Abstract

This article aims to describe the characteristics of assaults among youth victims of violence treated in Public Emergency Departments, according to sex. This is a descriptive study using data from the Brazilian Violence and Accidents Surveillance System based on a multicenter survey conducted by the Ministry of Health in 71 public emergency departments, located in 24 state capitals and the Federal District in 2011. Male subjects predominated among the victims (75.1%) and also among aggressors (83.1% and 69.7% of cases of violence against male and female victims, respectively). Among female victims, episodes of violence were more frequent at home (43.6%). The perpetrator was a stranger in 49.7% and 26.8% of cases among male and female victims, respectively, while the perpetrator was a partner or ex-partner in 3.9% and 31.5% cases, respectively (p < 0.001). Greater severity of injuries among men was consistent with the higher proportion of deaths in the first 24 hours (2.1%) compared to women (0.2%) (p < 0.001). The violence profile among youth victims treated in Public Emergency Departments was substantially different according to the sex of the victims. The results highlight the need to implement intersectoral policies, in line with the Brazilian Youth Statute.

Health surveys; Young adult; Violence; Sex

Introduction

Youth health patterns have been affected by economic and social changes and global policies during recent decades worldwide¹1. Krug EG, Mercy J, Dahlberg LL, Zwi AB. World report on violence and health. Lancet 2002; 360(9339):1083-1088.. In Brazil, the Youth Statute (Law No. 12852/2013)²2. Brasil. Presidência da República. Lei no 12.852, de 5 de agosto de 2013. Institui o Estatuto da Juventude e dispõe sobre os direitos dos jovens, os princípios e diretrizes das políticas públicas de juventude e o Sistema Nacional de Juventude - SINAJUVE. Diário Oficial da União 2013; 6 ago. was enacted in 2013. Among its principles and directives, the Statute includes the promotion of safe lives and the culture of peace, as well as the need for information management and the production of knowledge about youth, with the aim of developing intersectoral public policies, programmes and actions for youth. The Statute defines youth as being aged between 15 and 29 and in 2010 this corresponded to approximately 52 million young people or more than a quarter of the Brazilian population³3. Instituto Brasileiro de Geografia e Estatística (IBGE). Censo Demográfico de 2010. Rio de Janeiro: IBGE; 2010..

Injuries are the main causes of death among Brazilian youth. In 2013, 73.200 deaths due to violence and accidents were registered, with significant differences between the sexes: 80.5% were young males⁴4. Instituto Brasileiro de Geografia e Estatística (IBGE). Estatísticas do Registro Civil 2013. Rio de Janeiro: IBGE; 2013.. With regard to homicides, a predominance of male victims was found in all age groups in Brazil and in the Americas between 1999 and 2009⁵5. Gawryszewski VP, Sanhueza A, Martinez-Piedra R, Escamilla JA, Souza MFM. Homicídios na região das Américas: magnitude, distribuição e tendências, 1999-2009. Cien Saude Colet 2012; 17(12):3171-3182..

In Brazil high violence-related mortality rates are attributed to homicides in urban settings, whereby both aggressors and victims are mainly young men and social inequalities are one of the main determinants⁶6. Reichenheim ME, Souza ER, Moraes CL, Mello Jorge MHP, Silva CMFP, Souza Minayo MC. Violence and injuries in Brazil: The effect, progress made, and challenges ahead. Lancet 2011; 377(9781):1962-1975., this being different to the reality in the majority of World Health Organization (WHO) member countries where deaths due to assault are related to civil conflicts¹1. Krug EG, Mercy J, Dahlberg LL, Zwi AB. World report on violence and health. Lancet 2002; 360(9339):1083-1088..

In view of this, some studies have discussed differences in morbidity and mortality patterns as being particularly related to masculine role models⁷7. Schraiber LB, Figueiredo WS, Gomes R, Couto MT, Pinheiro TF, Machin R, Silva GSN, Valença O. Necessidades de saúde e masculinidades: atenção primária no cuidado aos homens. Cad Saude Publica 2010; 26(5):961-970.

8. Machin R, Couto MT, Silva GSN, Schraiber LB, Gomes R, Santos Figueiredo W, Valença OA, Pinheiro TF. Concepções de gênero, masculinidade e cuidados em saúde: estudo com profissionais de saúde da atenção primária. Cien Saude Colet 2011; 16(11):4503-4512.-⁹9. Moura EC, Santos W, Neves ACM, Gomes R, Schwarz E. Atencão à saúde dos homens no âmbito da Estratégia Saúde da Família. Cien Saude Colet 2014; 19(2):429-438.. According to Souza et al.¹⁰10. Souza ER, Lima MLC. Panorama da violência urbana no Brasil e suas capitais. Cien Saude Colet 2006; 11(Supl.):1211-22., men expose themselves more to risk situations because of masculinity reinforcing behaviours characterized by machismo and practices capable of causing premature death.

In turn, women are the main victims of domestic and family violence. Intimate partners are the main murderers of women. A systematic review revealed that approximately 40% of all murders of women worldwide are committed by intimate partners¹¹11. Stöckl H, Devries K, Rotstein A, Abrahams N, Campbell J, Watts C, Moreno CG. The global prevalence of intimate partner homicide: A systematic review. Lancet 2013; 382(9895):859-865.. A study conducted in the Brazilian states of São Paulo and Pernambuco in 2003 found that in approximately half the cases of violence against women, the aggressor was an intimate partner (including husbands, partners, boyfriends or ex-partners)¹²12. Schraiber LB, D’Oliveira AFPL, França-Junior I, Diniz S, Portella AP, Ludermir AB, Valença O, Couto MT. Prevalência da violência contra a mulher por parceiro íntimo em regiões do Brasil. Rev Saude Publica 2007; 41(5):797-807..

Violence has been described as a socio-historical phenomenon which is an important public health problem which therefore demands the formulation of specific policies and practices¹³13. Minayo MCS. Violência: um problema para a saúde dos brasileiros. In: Ministério da Saúde (MS). Impacto da violência na saúde dos Brasileiros. Brasília: MS; 2005. p. 9-41.. The recent enactment of the Youth Statute and the fact that violence among young people involves unique characteristics and marked differences between the sexes justify studies being performed on this issue capable of providing elements for tackling the problem of violence among youth in Brazil.

This article aims to describe the characteristics of assaults among youth victims of violence treated in Public Emergency Departments in Brazil, according to sex.

Method

This was a descriptive study using data on victims of violence treated at public emergency services provided by the Unified Health System (Sistema Único de Saúde - SUS). The data were obtained by means of a cross-sectional survey conducted in 2011 within the framework of the Violence and Accident Surveillance System (Sistema de Vigilância de Violências e Acidentes - VIVA).

For the purposes of this study, only young victims aged 15 to 29 were included who had received care at 71 emergency services located in 24 Brazilian state capitals and the Federal District. The capital cities of the states of Amazonas (Manaus) and São Paulo (São Paulo) were excluded owing to lost information.

The emergency services were selected from records held on the National Registry of Health Establishments using the following inclusion criteria: (1) being an emergency service provider and (2) being a referral service for external causes within the municipality.

The VIVA survey data were collected at each of the participating services over a period of 30 consecutive days, divided into sixty 12-hour shifts, between September and October 2011. The minimum sample size for each capital city was 2000 patient attendances. This number was arrived at by dividing the average number of attendances owing to external causes per shift at the same service in previous years. This information was obtained from the Unified Health System Hospital Information System (SIH/SUS) and from VIVA Surveys relating to services participating in the survey in previous years, namely 2006, 2007 and 2009).

The shifts were selected using probability sampling. The health establishments were considered to be conglomerates and the shifts corresponded to primary sampling units. All attendances owing to accidents and violence during the selected shifts were included in the VIVA Survey sample. Victims were excluded who sought care two or more times for the same complaint, such as return appointments and/or treatment complications. Additional information is available in a specific publication¹⁴14. Neves ACMN, Mascarenhas MDM, Silva MMAMN, Malta DC. Perfil das vítimas de violências e acidentes atendidas em serviços de urgência e emergência do Sistema Único de Saúde em capitais brasileiras - 2011. Epidemiol. Serv. Saúde 2012; 22(4):587-596..

Data was collected through interviews performed by trained interviewers using a standard form. The type of incident that led patients to seek care was classified according to the replies given during the interviews and in line with definitions contained in Chapter XX–External Causes of Morbidity and Mortality of the 10^th review of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Incidents classified as “assault/mistreatment” were selected for the purposes of this study.

The variables studied were:

- sex: male, female;

- age: 15-18, 19-24, 25-29;

- skin colour: white/yellow/indigenous, black or brown;

- consumption of alcoholic drink by the victim during six hours prior to the incident, either self-reported by the interviewee or suspected by the interviewer: no, yes;

- seeking care at another service for the same complaint before receiving care at the place of the interview: no, yes;

- day of the week on which the incident occurred: Monday to Friday, Saturday to Sunday;

- time of day/shift: morning (6 a.m. to 11:59 a.m.), afternoon (12 noon to 5:59 p.m.), night (6:00 p.m. to 11:59 p.m.) or early morning (12 midnight to 5:59 a.m.);

- nature of the assault: physical, sexual, psychological, other;

- means of assault: brute force/beating, firearm, sharp object, heavy objects, other;

- probable perpetrator of the assault, as reported by the victim: father/mother/other family member, partner/ex-partner, friend/acquaintance, law enforcement officer, stranger, other;

- sex of the probable perpetrator of the assault: male, female, both sexes;

- place of assault: household, public thoroughfare, bar or similar, other;

- nature of the injury: no injury, bruising, cut/laceration, sprain/dislocation, fracture, traumatic brain injury/multiple trauma, other;

- affected part of the body: head/neck, torso, upper and lower limbs, multiple organs, other;

- progression in the emergency service in the first 24 hours: discharge, admitted to hospital, outpatient service referral, referral to other service, left without being discharged, death).

The chi-square (Rao-Scott) test with a 95% significance level was used to investigate differences between proportions between the sexes in the variable categories studied. Analysis was performed with the assistance of Stata version 12 (StataCorp), using the survey module, given that the data were obtained through a complex sampling plan.

The 2011 VIVA Survey project was reviewed and approved by the Ministry of Health’s National Research Ethics Commission under Opinion No. 006/2011. Data was collected after obtaining verbal consent from the victims or from their legal guardians or persons accompanying them when they were under 18 years old or were unconscious.

Results

A total of 16,120 young people attended emergency services taking part in the 2011 VIVA Survey (11,461 males and 4,659 females). 1,894 (11.7%) of them were victims of violence, with males predominating (n = 1,422; 71.5%) in relation to females (n = 472; 24.9%).

Table 1 describes the characteristics of the victims and the incident for the entire sample and by sex. Almost half the young victims were aged 19 to 24 (45.3%), with no significant differences between the sexes (p = 0.157). More than two thirds (75.2%) had black or brown skin colour, also with no differences between the sexes (p = 0.150). Consumption of alcoholic drink during the six hours prior to the incident was reported in a higher proportion by male victims (52.8%) in relation to female victims (33.9%) (p < 0.001). Seeking care at another service for the same complaint was reported in 23.6% of the cases, with no differences between the sexes (p = 0.577).

Episodes of violence were more frequent on Saturdays and Sundays, accounting for 46.1% of incidents among males and 40.3% among females (Table 1, Figure 1).

As for the time of day the incident occurred, frequency was higher at night and in the early hours of the morning among males (34.4% and 27.3%, respectively) and at night and in the afternoon among females (36.0% and 27.7%, respectively) (Table 1). Figure 2 illustrates the distribution of incidents by sex and time of day. The volume of incidents can be seen to increase with effect from 7 p.m. in both sexes.

Statistically significant differences were found between the sexes in all characteristics of assault studied (p < 0.001) (Table 2). The most frequent form of assault was physical violence among males (99.2%) and females (97.9%). Among female victims, sexual (1.1%) and psychological (0.6%) violence was more frequent in relation to males (0.6% and zero, respectively). Brute force or beating was the main means of assault and was more frequent among female victims (58.7%) compared to male victims (35.9%). Assault with firearms was more frequent among male victims (23.1%) in relation to females (7.4%) (Table 2).

The main aggressors of female victims were partners or ex-partners (31.8%), whilst the aggressors of males were mainly strangers (27.1%). Assault by law enforcement officers was more frequent among males (4.1%) than among females (0.6%). Males stood out as the main perpetrators of assault, both against male victims (92.8%) and female victims (72.5%). Assault against male victims occurred most frequently in public thoroughfares (55.4%), whilst among females it occurred most frequently in the household (44.1%) (Table 2).

With regard to the nature of the injury, cuts or lacerations were most frequent in victims of both sexes (60.3% male and 49.8% female), followed by traumatisms (11.0% and 7.1%, respectively). During the first 24 hours after emergency care the majority of the victims were discharged, more so among females (77.2%) in relation to males (60.6%). Death occurred more frequently among males in the first 24 hours (2.1%) compared to females (0.2%) (Table 2).

Discussion

Marked differences were found between the characteristics of the victims and the characteristics of the assaults among young people attending public emergency services. Males were predominant among the victims and were also the main aggressors. Among males most assaults occurred in public thoroughfares and their perpetrators were strangers. Household incidents of violence were predominant among female victims and were perpetrated by partners, ex-partners, family members or acquaintances. A higher proportion of more serious injuries and deaths in the first 24 hours was found among male victims when compared to female victims. Another noteworthy finding was the high level of alcohol intake by assault victims, this being reported by more than half the male victims and one third of female victims.

The findings of this study are consistent with those of other studies conducted in Brazil and abroad⁵5. Gawryszewski VP, Sanhueza A, Martinez-Piedra R, Escamilla JA, Souza MFM. Homicídios na região das Américas: magnitude, distribuição e tendências, 1999-2009. Cien Saude Colet 2012; 17(12):3171-3182.,¹³13. Minayo MCS. Violência: um problema para a saúde dos brasileiros. In: Ministério da Saúde (MS). Impacto da violência na saúde dos Brasileiros. Brasília: MS; 2005. p. 9-41.,¹⁵15. Moura EC, Gomes R, Falcão MTC, Schwarz E, Neves ACM, Santos W. Gender inequalities in external cause mortality in Brazil, 2010. Cien Saude Colet 2015; 20(3):779-788. with regard to the predominance of males as both victims of assault and aggressors. A national study of morbidity and mortality among Brazilian youth owing to assault during the period 1996 to 2007 found a male:female sex ratio of 11.6 with regard to the number of deaths, 4.5 for the number of hospital admissions and 2.8 for the number of emergency attendances¹⁶16. Souza ER, Gomes R, Silva JG, Correia BSC, Silva MMA. Morbimortalidade de homens jovens brasileiros por agressão: expressão dos diferenciais de gênero. Cien Saude Colet 2012; 17(12):3243-3248..

Gender differences regarding patterns of morbidity and mortality, use of services and health needs as related to masculine role models have been widely discussed⁷7. Schraiber LB, Figueiredo WS, Gomes R, Couto MT, Pinheiro TF, Machin R, Silva GSN, Valença O. Necessidades de saúde e masculinidades: atenção primária no cuidado aos homens. Cad Saude Publica 2010; 26(5):961-970.. According to Alves et al.¹⁷17. Alves RA, Pinto LMN, Silveira AM, Oliveira GL, Melo EM. Homens, vítimas e autores de violência: A corrosão do espaço público e a perda da condição humana. Interface Commun Heal Educ. 2012; 16(43):871-883., the vulnerability of males is aggravated by their social and cultural origin which conditions them to taking on a dominant stance, seeing violence as something inherent to their nature, as well as putting them in the condition of both victims and perpetrators of violence.

In this study public thoroughfares were the most frequent place of assault among male victims and this is compatible with greater involvement of males in urban violence. A study of the characteristics of municipalities and the risk of homicide among males found that municipalities that had a larger number of inhabitants and were more urbanized had higher rates of homicide, reinforcing the idea of the role of demographic characteristics as explanatory components of the growth of violence in Brazil¹⁸18. Duarte EC, Garcia LP, Freitas LRS, Mansano NH, Monteiro RA, Ramalho WM. Associação ecológica entre características dos municípios e o risco de homicídios em homens adultos de 20-39 anos de idade no Brasil, 1999-2010. Cien Saude Colet 2012; 17(9):2259-2268..

Firearms were an important means of assault and involved almost a fifth of attendances. Almost one in four injuries among male victims were caused by firearms. A study conducted in Argentina covering the period from 1991 to 2006 found that 48.5% of victims of fatal injuries caused by firearms were aged 15 to 29¹⁹19. Zunino MG, Diez Roux AV, Souza ER. Homicidios por armas de fuego en Argentina, 1991-2006: un análisis de niveles múltiples. Cien Saude Colet 2012; 17(12):3219-3232.. Moreover, analysis of homicides in women of childbearing age undertaken in Recife/PE between 2003 and 2007 indicated that more than 80% of deaths occurred as a result of assaults in which firearms were used²⁰20. Silva LS, Menezes MLN, Lopes CLA, Corrêa MSM. Anos potenciais de vida perdidos por mulheres vítimas de homicídio na cidade do Recife, Pernambuco, Brasil. Cad Saude Publica 2011; 27(9):1721-1730..

Despite males being predominant among the victims of violence, the profile of female victim emergency care deserves reflection. Prevalent among these victims are less serious injuries and assault in circumstances consistent with domestic and family violence, with most incidents occurring at home. A study of deaths among women owing to assault in Brazil between 2001 and 2011 highlighted that on average 13.5 women per day die as a result of assault and that the profile of the majority of these deaths was consistent with situations of domestic and family violence against women²¹21. Garcia LP, Freitas LRS, Köfelmann DA. Avaliação do impacto da Lei Maria da Penha sobre a mortalidade de mulheres por agressões no Brasil, 2001-2011. Epidemiol e Serviços Saúde 2013; 22(3):383-394..

Nonfatal injuries correspond to the most direct effect of intimate partner violence which, in addition, is related to diverse harmful consequences for women’s health. It is estimated that among women who experience some kind of intimate partner violence, 42% suffered injuries²²22. World Health Organization (WHO). Global and regional estimates of violence against women prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: WHO; 2013., indicating the important public health burden of injuries caused by violence against women. The World Health Organization stresses the need to improve the ability of health services to identify victims of domestic violence and thus attempt to prevent risk of death from this cause²²22. World Health Organization (WHO). Global and regional estimates of violence against women prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: WHO; 2013..

It is noteworthy that approximately a quarter of young victims of violence had sought care at another service for the same incident, before receiving care at the place of the interview. This finding indicates the need for health services to be aware and prepared to attend to and to provide adequate care to victims.

The higher proportion of more serious injuries among men corroborates the findings of previous Viva Surveys. The 2009 Survey found that male adolescents aged 15 to 19 were more subject to more serious injuries requiring hospital admission within the first 24 hours after initial emergency care (18.3%) than younger individuals (5.6%)²³23. Malta DC, Mascarenhas MDM, Bernal RTI, Andrade SSCA, Neves ACM, Melo EM, Silva Júnior JB. Causas externas em adolescentes: atendimentos em serviços sentinelas de urgência e emergência nas Capitais Brasileiras - 2009. Cien Saude Colet 2012; 17(9):2291-2304..

The 2011 Survey found a high frequency of alcoholic beverage intake among young victims of assault. Alcohol use increases the risk of involvement in episodes of accidents and violence²⁴24. World Health Organization (WHO). Inequalites in young people´s health: Health Behavior in School-aged Children. International Report from 2005-2006. Genebra: WHO; 2008. (Health Policy for Children and Adolescents, No. 5).,²⁵25. Mascarenhas MDM, Neves ACM, Monteiro RA, Silva MMA, Malta DC. Emergency room visits due to external causes and alcohol consumption - Capitals and the Federal District, Brazil, 2011. Cien Saude Colet 2015; 20(4):1037-1046.. Data from the 2013 National Health Survey showed that the prevalence of abusive alcohol use among the Brazilian population was 3.3 times higher among males when compared to females and that the highest levels of prevalence were found in young adults aged 18 to 29 (18.8%)²⁶26. Garcia LP, Freitas LRS. Consumo abusivo de álcool no Brasil: resultados da Pesquisa Nacional de Saúde 2013. Epidemiol. Serv. Saúde 2015; 24(2):227-237..

A study conducted with 9^th grade elementary school students attending public and private schools in Brazil found that half (50.3%) of these adolescents had already begun drinking alcohol, showing early alcohol initiation which was even more frequent between those aged 12 to 13²⁷27. Malta DC, Mascarenhas MDM, Porto DL, Barreto SM, Morais Neto OL. Exposição ao álcool entre escolares e fatores associados. Rev Saude Publica 2014; 48(1):52-62.. This provides evidence of the need for protective legislative measures, as well as stricter inspection of alcohol sales to young people, especially in venues such as bars and the like which, in this study, appear as important places for the occurrence of assaults.

The findings of this study should be considered in the light of some limitations. With regard to external validity, it is important to highlight that the study population is that of individuals receiving care in public emergency services in 24 state capitals and the Federal District. As such, the results refer to this source population. Precise data is not available to estimate the percentage coverage of Brazil’s public emergency services, although more than half the Brazilians seeking health services in the two weeks prior to the 2008 National Household Sample Survey reported having received care in public health services²⁸28. Silva ZP, Ribeiro MCSA, Barata RB, Almeida MF. Perfil sociodemográfico e padrão de utilização dos serviços de saúde do Sistema Único de Saúde (SUS), 2003- 2008. Cien Saude Colet 2011; 16(9):3807-3816.. With regard to measurement errors, the outcome was built based on information reported by victims or people accompanying them. This fact may have resulted in some cases of assault not being taken into consideration owing to their being incorrectly classified as accidents, and may also have resulted in errors in classifying the perpetrators of assault, given that victims of domestic violence, for instance, may not reveal this information.

In conclusion, the characteristics of assaults on young people attending emergency services showed themselves to be substantially different depending on their sex. The Viva System has huge potential for generating evidence and inputs for public policies intended to address violence involving youth in Brazil. There is evident need for intersectoral public policies to be implemented aimed at preventing violence among this specific population, as provided for in the Youth Statute. In the case of young males, we suggest that actions should be directed above all to preventing urban violence and associated factors such as alcohol consumption and carrying firearms, whilst actions for young females should also include the prevention of domestic and family violence.

References

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