Introduction

Violence occurs in great magnitude all over the world and accounts for 1.3 million deaths every year.¹ Globally, it is the fourth leading cause of death in the general population and the leading cause of death among people aged 15-44.² In Brazil, in 2016, around 100,000 cases of violence against children and adolescents were reported. Despite probable underreporting, 2,200 of these cases were notified in the state of Amazonas, while Manaus, the state capital, had a violence rate of 149.1 reported cases per 100,000 children and adolescents.³

Monitoring and analysis of mortality from violent causes is extremely important. Notwithstanding, non-lethal violence occurring in relationships between parents and children cannot be ignored, nor when it involves other family members or acquaintances, among others. These forms of violence have physical, sexual, reproductive, psychological and behavioral consequences highly harmful to the health and well-being of those involved. They also have repercussions in society in general, resulting in intergenerational transmission of violence and delinquency in adolescence.⁴

In Brazil, notifying the authorities of violence against children and adolescents has been compulsory ever since the advent of the Statute of the Child and Adolescent (ECA) in 1990. Suspected and confirmed cases of violence must be reported to the local Child and Adolescent Protection Council.

Some time later, based on mapping of suspected and/or confirmed cases as one of the first steps in preparing actions to address violence, the Ministry of Health implanted its Violence and Accidence Surveillance system (VIVA) within the Brazilian National Health System (SUS). With effect from the creation of the Violence Module as part of the Notifiable Health Conditions Information System (Sinan) in 2011, as per Ministerial Ordinance GM/MS No. 104, published on January 25^th of the same year, violence was included on the list of compulsorily notifiable health conditions.⁵

Conducting sporadic studies in sentinel health services and monitoring epidemiological indicators generated by Sinan enable analysis of the profile of victims of violence, the places where it occurs most frequently and its trends in time and space.⁶ In order for the information generated to be useful for planning and implementing effective policies to address violence, it is fundamental for data to be valid, reliable, timely, up to date and to have high coverage.

Following VIVA recommendations, Manaus incorporated violence surveillance into Sinan in 2009. The information generated must be analyzed and publicized so that its relevance among the population can be estimated and so that the effectiveness of control measures can be evaluated. The success of this analysis depends on the quality of the system as a whole, right from case identification through to notification. The number of studies using VIVA data on the country’s Northern region is scarce and little is known about the quality of notification in this region of the country.

This study aims to describe cases of violence against children and adolescents and completeness of notification forms recorded on Sinan in relation to Manaus, AM, between 2009 and 2016.

Methods

This was a descriptive study of data from notification forms of interpersonal/self-inflicted violence held on Sinan in relation to Manaus for the period January 2009 to December 2016. Manaus is the capital of the state of Amazonas. It is located in Brazil’s Northern region and occupies a geographic area of 11,401.092km². According to the 2010 Demographic Census, its population was comprised of 2,145,444 inhabitants, 683,656 of whom were children and adolescents.⁷

Cases of violence against this age group are defined as: (i) violence against children, involving individuals aged 0 to 9 years old, and (ii) violence against adolescents, involving individuals aged 10 to 19 years old, whether suspected or confirmed, involving situations of domestic, sexual and self-inflicted violence, human trafficking, slave labor, child labor, legal intervention and homophobic violence, regardless of the victim’s sex.⁸

The variables listed below were studied in order to obtain a profile of the cases. It should be noted that these variables did not alter when the Sinan notification form was updated in June 2015. Variables characterizing victims (age, sex, race/skin color, schooling and presence of disability/disorder); variables characterizing the incident (notification source, type of violence, place, time of day, first time or recurrence, self-inflicted injury or interpersonal violence, and type of aggression); and variables characterizing the perpetrator (sex, relationship with the victim, suspected use of alcohol and number of people involved).

In order to estimate notification magnitude over the years selected, we calculated the notification rate for violence against children and violence against adolescents (per 100,000 inhabitants) by diving the number of cases per type of violence each year by the population aged 0-9 years old (children) and 10-19 years old (adolescents), as estimated by the Brazilian Institute of Geography and Statistics (IBGE) for the respective years under analysis. In addition to the notification rate, we also analyzed distribution of absolute and relative frequencies of notifications per year, considering the variables described above, for children and for adolescents. In order to analyze distribution of notification sources by healthcare level, we used the identification numbers of health service listed on the National Health Establishment Registry (CNES).

Analysis of completeness was done year by year, initially based on percentage completion of each field on the notification form, and then based on percentage completion of the form as a whole. In order to evaluate this latter aspect, we calculated the percentage of ‘unknown/blank’ fields in relation to the total number of fields on the notification form. With regard to compliance with Health Ministry guidelines, field completeness was considered to be: good, when 75.1% of forms had a given field filled in; regular, when between 50.1% and 75.0% were filled in; low, when 25.1% to 50.0% were filled in; and very low when 25% or less were filled in.⁹ The same cut-off points were used to assess form completeness as a whole. In the case of incidents with multiple choice variables, ‘unknown/blank’ data were defined as situations in which no reply options were given. The percentage of missing data per violence type was also assessed. The data were analyzed using version 3.2.2 of the R application.¹⁰

The study project was not submitted to a Research Ethics Committee because public domain secondary data were used, as provided by the Health Ministry’s Health Surveillance Secretariat (SVS/MS) in January 2018. The data did not disclose any information enabling case identification.

Results

During the period 2009-2016, 10,333 cases of violence involving children and adolescents were notified, divided between 4,638 children and 5,695 adolescents. There was a 51.9% increase in notifications involving children between the first and the last years analyzed. There was a 73.7% increase among adolescents in the same period.

Figure 1 shows notification rates according to the different types of violence against children and adolescents over the years. Sexual violence was the most reported type of violence against children, reaching a peak in 2013 with a rate corresponding to 135.3 cases per 100,000 children; the same occurred with adolescents, reaching a rate of 194.2 cases/100,000 adolescents in the same year.

Figure 1 - Notification rates (per 100,000 individuals) by type of violence in children (A) and adolescents (B), Manaus, Amazonas, 2009-2016 

Table 1 describes cases involving children, by year of notification. Taking these notifications as a whole, in almost half the cases the victim was between 1 and 5 years old. The percentage of cases of children under 1 year old was found to have doubled in the period studied, comparing 2009 with 2016. More than 2/3 of recorded cases of violence affected female children. Almost 70.0% of cases were of brown race/skin color. The majority of affected children did not attend school. Out of total cases of violence notified, 2.1% involved children diagnosed as having a disability or disorder.

The main sources of notification were high complexity healthcare services, divided between maternity hospitals (57.7%), general hospitals (39.7%) and accident and emergency services (2.6%). With effect from 2012, cases reported by other sectors, such as the Coroner’s Office (IML) and public schools, were also relevant sources of notification. The majority of violent episodes took place at the victim’s home. Although oscillations were observed over the years selected, a decrease was found in the number of records involving other places where violence occurred, taking the period as a whole. In more than ¼ of cases, violence occurred more than once during the child’s lifetime. Some 85.0% of situations were not self-inflicted.

A significant part of cases (30.3%) involved use of physical force/beating or threats as the type of aggression. The use of blunt, sharp or hot objects was also relevant in the final years of the study. With regard to the characteristics of the probable perpetrator, 57.2% were male. In 43.3% of notifications, the perpetrator was a parent of the victim. Finally, in ⅔ of the cases the perpetrators acted alone.

Table 2 shows the characteristics of notified cases of violence against adolescents. The most affected age range was that comprising 10-14 year-olds (70.7%). The female sex accounted for 87.4% of cases. The majority of these adolescents were of brown race/skin color (70.2%). Adolescent schooling level in around ⅔ of cases was incomplete elementary education. No form of disability or disorder was found in almost – of notifications. The main sources of notification were maternity hospitals (69.1%), general hospitals (23.0%) and accident and emergency services (7.9%). Primary healthcare accounted for only 2.0% of notifications. The victim’s home was the main place of occurrence (60.1%). Self-inflicted harm appeared in less than 4.0% of cases. Physical force and/or beating (29.7%) and threats (23.8%) were the most used types of aggression. Among adolescents a constantly increasing trend was also found in the use of other forms of aggression, including blunt and sharp objects, hot substances/objects and also poisoning/intoxication. Males were the main perpetrators throughout the entire period, accounting for 80.0% of cases. Despite a high percentage being characterized as ‘other’, a considerable part of the situations of violence were committed by friends or acquaintances. As with the group of children, in the majority of cases involving adolescents the perpetrators also acted alone (73.0%).

When considering the notification forms for the period 2009-2016, an increase was found in the percentage of unknown or blank information, above all in 2014 and 2015, for the fields referring to race/skin color, place of incident, recurrence, self-inflicted injury, sex of the perpetrator and number of people involved in the incident. When tabulating the percentage of missing data relating to these variables and types of violence, we found that the greater part of this missing information occurred in situations of sexual violence. In addition, more than 40.0% of notifications provided no information about the time of day of the incident or whether the perpetrator was suspected of alcohol use.

When analyzing notification form completeness as a whole, we found that completeness of 81.4% and 85.3% of notifications of violence against children and adolescents was good, 10.3% and 7.0% were classified as regular, 5.0% and 5.9% had low information recording, and 3.3% and 1.8% had very low completeness, respectively.

Table 3 shows completeness of notification forms of violence against children according to percentage completeness of each of the fields. Completeness was good for around 79.0% of fields analyzed. We found that required fields were fully filled in. Completeness was good in the first years of analysis but only regular in the following years for the fields recording victim’s race/skin color and diagnosis of victim having disability/disorder. When the form was initially implanted, victim’s occupation had low completeness, but in 2016 completeness was very low. With regard to characterization of the incident, we found that time, recurrence and circumstances of injury had very low completeness initially, increasing to regular in the final years analyzed. Completeness of the field for recording suspected alcohol use was regular for most of the period.

With regard to notifications involving adolescents (Table 4), completeness classification was good for 82.0% of fields over the entire analysis period. However, completeness of some fields, such as pregnant victim and victim diagnosed as having disability/disorder, for instance, was classified as regular in 2013 and 2014, respectively, and completeness of fields relating to occupation and recurrence was regular in 2015. On the other hand, completeness improved for the field recording the time of incident, which started as low and became regular with effect from 2013, while completeness of the injury circumstances field started as low and became good in the last year analyzed.

Discussion

This study pointed to an increase in the number of notified cases of violence against children and adolescents in Manaus between 2009 and 2013. The number of cases of violence involving children was lower than that involving adolescents. Sexual violence was the most notified type of violence. Variables comprising characterization of incident of violence and its probable perpetrator had the highest proportions of incompleteness.

The increase in the number of notified cases is related to evolution of the VIVA implantation process in Manaus, where initially only specialized and referral services integrated the system; while with effect from official publication of Ministerial Ordinance No. 104/2011,⁵ violence became a compulsorily notifiable condition at all levels of healthcare. In addition to greater coverage, according to the Manaus Public Health Department Sector for Preventing Risks to Health from External Causes, increased notification in 2013 coincides with the year in which the greatest number of training courses on violence surveillance institutionalization were held in Manaus. Notwithstanding, notification rates were found to have decreased with effect from 2015. It is possible that this reduction may be due to changes in instructions for filling in the notification form with effect from that year, when the recommendation was given to only record the main type of violence, so that other less relevant types at the time of notification were not included.

Sexual violence was the most frequently notified type among children and adolescents in Manaus during the study period. This result diverges from the majority of studies conducted in Brazil’s different regions,^11-22 which are conclusive as to negligence and physical violence being the most notified types of violence in childhood. Notwithstanding, a study conducted in Belém, capital of the state of o Pará, also found that sexual violence was the most frequently notified type (41.8%) among violence practiced against young people.²³ Given the context of VIVA implantation in Manaus, it is possible to postulate that greater occurrence of notification of sexual violence cases, in relation to other types of violence, may be due to the fact of the municipality having a Sexual Violence Victim Care Service (SAVVIS), which promotes compulsory notification of all cases. Other aspects which may have contributed to this situation lie in two facts: (i) Brazil’s Northern region having the largest number of child and adolescent sexual exploitation trafficking routes;²⁴ and (ii) the Child and Adolescent Protection Councils not adopting the intersectoral notification form, thus resulting in underreporting of other types of violence. It would be interesting for future studies to address the theme with the aim of investigating whether prioritizing cases of sexual violence is peculiar to Manaus or whether they are a regional characteristic.

The notifications analyzed showed that reported violence was higher among the one to five-year-old age group in children, and among the ten to fourteen age group in adolescents. Other studies also indicate that early childhood is the age group most at risk of violence, owing to the child being most dependent on its carer, reduced power of argumentation as a form of discipline and difficulty in countering violent attitudes.^17,25,26 If during the first year of life, negligence is the most common form of violence, with effect from being one year old other forms of violence begin to stand out, especially physical, sexual and psychological violence.¹¹

The greater part of reported violence against children and adolescents in Manaus was perpetrated against girls, for whom sexual violence tends to be more frequent.¹¹ However, this pattern is different to that presented in the majority of studies, in which males are the main victims, given that physical violence is the most commonly reported form.^11-13 With regard to race/skin color, in Manaus, differently to the rest of Brazil,²⁷ brown skin color was predominant regardless of whether cases involved children or adolescents. It was also found that the majority of children were not attending school and that a signification part of the adolescents had not yet completed their elementary education.

The majority of notifications of violence against children and adolescents were made by high complexity health services. This fact may reveal the severity of cases, related principally to sexual violence. On the other hand, this finding may also arise from health professionals in these services being better prepared. This scenario also suggests flaws in the process of detection and notification of situations of violence in primary healthcare centers, where comprehensive care and ability to identify situations of violence should be the key focus of attention, above all for the Family Health Strategy.²⁸

Studies using Sinan data also found evidence that the victim’s home was the place where violence most occurred among children and adolescents.^11,19,23 As indicated by other studies on this subject in Brazil, frequent use of physical force in these incidents may be related to abuse of power, authority, imposing limits and to the condition of being subordinated.^{11-14,16,17,20-22}

With regard to the perpetrators’ characteristics and kinship with children, the results presented in this study are similar to those of other research, by revealing, for example, that the main perpetrator was a family member.^{11,13-15,17,18} In the case of adolescents, however, friends or acquaintances of the victim were the main perpetrators of violence. This latter finding differs from studies conducted in that states of Rio Grande do Sul¹⁹ and Pernambuco,²² which pointed to legal guardians (father, mother, stepfather or stepmother) as being the main perpetrators of violence. On the other hand, greater frequency of just one perpetrator as found in this study, has also been reported by studies based on Brazil as a whole.²⁷

Generally speaking, both with regard to individual field completeness, and also completeness of entire notification forms, the results point to over 80% of situations being classified as having good completeness. However, among fields that are not required fields, such as race/skin color, disability/disorder, recurrence, suspected use of alcohol, place and time of incident, completeness classification oscillated over most of the years analyzed. A similar result was found by a previous study, conducted in Pernambuco, in which the authors indicated regular completeness of the fields intended to characterize violence (time of incident, place, recurrence, type of violence, type of aggression) and to characterize the probable perpetrator (sex, relationship with the victim),²⁹ and very low completeness for the following variables: schooling, time of incident and use of alcohol by the perpetrator.³⁰ It appears to be pertinent that the importance of this information for violence surveillance should be continually emphasized in health services throughout Brazil, since low completeness of the fields relating to them reduces not only the performance of municipal surveillance, but also hinders the development of specific actions aimed both at reducing case occurrence and also at case follow-up.

Despite the limitations found, inherent to studies using secondary data and inherent to the possibility of absence of certain information having compromised the description of notified cases, identification of the characteristics of the victims, incidents and perpetrators is extremely relevant for health service managers and/or health workers who wish to intervene in the cycle of violence. We hope that this study will give impetus to further studies dedicated to exploring other possibilities of analyzing this theme.

Contrary to the national scenario, sexual violence was the most notified type in Manaus, indicating the need for training aimed at detecting other types of violence (physical, psychological, negligence, child labor etc.) in the municipality. Improving the quality of the data analyzed requires notification monitoring, as well as continuing preparation of the health professionals involved. Progress in this area depends on correct identification of suspected cases and painstaking completion of the notification form, resulting from awareness raising actions aimed at health professionals in order to increase coverage and quality of form filling-in, since notification of violence against children and adolescents is a first step for actions to control this condition.