Sub-Saharan African hospitals have a unique opportunity to address intentional injury to children.

Intentional injury to children is a major, but neglected public health and human rights issue with devastating consequences on families and societies, particularly in low and middle-income countries (LMICs). Intentional injury is defined by the World Health Organization as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.”

As many as 7–10% of childhood injuries are intentional, and some studies suggest that the incidence is even higher in LMICs.2, 3, 4, 5, 6 Over three quarters of children in LMICs have reported violent discipline at home and among them, almost 20% experienced severe violence. The WHO reports that in Egypt and Ethiopia, 37% and 64% of all children, respectively, face severe physical punishment from their parents. In Malawi, violence against children is widespread with over half of all children reporting at least one episode of physical violence before the age of 18 years. Deaths following intentional injury are 3–4 times more common in Africa than in high-income countries.

Children who have suffered intentional injury are more likely to experience mental distress, indulge in smoking or drug use, suffer sexually transmitted infections (STI), or engage in other self-harming behaviours. Despite these serious, socially damaging sequelae, addressing child abuse in sub-Saharan Africa has not been seen as a priority.

The experience at a tertiary trauma centre in Lilongwe, Malawi suggests that intentional injury to children is common. Over a five-year period, almost one in ten of every paediatric injury episode presented was intentional and the demographic and clinical characteristics of their injuries differed from those of children with unintentional injuries. Victims of intentional injury were likely to be older and male, but even infants presented with assault-related injuries. Most injuries occurred at home and at night; and nearly half were in an urban setting. Both intentional and unintentional injuries had a low hospital admission rate and overall crude mortality was similar at around 1%.

Soft tissue injuries, especially to the head and face, were the most common intentional physical injuries. Victims were most often attacked with a sharp object such as a knife or stone or brick but the use of sharp objects increased substantially with the child’s age. The study did not include cases of sexual violence which are also under reported on the continent.8, 10, 11, 12

Health workers in sub-Saharan Africa are in a unique position to advocate for the health and safety of children as lack of a social infrastructure leaves children especially vulnerable. This can be accomplished in at least three ways. Firstly, clinicians who deal with traumatic injuries must understand the patterns of presentation of intentional injuries so as to identify victims of violence, provide appropriate clinical management, and help coordinate available social welfare programmes and inform law enforcement to prevent further harm.

Secondly, hospitals can improve access to care for these patients. Little is known of the extent of under-reported injuries and pre-hospital mortality, but it is clear that services are underused. For example, in Malawi, less than 10% of child victims of violence received professional help. It is reasonable to assume that, similarly, utilization is low throughout the region. Consequently, hospitals must develop strategies to expand access to such children. A common approach has been the development of One Stop Centres. Often these centres are situated in hospitals and provide comprehensive care, allowing victims of violence to access medical, psychosocial, police, and legal services at one time and in one place. Hospitals have the infrastructure and central location to spearhead these types of programmes.

Thirdly, trauma and tertiary care centres should promote widespread and effective preventative efforts. Non-physician clinician or community health worker-led outreach to local communities and programmes that empower school-based girls and boys can raise awareness and understanding, thereby empowering communities at the grass root level to take the lead in addressing violence against children. Health care providers are often held in high regard by the community and could be leaders in developing culturally appropriate programmes.

Addressing intentional injury to children in sub-Saharan Africa is daunting, given the severe resource constraints and diversity of cultural beliefs pertaining to the place of children in families and in society. However, children are among the most vulnerable populations we serve. In situations where few are standing up for victimized children, clinicians have a duty to fill the gap and make a difference in both prevention and management of intentional injuries to children.

Conflict of interest

The authors declare no conflict of interest. The views expressed in opinion pieces do not necessarily reflect the views of the African Journal of Emergency Medicine or the African Federation for Emergency Medicine and are solely the opinion of the author.