ABSTRACT:

Objective:

The aim of this study was to describe the profile of violence against women in different life cycles, according to the sociodemographic characteristics of the victims and offenders.

Methods:

A cross-sectional and exploratory study was performed based on 1,388 police reports during a four-year period, in a metropolitan area of Northeast Brazil. The dependent variable was the type of aggression suffered by the victims. The independent variables were sociodemographic characteristics of the victims and offenders. Statistical analysis included the χ² test (p < 0.05) and the decision tree analysis, through the Chi-squared Automatic Interaction Detector (CHAID) algorithm.

Results:

Cases of physical abuse (n = 644) were the most common, followed by threat (n = 415) and verbal aggression (n = 285). The violence profiles could be explained by the relationship between victims and offenders (p < 0.001) and age of the victims (p = 0.026 in Node 1; p = 0.019 in Node 3).

Conclusion:

It was observed that women in different stages of life are more exposed to different types of violence.

Keywords:
Violence; Violence against women; Life cycle stages; Public health; Epidemiology; Decision Trees

INTRODUCTION

One of the most extreme and perverse manifestations of gender inequality is through violence against women, which is a product of differences in power. It represents an important social phenomenon and a violation of human rights, significantly impacting health/sickness processes in addition to women’s perspectives on life.¹1. Ali TS, Krantz G, Gul R, Asad N, Johansson E, Mogren I. Gender roles and their influence on life prospects for women in urban Karachi, Pakistan: a qualitative study. Glob Health Action. 2011; 4: 7448. DOI: 10.3402/gha.v4i0.7448
https://doi.org/10.3402/gha.v4i0.7448... ^,22. Ali TS, Krantz G, Mogren I. Violence permeating daily life: a qualitative study investigating perspectives on violence among women in Karachi, Pakistan. Int J Womens Health. 2012; 4: 577-85. DOI: 10.2147/IJWH.S33325
https://doi.org/10.2147/IJWH.S33325... Violence against women covers cases that range from situations of psychological violence and threats to physical aggression.³3. Schraiber LB, D'Oliveira AF, França-Junior I, Diniz S, Portella AP, Ludermir AB, et al. Prevalence of intimate partner violence against women in regions of Brazil. Rev Saúde Pública. 2007; 41(5): 797-807. DOI: 10.1590/S0034-89102007000500014^,44. Leite MT, Figueiredo MF, Dias OV, Vieira MA, Souza e Souza LP, Mendes DC. Reports of violence against women in different life cycles. Rev Lat-Am Enfermagem. 2014; 22(1): 85-92. DOI: 10.1590/0104-1169.3186.2388
https://doi.org/10.1590/0104-1169.3186.2... ^,55. Rada C. Violence against women by male partners and against children within the family: prevalence, associated factors, and intergenerational transmission in Romania, a cross-sectional study. BMC Public Health. 2014; 14: 129. DOI: 10.1186/1471-2458-14-129
https://doi.org/10.1186/1471-2458-14-129... In Brazil, the subject-matter has gained even more attention after the implementation of the federal Law number 11,340, which has the objective of punishing cases of violence between intimate partners.⁶6. Brasil. Lei n. 11.340, de 7 de agosto de 2006. Lei Maria da Penha. Diário Oficial da União, 8 agosto 2006. Disponível em: http://www.planalto.gov.br/ccivil_03/_ato2004-2006/2006/lei/l11340.htm
http://www.planalto.gov.br/ccivil_03/_at...

In the first year of effective enforcement of this law, popularly known as the Maria da Penha law, the homicide rates against women experienced a small decrease; however, they immediately started growing substantially again until 2010, when a rate of 4.6 homicides for every 100 thousand women was registered, the largest number observed in the country until then⁷7. Waiselfisz JJ. Mapa da violência 2012: atualização: homicídios de mulheres no Brasil. Rio de Janeiro: Centro Brasileiro de Estudos Latino-americanos (Cebela); 2012.. In addition, violence committed by intimate partners is one of the most prevalent types of violence in Brazilian society, with around 55% of all cases, which converts into high emotional and social costs.⁸8. Schraiber LB, Barros CRS, Castilho EA. Violence against women by intimate partners: use of health services. Rev Bras Epidemiol. 2010; 13(2): 237-45. DOI: 10.1590/S1415-790X2010000200006
https://doi.org/10.1590/S1415-790X201000... It has also been reported that physical aggression is predominant, encompassing 44.2% of cases of violence against women assisted in the Single Health System (SUS).⁷7. Waiselfisz JJ. Mapa da violência 2012: atualização: homicídios de mulheres no Brasil. Rio de Janeiro: Centro Brasileiro de Estudos Latino-americanos (Cebela); 2012.

Various risk factors have been identified as relating to the occurrence of violence against women, including sociodemographic and socioeconomic characteristics, substance use, and history of having witnessed family violence in infancy or adolescence.⁵5. Rada C. Violence against women by male partners and against children within the family: prevalence, associated factors, and intergenerational transmission in Romania, a cross-sectional study. BMC Public Health. 2014; 14: 129. DOI: 10.1186/1471-2458-14-129
https://doi.org/10.1186/1471-2458-14-129... ^,99. Ali NS, Ali FN, Khuwaja AK, Nanji K. Factors associated with intimate partner violence against women in a mega city of South-Asia: multi-centre cross-sectional study. Hong Kong Med J 2014; 20(4): 297-303. DOI: 10.12809/hkmj134074
https://doi.org/10.12809/hkmj134074... These facts demonstrate that violence against women is multi-faceted and, under a socioecological perspective, is the product of complex interactions between individuals, families, communities, and social level factors.¹⁰10. Bazargan-Hejazi S, Medeiros S, Mohammadi R, Lin J, Dalal K. Patterns of intimate partner violence: a study of female victims in Malawi. J Inj Violence Res. 2013; 5(1): 38-50. DOI: 10.5249/jivr.v5i1.139
https://doi.org/10.5249/jivr.v5i1.139...

The consequences of being exposed to violence produce physical, psychological, economic, and social impacts.⁵5. Rada C. Violence against women by male partners and against children within the family: prevalence, associated factors, and intergenerational transmission in Romania, a cross-sectional study. BMC Public Health. 2014; 14: 129. DOI: 10.1186/1471-2458-14-129
https://doi.org/10.1186/1471-2458-14-129... Problems like depression, post-traumatic stress disorder (PTSD), and suicidal thoughts have been encountered in these victims.¹¹11. McLaughlin J, O'Carroll RE, O'Connor RC. Intimate partner abuse and suicidality: a systematic review. Clin Psychol Rev 2012; 32(8): 677-89. DOI: 10.1016/j.cpr.2012.08.002
https://doi.org/10.1016/j.cpr.2012.08.00... ^,1212. Avanci J, Assis S, Oliveira R. A cross-sectional analysis of women's mental health problems: examining the association with different types of violence among a sample of Brazilian mothers. BMC Women's Health 2013; 13: 20. DOI: 10.1186/1472-6874-13-20
https://doi.org/10.1186/1472-6874-13-20... If the sociodemographic characteristics of the victims of violence and the aggressors are not taken into consideration, intervention proposals to minimize the resulting consequences of this social phenomenon cannot be effective.¹⁰10. Bazargan-Hejazi S, Medeiros S, Mohammadi R, Lin J, Dalal K. Patterns of intimate partner violence: a study of female victims in Malawi. J Inj Violence Res. 2013; 5(1): 38-50. DOI: 10.5249/jivr.v5i1.139
https://doi.org/10.5249/jivr.v5i1.139...

There are few studies in the literature about violence against women that deal with the differences in victimization in accordance with the cycles of life, using Police records as a data source.⁴4. Leite MT, Figueiredo MF, Dias OV, Vieira MA, Souza e Souza LP, Mendes DC. Reports of violence against women in different life cycles. Rev Lat-Am Enfermagem. 2014; 22(1): 85-92. DOI: 10.1590/0104-1169.3186.2388
https://doi.org/10.1590/0104-1169.3186.2... ^,1313. Thomas KA, Sorenson SB, Joshi M. Police-documented incidents of intimate partner violence among young women. J Womens Health (Larchmt) 2010; 19(6): 1079-87. DOI: 10.1089/jwh.2009.1612
https://doi.org/10.1089/jwh.2009.1612... Information relative to the distribution of violence against women and the identification of the most vulnerable populations can substantially contribute to the direction of efforts destined for the creation of public policy related to surveillance, criminalization, prevention, social assistance, and rehabilitation.⁵5. Rada C. Violence against women by male partners and against children within the family: prevalence, associated factors, and intergenerational transmission in Romania, a cross-sectional study. BMC Public Health. 2014; 14: 129. DOI: 10.1186/1471-2458-14-129
https://doi.org/10.1186/1471-2458-14-129...

This study is one of the first in scientific literature that tried to trace the profile of violence against women in accordance with sociodemographic characteristics of the victims and aggressors through employment of the multivariable model of the decision tree, the Chi-squared Automatic Interaction Detector (CHAID), which is a promising instrument for approaches to public health.

METHODS

A cross-sectional and exploratory study was performed with the data from a Police station specialized in attending to women, who are victims of violence, located in a metropolitan region in the Northeast of Brazil, which has a population of 687,545 habitants, in accordance with the 2010 census.¹⁴4. Leite MT, Figueiredo MF, Dias OV, Vieira MA, Souza e Souza LP, Mendes DC. Reports of violence against women in different life cycles. Rev Lat-Am Enfermagem. 2014; 22(1): 85-92. DOI: 10.1590/0104-1169.3186.2388
https://doi.org/10.1590/0104-1169.3186.2...

All of the records of the victims that sought out the police station for having suffered physical and/or verbal violence were adopted as inclusion criteria during a period of four years (January 2008 to December 2011). The records that were inaccessible in the moment of collection because of judicial questions were excluded. Besides this, because the filling out of the records is by hand, the ones that were illegible, even after consulting an employee from the sector, were also excluded. During data collection, care was taken to observe the existence of repeated complaints with the goal of avoiding of the same case twice in the sample. The explicit recommendations in the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Declaration for observation studies were followed.

Before the data collection, a pilot study trying to adapt the form to be used was done. Three components of the team were subjected to calibration procedures for collecting data. The intra- and inter-examiner agreements were evaluated using the Kappa test, and both obtained K = 0,85 - 0,90, which are considered very good, allowing for the examiners to perform the study.

For data collection, a specific form was created with variables related to the sociodemographic characteristics of the victims (age, education, occupation, region where lived) and of the aggressors (sex, age, occupation, region where lives, and connection to the victim) and the violence characteristics (type, circumstance of aggression, day and period of occurrence). Age range was categorized into three subcategories: young adults (15-29 years old), adults (30-59 years old), and old people (elderly) (60 years old or more), with the objective of making the comprehension of the multivariate analysis results easier.

Physical violence was understood as cases, in which the victims were pushed, beaten, kicked, pulled by the hair, dragged, burned, or assaulted with an instrument. Verbal violence was characterized by situations of insult and humiliation. The cases of threat involved situations in which the aggressor psychologically abused the victim, threatening to assault her physically, torture her, kill her, or prevent her from visiting family and friends or make telephone calls to them.

Initially, the absolute frequencies and percentages of all the variables being studied were calculated. Afterward, a two-variable analysis was performed to test the association of all of the independent variables in relation to the type of aggression (physical and/or verbal, threat) utilizing the χ² test. Finally, trying to trace the profile of violence against women, all of the variables were inserted in a tree decision model through the CHAID algorithm, with the objective of identifying which explained the different types of aggression the most. Only the variables that obtained a p value adjusted < 0.05 remained in the final graph.

This method consists of decision rules that perform successive divisions throughout all of the data, in a way that makes it more and more homogenous with respect to a dependent variable. The decision tree utilizes a graph that begins with a root node, in which all of the observations from the sample are presented. The nodes produced in sequence represent the subdivisions of the data in groups that become more and more homogeneous, denominated as children nodes. When there is no more possibility for division, the nodes are called terminal nodes or leaves. ¹⁵15. Hair JF, Black WC, Babin JB, Anderson RE, Tatham RL. Multivariate data analysis. 7th edition. New Jersey: Prentice Hall; 2009.

The model was adjusted by means of successive binary divisions (nodes) throughout all of the data. The stop criteria that was adopted with the value p < 0.05 of the statistic χ² using the Bonferroni correction. The adjustment to the final model was evaluated by the estimation of general risk, which compares the differences between the expected value and the observed value through the model, indicating in which measures the tree correctly predicts the results.

The study was evaluated independently by a Research Ethics Committee and approved (n. º 02266.0.133.000-10). All of the rights of the victims were protected and all of the national and international precepts of research ethics with human beings were followed.

RESULTS

Around 1,388 police records of violence against women were analyzed. Cases of physical aggression predominated (n = 644), followed by threat (n = 415) and verbal aggression (n = 285). Table 1 shows the distribution of type of aggression (physical, verbal, and threat) according to sociodemographic characteristics of the victims. No significant statistical difference was verified of the level p < 0.05: age group (p = 0.144), education (p = 0.291), occupation (p = 0.615), and region lived (p = 0.628). Table 2 presents the distribution of type of aggression (physical, verbal, and threat) conforming to the sociodemographic characteristics of the aggressors, the circumstance, and the period of occurrence. Significant statistical difference was only verified for the variable connection of aggressor with the victim (p < 0,001), the rest of the variables presented a significance level higher than 0.05: sex (p = 0.363), age group (p = 0.362), occupation (p = 0.379), and region where lives (p = 0.389). In addition, no significant statistical difference was observed in the circumstances of aggression (p = 0.122), the day of the aggression (p = 0.453) or in the period of occurrence (p = 0.689).

Eight nodes constructed the final model of the decision tree. Figure 1 shows the multivariable analysis by means of the decision tree (CHAID) for violence against women (physical aggression, verbal aggression, and threat) adjusted for sociodemographic factors. It was found that the type of aggression that women suffer can be explained by the connection between aggressor and victim (p < 0.001) and age group of the victim (p = 0.026 in Node 1; p = 0.019 in Node 3). Three distinct groups were formed to explain aggression and the connection between aggressors and victims of this study: perpetrated aggression by the partner/boyfriend or a stranger (n = 528; 39.3%), by the ex-partner/ex-boyfriend (n = 536; 39.9%), and by family or people they know (n = 280; 20.8%).

DISCUSSION

The results showed that the most common type of violence against women corresponded to physical aggression, which is consistent with the results of another study performed in a Police Station Specialized in Assisting Women (DEAM) in the Brazilian state of São Paulo, which identified physical aggression as the type of violence most commonly reported.¹⁶16. Fonseca RM, Egry EY, Guedes RN, Gutierres AR, Tezzei FP. Violence against women: a study of the reports to police in the city of Itapevi, São Paulo, Brazil. Midwifery 2011; 27(4): 469-73. DOI: 10.1016/j.midw.2010.03.004
https://doi.org/10.1016/j.midw.2010.03.0... But both physical abuse and psychological abuse can negatively impact women’s health and quality of life.²2. Ali TS, Krantz G, Mogren I. Violence permeating daily life: a qualitative study investigating perspectives on violence among women in Karachi, Pakistan. Int J Womens Health. 2012; 4: 577-85. DOI: 10.2147/IJWH.S33325
https://doi.org/10.2147/IJWH.S33325... ^,55. Rada C. Violence against women by male partners and against children within the family: prevalence, associated factors, and intergenerational transmission in Romania, a cross-sectional study. BMC Public Health. 2014; 14: 129. DOI: 10.1186/1471-2458-14-129
https://doi.org/10.1186/1471-2458-14-129... However, it is necessary to combat and outline the subject of violence against women within all organizational levels of society, in such a way to involve individuals, families, communities, and the different social levels at the same time.²2. Ali TS, Krantz G, Mogren I. Violence permeating daily life: a qualitative study investigating perspectives on violence among women in Karachi, Pakistan. Int J Womens Health. 2012; 4: 577-85. DOI: 10.2147/IJWH.S33325
https://doi.org/10.2147/IJWH.S33325...

Cases of domestic violence against women remain prevalent. In Brazil, it has been reported that approximately 70% of situations of violence against women occur in the victim’s own residence.⁷7. Waiselfisz JJ. Mapa da violência 2012: atualização: homicídios de mulheres no Brasil. Rio de Janeiro: Centro Brasileiro de Estudos Latino-americanos (Cebela); 2012. The prevalence of domestic violence identified in the present study was greater than that found in studies done in Romenia⁵5. Rada C. Violence against women by male partners and against children within the family: prevalence, associated factors, and intergenerational transmission in Romania, a cross-sectional study. BMC Public Health. 2014; 14: 129. DOI: 10.1186/1471-2458-14-129
https://doi.org/10.1186/1471-2458-14-129... (56.3%) and in Saudi Arrabia¹⁷17. Fageeh WM. Factors associated with domestic violence: a cross-sectional survey among women in Jeddah, Saudi Arabia. BMJ Open 2014; 4(2). DOI: 10.1136/bmjopen-2013-004242
https://doi.org/10.1136/bmjopen-2013-004... (34%). As such, access to services, which offer attention, and support to the victims becomes fundamental.

In the distribution of types of aggression between younger women, in an age range of 15-29 years, adult women, in an age range of 30-59 years, and older women, with an age of 60 years or more, differences in victimization arise in accordance with life cycles, which agrees with previous studies from the literature.⁴4. Leite MT, Figueiredo MF, Dias OV, Vieira MA, Souza e Souza LP, Mendes DC. Reports of violence against women in different life cycles. Rev Lat-Am Enfermagem. 2014; 22(1): 85-92. DOI: 10.1590/0104-1169.3186.2388
https://doi.org/10.1590/0104-1169.3186.2... ^,1313. Thomas KA, Sorenson SB, Joshi M. Police-documented incidents of intimate partner violence among young women. J Womens Health (Larchmt) 2010; 19(6): 1079-87. DOI: 10.1089/jwh.2009.1612
https://doi.org/10.1089/jwh.2009.1612...

The average age of the victims was 35.72 (standard deviation - SD = 12.98; minimum 15 years; maximum: 94 years). Other studies developed in Brazil reported that adult women, generally between 20 and 49 years of age, represent the main victims of violence.⁴4. Leite MT, Figueiredo MF, Dias OV, Vieira MA, Souza e Souza LP, Mendes DC. Reports of violence against women in different life cycles. Rev Lat-Am Enfermagem. 2014; 22(1): 85-92. DOI: 10.1590/0104-1169.3186.2388
https://doi.org/10.1590/0104-1169.3186.2... ^,1616. Fonseca RM, Egry EY, Guedes RN, Gutierres AR, Tezzei FP. Violence against women: a study of the reports to police in the city of Itapevi, São Paulo, Brazil. Midwifery 2011; 27(4): 469-73. DOI: 10.1016/j.midw.2010.03.004
https://doi.org/10.1016/j.midw.2010.03.0... This age range is characterized by an important life stage of the women, with relation to their reproductive period and their attention and care for their children. A participant population survey from Multi-country Study on Women’s Health and Domestic Violence against Women, which included 790 women who live with children from 5 to 12 years old, residents of the municipality of São Paulo, SP, and in Zona da Mata in Pernambuco, showed that there can be repercussions of the violence against the women in the behavior of the children, indicating the need to adopt effective measures to confront it.¹⁹19. d'Oliveira AF, Schraiber LB, França-Junior I, Ludermir AB, Portella AP, Diniz CS, et al. Factors associated with intimate partner violence against Brazilian women. Rev Saúde Pública 2009; 43(2): 299-311. DOI: 10.1590/S0034-89102009005000013
https://doi.org/10.1590/S0034-8910200900...

Women with low levels of education reported a greater physical aggression victimization in comparison with women with higher educational levels; however, there was not a statistically significant difference.¹1. Ali TS, Krantz G, Gul R, Asad N, Johansson E, Mogren I. Gender roles and their influence on life prospects for women in urban Karachi, Pakistan: a qualitative study. Glob Health Action. 2011; 4: 7448. DOI: 10.3402/gha.v4i0.7448
https://doi.org/10.3402/gha.v4i0.7448... ^,22. Ali TS, Krantz G, Mogren I. Violence permeating daily life: a qualitative study investigating perspectives on violence among women in Karachi, Pakistan. Int J Womens Health. 2012; 4: 577-85. DOI: 10.2147/IJWH.S33325
https://doi.org/10.2147/IJWH.S33325... ^,55. Rada C. Violence against women by male partners and against children within the family: prevalence, associated factors, and intergenerational transmission in Romania, a cross-sectional study. BMC Public Health. 2014; 14: 129. DOI: 10.1186/1471-2458-14-129
https://doi.org/10.1186/1471-2458-14-129... ^,1010. Bazargan-Hejazi S, Medeiros S, Mohammadi R, Lin J, Dalal K. Patterns of intimate partner violence: a study of female victims in Malawi. J Inj Violence Res. 2013; 5(1): 38-50. DOI: 10.5249/jivr.v5i1.139
https://doi.org/10.5249/jivr.v5i1.139... ^,1919. d'Oliveira AF, Schraiber LB, França-Junior I, Ludermir AB, Portella AP, Diniz CS, et al. Factors associated with intimate partner violence against Brazilian women. Rev Saúde Pública 2009; 43(2): 299-311. DOI: 10.1590/S0034-89102009005000013
https://doi.org/10.1590/S0034-8910200900... It is probable that women with a higher level of education have more access to information and resources, and as such, are less tolerant of a relationship marked by abusive situations. ¹⁰10. Bazargan-Hejazi S, Medeiros S, Mohammadi R, Lin J, Dalal K. Patterns of intimate partner violence: a study of female victims in Malawi. J Inj Violence Res. 2013; 5(1): 38-50. DOI: 10.5249/jivr.v5i1.139
https://doi.org/10.5249/jivr.v5i1.139... Or, because of the fear of reporting, the possibility exists that many cases are underreported.

A study done in two Brazilian regions as part of the WHO Multi-country Study on Women’s Health and Domestic Violence against Women,¹⁹19. d'Oliveira AF, Schraiber LB, França-Junior I, Ludermir AB, Portella AP, Diniz CS, et al. Factors associated with intimate partner violence against Brazilian women. Rev Saúde Pública 2009; 43(2): 299-311. DOI: 10.1590/S0034-89102009005000013
https://doi.org/10.1590/S0034-8910200900... identified that having up to eight years of schooling was one of the factors associated with the occurrence of violence by an intimate partner. Similar results were found by a multicentric study by the World Health Organization (WHO) conducted through population-based surveys in Bangladesh, Brazil, Ethiopia, Japan, Namibia, Peru, Republic of Tanzania, Samoa, Serbia, and Montenegro, Thailand, which stressed the association between the woman or partner finishing secondary school and the decrease in intimate partner violence.²⁰20. Abramsky T, Watts CH, Garcia-Moreno C, Devries K, Kiss L, Ellsberg M, et al. What factors are associated with recent intimate partner violence? Findings from the WHO multi-country study on women's health and domestic violence. BMC Public Health 2011; 11: 109. DOI: 10.1186/1471-2458-11-109
https://doi.org/10.1186/1471-2458-11-109... In this scene, the role of education and the economic empowerment become notable in the context of social transformations centered around overcoming gender inequality and decreasing the levels of violence¹1. Ali TS, Krantz G, Gul R, Asad N, Johansson E, Mogren I. Gender roles and their influence on life prospects for women in urban Karachi, Pakistan: a qualitative study. Glob Health Action. 2011; 4: 7448. DOI: 10.3402/gha.v4i0.7448
https://doi.org/10.3402/gha.v4i0.7448... . It was not possible to analyze the differences in the levels of education between aggressors, which could constitute another factor in the association between education and violence against women.

A higher prevalence of physical and verbal violence and threats was observed among women who did not work in comparison with economically independent women, although a statistically significant difference has not existed. It is estimated that economically dependent women have a 1.5 times higher probability of being physically abused by her partner.¹⁷17. Fageeh WM. Factors associated with domestic violence: a cross-sectional survey among women in Jeddah, Saudi Arabia. BMJ Open 2014; 4(2). DOI: 10.1136/bmjopen-2013-004242
https://doi.org/10.1136/bmjopen-2013-004... Although the majority of causes of violence against women have been concentrated in urban zones, no statistically significant association was verified for any specific subcategory of violence. In this region, the agglomerate of people is greater than the agglomerate of cities that make up the sub-urban zone. Besides this, another point to highlight is that residents’ access to police stations in sub-urban regions is more difficult, as such there could be underreporting of violence in these areas. An extremely useful tool in these cases is geoprocessing.

Almost all of the aggressors were men (93%), confirming previous findings from the literature that say that women are more assaulted by men, and in the majority of cases have an intimate relationship with the victim.¹⁶16. Fonseca RM, Egry EY, Guedes RN, Gutierres AR, Tezzei FP. Violence against women: a study of the reports to police in the city of Itapevi, São Paulo, Brazil. Midwifery 2011; 27(4): 469-73. DOI: 10.1016/j.midw.2010.03.004
https://doi.org/10.1016/j.midw.2010.03.0... This result can be understood upon analyzing the problematic nature of the violence, keeping in minds questions of gender in Brazilian society. Men are still highly characterized by sexist practices and are present in the context of violence in different places, as they are the products and targets of subjectivity standards guided by models of gender and by unequal power relations.^21-2323. Schraiber LB, Barros CR, Couto MT, Figueiredo WS, de Albuquerque FP. Men, masculinity and violence: a study in primary health care services. Rev Bras Epidemiol 2012; 15(4): 790-803. DOI: 10.1590/S1415-790X2012000400011
https://doi.org/10.1590/S1415-790X201200... In Brazil, these issues are enhanced by the notorious socioeconomic inequalities of the population.²⁴24. Reichenheim ME, de Souza ER, Moraes CL, de Mello Jorge MH, da Silva CM, de Souza Minayo MC. Violence and injuries in Brazil: the effect, progress made, and challenges ahead. The Lancet 2011; 377(9781): 1962-75. DOI: 10.1016/S0140-6736(11)60053-6
https://doi.org/10.1016/S0140-6736(11)60... However, public managers should plan programs that involve men who have used violence against women, aiming to prevent it and minimize its repercussions in the health indicators of the population.

One of the peculiarities of the present study relates to the fact that the connection that the aggressor as with the victim seemed to influence in the type of aggression that was perpetrated.⁴4. Leite MT, Figueiredo MF, Dias OV, Vieira MA, Souza e Souza LP, Mendes DC. Reports of violence against women in different life cycles. Rev Lat-Am Enfermagem. 2014; 22(1): 85-92. DOI: 10.1590/0104-1169.3186.2388
https://doi.org/10.1590/0104-1169.3186.2... ^,1616. Fonseca RM, Egry EY, Guedes RN, Gutierres AR, Tezzei FP. Violence against women: a study of the reports to police in the city of Itapevi, São Paulo, Brazil. Midwifery 2011; 27(4): 469-73. DOI: 10.1016/j.midw.2010.03.004
https://doi.org/10.1016/j.midw.2010.03.0... From 20 to 50 years of age, partners represent the main aggressor agents, while over 60 years old, family members (especially children) and people they know (generally the caretakers) stand out in terms of the aggressor agent.⁷7. Waiselfisz JJ. Mapa da violência 2012: atualização: homicídios de mulheres no Brasil. Rio de Janeiro: Centro Brasileiro de Estudos Latino-americanos (Cebela); 2012.

With the objective of tracing the profile of violence against women in accordance with sociodemographic characteristics of the victims and aggressors, a multivariable model was constructed using a decision tree (CHAID). The use of this analysis is relatively new in investigations in the area of epidemiology and public health, as it is considered quite promising for the identification of populations at risk.²⁵25. Lemon SC, Roy J, Clark MA, Friedmann PD, Rakowski W. Classification and regression tree analysis in public health: methodological review and comparison with logistic regression. Ann Behav Med 2003; 26(3): 172-181. It is characterized by a data mining technique in which there is the systematization of the data with the purpose of obtaining decision making, which seems to be appropriate for epidemiological monitoring activities in health, since it can be directioned to conditions on the individual and population level.²⁶26. Borges CM, Campos ACV, Vargas AMD, Ferreira EF. Adult tooth loss profile in accordance with social capital and demographic and socioeconomic characteristics. Ciên Saúde Colet 2014; 19(6): 1849-58. DOI: 10.1590/1413-81232014196.02332013
https://doi.org/10.1590/1413-81232014196...

Subject-matter like profile of teeth loss in adults according to social capital,²⁶26. Borges CM, Campos ACV, Vargas AMD, Ferreira EF. Adult tooth loss profile in accordance with social capital and demographic and socioeconomic characteristics. Ciên Saúde Colet 2014; 19(6): 1849-58. DOI: 10.1590/1413-81232014196.02332013
https://doi.org/10.1590/1413-81232014196... risk factors for incidents of smoking,²⁷27. Piper ME, Loh WY, Smith SS, Japuntich SJ, Baker TB. Using decision tree analysis to identify risk factors for relapse to smoking. Subst Use Misuse 2011; 46(4): 492-510. DOI: 10.3109/10826081003682222
https://doi.org/10.3109/1082608100368222... and quality of life²⁸28. Campolina AG, Ciconelli RM. Quality of life and utility measures: clinical parameters for decision-making in health. Rev Panam Salud Publica 2006; 19(2): 128-36. DOI: 10.1590/S1020-49892006000200013
https://doi.org/10.1590/S1020-4989200600... have been addressed recently by means of a decision tree analysis. In the present study, the profile of violence against women may be explained by differences in relation to age range of the victims and the relationship they had with the aggressor. Observing the chart through the terminal nodes or leaves, the formation of three profiles was verified. The first profile was formed by adult women ­(30-59 years old) who suffered from physical aggression from their partner/boyfriend or from a stranger. In Rada’s study, it was found that 24-43% of people experienced some form of violence by an intimate partner during their lives.⁵5. Rada C. Violence against women by male partners and against children within the family: prevalence, associated factors, and intergenerational transmission in Romania, a cross-sectional study. BMC Public Health. 2014; 14: 129. DOI: 10.1186/1471-2458-14-129
https://doi.org/10.1186/1471-2458-14-129...

In developing countries like Brazil, violence committed by intimate partners is one of the most prevalent modalities, nevertheless many cases are not identified, and no type of reception, assistance, support, or referral is performed.²⁹29. Vieira EM, Perdona GCS, Almeida AM, Nakano AMS, Santos MA, Daltoso D, et al. Knowledge and attitudes of healthcare workers towards gender based violence. Rev Bras Epidemiol. 2009; 12(4): 566-77. DOI: 10.1590/S1415-790X2009000400007
https://doi.org/10.1590/S1415-790X200900... Coming from a socioecological perspective, the violence can be understood as a product of interaction between individuals, families, communities, and social level factors, producing physical, mental, and social harm among its victims. Therefore, integrative and participatory community approaches can facilitate the incorporation of voices and perspectives of women in programs aimed at reducing intimate partner violence.¹⁰10. Bazargan-Hejazi S, Medeiros S, Mohammadi R, Lin J, Dalal K. Patterns of intimate partner violence: a study of female victims in Malawi. J Inj Violence Res. 2013; 5(1): 38-50. DOI: 10.5249/jivr.v5i1.139
https://doi.org/10.5249/jivr.v5i1.139...

Different theoretical models can be used with the purpose of understanding why violence occurs in intimate relationships. Psychopathological models, sociological system theories of gender and family can be cited. Among them, the sociological theories show that low levels of education, socioeconomic condition, stress, lack of support from authorities (health services and social well-being), and a closed social network contribute to a larger occurrence of intimate partner violence.⁹9. Ali NS, Ali FN, Khuwaja AK, Nanji K. Factors associated with intimate partner violence against women in a mega city of South-Asia: multi-centre cross-sectional study. Hong Kong Med J 2014; 20(4): 297-303. DOI: 10.12809/hkmj134074
https://doi.org/10.12809/hkmj134074... The exposition of violence perpetrated by a partner may can bring up feelings of hatred and disaffection toward him. In tense situations, women tend to report symptoms of headaches, depression, and other mental disorders, like suicide attempts.²2. Ali TS, Krantz G, Mogren I. Violence permeating daily life: a qualitative study investigating perspectives on violence among women in Karachi, Pakistan. Int J Womens Health. 2012; 4: 577-85. DOI: 10.2147/IJWH.S33325
https://doi.org/10.2147/IJWH.S33325...

Profile 2 was formed of women who suffered threats from their ex-partner or ex-boyfriend. These results coincide with the observations in another study developed in a specialized police station in Minas Gerais, where threats constituted the most frequent type of violence against women.⁴4. Leite MT, Figueiredo MF, Dias OV, Vieira MA, Souza e Souza LP, Mendes DC. Reports of violence against women in different life cycles. Rev Lat-Am Enfermagem. 2014; 22(1): 85-92. DOI: 10.1590/0104-1169.3186.2388
https://doi.org/10.1590/0104-1169.3186.2... Exposure to threat and abusive language can result in frustration and social isolation.²2. Ali TS, Krantz G, Mogren I. Violence permeating daily life: a qualitative study investigating perspectives on violence among women in Karachi, Pakistan. Int J Womens Health. 2012; 4: 577-85. DOI: 10.2147/IJWH.S33325
https://doi.org/10.2147/IJWH.S33325... This highlights the importance of prevention and intervention measures, because these women are vulnerable to suffer from physical aggression or even death.

Profile 3 was formed of young women from 15 to 29 years and older, women of 60 years old or older, who suffered physical aggression from family members or people they knew. A study with a basis in Notafiable Diseases Information System (SINAN) verified that violence against elderly Brazilians is more common among women without marital interaction and are usually abused in the domestic sphere by people living with them. ³⁰30. Mascarenhas MD, Andrade SS, das Neves AC, Pedrosa AA, da Silva MM, Malta DC. Violence against the elderly: analysis of the reports made in the health sector - Brazil, 2010. Ciên Saúde Colet 2012; 17(9): 2331-41. DOI: 10.1590/S1413-81232012000900014
https://doi.org/10.1590/S1413-8123201200... These results call attention to the fact that in Brazil, an increase in the number of elderly people with the possibility of reaching older and older age groups has been observed, leading to changes in social policies and constituting major public health challenges.³¹31. Sanches APRA, Lebrão ML, Duarte YAO. Violence against aged people: a new issue? Saúde Soc 2008; 17(3): 90-100. DOI: 10.1590/S0104-12902008000300010
https://doi.org/10.1590/S0104-1290200800... Therefore, knowing the different manifestations of violence against the elderly population could support actions to face it, identifying vulnerability characteristics in which support networks can act efficiently.³²32. Duque AM, Leal MC, Marques AP, Eskinazi FM, Duque AM. Violence against the elderly in the home environment: prevalence and associated factors (Recife, State of Pernambuco). Ciên Saúde Colet 2012; 17(8): 2199-208. DOI: 10.1590/S1413-81232012000800030
https://doi.org/10.1590/S1413-8123201200...

In the last few years, the creation, articulation, integration, and consolidation of protection plans and networks and the guarantee of elderly people’s right in Brazil has been observed.³³33. Minayo MCS. The inclusion of violence in the health agenda: historical trajectory. Ciên Saúde Colet 2007; 11: 1259-67. DOI: 10.1590/S1413-81232006000500015
https://doi.org/10.1590/S1413-8123200600... ^,3434. de Souza ER, Minayo MC. The insertion of the violence against elderly theme at health care public policies in Brazil. Ciên Saúde Colet 2010; 15(6): 2659-68. DOI: 10.1590/S1413-81232010000600002
https://doi.org/10.1590/S1413-8123201000... Concrete actions are fundamental, keeping in mind that the elderly population grows quickly and situations of abuse and mistreatment become more and more evident. In this way, tracking cases of violence against elderly people and understanding the contextual and situational factors associated with it becomes crucial, and health professionals acting in the Family Health Strategy (ESF) are key pieces of this scene.

In function of the cross-sectional nature of the methodological design of this analysis, it was not possible to establish a causal relationship. Aside from this, the results should be interpreted with caution, because they highlight only a piece of the events, referring to the cases in which the victims decided to report the abuse to the police. Representative population studies and studies that deal with the occurrence of sexual violence should be performed, with the objectives of amplifying the existent knowledge about violence against women, evaluating the need for health services and contributing to the planning of intersectional actions to face this serious public health problem and violation of human rights.

On the other hand, the results obtained provide relevant information about the occurrence of violence against women and open space for discussion about new issues that could be addressed in future studies. The use of a decision tree analysis in the study of violence against women is innovative and very useful, because the natural hierarchy of the graph that was generated allows the researcher to map the final results, identify the determinant factors, and visualize subgroups of individuals with specific profiles that can be approached in the future by heath services and social assistance in a more direct way, something that is not always possible with the use of classical statistical techniques. Consequently, it is a very promising method to analyze data coming from epidemiological studies and public health, providing useful information to guide decision-making and support the planning of actions and public policies.

CONCLUSION

It was verified that differences in the forms of victimization of violence against women exist in accordance with the life cycles for the population being investigated. As such, the studies and health actions should consider the fact that women in different phases of life are more exposed to different types of violence.

It is vital that health professionals are attentive to the signs that emerged, not only physical aggression, but also psychological. The acknowledgment of violence against women as an important public health problem and a serious violence of human rights makes the adequate allocation of resources for the expansion of social care centers for victims of violence necessary. The current panorama requires an urgent look into all of the levels of political, social, judicial, and health organization.

ACKNOWLEDGMENTS

The authors thank the Specialized Women’s Police Station (DEM) from the municipality of Campina Grande, PB, Brazil, for the authorization of the management of data acquisition.

References

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