**3. Results and discussion**

We will initially present data on participant's previous experience with child abuse cases, for both groups. In sequence we will present the quantitative data from the instruments regarding pre and post measures, and lastly qualitative data will also be presented to compare changes in participants' views.

Increasing Awareness of Brazilian Family Health Team Professionals on Reporting Child Abuse: A Case Study 127

Reported

Intent to report

**Figure 1.** Frequency of participants who had previously reported child abuse and who would report, if

In summary, both groups had contact with child abuse cases, but there was a low frequency of reporting to Child Protection Services. Although several participants stated that they would indeed report child abuse if needed, they also said that lack of knowledge about the correct procedure or by difficulties in identifying these cases were barriers to be faced. This entry data reinforces the need for training to reduce misunderstandings and comply with

Table 3 presents frequency of responses given by participants in the *Questionnaire on Hypothetical Cases* [14] about which procedures would be adopted in a hypothetical situation

Procedures Before training (n=19) After training (n=18)

**Table 3.** Frequency and types of procedures given to a hypothetical situation of suspected neglect.

After the training, there was a marked increase in the decision to involve the Child Protection Services, as required by law. The category "*request assistance from the team*" maintained approximately the same level,, although the procedure is considered suitable

Call Child Protection 4 12 Request assistance from the team 8 7 Make home visits 9 2 Speak to parents or neighbors 7 2 Confirm the suspicion 3 1

current legislation, ensuring the protection of children.

**3.2. Evaluation of the training course** 

Note: more than one answer may be given

of suspected negligence.

for such situation.

needed.

## **3.1. Previous experience with child abuse**

Table 2 presents the distribution of participants who had contact with suspected or confirmed cases of physical abuse, sexual abuse, psychological abuse, and neglect, illustrating participants' previous experience.


**Table 2.** Previous experience of suspected or confirmed child abuse cases in frequency per modality of abuse (n=21, both groups combined).

The data indicates that at least once a particular health team member had previous contact with a child abuse case. Lack of previous involvement with sexual abuse cases was high (76% of participants), which may indicate difficulty or uncertainty in identifying such cases, as well as how under-reported this type of violence still is in this country. Although there were two different teams in different geographical areas, previous experience was similar among the groups.

Figure 1 illustrates how many participants had reported child abuse cases in the past, and how many would hypothetically report if a child abuse case occurred. Previously reported cases involved discussing the issue with the immediate boss or with colleagues. Most of the reported cases involved physical violence for both groups. Sexual violence cases were the most frequently reported in supposition.

The large difference between actual reported cases and intention of reporting may indicate socially acceptable answers to the instrument. Nevertheless, one has to consider the possibility that it may also reflect a genuine intention or high motivation to report, if they were to identify a child abuse case. Unfortunately, we were unable to verify if professionals past reporting experience did in fact take place, as CPS data was only gathered after the year 2008.

Among reasons given by participants not to report previously, "*not knowing how to do* it" was noteworthy. In addition, there were written comments on the instrument suggesting a new category "*the problem was solved in the workplace*", which seems to indicate that the professional found a temporary solution, instead of fulfilling the reporting law.

**Figure 1.** Frequency of participants who had previously reported child abuse and who would report, if needed.

In summary, both groups had contact with child abuse cases, but there was a low frequency of reporting to Child Protection Services. Although several participants stated that they would indeed report child abuse if needed, they also said that lack of knowledge about the correct procedure or by difficulties in identifying these cases were barriers to be faced. This entry data reinforces the need for training to reduce misunderstandings and comply with current legislation, ensuring the protection of children.

#### **3.2. Evaluation of the training course**

126 Child Abuse and Neglect – A Multidimensional Approach

compare changes in participants' views.

**3.1. Previous experience with child abuse** 

illustrating participants' previous experience.

Abuse

Physical

abuse (n=21, both groups combined).

most frequently reported in supposition.

among the groups.

We will initially present data on participant's previous experience with child abuse cases, for both groups. In sequence we will present the quantitative data from the instruments regarding pre and post measures, and lastly qualitative data will also be presented to

Table 2 presents the distribution of participants who had contact with suspected or confirmed cases of physical abuse, sexual abuse, psychological abuse, and neglect,

> Sexual Abuse

**Table 2.** Previous experience of suspected or confirmed child abuse cases in frequency per modality of

The data indicates that at least once a particular health team member had previous contact with a child abuse case. Lack of previous involvement with sexual abuse cases was high (76% of participants), which may indicate difficulty or uncertainty in identifying such cases, as well as how under-reported this type of violence still is in this country. Although there were two different teams in different geographical areas, previous experience was similar

Figure 1 illustrates how many participants had reported child abuse cases in the past, and how many would hypothetically report if a child abuse case occurred. Previously reported cases involved discussing the issue with the immediate boss or with colleagues. Most of the reported cases involved physical violence for both groups. Sexual violence cases were the

The large difference between actual reported cases and intention of reporting may indicate socially acceptable answers to the instrument. Nevertheless, one has to consider the possibility that it may also reflect a genuine intention or high motivation to report, if they were to identify a child abuse case. Unfortunately, we were unable to verify if professionals past reporting

Among reasons given by participants not to report previously, "*not knowing how to do* it" was noteworthy. In addition, there were written comments on the instrument suggesting a new category "*the problem was solved in the workplace*", which seems to indicate that the

experience did in fact take place, as CPS data was only gathered after the year 2008.

professional found a temporary solution, instead of fulfilling the reporting law.

Yes, once 6 4 7 5 Yes, more than once 4 0 5 7 No, never 10 16 8 7 No answer 1 1 1 2

Psychological

Abuse Negligence

**3. Results and discussion** 

Table 3 presents frequency of responses given by participants in the *Questionnaire on Hypothetical Cases* [14] about which procedures would be adopted in a hypothetical situation of suspected negligence.


Note: more than one answer may be given

**Table 3.** Frequency and types of procedures given to a hypothetical situation of suspected neglect.

After the training, there was a marked increase in the decision to involve the Child Protection Services, as required by law. The category "*request assistance from the team*" maintained approximately the same level,, although the procedure is considered suitable for such situation.

The procedure "*speaking to parents/neighbors*" had an expressive change, decreasing the frequency as indicated. Similar to speaking with parents, home visitation is a common procedure in the Family Health Program. Nevertheless, the professional role in this case involves speaking to the family, but not conducting an investigative interview, as this would not be appropriate. One of the training course topics was how should the professional behave if child abuse is suspected, without doing an investigation or adopting different professional boundaries.

Increasing Awareness of Brazilian Family Health Team Professionals on Reporting Child Abuse: A Case Study 129

**3.3. Professionals 'opinions about personal and work-related aspects of child** 

*Child Maltreatment Evaluations in Pediatric Primary Care* [27] responses were analyzed to see if the training had been responsible to change professionals 'opinions. The Wilcoxon test was conducted and significant changes of opinion between pre and post training (using both groups together) were seen for four instrument's questions (question 19 "*I feel competent to give a definitive opinion about physical abuse*" p = 0.027; question 25 "*I Know the law involved in the reporting child abuse/neglect"* p = 0.005; question 26 "*I know how to report a case of child who is being abused*" p = 0.013 and question 27 "*I feel comfortable in talking with families about child* 

It is somewhat frustrating that out of 32 questions, only 4 showed significant differences comparing pre-post results, suggesting that the training had little influence. However one must not discard the small size of the sample, difficulties answering the instrument, and the

The reasons provided in the instruments in general for not reporting child abuse corroborated the literature regarding the disbelief in CPS [10], lack of knowledge about activities of the Judiciary [12], lack of basic information to identify violence, peculiarities of each case which are influenced by professionals 'personal factors or by the structure of mostly insufficient services, [11], insufficient infrastructure and excessive workload of staff, and threats from the abuser to professionals, as well as fear of retaliation for living in the

After the training, some of these factors did not change (nor could they have been changed), such as the excessive workload, and lack of infrastructure, but the positive assessment made by participants following the visit from Child Protection and the Forensic Psychologist may have been responsible to improve the image of this institutions as being inoperative. Participants gave testimonials regarding the changes in receiving information: "*The training was invaluable for learning and knowledge. It was a great achievement for the team*. "(PA11 – Participant 11 from Group A), and" *The course we had was very satisfactory; it has given us a new* 

Monitoring of reporting behavior to Child Protection Services by health teams in the year preceding the training and afterwards was conducted. Group A reported *one* case to CPS after training and this same group had not reported *any* cases in the previous year. The report made by Group A employed the proper health notification form for child abuse, which was introduced in the training and it involved a sexual abuse case of 5 year old girl. The girl's mother who was pregnant had arrived for a routine check-up, and told the nurse that her daughter was *different* and that she thought her uncle might be doing "*the same thing to her daughter that he had done with her as a child*". Medical examination of the girl revealed a ruptured hymen. The team's nurse phoned the University, to confirm with the first author

fact that participants may have given socially accepted answers.

*view of things, which sometimes, we passed unnoticed* "(PA7).

**3.4. Effect of reporting behavior by participants** 

**abuse** 

*abuse"* p = 0.031).

same community [6].

Table 4 presents the procedures that would be adopted in a hypothetical situation involving suspected sexual abuse. The data illustrates that after the intervention, most participants would call Child Protection Services.


Note: more than one answer may be given

**Table 4.** Frequency and types of procedures given to a hypothetical situation of child sexual abuse.

More participants reported that they would call CPS, doubling before training data. However, the category "*speak to parents*" and "*speak to the child*" remained unchanged, and this may be an artifact of the vignette involved in the instrument.

The difficulties encountered by participants to the situations of neglect and sexual abuse presented in instrument [14] were similar for both groups, namely: possible resistance from the family to take responsibility for the abuse, fear of retaliation from the abuser, lack of experience with these cases, fear that CPS would not handle appropriately the reported case, fear of exposing the child and not knowing how to speak with the child. After the training, the most frequently cited difficulty was "*possible resistance from the family to take responsibility for the abuse and to receive help*".

Previous contact with the theme of child abuse during professional training was classified as "*none*", except for two participants (a Community Health Agent and a nurse) who had "*little"* experience and had attended talks about child abuse.
