URBAN VIOLENCE : EFFECTS AND CONSEQUENCES ON HEALTH CARE IN A FAMILY HEALTH UNIT

This study aimed to identify the effects of urban violence in the professionals ́ work of a Family Health Unit and analyze its consequences. This is a research with a qualitative approach of descriptive and exploratory type, whose participants were eight professionals from a Family Health Unit in a city in the metropolitan region II of the state of Rio de Janeiro. The data was collected by applying semi-structured interviews and proceeded to the content analysis to process them. It was identified that the police presence in the community ends up generating fear and tension among professionals interviewed. Urban violence ends up limiting access and provision of health actions, besides contributing to the illness of patients and health professionals. Thus, it is necessary a partnership between the education sectors, justice, and civil society so together they can collectively build effective ways for


INTRODUCTION
Violence is part of the society since biblical times, and it is an issue that has been highlighted in the news, being a discussion topic in many conferences and debates in the public health area in Brazil (1) .Currently, it has been considered a wide magnitude phenomenon, especially for its health consequences, causing sequels and early deaths (2) .
Urban violence has become a public health problem by causing deaths, injuries, physical trauma as well as mental and emotional health problems.It has reduced the quality of life of individuals and the community, showed an inadequacy of the organizational structure of health care services, bringing new medical problems, highlighting the need for interdisciplinary, intersectoral actions to meet the needs of the citizens (1) .
More than one million people die each year worldwide, and many others suffer non-fatal injuries from violent causes (3) .The rates of mortality from violence have been growing since the 80s.In 2009, approximately 139,000 people died from violence and accidents in the country, and 50,472 of them were victims of homicide (4) .
In 2002, the World Health Organization (WHO) published a report entitled the World Report on Violence and Health that defines violence as: The intentional use of physical force or power, real or threatened, against oneself, against another person, or against a group or community that results in a high probability of resulting in injury, death, psychological harm, developmental disability or deprivation (3:5) .This is a broad definition since it does not reduce the violence only to injuries or deaths limiting the consequences that this can bring to the society, covering the damage as disability, deprivation and psychological damage that also represent major implications for the individual´s life and the community.
Currently, the following characteristics of violence prevail in the country: the goal for profit, the relationship between legal and illegal and associated organizations, a fact related to the growing number of murders and high crime rates (5) .
By linking the topic with public health problems, the health sector admits its participation in other sectors of society and the people in building citizenship and quality of life of these people, performing specific actions such as health promotion strategies and prevention of diseases and disorders (3) .
As the primary care is one of the patients´ input ways to the Unified Health System (SUS), the professionals who work there faced daily with the need to act against medical and social problems, urban violence among them.
The phenomenon of urban violence and its copying by the health professionals and services are recent and not part of the everyday practices of this area.These events also cause tension and fear in professionals who often do not know how to act and behave in such situations.Maybe it is because the training of these professionals is still grounded in the biomedical, curative model, and when they encounter a social, complex phenomenon requiring a broad, comprehensive and multidisciplinary approach, they still do not know how to act.
In this sense, this study sought to identify the repercussions of urban violence in the work of professionals of a Family Health Unit and analyze its consequences.

METHOD
A survey was conducted with a qualitative approach of the exploratory and descriptive type to achieve the proposed objectives.The study took place in a family health unit located in a municipality of the Metropolitan Region II of the state of Rio de Janeiro, where the researchers worked in teaching and assistance during 2012.Participants were community health agents (ACS), nursing technicians, nurses and doctors totaling eight health professionals, whose selection was based on the following inclusion criteria: acting on the unit for more than six months and accepting freely participate in the research by signing the Informed Consent Form (TCLE).Exclusion criteria were: subjects who for some reason were away from their activities in the period during data collection.
For data collection, the semi-structured interviews were used that consisted of questions: During the time that you exercise your profession in this unit, did you experience the occurrence of urban violence on the place?If yes, when and how was it?Tell us about it; has violence in the territory caused damage to your service in the unit?If so, tell us how; do you think that violence has consequences for your health?and, for the health of patients in this unit?Do you develop a specific strategy to address violence in everyday life?If so, what are they?This type of instrument allows the interviewee to discuss freely the theme.
Interviews were conducted in an appropriate room of the unit, and were recorded with a digital recorder.,The letter "E" and the number sequentially to each participant to transcribe their testimony were used to preserve the identity of respondents.Data collection occurred from February to March 2013.For the data analysis, the content analysis proposed by Bardin was used, meeting the recommended three stages: preanalysis, material exploration, and treatment of results and interpretation (6) .
The ethical principles defended by Resolution 466 of December 12, 2012, have been met, and the project was approved by the Research Ethics Committee of the University Hospital Antônio Pedro, Fluminense Federal University, under the number 53792, CAEE 04612912.6.0000.5243.

RESULTS AND DISCUSSIONS
The originated discussions analyzing the speeches of the participants gave rise to four thematic categories: "The daily life of urban violence in the territory", "Violence in the territory as a limiting factor in the health care", "The impact of violence on health professionals and patients" and "The fragility of the coping strategies of violence".

The daily life of urban violence in the territory
Urban violence is a social phenomenon that affects the dynamics of the work of family health teams by being inserted mostly in large urban peripheries and act in a context of direct contact with the problem.The national public policy that guides and directs the organization of family health points that the teams should be aware of this phenomenon and take it as a working operation scenarios (7) .
In this category, most of the respondents (87.5%) said they had experienced some urban violence during their role in the family health unit, and this has presented mainly in clashes between police officers and traffickers, as shown in the statement below: I had the opportunity to be in the community doing home visits, and suddenly the police were there, and clashes between traffickers and police happened.Moreover, we go through this disorder, without knowing what to do, not knowing whether go down or goes to someone´s home.Outside, sometimes we were stopped and questioned, wondering where we are what we are doing.However, I think the case of even greater violence was that I was in the community visit and during a shootout I did not know what to do.(E 2) It can be seen that health professionals are also exposed to violence that affects this territory in the daily lives of their work, even they are in uniform and carrying ID, they are approached about their role in the community.This has caused fear, tension and difficulties in decision-making by these professionals.In this sense, professionals also become target to witness the different forms of violence in the community, leaving them vulnerable in the territory of operation as can be seen in the statements below: Other situations that we usually experience sometimes is the entrance to the police with weapons here in the health center, this has happened a couple of times.One, it was to look for drugs inside the unit, arguing that there be the possibility of traffickers hiding drugs or weapons here.(E 4) It was a situation where there was a murder of a citizen of our area, and another citizen was hit by a firearm, and he was here in the community housed somewhere, and the police were looking for him.This time, I got very apprehensive when police were looking for someone or something because we know the risk to happen a shootout, and the stray bullet is too large then it is a moment that we get very tense than usual.(E 6) The visits conducted by the police promptly, sometimes discontinued and without the association of other kinds of actions, has been proven extremely ineffective in combating urban violence within these territories.These actions can produce casualties, including among the civilian population of these localities, contributing to the consolidation of a strong sense of hostility and resentment among the population to this institution within the communities (8) .
It is proved by the testimony of professionals that the police presence in the territory generates some discomfort, tension or greater exposure to situations where there may be the risk of a "stray bullet".It would be up to the police, the State representative within communities, to be present at that location to provide security, but still end up generating more fear and insecurity to individuals.

Violence in the territory as a limiting factor in the health care
Most participants (75%) state that in different ways and at different times violence limits the access and supply of actions developed by the professionals as can be seen below: Many times, it is a situation that requires closing the unit when there is an armed conflict that is a relatively common situation [...].It ends up with an absurd lack in care in the unit, by the impact of a negative result, because we have an agenda to fulfill and some things and end up having that things.(E 4) The progress of pregnant women groups, we had to postpone childcare groups having one after the other, we had to postpone several of them.(E 5) It is a guiding proposed of the family health having individuals, families and communities actively participating in the health-disease process, through individual and collective actions, in their physical and social environment.However, this proposal loses its focus when faced with urban violence in the territory, a serious social problem that interferes with the development of actions by team members (9) .
Before the violent events in the territory, there is an urgent need for re-planning of activities.Consultations, educational groups, among others, end up being rescheduled.When the unit keeps its operation to date of more violence, the number of consultations significantly decreases, and the demand for health services is reduced, as is reported in the following lines: Patients also bring many complaints due to violence, those who come here often because the health center is empty because they do not come.So, we delay routine consultations, vaccines, pregnant women.Therefore, all our progress, the treatments of our patients are completely disorganized when it happens.(E 6) The quality of my work fell, because I cannot visits them, I cannot move around the territory so it can understand it as a whole, I'm limited, I am restricted.Moreover, so for me I fell my income, I cannot produce, then do not show service then it influences enough.(E 8) By associating violence and its impact on their health services, it is possible to see that there is the indirect violence that occurs in the service of these units in communities in situations of violence, where the routine interaction and testimony of external violence (personal contact or with indirect victims of violence) could result in stopping working, creating stress, absenteeism, disruption of interpersonal relationship beyond the disruption in work organization (10) .
Thus, for the vast majority of participants, producing care actions to individuals, families and communities in a comprehensive way considering their particularities and specificities, it becomes a challenge to an area frequently affected by urban violence.
The relocation of activities is also reported in other studies, showing how violence is an obstacle to the professionals who work in family health, mainly because the activities are provided directly in the community and at home, exposing the professional to violent territories (9,11) .
However, some respondents, especially the ACS, highlighted that urban violence in the territory does not compromise doing when this is realized outside the unit.Probably this fact is given by the familiarity of this actor with the territory.
In my service, it never hurts, especially because I do not work in the unit, I work on the streets, in the community, on home visits.(E 2) This ASC professional has the distinction of being resident in the community where he operates.The ACS lives with the similar situations of services´ users, which enable to create a closer relationship with the locals and understand the local reality.He is often accessed by other team members on visits to the territory, as an attempt to protect and continuity of actions.However, it is important that the ACS also experience the same violence: as a resident of the territory and as an employee of the health unit (12) .This feature may indicate the naturalization of violence by ACS, who confronts it as a routine event in his personal and professional life.

The impact of violence on health professionals and patients
Professionals highlighted in their statements that the violence in the territory has contributed to the illness both of them as patients they care.Most of the interviews showed decompensation of mental health emerging as one of the main consequences of violence on the health of individuals.
For patients, there is a direct influence on their health particularly to mental health, we have many cases of mental suffering mainly because of violence.People who have lost their families have lost children, women who have lost young children, brother, sister, relatives, all this creates a hardship on people and ends up causing many health problems but the unit's patients.(E 2) The psychological impact is generalized, with many professionals in the unit and with patients who live near the places where there are conflicts.They always come with this type of complaints, nervousness, anxiety; then it is very evident the impact of violence on the health of people, is the broader term.You can live it in practice, and closely observe the negative changes that occur in people when they are exposed to direct or indirect violence.(E 4) Living with violence in daily work is generating the exposure of workers to hazardous situations that may give rise to feelings of impotence to unsafe conditions, failure to recognize these efforts, fear of risk of exposure and sense of moral integrity and physical threatens.As a result, these situations can produce feelings of vulnerability and psychological distress in the entire team (10) .
Faced with this complex phenomenon and this coping difficulties of the reality, professionals can suffer psychologically, with losses to both their emotional well-being as service to communities.The stress experienced Cienc Cuid Saude 2015 Out/Dez; 14(4):1445-1452 on a daily basis, to generate emotional exhaustion, loss of personal relationships and decreased job satisfaction, has contributed to the high turnover of professionals in family health (13) .
It begins with the emotional, with psychosomatic illnesses, and then they may end up reflecting a physical disease that has already happened.So I came here I had a hypertensive peak, and I had to start treating me because of that [...].(E 6)   Before the whole situation, and exposure in their daily lives, there are people who despite having fallen ill because of the violence they create personal protective mechanisms to this situation to go ahead, as testimony below.
Particularly to me it brought me many problems.It brought me depression, fear.Today we have a tendency, thank God the human being has a tendency to adapt, get used a little actual experiences [...].I just suffer the proportion is slightly smaller, not as much as in the beginning, you will adapt, you will trying to keep up.(E 3) The human being can recover psychologically even when subjected to hardship and violence, facing them, being transformed by them and eventually overcoming them.From this moment, the individual learns to cope with adversity and without submitting to them (14) .

A The fragility of the coping strategies of violence
Addressing violence in the territory is still a challenge for professionals and managers.The strategies adopted individually as no confrontation of the problem, not questioning and reduced intercommunication between sectors, seem to be part of the arsenal of actions of the professionals.Thus, the negotiations that guide health practices in the territory leave spaces for not solving the problem of violence.
Look, there is no strategy so specific, what we try is not to get too involved, do you understand, do not get knowing a lot, not find out much of what is happening, even because we have no way to influence, we cannot solve this situation.Therefore, I pray a lot to God to protect us [...].However, then, a strategy, a situation that will not have, because it is something that happens when runs away much of the control of us all because it depends on what's going on [...].I think this strategy should be organized in a way that involves the community, various sectors, various spheres, not only us.(E 6)   According to the testimony and previous studies on violence, it is necessary community participation in fighting against violence, together with other sectors of society such as non-governmental organizations (NGOs), religious institutions, neighborhood associations, so that together they plan and implement effective actions to combat and coping violence (15) .
The family health units have a direct relationship with the association of residents, since the health professionals working are employed by associations through comanagement agreement established between the government and civil society.Thus, actions could be thought of the community by establishing partnerships between the health sector and civil society, but these are still individual and non-institutionalized movements.
We do meetings with the president of the Association, so that when the community has these disorders like an invasion, we close the unit.This has been combined with Him.(E 7).
It is important to highlight that any violent crime prevention strategy should consider the existence of some factors that predispose the occurrence of violent acts.In this sense, any preventive action should be multisectoral nature.Considering that violence is a complex and multifaceted phenomenon, prevention programs to its occurrence should also be interdisciplinary in attaining success because no action alone has such positive results as those that are developed in an integrated way (16) .
So far we cannot stop to work it in a rational way because it is a little tricky, a very great emotional instability.It might be a further proposal.However, the ideal would be to have a comprehensive way to confront violence and not the only repression, and is just trying to quell the violence at its source.(E 4)   Through this statement, it is proven that the movement to resize the issue of violence is very fragile, often focused on enforcement and Cienc Cuid Saude 2015 Out/Dez; 14(4):1445-1452 not prevention actions.There are also specific movements of some professionals to combat the violence, as shown in the statement below: Promote peaceful attitudes to the citizen.I think this would be one of the contributions that we as a health unit could give, it's not very direct to maintain a permanent campaign in clear medical consultation, counseling to assess the patient what was his attitude towards right situation, what happened, what could have been done to avoid, always a moment of reflection, I think we can help a lot in that.(E 4)   As well as violence by its complexity should be seen by a number subjects, strategies for solving it need to be discussed collectively with the various sectors of society, so that together we can develop proposals and effective action and can strengthen, and encourage all involved levels.

CONCLUSION
This study enabled to note the fear and tension that is generated when the professional police are present in the community.As already evidenced, police were created to bring security to the population.However, the everyday reality is quite different.With its presence, relationships and work processes become complex, often away patients to search for the service.
As the limitations of health actions, it was highlighted that violence in the territory harms to health services and actions on the unit where were highlighted: unit closure, cancelation of groups that were scheduled, delays in clinical practice, vaccination of children and monitoring of pregnant women.So, there is the need for all staff perform a new action planning that were discontinued during this period, so that patients are not harmed and that the face of all odds has quality care, resolute and full, as recommended by the SUS.
Another aspect that was evident was that violence in this territory has contributed to the illness of both professionals and patients assisted by them.Professionals reported the emergence of diseases such as depression, hypertension, beyond fear, a fact that has led some to seek such treatment/help with other professionals.From the perspective of the professionals interviewed, the main complaints that lead patients to seek the unit are: anxiety, nervousness, difficulty sleeping and decompensation of underlying diseases such as diabetes and hypertension.
Finally, it was evidenced by the speeches of professionals that there are no specific strategies for urban violence.It was reported in some lines, unit closing as the way to solve the problem, or else non-involvement with the situation.In only one unit, it was observed that the professional during his performance in the unit makes moments of reflections with patients about behaviors taken, being a non-institutional effort to promote peaceful attitudes.Thus, it becomes an urgent priority to discussed collectively, institutionally, ways to combat the violence in this country.
Therefore, urban violence is a social reality in this territory, and it was confirmed by the statements it committed to the very health professionals work processes, and the way of life and health of patients and professionals needing to be collective reflection object of society.
It is expected that this study can contribute to the reflection of health workers who work in primary care on the theme of urban violence and to provide support for the development of other studies that use an interdisciplinary approach to the subject, and foster further discussion in collective spaces about coping strategies for this phenomenon.
VIOLENCIA URBANA: REPERCUSIONES Y CONSECUENCIAS EN LA ATENCIÓN A LA SALUD EN UNA UNIDAD DE SALUD DE LA FAMILIA RESUMEN Este estudio tuvo el objetivo de identificar las repercusiones de la violencia urbana en el trabajo de los profesionales de una unidad de Salud de la Familia y analizar sus consecuencias.Se trata de una investigación con abordaje cualitativo del tipo descriptivo-exploratorio cuyos participantes fueron 8 (ocho) profesionales de una unidad de Salud de la Familia de un municipio de la Región Metropolitana II del estado de Rio de Janeiro.La recolección de datos se llevó a cabo a través de la aplicación de entrevistas semiestructuradas y se procedió al análisis de contenido para su tratamiento.Fue identificado que la presencia de la policía en la comunidad acaba generando miedo y tensión entre los profesionales entrevistados.La violencia urbana acaba limitando el acceso y la oferta de acciones de salud, además de contribuir para la enfermedad de los usuarios y profesionales de salud.Por lo tanto, hay la necesidad de la colaboración entre los sectores educación, justicia y sociedad civil para que juntos puedan construir colectivamente formas efectivas para el enfrentamiento de la violencia urbana.