Abstract

This study explored the characteristics of violence against adolescents who received treatment at urgent and emergency care centers participating in the 2014 Violence and Accident Surveillance System (Sistema de Vigilância de Violências e Acidentes, VIVA) survey and determined the association between demographic variables and the characteristics of violent events. The sample was composed of 815 adolescents who responded to the 2014 VIVA survey. Correspondence analysis was used to determine possible associations between the variables. Victims were predominantly males and the most common form of aggression was the use of firearms and sharp objects. Among males aged between 15 and 19 years, violent acts were predominantly committed in public thoroughfares and by strangers, and the most common injuries consisted of fractures and cuts, while among younger adolescents aged between 10 and 14 years the most common form of aggression was threats made by friends at school. The most common place of occurrence among females was the home. It is concluded that violence against adolescents permeates the chief agencies of socialization – the family and school – demonstrating the need to mobilize the whole society in tackling this problem.

Violence; Adolescent; Aggression; External cause; Surveillance

Introduction

External causes are the leading cause of morbidity and mortality among adolescents. According to the World Health Organization (WHO), an estimated 875,000 deaths per year among adolescents are due to external causes¹1. World Health Organization (WHO), United Nations Children’s Fund (UNICEF). Child and adolescent injury prevention: a global call to action. Genebra: WHO, UNICEF; 2005.^,22. Hyder AA, Puvanachandra P, Tran NH.Child and adolescent injuries: a new agenda for child health. Inj Prev 2008; 14:67.. Studies have shown that violence suffered during childhood and adolescence can have devastating physical and psychosocial consequences and has a direct impact on quality of life³3. World Health Organization (WHO). Health topics: adolescent health. Geneva: WHO; 2010. [acessado 2010 jan 30]. Disponível em: http://www.who.int/topics/adolescent_health/en/.
http://www.who.int/topics/adolescent_hea... ^,44. Morais RLGL, Sales ZN, Rodrigues VP, Oliveira JS. Ações de proteção à crianças e adolescentes em situação de violência. Rev enferm UFPE on line 2016 abr-jun [acessado 2017 fev 10]; 8(2):1645-1653. Disponível em: http://www.seer.unirio.br/index.php/cuidadofundamental/article/view/4688/pdf_1901.
http://www.seer.unirio.br/index.php/cuid... . Moreover, violence can have lasting health effects, such disability and psychiatric disorders¹. Besides the toll of human misery, violence against adolescents also results in elevated care costs and is a major public health problem⁵5. World Health Organization (WHO). World report on child injury prevention. Geneva: WHO, Unicef; 2008.

6. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. World report on violence and health. Geneva: World Health Organization; 2002.

7. World Health Organization (WHO). World report on road traffic injury prevention. Geneva: WHO; 2004.^-88. Malta DC, Sardinha LMV, Mendes I, Barreto SM, Giatti L, Castro IRR, Moura L, Dias AJR, Crespo C.Vivência de violência entre escolares brasileiros: resultados da Pesquisa Nacional de Saúde do Escolar (PeNSE).Cien Saude Colet 2010; 15(2):3053-3063..

The WHO define violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation”⁶6. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. World report on violence and health. Geneva: World Health Organization; 2002.. Violence is a multifaceted problem associated with economic and social inequality, cultural factors, and the distinctive subjective and behavioral characteristics of different societies⁸8. Malta DC, Sardinha LMV, Mendes I, Barreto SM, Giatti L, Castro IRR, Moura L, Dias AJR, Crespo C.Vivência de violência entre escolares brasileiros: resultados da Pesquisa Nacional de Saúde do Escolar (PeNSE).Cien Saude Colet 2010; 15(2):3053-3063.

9. Costa DKG, Reichert LP, França JRFS, Collet N, Reichert APS.Concepções e práticas dos profissionais de saúde acerca da violência intrafamiliar contra crianças e adolescentes. Trab. Educ. Saúde 2015; 13(2):79-95.^-1010. Minayo MCS. Violência e Saúde. Rio de Janeiro: Editora Fiocruz; 2006..

In Brazil in 2013, external causes led the admission of 143,070 patients aged between 10 and 19 years to hospitals run by the Unified Health System (Sistema Único de Saúde – SUS) and resulted in 18,296 deaths¹¹11. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Saúde Brasil 2015: uma análise da situação de saúde e das causas externas. Brasília: MS; 2016..

Studies show high levels of exposure to violence characterized by domination, exploitation, and oppression¹⁰10. Minayo MCS. Violência e Saúde. Rio de Janeiro: Editora Fiocruz; 2006. among children and adolescents within the family and in school and community settings¹²12. Paixão GPN, Santos NJS, Matos LSL, Santos CKFS, Nascimento DE, Bittencourt IS, Silva RS. Violência escolar: percepções de adolescentes. Rev Cuid 2014; 5(2):717-722.. The most common forms of violence against children are neglect and abandonment, and physical, psychological, and sexual violence, while violence is predominantly committed by parents within the home¹³13. Santos TMB, Cardoso MD, Pitangui ACR, Santos YGC, Paiva SM, Melo JPR, Silva LMP.Completitude das notificações de violência perpetrada contra adolescentes em Pernambuco Brasil. Cien Saude Colet 2016; 21(12):3907-3916.. The most common form of violence against adolescents is physical violence (assault) inside and outside the home, often committed by strangers and particularly associated with inequality and the use of alcohol and other drugs⁸8. Malta DC, Sardinha LMV, Mendes I, Barreto SM, Giatti L, Castro IRR, Moura L, Dias AJR, Crespo C.Vivência de violência entre escolares brasileiros: resultados da Pesquisa Nacional de Saúde do Escolar (PeNSE).Cien Saude Colet 2010; 15(2):3053-3063.^,1414. Brasil. Ministério da Saúde (MS). Sistema de Vigilância de Violências e Acidentes (Viva): 2014. Brasília: MS; 2016..

Adolescents are particularly vulnerable, meaning that it is important to develop health promotion and disease prevention policies and programs specifically geared towards this group²2. Hyder AA, Puvanachandra P, Tran NH.Child and adolescent injuries: a new agenda for child health. Inj Prev 2008; 14:67.. Studies have shown that the continuous monitoring of external causes and violence against adolescents is essential for effective policy implementation¹⁴14. Brasil. Ministério da Saúde (MS). Sistema de Vigilância de Violências e Acidentes (Viva): 2014. Brasília: MS; 2016.. However, studies of violence in this age group tend to be qualitative⁹9. Costa DKG, Reichert LP, França JRFS, Collet N, Reichert APS.Concepções e práticas dos profissionais de saúde acerca da violência intrafamiliar contra crianças e adolescentes. Trab. Educ. Saúde 2015; 13(2):79-95.^,1212. Paixão GPN, Santos NJS, Matos LSL, Santos CKFS, Nascimento DE, Bittencourt IS, Silva RS. Violência escolar: percepções de adolescentes. Rev Cuid 2014; 5(2):717-722., rely on hospital admission and mortality databases¹¹11. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Saúde Brasil 2015: uma análise da situação de saúde e das causas externas. Brasília: MS; 2016., and focus on the local level¹³13. Santos TMB, Cardoso MD, Pitangui ACR, Santos YGC, Paiva SM, Melo JPR, Silva LMP.Completitude das notificações de violência perpetrada contra adolescentes em Pernambuco Brasil. Cien Saude Colet 2016; 21(12):3907-3916. and, as a result, national studies of violence in this age group remain scarce.

In 2006, the Ministry of Health introduced the Violence and Accident Surveillance System (Sistema de Vigilância de Violências e Acidentes - VIVA), which has two components: a) A local-level survey conducted in sentinel urgent and emergency care centers (serviços sentinelas de urgência e emergência), the most recent of which was undertaken in 2014; and b) Continuing surveillance based on the compulsory notification of domestic and sexual violence and other types of interpersonal and self-inflicted violence.

Studies have shown that violence is more prevalent among young men⁶6. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. World report on violence and health. Geneva: World Health Organization; 2002.. However, important aspects of this problem, including the perpetrators, place of occurrence, and forms of violence, remain relatively unexplored. The VIVA survey provides important data on the characteristics and circumstances of violent events involving adolescents in Brazil’s state capitals. Warranted by the high levels of morbidity and mortality associated with violence against adolescents, the present study analyzes this data with a view to providing new insights into the problem that help fill these gaps in knowledge, thus providing important inputs to inform policy-making and violence prevention measures.

In light of the above, using the 2014 VIVA survey data, this study explored the characteristics of violence against adolescents and sought to determine the association between demographic variables and the characteristics of the violent event (form of aggression, perpetrators, place of occurrence, and nature of injury).

Methods

A cross-sectional study was conducted using the 2014 VIVA survey data on adolescent victims of violence (n = 815). The survey was conducted in 86 sentinel urgent and emergency care centers located in the Federal District and 24 state capitals. The state capitals Florianópolis (State of Santa Catarina) and Cuiabá (State of Mato Grosso) were not included in the study because the survey was not undertaken in these cities¹⁴14. Brasil. Ministério da Saúde (MS). Sistema de Vigilância de Violências e Acidentes (Viva): 2014. Brasília: MS; 2016.. The VIVA survey used standardized data collection procedures across all centers. To this end, prior to conducting research, local health managers were trained in the use of data collection techniques through a course provided by the Directorate of Noncommunicable Disease Surveillance (Diretoria de Vigilância de Doenças e Agravos Não Transmissíveis) of the Ministry of Health¹⁴14. Brasil. Ministério da Saúde (MS). Sistema de Vigilância de Violências e Acidentes (Viva): 2014. Brasília: MS; 2016.^,1515. Malta DC, Mascarenhas MDM, Silva MMA, Carvalho MGO, Barufaldi LA, Avanci JQ, Bernal RT. A ocorrência de causas externas na infância em serviços de urgência: aspectos epidemiológicos, Brasil, 2014. Cien Saude Colet 2016; 21(12):3729-3744._.

The study sample was composed of people who sought treatment at the urgent and emergency care centers included in the 2014 VIVA survey. The sample was obtained using single-stage cluster sampling, where the primary sampling unit was 12-hour shifts. The shifts were randomly selected from a total of 60 units calculated based on a 30-day data collection period made up of two shifts per day (one day shift and night shift). The total survey sample comprised 55,950 respondents. The overall sample and collection procedures are described in greater detail in previous publications¹⁴14. Brasil. Ministério da Saúde (MS). Sistema de Vigilância de Violências e Acidentes (Viva): 2014. Brasília: MS; 2016.^,1515. Malta DC, Mascarenhas MDM, Silva MMA, Carvalho MGO, Barufaldi LA, Avanci JQ, Bernal RT. A ocorrência de causas externas na infância em serviços de urgência: aspectos epidemiológicos, Brasil, 2014. Cien Saude Colet 2016; 21(12):3729-3744..

The present study focused on adolescents aged between 10 and 19 years who had been physically assaulted³3. World Health Organization (WHO). Health topics: adolescent health. Geneva: WHO; 2010. [acessado 2010 jan 30]. Disponível em: http://www.who.int/topics/adolescent_health/en/.
http://www.who.int/topics/adolescent_hea... . The sample was divided into two age groups (10 to 14 years and 15 to 19 years) for comparative purposes.

Correspondence analysis was used to determine possible associations between the variables. This technique allows the researcher to consider a large number of qualitative variables across a wide range of categories¹⁶16. Mingoti SA. Análise de Dados Através de Métodos Estatísticos Multivariados. Uma Abordagem Aplicada. Belo Horizonte: UFMG; 2005.^,1717. Souza AMR. Análise de Correspondência [dissertação]. São Paulo: Universidade de São Paulo; 1982..

Correspondence analysis is a descriptive/exploratory technique that graphically displays associations between variables. The variables are arranged in rows and columns, each of which is depicted as a point. The degree of association between two variables is measured by the distance between the points, where the shorter the distance between the categories row and categories column the stronger the association and vice versa¹⁷17. Souza AMR. Análise de Correspondência [dissertação]. São Paulo: Universidade de São Paulo; 1982.^,1818. Souza AC, Bastos RR, Vieira MT. Análise de Correspondência Simples e Múltipça para Dados Amostrais Complexos. [acessado 2010 ago 18]. Disponível em: http://www.ime.unicamp.br/sinape/sites/default/files/Artigo%20Sinape%20v2.pdf
http://www.ime.unicamp.br/sinape/sites/d... .

Correspondence analysis was conducted using demographic variables (variables column) and the characteristics of the violent event (variables row) included in the standardized form used in the VIVA survey. Variables column: sex and age group (10 to 14 years and 15 to 19 years). Variables row: a) form of aggression (bodily force/beating, firearms, poisoning, sharp/blunt object, threat); b) relationship between victim/perpetrator (father or mother, family member, friend, stranger); c) place of occurrence (at home, at school, recreational area, public thoroughfare); d) nature of injury (without injury, bruise/sprain/joint dislocation, cut/wound, fracture/amputation/trauma) (Chart 1).

Simple correspondence analysis was used to determine the profile of adolescents subjected to violence. Given that the data was obtained using a complex sampling design, we first constructed expanded contingency tables (total number of adolescents treated) and, subsequently, based on these tables, we constructed the matching graph. The estimator¹⁸18. Souza AC, Bastos RR, Vieira MT. Análise de Correspondência Simples e Múltipça para Dados Amostrais Complexos. [acessado 2010 ago 18]. Disponível em: http://www.ime.unicamp.br/sinape/sites/default/files/Artigo%20Sinape%20v2.pdf
http://www.ime.unicamp.br/sinape/sites/d... ^,1919. STATACORP - Stata Survey Data Reference Manual. College Station: Stata Corporation; 2003. for the total number of adolescents who received treatment related to a violent event in sentinel urgent and emergency care centers over the 30-day period is given by the expression:

where:

w_hij is the sampling weight in the h-th stratum (nces), i-th emergency care center (shift), and j -th number of elements of the h-th stratum of the i-th emergency care center

y_hij is the observed value of the variable (1 if observed and 0 if it is missing) in the h-th stratum, i-th emergency care center and j-th number of elements of the h-th stratum of the i-th emergency care center.

The research project was approved by the National Research Ethics Committee.

Results

The contingency table shown in Table 1 displays the data set expanded according to the sampling weight. The column shows the age and sex of the victims, while the rows display the form of aggression, place of occurrence, nature of injury, and perpetrator. Victims were predominantly males aged between 15 and 19 years. The most common form of aggression among males was bodily force/beating, followed by use of firearm and poisoning, while among women it was bodily force/beating, followed by poisoning. The most common place of occurrence among women was at home, followed by public thoroughfare and at school, while for men it was public thoroughfare, followed by at home and at school. The most common place of occurrence among adolescents aged between 10 and 14 years was at school. The most common injury was cuts and wounds, followed by bruise/sprain/joint dislocation. The most common perpetrators of violence committed against males and adolescents aged between 15 and 19 years were strangers.

Table 2 shows the results of the correspondence analysis. The first column shows the number of dimensions necessary to explain 100% of joint variation for the two variables. The last two columns show the simple and cumulative proportion of explained variance for each dimension. The two first dimensions explain 100% of total variation (first dimension 84.6% and second 15.4%). The results of the chi-square test of independence show that the null hypothesis of independence between the row and column variables can be rejected. Therefore, it can be concluded that there is an association between demographic variables and the characteristics of the violent event.

Table 3 shows the characteristics of the violent event and demographic variables that make up each dimension. Form of aggression was the variable that contributed most to dimension 1 (26%), followed by perpetrator (24%) and nature of injury (24%). The demographic variable that contributed most to dimension 1 was age (55%). Place of occurrence was the variable that contributed most to dimension 2 (59%), followed by perpetrator (22%). The demographic variable that contributed most to dimension 2 was sex (55%).

Figure 1 shows the association between the demographic variables and characteristics of the violent event in both dimensions. Dimension 1 explains 15.4%, while dimension 2 explains 84.6%. The distance between points shows the following associations: A) being female and the variables place of occurrence at home, perpetrators being parents, and less serious violence or without injury; B) being male and the variables form of aggression firearm and sharp object. C) Being aged between 15 and 19 years and the variables nature of injury fracture and cuts, place of occurrence public thoroughfare, and perpetrator being a stranger. D) Being aged between 10 and 14 years and the variables form of aggression threat, perpetrators being a friend, and place of occurrence at school.

Discussion

The findings of the present study show that victims of violence were predominantly males. Previous studies have highlighted that being male is a predictor of violent behavior¹¹11. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Saúde Brasil 2015: uma análise da situação de saúde e das causas externas. Brasília: MS; 2016.^,2020. Peltzer K.Injury and social determinants among in-school adolescents in six African countries. Inj Prev 2008; 14(6):381-388.^,2121. Souza ER. Masculinidade e violência no Brasil: contribuições para a reflexão no campo da saúde. Cien Saude Colet 2005; 10(1):59-70.. Culturally enrooted gender differences are suggestive of a male-chauvinist perspective that manifests itself in the games children play. While boys prefer to play with guns and swords, girls play with dolls, meaning that boys have a natural tendency towards domineering and aggressive behaviour¹⁰10. Minayo MCS. Violência e Saúde. Rio de Janeiro: Editora Fiocruz; 2006.^,2121. Souza ER. Masculinidade e violência no Brasil: contribuições para a reflexão no campo da saúde. Cien Saude Colet 2005; 10(1):59-70.

22. Minayo MC.Laços perigosos entre machismo e violência. Cien Saude Colet 2005; 10(1):18-34.^-2323. Minayo MC, Constantino P.Visão ecossistêmica do homicídio. Cien Saude Colet 2012; 17(12):3269-3278.. Authors also highlight that factors such as stimulation and the fact that boys tend to be given greater freedom outside the domestic walls may result in greater exposure to risk in all age groups from childhood to adulthood¹⁰10. Minayo MCS. Violência e Saúde. Rio de Janeiro: Editora Fiocruz; 2006.^,2121. Souza ER. Masculinidade e violência no Brasil: contribuições para a reflexão no campo da saúde. Cien Saude Colet 2005; 10(1):59-70.

22. Minayo MC.Laços perigosos entre machismo e violência. Cien Saude Colet 2005; 10(1):18-34.^-2323. Minayo MC, Constantino P.Visão ecossistêmica do homicídio. Cien Saude Colet 2012; 17(12):3269-3278..

The present study shows that older adolescents (those aged between 15 and 19 years) are more susceptible to violence committed in public thoroughfares, which is consistent with the findings of other studies¹1. World Health Organization (WHO), United Nations Children’s Fund (UNICEF). Child and adolescent injury prevention: a global call to action. Genebra: WHO, UNICEF; 2005.^,1111. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Saúde Brasil 2015: uma análise da situação de saúde e das causas externas. Brasília: MS; 2016._. This reflects lifestyle habits such as going out, partying, and clubbing more often than girls, meaning that male adolescents are more exposed to risk in public spaces, as shown by other studies²⁴24. Malta DC, Mascarenhas MDM, Bernal RTI, Andrade SSCA, Neves ACM, Melo EM, Júnior JBS.Causas externas em adolescentes: atendimentos em serviços sentinelas de urgência e emergência nas Capitais Brasileiras – 2009. Cien Saude Colet 2012; 17(9):2291-2304.

25. Barros MDA, Ximenes R, Lima MLC.Mortalidade por causas externas em crianças e adolescentes: tendências de 1979 a 1995. Rev Saude Publica 2001; 35(2):142-149.

26. Reichenheim ME, Souza ER, Moraes CL, Mello-Jorge MHP, Silva CMFP, Minayo MCS. Violência e lesões no Brasil: efeitos, avanços alcançados e desafios futuros. Lancet 2011; 6736(11):75-89. [acessado 2012 fev 24]. Disponível em: http://download.thelancet.com/flatcontentassets/pdfs/brazil/brazilpor5.pdf
http://download.thelancet.com/flatconten... ^-2727. Gaspar VLV, Lamounier JA, Cunha FMA, Gaspar JC.Fatores relacionados a hospitalizações por injúrias em crianças e adolescentes. J. Pediatr 2004; 80(6):447-452.. Girls, on the other hand, are more likely to suffer violence at home, which is consistent with the findings of previous studies showing that the most common perpetrators of violence against children are parents or the mother’s boyfriend or partner²⁷27. Gaspar VLV, Lamounier JA, Cunha FMA, Gaspar JC.Fatores relacionados a hospitalizações por injúrias em crianças e adolescentes. J. Pediatr 2004; 80(6):447-452.

28. Rates SMM, Melo EM, Mascarenhas MDM, Malta DC. Violência infantil: uma análise das notificações compulsórias, Brasil 2011. Cien Saude Colet 2015; 20(3):655-665.

29. Schraiber LB, D’Oliveira AFPL, Couto MT.Violência e saúde: estudos científicos recentes. Rev Saude Publica 2006; 40(N esp):112-120.^-3030. Couto MT, Schraiber LB. Homens, saúde e violência: novas questões de gênero no campo da saúde coletiva. In: Minayo MCS, Coimbra JCEA, organizadores. Críticas e atuantes: Ciências Sociais e Humanas em Saúde na América Latina. Rio de Janeiro: Fiocruz; 2005. p. 687-706..

Studies show that violence against girls committed at home by parents creates a “vicious circle” of domination, causing fear, anguish and silence, and often leading to fatalities²⁹29. Schraiber LB, D’Oliveira AFPL, Couto MT.Violência e saúde: estudos científicos recentes. Rev Saude Publica 2006; 40(N esp):112-120.^,3030. Couto MT, Schraiber LB. Homens, saúde e violência: novas questões de gênero no campo da saúde coletiva. In: Minayo MCS, Coimbra JCEA, organizadores. Críticas e atuantes: Ciências Sociais e Humanas em Saúde na América Latina. Rio de Janeiro: Fiocruz; 2005. p. 687-706.. Schraiber et al.²⁹29. Schraiber LB, D’Oliveira AFPL, Couto MT.Violência e saúde: estudos científicos recentes. Rev Saude Publica 2006; 40(N esp):112-120. suggest that gender differences in the effects of exposure to violence exist. In the case of girls, acts of violence are transformed into common everyday occurrences, while among boys, they generally perpetuate macho behavior, turning the victims into future perpetrators²⁹29. Schraiber LB, D’Oliveira AFPL, Couto MT.Violência e saúde: estudos científicos recentes. Rev Saude Publica 2006; 40(N esp):112-120.^,3030. Couto MT, Schraiber LB. Homens, saúde e violência: novas questões de gênero no campo da saúde coletiva. In: Minayo MCS, Coimbra JCEA, organizadores. Críticas e atuantes: Ciências Sociais e Humanas em Saúde na América Latina. Rio de Janeiro: Fiocruz; 2005. p. 687-706.. These gender differences reflect a cultural tendency to trivialize and accept violence²⁹29. Schraiber LB, D’Oliveira AFPL, Couto MT.Violência e saúde: estudos científicos recentes. Rev Saude Publica 2006; 40(N esp):112-120..

In the category nature of injury, violent events were predominantly without injury among girls and threats among boys aged between 10 and 14 years. However, more serious injuries were observed among male adolescents aged between 15 and 19 years, such as bodily force/beating, fractures, cuts, and sprains. The majority of violence against this age group was committed in public thoroughfares and the perpetrators were predominantly strangers. As shown by previous studies¹¹11. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Saúde Brasil 2015: uma análise da situação de saúde e das causas externas. Brasília: MS; 2016.^,2626. Reichenheim ME, Souza ER, Moraes CL, Mello-Jorge MHP, Silva CMFP, Minayo MCS. Violência e lesões no Brasil: efeitos, avanços alcançados e desafios futuros. Lancet 2011; 6736(11):75-89. [acessado 2012 fev 24]. Disponível em: http://download.thelancet.com/flatcontentassets/pdfs/brazil/brazilpor5.pdf
http://download.thelancet.com/flatconten... , the greater vulnerability of older male adolescents and young men to violence is due to male super-mortality and the fact that men are at increased risk of violence.

This is the first study of the VIVA survey to observe statistically significant levels of violence in the form of threats committed against younger adolescents (aged between 10 and 14 years) by friends at school. Bullying consists of threats and insults made by friends or classmates, but can also involve the use of physical force³²32. Oliveira WA, Silva MAI, Silva JL, Mello FCM, Prado RR, Malta DC.Associations between the practice of bullying and individual and contextual variables from the aggressors’ perspective. J Pediatr (Rio J) [Internet]. 2016 [cited 2016 Dec 17]; 92:32-39. Available from: http://dx.doi.org/10.1016/j.jpedp.2015.06.002
http://dx.doi.org/10.1016/j.jpedp.2015.0... . This problem has been studied by surveys of adolescents, such as the National School Health Survey (Pesquisa Nacional de Saúde do Escolar -PeNSE)³¹31. Malta DC, Prado RR, Dias AJ, Mello FC, Silva MA, Costa MR, Caiaffa WT.Bullying and associated factors among Brazilian adolescents: analysis of the National Adolescent School-based Health Survey (PeNSE 2012). Rev Bras Epidemiol 2014; 17:131-145.^,3232. Oliveira WA, Silva MAI, Silva JL, Mello FCM, Prado RR, Malta DC.Associations between the practice of bullying and individual and contextual variables from the aggressors’ perspective. J Pediatr (Rio J) [Internet]. 2016 [cited 2016 Dec 17]; 92:32-39. Available from: http://dx.doi.org/10.1016/j.jpedp.2015.06.002
http://dx.doi.org/10.1016/j.jpedp.2015.0... . Studies have shown that there is a significant association between violence experienced by adolescents and involvement in acts of violence at school, either as victims or perpetrators³³33. Völkl-Kernstock S, Huemer J, Jandl-Jager E, Abensberg-Traun M, Marecek S, Pellegrini E, Plattner B, Skala K.Experiences of Domestic and School Violence Among Child and Adolescent Psychiatric Outpatients Child. Psychiatry Hum Dev 2016; 47(5):691-695..

Despite not including specific questions about this issue, the findings of the VIVA survey were consistent with those of other studies that showed that violence against school children in the form of threats and the use of fear particularly affects younger adolescents³¹31. Malta DC, Prado RR, Dias AJ, Mello FC, Silva MA, Costa MR, Caiaffa WT.Bullying and associated factors among Brazilian adolescents: analysis of the National Adolescent School-based Health Survey (PeNSE 2012). Rev Bras Epidemiol 2014; 17:131-145.^,3232. Oliveira WA, Silva MAI, Silva JL, Mello FCM, Prado RR, Malta DC.Associations between the practice of bullying and individual and contextual variables from the aggressors’ perspective. J Pediatr (Rio J) [Internet]. 2016 [cited 2016 Dec 17]; 92:32-39. Available from: http://dx.doi.org/10.1016/j.jpedp.2015.06.002
http://dx.doi.org/10.1016/j.jpedp.2015.0... It is also important to note the fact that victims sought treatment at urgent and emergency care centers, probably suggesting that they were victims of more serious violent events resulting in injury, thus demonstrating that tackling violence at school should be a priority.

The problem of violence between adolescents highlighted by the present study gains even greater importance when we consider both the immediate and long-term consequences of violence, not only for the individual victim, but also for society as a whole. Violence committed against adolescents at home is associated with the development of aggressive behavior³⁴34. López-Soler C, Alcántara-López M, Castro M, Sánchez-Meca J, Fernández V.The Association between Maternal Exposure to Intimate Partner Violence and Emotional and Behavioral Problems in Spanish Children and Adolescents. J Fam Viol 2017; 32(2):135-144. and mental disorders³⁴34. López-Soler C, Alcántara-López M, Castro M, Sánchez-Meca J, Fernández V.The Association between Maternal Exposure to Intimate Partner Violence and Emotional and Behavioral Problems in Spanish Children and Adolescents. J Fam Viol 2017; 32(2):135-144.^,3535. Gallo EAG, De Mola CL, Wehrmeister F, Gonçalves H, Kieling C, Murray J.Childhood maltreatment preceding depressive disorder at age 18 years: A prospective Brazilian birth cohort study. J Affect Disord 2017; 217:218-224.. Violence against adolescents, in whatever form, is associated with aggressive behavior and, therefore, leads to more violence³⁶36. Foshee VA, McNaughton Reyes HL, Chen MS, Ennett ST, Basile KC, DeGue S, Vivolo-Kantor AM, Moracco KE, Bowling JM.Shared Risk Factors for the Perpetration of Physical Dating Violence, Bullying, and Sexual Harassment Among Adolescents Exposed to Domestic Violence. J Youth Adolescence 2016; 45(4):672-686..

Acts of violence against children and adolescents are an obstacle to individual development and constitute a major public health problem. The Child and Adolescent Statute (Law 8.069/1990)³⁷37. Brasil. Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente, e dá outras providências. Diário Oficial da União 1990; 16 jul. provides special rights and full protection to adolescents and requires the compulsory notification of suspected and confirmed cases of violence and maltreatment of children and adolescents by health professionals. The statute provides that it is the duty of the family, community, general society, and the government to ensure, as an absolute priority, the protection of the rights to life, health, food, and education, meaning that it is absolutely imperative that the government advances protection measures.

The present study innovated by using correspondence analysis, a technique which allows for the graphical display of associations between a wide array of variables¹⁸18. Souza AC, Bastos RR, Vieira MT. Análise de Correspondência Simples e Múltipça para Dados Amostrais Complexos. [acessado 2010 ago 18]. Disponível em: http://www.ime.unicamp.br/sinape/sites/default/files/Artigo%20Sinape%20v2.pdf
http://www.ime.unicamp.br/sinape/sites/d... .

One of the limitations of this study is the possible omission of information regarding violent events by adolescents and/or their parents or guardians due to the delicate nature of this issue. Furthermore, on the one hand, the use of urgent and emergency centers as the primary source of data has its advantages because these centers are specialized in treating patients involved in incidents involving external causes. On the other hand, they do not necessarily offer a true representation of the target population. However, in the majority of the capitals included in this study, public hospitals are referral centers for incidents involving external causes and we therefore believe that the sample serves as a proxy for the target population. Finally, it is important to note that the methodology used in this study is best suited to exploratory research, hence further research could complement our findings.

Based on the study findings, it is recommended that the next editions of the VIVA survey include specific questions regarding bullying, which was shown to be common at school, especially among younger adolescents.

Conclusion

Violence against adolescents is a major public health problem. Our findings show that victims were predominantly males aged between 15 and 19 years and that violent acts were predominantly committed in public thoroughfares and by strangers, while among younger adolescents aged between 10 and 14 years the most common place of violence was the school. The most common place of violence against female adolescents was the home. The VIVA survey is a vital instrument for bringing greater visibility to this issue. The present study highlights that violence occurs in the chief agencies of socialization – the family, school, and community – demonstrating the need to mobilize the whole society in tackling this problem.

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