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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 12  |  Page : 1766-1772

Family physicians in an Eastern Turkish City need training on child abuse and neglect: A cross-sectional study


1 Department of Public Health, Atatürk University Medical Faculty, Erzurum, Turkey
2 Menemen Family Health Center, Izmir, Turkey
3 Institute of Family Medicine and Health Research, Munich Technical University, Germany

Date of Submission08-Dec-2020
Date of Acceptance07-Jun-2021
Date of Web Publication09-Dec-2021

Correspondence Address:
Prof. E O Calikoglu
Atatürk University Medical Faculty, Department of Public Health, 25240 Erzurum
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_678_20

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   Abstract 


Aim: The study's purpose was to determine the knowledge, competencies, and approaches of family physicians in recognizing the signs of child neglect and abuse. Methods: This cross-sectional study was conducted between 1 March and 30 August 2019 in the Erzurum province in Turkey. The population of the study was family physicians working in primary care. The data were collected with an instrument that included the Scale of Diagnosing the Symptoms and Risks of Child Abuse and Neglect (SDRCAN) and a socio-demographic information form. Results: The mean age was 37.40 ± 8.78 years (min. 26, max. 60). Of the participants, 103 (n = 58.5%) were men. The most common types of encountered child abuse/neglect were physical abuse or neglect (each 27.8%, n = 49). Having received education on child abuse/neglect among participants was only 44.9% (n = 79). On the other hand, the rate of having encountered any child abuse/neglect was 40.3% (n = 71). Another result of this study is the proportion of family physicians feeling weak regarding history taking (30.7%, n = 54), physical exam (17.0%, n = 30), and cooperation with the authorities (13.1%, n = 23). Additionally, the different responses among the participants about action in case of encountering child abuse/neglect were remarkable. Being a woman was one prominent factor that increased the SDRCAN score (P < 0.001). Conclusion: The awareness and knowledge of family physicians in Erzurum about child maltreatment are inadequate. We recommend focusing on child maltreatment, especially in medical faculties, including this issue in the standard core curriculums, and organizing intermittent in-service training programs during the post-graduate working period.

Keywords: Child abuse, education, family, physicians, Turkey


How to cite this article:
Calikoglu E O, Atila D, Akturk Z. Family physicians in an Eastern Turkish City need training on child abuse and neglect: A cross-sectional study. Niger J Clin Pract 2021;24:1766-72

How to cite this URL:
Calikoglu E O, Atila D, Akturk Z. Family physicians in an Eastern Turkish City need training on child abuse and neglect: A cross-sectional study. Niger J Clin Pract [serial online] 2021 [cited 2022 Dec 3];24:1766-72. Available from: https://www.njcponline.com/text.asp?2021/24/12/1766/332085




   Introduction Top


Background/rationale

The World Health Organization (WHO) defines child abuse as: “To be exposed to all kinds of attitudes and behaviors, including commercial advertising or all other forms of influence, that causes physical and/or emotional, sexual, negligence or negligence that negatively affect the health, growth, and development of the child”.[1]

Child maltreatment has significant and lasting effects that threaten the future of children and can extend into adulthood. Exposure to violence at an early age can impair brain development and have lifelong physical and mental health consequences. Violence against children also reduces the productive capacity of future generations.[2]

The issue of child abuse has become increasingly substantial in the last 30–40 years, both medically and socially.[3] As a matter of fact, it has been reported as a major public health problem affecting at least 55 million children in the European region.[1] Another very sad data is that 1/5th of females and 1/13th of males report sexual abuse between the ages of 0-17.[4] Additionally, the 28th edition of the annual Child Maltreatment report in the United States declared that three-quarters (74.9%) of victims were neglected, 18.3% were physical, while 8.6% were sexually abused. Besides, 7.1% of victims also experienced 'other' abuse, such as abuse or threats of negligence, drug/alcohol addiction, and lack of supervision.[5]

Unfortunately, child abuse rates in Turkey are quite high too. One study shows that child maltreatment in Turkey is 43.5%, the most common form being physical neglect (65.1% in males and 40.4% in females). Emotional abuse and physical abuse are the next most commonly reported types of reported maltreatments.[6]

Family Medicine is a clinical specialty based on primary care services with an evidence base and clinical practice. Family physicians are the first medical contact point and take ongoing responsibility for providing the patient's comprehensive care.[7] Therefore, it is of great importance that they are competent in recognizing and evaluating child abuse. However, studies have shown that not only family physicians but also pediatric doctors need education on child neglect and abuse.[8]

Objectives

This study aimed to determine the knowledge, competencies, and approaches of family physicians in recognizing child neglect and abuse signs.


   Methods Top


Study design

This cross-sectional study was conducted between 1 March and 30 August 2019 in the Erzurum province of Turkey. The population of the study was family physicians actively working in primary care during the study dates.

Ethical approval (numbered B.30.2ATA.0.01.00/59, dated 13 February 2019) was obtained from the Atatürk University Faculty of Medicine Clinical Research Ethics Committee. The reporting of the study was done per STROBE guidelines.[9]

Setting

Erzurum is a city in Eastern Anatolia. It is located 1900 meters (6233 feet) above sea level. According to 2019 data, the population of Erzurum was 762,848 people.[10] During the study, 229 family physicians were working in Erzurum (113 in the city center, and 116 in the districts).[11]

Participants

All family doctors working in Erzurum as primary care physicians during the study were invited to participate. Since the participation of all doctors was targeted, no sample size was calculated. It was aimed to reach all physicians (n = 229), 176 (76.8%) of them participated [Figure 1].
Figure 1: Study flow diagram

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Variables

The primary outcome variable of the study was the Scale of Diagnosing the Symptoms and Risks of Child Abuse and Neglect (SDRCAN) score. Other variables were age, sex, marital status, having children, number of children, duration in the profession, number of registered children, presence of neighboring child-related institutions (such as kindergarten, school, daycare units), having received education on child abuse/neglect, having encountered any child abuse/neglect, counseling the caregiver, collaboration with authorities, and reporting of maltreatment cases.

The data collection form included the SDRCAN instrument[12] and socio-demographic information. After giving verbal information about the study, the doctors were asked for self-complete and return the data collection forms.

The SDRCAN has 67 items with 5-point Likert-type responses. It's subscales include physical symptoms of abuse on the child (19 items), behavioral symptoms of child abuse (15 items), signs of neglect on the child (7 items), parental characteristics prone to neglect and abuse (13 items), characteristics of children prone to neglect and abuse (5 items), and family characteristics (8 items). Cronbach's α of the original scale was reported as 0.92.[12] In this study, the Cronbach α value of the scale was found to be 0.90.

Statistical methods

Statistical analysis was done using the Statistical Package for the Social Sciences (SPSS) software program, version 25.0 (Chicago, Illinois). Results were presented as mean and standard deviations for numerical data and frequency and percentage for categorical variables. The suitability of variables to normal distribution was evaluated using the Shapiro–Wilk's test. Parametric variables were compared using the independent samples t-test or Mann–Whitney U test. Besides, a Linear regression analysis was performed. For the statistical significance, a value of P < 0.05 was considered sufficient.


   Results Top


Participants

Data for 176 participants were analyzed. The mean age was 37.40 ± 8.78 years (min. 26, max. 60). Of the participants, 103 (n = 58.5%) were men. The majority (n = 136, 77.3%) were married, while 35 (19.9%) were single, and 5 (2.8%) were divorced or widowed. Hundred and twenty GPs (68.2%) had children. The median number of children, duration in the profession, and children registered to the practice were 2 (min. 1, max. 4), 10 (min. 2, max. 33), and 240 (min. 1, max. 550), respectively.

Descriptive data

The most common types of encountered child abuse/neglect were physical abuse or neglect. Those having received specific education on the topic and GPs having encountered some cases of abuse/neglect were less than half of the participants. The state attorney was the main authority of reporting incidents [Table 1].
Table 1: Descriptive findings concerning child abuse/neglect

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Outcome data

When the Scale of diagnosing symptoms and risks of child abuse and neglect (SDRCAN) score was compared concerning participant features; the score of females was significantly higher than males (t = 4.954, P < 0.001). Additionally, experiencing any child abuse or neglect also significantly affected the SDRCAN score (t = 2.176, P = 0.031). Furthermore, encountering with physical abuse or neglect increased the total SDRCAN score significantly (t = 2.687, P = 0.008; t = 2.885, P = 0.004, respectively) [Table 2]. History taking as an area of challenge was a reason for high SDRCAN scores as was preparation of a forensic report in case of encountering child abuse or neglect [Table 3].
Table 2: Comparison of the mean SDRCAN scores concerning participants characteristics

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Table 3: Comparison of the mean SDRCAN scores regarding participants' responses

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Higher SDRCAN scores in females compared to males persisted in all subscales. However, the highest difference was observed in the mean 'child features' subscale scores [Table 4].
Table 4: Comparison of subscale scores by sex

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The linear regression model for predicting the SDRCAN scores was significant (F = 7.778, P < 0.001) with an R square of 24.5%. This model was created by using dummy variables that were significant in binary comparisons and the duration of the profession. The significant variables in the model were sex (P = 0.010), counseling the caregiver (P < 0.001), and psychological abuse (P = 0.002) [Table 5].
Table 5: Linear regression analysis computer output

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   Discussion Top


Key results

Having received education on child abuse/neglect among participants was only 44.9%. On the other hand, the rate of having faced any child abuse/neglect was 40.3%. The most common child maltreatments encountered by the participants were neglect (27.8%) and physical abuse (27.8%). Other key findings of this study were the rate of family physicians feeling weak in terms of history taking (30.7%), physical exam (17.0%), and cooperation with the authorities (13.1%). Additionally, the different responses among the participants about action in case of encountering maltreatment were remarkable. Being a woman was one of the prominent factors that increased the SDRCAN score.

Limitations

This study bears the limitations of self-reporting questionnaires. The data were obtained only from the participants and did not contain observational findings, which can be considered a limitation. Inclusion of confounding factors, such as childhood experiences and cultural differences concerning child maltreatment, could provide extra valuable information.

Interpretation

Child maltreatment is a worldwide serious problem. In 2017, 1 billion children between the ages of 2 and 17 were reported to have been subjected to different types of violence (physical, emotional, or sexual).[13] According to the Turkey Child Abuse and Domestic Violence report[14] conducted in children aged 7-18 years, 51% experienced emotional abuse, 43% had physical abuse, 3% were exposed to sexual abuse, and 25% were neglected.

In order to minimize the negative consequences of child neglect and abuse, the abuse should be detected and terminated as soon as possible, and the victim removed from the environment of abuse and taken under treatment and surveillance.[15] Hence, family physicians who can play several substantial roles in the prevention of child abuse and negligence must be informed about child maltreatment and neglect.[16] Unfortunately, our findings show that the knowledge on this subject among family physicians is insufficient. As a matter of fact, most of the participants stated that they did not receive training on child abuse or neglect. Therefore, we assume that some cases may have been missed. In fact, there is evidence supporting this concern.[17]

Even worse, this shortcoming of education has existed for a long time. Indeed, in a study conducted with midwives and nurses in 1998, only 23.9% of the participants stated that they received training on child maltreatment during their school period, while 76.9% did not receive any training on this subject.[12] Besides, in their study with physicians and nurses in 2006, Kocaer et al.[18] reported that 48.6% of physicians and 27.9% of nurses were educated about this issue during their university education. Furthermore, in the study conducted by Kara et al. in 2013 with pediatric assistants, pediatricians, and general practitioners in Ankara, 62.5% of the participants stated that they did not receive training on child abuse and neglect during their training.[18]

The shortage of education is not only an issue for Turkey, but also for most other countries. For instance, a study conducted in Italy with pediatricians and family physicians showed a lack of knowledge among participants.[20] Similarly, inadequate training has been reported among primary care physicians in the USA.[21] Additionally, the findings of this study revealed that education in Turkey should focus on history taking, physical exam, and cooperation with the authorities.

Recently, a study reported that women healthcare workers and those trained on child maltreatment had higher SDRCAN scores.[22] Other studies have also shown that women are more sensitive, as well as susceptible to child abuse and neglect.[23],[24] As a matter of fact, the sensitivity of the female gender to violence against children was reported to be higher because they suffered the most.[25] Furthermore, it has been stated that doctors with little awareness pay less attention to child abuse and neglect.[26]

In line with previous studies, our findings point to higher SDRCAN scores in women compared to men. In addition, this difference was seen in all subscales. However, training did not significantly affect participants' scores. Furthermore, we do not know the contents of the educations provided in different medical schools, and Turkey lacks a standard educational approach in this issue.

Another surprising finding of the study was that those with longer professional work experience did not have significantly higher SDRCAN scores. Younger doctors may have had higher scores due to the inclusion of training on child abuse in medical schools in recent years. Perhaps this effect negated the advantage of the experience. Another data supporting our claim is the scores of those who have a longer duration in the profession were higher in a study conducted in Ankara in 2010.[19]

Communication with institutions and legal processes are among the perceived weaknesses of physicians who encounter child abuse and neglect in their professional life.[19],[20] The findings of our study were in line with the literature. The lack of confidence in reporting can negatively affect the victim's prognosis.[27] Thus, uncertainty about reporting child maltreatment found in this study should be eliminated as soon as possible with appropriate training. Diagnostic uncertainty has been shown to be the root cause of the lack of reporting among doctors.[28],[29]

The most common types of child maltreatment encountered in this study were physical abuse and neglect. Physical abuse and neglect were generally reported as the most common forms of maltreatment of children.[30],[31] Since physical abuse is more concrete and dramatic, the rate of detection by doctors may be higher.


   Conclusion Top


The awareness and knowledge of family physicians working in Erzurum about child maltreatment are not sufficient. For this reason, we recommend focusing more on child neglect and abuse, especially in medical faculties, to include this issue in the standard core curriculums, and to organize intermittent in-service training programs during the post-graduate working period. Raising the awareness of healthcare professionals about child maltreatment will improve the recognition and attitudes about neglected phenomena.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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31.
Alsaleem SA, Alsaleem MA, Asiri AM, Alkhidhran SS, Alqahtani WSS, Alzahrani MS, et al. Knowledge and attitude regarding child abuse among primary health care physician in Abha, Saudi Arabia, 2018. J Fam Med Prim Care 2019;8:706-10.  Back to cited text no. 31
    


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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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