Violence in Immigrants : Effects on Health , Perception of Discrimination and Loneliness

The objective of this study was to analyze the prevalence of violence against Brazilian immigrant women since their arrival in Portugal and to know the consequences of this violence on the women's experience, specifically on health, perception of discrimination and loneliness. Conducted in the first half of 2016, with 682 women over 18 years of age living in Portugal for more than three months. Two types of collection were instituted: online, through the Limasurvey Platform, and in person, at the Consulate General of Brazil in Porto and Lisbon and in the Mais Association, applying the Discrimination Perceptions, Loneliness Scales (ULS-6) and Mental Health Problems. The results suggest that Brazilian women who have been targets of violence in Portugal have a worse perception of their health, a higher perception of discrimination, a higher level of solitude and more mental problems, which indicates that this group of immigrants has some vulnerabilities in the country, since violence has a harmful effect on physical and mental health. It is believed to be crucial to create a policy that aims at transforming actions aimed at strengthening the citizen and collective consciousness of these immigrant women. Violence in Immigrants: Effects on Health, Perception of Discrimination and Loneliness ORIGINAL Eliany Nazaré Oliveira1, Félix Neto2, Gleisson Ferreira Lima3


Introduction
According to the United Nations, the number of international migrants worldwide has been growing rapidly.In the year 2000, there were 173 million; in 2010, totaled 222 million and in 2015, reached 244 million.An important phenomenon has occurred in transnational migrations: feminization.In Europe, the percentage of women in 2000 was 51.6, rising to 52.4 per cent in 2015.[1] Immigrants face many challenges when they settle in a foreign country.In the case of women, it implies greater vulnerability in situations of exclusion, such as domestic violence, rape, trafficking, sexual exploitation, female genital mutilation.In migratory contexts, it can mean increased risks in case of social and economic exclusion, both in pregnancy and in the health of the newborn.[2] For the United Nations, despite the benefits of migration, immigrants in general are the most vulnerable in society.They are often the first to lose their jobs when the economic downturn often occurs, working for lower wages, longer hours and worse working conditions.While for many, migration is a training experience, others coexist with human rights violations, abuses and discrimination, particularly women and children are often victims of trafficking in human beings and various forms of violence.[3] Throughout the world, in both rich and poor countries, women are being beaten, trafficked, raped and killed.These human rights abuses not only cause great damage, but also affect the fabric of entire societies.[4] In the international literature on violence against immigrant women there are some important researches that deal with the subject from some perspectives.[5][6][7][8][9][10][11][12][13] However, studies that associate the influence of the violence suffered to the state of general health, perception of discrimination, level of solitude and mental health problems of immigrants were not located in official scientific platforms.
Portugal follows this immigrant growth and the phenomenon of feminization.Among the immigrant population, Brazilians are in greater numbers.Regarding this group, the Foreigners and Borders Service states that the Brazilian population with official visas in Portugal totaled 87,493 individuals (53,537 women and 33,956 men).[14] The multiple forms of violence that affect Brazilian immigrants in Portugal are evidenced empirically in everyday life.In general, these demands come to the aid and protection agencies, in the form of a request for help.The violence suffered by these people is the product of social relations constructed unevenly and generally materialized against those who find themselves in some physical, emotional and social disadvantage.Social and economic inequality (poverty/misery/social exclusion) and discrimination of gender, race/ethnicity and sexual orientation are factors that leave people in a situation of greater vulnerability.[15] When investigating cases of violence in the Association of Women Against Violence (AMCV) in 2004, 23% of the total number of new situations they encountered were women of foreign origin, mostly from Portuguese-speaking African countries and Brazil.[16] Violence against Brazilian immigrants in Portugal becomes more complex, as it is exercised in the form of discrimination, in some cases understood as racism that has been shown in the labor market and in daily social interactions.[17] The trajectory of women victims of violence is often a long and lonely journey.Fear of reprisals, feelings of shame, economic dependence, fear of losing children, and other similarly important aspects contribute to the violence remaining in the family space and not being denounced.In the case of immigrant women, the road to denunciation may be even longer.[18] Immigrant women suffer exactly the same crimes as other women in Portugal.The situation is aggravated when it comes to women in irregular situations, illegal and undocumented, since state agencies, as well as associations and NGOs cannot intervene as much as they would like.They are women who are even less likely to flee from violence because they are more helpless.
The need for a greater understanding of the phenomenon of violence and its implications in the adaptation of immigrant women to the psychosocial aspects involving the health-disease process, discrimination and loneliness are important, since these are important elements for the measurement of the quality of life of a specific group.
The contextualization developed in the above paragraphs justifies the object of study proposed in this article: The phenomenon of violence experienced by Brazilian immigrant women since their arrival in Portugal and the influence on health, perception of discrimination and loneliness.Therefore, this research was designed with two objectives: the first is to analyze the prevalence of violence against Brazilian immigrant women since their arrival in Portugal; the second seeks to know the consequences of having been subjected to violence in Portugal in the psychosocial aspects of women's experience, specifically in terms of health, perception of discrimination and loneliness.In this scenario, we present a question of study and four hypotheses.
• Q1: To what extent do Brazilian women consider that they have been subjected to violence since their arrival in Portugal and in what ways?• H1: It is expected that Brazilian women who have been subjected to violence will show a worse perception of their health.• H2: It is expected that Brazilian women who have been subjected to violence reveal a greater perception of discrimination.• H3: Brazilian women who have been subjected to violence are expected to reveal a higher level of loneliness.• H4: It is expected that Brazilian women who have been subjected to violence will reveal more mental health problems.

Method
Cross-sectional study conducted in the first half of 2016 in Portugal, with 682 Brazilian immigrant women over 18 years of age living in the country for more than three months.The sample size was calculated using the formula for the infinite population ratio.Regarding the nationality of the spouse, of the women who have a husband, 57% are of Portuguese nationality and 37%, Brazilian; (four elements), Angolan, Cape Verdean and Spanish (two elements each), as well as German, British, Dutch and Senegalese nationalities (one Element each).
As for the children, 58.4% said they had children and 41.6% did not have children.In the subsample of those with children, 45% have a child, 40% have two, 12% have three, 3% have four and 0.3% (one woman) have five children.
Regarding the level of schooling, Brazilian immigrants present the following: 5% have incomplete elementary education and 5% have complete elementary education; 8% have incomplete secondary education and 25% have completed secondary education; 15% have incomplete higher education and 15% have completed higher education and 27% have postgraduate studies.The situation of housing, with whom they live in Portugal, 69% live with their own family, 15% live alone, 6% with Brazilian friends and 10% with Portuguese family.
The labor market and the labor market are as follows: 21% are unemployed, 44% are employed, 17% are students, 5% are students and workers, and 13% are housewives.

Instruments
As for the instruments, a survey with three scales was used to evaluate the perception of discrimination, loneliness, mental health problems and other psychosocial issues.
The Discrimination Perceptual Scale includes five items, assessing the feeling of not being accepted in society because of their ethnicity.An example of an item is: "I was taken or insulted because I was Brazilian".[20] Participants responded on a five-point scale from "strongly disagreeing" (1) to "strongly agreeing" (5).In this study, the scale had an internal consistency of 0.90.
The Solitude Scale was included in the questionnaire used in Portugal based on a previous study 21 .The Portuguese short version of the Solitude Magazine Scale [22] was used, consisting of six items (ULS-6).[21,23] An example of an item is: "I miss comradeship."Participants were asked to indicate how often they felt this way (never/rarely/sometimes/often).In this study, the scale had an internal consistency of 0.82.
The Mental Health Problem Scale consists of fifteen items that allow the evaluation of depression, anxiety and psychosomatic symptoms, with five items for each of these three areas 24 .Participants responded on a five-point scale from "never" (1) to "often" (5).Examples of items are: "I feel tired," "I feel agitated," and "I feel unhappy and sad" that correspond, respectively, to psychosomatic symptoms of anxiety and depression.The internal consistency of this scale was 0.96.
A questionnaire identifying psychosocial characteristics was included.In addition to requesting the characterization of the subjects from the age, housing, schooling, employment status, marital status, offspring and length of residence in the country, participants were also asked to evaluate their health through the question "In Overall, you would say that your health is"?This question was rated on a five-point scale from one (very bad) to five (excellent).
In the end, it was asked if they had already suffered some kind of violence in Portugal since their arrival.The answer being positive, they pointed out the types, the aggressors and if they looked for some type of aid to the confrontation of the situation.

Procedures
The research was presented to the Brazilian Consulate General in Porto, Lisbon, Faro, the Brazilian Embassy in Lisbon and the Associação Brasil.These bodies have significantly supported the identification and approach of Brazilian women living in Portugal.The data collection took place from July to September 2016 and two modalities were instituted: online, through the Limasurvey Platform, and in person, at the Consulate General of Brazil in Porto and in Lisbon and in the More Brasil Association.To increase the online approach, a Facebook group was created entitled: Brazilian people living in Portugal.The survey respondent's link was made available on social networks, the official pages of the Mais Brazil Association, the Brazilian Consulate General in Faro and the Brazilian Embassy in Portugal, as well as the group created by the researchers on Facebook: Brazilian people living in Portugal.The approach and face-to-face identification were developed at the Consulate General of Brazil in Porto and in Lisbon and in the Mais Brazil Association.The research was presented with regard to the objectives, the method used and their social importance.Subsequently, voluntary participation was requested to complete the survey.It is noteworthy that, in both modalities of approaches, the participants declared their agreement through the Informed Consent Term.
As inclusion criteria, women were adopted as a Brazilian woman, living in Portugal for more than three months and being over 18 years of age.It is important to highlight that this work was developed within a broader research entitled: Health status and quality of life of Brazilian immigrants in Portugal, which obtained a favorable opinion from the Ethics and Research Committee of the Vale do Acaraú State University (UVA) No. 1,692,063.[25] The data were compiled in the Limasurveye Platform processing was performed by the Statistical Package for the Social Sciences Program -SPSS, version 24.0.The parametric t test was used to define the inferential analyzes, [26][27] and for the analysis of the internal consistency of the scales, Cronbach's Alpha test was adopted.[28]

Results
In the sample, 26.9% already suffered or went through some type of violence in Portugal and 73.1% declared that they had not been subjected to any type of violence.One draws attention to the biases of the research: some women may have stated that they have not suffered any type of violence because they do not remember at the time of the research or even because they do not perceive themselves as victims of violence.(Table 1) When examining the relationship between having been subjected to violence since the arrival in Portugal of Brazilian women and some sociodemographic variables, the situation is presented as follows.(Table 2) The effect of the age of these women was not statistically significant, [F (1, 672) = 1.41, p = .24].In relation to the women who reported the number of weekly hours of work, their effect was also not significant, [F (1,324) = .11,p = .74].
The length of stay in Portugal is significantly associated with having been subjected to violence, [χ 2 (1, 675) = 5.90, p = .02].There is a lower proportion of women who have lived in Portugal for less than a year (16.8%) than a year ago or more (28.8%)who reported being subjected to violence.There is also a significant association between marital status and violence, [χ 2 (1, 675) = 5.90, p = .02].There is a greater proportion of single women (31.5%) than in other situations (married, de facto union, divorced, widowed) (23.9%) who were subjected to violence.There is no significant association between having children, [χ 2 (1, 673) = .92,p = .19],level of schooling, [χ 2 (1, 675) = .57,p = .45]Been subjected to violence.Finally, there is a marginally significant association with immigrants, [χ 2 (1, 671) = 2.86, p = .09].There is a tendency for women living alone (34%) to have been more targeted for violence than those living with them (25.8%).
In the subsample of 182 cases, 26.9%, who reported having suffered violence in Portugal, also identified the types characterizing the situation: 23.6% have already suffered psychological/moral violence; 12.7% have already been bullied; 7.5%  3 indicate that 14.9% say that their health is excellent; 32.9%, which is very good; 46.8%, which is good; 5%, which is bad and 0.4%, which is very bad.Consequently, the findings indicate that the Brazilian women surveyed positively evaluated their health status, where 94.6% said they were healthy.
In the search for answers to constructed hypotheses, the data in Table 4 show the influence of the violence suffered in relation to the perception of health, perception of discrimination, level of solitude and mental health problems.
The influence of violence on health perception is statistically significant [t (674) = 4.87, p <.001)].The mean of the Health Perceptions Scale is higher for those who have suffered some type of violence in Portugal (M = 2.68) than for those who did not suffer any type of violence (M = 2.34).Therefore, it can be concluded that the perception of health is more negative for those who have already suffered some type of violence in Portugal.
The effect of having suffered violence, in the perception of discrimination, is shown to be statistically significant [t (673) = 14.00, p <.001)].The average of the Discrimination Perceptions Scale is higher for those who have suffered some type of violence in Portugal (M = 3.84) than for those who did not suffer any type of violence (M = 2.51).Therefore, it can be concluded that the perception of discrimination is higher for those who have already suffered violence.
The effect of having suffered violence at the level of loneliness is shown to be statistically significant [t (674) = 8.96, p <.001)].The mean of the Solitude Scale (ULS-6) is higher for those who have suffered some type of violence in Portugal (M = 2.68) than for those who did not suffer any type of violence (M = 2.34).Therefore, it can be concluded that loneliness is superior for those who have already suffered violence.
The effect of having experienced situations of violence was significant in the reduction of mental health, [t (674) = 5.45, p <.001)].The Mental Health Scale average is higher for those who have already  suffered some type of violence in Portugal (M = 2.51) than in those who did not suffer any type of violence (M = 2.09).Therefore, it can be concluded that mental health is inferior for those who have already suffered violence.
The results show that the group of Brazilian immigrants living in Portugal, who reported having suffered some type of violence, had a lower perception of health, a perception of higher discrimination, a higher level of solitude and more mental health problems compared to who did not suffer violence.

Discussion
The study raises a question: To what extent do Brazilian women consider that they have been subjected to violence since their arrival in Portugal and what are their forms?It also presents four hypotheses, all of which have been confirmed.Brazilian women who have been subjected to violence in Portugal have a worse perception of their health, a greater perception of discrimination, a higher level of solitude and more mental problems.
It was possible to characterize the types of violence faced, the aggressors and the forms of support sought.Just like in this, few women have reported sexual violence in intimate relationships.Women's stories suggest that sexual violence, in the context of intimate relationships, is not often discussed, especially in specific research surveys on the subject [29].Emotional abuse and psychological violence were the main types revealed by the women interviewed.On interpersonal violence (IPV) against immigrant women, Pitts states: "It occurs in all ethnic and racial groups and affects women of all ages and socioeconomic backgrounds.Battered women of Latin American descent are less likely to seek formal help, these women are more likely to spend more time in abusive relationships before seeking help.[13] Violence is a scourge that affects both developing countries and nations and the most privileged populations.In Portugal, it is estimated that one third of women have already suffered some form of violence, whether physical, sexual or psychological.
When it comes to immigrant women this context becomes even more complex.The trajectory of women victims of violence is often a long and lonely journey.Fear of reprisals, feelings of shame, economic dependence, fear of losing children, and other equally important aspects contribute to violence remaining in the family space and not being denounced.In the case of immigrant women, the road to denunciation may be even longer.
The context in which these immigrants live can make it difficult to cope with any type of violence.Many will find it difficult to deal with the cultural patterns of the host country, which makes them more vulnerable to various situations of violation of rights.[30] There are some authors who associate the violence suffered with the loss of capacity of management of the life and the physical and mental illness.There is an unleashing of events that are crucial to the health imbalance.Victims of violence coexist with a high stress load.This, in turn, generates psychic suffering, favoring the onset of mental illness, at the individual and collective levels.[31] In this perspective, it is worth emphasizing that the triad of events under discussion is included in the mental health-disease process, which is a dynamic and particular expression of the living conditions of individuals and of human collectivities, representing the different qualities of the vital process and the different skills to face challenges, aggressions, conflicts, changes.
Regarding the self-perception of health, the findings indicate that the Brazilian women surveyed positively evaluated their health status, since the majority affirm to be healthy.In a study about quality of life in the migratory context, with selfrated health, the immigrants surveyed have a positive self-assessment of their general conditions.[32] It is worth inferring that the quality of life and health is reflected in the evaluation that each one makes regarding its conditions, involving subjective and objective elements.A national survey on immigrant health compared the health of the Portuguese with residents of Portugal from other countries.The results showed that the self-perception of health status was more positive among immigrants than among Portuguese (immigrants: 62.8%, Portuguese: 48.4%).However, in the first group, this favorable assessment decreased with the length of stay in the country, never reaching the values observed in the Portuguese population.When comparing this indicator by sex, it was found that men, both immigrants and Portuguese had a more favorable self-perception of health status than women [33].
The World Health Organization draws attention to a broader context: migration and health issues associated with it are crucial challenges for governments and societies.It is known that approaches to managing the consequences of migration and health care are increasing challenges associated with the volume, speed, diversity and disparity of modern migration.
The most important results demonstrate the influence that violence exerts on the perception of health, the perception of discrimination, solitude and mental health in Brazilian immigrant women living in Portugal.In this study, the perception of health is more negative for those who have already suffered some type of violence.Mental health is lower for women who have suffered from some type of violence and the perception of discrimination is higher for those who have been victims of violence.
The various types of violence faced by immigrants, whether women or men, will have a decisive influence on their ability to make choices and adopt healthy behaviors to address problems as a consequence, making them more vulnerable to psychological disorders and physical illness.In most cases, the structural problems faced by immigrant women, such as discriminatory policies at work, are immigration criteria that can be considered as individual problems (problems of adaptation).
Prejudice generally has a negative attribution, of discredit in society, linked to discrimination and exclusion.Because prejudice is morally condemned and discrimination is legally subject to punishment, its manifestations have become increasingly subtle, disguised, making it difficult to gather evidence that has legal validity in many countries.Many discriminations become normative, and some are already stated as rules, for example, the preference for non-immigrant women to enter the labor market.[35] Regarding the various forms of violence against immigrant women, today a significant number of women working as domestic workers or in poor conditions in Europe have a university education and find in these occupations the best alternative for generating income.[36] Some are married and leave their children in countries of origin whose rulers enjoy great advantages with the remittances of money entering their territories through these migratory flows.
Study "Stereotypes and violence against Brazilian immigrants in the Portuguese average" reveals, based on the sources analyzed, that the illegal immigrant is represented as a transgressor of the law, criminalized by its illegality or by the xenophobic society as "prostitute", "escort","husband thief".This image of the immigrant promotes their social isolation.[37] In analyzing the violent processes affecting immigrant women, it is understood that this violence, which establishes what the other is not or what it is, denies or affirms otherness by assigning negative or positive values to it.Racial, sexual, gender, physical, emotional, etc., is exercised by those who have some kind of power in society.But this does not mean that this way of relating to the other and the values produced are unalterable.
In this scenario of migration, violence and gender, important reflections must be made.In the field of immigrant health, it is worth mentioning that the violent processes that affect them are considered harmful and harmful to their physical and mental health.European studies affirm the predominance of social representations and stereotypes of the immigrant as a fragile person from the point of view of mental health, strange, exotic, threatening and dangerous.[38] Such perceptions and metaphors permeate the social and interpersonal relations between immigrants and the native population, triggering feelings of low self-esteem, sociocultural isolation, affective deficiencies and feelings of rejection, which often lead to depressive states, configuring the so-called "Ulysses Syndrome", multiple and chronic stress syndrome linked to immigration.In the article: Identities in Crisis: immigrants, emotions and mental health in Portugal, [39] the author presents this information: the medical reading of the migratory process is hegemonic, since the European Parliament is supporting several investigations about this disease, and this category may be included in the next issue of DSM.On the internet page of the High Commission for Immigration and Intercultural Dialogue (ACIDI, Portugal), Ulysses Syndrome is indicated as a psychological illness caused by loneliness, the feeling of failure, the hardness of the daily struggle for survival and fear and lack of trust in institutions, which is increasingly affecting immigrants, to the point that thousands of cases have already been diagnosed.
The phenomenon of migration deserves to the health-disease process of immigrants, since it can influence the appearance of physical and mental illnesses.In the case of the Brazilian women studied, the determinants that influence the quality of life and health in Portugal became evident.

Conclusion
This article had the intention of knowing if the Brazilian women in Portugal consider themselves to have been the target of some type of violence.To characterize the forms of conditioners of the declared violence and to relate the violence suffered with the psychosocial constructs: health perception, perceived discrimination, solitude and mental health.The four hypotheses raised were confirmed, that is, the violence suffered by Brazilians living in Portugal influenced the negative levels of health perception, the higher perception of discrimination, the higher degree of loneliness and the more negative levels of mental health.The result suggests that this group of immigrants has some vulnerabilities in the host country, since violence generates harmful effects on physical and mental health.Some particularities of the situational context, for example, the types of violence suffered and the aids triggered are important diagnoses for the construction of strategies of support and protection to this population group.It is understood that all these aspects need further analysis, but it is also considered that the material presented in this article can be a starting point for the reflection and production of knowledge on the issue of immigrant women, mainly related to migration and violence .
The limitations of this study can be considered because it has not included a qualitative deepening where the context of situations of violence, loneliness and discrimination could be a counterpoint, enriching the presented diagnosis.This study provides new insights on the violence suffered by immigrant women in Portugal, but there is a need for a deeper understanding of the context and forms of coping to overcome the problem, and studies are suggested that capture the causal mechanisms, the conditioning and the consequences of violent processes.
Finally, it is believed to be crucial to create a policy that aims at transforming actions aimed at strengthening the citizen and collective awareness of these immigrant women against the various forms of violence, not reducing them to the category of passive victims, nor subjecting them to stigmatization and exclusion in the country they have chosen to live.

Aknowledgements
To the College of Science of Education and Psychology of the University of Porto -Portugal, to the State University Vale do Acaraú-UVA, Ceará, Brazil and to the Government of the State of Ceará.

Table 2 .
Prevalence of violence against Brazilian immigrant women since their arrival in Portugal due to sociodemographic variables.

Table 1 .
Prevalence of violence in Brazilian immigrant women since their arrival in Portugal.

Table 4 .
Influence of violence on the perception of health, discrimination, solitude and mental health in Brazilian immigrant women living in Portugal.

Table 3 .
Perception of the general health status declared by Brazilian immigrant women living in Portugal.
In general you would say your health is... F %