João de Deus Quirino Filho¹, Vânia Barbosa do Nascimento¹, Modesto LeiteRolimNeto^*2

1. Programa de Pós- GraduaçãoemCiências da Saúde, Faculdade de Medicina, FMABC, Santo André, São Paulo, SP, Brazil

2. Universidade Federal do Cariri – UFCA, Faculdade de Medicina, Barbalha, Ceará, Brazil

^*Corresponding author: Modesto Leite Rolim Neto,Federal University of Cariri,UFCASchool of MedicineBarbalhaCearaBrazil

Abstract

The number of Brazilian children and adolescents’ cases involved in violent events has been significantly increasing each year. The perverse character of social differentiation that several races suffer in the country becomes evident based on the numbers of violence against the white population.Methods: We conducted a systematic literature review with meta-analysis searching for original articles in the Scopus and Biblioteca Virtual emSaúde (Health Virtual Library, BVS) electronic databases, in which the latter hosts databases like MEDLINE and LILACS. We calculated ratio meta-analysis considering the model and method of random effects with the support of the Stata Program 14.0. We also used the metabias calculation and demonstration to verify the investigated effect, even in small samples.Results: The search resulted in studies developed in foreign countries and in Brazil, even though the number of articles found in Brazil (n=15) is rare compared with foreign countries (n=125). Results are a more faithful violence cut in the health of adolescents than of black children, considering that we only found a few studies focused on children about this theme. The most used age in the studies was 12 to 19 years. Evidence show that the violence effect in the health of African descent populations is significant even in small studies.Conclusion: Violence is a factor with important repercussions related to the health-disease process in the African descent population during the youth. Ethnic disparities regarding deaths of black adolescents due to violent causes are the extreme outcome of this factor. Being adolescent and black in Brazil implies a three times higher chance of evolving to death if compared with a white adolescent.

Keywords: Children, Adolescents, African descents, Violence, health

Introduction

The number of Brazilian children and adolescents cases involved in violent events has been significantly increasing each year, especially in groups that are more subject to the process of socioeconomic vulnerability.Black young subjects represent most part of these cases and they many times identify their life opportunities connected with marginality or even being exposed to communities without better housing and security conditions[1].Hence, Brazilian favelas [slums] and peripheral communities are spaces open for the reproduction of violent situations due to a historical process of social inequality and exclusion of these regions[2].

The perverse character of social differentiation that several races suffer in the country becomes evident based on the numbers of violence against the white population that has presented a decrease, whereas the black population statistically suffers increasingly more and faces themselves every day with sequelae due to a disproportional social that creates victims of a society that values the act of having assets, but that does not provide their members with an equalitarian form of finding licit paths to achieve it[2,3]. Using information and creating a panorama with what scientific papers discuss on the theme become essential for trying to understand how these biopsychosocial processes deal with the presence of violent acts in their base communities.

Despite the alarming situational context that Brazil presents, this is not a problem that affects only this South American nation[1,4].Consequently, comparing and using articles focused on the same thematic aspect in another region of the world, which despite its larger development, has also been through the same historical events related to slavery, to a cultural process of ethnic exclusion and miscegenation of a population that is essential derived from immigrants, becomes a coherent path to complete the information needed to perform a summary in the formats needed for the work[2-4].It becomes important correlating the way how both societies got organized regarding exposure of the black young subject to violence as a public health problem that should be combated in an inter-sectorial way[4].

Evidence that demonstrate health consequences of violence against the black youth continue rare in Brazil, and the real impacts of ethnic disparities on the country still need to be better clarified by scientific studies.Hence, this study aimed to characterize relevant evidence for determining the effects of African descent children and adolescent's exposure to violence and its impacts on health, using the international protocol PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses).

Methods

We conducted a systematic literature review with meta-analysis searching for original articles in the electronic databases scopus and biblioteca virtual emsaúde (health virtual library, bvs), which hosts databases like medline and lilacs, using the keywords (mesh) african continental ancestry group (1) africanamericans (2) violence (3) adolescent (4), and child (5). inscopus, we searched for the words 2 and 3 and 4 and 5 with limitation to document type (article) and study area (medicine). inbvs, however, the search for 1 and 3 and 4 or 5 was conducted without data filters or restrictions.

Analysis of results was based on the following inclusion criteria that had been previously determined(1) studies related to violence in African descent children and adolescents; (2) studies with approach of relevant aspects to the health of black young subjects exposed to violence(3) original texts with full text available online(4) analytical, descriptive or experimental studies, except for case reports.In addition to these, we used the following exclusion criteria(1) articles out of the theme, among them studies without ethnical focus or with a sample of a different age range compared with the studied objective; (2) reports; (3) Systematic or integrative literature reviews; (4) grey literature; (5) free online unavailable text.

We calculated ratio meta-analysis considering the model and method of random effects with the support of the Stata Program 14.0. We also used the metabias calculation and demonstration to verify the investigated effect, even in small samples.

Results

The search resulted in studies developed in foreign countries and in Brazil, even though the number of articles found in Brazil (n=15) is rare compared with foreign countries (n=125).Results are a more faithful violence cut in the health of adolescents than of black children, considering that we only found a few studies focused on children about this theme.The most used age in the studies was 12 to 19 years.Thus, the review was developed from profiles of national and international health of children and adolescents suffering or who suffered any kind of violence (Figure 1).

Figure 1.Number of articles per origin countries of the studies included in the review.

Source: Author’s ownership

According to the explained method, the first result was 149 articles.After the identification of repeated papers (n=09), we removed 96 articles during the screening phase.In the final selection, we determined that 30 of the 44 remaining articles, based on the mentioned eligibility criteria, would form the review results (Figure2).All the chosen articles are distributed in a spreadsheet that provides information of the authors, database, detailed sampling, and main findings used for the analysis (Table 1).

Figure 2.Flowchart showing the selection of studies for the review.

Source: Schematic representation of the studies included in the systematic review using a checklist and flow diagram of the PRISMA Protocol.

Table 1. Representative matrix chart of data synthesis

Figure 3 contains the meta-analysis of study proportion.The same or close effects are expected to happen for equal or similar samples.We found a significant general effect (p=0.00) for the analysis purpose in the context of violence directed to black people.In addition, the weight attributed to each study was homogeneous; therefore, the expected effect regarding violence in the studied population occurs in different contexts, thus decreasing the chances of randomness.(Figure4) provides the meta-bias analysis for estimating the effect even in small studies and samples. Metabias evidence show that the violence effect in the health of African descent populations is significant even in small studies.

Figure 3.Meta-analysis of the proportion of the selected studies

Source: Author’s ownership

Figure 4.Meta-bias of the selected studies

Source: Author’s ownership

Discussion

Results found in Brazil are associated with more prevalent death risks that are lived by black adolescents, indicating fatality due to external causes as the main indicator of violence that assails this population.We did not find studies involving Brazilian children.

Black and male adolescents were the largest group at risk of dying due to external causes, such as homicides, transportation accidents, and suicide.In homicide cases, most of the victims were aged 15 to 18 years[1,2].In some demographic regions of Brazil, we noticed that the largest population density of these individuals is associated with higher numbers of homicides, and the opposite is also true.Based on such analysis, we concluded that this population is found in socioeconomic vulnerability conditions resulting in a situation of exposure to some kinds of exemplified violence[5].

In addition, violence associated with ethnic and age condition of these individuals shows the selectivity of the truculence that mainly affects black adolescents of lower income and lower educational level[6].Thus, studies converge on considering the ethnic question as a marker of social inequality, and a black adolescent has 3 times more chances of dying in comparison with a white adolescent[7].

Internationally speaking, death of children and adolescents was pointed out as a consequence of legal community interventions mediated by fire guns.Relevance of the result is given by the increasing number of cases that victimize pediatric patients, especially black children, considering that the lethality in these cases increases in almost 4 times[8].

Impacts on the physiology of black children and adolescents exposed to community violence

Exposure to violence may be a predictor of the appearance of several physiological mechanisms related to stress.Some studies have reported their direct effects in homeostasis of the organisms from black children and adolescents.

The community and domestic violence may influence alterations in the organism of victims exposed to violence, such as: decrease of the telomer length and more reactivity in the cortisol release, in which increase in the number of convenience stores close the victims’ house, more contact with drinks derived from ethanol and high rate of violent crimes are factors that directly interact.Such findings suggest that adverse effects related to the community where African American children and adolescents live result in biological stress able to influence their long-term growth and development[8].

The increase of incidence and prevalence of asthma and total serum IgE rates may be justified on the ethnic question and interaction with gun violence[9].In adolescence case, the main correspondence found was between sleep disorders and stress in the poorest neighborhoods.We found a three-way interaction (age, gender and exposure to violence) that suggests sleep alteration of the women who were mostly affected by exposure to violence, especially during the first years of adolescence.Results conclude that such associations may have a connection with low income of African American children and lower access to health services, which once more expose the vulnerability of these individuals [9,10].

Consequences of living with community violence and its association with substance use

There is a great agreement in the articles regarding the environmental issue when the consequences caused by violent experiences are worsened. The way the environment prepares the individual is extremely important for the occurrence of these acts and more and more adolescents are exposed both as victims and as witnesses[11],however it is not a determiner[12].The absence of great social interaction is extremely harmful for young minds being developed. It also affects the efficiency of social works that are being developed in the region for trying to change bad levels.The presence of violence cases in their communities, especially when it affects one of its family members, is the origin of problems involving anxiety disorder, depression and posttraumatic stress. In a study where students from the sixth to the eighth grade were followed-up by psychologists to assess their conditions, we found that if a child suffers any traumatic violent event in a year, he/she will usually present psychiatric syndromes in the next years of learning[13-16].

When violence includes the sexual area, a cyclic phenomenon happens, in which mothers who experience sexual violence in the youth present more chances of their daughters experiencing this occasion[13-17].In a study where women were separated by their races in the connection with risk factors, black women were more associated with power abuse of guardians than other races; in addition, there is a higher propension to continuing sexual abuse cases without an intervention[13].Black girls are more exposed to sexual violence, whereas young African-American male subjects are more inclined to gang fights, and these factors even influence the initiation of the youngster's sexual life and in safe sex practices due to larger relation with breaking the rules, lower exposure to information or even no hope regarding the future. Violence is unquestionably a great source of low self-esteem in young black subjects[11,12,14,17].

It is extremely important to emphasize that some factors might subtract the negative effects of exposure to traumatic violent events[11,14,18], including presence of proper social interaction, well-structured family that can provide the adolescent a great quality of life both financially and psychologically speaking, quality school that provides refugee to the victim and new meaning of the occurrences with a better perspective of the future [18]. Therefore, the lack of social engagement provides the individual a determinism that makes him/her search for meaning by spreading more violence acts. These young subjects are usually more inclined to developing depressive and anxiety disorder[12,18, 19].These factors might be associated with several occurrences: from non-exposure to such events in a recurrent way due to more care for prevention to the opening of different ways of suppressing the violent and depressive trends that may arise. The young black subject is deeply associated with all these statistics because he/she historically populates most of the population residing in violent areas due to a historical process of social segregation and inequality[18].

The association of chemical substance abuse with the attempt of dealing with syndromes caused by posttraumatic stress related to violent events is widely diffused in medicine, and the black population suffers even more with these factors, because they comprise, as mentioned, the greatest part of the population residing in dangerous areas with lower economical levels, which also provides cheaper drugs and, as a consequence, more dangerous drugs[20].If, for girls, the presence of undesired labors and rapes are relevant components of addiction causes, black young subjects are more inclined to associate violence acts with the use of licit and illicit drugs. The explained factors, which promote improvement of the perspective for a better future as a way to prevent cases of psychologic crises, are also necessary to prevent the use of substances[20-23].This is the case of marijuana, which use is 1.3 times higher in neighborhoods of lower income with lower government support and with history of violent cases[21,11]. The lack of a fix home is also pointed out as one of the greatest causes of exposure of adolescents to wild acts. Such population is mostly formed by black people, especially in poorer regions,who end up being the origin of several non-positive data[22,23].

Exposure to violence and impacts on mental health

Results found an association for young black subjects between being victim of violence, as well as being exposed to community violence situations, and mental health disorders.Hence, the strongest related condition, especially with exposure to community violence, were posttraumatic stress – PTS [24,25]and depression symptoms[12,14,18,23].

Exposure of the young person to community violence is initially related to PTS development.Numbness and hyperexcitability symptoms were specially found as participants of relations between exposure to violence, disorders and symptoms, in such a way that these are the posttraumatic stress symptoms that may partially measure its relation with depression, mainly in young people from the sixth, seventh, and eighth grades[24].Hyperexcitability is characterized by the American Psychiatric Association as persistent manifestations of excitability, such as difficulty to sleep, irritability, concentration problems, and exaggerated response to scare[22-24].But numbness of general responsivity, otherwise, reveals as a decreased interest in activities, affect restrictions and shortened future sensation, which is commonly associated with evasion from the stimulus associated with trauma[24].From this study, several other aspects relating violence in African American descents and development of depressive symptoms also became evident, respecting some differences and particularities, such as gender.In addition to exposure to community violence situations and trauma, childhood mistreatment was another factor that significantly predicted depressive symptoms and violence during adolescence. It therefore worsens the context in which the prevalence of childhood mistreatments is higher for black boys than for white boys[14].

Witnessing a violence incident against a family member or close friend is also associated with the development of depressive symptoms, although important considerations regarding gender and proximity to victim should be made.Thus, witnessing violence against a close friend was associated with anxiety for men, but not for women.In addition, when the witnessed incident occurred with outsiders, the demonstrated relation was behavioral alterations, more specifically problems with aggression for men[12].

Another factor in the subscale of relationship problems influences the relations analyzed in this section.Results revealed association between internalization symptoms of depression or anxiety and African descent young people of low income who did not trust their intimacies for adults.In a counterintuitive manner, young people who trust more frequently in adults and maintain less questions of private character had a more shocking association between exposure to violence and internalizing suffering[26].

Risk behaviors related to community violence exposure

Results suggest ethnic differences for changes in severe punishments applied by guardians that although present in general lines as a falling curve, such fall is only significant for families of young white people[27].Furthermore, young black people have more chances of witnessing threat or injury due to gun fire[13].These results bring ethnic disparities into question again regarding exposure to violence and victimization, but they do not remain without meaning, considering they also show their relevant consequences.

Sexual risk behavior was the main behavioral outcome associated with exposure to violence[13,28,29].Sexual risk behavior, sexual debut, number of partners and inconsistence in condom use were mediated by violence-related factors with peculiarities according to gender and sexual orientation.Based on this view, aggression situations establish a relation between exposure to community violence and sexual debut for both genders.More specifically for young girls exposed to violence, negative perceptions of their friends' attitudes regarding safe sex was also related to the way how the sexual debut happens.Regarding sexual risk, otherwise, the most relevant connection happened between male young black boys and exposure to community violence[13].

Other results analyzed young African-American girls of low income searching treatment for mental health conditions, in a way that exposure to community violence was associated with a trend of developing increased sexual risk behaviors, a relation that has been kept throughout time[29]. On the sphere of victimization by violence, especially children's abuse, a sample of HIV-positive men who had sexual intercourse with other men, showed that abuse between the ages of 12 and 16 may be associated with having more than 3 sexual partners of the male sex in the last 6 months[28].

Besides sexual risk, another important outcome was the relation with development of aggressive behaviors[12,14,19,30].Series of results discussed the development of less pro-social behaviors and more hostile and aggressive personalities as questions related to violence.Young people who have history of violent incidents, were exposed to violence in some way or were even victims of violence may develop behavioral problems with aggressiveness, after the respective exceptions have been made for differences of sex and level of closeness with the victim.Within this perspective, and similarly to exposure to violence, mistreatment during childhood is associated with violence in adolescence[14].

Witnessing violence against outsiders was associated with more aggressive behavior specifically for men, an outcome found for both genders in a situation of violence directed to a friend or acquaintance.In addition, witnessing a violence incident against a family member was more associated with aggression only for females.Aggressive reactions are the outcome of situations where the young person witnesses violent incidents and that may be understood by the threatening feeling noticed by witnesses in that moment, who then start to project a risk of also becoming victims[12].

Other social relations were specially related with exposure to violence, such as being in a street situation and being socially misadjusted.Results highlight a discrete association between being socially misadjusted and at higher risk of being exposed to violence.It is noteworthy that this relation is established in a more intense way when revealing young people who had more community experiences of exposure to violence as less inclined to being socially misadjusted[31,32].Regarding the later lack of housing, violence has been an important influencing factor for both genders, as well as for smaller bonds with school, depressive humor and running away from home.Adolescence parenthood was a significant factor only for the female gender, whereas the use of substances was a factor only for the male gender[23].

High insensitivity marks found in boys, condition still obscure and defined as Callous-unemotional (or restricted affect) were associated with some risk behaviors analyzed up to now.Results suggest that young people with high-level restricted affect were not only more inclined to committing violent acts if they had been exposed to violence, but also had a higher trend of sexual delinquency[33].

Conclusion

Violence is a factor with important repercussions related to the health-disease process in the African descent population during the youth.Ethnic disparities regarding deaths of black adolescents due to violent causes are the extreme outcome of this factor.Being adolescent and black in Brazil implies a three times higher chance of evolving to death if compared with a white adolescent.However, other direct impacts of exposure to violence are similarly relevant, evidenced mainly in African American adolescents due to the unavailability of studies in Brazil.

The possible negative outcomes for black children and adolescent's health who are victims of violent situations or have been exposed to violent contexts in their communities are diverse.Nevertheless, we must highlight that the existence of full health policies and the prevision of rights do not necessarily ensure their full exercise.Understanding these outcomes and, therefore, their real impacts is vital for effectuating the insertion of violence against the black youth in Brazil with a problematic regarding the health area, but that requires multi-sector efforts for their resolution.

Authors contributions

MLRN designed the review, developed the inclusion criteria, screened titles and abstracts, appraised the quality of included papers, and drafted the manuscript. JDQF reviewed the study protocol and inclusion criteria and provided substantial input to the manuscript. VBN and MLRN reviewed the study protocol. JDQF read and screened articles for inclusion. All authors critically reviewed drafts and approved the final manuscript.

Acknowledgements

The authors thank Research Group: Suicidology-Federal University of Ceará - UFC and National Council for Scientific and Technological Development-CNPq - body linked to the Ministry of Science, Technology and Scientific Writing Lab, Medicine School – Federal University of Cariri – UFCA

Funding

The Research Group: Suicidology-Federal University of Ceará - UFC / National Council for Scientific and Technological Development-CNPq - body linked to the Ministry of Science, Technology and Innovation to encourage research in Brazil.

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Received: May 28, 2020;
Accepted: June 16, 2020;
Published: June 18, 2020.

To cite this article : QuirinoFilho JDD, Nascimento VBD, Neto MLR.Exposure of Children and Adolescents to Violence and Its Impacts on Health: A Systematic Review with Meta-Analysis."Health Education and Public Health.2020; 3:4.

© QuirinoFilho JDD, et al.2020.