Introduction

Child abuse, which is defined by World Health Organization (WHO) as behaviors which are conducted knowingly or unknowingly by an adult, the society or the country, and which negatively affects a child’s health, physical and social development, is in its widest sense conducting behaviors which are not accepted in that society to a child by an adult within a specific period of time (1). Child abuse is an important problem that is seen in all parts of the world. Although the type of abuse differs depending on factors such as gender, geographical region, and other factors, it is seen within a wide range of 1-35% (1,2). While the incidence of child abuse is 10-53% in Turkey, this rate is around 1-10% globally (3).

Neglect and abuse are familial function disorders that have multiple psychosocial, individual, and environmental reasons. They are difficult to define, and they require health professionals to be suspicious when they meet the family and the child for the first time (1). Some factors about the health system prevent the patient and the physician from being together within a necessary and extended period of examination, and this makes early diagnosis difficult. This situation can lead to the continuation of neglect/abuse. This way, undiagnosed neglect/abuse causes chronic abuse and increased death and disease rates (1,4). WHO emphasizes that it is among the responsibilities of health professionals to provide a proper diagnosis, protection, and treatment conditions to neglected and abused children (5). It is emphasized as an issue in literature for health workers to be aware of the physical and behavioral characteristics of child abuse and to have sufficient proficiency in treating, preventing, and reporting child abuse (6).

In this study, knowledge levels and attitudes of emergency physicians on the issue of child abuse and neglect were assessed within the scope of literature.

Materials and Methods

Study Design, Population and Data Collection

Approval was obtained from Ordu University Clinical Researches Ethical Board (decision number: 2018/155) for the study. Male and female physicians who worked in the emergency services of state hospitals in Ordu province provincial directorate of health between the dates 01.06.2018 and 01.09.2018 and who volunteered to participate were included in the study. A total of 10 physicians who did not want to participate in the study and those who filled in the question forms incompletely were excluded.

In addition to a 28-item questionnaire form that assessed participants’ demographic characteristics and their attitudes towards children, the “Child Abuse Knowledge scale” with 25 items, which was developed and examined for validity and reliability by Kara et al. (7), was given to the participants. In the knowledge scale, each question included three answers consisting of the words “yes”, “no”, and “no idea”; the answers to questions 14, 16, 21, and 23 were “no”, while the others were “yes”. Each correct answer was accepted as “1 point” and knowledge scores were calculated separately for five sections as “history”, “examination”, “radiology”, “risk groups” and “symptoms”. Also, scores of the sections were added, and a total knowledge score was obtained on the issue of child abuse and neglect (7). After the informed consent of the physicians within the sample group was obtained, the questionnaire and the scale were filled in by the physicians who participated in the study. The number of participants in the study was determined to be 125 according to Tavsancil’s “sample volume in the scale studies should be at least five times the minimum of each scale item” recommendation (8).

Statistical Analysis

A statistical package program was used for statistical analysis. Descriptive analysis of assessment results was given as numbers and percentages for categorical variables and as mean, standard deviation, minimum, and maximum for numerical variables. A chi-square test was used for the analysis of categorical variables. Shapiro Wilk test was used to determine the appropriateness of scale scores to a normal distribution. The Mann-Whitney U test was used for non-normally distributed variables between two groups and the Kruskal-Wallis test for non-normally distributed parameters between more than two groups. p<0.05 was considered as statistically significant.

Results

A total of 127 physicians, 66 (52.0%) female and 61 (48.0%) male, participated in the study. The mean age of the physicians was 29.44±5.42 years (range: 23-54). Forty point two percent of the physicians were married, while 76% were single, and 28.3% had children. Seventy-three point two percent of the physicians who participated in the study were general practitioners, while 26.8% were emergency medicine specialists. In terms of years in the profession, the minimum period in the profession was one year, while the maximum period was 29 years, with an average of 4.98±4.49 years. The mean time spent in the emergency service was found as 3.76±3.74 years.

While no statistically significant difference was found between general practitioners and specialists in terms of having received forensic medicine education before graduation, the rate of having received training about child abuse was found to be statistically significantly higher in general practitioners when compared with specialists (p<0.001). While physician groups were not homogeneous in terms of pre-graduation training, they formed a homogeneous group in terms of post-graduation training (Table 1).

The rate of physicians who came across child abuse cases was found to be 57.5%. Eight of these physicians stated that they performed a genital examination for sexual abuse cases in the emergency service, and they also stated that they did not experience any problems with the examination. Thirteen point four percent of the physicians stated that the children who referred to emergency service for being poisoned could not be assessed as “child abuse”. Eighty-six point six percent of the physicians stated that child abuse cases required a multidisciplinary approach, and 80.8% thought that child abuse should not be considered as unidimensional and that reports should not be prepared without making the required consultations for the child’s examination (pediatric psychiatry, general surgery, pediatric diseases, gynecology, infectious diseases, and forensic science). While 55.9% of the physicians stated that it would be suitable for child monitoring centres (CMC) to assess all kinds of abuse cases so that child abuse cases could be appropriately assessed, 3.1% stated that it would be enough for only sexual abuse cases to be assessed at CMC, and other cases could be resolved at emergency services and polyclinics. It was found to be statistically significant that emergency physicians frequently came across child abuse cases (p<0.001). In terms of the question of which abuse cases referred to the emergency service the most, both groups answered this question as “neglect” the most and statistically significant difference was found between the two groups (p=0.005). Also, general practitioners answered the question of which abuse group was missed the most in the emergency service due to difficulties of diagnosis as “emotional abuse,” and statistically significant difference was found between the answers of both groups (p=0.027) (Table 2). Fifty-nine point eight percent of the physicians stated that when symptoms of child abuse were found in a child who was brought to the emergency service for another reason, they would accept the case as a judicial case, write a judicial report and inform the judicial authorities. Thirty-five point five percent of the participants stated that it would be suitable to get a consultation from physicians such as forensic medicine and pediatric surgery physicians and/or be supported by organizations such as CMC, etc. and to make a decision afterward. All of the physicians stated that they prepared judicial reports when such cases were defined. Fifteen point seven percent of the physicians stated that there were no criminal sanctions when no reports were made, while others reported that there were criminal sanctions, and 41.7% stated that this sanction was one year of imprisonment. In terms of the existing legal sanctions in Turkish Penal Code (TPC) about sexual abuse crime conducted against children, 55.1% of the physicians described these sanctions as mild, while 20.5% described them as very mild, 15.7% as sufficient, 3.9% as severe and 4.7% as very severe.

It was found that the physicians who participated in the study got a minimum of 11 points from the Child Neglect and Abuse Information scale, while they got a maximum of 25 points. The standard mean of the total scale scores was 20.98±2.96, and Table 3 presents the results of physicians’ total score averages in terms of some of the characteristics of physicians. In the post hoc test (with Bonferroni), it was seen that total test mean scores were according to the statistically significant low between 34-38 age group of physicians and 23-28 (p=0.01) and 29-33 age groups of physicians (p=0.03). Also, the total test score of the physicians who received pre-graduation child abuse education and found this education to be adequate was found to be statistically higher than the physicians who found it to be inadequate (p=0.05).

Average scores of the subdivisions of Child Neglect and Abuse Information scale were 5.83±0.46 for part 1, 5.48±0.76 for part 2, 2.07±0.79 for part 3, 4.37±1.37 for part 4 and 3.22±0.92 for part 5. The distribution of divisional and total points “Child Neglect and Abuse Knowledge scale” received by physicians was showed in Table 4.

Discussion

In our country where anyone who is younger than 18 years of age is considered as children, child abuse is a significant public health issue with medical, legal, and social aspects, which can cause serious injuries, disabilities, and even death (9-11). Recently, our country lets in too many immigrants, and in complex situations that can develop with the problems of immigrant children, the solution is expected from physicians. Various studies conducted show that the rates of child abuse among judicial cases that refer to emergency services differ between 18-43% (12-14). In the case of a correct assessment of the symptoms by the physician, the diagnosis of child abuse is considered to be the first step in the solution of the problem.

In a study conducted in the province of Ankara, it was found that 82% of pediatricians, 70.5% of pediatrician assistants, and 54.8% of general practitioners came across abuse and neglect cases or suspicion (9). In a thesis study, it was found that the rate of coming across child abuse and neglect cases in the past year was 21.1% and that all participants, in general, had a lack of knowledge and experience about child abuse and neglect (15). Similar to other studies, the rate of child abuse in emergency services was found as 53%. In another study conducted in Kuwait, it was found that 14% of pediatricians did not come across a suspicious child abuse case all through their lives (16). In another study conducted in Sweden, very low rates of cases were found in primary health care providers, and it was even emphasized that a physician who worked more than 30 years did not come across any cases (17). In our study, all of the physicians stated that they reported when cases were diagnosed. Also, while 86.6% of the physicians in the study group were advocates of a multidisciplinary approach, only 34.6% stated that they would report after they got the views of related units and polyclinics about child abuse and 55.9% stated that they would report immediately when they found symptoms of abuse. In another study conducted in our country, 85% of the physicians stated that they would think about reporting if they came across abuse cases or suspicion (9). In the same study, the reasons why physicians did not report were respectively as follows; not having enough information about child abuse and neglect, not knowing where they should report, not having time to allocate to this issue, security concerns, thinking that the child will get harm later, thinking that the child will be separated from the family and other reasons (9). In a national study conducted in America, it was found that only a small number of pediatricians did not report in cases that had injuries suspicious in terms of child abuse (18-20). The reason why physicians did not report was the fact that a definitive diagnosis was not made for abuse and that they believed the problem could be solved within the family (20). In another study conducted in North Carolina, it was stated that 10% of the participants did not report suspected child abuse and neglect cases, and the reason for this was the fact that they thought the court was a painful and sad experience for children (21). While physical abuse is a situation which is frequently realized since relatively a higher number of symptoms are together when compared with other types of abuse, it is known that the rates of recognizing physical abuse are lower as long as physical abuse and sexual abuse are a combined component. In our study, physicians stated that the most frequent number of cases (56.6%) that referred to the emergency service was neglect cases, with physical abuse (29.9%) as the second most frequent number of cases.

In a study they conducted on pediatricians and general practitioners, Kara et al. (7) found similar to the results of our study that the most frequently seen cases were neglect with 45.8%, with physical abuse second most frequently seen with a rate of 23.6%. In our country, child abuse is a judicial case that should be reported when diagnosed, and there is a criminal sanction when it is not reported in terms of health professionals according to the item 280 of TPC. This is defined as one year of imprisonment in the penal code. In our study, while 15.7% of the physicians stated that there were no criminal sanctions when no reports were made, 41.7% stated that criminal sanction was one year of imprisonment when no reports were made.

In terms of the question of “your opinions about the existing criminal sanctions in TPC related with sexual abuse crime committed against children”, 75.6% of the physicians stated that they found these sanctions as mild, while 8.6% stated that they found these sanctions as severe. Trials about abuse crimes for children include applications that cause discussion before society. These discussions sometimes result from the legislation, sometimes from the verdicts and applications of judicial authorities and sometimes from the attitudes of legal structuring (22). Provisions that organize the crimes against sexual immunity in TPC have been exposed to changes many times since 01/06/2005 when TPC came in force. After the Supreme Court canceled item 103/2 of TPC with the justification that “it cannot be said that the amount of penalty specified is in the rate or extent that will allow the purpose aimed to reach with this penalty. Since the rule predicts an excessive sanction as it is, it is against the principle of law and state”, item 103/1 was also canceled with similar justifications (23). After this verdict of the Supreme Court, the real question that caused serious discussions was how to approach crime when the offender of the crime was also a child in crimes committed against sexual immunity (22). When considered in terms of this and other aspects, although the law is sufficient, it may be considered as mild by physicians may be due to differences in practice or as a result of decisions made.

In our study, results parallel to the results of the study conducted in Ankara were found in terms of the scores taken from the scale (7). It was seen that the scale scores of the female gender and 33 years old and under physician groups were statistically significantly higher in our study. In a study conducted in 1997 in the USA on 393 physicians who were pediatricians, family physicians, and emergency physicians, it was found that adult female participants were more sensitive than male participants in terms of child abuse (24). It is thought that the reason why younger physicians had higher levels of knowledge was the fact that as stated in Demir’s thesis, importance and place were given to the issue of “child abuse” in medical faculty curriculums, especially recently (15).

Conclusion

In conclusion, emergency physicians come across child abuse cases more frequently when compared with general practitioners, and they think that their education about child abuse is insufficient. This questionnaire conducted on emergency physicians in the province of Ordu showed that pre- or post-graduate training conducted on the issue could develop physicians’ attitudes and behaviors against child abuse cases. Also, it is an important issue that in-hospital coordination should be built and developed between branches related to the issue and emergency services for the multidisciplinary approach required and considered as necessary by emergency physicians. We believe that assessing for abuse in each child examined and cooperating with the related institutions and physicians when having suspicions on the issue can develop a mechanism that can prevent missing cases.

Ethics

Ethics Committee Approval: Ethics committee approval was received for this study from the Ordu University Clinical Researches Ethical Board (decision number: 2018/155).

Informed Consent: Written informed consent was obtained from all participants in this study.

Peer-review: Externally and internally peer-reviewed.

Author Contributions

Concept: A.A, H.Y.T., Design A.A., Data Collection and/or Processing: A.A, H.Y.T., Analysis or Interpretation: A.A, H.Y.T., Literature Search: A.A, H.Y.T., Writing: A.A, H.Y.T.

Conflict of Interest: The authors have no conflict of interest to declare.

Financial Disclosure: The authors declared that this study had received no financial support.