Abstract

The authors conducted a literature review on the theme of violence and health published in the Brazilian public health journal “Ciência & Saúde Coletiva” (C&SC) from 1996 to 2019. The search also included two other Brazilian journals, “Cadernos de Saúde Pública” (CSP) and “Revista de Saúde Pública” (RSP) and two international journals, the “American Journal of Public Health” (AJPH) and the “Pan American Journal of Public Health” (PAJPH), totaling 1,179 articles. The analysis aggregated each journal’s material in eleven themes, based on conceptual affinity. For the articles from C&SC, the authors analyzed variables such as year of publication, area of knowledge, institution’s region, study scope, methodology, and target population. The analysis found that C&SC gave visibility to violence and health, standing out from the other journals since 2009. External causes, children and adolescents, quantitative studies, municipal and national scope, and institutions located in the Southeast region of Brazil predominated. There are gaps in topics such as self-mutilation and vulnerable populations, among other areas where more studies and publications should be encouraged.

Key words:
Violence; External causes; Intrafamily violence; Information systems; Health services

Introduction

In 1993, the Pan-American Health Organization (PAHO) issued a resolution on the problem of violence and health, and in 1994 a Plan for the Americas was launched for the prevention of violence¹1 Organización Panamericana de la Salud (OPAS). Resolución XIX: Violencia y Salud. Washington: Opas; 1993. (Mimeo)^,22 Organización Panamericana de la Salud (OPAS). Salud y Violencia: Plan de Acción Regional. Washington: Opas; 1994. (Mimeo). In 1996, the World Health Organization’s 49^th Assembly adopted violence as a serious public health issue and urged member countries to develop their policies and actions in relation to the theme.

Five years later, the Brazilian Ministry of Health proposed its National Policy for the Reduction of Morbidity and Mortality from Accidents and Violence (hereinafter PNRMAV)³3 Brasil. Ministério da Saúde (MS). Portaria GM/MS n°737, de 16 de maio de 2001. Política Nacional de Redução da Morbimortalidade por Acidentes e Violências. Diário Oficial da União 2001; 18 maio.. Since then, the Ministry of Health began to invest in violence prevention and health promotion programs, aimed at reducing injuries and deaths from violent events⁴4 Brasil. Ministério da Saúde (MS). Impacto da violência na saúde dos brasileiros. Brasília: MS; 2005.. The Ministry thus expanded and created services to assist persons in situations of violence, oriented and raised the population’s awareness, and trained professionals in the Unified Health System (SUS) to deal with cases of violence. In epidemiological surveillance, the data quality was improved in the public databases, and new systems were developed on the theme, thereby accumulating a body of knowledges on violence in the area of health, among other initiatives.

In 20 years, Brazil witnessed important growth in the number of research groups and professionals focused on studying, training, and working with individuals and groups that are more vulnerable to interpersonal, community, and structural violence. This process gave visibility to the theme in general and its specificities, disseminating knowledge through public health forums and scientific publications.

The current article aimed to report on a review of articles in the public health journal Ciência & Saúde Coletiva (C&SC) on the theme of violence and accidents in the journal’s 25 years, seeking to identify the magnitude of this research output, the most frequent themes and groups, and the gaps in the research.

Methodology

This is a review of the literature published in the journal Ciência & Saúde Coletiva (C&SC) on the theme of violence and accidents from 1996 to 2019.

As descriptors, the search used the terms violence or its correlates: abuse, maltreatment, assault, aggression, ethnic violence, conflict, prejudice, discrimination, inequality, homicide, suicide, accidents, external causes, and homophobia. These terms were searched both generically and associated with specific groups (children, adolescents, women, elderly, persons with disabilities, indigenous peoples, African descendants, LGBTI⁺), in Portuguese and English. The titles, abstracts, and keywords were verified for their pertinence to the theme. Only land transport accidents (LTA) were included, due to their magnitude and case fatality, excluding all the other accidents. Duplicate articles and opinion pieces, editorials, book reviews, or articles that did not address violence or LTA were excluded.

The attempt was made to provide an overview of the published material, analyzing variables such as themes and subthemes, area of knowledge, institution’s region, study’s scope, methodology, and study population. For the analysis, the body of material was classified in eleven themes. Some of them were already consolidated in the literature, such as external causes, intrafamily violence, gender violence, mental disorders, reporting/monitoring and surveillance, violence and school, crime and delinquency, and violence in the media. Other articles were grouped in themes according to conceptual similarity, such as care for persons in situations of violence, theoretical/methodological studies, and social violence in general.

For purposes of comparison with the production on violence in other important journals, we used the same search strategy and classification of the material. The following journals were selected: Cadernos de Saúde Pública/Reports in Public Health (CSP), Revista de Saúde Pública (RSP), American Journal of Public Health (AJPH), and Pan American Journal of Public Health (PAJPH).

After the exclusions, the body of literature analyzed consisted of 374 articles in C&SC. Besides these, we located 237 articles in CSP, 155 in RSP, 292 in AJPH, and 121 in PAJPH, totaling 1,179 articles in all.

Results

In the year 1999, C&SC published the thematic edition entitled Is it possible to prevent violence? Following this inaugural edition, there were few publications on the theme in the subsequent years, with 10 articles in 2005 and 15 in 2006, when another thematic edition was launched. Since 2009 there has been a substantial increase in the publications, with peaks that year and in 2017.

Graph 1 illustrates the theme of violence as the object of publications over the course of the period by the five periodicals, with greater concentration since the early 2000s. However, C&SC showed a different pattern from the other journals, with more publications in every year since 2009, except in 2014, when it was surpassed by AJPH.

The international periodicals featured the production by AJPH, which published 10 or more articles a year on violence in most of the period, totaling 292 articles. PAJPH published 121 articles, with the highest output in 1999 (14 articles) and 2015 (13 articles) (Graph 1).

Table 1 shows that the principal theme published in the periodicals was external causes, except for RSP, with a predominant focus on intrafamily violence. Interestingly, the theme of care for persons in situations of violence occupied relevant space in C&SC. Gender violence appears as the second most frequently published theme in CSP and AJPH. The other themes showed a more heterogeneous and less frequent presence in the publications.

Table 2 describes the material on violence published in C&SC. An important share of the studies involved partnerships between institutions from two or more regions of Brazil. Institutions from Southeast Brazil accounted alone for the publication of 142 articles, the Northeast for 41 articles, the South for 29, the Central-West for six, and the North for one. Nineteen articles reported on partnerships between Brazilian and international institutions.

The authors’ institutions featured Fiocruz, University of São Paulo, Federal University of Minas Gerais, Federal University of Rio Grande do Sul, University of Fortaleza, and University of Brasília. The Brazilian Ministry of Health collaborated with 35 studies. State or municipal health departments participated in or entirely developed 29 studies. Forty-three percent of the studies addressed municipal data, 33.4% involved national data, and 12.6% international data.

Quantitative methods were used in 48.7% of the articles, especially in exploratory studies (96) and surveys (52). Twenty-nine review articles were found. The qualitative methodologies were more diversified, including psychosocial autopsy, ethnographic studies, document studies, and case studies, among other methods. Fifteen percent of the articles involved both quantitative and qualitative approaches.

Children/adolescents and young people were studied in 30.5% of the articles. In addition, 23.8% of the articles focused on the general population, 12.0% on the elderly, and 10.7% on professional groups. Women were the focus of 9.1% of the articles, while only one study addressed pregnant women as a group. Indigenous people, migrants, prison inmates, drug users, and LGBTI⁺, among others, were the object of only one or two publications each.

The studies used data from the Brazilian Mortality Information System (SIM) in 45 publications, the Hospital Information System (SIH) in 10, and the National Information System on Diseases of Notification (SINAN) in 37 articles.

Analysis of specific themes and subthemes

External causes, or the set of events that includes accidents (including land transport accidents) and violence (self-inflicted and inflicted by others), included in the International Classification of Diseases, 10^th revision (ICD-10), was the category represented in the largest share of publications (34.2%). This is no coincidence, since the growing lethal and non-lethal epidemiological indicators of these events since the 1980s showed the relevance of violence in the Brazilian population’s morbidity and mortality.

Articles on external causes (128) appeared throughout the 25-year period and increased numerically, especially in the second decade of the 21^st century (Graph 2). The analysis thus disaggregated the publications on external causes according to its principal subthemes.

C&SC launched its publications on external causes in 2005, when Laurenti et al.⁵5 Laurenti R, Jorge MHPM, Gotlieb SLD. Perfil epidemiológico da morbi-mortalidade masculina. Cien Saude Colet 2005; 10(1):35-46. analyzed the epidemiological profile of male and female morbidity and mortality from these causes. In the overall analysis, diseases of the circulatory system were the leading causes of deaths, with accidents and violence ranking second. In 2006, the journal published the seminal paper by Concha-Eastman and Malo⁶6 Concha-Eastman A, Malo M. Da repressão à prevenção da violência: desafio para a sociedade civil e para o setor saúde. Cien Saude Colet 2006; 11(2):339-348., which presented the proposal by the Pan American Health Organization (PAHO) for the prevention of violence, based on the guidelines of the World Report on Violence and Health by the WHO⁷7 Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano, organizadores. World report on violence and health. Geneva: World Health Organization (WHO); 2002.. Concha-Eastman and Malo⁶6 Concha-Eastman A, Malo M. Da repressão à prevenção da violência: desafio para a sociedade civil e para o setor saúde. Cien Saude Colet 2006; 11(2):339-348. showed that the theme had already been incorporated by the health sector, but that it did not occupy an outstanding place in the population’s health problems. They concluded by linking the prevention of violence to the Millennium Development Goals.

The articles by Spinelli et al.⁸8 Spinelli H, Alazraqui M, Zunino G, Hernán O, Poggese H, Concaro C, Porterie S. Mortes e crimes cometidos com armas de fogo na Cidade Autônoma de Buenos Aires, 2002. Cien Saude Colet 2006; 11(Supl.):1235-1246., Franco et al.⁹9 Franco S, Suarez CM, Naranjo CB, Báez LC, Rozo P. Efeitos do conflito armado sobre a vida e a saúde na Colômbia. Cien Saude Colet 2006; 11(2):349-361., Gonzalez-Perez et al.¹⁰10 González-Pérez GJ, Vega-López MG, Cabrera-Pivaral CE, Vega-López A, Muñoz De La Torre A. Mortalidad por homicidios en México: tendencias, variaciones socio-geográficas y factores asociados. Cien Saude Colet 2012; 17(12):3195-3208.^,1111 Gonzalez-Perez GJ, Vega-Lopez MG, Flores-Villavicencio ME. El incremento de la mortalidad por armas de fuego y su relación con el estancamiento de la esperanza de vida en México. Cien Saude Colet 2017; 22(9):2861-2872., and Aleman et al.¹²12 Aleman A, Colistro V, Colomar M, Cavalleri F, Alegretti M, Buglioli M. Carga de enfermedad de los adolescentes en Uruguay y su comparación con la de América Latina y el Caribe. Cien Saude Colet 2018; 23(9):2813-2820. furnish a view of the impacts from violence in Argentina, Colombia, Mexico, and Uruguay, respectively. They showed that although the violence affecting these countries has specificities, it also displays similar patterns in the events and the most heavily affected groups.

In Brazil, Souza and Lima¹³13 Souza ER, Lima MLC. Panorama da violência urbana no Brasil e suas capitais. Cien Saude Colet 2006; 11(2):363-373. analyzed the morbidity and mortality from accidents and violence in the country as a whole and the state capitals. The article highlighted the persistently high rates of homicides and land transport deaths, and the dissemination of homicides to municipalities in the greater metropolitan areas and the states’ interior. The authors identified higher morbidity than mortality. Several years later, Moura et al.¹⁴14 Moura EC, Gomes R, Falcão MTC, Schwarz E, Neves ACM, Santos W. Desigualdades de gênero na mortalidade por causas externas no Brasil, 2010. Cien Saude Colet 2015; 20(3):779-788. estimated the mortality from external causes in Brazil with data from 2010 and reaffirmed the higher mortality ratio in men, nearly nine times higher than in women, mainly in the North and Northeast regions. The risk was also higher in young people. Men died more from aggression and LTA. More recently, Saltarelli et al.¹⁵15 Saltarelli RMF, Prado RR, Monteiro RA, Machado IE, Teixeira BSM, Malta DC. Mortes evitáveis por ações do Sistema Único de Saúde na população da Região Sudeste do Brasil. Cien Saude Colet 2019; 24(3):887-898. analyzed the mortality trend in the population from 5 to 69 years of age, in the Southeast region, and in the states and Federal District. They identified a decline in the mortality rate in the Southeast region from avoidable and unavoidable causes. The highest avoidable death rates were from chronic noncommunicable diseases and external causes.

At least eight studies on violence-related morbidity drew on data from the 2009 and 2014 editions of the VIVA Survey (a component of the program Surveillance of Violence and Accidents - VIVA), including Rodrigues et al.¹⁶16 Rodrigues CS, Malta DC, Godinho T, Mascarenhas MDM, Silva MMA, Silva RE. Acidentes e violências entre mulheres atendidas em Serviços de Emergência Sentinela - Brasil, 2009. Cien Saude Colet 2012; 17(9):2319-2329., Malta et al.¹⁷17 Malta DC, Mascarenhas MDM, Silva MMA, Carvalho MGO, Barufaldi LA, Avanci JQ, Bernal RTI. A ocorrência de causas externas na infância em serviços de urgência: aspectos epidemiológicos, Brasil, 2014. Cien Saude Colet 2016; 21(12):3729-3744., and Souto et al.¹⁸18 Souto RMCV, Barufaldi LA, Nico LS, Freitas MG. Perfil epidemiológico do atendimento por violência nos serviços públicos de urgência e emergência em capitais brasileiras, Viva 2014. Cien Saude Colet 2017; 22(9):2811-2823. These studies revealed a wealth of data on care for victims of accidents and violence in urgent/emergency services in Brazil’s state capitals and the Federal District. This information allowed depicting the characteristics of the incidents, victims, and perpetrators. The National Health Survey of 2013 was also used in an article that described the prevalence of violence committed by persons known to the victims¹⁹19 Mascarenhas MDM, Sinimbu RB, Malta DC, Silva MMA, Santos AF, Vieira MLFP, Szwarcwald CL. Violência cometida por pessoa conhecida - Brasil, 2013. Cien Saude Colet 2017; 22(11):3763-3772..

Throughout the 25-year period, the articles produced a diverse body of knowledge on morbidity and mortality from external causes. For example, they described the profiles of the groups most heavily affected (males, young people, blacks, and the poor), associated factors (alcohol consumption, poor socioeconomic status, gender, use of cold steel weapons, and especially use of firearms).

The subtheme suicide appeared in 41 articles or 32% of the publications on external causes. The first article on this theme was published by C&SC in 2006. The years 2012 and 2015 stood out with the most articles, published in thematic issues. On the other hand, there were at least four years in which there were no articles on suicide.

The publications on suicide showed that young men predominated in terms of mortality, since they used more lethal means such as hanging and firearms, while women were more involved in attempted suicides, using less lethal means such as nonmedicinal substances, drugs, and medicines²⁰20 Souza ER, Minayo MCS, Cavalcante FG. O impacto do suicídio sobre a morbimortalidade na população de Itabira. Cien Saude Colet 2006; 11(2):409-418..

Studies on suicide and attempted suicide among adolescents recommended redirecting health practices, requiring the Unified Health System (SUS) and society to adopt policies that value life²¹21 Vieira LJES, Freitas MLV, Pordeus AMJ, Lira SVG, Silva JG. "Amor não correspondido": discursos de adolescentes que tentaram suicídio. Cien Saude Colet 2009; 14(5):1825-1834.. The studies also emphasized the need to rethink and review medical practice, due to underreporting, discrepancy in diagnoses, and failure to refer cases to the respective authorities²²22 Alves MAG, Cadete MMM. Tentativa de suicídio infanto-juvenil: lesão da parte ou do todo? Cien Saude Colet 2015; 20(1):75-84.. They highlighted the weaknesses and the need to improve the data in the information systems in general and the urgency of implementing suicide prevention programs and training for professionals at different levels of healthcare. According to some studies, deaths from poisoning reflect the consumption patterns for medicines in Brazil and the need to improve health surveillance policies. Finally, they emphasized that the scarcity of Brazilian studies on suicide in childhood may contribute to its invisibility and hinder the implementation of health promotion and treatment programs.

The subtheme homicide totaled 24 articles, 18.8% of the articles on external causes. In the 25-year period, the journal’s first article on homicide was in 2011, after which the theme was included every year in the articles except for 2013 and 2015. The largest concentration was in 2012, with 10 articles.

The articles that described the victims’ profile identified them mainly as young men from 15 to 29 years of age, in whom the rates were several times higher than in women.

Various factors were associated with homicide incidence, such as municipalities with larger populations, higher fertility rates, higher illiteracy rates, greater inequality, and greater urbanization²³23 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.. Peres et al.²⁴24 Peres MFT, Almeida JF, Vicentin D, Ruotti C, Nery MB, Cerda M, Cardia N, Adorno S. Evolução dos homicídios e indicadores de segurança pública no Município de São Paulo entre 1996 a 2008: um estudo ecológico de séries temporais. Cien Saude Colet 2012; 17(12):3249-3257. found an association between deaths and incarceration rates and policing in the city of São Paulo and concluded that public security activities lost the explanatory power for the reduction of homicides after controlling for unemployment rate and reduction in the proportion of young people. Meneghel et al.²⁵25 Meneghel SN, Rosa BAR, Ceccon RF, Hirakata VN, Danilevicz IM. Feminicídios: estudo em capitais e municípios brasileiros de grande porte populacional. Cien Saude Colet 2017; 22(9):2963-2970. found a negative association between poverty and female deaths, which the authors identified as a paradox, since the women who died in wealthy regions of Brazil were mostly poor. They also found an association between gender violence, fundamentalisms, and urban violence. Davila and Pardo-Montano²⁶26 Davila CA, Pardo-Montano AM. Factores socioeconómicos asociados con la mortalidad por homicidios en Colombia, 2000-2014. Cien Saude Colet 2019; 24(8):2793-2804. found that economic growth and inequality were negatively associated with homicide rate, while unemployment showed a positive relationship, and poverty had no significant effect.

The subtheme land transport accidents (LTA) was studied in 21 articles (16.4% of the publications on external causes). This theme was first published by the journal in 1999, reappearing in 2005 and later in 2010, showing some breaks in the 25-year period.

The publications on LTA used various data sources from large national surveys, in addition to data from the Mortality Information System and hospital emergency departments

Based on large national surveys, the studies were able to verify the prevalence rates of important relevant variables for LTA, such as the use of protective equipment and users’ risk behaviors. They involved a wide variety of analyses that described the accident’s circumstances and the profile of the persons involved in it (especially young men) and that were treated in health services. They identified time trends and conducted spatial analyses and analyses of associations with risk factors and predictive factors for LTA. Some articles found an association between abusive and frequent alcohol consumption and LTA.

Motorcyclists were the most frequently studied transportation users, but other users such as pedestrians, cyclists, and vehicle occupants were also studied. Two articles analyzed truck drivers and motorcycle couriers as professional groups.

In terms of prevention, the authors proposed action programs to prevent traffic accidents in children and adolescents; measures to prevent accidents involving motorcycle couriers; and monitoring of drivers’ blood alcohol levels. They concluded that the magnitude of traffic injuries justifies the promotion and enforcement of preventive and legislative measures to reduce LTA.

Finally, the article by Pavarino Filho²⁷27 Pavarino Filho RV. As Declarações de Moscou e Brasília sobre a segurança no trânsito - um paralelo entre dois momentos no tema da saúde. Cien Saude Colet 2016; 21(12):3649-3660. discussed the two multi-sector global conferences on traffic safety, one in Moscow in 2009 and the other in Brasília in 2015, which adopted Declarations with firm proposals for guidelines, policies, and legal provisions for the items related to health. These initiatives highlighted the involvement of the WHO with traffic safety and the health sector’s expanded engagement with the issue. The health sector shifted from traditional contributions to include health promotion, with an emphasis on inter-sector collaboration and issues influenced by the 2030 Agenda²⁸28 United Nations General Assembly. Transforming our world: the 2030 Agenda for Sustainable Development, 21 October 2015, A/RES/70/1. [document on the Internet].2015 Oct. [cited 2020 Jun 7] Available at: https://www.refworld.org/docid/57b6e3e44.html
https://www.refworld.org/docid/57b6e3e44... .

The articles (63) that addressed the theme of care for persons in situations of violence consisted of the following subthemes: care, intervention, policy analysis, services assessment, and prevention of violence, representing 16.8% of the publications. The articles were concentrated mainly in 2009 and 2010. The majority evaluated health services, analyzing policies and data from the Surveillance System for Accidents and Violence (VIVA)²⁹29 Brasil. Ministério da Saúde (MS). Viva: vigilância de violências e acidentes, 2006 e 2007. Brasília: MS; 2009. [acessado 2020 Jun 7]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/viva_vigilancia_violencias_acidentes.pdf.

30 Brasil. Ministério da Saúde (MS). Viva: vigilância de violências e acidentes, 2008 e 2009. Brasília: MS; 2010. [acessado 2020 Jun 7]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/viva_2008_2009_violencias_acidentes.pdf

31 Brasil. Ministério da Saúde (MS). Viva: vigilância de violências e acidentes, 2009, 2010 e 2011. Brasília: MS; 2013. [acessado 2020 Jun 7]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/viva_ 2009_2011_versao_eletronica.pdf^-3232 Brasil. Ministério da Saúde (MS). Viva: Vigilância de Violências e Acidentes: 2013 e 2014 [recurso eletrônico]. Brasília: MS; 2017. [acessado 2020 Jun 7]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/viva_vigilancia_violencia_acidentes_2013_2014.pdf. These studies generally sought to characterize the services that treated the victims, performed situational diagnoses, investigated the administrators’ participation in planning activities, and analyzed the implementation of policies to prevent violence. These articles demonstrate the capillarity of the PNMRAV³3 Brasil. Ministério da Saúde (MS). Portaria GM/MS n°737, de 16 de maio de 2001. Política Nacional de Redução da Morbimortalidade por Acidentes e Violências. Diário Oficial da União 2001; 18 maio. and the growth in the number of researchers from various regions of Brazil focused on the theme of violence. The articles focused on prevention referred mainly to the adoption of these measures in primary, prehospital, and hospital care and rehabilitation. The age group most frequently analyzed was children and adolescents and their families in situations of violence. Some articles analyzed consolidated experiences in the prevention of violence, such as suicide, and the building of inter-sector networks of protection. Other articles focused on healthcare professionals as key actors for the identification of different forms of violence.

In the journal’s 25 years, 44 articles focused on intrafamily violence, representing 11.8% of the body of material. Five articles were published in 1999, but only three articles were published from 2000 to 2008. Since 2009, the theme maintained a constant but smaller presence, with an average of two articles a year and with peaks in 2009 and 2019, with five articles each. Children/adolescents, women, and elderly were the main target groups. However, there were also articles on families, health professionals, and aggressors. The articles focused on various types of violence (physical, psychological, sexual, negligence), their impacts on the consequences for health, and the victims’ profile. The outstanding article by Reichenheim et al.³³33 Reichenheim ME, Hasselmann MH, Moraes CL. Consequências da violência familiar na saúde da criança e do adolescente: contribuições para a elaboração de propostas de ação. Cien Saude Colet 1999; 4(1):109-121. was a pioneering study on the subtheme of intrafamily violence.

During the 25 years, 33 articles (8.8% of the total) addressed the theme of gender violence or violence against vulnerable groups. The journal published its first article in this area in 2000. However, the theme remained almost absent until 2009, when six articles were published, followed by a smaller presence in the following years. The years 2017 and 2019 saw five and six articles, respectively. Most of the studies focused on violence against women, whether or not in the context of affective and sexual relations. They addressed sexual violence, obstetric violence, violence against incarcerated women and incarcerated pregnant women, against female workers, and against rural women. The journal published little research on violence and indigenous people, persons with disabilities, institutionalized children, and sexual minorities. One article involved male aggressors, and another reflected on the issue of masculinity and violence. The only article on the indigenous population highlighted this group’s increased vulnerability to health problems³⁴34 Coimbra Júnior CEA, Santos RV. Saúde, minorias e desigualdade: algumas teias de inter-relações, com ênfase nos povos indígenas no Brasil. Cien Saude Colet 2000; 5(1):125-132.. Among the articles with a focus on the LGBTI⁺ population, one study was on homophobia and vulnerability to HIV/AIDS in a group of travestites³⁵35 Sousa PJ, Ferreira LOC, Sá JB. Estudo descritivo da homofobia e vulnerabilidade ao HIV/Aids das travestis da Região Metropolitana do Recife, Brasil. Cien Saude Colet 2013; 18(8):2239-2251., and the other was on the relationship between homophobic bullying and self-esteem among young members of sexual minorities in Quebec, Canada³⁶36 Blais M, Gervais J, Hebert M. Homofobia internalizada como mediador parcial do bullying homofóbico e autoestima entre jovens de minorias sexuais em Quebec (Canadá). Cien Saude Colet 2014; 19(3):727-735..

Publications on the theme of mental disorders (24 articles) represented 6.4% of the total and were concentrated in 2009. The studies mainly referred to the relationship between violence and mental disorders in children and adolescents. They were mostly Brazilian studies, while two articles resulted from international studies, one in Quebec, Canada³⁷37 Hebert M, Lavoie F, Blais M. Post Traumatic Stress Disorder/PTSD in adolescent victims of sexual abuse: resilience and social support as protection factors. Cien Saude Colet 2014; 19(3):685-694., and the other in Chiapas, Mexico³⁸38 Lara GAG, Zúñiga JO, Pérez OC, Solís SH, Jiménez CEP, Méndez MC. Variables predictoras de la ideación suicida y sintomatología depresiva en adolescentes de Chiapas, México. Cien Saude Colet 2018; 23(4):1089-1096.. The majority emphasized the need to promote public policies for the care of mental health problems resulting from violence such as depression, aggressive behavior, and suicidal ideation and suicide attempts. Violence against elderly persons was highlighted in the issue of suicide and attempted suicide, with a study in Turkey³⁹39 Aslan M, Hocaoglu C, Bahceci B. Description of suicide ideation among older adults and a psychological profile: a cross-sectional study in Turkey. Cien Saude Colet 2019; 24(5):1865-1874.. Two studies from Latin American and Caribbean addressed political violence and the effects of armed conflicts on the population’s mental health. An article from Colombia discussed the African-descendant population’s mechanisms for coping with the country’s political violence⁴⁰40 Bonilla-Escobar FJ, Osorio-Cuellar GV, Pacichana-Quinayáz SG, Sánchez-Rentería G, Fandiño-Losada A, Gutiérrez MI. Do not forget culture when implementing mental health interventions for violence survivors. Cien Saude Colet 2017; 22(9):3053-3059..

The theme of theoretical and methodological studies was covered in 18 articles (4.8% of the total). Articles on these issues were present in editions of C&SC since 1999, but sporadically. That year, the articles dwelt on public health policies for the prevention of violence, pointing to possibilities and difficulties for action; the role of public policies to confront structural violence; and finally, a diagnosis of factors that allowed the growth of criminal violence in Brazil⁴¹41 Chesnais JC. A violência no Brasil: causas e recomendações políticas para a sua prevenção. Cien Saude Colet 1999; 4(1):53-69.. In the wake of publication of the PNRMAV³3 Brasil. Ministério da Saúde (MS). Portaria GM/MS n°737, de 16 de maio de 2001. Política Nacional de Redução da Morbimortalidade por Acidentes e Violências. Diário Oficial da União 2001; 18 maio. and the World Report on Violence and Health⁷7 Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano, organizadores. World report on violence and health. Geneva: World Health Organization (WHO); 2002., the journal’s second edition in 2006 featured three articles that reflected on this historical moment. One of them conducted a synthesis of the WHO report, with concepts and definitions, nature and typology of violence, and the approach to violence with the ecological model⁴²42 Dahlberg LL, Krug EG. Violência: um problema global de saúde pública. Cien Saude Colet 2006; 11(Supl.):1163-1178.. The paper by Wieviorka⁴³43 Wieviorka M. Violência hoje. Cien Saude Colet 2006; 11(Supl.):1147-1153. discussed contemporary violence in the historical context. Finally, the article by Minayo⁴⁴44 Minayo MCS. A inclusão da violência na agenda da saúde: trajetória histórica. Cien Saude Colet 2006; 11(Supl.):1259-1267. dealt with the inclusion of the theme of violence on the health agenda and how it gained legitimacy based on collaboration by different stakeholders such as the Ministry of Health, social movements, academics, and professionals.

Seventeen articles (4.5%) addressed the theme of violence and school _. These included studies that analyzed data on violence in the 2009, 2012, and 2015 editions of the National School Health Survey (PeNSE). Bullying was the most frequent theme in this area in the journal’s publications. These articles generally identified the need for action to prevent bullying both inside and outside schools. A study in Mexico related bullying to students’ quality of life. Another article discussed violence prevention measures in the Brazilian and Portuguese school systems. The other studies discussed violence in schools in urban, rural, and community spaces, and another detected maxillofacial lesions in children and adolescents who were victims of physical violence in school.

Seventeen articles (4.5%) were found on the theme of reporting/monitoring/surveillance of violence, 14 of which were published since 2012. The first article on this theme was published in 1999 and focused on conceptual and operational aspects of the surveillance of accidents and violence⁴⁵45 Waldman EA, Mello Jorge MH. Vigilância para acidentes e violência: instrumento para estratégias de prevenção e controle. Cien Saude Colet 1999; 4(1):71-79., seeking to identify differences from the surveillance of other health problems. The other articles included in this category can be divided into three watersheds: (1) work by healthcare professionals in the surveillance of accidents and violence; (2) surveillance data on different target groups (children, adolescents, and elderly, especially); and (3) quality and reliability of data systems.

The theme of social violence in general also included the subthemes of collective violence, forced migration, human trafficking, urban violence, and sexual violence and/or exploitation, represented in 16 articles (4.3%) in the total body of material, but sporadically. Two articles discussed collective violence: the first, in 1999, reflected on the causes of violent mass events such as brawls between football cheering sections; the reference for the second was ethnic, national, religious, and ideological groups whose belonging began in childhood, indicating that threats to collective identity may trigger episodes of mass violence and impact collective health.

Four articles analyzed urban violence: (1) violence based on the social imaginary of society’s more privileged classes; (2) resistance by young urban slumdwellers to the image associating poverty with violence; (3) the need for public policies to serve adolescents living in low-income urban communities; and (4) risks for military and civilian police officers and the implications for their health in large and medium-sized cities. Four articles analyzed the subtheme of sexual violence and sexual exploitation: (a) prevention programs; (b) association between sexual abuse and mental health problems in children and youth; (c) factors associated with confirmation of childhood sexual abuse in the forensic medical examination; and (d) records of tests for evidence of sexual abuse at the Forensic Medical Institute. Articles on forced migrations, human trafficking, and slave labor were rare during the 25-year period.

The theme of crime and delinquency was discussed in 13 articles, or 3.5% of the journal’s publications. The authors addressed the factors that lead young people to enter the world of crime, but also the paths leading them to make a break with delinquency. Some of the publications depicted aspects of delinquency such as gender issues in order to distinguish between male and female crime; demographic and socioeconomic aspects; and family and community characteristics in the realities of Brazil and Colombia. One article discussed mental disorders, highlighting the importance of mental health services in the rehabilitation of young criminal offenders, and another criticized the medicalization of these young people. Two articles discussed the relationship with the Criminal Justice System: one discussed the flaws and gaps in forensic medical examination of corpses which could have backed law enforcement investigations on homicides; the other investigated law enforcement personnel on procedures for interviews with children and adolescents in cases of alleged sexual crimes. Only one study analyzed the portrayals of young criminal offenders by the press. The theme of violence in the media as a public health problem was also a gap in the 25 years of publication by the journal C&SC.

Discussion

After PAHO emphasized the importance of preventing violence in the Americas, in 1993 and 1994, Cadernos de Saúde Pública/Reports in Public Health (CSP) published its first thematic issue in 1994 on “The Impact of Social Violence on Health”, as an anthology of relevant studies mainly in the social sciences and epidemiology. CSP was thus the forerunner in Brazil in scientific production on the theme of violence and health, compared to C&SC, which only published a thematic edition in 1999.

Most of the published studies produced information and knowledge on the problem’s extent and trends and the vulnerable groups’ socioeconomic profiles, both through epidemiological analyses and the description of data from services. The themes that were addressed mostly by qualitative methods were anchored in the social theories, in the respective actors’ representations, opinions, and perceptions. Some studies were more strategic, seeking to establish a dialogue with services and networks for health promotion, prevention, protection, and care.

The most widely studied target population was children and adolescents, perhaps because this was the first group in which the health sector identified victimization from violence, starting in the 1960s, spawning the creation of services to care for these cases and to protect this group.

The fact that Southeast Brazil had the largest share of published studies can be explained by the existence of more academic institutions in this region of the country. Meanwhile, the findings showed the negligible production of studies in North and Central-West Brazil, pointing to the need for incentives for research and dissemination of scientific knowledge in these two regions.

As for the studies’ scope, there was a considerable share of articles in which the research was done at the municipal (local) level, illustrating the theme’s capillarity in Brazil and the space assigned by the Journal C&SC to these studies. Local studies are just as important as national ones to back policy planning.

The fact that external causes were the preponderant theme in publications in four out of five of the periodicals analyzed here can be explained by the magnitude and growth of these events in the world, consisting especially of homicides, land transport accidents, and suicides. In addition, this theme has been present historically in the International Classification of Diseases and has been used as a thermometer for social violence. Since the 1970s, a few Brazilian researchers at the School of Public Health of the University of São Paulo (USP) had already been studying and publishing on external causes in Brazilian periodicals⁴⁶46 Mello Jorge MHP, Gotlieb SLD. Acidentes, envenenamentos e violências como causa de morte no município de São Paulo. Rev Saude Publica 1976; 10(1):45-55.^,4747 Mello Jorge, MHP. Mortalidade por causas violentas no Município de São Paulo [tese]. São Paulo: Universidade de São Paulo; 1979..

Indicators of external causes have been used as a thermometer for violence in societies. Thus, studies of historical series that analyze morbidity and mortality trends from these causes in more recent years had to be performed and published, taking into account specific and particularly vulnerable groups such as the black population, LGBTI⁺, indigenous peoples, quilombola (maroon) communities, and women, among others. Curiously, it was not until 2017 that studies on femicide began to appear in the journal⁴⁸48 Souza ER, Meira KC, Ribeiro AP, Santos J, Guimarães RM, Borges LF, Oliveira LV, Simões TC. Homicídios de mulheres nas distintas regiões brasileiras nos últimos 35 anos: análise do efeito da idade-período e coorte de nascimento. Cien Saude Colet 2017; 22(9):2949-2962.^,4949 Leite FMC, Mascarello KC, Almeida APSC, Fávero JL, Santos AS, Silva ICM, Wehrmeister FC. Análise da tendência da mortalidade feminina por agressão no Brasil, estados e regiões. Cien Saude Colet 2017; 22(9):2971-2978..

Aspects such as gender, age bracket, and more vulnerable territories were practically absent as targets of studies on external causes and homicide. Although these aspects are determinants of health conditions, they tend more to be the object of social, anthropological, demographic, or historical studies on the theme of violence, predominantly published in journals specific to these other fields.

There were relatively few articles published on homicides and land transport accidents, considering the magnitude of these events in Brazil. There have not even appeared in the publications for several years. The studies on LTA that analyze the issue of drinking and driving are incipient, and there are no articles at all on bus drivers or app-based drivers, for example. There is a clear need to publish studies that address both the theoretical framework and analyses and socioeconomic and contextual aspects that expand the individualized approach to this problem and that allow overcoming the notion of the “accidental” nature of traffic injuries and deaths. A systemic perspective may be highly useful in this regard. This point deserves greater attention in the debate, as well as in incentives and support for inter-sector public policies for violence prevention in general and prevention of LTA in particular. Still, some strides in the leading role of interdisciplinary and inter-sector traffic-related health measures are discussed in the Sustainable Development Goals (SDGs) of the 2030 Agenda²⁸28 United Nations General Assembly. Transforming our world: the 2030 Agenda for Sustainable Development, 21 October 2015, A/RES/70/1. [document on the Internet].2015 Oct. [cited 2020 Jun 7] Available at: https://www.refworld.org/docid/57b6e3e44.html
https://www.refworld.org/docid/57b6e3e44... .

The above-mentioned critique may also apply to the theme of suicide, which the predominant analyses invariably view as an issue of individual mental disorders and rarely expand the theoretical view to address the social context. The theme of self-mutilation, so interwoven with suicide attempts and suicides, has not even appeared in recent years in any article. During the COVID 19 pandemic, reports of domestic violence have increased, and it is likely that ideations, suicide attempts, and suicides have also become more frequent, indicating the need for studies on the forms of violence evidenced during the pandemic.

Gender violence and intrafamily violence were among the most extensively studied themes in Brazil and the world and were been featured in the publications, influenced both by the high prevalence rates and the global policy agendas in defense of the rights of women, children, and adolescents.

The Journal C&SC contributed significantly to the visibility of the theme of care for persons in situations of violence in Brazil. This emphasizes the efforts by the Unified Health System (SUS) and other institutions in Brazilian society to upgrade the services and train the professionals to deal with various forms of violence. However, the discontinuity and scarcity of studies on the characteristics of care for victims hinder attempts to verify the distribution of the network of services across the national territory, the types of care and interventions that are offered, the social groups that rely on these services, and the indicators that can back measures for the prevention of violence in the country.

Finally, the analysis showed that there are few articles in C&SC on the themes of collective violence, forced migration, human trafficking, sexual violence and/or exploitation, and media and violence, despite the severity of these forms of violence for individual and collective health, particularly in the intersections with the issues of gender, age bracket, and ethnicity and skin color.

Conclusions

Throughout its 25 years, the Journal C&SC played the important role of giving visibility to the theme of violence in the public health field in Brazil. This alone is reason for collective celebration by researchers and others interested in this subject of great relevance for public health in Brazil.

Another key point is the positive nature of studies that used the existing public data systems in Brazil. Based on these analyses, the studies successfully disseminate data on violence and identify the characteristics of the victims, the aggressors, and the types of violence. Thanks to the data systems, it was possible to obtain extensive knowledge on the forms of violence impacting the Brazilian population and to back public policies for the prevention and reduction of morbidity and mortality from these events. Additionally, these studies contributed to the improvement and feedback of information for these systems.

Despite the many positive aspects, it is important for C&SC to organize calls for articles that address the various possibilities for intersections between themes, as well as to give visibility to further key themes in the current public health scenario.

References

Publication Dates

History