Severity of maxillofacial injuries and associated factors in brazilian women victims of domestic violence

Objective: The aim of this study was to determine the profile and prevalence of maxillofacial injury (MFI) and to assess associated factors in women victims of domestic violence. Methodology: This was a cross-sectional and analytical study that evaluated 514 records of women victims of domestic violence diagnosed with MFI attended at a public reference urgency and trauma hospital in Northeastern Brazil. Descriptive and multivariate statistics were performed using Poisson regression. Results: The prevalence of fractures and facial lacerations was 80.2% and 19.8%, respectively, the majority with low severity (92.1%). Associations were observed between MFI severity and alcohol / drug consumption by the perpetrator (PR=0.251; 95%CI=0.106-0.595; p=0.002) and the night shift (PR=4.675; 95%CI= 1.745-12.525; p=0.002). Correlations were found between MFI severity and length of hospital stay (r=0.148; p<0.01). Conclusions: The prevalence of fractures was considered high and MFI severity was associated with longer hospital stay and alcohol / drug consumption by the perpetrator and the night shift. Strategies need to be adopted as improving the quality of health care for users, social investment in women in vulnerability, overt supervision by security agencies, as well as the implementation of educational programs focused on preventing this condition.


Introduction
Domestic violence against women is considered a public health problem, in addition being a fundamental violation of human rights. Around the world, around 30% of women have suffered physical and / or sexual violence by an intimate partner at some point of their lives (World Health Organization, 2020). In Brazil, according to the Information System for Notifiable Diseases (SINAN), in 2017, of the total number of violence notifications, 71.8% involved women (Brazil, 2020).
Intimate partner violence is associated with several negative outcomes for female health, such as abortion, low birth weight, premature birth (Sigalla, et al., 2017), use of alcohol and other drugs, depression, non-fatal injuries and death due to homicide (Stöckl, et al., 2013). Head, neck, and face are the most common sites of injuries related to intimate partner violence (Castro, et al, 2017;World Health Organization, 2020). Research, Society andDevelopment, v. 9, n. 9, e317997306, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i9.7306 4 When aggression involves the facial region, victims suffer from physical and emotional consequences, which cause, among other consequences, low self-esteem, shame, humiliation, and severe psychological suffering (Rodrigues, et al., 2020). Aggressions in this region aim to disqualify the victim's identity, acting as a factor of intimidation (World Health Organization, 2020). In addition, the choice of the face as the site of aggression is due to the intention of injuring a part of the human body considered as a symbol of beauty, especially for women (Silva, et al., 2014).
Maxillofacial injury (MFI) causes high morbidity and socioeconomic losses (Ramalingam, 2015). In 2019, hospital procedures resulting from fractures of the skull and facial bones performed in Brazil and made available by the Hospital Information System (SIH) accounted for 30,055 hospitalizations, reaching a total amount of US$ 9,144,169.55, 131,324 days of hospital stay and average of 4.4 days, with the Southeastern region concentrating 34.3% of total expenses, followed by the Northeastern region, with 27.9% (Brazil, 2020).
The scales for evaluating the MFI severity provide important information, as they allow the comprehensibility in communication among health professionals and can act as a prognostic tool for the patient and the management team (Garcez, et al., 2019). The Facial Injury Severity Scale (FISS) is an easily calculated scale predictive of facial trauma severity based on its relationship with hospital treatment expenses, being also an indicator of hospitalization time (Bagheri, et al., 2006).
The epidemiological knowledge of the profile of victims and patterns of facial trauma is of fundamental importance for the development of improvements in health services and for the establishment of preventive and safety measures (de Macedo Bernardino, et al., 2018). In this context, this study aimed to determine the profile and prevalence of MFI and to evaluate factors associated with facial trauma severity in women victims of domestic violence.

Study Design and Location
This is a cross-sectional and analytical study that evaluated the medical records of women victims of domestic violence with facial injuries attended at a public reference urgency and trauma hospital in Northeastern Brazil. Research, Society and Development, v. 9, n. 9, e317997306, 2020 (CC BY 4 Fisher's Exact test was used to identify possible associations between dependent and Research, Society and Development, v. 9, n. 9, e317997306, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i9.7306 6 independent variables. Variables with p <0.2 were included in the Poisson regression analysis with robust variance and used to obtain gross and adjusted prevalence ratio (PR), with respective 95% confidence intervals (95%CI). Variables that did not significantly contribute to the explanation of variable severity of facial trauma were excluded from the model. As data distribution was non-parametric, the non-parametric Spearman correlation test was adopted.
The significance level adopted was 5%.

Ethical Considerations
This study was approved by the hospital management and by the Human Research Ethics Committee (CAAE 3763318.8.0000.5188), according to guidelines contained in Resolution No. 466/12, of the National Health Council of Brazil and precepts of the Declaration of Helsinki.

Results
Of women victims of domestic violence with facial injuries (n = 514), 329 (64.0%) had fractures and facial lacerations, with mean age of 22.45 ± 11.09 years, median of 18 years, minimum age of 14 years and maximum of 77 years. Table 1 shows the distribution of victims of violence according to sociodemographic data. There was predominance of Brown / Black women (59.3%), aged ≤ 18 years (52.9%), with schooling> 8 years of study (67.5%), who live with monthly family income above 1 Brazilian minimum wage -equivalent to US$ 198 (60.2%), without partner (74.2%) and residents in the urban area (76.6%). Table 2 shows the distribution of victims according to the characteristics of perpetrator and aggressions. The aggressor, in most cases, is the victim's partner / ex-partner (82.7%), in 85.7% of cases, was the first assault and in 65.7%, is an alcohol / drug user. The most prevalent type of aggression was physical violence (52.9%), practiced during the day shift (59.0%) and at the weekend / holiday (53.5%). Table 3 shows the MFI characteristics. The prevalence of injuries was 80.2%, of the nasal type (44.7%) and with associated head / neck injuries (43.5%). MFI occurred more frequently in the middle third (59.6%), with minor injuries (92.1%). Regarding the treatment modality, most victims needed closed fracture reduction (67.4%). Research, Society andDevelopment, v. 9, n. 9, e317997306, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i9.7306 7 The mean score of the FISS scale was 1.4 ± 1.09, median of 1.00, minimum score of 1 and maximum of 6. The average length of hospital stay was 1.33 ± 1.76 days, median of 1 day, minimum of 0 days and maximum of 9 days. Table 4 shows the distribution of trauma severity according to variables related to the victim's profile and characteristics of perpetrator and aggressions; in the bivariate analysis, significant association was found between MFI severity and the first assault / recurrence (p=0.035), alcohol / drug consumption (p=0.001) and the shift of occurrence (p=0.001).
Multiple regression model was used to assess associations of variables (Table 5). In the crude analysis, the severity of MFI was associated with alcohol / drug consumption by the perpetrator and the shift of occurrence; when adjusted, it maintained its significance; the prevalence of more severe trauma was 75% lower among perpetrators users of alcohol / drugs (p=0.002) and victims assaulted during the night shift were 4.67 times more likely of having more severe trauma (p=0.002).
Weak positive correlation was found between MFI severity and length of hospital stay (r = 0.148; p <0.01) (data not shown).

Discussion
The occurrence of MFI resulting from domestic violence can be influenced by socioeconomic, cultural, circumstantial, geographical, and environmental factors (World Health Organization, 2020). Recent research has shown that men and women at different stages of life have different profiles of victims of violence and MFI (de Macedo Bernardino, et al., 2018).Although some studies have identified higher proportion of men as victims of MFI (de Macedo Bernardino, et al., 2018;Laureano, et al., 2019;Sousa, et al., 2016), there is a trend towards an increase in the number of female victims and reduction of male victims (Rodrigues, et al., 2020;Barbosa, et al., 2019).
The dental literature presents results with different MFI prevalence. While in Brazil, 56.3% of women victims of physical aggression had MFI (Garcez, et al., 2019), in England, it corresponded to 77.8% of cases (Boyes & Fan, 2019). In the present study, of women victims of domestic violence, 64.0% had facial fractures and lacerations. This result may still be underestimated, since many women do not seek health services to treat injuries caused by violence and, when they do they may be reluctant to declare the true cause of the injury (World Health Organization, 2020). Research, Society and Development, v. 9, n. 9, e317997306, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i9.7306

Conclusion
The prevalence of fractures was considered high and MFI severity was associated with longer hospital stay and alcohol / drug consumption by the perpetrator and the night shift.
Strategies can be adopted to understand factors associated with MFI, as well as improving the quality of health care for users, such as social investment in women in vulnerability, overt supervision by security agencies, as well as the implementation of educational programs focused on preventing this injury.