Abstract

Child abuse and neglect is a widespread and pressing issue, with serious and long-term adverse effects on children’s physical and psychological health. Pediatricians play a crucial role in detecting and addressing cases; however, studies have shown challenges in reporting cases encountered in clinical practice. This study aims to examine pediatricians’ attitudes towards reporting cases of child abuse and neglect encountered in their clinical practices, as well as the factors influencing these attitudes.

A descriptive cross-sectional study was conducted among pediatricians in Istanbul. Data collected included sociodemographic characteristics, knowledge and formal training about child neglect and abuse, attitudes about dealing with it, experience, and reporting behavior. The data was collected through a self-administered online questionnaire. The study provides insights into the current awareness and response of Istanbul’s pediatricians towards child neglect and abuse. The data were analyzed using SPSS 22, employing descriptive and comparative statistics such as frequency, mean, standard deviation, and correlation tests. Ethical approval was obtained from the Istanbul Medipol University Ethics Committee. The study was conducted in accordance with the Declaration of Helsinki and online consent was obtained from the participants.

The study involved 126 pediatricians. Results showed that pediatricians had generally positive attitudes toward reporting child neglect and abuse. Gender and marital status did not significantly influence attitudes, but pediatricians who were parents scored higher on reporting Responsibility. Additionally, it was shown that those with more professional experience had a higher reporting responsibility score. Structured training on child abuse and neglect has been shown to increase pediatricians’ reporting responsibility scores and exhibit less anxious attitudes.

This study highlights pediatricians’ positive attitudes toward reporting child abuse and neglect and identifies influencing factors such as training, professional experience, and collaboration. It emphasizes the importance of addressing challenges like awareness of reporting procedures and concerns about negative consequences. Comprehensive training, clear reporting protocols, and multidisciplinary collaboration are essential for increasing reporting rates and improving the detection of child abuse and neglect. The study contributes to enhancing child protection systems in Turkey by providing insights into pediatricians’ attitudes toward reporting child abuse and neglect.

Introduction

Child abuse and neglect is a ubiquitous problem that has serious physical and psychological consequences for children and continues throughout their lives (1). International studies show that between 16% and 36% of children worldwide have experienced some form of abuse (1). Timely identification and intervention are vital for the prevention of child abuse and neglect (1, 2).

As health care providers, pediatricians have a pivotal position in identifying and addressing conditions essential to children’s well-being and protection (3, 4). Phycians have a moral and legal responsibility to report these cases to the relevant authorities to provide early intervention to victims and perpetrators and prevent further abuse (3, 5).

Studies conducted by the American Academy of Pediatrics revealed that 45-57% of pediatricians stated that they treated or counseled injuries resulting from child abuse in the previous year (2). However, in studies conducted, health professionals, including pediatricians, did not report such high figures in reporting cases of abuse. 64% of primary care physicians agreed that child abuse is underreported (6).

When the studies in the literature are examined, the factors that prevent reporting include insufficient knowledge and experience in recognizing and reporting child maltreatment, attachment to the family or fear of caregivers’ reactions, negative reporting experiences resulting from lack of feedback from child protection agencies or perceived ineffectiveness of child protection (7, 8). Phycians are often afraid of making mistakes or accusing someone of negligent or abusive behavior toward children (4). Phycians are afraid to report child abuse because of the risk of losing patients, being sued, and having to testify in court (9, 10).

Some studies have specifically drawn attention to the impact of education and training on reporting behavior. Compared to those who did not report, one study found that those who reported were 10 times more likely to have received training regarding child abuse and neglect in the past five years (11). The training was found to make a difference in reporting. However, it could not be concluded whether the training increased the identification of child maltreatment or increased clinicians’ comfort with reporting. It has been found that completing child protection training increases reporting preparedness and that those who have received training are significantly more likely to report their suspicions (9, 11).

Studies conducted over the last 25 years have shown that the behavior of health professionals in reporting child abuse is affected by negative and positive attitudes toward reporting, and attention has also been drawn to the issue of attitudes. While negative attitudes hinder reporting, positive attitudes make reporting easier (11).

People approach almost every issue related to social life in line with the attitudes they have acquired or adopted until then and behave when necessary (12). Attitude research also attempts to identify and measure people’s opinions or preferences on various issues. An important reason why attitudes are such a fundamental subject of study in social psychology is that it is assumed that attitudes affect and even determine behavior (13).

Although there are no validated measures of health professionals’ attitudes in reporting child abuse and neglect, initial assessment tools have been created and validated for use in other settings. The Teachers’ Attitudes to Reporting Child Sexual Abuse Scale (TRAS-CSA) was originally developed by Walsh and colleagues (14, 15). This attitude scale is based on Ajzen’s Theory of Planned Behavior (TPB), with items reflecting the model’s cognitive, behavioral, and emotional components (16).

According to the TPB, a person’s behavioral attitudes, perceptions of control, and subjective norms are related to the intention to perform a particular behavior. Intention to engage in a behavior predicts behavioral outcomes. Applying this theory to reporting child maltreatment, an individual’s attitude toward reporting, the opinions of colleagues and supervisors, and perceptions of control over reporting may predict the intention to report suspected maltreatment. These components are related to whether a report is made later (16).

There is increasing interest in combating child abuse and neglect in pediatric practice in Turkey. Legal procedures require healthcare professionals to report suspected cases. This means that pediatricians must diagnose, provide treatment, and manage the legal complexities that come with cases of child abuse and neglect. However, there are problems with reporting behavior, which is mandatory in practical life.

Problems and possible reasons for pediatricians’ behavior in reporting child abuse and neglect cases have been mentioned in the literature. However, studies on the attitude of reporting child maltreatment are rare. In this study, aiming to evaluate the attitude, which is considered the beginning of the formation of behavior, the attitudes of pediatricians towards reporting child abuse and neglect cases they encounter in their clinical practices were evaluated, and the findings were discussed in the light of theories that try to explain the formation of attitude and its transformation into behavior.

Materials and Methods

Study Design

This study is a descriptive online cross sectional survey conducted among pediatricians. The participants were selected using the snowball sampling technique. The study aimed to gather information on sociodemographic characteristics, knowledge, formal training on child maltreatment, attitude towards dealing with child maltreatment, and experience and reporting behavior related to child maltreatment cases. Data collection was carried out by means of a self-administered online questionnaire. The study targeted pediatricians working in Istanbul, and all pediatricians who could be reached via the internet were included in the study using the snowball sampling method. Initially, a person with a wide network of contacts was contacted to distribute the questionnaire. With their assistance, the questionnaire was delivered to other participants through the Google Forms online platform. The participants completed an online sociodemographic data form and the Healthcare Provider Attitudes Toward Child Maltreatment Reporting Scale. This study design facilitated a comprehensive exploration of the attitudes and experiences of pediatricians in Istanbul regarding child maltreatment reporting.

Measurement

The “Healthcare Provider Attitudes Scale Toward Child Maltreatment Reporting” created by Singh et al. (17) was used in the study. Turan and Erdoğan (18) evaluated the validation and reliability of the self-report scale consisting of 21 questions in the Turkish context in 2019. Two items were removed from the scale in this evaluation because their item-total correlation value was below 0.20. These items are “I hesitate to report child abuse because I worry it may result in family/social revenge” and “I am familiar with the procedures for reporting child abuse.” are the items. In Turan and Erdoğan (18) study, the Cronbach Alpha coefficient of the scale was found to be 0.83. The items in the scale were evaluated using principal component analysis with varimax rotation, and the factor loadings of 19 items were between 0.33 and 0.91. The scale explained 50.25% of the total variance with two factors. The scale has two subscales: Reporting Responsibility and Concerns about Reporting. The first subscale, Reporting Responsibility, consists of 10 items, and the Concerns about Reporting subscale consists of 9 items.

Participants rated their level of agreement with survey items on a 5-point Likert scale (1=strongly disagree, 5=strongly agree). Items were coded so that higher scores indicated higher levels of adherence to maltreatment reporting roles, greater confidence in the system’s effectiveness in responding appropriately to reports, and less concern about the potential negative consequences of reporting suspected maltreatment.

On the scale, the lowest score is 1, and the highest score is 5 for each item. The lowest score from the total scale score is 19, and the highest score is 95, while the lowest score from the Reporting Responsibility subscale is 10 and the highest score is 50. The lowest score from the Concerns About Reporting subscale is 9, and the highest is 45.

Statistical Analysis

The data obtained in the study were entered into the SPSS 22 (Statistical Package for the Social Sciences) statistical package program and evaluated with descriptive and comparative statistical analyses. Descriptive statistics are presented with frequency, percentage, mean, standard deviation, median, minimum, maximum, 25%-75% percentile (Q1-Q3), or IQR values. The normality assumption was checked by examining the histogram, q-q plot, skewness, and kurtosis values with the Shapiro-Wilk Test. In analyzing the difference between the numerical data of the two groups, the Independent Samples t-test was used to see if the data conformed to a normal distribution, and the Mann-Whitney U Test was used to see if it did not. Relationships between numerical data were evaluated with the Pearson Correlation Test when the data conformed to a normal distribution and with the Spearman Correlation Test when they did not. Evaluation of categorical data was done with the chi-square test. For relationships between categorical data, Pearson chi-square was used when the proportion of cells with an expected value of less than 5 was less than 20%, and Fisher’s exact test was used when it was greater than 20%. The p<0.05 level was accepted as the threshold value for statistical significance. The results obtained are shown in tables.

Compliance with Ethical Standards

For ethical approval of this study, permission was received from the Istanbul Medipol University Ethics Committee dated 18.02.2022 and numbered E-1084 0098-772.02-1195.

All participants approved the online informed consent form. The study complies with the Declaration of Helsinki.

Results

The study involved 126 pediatricians. They responded to an online questionnaire. Ninety-one respondents (72.2%) were female and 35 (27.8%) were male. The mean age was 40.64±8.29 years. Table 1 presents a summary of the sociodemographic traits of the subjects.

The Scale for Determining Health Workers’ Attitudes Towards Reporting Child Abuse has two sub-factors: Reporting Responsibility and Concerns About Reporting. The participants’ mean total scale score was 70.50±6.83. The mean scores for Reporting Responsibility and Concerns About Reporting were 39.72±3.22 and 30.78±4.95, correspondingly. The characteristics of the total score and the sub-factors are more detailed in Table 2.

The analysis of Table 3 details the connection between the sociodemographic traits of participants and the mean scale scores. No statistical differences in scale and sub-factor scores concerning gender and marital status were found. The mean Reporting Responsibility score of participants with children is 40.06±2.88, whereas participants without children scored an average of 38.76±3.92, with a statistically significant difference.

The mean scores of individuals with less than 5 years of professional experience were significantly lower than their counterparts with over 5 years of experience. Among those with less than 10 years of professional experience, only their Responsibility to Report scores were significantly lower than those with more than 10 years of professional experience (refer to Table 3).

Those participants who received structured training on child abuse and neglect (CAN) achieved statistically significantly higher average scores for Responsibility for Reporting and the overall scale. In contrast, the average scores for Concern about Reporting were comparable (see Table 3).

Statistical differences were observed in the mean scores of Responsibility for reporting and the overall scale between individuals who received structured training on child protection systems (CPS) in our country and those who did not (see Table 3). However, the mean scores for concern about reporting were comparable between the two groups.

A statistically significant increase was observed in favor of individuals who received structured training on current legal regulations concerning child abuse and neglect, as compared to those who did not receive such training. The improvement was noted in the overall scale and sub-factor mean scores (Table 3).

Discussion

Attitude is general and relatively permanent positive or negative feelings about someone, object, or issue. An important point to understand from this definition is that everyone’s attitude toward objects may differ. For one person, for example, the global warming problem is an object of attitude, while another person may not even be aware of the global warming problem. Again, while a person, object, or subject is not an attitude object for someone, it may later become an attitude object with experience.

The findings of this study shed light on pediatricians’ views regarding their attitudes toward reporting child maltreatment. In this study, scores above the middle score obtained from the attitude scale indicate that pediatricians show caution and feel Responsibility in reporting child maltreatment, meaning that reporting child maltreatment among pediatricians is an important attitude objective. This is encouraging, given how important reporting abuse is to the safety and well-being of children (8, 19, 20).

At the same time, one of the structural features of attitudes is that they are unipolar or bipolar. When we want to evaluate an attitude on an evaluation line, we may want to know the area covered by this line. When we look at pediatricians’ attitudes in reporting CAN cases in our study, this attitude is between -2 and +2 on the evaluation line. The scale is a Likert-type scale, and the answers range from strongly agree to disagree strongly. We can think of the “I am undecided” option as neutral in attitude, that is, point 0, and the sensitivity towards reporting as point -2 when I strongly disagree, point -1 when I disagree, point +1 when I agree, and point +2 when I strongly agree. When the scores obtained from the scale are examined, we see no negative attitude in the reporting responsibility subscale. The reporting attitude of pediatricians is positive and strong as seen in the literature (21-23).

Positive and strong attitudes are important factors that enable attitudes to turn into behavior. Reporting Responsibility was high in this study (21, 24, 25). All participants scored above neutral. However, the % of participants whose level of concern about reporting was more negative than neutral, that is, had high concern, was 21.4%. In this case, we thought that although the participants’ level of responsibility was high, their anxiety level might be an important factor that prevented their attitudes from turning into behavior.

In many cases, attitudes and subjective norms are sufficient to reveal the intention for behavior (21, 25). However, sometimes there may be such situations that, although both of these determinants reveal the intention to behave, the person may still ask, “Can I really do this behavior?” Researchers later added a third component to their original theory: perceived behavioral control. This is the person’s perception of how difficult or easy the behavior is. According to the theory, if people believe that they do not have the ability for the behavior they plan to do or do not have enough resources for it, the intention for the behavior will not be formed despite their attitudes and subjective norms towards the behavior (16).

The study examined the relationship between the participants’ sociodemographic characteristics and the scale score averages. It is noteworthy that the gender and marital status of the participants did not have a statistically significant effect on the scale and sub-factor scores. This implies that these sociodemographic factors do not influence pediatricians’ attitudes toward reporting child abuse. However, it is noteworthy that additional sociodemographic characteristics, including parenthood, significantly correlated with reporting responsibility. Pediatricians with children demonstrated a higher mean score on Reporting responsibility than those without children. This study implies that personal experience as a parent may influence pediatricians’ sense of obligation to report child abuse. This may be due to increased empathy and understanding of child protection. Research shows that individual experiences affect reporting attitudes toward child neglect and abuse (10, 21, 26).

Additionally, the study found that professional experience also influences pediatricians’ perspectives on reporting child abuse. Pediatricians with more professional experience, particularly those with more than 5 years and more than 10 years of experience, achieved higher mean scores in Reporting Responsibility and Concern about Reporting, respectively. This discovery suggests that as pediatricians gain more expertise in their field, they may develop a deeper understanding of its importance, consistent with previous research (3, 27).

Having direct experience with the event that is the subject of the attitude increases the relationship between attitude and behavior. Such experiences increase the certainty of one’s attitude and knowledge of the object of attitude. Studies have shown that attitudes formed through direct experience almost always determine a person’s subsequent actions than those not so formed (28). This information may prevent participants with no experience with CAN reporting from turning their attitudes into behavior. Because the level of concern still exists at a certain level among healthcare professionals. We found that especially participants with less professional experience had high anxiety. Pediatricians’ ability to communicate with a specialist who is more experienced in intrauterine reporting can reduce the anxiety caused by the first experience and prevent giving up on reporting. For this reason, it may be beneficial to establish support unit lines where maritime cases are evaluated by a few experts and the number of experts is insufficient.

Another important finding of the study was that pediatricians who received structured training on child abuse and neglect had higher Reporting Responsibility and total scale score averages than those who did not. This highlights the importance of education and training in improving pediatricians’ attitudes and sense of responsibility toward reporting child abuse. Pediatricians need to have the appropriate knowledge and skills to identify and handle cases of child abuse effectively (19, 20, 27).

Although the study witnessed generally positive attitudes, it also revealed some of the challenges and concerns pediatricians face when reporting child abuse. Participants expressed concerns about the reporting process, such as not knowing where and how to report, time constraints due to high workload, and undesirable reporting consequences. Research has shown that healthcare professionals experience anxiety when reporting incidents due to uncertainty about the process, psychosocial distress, and possible social repercussions. The study highlights the need for comprehensive educational programs that address not only the importance of reporting child abuse but also the practical steps of reporting it (14, 21, 26).

Additionally, the research highlighted the value of incorporating a multidisciplinary team approach in the management of cases involving child abuse. Cooperation and consultation with professionals in the field of child protection, as well as the exchange of information with child protection services, can facilitate improving reporting and practices. It is crucial to consider the implications of these findings for policy and practice. Mandatory reporting policies aim to increase the detection of cases of child abuse by professionals who are legally bound to report suspected cases. However, concerns have been raised about over-reporting and the potential for criminalization of child abuse concerns. When implementing mandatory reporting policies, it is crucial to balance the reporting obligation and the use of professional judgment, considering socio-cultural factors.

Funding is needed to establish epidemiological monitoring, preventive programs, and clear and adaptable reporting procedures to address these concerns and facilitate effective reporting. Pediatricians should be provided with in-service training to ensure they have the necessary expertise, competencies, and assistance to fulfill their reporting obligations. Ongoing research and evaluation are important to identify factors that influence reporting practices among pediatricians and to design tailored approaches to increase reporting rates while minimizing potential barriers.

This study provides valuable information regarding pediatricians’ attitudes toward reporting child abuse. It highlights the importance of education, professional experience, and a multidisciplinary team approach in shaping pediatricians’ attitudes and practices toward reporting child abuse. These results can inform the creation of strategies, policies, and educational programs aimed at improving the detection and reporting of child abuse and thus promoting the protection and welfare of minors.

Conclusion

The study concludes that pediatricians have a positive attitude toward reporting child abuse. Their professional experience and structured training on child abuse and neglect contribute to a sense of Responsibility and understanding of the importance of reporting. However, the study also reveals the need for comprehensive training and support to address challenges related to the reporting process and concerns about potential negative consequences. The findings underscore the importance of a collaborative team approach, continued funding for prevention programs, and transparent reporting processes. By addressing these factors, we can enhance the identification and reporting of child abuse, ultimately advancing the safety and welfare of children.