Background
Child maltreatment is a raising concern in public health and social welfare in Japan [
1] The reported number of suspected cases of child maltreatment is increasing, from 37,323 in 2006 to 122,575 in 2016 [
2]. According to the Ministry of Health, Labour and Welfare (MHLW) of Japan, child maltreatment is categorised into four essential types, physical, sexual or psychological (including witnessing domestic violence, WDV) abuse and neglect [
3]. Exposure to multiple types and repeated episodes of maltreatment during childhood is associated with high risks to enormous adverse health outcomes, causing a significant social and economic burden on individuals, families, and societies. Those adverse outcomes during childhood include child death, injuries and disabilities, developmental and behavioural problems. Moreover, the related physical and mental health conditions persist into adulthood, leading to the onset of chronic diseases, depression, drug, alcohol misuse and risk sexual behaviour, suicide ideation [
4,
5].
The government has introduced a couple of protective measures, with increasing public budget [
6‐
8]. Assessment of costs and burden of disease helps development of resource allocation and priority setting in public sector. Paralleling with growing concerns on child maltreatment, the number of the related analysis of the prevalence, health consequences and economic burden is increasing. So far, for the economic burden there are two typical research frameworks: one is a comprehensively costs evaluation from healthcare, social, educational areas, and loss in productivity et al. [
9‐
13]; another one is to measure related economic and disease burden [
14,
15]. Wada et al. (2014) reported the social costs of child abuse in Japan included direct costs of dealing with abuse and the indirect costs related to long-term damage from abuse during the fiscal year 2012. On the other hand, the first framework is likely to underestimate long-term deleterious effects of child maltreatment, on which evidence derived from longitudinal studies is less available compared to that on the short-term counterpart [
16]. By integrating previous evidence, our cost-of-illness study aimed to assess lifetime economic and disease burden of mortality and morbidities attributed to child maltreatment based on the later framework, in order to address the evidence gap. We extended cost calculations for monetary values converted from Disability Adjusted Life Years (DALYs), covering related mortality and morbidities [
17].
Discussion
Our results indicated that disease and economic burden attributable to child maltreatment is substantial. In particular, that originated from the long-term health consequences accounts for the majority.
Based on literature review, the pooled incidence of child maltreatment in Japan is much higher than officially reported, which is consistent with the findings of other studies [
10,
12,
35]. Because of difficulty to identify the actual cases and a public attitude to consider child abuse as a private affair in the society, the officially reported cases are likely to represent the tip of an iceberg.
Psychological abuse (including WDV) represented the majority of reported cases. The results of the literature review also showed a gender difference in the prevalence of the four types of child abuse (size weighted mean values), girls were found to be more likely to experience the harmful practices compared to boys, particularly sexual abuse. This tendency was also observed in other countries in East Asia and Pacific region [
15]. Comparing those living in other countries in the East Asia and Pacific region [
15,
23], Japanese children tended to less likely to experience physical abuse (boys: 8.40% vs. 16.76%; girls: 6.69% vs. 15.42%).
Although it is difficult to directly compare the results across different study settings due to the different methodologies, parameters and target populations adopted, the ingredients of the lifetime economic and disease burden considered in our study, including medical costs and monetary value of disease burden, are similar to that adopted in previous studies [
10,
12]. Still our results showed that the disease burden was about 7–8 times of the conservative estimation due to the huge gap of incidence generated from literature and that officially reported. The number is consistent with an Australian research that showed a wide distribution of the annual prevalence, ranging from 0.85 to 4.6% [
12]. In the conservative lifetime course simulation, the initial victim age is assumed to be 7 years old according to an age-weighted incidence calculation based on official reported cases, which was also consistent with previous studies [
9].
Our study in particular highlighted DALYs in long-term attributable to child maltreatment, accounting for a relevant proportion (81.3%) in the overall lifetime costs. The estimation of disease burden attributed to child maltreatment (1,047,580 DALYs) was comparable to the total DALYs due to colon and rectum cancers (1,043,335 DALYs in 2015), or stomach cancer (1,002,252 DALYs in 2015) [
30].
To our knowledge, this is the first study to estimate lifetime economic burden of child maltreatment in Japan based on an epidemiological model. The idea of this method is to convert disease-induced losses of well-being into economic terms by multiplying the annual number of lost life years due to disease by sub-reginal per capita income. So far, few studies had ever taken this part of costs into account, potentially leading to an underestimation of health and economic impacts of child maltreatment. In addition, we adopted conservative calculation methodology in the sensitivity analyses to estimate the burden of child maltreatment for more reliable range estimations.
There are several limitations to this study.
First, the co-occurrence of multiple types of child abuse is prevalent [
35], resulting in difficulties to identify the adverse effects separately. In order to minimize possible consequent overestimation, we used the pooled ORs of multiple adverse childhood health experiences instead of each types of child maltreatment and its severity.
Second, we focused on the economic burden due to the mortality and morbidity of child maltreatment but did not consider non-health human capital aspects, to address the knowledge gap.
Third, like other economic burden estimation studies, the availability of data on the related medical costs were limited. We nevertheless targeted major health consequences and explored their unit costs for the estimates [
26].
Recently in Japan, a continuum of intensive supports to mothers and child-rearing families encompassing the reproductive cycle has been widely implemented in most local authorities. Such an integral approach serves as an essential preventive strategy against child maltreatment and other harmful practices by early detection and intervention of high-risk households in pregnancy, postpartum and child-rearing periods. This study can provide decision makers information on the economic burden of child maltreatment, as well as an important input in future economic evaluations (cost-effectiveness analysis) on currently ongoing intervention and policy. In addition, our results hint an emphasis on preventive interventions on suicide attempts and depression, which are top causes of the attributable disease burden due to child maltreatment.
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