569059

research-article2015
JIVXXX10.1177/0886260515569059Journal of Interpersonal ViolenceRalo et al.

Article
Journal of Interpersonal Violence
1­–16
Prevalence of Family © The Author(s) 2015
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DOI: 10.1177/0886260515569059
Factors Among In-School jiv.sagepub.com

Adolescents in São Paulo,

SP, Brazil

Janaina Maria Ralo,1 Neia Schor,1

Carlos Mendes Tavares,2 and Valter Silva3

Abstract
Family violence is a social and public health issue across the world for many
populations and affects many different types of people, for example, children,
women, and vulnerable adults. Adolescents are one of the main victims of
this important phenomenon. This article estimates the prevalence of family
violence in adolescents and associated factors. The study was carried out in
2012 with a probability and representative sample of 656 adolescents aged
between 11 and 17 years who were enrolled at public schools located in the
extreme South of the city of São Paulo. The association was tested by the
proportion test, Pearson’s chi-square or Fischer’s exact test, and Poisson
regression adjusted by robust variance estimation, considering a level of
significance of 5%. Among adolescents, 38.9% reported having been victims
of family violence. Women were victimized with higher frequency (44.1%).
The factors associated with prevalence of family violence were being of the
female sex (prevalence ratio [PR] = 1.47; 95% confidence interval [CI] =
[1.20, 1.80]) and living only with the father (PR = 1.52; 95% CI = [1.11, 2.08]).

1Universidade de São Paulo, Brazil

2Universidade da Integração Internacional da Lusofonia Afro-Brasileira, Redenção, Brazil
3Universidade Federal de São Paulo, São Paulo, Brazil

Corresponding Author:
Janaina Maria Ralo, Avenida Miguel Stéfano, 400 apto 85 Saúde São Paulo CEP 04301-000,
Brazil.
Email: janainaralo@gmail.com

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2 Journal of Interpersonal Violence 

The prevalence of adolescents who were victims of family violence is high;

however, special attention must be paid to women and adolescents who live
only with their father—they were established, in this study, as a risk group.
Epidemiological studies of this nature are important to reveal the reality of
family violence and to aid the construction of intersectoral public policies to
promote health, prevent violence, and foster a peaceful culture.

Keywords
domestic violence, adolescent, population’s characteristics, alcohol
consumption, illicit drugs

Introduction
Violence has become one of the most serious social and public health prob-
lems across the world (Krug, Mercy, Dahlberg, & Zwi, 2002). Although its
contribution to mortality by external causes is low, family violence is an
expressive problem that causes severe and long-lasting consequences for
individuals, families, and the society (Peden, Oyegbite, & Ozanne-Smith,
2008). According to World Health Organization (WHO; Peden et al., 2008),
violence can be defined as the intentional use of physical force or power,
threatened or actual, against oneself, another person, or against a group or
community, which either results in or has a high likelihood of resulting in
injury, death, psychological harm, maldevelopment, or deprivation. In addi-
tion, it is divided into typologies according to characteristics of those who
commit them: self-directed, collective, and interpersonal, in which the vio-
lence occurs between family members. It can be committed inside and out-
side the home by any member of the family who is in a power relationship
with the victim. It also includes people who are playing the role of father or
mother, even if there are no blood ties (Azevedo & Guerra, 1989; Day,
Lisieux, Zoratto, 2003). The term family violence is interpreted by many as
violence between partners and occurs only in the home setting. However,
family violence can include events that occur outside the home environment
and from an expanded family, that is, grandparents, aunts and uncles, cous-
ins, stepfathers, and stepmothers, all living nearby or in the same household.
In addition, family violence is the official term used by Medical Subject
Headings (MeSH) as a controlled vocabulary for the purpose of indexing
journal articles and books under the theme. It is manifested in several forms
and with different severity levels, and it can be classified according to the
following natures: physical, sexual, and psychological violence, and negli-
gence (Brasil, 2001; Peden et al., 2008).

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Ralo et al. 3

An inquiry carried out in 2008 (Brasil, 2010) at urgency and emergency

services in 22 cities distributed in 15 states of Brazil using data derived from
the Notification/Investigation Form for Domestic, Sexual, and/or other types
of Violence has shown that 27% (n = 2,389) of the registered cases occurred
among individuals aged 10 to 19 years; the highest proportion was identified
among women (28.8%; n = 1,798). In the majority of cases, there was only
one perpetrator (69.4%) of the male sex (66.3%) who had a close relationship
with the victim, usually a spouse (14.1%), friend (14.0%), father (8.3%), or
mother (8.6%). Alcohol consumption by the perpetrator was observed in
29.6% of the occurrences, ranging from 22.7% among men to 30.3% among
women.
Studies have shown that the consequences of the exposure to family vio-
lence include an increased chance of reproducing transgressive and violent
behaviors, early initiation into sexual life and risk behavior, and a higher
chance of presenting depressive symptoms (Avanci, Assis, & Oliveira, 2008;
Bordin, Silvestre, Nascimento, & Duarte, 2006; Teixeira & Taquette, 2010).
The majority of studies about family violence in minors focuses on phase
childhood, without taking into account its specificities; in addition, they use
specific groups—such as victims assisted in health care services, shelters,
and organizations such as the Child Protective Services, and pregnant adoles-
cents—or are restricted to one of the typologies of violence (Ferriani,
Bertolucci, & Silva, 2008; Marinheiro, 2003). Other studies, through the
qualitative methodological approach, are limited to the evaluation of health
care services or to the health care professional’s responsibility for the notifi-
cation of cases of family violence (Brito, Zanetta, & Mendonça, 2005; Saliba,
Garbin, Garbin, & Dossi, 2007).
Thus, it is possible to state that studies that investigate the prevalence of
family violence among adolescents in its completeness are still scarce; this
scarcity contributes to social invisibility, as this is a phenomenon that is
installed in the intimacy of family life and is based on the establishment of
abusive power relationships. Therefore, the present study aimed to identify
the prevalence of family violence and to estimate related factors among in-
school adolescents.

Method
This is a cross-sectional study with a probability sample that is representative
of adolescents studying at public schools located in the extreme South region
of the city of São Paulo, and it was carried out during the period from May to
August 2012. The criterion for inclusion in the research was being regularly
enrolled in the eighth or ninth grades of elementary school or in the first

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4 Journal of Interpersonal Violence 

grades of high school. These grades were chosen because they encompass
adolescents who are in an intermediate phase of adolescence: They are nei-
ther in the extreme of childhood, nor in the borders of youth (Conselho
Nacional dos Direitos da Criança e do Adolescente [National Council for the
Rights of the Child and the Adolescent][CONANDA], 1990; Peden et al.,
2008). Furthermore, it was expected that they had a higher degree of under-
standing of the data collection instrument in terms of reading and filling it in.
A probability sampling technique with a single-stage sampling plan was
used (cluster sampling). It included division by schools with a draw (in all the
selected schools) of classes by year of study and the subsequent listing of all
students who had the characteristics of interest to the study.
Sample size was calculated based on the percentage of adolescents who
were victims of family violence, estimated at 50%, with sampling error esti-
mated at 4% and with a 95% CI. The prevalence of 50% was chosen because
national studies provide data of health and police notification of violence
(BRAZIL, 2010); they did not offer certainty about accuracy due to under-
reporting. Moreover, the prevalence of 50% ensures the largest possible sam-
ple. The calculated sample size corresponded to 600 adolescents, and 15%
were added to this figure to include the possibility of loss of sample. Thus,
the final planned sample comprised 690 adolescents.
The study’s aim, the procedure, the voluntary nature of participation, and
the guarantee of anonymity of individual information were explained to all
the participants. The parents or guardians were requested to sign a consent
document that had been previously approved by the Research Ethics
Committee of the School of Public Health of the Universidade de São Paulo,
under the opinion no. 121/12, on June 4, 2012.
A self-administered questionnaire was used, in which the majority of the
questions were closed and there were some open ones. The questions were
based on studies validated in the academic environment (Schraiber, Latorre,
& França-Junior, 2010; Tavares, 2009; Vital, 2010), and this type of question-
naire has proved to be highly efficient in studies of special groups (Schraiber,
D’oliveira, França-Junior, & Grupo de estudos em População, Sexualidade e
Aids, 2008). The questionnaire was administered during class time for an
average of 40 min.
The study’s dependent variable was victimization by family violence,
according to the adolescent’s report, in the 6 months prior to the research as
there was a higher chance that they would recall the event to avoid memory
biases. It was inferred from the marking of at least one of the affirmatives of
the question: “Mark with an X if in the last six months someone in your home
treated you in the following way” and defined as “family violence.” The
event was categorized as true if there were one or more answers marked, and
the event was categorized as false if the item “no one in my home treated me

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Ralo et al. 5

like this in the last six months” was marked. The exposure factors (i.e., inde-
pendent variables) were the following: sex, age, skin color/race, religion,
housing conditions, number of inhabitants, cohabitation, and use of alcohol
and drugs by family members.
The descriptive analysis was presented by absolute (n) and relative (%)
frequencies. Differences in the proportions between the groups of victimized
and non-victimized adolescents by family violence were first compared in
relation to each factor individually by means of Pearson’s chi-square test or
Fischer’s exact test.
Subsequently, these groups were compared in relation to the diverse asso-
ciated factors. To calculate the PR, a 95% CI was used as well as the obten-
tion of multiple analysis; PR is the analogous surrogate of relative risk for
cross-sectional studies and it was determined by PRs between victims and
non-victims. The associated factors that presented values of p < 20% in the
univariate analysis were included in the multiple Poisson regression model
and were adjusted by robust variance estimation. A significance level of 5%
was adopted.

Results
Among the 690 adolescents included, there was 5% of loss of sample due the
following reasons: incorrect answers to the instrument and/or adolescents
who refused to participate in the study. These losses were not statistically
important so as to negatively affect the representativeness of the sample,
because they were within what had been predicted by the sample calculation
(i.e., 600 adolescents plus 15%). Therefore, the final sample was representa-
tive and encompassed 656 adolescents effectively studied.
A little more than 1/3 of the in-school adolescents reported that they had
been victims of family violence, and this was more frequent among female
adolescents who stated being aged between 14 and 15 years and who lived
with their parents (Table 1).
When the relationship between adolescent and perpetrator was estab-
lished, it was verified that siblings were perpetrators of violent acts more
frequently (Figure 1).
Both in the univariate and in the multiple models, the factors associated
with family violence were being of the female sex and cohabiting only with
the father (Tables 2 and 3).

Discussion
This is one of the few Brazilian studies that have identified the magnitude of
family violence in its diverse typologies among in-school adolescents and the

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6 Journal of Interpersonal Violence 

Table 1.  Distribution of the In-School Adolescents According to Family Violence

and Possible Associated Variables—City of São Paulo (Extreme South Region), SP,
Brazil, 2012.
Non-Victim Victim Total

Variable n % n % n % p

Sex (n = 649)a .001*

 Male 186 68.9 84 31.1 270 41.6  
 Female 212 55.9 167 44.1 379 58.4  
 Total 398 61.3 251 38.7 649 100.0  
Age (n = 647)a .135
  11 to 13 209 64.3 116 35.7 325 50.2  
  14 to 15 171 57.2 128 42.8 299 46.2  
  16 to 17 12 52.2 11 47.8 23 3.6  
 Total 392 60.6 255 39.4 647 100.0  
Skin color/race (n = 656) .312
 White 103 60.6 67 39.4 170 25.9  
  Mixed ethnicity (Black and 179 60.5 117 39.5 296 45.1  
White)
 Yellow 21 52.5 19 47.5 40 6.1  
 Indigenous 10 47.6 11 52.4 21 3.2  
 Othersb 30 71.4 12 28.6 42 6.4  
 Black 58 66.7 29 33.3 87 13.3  
 Total 401 61.1 255 38.9 656 100.0  
Religion (n = 653)a .492
  Has a religionc 288 61.9 177 38.1 465 71.2  
  Does not have a religiond 111 59.0 77 41.0 188 28.8  
 Total 399 61.1 254 38.9 653 100.0  
Housing conditionse (n = 656) .459
  Has access to the 3 resources 283 62.1 173 37.9 456 69.5  
  Does not have access to the 3 118 59.0 82 41.0 200 30.5  
resources together
 Total 401 61.1 255 38.9 656 100.0  
Number of inhabitants (n = .319
655)a
  Less than 3 13 72.2 5 27.8 18 2.7  
  3 to 4 159 64.4 88 35.6 247 37.7  
  5 to 6 175 57.8 128 42.2 303 46.3  
  More than 6 54 62.1 33 37.9 87 13.3  
 Total 401 61.2 254 38.8 655 100.0  
Cohabitation (n = 656) .026*
  Father and mother 282 64.5 155 35.5 437 66.6  
  Just the mother 103 56.9 78 43.1 181 27.6  
  Just the father 10 41.7 14 58.3 24 3.7  
  None of the parents 6 42.9 8 57.1 14 2.1  
 Total 401 61.1 255 38.9 656 100.0  
(continued)

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Ralo et al. 7

Table 1.  (continued)

Non-Victim Victim Total

Variable n % n % n % p

Alcohol consumption among .983

family members (n = 656)
 No 228 62.6 136 37.4 364 55.5  
 Yes 173 59.2 119 40.8 292 44.5  
 Total 401 61.1 255 38.9 656 100.0  
Drug use among family members .388
(n = 656)
 No 375 60.9 241 39.1 616 93.9  
 Yes 26 65.0 14 35.0 40 6.1  
 Total 401 61.1 255 38.9 656 100.0  
aData referring to adolescents who did not answer the variable in question were excluded.
bDoes not know or did not answer.
cCatholic; Evangelical/Protestant, Spiritist.
dI do not have a religion but I believe in God; I do not believe in God.
eConcerning access to the resources: water, electricity, and sewage.

*p < .05 by Pearson’s chi-square test or by Fischer’s exact test.

100

80
Prevalence (%)

60
50.2

40
32.7

22.7
20
11.1

0
Father Mother Siblings Othersa
Perpetrators of the violence as reported by adolescentsb

Figure 1.  Prevalence of victimization by family violence according to relationship

with the perpetrators. City of São Paulo (extreme South region)—SP, Brazil, 2012.
aOthers: grandparents, uncles and aunts, cousins, stepfather/stepmother.
bMultiple choice question reported by adolescents.

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8 Journal of Interpersonal Violence 

Table 2.  Estimations of the Univariate Poisson Regression Model With Robust
Variation for Family Violence—City of São Paulo (Extreme South Region), SP,
Brazil, 2012.

Family Violence

Variable PR 95% CI p
Sex
  Male (reference)  
 Female 1.42 [1.15, 1.75] .001*
Age
  11 to 13 years (reference)  
  14 to 15 years 1.20 [0.99, 1.46] .069*
  16 to 17 years 1.34 [0.85, 2.10] .204
Cohabitation
  Father and mother (reference)  
  Just the mother 1.21 [0.99, 1.50] .069
  Just the father 1.64 [1.15, 2.36] .007*
  None of the parents 1.61 [1.01, 2.58] .047*
Skin color/race
  White (reference)  
  Mixed ethnicity (Black and White) 1.00 [0.79, 1.27] .980
 Yellow 1.21 [0.83, 1.75] .330
 Indigenous 1.33 [0.85, 2.08] .214
 Others 0.72 [0.43, 1.21] .219
 Black 0.85 [0.60, 1.20] .349
Religion
  Has a religion (reference)  
  Does not have a religion 1.08 [0.87, 1.32] .488
Resources
  Has access to the 3 resources (reference)  
  Does not have access to the 3 resources together 1.08 [0.88, 1.32] .455
Number of inhabitants
  3 to 4 (reference)  
  Less than 3 0.78 [0.36, 1.67] .523
  5 to 6 1.19 [0.96, 1.47] .117
  More than 6 1.06 [0.78, 1.46] .698
Alcohol consumption among family members
  No (reference)  
 Yes 1.08 [0.89, 1.31] .431
Drug use among family members
  No (reference)  
 Yes 0.89 [0.58, 1.37] .601

Note. PR = prevalence ratio; CI = confidence interval.

*p ≤ .20 by univariate Poisson regression, with robust variance.

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Ralo et al. 9

Table 3.  Estimation of the Multiple Poisson Regression Model With Robust
Variance for Family Violencea—City of São Paulo (Extreme South Region), SP,
Brazil, 2012.

Family Violence

Variable PR 95% CI p
Sex
  Male (reference)  
 Female 1.47 [1.20, 1.80] <.001*
Age
  11 to 13 years (reference)  
  14 to 15 years 1.16 [0.96, 1.41] .124
  16 to 17 years 1.38 [0.92, 2.07] .120
Cohabitation
  Father and mother (reference)  
  Just the mother 1.16 [0.94, 1.42] .160
  Just the father 1.52 [1.11, 2.08] .008*
  None of the parents 1.53 [0.88, 2.67] .132

Note. PR = prevalence ratio; CI = confidence interval.

aInclusion of the variables, simultaneously, with p < .20 in Table 2.

*p < .05 according to the multiple Poisson regression with robust variance.

associated factors of this family violence. It enables us to understand a sce-

nario of violence among adolescents that goes beyond biophysiological
issues and strengthens the importance of studying violence distinctly from
the vital cycle of childhood, considering its multiplicity as depending on the
social, cultural, and political context in which the adolescent is included
(Castellar, 1989).
Among the studied population, family violence was expressive, similar to
what was observed in the city of Ribeirão Preto, State of São Paulo, Brazil
(44.1%; Bazon, 2008), in Egypt and Mexico (14% and 17%, respectively;
Rivera et al., 2005), and in India (20.9% physical violence, 21.9% psycho-
logical violence, 18.1% sexual violence; Deb & Modak, 2010), and differ-
ently from the findings of the Pesquisa Nacional de Saúde dos Escolares
(PeNSE—National Research on School Children’s and Adolescents’ Health)
where 9.5% of physical aggression was found to be perpetrated by an adult in
the family (IBGE, 2009).
Women were the main victims, despite the fact that the prevalence was
also expressive among men; this finding corroborates studies that reiterate
the influence of the sociocultural context and the importance of considering

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10 Journal of Interpersonal Violence 

family violence experiences in the perspective of gender (Bott, Guedes,

Goodwin, & Mendoza, 2012; Brasil, 2010; Deb & Modak, 2010; D’Oliveira,
Schraiber, & França-Junior, 2009; Rivera et al., 2005; Schraiber, D’oliveira,
França-Junior, & Pinho, 2002). In this sense, the consequences of the event
to the life and health of boys and girls are manifested in different ways: from
eating disorders (Bifulco, Moran, & Baines, 2002) and somatic disorders
(Schoemaker, Smit, Bijl, & Volleberg, 2002) to repercussions on mental
health (Assis, Avanci, Pesce, & Ximenes, 2009) such as depression and anxi-
ety (Liu, Alloy, Abramson, & Whithouse, 2009). Therefore, public policies
are required that take into account the specificity of each group (Holt,
Buckley, &Whelan, 2008).
In this study, siblings were the major perpetrators of violence, similar to
what was found in the city of João Pessoa, Northeastern Brazil (Cavalcanti &
Duarte, 2004) and unlike the findings related to adolescents in India (i.e.,
28.6% of the cases of physical violence were caused by the father and 38.8%
of the cases of psychological violence were caused by the mother; Ellsberg,
Jansen, & Heise, 2006). Thus, there is the possibility of a recurrent practice
used for solving conflicts that is extended to all the people in the domestic
environment. This indicates a vicious circle of the aggressions in the rela-
tional universe (Teixeira & Taquette, 2010), as it has been shown by the
increased risk of suffering violence perpetrated by an intimate partner in
adult life among those who suffered physical violence perpetrated by the par-
ents and who experienced violence among the parents, which reaffirms the
cycle of family violence (Assis, Avanci, Santos, Malaquias, & Oliveira, 2004;
D’Oliveira et al., 2009).
Studies have observed high prevalence of alcohol and drug consumption
among family violence perpetrators and have associated this consumption
with an increased chance of occurrence of the event (Jewkes, Levin, & Penn-
Kekana, 2002; Paredes & Ventura, 2010; Reichenheim, de Souza, & Moraes,
2011; Teixeira & Taquette, 2010); this was not observed in this study, and its
prevalence was found to be independent of the occurrence of family violence.
However, the absence of a statistically significant association is not surpris-
ing because alcohol consumption in Brazil (8.7 L/year/person) is a sociocul-
tural habit that is higher than the world’s mean (6.2 L/year/person) and will
increase until 2025 (10.1 L/year/person; WHO, 2014). Although there was no
association, an expressive prevalence of the use of such psychoactive sub-
stances was observed among the perpetrators, regardless of whether or not
they were victimized by family violence.
In a study about beliefs and perceptions of family conflicts, it was observed
that adolescents who had experienced a situation of violence of the father
against the mother did not attribute the cause, obligatorily, to alcohol use;

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Ralo et al. 11

rather, they explained the occurrence in terms of sociocultural factors.

However, adolescents who had not experienced it attributed it to the use of
alcohol (Sani, 2003). Sociodemographic characteristics, which also predict
socioeconomic aspects, were mostly not associated with family violence
among adolescents, except for cohabitation and sex, similar to the findings of
other studies (Nagassar, Rawlins, & Sampson, 2010).
Although cross-sectional studies may be less expensive in time and money
compared with other designs (e.g., cohort studies), it has been observed that
this study design does not enable one to establish inferences to determine the
direction of events to establish the causal effect. Thus, it suggests that longi-
tudinal studies should be conducted for the identification and understanding
of risk factors for the event. Other important point is the considerable amount
of our reviewed literature, which were published in Portuguese and may be a
limitation in some contexts. However, Brazil is a developing country with a
continental dimension; thus, there is a considerable heterogeneity and our
literature review supports the context of the present study.
Methodological elements of this study can be considered as strong points.
For example, the way in which the main outcome was estimated—the listing
of violence situations with the possibility of multiple markings according to
what had been experienced by the adolescents instead of directly questioning
whether they had been exposed to family violence or not—was an advantage
of this study methodology. The strategy allowed reducing the risk of biases,
a theme that when affected by the issue of secrecy must be considered. For
example, the adolescents are very susceptible to declaration of biases, as can
be found in other studies of this nature, although the sample is representative
to the place of study.
Therefore, the possibility of extending this study to other localities and
populations should be considered, as the research is capable to detect the
family violence and can be useful to help understand the reality of family
violence and the risk situations for the occurrence of the event among adoles-
cents as well as their associated factors.
The prevalence of adolescents who were victims of family violence is
high; however, special attention must be paid to women and adolescents who
live only with their father—they were established, in this study, as a risk
group. Finally, the findings of this study indicate the need for intersectoral
public policies. These policies should seek to enhance health promotion, vio-
lence prevention, and peace culture and should be guided by the gender per-
spective. According to Peden et al. (2008), protection and support are
expected from the families, but they can also be a source of risk. Therefore,
the public policies should also be to break the stereotype that violence is an
effective method of education and discipline perpetrated by the family.

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12 Journal of Interpersonal Violence 

Authors’ Note
The author J.M.R. collected the data, wrote the article, reviewed the literature, per-
formed the statistical analysis, interpreted the data, and revised the manuscript criti-
cally. N.S. helped in the conception and designing, interpreted the data, and conducted
a final and critical revision of the article. C.M.T. helped in the conception and design-
ing of the article, revised the writing, and helped with the statistical analysis and data
interpretation. V.S. helped in the conception and designing, statistical analysis, data
interpretation, and final revision. All authors approve the final version.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.

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Author Biographies
Janaina Maria Ralo is an occupational therapist and has a MSc degree in Public
Health from Universidade de São Paulo, with specialization course in family health.
Her focus of study is on public health, collective health, epidemiology, adolescence
and violence.

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16 Journal of Interpersonal Violence 

Neia Schor is a Full Professor of Universidade de São Paulo and has a PhD degree in
Public Health from Universidade de São Paulo. Her focus of study is on adolescence,
reprodutive health, contraception and gender.
Carlos Mendes Tavares is a statistician and has PhD degree in Public Health from
Universidade de São Paulo. His focus of study is on statistic, epidemiology and public
health releted to sexualit, reproductive health, violence and HIV/AIDS
Valter Silva is a methodologist and has a PhD degree in Evidence-Based Health from
Universidade Federal de São Paulo. His focus of study is on methods of research,
evidence-based health, systematic review, clinical epidemiology and chronic non-
communicable disease.

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