ABSTRACT:

Introduction:

The isolated negative impacts of community violence and family violence on individuals’ self-rated health (SRH) are known, but there is little evidence on the combined effect of these two types of interpersonal violence.

Objective:

To analyze the association between exposure to community violence/by strangers and family violence/by acquaintances and negative SRH, distinguishing the type of violence suffered and also considering its cumulative exposure.

Methods:

Epidemiological cross-sectional study developed with data from the National Health Survey (PNS) 2013. Crude multinominal logistic regression models were performed and adjusted to test the association of variables.

Results:

All types of violence analyzed were associated with negative SRH. Isolated community/unknown interpersonal violence was associated with SRH as regular (odds ratio - OR = 1.38) and bad (OR = 1.79). Exposure to family violence/by acquaintances was associated with regular (OR = 1.52) and bad (OR = 2.70) self-assessment. Concomitant exposure to the two types of violence was associated with regular (OR = 4.00) and bad (OR = 7.81) health assessments, with this association being of greater magnitude than those for isolated violence.

Conclusion:

The cumulative effect of exposure to family/known and community/unknown violence enhances the negative assessment of health status. Health professionals must be aware of the multivitaminization and its impact on the health of victims who access health services.

Keywords:
Exposure to violence; Self-assessment; Health surveys

INTRODUCTION

According to the World Health Organization (WHO), violence is “the intentional use of physical force or power, real or as a threat, against oneself, against another person, or against a group or a community, which results or is very likely to result in injury, death, psychological damage, developmental disability or deprivation¹1. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. Relatório mundial sobre violência e saúde. Genebra: Organização Mundial da Saúde; 2002.^”.

Also according to the WHO, interpersonal violence (IV) can be of a community type (CIV), when the perpetrator is from outside the family circle and the location of the occurrence are generally public spaces, or of a family type (FIV), when committed by known people and mostly indoors¹1. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. Relatório mundial sobre violência e saúde. Genebra: Organização Mundial da Saúde; 2002..

In Brazil, deaths from IV grew significantly in the late 1980s²2. Souza ER. Homicídios no Brasil: o grande vilão da saúde pública na década de 80. Cad Saúde Pública 1994; 10(Supl. 1): S45-S60. http://dx.doi.org/10.1590/S0102-311X1994000500004
https://doi.org/http://dx.doi.org/10.159... and since then they have been the number one cause of death in the young population (15 to 24 years old) and among the lost of potential years of life³3. Reichenheim ME, de Souza ER, Moraes CL, de Mello Jorge MHP, da Silva CMFP, de Souza Minayo MC. Violence and injuries in Brazil: the effect, progress made, and challenges ahead. Lancet 2011; 377(9781): 1962-75. https://doi.org/10.1016/S0140-6736(11)60053-6
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The negative health impacts caused by violence are recognized worldwide¹1. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. Relatório mundial sobre violência e saúde. Genebra: Organização Mundial da Saúde; 2002.^,22. Souza ER. Homicídios no Brasil: o grande vilão da saúde pública na década de 80. Cad Saúde Pública 1994; 10(Supl. 1): S45-S60. http://dx.doi.org/10.1590/S0102-311X1994000500004
https://doi.org/http://dx.doi.org/10.159... . CIV exposure is associated with depression, aggressive behaviors, post-traumatic stress disorder and chronic pain⁷7. Eisenman DP, Gelberg L, Liu H, Shapiro MF. Mental health and health-related quality of life among adult Latino primary care patients living in the United States with previous exposure to political violence. JAMA 2003; 290(5): 627-34. https://doi.org/10.1001/jama.290.5.627
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Despite efforts in research related to violence, the effects of exposure on health are not always recognized¹⁷17. Kiss LB, Schraiber LB, D’Oliveira AFPL. Possibilidades de uma rede intersetorial de atendimento a mulheres em situação de violência. Interface [Internet]. 2007 [acessado em 10 ago. 2018]; 11(23): 485-501. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-32832007000300007&lng=pt&tlng=pt http://dx.doi.org/10.1590/S1414-32832007000300007
http://www.scielo.br/scielo.php?script=s... . Thus, self-rated health (SRH) has been considered an important indicator for measuring such effects¹⁸18. Jylhä M. What is self-rated health and why does it predict mortality? Towards a unified conceptual model. Soc Sci Med 2009; 69(3): 307-16. https://doi.org/10.1016/j.socscimed.2009.05.013
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http://www.scielo.br/scielo.php?script=s... . SRH consists of the perception that individuals have of their own health¹⁸18. Jylhä M. What is self-rated health and why does it predict mortality? Towards a unified conceptual model. Soc Sci Med 2009; 69(3): 307-16. https://doi.org/10.1016/j.socscimed.2009.05.013
https://doi.org/https://doi.org/10.1016/... . Studies show that the tool plays an important role in predicting mortality, morbidity and shorter survival even when clinical measures are taken into account²¹21. Wright RJ. Health Effects of Socially Toxic Neighborhoods: The Violence and Urban Asthma Paradigm. Clin Chest Med [Internet]. 2006 [acessado em 12 maio 2017]; 27(3): 413-21. Disponível em: Disponível em: http://linkinghub.elsevier.com/retrieve/pii/S0272523106000414 https://doi.org/10.1016/j.ccm.2006.04.003
http://linkinghub.elsevier.com/retrieve/... ^,2222. Barros MB de A, Zanchetta LM, Moura EC de, Malta DC. Auto-avaliação da saúde e fatores associados, Brasil, 2006. Rev Saúde Pública [Internet] 2009 [acessado em 29 jan. 2018]; 43(Supl. 2): 27-37. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-89102009000900005&lng=pt&tlng=pt http://dx.doi.org/10.1590/S0034-89102009000900005
http://www.scielo.br/scielo.php?script=s... ^,2323. Idler E, Benyamini Y. Self-rated health and mortality: A review of twenty-seven community studies. J Health Soc Behav 1997; 38(1): 21-37., in addition to being an indicator of easy applicability and reproducibility²³23. Idler E, Benyamini Y. Self-rated health and mortality: A review of twenty-seven community studies. J Health Soc Behav 1997; 38(1): 21-37..

Individuals exposed to FIV/by acquaintances or CIV/by strangers have negative SRH and worsening quality of life, with a consequent increase in demands for the health service²⁴24. Bowling A. Measuring disease: a review of disease-specific quality of life measurement scales. 2ª ed. Buckingham: Open University Press; 2001.^,2525. Brasil. Ministério da Saúde. Impacto da violência na saúde dos brasileiros. Série B. Textos Básicos de Saúde [Internet]. 2005 [acessado em 25 set. 2018]. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/impacto_violencia.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ^,2727. Minayo MC de S. A inclusão da violência na agenda da saúde: trajetória histórica. Ciên Saúde Colet [Internet] 2006 [acessado em 9 maio 2017]; 11(Supl.): 1259-67. Disponível em: Disponível em: http://www.scielo.br/pdf/csc/v11s0/a15v11s0.pdf
http://www.scielo.br/pdf/csc/v11s0/a15v1... . There is evidence that cumulative exposure to violence is associated with depression²⁸28. Margolin G, Vickerman KA, Oliver PH, Gordis EB. Violence exposure in multiple interpersonal domains: Cumulative and differential effects. J Adolesc Heal [Internet] 2010 [acessado em 29 jan. 2018]; 47(2): 198-205. Disponível em: http://dx.doi.org/10.1016/j.jadohealth.2010.01.020
https://doi.org/http://dx.doi.org/10.101... , anxiety²⁸28. Margolin G, Vickerman KA, Oliver PH, Gordis EB. Violence exposure in multiple interpersonal domains: Cumulative and differential effects. J Adolesc Heal [Internet] 2010 [acessado em 29 jan. 2018]; 47(2): 198-205. Disponível em: http://dx.doi.org/10.1016/j.jadohealth.2010.01.020
https://doi.org/http://dx.doi.org/10.101... , greater use of mental health services²⁹29. Cho H, Kown I. Intimate partner violence, cumulative violence exposure, and mental health service. Community Mental Health J 2018; 54(3): 259-66. https://doi.org/10.1007/s10597-017-0204-x
https://doi.org/https://doi.org/10.1007/... , symptoms of post-traumatic stress³⁰30. Dubow EF, Boxer P, Huesmann LR, Landau S, Dvir S, Shikaki K, et al. Cumulative Effects of Exposure to Violence on Post traumatic Stress in Palestinian and Israeli Youth. J Clin Child Adolesc Psychol 2012; 41(6): 837-44. https://doi.org/10.1080/15374416.2012.675571
https://doi.org/https://doi.org/10.1080/... ^,3131. Kadra G, Dean K, Hotopf M, Hatch SL. Investigating exposure to violence and mental health in a diverse urban community sample: data from the South East London Community Health (SELCoH) survey. PLoS One 2014; 9(4): e93660. https://doi.org/10.1371/journal.pone.0093660
https://doi.org/https://doi.org/10.1371/... , common mental disorders³¹31. Kadra G, Dean K, Hotopf M, Hatch SL. Investigating exposure to violence and mental health in a diverse urban community sample: data from the South East London Community Health (SELCoH) survey. PLoS One 2014; 9(4): e93660. https://doi.org/10.1371/journal.pone.0093660
https://doi.org/https://doi.org/10.1371/... , use of alcohol and drugs³¹31. Kadra G, Dean K, Hotopf M, Hatch SL. Investigating exposure to violence and mental health in a diverse urban community sample: data from the South East London Community Health (SELCoH) survey. PLoS One 2014; 9(4): e93660. https://doi.org/10.1371/journal.pone.0093660
https://doi.org/https://doi.org/10.1371/... , less satisfaction with life³²32. Silva DG, Dell’Aglio DD. Exposure to Domestic and Community Violence and Subjective Well-Being in Adolescents. Paidéia (Ribeirão Preto) 2016; 26(65): 299-305. http://dx.doi.org/10.1590/1982-43272665201603
https://doi.org/http://dx.doi.org/10.159... , accumulated negative health effects²⁸28. Margolin G, Vickerman KA, Oliver PH, Gordis EB. Violence exposure in multiple interpersonal domains: Cumulative and differential effects. J Adolesc Heal [Internet] 2010 [acessado em 29 jan. 2018]; 47(2): 198-205. Disponível em: http://dx.doi.org/10.1016/j.jadohealth.2010.01.020
https://doi.org/http://dx.doi.org/10.101... , and worse health status assessment³³33. Boynton-Jarrett R, Ryan LM, Berkman LF, Wright R. Cumulative Violence Exposure and Self-rated health: Longitudinal Study of Adolescents in the United States. Pediatrics 2008; 122(5): 961-70. https://doi.org/10.1542/peds.2007-3063
https://doi.org/https://doi.org/10.1542/... . Although few studies have sought to understand the effect of exposure to both types of violence (community/by strangers and family/by acquaintances) simultaneously in SRH, the results point to a worse perception of health when both types are present in an accumulated manner²⁸28. Margolin G, Vickerman KA, Oliver PH, Gordis EB. Violence exposure in multiple interpersonal domains: Cumulative and differential effects. J Adolesc Heal [Internet] 2010 [acessado em 29 jan. 2018]; 47(2): 198-205. Disponível em: http://dx.doi.org/10.1016/j.jadohealth.2010.01.020
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https://doi.org/http://dx.doi.org/10.159... ^,3333. Boynton-Jarrett R, Ryan LM, Berkman LF, Wright R. Cumulative Violence Exposure and Self-rated health: Longitudinal Study of Adolescents in the United States. Pediatrics 2008; 122(5): 961-70. https://doi.org/10.1542/peds.2007-3063
https://doi.org/https://doi.org/10.1542/... .

The effect of concomitant exposure to CIV and FIV on SRH can be understood through the risk accumulation model, according to which the overlap of adverse experiences has a cumulative negative effect on health. This model has been used to explore the effects of adverse experiences in childhood, which trigger physiological responses to acute and chronic stress³³33. Boynton-Jarrett R, Ryan LM, Berkman LF, Wright R. Cumulative Violence Exposure and Self-rated health: Longitudinal Study of Adolescents in the United States. Pediatrics 2008; 122(5): 961-70. https://doi.org/10.1542/peds.2007-3063
https://doi.org/https://doi.org/10.1542/... . Exposure to violence can be considered a social stressor that, when present, triggers humoral and neurophysiological responses that produce negative health outcomes²¹21. Wright RJ. Health Effects of Socially Toxic Neighborhoods: The Violence and Urban Asthma Paradigm. Clin Chest Med [Internet]. 2006 [acessado em 12 maio 2017]; 27(3): 413-21. Disponível em: Disponível em: http://linkinghub.elsevier.com/retrieve/pii/S0272523106000414 https://doi.org/10.1016/j.ccm.2006.04.003
http://linkinghub.elsevier.com/retrieve/... . Most studies consider the effect of a same type of violence (CIV or FIV) with victimization accumulated over time, with few addressing the accumulated exposure to community and family violence³⁴34. Lopes CS, Moraes CL, Junger WL, Werneck GL, Ponce de Leon AC, Faerstein E. Direct and indirect exposure to violence and psychological distress among civil servants in Rio de Janeiro, Brazil: a prospective cohort study. BMC Psychiatry 2015; 15: 109. https://doi.org/10.1186/s12888-015-0487-9
https://doi.org/https://doi.org/10.1186/... .

Our objective was to analyze the association of negative SRH with exposure to FIV/by acquaintances, to CIV/by strangers and both, after adjusting for sociodemographic variables in the Brazilian population over 18 years of age.

METHODS

This study was developed with secondary data from the National Health Survey (Pesquisa Nacional de Saúde - PNS) 2013 - Perception of health status, lifestyles and chronic diseases - , a cross-sectional investigation. Participants of PNS 2013 comprise a subsample of the master sample of the Integrated System of Household Research (Sistema Integrado de Pesquisas Domiciliares - SIPD) of the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística - IBGE). Random sampling by clusters in three stages with stratification was used³⁵35. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde: 2013. Percepção do estado de saúde, estilos de vida e doenças crônicas. Brasil: Instituto Brasileiro de Geografia e Estatística; 2014. v. 41. 81 p..

The surveyed population covered 81,167 private households visited across the country. Of these, 69,994 were occupied. For individual interviews, 64,308 residents aged over 18 years were selected, of whom 2,389 were not found and 1,717 refused to answer the investigation, obtaining a final sample of 60,202 individuals³⁵35. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde: 2013. Percepção do estado de saúde, estilos de vida e doenças crônicas. Brasil: Instituto Brasileiro de Geografia e Estatística; 2014. v. 41. 81 p.^,3636. Souza-Júnior PRB de, Freitas MPS de, Antonaci G de A, Szwarcwald CL. Desenho da amostra da Pesquisa Nacional de Saúde 2013. Epidemiol Serv Saúde [Internet] 2015 [acessado em 7 set. 2018]; 24(2): 207-16. Disponível em: Disponível em: http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S2237-96222015000200207&lng=en&nrm=iso&tlng=en
http://www.scielosp.org/scielo.php?scrip... . All individuals in the final sample were eligible for this study.

Exposure to IV in the 12 months prior to the application of the questionnaire was the independent variable. The elaboration of this variable used the following questions:

The variable exposure to IV was created with four categories:

SRH was the dependent variable, obtained by asking the following question: in general, how do you evaluate your health? The response options were categorized as: very good/good, regular and very bad/bad.

The following covariables were used for adjustment: gender (male or female), age (categorized by quartiles), race/color (white, black, yellow, brown, indigenous), region of residence in the country (North, Northeast, Central-West, South and Southeast), education (selected as a proxy for socioeconomic conditions and categorized as complete/incomplete higher education, complete/incomplete high school, complete/incomplete elementary school and without education) and score of harmful behaviors to health. For this score, the variables used were binge drinking (ingestion of five or more doses of alcoholic beverages in a single day or time in the month, classified as 0, that is, without binge drinking, 1, equivalent to up to four episodes of binge drinking, and 2, corresponding to more than four binge drinking episodes per month), not performing physical activities and using tobacco, both with two categories each. The answers given were added up, resulting in a score with values ​​ranging from 0 to 4.

STATISTICAL ANALYSIS

The data were analyzed in Stata version 12.0, and all variables, worked in the categorical way. Initially, a descriptive analysis of the data was carried out using proportions calculations. To analyze the raw association (bivariate), the proportions of SRH (very good/good, regular and bad/very bad) by category of independent variables were calculated, and Pearson’s χ² test was used.

For the analysis of the association between exposure to violence and SRH, raw and adjusted multinominal logistic regression was conducted for all covariates. To analyze the existence of a linear trend in the odds ratio (OR) between the types of exposure to violence (community, family, and combined community and family), the χ² trend test was applied.

The analyzes considered the sample structure with strata and sample weights. Statistical significance was assumed arbitrarily at 5%.

The project was sent to the Research Ethics Committee of the Faculty of Medicine of the University of São Paulo and approved, with the Presentation Certificate for Ethical Appreciation (Certificado de Apresentação para Apreciação Ética - CAAE) 61603516.2.0000.0065 and opinion number 1.818.294.

RESULTS

Table 1 shows the characteristics of the studied population. Most individuals were female (52.89%), between 18 and 30 years old (28.33%), complete or incomplete primary level (35.16%), white (47.46%), from the Northeast Region of the country (26.62%), and with harmful health behavior (58.04%). Most of them (66.13%) rated their health as good and 5.44% of respondents were victims of some type of violence.

A greater proportion of women rated their health as regular (30.76%) and bad (7.25%) when compared to men. The percentage of negative SRH was increasing between the age categories and decreasing between the education categories. Whites were the ones who had the lowest proportion of health status assessment as bad (5.36%). The lowest proportion of negative SRH was found among respondents who had no harmful health behavior (2.88%). Exposure to FIV and combined exposure to FIV and CIV were associated with higher proportions of negative evaluation (11.19 and 11.52%, respectively).

Exposure to CIV/by unknown person alone in the raw analysis was not associated with regular or bad SRH, however in the adjusted model it was possible to evidence such an association (Table 2). FIV/by acquainted person alone proved to be linked to regular and bad/very bad SRH in both the crude and adjusted models. After the adjustments, the chance of an SRH as bad/very bad among those exposed to FIV was about three times higher than among those not exposed to violence (OR = 2.70; 95% confidence interval - 95%CI 2.06 - 3.53), and regular assessment, 1.52 times higher than among those not exposed (OR = 1.52; 95%CI 1.25 - 1.85).

Polyvitimization, in turn, was the category with the highest magnitude of association, when we considered the point estimate of OR. Individuals who were exposed to polyvitimization were four times more likely to rate their health as regular (95%CI 2.33 - 6.88) and 7.81 times more likely to rate their health as bad (95%CI 3.04 - 20, 06).

In the case of regular assessment, there is no overlapping of the confidence intervals (CI) found for exposure to exclusive CIV or exclusive FIV and combined exposure. In the bad evaluation, there is no overlapping of the CI found for exposure to exclusive CIV and concomitant exposure, but there is an overlap between the CI found for exposure to exclusive and concomitant FIV. The trend analysis in the OR shows that there is a significant trend that points to the linear growth of the magnitude of the association between the exposure categories.

DISCUSSION

Our results confirm the existence of negative health effects associated with exposure to FIV/by acquainted person. Women exposed to IPV most often have negative perceptions about their health status³⁷37. Lown EA, Schmidt LA, Wiley J. Interpersonal violence among women seeking welfare: unraveling lives. Am J Public Health 2006; 96(8): 1409-15. https://dx.doi.org/10.2105%2FAJPH.2004.057786
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https://doi.org/https://doi.org/10.1016/... ^,3939. Coker AL, Follingstad DR, Garcia LS, Bush HM. Intimate partner violence and women’s cancer quality of life. Cancer Causes Control 2017; 28(1): 23-39. https://dx.doi.org/10.1007%2Fs10552-016-0833-3
https://doi.org/https://dx.doi.org/10.10... ^,4040. Mendonça MFS, Ludermir AB. Intimate partner violence and incidence of common mental disorder. Rev Saúde Pública 2017; 51: 32. http://dx.doi.org/10.1590/s1518-8787.2017051006912
https://doi.org/http://dx.doi.org/10.159... . Similar results were found among men victims of IPV³⁹39. Coker AL, Follingstad DR, Garcia LS, Bush HM. Intimate partner violence and women’s cancer quality of life. Cancer Causes Control 2017; 28(1): 23-39. https://dx.doi.org/10.1007%2Fs10552-016-0833-3
https://doi.org/https://dx.doi.org/10.10... , among the elderly⁴¹41. Giraldo-Rodríguez L, Rosas-Carrasco O, Mino-León D. Abuse in Mexican Older Adults with Long-Term Disability: National Prevalence and Associated Factors. J Am Geriatr Soc 2015; 63(8): 1594-600. https://doi.org/10.1111/jgs.13552
https://doi.org/https://doi.org/10.1111/... ^,4242. Centers for Disease Control and Prevention. Elder Abuse: Consequences [Internet]. Centers for Disease Control and Prevention. [acessado em 25 set. 2018]. Disponível em: Disponível em: http://www.cdc.gov/violenceprevention/elderabuse/consequences.html
http://www.cdc.gov/violenceprevention/el... , children, adolescents, and young people²⁸28. Margolin G, Vickerman KA, Oliver PH, Gordis EB. Violence exposure in multiple interpersonal domains: Cumulative and differential effects. J Adolesc Heal [Internet] 2010 [acessado em 29 jan. 2018]; 47(2): 198-205. Disponível em: http://dx.doi.org/10.1016/j.jadohealth.2010.01.020
https://doi.org/http://dx.doi.org/10.101... ^,4343. WHO. Preventing youth violence: an overview of the evidence. Genebra: World Health Organization ; 2015..

The health implications of CIV are increasingly studied. As with our findings, existing research makes it clear that victims of CIV assess their health more negatively, use health services more regularly, report more physical health problems, and exhibit health risk behaviors more frequently¹1. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. Relatório mundial sobre violência e saúde. Genebra: Organização Mundial da Saúde; 2002.^,22. Souza ER. Homicídios no Brasil: o grande vilão da saúde pública na década de 80. Cad Saúde Pública 1994; 10(Supl. 1): S45-S60. http://dx.doi.org/10.1590/S0102-311X1994000500004
https://doi.org/http://dx.doi.org/10.159... ^,77. Eisenman DP, Gelberg L, Liu H, Shapiro MF. Mental health and health-related quality of life among adult Latino primary care patients living in the United States with previous exposure to political violence. JAMA 2003; 290(5): 627-34. https://doi.org/10.1001/jama.290.5.627
https://doi.org/https://doi.org/10.1001/... ^,1010. Peres MFT, Ruotti C. Violência urbana e saúde. Rev USP [Internet] 2015 [acessado em 12 abr. 2018]; (107): 65-78. Disponível em: Disponível em: http://www.revistas.usp.br/revusp/article/view/115114
http://www.revistas.usp.br/revusp/articl... ^,2121. Wright RJ. Health Effects of Socially Toxic Neighborhoods: The Violence and Urban Asthma Paradigm. Clin Chest Med [Internet]. 2006 [acessado em 12 maio 2017]; 27(3): 413-21. Disponível em: Disponível em: http://linkinghub.elsevier.com/retrieve/pii/S0272523106000414 https://doi.org/10.1016/j.ccm.2006.04.003
http://linkinghub.elsevier.com/retrieve/... ^,3232. Silva DG, Dell’Aglio DD. Exposure to Domestic and Community Violence and Subjective Well-Being in Adolescents. Paidéia (Ribeirão Preto) 2016; 26(65): 299-305. http://dx.doi.org/10.1590/1982-43272665201603
https://doi.org/http://dx.doi.org/10.159... ^,4444. Decker MR, Peitzmeier S, Olumide A, Acharya R, Ojengbede O, Covarrubias L, et al. Prevalence and health impact of intimate partner violence and non-partner sexual violence among female adolescents aged 15-19 years in vulnerable urban environments: A multi-country study. J Adolesc Health 2014; 55(6 Supl.): S58-67. https://doi.org/10.1016/j.jadohealth.2014.08.022
https://doi.org/https://doi.org/10.1016/... ^,4848. Wright RJ, Mitchell H, Visness CM, Cohen S, Stout J, Evans R, et al. Community Violence and Asthma Morbidity: The Inner-City Asthma Study. Am J Public Health 2004; 94(4): 625-32. https://doi.org/10.2105/ajph.94.4.625
https://doi.org/https://doi.org/10.2105/... ^,4747. James S, Donnelly L, Brooks-Gun J, McLanahan S. Links between childhood exposure to violent contexts and Risky Adolescents Health Behaviors. J Adolesc Health 2018; 63(1): 94-101. https://doi.org/10.1016/j.jadohealth.2018.01.013
https://doi.org/https://doi.org/10.1016/... .

Accumulated exposure to violence has also been the subject of studies. It is assumed that the overlap of exposures to negative events, which produce stress, leads to a cumulative increase in health risk³²32. Silva DG, Dell’Aglio DD. Exposure to Domestic and Community Violence and Subjective Well-Being in Adolescents. Paidéia (Ribeirão Preto) 2016; 26(65): 299-305. http://dx.doi.org/10.1590/1982-43272665201603
https://doi.org/http://dx.doi.org/10.159... ^,3333. Boynton-Jarrett R, Ryan LM, Berkman LF, Wright R. Cumulative Violence Exposure and Self-rated health: Longitudinal Study of Adolescents in the United States. Pediatrics 2008; 122(5): 961-70. https://doi.org/10.1542/peds.2007-3063
https://doi.org/https://doi.org/10.1542/... ^,3434. Lopes CS, Moraes CL, Junger WL, Werneck GL, Ponce de Leon AC, Faerstein E. Direct and indirect exposure to violence and psychological distress among civil servants in Rio de Janeiro, Brazil: a prospective cohort study. BMC Psychiatry 2015; 15: 109. https://doi.org/10.1186/s12888-015-0487-9
https://doi.org/https://doi.org/10.1186/... . Kadra et al.³¹31. Kadra G, Dean K, Hotopf M, Hatch SL. Investigating exposure to violence and mental health in a diverse urban community sample: data from the South East London Community Health (SELCoH) survey. PLoS One 2014; 9(4): e93660. https://doi.org/10.1371/journal.pone.0093660
https://doi.org/https://doi.org/10.1371/... investigated the effect of overlapping violent experiences in life (victimization, perpetration, and testimony) on the mental health of adults (over 16 years old) in a population-based cross-sectional study in South London and found that prevalence of common mental disorders, drug use and alcohol abuse increases significantly with the increase in the number of experiences.

Polyvitimization in IPV victims, in turn, is associated to a higher frequency of use of mental health services, according to a study conducted with a sample of adult women (over 18 years old) in the United States²⁹29. Cho H, Kown I. Intimate partner violence, cumulative violence exposure, and mental health service. Community Mental Health J 2018; 54(3): 259-66. https://doi.org/10.1007/s10597-017-0204-x
https://doi.org/https://doi.org/10.1007/... . The results are consistent when considering the effects of accumulated exposure to different types of violence.

Margolin et al.²⁸28. Margolin G, Vickerman KA, Oliver PH, Gordis EB. Violence exposure in multiple interpersonal domains: Cumulative and differential effects. J Adolesc Heal [Internet] 2010 [acessado em 29 jan. 2018]; 47(2): 198-205. Disponível em: http://dx.doi.org/10.1016/j.jadohealth.2010.01.020
https://doi.org/http://dx.doi.org/10.101... examined the cumulative effect of exposure to IPV and CIV in young people and noted an increased risk of somatic symptoms (relative risk - RR = 1.12; p <0.05), depressive symptoms (RR = 1.77 ; p <0.001), and anxiety (RR = 1.58; p <0.001) associated with an increase in the number of victimization experiences. Dubow et al.³⁰30. Dubow EF, Boxer P, Huesmann LR, Landau S, Dvir S, Shikaki K, et al. Cumulative Effects of Exposure to Violence on Post traumatic Stress in Palestinian and Israeli Youth. J Clin Child Adolesc Psychol 2012; 41(6): 837-44. https://doi.org/10.1080/15374416.2012.675571
https://doi.org/https://doi.org/10.1080/... reported a higher risk of depression in young Palestinians exposed to different types of violence (ethnic-political, community, family, and at school). In Brazil³²32. Silva DG, Dell’Aglio DD. Exposure to Domestic and Community Violence and Subjective Well-Being in Adolescents. Paidéia (Ribeirão Preto) 2016; 26(65): 299-305. http://dx.doi.org/10.1590/1982-43272665201603
https://doi.org/http://dx.doi.org/10.159... , a study sought to investigate the effects of exposure to family and extra-family violence on the subjective well-being of adolescents and found a negative and significant association, indicating that the accumulation of experiences is related to lower subjective well-being. These surveys use different methodologies, which makes comparison difficult, however all point to an accumulated risk effect. Our results confirm these findings and signal an increased risk of negative SRH when accumulated exposure to FIV and CIV.

Efforts have been made to understand the pathophysiological mechanisms of health effects associated with exposure to violence. The studies carried out by Wright⁴⁸48. Wright RJ, Mitchell H, Visness CM, Cohen S, Stout J, Evans R, et al. Community Violence and Asthma Morbidity: The Inner-City Asthma Study. Am J Public Health 2004; 94(4): 625-32. https://doi.org/10.2105/ajph.94.4.625
https://doi.org/https://doi.org/10.2105/... are a landmark on the effects of exposure to violence in childhood asthma. According to the author, community violence works as a psychosocial stressor, activating neurophysiological mechanisms of acute and/or chronic response to stress and influencing allostasis. Changes in the levels of cytokines, catecholamines and cortisol explain, for the author, the health effects of exposure to violence. The permanent experience in situations of violence, resulting, for example, from an abusive relationship with an intimate partner, or from living in a neighborhood with high levels of violence, leads to chronic hyperactivity of these mediators, with effects on health and well-being²¹21. Wright RJ. Health Effects of Socially Toxic Neighborhoods: The Violence and Urban Asthma Paradigm. Clin Chest Med [Internet]. 2006 [acessado em 12 maio 2017]; 27(3): 413-21. Disponível em: Disponível em: http://linkinghub.elsevier.com/retrieve/pii/S0272523106000414 https://doi.org/10.1016/j.ccm.2006.04.003
http://linkinghub.elsevier.com/retrieve/... ^,4949. Juster R-P, McEwen BS, Lupien SJ. Allostatic load biomarkers of chronic stress and impact on health and cognition. Neurosci Biobehav Rev [Internet] 2010 [acessado em 9 maio 2017]; 35(1): 2-16. Disponível em: http://dx.doi.org/10.1016/j.neubiorev.2009.10.002
https://doi.org/http://dx.doi.org/10.101... ^,5050. Mattei J, Demissie S, Falcon LM, Ordovas JM, Tucker K. Allostatic load is associated with chronic conditions in the Boston Puerto Rican Health Study. Soc Sci Med [Internet] 2010 [acessado em 9 maio 2017]; 70(12): 1988-96. Disponível em: https://doi.org/10.1016/j.socscimed.2010.02.024
https://doi.org/https://doi.org/10.1016/... ^,5151. McEwen BS, Stellar E. Stress and the individual. Mechanisms leading to disease. Arch Intern Med [Internet] 1993 [acessado em 12 maio 2017]; 153(18): 2093-101. Disponível em: http://www.ncbi.nlm.nih.gov/pubmed/8379800
https://doi.org/http://www.ncbi.nlm.nih.... .

Wright⁴⁸48. Wright RJ, Mitchell H, Visness CM, Cohen S, Stout J, Evans R, et al. Community Violence and Asthma Morbidity: The Inner-City Asthma Study. Am J Public Health 2004; 94(4): 625-32. https://doi.org/10.2105/ajph.94.4.625
https://doi.org/https://doi.org/10.2105/... also points out that exposure to violence leads to behavioral changes due to the feeling of insecurity and fear, loss of control over the external environment and life itself, which is related to the greater adoption of health risk behaviors, such as smoking, alcohol abuse, physical inactivity, and changes in eating habits, factors that in turn are associated with negative health effects and negative SRH²¹21. Wright RJ. Health Effects of Socially Toxic Neighborhoods: The Violence and Urban Asthma Paradigm. Clin Chest Med [Internet]. 2006 [acessado em 12 maio 2017]; 27(3): 413-21. Disponível em: Disponível em: http://linkinghub.elsevier.com/retrieve/pii/S0272523106000414 https://doi.org/10.1016/j.ccm.2006.04.003
http://linkinghub.elsevier.com/retrieve/... .

Our results show that the association between FIV/by acquainted person and negative SRH was greater than that of CIV/by acquainted person and SRH, and that of polyvitimization with SRH was superior to that of FIV/by acquainted person with SRH. By understanding violence as a psychosocial stressor, it is possible to understand such findings, as the characteristics between the types of violence differ, making it possible to consider each type of violence as a new stressor. FIV occurs among acquaintances, often in a chronic form, and usually within the home, which should be a safe environment.

In this way, it is possible to understand the increased strength of association between the categories analyzed and, therefore, to emphasize that polyvictimization further enhances the stressor effect of exposure to violence. This cumulative effect was also demonstrated in a longitudinal study carried out with adolescents in 2008, in which a strong gradual association was observed between cumulative exposure to violence and negative SRH, this association being 38% greater for each additional exposure to violence and 4.6 times greater in comparison to those who have not suffered any violence³³33. Boynton-Jarrett R, Ryan LM, Berkman LF, Wright R. Cumulative Violence Exposure and Self-rated health: Longitudinal Study of Adolescents in the United States. Pediatrics 2008; 122(5): 961-70. https://doi.org/10.1542/peds.2007-3063
https://doi.org/https://doi.org/10.1542/... .

Our results need to be analyzed considering the limitations of the present study. The first is that exposure to violence was measured by means of a single general question, and not by different questions about specific acts or situations of violence suffered, such as having been beaten with a slap, having been the victim of humiliation, cursing or have been forced into sex. This way of approaching victimization is recommended as a strategy to minimize information bias and consequent underestimation and incorrect classification, since the perception of violence varies between people, time and different cultures⁵²52. Minayo MC de S, Souza ER. Violência sob o olhar da saúde: a infra-política da contemporaneidade brasileira. Rio de Janeiro: Editora Fiocruz; 2003. 284 p.. As a result, prevalences found may be underestimated. In addition, indirect victimization and perceived violence in the community and its effects were not assessed. Another aspect to be taken into account is that the questions refer to violence by unknown or known people. The latter group includes family members, friends and close acquaintances. It should be noted, however, that most cases (60.6%) are related to victimization by family members.

Although there are instruments translated and validated for Brazil that are more sensitive for detecting cases of violence, their use in a nationwide population-based survey is difficult to apply, as they increase time and complex data collection. In addition, these validated instruments are, in most cases, used in a specific exposure group⁵³53. Reichenheim ME, Moraes CL. Psychometric properties of the Portuguese version of the Conflict Tactics Scales: Parent-child Version (CTSPC) used to identify child abuse. Cad Saúde Pública [Internet]. 2006 [acessado em 12 maio 2017]; 22(3): 503-15. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2006000300005&lng=en&tlng=en http://dx.doi.org/10.1590/S0102-311X2006000300005
http://www.scielo.br/scielo.php?script=s... ^,5454. Moraes CL, Hasselmann MH, Reichenheim ME. Adaptação transcultural para o português do instrumento “Revised Conflict Tactics Scales (CTS2)” utilizado para identificar violência entre casais. Cad Saúde Pública [Internet] 2002 [acessado em 7 ago. 2018]; 18(1): 163-76. Disponível em: http://dx.doi.org/10.1590/S0102-311X2002000100017
https://doi.org/http://dx.doi.org/10.159... ^,5555. Paixão Jr. CM, Reichenheim ME, Moraes CL, Coutinho ESF, Veras RP. Adaptação transcultural para o Brasil do instrumento Caregiver Abuse Screen (CASE) para detecção de violência de cuidadores contra idosos. Cad Saúde Pública [Internet] 2007 [acessado em 6 ago. 2018]; 23(9): 2013-22. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2007000900010&lng=pt&tlng=pt http://dx.doi.org/10.1590/S0102-311X2007000900010
http://www.scielo.br/scielo.php?script=s... ^,5656. Schraiber LB, Latorre M do RDO, França Jr. I, Segri NJ, D’Oliveira AFPL. Validade do instrumento WHO VAW STUDY para estimar violência de gênero contra a mulher. Rev Saúde Pública [Internet] 2010 [acessado em 30 jan. 2018]; 44(4): 658-66. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-89102010000400009&lng=pt&tlng=pt http://dx.doi.org/10.1590/S0034-89102010000400009
http://www.scielo.br/scielo.php?script=s... . Thus, it is possible that non-differential classification errors have occurred and that there is an underestimation in the estimates of violence.

Chronic diseases and/or depression were not included as an adjustment variable in our model. Both can have great influence on SRH and be associated with violence. This condition would imply including them in our model as variables with confounding potential, therefore requiring their inclusion as an adjustment variable in the model. It was done so because violence in the PNS was measured in the last 12 months and chronic diseases have no time limit. Therefore, it is not possible to know whether a chronic disease is pre-existing to violence or not.

Furthermore, from a theoretical-conceptual point of view, chronic diseases would be, when and if triggered by the stress mechanisms related to exposure to violence (as one of the factors, not the only one), better conceived as a mediating variable (exposure increases the risk of developing chronic diseases, which, in turn, increases the risk of poor health status assessment), and not as confusing. In this case, the inclusion of the variable to adjust the model would be incorrect. This made us choose not to include chronic diseases in our model as an adjustment variable. The same can be said about depression. PNS uses the Patient Health Questionnaire-9 (PHQ-9) to measure the presence of depression, with a 15-day time reference. However, we consider that depression is better conceived as a mediating variable, and not a confusion variable, which would make the adjustment incorrect.

It should also be noted that our objective in this article was not to explore mechanisms or means of mediation, but only to verify the association between exposure to violence and assessment of health status, taking into account combined exposure to family and community violence.

Furthermore, the literature points out that there are other factors associated with exposure to violence that can contribute to negative SRH, such as anxiety and post-traumatic stress, which were not measured by the PNS and, therefore, could not be adjusted in our final model⁶6. World Health Organization. Global status report on violence prevention 2014 Genebra: World Health Organization; 2014.^,88. Fairbrook SW. The Physical and Mental Health Effects of Community Violence Exposure in Pre-Adolescent and Adolescent Youth. J Student Nurs 2013; 6(1): 7-14.^,2020. Aquino NMR De, Sun SY, Oliveira EM De, Martins MDG, Silva JDF Da, Mattar R. Violência sexual e associação com a percepção individual de saúde entre mulheres gestantes. Rev Saúde Pública [Internet] 2009 [acessado em 9 maio 2017]; 43(6): 954-60. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-89102009000600006&lng=pt&tlng=pt http://dx.doi.org/10.1590/S0034-89102009005000068
http://www.scielo.br/scielo.php?script=s... .

The transversal nature of the study does not allow us to make longitudinal inferences about the direction of the studied association, however there is a considerable amount of studies that reinforce the hypothesis of association in the sense that violence causes worse SRH, and not the other way around⁸8. Fairbrook SW. The Physical and Mental Health Effects of Community Violence Exposure in Pre-Adolescent and Adolescent Youth. J Student Nurs 2013; 6(1): 7-14.^,2727. Minayo MC de S. A inclusão da violência na agenda da saúde: trajetória histórica. Ciên Saúde Colet [Internet] 2006 [acessado em 9 maio 2017]; 11(Supl.): 1259-67. Disponível em: Disponível em: http://www.scielo.br/pdf/csc/v11s0/a15v11s0.pdf
http://www.scielo.br/pdf/csc/v11s0/a15v1... ^,3131. Kadra G, Dean K, Hotopf M, Hatch SL. Investigating exposure to violence and mental health in a diverse urban community sample: data from the South East London Community Health (SELCoH) survey. PLoS One 2014; 9(4): e93660. https://doi.org/10.1371/journal.pone.0093660
https://doi.org/https://doi.org/10.1371/... ^,5757. Theme Filha MM, Szwarcwald CL, Souza Junior PRB de. Medidas de morbidade referida e inter-relações com dimensões de saúde. Rev Saúde Pública [Internet] 2008 [acessado em 9 maio 2018]; 42(1): 73-81. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-89102008000100010&lng=pt&nrm=iso&tlng=en http://dx.doi.org/10.1590/S0034-89102008000100010
http://www.scielo.br/scielo.php?script=s... ^,5858. Svedberg P, Bardage C, Sandin S, Pedersen NL. A prospective study of health, life-style and psychosocial predictors of self-rated health. Eur J Epidemiol [Internet] 2006 [acessado em 7 set. 2018]; 21: 767-76. Disponível em: Disponível em: http://link.springer.com/10.1007/s10654-006-9064-3 https://doi.org/10.1007/s10654-006-9064-3
http://link.springer.com/10.1007/s10654-... .

It is important to remember that, in order to estimate the socioeconomic status of individuals and their families, we chose to use education as a proxy for socioeconomic status, thus avoiding the problem of multicollinearity in our model. It is known that there is a strong association between income and education, but it is possible that there is residual confusion in income, which is associated with both violence and worse SRH.

Among the strong points, it is highlighted that this is a study with a representative sample of the Brazilian population of home base, with high response rate (91.9%), which reduces the possibility of selection bias. The large sample size can also be considered an advantage, allowing the study of events of low prevalence. It should be noted, however, that this same sample size is able to explain the finding of statistically significant differences for associations of small magnitude.

CONCLUSION

The present study allowed us to observe the association between exposure to violence and negative SRH. Furthermore, it pointed out that exposure to both types of violence greatly increases the chance of a negative assessment of health status.

Although specialized services for caring for victims of community violence are still rare in Brazil, specialized services for caring for victims of family violence are common. The potentiation of the stressor effect of violence through polyvitimization in negative SRH, evidenced by our study, signals the need for these services to be aware of joint exposure to family and community violence. This is more relevant when we consider that in Brazil urban violence is assessed as endemic, there is an increase in State violence and the structural collapse of public policies, which reinforces the possibility of polyvictimization⁶6. World Health Organization. Global status report on violence prevention 2014 Genebra: World Health Organization; 2014..

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