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Conteúdo (article):

VIOLENCE AGAINST WOMEN IN LIFE: STUDY AMONG PRIMARY CARE US-ERS
Ione Barbosa dos Santos1, Franciéle Marabotti Costa Leite2, Maria Helena Costa Amorim3, Paulete Maria Ambrósio Maciel4 e Denise Petrucci Gigante 5
1Prefeitura Municipal de Vitória, Secretaria Municipal de Saúde. Vitória, ES, Brasil. E-mail: ilubarsantos@hotmail.com
2Departamento de Enfermagem. Programa de Pós-graduação em Enfermagem e Programa de Pós-graduação em Saúde Coletiva. Universidade Federal do Espírito Santo. Vitória, ES, Brasil. E-mail: francielemarabotti@gmail.com
3Programa de Pós-graduação em Enfermagem e Programa de Pós-graduação em Saúde Coletiva. Universidade Federal do Espírito Santo. Vitória, ES, Brasil. E-mail: mhcamorim@yahoo.com
4Programa de Pós-Graduação em Enfermagem. Universidade Federal do Espírito Santo. Vitória, ES, Brasil. E-mail: pauleteambrosio@yahoo.com.br
5Departamento de Nutrição. Programa de Pós-Graduação em Epidemiologia. Universidade Federal de Pelotas. Pelotas, RS, Brasil. E-mail: denise.epi@gmail.com

RESUMO
Objetivo: Estimar a prevalência e os fatores associados à violência praticada por parceiro íntimo, ao longo da vida, entre as usuárias da Atenção Primária. Método: Estudo transversal com mulheres de 20 a 59 anos. O rastreio das violências foi feito pelo instrumento da Organização Mundial de Saúde. Regressão de Poisson foi utilizada para análise bruta e ajustada. Resultados: Participaram 991 mulheres. As prevalências de violência, ao longo da vida, foram: psicológica 57,6% (IC95%: 54,6–60,7); física 39,3% (IC95% 36,2–42,3) e sexual 18,0% (IC95% 15,7–20,5). Mulheres com até oito anos de estudo, divorciadas ou separadas, cujas mães sofreram violência por parceiro íntimo, que relataram uso de drogas e vivenciaram a violência sexual na infância apresentaram maiores prevalências das três violências. A religião esteve associada às violências psicológica e sexual e o uso de cigarro às violências física e psicológica. Participantes de menor renda familiar tiveram maiores prevalências de violência física. Conclusão: elevada prevalência de violência cometida pelo parceiro íntimo ao longo da vida entre as usuárias. Piores condições socioeconômicas, comportamentos de risco e histórico de agressão estão associados à maior ocorrência deste agravo.
Palavras-chave: Violência. Fatores socioeconômicos. Maus-tratos conjugais. Violência por parceiro íntimo. Violência doméstica.

ABSTRACT
Objective: To estimate the prevalence and factors associated with intimate partner violence among primary care users. Methods: This is a cross-sectional study with women aged 20 to 59 years. Physical, sexual and psychological violence was screened by the World Health Organization instrument. Poisson regression was used for crude and adjusted analysis. Results: Nine hundred ninety-one women participated in the study. The prevalence of violence throughout the lifespan was: psychological 57.6% (95% CI 54.6-60.7); physical 39.3% (95% CI 36.2-42.3) and sexual 18.0% (95% CI 15.7-20.5). Women with up to eight years of schooling, divorced or separated, whose mothers suffered intimate partner violence, who reported drug use and experienced sexual violence in childhood showed a higher prevalence of the three types of violence. Religion was associated with psychological and sexual violence and the use of cigarettes to physical and psychological violence. Participants with lower household income had a higher prevalence of physical violence. Conclusion: A high prevalence of intimate partner violence was identified among users. Worse socioeconomic conditions, risk behaviors and a history of assault are associated with greater occurrence of this problem.
Keywords: Violence. Socioeconomic factors. Marital abuse. Intimate partner violence. Domestic violence.
INTRODUCTION
Violence against women is a complex phenomenon based on gender relationships, which triggers physical, psychological harm or suffering to women1. This condition is a worldwide problem and builds on unequal power relationships, that is, it is a type of violence motivated by the unequal gender condition, which begins in the family universe, and gender relation-ships are established hierarchically2.
According to the World Health Organization, in 2013, 30% of women in the world had al-ready been victims of intimate partner violence3. In Brazil, a population-based study with a representative sample of 15 years or more showed that 43% of Brazilians reported having suffered violence by men in their life; one-third admitted having suffered some form of physi-cal violence, 13% sexual and 27% psychological. Husbands, former husbands, boyfriends and former boyfriends were the main perpetrators, ranging from 88% of slaps and shoves to 79% of perpetrators of forced sex4.
This high-prevalence social phenomenon dramatically affects women’s health and lifestyle5. The damage caused by such violence can last a lifetime and reach generations, with severe effects on health, education, work, crime and economic well-being of individuals, families, communities and societies6, thus being a great concern for the Brazilian population and the health sector, since it can lead to deaths and physical and emotional traumas7. Therefore, the knowledge and proper posture of the professionals in the care of the victims, identifying and notifying the cases is crucial, since the health services should receive and support, and not be an obstacle for the victims8.
However, the literature indicates that the suffering of women in a situation of violence is not yet seen as an element that deserves intervention from health professionals unless there is some objective anatomopathological basis to justify it. In the latter case, the interpretation of disease can be accepted, and violence loses meaning and relevance and tends to be disregard-ed7. The practices of primary care teams in the face of situations of domestic violence are still challenging and are a dilemma for the construction of comprehensive care. The professionals’ unpreparedness in addressing situations of violence is added to their conception of the phe-nomenon and its causes, the actions developed (or not) and the relationship established with the family and other stakeholders of the intersectoral network9.
Given the above, considering the violence a health problem and the absence of studies that address the occurrence of this phenomenon during the life of women in the city of Vitória, this research aimed to estimate the prevalence and factors associated with intimate partner violence throughout the life among primary care users.
METHODS
This is a cross-sectional epidemiological study carried out with data from a primary research on violence against women in the municipality of Vitória, Espírito Santo, conducted in the period from March to September 2014, in all health facilities (US) of the municipality with a Family Health Strategy (ESF) or Community Health Workers Program (PACS), totaling 26 establishments. The municipality of Vitória, capital of the Espírito Santo State, has 327,801 inhabitants10 and a Human Development Index (HDI) of 0.84511.
The sample size calculation considered an acceptable margin of error of 5% and a 95% confi-dence level. We considered a 95% confidence level, 80% power and an exposed/unexposed ratio of 1:1 to study the association with risk factors. Ten percent were added for possible losses and 30% for adjusted analyses, requiring a total of 998 women. We used the propor-tional sampling by health facility technique.
Women were approached in the US and invited to participate in the study and, after accepting and signing the Consent Form, were interviewed individually, with only the respondent and a duly trained interviewer, in a reserved space in the US. Patients who had an intimate partner at the time of the interview or in the last 12 months were included in the study. Intimate part-ners were defined as partners or former partners, regardless of the formal relationship, and current boyfriends, provided they were having sexual intercourse. Exclusion criterion adopted was women with intellectual or sensorial deficits unable to communicate. Regarding this re-search, we used the database containing socioeconomic characteristics: age (categorized by decades); self-reported skin color (white, black and brown), excluding indigenous or Asian origin because they are a negligible group and no inference of the results is possible; schooling (up to eight years, nine years or more); household income at the time of the interview (> = 1500; 1501-2924; <2925); marital status (married, single, divorced or separated, and in com-mon-law marriage); religion (Catholic or evangelical – yes, no). To identify the family expe-rience and life of violence the following were asked, respectively: “Has your mother ever suffered any intimate partner violence?” (yes/no) and “Did you suffer sexual violence in childhood?” (yes/no). Regarding the behavioral characteristics, we asked about: doses of al-coholic drink intake (less than or equal to two, more than two and up to eight, or more than eight doses). One dose corresponded, on average, to a 350 ml can of beer or draft, a 90 ml wine glass, a 30 ml distillate dose, a can or a small bottle of any iced beverage; tobacco use (distributed in two categories: smokers – smoked at least one cigarette per day; non-smokers, who included former smokers) and history of drug use (drug use ever in life – yes; no).
The second instrument applied was the short version of the questionnaire of the World Health Organization (WHO) entitled “World Health Organization Violence Against Women” (WHO VAW STUDY)12, validated for use in Brazil, containing 13 questions that determine the end-points in studies: psychological, physical, and sexual violence perpetrated by the intimate partner throughout life. Violence was considered present when women answered “yes” to one of the items of the instrument. It is worth mentioning that all the participants received a folder containing the primary services for women in situations of violence at the end of the interview and, if necessary, referrals were made to the center for the care for the victims of the munici-pality of Vitória.
Stata 13.0 was used to analyze data. For the bivariate analysis, which investigated the associa-tion between the outcomes and the exposures under study, we used the chi-square or Fisher exact test according to assumptions. The multivariate analysis was evaluated using the Poisson regression, with a robust, crude and adjusted variance for control of the confounding factors according to the hierarchical model (Figure 1). Concerning input to the model, a p-value was not determined so as not to exclude possible confounding factors; the permanence in the model was determined by the value of p <0.05. The Research Ethics Committee of the Feder-al University of Espírito Santo approved this study under Opinion Nº 470.744/2013), on No-vember 27, 2013.
RESULTS
A total of 991 women were interviewed, i.e., seven women refused to participate in the study. Among the participants, a lifelong predominance of psychological violence was found, with a prevalence of 57.6% (95% CI: 54.6-60.7). Physical violence was the second most prevalent, with 39.3% (95% CI 36.2-42.3). Violence with the lowest prevalence was sexual, with 18.0% (95% CI 15.7-20.5). (Data not shown in Table).
In assessing the prevalence of violence according to the characteristics under study (Table 1), a higher prevalence of psychological, physical and sexual abuse committed by the partner in life among women with up to eight years of schooling, belonging to the group of lower household income, divorced/separated, whose mother suffered intimate partner violence, smokers and with a history of drug use was identified. Evangelical women evidenced higher frequencies of physical and sexual violence. Participants in the research with a history of sex-ual violence in childhood had a higher occurrence of intimate partner psychological and sexual abuse throughout life. Also, women who drink more than eight doses of alcohol are among the group with the highest prevalence of psychological and physical violence (p <0.05).
Table 2 shows the crude and adjusted analysis of the effects of socioeconomic, behavioral, and family and life experience on partner psychological violence throughout life variables. After adjustment, psychological violence was associated with schooling, marital status, evan-gelical religion, maternal IPV history, sexual violence in childhood, smoking and drug use (p<0.05). Women with up to eight years of education, whose mother has suffered some inti-mate partner violence, who were sexually abused or are smokers, have a 20% higher frequency of partner psychological abuse over the lifetime when compared to those with higher edu-cation, with no maternal and personal violence history and non-smokers. Likewise, the preva-lence of this condition was 70% more likely among the separated or divorced women when compared to married women (PR: 1.70; 95% CI: 1.37-2.10). Women who have already used drugs are 1.37 more likely to experience psychological violence compared to non-drug users (PR: 1.37, 95% CI: 1.21-1.55). It is also observed that having referred to being evangelical increased by 12% the prevalence of psychological violence (PR: 1.12; 95% CI: 1.01-1.24).
After adjusting for the confounding factors, we verified that the partner physical violence in life was almost 2.27 times more prevalent in divorced and separated women when compared to married ones. As for household income and schooling, an increase in this type of abuse was observed in 41% of the women in the lower income group (≤ to R$ 1,500.00 / month), when compared to the higher income group (R$ 2,925.00/month), and 33% among those with lower schooling (up to eight years of schooling). Women who smoke and with a history of drug use are among the groups with the highest prevalence of physical violence, respectively: 34% and 64% when compared to those who did not report such behaviors. Regarding family and life experience, an increase of 27% is noted among those whose mother has already been beaten by the partner. Among those with a history of sexual violence in childhood, the prevalence of physical violence is 45% higher than those who did not suffer from this abuse in childhood (Table 3).
Table 4 shows the crude and adjusted analysis for intimate partner sexual violence throughout life. After adjustment, a 2.18 times greater prevalence of this violence is observed among di-vorced or separated women, when compared to married women. Those with up to eight years of schooling have a 63% higher incidence of sexual abuse compared to those with higher schooling. Sexual violence was still twice as prevalent in women who had been sexually abused in childhood and had used drugs compared with those who denied these facts. Another point to highlight is the 33% increase in intimate partner sexual abuse in life in evangelical women, compared to those who do not belong to this group. There was a higher prevalence of sexual violence among those whose mother has been beaten by the intimate partner (PR: 1.37, 95% CI: 1.03-1.84).
DISCUSSION
This study reveals a high prevalence of intimate partner violence throughout life among female PHC users in the city of Vitória, and psychological violence was the most prevalent (P=57.6% CI 95%: 54.6-60.7), confirming the findings of a cross-sectional study conducted in 2014, with women in the city of Recife, Pernambuco, where psychological abuse was also the most frequent13. For some authors, this type of violence may be more easily shared due to factors that may involve fear of further assaults or shame of talking about relationship abuse6. It is important to highlight the relevance of analyzing the occurrence of psychological violence and ways to prevent it since it is considered the starting point that triggers all other forms of violence14.
The second type of abuse was physical violence (P= 39.3%, 95% CI 36.2-42.3), with preva-lence similar to that of other national studies15, and although the frequency of partner sexual violence has been the lowest among type of violence investigated (P=18.0%, 95% CI 15.7-20.5), it was higher than the prevalence revealed by another study conducted in Brazil, at 13.6%13. It is believed that several factors contribute to the fact that sexual violence within relationships of solid partnerships is difficult to recognize and delimit, among them, the fact that women do not understand forced sex as violence if they are married or live with the per-petrator. In some countries, while rape has already been recognized as a crime in marriage, in others, the husband still has the legal right to unlimited sexual access to his wife16.
The study identified the association of violence with socioeconomic variables. The lower level of schooling was associated with higher prevalence of violence, corroborating another study17. It is believed that women’s enlightenment leads to lower tolerance for violence. The more women qualify, the more they are likely to find paid work, thus improving self-esteem and independence18. It is also suggested that women with higher education levels would have more resources to achieve greater autonomy and could have more skills to recognize and break with abusive relationships15.
The association of physical violence throughout life with lower income levels was also evi-denced. In this context, despite the violence affecting all socioeconomic groups, more impov-erished women are primarily affected19. These findings are probably explained, since women in a situation of violence, with low social and economic conditions, may have more significant difficulties in decision making in order to break with the violent relationship, considering that she does not have financial autonomy20.
It is also important to reflect on the fact that exposure to violence has adverse effects on school performance21. This can be related to the lower level of schooling of the victims and, thus, to lower income and occupation of less valued positions22. Also, the higher prevalence of domestic violence among poorer households may suggest that the mechanism of intergen-erational transmission of violence may be related to the low intergenerational income mobility. A negative relationship is noted between the prevalence of domestic violence and income, both against parents’ income and women’s current income23.
Consistent with the literature15, the study also revealed a high prevalence of violence among separated and divorced females, suggesting that many women can break free from the situa-tion of violence, breaking with the stereotype that intimate partner violence is a hopelessly chronic situation.
The condition referred to as “mother victim of intimate partner violence” was associated with violence. The literature indicates that a family environment with a history of violence wit-nessed or endured in childhood can trigger a space for violent behavior. Also, it may suggest a gender vulnerability highly related to the violence experienced in adult life. Thus, it is sug-gested that patterns of violence in the family can reproduce through generations24.
Women smokers and those with a history of drug use showed a higher prevalence of physical and psychological violence throughout their lives. However, sexual violence revealed associa-tion only with drug use. The literature confirms higher frequencies of intimate partner vio-lence13 among women with high-risk behavior, such as drug use. Also, it is worth reflecting that experiencing a situation of violence can make women more likely to report alcohol and illicit drug use to address the violent event25,26, or violence in its various forms can lead to the act of smoking to minimize and support this problem27.
The present research reveals that psychological, physical and sexual violence have a significant association with the evangelical religion, a finding that is similar to that pointed out in a recent systematic review that shows that domestic violence is associated with religion28. Thus, the literature suggests a search for religion as a way to support or overcome violence29.
It is also worth reflecting that the confrontation of violence, that is, the act of denouncing or deciding to break with the silence in the face of the situation of violence, has both facilitating and hindering aspects. Personal attitudes such as feelings of exhaustion, outrage and aware-ness of the potential risk of life are among the facilitating aspects, and the hindering factors include fear, guilt and shame, as well as family, material and institutional barriers30. In this context, it is necessary to allocate adequate human resources to expand care centers for vic-tims of violence, considering violence against women an essential public health issue31.
Some limitations of this study must be highlighted. The first of these is that it was conducted in the health service. Thus, the participation of women of better socioeconomic status with access to health insurance may have been lower, and although it is known that the occurrence of violence was lower among these women, it may be that the associations were even stronger with the lowest socioeconomic condition.
Also, there may have been less participation of women in situations of violence that might be inhibited to seek the US. However, the high prevalence of violence identified may suggest that this problem would be even more significant if these women were included in the study. Finally, the cross-sectional design prevents the cause-and-effect relationship between the var-iables. However, strong associations show the importance of establishing measures of inter-ventions concerning the exposures that trigger the highest occurrence of victimization.
CONCLUSION
This study met the proposed objective and evidenced the high prevalence of intimate partner violence throughout life among primary care users in the city of Vitória and the association of psychological, physical and sexual violence with sociodemographic, behavioral and personal and maternal experiences of violence.
Finally, it is understood that this research brings essential contributions to the area of public health, indicating new looks and ways to care for women in situations of violence. Before the sizeable extent of the problem revealed, there is a need to implement detection-sensitive in-struments and instruments that focus on violence in the daily routine of primary care services, thus promoting greater visibility to violence against women, as well as the promotion of trained caregivers attending these victims in an integrated way.
Collaborators:
IBS – Data interpretation, drafting of paper, critical review and approval of the version to be published. MHCA – Critical review and approval of the version to be published. DPG – De-sign, analysis, data interpretation, critical review and approval of the version to be published. PMAM – Critical review and approval of the version to be published. FMCL – Conception, design, analysis, data interpretation and approval of the version to be published.

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