Violence Against Elderly People : Characterization of the Data Reported by the Notification of Injury Information System ( SINAN )

Result: It was possible to identify that the majority of the elderly were males, with a mean age of 78.3 years, of brown color, who had schooling, married/stable union, retired and had no physical or mental disabilities. In relation to the type of violence suffered by the elderly, physical violence had more notifications. The place of occurrence was Violence Against Elderly People: Characterization of the Data Reported by the Notification of Injury Information System (SINAN)


Introduction
At the biologic level, aging is associated with the accumulation of a wide variety of molecular and cellular damage.Over time, this damage leads to a gradual loss in physiological reserves, an increased risk of contracting various diseases.Old age often involves significant changes, besides biological losses [1] With the aging and physical and/or emotional dependency of the elderly, conflicts can arise within the family, and social and institutional spheres.Violence against the elderly is considered a public health problem and is often linked to the dependency process.It is defined as any act, single or repetitive, or omission, that occurs in any supposedly trustworthy relationship that causes harm or discomfort and reduces the quality of life of the elderly.It can be classified in different forms as: physical violence, psychological violence, sexual abuse, financial abuse, neglect and abandonment [2] Violence against the elderly person can be visible or invisible: the visible ones are the deaths and injuries; the invisible ones are those that occur without hurting the body, but they cause suffering, hopelessness, depression and fear.The nature of violence against the elderly can manifest itself in a variety of ways: physical, psychological, sexual abuse, neglect, abandonment, financial abuse and self-neglect.Physical abuse is the most visible form of violence and usually occurs through pushing, pinching, slapping.Psychological abuse corresponds to all forms of scorn, contempt, prejudice and discrimination.Sexual violence refers to the act that occurs in straight or homosexual relationships.Abandonment is one of the most perverse forms of violence against the elderly and includes, for example, removing them from their homes, changing their place in the home in favor of the younger ones, leading them to a long-term institution against their will.Neglect is another important category to explain the various forms of neglect and contempt towards the elderly.Economic/financial abuse refers mainly to family disputes over possession of assets or pensions.Self-inflicted violence consists of self-neglect in which the elderly themselves mistreat themselves, which are suicides and consummate suicide [3].
Violence against the elderly is defined by the World Health Organization as acts or omissions committed once or many times that impair the physical and emotional integrity of the elderly, impeding the performance of their social role.Violence occurs as a breach of positive expectancy on the part of the people who surround them, especially children, spouses, relatives, caregivers, the community and society in general [1].
in the elderly's own houses and the relation between aggressor and victim was unknown.
Violence against the elderly is any act or omission practiced in a public or private place that causes death, damage or physical or psychological suffering [4].There are several factors that allow the occurrence of violence against the elderly, such as: physical and mental disability, personal and financial problems, stress and unprepared caregivers in face of dependency, and impairment of cognitive and functional capacity.Such factors bring consequences for both the victims and their families, which is a major challenge for health services and high costs for the state [5].
Violence has become the objective of epidemiological surveillance in Brazil since 2006, through the implementation of the Violence and Accident Surveillance (VIVA) system.Since 2009, these data have become part of the Notification of Injury Information System (SINAN), which facilitated the expansion of VIVA.By means of ordinance MS/GM No. 104/2011, violence was included in the list of injuries of compulsory notification throughout the national territory [3].Violence notification is a protection instrument that allows knowing the magnitude and severity of violence, with the purpose of promoting surveillance, promotion and protection actions through articulation, structuring and integration with the service network of each municipality, state and Union.The notification should not be regarded as a complaint nor as an instrument for punishment, but as a protective process [6].
Notifying the occurrence or suspicion of violence is mandatory for health professionals, and a fundamental tool for epidemiological surveillance and the definition of public policies for prevention and intervention.Many professionals, because of the lack of knowledge and insecurity of health professionals, end up not notifying cases of violence, mainly against the elderly.The services available for notifying violence will allow the professional to conduct cases with safety and skill [7].
According to several studies on violence against the elderly, in general, the majority of victims are women aged between 60 and 80 years, of brown color, with low schooling, having no disability or disorder, and generally violence occurs within their own residence.The most common form of violence is physical violence, followed by neglect/abandonment [8].
Violence against the elderly is defined as a social phenomenon, since violence is considered a violation of human rights, especially when it comes to a vulnerable population.Violence against the elderly has expanded greatly in recent years, and this phenomenon requires research as soon as possible.The problem of violence involves not only the elderly, but their family, the community and also the professionals who provide care for them, and this arouse our interest in carrying out this research.
Thus, the objectives of the study were: to identify the social characteristics of the elderly in a situation of violence, reported by SINAN in the municipality of Porto Nacional -TO in the year 2014, characterize the most reported forms of violence, place of occurrence, means of aggression, and the relationship with the elderly.

Method
This is an epidemiological, descriptive and exploratory study with a quantitative approach, using secondary data from the municipal health department of Porto Nacional in the Epidemiological and Sanitary Surveillance sector, based on data from SINAN.
During the survey, authors analyzed the 130 violence reporting forms of the year 2014.From this moment, a detailed reading of these files was carried out with the objective of identifying the inclusion criterion, elderly people over sixty years, old and the exclusion criterion, those aged under sixty years of age, reaching the total of five seniors.
After this reading, researchers found a difficulty in relation to the time of the research and the number of the sample.Obviously, the size of the popu-lation in this study does not allow evaluating with such precision the characteristics of the elderly in situations of violence.This implies that the services that provide care have not been reporting all cases of violence against the elderly.
Data collection took place in April 2016 through the Individual Notification/Investigation form (Domestic Violence, Sexual and/or other Interpersonal Violence) available on the Internet.The variables selected were: gender, age, race, schooling, marital status, whether there is any type of disability, forms of violence, place of occurrence, means of aggression and relationship with the victim.
The data obtained were launched with the help of Excel tables and analyzed through BioEstat 5.0.The presentation was in the form of graphs and tables, which were later discussed and based on other studies previously published.
The research was approved by the Research Ethics Committee (CEP) of the Faculdade Presidente Antônio Carlos/Instituto Tocantinense Presidente Antônio Carlos Porto (FAPAC/ITPAC) Araguaína Campus, Tocantins, Brazil, under the opinion of No. 1,244,282, 466/12 of the National Health Council.The anonymity and confidentiality of the information in the registries were guaranteed to preserve the identity of the individuals that composed the analyzed database.

Results
The data showed that, of the total cases reported, the majority of seniors was male, four (80%), and only one female (20%) was registered.The mean age of the elderly was 78.3 years, ranging from 60 to 84 years.In relation to the age group, those aged 60-69 years, two (40%), and those 80 or older, two (40%), stood out.Regarding skin color, all the five (100%) reported being brown.With regard to schooling, it was possible to find one case of illiteracy for the female gender and two with a complete superior among male seniors.Analyzing this variable, there was prevalence of those who had completed higher education, two (40%).It was observed that most of them were married/stable union, three 03 (60%).The majority was retired, four (80%).In the variable deficiency, all five (100%) reported not having physical or mental deficiencies.The demographic social characteristics of the elderly are represented in the Table 1  The characteristics of violence against the elderly related to forms of violence, place of occurrence, means of aggression, relationship with the victim and outcome of the cases are represented in the Table 2.
Regarding the forms of violence, physical violence was prevalent, with 100% of cases.Regarding the place of occurrence, there was prevalence of episodes of violence that were perpetrated at the senior's residence (80%); the means of aggression was by body strength, four (80%).Most reported not knowing the relationship between aggressor and victim, four (80%), but in one case (20%) the offender was the child.The result does not agree with the studies carried out on violence against the elderly, since, generally when violence happens inside the senior's residence, the main aggressor is the child.According to this data, many older people prefer not to declare the type of aggressor and their relationship with them.This may be due to fear of denouncing the aggressor.
Studies have identified that the most reported place of the occurrence of violence against the elderly was the residence, for both gender.The most reported type of violence was physical violence, followed by neglect/abandonment, and finally psychological violence.As for the aggressor, the child was the main aggressor, and in most of the cases reported, the aggressor was male [8,9].

Discussion
Violence against the elderly is considered a serious public health problem and has been occurring at all social levels in all countries of the world, regardless of culture or ethnicity.And it has great consequences for the health of the elderly, their family and society.
Violence against the elderly, also called physical, psychological and sexual abuse, as well as abandonment, negligence, financial abuse and self-neglect.Neglect is one of the most prevalent forms of vio-lence, both in homes and institutions.It generates physical, emotional and social injuries and traumas [9].
The notification of cases of violence is extremely important, since it is an instrument to combat violence.However, studies show that there have been difficulties for the notifications, since many elderly people do not have a perception about the forms of violence that can be perpetrated against them or because they feel frightened to denounce the act of violence or abuse due to several factors such as: fear of being institutionalized, guilt, embarrassment and low self-esteem.In addition, many professionals experience difficulties in identifying maltreatment, thus favoring underreporting.
From the results found, it is understood that professionals have not been reporting all cases of violence against the elderly.This is a very serious issue, since these are vulnerable people, over 60 years old, and this situation needs to be notified.According to the survey, the municipality of Porto Nacional has a population of 4,401 elderly people, corresponding to 8.84% of the population, and these results show that only five (100%) suffered some type of violence.So, the results point out either there is need for a better investigation, or the cases have not been being notified or there has been an underreporting.
In the Senior Citizens' Statute, art.19, it is expected that health professionals are required to report cases of violence and art.57 shows that those who fail to communicate to the responsible authority the crimes against the elderly should respond for an administrative infraction [10] Regarding the characteristics of the victims, the elderly men were the majority.This date does not match the research of São Paulo [11], which says that the different studies show that in violence within the family, the profile of the victim is usually a woman, a widow, over 75 years of age and because they are considered a fragile gender, they are more vulnerable to violence; as well as in the study of Jardim [12], in which 62.5% of the cases of violence against the elderly involved women.
Although the mean age has been 78.3 years, there is no highlight for any age group when the sample is evaluated as a whole.When the gender is evaluated, it is noted that the dominant age group among men is > 80 years, which can be related to the functional and cognitive limitations resulting from this age.
When analyzing the skin color, the brown one was predominant in all the cases.It is believed that these data are related to the predominance of this skin color in the North region.These data are similar to the study of Pinheiro et al. [1], in which 1008 (54.4%) victims of the registered cases were brown.
It was found that the majority of the elderly were married/in consensual union.These findings corroborate with the study of Oliveira [13], which showed that the most victimized elderly were those who had a partner.In a way, this contradicted another study, which showed that the widowed and unmarried seniors were the main victims of violence [1,4].
With regard to schooling, violence was more present among those who were literate.However, other studies have shown that not being literate is associated with an increase in the probability of the elderly experiencing violence.
Lack of schooling alone is not a risk factor, but rather the implications of it, such as difficulties or inability to read, which results in less access to information on ways to prevent or solve problems [15].
Most of the elderly were retired, which can be a contributing factor to violence.The data are similar to Pinheiro et al. [2] in which 61.3% of the victims were social welfare beneficiaries with potential risk of violence within the family.
None of the elderly reported having physical or mental disabilities.It is known that one of the risk factors for violence in the elderly is the physical or mental impairment and the consequent dependence that this situation causes.
The need for care and permanent care may imply a physical and emotional overload for family members and caregivers, which can lead to a potentially conflictive situation and be a propelling factor for occurrence of violence against the elderly [12].
In relation to the form of violence that was most perpetrated against the elderly, physical violence predominated, which can be explained by the physical fragility of the elderly or because it is more easily detected by health professionals.These data are similar to the study of Gil et al. [16], which indicated physical violence (87.7%) as the most reported.Contrary to these results, the study of Jardim [12], referred to negligence as the most reported (41.92%), followed by violence due to abandonment, which appeared with 37.50%, financial violence, with 8.33%, psychological violence, with 4.17%, and finally physical violence, with 2.08% of cases of violence against the elderly.
It is worth emphasizing that violence against the elderly can occur in many ways and often its identification becomes difficult depending on the cultural context in which it occurs, or even because the elderly themselves, due to fear, do not denounce their aggressors [17].
The residence was the site of the highest occurrence of reports of violence.One of the explanations is the generation conflict.The study of Mascarenhas et al. [18] also identified that most episodes of violence against the elderly occurred at the victim's home, with (78.8%) of the registered cases.
As for the means of aggression, body strength was the most prevalent.Regarding the relationship between the aggressor and the victim, reports said it was unknown.This finding may be linked to the fact that the elderly are afraid to reveal the abuser, who is usually a family member.However, in Souza et al. [19], the perpetrator is usually the male child, followed by daughters-in-law and sons-in-law.

Conclusion
The results revealed that the majority of the elderly were male, with a mean age of 78.3 years, of brown color, literate, married/stable union, retired and had no physical or mental disabilities.In relation to the characteristics of the violence, it was revealed that, among the different forms that can affect the elderly, physical violence was most reported; the place of occurrence was in their own residence, by means of body strength, and the relationship between aggressor and victim was unknown.
This study is limited because its result does not reveal the actual condition of the characteristics of the elderly undergoing situations of violence in the municipality of Porto Nacional, in 2014, since there may have been omissions by health professionals or even the absence of a complaint by the victims, which led to a reduction in the number of registered occurrences.
The results found in this study highlight the importance of notifications.The study can be seen as a starting point for improving the professionals' knowledge about this reality that involves the elderly people.These professionals should be alert to any and all signs of violence involving the elderly.The actions to prevent violence must include the training of professionals who serve the elderly through existing protocols for the identification, evaluation and follow-up of cases of neglect against the elderly.

Table 1 .
. Distribution of the sample in relation to the social characteristics of the elderly victims of violence reported by SINAN in 2014 in Porto Nacional, Tocantins, Brazil, by gender.

Table 2 .
Distribution of the sample in relation to the type of violence against the elderly, place of violence, means of aggression, relationship with the victim and evolution reported by SINAN in 2014 in Porto Nacional, Tocantins, Brazil.
Source: Data collected during the survey, April 2016.*: Other records were deleted for not being notified.Source: Data collected during the survey, April 2016.