribute to an increase in consumption of alcohol, tobacco and other drugs as an attempt to relieve the suffering experienced10,11. Physical violence can double the chances of childhood behavioral disorders, or even lead to lifelong psychological trauma, such as the development of eating disorders, depression, anxiety, post-traumatic stress, attention deficit, and disruptive behavior11–14 .
To contribute to the monitoring of the health status of populations in order to formulate and evaluate health policies and programs, and as violence against children and adolescents is a public health problem with a harmful impact, the specific objective of this study is to analyze the prevalences and factors associated with IPV among 9th grade school students in 2009, 2012 and 2015 in Brazil and its macroregions, consulting data from the National School Health Survey (PeNSE). Accessing this database, only three published articles were found14–16 mentioning IPV as an outcome. Thus, in addition to expanding the debate on the theme, this study seeks to present the IPV in three years of the PeNSE data and those of different macroregions.
Methods
PeNSE has a cross-sectional school base and monitors the Brazilian adolescent population (10 - 19) in public and private schools, in urban and rural zones, 26 state capitals and the Federal District. The survey is conducted by the Ministry of Health (MS) and the Brazilian Geography and Statistics Institute (IBGE), with the support of the Ministry of Education (MEC), the editions being 2009, 2012, 2015 and 2019. This study analyzed data from only the first three editions, since, in 2019, the outcome (IPV) was collected in a period different from those of the other years. Data collection was performed through a structured, self-applied questionnaire among the students present on the day of the interview. The inquiry followed the research methodology developed by the WHO entitled “Global School-Based Student Health Survey (GSHS)”. The sampling process was carried out by conglomerates in two stages, whose schools correspond to the first selection stage and the classes of students enrolled for the second stage. All students of the selected classes were invited to participate. Detailed information about the PeNSE methodology is available in the 200917, 201218 and 201519 reports.
The outcome of interest to this study is IPV victimization committed by adults. To evaluate IPV prevalence, PeNSE posed the question: "In the last 30 days, have you been physically assaulted by an adult in your family? If so, how many times?" All students who responded “Yes” and had suffered one or more aggressions in the stipulated period were considered victims. The IPV outcome was also presented in the years 2009, 2012 and 2015 of the PeNSE, which allowed a precise analysis of the data.
Regarding independent variables, the analysis considered: the country region (Northeast; North; Midwest; South; Southeast); self-declared race (white; black; brown; yellow; indigenous), age in complete years (≤ 13; 14; 15; ≥ 16); mother’s educational level in years of study (0; 1 to 8; 9 to 11; ≥ 12 ); parental/guardian supervision (knowledge of what their children did in their free time), school follow-up (verification by those responsible for supervising homework), family understanding (regarding concerns and problems experienced), invasion of privacy (those responsible interfered with their things without permission), alcohol consumption and taking illicit drugs (marijuana, cocaine, crack, glue, loló, lança-perfume, ecstasy, oxy, among others) in the last 30 days. The choice of independent variables took into account those that, according to the literature, were related to IPV and available in the PeNSE questionnaires. For the purpose of comparison among the years evaluated, the questions maintained the same format and range of answer options.
The data were analyzed in the STATA Statistical Program (version 13). All the analyses used the svy prefix, which estimates the sample weights in complex sampling. The absolute and relative frequencies of the variables were described by means of tables. Bivariate analyses were performed to test the association between the dependent variable and the independent variables using the chi-square test, results being expressed in prevalences. Gross and adjusted analyses for potential confusion factors were performed by means of Poisson\'s regression, obtaining prevalence ratios (PR) and 95% confidence intervals (CI95%). The adjusted analyses were conducted according to a two-level hierarchical model. The first level consisted of socio-demographic variables: gender, race and self-declared color, age, and mother’s education. The second level was constituted of family and behavioral context variables: parent/guardian supervision, following the child’s school activity, family understanding, alcohol consumption and illicit drug-taking. In the statistical modeling, the backward selection strategy was used, in which variables with p<0.20 were kept at subsequent levels for confusion control, adopting a 5% significance level. The research was guide by Law No. 13.010/2014, Estatuto da Criança e do Adolescente [Children and Adolescents Statute], and each data collection was approved by the Comissão Nacional de Ética em Pesquisa (CONEP) [National Research Ethics Commission].
Results
Among the students evaluated in the PeNSE, the surveys carried out in 2009, 2012 and 2015, with totals of 60,905, 108,793, 102,072 students, respectively, presented information about IPV and comprised the samples of this study.
Table 1 presents the characteristics of the sample in each year evaluated. Regarding the socio-demographic characteristics, in all the years evaluated, the highest proportion in each sample consisted of 14-year-old, brown-skinned, female students whose mothers had studied between 1 and 8 years. With regard to the family context, it was observed that in 2009 about 30% of parents and/or guardians did not supervise their children’s lives at school, this percentage becoming lower in 2012 and 2015, (16% and 11%, respectively). Besides this, in 2012 and 2015, approximately a quarter of the sample did not receive school monitoring, and about 18% of students reported absence of family understanding, while more than half of the respondents reported feeling that their privacy was invaded by parents/guardians. Regarding student behavior, there was a reduction in alcohol consumption between 2009 and 2015, while the taking of illicit drugs was higher in 2012 than in the other years).
Graph 1 demonstrates the prevalence of IPV in terms of the PeNSE and macroregions over the years. Overall, a higher proportion of IPV was observed in 2015, compared to other years, in all regions. Furthermore, it was also noted that there was an increase in IPV between 2009 and 2012 in all regions and years, except in the Southeast, where IPV was lower in 2012.
Table 2 presents the results of the gross and adjusted analyses for the three years under study. In the gross analysis, IPV was associated with most of the variables studied, except in 2012, and with the mother’s educational level in 2009. After adjustment, the same associations observed in the gross analysis remained, except for supervision by parents/guardians in 2012.
Table 3 presents the results of the gross and adjusted analyses (prevalence ratio, PR) of IPV, stratified by macroregion and year, considering gender exposure. In general, it was observed that girls were more likely to suffer IPV than boys in different regions and years. In the three-year period evaluated, after adjustment, PR ranged from 0.97 to 1.44. In 2009, girls residing in the Midwest showed a higher likelihood of IPV, about 1.3 times higher than boys in the same region. Association in the same direction was also observed in the North. In 2012, the largest exposure to IPV was in the South among girls, while no statistically significant association among students was observed in the Southeast. In 2015, after adjustment, a significant association was observed in the Midwest and South, and, among girls in the South, there was the largest measure of observed effect, compared to the boys of the same region.
Discussion
IPV victimization was greater for female students, who self-declared their race and skin color as black, brown, yellow or indigenous, aged 15 and 16, and whose mothers had less education (0 years of study). Parent/guardian supervision, school monitoring, family understanding, privacy invasion, alcohol consumption and illicit drug-taking were also associated with IPV.
The percentage of students who suffered IPV underwent a progressive increase in the period analyzed, from 9.4% in 2009 to 11.6% in 2012 and 16% in 2015. Being female increased the likelihood of suffering IPV in different macroregions, as stated in previous studies20,21. The greater susceptibility to IPV exposure among girls can be explained in part by differences in gender roles and unequal treatment among family members, reflecting a cultural tendency to trivialize and accept violence against women, in addition to perpetuation of the cycle of violence of domination, threat and silence15,22–24.
Regarding the different Brazilian macroregions, the highest IPV rate may be related to poverty and social inequality rates. According to the National Continuous Household Sample Survey25, the proportions of people at/below poverty level were 36.4% in the Northeast, 33.9% in the North, 29% in the Southeast, 28.4% in the Midwest, and 24% in the South. The high figure in the Northeast significantly influences calculation of the contribution of poverty, as the region is poor and densely populated. Meanwhile, the Southeast is the region that most contributes to inequality in the country - 64.9%, which is because the population density in the region is high and concentrates most of the GDP generation, while there is a large proportion of low-income earners. This region is followed by the South (10.6%), Northeast (9.7%), Midwest (8.5%) and North (2.7%).
These areas are more affected by violence due to overlapping deprivation or the presence of concentrated economic, educational, family structure disadvantages, which have been considered as sources of risk for children and adolescents26. Furthermore, great exposure to violence and fear can result in less communication among people, less identification of common problems and less collective action. Often, fear or victimization experience leads people to adopt self-protective measures that distance them even more from each other. At the extreme, these measures may have the effect of reducing social cohesion27.
The students who self-declared their race and color were more exposed to IPV than those who were white. This scenario is indicative of racial inequality when focusing on violence that affects the young. Health professionals from the Centro de Atenção Psicossocial Infantojuvenil (Capsij) [children\'s psycho-social care center] report that physical violence is among the main types of violence experienced by black children and adolescents, family members being one of the main agents28. Thus, the greatest prevalence IPV victims in this group may be related to unfavorable, unequal socio-economic conditions, such as precarious living environments, drug-taking and trafficking, as well as unequal access to health services29. For example, many incidents of violence against black children are not referred to the Conselho Tutelar [Guardianship Council], or the agency faces difficulty ensuring victims\' rights due to less effective actions, more revictimization and naturalization of violence in this population as a result of structural racism30.
The vulnerability of racial minorities is also understood in the light of the accumulation of stressors through concentration of power, privileges and resources that submit individuals to a reality of more frequent stressful experiences, limited possibility of social transformation and lower stress control capacity31.
The skin color and physical traits may be intrinsically linked to the distribution of affections that privilege those closer to the aesthetics of whiteness, to the detriment of those identified as having characteristics more associated with black people32. Brown and black people presented higher values of rejection within the family and greater perception of everyday discrimination, experienced in ordinary situations through differences in treatment and devaluation. Violent messages transmitted by the family, whether implicit or not, help to create internalized racism that, in some cases, leads to depression or material consequences that limit access to education, thus causing fragile self-esteem33.
Moreover, it is clear that the way of bringing up children relates to position in the social hierarchy. From this perspective, it is understood that practices, language use, interaction with institutions, that is, the formation of children\'s cultural and human capital differs according to their social class34.
Regarding age, students belonging to the upper range (15 and 16 or over) were more exposed to IPV. A survey conducted with data from the National Survey of Children\'s Exposure to Violence (Natscev) of 2008, 2011 and 2014 with young people from 10 to 17 (n = 13,052) revealed that more than one third suffered physical aggression during the years of the study, and about 50% of this sample lay between 14 and 1735. The relationship between the occurrence of IPV and age can be attributed to a variety of factors, which encompass the characteristics of adolescents, parent(s)/guardian(s), the local community, as well as the social, economic and cultural aspects36. Adolescence is a phase when the young tend to confront established order, rules and parents, due to ignorance, misunderstanding and intolerance, leading to use of physical strength as a means of control37,38.
Iin 2012 and 2015, the IPV prevalence was also greater among students whose mothers had not been educated. Other studies also found that physical violence was higher among students whose parents had less education39,40. In this context, education emerges as a crucial element in IPV prevention. This is due to the fact that education promotes a culture of tolerance and respect for human rights, since less educated parents/guardians have a more limited repertoire of emotional regulation skills, and become less equipped to create positive responses to cope with tension and adversity, leading to a greater chance of escalation to aggressive episodes. Thus, there is a generational cycle of low parental education, low income, scarce emotional control capacity, and situations of violence in the family15.
Regarding the family context, in 2009 and 2015, IPV was more frequent in students who were not supervised by their parents/guardians. In 2012 and 2015, not being monitored at school by parents and not being understood about their concerns and problems were also prevalent characteristics in such victims.
During adolescence, the individual experiences moments of imbalance and extreme instability, feelings of insecurity, confused, distressed, wronged and misunderstood, which can negatively influence his/her relationship with people closer to their social circle, and cause problems. However, this crisis can be considered normative as it is of paramount importance for the psychological development of individuals41. The experience of adolescence is a process that affects not only the individual, but the whole social and family environment, since, during this period, there is an increase in fights and disputes between children and those responsible for their upbringing, since there is a need for constant negotiation between generations and values. However, through dialogue and understanding, these moments can lead to growth in harmony between parents and children42. In this phase of development, dialogue is essential because, in this phase adolescents need the guidance and understanding of parents. Lack of dialogue in the family environment can, therefore, cause or, in certain cases, accentuate some difficulties, especially in terms of relationships, and may even affect the well-being and psychic health of adolescents. Other researchers understand that dialogue, affection and respect, create harmony and give more genuine effectiveness in the relationship between parents and adolescents, thus ensuring more confidence in themselves to deal with their age-related issues43.
Thus, the practices of supervising, accompanying, knowing the routine of the child and his/her relationships help in establishing a bond, affection and dialogue. These factors can contribute to healthy coexistence and co-operation practices, creating assertive spaces through non-violent relationships44.
Furthermore, in relation to the family context, in 2012 and 2015, having privacy invaded by a parent/guardian was also a prevalent characteristic among IPV victims. This feature may highlight an unstable family environment in which a relationship based on dynamics of power and domination/subordination could occur23,45. In these relationships, parents and children are in asymmetrical positions of power, playing strict roles and creating their own dynamics, which differ from one family group to another9. It is noteworthy that the intimacy of children and adolescents is a right guaranteed by the ECA, which mentions respect and privacy, as well as preservation of personal spaces and objects, image, identity, autonomy, values and beliefs46. Thus, having parents who, while accompanying and monitoring the child’s activities, also respect his/her inner “world” and concrete objects, were described as protective shields against IPV15.
IPV was also more prevalent among students who consumed alcohol and took illegal drugs. However, the relationship between IPV and drug addiction in adolescence may have a bidirectional relationship16. For example, in a study among adolescents (12 - 17), those taking marijuana were prone to experiencing situations of physical aggression47. This IPV exposure can increase the feeling of insecurity, which, by generating internal tensions, could explain the construction of negative stress relief strategies through higher drug and substance consumption by these adolescents. On the other hand, drugs, whether legal or not, also bring adolescents closer to situations of violence. Therefore, alcohol and other drugs consumed by adolescents may be a cause or consequence of IPV16. Moreover, the family environment of students who reported drug-taking and alcohol consumption is, most of the time, one in which there is pathological functioning regarding communication, establishment of rules and limits, and lack of affection41. These young people regard the family as negative, lacking a close bond and support, and without well-defined roles48. Thus, the adolescent who is not welcomed, seeks sources of reinforcement, possibly including involvement with groups of other young people who also come from distanced families and take substances in an attempt to compensate for the emptiness left by the family49,50.
The presence of multiple risk indicators reported by adolescents may reveal that IPV is a form of manifestation of the fragility of these family interactions. Just as the causes are diverse, the solutions to this problem will also be complex and multidirectional. Among all types of violence, that of intrafamily has particularities that require attention due to its complexity5. Because it constitutes violence committed by actors that should play protective roles, it is important to understand the context. Understanding the vulnerabilities in which adolescents are placed is essential to formulate strategies for health promotion according to their needs and experiences in order to aid the direction of public policies, promote improvement of health indicators and prevent exposure to risk in this phase.
The systematization, analysis and interpretation of the data has characterized IPV through risk factors associated with school adolescents. However, the limitations of the study should be considered. First, the research was conducted among adolescents who attend school and were present on the day of the survey, thus often not including students with low school attendance due to their social, family and emotional context, which are factors highly related to situations of violence . In addition, due to the greater or lesser social acceptance of the behavior researched, the information self-declared by the adolescents was susceptible to underestimation or overlooking of the indicators studied. However, as a positive point, we mention the use of self-applied data collection instruments, as well as the guarantee of confidentiality, thus minimizing the possibility of occurrence of bias. Finally, the IPV data in 2019 were collected in a different period , thus precluding them from this study.
Regarding the positive aspects, the study stands out due to its use of data from a broad national, school-based, and representative sample of the population studied, as well as the analysis spanning three years of study. Also, PeNSE uses primary data, unlike most violence data that include services or health systems that are susceptible to underlying bias.
Final Considerations
The results indicated a greater prevalence of physical violence perpetrated intrafamily against girls in different macroregions, non-white and older adolescents, children with a low educational level, and risk factors regarding lack of supervision by parents/guardians, school follow-up and family understanding, plus invasion of privacy, alcohol and illegal drug consumption. Thus, for prevention and decreased IPV, public policies that foster health, education and social development actions must be implemented. These strategies may involve improving parents’ educational practices to become democratic and promote mutual respect. The school and education professionals, as central actors in preventing and responding to violence, can also promote continuing education, reflections and discussions in study groups, seminars and workshops, as well as production of didactic-pedagogical support material.
From analysis of the results, it is suggested that, in new approaches to the theme, the same questions and answers be used in surveys, as well as the same application periodicity aiming at enhanced data analysis. Finally, it is important to emphasize that, while there are public policies to prevent and confront IPV, it was found that it is necessary to incorporate gender and racial aspects in the construction of education, health, social assistance and public security policies so as to be conducive to construction of protective factors for populations with high risk factors.

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