A cross-sectional exploratory study of knowledge, attitudes, and practices of emergency health care providers in the assessment of child maltreatment in Maputo, Mozambique

Child maltreatment (CM), the physical, sexual and emotional abuse, neglect, or exploitation of under 18 populations carries a heavy social cost and is a serious human rights and public health issue [1‐3]. Distinct from other forms of violence against children, child maltreatment CM refers specifically to acts perpetrated by parents or caregivers [4]. CM is alarmingly pervasive; globally, an estimated 60% of children aged 2–14 experience frequent physical punishment and as many as 70% are victims of psychological abuse from their caregivers [5]. Rates of CM are the highest in low-income countries, particularly in the African region where the heaviest burden is observed [5‐7]. Studies from Africa have found that between 75 and 94.4% of children experienced physical abuse from caregivers in the past year and 58.3–64% experienced emotional abuse [6, 8, 9]. The highest prevalence of child sexual abuse is also seen in Africa, with 34.4% of children experiencing a form before the age of 18 [10]. CM causes a range of long-term physical and mental sequelae, including neurological, cognitive, affective, and social disorders [11, 12], and is associated with poor school performance [13] and internalized acceptance towards gender-based violent attitudes in girls [14].

CM is closely tied to the social and cultural context. Numerous studies from Africa point towards poor knowledge of what constitutes abuse and accepting attitudes of abusive behaviors in cultures where corporal punishment and other forms of harsh discipline are entrenched in traditions and commonly practiced as main drivers [15‐18].CM is also associated with poverty and socioeconomic status [8, 19, 20] and exposure to other forms of violence, namely domestic violence, within the household [14, 21]. Due to the normalization of CM, cases are rarely reported and it’s often termed a silent phenomenon [4, 22‐25]. Literature from high-income countries suggests that training health care providers to be aware of abusive behaviors, recognize warning signs, and refer suspected cases to appropriate services might be one effective form of intervention and prevention [26‐29]. This is due to the fact emergency departments are often critical entry points into crisis response systems [30]. Despite the potential for emergency care services (ECS) to act as a first line of defense against CM, studies of this population from Sub-Saharan Africa are limited.

Existing studies from the region related to CM management in a hospital tend to focus on the profile of injuries, rather than health care providers. One study of physicians in the region found poor knowledge in correctly diagnosing cases of CM [31]. Yet, studies from ECS in Africa have found the burden of intentional injuries to be higher, between 18 and 21.3% [32, 33]. Training health care providers to recognize warning signs of CM is critical for timely intervention and prevention [27, 34]. Given the cultural context, knowledge of symptoms of CM alone may be insufficient. Thus, there is a need for reliable studies from Africa that take a holistic approach to examining barriers to diagnosis and intervention in suspected CM, which may include limited knowledge [31, 34], negative attitudes towards their role to intervene [23], and uncertainty in diagnosing and confusion about their responsibility to report cases [35, 36]. Consequently, there is a need for reliable studies to better understand current deficiencies and their determinants in the diagnosis and case management of child maltreatment victims in emergency departments.

In Mozambique, a low-income country in Southeast Africa, 5696 cases of violence against children were reported to police authorities and 190,000 cases were reported to the Child Help Line (A Linha Fala Criança) in 2015 alone [33].The actual prevalence of CM is likely underestimated due to fragmented surveillance, limited legal infrastructure, and the absence of children’s rights protections [22]. While the Ministry of Health has recently adopted a new approach centered on education and preparedness, the capacity to identify and treat CM in emergency care services in Mozambique (ECS) is still unknown. This study aims to advance current understandings of ECS providers’ knowledge, attitudes, and practices in identifying and intervening in situations of CM. Findings will assist in highlighting key areas to focus policies and trainings to support response capacity for this first line of defense.

Of the 60 health professionals identified as eligible, 49 (81.6%) consented to participate and were interviewed. Physicians made up 60% of health professionals interviewed. The final sample was composed primarily of women (69.4%). The mean respondent age was 32 years and most respondents were between 25 and 45 years (81.6%). Generalist physicians made up 57.1% of respondents. Table 1 details the sociodemographic characteristics and professional classifications of study participants.

Data on previous education and training specific to CM was also collected to characterize health care providers’ background (Table 2). On identifying or responding to CM, 83.6% of respondents disclosed having received no education/training or almost no education/training. Only 14.3% of respondents indicated having received some education/training specific to CM. Regarding knowledge, health care providers interviewed were asked to cite the main forms of CM (Table 3); 61.2% of respondents cited physical violence/aggression as being a main form of CM, 26.5% cited sexual abuse, and 12.2% cited emotional/psychological abuse. Although the majority of respondents reported physical violence/aggression as the main form of CM, 8.2% of respondents did not identify any of the forms of CM.

Knowledge of health care providers to recognize CM was also measured based on awareness of typical physical symptoms. Approximately 38.8% of the health care providers surveyed identified scarring and bruising at different stages of healing, 32.6% identified marks on the body in the form of objects such as a belt or cigarette burn, 4.1% identified burns, and 2.0% identified the presence of a sexually transmitted infection. Additional symptoms were mentioned by 20.4% of respondents; including malnutrition, scratches, ecchymosis, abrasions, and redness of the lips, lacerations in the case of sexual abuse, swelling, fear, ulceration, and depression. It is important to note that 8.2% of health care providers revealed that they did not know the typical physical symptoms of CM.

In relation to attitudes, 87.7% of respondents strongly agreed or agreed that health care providers hold an important role in the prevention of CM. Only 8.2% disagreed that health care providers hold an important role in the prevention of CM. Respondents were also asked their level of agreement with the attitude that “victim follow-up is not required because it is not important.” A majority of respondents (86.2%) strongly disagreed or disagreed with that statement; only 10.2% strongly agreed or agreed. In contrast, health care providers expressed low confidence diagnosing and treating CM (Table 4). Over half (51.1%) strongly disagreed or disagreed that they felt confident diagnosing and treating CM.

To examine practices, participants were asked about the existence of a standard protocol for the care of victims of CM. Just 55.1% of respondents correctly stated that there is not a care protocol for cases of CM, while 24.5% incorrectly referred to an existing care protocol, and 16.3% did not know if such a protocol is in place. Respondents were then asked if they know where to refer for further treatment (Table 5). Most respondents (69.3%) strongly agreed or agreed that they know where to refer victims; 14.3% strongly disagreed or disagreed and 14.3% of respondents admitted that they do not know.

Our study is one of the first evaluations in a LIC of the knowledge and practice deficiencies in diagnosing and treating CM in an emergency department. Health care providers in ECS are the front line of the health system and can reduce harm by identifying CM when and before it happens. This study adds much needed literature on Sub-Saharan Africa, where rates are among the highest in the world [5‐7]. The latest global guidelines for the prevention of CM emphasize the vital role of the health sectors of LMICs and our study offers evidence to guide the creation of new policies and investment in human resources in this context [25]. We found a significant gap in health care providers’ knowledge of the forms of CM and their symptoms beyond physical violence. The attitudes expressed by health care providers overwhelmingly suggest agreement with their role to intervene. However, our findings reveal a disconnect between the attitudes held by health care providers and the training they receive; one plausible explanation for this discrepancy is a lack of consensus and blurred boundaries around what constitutes CM amid a context in which the harsh punishment of children in normalized and widespread.

A slight majority (61.2%) of participants identified physical violence as a main form of CM. Yet, only 26.5% cited sexual violence and even fewer (12.2 and 10.2%, respectively) referred to psychological abuse and exploitation. Conformingly, bruises/scarring and marks on the body were the most frequently mentioned symptoms, and responses pointing to symptoms of sexual abuse were virtually absent. These findings of health care providers having knowledge predominantly of physical abuse are consistent with those of CM studies in international literature [37, 38]. A central challenge in the correct diagnosis of CM is that fact that most pediatric injuries globally (90%) are in fact unintentional and occur without malice [39]. Accordingly, future interventions to educate health care providers and increase knowledge should focus on individual-level risk factors for CM and encourage consideration of patient history and demographics in the assessment. Moreover, there is a need to better understand and treat negligence and emotional abuse as forms of CM, as well as provide long-term support to victims [26, 37, 38, 40].

Despite a limited knowledge base, the attitudes expressed in our study show strong agreement that health care providers have an important role in preventing CM, as 87.7% of respondents agreed. Similar attitudes regarding a responsibility to document, report, and treat suspected CM have been affirmed in some previous studies of diverse health care providers [37, 41]. Likewise, attitudes indicated a strong commitment to appropriately managing cases of CM, with an overwhelming majority of participants disagreeing that victim follow-up is not important. At the same time, over half of our participants did not feel confident in diagnosing and treating CM; only 2.1% strongly agreed that they felt confident. This is not surprising as 71.4% of participants did not receive any education or training specific to CM. Health care providers who have received training specific to CM have been found to have significantly greater knowledge of reporting procedures, compared to physicians who did not receive training specific to CM [27]. Although, it is important to consider the extent to which the presence of training within the medical curricula of countries may be indicative of broader social and cultural infrastructure concerned with and understanding of CM, rather than a targeted intervention. Regardless, the attitudes present in our study suggest that these health care providers would be open to education and training to build awareness and understanding around CM and increase knowledge and adherence of best practices.

What our findings do communicate is an apparent gap between attitudes and current practices. Responses implied a limited understanding of protocols and laws. For example, slightly half of participants correctly indicated that the hospital does not have an existing care protocol for cases of CM and approximately one-third stated that they did not know the referral process for suspected cases of CM. Lack of training specific to CM and its symptoms may be partially responsible for this disconnect; however, the cultural context might have more of an influence. Globally, in high-income and LMIC alike, training to recognize and follow CM protocols in medical curriculums is minimal and only a small part of overall education [27, 31, 42]. For example, in the United States, only one state mandates that physicians complete the Identification and Reporting of Child Abuse and Maltreatment course before licensing [42]. Yet, poor knowledge of what constitutes CM and lack of best reporting practices are not observed uniformly across countries; studies from other countries have found baseline physician knowledge and reporting to be higher, although still limited in some respects [27, 29, 43, 44]. Health care providers in our sample are operating within a context where the harsh punishment of children is normalized; in the region, there has been found to be poor societal knowledge of what constitutes abuse and accepting attitudes towards such behaviors in community-based surveys [15]. Consequently, a major barrier to improving the capacity of health care providers to intervene is not a lack of concern or acceptance of CM, but rather the difficulty in training physicians to recognize normalized and accepted behaviors as in fact acts of CM within their community threshold. To accomplish this, awareness around definitions of CM and risk factors should be the focal point of training, rather than purely knowledge-based instruction around symptoms. These interventions in health care providers are needed jointly with administrative reforms in the hospital to strengthen coordination between the health system and the legal authorities. MGH where our study was based currently does not have a care protocol specific to CM, although health care providers in Mozambique are obligated by law to report suspected CM to the police [45].

Child maltreatment is a leading public health problem internationally. Health care providers in ECS play an important role in the prevention and management of cases of CM through appropriate services and referrals. This study found that ECS providers working at Mavalane General Hospital in Maputo, Mozambique, have limited knowledge of the forms of child maltreatment and their associated symptoms beyond physical abuse and most have not received training on the topic. Attitudes expressed by health care providers suggest a strong commitment to their role and openness to CM training. Thus, investing in programs to raise awareness to confront sociocultural attitudes and recognize warning signs integrated with education and training to build skills and confidence have the potential to strengthen response capacity to improve care for victims of CM in Mozambique and other LICs.