THE PERCEPTION OF CONSULTANTS AND THE POST-GRADUATION RESIDENTS ABOUT THE BARRIERS TO THE REPORTING OF SUSPECTED CASES OF CHILD ABUSE AND NEGLIGENCE

Background: Childhood is a dynamic stage of life and experiences endured by the child during this stage can have everlasting effects on one’s life. Statistically significant associations were observed between physical abuse, emotional abuse, and neglect and depressive disorders. Objective: To determine the perception of consultants and post-graduation residents regarding barriers to the reporting of suspected cases of child abuse and negligence. Methods: This observational cross-sectional study was carried out on a population of 108 doctors including consultants and post-graduation residents of various specialities and clinical experience in the wards of various specialities at two teaching hospitals of Lahore. A questionnaire consisting of two components demographics and second component based on variables studied by another research on child abuse in Turkey which was administered in a pilot study done in Lahore General Hospital, and validated; was then applied to a population of 108 doctors including consultants and post-graduation residents of various specialities and clinical experience at two teaching hospitals of Lahore. All the data was entered and analysed by using SPSS V-20. Effect modifiers like age, gender, qualification and duration of training was controlled by stratification and post-stratification chi-square test was applied. P-value ≤ 0.05 was taken as significant. Results: “Lack of knowledge about the process of reporting” was the most frequent variable reported as a barrier by 80.6% of the doctors studied among whom 25% were consultants and 55.6% were residents with a p-value of 0.00027. “Difficulties that might be faced during legal process” was the second most frequently reported barrier by 77.8% (30.6% of consultants and 47.2% of residents) of the doctors studied. Conclusion: The deficiency of guidelines on the process of reporting is considered by the doctors studied as the most frequent barrier to the reporting of suspected cases of child abuse and negligence.


INTRODUCTION
Childhood is a dynamic stage of life and experiences endured by the child during this stage can have everlasting effects on one's life.Statistically significant associations were observed between physical abuse, emotional abuse, and neglect and depressive disorders. 3Significant associations have been found between early life's traumas i.e. abuse (sexual and/or physical) and neglect status and the Cambridge Neuropsychological Test Automated Battery (CANTAB) measures of memory and executive and emotional functioning. 4Like any other health problem, the child maltreatment is significant because its effect on the mental health and productivity of individuals can incur substantial social and economic loss.The total economic burden is estimated to be $585 billion in USA from the new fatal and non-fatal child maltreatment cases in 2008. 5The mental health outcomes of child abuse and neglect are influenced by sex and race of the victim. 6Clinicians and researchers emphasize to be cautious around this topic as the different ethnic groups have differential cross-cultural definitions of child maltreatment.In Pakistan, much emphasis has been placed on child abuse (both sexual and physical) in the past few years especially after the appearance of Kasur scandal.After the parliament passed Child Protection System bill, 2014, Government of the Punjab set up the Bureau for Child Protection and Welfare that rehabilitates the deprived and abused children.Health professionals working with children and their families in Pakistan are required by the Criminal Law Amendment Bill, 2015 to report to government authorities any reasonable suspicion of child abuse and/or neglect.The health professionals need further training in the framework and specific skills for discussing concerns about maltreatment and reporting to child protective services with the caregivers. 2 Child neglect is a problem of considerable extent, but seems to be a neglected phenomenon in scientific research.This is illustrated by the deplorable dearth of studies on child neglect, especially in low-resource countries. 1Despite being the subject of great attention in recent years, the concept of child maltreatment remains difficult to study in Pakistan as little research has been done in our country on this important topic.Although, UNICEF has initiated the establishment of Child Protection Monitoring and Data Collecting System in Pakistan; yet the data available is insufficient and to quote the Pakistan Annual Report 2015 9 by UNICEF "reliable and upto-date data on child protection concerns is critically lacking".Review of the previous studies on this topic shows that in East Turkey, the rate of encountering child abuse and negligence by physicians and nurses is 38.6%. 7One-seventh of the practitioners and residents reported that they would not make a legal notice if they confronted with a case or suspicious case of child abuse and neglect. 8Under-reporting of the abuse and neglect cases is a problem all over the world.The following were the common reasons for underreporting of child abuse and neglect cases: insufficient knowledge of child abuse and neglect (78 %), 8 lack of knowledge of where to make a legal notice (68.7 %), 8 difficulties that may be faced during the legal process (58.4%), 7 Lack of knowledge about the process of reporting (36.5%), 7 Fear that the child may later be in a worse state after the reporting (31%), 7 Unwillingness to get involved with issues that should stay inside the family (21.7%), 7hinking that social services will not be interested (20.4%). 7akistan is one of the countries with highest population of children and adolescents.UNICEF Representative for Pakistan, Martin Mogwanja, stated at the launch of National Campaign against Child Abuse in 2008 that roughly 70 per cent of Pakistani children experience physical and psychological abuse.And that the abuse is not only relegated to the home, but often happens in schools, madrassahs, childcare centres, places of work and entertainment, jails, detention centres and on the streets. 10Paediatricians and post-graduation residents who provide health-care to children can play a pivotal role in recognition and reporting of such cases, thus preventing the devastating outcomes as mentioned above, so I have designed this study to determine the factors that may act as barriers to them in reporting of these cases.

OBJECTIVE
To determine the perception of paediatricians and paediatric post-graduation residents regarding barriers to the reporting of suspicious cases of child abuse and negligence.Child Abuse and Negligence: Intentional use of physical force, sexual molestation or words/behaviour from the care giver conveying that the child (under 18 years) is worthless, unwanted or endangered that cause harm or potential harm to the child; though, harm may not be the intended consequence and failure to provide the care to the child necessary for normal growth and development and leaving the child unattended in potentially dangerous environments.Insufficient knowledge of doctors about child abuse and neglect: Doctors may not be fully aware of the acts of parents/care-giver that may constitute as abuse and negligence and regarded as punishable crimes by the law of Pakistan (Child Protection System bill, 2014).Lack of knowledge of where to make a legal notice: The doctors may not be aware of the contact details of Child Protection Bureau's office or a legal counsellor if they intend to pursue the case legally Lack of knowledge about the process of reporting: Doctors may not be aware of the method of writing the report and have specific skills for discussing concerns about maltreatment and reporting to child protective services with the caregivers Difficulties in legal process: Time consumption in the court, strong political connections and resultant influence of the child abusers and intricacy of legal issues may be a few of the difficulties that the doctors may face in the legal process.Thinking that social services will not be interested: Doctors might think certain acts of negligence/abuse so trivial that they may mistakenly think that the issue isn't grave enough to be brought to the knowledge of the authorities Unwillingness to get involved with issues that should stay inside the family: The doctors may regard certain acts of abuse and neglect to be the family's personal issue in which strangers should not intervene be it health-care provider.Childhood maltreatment can have a significant impact on a person's life.Early reporting of such cases leading to early detection and intervention can save the child from the devastating consequences.Doctors especially paediatricians directly deal with the children who suffered by child abuse and negligence.They can report any help to catch the culprits.It is important to find out their perspective and the difficulties they perceive in this process which is the aim of this study.This will help the authorities in deciding their next strategies to deal with the menace of child abuse.Eliminating the barriers to the reporting of such cases highlighted by this study will be a big step towards the safety of our children.

METHODS
The current study design was cross-sectional study which refers to a study in which subjects of different ages are compared at the same time.The data was collected from the three institutes of Lahore.The Lahore General Hospital, The Children Hospital and Institute of Child Health, Lahore.The study took 6 months for its completion The non probability Convenient Sampling technique was used in order to collect the data of the research.By using WHO sample size calculator: P = 20.4% 9 Confidence Interval = 95%, Absolute precision = 10% Sample size = 70 Post-graduation residents of FCPS program (first or second fellowship) who have experience of working in paediatric medicine and allied specialities, surgery and allied specialities or radiology at-least for six months after their registration from PMDC; and the consultant paediatricians at the above-mentioned hospital.Trainees of MCPS or MS/MD programs; doctors lacking 6 months' experience after registration with PMDC.Data was entered in the Performa by the researcher after interview with the residents and paediatricians in different wards of the hospitals who meet the inclusion criteria.All the doctors involved in the study was informed about the aim and the protocol of the study and invited to participate.The Performa was a structured questionnaire: the first section contains items related to demographic variables i.e. age, gender, specialty, qualification and duration of training.The second section comprises 7 close-ended questions based on the outcome variables (whose operational definitions have been given above) i.e the most frequent variables studied in two previous studies 7,8 that act as barriers to doctors in reporting the child abuse and negligence cases.The last question is an open-ended question asking the participants of any other reason they could think of i.e.Not mentioned in the questionnaire.The aim of adding this last question to the preforma is to drive new variables from this study that can be studied in the future.All the data was entered and analysed by using SPSS V-20.Mean and standard deviation was calculated for quantitative variables like age and duration of training.Frequency and percentage were calculated for the qualitative variables like gender, specialty and qualification.Effect modifiers like age, gender, qualification and duration of training was controlled by stratification and post-stratification chi-square test was applied.P-value ≤ 0.05 was taken as significant.

RESULTS
Out of total, 69.4% of the doctors agreed that "insufficient knowledge about child abuse and neglect" was a barrier to reporting of such cases out of which 22.2% were consultants and 47.2% were residents.50% of residents and 19.4% of consultants (total= 69.4%) agreed that "lack of knowledge of where to make a legal notice" was a barrier to the reporting.80.6% of the paediatricians among whom 25% were consultants and 55.6% were residents agreed that "lack of knowledge about the process of reporting" was a barrier.77.8% (30.6% of consultants and 47.2% of residents) of them believed that "difficulties that might be faced during legal process" was a barrier in the reporting.50% of paediatricians agreed that "fear that child may later be in a worse state after the reporting" was a barrier as well.69.3% agreed that "unwillingness to get involved in the issues that should stay inside the family" was a barrier.36.1% of them agreed "thinking that social services will not be interested" was a barrier.

DISCUSSION
In our study, the most commonly reported barriers to child abuse and negligence cases were "lack of knowledge about the process of reporting" and "difficulties that might be faced during the process of reporting".A study done in 2016 11 in pre-hospital emergency settings showed "uncertainty related to the child abuse and negligence" and "fear of being wrong".These barriers are usually the result of lack of knowledge and proper training in recognizing child abuse and negligence cases, this can lead to difficulty in differentiating accidental injuries from those inflicted by the care-giver and so on.So, the results of this study correspond to that of ours by highlighting "lack of knowledge and training" as a very important barrier.Another study done in Saudi Arabia 12 among nurses in a hospital revealed that uncertainty about the possibility of abuse; lack of awareness about how and where to report and having previous bad experiences after reporting of some cases were the barriers perceived by them.Similar findings were obtained from a study done in Palestine on nurses 14 57% of whom reported that unavailability of formal training on the identification and reporting of the cases of child abuse and negligence was a barrier to reporting of such cases.Another qualitative study done on both teachers and public health nurses inferred that they lacked definite knowledge of child abuse and negligence 15 .A review study that included 56 papers published in English and Persian languages from 1973 to 2017 13 found out that one of the most important reasons of under-reporting is "the knowledge of healthcare professionals" on the topic of child abuse and negligence.Beliefs of the healthcare providers, poor communication, weak legal process, violating the privacy of the family were also regarded as important barriers to the reporting of such cases.All of these factors have been studied in our study as well and among these "lack of knowledge of where to make a legal notice" and "unwillingness to get involved in the issues that should stay inside the family" were the commoner ones which correspond with the first three factors described before in the review study.Beliefs of the healthcare providers are important factor serving as a barrier to the reporting of the abuse cases as 30% of the nurses surveyed in Palestine did not think child abuse as a serious issue and were not interested in getting trained for it 14 .

CONCLUSION
The deficiency of guidelines on the process of reporting is considered by the doctors studied as the most frequent