INTRODUCTION

Violence is a major cause of morbidity and mortality in children and teenagers¹. Given the consequences for the victims’ physical and psychological health, this is a topic that must be widely debated in all public policy sectors. However, the initial and continuing training of health professionals is focused almost exclusively on the health-disease binomial, which results in the professionals’ unpreparedness to face situations such as Violence Against Children and Teenagers (VACT)^2),(3.

The study by Koifman et al.⁴ carried out with medical students at Universidade Federal Fluminense, showed that the majority of participants (53%) had never had access to the VACT topic during undergraduate school. The subject was considered to have been adequately addressed by only 9% of the students, who had no doubts about the subject, while 44% reported not feeling prepared to deal with this issue in their professional practice. Also in the same study, during interviews with resident physicians, half of them reported not having had training experiences related to the topic and only one participant stated that he felt confident in his capacity to identify cases, although he showed inaccurate knowledge about the correct conduct to be followed in the presence of a VACT case⁴. These findings are similar to the results obtained in the study conducted by Margarido et al.⁵ and Nunes et al.⁶ with doctors working in the Family Health Program (currently called Family Health Strategy - FHS).

Similarly, another study carried out with medical, dentistry and nursing students from Universidade Federal de Santa Catarina⁷ showed that the concept of violence among the interviewees is related only to the physical damage caused to the victim. The feelings most frequently reported by the participants when treating VACT cases were fear and impotence, since, for the students, there is a distancing between the professional and the population’s social problems. In the curriculum of these courses, the researchers conclude, little is discussed about protocols for assisting victims of violence⁷. The lack of technical information leads to these professionals’ unpreparedness to recognize VACT, especially in cases with more subtle signs and symptoms⁴. In the study by Silveira et al.⁸, carried out with professionals from the Basic Health Units (BHU), it was found that physical signs and symptoms are prioritized, to the detriment of behavioral and emotional symptoms.

The raising of suspicion depends on the professionals’ emotional aspects and the technical training they receive^9),(7. Moreover, there is an underreporting of VACT cases due to the fear of legal involvement that this conduct entails, as well as the absence of legal mechanisms to protect the professional and, even, due to the threats they suffered by the perpetrators of violence^10),(11. The absence of spaces for initial and continuing training, the excess of routine activities, the limited time to carry out consultations, the lack of privacy to establish a dialogue with patients and the reduced resources also contribute to the underdetection of VACT cases¹².

However, treatment at an emergency room, BHU, FHS, outpatient clinic or office is often the first possibility to recognize violence. Doctors, nurses and other health professionals should be aware of the risk factors, signs and symptoms identified in patients. Therefore, it is necessary to incorporate ways to alleviate the theoretical and practical learning deficit on the VACT topic into the undergraduate and postgraduate curricula^12),(13),(4.

In Brazil, as well as in several countries around the world, there are legal implications for health professionals who fail to notify public authorities about a suspected case of VACT. The Child and Adolescent Statute - ECA (Estatuto da Criança e do Adolescente)¹⁴ in its Article 245 states that “it as a crime for the physician, teacher or individual responsible for the health care and elementary education, pre-school or daycare, to fail to report to the competent authority about the cases they are aware of, which involve suspicion or confirmation of mistreatment against children or adolescents”, under penalty of a fine of three to twenty reference salaries, twice as much in case of re-incidence. Therefore, health professionals need to deal with different types of feelings and situations for which they do not feel prepared, although they might answer legally for their actions^6),(9.

The reporting of VACT cases identified in health services is essential for the interruption of the violence cycle and to refer victims to the psychosocial care network. The notification of cases, either suspected or confirmed, is present in the Codes of Ethics of several health professionals and does not constitute breach of confidentiality. Ordinance n. 104 of the Ministry of Health establishes the compulsory notification of new cases of diseases and injuries, including violence, and Ordinance n. 1968, of October 2001, establishes that those responsible for the health units of the Unified Health System (SUS) must notify the Child Protective Services of any suspected or confirmed case of VACT^10),(11),(9.

Given the possible consequences of violence in the lives of children and teenagers, it is understood as essential to include content about this phenomenon in the initial and continuing education of health professionals. The absence of training spaces has implications on the difficulty of recognizing and referring cases, perpetuating the condition of the violation of rights. Therefore, it is essential to develop pedagogical proposals and educational models on the topic that can contribute to the training of these professionals, enabling them to be better prepared when faced with VACT cases.

Based on these considerations, the aim of this article was to evaluate the effectiveness of an intervention program designed to allow students and health professionals to recognize and refer VACT cases. As a secondary objective, we aimed to verify at what level of training (undergraduate, postgraduate and working professional) such an intervention would have a greater effect.

METHOD

This research is a quasi-experimental study, of which design was based on an analysis that used pre- and post-test with a non-equivalent control group¹⁶. Therefore, the field research was structured with a group that participated in the intervention program (Experimental Group - EG) and another that did not participate in any phase (Control Group - CG). Both groups were evaluated regarding their knowledge about the VACT topic, before and after the end of the intervention. Although the fieldwork produced qualitative and quantitative data to assess the program effectiveness, priority was given to data from the quantitative analysis in this article.

RESULTS

After applying the questionnaires to the EG and CG in the pre and post-test stages, the instrument items were analyzed to assess the effectiveness of the intervention. Table 2 shows the results by categories in which the questionnaire items were grouped: acceptance and naturalization of VACT, physical violence, sexual violence, psychological violence, neglect and professional performance.

No statistical difference was observed between the pre- and post-test in any of the categories in the CG. As for the EG, , there were statistically significant alterations in all the assessed dimensions, which proves that the intervention brought changes to the previous conceptions the participants had about the VACT topic. The significant difference that occurred in the professional performance category is highlighted, showing that after the training was provided, the participants felt more capable and confident regarding their performance in the presence of VACT cases, as well as safer for referral to the child and adolescent protection network.

When comparing the answers obtained in the questionnaires between the three groups (undergraduate students, postgraduate students and health professionals) aiming to verify in which group an intervention such as this would be more effective, it was found that there was no statistical difference between the groups (Table 3), although it is important to highlight that there were statistically significant improvements in the participants’ VACT perceptions in all groups, as shown in Table 2. These data show that educational models or training programs on the VACT topic can be proposed at any stage of the health professionals’ training (at the undergraduate level, at the postgraduate level and as continuing education actions).

DISCUSSION

The Ministry of Health defines violence against children and teenagers as “any act or omission by parents, relatives, guardians, institutions and, ultimately, society in general, which result in physical, emotional, sexual and moral damage to the victims”²⁰. It is necessary for professionals to accept that this is also a problem in the healthcare area and understand that they have a fundamental role regarding the coping with VACT. Mainly pediatric doctors and nurses, who are often responsible for the first assistance to victims, should be alert to cases that raise any suspicion^13),(4.

In addition to all clinical procedures, it is the duty of the pediatrician, together with the health team, to assess the severity, the risk of re-victimization and refer the complaint to the Child Protection Services and notification to SINAN (Information System for Notifiable Diseases). These conducts must be taken in any cases of suspicion or confirmation of violence, in addition to hospitalization in the presence of a severe case or risk for the child^21),(22. However, health professionals still have many difficulties regarding the VACT topic. For that reason, improving the courses offered in the educational institutions responsible for undergraduate and postgraduate students and continuing education in health is understood as essential. The gaps in the training process lead to a lack of information for the recognition and referral of cases²³.

This study showed that a well-structured training program produces important changes in the conception of health professionals and students about VACT, whereas it also collaborates to make them feel better prepared to deal with these demands. Despite the findings of this investigation, Christian²⁴ states that, in the international context, there are no surveys on the quantity and quality of programs designed specifically to prepare medical students for the VACT topic. Similarly, Gebara and Lourenço²⁵ state that health professionals in the Brazilian context do not have training spaces to allow them to deal with this type of demand, and in many cases, knowledge on the subject occurs on their own initiative.

Studies carried out in the 1990s, such as the one by Dubowitz and Black²⁶, already indicated that by offering a series of 6 seminars, with each session lasting 90 minutes, was already capable of significantly increasing the knowledge of medical residency students about the violation of the rights of children and adolescents. The findings of the present study reinforce this statement, as a 20-hour program showed to be effective and a successful endeavor. Moreover, the positive results were also extended to undergraduate students and professionals working in different public health policies.

Lise and Motta²⁷ claim that VACT affects all socioeconomic, ethnic and religious strata. However, its effects are even more critical in groups exposed to situations of social vulnerability, especially those from families facing unemployment, caregivers’ low level of schooling and scarcity of resources. On this subject, Christian²⁴ warns that health students and professionals, especially in the medical field, might not understand the complexity of VACT precisely because they come from groups that are more socioeconomically favored. It is necessary that intervention programs for this group contextualize, in a non-stigmatized way, the sociocultural reality of families that, at times, also become victims of a perverse, excluding social organization model that promotes violence.

An urgent task for educational institutions that offer initial and continuing training courses for health professionals is the inclusion of disciplines and permanent training spaces that address these topics²⁸. However, for Margarido et al⁵, the training curricula for medical professionals insist on decontextualized and uncritical teaching programs of social reality. Also according to the aforementioned authors, the curricula of these courses mainly respond to market demands and elitist practices, which ends up generating “a gap between the number of students graduating from training centers and the demands of public health services” ( p. 408).

This article does not aim to defend that it is the health professionals’ exclusive responsibility to act in the identification of existing cases of VACT. But, unquestionably, these professionals can be decisive in recognizing this reality and greatly strengthening the victims’ protection network. This study shows that training programs can qualify the professionals’ conceptions, as well as help them feel more prepared to deal with these demands. However, it is necessary a collective effort to ensure that these contents are purposefully incorporated in the training process at all levels, from undergraduate school to continuing education.

FINAL CONSIDERATIONS

The objective of the study was to evaluate the effectiveness of an intervention model, aimed at students and professionals in the health area, capable of helping them in the identification and referral of cases of violence against children and teenagers. Moreover, we aimed to verify at what level of training such program would be the most effective. It was demonstrated, through statistical analysis, that the program was effective and achieved the proposed objectives, that is, it positively changed the previous concepts of students and professionals and prepared them for managing and dealing with VACT cases. It was also found that programs of this size produce positive results in students and professionals with different types of training and experience, which suggests that educational actions about VACT should be included in initial and continuing training programs in the health area courses.

This study has some limitations, such as, for instance, the impossibility of implementing the assessment of the follow-up level or even following the professionals and students longitudinally to verify the practical application of the knowledge acquired in the program. Therefore, it is recommended that future studies monitor and evaluate the performance of students and professionals in real-life situations. It is also noteworthy the fact that there are questions about the gains obtained from participating in a short-term program only, such as in this study. The specialized literature contains a wide debate on the need for such actions as this to be included intermittently in the training of health professionals. Therefore, this investigation raises new investigative questions and makes researchers in the area address the dilemmas that still persist on the topic.