Abstract
There is a significant dearth of information on available social infrastructures for helping victims of child abuse among all cadres of primary health-care workers. The aim of this study was to assess the level of awareness of social and legal structures among primary health-care workers, which can help in reducing incidences and taking action. The survey was a cross-sectional survey of 20 primary health-care centers and 86 health workers in Ogun State, Southwest Nigeria. The result showed a low level of awareness among health workers. A large percentage of health workers were unaware of any social infrastructure or hospital protocol for child abuse reporting: 68.4% of medical officers, 54.5% of nurses, and 66.7% of other health workers. There is a need for deliberate training among health workers on social infrastructure, which can help victims of child abuse.
Child abuse and molestation is a silently growing pandemic in Nigeria.1,2 Much attention has been drawn to the magnitude of the problem by the almost-daily mass media reports. Understanding the rise, trajectory, extent, and penetration of child abuse highlights an urgent need for deliberate action. In the early 80s, there were very few studies on this issue in Nigeria. 3 This was due to a generally perceived orientation that it was rare in our culture and was more of a western problem.4,5 Furthermore, it was eclipsed by the perennial reports of malnutrition and child mortality. 4 However, in the decades that followed, an upsurge of studies on child abuse and molestation arose in various localities in Nigeria. Various prevalence rates have been reported depending on the location of the study. In a study among females in Northern Nigeria state, the authors reported a lifetime prevalence rate of 47.7% of sexual molestation. 6 The United Nation Children Fund survey in 2015 reported that 60% of children younger than 18 years had experienced some form of violence. 7
Largely, the cases reported do not show the actual prevalence, as many cases are not officially reported.5,6. Significant limitations exist in fully capturing the extent of the problem due to a stigmatizing perception and negative view of victims of child abuse in Nigeria.6,8 These often constitute a major barrier in reporting and tackling the issues in official surveys.
Undoubtedly, the health worker plays an important linkage role in child care within various communities in Nigeria. They are often close to their local communities and can easily assess vital information from patients and caregivers on goings-on in households. Their role in communities enables them to be trusted with information and support from their clients. Their strategic importance in communities also enables them to interrelate with social services and agencies of government as well as to identify children who need protection. 9 They can be the source of information on social infrastructures available within their communities.
Moreover, to make the health worker in primary health care as major participants in reporting largely depends on their knowledge and capacity to identify and assess children who suffer abuse. Also, awareness of agencies of government and the legal issues involved in cases of child abuse and molestation will be of great advantage in interfacing with government and non-government agencies when handling these cases. We are unaware of any published study that has explored health worker’s awareness of social structures that help victims of child abuse.
Within this background, our aim was to survey the awareness of social structures among health workers involved in primary care. We sought to explore the level of knowledge of social services and knowledge of official protocol and legal issues involved in child abuse by health workers within the primary health-care centers in the southwestern state of Nigeria.
Methods
Study Design and Setting
The design was a cross-sectional survey of all health-care workers in 20 primary health centers, one from each of the 20 local governments in the state. The primary health care was chosen due to (a) ease of road access, (b) sizeable population of health-care workers, (c) areas of population and geographical coverage, and (d) number of villages or towns it serves (a minimum of two villages).
Since there were no official statistics on the number of primary health-care workers in the various locations, we relied on earlier studies within the state to estimate expected number of primary health-care staff. In a recent study, Adebowale et al., 10 estimated four primary health worker in each primary health center per local government in their sampling size (N=80), whereas Campbell and Ebuchi 11 used a sampling size of 200 primary health-care workers, with equal sample size from urban (N = 100) and rural (N = 100).
To get our sampling size, we averaged the two sampling sizes:
100 + 80/2 = 90
To allow for attrition, we aimed to recruit 120 primary health workers.
The Medical Officer of Health or Nursing Officer in charge (where there was no Medical Officer of Health) was contacted in the various primary health-care centers, and explanation of the purpose of the survey was given. Permission was sought, participation was voluntary, and anonymity was ensured. Written or verbal consent was given by the participating health workers.
Selection of Health-Care Workers
Our criteria for the selection of health workers included all medical officers, nursing staff, and trained health worker with diplomas from school of health technology or certificates in public health working in these centers; exception was only given to those who declined to participate.
Ethical Approval
Ethical approval and introductory letters were obtained from the Department of Medicine, Olabisi Onabanjo University, Ogun State. It was part of a much larger study that involved the evaluation of human immunodeficiency virus and perception of health-care workers and that had earlier been reviewed by the internal review board of the institution.
Instrument
In designing the self-report questionnaire, group discussions ) were made with community physicians, pediatricians, and psychiatrists. The questionnaire was pretested within Olabisi Onabanjo University Teaching Hospital, Shagamu, Ogun State, Nigeria. The final draft of the questionnaire consisted of two sections. The first section contained sociodemographic data such as age, sex, years of training, designation, and type of staff. The second section consisted of a 6-item part which explored the following questions:
Recent reading of literature on child abuse (How long ago have you in last 1 year)A. Have you read any academic literature on child abuse or molestation or attended seminars or conferences on child abuse or molestation? Awareness of child abuse protocol in their centerA. Are you aware of any official or hospital protocol on child abuse? Do you routinely ask about child abuse or molestation or abuse? Awareness of any formal way of reporting child abuse to government authorities Awareness of any social service or non-governmental organization involved in child abuse Awareness of legal punishment for child abusers.
The average time was about 4 minutes and 24 seconds.
Results
Sociodemographic Characteristics
Out of the 113 health-care staff in the 20 primary health-care centers surveyed, 86 fully completed and duly returned the questionnaires. As shown in Table 1, the sociodemographic characteristics show that the average age was 36.30 ± 9.03 years, and there were more females (65.1%) than males (34.9%). Medical officers made up the lowest population of health workers constituting 22.1% of the total primary health-care workers. More than three quarters (72%, n=62) had been in practice for about 10 years.
Sociodemographic Profile of Participants.
Awareness of Child Abuse Among Primary Health-Care Workers
Awareness of child molestation across sociodemographic variables is shown in Table 2. Interestingly, there were no significant differences in awareness across all the sociodemographics. In Item 1 (Have you read material on child molestation in the last 1 year?), we found out that nurses (86.4%) had the highest proportion of those who had read more about child molestation in the last 1 year, compared with medical officers (79.0%) and other health workers (69.0%) at p= .85 using Fisher’s Exact Test (FET). It was also noticed that those within the oldest age range (53–63 years) had the highest percentage, with 85.7% reporting that they have read about child molestation in the last 1 year (p=.47). Females had the lowest proportion of those who had read about child abuse or molestation (71.4%, n=40) compared with males (80.0%, n=24). Across sociodemographics, there were higher proportion of persons who were not aware of any hospital protocol for reporting child molestation as shown in Table 2. Medical officers had the highest proportion of those who were not aware (68.4%, n=13), compared with 54.5% (n= 12) of nurses and 66.7% (n=30) of other health workers at p=.88 (FET).
Awareness of Social Structures for Child Molestation and Abuse Among Health-Care Workers.
Importantly, on Item 3 (Do you routinely ask about child abuse or molestation?), medical officers had the highest proportion of those who do not routinely ask about child molestation when seeing children (79.0%), compared with health workers (71.0%), and nurses (45.5%) at p=.58 (FET). On Item 6 (Are you aware of any social service involved in child abuse), we found out that there was a higher proportion of health-care staff who were not aware of social service and nongovernmental organization that are involved in help in children who are molested.
Discussion
Our study highlighted a major drought of awareness and knowledge among primary health-care workers regarding child abuse and social infrastructures and services that can help victims. The dearth of awareness and knowledge potentially impedes reporting, identifying, and taking action in our society. Unfortunately, the results of our survey seem to suggest that lack of awareness cuts across every cadre of health-care worker in the primary health-care centers in the state. This probably highlights a training deficiency among primary health-care staff in areas of child abuse or probably poor attention among medical officers and other health-care staff.
Sadly noticeable is the low level of awareness of a formal protocol for reporting child abuse or molestation and knowledge of social services or non-governmental organizations that may help victims. This may imply that at the level of clinical presentations or consultations, victims and their caregivers will not be directed to any government services that cater for such and possibly no deliberate action taken at primary care centers to save victims from further abuse. Another disturbing trend in our study was the dearth of knowledge within the younger age groups (20 to 30 years and 31 to 41 years), as shown in Table 2. These statistics probably suggest a generational gap in knowledge among health workers and present an unfavorable picture. A sizeable portion of health-care staff had very little knowledge of ways of reporting child molestation within their primary health-care centers, probably due to the lack of formal training in this group of young health workers. This unsavory dearth of awareness portends a negative cloud of despair for victims and caregivers reporting to primary health-care workers. Despite the strategic importance of the primary health-care worker in various local communities, health workers may not be able to act as important interphase with agencies of government in helping victims to formally report and take definitive action that will provide help for victims. Furthermore, no deliberate course of training exists for health-care workers and consequently depriving primary health-care centers of needed manpower that can help in combating child abuse and molestation.
Another uncomfortable finding in our study was that more than three quarters of medical officers and local health workers, except for nurses, do not enquire routinely about child molestation. These may be attributable to poor understanding of the extent of the problem. Regardless of the knowledge that child abuse is common, it has really not translated in actual clinical practice in primary health-care centers for most medical officers and other health-care staff. Adding to our grim statistics, many health-care workers are unaware of the legal consequences of child molestation and abuse, so they may not educate caregivers on the options that are legally open to them to seek prosecution.
Our study findings are similar to some studies that have assessed the knowledge of community or primary care workers in other areas of the world. 11 Although we could not find very similar study on child molestation, a recent study reported findings of poor dearth of knowledge among health-care workers in other areas of child care. 12 Invariably, the need for training of primary health-care workers is obvious from the survey we conducted. Deliberate efforts should be pursued in training the primary health workers on social infrastructure and services available in the country. This will help arm the primary health-care staff with available information to interphase with agencies of government and help to report such cases in order to help victims and data collection in such communities. Nigeria has been a signatory to the child rights, but very low activity has been channeled toward the training of primary care workers. To our knowledge, apart from one state in Nigeria, there is no national protocol specifically designed for health-care staff.
Conclusion
The study mainly highlights the dearth of knowledge of social infrastructures and the lack of social linkages within primary care system in a southwestern state in Nigeria. There is a seemingly dearth of knowledge of many health workers inclusive of medical officers. This requires a massive training and awareness of the need to interphase with the few social infrastructures in Nigeria.
Limitations
Our study has significant limitations: the small sample size limits the generalization of the survey, which was due to the low staff population in most of the primary health centers. We failed to specifically enquire about the identification of victims. We are also mindful that the self-reporting nature of the questionnaire may be subject to information distortion. There is a need for more extensive and better randomized study.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.