ABSTRACT

Objective:

To estimate the prevalence and factors associated with intimate partner violence against adult women in Brazil.

Methods:

Quantitative cross-sectional epidemiological study using the database of the National Survey of Health 2019. The prevalence in the last 12 months and crude and adjusted prevalence ratios of intimate partner violence were calculated, stratified by sociodemographic characteristics.

Results:

Intimate partner violence was reported by 7.60% of Brazilian women aged from 18 to 59 years, with higher prevalence among younger women (8.96%), black women (9.05%), those with lower education level (8.55%) and low income (8.68%). After adjusted analysis, the age groups of 18–24 years old (PRadj: 1.41) and 25–39 years old (PRadj: 1.42) and income lower than one minimum wage (PRadj: 1.55) remained associated with intimate partner violence.

Conclusions:

Intimate partner violence was associated with younger and poorest women. This result points to the need to develop intersectoral policies, especially those aimed at reducing social inequalities and at the coping with intimate partner violence among adult women.

Keywords:
Intimate partner violence; Gender-based violence; Epidemiology; Cross-sectional studies; Health surveys

INTRODUCTION

Intimate partner violence (IPV), understood as “any behavior within an intimate relationship that causes physical, sexual, or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse, and controlling behaviors” displayed by current or previous partners¹1. World Health Organization, London School of Hygiene and Tropical Medicine. Preventing intimate partner and sexual violence against women: taking action and generating evidence. Geneva: World Health Organization; 2010. 94 p., constitutes a global public health issue and an evident attack on Human Rights²2. Brasil. Presidência da República. Secretaria de Políticas para as Mulheres. Secretaria Nacional de Enfrentamento à Violência contra as Mulheres. Política nacional de enfrentamento à violência contra as mulheres. Brasília: Secretaria de Políticas para as Mulheres; 2011..

Estimates from the World Health Organization (WHO) indicate that approximately 30% of women over 15 years of age have been victims of physical and sexual IPV at least once in their lives³3. World Health Organization. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: World Health Organization; 2013. 51 p.. For Brazil, a meta-analysis carried out by the Pan American Health Organization (PAHO) in 2019 concluded that 16.7% of women aged between 15 and 49 years suffered physical and/or sexual IPV in their lifetime and 3.1% in the last year⁴4. Bott S, Guedes A, Ruiz-Celis AP, Mendoza JA. Intimate partner violence in the Americas: a systematic review and reanalysis of national prevalence estimates. Rev Panam Salud Pública 2019; 43 (e26). Available at: http://iris.paho.org/xmlui/handle/123456789/50485
http://iris.paho.org/xmlui/handle/123456... . More than an isolated event in a woman’s life, IPV can be part of a continuous pattern of abuse⁵5. Bott S, Guedes A, Goodwin M, Adams Mendoza J. Violencia contra las mujeres en America Latina y el Caribe: Analisis comparativo de datos poblacionales de 12 paises. Washington: Organizacion Panamericana de la Salud; 2014. 164 p. and, in Brazil, approximately 33% of women victims of IPV report recurrence of violence⁶6. Barros CRS, Schraiber LB. Intimate partner violence reported by female and male users of healthcare units. Rev Saude Publica 2017; 51: 1-10. https://doi.org/10.1590/S1518-8787.2017051006385
https://doi.org/10.1590/S1518-8787.20170... .

IPV is an important cause of morbidity and disability, being recognized as a determinant of health and well-being, in addition to increasing the risk of premature death, not only directly, but also due to the development of health problems⁷7. Sandoval GA, Marinho F, Delaney R, Pinto IV, Lima CMD, Costa RM, et al. Mortality risk among women exposed to violence in Brazil: a population-based exploratory analysis. Public Health 2020; 179: 45-50. https://doi.org/10.1016/j.puhe.2019.09.019
https://doi.org/10.1016/j.puhe.2019.09.0... . It is estimated that, in the last 20 years, approximately 175 thousand disability-adjusted life years (DALY) were lost per year in Brazil as a result of IPV, and more than 80 thousand potential years of life lost (YLL) among women aged 15–49 years in 2019⁸8. Institute for Health Metrics and Evaluation. GBD Compare. Seattle: University of Washington; 2020. [cited on May 24, 2021]. Available at: http://vizhub.healthdata.org/gbd-compare
http://vizhub.healthdata.org/gbd-compare... .

IPV is associated with social inequities, and studies show higher prevalence of IPV among black women and those whit lower education levels⁹9. Yakubovich AR, Stöckl H, Murray J, Melendez-Torres GJ, Steinert JI, Glavin CEY, et al. Risk and protective factors for intimate partner violence against women: Systematic review and meta-analyses of prospective–longitudinal studies. Am J Public Health 2018; 108 (7): e1-11. https://doi.org/10.2105/AJPH.2018.304428
https://doi.org/10.2105/AJPH.2018.304428... . The fact that IPV is associated with regions with a higher rate of male homicides¹⁰10. Meneghel SN, Rosa BAR, Ceccon RF, Hirakata VN, Danilevicz IM. Feminicídios: estudo em capitais e municípios brasileiros de grande porte populacional. Cien Saude Colet 2017; 22 (9): 2963-70. https://doi.org/10.1590/1413-81232017229.22732015
https://doi.org/10.1590/1413-81232017229... and that both injuries are related to socioeconomic inequalities shows that Public Health has an important role in understanding the complex interaction between economic disadvantages and health-disease processes¹¹11. Wanzinack C, Signorelli MC, Reis C. Homicides and socio-environmental determinants of health in Brazil: a systematic literature review. Cad Saude Publica 2018; 34 (12): e00012818. https://doi.org/10.1590/0102-311X00012818
https://doi.org/10.1590/0102-311X0001281... , in such a way that monitoring the factors associated with IPV becomes essential.

In this context, the National Survey of Health (Pesquisa Nacional de Saúde – PNS), considered the most important study among Brazilian health surveys, being the largest, most complete and comprehensive health research ever conducted in the country¹²12. Malta DC, Szwarcwald CL, Silva Júnior JB. Primeiros resultados da análise do laboratório da Pesquisa Nacional de Saúde. Rev Bras Epidemiol 2019; 22 (Suppl 2): 2-4. https://doi.org/10.1590/1980-549720190001.supl.2
https://doi.org/10.1590/1980-54972019000... , provides information on the health determinants, conditions, and needs of the population, allowing for the implementation of consistent measures capable of assisting in the development of public policies and achieving greater effectiveness in health interventions¹³13. Szwarcwald CL, Malta DC, Pereira CA, Vieira MLFP, Conde WL, Souza Júnior PRB, et al. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação. Cien Saude Colet 2014; 19 (2): 333-42. https://doi.org/10.1590/1413-81232014192.14072012
https://doi.org/10.1590/1413-81232014192... .

It is noteworthy that in Brazil, no previous nationwide study estimated IPV and its subtypes in a representative sample of the population. Broadening the knowledge of IPV among women is essential for the production of coping strategies, thus guaranteeing women’s right to life and equity.

Considering the importance of studying IPV and the magnitude of PNS for public policies, this study aimed to estimate the prevalence and factors associated with IPV suffered by adult women in the country.

METHODS

Study Design and Data Source

Cross-sectional epidemiological study, with an analytical character and a quantitative approach, using data from the PNS 2019. The research evaluated individuals aged 15 years or older residing in permanent private households in Brazil.

The PNS sample originated from a previously established master sample and consisted of a three-stage cluster sampling plan of selection: census tracts or set of sectors (primary units), households (secondary units), and adult residents (tertiary units). The minimum size defined for the sample was 108,525 and the final sample was 94,114 households with one interview conducted, with a response rate of 93.6% (n=90,846). For the present study, women aged 18–59 years who responded to the violence module were selected (n=34,334). More details about the PNS methodology can be seen in a specific publication¹⁴14. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. Pesquisa Nacional de Saúde 2019: histórico, métodos e perspectivas. Epidemiol e Serviços Saude 2020; 29 (5): e2020315. http://doi.org/10.1590/s1679-49742020000500004
http://doi.org/10.1590/s1679-49742020000... .

Variables

The outcome variable, IPV, was constructed using the questions from the violence module (V). In 2019, this questionnaire module was reformulated, allowing for better characterization of the types of suffered violence, in addition to identifying the perpetrators of each type and their link with the victim.

The selected sociodemographic variables were: age group (18–24 years; 25–39 years; and 40–59 years); education level (no formal education and some elementary school; elementary school and some high school; high school and some college; college degree); race/skin color (white, black and mixed-race); region (North, Northeast, Southeast, South, and Midwest); income (up to one minimum wage [MW]; more than one to three MW; more than three to five MW; more than five MW). The Asian and Indigenous races/skin colors are included in the total, but the Brazilian Institute of Geography and Statistics does not disclose these data in a discriminated way due to the small number of observations and high coefficient of variation.

Data Analysis

In the descriptive analysis, the prevalence rates and their respective 95% confidence intervals (95%CI) of total IPV were calculated according to sociodemographic characteristics.

In order to assess factors associated with IPV, the prevalence ratios (PR) and their respective 95%CI were estimated using the Poisson regression model with robust variance. First, bivariate analyses were carried out between the IPV (outcome) and each sociodemographic variable (explanatory), and the crude PRs (PRc) were estimated. Subsequently, the multivariate model was performed, in which the explanatory variables with at least one category presenting a p-value ≤0.20 were gradually included in the model. The final model was considered at a significance level of 5%.

Due to the complex sampling design and the different selection probabilities, the PNS analysis requires prior definition of sample weights for selected households and residents. The final weigh considered results from the inverse of the expressions of selection probability of each stage of the sample and comprises the correction of nonresponses and adjustments to the population totals¹⁴14. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. Pesquisa Nacional de Saúde 2019: histórico, métodos e perspectivas. Epidemiol e Serviços Saude 2020; 29 (5): e2020315. http://doi.org/10.1590/s1679-49742020000500004
http://doi.org/10.1590/s1679-49742020000... .

The Software for Statistics and Data Science (Stata), version 14.0, was used for data analysis through the survey module, which considers the effects of the sampling plan.

Ethical Aspects

All participants informed consent at the time of the interview. The PNS project was submitted to the National Commission of Ethics in Research/National Council of Health (Brazilian Ministry of Health) and approved under Opinion No. 3.529,376, issued on August 23, 2019. This study used secondary data from PNS and therefore did not need to be considered by the research ethics committee, in accordance with Resolution No. 466/2012.

RESULTS

A total of 34,334 women were evaluated. Most aged between 40–59 years (46.16%), had education level from high school to some college (41.20%), self-reported to be mixed-race (45.25%), resided in the southeast region (42.65%), and earned up to one MW per month (56.21%) (Table 1).

The total prevalence of IPV was 7.60%, with psychological violence accounting for the highest prevalence (7.07%), followed by physical (2.75%) and sexual (0.68%) violence (Figure 1).

A higher prevalence of IPV was observed in women aged 18–24 years (8.96%), followed by women aged 25–39 years (8.88%). Younger women had 47% higher prevalence (p<0.01) than women aged 40–59 years (6.08%), and those with intermediate age, 46% higher than older women (p<0.01). The prevalence in women with lower education level (8.55%) was 26% (p=0.040) higher than the prevalence in women with a college degree (6.79%); in those who self-reported to be black (9.05%), it was 25% (p=0.049) higher than among women who self-reported to be white (7.22%); of women with income lower than one MW (8.68%), it was 65% (p=0.007) higher than that of women who earned more than five MW (5.26%). Among the Brazilian regions, the Northeast had the highest prevalence (8.17%) and the South, the lowest prevalence (6.77%) (Table 2).

In the multivariate model, it was observed that women aged 18–24 years (PRadj: 1.41) and 25–39 years (PRadj: 1.42) had higher prevalence rates of IPV, in addition to those with income lower than one MW (PRadj: 1.55). The other variables did not show a statistically significant difference (Table 3).

DISCUSSION

IPV was reported by approximately 8% of Brazilian women, with a higher prevalence of psychological violence. Stratified by sociodemographic characteristics, the highest prevalence rates were verified among the youngest women, with lower education level, who self-reported black skin color, residents of the northeast region, and with lower income. In the adjusted model, age (women aged 18–24 years and 25–39 years) and low income remained associated.

Changing the violence module in the PNS 2019 questionnaire broadened the possibility of studying IPV in a population-based health survey, analyzing its subtypes. The prevalence of IPV found in this study was 7.60%. A study carried out with the PNS 2013 found a prevalence of 3.10% of violence against women committed by people they knew, which also included family, friends, and neighbors¹⁵15. Mascarenhas MDM, Sinimbu RB, Malta DC, Silva MMA, Santos AF, Vieira MLFP, et al. Violência cometida por pessoa conhecida - Brasil, 2013. Cien Saude Colet 2017; 22 (11): 3763-71. https://doi.org/10.1590/1413-812320172211.08672016
https://doi.org/10.1590/1413-81232017221... . Another study with the same survey found a 1.58% prevalence of IPV among women¹⁶16. Silva AN, Azeredo CM. Associação entre vitimização por violência entre parceiros íntimos e depressão em adultos brasileiros. Cien Saude Colet 2019; 24 (7): 2691-700. https:/doi.org/10.1590/1413-81232018247.25002017
https:/doi.org/10.1590/1413-81232018247.... . However, the focus of PNS 2013 was only on physical violence and aggression¹⁷17. Instituto Brasileiro de Geografia e Estatística. Coordenação de Trabalho e Rendimento. Pesquisa nacional de saúde 2013: acesso e utilização dos serviços de saúde, acidentes e violências: Brasil, grandes regiões e unidades da federação. Rio de Janeiro: IBGE; 2015., which may have led to an underestimation of IPV. In 2012, a population-based survey conducted by the National Institute of Public Policies on Alcohol and Other Drugs (Instituto Nacional de Políticas Públicas do Álcool e Outras Drogas – INPAD) found a prevalence of 6.3% of IPV among adult women¹⁸18. Ally EZ, Laranjeira R, Viana MC, Pinsky I, Caetano R, Mitsuhiro S, et al. Intimate partner violence trends in Brazil: data from two waves of the Brazilian National Alcohol and Drugs Survey. Rev Bras Psiquiatr 2016; 38 (2): 98-105. https://doi.org/10.1590/1516-4446-2015-1798
https://doi.org/10.1590/1516-4446-2015-1... , a percentage close to that found in the present study. It is noteworthy that the aforementioned study was restricted to women who lived with their partners.

IPV against women is one of the forms that gender-based violence can take. This violence can be understood as a power relationship established from the social roles imposed on women and men that transcends the biological characteristics of each one¹⁹19. Santos RG, Moreira JG, Fonseca ALG, Gomes Filho ADS, Ifadireó MM. Violência contra a Mulher à partir das teorias de gênero. ID line Rev Psicol 2019 [cited on May 24, 2021]; 13 (44): 97-117. Available at: https://idonline.emnuvens.com.br/id/article/view/1476
https://idonline.emnuvens.com.br/id/arti... . The description of masculinity is based on notions of dominance, insensitivity and honor, which lead to the interpretation of violence as an inherent characteristic of men²⁰20. Santos CM, Izumino WP. Violência contra as mulheres e violência de gênero: notas sobre estudos feministas no Brasil. Estud Interdiscip Am Lat y el Caribe 2005 [cited on May 26, 2021]; 16 (1): 147-64. Available at: https://dialnet.unirioja.es/servlet/articulo?codigo=4004126
https://dialnet.unirioja.es/servlet/arti... . At the same time, there is the construction of the ideal of a woman, who must be obedient, take care of the house and children, and remain faithful to her partner²¹21. Pedro CB, Guedes OS. As conquistas do movimento feminista como expressão do protagonismo social das mulheres. An do I Simpósio sobre Estud Gênero e Políticas Públicas 2010 [cited on May 26, 2021]; 1-10. Available at: http://www.uel.br/eventos/gpp/pages/arquivos/1.ClaudiaBraganca.pdf
http://www.uel.br/eventos/gpp/pages/arqu... . Hence, there is an idea of the man’s possession of the woman, justifying obsessive jealousy and controlling behavior, with psychological abuse being a means of domination⁵5. Bott S, Guedes A, Goodwin M, Adams Mendoza J. Violencia contra las mujeres en America Latina y el Caribe: Analisis comparativo de datos poblacionales de 12 paises. Washington: Organizacion Panamericana de la Salud; 2014. 164 p.. Several cultures naturalize IPV and consider that, to repress women and reaffirm the hierarchy of the relationship, men have the right to inflict physical punishment on their partners and to have sexual relations against their will²²22. Krug EG, Dahlber LL, Mercy JA, Zwi AB, Lozano R. World report on violence and health. Geneva: World Health Organization; 2002. 380 p..

In this perspective, the several types of violence are often superimposed: psychological violence is the one that most often occurs in isolation, though it is also accompanied by the other two types (sexual and physical violence)²³23. Schraiber LB, d’Oliveira AFPL, França-Junior I, Diniz S, Portella AP, Ludermir AB, et al. Prevalência da violência contra a mulher por parceiro íntimo em regiões do Brasil. Rev Saude Publica 2007; 41 (5): 797-807. https://doi.org/10.1590/S0034-89102007000500014
https://doi.org/10.1590/S0034-8910200700... ; and physical violence is accompanied by psychological coercion and sexual abuse²⁴24. Campbell JC. Health consequences of intimate partner violence. Lancet 2002; 359 (9314): 1331-6. https://doi.org/10.1016/S0140-6736(02)08336-8
https://doi.org/10.1016/S0140-6736(02)08... . Overall, sexual violence committed by an intimate partner is not recognized by women due to the patriarchal culture that associates sexual practice with the wife’s duty, even if in a non-consensual way²³23. Schraiber LB, d’Oliveira AFPL, França-Junior I, Diniz S, Portella AP, Ludermir AB, et al. Prevalência da violência contra a mulher por parceiro íntimo em regiões do Brasil. Rev Saude Publica 2007; 41 (5): 797-807. https://doi.org/10.1590/S0034-89102007000500014
https://doi.org/10.1590/S0034-8910200700... . Schraiber et al. ²³23. Schraiber LB, d’Oliveira AFPL, França-Junior I, Diniz S, Portella AP, Ludermir AB, et al. Prevalência da violência contra a mulher por parceiro íntimo em regiões do Brasil. Rev Saude Publica 2007; 41 (5): 797-807. https://doi.org/10.1590/S0034-89102007000500014
https://doi.org/10.1590/S0034-8910200700... analyzed the prevalence rates found in a cross-sectional study carried out by the WHO between 2000 and 2003 and concluded that psychological violence had a prevalence of 37.6% in the city of São Paulo [SP] (state of São Paulo, Brazil) and 32% in the Zona da Mata Pernambucana region [ZMP] (state of Pernambuco, Brazil). Physical (8.5% in SP and 4.1% in ZMP) and sexual (0.5% in SP and 1.9% in ZMP) violence had similar prevalence to the present study.

In the present study, higher prevalence rates of IPV were observed in younger women, an association that remained significant after adjustment for other variables. Similar results were found in other studies. The WHO study, for example, showed that in Brazil IPV was concentrated in the aged group of 20–39 years²³23. Schraiber LB, d’Oliveira AFPL, França-Junior I, Diniz S, Portella AP, Ludermir AB, et al. Prevalência da violência contra a mulher por parceiro íntimo em regiões do Brasil. Rev Saude Publica 2007; 41 (5): 797-807. https://doi.org/10.1590/S0034-89102007000500014
https://doi.org/10.1590/S0034-8910200700... . Another study with notification data from the Notifiable Diseases Information System, between 2011 and 2017, also showed higher proportions of IPV in this same age group²⁵25. Mascarenhas MDM, Tomaz GR, Meneses GMS, Rodrigues MTP, Pereira VOM, Corassa RB. Análise das notificações de violência por parceiro íntimo contra mulheres, Brasil, 2011-2017. Rev Bras Epidemiol 2020; 23 (Suppl 1): E200007. https://doi.org/10.1590/1980-549720200007.supl.1
https://doi.org/10.1590/1980-54972020000... . A possible explanation for this finding is due to the fact that younger women may find themselves more dependent on their partner to take care of their children and provide for the house²⁶26. Bernardino IM, Barbosa KGN, Nóbrega LM, Cavalcante GMS, Ferreira EF e D’Avila S. Violência contra mulheres em diferentes estágios do ciclo de vida no Brasil: um estudo exploratório. Rev Bras Epidemiol 2016; 19 (4): 740-52. https://doi.org/10.1590/1980-5497201600040005
https://doi.org/10.1590/1980-54972016000... . Conversely, older women may have greater financial and social autonomy, which gives them an advantage to disentangle themselves from abusive relationships²⁷27. Garcia LP, Duarte EC, Freitas LRS, Silva GDM. Violência doméstica e familiar contra a mulher: estudo de casos e controles com vítimas atendidas em serviços de urgência e emergência. Cad Saude Publica 2016; 32 (4): e00011415. https://doi.org/10.1590/0102-311X00011415
https://doi.org/10.1590/0102-311X0001141... .

This study showed a decrease in the prevalence of IPV among more educated women. It is known that women with higher level of education have greater access to the social, cultural, and financial resources required to interrupt the cycle of violence²⁵25. Mascarenhas MDM, Tomaz GR, Meneses GMS, Rodrigues MTP, Pereira VOM, Corassa RB. Análise das notificações de violência por parceiro íntimo contra mulheres, Brasil, 2011-2017. Rev Bras Epidemiol 2020; 23 (Suppl 1): E200007. https://doi.org/10.1590/1980-549720200007.supl.1
https://doi.org/10.1590/1980-54972020000... . A descriptive study with data from urgent and emergency care services surveyed by the Violence and Accident Surveillance System (VIVA Survey) 2014 showed that, among victims of IPV, more than half had low education level²⁸28. Garcia LP, Silva GDM. Violência por parceiro íntimo: perfil dos atendimentos em serviços de urgência e emergência nas capitais dos estados brasileiros, 2014. Cad Saude Publica 2018; 34 (4): e00062317. https://doi.org/10.1590/0102-311X00062317
https://doi.org/10.1590/0102-311X0006231... . This fact is corroborated by a systematic review with meta-analysis published in 2018, in which the results showed that women without high school education were 40% more likely to experience IPV in adulthood⁹9. Yakubovich AR, Stöckl H, Murray J, Melendez-Torres GJ, Steinert JI, Glavin CEY, et al. Risk and protective factors for intimate partner violence against women: Systematic review and meta-analyses of prospective–longitudinal studies. Am J Public Health 2018; 108 (7): e1-11. https://doi.org/10.2105/AJPH.2018.304428
https://doi.org/10.2105/AJPH.2018.304428... . Although education has not remained in the multivariate model, income did, and it is known that education is a prerequisite for entering the labor market, being a proxy for income²⁹29. Gomes NP, Diniz NMF, Camargo CL, Silva MP. Homens e mulheres em vivência de violência conjugal: características socioeconômicas. Rev Gaúcha Enferm 2012; 33 (2): 109-16. https://doi.org/10.1590/S1983-14472012000200016
https://doi.org/10.1590/S1983-1447201200... .

IPV was higher in women who self-reported to be black, which is corroborated by the literature. A study showed that women who self-reported to be white are 28% less likely to be victims of IPV⁹9. Yakubovich AR, Stöckl H, Murray J, Melendez-Torres GJ, Steinert JI, Glavin CEY, et al. Risk and protective factors for intimate partner violence against women: Systematic review and meta-analyses of prospective–longitudinal studies. Am J Public Health 2018; 108 (7): e1-11. https://doi.org/10.2105/AJPH.2018.304428
https://doi.org/10.2105/AJPH.2018.304428... , whereas an ecological study that used the standardized mean coefficient of female mortality from aggression as a marker of femicide in the 2007–2009 and 2011–2013 trienniums concluded that black women are twice as likely to die from this cause compared to white women¹⁰10. Meneghel SN, Rosa BAR, Ceccon RF, Hirakata VN, Danilevicz IM. Feminicídios: estudo em capitais e municípios brasileiros de grande porte populacional. Cien Saude Colet 2017; 22 (9): 2963-70. https://doi.org/10.1590/1413-81232017229.22732015
https://doi.org/10.1590/1413-81232017229... . Race cannot be understood only based on genetic variations³⁰30. Pearce N, Foliaki S, Sporle A, Cunningham C. Genetics, race, ethnicity, and health. BMJ 2004; 328 (7447): 1070-2. https://doi.org/10.1136/bmj.328.7447.1070
https://doi.org/10.1136/bmj.328.7447.107... ; it is rather considered a social variable that carries the weight of historical and cultural constructions and represents an important determinant of the lack of equity in health among racial groups³¹31. Araújo EM, Costa MCN, Hogan VK, Araújo TM, Dias AB, Oliveira LOA. A utilização da variável raça/cor em Saúde Pública: possibilidades e limites. Interface (Botucatu) 2009; 13 (31): 383-94. https://doi.org/10.1590/S1414-32832009000400012
https://doi.org/10.1590/S1414-3283200900... . In Brazil, the black race is deemed as a marker of social disadvantage, acting as a proxy for unfavorable socioeconomic situations³²32. Capaldi DM, Knoble NB, Shortt JW, Kim HK. A systematic review of risk factors for intimate partner violence. Partner Abuse 2012; 3 (2): 231-80. https://doi.org/10.1891/1946-6560.3.2.231
https://doi.org/10.1891/1946-6560.3.2.23... . In the current study, race/skin color did not remain in the final model; nevertheless, there may be a relationship between race, education, and income. Therefore, mixed-race and black women do not necessarily suffer more IPV, but they accumulate vulnerabilities, which can lead to difficulty in disentangling from the aggressor and chronic situations of violence.

This study found an association between IPV and low income. IPV is related to controlling attitudes of the partner, which often prevent women from leaving their homes and damage their social relationships⁵5. Bott S, Guedes A, Goodwin M, Adams Mendoza J. Violencia contra las mujeres en America Latina y el Caribe: Analisis comparativo de datos poblacionales de 12 paises. Washington: Organizacion Panamericana de la Salud; 2014. 164 p.. This context can favor lesser financial autonomy for women and a decrease in their income³³33. Wathen CN, MacGregor JCD, MacQuarrie BJ. Relationships among intimate partner violence, work, and health. J Interpers Violence 2018; 33 (14): 2268-90. https://doi.org/10.1177/0886260515624236
https://doi.org/10.1177/0886260515624236... . Furthermore, women victims of IPV have higher rates of absenteeism, that is, absence from work, which leads to job instability and increases women’s dependence on their aggressor, contributing to greater exposure to IPV³⁴34. Goodman LA, Smyth KF, Borges AM, Singer R. When crises collide: how intimate partner violence and poverty intersect to shape women’s mental health and coping? Trauma Violence Abuse 2009; 10 (4): 306-29. https://doi.org/10.1177/1524838009339754
https://doi.org/10.1177/1524838009339754... . In the adjusted model, the association between low income and IPV remained significant, a result that reinforces the importance of policies for combating violence against women to rethink strategies beyond the protection of women and punishment of aggressors, advancing in ensuring financial autonomy and right to housing, which will make it possible to break the cycle of IPV.

In the regional context, a population-based study conducted in 16 state capitals of Brazil showed that states in the South, Southeast and Midwest had 11.2% prevalence of severe physical violence, whereas in the North and Northeast this prevalence was 19%³⁵35. Reichenheim ME, Moraes CL, Szklo A, Hasselmann MH, Souza ER, Lozana JA, et al. The magnitude of intimate partner violence in Brazil: portraits from 15 capital cities and the Federal District. Cad Saude Publica 2006; 22 (2): 425-37. https://doi.org/10.1590/S0102-311X2006000200020
https://doi.org/10.1590/S0102-311X200600... . By classifying the types of violence according to severity, the comparison with the current study may not be reliable. In addition, in the current study, although the prevalence of IPV was higher in the Northeast compared with the South, this association no longer existed in the final model. Regional differences for IPV seem to be explained by the disparity in the rates of unemployment and urban violence in the communities in addition to macro-structural factors that refer to cultural norms about gender, access to public policies on welfare, education and employment³⁵35. Reichenheim ME, Moraes CL, Szklo A, Hasselmann MH, Souza ER, Lozana JA, et al. The magnitude of intimate partner violence in Brazil: portraits from 15 capital cities and the Federal District. Cad Saude Publica 2006; 22 (2): 425-37. https://doi.org/10.1590/S0102-311X2006000200020
https://doi.org/10.1590/S0102-311X200600... . Local studies are necessary to identify regions with the highest concentration of violence.

Gathering data on IPV generates pieces of evidence that serve as a valuable guide for the development of programs and public policies capable of leading to a reduction in violence²²22. Krug EG, Dahlber LL, Mercy JA, Zwi AB, Lozano R. World report on violence and health. Geneva: World Health Organization; 2002. 380 p.. Unfortunately, the political, economic, and social crises that began in 2015 and the austerity measures established by Constitutional Amendment 95 in 2016, which limited public spending for 20 years, brought dismantling and setbacks in social protection policies for the Brazilian population and unequally affected vulnerable groups³⁶36. Rasella D, Basu S, Hone T, Paes-Sousa R, Ocké-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: A nationwide microsimulation study. PLoS Med 2018; 15 (5): e1002570. https://doi.org/10.1371/journal.pmed.1002570
https://doi.org/10.1371/journal.pmed.100... . With regard to IPV, the National Secretariat of Policies for Women has been drained and, in 2019, the Casa da Mulher Brasileira assistance program, which aims to integrate, in the same place, legal and assistance services for women in situations of violence³⁷37. Menicucci E. Casa da Mulher Brasileira começa a virar realidade. Correio Braziliense. 2014 [cited on May 24, 2021]; Available at: http://www.observatoriodegenero.gov.br/menu/noticias/casa-da-mulher-brasileira-comeca-a-virar-realidade-artigo-2013-eleonora-menicucci
http://www.observatoriodegenero.gov.br/m... , did not receive any investment³⁸38. Confederação nacional dos trabalhadores na saúde. Governo corta verba de pasta que combate violência doméstica. 2020 [cited on May 24, 2021]; Available at: https://cnts.org.br/noticias/governo-corta-verba-de-pasta-que-combate-violencia-domestica/
https://cnts.org.br/noticias/governo-cor... . In the current government, the conservative discourse legitimizes male domination over women³⁹39. Barbiéri LF. Damares diz que na “concepção cristã” mulher deve ser “submissa” ao homem no casamento. G1; 2019 [cited on May 24, 2021]; Available at: https://g1.globo.com/politica/noticia/2019/04/16/damares-diz-que-em-sua-concepcao-crista-mulher-deve-ser-submissa-ao-homem-no-casamento.ghtml
https://g1.globo.com/politica/noticia/20... and conceals structural machismo, palpable in the official stance against abortion in any circumstance⁴⁰40. Cazarré M. Ministra Damares fala contra aborto no Parlamento argentino. Agência Brasil [Internet]. 2019 [cited on May 24, 2021]; Available at: https://agenciabrasil.ebc.com.br/internacional/noticia/2019-05/ministra-damares-fala-contra-aborto-no-parlamento-argentino
https://agenciabrasil.ebc.com.br/interna... , including an attempt to prevent care for victims of rape⁴¹41. Vila-Nova C. Ministra Damares Alves agiu para impedir aborto em criança de 10 anos. Folha de São Paulo. 2020 [cited on May 24, 2021]; Available at: https://www1.folha.uol.com.br/cotidiano/2020/09/ministra-damares-alves-agiu-para-impedir-aborto-de-crianca-de-10-anos.shtml
https://www1.folha.uol.com.br/cotidiano/... . Furthermore, measures to facilitate access to weapons can increase the risk of women in situations of violence, a fact that has already been evidenced by the increase in femicide rates in the country⁴²42. Sudré L. A crise tem rosto de mulher: elas são as mais afetadas pela precarização no país. Brasil de Fato. 2020 [cited on May 24, 2021]; Available at: https://www.brasildefato.com.br/2020/03/08/a-crise-tem-rosto-de-mulher-precarizacao-e-desmonte-de-politicas-afetam-mais-elas
https://www.brasildefato.com.br/2020/03/... .

Among the limitations of the study, the cross-sectional design is highlighted, which makes it impossible to determine causality. In addition, the sample excludes populations of homeless people, those living in asylums, quilombos, and villages. It is believed that the prevalence of IPV is underestimated, as women are more likely to hide the occurrence of a violent act due to the stigmatization of this condition⁴³43. Ellsberg M, Heise L, Pena R, Agurto S, Winkvist A. Researching domestic violence against women: methodological and ethical considerations. Stud Fam Plann 2001; 32 (1): 1-16. https://doi.org/10.1111/j.1728-4465.2001.00001.x
https://doi.org/10.1111/j.1728-4465.2001... . The adopted measures seeking to minimize this limitation were ensuring privacy in the interview, keeping the woman away from a possible aggressor, and enabling the response to the module directly on the device, in such a way to minimize possible embarrassment. Moreover, to reduce the lack of understanding of the suffered violence, several situations were specified to better characterize the events. However, the questions were restricted to psychological, physical, and sexual violence, not addressing other types, such as patrimonial and moral violence, which are more difficult to define.

In conclusion, the PNS 2019 data show that IPV is related to macro-social (social class, race/skin color as a proxy for inequality and education) and generational factors. IPV can be avoided and its impact can be minimized. This depends on the intersectoral articulation of the areas of health, law, public safety, and education, aiming to act in an integrated manner in the development of policies for the protection of life, integrity, and the rights of women. The National Policy on Combating Violence Against Women must direct its attention to guaranteeing the right to education, income, employment, health, and housing.

It is noteworthy that, for the first time, the PNS deepened the investigation of IPV in a representative sample of the Brazilian population, specifying different situations to better characterize the event and discriminate the aggressor from each type of violence. In this sense, the findings of this study will support the surveillance of violence, monitor compliance with the goals of the 2030 Agenda for Sustainable Development⁴⁴44. United Nations. Transforming our world: the 2030 agenda for sustainable development. New York: United Nations; 2015., as well as help in the formulation of public policies aimed at reducing social inequalities and inequities. In addition, this study allows the development of a baseline of information from the PNS on IPV that will assist in monitoring the developments that have taken place in society due to the conservative position and the restriction of rights that the country is currently undergoing.

Acknowledgments

We would like to thank the National Council for Scientific and Technological Development for the productivity grant to author Deborah Carvalho Malta. And to the Coordination for the Improvement of Higher Education Personnel for the doctoral scholarship of the author Fabiana Martins Dias de Andrade.

REFERENCES

Publication Dates

History