Abstract

This article analyzed the Violence Prevention and Health Promotion Centers (NPVPS) implementation process established by the National Policy for Reducing Morbimortality from Accidents and Violence (PNRMAV). We provided a historical background of its creation. We analyzed data from 531 questionnaires and 63 interviews from an evaluative survey with managers and professionals from the three care levels on the topic. We described quantitative data and performed a content analysis of the interviews. We identified state centers in 56.2% of primary care units, 63.5% in hospital and pre-hospital units, and 54.4% in rehabilitation units, and municipal centers in 18.8% of the first, 31.5% of the second, and 29.1% of the third. The State centers support 83.8% of the primary care units in the municipalities, 84.1% of pre-hospital and hospital care, and 79.2% of rehabilitation units. Municipal centers support Health Units in the following proportions: 96.2% of primary care, 97.1% of pre-hospital and hospital care, and 93.1% of rehabilitation units. The study found several problems in the centers’ functioning, although the respondents reaffirmed the support they receive.

Key words:
Violence Prevention Center; Health policy; Accident prevention

A brief introduction to the Violence Prevention and Health Promotion Centers (NPVPS)

Violence was only recognized worldwide as a problem to be addressed by the health sector in the 1990s, and one of the main milestones was the 49^th World Assembly of the World Health Organization (WHO)¹1 World Health Organization (WHO). World Health Assembly: Prevention of violence: public health priority (WHA 49.25). Geneva: WHO; 1996., in which this topic and its prevention were considered a priority. At the time, the WHO urged member countries to develop their prevention policies based on the health sector. Previously, the Pan American Health Organization (PAHO) was concerned about the high violence levels in Latin American countries and had already spoken out about the need for the health sector to address the issue with a focus on prevention, not just from the traditional biomedical perspective²2 Organización Panamericana de Salud (OPAS). Violencia y salud. Resolución n. XIX. Washington, D.C.: OPAS; 1994.^,33 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..

WHO’s guidance was accepted by the Brazilian Ministry of Health, and the National Policy for Reducing Morbimortality from Accidents and Violence (PNRMAV) was established through Ordinance No. 737 MS/GM of 2001. The actions of this Policy were coordinated by the then Health Care Secretariat/SAS and later by the Secretariat of Health Surveillance/SVS. However, the strategies for its implementation and deployment were only consolidated by Ordinance No. 936 MS/GM of May 19, 2004, which provided for the structuring of the National Network for Violence Prevention and Health Promotion (RNPVPS) and the Implementation and Implantation of Violence Prevention Centers in States and Municipalities⁴4 Brasil. Ministério da Saúde (MS). Portaria MS nº 936, de 18 de maio de 2004. Dispõe sobre a estruturação da Rede Nacional de Prevenção da Violência e Promoção da Saúde e a Implantação e Implementação de Núcleos de Prevenção à Violência em Estados e Municípios. Diário Oficial da União; 2004..

Article 4 of this Ordinance defined the responsibilities of the RNPVPS components and the State, Municipal, and Academic Centers. The State Centers must develop a plan at this level, with intersectoral and intermunicipal actions for violence prevention and health promotion, provide advice, and monitor the plans of the municipal centers; promote actions to report the various violence types, improving information; stimulate studies and scientific research on the subject and run training activities for managers and professionals to care for victims and promote health and peace⁴4 Brasil. Ministério da Saúde (MS). Portaria MS nº 936, de 18 de maio de 2004. Dispõe sobre a estruturação da Rede Nacional de Prevenção da Violência e Promoção da Saúde e a Implantação e Implementação de Núcleos de Prevenção à Violência em Estados e Municípios. Diário Oficial da União; 2004.. Municipal centers also have these responsibilities and some other local proximity responsibilities.

The academic centers were established to produce evidence and technical-scientific events, develop dissemination plans, contribute to the training of health professionals, and improve reporting strategies and the quality of information on accidents and violence⁴4 Brasil. Ministério da Saúde (MS). Portaria MS nº 936, de 18 de maio de 2004. Dispõe sobre a estruturação da Rede Nacional de Prevenção da Violência e Promoção da Saúde e a Implantação e Implementação de Núcleos de Prevenção à Violência em Estados e Municípios. Diário Oficial da União; 2004..

The actions planned for the centers’ activities are broad and aim primarily to prevent violence and promote health. They can be incorporated into all care levels, considering the specificities of each. These bodies are essential devices promoted by the SVS/MS (currently and henceforth called the Health and Environmental Surveillance Secretariat - SVSA) through agreements signed at the time with municipalities that were priorities because they had more than 100,000 inhabitants and high rates of deaths from violent causes, and later, through notices financing projects to strengthen the centers.

In the early years, some experiences aimed at implementing and implanting the Policy were evaluated, as provided for in its recommendations, which is the case of studies on municipal experiences of reducing morbimortality due to traffic accidents⁵5 Souza ER, coordenadora. Projeto de assessoria, capacitação e avaliação das ações de implantação da Política Nacional de Redução da Morbimortalidade por Acidentes e Violências. Rio de Janeiro: CLAVES/ENSP/Fiocruz; 2008.

6 Souza ER, Njaine K, coordenadores. Avaliação do processo de implantação e implementação do programa de redução da morbimortalidade por acidentes de trânsito. Rio de Janeiro: CLAVES/ENSP/Fiocruz; 2009.^-77 Souza ER, Ribeiro AP, Sousa CAM, Valadares FC, Silva JG, Njaine K, Minayo MCS. Vidas preservadas: experiências intersetoriais de prevenção dos acidentes de trânsito. São Paulo: Hucitec; 2014., on prevention centers in the state of Espírito Santo⁵5 Souza ER, coordenadora. Projeto de assessoria, capacitação e avaliação das ações de implantação da Política Nacional de Redução da Morbimortalidade por Acidentes e Violências. Rio de Janeiro: CLAVES/ENSP/Fiocruz; 2008., on centers in macro-regions of the country⁸8 Deslandes SF, Souza ER, organizadores. Avaliação do processo de implantação e implementação de Núcleos de Prevenção de Violências e Promoção da Saúde. Rio de Janeiro: CLAVES/ENSP/Fiocruz; 2011., and on centers for the prevention of accidents and violence in general, which the Ministry of Health⁹9 Souza ER, coordenadora. Avaliação dos Núcleos de Prevenção à Violência e Promoção da Saúde do Brasil frente à Política de Redução de Morbimortalidade por Acidentes e Violências. Rio de Janeiro: CLAVES/ENSP/Fiocruz; 2012. was supporting.

This article investigates the status of the different Centers for Violence Prevention and Health Promotion/NPVPS in Brazil two decades after their conception and implementation.

Methods

We analyzed data from an evaluation study on the implementation of the PNRMAV, developed at the Jorge Careli Department of Studies on Violence and Health (CLAVES), the Oswaldo Cruz Foundation (Fiocruz), from 2020 to 2023 in the national territory. The study used quantitative and qualitative methods and different data collection techniques¹⁰10 Denzin NK. The research act. Chicago: Aldine Publishing Company; 1973.

11 Minayo MCS, Sanchez O. Quantitativo-qualitativo: oposição ou complementaridade? Cad Saude Publica 1993; 9(3):239-262.^-1212 Minayo MCS, Assis SG, Souza ER, organizadores. Avaliação por triangulação de métodos. Avaliação de Programas Sociais. Rio de janeiro: Editora Fiocruz; 2005. and integrated the vision of the stakeholders who build the policy as subjects who self-evaluate¹³13 Minayo MCS. O Desafio do Conhecimento: pesquisa qualitativa em saúde. 9ª ed. São Paulo: Hucitec, Abrasco; 2006..

For the quantitative stage, three closed-ended self-assessment questionnaires were prepared, one for each care level, with questions about the structure, processes, and results achieved in implementing the policy. Only one open-ended question asked which policy guidelines the respondents considered to have better or worse implementation, and why. The questionnaires were simultaneously emailed to the health secretaries of all municipalities in the country. The RedCap platform was used for data collection. After the questionnaires were sent, due to the low response rate and many emails being returned, new ones were sent in an updated list and several requests for responses were made with new deadlines to complete them. This process occurred from July to November 2021.

All states responded to at least one questionnaire, but among the capitals, Florianópolis, João Pessoa, Rio Branco, Salvador, and Vitoria did not provide any information. The percentage of adherence was higher in the larger cities. In the regions, percentages were North (32.3%), Northeast (15.6%), Southeast (19.5%), South (17.0%), and Midwest (25.0%).

Despite several requests and extensions to the questionnaire completion deadline, only 531 municipalities completed the survey: 290 for Primary Care, 128 for Pre-Hospital and Hospital Care, and 113 for Rehabilitation Care. Notably, the survey occurred during the COVID-19 pandemic, when health services were fully involved and overwhelmed with providing care to victims of the disease.

This article analyzes the following topics: the availability and support of NPVPS to health services in states and municipalities; the dissemination of centers; the management group’s support for consolidating accidents and violence topics at the three care levels; and the participation of the Municipal Health Council in actions and proposals related to the prevention of these events.

Support for a state center includes activities such as developing a plan with intersectoral and intermunicipal actions for violence prevention and health promotion, providing advice and monitoring to municipal centers, and promoting actions to report violence and improve the information. Municipal centers have these responsibilities, among others, within their management sphere. Academic centers were designed to support the production of studies and research and train managers and professionals on both topics, with health promotion as a parameter⁴4 Brasil. Ministério da Saúde (MS). Portaria MS nº 936, de 18 de maio de 2004. Dispõe sobre a estruturação da Rede Nacional de Prevenção da Violência e Promoção da Saúde e a Implantação e Implementação de Núcleos de Prevenção à Violência em Estados e Municípios. Diário Oficial da União; 2004.. The management group coordinates the management of intra- and inter-sectoral actions in the municipality or state. It must be formed by representatives of services and institutions responsible for monitoring the PNRMAV’s implementation. Therefore, it provides strategic support in developing standards and protocols for training human and technological resources and monitoring actions.

Quantitative data (absolute and relative numbers) from the questionnaires were analyzed by the total number of participants, Brazilian capitals and regions of the country, and by municipality size (<99,999 inhabitants and 100,000 or more inhabitants). The total numbers in the tables correspond to each line and vary depending on the non-completion regarding that line or option.

Semi-structured interviews were conducted with managers and professionals from the three care levels and with representatives from municipal and state centers in the country, based on a roadmap with common and specific questions for the care levels (primary, pre-hospital, hospital, and rehabilitation) and administration (municipal/state). Due to the COVID-19 pandemic, all 63 interviews were conducted remotely via Google Meet in 2022. All were recorded and transcribed by specialized professionals and lasted, on average, one hour. They involved people from the 26 Brazilian state capitals and the Federal District, besides some rural cities, two from each central region, selected by population size and performance in implementing the Policy guidelines. Health managers were contacted by telephone or email available on the websites of the health secretariats of each municipality and state, and invited to participate in the study and indicate people to be interviewed. This process required many scheduling, interview cancellations, and search for new contacts.

The interview questions analyzed in this article refer to the historical trajectory of the PNRMAV’s implementation in municipalities and states, and the support of municipal centers to health units and state centers to municipalities. The material collected was analyzed in its content by thematic modality, as recommended by Bardin¹⁴14 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011. and Triviños¹⁵15 Triviños ANS. Introdução à pesquisa em ciências sociais: a pesquisa qualitativa em educação. São Paulo: Atlas; 1987..

The Research Ethics Committee of the National School of Public Health of Fiocruz approved the research under Opinion No. 4.732.884 dated May 25, 2021. All participants in the quantitative and qualitative stages signed the Informed Consent Registry.

Results

Primary care

The responses regarding Primary Care regarding the availability of NPVPS in municipal and state health secretariats and the support provided by these devices show that in all participating municipalities, the centers are instead found in state secretariats (56.2%) than municipal secretariats (18.8%). The percentages of support are high in the state (83.8% provide support to municipalities) and municipal centers (96.2% support primary care network services). Compared to the total number of responding municipalities, the percentages of available centers are higher in the capitals, especially those linked to municipal (66.7%) and state (62.5%) secretariats. The support from state centers to municipalities (88.9%) and from municipal centers to PHC units (100%) is also high.

In large regions of the country, centers are instead found in state health secretariats than in municipal secretariats in small and large cities, which is interesting because primary care is generally under municipal management, even in smaller cities.

In short, we observed among the participants that: a) the North does not have municipal centers in small cities, and the percentage is low (33.3%) even in larger cities. The availability of state centers stands out, which can be a reference for small and large cities (64.3%). However, regardless of size, the municipalities state that they count on the support of these facilities when they are available; b) in the Northeast, the centers are instead found in the state secretariats, in small (59.2%) and large cities (66.7%); the Southeast has percentages above 50% for the presence of state and municipal centers in small and large cities; d) in the South, the centers are instead found in the state health secretariats than in the municipal ones in small and large municipalities. The percentages of support offered by the centers to the municipalities and the primary care services of small and large municipalities are high; e) in the Midwest, smaller cities have a meager percentage of municipal centers (5%). Their frequency in state secretariats is 45%, but below what is observed in smaller cities in other Brazilian regions. This differs from what occurs in cities with 100,000 or more inhabitants in this region, where state and municipal centers are available in most responding municipalities and are active, offering support to services.

The frequency with which NPVPS are disseminated in the units of the Primary Care network was investigated. Most respondents reported that the PHC does not have centers distributed throughout the units of its network, which occurs in all municipalities, capitals, and regions of the country studied, regardless of the size of the municipalities (Table 1). Even when available, the frequency with which the centers are in the PHC units is low, as can be seen in the percentages regarding the different response options in the different regions. A slightly better situation is observed in the Southeast, with a higher frequency of centers in all PHC units in the larger (10.4%) and smaller cities (14.3%).

We can observe that 32.2% of the 286 participating municipalities have an intersectoral management group for the issue of accidents and violence, and only 5.2% have an intrasectoral management group; most (62.6%) do not have this body. The capitals display a better situation since 55.5% of the 18 respondents stated that they have an intersectoral management group and 16.7% an intrasectoral group at the primary care level, although this body is unavailable in 27.8%.

In Brazilian regions, the availability of an intersectoral management group for the issue of violence ranges from 20.0% in small municipalities in the Northeast to 57.1% in the largest cities in the Midwest. Higher percentages were found in municipalities with 100,000 or more inhabitants compared to small cities. As for intrasectoral management groups, the percentages found were low and ranged from zero to 20.0%. The lack of a management group predominates in small municipalities, ranging from 59.2% in the Southeast to 78.6% in the North.

In the case of a management group for violence and accidents, in 91.5% of the 106 municipalities and 76.9% of the thirteen capitals, the respondents answered that it supports the PHC network units. The same situation is found in all regions of the country, regardless of the size of their municipalities. The exception is the large municipalities in the North and Northeast, where 40% and 75% of them do not have this support. In other words, the support is adequate when the management group is available.

The Municipal Health Council rarely participates in discussions and proposals for actions and policies on accidents and violence at the PHC level. The exception occurs in the larger municipalities of the Midwest, where half reported that the Council participates, and in the Northeast, where 42.9% of municipalities responded that the Council participates in most or almost always of the discussions and proposals.

Pre-Hospital and Hospital Care

At the pre-hospital and hospital care (APHH) levels, for all participating municipalities, the most available centers were those of the state secretariats (63.5%) and those of the municipal bodies (31.5%). Around 84.1% and 97.1% of these, respectively, support professionals. In the capitals, more centers operate mainly within the municipal health secretariats (71.4%). According to respondents, we have full support of the state centers to the municipalities and municipal centers to the units of the APHH network.

In short, those who responded about the availability and functioning of centers in pre-hospital and hospital units confirmed that centers are more frequently found in state health secretariats than municipal health secretariats. This is logical because it reflects the link between network services and state management.

By region, we observed among the participants that: a) In the North, 62.5% of small cities and 33.3% of larger cities reported the availability of centers in the state secretariats; b) The Northeast also has more state centers, in small and larger municipalities; c) In contrast, in the Southeast the availability of centers in the municipal secretariats of larger municipalities was more cited (66.6%), with less support from state centers to municipalities; d) In the South, centers are instead found in state secretariats; they provide support to small municipalities and are unavailable in the municipal secretariats of larger cities; e) The Midwest is the only region where all of the larger municipalities that responded about the pre-hospital and hospital care network stated that there are state and municipal centers that support them.

Most of the municipalities studied reported the unavailability of NPVPS in the pre-hospital and hospital care network units (Table 2), which was found in 74.9% of the responding municipalities and 57.1% of the capitals. Exceptions can be highlighted: around 10% of these centers are available in the capitals and some regions. The Midwest seems to be in a better situation, in small and large municipalities, and the Southeast, in the largest municipalities.

Approximately 32.4% of the 531 municipalities that responded to the survey questionnaires have an intersectoral management group to address violence in pre-hospital and hospital bodies. The organization is intrasectoral in only 4.5% of them. Most (63.1%) do not have this critical body. Also, in the seven Brazilian capitals that responded to this survey question, 42.9% have an intersectoral management group, 14.2% have an intrasectoral group, and 42.9% have neither.

In the country’s regions, most responding municipalities reported the unavailability of an intersectoral or intrasectoral management group for the issue of violence at the pre-hospital and hospital care levels. The availability of an intersectoral management group was mentioned more frequently in the largest responding municipalities in the Northeast (66.7%), Southeast (55.6%), and Midwest (50.0%). Intrasectoral management groups are unavailable in the Northeast and Southeast, small cities in the North, and larger cities in the South. However, they were mentioned in 33.3% and 50.0% of large municipalities in the North and Midwest, respectively, and by 11.1% of small municipalities in the South.

Support from the management group to address the issue of violence at the pre-hospital and hospital care levels was reported by 94.4% of the 36 municipalities, and three capitals responded to this question.

According to study participants, all regions of the country, regardless of the size of their municipalities, showed high percentages of support from the management group for the topic at the pre-hospital and hospital care levels. The only exception is the North because none of the larger municipalities responded to this question.

Rehabilitation Care

According to the group of professionals and managers linked to rehabilitation in the municipalities that responded to the questionnaire (111), the NPVPS are available in 54.4% of the state health secretariats, and 79.25% of them said that they support the actions in their area. Only 29.1% of the survey participants confirmed the availability of centers in the municipal health secretariats. However, 93.1% of those who positively stated that the centers support the units of the rehabilitation network.

Municipal centers predominated in the rehabilitation units of the capitals that participated in the survey (71.4% versus 50.0% state centers). However, all the participants from the capitals who answered this question confirmed the positive support state bodies offered them.

In all regions, the availability of prevention centers in rehabilitation bodies in small cities and larger municipalities in the Southeast and South was considered low, although their support is recognized when available, except for in the North, where the topic question was not even answered.

Table 3 shows the frequency with which NPVPS is available at the rehabilitation level. Centers are unavailable in 69.1% of the responding municipalities, which was also found in 42.9% of the participating capitals and regions of the country, regardless of the size of the municipalities. However, 42.9% of the capitals reported the availability of NPVPS in some rehabilitation units. The Midwest is the great positive exception, as 66.7% of the larger municipalities reported having centers in all units of this network.

According to the participants, 35.5% of the 110 municipalities that reported on the rehabilitation care level have an intersectoral management group for accidents and violence. However, only 10.0% have an intrasectoral management group. Notably, most (54.5%) do not have any body.

Approximately 42.9% of the seven participating capitals have an intersectoral management group and the same percentage of intrasectoral groups. However, 14.3% reported not having these groups in the rehabilitation network. Likewise, in the Brazilian regions, interviews revealed the lack of intersectoral or intrasectoral management groups focused on the issue of violence and accidents. Half of the largest municipalities in the Southeast and South reported having an intersectoral management group in the healthcare network, also found in the small cities of the second region. Notably, 66.7% of the participants from the largest cities in the Midwest reported having an intrasectoral management group for the issue of violence in their territories. However, they said nothing about the situation in the small municipalities.

We underscore that 50.5% of all responding municipalities and 66.7% of the largest municipalities in the South said that the Municipal Health Councils primarily participate in discussions and proposals for actions and policies on accidents and violence at the rehabilitation level. In contrast, we observed 60.0% or more negative responses regarding the Councils’ participation in the capitals and the Northeast, Southeast, and Midwest.

Quantitative data summary

The data that summarize the information provided by the 531 municipalities on the availability and performance of the centers can be condensed as follows:

- Quantitative data show highly variable percentages of implementation of Prevention Centers, especially by Municipal Health Secretariats. At the three care levels, the Southeast and South stand out as relatively more positive regarding the availability of these bodies at the state and municipal levels in capitals and larger cities. However, the centers are still a distant reality in small locations in all Brazilian regions.

- Centers in the State Health Secretariats that serve the PNRMAV: 56.2% in primary care, 63.5% in pre-hospital and hospital care, and 54.4% in rehabilitation care. The support they provide to municipalities was highly recognized by 83.8% of those working in primary care, 84.1% in pre-hospital and hospital care, and 79.2% in rehabilitation care.

- Centers in Municipal Secretariats: 18.8% provide primary care, 31.5% provide pre-hospital and hospital care, and 29.1% provide rehabilitation care. These centers are known to support health units: 96.2% provide primary care, 97.1% provide pre-hospital and hospital care, and 93.1% provide rehabilitation care.

The qualitative analysis of the interviews delved deeper into some aspects not covered by the quantitative study, such as the movement of creation, advances, and impasses of the centers in the municipalities and capitals. The results comprise the summary in Chart 1, which shows the varying situations.

Chart 1 shows the availability of the centers and the support they provide to municipalities and health units, which means that the PNRMAV has become present in the system. However, it is also clear that there is still a long way to go before this policy is institutionalized. There are emblematic cases, such as those of São Paulo and Fortaleza, which have implemented Prevention Centers in all PHC units. In the Midwest, all capitals have prevention centers or devices that operate similarly. However, the availability of this institution was not mentioned in any small municipality, but this was not a widespread movement.

We observed that awareness did not stem from the Ministry of Health in some places, although the preventive and peace culture logic is the same. This is the case of Curitiba, where the implementation of the local proposal derived from the Institute of Urban Planning and Research (IPPUC) in 1998 was concerned about the mistreatment of children and adolescents. This situation is also the case in Porto Alegre, with the “Violence Observatory” that gathers and coordinates the views and proposals of several municipal secretariats.

Besides a still fragile implementation process - perhaps due to the Policy’s specificity, which is not based on biomedical logic and operates within a complex model - some deviations deserve attention: in specific places, the actions of what is called the “center” are closer to the functioning of the service of the epidemiological surveillance sector for diseases due to external causes and its activity is limited to the data epidemiological monitoring.

Discussion

In Brazil, the PNRMAV has existed for 23 years and was an essential milestone in a public proposal for healthcare for people in situations of violence and accidents¹⁶16 Minayo MCS, Souza ER, Silva MMA, Assis SG. Institucionalização do tema da violência no SUS: avanços e desafios. Cien Saude Colet 2018; 23(6):2007-2016.. As an operational concept, the Ministry of Health created the Prevention Centers, as described in the introduction, to implement this proposal.

This study aimed to identify where these Centers are, how they are, and how they operate in practice. However, the research work was severely hampered by the COVID-19 pandemic. The healthcare professionals involved in the PNRMAV were overwhelmed with work, which is entirely understandable. However, while not representative, the data presented in the study points to several issues: the centers lack financial, human, equipment, and ongoing health professional training investments to address the issue. Moreover, the PNRMAV and its strategies for preventing violence and promoting health need to be universalized and reach small municipalities in all Brazilian regions.

In an evaluative study conducted in 2012, Souza et al.⁹9 Souza ER, coordenadora. Avaliação dos Núcleos de Prevenção à Violência e Promoção da Saúde do Brasil frente à Política de Redução de Morbimortalidade por Acidentes e Violências. Rio de Janeiro: CLAVES/ENSP/Fiocruz; 2012. estimated that they found 430 municipal centers and 23 state centers reported by the Ministry of Health. However, 13% of the municipal and 8.7% of the state centers had not yet been implemented, although they had received resources. The study included the participation of 185 (49.5%) municipal centers and 15 (71.4%) state centers. More than half of them performed well, but 42.7% needed support to adapt their performance. Although most centers complied well with the guidelines for team composition and qualification (75.1%) and notification implementation (72.4%), the authors highlighted that 46.5% of the centers admitted difficulties training their professionals. At the time, there was already a lack of availability of health professionals (59.5%) and professionals from other sectors (50.8%) to perform the actions planned for the centers.

Approximately two decades after the creation of the NPVPS, this research shows that the centers have been essential for supporting health units at all three levels where they have been institutionalized. Unlike the previous study⁹9 Souza ER, coordenadora. Avaliação dos Núcleos de Prevenção à Violência e Promoção da Saúde do Brasil frente à Política de Redução de Morbimortalidade por Acidentes e Violências. Rio de Janeiro: CLAVES/ENSP/Fiocruz; 2012., in which the municipal centers were more prominent and the state centers were still questioning their objectives and functions, the current results show that the state centers are more present and active, especially regarding supporting small cities where these bodies are unavailable.

The founding documents emphasize that the centers were created as a strategy of the PNRMAV to guide, encourage, and act intra and intersectorally in preventing accidents and violence and promoting health and a peace culture. However, gradually and given the lack of the Ministry of Health’s highly incisive action, a redirection occurred in specific municipalities that considered local needs more than the broader recommendations of the policy. For example, some cities have multiplied in geographic or administrative subdivisions: this is the case of São Paulo-SP, the Federal District, and Rio de Janeiro-RJ, which have decentralized the functions and activities assigned to the centers. Other municipalities simply do not have this device, suggesting that there is still a need for more incentives to create and implement more appropriate forms of what corresponds to the function of each, above all, regarding the need to support small municipalities.

Data show that the centers are mainly located in large municipalities, which is predictable. These sociocultural spaces gather the highest incidence of accidents and violence, and it is where the network of services to assist victims is located. Likewise, there was an incentive from the Ministry of Health, which initially supported the creation of centers in municipalities with more than 100,000 inhabitants and high rates of deaths from violent causes⁴4 Brasil. Ministério da Saúde (MS). Portaria MS nº 936, de 18 de maio de 2004. Dispõe sobre a estruturação da Rede Nacional de Prevenção da Violência e Promoção da Saúde e a Implantação e Implementação de Núcleos de Prevenção à Violência em Estados e Municípios. Diário Oficial da União; 2004..

In the national context, there is little research on the role and effectiveness of accident and violence prevention centers. However, some studies are mentioned here. A study by Sá et al.¹⁷17 Sá RM, Lorenzato EA, Melman J. Núcleo de Prevenção da Violência: estratégia para a organização e fortalecimento da rede de cuidado à pessoa em situação de violência no município de São Paulo. In: XXX Congresso de Secretários Municipais de Saúde do Estado de São Paulo [Internet]. 2016 abr 13-15 [acessado 2023 jun 10]. Disponível em: https://docs.bvsalud.org/biblioref/sms-sp/2016/sms-11814/sms-11814-8887.pdf.
https://docs.bvsalud.org/biblioref/sms-s... in São Paulo stands out. The authors highlight some fundamental positive points: the centers are located in health units and are spaces for discussion about people in situations of violence and for the training and performance of health professionals. Identifying expressions of violence, understanding the physical and subjective repercussions, and developing strategies to support victims are all addressed there. The authors emphasize the importance of having a care network in which professionals know the need to provide support, agree on care flows, and develop protocols and management¹⁷17 Sá RM, Lorenzato EA, Melman J. Núcleo de Prevenção da Violência: estratégia para a organização e fortalecimento da rede de cuidado à pessoa em situação de violência no município de São Paulo. In: XXX Congresso de Secretários Municipais de Saúde do Estado de São Paulo [Internet]. 2016 abr 13-15 [acessado 2023 jun 10]. Disponível em: https://docs.bvsalud.org/biblioref/sms-sp/2016/sms-11814/sms-11814-8887.pdf.
https://docs.bvsalud.org/biblioref/sms-s... .

Santos¹⁸18 Santos KD. Atenção básica à saúde e enfrentamento da violência: um olhar a partir dos Núcleos de Prevenção (NP) na cidade de São Paulo [tese]. São Paulo: Instituto de Psicologia, Universidade de São Paulo; 2020. also researched the São Paulo centers and emphasized their challenges, which are difficulty in coordinating and dialoguing with other policies and bodies due to the lack of clarity about each institution’s role, the distress of health professionals who work with the issue, the deterioration of the physical space of some care units, and the lack of institutional support to address situations of violence that occur inside and outside health units.

In a study on the centers in Olinda, State of Pernambuco, Silva¹⁹19 Silva FF. Análise das ações de Prevenção da Violência e Promoção da Saúde no município de Olinda: estudo de caso [dissertação]. Pernambuco: Programa de Pós-Graduação Integrado em Saúde Coletiva, Universidade Federal de Pernambuco; 2012. also highlights the difficulties in implementing the PNRMAV and the center in the municipality: constant political and administrative changes, lack of specific physical space for implementing the actions, inadequate infrastructure, and difficulties in the travel of health professionals. The author also points out a fundamental issue: violence and accidents were not the subject of the basic training of professionals.

Lopes and Silveira²⁰20 Lopes RO, Silveira PS. A atuação do Núcleo de Prevenção de Violências e Promoção da Saúde de Itabuna-BA de 2015 e 2016: uma articulação entre saúde pública e direitos humanos. Opará 2020; 8:e132013. investigated the performance of the NPVPS of Itabuna/Bahia in 2015 and 2016. They found that the center valued the implementation of intersectoral actions, from notification to participation in social control events. However, they noted the lack of detail on the actions undertaken and of an assessment of their impact, which limits the understanding of the action’s scope.

The research findings above corroborate what was found in this study about the relevance of the centers as spaces for implementing the PNRMAV, on the one hand, and on the other, about the practical difficulties brought by an activity of this nature. In general, the respondents who are part of municipal and state centers - although described with different formats and nomenclatures - are those who understand the development of the policy and practices best and those who spoke the most and best about the topic, both about what they have been achieving and the obstacles to their action. Many of the members of the groups are personally involved in combating violence, are familiar with the Policy, and are committed, often individually, to ensuring that it continues to be implemented. This certainly influenced their appointment by the managers to speak about monitoring and reporting, care, training of professionals, care networks, and actions to prevent accidents and violence. These people are called and call themselves “responsible” for the issue of violence and accidents in the municipalities and states.

On the contrary, in the current research, it was hard to find managers from the three care levels who knew about the policy and the centers and were willing to discuss the subject.

An issue permeates the work of many centers coordinated by professionals from the surveillance sectors: the emphasis is not on health promotion and accident and violence prevention but solely on data qualification. This reductionism perhaps reflects that the management of the PNRMAV is, at the federal level, under the responsibility of the Secretariat of Health and Environmental Surveillance, which ensures greater visibility for monitoring and reporting actions. Interviews with health managers and professionals make it very clear that the Ministry is currently underinvesting in the issue of violence - aligned with the recommendations of the World Health Organization in its 2002 report. Tasks and responsibilities for the issue are concentrated in the hands of highly committed technicians but with almost no decision-making power and no political, technical, or financial support. Some work without the necessary clarity as to whether they are part of a surveillance sector or members of a center (the central or federal).

Final considerations

Notably, some respondents had difficulty discussing the creation, availability, and permanence of the centers in their cities and states and the fact that many of these facilities have taken on other characteristics, functions, and names. These findings seem to derive from the high turnover of health professionals and the lack of technical, political, and financial support for implementing the PNRMAV and achieving a good center performance. There is even a lack of official data on which centers remain active and which have been deactivated, which points to the need for more accurate analysis and greater participation by federal and state management in encouraging and monitoring the centers.

We should emphasize that it is crucial to continue prevention actions for the most diverse types of violence and accidents. Investments are needed to expand teams and increase support from municipal secretariats, state centers, and the Ministry of Health to make this a reality so that both issues are prioritized. The data presented here show that the availability of prevention centers that function within their purpose and at total capacity positively affects people, their health, and the construction of peace.

References

Publication Dates

History