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 Table of Contents  
REVIEW ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 110-116

Challenges of reporting child abuse by healthcare professionals: A narrative review


1 M.Sc. Student of Midwifery counseling, Student Research Committee, Nasibeh Nursing and Midwifery Faculty, Mazandaran University of Medical Science, Sari, Iran
2 Department of Reproductive Health and Midwifery, Nasibeh Nursing and Midwifery Faculty, Mazandaran University of Medical Sciences; Sexual and Reproductive Health Research Center, Sari, Iran

Date of Submission07-May-2017
Date of Acceptance11-Aug-2017
Date of Web Publication29-May-2018

Correspondence Address:
Dr. Zohreh Shahhosseini
Department of Reproductive Health and Midwifery, Nasibeh Nursing and Midwifery Faculty, Mazandaran University of Medical Sciences, Sari
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JNMS.JNMS_3_17

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  Abstract 

Child abuse is one of the most challenging social problems worldwide. Failure to report child abuse may lead to the aggravation of the situation and increase the probability of further abuses. This study aimed to determine the challenges of child abuse reports by healthcare professionals. This narrative review study was conducted through searching the databases such as Google Scholar, PubMed, Web of Science, Scopus, and ProQuest. The inclusion criterion was studies in Persian and English languages which published in scientific journals between 1978 and 2017 and also refer to reporting child maltreatment. Studies which, despite referring to a child abuse, did not refer to the barriers to the reporting of child abuse were discarded from further analysis. 56 papers were used to write the present paper. The results of this study organized into four categories: individual barriers (knowledge of healthcare professionals, their attitudes and beliefs, their inadequate experiences, and uncertainty of the diagnosis), interpersonal barriers (fear of disconnecting therapeutic relationships and violation of privacy and secrecy principles), organizational barriers (poor communication and weak legal processes for reporting), and situational barriers (victims' characteristics and available evidence). Given the reporting of child abuse by healthcare professionals is affected by multiple factors such as individual, interpersonal, organizational, and situational factors, so considering a comprehensive and collaborative program for this public problem in all levels is important.

Keywords: Child abuse, Child maltreatment, Child mistreatment, Healthcare professionals, Narrative review Child abuse, child maltreatment, child mistreatment, healthcare professionals, narrative review


How to cite this article:
Azizi M, Shahhosseini Z. Challenges of reporting child abuse by healthcare professionals: A narrative review. J Nurs Midwifery Sci 2017;4:110-6

How to cite this URL:
Azizi M, Shahhosseini Z. Challenges of reporting child abuse by healthcare professionals: A narrative review. J Nurs Midwifery Sci [serial online] 2017 [cited 2019 Jan 21];4:110-6. Available from: http://www.jnmsjournal.org/text.asp?2017/4/3/110/220650


  Introduction Top


Child abuse is one of the most challenging social problems in today's society, which seriously threatens the health and well-being of children, families, and communities.[1],[2],[3],[4],[5],[6],[7],[8] Child abuse, by definition, is any act which results in physical, sexual, and emotional injury to children.[9],[10] Studies show that the problem occurs in all societies with different economic and social characteristics, and its prevalence is increasing worldwide and also has imposed huge costs on the healthcare systems.[5],[9],[11],[12] According to the World Health Organization, each year approximately, 40 million children worldwide are victims of sexual abuse, 23% of children suffer from physical abuse and 36% suffer from emotional abuse.[13] In addition, according to results of a study in America, the prevalence of abuse in 18-year-old children, as reported by child protection services, was 12.5%.[14],[15] In Iran, the prevalence of physical maltreatment was reported 38.5% and 43.3% in the student at home and school, respectively.[16] In another study in Tehran, the prevalence of sexual abuse was estimated 20.9%.[17]

Several factors are involved in the possible occurrence of child abuse,[18],[19] among which one can refer to factors such as poverty, lack of recreational facilities, birth defects or disabilities, depression and psychological problems in the family, domestic violence, and living in dangerous neighborhoods.[9],[20],[21] Child abuse is associated with short- and long-term consequences such as anxiety, depression, eating disorders, mood disorders, behavioral problems, impaired social functioning, poor school performance, increased drug use, thoughts about and attempts of suicide, sexually transmitted diseases, risky sexual behavior, and chronic diseases.[9],[10],[11],[22],[23],[24],[25],[26]

Due to their childcare role, healthcare professionals play an important role in the identification and investigation of cases of child abuse,[3],[5],[11] and part of their responsibilities is to prevent child abuse and provide treatment and support for abused children. Although in recent years, tremendous growth has been observed in the knowledge and sensitivity of the healthcare professional for organizing the cases of child abuse, they have still little knowledge about the best strategies to cope with child abuse cases and there is also little willingness among them to report cases of suspected sexual abuse of children.[7],[18],[20],[27]

In an effort to support and help abused children, some countries have enacted laws mandating the reporting of child abuse which oblige healthcare professionals to report suspected cases of child abuse.[18],[28] However, despite the legal obligations to report cases of suspected abuse,[5],[23] studies show that many healthcare professionals are unaware of the regulations for abuse reporting [1],[29] and the real number of child abuse cases worldwide is far more than the overall cases which healthcare professionals identify and report.[1],[30] Results of a study also show that 40% of healthcare professionals, under some circumstances defy the laws regarding the reporting of child abuse cases.[4],[31] Furthermore, a study in Taiwan showed that nurses have been reported to believe that they have no responsibility for identifying and reporting cases of child abuse even when it is suspected.[8]

Since child abuse may bring about adverse consequences, reporting this issue is of high importance. The literature review shows that there is no review study to classify all these barriers together. As well as studies have shown that only obstacles in some healthcare providers such as doctors or nurses were assessed separately, but in the present study, barriers to reporting in all group of healthcare providers such as nurses, physicians, and pediatricians were examined. Moreover, since failure to report this issue may lead to the aggravation of the situation and increase the probability of further abuses, identifying the challenges and consequences of failure to report the cases of child abuse is an important consideration.[20],[22] Therefore, this study was conducted with the aim of determining the challenges of child abuse reports by healthcare professionals.


  Materials and Methods Top


This study was a narrative review with systematic search which was conducted in four stages.

Identifying the research question

What challenges do healthcare professionals encounter in reporting cases of child abuse?

Searching strategies for identifying related studies and the procedure to select studies

Based on the research question, researchers independently began the initial search in Google Scholar and the more specifically in PubMed, Web of Science, Scopus, and ProQuest Text Word, using the Medical Subject Heading with keywords (“child abuse 'OR' child sexual abuse 'OR' psychological abuse” 'OR' “physical abuse 'OR' child maltreatment 'OR' child neglect 'AND' (“reporting 'OR' child abuse reporting 'OR' reporting suspected child abuse 'OR' report 'OR' child abuse reporting laws 'OR' child abuse disclosure”) AND (“physicians 'OR' nurses 'OR' healthcare providers 'OR' pediatric”) AND (“challenges 'OR' barriers 'OR' legal barriers 'OR' ethical barriers 'OR' cultural barriers 'OR' personal barriers”) from September 2016 to January 2017 and related articles published between 1978 and 2017 were extracted. Overall, 558 papers were extracted through the initial search. After discarding repetitious papers (n = 245), the remaining papers were screened in two stages. In the first stage, the titles and abstracts of all remaining papers were independently reviewed by two researchers Marzieh Azizi (M.A) and Zohreh Shahhosseini (Z. Sh) and those which met the entry requirement and answered the research questions were selected. The entry requirement or inclusion criterion was studied in Persian and English languages which published in scientific journals and also refer to reporting child maltreatment. In this stage, 97 papers were discarded from the study. In the second stage of screening, the full texts of all remaining papers were reviewed and those which, despite referring to a child abuse case, did not refer to the barriers to the reporting of child abuse (n = 92) and were not related to the aim of the study (n = 70), were discarded from the further analysis. Moreover, the reference lists of the selected papers were checked to find more papers and to conduct the search with a higher sensitivity and precision. At the end, 56 papers were used to write the current review study [Figure 1].
Figure 1: Process of search

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Ethical considerations

The authors took into account the ethical considerations and general standards for publication including avoiding plagiarism and multiple and simultaneous submissions as well as respecting the intellectual property rights of the reviewed papers.

Summarizing, extracting, and reporting the data

Having selected the studies from the previous stage, the researchers then carefully studied all the relevant papers and they extracted and organized the information they needed for the current study. The results of reviewing the studies led to the extraction of the paper and organization of the content on the challenges of child abuse reports into 4 main categories and 10 subcategories based on the importance of barriers had been mentioned in the assessed articles.


  Results Top


The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline [Figure 1]. The results of the current study led to the organization of the challenges of child abuse reports by healthcare professionals into four major categories. These categories include individual, interpersonal, organizational, and situational barriers [Table 1].
Table 1: Challenges of reporting child abuse by healthcare professionals

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Individual barriers

Individual barriers refer to personal barriers of healthcare professionals which prohibit the reporting process. As the results of the reviewed studies indicate, several individuals' factors influence the decision to report child abuse cases, among which the following can be referred to.

Knowledge of the healthcare professionals

One of the strongest predictors of child abuse reports is the knowledge of healthcare professionals on this issue.[2],[3],[23],[32],[33],[34],[35] That is, the knowledge of healthcare professionals of the rules, procedures, and the way to report child abuse is among the important factors in the decision to report such cases [1],[5],[21],[23],[28],[32],[33] Research shows employees who were previously trained in recognizing child abuse were more likely to report suspected cases.[1],[7],[8],[35],[36],[37],[38] It seems that during training courses, healthcare professionals find the opportunity to discuss their problems and uncertainty for reporting child abuse cases and they can overcome their stress to report these cases.[23],[27],[35] Moreover, it is thought that healthcare professionals' inadequate knowledge of the laws which stipulate the reporting of child abuse is a decisive factor in their failure to comply with such rules.[1]

Attitudes and beliefs of the healthcare providers

Studies show that some healthcare professionals, despite claiming to have adequate knowledge of child abuse, have some misconceptions which make them avoid reporting such cases.[4],[8],[36] It seems that the attitudes and beliefs of healthcare professionals about the decision to report child abuse are under the influence of the outcomes of their previous experiences of reporting.[1],[35] Results of studies also refer to other factors such fear of threats, retaliation by the family of the child, fear of family's dissatisfaction,[35],[44] fear of isolation and stigma in children,[23] the breakdown of the family structure, fear of worsening the situation of children, repetition of the abuse of children,[4],[7],[18],[35],[40],[41],[42] and uncertainty about the children's future,[10],[43] which may persuade the healthcare professionals not to report child abuse.

Inadequate experience of healthcare professionals

Since child abuse is a sensitive issue,[5] inadequate experience of the healthcare professionals and their ineffective techniques for interviewing with these victims [4],[21],[24] can influence the report of child maltreatment.[4],[42],[43] It seems the unwillingness or the slight inclination of healthcare professionals can be improved through vocational training within the organization, providing practical support for them and through further educational programs.[9],[1],[5],[21],[23],[28],[32],[33] Other features of the healthcare professionals which are associated with the decision to report child abuse include years of work experience, training received in recognition of child abuse [32] and prior exposure to abused children.[1],[44]

Uncertainty of the diagnosis

Studies show that due to the difficulty of proving child maltreatment or child neglect, fear of inaccurate diagnosis or judgment, many health professionals avoid involving in sensitive issues such as child abuse and reporting suspected cases.[2],[34] Studies show that correct diagnosis of child abuse cases can be challenging because the distinction between cases of child abuse and physical damage caused by an accident can be extremely difficult for healthcare professionals, especially in cases where they are unable to identify signs and symptoms of child abuse.[4],[9],[10],[20],[30],[35] Before healthcare professionals decide to report child abuse to child protection services, they must be assured to a large extent of the possibility of child abuse.[27],[32]

Interpersonal barriers

In addition to individual barriers of reporting child abuse, there are some interpersonal barriers for healthcare providers in the process of child abuse reporting. This category refers to barriers regarding the patient–doctor relationship.

Fear of disconnecting therapeutic relationship

Based on the experiences of service providers, after reporting the child abuse, families of exploited children often may not refer to receive essential health services.[4],[18],[45] Hence, there will be the risk that these families will lose health services, and healthcare professionals will lose the opportunity to monitor the well-being of the child and the possible intervention to improve individual and social performance of such children and their families.[31],[43] Mandatory reporting by healthcare professionals also causes parents to avoid bringing their children to receive medical treatment in case of future abuse. Therefore, some believe that children protection services should only be used when they are helpful to children and their families.[43]

Violation of privacy and secrecy principles

Some healthcare professionals believe that the commitment to mandatory reporting of child abuse endangers the confidential relationship between therapist and patient and many of them do not agree with the laws in this area.[24],[27],[39],[43] The reason for this concern may be that the report may require the doctor to breach his or her confidential relationship with the patient, which ultimately and as a result of the disconnection of the therapeutic relationship, leads to the loss of confidence of children and their families.[1],[9],[43]

Organizational barriers

One of the important barriers of reporting child abuse is related with organizational issues. This category refers to barriers of working environment which effect on reporting decisions. Factors regarded as organizational barriers are included poor communication, weak legal processes for reporting.

Poor communication

One of the key points in the intervention for child protection is the cooperation of healthcare professionals and social workers of the child protection system.[18],[36] Continuous cooperation between experts and child protection system leads to the sharing of more information and eventually increases healthcare professionals' reports of child abuse cases.[43] On the contrary, the lack of confidence in the child protection system is an obstacle on the way of reporting child abuse by healthcare professionals. The reasons for this lack of trust include factors such as inadequate interaction between child protection systems and healthcare professionals and the lack of detailed information on the progress and follow-up of exploited children.[4],[21],[28],[36]

Weak legal processes for reporting

Defects in laws and misinterpretation of the rules related to child abuse,[4],[23] lack of a precise definition of the rules in healthcare systems,[23] and lack of implementation strategies are among legal barriers to the reporting of child abuse by healthcare professionals. In this regard, legal protection for those who report child abuse is a significant factor in deciding to report child abuse.[40] Some healthcare professionals believed they were not supported by social services and medical jurisprudence, and they viewed reporting child abuse a stressful factor in their current job.[21],[31] Healthcare professionals say they do not take the legal liability of these issues and they are not willing to engage in a legal process, including the possibility of appearance in courts to report cases of child abuse.[7],[23],[40],[43],[54]

Situational barriers

Situational barriers refer to conditions that may affect the health care profession's decision to report child abuse. Among the situational factors one can refer to characteristics of the victims, and the available evidence on the child abuse cases.[1],[4]

Victim characteristics

One aspect of situational factors which influences the reporting of cases of child abuse by healthcare professionals is the characteristics of the victims. One of these features is victims' age;[46],[47],[48] doctors report abuses in children younger than 16 years more frequently [1] and abuse of older children is less likely to be reported.[38],[48],[49] There is limited information on the gender of victims and only some studies have shown that the gender of victims had no connection with the decision to report cases of abuse.[50],[51],[52],[53]

Other situational factors which influence the decision to report a case include the type and severity of child abuse,[1],[2],[38],[48] because healthcare professionals believe that there is more legal obligation to report sexual abuse compare to physical abuse or neglect.[3],[38],[39] Healthcare professionals are also less inclined to report mild abuse.[1] In addition, abuses which have occurred recently are more likely to be reported compared to those which occurred in the past.[45] The extent of damage,[42]

The available evidence

The quality of the evidence of child abuse available to healthcare professionals is one of the key components in the decision to report such cases [7],[37],[38] and factors such as doctor's level of certainty of abuse depend on the evidence available on child abuse.[29] Although children's and their families' statements have a vital role in the decision to report,[27] acceptance of parents' explanations by healthcare professionals is often delayed until detailed information about the damage is obtained for making an informed decision.[27],[33] However, a study showed that achieving sufficient evidence to confirm the incidence of child abuse is not always easy so that in many cases doctors discover the incidence of child abuse, but because of the difficulty in collecting evidence, they avoid reporting it.[9] There is also a time limit for reporting child abuse, so that existing laws require healthcare professionals to report cases of suspected abuse within 24 h, and the laws require social workers to collect information within 3 days of the event. These requirements emphasize the urgency of the problem.[40],[49]


  Discussion Top


The present study aimed to determine the challenges of reporting child abuse by healthcare professionals. The results of this study showed that challenges of reporting child abuse can be categorized into individuals, interpersonal, organizational, and situational barriers. Subjective beliefs, attitudes toward child abuse, and professional liability perspective on the child abuse subject are the significant predictors of reporting behavior by healthcare professionals.[2]

Results of a study regarding the role of knowledge of healthcare professionals as one of the individual's factors in reporting showed that more pediatrics with little knowledge and inability to identify children with genital abnormality refused to report cases of suspected abuse of children.[27] However, sometimes, the lack of knowledge is not the main reason for failing to report suspected cases. So that even with increasing levels of knowledge, some clinicians may be reluctant to report suspected cases when are faced with child abuse.[9],[32]

Studies have shown that different groups of healthcare professionals, such as nurses, pediatricians, family physicians, and general practitioners are different in the level of their knowledge regarding child abuse and legal obligation to report.[3] In a survey conducted in different group of healthcare professionals regarding the rate of reporting of child abuse, results showed that pediatricians were more sensitive to child abuse issues and were more responsible to report suspected cases.[32]

Other individuals barriers such as negative experience or failure to report child abuse,[23],[41] lack of legal protection for reporters in the workplace, and inquiry by doctors and managers of healthcare centers or hospitals are among the main reasons stated for the healthcare professionals' decision not to report cases of child abuse.[1],[23],[42]

The lack of clear guidelines and protocols for detecting and reporting incidents of child abuse can lead to a reduction in the accurate identification of child abuse cases.[2],[7],[10],[30],[44] Studies on report of child abuse have shown that due to their higher confidence, doctors are more willing and motivated to report cases of abuse, compared to other healthcare professionals.[2],[7],[28] Creating support structures and providing the required training for increasing the awareness and knowledge of healthcare professionals of the existing laws for child abuse report plays an important role in facilitating the decision-making process on reporting cases of child abuse.[55],[56]

According to results of studies, sympathy for the family of the child in cases where families are reluctant to report,[23] feeling of betrayal to families in cases where there are intimate relationships between the therapist and the children's family [10],[21] and familiarity with the children's families are some important interpersonal barriers to reporting child abuse.[18],[28],[41],[43]

Among organizational barriers of not reporting child abuse was healthcare professionals' low awareness or poor understanding of the role of child protecting system in child abuse cases, which leads to negative feelings toward the staff of these systems.[10],[43] Some healthcare professionals believe that because of the poor performance of child protection systems, they themselves can do a more effective intervention, and they can provide the required training and care for the children and their families.[10],[28],[30],[31],[34],[42]

From limitations of this study is the quality assessment of the included studies was not conducted. Furthermore, the gray literature and other languages articles expect Persian and English were not included.


  Conclusions Top


Given the reporting of child abuse by healthcare professionals is affected by multiple factors such as individual, interpersonal, organizational, and situational factors, so considering a comprehensive and collaborative program for this public problem in all levels is important. Given the importance of reporting cases of child abuse, it is recommended that health policymaker devise special programs for different groups such as children and their families to improve or fill in the gap in the reporting of child maltreatment. Moreover, to increase healthcare professional's reports of child abuse, it is of high importance to review the existing laws for child abuse report, and this may also lead to a decrease in the incidence of child abuse.

Application in research

Given the mentioned limitations, this study researchers proposed that a systematic review or clinical trial regarding barriers of reporting child abuse will be required and useful.

Application in practice

Establishment an educational course for healthcare professionals to familiar those toward reporting child abuse are recommended. Among other suggestions of this study in practice is to hold educational classes for students of different medical sciences to familiarize them with the topic and to teach them the techniques required for proper diagnosis of child abuse.

Conflicts of interest

There are no conflicts of interest.

Authors' contributions

All authors contributed equally to the writing of the scientific proposal, data collection, and manuscript drafting. The final manuscript was reviewed and approved by all the authors.

Financial support and sponsorship

Nil.

Acknowledgment

We sincerely appreciate Mazandaran University of Medical Sciences and the student research committee for providing funds for this project. (Grant number: 96-85).

 
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