A descriptive study on child sexual abuse act in India.

Background: Child sexual abuse (CSA) is a significant public health problem. Health care professionals can play an important role in the identification and reporting of such cases. This study was conducted to assess the awareness level among doctors working in a medical Institute about CSA. Materials and
Methods: This is a cross-sectional descriptive study. Data was collected using a closed-ended structured questionnaire. Descriptive analysis was done to compute percentages and frequencies. Respondents' educational qualification, as well as the relationship between their level of education and their awareness of child abuse, was also assessed.
Results: Nearly 70% of respondents came across child abuse cases, wherein sexual abuse was found to be the commonest (58%), followed by physical abuse (28%). Nearly 40% of child abuse cases were reported in the hospital where they worked, while 15% of child abuse cases occurred in other hospital areas. The study also revealed that 81% of respondents had knowledge about child sexual abuse. However, only 34% were aware of the repercussions of non-reporting of a child abuse case. Nearly 64% of respondents had an idea about an online complaint system for child abuse, and 70% were aware of the availability of a one-stop centre at a respondent's hospital. The majority (68%) were aware of the POCSO (Protection of Children from Sexual Offences) Act on sexual abuse. On seeking information regarding evidence of anal sexual abuse among children and adolescents, 36% were completely aware, and 13% were partly aware of it.
Conclusion: There is a need for continued education and advancement of all health care professionals to improve the diagnosis and reporting of CSA. Copyright:

Introduction

Child sexual abuse (CSA) has been recognised as a major public health problem impairing the health and welfare of children worldwide. The effects of CSA can be profound and life-altering for victims.[1] Child abuse, therefore, requires multi-disciplinary support from medical, legal, psychological and sociological dimensions. Here, the role of healthcare professionals is vital to not only detect abuse but also to inform relevant interventions.[2] However, physicians often under-identify and under-report cases of child abuse, which may lead to continued trauma and severe consequences.[3] It has been reported that 5–10% of children die, and 35–50% have major injuries in cases where children are admitted to the emergency rooms or other medical units and are not thoroughly evaluated and sent home.[4] Some of the major challenges reported by healthcare professionals to report child abuse are lack of knowledge, inadequate experience, the uncertainty of diagnosis, poor communication, fear of disconnecting therapeutic relationships, etc.[5] However, there is a dearth of literature regarding the awareness of healthcare professionals about child abuse in low and middle-income countries, such as India.

India is a country of youth, where more than forty percent of its population is below the age of 18 years. In fact, 19% of the world’s children live in India.[6] Various initiatives and legislative acts, including the Indian penal code 1860, the Immoral Traffic (Prevention) Act, 1956, the Protection of Children against Sexual Offences (POCSO) Act 2012, etc., are being implemented in the country for addressing the issue of Child Abuse. Despite that, the prevalence of all forms of child abuse which includes physical abuse (66%), sexual abuse (50%) and emotional abuse (50%), is extremely high in India as per a survey conducted by the Government of India, Ministry of Women and Child Development (2007).[7] A more recent study by the National Commission for Protection of Child Rights (NCPCR), conducted amongst 6,632 children respondents in seven states, revealed 99% of children face corporal punishment in schools.[8]

The present study was conducted to assess the level of awareness among doctors working in a medical institute about child abuse and negligence and to recommend appropriate solutions to the problems of healthcare personnel on this issue.

Methods

Study design

The study was a descriptive cross-sectional study. This study was envisaged as a part of the workshop, conducted in March 2018, for creating awareness regarding the provisions of the POCSO act, medico-legal examinations, forensic evidence collection, social-psychological aspects and its implementation.

Participants and data collection

Junior and Senior Resident doctors at the Post Graduate Institute of Medical Education and Research, Chandigarh, were invited to participate in the study. A closed-ended structured questionnaire in English was developed and pre-tested for data collection. The questionnaire was developed by researchers after an intensive literature review and expert consultation for any suggestions, amendments, or modifications. The questionnaire consisted of twenty questions seeking general information on the experience of child abuse, awareness regarding findings of a national study on child abuse, sexual assault (POCSO Act), medical examination of the child abuse victim, specification of POCSO Act, clinical examination of sexual abuse, practices (Doctor/Hospital), signs of anogenital injury, correlates of sexual abuse, evidence of sexual abuse (communicable disease), evidence of anal sexual abuse (child/adolescents), location of one-stop centre within an institution and the first action taken when a child approaches for medical care [Annexure 1].

Ethics

Confidentiality and anonymity of the respondent was maintained. The study was approved by the institutional ethical committee. Prior to the interview, verbal consent was taken from the respondents, and they were informed about the aim and methodology of the study.

Data analysis

Data were entered and coded for statistical analysis in software SPSS version 21. Descriptive statistical analysis was done. Frequency and percent distribution were reported for all data variables. We also assessed the differences in awareness levels about child abuse vis-a-vis the level of educational qualification of the healthcare personnel.

Results

Exposure to child abuse cases

The majority (70%) of the participants were Junior Residents, followed by 24.5% Senior Residents. Nearly 70% of respondents came across child abuse cases wherein sexual abuse was found to be the commonest (58%), followed by physical abuse (28%). About 28% did not respond while seeking information on the type of child abuse. Nearly 40% of child abuse cases were reported in the hospital where they worked, while 15% of child abuse cases occurred in other hospital areas. It was found that 40% of doctors came across child abuse cases less than two times while 19% of childrencame across 2–5 times and 19% more than five times in their career [Table 1].

Table 1

Exposure to child abuse cases

Parameter	n	%
Total	53	100
Respondent Status
Undergraduate	37	69.8
Postgraduate	13	24.5
Others	3	5.7
Came across the child abuse case
Yes	37	69.8
No	14	26.4
No response	2	3.8
Type of abuse (came across)
Sexual	31	58
Physical	15	28
No Response	15	28
Place of child abuse
Own College	21	39.6
Other hospital	8	15.1
Both	1	1.9
Not Applicable/No Response	23	43.4
Number of child abuse cases seen
<2	21	39.6
2-5 cases	10	18.9
>5 cases	10	18.9
No Response	12	22.6

Awareness regarding child abuse

Nearly 81% of the respondents had knowledge about child abuse. However, only 34% were aware of the repercussions of non-reporting of a child abuse case. Nearly 64% of respondents knew about the online complaint system for child abuse and 70% were aware of the availability of one-stop centre at a respondent’s hospital. [Table 2]

Table 2

Awareness (%) among health care professionals about the child abuse act (POCSO)

Awareness about	Undergraduate		Postgraduate		Others		Total
	n	%	n	%	n	%	n	%
Child abuse act	31	83.8	10	76.9	2	66.7	43	81.1
Consequences of non-reporting of child abuse	13	35.1	5	38.5	0	0.0	18	34.0
Online complaint system	25	67.6	8	61.5	1	33.3	34	64.2
Availability of one stop centre at respondent’s hospital	25	67.6	9	69.2	3	100.0	37	69.8

Note: ‘N’ and percentage given in the table represents the correct responses

Awareness regarding Child Abuse Act

Nearly 42% were not aware of estimates of a national-level study on child abuse, while 26% responded correctly. Around 17% of respondents were partially correct. The majority of respondents (68%) knew about POCSO Act on sexual abuse, followed by 11% with partial awareness and 17% with no awareness. [Table 3]

Table 3

Awareness (%) among health care professionals about guidelines of the child abuse act (POCSO)

Awareness about	Undergraduate		Postgraduate		Others		Total
	n	%	n	%	n	%	n	%
Findings of national study on child abuse
Correct	9	24.3	3	23.1	2	66.7	14	26.4
Partly correct	7	18.9	2	15.4	0	0.0	9	17.0
Incorrect	18	48.6	3	23.1	1	33.3	22	41.5
No response	3	8.1	5	38.5	0	0.0	8	15.1
Sexual assault (POCSO act)
Correct	27	73.0	10	76.9	0	0.0	37	69.8
Partly correct	5	13.5	1	7.7	0	0.0	6	11.3
Incorrect	3	8.1	2	15.4	3	100.0	8	15.1
No response	2	5.4	0	0.0	0	0.0	2	3.8
Medical examination of child abuse victim
Correct	3	8.1	4	30.8	0	0.0	7	13.2
Partly correct	5	13.5	1	7.7	0	0.0	6	11.3
Incorrect	27	73.0	8	61.5	3	100.0	38	71.7
No response	2	5.4	0	0.0	0	0.0	2	3.8
Specification of POCSO act
Correct	18	48.6	7	53.8	0	0.0	25	47.2
Partly correct	4	10.8	2	15.4	1	33.3	7	13.2
Incorrect	13	35.1	4	30.8	2	66.7	19	35.8
No response	2	5.4	0	0.0	0	0.0	2	3.8
Findings of clinical examination of sexual abuse
Correct	0	0.0	0	0.0	1	33.3	1	1.9
Partly correct	5	13.5	1	7.7	0	0.0	6	11.3
Incorrect	31	83.8	9	69.2	0	0.0	40	75.5
No response	1	2.7	3	23.1	2	66.7	6	11.3
Practices (Doctor/Hospital)
Correct	8	21.6	5	38.5	2	66.7	15	28.3
Partly correct	6	16.2	4	30.8	0	0.0	10	18.9
Incorrect	23	62.2	4	30.8	1	33.3	28	52.8
No response	0	0.0	0	0.0	0	0.0	0	0.0
Signs of anogenital injury
Correct	12	32.4	4	30.8	0	0.0	16	30.2
Partly correct	7	18.9	3	23.1	1	33.3	11	20.8
Incorrect	16	43.2	4	30.8	2	66.7	22	41.5
No response	2	5.4	2	15.4	0	0.0	4	7.5
Correlates of sexual abuse
Correct	8	21.6	3	23.1	2	66.7	13	24.5
Partly correct	14	37.8	5	38.5	0	0.0	19	35.8
Incorrect	14	37.8	4	30.8	1	33.3	19	35.8
No response	1	2.7	1	7.7	0	0.0	2	3.8
Evidence of sexual abuse (communicable disease)
Correct	29	78.4	10	76.9	1	33.3	40	75.5
Partly correct	2	5.4	2	15.4	0	0.0	4	7.5
Incorrect	5	13.5	0	0.0	1	33.3	6	11.3
No response	1	2.7	1	7.7	1	33.3	3	5.7
Evidence of sexual abuse (boys)
Correct	10	27.0	3	23.1	0	0.0	13	24.5
Partly correct	4	10.8	0	0.0	1	33.3	5	9.4
Incorrect	22	59.5	9	69.2	0	0.0	31	58.5
No response	1	2.7	1	7.7	2	66.7	4	7.5
Evidence of anal sexual abuse (child/adolescents)
Correct	14	37.8	5	38.5	0	0.0	19	35.8
Partly correct	5	13.5	1	7.7	1	33.3	7	13.2
Incorrect	16	43.2	6	46.2	0	0.0	22	41.5
No response	2	5.4	1	7.7	2	66.7	5	9.4
Location of one stop centre within institution
Correct	6	16.2	3	23.1	1	33.3	10	18.9
Partly correct	0	0.0	0	0.0	0	0.0	0	0.0
Incorrect	18	48.6	7	53.8	2	66.7	27	50.9
No response	13	35.1	3	23.1	0	0.0	16	30.2
First action taken when a child approaches for medical care
Correct	5	13.5	1	7.7	3	100.0	9	17.0
Partly correct	1	2.7	0	0.0	0	0.0	1	1.9
Incorrect	29	78.4	12	92.3	0	0.0	41	77.4
No response	2	5.4	0	0.0	0	0.0	2	3.8

*Multiple responses were allowed. ‘Partly correct’ means more than one response for a question out of which one response is the correct answer

Our study also revealed that the majority of the respondents (72%) had incorrect knowledge about the medical examination of a child abuse victim. The study also tried to seek information on awareness regarding the specification of the POCSO Act, wherein 47% ofo respondents were correct while 35% and 13% of respondents were incorrect and partly correct, respectively. The information on awareness regarding findings of clinical examination of sexual abuse was also sought where it was found that the majority (76%) were incorrect, followed by 11% being partly correct. The study depicted that 52% of respondents were aware of child abuse practices by doctors and hospitals, while 28% had incorrect knowledge and 19% were partly correct.

The respondents were inquired about knowledge regarding signs of anogenital injury where 41% had incorrect knowledge, followed by 30% with correct and 21% with partly correct knowledge. Knowledge regarding correlates of sexual abuse was also assessed. Around one-third (i.e., 36%) were incorrect and only one-fourth had correct knowledge.

In regard to evidence of sexual abuse in relation to communicable disease, three-fourths of the participants were aware of it. However, in the context of evidence on sexual abuse by boys, 58% were unaware, followed by 25% being aware of the same. While seeking information on evidence of anal sexual abuse among children and adolescents, 42% were not aware and 36% had awareness regarding it.

The study sought information on awareness regarding the location of a one-stop centre within the institution of respondents. More than half (51%) were unaware, and only 19% were aware of the location of a one-stop centre within the Institute. The knowledge of respondents was also assessed for the first action taken when a child approaches medical care, to which 77% were unaware while only 17% answered correctly. [Table 3]

Discussion

The World Health Organization emphasizes that diagnosis, protection and maintenance of suitable treatment conditions for the abused and neglected children are among the responsibilities of healthcare professionals.[9] The child protection law obliges physicians and other personnel working in healthcare to report the suspected cases of child abuse and negligence in many countries.[10]

Besides the preventive affords about child abuse that may result in significant injuries and death, recognition of those who are exposed to abuse and initiating the legal process and protection of the abused children is very important. Therefore, physicians and nurses should consider the possibility of child abuse in cases they encounter, request necessary consultations, and keep the child under observation in cases in which they are unable to make a definitive decision.[11] In cases of suspected child abuse and negligence, the correct approach is reporting the case and protecting the child.[12]

Our study assessed the awareness and knowledge of doctors with regard to CSA. The results provide valuable information which can help to improve the training of health care professionals, particularly in the identification and reporting of suspected cases of CSA.

The present study also revealed that 81% of doctors included in the study had knowledge about child abuse. Another study by Olatosi et al.[13] also found that healthcare professionals had good theoretical knowledge of the different forms of CSA, with an average score of 95.2%. Findings from the present study are comparable to previous similar studies where the dentists had adequate knowledge of the different forms of CSA.[14151617] Alnasser et al.[18] found that the Saudi medical students, paediatrics trainees, and paediatricians have good basic knowledge about child abuse. The study concluded that experienced physicians were more knowledgeable and more likely to report about child abuse and negligence. In China, Li et al.[19] reported that there was insufficient knowledge of the healthcare provider toward child abuse. This difference may be including all health professions in that study.

Garrussi et al.[20] determined in their study that 65% of the physicians had encountered child abuse and negligence, but only 4.5% of them had reported the cases. Approximately 85% of the physicians in a recently conducted study mentioned that they thought they would report the case or suspected case of abuse if they ever came across one.[21] In the present study, 70% came across child abuse cases, and 34% were aware of the consequences of non-reporting of child abuse cases. Nearly 64% of respondents had an idea about an online complaint system for child abus, e and 70% were aware of the availability of a one-stop centre at a respondent’s hospital.

Kraus and Jandl-Jager[22] found that the majority of physicians recognized the most common symptoms of child abuse. Yadav and his colleague[22] observed that most of the family physicians had inadequate knowledge about the identification and management of cases of child abuse. Other studies, such as Hynniewta et al.,[23] that explore awareness among other important persons like teachers, make a sense in the detection and prevention of child abuse and neglect. It found that the majority (84%) of the school teachers had average knowledge of child abuse and 10% and 6% of them had good and poor knowledge, respectively. In the present study, it was found that these findings reflect the importance of raising awareness among physicians and teachers as caregivers and contact caregivers with children.

Limitations

Firstly, the present study did not capture the risk factors of child abuse which may be useful while reporting results in such studies to inform the government and policymakers. Thus, the preventive strategies may be then promoted to avoid specific risk factors for effective child protection service delivery. Secondly, the sample size is small (53) and may not be generalizable.

Conclusion

The major priority during the evaluation of a child abuse case is taking into consideration the benefits to the child. Formation of a multi-disciplinary team consisting of personnel working in different fields who have received necessary education about child abuse and evaluation of the cases by this team is an important first step. Procedures include the steps that should be followed for these cases in polyclinics and emergency departments, and physicians and nurses should have practical education about the subject. All these efforts can help in reducing the rates of child abuse cases in our country. More research on the economic impact of child abuse such as child trafficking, child labour, commercial sexual exploitation, the direct financial healthcare implications of abused children presenting to healthcare providers, and the association of socio-economic characteristics with child protection will go a long way to convince governments to re-source local child protection and prevention services. The findings of the study emphasize the urgent need for continued education and advancement of all health care professionals to improve the diagnosis and reporting of CSA. The results of the study emphasize raising awareness and knowledge about child abuse through continuous education programs for the solution of the problems faced during the diagnosis and the reporting process.[24] Besides the management of child abuse cases, there is a need to focus on preventive strategies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.