Claudia Leite Moraes

Violence and injuries in Brazil: the effect, progress made, and challenges ahead

Although there are signs of decline, homicides and traffic-related injuries and deaths in Brazil account for almost two-thirds of all deaths from external causes. In 2007, the homicide rate was 26·8 per 100,000 people and traffic-related mortality was 23·5 per 100,000. Domestic violence might not lead to as many deaths, but its share of violence-related morbidity is large. These are important public health problems that lead to enormous individual and collective costs. Young, black, and poor men are the main victims and perpetrators of community violence, whereas poor black women and children are the main victims of domestic violence. Regional differentials are also substantial. Besides the sociocultural determinants, much of the violence in Brazil has been associated with the misuse of alcohol and illicit drugs, and the wide availability of firearms. The high traffic-related morbidity and mortality in Brazil have been linked to the chosen model for the transport system that has given priority to roads and private-car use without offering adequate infrastructure. The system is often poorly equipped to deal with violations of traffic rules. In response to the major problems of violence and injuries, Brazil has greatly advanced in terms of legislation and action plans. The main challenge is to assess these advances to identify, extend, integrate, and continue the successful ones.

Semantic equivalence of the Portuguese version of the Abuse Assessment Screen tool used for the screening of violence against pregnant women

INTRODUCTION Research programs and actions regarding family violence have been growing steadily. Therefore, theres a need to develop data collection tools. In Brazil, further problems come up since tools that have been developed elsewhere need to be adapted and translated. This study focuses on the Abuse Assessment Screening (AAS) used to detect violence against pregnant women. The objective is to evaluate the semantic equivalence between the original tool in English and two Portuguese versions, and propose a synthetic version to be used in the field. METHODS The evaluation of semantic equivalence was carried out in 4 steps: (1) translation, (2) back translation, (3) formal appreciation of equivalence and (4) a final critical assessment by family violence experts. RESULTS Translation, back translation and the steps 3 and 4 assessment are presented for each item of the tool, along with the original in English. The text covers each discussion that led to the final version. Both versions were quite similar in 14 out of 15 items. Nevertheless, the second version showed to be slightly more adequate although for some items the decision was to combine both versions or, in one case, use an item from version 1. CONCLUSION The procedure undertaken in this study is discussed in the light of Herdman et al.s proposal (1998) regarding transcultural equivalence. The study also stresses the importance of using more than one version in the process and the appropriateness of including an additional step about the assessment of the target populations understanding of the tool.

Portuguese-language cross-cultural adaptation of the Revised Conflict Tactics Scales (CTS2), an instrument used to identify violence in couples

This article concerns the evaluation of cross-cultural equivalence between the Revised Conflict Tactics Scales (CTS2) originally developed in English and used to identify violence in couples and a Portuguese-language version for use in Brazil. Besides a broad literature review, evaluation of conceptual and item equivalences involved expert discussion groups focusing on the existence and pertinence of the underlying theoretical concepts and corresponding component items in the Brazilian context. Semantic equivalence involved the following steps: two translations and respective back-translations; an evaluation regarding referential and general (connotative) equivalence between the original instrument and each version; further discussions with experts in order to define the final version; and pre-testing the latter on 774 women. It was possible to establish high-quality conceptual, item, and semantic equivalence between the Portuguese-language version and the original CTS2. Acceptability of the version was excellent. Although the results were encouraging, they should be reevaluated in the light of forthcoming psychometric analysis (measurement equivalence).

Domestic violence during pregnancy in Rio de Janeiro, Brazil

Objectives: To estimate the prevalence and risk groups of domestic violence during pregnancy among public health care users in Rio de Janeiro, Brazil. The study focuses on violence perpetrated by both women and partners. Method: 526 women giving birth at term in public maternities from March to October 2000 were randomly selected and interviewers used the Revised Conflict Tactics Scales (CTS2). Results: 33.8% [95% confidence interval (CI): 28.8–37.0%] of the respondents reported some form of physical violence and 16.5% (95% CI: 13.3–19.8%) referred to severe forms. A total of 78.3% (95% CI: 74.8–81.8%), 9.9% (95% CI: 7.5–12.7%) and 15.6% (95% CI: 12.6–18.9%) reported psychological aggression, sexual coercion and injuries, respectively. Physical violence mainly occurred among adolescent women with less schooling, who did not work outside the home, with fewer prenatal appointments, and with little social support. Families with more under‐five children, alcohol and drug abuse, and low socio‐economic status were also involved more frequently. Conclusion: High prevalence rates for various forms of domestic violence in Brazil suggest that the issue should be viewed as a major public health problem.

Cross-cultural measurement equivalence of the Revised Conflict Tactics Scales (CTS2) Portuguese version used to identify violence within couples

Following a previous evaluation of concept, item and semantic equivalences, this paper assesses the measurement equivalence between a Portuguese version of Revised Conflict Tactics Scales (CTS2) and the original instrument conceived in English. The CTS2 has been widely used to tap violence between couples. An intra-observer reliability evaluation involved 165 replications carried out within a 24-48 hour period. Kappa point-estimates were above 0.75 for all scales except sexual coercion. The analysis of internal consistency concerned 768 subjects with complete sets of items. Kuder-Richardson-20 estimates ranged from 0.65 to 0.86. Results were similar to those found in the original instrument in English for the negotiation, psychological aggression and physical violence scales, yet not so for the sexual coercion and injury scales. Factor analysis identified factors with a recognizable correspondence to the underlying dimensions, although a few inconsistencies were detected. For the assessment of construct validity (n = 528) associations between the instruments scales were evaluated, as well as the relationships between violence and putative underlying dimensions. Overall, the findings suggest that the version can be used in the Brazilian context, although further investigation should be carried out to unveil some important remaining issues.This study was conducted to establish the frequency of hemoglobinopathies among newborns undergoing screening tests for metabolic diseases at the University Hospital (Hospital de Clínicas) in Porto Alegre, Rio Grande do Sul, Brazil. Testing for abnormal hemoglobins was performed by isoelectric focusing electrophoresis on agarose gel with blood obtained by heel stick and applied to filter paper. For confirmatory testing of abnormal neonatal screening, a venopuncture blood sample was obtained from the infant and parents and then submitted to hemoglobin electrophoresis on cellulose acetate at pH 8.6 and citrate agar at pH 6.2. A total of 1,615 subjects were studied: 20 samples showed the Hb S pattern and six samples showed Hb C. Thus, frequency of the sickle cell gene was 1.2% and that of the Hb C gene was 0.4%, regardless of race or origin. These data suggest that the inclusion of universal neonatal screening for hemoglobinopathies in the ongoing projects for the detection of phenylketonuria and congenital hypothyroidism has many advantages and should be considered in health programs.

Comparison between the abuse assessment screen and the revised conflict tactics scales for measuring physical violence during pregnancy

Study objective: Because of the promise of its ability to quickly identify cases of violence against women during pregnancy, the abuse assessment screen (AAS) should be the focus of numerous psychometric evaluations. This paper assesses its measurement accuracy compared with the revised conflict tactics scales (CTS2) used as standard. Design: Cross sectional study. Besides several ancillary questions, the AAS consists of three anchor questions about violence against pregnant women. These are inclusive, respectively covering lifetime, preceding 12 months, and pregnancy periods. These questions are the main focus of this article. The CTS2 physical aggression scale consists of 12 items divided into minor and severe subscales. A positive event is defined as having at least one positive item in the respective subscale. The 12 item score is also used. Setting and participants: The instruments were applied to 748 women, 24 to 72 hours after delivery in three major public sector maternity wards of Rio de Janeiro from March to September 2000. Main results: According to the CTS2, prevalences of minor and severe physical violence perpetrated against a pregnant woman are 18.4% (95% CI 15.7 to 21.4) and 7.6% (95% CI 5.8 to 9.8), respectively. Taking these subscales as standards, sensitivities are 31.9% (95% CI 24.9 to 40.3) and 61.4% (95% CI 47.6 to 74.0), respectively. Specificities are above 97%. Conclusion: These findings are somewhat worrying because the number of victims who are not identified and offered assistance is considerable. On a practical note, it would be sensible not to use the AAS as a stand alone screening tool until more evidence is gathered.

Conseqüências da violência familiar na saúde da criança e do adolescente: contribuições para a elaboração de propostas de ação

No Brasil, o conhecimento sobre a dimensao da violencia familiar e ainda escasso. Todavia, existem evidencias apontando para um cenario merecedor de enfrentamento imediato. Nesta perspectiva, o presente artigo destaca o campo das investigacoes sobre o tema, procurando explicitamente fazer uma ponte entre a apropriacao do conhecimento gerado e efetivas propostas de acao. O artigo divide-se em cinco partes. Inicialmente, e discutida a importância da violencia familiar no cenario de morbi-mortalidade de criancas e adolescentes A seguir, procura-se mapear as principais linhas de investigacao sobre o tema, sugerindo uma tipologia de estudos da area. A terceira sessao explora com mais enfase as investigacoes que avaliam as consequencias do fenomeno na saude de criancas e adolescentes. Na quarta secao, sao discutidos os possiveis elos entre o conhecimento a ser gerado nesse âmbito e as propostas de acao para o enfrentando da violencia familiar. Na ultima secao, sao feitas algumas consideracoes sobre a importância do enfoque familiar em oposicao ao individual; do multidisciplinar, em vez da abordagem compartimentalizada; e sobre a necessidade de integracao das varias agencias e servicos envolvidos com a violencia familiar.

Co-occurrence of physical violence against partners and their children in health services

OBJECTIVE To profile the co-occurrence of physical violence against partners and their children in a population attending a health care service, according to different socioeconomic and demographic characteristics. METHODS A cross-sectional study on family violence and pre-term delivery was carried out in the city of Rio de Janeiro, Brazil, in 2000. Households of women living with a partner and at least one child (or stepchild) aged less than 18 years were eligible to the study (n=205). Socioeconomic, demographic, and life style variables for the family couple were considered as potential predictors of violence. The outcome variable was assessed at four levels: no physical violence in the household; physical violence against partners, physical violence against at least one child or co-occurrence of both. A multinomial logit model was used for projecting the respective prevalences according to a range of selected descriptors. RESULTS The risk factors associated to greater risk of the outcome were: maternal age >25; partner with less than eight years of schooling; presence of >2 children under the age of five in the household; and alcohol/illicit drug abuse by the partner. In households with all those characteristics, the joint projected prevalence of violence against partners and their children was 90.2%, and as much as 60.6% accounted for the co-occurrence of both. In the absence of those factors, estimates were significantly lower (18.9% and 0.2%, respectively). CONCLUSIONS Health providers should not only anticipate a situational gradient, but also be aware there is an increasingly higher risk of violence comprising the whole family group.

Rastreamento de uso de álcool por gestantes de serviços públicos de saúde do Rio de Janeiro

OBJETIVO: Avaliar a prevalencia de casos suspeitos de uso inadequado de alcool durante a gestacao entre mulheres atendidas na rede publica de saude. METODOS: Estudo transversal com 537 parturientes selecionadas aleatoriamente em maternidades publicas do Rio de Janeiro entre marco e outubro de 2000. Entrevistadoras adequadamente treinadas identificaram os casos suspeitos de uso inadequado de alcool utilizando os instrumentos Cut-down, Annoyed, Guilty e Eye-opener (CAGE), Tolerance Cut-down, Annoyed e Eye-opener (T-ACE) e Tolerance Worry Eye-opener Annoyed Cut-down (TWEAK). Na analise segundo variaveis socioeconomicas e demograficas utilizou-se o teste qui-quadrado. RESULTADOS: Cerca de 40% das mulheres relataram fazer uso de algum tipo de bebida alcoolica durante a gestacao, sendo a cerveja a bebida mais consumida (83,9%). Dependendo do instrumento de identificacao, estimou-se que entre 7,3% e 26,1% das mulheres eram casos suspeitos de uso inadequado de alcool. A suspeicao de utilizacao inadequada foi mais comum entre as mulheres de idade mais avancada; de baixa escolaridade; que nao se declararam brancas; que nao viviam com companheiro; que relataram tabagismo e uso de drogas ilicitas por um dos membros do casal; e com pouco apoio social. CONCLUSOES: A alta prevalencia de suspeicao de uso inadequado de alcool e sua superposicao com diferentes fatores de risco para desfechos deleterios na gestacao indicam um importante problema de saude publica, merecendo ser rotineiramente rastreada durante o acompanhamento pe-natal.

[Detection of child abuse: missed opportunities in emergency rooms in Rio de Janeiro, Brazil].

Emergency rooms require special consideration since their often-distressful routines may hamper the detection and handling of family violence cases. This study estimated the magnitude of violence against children reported by users of two emergency hospitals in Rio de Janeiro, Brazil. It also evaluated the degree of underreporting by contrasting the present findings to cases reported routinely. 524 parents/guardians of children under 12 treated at the hospitals from January to March 2005 were interviewed. Twelve-month prevalence of family violence was measured with the Conflict Tactics Scales: Parent-Child (CTSPC). All cases reported by staff and officially recorded in the preceding year were identified. Prevalence of psychological aggression, negligence, and physical violence were 94.8% (95%CI: 92.9-96.2), 60.3% (95%CI: 55.9-64.7), and 47.2% (95%CI: 42.7-51.8), respectively. However, the corresponding prevalence rates according to routinely reported information were 0.007% (95%CI: 0.003-0.013), 0.24% (95%CI: 0.22-0.27), and 0.03% (95%CI: 0.02-0.04). This striking difference suggests that case identification and strategies to report violence against children in emergency rooms need to be reevaluated.