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Violence against children and adolescents as perceived by health personnel


Rebeca Pinheiro de SantanaI; Judith Sena da Silva SantanaII

I Master in Public Health. Professor, State University of Feira de Santana. Feira de Santana, Bahia, Brazil. E-mail:
II Postdoc in Social Studies on Childhood. Professor, State University of Feira de Santana. Bahia, Brazil. E-mail:





Objective: to understand how health personnel providing care at public hospitals perceive violence against children and adolescents. Method: in this qualitative study of 20 health personnel at two hospitals of the Unified Health System (SUS) in Feira de Santana, Bahia, data were collected by semi-structured interview in the second half of 2010 and categorized by content analysis. The project was approved by the research ethics committee (CAAE 0054.0.059.000-10). Results: the interviews revealed three categories: violence as a violation of integrity; the nature and locus of violence; and violence as a multicausal phenomenon. Conclusion: how professionals perceive violence is reflected in how they grasp and configure its impacts on the health of children and adolescents and on the care provided, and also contributes to understanding possible referrals.

Keywords: Violence; child; adolescent; perception.




The understanding of a phenomenon in different contexts and multiple interpretations is linked to the experiences to which subjects are exposed and are characterized as determinants in the construction of meanings seized by an individual or a group. This construction is based on how reality is interpreted not only how reality is expressed.

Perception is one of the functions imposed to the brain that intents to give meanings and sensory stimuli through experiences lived. Based on these experiences, individuals are able to acquire, organize, interpret and assign meaning to things of their immediate environment, which can change as new information is acquired1.

The phenomenon of violence is complex and multifactorial, manifested in different ways and in different contexts, and can receive multiple meanings. Violence can be observed in various situations and explained under different approaches and this complicates its thorough understanding2-8.

The difficulty in understanding comes from the fact that violence is subjective, polysemic and controversial, perceived in various forms 9 that vary according to social group or territory, degree of tolerance of its manifestations, the way it is expressed in various economic levels and standards of each society and each person7.

In this article, we aim to understand the perception that health professionals who work in public hospitals have about violence against children and adolescents. This is anchored in the understanding that these professionals are in a strategic position to identify risks and identify possible victims, because they are often faced with the care of cases resulting from episodes of violence.



The term violence seems neutral, but who studies violent events discovers that they refer to social events circumscribed in the cultural, historical and social realities. They refer to conflicts of authority, struggles for power and willingness to dominate, to own and to annihilate others or their properies10,11.

Manifestations of violence depend on social norms and customs or legal apparatus of society and are changing according to times, places and circumstances; while some are tolerated, others are condemned. Local culture may determine such manifestations as part of everyday life, causing different feelings in people, arousing feelings of fear and distrust.12-14.

Etymologically, the word violence comes from the Latin violentia, which is associated with the use of physical force, whose use against something or against someone gains a violent character13. Although the origin of the word is linked to physical strength, violence goes beyond physical damage, as it includes emotional, moral and spiritual aspects, incurring negative consequences to health.

There are attempts to conceptualize violence in the various areas of knowledge. However, more important than defining it, violence has to be perceived as a social, complex, multi-causal, historical and networking phenomenon. The network idea takes into account that violence is not an abstract element and is manifested in society as the violence of wars, violence between classes or family members, among others15.

Although violence occurs among all age groups, children and adolescents are more vulnerable because they are in the process of growth and development, and they are also the ones that suffer the greatest impact on health7-9.

In cases where the victim needs to be referred to hospital care, health professionals are the first to be faced with the care of victims of violence. The real reason, however, is not declared, but it is masked by other problems and symptoms. Therefore, a watchful and critical eye of the healthcare team is fundamental to identify problems - whether of physical, sexual or emotional nature - looking for their correlation with a possible violent event8,12,14,15.



This is a research with qualitative approach due to the subjective nature of the object of study, since the analyzed phenomenon is dynamic and takes place in relations with the context in which it is inserted.

The study was conducted in two public hospitals in the city of Feira de Santana - BA which provide care to children and adolescents through the National Health System. Ona was a general hospital and the other was specialized in the care of children.

Study subjects were 20 healthcare professionals, 11 from the specialized hospital and nine from the general hospital. Participants consisted of four doctors, six nurses, four social workers, two psychologists and four nursing technicians. The age range was 22-48 years and the service time in the hospital ranged from 3 months to 20 years of professional practice. Respondents were randomly chosen and numbered according to interview order to preserve anonymity.

Data collection occurred in the second half of 2010 and was conducted through semi-structured interviews, with the help of voice recorder. To achieve the proposed goal, we adopted the thematic content analysis, following the steps of pre-analysis, exploration of material and processing of results. Categorization was made based on semantic criteria with themes that emerged from the corpus of the analysis16.

The study was approved by the Ethics Committee of the State University of Feira de Santana under protocol nº 055/2010 CAAE 0054.0.059.000-10 and the interview was processed after voluntary consent of subjects through signing of the Informed Consent. Rules for studies involving human subjects were respected.



The analysis of the notions and information that emerged from the data collected in the interviews were divided resulted in three categories.

Violence as a violation of integrity

When conceptualizing violence, health professionals converge in the sense that this is characterized as a violation, act, action or attitude that infringes, violates or offends the other:

[...] any act, attitude that happens in the sense of infringing the limits of the other. (I13)

Any type of violation is violence. (I17)

Even with varied expressions in different contexts, violence is considered worldwide as a violation of rights, manifested as the exercise of domination of one being over another7,17. This term is also used by the Ministry of Health to affirm that violence and its negative consequences violate human rights12.

However, in order to be considered a violation, it is necessary that interaction between two actors take place - the abused and the abuser. The abuser is not always represented by an individual but by a group or by institutional practices inspired by rules that limit the autonomy and the exercise of human rights by the individual or the collective 7,16.

The term aggression was also used by professionals to refer to an action that produces physical or psychological harm to the person or to a property18.

[...] aggression to psychological or physical integrity of a person. (I19)

In a previous study carried out with nurses working in hospital care for children and adolescents admitted to emergency unit or admitted to pediatrics, the interviewees also use the term aggression in their considerations to conceptualize violence18. Violence is associated primarily to the use of physical force and this is the term that is closer to the etymology of the word violence13,14.

[...] a behavior that causes harm to another person. It is an action of one person against another, or against an object that will cause some damage on it. (I14)

The intentional use of physical force or power mentioned by subjects is also present in the concept of violence used by the World Health Organization (WHO)19: 1165.

Considering the intention as what it is purposed to be practiced, or what it is desired to achieve, violence is directly linked to the attacker's intention to achieve its ultimate goal of generating damage to the other, the one that is in the is in a position of less physical force or power.

It is important to emphasize that violence goes beyond physical damage, but it includes emotional, moral and spiritual spheres, and affects the social and other dimensions of the person19.

[...] everything that hurts the physical and emotional dignity and morals of children. Whether sexual violence, physical violence, aggression or even moral violence, psychological violence, which is one that interferes with children's emotional state as a whole. (I1)

The different forms of violence include any excessive act, qualitatively distinct, observed as the exercise of power in social relations9 . Forcing and coercing cause harm to individuals or social groups, whether representing a social class or category, or a gender or an ethnicity, age or a distinct cultural group.

Nature and locus of violence

The concepts presented appear linked to the nature of aggressions, explaining that violent acts can be physical, sexual, psychological, or caused by negligence or deprivation. Perceptions demonstrate progress in the understanding of violence as something not restricted to the physical aspect, or visible aspect, but also to what may not be apparent to the eye.

This finding is relevant because the attitude of professionals regarding violence practiced against children and adolescents is closely related to the visibility or lack of visibility that the problem has in their daily routine20.

A study conducted in Rio de Janeiro found that, for healthcare professionals, violence also has various levels and types, but it is basically related to explicit aspects, covering abuses to the body, and to subtle aspects, when related to injuries to psychic development and citizenship21.

Psychological abuse appears in the reports as a type already recognized by the denomination and its forms of expression such as a threat, coercion, moral abuse and verbal aggression.

[...] it is not only the physical part. People suffer both moral and verbal violence. (I8)

The recognition of psychological violence deserves consideration because professionals can be more attentive and knowledgeable about the subject. The Brazilian Society of Pediatrics stresses that psychological abuse, despite being often embedded in other types of violence, has a subtle character and the lack of immediate evidence makes it difficult to identify it, with the risk of causing serious damage to the biopsychosocial development of the child22.

Because violence is usually recognized in acts such as murder, fights, among others, its understanding is restricted to actions that causes death or injury. However, violence can be implied in a subtle way, unnoticed, as it may happen in words, in gestures, and even indifference18.

Verbal aggression is emphasized by respondents as a form of expression of psychological violence that may offend, represent a psychological torture and cause chastisement or torment to the person who is attacked. It is characterized by the use of symbolic or verbal means that hurt or harm the child or adolescent9.

[...] the way you talk to the person, a word that offends. (I6)

However, psychological violence can be expressed by other ways, including: rejection, isolation, terror, neglect, corruption, and creation of unreal or extreme expectations4. These events cause damage because the negative interference of the adult on the child and its social competence builds a pattern of destructive behavior23.

The attacker causes children or adolescents isolation from common experiences to their age and social environment by preventing them from making friends; the atacker does not stimulate their emotional and intellectual growth; establishes fear; does not recognize their value and legitimacy of their needs; corrupts the victim by inducing to prostitution, crime or drug use; requiring or creating extremely unrealistic expectations, so as to cause deep damage to their mental structure 23,24.

Sexual abuse, in turn, is for many the most striking act of violence against children and adolescents, because this means submiting the young individual to unusual practices for their age group, promoting deep damage to these beings.

The abuse itself, abusive sexual practices[...]. (I10)

It will be difficult, after an abuse, for the child to maintain some kind of relationship in the future with someone. (I17)

Neglect refers to omissions or failure of parents or guardians in meeting the basic needs for the physical, emotional and social development in one or more of the following areas: health, education, emotional well being, development, nutrition, shelter and safe living conditions; and abandoning represents the extreme form of this type of violence 12,25,26. Respondents exemplify the lack of attention to diet, hygiene and medicines that the child should receive as the denial of necessary support for their healthy growth and development:

We observe abusive treatment, lack of care with food, hygiene and all support. (I1)

The child must take medication and he does not take [...]. (I7)

Negligence, besides being a violence perpetrated, also opens the way for other violence because when children are not protected by their leaders, they are more susceptible to free interference from other offenders who take advantage of carelessness.

There is also the superposition of violence17. It is possible that the person who suffers a physical or sexual violence is also suffering psychological violence, especially when the victim feels compelled not to reveal the violence that suffers.

Violence was also addressed under its locus of action. This may occur inside and outside home, and domestic violence is the one that occurs in the home environment and can be practiced by a family member (intrafamily) or not (outside the family)24.

[...] occurs in the very home... Battering, sexual abuse [...]. (I18)

In the family environment, children and adolescents are victims of parents or relatives who have legal and moral responsibility to protect them and guide them. This means the child experiences the unpleasantness of aggression in the environment in which it should receive protection and care27. An important aspect relates to the use of physical punishment as an instrument used in the education of children. Parents tend to defend this form of discipline, which may favor the trivialization and become chronic physical domestic violence.

In the case of violence outside the family, the school has been the scene where the most scabrous scenes take place4. This theme, although recent in studies, was also addressed by subjects and directs attention to peer violence, which may be the result of a society that has violence as a culturally established element.

And, there is school violence. There was this teenager, 13 years old, who came here last week, beaten with brass knuckles, a weapon that they use between the fingers. The boy came here with the face very swollen, with a broken nose and went to surgery. Three school mates did it. (I18)

Peer violence or bullying has been a reality in schools for a long time and is often considered a normal process in a culture of silence that contributes to its perpetuation. Bullying is an aggressive behavior involving aspects of imbalance of power exercised by intimidation of the weakest, with the premeditated intent to cause damage, and that is repeated over time28,29.

Bullying can be directly expressed, physically or verbally, or even through gestures. It is indirect or relational by social exclusion or rumors that may intimidate the victim. Recently, cyberbullying has come into scene. This refers to bullying through Internet, by the use of blogs, E-mail, chats and mobile phones, to send intimidating or insulting messages.

School violence is extremely worrying, especially when it comes to that practiced among adolescents as these, as its a typical feature of the life stage they are, seek to identify themselves with groups that have similar behaviour, moving away from what is taught by parents. Thus, if an individual acts violently in this stage, this may take others from their group to act in the same way, leading to an increase in delinquency and reproduction of violence in different contexts.

Violence as a multifactorial phenomenon

In the perception of subjects, the following aspects appeared as what they considered triggering or determinant factors of violence: bursts of anger, lack of patience, poor family structure, drugs and poverty.

Aspects converge on the ecological model to explain the roots of violence proposed by the WHO24 which conceives the violence arising from the interaction of individual, relational, social, cultural and environmental factors, considering the understanding of these factors as one of the most important steps in the public health approach to prevention against violence.

Bursts of anger and lack of patience relate to biological factors and personal history that individuals bring out in their behavior. Impulsivity, abuse of chemicals and past history of aggression and abuse are considered the first level of this model. This level focuses on the individual characteristics that increase the likelihood of being a victim or a perpetrator:

It was a moment of anger that ended up in the aggression. (I7)

Drugs in the family or poverty itself. They have no patience with children. (I19)

Although the low level of education is cited as one of these factors, there is controversy in the sense that this is not a defining element for the condition of being an attacker. Thus, the low level of education, cited by WHO, is rather understood as referring to lack of access to information, education and basic fundamental rights, which represents structural violence in itself.

The relational aspect, the second level of the ecological model, explores how proximal social relationships with peers, intimate partners and family members increase the risk of victimization. The everyday interaction in the home with an abuser may increase the opportunity for attacks. As individuals are connected in a continuous relationship, it is likely in these cases that the victim will be repeatedly abused23,24.

[...] a sibling taking care of the other. And they go along with neighbors, very often, with friends in the house, go out to play... They loose control, really (I15).

Community contexts in which social relationships are inserted, whether schools, workplaces and neighborhoods, represent the third level of the model, which seeks to identify characteristics of the scenarios associated with the fact of being victims or perpetrators. High level of residential mobility, heterogeneity and high population density, involvement in drug trafficking, unemployment and social isolation are more likely to favor violent experiences. The opportunities for violence are greater in areas of poverty or physical deterioration, or where there are little institutional support. Although poverty is not a condition for the practice of violence,

this most often occurs in the lower middle class (I2).

[...] In the lower class, everyone needs to work and they leave the child with the neighbor. (I15)

Several studies indicate hunger, poverty, unemployment and poor socioeconomic conditions as causes of violence. Furthermore, in addition to family conflicts, there are socio-demographic characteristics such as low maternal education, low parental age, low family socioeconomic status, presence of many children in the same house, being a male, belonging to racial/ethnic minority groups and experiencing the difficulties of life in urban centers. Some of these relationships are not clear, but socio-cultural aspects, forms of family structure, styles of parental care, discipline and family supervision are among the most accepted explanations9,18,30.

Although poverty is a structural cause, this is not the explanation for violence in Brazil30. In the specific case of children and adolescents, it is important to consider that although the majority of reported cases come from lower classes, violence is present in all social classes and reflects mainly the structural and cultural violence18.

Brazilian society is historically built on violent relationships and the country still lives under conditions of exploitation and inequality, where relations of social injustice destroy community and solidarity ties, producing subjects gradually less attached to each other.

[...] boy or girl, no matter the social environment, no matter the family. (I16)

The fourth level of the model, examines societal factors that influence rates of violence, create an acceptable atmosphere, decrease inhibition against violence, and support divisions between segments of society24. Health, educational, economic and social policies that maintain high levels of economic or social inequality between groups are examples of these factors31.

While this level was not reported in the statements of subjects in this study, they are considered very important to explain violence. They include the violence of social policies that leave children and adolescents out of school, depriving them from physical and mental adequate development, motivated by the lack of food which force them to work early to fight for survival4,31.



Although there is no an unanimous concept, respondents perceive and relate violence to the main issues raised by scholars who present violence as a complex and delicate subject, because of its meanings, because of the representation of anulation of a subject and because of the exposure of spaces and moments of great intimacy and privacy of individuals.

Professionals perceive the phenomenon as multifactorial, something that causes damage to the development, affects the health and all aspects of life of children and adolescents, from the violation of their physical, psychological, social and sexual integrity. They also reinforce the collective repercussions, including families and society as a whole, and that this is a reality that must be addressed and be the subject of effective public policies.

The perception of the health team reflected in the design of comprehensive health care for children and adolescents and contributed to the understanding of the possible referrals. It is clear, however, that when considering a complex and multifactorial phenomenon, encompassing many meanings, the topic is not complete with the view of health professionals only, what can be seen as a limitation of this study.

The disciplines that seek concepts in this area should establish a mutually dependent relationship to understand violence by the approximation of realities that describe the phenomenon in a peculiar way, combining methodology and ethics.

The health sector or other sector alone will not solve the problem of violence, but the joint efforts of society, community, family and individuals, through public policies that rule over essential aspects to the existence of a comprehensive state of rights.



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Direitos autorais 2016 Rebeca Pinheiro de Santana, Judith Sena da Silva Santana

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