Assessment of knowledge, attitude, and practice of child abuse amongst health care professionals working in tertiary care hospitals of Karachi, Pakistan.

INTRODUCTION: UNICEF report (2004) states that a significant percentage of total child population under the age of 5 years suffered malnutrition. Child sexual abuse remains undiscussed across Pakistan. Health care professionals (HCPs) are usually the first notifiers of child abuse and are ethically obliged to manage and report it.
OBJECTIVE: This study was conducted to assess HCPs' response in dealing with patients of child abuse. With a better understanding, we can have a better outcome for the victims.
METHODS: A total of 101 participants filled out a structured questionnaire by HCPs working in three tertiary hospitals of Karachi i.e., Aga Khan University, National Institute of Child Health (NICH), and Civil Hospital. Data were entered into SPSS 19.0.
RESULTS: HCPs believed that young male relatives were thought to be most likely the offender, and that every child regardless of class is prone to get abused triggered by financial stressors and the absence of parents. Proper physical exams helped identify cases. A proper system of reporting was required in hospitals, but HCPs were reluctant to report the cases to authorities. There was a significant difference noted between public and private hospitals.
CONCLUSION: Our findings indicate that HCPs have limited knowledge in defining various types of abuse and most were unaware of any reporting facility in hospitals. Senior HCPs as consultants have a better understanding of child abuse than nurses or interns. Mandatory reporting should be implicated so that prompt action could be taken. There could be a more successful outcome of managing a child abuse victim with proper training. Copyright:

Introduction

According to the World Health Organization (WHO), child abuse is defined as, “all forms of physical and emotional ill-treatment, sexual abuse, neglect, and exploitation that result in actual or potential harm to the child's health, development, or dignity.

Within this broad definition, five subtypes can be distinguished:

physical abuse;

sexual abuse;

neglect and negligent treatment;

emotional abuse;

and exploitation.”[1]

In Pakistani culture the idea of discipline is misconstrued, physical punishment at home or schools has become a necessary part of disciplinary strategies. Each year, 50,000 children with injuries are thought to be due to physical punishment, with many requiring hospitalization.[2] Child labor is also prevalent in Pakistan; an estimated 8 million children under the age of 15 years are believed to be involved in these practices.[2]

According to the data shared by Sahil, (an NGO working for child's rights) 66% of the victims were abused by acquaintances such as family members, teachers, and friends. This highlights that most abuse is perpetrated by people close to children. Thirty-three percent of children were abused by strangers such as drivers, policemen, and landlords.[2] It is believed that children in Pakistan live under the worst conditions when compared to any other South Asian country.[3]

Health providers offer an important point of contact for children who have been abused and, therefore, should be skilled in diagnosing and identifying the manifestations associated with abuse.[4] Obtaining a detailed history and judging parent-child interaction are important tools of identification.[5] Lack of clinician's knowledge or clinical experience more often results in misdiagnosis and under-reporting of the cases of abuse.[6]

According to a study, physicians are usually hesitant in reporting the case because they are not certain and have past negative experiences with reporting or due to lack of benefit to the child.[78] According to a study in India, HCPs have a poor attitude and knowledge of child abuse and neglect under the code of conduct and law, and there is insufficient available information regarding this.[9]

To the best of our knowledge, there is no study on the knowledge, attitude, and practice (KAP) of health professionals regarding child abuse in Pakistan. This study is being carried out to determine the awareness and knowledge of child abuse and its management among physicians and nurses. The main purpose of this study is to evaluate the knowledge, attitude, and practice of health care professionals (HCP) working in a pediatric emergency department of government and private tertiary-care hospitals.

Materials and Methods

Methods

A cross-sectional study was conducted over two months from October 2019 to December 2019. A structured questionnaire was administered to health care professionals i.e. physicians, nurses, and residents working in the emergency department of three of the biggest tertiary care centers of Karachi i.e., Aga Khan University, National Institute of Child Health (NICH), and Civil Hospital. Medical students were trained to collect data and obtain informed consent from the participants. By using “sample size for proportion,” taking a 95% confidence interval, and supposing the probability of achieving the desired result is 50% out of a total population of 140 emergency medicine professionals in all three hospitals, a sample size of 103 was computed. A total of 101 participants were selected via convenience sampling.

Data analysis

Data were double entered in EpiData (version 3.2) by two different entry operators to avoid keypunching errors. The dual cleaned data was converted and analyzed in SPSS (version 19.0). Descriptive statistics were used to describe a patient's demographics in terms of frequencies and their percentages. A Chi-square test or Fisher's exact test was used for a qualitative outcome to see the association between different groups like the type of hospital and caregiver type. P value < 0.05 was taken as significant.

Results

The majority of the respondents were female 58.4% (n = 59). The data was collected from Karachi's three tertiary care hospitals including both private and public sectors [Table 1].

Table 1

Selected characteristics of study participants (n=101)

	n (%)
Gender
Male	42 (41.6)
Female	59 (58.4)
n	101
Years of experience
<2 years	26 (25.7)
2-4 years	37 (36.6)
>4 years	38 (37.6)
n	101
Job title
Intern	19 (18.8)
Resident	48 (47.5)
Consultant	8 (7.9)
Nurse	26 (25.7)
n	101
Institute
National institute of child health	34 (33.7)
Civil hospital Karachi	33 (32.7)
Aga khan university hospital	34 (33.7)
n	101

A total of 45.5% (n = 46) of HCP's believed family members were the most common perpetrators of child abuse; 47.5% (n = 48) of the respondents said that young adults are most likely to become offenders of child abuse. A total of 60.4% (n = 61) of the HCP's stated males were most likely to be the offender; females being chosen by 14.9% (n = 15) of the respondents, and 13.9% (n = 14) believed there was no difference between genders. According to the type of child abuse, the most commonly identified was sexual abuse (88.1%) (n = 89), and the least common form identified was psychological abuse (55.4%) (n = 56). A total of 78.2% (n = 79) of the HCPs reported that the main factor triggering child maltreatment were financial stresses and poverty while 71.3% (n = 72) the respondents believed that the main factor responsible for triggering sexual abuse was the absence of a parent in the house, and 63.4% (n = 64) believed emotional abuse was caused by family disputes. A total of 42.6% (n = 44) of the HCPs were hesitant in reporting the suspected case because they feared that the circumstances will become worse for the child. A total of 56.4% (n = 57) of the HCPs responded that they have detected a case of abuse rarely. A total of 50.5% (n = 51) of the HCPs agreed that they do not immediately report the case because they do not want to intervene in the victim's issue [Table 2].

Table 2

Knowledge, attitude, and practice related to child abuse of HCPs

Knowledge	n (%)
Who is most likely to be an offender?
Drug Addict	12 (11.9)
Sexually Frustrated Person	14 (13.9)
Insane Person	4 (4)
Family Member/Relative	46 (45.5)
Guards/Drivers	7 (6.9)
Not Sure	12 (11.9)
Others	6 (5.9)
	101
What is the most common age group of offenders?
Same age as a child	4 (4)
Older Child	10 (9.9)
Young Adults	48 (47.5)
Elderly	16 (15.8)
Anyone	19 (18.8)
Not sure	4 (4)
	101
Who is more likely to be an offender?
Male > Female	61 (60.4)
Female > Male	15 (14.9)
Male=Female	14 (13.9)
Not sure	11 (10.9)
	101
What types of child abuse are you aware of?*
verbal abuse	63 (62.4)
sexual abuse	89 (88.1)
physical abuse	84 (83.2)
psychological abuse	56 (55.4)
Neglect	61 (60.4)
n	101
What are the factors that trigger child maltreatment or neglect?*
Unwanted/Unplanned child	38 (37.6)
Child born with disabilities	35 (34.7)
Financial stressor/poverty	79 (78.2)
	101
What are the factors that trigger child sexual abuse?*
Provocative clothing	19 (18.8)
Absence of parent in the house	72 (71.3)
Presence of nonbiological care taker in the house	44 (43.6)
	101
What are the factors that trigger child emotional abuse?*
Various family conflicts	64 (63.4)
Adult substance abuse	44 (43.6)
Poor mental health of either of the parents	50 (49.5)
	101
Attitude
What are the factors that make you hesitant to report child abuse?*
Limited knowledge of child abuse	18 (17.8)
Do not know how to report	39 (38.6)
Uncertainty that the report will help the child or not	35 (34.7)
Fear that reporting will make it worse for the child	43 (42.6)
Previous bad experiences	9 (8.9)
Total	101

*Multiple response variables

There was a sharp contrast between the public and private hospital respondents. A total of 29.4% (n = 10) of the private setup respondents compared to 47.8% (n = 32) of public setup respondents knew about a reporting system. Our result also indicated that 46.3% (n = 31) of the HCPs at public hospitals knew the protocol to manage a suspected case of child abuse. On the contrary, only 23.5% (n = 8) of the HCPs working in the private hospital were aware of any pre-existing protocol at their hospital. We noted that 53.7% (n = 36) of the HCPs practicing at public hospitals reported a suspected case, whereas only 17.6% (n = 6) of the respondents working in private hospitals eported a suspected case of abuse [Table 3].

Table 3

Awareness and management of child abuse by HCPs and type of hospital

	Public Hospital n (%)	Private Hospital n (%)	P
Is there any reporting system at your workplace or not?
Yes	32 (47.8)	10 (29.4)	0.113
No	35 (52.2)	24 (70.6)
n	67	34	101
Is there any protocol to manage a child abuse victim in your practice?
Yes	31 (46.3)	8 (23.5)	0.151
No	18 (26.9)	14 (41.2)
Not sure	18 (26.9)	12 (35.3)
n	67	34	101
Did you report it to the authorities, if available?
Yes	36 (53.7)	6 (17.6)	0.010
No	21 (31.3)	22 (64.7)
Reporting facility is not available at my work place	10 (14.9)	6 (17.6)
n	67	34	101
How many times have you suspected or recognized any case of abuse
Never	36 (53.7)	6 (17.6)	<0.001
Sometimes	21 (31.3)	22 (64.7)
Usually	10 (14.9)	6 (17.6)
Always	10 (14.9)	6 (17.6)
n	67	34	10

In the last 5 years, only 18.8% (n = 19) participated in continued medical education. A total of 88.1% (n = 88) of the HCPs believed that if there was a proper system of reporting at their respective institute, they would report the suspected case.

A total of 41.6% (n = 42) of the respondents strongly agreed that early detection of child abuse is a significant tool in preventing its recurrence. A total of 60.4% (n = 61) believed that training programs should be introduced so they can benefit from them, and a total of 50.5% (n = 51) strongly agreed that there is a need for a proper protocol to manage a suspect case in their respective hospital.

Discussion

This study is the first of its kind to be conducted in Karachi. It covers three tertiary care hospitals, which include both private and public sectors that receive the highest population of pediatric emergencies. In our study, the results suggested that there is a difference between the knowledge, attitude, and practice of HCPs across private and public sectors. HCP's identified relatives as the most likely offenders and believed that males belonging to young age groups are prone to be perpetrators of abuse. According to the study, our respondents believed that the most common offender is a family member or relative and most likely to be a male belonging to the young age group. However, according to the literature, males and females are equally likely to be a perpetrator.[10]

However, here HCPs were more likely to recognize sexual abuse as a type of abuse when compared to other types. Under-reporting of child abuse cases was not only because of misdiagnosis by HCPs but also because of the family's choice to keep the case confidential.[11]

HCPs readily recognized the need to identify sexual abuse; however,

there was less understanding of their role in the identification of emotional or psychological abuse. Emotional abuse is known to have a profound effect on a child's development and mental health; therefore, physicians should be equipped to recognize this form of abuse as well as all other types according to the WHO definition.[12]

Furthermore, HCPs in the public sector reported more cases of child abuse when compared to those working in the private sector. As regards to socioeconomic status, HCPs believed that lower-class populations are more at a risk of child abuse.

Furthermore, HCPs in the public sector reported more cases of child abuse when compared to those working in the private sector.

In both public sector institutions, 78.8%–91.2% of the respondents said that they had suspected/recognized child abuse cases, out of which 53.7% reported it. On the other hand, in private sector hospitals, only 47.1% of the respondents had ever suspected or recognized abuse, and only 17.6% reported this to authorities. All medico-legal cases presenting in private hospitals are given first aid treatment and are then sent to public hospitals where a medico-legal team examines the patient. The absence of a medico-legal officer at private hospitals may be the reason for a lack of knowledge regarding the reporting of suspected cases in a private setting.[13]

Our data indicate that in the last 5 years, only 18.8% of people attended various CME's - Continuing Medical Education on the topic of child abuse. This shows the lack of education and reinforcement of steps and[14] knowledge regarding this grave issue, which has such great socioeconomic consequences. Continuing medical education should cover not only on methods of identification but also management and possible outcomes of underreporting.[15] This multidisciplinary topic must be included in the curricula of medical studies and other professions dealing with children.[16]

Child abuse is one of the most important issues to deal with in the pediatric emergency department and lack of knowledge can result in long-term suffering of the patient. There are significant gaps in the current postgraduate training program of emergency medicine and one of the most important is the fact that there is no well-established emergency medicine fellowship examination in Pakistan. The Emergency Medicine Fellow of College of Physicians and Surgeons Pakistan program just commenced with the first graduates in the last few years. Although it will take some time before the program becomes well established but keeping in mind the increasingly high rates of child abuse, this issue demands the change and improvement of the curriculum to include such training and pattern recognition for our new physicians and change their attitude regarding this problem.

Limitations

The study design did not allow a large sample size to be used. Furthermore, the number of consultants used in this study is low. As participation was voluntary, a potential limitation could be recruitment bias. The research articles about this issue are very limited in this part of the world due to the under-reporting of cases. A similar study should be conducted on non–health care professionals to understand the disparity between the two populations.

Conclusions

This study indicates that there are gaps in knowledge of HCPS, regarding the diagnosis of various types of abuse. Most of the physicians/nurses are unaware of the existing reporting facility available at their respective hospitals. Therefore, there is a need for the introduction of a systematic approach to HCPs education regarding child abuse. Hospitals should follow proper guidelines on how to approach a suspected case and train physicians including nurses accordingly.

Ethics statement and conflict of interest disclosures

Human subjects: Consent was obtained from all the participants in this study. The Aga Khan University Ethics Committee issued approval 2974-EM-ERC-l9. This study was approved by the Ethics Committee of The Aga Khan Hospital, Karachi. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous 3 years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. Yes, 14th October 2019.

Declaration of participant consent

The authors certify that they have obtained all appropriate participant consent forms. In the form the participant(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.