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

128 Child Abuse and Neglect – A Multidimensional Approach

different professional boundaries.

would call Child Protection Services.

Note: more than one answer may be given

*for the abuse and to receive help*".

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

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

(n=19)

After training

(n=18)

Procedure Before training

Request assistance from team 10 6 Call Child Protection/Police 6 12 Refer to a psychologist 0 1 Visit/communicate school 2 4 Speak to parents/neighbors 5 4

Speak to the victim (child) 2 2

Making home visits 2 1

this may be an artifact of the vignette involved in the instrument.

experience and had attended talks about child abuse.

**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

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* 

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"*

*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 abuse"* p = 0.031).

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 fact that participants may have given socially accepted answers.

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 same community [6].

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

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

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

that all the necessary steps had been taken, and indeed the suggested procedure (reporting to CPS) had been adopted by the team.

Increasing Awareness of Brazilian Family Health Team Professionals on Reporting Child Abuse: A Case Study 131

To Brazil's Ministry of Health [37] the main consequences of notification are: facilitating a registration system with trusted information and to ensure that victims are receiving support in institutional routines [20]. In spite of this assertion, systematic record keeping is no guarantee of its proper use or potential. The data itself is not useful if it does not help to support concrete public policies and actions at the local level. Reporting per se does not warrant that proper service is incorporated into the routine of the unit. There is a risk that a professional may fill out a reporting form and subsequently feel that his/her responsibility is over. However, it is felt that continuing education on child abuse prevention may reduce this risk by empowering professionals and adding new elements for case analysis, such as

The goal of this study was to to increase awareness of Family Health Program professionals for preventing child abuse, by evaluating a training course to identify and report abuse. The choice of these professionals was based on the literature that indicates that training the team

Results indicated that there were positive changes of opinion and attitudes facing the topic of child abuse. From a quantitative point of view, results were not as robust as expected. Perhaps the instruments used in the study were not sensitive enough to observe changes, which would require investment in the construction of questionnaires with proper psychometric data, tested in large scale. Additionally, the reduced sample may have hampered the detection of quantitative improvements. From a qualitative viewpoint, on the basis of consumer satisfaction, the results were very encouraging. Additionally, there seems to have been initiated a systematic engagement with Child Protection Services, which did

The prompt acceptability by staff, with which the teams agreed to take part of this training, reflects an interested and motivated attitude to learn about child abuse. However, because we provided training to a team in operation, many challenges had to be overcome as, for example, the insertion of a researcher in the teams and the floating of professionals during meetings for various reasons, hindering attendance. Initial questionnaire data confirmed that there was a lack of familiarity with the topic and, this way, basic concepts such as the fact that humiliating a child corresponds to psychological violence, had to be discussed with

One aspect that may have contributed to participants' positive course evaluation were the visits from CPS staff and the forensic psychologist, which helped to provide a realistic picture of the work involved, diminishing negative impressions. Some of the comments professionals made after such visits were: "*now I understand how Child Protection Services work, it was very enlightening*" (PA1), and "*It was enough to get a sense of how difficult it is to work* 

as a whole is more efficient than just training professionals individually [22].

identifying risk and protective factors.

**4. Conclusions** 

not exist before.

the teams.

*there*" (PA6).

Group B began the study without a history of reporting to CPS, but just before their training (while Group A had started to receive training), Group B made a report of a suspected case of sexual abuse. One may speculate if this reporting behavior was prompted by familiarity with the topic provided by the instruments. The reported case involved a 9 month-child, female, who was taken to Family Health Unit by her aunt because the baby had a rash in the genital area. Two professionals examined the child separately and found that the genital region did not have a rash, but was indeed, edematous and red, signaling possible sexual abuse. The girl's aunt told both professionals that she suspected sexual abuse by the child's stepfather. CPS was, then, called and a letter by the physician indicating possible sexual abuse was forwarded as well. When the first author examined this case at CPS, there was also a letter from the child's mother among the documentation, registering a complaint against the physician, as she felt that the reporting was aimed at harming her family.

According to staff reports, the child was sent for an exam at the city's Legal Medical Institute, but supposedly the expert had written that that "*because there is no hymen rupture one cannot claim that there was sexual abuse"*. The family moved away from the neighborhood, and no longer visited that particular health unit. During the first training meeting with Group B, the case was narrated, and assessed by the team as an example of failure from the protection network. The general opinion was that even when the professional fulfilled his/her role, there were no guarantees that the case would have a proper resolution, point that was often discussed throughout the course.

This case illustrates the difficulties and shortcomings of the Protection Network and how difficult it is to prosecute child sexual abuse cases in the city [36]. The case also illustrates the need for ongoing training of all agencies involved, including experts from the Forensic Institute, who conduct medical examinations of children who may have been sexually abused.

After training, one more report record was observed by Group B, which may indicate that the intervention helped to overcome the initial negative experience. There is however another complication concerning notifications to CPS by Group B. At the fifth meeting in which a CPS staff made a presentation to the group, health participants reported five cases during this visit (two cases involving adolescents with drug involvement, a case of suspected neglect and two cases of physical violence). CPS staff wrote down names and addresses of the five children, explaining that he would refer them to other staff members of CPS. Nevertheless, no such records existed when the first author examined CPS data, but one cannot say that the reporting steps were not taken because the cases could have been "old" in the sense of previously reported, and therefore inaccessible in their data base.

Despite the low number of reporting done by the groups after the training, the fact that they existed may be considered an important step and positive result, given the very low contact staff reported having had previously with sexual abuse cases.

To Brazil's Ministry of Health [37] the main consequences of notification are: facilitating a registration system with trusted information and to ensure that victims are receiving support in institutional routines [20]. In spite of this assertion, systematic record keeping is no guarantee of its proper use or potential. The data itself is not useful if it does not help to support concrete public policies and actions at the local level. Reporting per se does not warrant that proper service is incorporated into the routine of the unit. There is a risk that a professional may fill out a reporting form and subsequently feel that his/her responsibility is over. However, it is felt that continuing education on child abuse prevention may reduce this risk by empowering professionals and adding new elements for case analysis, such as identifying risk and protective factors.
