Background
Violence against children (VAC) is a human rights violation and global public health problem. Negative and lifelong effects are associated with VAC, including impacts on physical, mental, and reproductive health as well as social and cognitive development [
1]. VAC is defined as any physical or sexual abuse, or neglect; which are often categorized as “child abuse”, “child maltreatment” and other variations of these terms in the published literature. Further, VAC includes all forms of physical and sexual violence and emotional abuse, neglect, negligent treatment and exploitation that is perpetrated against minors aged 18 years and under [
2,
3]. VAC is also associated with other forms of violence in the household, such as intimate partner violence and intergenerational cycles of violence [
4]. Further, VAC has negative impacts on educational attainment of survivors, as well as labor and productivity when survivors reach adulthood [
5]. At the societal level, VAC has multiple costs that impact development. These include direct costs, such as the medical costs of treatment and visits to health care providers; indirect costs, such as lost productivity, disability, decreased quality of life, and premature death; and costs borne by the justice system and institutions, including costs for social welfare and foster care, expenditures associated with apprehending and prosecuting offenders, and costs to the educational system [
1].
Every year, over half of the world’s children are victims of physical, sexual, and emotional violence [
6]. Prevalence estimates of recent violence (past 12 months) among children have suggested that over 30 % of children in Latin America experienced recent violence [
7]. However, in the LAC region, population-based studies are heterogeneous in methodology and definitions challenging any comparisons of estimates calculated for childhood physical and sexual violence across settings and countries. In El Salvador, a nationally representative study reported that 42 % of women and 62 % of men reported physical violence before age 15 years [
8]. In Guatemala and Honduras, 5 % and 8 %, respectively, of adult women reported experiencing sexual violence during childhood [
8]. Given the diversity of definitions used across studies and settings, the stigma associated with being identified as a VAC victim, as well as the regulatory and ethical issues associated with conducting surveys/interviews with children on their experiences of VAC [
9], existing estimates of prevalence in VAC is likely an underestimate of the true prevalence in LAC.
Within this context, national health protocols are instrumental in enhancing multi-sectoral collaboration and guiding the different sectors in responding to children in need of protection, treatment, care and referral. Healthcare professionals are in a unique position to raise awareness of VAC as a public health issue and to promote both prevention and response of VAC within and outside of healthcare settings [
9]. Health professionals have frequent contact with parents/caregivers and children, such as during routine visits for required vaccinations or school physical exams and/or for common childhood illnesses as well as when children seek services in the emergency department for an injury. Health professionals should not only be able to identify children in dangerous situations when there are visible injuries, but also have the skills to identify a child survivor even when the patient’s chief complaint is seemingly unrelated to violence, abuse or neglect [
9].
The Pan American Health Organization/World Health Organization Regional Office for the Americas (PAHO/WHO) and UNICEF Latin America and the Caribbean Regional Office (LACRO) has VAC prevention and response as a major focus of their programs. As such, PAHO/WHO and UNICEF are collaborating to partner with governments to develop, implement and monitor evidence-based health sector protocols to provide guidance to health care professionals in meeting their critical role in VAC prevention and response. All countries in LAC have ratified the UN Convention on the Rights of the Child (CRC), and in recent years, Argentina, Bolivia, Brazil, Costa Rica, Honduras, Nicaragua, Peru, Uruguay, and Venezuela have made important steps to address VAC through the full legal prohibition of corporal punishment [
10]. Several countries, such as El Salvador, Guatemala, Honduras, and Nicaragua, also supported development of or revisions to national protocols or guidelines intended to guide the health sector’s response to VAC [
11]. In LAC, child protection falls under the mandate of what is generally referred to as Comprehensive National Child Protection Systems (Sistemas Nacionales de Protección Integral) [
12]. Though diverse, these systems generally intend to coordinate the relations among all government and non-governmental agencies who comprise the Child Protection Systems in order to ensure children are protected against or provided with appropriate care following violence, abuse, or neglect. It is unknown the extent to which national protocols have been developed in LAC to guide response by health professionals to VAC and how protocols have impacted the identification, care, treatment and referrals of children from the health sector to appropriate protections services.
The overall purpose of this study is to collaboratively assess the health sector’s response to VAC within the LAC region, by reviewing both national health sectors protocols for VAC and published research articles, particularly those discussing health sector response to physical violence, sexual violence, and neglect, in order to provide guidance and recommendations to strengthen national health sector response to VAC.
Methods
To achieve this purpose, we conducted a comprehensive review, which included two different data sources and parallel activities: 1) collection and review of existing LAC national protocols for the identification and provision of health care to child survivors of violence, abuse and neglect; and 2) systematic review of published articles and reports to examine current types of response, training, interventions, and collaborations between the child protection and health sectors to address VAC.
Review of clinical protocols
In collaboration with PAHO and UNICEF, the team solicited country-level health sector protocols using email requests disseminated by PAHO/UNICEF colleagues to focal points in each of the 43 LAC country offices. Email recipients were informed about the purpose of the project and asked to collaborate by providing the project team with an electronic copy of the most recent national VAC protocol for the health sector response. Two reminder emails were subsequently sent to country focal points over a two-month period to follow-up with the request if the national protocol had not been received.
The review of the health sector protocols focused on identification of guidance offered to health care professionals in support of optimal response to violence, abuse and neglect of children. We adapted an existing review matrix developed to assess protocols addressing violence against women [
13] and included the following categories: purpose of the protocol, definition of child physical abuse, definition of child sexual abuse, components of access to care (e.g., service hours), health care professionals and roles referenced, components of services/actions recommended, treatment plans/follow up, and mandatory reporting requirements.
Systematic review of peer reviewed publications
The systematic review of peer-reviewed public health, medicine, and nursing literature was conducted to map the reported health sector response, guiding curriculum, interagency collaboration, as well as strengths and weaknesses of the current health sector response to VAC in the LAC region. Searched databases included Pubmed, Embase, PsycInfo, CINAHL, and LILACS and the review was conducted following PRISMA guidelines [
14]. The first four databases index global publications from scientific, health, and nursing sources. PAHO and WHO jointly developed the LILACS database to index scientific and technical literature from the LAC region (
http://lilacs.bvsalud.org/en/). A public health informationist collaborated with the authors to develop search terms and conduct the database searches. Databases were searched between the dates of 27 January 2005 and 26 January 2015. Searches followed controlled vocabulary and keywords, which were used in combination for the concepts of child abuse, health sector response, and LAC countries with no restriction on language of the publication/report. Index specific search terms are provided in the Additional file
1. Identified publications were compiled in an Endnote reference manager (Thomson Reuters, Version 7) and duplicates were removed. A title and abstract review was used to identify eligible literature and was followed by a full text review and data extraction of eligible publications. Reviews and data extraction of English and Spanish articles were conducted by two of the authors (AW and CA). Two research assistants who were fluent in Portuguese (native speakers from Brazil) reviewed and extracted relevant data from literature published in Portuguese language. All data extraction was documented in English; while no formal translation process was used, selected studies were discussed amongst the authors and research assistants to verify content and applicability to the study purpose. Figure
1 provides the PRISMA flow diagram.
Peer reviewed publications were included if they met the following criteria: participants included children (up to age 18) and/or health care professionals (physicians, social workers, nurses, or health administrators); study population was in a LAC country; study addressed health sector activities, training, and/or policies regarding child (up to age 18) violence, abuse, neglect and protection; or were intervention studies with VAC related outcomes; and were original research articles or reports that addressed the above criteria. Publications were excluded if they focused exclusively on prevalence or sequelae of VAC without reporting any health service or other service provided; focused on domestic violence/abuse of adults but did not include children; did not include full texts (were abstracts only); or if the study population was not in LAC countries – e.g., child abuse among Latino populations in the U.S. As noted above, the purpose of the systematic review was to examine the current types of health sector response for VAC, evaluating the quality of the studies presented in the publications was not a component of this review.
To identify the health sector response and linkages to other relevant sectors, such as child protection, criminal justice, legal system, we developed data extraction forms pertaining to three domains: 1) health services and linkages to other related services; 2) training/curriculum/ health professional response to VAC; and, 3) health sector based interventions to prevent or respond to VAC. Additional information related to the study design (location, year of study, design, sample size, population) were also included for data extraction. Table
1 displays the types of data that were extracted from the published literature for each domain. Trained research assistants and co-authors fluent in Portuguese or Spanish independently extracted data from identified articles. All extracted data were reviewed for accuracy by one of the first authors (AW).
Table 1
Key domains and data extracted from peer reviewed literature in the LAC region
Categories: | Study (Author, year pub), | Study (Author, year pub), | Study (Author, year pub), |
Country, | Country, | Country, |
Year(s) of study, | Year(s) of study, | Year(s) of study, |
Study design, sample size (N), and target population | Targeted profession/ degree for training | Study design, sample size (N), and target population |
Accessibility of services, | Training content | Intervention description |
Types of services offered, | Duration of training | Identified gaps/limitations |
Linkage to other services, | Method of evaluation | Results/Impact |
Follow-up plans | Identified gaps/limitations. | |
Identified gaps/limitations. | Results/Impact | |
Results/Impact | | |
Discussion
The purpose of this review was to describe the national health sector’s response to VAC within the LAC region using both national protocols and published articles. This review has revealed that, in spite of the prevalence and sequelae associated with VAC, best practices for responding to VAC particularly in resource-constrained areas remain limited. The content of national protocols reviewed and findings of health sector response varied tremendously with the majority of protocols providing limited guidance for VAC response to health care professionals; these findings validate the need for developing and implementing evidence-based policy and protocols that include opportunities for pre- and in-service training, tools to enhance identification, survivor-centered treatment and care, referrals to other service sectors and ongoing follow-up and psychosocial support to the child survivor and family as appropriate. Strengthening national protocols through broad dissemination of protocols with training on implementation and adherence, as well as research and monitoring will enhance the health sector’s effectiveness in prevention and response to VAC.
Overview of national protocols
Our review of national protocols found that across the pool of submitted protocols, core components, such as definitions of VAC or specific types of violence, and signs and symptoms of VAC were included, though to varying degrees. Age limits and considerations of power dynamics were also included in these definitions and are important features which may facilitate greater awareness of violence, abuse and neglect, particularly in situations where physical injuries or symptoms of violence, abuse and neglect may not be apparent. Inclusion of definitions of VAC in protocols is critical to preventing ambiguity in health providers’ understanding of what constitutes violence, abuse and neglect and, ultimately, strengthening their understanding of role and responsibility in response once VAC is identified. We also noted multiple gaps in the national protocols on identification and management of suspected cases of VAC within health care settings; particularly in cases without obvious injuries or other signs/symptoms. As most health care professionals likely inspect for substantial physical evidence, such as injuries to justify suspicion, evidence suggests that not all forms of violence have obvious signs and symptoms [
99‐
101]. Evidence remains lacking on how to best guide providers on identification of cases of suspected VAC in cases where physical signs/symptoms are absent. It remains important to include within protocol guidance instructions for health care professionals to be attuned to “minor” injuries or patterns of health care visits, injuries that do not match explanation, or vague complaints that can also be associated with VAC.
The level of detail and extent of guidance for treatment, referral and follow-up care was heterogeneous across protocols and often reflective of the target population anticipated to utilize the protocol. The plan of care for survivors of sexual violence presented in 15 of the submitted LAC country protocols aligned with recommendations for clinical management of sexual violence [
102]. However, only two protocols (Chile and Trinidad & Tobago) specified clinical management for child and adolescent survivors of sexual assault. All other country protocols did not provide any clear delineation between clinical management of adolescents (14 years and older) versus younger children. More evidence is needed in low and middle-income countries to determine best practices for responding to the child and adolescent sexual violence among other forms of VAC. To this end, WHO is currently developing policy and clinical guidelines on child maltreatment and sexual violence against children and adolescents [
103,
104].
Evidence for recommendations within national protocols
Evidence for plans of care
Multiple protocols included recommendations for follow-up care for the child after violence/neglect has been suspected. Protocols from five countries recommended home visits (Chile, El Salvador, St. Vincent & Grenadines, Uruguay, and Peru) and cognitive behavior therapy (CBT) (Chile) for survivors and family members [
26,
39,
42]. The recommendation for home visits was based on findings from the Olds Home Visit Model [
105]. However, the Olds Model includes multiple home visits addressing several issues, such as maternal well-being and parenting skills for example. None of the protocols reviewed described what prevention and response activities related to VAC should be included in the home visit. Given that the model requires extensive training for home visitors prior to implementing, the Olds Model as is, may not be practical for settings with limited resources for training of health care professionals [
105]. Cluster randomized controlled trials from other resource-limited settings have demonstrated reductions in specific unintentional injuries, such as burns and poisonings, among children aged 10 years and younger through the use of a paraprofessional home visitation program (HVP) [
106]. Similarly, in the U.S. the SafeCare protocol, which aims to prevent child maltreatment and increase protective factors, was adapted and implemented among low-income Latino families [
107]. Employing paraprofessionals with diverse educational backgrounds, the study demonstrated feasibility for use among this population. Taken together, such approaches may be adapted for home visits targeting VAC prevention across diverse settings in the LAC region.
There is a dearth of evidence on which to base recommendations on best practices for service provision for prevention and response to VAC. However, there is a growing body of literature on “trauma-informed care” (TIC) and the use of a “trauma-informed approach” to caring for survivors, with evidence suggesting improvements in post-traumatic symptoms and behavior problems among child survivors, patient-provider relationships [
108], and broader improvements in collaboration across sectors [
109,
110]. TIC is a commitment from the health care organization and all staff at all levels to reduce the risk of re-traumatizing the child when providing treatment and follow-up services [
111,
112]. In this model, staff members are expected to understand the potential impact of trauma on individuals, families, and communities and be able to recognize the signs of trauma and responding appropriately. More importantly, the organization or system offering TIC, must have policies and procedures that would not further exacerbate the sequelae from trauma [
113]. Components of TIC include creating a safe environment for the survivor, fostering trust and transparency with the survivor and his/her family, allowing the survivor to be a partner and be involved in the decision-making about his/her care, and being culturally-sensitive.
Though most research to-date comes from settings outside of LAC, it is a possible that such a model could be adapted to settings in the LAC region. In fact, this review found that elements of TIC were apparent in almost all (90 %) of the protocols. For example protocols from 20 countries recommended creating a safe environment for survivors and providing patient-centered care. Also, protocols recommended conducting an interview in a way that is non-judgmental and encourages the patient to tell his/her story about the violence/neglect. Less apparent in the protocols was guidance on fostering trust and transparency with survivors and family members, as appropriate. Such recommendations would typically describe methods about how the provider should communicate with both the child and family member/caretaker to inform them of why inquiries about violence/abuse were being made. Additionally, recommendations should encourage communication to inform the patient/family that the disclosure, history, and assessment information will be used ultimately to help the child survivor recover and prevent reoccurrence rather than focusing on identification and punishment of the perpetrator [
9].
Mandatory reporting
Mandatory reporting of suspected VAC to either a child protection agency or the police was present in about half submitted protocols. One rationale for mandatory reporting is that it communicates that VAC is not tolerated and obligates providers in the health sectors and other sectors to act on the care through reports to authorities [
101,
114]. Gilbert (2009) raises the potential harms associated with providers' mandatory reporting of VAC as follows: “we do not know whether the process from recognition to reporting and subsequent interventions by child protection agencies improves lives of children overall.”(2009, p.168). This point is particularly relevant in low-resource settings in which alternative options for safety for child survivors (e.g., foster care, group homes, safe houses, shelters) may not be available when children are removed from homes. Further, evidence from the systematic review suggests that providers have limited awareness of reporting requirement or confidence in their ability to respond to VAC and concern about potential legal proceedings, even when reporting is mandatory. As a result, health professional describe low levels of reporting VAC to appropriate authorities [
69,
86,
87,
90,
96]. Wekerle [
114] argues that mandatory reporting should be conceptualized as part of a continuum of care, such that it is not the only intervention but the starting point to promoting resiliency and supporting the child survivor.
Gaps & strengths of the current health sector response to violence against children in the LAC region
Despite the existence of guidance on services for VAC survivors in some protocols, our systematic review found that most publications initially identified by the search (and subsequently excluded) often reported statistics related to types of VAC reported in the health sector, child characteristics, and risk factors for VAC but did not focus the types of services provided to the child, including referrals and follow-up care. This dearth of information does not necessarily imply that such services are not being provided to child survivors; however, it does highlight the low prioritization of evaluation of service provision and health sector intervention for VAC and, ultimately, the gap that exists between research, policy, and programming. The development and implementation of health sector protocols and programs, however, require ongoing evaluation and monitoring, at the minimum, for continued quality improvement.
A clear gap across protocols was the limited dissemination of the protocol to target audiences, lack of strategies for implementation and of health professional and other service sector training. Findings from the systematic review mirrored these observations. In fact, most salient was the finding from the review of the existing scientific literature in LAC that most health professionals have limited to no training with respect to providing care for VAC, are unaware of reporting requirements and protocols, and/or of steps for reporting or intervening on suspected VAC cases [
69,
86,
87,
90,
96]. Further, health professionals who do report cases or suspected cases of VAC are often frustrated by the lack of follow-up by child protection or child welfare systems, as they are left unaware of what happens to the survivors after the report and fear that the child remains at risk for VAC. Health professionals indicate that the lack of follow-up on cases leads to their hesitation to report VAC. Taken together, these issues highlight the importance of developing a clear dissemination plan for national protocols, appropriate interdisciplinary training centered on the components of the national protocol, and feedback mechanisms for the health sector and professionals who are involved in the VAC case.
An important strength to build upon is the recognition in protocols and in the literature that an interdisciplinary response to VAC is needed. Often noted in the studies from Brazil was the importance of training on response for VAC for diverse health professional providers, such as dentists and other health providers such as audiologists, with whom children come in regular contact [
93,
115,
116]. Nurses were also noted to be at the forefront of care and well positioned to identify potential VAC; however, given limited access to protocols and training on referral pathways, nurses are not always aware of how to effectively respond with the goal of increasing child safety [
72,
117,
118]. Indeed, collaboration across diverse health sector providers can strengthen prevention and response to VAC.
Research from Brazil provided evidence of positive outcomes associated with interdisciplinary collaboration and linkage to respond to VAC. Findings from the Program of Integrated and Referential Actions (PAIR) in Brazil, a national program that aims to integrate all services to children survivors of violence, suggests that this approach was successful in strengthening access of children and families to the Tutelary Council for investigation of suspected cases of violence/neglect [
62]. As a cross-sectional study, however, assessment of long-term improvements and impact is limited. Broader insights on systems-level approaches may be obtained from the literature on IPV, reviews of which found that successful programs had onsite, dedicated staff who had the expertise to support the survivor. Such support may not be feasible in all LAC health care settings; however, professionals could, at a minimum, be provided with a protocol that included contact information for national or local hotline or programs with experts to provide guidance on cases of VAC [
119]. All country protocols addressed the importance of community involvement in responding to VAC. Indeed, the BTS model from Trinidad & Tobago, which provided an interdisciplinary team of health professional and social workers to partner with the community for education and skills building, is one example of a community-based effort to prevent and respond to VAC [
80]. Subsequently, this program has been scaled up in all Eastern Caribbean countries with support by UNICEF [
120]. A partnership between such community groups and health care settings would be a way for both to effectively respond to VAC.
Limitations
This review may be viewed in light of several limitations. Overall, protocols and peer-reviewed publications were available for approximately half of the target countries. This leaves questions about the availability and quality of national protocols on VAC in several LAC countries for which data were missing. Further questions remain on availability and types of guidance for countries lacking protocols and on the forms and quality of service provided to child survivors and families, given that no assessment was found to evaluate the quality of care from the survivors’ perspective. Findings from submitted protocols and identified publications may not be generalized to the entirety of LAC countries. We initially envisioned that peer reviewed publications would enable us to map what is being done in the field juxtaposed to the recommendations included in the national protocols. However, there was a substantial gap in the literature on the types of services provided, quality of care, referrals, and follow-up care for survivors of VAC. This gap in the literature prevented such mapping efforts and leaves questions about what services across the multiple sectors are actually being provided and how these services are related to the national protocols. Moreover, identified publications tended to be of relatively small sample sizes and report cross-sectional studies and qualitative research, limiting assessment of effectiveness, impact, and coverage of services.
Acknowledgments
The authors thank PAHO/WHO, UNICEF for their interest and support of this review. Many thanks are due to the country offices who submitted national protocols as well as to Lori Rosman, Public Health Informationist who supported the development of search terms, and our Research Assistants, Carol Silva, Paloma Cesar De Sales, and Sabrina Mikael who supported the literature search and date extraction. We thoughtfully acknowledge the countless survivors of VAC and service providers who are dedicated to the response and prevention of VAC in the Latin American and Caribbean region.