Violence and Primary Health Care: perceptions and experiences of professionals and users

Elisane Adriana Santos Rodrigues Ricardo Tavares Victor Hugo Melo Jandira Maciel da Silva Elza Machado de Melo About the authors

ABSTRACT

This study aimed to compare experiences and perceptions of users and health professionals on violence in the context of Primary Health Care. It is a cross-sectional study of qualitative and quantitative nature conducted in Ribeirão das Neves (Minas Gerais), in which semi-structured interviews were carried out using questionnaires applicable to users (n= 628) and self-administered to professionals (n=300). Descriptive analysis was performed - distribution of simple frequency, cross and bivariate - and correspondence analysis comparing the responses of users and professionals, stored in two different databases. The Thematic Categorical Content Analysis enabled the construction of three categories of analysis - from which were discussed and jointly, the quantitative and qualitative results: 1) Violence as a health problem; 2) Completeness of Care; 3) Social Participation. It is noted that violence permeates everyday life and activity of users and professionals, behaving as an event that deserves deepening by who is suffering, living and dealing with the problem. The social participation spaces were recognized as an important strategy of community inclusion in the discussion of their problems. However, users and professionals differ on the role of health care in addressing and violence. Primary care has great potential to produce quality of care but apparently does not accomplish it when deals with the violence approach.

KEYWORDS
Violence; Primary Health Care; Family Health Strategy; Health services; Social participation

Introduction

Violence has become an object of study and a necessary and current field of action, being considered as a complex problem, capable of interfering in the quality of life of people and societies. The term translates into human actions of individuals, groups, classes or nations that cause death or that affect the physical, moral, mental or spiritual integrity of other human beings11 Minayo MCS. Violência e Saúde. Rio de Janeiro: Fiocruz; 2006.. It is a growing demand for health services and has an important impact on the lives of the men and women involved.

The health sector, in turn, is a space with great potential to approach violence. The performance of the professionals is decisive and, depending on their suitability and quality, can contribute to the prevention, attention and development of studies about the problem. The notification of violence was inserted in the Notification of Injury Information System (Sinan) in 2009 and, in 2011, became part of the National List of Obligatory Notification. Currently, the National List of Obligatory Notification of diseases, injuries and public health events in public and private health services throughout the national territory is regulated in the Ministry of Health Ordinance nº 1.271 of June 6, 2014. In addition to revoking Ordinance nº 104, of January 25, 2011, this List reiterated the notification of the violence. Such measures provide information on violent incidents involving persons who have been assisted in the health system and universalize the notification for all health services22 Cerqueira D, Coelho DSC, Ferreira H. Estupro no Brasil: vítimas, autores, fatores situacionais e evolução das notificações no sistema de saúde entre 2011 e 2014. Rev. Bras. Segur. Pública. [internet]. 2017 fev-mar [acesso em 2018 jan 4]; 11(1):24-48. Disponível em: http://www.ipea.gov.br/portal/.
http://www.ipea.gov.br/portal/...
.

Addressing situations of violence is not simple, nor are there ready solutions. Violence and accidents are responsible for much of the transformation in the health profile, imposing actions on social determinants, encompassing broad aspects ranging from lifestyle to environmental, economic, cultural and social relations33 Apostólico MR, Hino P, Egry EY. As possibilidades de enfrentamento da violência infantil na consulta de enfermagem sistematizada. Rev. Esc. Enferm. USP. [internet]. 2013 [acesso em 2017 dez 10]; 47(2):320-7. Disponível em: http://dx.doi.org/10.1590/S0080-62342013000200007.
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. Exactly in the performance of this task lies one of the greatest challenges of the Unified Health System (SUS) and, certainly, one of its limits44 Silva LA, Casotti CA, Chaves SCL. A produção científica brasileira sobre a estratégia saúde da família e a mudança no modelo de atenção. Ciênc. Saúde Colet. [internet]. 2013 [acesso em 2017 dez 5]; 18(1):221-32. Disponível em: http://doi.org/10.1590/s1413-81232013000100023.
http://doi.org/10.1590/s1413-81232013000...
. Primary Health Care (PHC), by promoting closer relations with users, strengthening the bond, establishing relationships of trust and fostering the creation of spaces for dialogue and participation, is a robust alternative to such confrontations55 Sousa MF. A reconstrução da saúde da família no Brasil: diversidade e incompletude. In: Sousa MF, Franco MS, Mendonça AVM, organizadores. Saúde da família nos municípios brasileiros: os reflexos dos 20 anos do espelho do futuro. Campinas, SP: Saberes; 2014. p. 40-76.. The purpose of this study is to analyze the correspondence between experiences and perceptions of users and health professionals related to violence, within the scope of PHC.

Methods

This is a cross-sectional study of quali-quantitative nature, whose methodology consists in carrying out semi-structured interviews with users and self-administered questionnaires with professionals from all Basic Health Units (BHU) of the municipality of Ribeirão das Neves (MG) located in the metropolitan region of Belo Horizonte, with a population of 322.659 inhabitants, in 201566 Cerqueira D, Lima RS, Bueno S, et al. Atlas da Violência 2017 [internet]. Rio de Janeiro: IPEA; São Paulo: FBSP; 2017 [acesso em 2018 jan 5]. Disponível em: http://www.ipea.gov.br/portal/images/170602_atlas_da_violencia_2017.pdf.
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.

The Primary Health Care network of the municipality counts on 58 BHU, with 53 Family Health Units and 05 traditional primary care units (Basic Reference Units - UBR), distributed in the 05 Health Regions of the city77 Ribeirão das Neves. Secretaria Municipal de Saúde de Ribeirão das Neves. Arq Ribeirão das Neves 2014 [acesso em 2018 jun 6]. Disponível em: http://www.ribeiraodasneves.mg.gov.br/organograma/unidade/secretaria-de-saude/.
http://www.ribeiraodasneves.mg.gov.br/or...
, each unit counting on one family health team.

The sample of users was calculated with a margin of error of 3.71% for more or less, with their recruitment distributed among the units, 10 to 12 users in each of them. The interviews occurred within the services from a semi-structured questionnaire. Users were selected on a first-come, first-served basis according to a random number table. Inclusion criteria were: to be a resident of the place for more than one year, to be over 18 years of age and to have been treated at the BHU, at least once before the interview.

For professionals were used semi-structured and self-administered questionnaires with different profiles. For the higher education level, all the professionals of the family health teams were considered, including those inserted in the teams of the Family Health Support Center (Nasf). The questionnaires were also answered by the Community Health Workers (CHW), the nursing auxiliaries and the administrative staff. All of them fulfilled the following inclusion criteria: acting for at least one year in that health facility.

The questionnaires were elaborated by the team of researchers, based on the subsidies of updated literature on the subject and the models of available instruments already tested and used, especially, the questionnaires of the Project for the Expansion and Consolidation of the Family Health (Proesf) and the National Health Survey (PNS). They were tested with users and professionals in the municipality itself. The data were stored in two databases - one of users and one of professionals - using SPSS software - Statistical Package for Social Sciences, version 19.0.

For the quantitative analysis it was used descriptive analysis, namely, simple frequency distribution and three-way cross and also bivariate analysis using difference test between two proportions. Correspondence Analysis was also carried out, a specific method for working categorical data to reveal patterns of relationships between categories. The two databases were used, relating, in this way, variables referring to users with the same variables referring to professionals.

Four (4) dependent variables of users and professionals were used, as shown in chart 1. These are as follows: V1 - Have you ever witnessed any violent events in the neighborhood and/or neighborhood of the unit; V2 - Do you know anyone who was murdered in the neighborhood and/or neighborhood of the unit; V3 - Do you think it is possible to prevent violence and V4 - Do you consider that one of the functions of the unit is to prevent violence.

Chart 1
Dependent variables regarding users and professionals, (N = 928). Ribeirão das Neves, 2013

For the qualitative analysis, all interviewees (users and professionals) who answered affirmatively to variable 4 of table 1 and who did not leave variable 5 blank, totaling 350 users and 207 professionals, were included. Variable 5, table 1, deals with 'Perception about what are the functions of health in the prevention of violence'.

Table 1
Distribution and test of the difference between two ratios (R x non R): users and professionals, (N = 928). Ribeirão das Neves, 2013

Content analysis was used. The technique of Thematic Categorical Content Analysis was applied which corresponds to the categorization of the discourses by means of processes of dismemberment of the text in units, according to analogical themes88 Bardin L. Análise de conteúdo. Lisboa: Edições 7; 1977.. The categories of analysis were defined based on the articulation between the qualitative information, the ones coming from the quantitative instruments and the literature subsidies. Three categories of analysis, thus, were created: Violence as a health problem, Integrality of Care and Social Participation, under which, in an intertwined way, quantitative and qualitative results were discussed.

The project was approved by the Research Ethics Committee of the Federal University of Minas Gerais (Coep/UFMG) under opinion 01140812.1.0000.5149. All participants signed a free and informed consent form.

Results

The interviewed population was composed of 928 individuals, with 628 users and 300 health professionals. The sociodemographic profile of the interviewees is shown in table 1.

It is verified on table 2 the three-way cross-frequency distribution of the dependent variables. Having witnessed a violent event is much more frequent among users. As for the aspects related to knowing someone who has been murdered in the territory and believing that it is possible to prevent violence, the vision of the two groups is similar, besides being high the percentage of positive responses. In both groups, most interviewees acknowledge that the approach to violence is a function of PHC, but is more frequent among professionals. It is observed that the professionals tended more not to witness violent event and to not know victims of murder in the region in which they work. Although this index is lower than that among users it is high and, probably, is due to the fact that many professionals, but not all, reside in the territory in which they work.

Table 2
Distribution of three-way cross-frequency on the dependent variables of users and professionals (N = 928). Ribeirão das Neves, 2013

Figure 1 shows the map of the correspondence between user and professional opinions according to the variables studied. Dimensions 1 and 2 represent, together, 99.8% of the variability of the original data. In other words, only 0.2% is lost when representing these data in these two dimensions. For the interpretation of the association between variables V1, V2, V3 and V4 and the opinions U-Yes, P-Yes, U-No, P-No, table 3 should be analyzed. On the contributions of dimensions 1 and 2 on variables V1, V2, V3 and V4, it is observed that for the variables V1, V2 and V3, the interpretation must be done in dimension 1. This is because this dimension explains the largest percentages of inertia for each one (99.7% for V1, 62.0% for V2 and 99.2% for V3). The variable V4, in turn, must be interpreted in dimension 2, because this dimension explains 95.3% of the inertia related to it.

Figure 1
Correspondence map of user and professional opinions and variables studiedU_Yes – users who answered yes; U_No – users who answered no; P_Yes – professionals who answered yes; P_No – professionals who answered no; V1 – Has witnessed a violent event in the neighborhood or neighborhood of the unit; V2 – Has met someone who was murdered in the neighborhood or neighborhood of the unit; V3 – It is possible to prevent violence; V4 – It is one of the functions of the unit to prevent violence.
Table 3
Relative contributions of dimensions 1 and 2 on row profiles (variables) and column profiles (opinions)

Table 3 also shows the contributions related to dimensions 1 and 2 on the opinions of users and professionals about the studied variables (U_Yes, U_No, P_Yes and P_No), being verified that all of them must be interpreted in dimension 1, since this dimension explains 95.4%, 95.5%, 82.5% and 91.9% of inertia concerning the opinions U_Yes, U_No, P_Yes and P_No, respectively.

Guided by table 3, it is verified, in the Correspondence Map (figure 1), for variable V2 (Knew someone who was murdered in the neighborhood or neighborhood of the unit) the association between affirmative answers of the users (U_Yes) and affirmative answers of the professionals (P_Yes), as well as an association between negative answers of the users and negative answers of the professionals. For variable V3 (It is possible to prevent violence), there is only association of affirmative responses of users (U_Yes) and professionals (P_Yes); for the variable V1 (Have witnessed a violent event in the neighborhood or neighborhood of the unit), there is an association between the negative answers of the users (U_No) and professionals (P_No). For the variable V4 (it is one of the functions of the unit the prevention of violence), however, the association between 'affirmative' responses of the professionals (P_Yes) and the 'negative' responses of the users (U_No) is verified. It is also possible to analyze the associations within the same profile, and in this case, the fact that the variable V4 is sufficiently separated from the other variables is highlighted, with special attention to the variable V3, indicating that the user's belief in the prevention of violence is not associated with the possibility of action of the health units.

Discussion

Violence as a health problem

The percentage of users and professionals who say they have witnessed violence (V1) or meet someone who has already been killed in the neighborhood of the health unit (V2), clearly shows that violence is a problem that affects the population of the territory studied. The fact that the sample was mostly composed of women expresses the real predominance of the female sex in the PHC services and does not imply, for the studied universe, any bias in the results. However, such a finding may stimulate the opening of new studies to deepen the discussion of violence among the male population that attends PHC.

The association found in the correspondence analysis for V2, both between the positive and negative responses of users and professionals, shows that, from the point of view of knowledge of the problem, users and professionals are close to each other, therefore, that professionals are aware of this situation experienced by users. Being PHC the level of attention that acts with greater capillarity and approach to the needs of the populations of the reference territories, the result highlights the need to include and favor the approach of violence in its work99 Carlos DM, Pádua EMM, Ferriani MGC. Violência contra crianças e adolescentes: o olhar da Atenção Primária à Saúde. Rev. Bras. Enferm [internet]. 2017 maio-jun [acesso em 2018 jan 7]; 70(3):537-44. Disponível em: http://dx.doi.org/10.1590/0034-7167-2016-0471.
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. The situation, however, is distinct when analyzing the opinions of users and professionals on the role of health in addressing violence (V4). In this case, there is an association between the opposing positions of these two actors, as well as a greater distance from this variable in relation to the others, suggesting that, although there is a recognition of the problem by professionals, it has not yet translated into effective actions or practice, which can be viewed and accepted by users. This fact could be related, on the one hand, to the limitations of the training of professionals still impregnated with the logic of productivity and the biomedical model, avoiding the construction of work processes based on the bond, reception, interdisciplinarity, focusing on the subject and the needs of the population1010 Durand MK, Heidemann ITSB. Promoção da autonomia da mulher na consulta de enfermagem em saúde da família. Rev. Esc. Enferm. USP [internet]. 2013 [acesso em 2017 nov 25]; 47(2):288-95. Disponível em: http://www.scielo.br/pdf/reeusp/v47n2/03.pdf.
http://www.scielo.br/pdf/reeusp/v47n2/03...
,1111 Signorelli MC, Auad D, Pereira PPG. Violência doméstica contra mulheres e a atuação profissional na atenção primária à saúde: um estudo etnográfico em Matinhos, Paraná, Brasil. Cad. Saúde Pública. [internet]. 2013 [acesso em 2017 nov 4]; 29(6):1230-40. Disponível em: http://www.scielo.br/pdf/csp/v29n6/a19v29n6.pdf.
http://www.scielo.br/pdf/csp/v29n6/a19v2...
. Considering such conditions, the authors are right to emphasize the need to invest in the qualification of care and in the training of PHC professionals44 Silva LA, Casotti CA, Chaves SCL. A produção científica brasileira sobre a estratégia saúde da família e a mudança no modelo de atenção. Ciênc. Saúde Colet. [internet]. 2013 [acesso em 2017 dez 5]; 18(1):221-32. Disponível em: http://doi.org/10.1590/s1413-81232013000100023.
http://doi.org/10.1590/s1413-81232013000...
,99 Carlos DM, Pádua EMM, Ferriani MGC. Violência contra crianças e adolescentes: o olhar da Atenção Primária à Saúde. Rev. Bras. Enferm [internet]. 2017 maio-jun [acesso em 2018 jan 7]; 70(3):537-44. Disponível em: http://dx.doi.org/10.1590/0034-7167-2016-0471.
http://dx.doi.org/10.1590/0034-7167-2016...
. On the other hand, one must not forget the ineffectiveness of the continuing education programs of the professionals, that is, the inability of the training courses taught to promote the acquisition of skills and transform learning into practical action1212 Jewkes R. What works to prevent violence against women and girls - Evidence Reviews Paper 3: Response mechanisms to prevent violence against women and girls. What works to prevent violence (Reino Unido) [internet]. 2015 [acesso em 2016 jul 20]. Disponível em: http://www.whatworks.co.za/resources/all-resources/publications.
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13 Berger SMD, Barbosa RHS, Soares CT, et al. Formação de agentes comunitárias de saúde para o enfrentamento da violência de gênero: contribuições da educação popular e da pedagogia feminista. Interface [internet]. 2014 [acesso em 2017 nov 20]; 18(2):1241-53. Disponível em: https://doi.org/10.1590/1807-57622013.0322.
https://doi.org/10.1590/1807-57622013.03...

14 Huacuz Elías MG. Desde la complejidad y la ética de la investigación: paradojas de los discursos biomédicos sobre la violencia de género en méxico. Soc. Estado [internet]. 2014 [acesso em 2017 dez 5]; 29(2):401-14. Disponível em: http://doi.org/10.1590/S0102-69922014000200005.
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-1515 Lima CA, Deslandes S. Sexual violence against women in Brazil: achievements and challenges of the health sector in the 2000s. Saude Soc [internet]. 2014 [acesso em 2017 dez 20]; 23(3):787-800. Disponível em: http://doi.org/10.1590/S1413-81232012000400025.
http://doi.org/10.1590/S1413-81232012000...
. There are still other factors, for example, the lack of support and protection for professionals dealing with cases of violence in their daily lives33 Apostólico MR, Hino P, Egry EY. As possibilidades de enfrentamento da violência infantil na consulta de enfermagem sistematizada. Rev. Esc. Enferm. USP. [internet]. 2013 [acesso em 2017 dez 10]; 47(2):320-7. Disponível em: http://dx.doi.org/10.1590/S0080-62342013000200007.
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and the difficulty of articulating them in a network, since in order to deal with situations of violence, professionals need to know the network and effectively carry out the initial reception, orientation, notification and referrals1616 Arboit J, Padoin SMM, Vieira LB, et al. Atenção à saúde de mulheres em situação de violência: desarticulação dos profissionais em rede. Rev. Esc. Enferm. USP [internet]. 2017 abr [acesso em 2018 jan 7]; 51(03):e03207. Disponível em: http://dx.doi.org/10.1590/s1980-220x2016113303207.
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.

The distancing between users and professionals increases when, in place of interpersonal and community violence, enter the scene, other types of violence, such as, lack of access to social rights, especially, in this case, quality health care, respectful and guided treatment in listening and reciprocal recognition between subjects. This is what the qualitative analysis shows: such concerns appear in the speeches of the users, but not in the speech of the professionals, turning to the initial discussion, the profile of the professional, more concerned with the logic of productivity, less affect to intersubjective relations1010 Durand MK, Heidemann ITSB. Promoção da autonomia da mulher na consulta de enfermagem em saúde da família. Rev. Esc. Enferm. USP [internet]. 2013 [acesso em 2017 nov 25]; 47(2):288-95. Disponível em: http://www.scielo.br/pdf/reeusp/v47n2/03.pdf.
http://www.scielo.br/pdf/reeusp/v47n2/03...
,1111 Signorelli MC, Auad D, Pereira PPG. Violência doméstica contra mulheres e a atuação profissional na atenção primária à saúde: um estudo etnográfico em Matinhos, Paraná, Brasil. Cad. Saúde Pública. [internet]. 2013 [acesso em 2017 nov 4]; 29(6):1230-40. Disponível em: http://www.scielo.br/pdf/csp/v29n6/a19v29n6.pdf.
http://www.scielo.br/pdf/csp/v29n6/a19v2...
,1717 Villela WV, Vianna LA, Carneiro L, et al. Ambigüidades e contradições no atendimento de mulheres que sofrem violência. Saúde soc. [internet]. 2014 [acesso em 2017 dez 5]; 20(1):113-123. Disponível em: http://doi.org/10.1590/S0104-12902011000100014.
http://doi.org/10.1590/S0104-12902011000...
. Also, only users speak of institutional violence and express dissatisfaction with the inadequacy of physical space, lack of privacy, impersonality as explicit forms and that cause more violence. Moreover, as Schek et al.1818 Schek G, Silva MRS, Lacharité C, et al. Rev. Latino-Am. Enfermagem. [internet]. 2017 [acesso em 2018 jan 4]; 25:e2889. Disponível em: http://www.scielo.br/pdf/rlae/v25/pt_0104-1169-rlae-25-e2889.pdf.
http://www.scielo.br/pdf/rlae/v25/pt_010...
mention, the high demand for care may contribute to the insufficient registration of suspected or confirmed cases that require more time to approach.

Integrality of care

The knowledge and recognition of violence as a relevant problem for the population linked to PHC, as can be seen, shows a certain mismatch between users and professionals, showing the need for new approaches, whose implementation must necessarily lead to the resumption of basic precepts of PHC, especially, for the case, integrality, indispensable in the face of complexity and multiple damages caused by violence33 Apostólico MR, Hino P, Egry EY. As possibilidades de enfrentamento da violência infantil na consulta de enfermagem sistematizada. Rev. Esc. Enferm. USP. [internet]. 2013 [acesso em 2017 dez 10]; 47(2):320-7. Disponível em: http://dx.doi.org/10.1590/S0080-62342013000200007.
http://dx.doi.org/10.1590/S0080-62342013...
,1919 Pedrosa CM, Diniz CSGD, Moura VGAL. O programa iluminar campinas: a construção de uma política intersetorial e interinstitucional para o enfrentamento da violência como um problema social. Ciênc. Saúde Colet. [internet]. 2016 [acesso em 2017 dez 20]; 21(6):1879-87. Disponível em: https://doi.org/10.1590/1413-81232015216.07822016.
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,2020 Duque LF, Montoya NE, Restrepo A. Aggressors and resilient youths in Medellin, Colombia: the need for a paradigm shift in order to overcome violence. Cad. Saúde Pública. [internet]. 2013 [acesso em 2017 nov 20]; 29(11):2208-16. Disponível em: http://dx.doi.org/10.1590/0102-311x00178212.
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. However, the predominance of the biomedical model, centered in the biological body, almost always disregarding the subjectivity and the cultural aspects of human life, makes such solution not so simple or of immediate reach99 Carlos DM, Pádua EMM, Ferriani MGC. Violência contra crianças e adolescentes: o olhar da Atenção Primária à Saúde. Rev. Bras. Enferm [internet]. 2017 maio-jun [acesso em 2018 jan 7]; 70(3):537-44. Disponível em: http://dx.doi.org/10.1590/0034-7167-2016-0471.
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,2121 Netto MFV, Deslandes S. As estratégias da saúde da família no enfrentamento das violências envolvendo adolescentes. Ciênc. Saúde Colet. [internet]. 2016 [acesso em 2017 dez 12]; 21(5):1583-95. Disponível em: https://doi.org/10.1590/1413-81232015215.145420.
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,2222 Soares JSF, Lopes MJM, Njaine K. Violência nos relacionamentos afetivo-sexuais entre adolescentes de Porto Alegre, Rio Grande do Sul, Brasil: busca de ajuda e rede de apoio. Cad. Saúde Pública. [internet]. 2013 [acesso em 2017 nov 20]; 29(6):1121-30. Disponível em: http://doi.org/10.1590/S0102-311X2013000600009.
http://doi.org/10.1590/S0102-311X2013000...
.

In the qualitative analysis, on the perception about what are the health functions in the prevention of violence (V5), users and professionals report, it is true, the performance of multiple and diverse actions to prevent violence; on the other hand, point to the need to advance in terms of quality of care, guarantee of safety in the units, construction of discussion spaces, and actions to promote and protect health addressed to the general population. Also worthy of note is the fact that users are concerned about taking care of the violence installed, making clear the existing gaps.

It is common, among professionals, the perception that the approach to violence should be carried out by specialized professionals, implying an attitude of transferring responsibility for care1717 Villela WV, Vianna LA, Carneiro L, et al. Ambigüidades e contradições no atendimento de mulheres que sofrem violência. Saúde soc. [internet]. 2014 [acesso em 2017 dez 5]; 20(1):113-123. Disponível em: http://doi.org/10.1590/S0104-12902011000100014.
http://doi.org/10.1590/S0104-12902011000...
. Home visits and the performance of the CHW in the approach to violence have been identified as strategies of great potential33 Apostólico MR, Hino P, Egry EY. As possibilidades de enfrentamento da violência infantil na consulta de enfermagem sistematizada. Rev. Esc. Enferm. USP. [internet]. 2013 [acesso em 2017 dez 10]; 47(2):320-7. Disponível em: http://dx.doi.org/10.1590/S0080-62342013000200007.
http://dx.doi.org/10.1590/S0080-62342013...
,1111 Signorelli MC, Auad D, Pereira PPG. Violência doméstica contra mulheres e a atuação profissional na atenção primária à saúde: um estudo etnográfico em Matinhos, Paraná, Brasil. Cad. Saúde Pública. [internet]. 2013 [acesso em 2017 nov 4]; 29(6):1230-40. Disponível em: http://www.scielo.br/pdf/csp/v29n6/a19v29n6.pdf.
http://www.scielo.br/pdf/csp/v29n6/a19v2...
to identify situations of domestic violence and to prevent child abuse1313 Berger SMD, Barbosa RHS, Soares CT, et al. Formação de agentes comunitárias de saúde para o enfrentamento da violência de gênero: contribuições da educação popular e da pedagogia feminista. Interface [internet]. 2014 [acesso em 2017 nov 20]; 18(2):1241-53. Disponível em: https://doi.org/10.1590/1807-57622013.0322.
https://doi.org/10.1590/1807-57622013.03...
. Interestingly, most interviewees do not cite such strategies inherent in the structure and functioning of PHC as alternatives for coping with and combating violence.

Social participation

The previous discussion refers directly to the matter of social participation and the praxis of autonomy as a central element of health promotion and violence prevention2323 Tavares R, Catalan VDB, Romano PMM, et al. Homicídios e vulnerabilidade social. Ciênc. Saúde Colet. [internet]. 2016 [acesso em 2017 dez 5]; 21(3):923-934. Disponível em: http://doi.org/10.1590/1413-81232015213.12362015.
http://doi.org/10.1590/1413-81232015213....
,2424 Avritzer L. A qualidade da democracia e a questão da efetividade da participação: mapeando o debate. In: Pires RRC, organizador. Efetividade das instituições participativas no Brasil: estratégias de avaliação. Brasília, DF: Ipea; 2011. p. 13-28.. It is highlighted, here, the suggestions most expressively found in the speeches of the users, namely, the construction and involvement in continuous collective actions in the form of meetings, groups, space for discussion and dialogue, debates, conversation, clarification of views, interaction with the community, testimonies and participation to approach violence. This situation demonstrates that the population signals the construction of more democratic spaces of discussion, not only of health, but also of violence, in which everyone can actually debate the problem, in order to transcend the vertical model of transmission of information and knowledge2323 Tavares R, Catalan VDB, Romano PMM, et al. Homicídios e vulnerabilidade social. Ciênc. Saúde Colet. [internet]. 2016 [acesso em 2017 dez 5]; 21(3):923-934. Disponível em: http://doi.org/10.1590/1413-81232015213.12362015.
http://doi.org/10.1590/1413-81232015213....
.

For Habermas, linguistic communication and dialogue are a way out of the alienation of society that recovers there its autonomy and identity2525 Habermas J. A crise de legitimação no capitalismo tardio. Tradução Vamirehchacon. Rio de Janeiro: Edições Tempo Brasileiro; 2002.. Civil society, in this model, is distinct from the system of economic action and public administration, becoming the social basis of autonomous public spaces that generate communicative power, from the construction of opinion and collective will, which then becomes the propitious power to be used at the administrative level. The author emphasizes that communicative action not only defines the strength of the capacity of integration of the society but also the construction of autonomous public spaces of will formation, fundamental for the demarcation of the borders of the other two media, money and administrative power2626 Habermas J. Três modelos normativos de democracia. Lua Nova 1995; (36):39-53..

Both the communicative dimension of public debate and that which is present in everyday life, in the informal interactions between people in their social environment, and which are the basis of the first, occur within the framework that Habermas calls the world of life. However, in later capitalist societies, the powers, administrative and economic, enter the world of life, preventing interactive relations from establishing themselves. The view of the interviewees, especially of the users, approximates to such theoretical presuppositions, which are translated by the creation of spaces of conversation and collective production of knowledge and practices. Durand and Heidemann1010 Durand MK, Heidemann ITSB. Promoção da autonomia da mulher na consulta de enfermagem em saúde da família. Rev. Esc. Enferm. USP [internet]. 2013 [acesso em 2017 nov 25]; 47(2):288-95. Disponível em: http://www.scielo.br/pdf/reeusp/v47n2/03.pdf.
http://www.scielo.br/pdf/reeusp/v47n2/03...
reiterate the need to intensify such practices with the aim of promoting dialogue and acceptance.

Conclusions

Violence is one of the most complex problems and difficult to approach in the health area. Dealing with people in situations of violence involves technical, social, psychological, and multiple skills. It was verified that violence pervades the daily life and performance of users and health professionals in the municipality studied. And that, somehow, there are possibilities of intervention, since professionals and users believe in this proposal - in a different way, it is true - in the sense that it is possible to prevent violence and that health should act in this prevention.

If, on the one hand, this study demonstrates the presence of violence in the context of life and performance of users and professionals, on the other hand, it shows that the problem needs to be better recognized by the PHC and treated in a systematic way, based on the improvement of professional practices. The principle of networking must be strengthened, in an intersectoral, integrated and consistent manner. The emphasis on participatory proposals, considered as decisive in approaching the problem, reinforces the existence of a fertile context for the development of discussions, debates and conversations in the light of objectives that promote and rescue relationships of solidarity.

  • Financial support: non-existent

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History

  • Received
    30 Apr 2017
  • Accepted
    24 Nov 2018
  • Publication
    Dec 2018
Centro Brasileiro de Estudos de Saúde RJ - Brazil
E-mail: revista@saudeemdebate.org.br