Practice of Disciplinary Methods and Factors Associated With Belief for Physical Punishment Among Malaysian Parents: Findings From NHMS 2016.

The belief in the effectiveness of physical punishment is an important predictor for its use. The objectives of this study was to describe the factors associated with the belief for physical punishment toward children 1 to 5 years of age among Malaysian parents. Data was collected as part of the Malaysian National Health and Morbidity Survey (NHMS) 2016. The respondents were asked if they believed that physical punishment is needed to raise a child properly. A total of 60.0% of Malaysian parents believed in the need for physical punishment, with 54.3% practising it. Parents who believed in physical punishment had more than 2 times a higher likelihood of practising it (odds ratio 2.57) than those who did not. Parents need to be taught to respond positively to children's behavior and anger management strategies in difficult parenting situations.

Introduction

Children are the leaders of tomorrow, the future of the nation and drivers of the global course in coming years. The United Nations has adopted Resolutions to protect children as a major international priority by including it in the Sustainable Developmental Goals (SDG), target 16.2, which aims to end all forms of violence against children by 2030. The World Health Organization (WHO) defines violence on a child as the intentional use of physical force or power, threatened or actual, against a child, by an individual or group, that either results in or has a high likelihood of resulting in actual or potential harm to the child’s health, survival, development or dignity.

One of the topics that has been intensely debated regarding violence against children has been the use of violent punishments toward children, often in the name of disciplining the child. Child discipline is meant to change the behavior of the child, teach them how to fit into the real world, act as a foundation for the child’s own self-discipline and help them mature as good adults. There is rather conclusive evidence in medical literature to support that despite immediate compliance, physical punishments results in lower levels of moral internalization in the child.

Studies have shown that children who have been physically punished subsequently demonstrate more aggressive behavior when they grow older, have reduced cognitive test scores, and present with increased lifetime rates of anxiety disorders, depression, and alcohol abuse.[5-8] Even though there are some quarters that claim this is an over-exaggeration of the effects of physical punishments, it is almost undoubted that this practice carries at least some negative consequences on the child. Despite the growing evidence against this practice, United Nations Children’s Fund (UNICEF) reported in 2014 that globally, 4 out of 5 children are still subjected to violent punishments.

The belief in the effectiveness of physical punishments is an important predictor toward its use. Even in countries such as Sweden and Finland, both with long standing laws against use of physical punishment against children, cultural difference still account for inter-country differences in parents belief in the use of physical punishment. In Asian families, physical punishments are considered customary and a power relationship to teach children hierarchy, to obey elders. Furthermore, parents tend to believe that it is within their right to determine how they discipline their own children.

The objectives of this study was to describe the disciplinary methods, belief for physical punishment and factors associated with the belief for physical punishment toward children 1 to 5 years of age among Malaysian parents.

Methodology

Data Source and Sampling

Data was collected as part of the Malaysian National Health and Morbidity Survey (NHMS) 2016. This population based survey was carried out between February and May 2016. Two stage stratified random sampling design was used to obtain national representativeness. The primary stratum was made up of the states in Malaysia and the secondary stratum the districts within the primary stratum. The living quarters were the sampling unit and was based on birth registration data provided by the Malaysian National Registration Department. Detailed methodology on the national survey is provided in the report.

Face-to-face interview was carried out on each household with at least 1 child between 1 and 5 years of age. Information sheet was given to every respondent and written informed consent was taken before each interview. Ethical approval for this study was obtained from the Malaysian Medical Research Ethics Committee (MREC) with the registration number NMRR-15-511-25359.

Instruments

The questions on disciplinary practices was obtained from the Multiple Indicator Cluster Surveys (MICS) questionnaire designed by United Nations Children’s Fund (UNICEF). Local medical and public health experts discussed and adapted the questionnaire for local use. The broad structure and content of each specific item within the questionnaire was maintained. The adapted questionnaire was subsequently translated into Bahasa Malaysia, the national language. Face-to-face interview, using mobile devices, was used by trained research assistants for data collection.

Measures and Definition of Variables

Socio-demographic variables of the parents were collected in the interview. This includes the age, education level and occupation of both parents. The ethnicity of the parent, the locality of residence, marital status of the parents, number of children below 5 years of age in the household and the total household income was also collected. Locality of residence was divided to urban or rural locality based on stratification by the Department of Statistics Malaysia. All socio-demographic variables were categorized.

Based on the MICS questionnaire, there were 3 questions on non-violent disciplinary practice, 2 questions on use of psychological aggression, and 5 questions on use of physical punishment. The response was to capture if the respondent or any family member, as a collective action of all the adults in the household, used each of the disciplinary on a child in the past 1 month. The respondents were further asked if they believed that physical punishment is needed to bring up, raise or educate a child properly.

Individual questions on the disciplinary practices were combined into 3 main measurement scales to aggregate the findings; non-violent discipline, psychological aggression and physical punishment. The use of one or more of the disciplinary practice was categorized to the respective category. Table 1 lists the practices of each of these subscales.

Table 1.

Child Discipline Scales.

Psychological aggression

Scold with harsh tone

Called dumb, lazy etc.

Physical punishment

Shook him/her

Spanked or hit on bottom with bare hand

Hit on bottom or elsewhere on body with rattan stick, feather duster, hanger etc.

Hit, slapped, pinched on the hand, arm or leg

Slapped face, hit head or twisted/pulled ear

Non-violent discipline

Forbade something liked e.g. watching TV, favorite toy or going to playground

Explained why behavior was wrong

Gave something else to do

For the purpose of this study, we excluded the responses by caregivers or relatives in the household, to only include responses by Malaysian parents. As the questions on disciplinary practice were asked for each child between the ages of 1 and 5, a positive response to the practice for any child was taken as the parents practicing the form of disciplinary method.

Data Analysis

Complex sample analysis, taking into account the study design and sampling weights, was used for all descriptive analysis and the univariate and multivariate logistic regression analysis. All analysis was described using 95% confidence interval and a P value of <.05 was considered to be significant. Variables with P value <.20 in univariate analysis was selected for main effects in multivariate logistic regression. All statistical analysis was carried out using SPSS Statistical Software Ver. 23.0.

Results

Of the 11 388 households selected for the survey, the overall success rate was 89.0%. A total of 9496 responses from Malaysian parents on their disciplinary practice and belief was recorded. Table 2 presents the demographic characteristics of the respondents of this study.

Table 2.

Demographic characteristics of respondents (N = 9496).

	Frequency (Percentage)
Ethnicity
Malay	6838 (72.0)
Chinese	1147 (12.1)
Indian	426 (4.5)
Others	1085 (11.4)
Locality
Urban	5628 (59.3)
Rural	3868 (40.7)
Marital status of parents
Single, divorced, widowed	167 (1.8)
Married or cohabiting	9269 (98.2)
Number of children
1	5954 (62.7)
2	3336 (35.1)
3 or more	206 (2.2)
Age of mother
Less than 30	3734 (39.6)
30-39	5109 (54.1)
40 and above	593 (6.3)
Age of father
Less than 30	2165 (23.9)
30-39	5137 (56.7)
40 and above	1760 (19.4)
Education of mother
No formal/Primary	1084 (11.5)
Secondary	4907 (52.1)
Tertiary	3426 (36.4)
Education of father
No formal/Primary	1204 (13.3)
Secondary	4975 (55.1)
Tertiary	2857 (31.6)
Occupation of mother
Public	2320 (24.6)
Private	2137 (22.7)
Self-employed	712 (7.6)
Unemployed	4257 (45.2)
Occupation of father
Public	2214 (23.3)
Private	4254 (47.0)
Self-employed	2507 (27.7)
Unemployed	79 (0.9)
Household income
Less than RM 1000	1036 (10.9)
RM 1000-RM 1999	1479 (15.6)
RM 2000-RM 2999	1556 (16.4)
RM 3000-RM 3999	1278 (13.5)
RM 4000-RM 4999	951 (10.0)
RM 5000 and above	3194 (33.6)

Figure 1 illustrates the prevalence of disciplinary methods practised by Malaysian parents on their children aged 1 to 5 years of age. The most common disciplinary method was “explaining why the behavior was wrong” at 94.1%, followed by “giving the child something else to do” at 78.7%. Both these practices are non-violent disciplinary methods. “Calling the child dumb, lazy, etc.,” a form of psychological aggression, was the least common at 2.5%. This was followed 3.1% of parents “shaking the child,” a form of physical punishment. Approximately 3 out of 5 Malaysian parents believed that physical punishment is needed to bring up a child.

Figure 1.

Prevalence of disciplinary methods and belief for violent discipline.

A parent however used various different disciplinary practice on their children. As seen in Figure 2, most parents, 42.1%, used a combination of non-violent punishment, psychological aggression and physical punishment in disciplining their children. Almost 30% of parents used only non-violent discipline, with only 0.1% having used only psychological aggression and 0.2% only physical punishments.

Figure 2.

Prevalence of disciplinary method by disciplinary scales.

It was found that a total of 60.0% of parents believed in the need for physical punishment. On the other hand, 54.3% of parents reported practising physical punishment. On further analysis, variation was found between the practice and belief for physical punishment among Malaysian parents. As shown in Table 3, 16.2% of parents practise physical punishment despite not believing in the need for it, while a total of 21.9% did not practice physical punishment despite believing in the need for physical punishment. Parents who believed in physical punishment were significantly more likely, with an odds ratio of 2.57, to practice physical punishments.

Table 3.

Prevalence of practise by belief for physical punishment.

		Practices Physical Punishment (95% CI)		Odds Ratio	Chi Square test P value
		No	Yes
Believes in Physical Punishment (95% CI)	No	23.8% (22.3-25.4)	16.2% (14.8-17.6)	2.57	<.001
	Yes	21.9% (20.1-23.7)	38.1% (35.9-40.5)

Univariate analysis, as seen in Table 4, shows that sociodemographic factors were a strong predictor for belief in physical punishment among Malaysian parents. The number of children below 5 years of age in the family, the age of the mother, education level of the mother and father and the total household income were all significant predictors for belief in physical punishment.

Table 4.

Univariate Logistic Regression for Factors Associated with Belief for Physical Punishment.

	Crude odds ratio	95% Confidence Interval		P value
		Lower limit	Upper limit
Ethnicity
Malay	1.00	—	—
Chinese	0.89	0.70	1.13	.344
Indian	1.00	0.70	1.42	.998
Others	1.17	0.94	1.47	.157
Locality
Urban	1.02	0.86	1.21	.819
Rural	1.00	—	—
Marital status of parents
Single, divorced, widowed	0.59	0.32	1.12	.105
Married or cohabiting	1.00	—	—
Number of children
1	1.00	—	—
2	1.64	1.37	1.96	<.001
3 or more	2.13	1.26	3.59	.005
Age of mother
Less than 30	1.00	—	—
30-39	1.00	0.84	1.21	.972
40 and above	0.65	0.47	0.89	.008
Age of father
Less than 30	1.00	—	—
30-39	1.01	0.83	1.23	.939
40 and above	0.83	0.65	1.06	.138
Education of mother
No formal/Primary	1.28	0.95	1.72	.103
Secondary	1.26	1.03	1.54	.024
Tertiary	1.00	—	—
Education of father
No formal/Primary	1.65	1.25	2.17	<.001
Secondary	1.33	1.07	1.64	.009
Tertiary	1.00	—	—
Occupation of mother
Public	1.00	—	—
Private	0.84	0.63	1.10	.206
Self-employed	0.89	0.64	1.23	.465
Unemployed	1.16	0.92	1.46	.206
Occupation of father
Public	1.00	—	—
Private	0.92	0.72	1.17	.487
Self-employed	0.99	0.76	1.27	.912
Unemployed	0.70	0.34	1.46	.342
Household income
Less RM 1000	1.80	1.35	2.39	<.001
RM 1000-1999	1.33	1.03	1.71	.029
RM 2000-2999	1.29	0.98	1.70	.067
RM 3000-3999	1.33	1.02	1.72	.034
RM 4000-4999	1.12	0.79	1.60	.522
RM 5000 above	1.00	—	—

Table 5 shows the results of the multivariate analysis. Parents with 2 children had 1.71 odds (aOR = 1.71, 95% CI 1.42-2.06, P < .001), while parents with 3 or more children had 2.28 odds (aOR = 2.28, 95% CI 1.34-3.89, P = .002) of believing in physical punishment compared to parents with 1 child. Fathers with no formal or primary level education had 1.45 odds (aOR = 1.45, 95% CI 1.04-2.03, P = .028) of believing in physical punishment compared to fathers with tertiary education and households with less than RM 1000 income had 1.77 odds (aOR = 1.77, 95% CI 1.24-2.53, P = .002) of believing in physical punishment compared to households with income of RM 5000 and above.

Table 5.

Multivariate Logistic Regression for Factors Associated with Belief for Physical Punishment.

	Adjusted odds ratio	95% Confidence interval		P value
		Lower limit	Upper limit
Ethnicity
Malay	1.00	—	—
Chinese	0.95	0.74	1.23	.702
Indian	1.00	0.70	1.43	.989
Others	0.97	0.76	1.24	.836
Marital status of parents
Single, divorced, widowed	2.62	0.38	18.13	.330
Married or cohabiting	1.00	—	—
Number of children
1	1.00	—	—
2	1.71	1.42	2.06	<.001
3 or more	2.28	1.34	3.89	.002
Age of mother
Less than 30	1.00	—	—
30-39	1.13	0.88	1.44	.340
40 and above	0.79	0.52	1.20	.273
Age of father
Less than 30	1.00	—	—
30-39	0.97	0.76	1.25	.829
40 and above	0.82	0.60	1.13	.220
Education of mother
No formal/Primary	0.90	0.62	1.30	.575
Secondary	1.03	0.81	1.32	.800
Tertiary	1.00	—	—
Education of father
No formal/Primary	1.45	1.04	2.03	.028
Secondary	1.18	0.93	1.50	.185
Tertiary	1.00	—	—
Household income
Less RM 1000	1.77	1.24	2.53	.002
RM 1000-1999	1.31	0.97	1.77	.074
RM 2000-2999	1.23	0.91	1.68	.183
RM 3000-3999	1.23	0.92	1.63	.160
RM 4000-4999	1.17	0.83	1.65	.373
RM 5000 above	1.00	—	—

Classification table-62.4%, Nagelkerke Pseudo R2 = 0.046, Hosmer-Lemeshow Goodness of Fit P = .771.

Discussion

This study found that most of the parents in Malaysia practiced non-violent disciplinary methods, such as explaining to the child why the behavior was wrong and giving the child something else to do. The use of physical punishments, such as hitting the child with a cane, slapping and hitting on the head and shaking the child was relatively low, as was the use of psychologically aggressive methods, such as calling the child names. However, the use of non-violent punishment appears to be more often than not accompanied by other violent punishment methods. These parents may be resorting to violent punishment methods when non-violent punishments when first used were found to be ineffective. This is supported by the extremely low prevalence of parents who use physical punishment and psychological aggression in isolation. This also suggests that parents accept physical punishment as a normal means of raising a child and control of the child’s behavior in a caring and nurturing relationship.

In Malaysia, 3 out of 5 parents believe that physical punishment is needed to raise a child. The significant influence of socio-cultural practices results in a wide variance in international figures, ranging from less than 10% in some countries to over 70% as reported by parents in America.[17,18] Parents in Malaysia who believed in physical punishment were found to be twice more likely to practice physical punishment. This is in agreement with other studies that have described the same association, and to be present across culturally different countries across the globe.

However, an issue of concern is the relatively large number of Malaysian parents who practice physical punishment despite not believing in the need for it. This incongruity has been linked with parental psychological distress at home, and results in higher depressive symptoms in the child. The authors of a study carried among mothers in America postulated that the high level or anger and frustration experienced causes the parent to violate their own philosophy, may administer harsher punishments, and less associated with reasoning, causing blunting of the child’s awareness of when and why the punishment is administered which ultimately leads toward the higher depressive symptoms in the child.

Compared to those with 1 child under 5 years, parents with 2 children under 5 years were found to be more significantly associated with the belief in the need for physical punishment. The odds were even higher for parents with 3 or more children. This could be due to the higher parental stress experienced due to the number of young children at home, a need for immediate compliance due to the parenting demands which, ultimately, manifest as physical aggression toward the child. However, an interesting study comparing disciplinary practices of mothers from Hong Kong and mainland China found that due to the single child policy in China, mothers in China were less likely to adopt authoritative disciplinary practices as they were more tender, and over-indulgent to the point of spoiling the child by satisfying their every need. Households with lower income and with fathers with no or primary level education were also found to be associated with the belief in the need for physical punishment which is consistent with other studies that have found that parents in lower socioeconomic status are more likely to endorse physical punishment.

The Child Act 2001 (Act 611) is the legislation in place to protect children in Malaysia against actual or any risk of physical, sexual and emotional injury. This Law however does not explicitly prohibit or protect a child against institutional use or physical punishments carried out at home. As of early 2018, there are 53 countries that have legally prohibited physical punishment in all settings. A legislative ban on physical punishment does indeed result in reduced physical punishment toward children.[26,27] However, laws against physical punishments toward children is not a one-stop solution as parents’ attitude and cultural factors such as acceptable levels of physical discipline, still play a significant role in the continued use of corporal punishment.[11,28]

Taking Sweden as a case study, one of the first countries to ban physical punishment, the diminishing belief in the appropriateness of physical punishment among Swedish society has led to successful legal implementation banning physical punishment. Tackling societal beliefs toward physical punishment should precede any legislative bans as the absence of attitude change within the society has significant limitations toward curbing this practice.[27,30] Thus, although legal bans on physical punishment is an important step, this is not sufficient to change belief and behavior in the absence of public awareness of the negative effects of physical punishment and educational materials to parents on positive disciplinary methods.[18,31]

Tackling the belief in the need for physical punishment within the society involves many complex issues that needs to be addressed simultaneously. Intervention studies have also shown that educating parents on positive parenting techniques, alternatives to physical punishment and negative effects of physical punishment does reduce parents endorsement of physical punishment, however, one must keep in mind that cultural norms still play are major role toward the parents approval of physical punishment. Parents may believe in the need for physical punishment in order to obtain immediate cessation of misbehavior and if it is more effective in the long run to protect the child from dangers in the future, despite being aware of the negative effects of physical punishments. Furthermore, as other studies have put forward, this study findings support the notion that Malaysian parents need to be also taught to respond positively to children’s behavior and in anger management strategies in difficult parenting situations, in addition to the awareness of the negative effects of physical punishments toward chlildren.[10,34]

Even though advice from healthcare professionals play a pivotal role toward the parent’s chid disciplinary practices, healthcare professionals have been found to be reluctant to openly discuss this issue with parents or even discourage its use.[35,36] Healthcare professionals need to take the lead to encourage the use of non-violent disciplinary methods toward children and educate parents of the negative effects of physical punishment. Our study highlights that Malaysian parents, especially those with a number of young children at home and those from the lower socio-economic background, are the most in need for these interventions. Training healthcare professionals to deliver positive parenting methods have been shown to have positive results on parent’s disciplinary practices, keeping in mind that the advice has to be delivered in a culturally appropriate manner.[37-39]

Some of the inherent limitations of this study must be recognized. In this study, a causal relationship cannot be established as this is a cross sectional study. However, the large sample size and nationally representative sample obtained increases the credibility of this study findings. We acknowledge that there may be inaccuracies in the self-reporting by parents on the disciplinary methods practiced. However, as this study focuses on practices on children 1 to 5 years of age, the study is unable to circumvent this limitation. Furthermore, the practice of the disciplinary method is collected as a collective action of the adults in the household, and may not necessarily represent the practice of the parents themselves. Neither do we take into account the characteristics of the primary caregiver or the length of time the child spends time with these caregivers as this information was not captured within the scope of this study.

Conclusion

In view of the large prevalence of Malaysian parents who belief in the need for physical punishment, the time is now for the government, non-governmental organizations and the healthcare fraternity to step up efforts toward reducing the use and the belief in the need for physical punishment toward children through interventions such as parental education and public awareness campaigns. This should be the first step before any legal intervention can be successfully undertaken in Malaysia.

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Supplemental material, sj-docx-1-gph-10.1177_2333794X221113820 for Practice of Disciplinary Methods and Factors Associated With Belief for Physical Punishment Among Malaysian Parents: Findings From NHMS 2016 by Shubash Shander Ganapathy, Rajini Sooryanarayana, Nik Mazlina Mohammad and Rosliza Abdul Manaf in Global Pediatric Health