ABSTRACT

Objective:

To describe and analyze notifications and the temporal trend of violence against women living in rural contexts in Brazil, from 2011 to 2020.

Methods:

Ecological time-series study of a descriptive and analytical nature, with data from the Notifiable Diseases Information System on violence against women aged 18 to 59 years, in rural areas, from 2011 to 2020, in Brazil. The analyses were descriptive and trend-related, with the regression model using inflection points (joinpoint) and calculation of the annual percent change (APC) and the average annual percent change (AAPC).

Results:

A total of 79,229 notifications of violence against rural women were recorded. The most reported violence was physical (77.6%), psychological/moral (36.5%), and sexual (6.2%). They occurred, above all, among young, Black, married women with low levels of education. They were committed, in most cases, at home and, mainly, by a male partner. APC was statistically increasing throughout the studied period in Brazil, in the North, Midwest, South, and Northeast regions, including 18 states and the Federal District (DF). As for AAPC, all country, region, state, and DF rates showed a statistically increasing trend.

Conclusion:

In view of the increasing reported cases of violence against rural women throughout the country, which are mainly committed by people they are related to and in their own home, it is encouraged to reinforce the training of health professionals to improve and expand the process of notification as an instrument of care for women in situations of violence.

Keywords:
Violence against women; Gender-based violence; Rural population; Health information systems; Notification

INTRODUCTION

Violence against women is understood as any action or conduct based on gender, including that resulting from discrimination or ethnic inequality, that causes death, harm, or physical, sexual, or psychological suffering¹1 Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei n° 10.778, de 24 de novembro de 2003. Estabelece a notificação compulsória, no território nacional, do caso de violência contra a mulher que for atendida em serviços de saúde públicos ou privados [Internet]. Brasília (DF): Diário Oficial da União; 2003 [cited on Apr. 15, 2024]. Available at: https://www.planalto.gov.br/ccivil_03/leis/2003/l10.778.htm
https://www.planalto.gov.br/ccivil_03/le... . In Brazil, it is estimated that, on average, 18.6 million women aged 16 and over suffered some form of violence throughout 2022; the most frequent were: verbal abuse, stalking, threats, and physical assault²2 Fórum Brasileiro de Segurança Pública. Visível e invisível: a vitimização de mulheres no Brasil [Internet]. Brasília: Fórum Brasileiro de Segurança Pública; 2023 [cited on Apr. 15, 2024]. Available at: https://forumseguranca.org.br/wp-content/uploads/2023/03/visiveleinvisivel-2023-relatorio.pdf
https://forumseguranca.org.br/wp-content... .

The data, like most research, do not differentiate between women living in urban and rural areas, and this lack of information regarding women living in rural contexts contributed to the invisibility of the issue and, consequently, fewer actions to combat violence in this context³3 Soares RAS, Pessoa VM, Moraes RM, Mendonça AVM, Freitas RWJF, Carneiro FF. Saúde e violência contra as mulheres do campo, da floresta e das águas: desafios para o SUS. In: Carneiro FF, Pessoa VM, Teixeira AA, orgs. Campo, floresta e águas práticas e saberes em saúde. Brasília: Editora UnB; 2017. p. 127-49. https://doi.org/10.7476/9786558460510.0008
https://doi.org/10.7476/9786558460510.00... .

The rural context encompasses a series of particularities, such as the absence of neighbors and relatives, lack of financial autonomy, social and geographic isolation, and distance from health and protection services, which are normally located in urban centers⁴4 Bueno ALM, Lopes MJM. Cartografias de violências contra mulheres rurais. In: Mesquita MO, Riquinho DL, Gerhardt TE, Ruiz ENF, orgs. Saúde coletiva, desenvolvimento e (in)sustentabilidades no rural. Porto Alegre: Editora da UFRGS; 2018. p. 145-60.–⁶6 Costa MC, Silva EB, Arboit J, Honnef F, Marques KA, Barbieri J, et al. Violência doméstica contra a mulher em contexto rural: reconhecimento das estratégias de atenção. Rev Bras Promoç Saúde 2019; 32: 9271. https://doi.org/10.5020/18061230.2019.9271
https://doi.org/10.5020/18061230.2019.92... . Hence, "rural women find empowerment in adversities such as exclusion and difficulties in accessing health and safety services"⁴4 Bueno ALM, Lopes MJM. Cartografias de violências contra mulheres rurais. In: Mesquita MO, Riquinho DL, Gerhardt TE, Ruiz ENF, orgs. Saúde coletiva, desenvolvimento e (in)sustentabilidades no rural. Porto Alegre: Editora da UFRGS; 2018. p. 145-60.. These adversities, rooted in gender oppression, contribute to strengthening the silencing of these women.

Among the few publications on violence against women living in rural contexts, we highlight a study whose authors used data from the Notifiable Diseases Information System (Sistema de Informação de Agravos de Notificação – SINAN), from 2010 to 2012, with 7,197 notifications against adult Brazilian rural women. The most reported types of violence were physical (76.8%), psychological/moral (38.4%), and sexual (7.4%)²2 Fórum Brasileiro de Segurança Pública. Visível e invisível: a vitimização de mulheres no Brasil [Internet]. Brasília: Fórum Brasileiro de Segurança Pública; 2023 [cited on Apr. 15, 2024]. Available at: https://forumseguranca.org.br/wp-content/uploads/2023/03/visiveleinvisivel-2023-relatorio.pdf
https://forumseguranca.org.br/wp-content... . Authors of another more recent study, with data from the National Survey of Health (2019), observed the experience of psychological (18.0%), physical (4.4%), and sexual (1.5%) violence, in the last 12 months, by women in rural areas aged 18 to 59 years⁷7 Stochero L, Pinto LW. Prevalência e fatores associados à violência contra as mulheres rurais: um estudo transversal, Pesquisa Nacional de Saúde, 2019. Ciênc Saúde Coletiva 2024; 29(1): e20452022. https://doi.org/10.1590/1413-81232024291.20452022
https://doi.org/10.1590/1413-81232024291... . In both studies, the aggressors were mostly acquaintances, and the residence was the main place of occurrence⁷7 Stochero L, Pinto LW. Prevalência e fatores associados à violência contra as mulheres rurais: um estudo transversal, Pesquisa Nacional de Saúde, 2019. Ciênc Saúde Coletiva 2024; 29(1): e20452022. https://doi.org/10.1590/1413-81232024291.20452022
https://doi.org/10.1590/1413-81232024291... .

The health sector has an important role in tackling violence against women⁴4 Bueno ALM, Lopes MJM. Cartografias de violências contra mulheres rurais. In: Mesquita MO, Riquinho DL, Gerhardt TE, Ruiz ENF, orgs. Saúde coletiva, desenvolvimento e (in)sustentabilidades no rural. Porto Alegre: Editora da UFRGS; 2018. p. 145-60.,⁸8 Souza MB, Silva MFS. Estratégias de enfrentamento de mulheres vítimas de violência doméstica: uma revisão da literatura brasileira. Pensando Fam 2019; 23(1): 153-66.. Health professionals are responsible for identifying, welcoming, and attentively and carefully listening to women, guiding, monitoring, and referring cases of violence as well as recording them in medical records and reporting them⁸8 Souza MB, Silva MFS. Estratégias de enfrentamento de mulheres vítimas de violência doméstica: uma revisão da literatura brasileira. Pensando Fam 2019; 23(1): 153-66.. Notification is a key element for women's comprehensive care, removing cases of violence from invisibility, preventing repeated violence, and allowing for the network of protection and guarantee of rights to be activated and articulated⁹9 Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria n° 104, de 25 de janeiro de 2011. Define as terminologias adotadas em legislação nacional, conforme o disposto no Regulamento Sanitário Internacional 2005 (RSI 2005), a relação de doenças, agravos e eventos em saúde pública de notificação compulsória em todo o território nacional e estabelece fluxo, critérios, responsabilidades e atribuições aos profissionais e serviços de saúde [Internet]. Brasília (DF): Diário Oficial da União; 2011 [cited on Apr. 15, 2024]. Available at: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt0104_25_01_2011.html
https://bvsms.saude.gov.br/bvs/saudelegi... .

Violence against rural women is a public health issue. Rural contexts can increase violence, prevent people from asking for help, and cause women to remain in situations of violence for longer. Nationwide studies on this topic are still scarce, making the problem invisible. In the present study we aim to help fill this gap and expand knowledge on this topic. Our objective is to describe and analyze the notifications and temporal trends of violence against women living in rural contexts in Brazil, from 2011 to 2020.

METHODS

Study design

This is an ecological, time-series study of a descriptive and analytical nature, using as a data source the SINAN notification forms on violence against women aged 18 to 59 years, living in rural areas, in the period from 2011 to 2020, from all states in Brazil. The choice of the beginning of the analysis period was due to Ordinance No. 104/2011, according to which domestic and sexual violence was defined as a compulsorily notifiable offense and notifications of violence for all health services were universalized⁹9 Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria n° 104, de 25 de janeiro de 2011. Define as terminologias adotadas em legislação nacional, conforme o disposto no Regulamento Sanitário Internacional 2005 (RSI 2005), a relação de doenças, agravos e eventos em saúde pública de notificação compulsória em todo o território nacional e estabelece fluxo, critérios, responsabilidades e atribuições aos profissionais e serviços de saúde [Internet]. Brasília (DF): Diário Oficial da União; 2011 [cited on Apr. 15, 2024]. Available at: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt0104_25_01_2011.html
https://bvsms.saude.gov.br/bvs/saudelegi... .

Study variables

Types of violence: physical, psychological/moral, sexual, torture, financial/economic, self-inflicted, human trafficking, neglect/abandonment, violence by legal intervention, and others¹⁰10 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e, Promoção da Saúde. Viva: instrutivo notificação de violência interpessoal e autoprovocada. 2a ed. Brasília: Ministério da Saúde; 2016..

In the "area of residence" field, the rural option was used, defined as "an area with characteristics typical of the countryside, with a dispersed population, relatively far from administrative centers, limited access to public services, agricultural production"¹⁰10 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e, Promoção da Saúde. Viva: instrutivo notificação de violência interpessoal e autoprovocada. 2a ed. Brasília: Ministério da Saúde; 2016..

Sociodemographic variables: age (18–29, 30–39, 40–49, and 50–59 years), ethnicity/skin color (white, brown/Black, Indigenous, Asian, and unknown), marital status (single, married/consensual union, widow, separated, unknown), and level of education (illiterate/some elementary school, elementary school/some high school, high school/some college education, and college education).

Event characteristics variables: place of occurrence (residence/collective housing, the street, other locations — school, sports venue, bar/similar, shops/services, industries/construction, others —, unknown) and recurrence (yes, no, unknown).

Aggressor's characteristics variables: sex of the likely aggressor (man, woman, both sexes, unknown), number of people involved (one, two or more, unknown), and relationship with the likely aggressor (spouse/boyfriend, former spouse/ex-boyfriend, stranger, relative — father, mother, stepmother, stepfather, son, brother —, friends/acquaintances, others — person with institutional relationship, boss/employer, police officer/law enforcement officer).

Referral location variables: health network, social welfare network, office on violence against women, public prosecutor's office, women's police station, other police stations, human rights reference center, and public defender's office.

For the temporal analysis, the variable "state of occurrence" was used, organized according to regions (North, Northeast, Southeast, South, and Midwest) and country. Population projections were made considering the proportion of women aged 18 to 59 years in rural areas for each region (country, region, state, and Federal District – DF), between 2000 and 2010. To make the proportion projections for the years 2011 to 2020, the following equation was used: π_year=π_{previous year}+(π₂₀₁₀-π₂₀₀₀)/10, where π_year is the proportion of women aged 18 to 59 years in rural areas in relation to the region in a given year. The final projection considers the estimates from the Brazilian Institute of Geography and Statistics (IBGE)¹¹11 Instituto Brasileiro de Geografia e Estatística. Projeção da população do Brasil e Unidades da Federação por sexo e idade para o período 2010-2060 [Internet]. 2018 [cited on Apr. 15, 2024]. Available at: https://www.ibge.gov.br/estatisticas/sociais/populacao/9109-projecao-da-populacao.html
https://www.ibge.gov.br/estatisticas/soc... and the proportion projections (π_year): N_year=π_year×I_year, where N_year is the population of women aged 18 to 59 years, from the rural area of a region in a given year; π_year is the proportion of women aged 18 to 59 years, from the rural area, in relation to the region in a given year; and I_year is the official IBGE projection of the population of a region in a given year.

Data analysis

The sociodemographic characteristics and events were descriptively analyzed according to the most reported types of violence (physical, psychological/moral, and sexual). The homogeneity of frequencies was assessed using the χ² test, considering p<0.05 and their respective 95% confidence intervals (CI).

For the response variable, that is, the notification rate, the total number of notifications of all types of violence (physical, psychological/moral, sexual, torture, financial/economic, self-inflicted, human trafficking, neglect/abandonment, and legal intervention) against adult women (aged 18 to 59 years) in rural areas in each year (from 2011 to 2020) and geographic region (state, Federal District, and region) was considered as the numerator; and, as the explanatory variable, that is, the denominator, the population of adult women in rural areas, according to geographic region, in each year, according to the calculations of population projections x100 thousand: total number of notifications of violence against adult women in rural areas in each year and geographic region/total number of adult women in rural areas in each year and geographic region x100 thousand. The annual average of notification rates was calculated using the obtained quotient, divided by the total number of years of study x100 thousand. The R program version 4.2.3 was used for the analyses.

For temporal trend analyses, the notification rates of all types of violence were used based on the inflection point regression model (joinpoint regression analysis) for violence rates, according to geographic region (state, DF, and region). With this model it is possible to evaluate whether a line with multiple segments is statistically better at describing the temporal evolution of a dataset than a straight line or one with fewer segments¹²12 Kim HJ, Fay MP, Feuer EJ, Midthune DN. Permutation tests for joinpoint regression with applications to cancer rates. Stat Med 2000; 19(3): 335-51. https://doi.org/10.1002/(sici)1097-0258(20000215)19:3≤335::aid-sim336≥3.0.co;2-z
https://doi.org/10.1002/(sici)1097-0258(... . Thus, the values of the annual percent change (APC) and the average annual percent change (AAPC) are estimated, considering 95%CI and a 5% significance level, enabling to identify the trends: stationary (p>0.05), upward (p<0.05 and positive regression coefficient), and downward (p<0.05 and negative regression coefficient)¹²12 Kim HJ, Fay MP, Feuer EJ, Midthune DN. Permutation tests for joinpoint regression with applications to cancer rates. Stat Med 2000; 19(3): 335-51. https://doi.org/10.1002/(sici)1097-0258(20000215)19:3≤335::aid-sim336≥3.0.co;2-z
https://doi.org/10.1002/(sici)1097-0258(... ,¹³13 Aragão CMC, Mascarenhas MDM. Tendência temporal das notificações de lesão autoprovocada em adolescentes no ambiente escolar, Brasil, 2011-2018. Epidemiol Serv Saúde 2022; 31(1): e2021820. https://doi.org/10.1590/S1679-49742022000100028
https://doi.org/10.1590/S1679-4974202200... . The analyses were performed in the Joinpoint Regression Program, version 5.1.0.0.

Ethical aspects

The research was approved by the Research Ethics Committee of the Escola Nacional de Saúde Pública Sergio Arouca/Fiocruz, on May 9, 2022, under opinion No. 5.395.759. The database was provided by the Brazilian Ministry of Health.

RESULTS

A total of 79,229 thousand notifications of violence against rural women, aged 18 to 59 years, in Brazil, were reported from 2011 to 2020, of which 60,819 (77.6%) were physical violence, 28,544 (36.5%) psychological/moral violence, and 4,873 (6.2%) sexual violence. In Table 1, all variables were statistically significant (p<0.05). Regarding age, in physical, psychological/moral, and sexual violence, notifications of women aged 18 to 29 and 30 to 39 years predominated. As for ethnicity/skin color, in the three types of violence, notifications of brown/Black women were the majority. Concerning marital status, married women accounted for half or more of the reports of psychological/moral and physical violence, followed by single women. As for sexual violence, single women accounted for the majority of notifications, followed by married women. Regarding level of education, women who were illiterate/had some elementary school represented the majority of notifications in all types of violence.

In Table 2, all variables were statistically significant (p<0.05). The residence was the main place where physical, psychological/moral, and sexual violence occurred. In notifications of sexual violence, in addition to the residence, the street and other locations are also significant. Recurrence was higher in physical and psychological/moral violence than in sexual violence. In the three types of violence, regarding the sex of the probable aggressor, the predominance was man and the number of people involved was one person. The largest proportion of notifications of physical and psychological/moral violence were by the spouse/boyfriend; in the case of sexual violence, the majority were by strangers, followed by friends/acquaintances, and spouse or boyfriend. The health network was the predominant referral location for the three cases of violence, followed by referrals to other police stations.

In Table 3 we can observe that in all states there was growth over the period. Considering 2020, the first year of the new coronavirus (COVID-19) pandemic and social restrictions, we observed a slight decrease in the rates in 17 states, such as Amapá, Tocantins, most states in the Northeast, all in the South region, and Goiás. This decrease was reflected in the country's rate, which dropped from 162.8 in 2019 to 142.6 in 2020.

In the APC, the notification rates of violence against rural women in Brazil, according to the regression model, had two inflection points, and the trends were classified as upward. The North and Midwest regions had two inflection points (2011–2013 and 2013–2020), classified as upward; the Southeast had an increasing inflection point in the first four years and then stationary; the South and Northeast had an inflection point demonstrating continuous increase throughout the period. Regarding the states (18) and the DF, there were one and two inflection points with an upward trend, five with an upward trend in the first three/four years, and then stationary in the remaining period. Pará was the only state with a stationary trend from 2011 to 2013, and an upward trend for the remaining period; and Goiás was the only one that only had a stationary trend at three inflection points. In the AAPC, all country, region, states, and DF rates showed statistically significant increasing temporal behavior (Table 4).

DISCUSSION

Among the characteristics of notifications of physical, psychological/moral, and sexual violence against rural women, we observed a higher frequency among women aged 18 to 39 years, brown/Black, married, single, and with low levels of education. The residence was identified as the main place where violence occurred, which was recurrent, especially in physical, psychological/moral terms, and was mostly perpetrated by a single man. The aggressor, in most cases, was the spouse/boyfriend, but in sexual cases known and unknown aggressors were also identified. Mostly, notification rates of violence against rural women increased throughout the studied period and, in 2020, the first year of the COVID-19 pandemic, there was no significant decrease.

The characteristics of women highlighted in this study corroborate other research¹1 Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei n° 10.778, de 24 de novembro de 2003. Estabelece a notificação compulsória, no território nacional, do caso de violência contra a mulher que for atendida em serviços de saúde públicos ou privados [Internet]. Brasília (DF): Diário Oficial da União; 2003 [cited on Apr. 15, 2024]. Available at: https://www.planalto.gov.br/ccivil_03/leis/2003/l10.778.htm
https://www.planalto.gov.br/ccivil_03/le... ,¹⁴14 Monteiro MFG, Romio JAF, Drezett J. Existe diferença de raça/cor do feminicídio no Brasil?: A desigualdade das taxas de mortalidade por causas violentas entre mulheres brancas e negras. J Hum Growth Dev 2021; 31(2): 358-66. https://doi.org/10.36311/jhgd.v31.12257
https://doi.org/10.36311/jhgd.v31.12257... . Intentional violent deaths (IVD) especially victimize young women, and femicide occurred in practically all age groups, but with a higher prevalence of deaths throughout women's reproductive lives. Among the biggest victims of femicide and IVD are Black women. Furthermore, in femicides, the main perpetrator is the victim's partner or ex-partner, and the residence is the main place of occurrence¹²12 Kim HJ, Fay MP, Feuer EJ, Midthune DN. Permutation tests for joinpoint regression with applications to cancer rates. Stat Med 2000; 19(3): 335-51. https://doi.org/10.1002/(sici)1097-0258(20000215)19:3≤335::aid-sim336≥3.0.co;2-z
https://doi.org/10.1002/(sici)1097-0258(... . Femicide is the ultimate expression of gender-based violence, and researchers emphasize that women with prior notification of violence are at greater risk of femicide compared to the general female population¹⁴14 Monteiro MFG, Romio JAF, Drezett J. Existe diferença de raça/cor do feminicídio no Brasil?: A desigualdade das taxas de mortalidade por causas violentas entre mulheres brancas e negras. J Hum Growth Dev 2021; 31(2): 358-66. https://doi.org/10.36311/jhgd.v31.12257
https://doi.org/10.36311/jhgd.v31.12257... ,¹⁵15 Barufaldi LA, Souto RMCV, Correia RSB, Montenegro MMS, Pinto IV, Silva MMA, et al. Violência de gênero: comparação da mortalidade por agressão em mulheres com e sem notificação prévia de violência. Ciênc Saúde Colet 2017; 22(9): 2929-38. https://doi.org/10.1590/1413-81232017229.12712017
https://doi.org/10.1590/1413-81232017229... .

Regarding low levels of education, in the case of rural women, according to the Agricultural Census (2017), more than 60.0% of them had completed elementary school. Rural women often drop out of school due to the need to help with family work, poor conditions/lack of school transport, and early marriage. The latter is more pronounced in rural areas in Brazil¹⁵15 Barufaldi LA, Souto RMCV, Correia RSB, Montenegro MMS, Pinto IV, Silva MMA, et al. Violência de gênero: comparação da mortalidade por agressão em mulheres com e sem notificação prévia de violência. Ciênc Saúde Colet 2017; 22(9): 2929-38. https://doi.org/10.1590/1413-81232017229.12712017
https://doi.org/10.1590/1413-81232017229... . Early marriage is often motivated by the young woman's search for more freedom to leave home and have a better life, without violence or poverty. But what happens is that the teenager becomes pregnant and drops out of school, reducing her chances of formal employment, becoming dependent on her partner, limited to domestic services, and vulnerable to violence¹⁶16 Taylor A, Lauro G, Segundo M, Greene ME. Ela vai no meu barco: casamento na infância e adolescência no Brasil. Resultados de pesquisa de método misto. Rio de Janeiro: Instituto Promundo & Promundo-US; 2015.. This datum is reinforced by IBGE, which identified, in 2023, the need for work, domestic chores/caring for people, and pregnancy as the main reasons for school dropout among women aged 15 to 29 years, especially among Black and brown women¹⁷17 Instituto Brasileiro de Geografia e Estatística. Uma em cada quatro mulheres de 15 a 29 anos não estudava e nem estava ocupada em 2023 [Internet]. 2024 [cited on Apr. 15, 2024]. Available at: https://agenciadenoticias.ibge.gov.br/agencia-noticias/2012-agencia-de-noticias/noticias/39531-uma-em-cada-quatro-mulheres-de-15-a-29-anos-nao-estudava-e-nem-estava-ocupada-em-2023
https://agenciadenoticias.ibge.gov.br/ag... .

Physical violence was also the most mentioned in other studies on rural women¹⁸18 Griiboski RA, Guilhem D, Moura LA. Occurrence of violence caused by intimate partners in brazilian rural working women: a descriptive study. Online Braz J Nurs 2015; 14(2): 151-60. https://doi.org/10.17665/1676-4285.20154653
https://doi.org/10.17665/1676-4285.20154... ,¹⁹19 Siqueira VB, Oliveira LMSR, Siqueira MAS, Nascimento EA. Trabalhadoras rurais: relações de trabalho e percepções sobre eventos violentos. Rev Enferm UFPE on line 2017; 11(4): 1662-5. https://doi.org/10.5205/reuol.9763-85423-1-SM.1104201714
https://doi.org/10.5205/reuol.9763-85423... , which may be due to the fact that this violence is more known and recognized and generates visible injuries that require treatment in health services²⁰20 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde e Ambiente. Boletim Epidemiológico: Saúde da mulher brasileira: uma perspectiva integrada entre vigilância e atenção à saúde. Número Especial. Brasília: Vigilância em Saúde e Ambiente; 2023.. Authors of a study conducted with rural workers in the state of Pernambuco, Brazil, on their perception of violence, showed that a large proportion of these women considered violence only to be events that left physical marks¹⁹19 Siqueira VB, Oliveira LMSR, Siqueira MAS, Nascimento EA. Trabalhadoras rurais: relações de trabalho e percepções sobre eventos violentos. Rev Enferm UFPE on line 2017; 11(4): 1662-5. https://doi.org/10.5205/reuol.9763-85423-1-SM.1104201714
https://doi.org/10.5205/reuol.9763-85423... . Conversely, psychological violence may be more present in women's lives, but it may be underreported because it is a type of violence that is difficult for women themselves or health professionals to identify²⁰20 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde e Ambiente. Boletim Epidemiológico: Saúde da mulher brasileira: uma perspectiva integrada entre vigilância e atenção à saúde. Número Especial. Brasília: Vigilância em Saúde e Ambiente; 2023.,²¹21 Guimarães MC, Pedroza RLS. Violência contra a mulher: problematizando definições teóricas, filosóficas e jurídicas. Psicol Soc 2015; 27(2): 256-66. https://doi.org/10.1590/1807-03102015v27n2p256
https://doi.org/10.1590/1807-03102015v27... .

As for sexual violence, the results draw attention to young, single, Black/brown women, whose aggressors are strangers, acquaintances, or male partners, and it often happens once. There is still a naturalization in society of sexual violence in certain situations, whether because the partner believes he has "conjugal rights" over the woman, or because strange men, or even acquaintances, are supported by a patriarchal and sexist culture of control and imposition of power over female bodies, evidencing the lack of safety for women inside and outside their homes²¹21 Guimarães MC, Pedroza RLS. Violência contra a mulher: problematizando definições teóricas, filosóficas e jurídicas. Psicol Soc 2015; 27(2): 256-66. https://doi.org/10.1590/1807-03102015v27n2p256
https://doi.org/10.1590/1807-03102015v27... . Furthermore, Black women's lives have been marked by several types of violence over the centuries. The intersectional perspective contributes to the discussion of violence that permeates the dimensions of gender, race, and class, which increase the vulnerabilities and inequalities experienced by Black women²²22 Melo CM, Soares MQ, Bevilacqua PD. Violência sexual: avaliação dos casos e da atenção às mulheres em unidades de saúde especializadas e não especializadas. Ciênc Saúde Coletiva 2022; 27(9): 3715-28. https://doi.org/10.1590/1413-81232022279.07242022
https://doi.org/10.1590/1413-81232022279... ,²³23 Galvão I. Mapa da violência contra mulheres negras: reflexões sobre racismo e gênero na sociedade brasileira. Revista de Direito 2021; 13(2): 1-17. https://doi.org/10.32361/2021130211520
https://doi.org/10.32361/2021130211520... .

The results may still be underestimated, as women have difficulty seeking assistance services due to fear of judgment, feelings of guilt, or shame. When sexual violence occurs between intimate partners, women also tend to remain silent due to cultural, religious, and social beliefs, which keep intimate relationship issues in the private domain²⁴24 Delziovo CR, Bolsoni CC, Nazário NO, Coelho EBS. Características dos casos de violência sexual contra mulheres adolescentes e adultas notificados pelos serviços públicos de saúde em Santa Catarina, Brasil. Cad Saúde Pública 2017; 33(6): e00002716. https://doi.org/10.1590/0102-311X00002716
https://doi.org/10.1590/0102-311X0000271... .

Violence against rural women was shown to be mostly recurrent and to occur in their own residences. Often, violence does not begin with a serious assault, but it is masked by subtle forms of violence, such as "overprotection" and "jealousy," which make the woman feel guilty and begin to tolerate the assaults — which, in turn, paves the way for other types of violence (physical, patrimonial, sexual) and their repetition²⁵25 Barros R, Souza J. Crimes contra a mulher: análise de reincidência dos crimes domésticos [Internet]. 2021 [cited on Apr. 15, 2024]. Available at: https://repositorio.animaeducacao.com.br/handle/ANIMA/14164
https://repositorio.animaeducacao.com.br... ,²⁶26 Saffioti H. Gênero, patriarcado, violência. 2a ed. São Paulo: Expressão Poppular; Fundação Perseu Abramo; 2015.. In this case, the home becomes a place of affection and tension in which the woman isolates herself out of fear or shame, feels lonely and, over time, can develop low self-esteem, anxiety, emotional dependence, depression, etc.²⁷27 Silva SCM, Silva VAA, Hanna LMO. Danos psicológicos causados pela violência doméstica contra a mulher. Brazilian Journal of Implantology and Health Sciences. 2023; 5(4): 338-51. https://doi.org/10.36557/2674-8169.2023v5n4p338-351
https://doi.org/10.36557/2674-8169.2023v... .

The health network was the main referral location. This may occur because it is usually sought after in the most serious situations of physical or sexual violence, or when mental health is already severely affected, in such a way that other referrals for treatment or monitoring are necessary⁴4 Bueno ALM, Lopes MJM. Cartografias de violências contra mulheres rurais. In: Mesquita MO, Riquinho DL, Gerhardt TE, Ruiz ENF, orgs. Saúde coletiva, desenvolvimento e (in)sustentabilidades no rural. Porto Alegre: Editora da UFRGS; 2018. p. 145-60.,²⁸28 Andrade LJO, Martins AKL. Violência e suas implicações no campo da saúde mental das mulheres: uma revisão integrativa da literatura no âmbito da Psicologia. Revista Ciências Humanas. 2023; 16(34): 1-13. https://doi.org/10.32813/2179-1120.2023.v16.n1.a901
https://doi.org/10.32813/2179-1120.2023.... . The other locations were police stations and the social welfare network, which generally exist even in small municipalities. Conversely, women's police stations and the Office on Violence Against Women tend to be concentrated in larger cities. According to Revista AzMina [AzMina Magazine]²⁹29 Bertho H, Moura R, Coelho G. Só 7% das cidades brasileiras contam com delegacia da mulher [Internet]. Revista AzMina; 2021 [cited on Apr. 15, 2024]. Available at: https://azmina.com.br/reportagens/so-7-das-cidades-brasileiras-contam-com-delegacia-da-mulher/
https://azmina.com.br/reportagens/so-7-d... , until 2020, only 7.0% of Brazilian cities had a Women's Police Station. In small municipalities, only nine of the 3,600 cities with up to 20 thousand inhabitants had a Women's Police Station. In other words, women end up looking for regular police stations, where they are not always welcome, and suffer another type of violence: institutional violence²²22 Melo CM, Soares MQ, Bevilacqua PD. Violência sexual: avaliação dos casos e da atenção às mulheres em unidades de saúde especializadas e não especializadas. Ciênc Saúde Coletiva 2022; 27(9): 3715-28. https://doi.org/10.1590/1413-81232022279.07242022
https://doi.org/10.1590/1413-81232022279... .

Regarding the increase in the annual rates of violence notification in the states, one explanation for this scenario may be the improvement in epidemiological surveillance over the years. Since the universalization of notification of interpersonal/self-inflicted violence in 2011, there has been a substantial increase in SINAN coverage in Brazil. For instance, the country ranged from 2,114 notifying municipalities (38.0%) in 2011 to 4,381 notifying municipalities (78.7%) in 2018. The higher rates in the Southeast are related to the better functioning of surveillance (89.4% coverage in 2018)³⁰30 Brasil. Secretaria de Vigilância em Saúde. Ministério da Saúde. Coordenação-Geral de Vigilância de Doenças e Agravos Não Transmissíveis. Vigilância de violências e acidentes no Brasil: análise da cobertura da notificação compulsória de violência interpessoal/autoprovocada nos municípios brasileiros [Internet]. Boletim Epidemiológico 2020; 51(4): 11-7 [cited on Oct. 08, 2024]. Available at: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/boletins/epidemiologicos/edicoes/2020/boletim-epidemiologico-vol-51-no-04.pdf/view
https://www.gov.br/saude/pt-br/centrais-... .

It is also worth noting the decrease in notification rates during the first year of the COVID-19 pandemic, possibly influenced by the imposition of social isolation. Conversely, this decrease was not statistically significant, which perhaps indicates the severity of the cases of violence that led these women, in the midst of a pandemic, to leave their homes and reach out the health sector.

Despite the increase in notification coverage, underreporting still persists. Difficulties in recognizing cases of violence and lack of training among professionals to recognize and report violence are some of the existing limitations¹⁵15 Barufaldi LA, Souto RMCV, Correia RSB, Montenegro MMS, Pinto IV, Silva MMA, et al. Violência de gênero: comparação da mortalidade por agressão em mulheres com e sem notificação prévia de violência. Ciênc Saúde Colet 2017; 22(9): 2929-38. https://doi.org/10.1590/1413-81232017229.12712017
https://doi.org/10.1590/1413-81232017229... ,³¹31 Cruz NM, Melo MCP, Duarte MVG, Barros VRP, Sarmento SS. Trajetórias atuais da gestão do SUS no enfrentamento à violência de gênero: uma revisão narrativa. Revista Baiana de Saúde Pública 2021; 45(2): 160-71. https://doi.org/10.22278/2318-2660.2021.v45.n2.a3397
https://doi.org/10.22278/2318-2660.2021.... –³³33 Alcantara MCM, Souza RR de, Caetano LG de A, Louzada CF, Silveira ARP, Lima J de O, et al. Subnotificação e invisibilidade da violência contra a mulher. Rev Med. 2016; 26;Supl 8.. Furthermore, the health sector is still not fully recognized as a gateway to the Office on Violence Against Women. When women seek support, they generally turn first to people they trust, and when violence becomes extreme, such as in cases of physical injuries or threats, they seek out the health sector or police stations⁴4 Bueno ALM, Lopes MJM. Cartografias de violências contra mulheres rurais. In: Mesquita MO, Riquinho DL, Gerhardt TE, Ruiz ENF, orgs. Saúde coletiva, desenvolvimento e (in)sustentabilidades no rural. Porto Alegre: Editora da UFRGS; 2018. p. 145-60.,⁷7 Stochero L, Pinto LW. Prevalência e fatores associados à violência contra as mulheres rurais: um estudo transversal, Pesquisa Nacional de Saúde, 2019. Ciênc Saúde Coletiva 2024; 29(1): e20452022. https://doi.org/10.1590/1413-81232024291.20452022
https://doi.org/10.1590/1413-81232024291... ,²⁸28 Andrade LJO, Martins AKL. Violência e suas implicações no campo da saúde mental das mulheres: uma revisão integrativa da literatura no âmbito da Psicologia. Revista Ciências Humanas. 2023; 16(34): 1-13. https://doi.org/10.32813/2179-1120.2023.v16.n1.a901
https://doi.org/10.32813/2179-1120.2023.... ,³⁴34 Vasconcelos NM, Bernal RTI, Souza JB, Bordoni PHC, Stein C, Coll CVN, et al. Underreporting of Violence Against Women: an analysis of two data sources. Cien Saude Colet 2024; 29(10): e07732023. https://doi.org/10.1590/1413-812320242910.07732023
https://doi.org/10.1590/1413-81232024291... .

Another aspect is small municipalities, where women may feel embarrassed to seek health services to report the violence they have suffered, remaining in violent relationships for a long time. Professionals, in turn, may have difficulty reporting for fear of reprisals from the aggressor¹⁹19 Siqueira VB, Oliveira LMSR, Siqueira MAS, Nascimento EA. Trabalhadoras rurais: relações de trabalho e percepções sobre eventos violentos. Rev Enferm UFPE on line 2017; 11(4): 1662-5. https://doi.org/10.5205/reuol.9763-85423-1-SM.1104201714
https://doi.org/10.5205/reuol.9763-85423... ,³²32 Kind L, Orsini MLP, Nepomuceno V, Gonçalves L, Souza GA, Ferreira MFF. Subnotificação e (in)visibilidade da violência contra mulheres na atenção primária à saúde. Cad Saúde Pública 2013; 29(9): 1805-15. https://doi.org/10.1590/0102-311X00096312
https://doi.org/10.1590/0102-311X0009631... .

In order to take effective action to combat violence, it is necessary to consider the specificities of the rural context: lack of information, absence of telephone and Internet services, geographic isolation, lack of public transport, and long distances to urban areas and between neighbors/family members⁴4 Bueno ALM, Lopes MJM. Cartografias de violências contra mulheres rurais. In: Mesquita MO, Riquinho DL, Gerhardt TE, Ruiz ENF, orgs. Saúde coletiva, desenvolvimento e (in)sustentabilidades no rural. Porto Alegre: Editora da UFRGS; 2018. p. 145-60.–⁶6 Costa MC, Silva EB, Arboit J, Honnef F, Marques KA, Barbieri J, et al. Violência doméstica contra a mulher em contexto rural: reconhecimento das estratégias de atenção. Rev Bras Promoç Saúde 2019; 32: 9271. https://doi.org/10.5020/18061230.2019.9271
https://doi.org/10.5020/18061230.2019.92... ,³⁵35 Scott P, Nascimento FS, Cordeiro R, Nanes G. Redes de enfrentamento da violência contra mulheres no Sertão de Pernambuco. Rev Estud Feministas 2016; 24(3): 851-70. https://doi.org/10.1590/1806-9584-2016v24n3p851
https://doi.org/10.1590/1806-9584-2016v2... . Interventions are needed in the health sector, such as more training for health professionals in the process of identifying, reporting, and supporting rural women in situations of violence, especially community health agents, who are closest to women; integration of health, assistance, and security services, as the issue of violence requires intersectional and comprehensive care, which is also present in rural areas.

The limitations of this study are inherent in the use of secondary data, as some records may present low completeness and underreporting. Vasconcelos et al.³⁴34 Vasconcelos NM, Bernal RTI, Souza JB, Bordoni PHC, Stein C, Coll CVN, et al. Underreporting of Violence Against Women: an analysis of two data sources. Cien Saude Colet 2024; 29(10): e07732023. https://doi.org/10.1590/1413-812320242910.07732023
https://doi.org/10.1590/1413-81232024291... estimated that, in 2019, underreporting of violence against women in Brazil was 98.5, 75.9, and 89.4% for psychological, physical, and sexual violence, respectively. The same woman may appear more than once on the database, but as the database is not identified, repetitions could not be excluded.

The results presented in this article help to identify the main characteristics of women and violent events. Reported cases of violence against rural women increased between 2011 and 2020 throughout the country. Furthermore, the greater vulnerability of young, Black, married or single women with low levels of education stands out. We emphasize that actions to combat the violence must consider that violence occurs mainly by people close to women's relationships and in the home itself, which makes it more difficult for individuals themselves to speak out and for health professionals to identify the violence. Strengthening the training of health professionals is encouraged to improve and expand the notification process as a tool for caring for women in situations of violence, considering rural contexts and their specificities.

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