**1. Introduction**

116 Child Abuse and Neglect – A Multidimensional Approach

Pretoria: Van Schaik.

27-36.

Johannesburg: Jonathan Ball.

*Organised Crime*. United Nations: Geneva.

United Nations Children's Fund (UNICEF). (2003). *Trafficking in human beings especially* 

United Nations. 2000. *Protocol to prevent, suppress and punish trafficking in persons, especially women and children, supplementing the United Nations Convention against Transnational* 

United Nations Office on Drugs and Crime (UNODC). (2007). *Situational assessment of human trafficking: a 2005 situational assessment of human trafficking in the SADC region, a survey of* 

Van der Hoven, A., & Maree, A. (2005). Victimisation risk factors, repeat victimisation and victim profiling. In Davis, L., & Snyman, R. (Eds). *Victimology in South Africa* (55-71).

Van der Merwe, N. (2009). A quantitative study on the pro-violence attitudes among learners in South Africa. *Crimsa Bi-annual Conference* 28-30 September, Pretoria. Van Onselen, C. 1984. *The small matter of a horse: the life of Nongoloza Mathebula 1867-1948*.

Van der Watt, M. (2009). Trafficking: best practices, a case illustration. *Towards multidisciplinary expertise in handling child abuse – A focus on trafficking* – Pretoria: 4-6 May. Wambugu, L. (2003). Searching for sanctuary: refugee women in South Africa. *Agenda, 55*,

*women and children in Africa*. Italy: UNICEF Innocenti Research Centre.

*South Africa, Zimbabwe and Mozambique*. Hatfield: UNODC.

There are diverse and countless cases of child abuse reported by the media, giving the general public the impression that its number has drastically increased. We know that is not the case. Child abuse is, unfortunately, a very old habit in need of change, and it is, in fact being changed. Many cases come to health professionals in the very beginning, such as when a nurse witnesses a mother humiliating a child who refuses to eat. Unfortunately, many cases also appear only when it is too late, as when a physician signs a death certificate in a child abuse fatality.

This paper aims at pointing out the need for changes in health professional training regarding child abuse - a public health issue which directly affects individual and collective health. Preventing and coping with abuse demands the formulation of specific policies and organizational practices and services for the sector [1]. The World Report on Violence and the World Health Organization [2] mention that psychiatric disorders, depression, anxiety, substance abuse, and aggression, feelings of shame or cognitive disorders, posttraumatic stress, sleep disorders, thoughts and suicidal behavior, as potential consequences of child abuse. In addition, adult diseases, such as ischemic heart disease, cancer, chronic lung disease, irritable bowel syndrome and fibromyalgia may be intensified due to child abuse experiences.

A considerable amount of money is spent on treating cases related to child abuse. This includes: a) offender arrests and subsequent court issues, b) abuse investigation reports, c) mental health services for adults with a child abuse history; d) especial educational support; e) expenses associated with foster care and adoption; and f) costs in the employment sector due to absenteeism and low productivity [2]. In the health system, child abuse is responsible

© 2012 Bannwart and Williams, licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2012 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

for increases in emergency assistance, and rehabilitation expenses, the latter more costly than most conventional medical procedures [1].

Increasing Awareness of Brazilian Family Health Team Professionals on Reporting Child Abuse: A Case Study 119

services, resulting in false demands, illustrating , thus, the need for effective communication

A survey [9] analyzed the child abuse reporting process with 359 family health team professionals in the city of Fortaleza, Northeast Brazil, showing that reporting by professionals happens sporadically, rather than systematically. In that sense, the development of programs for continuing education and the increase of professional network support may reduce insecurity, and increase the number of child abuse reported cases.

Insecurity and difficulties faced by health professionals in identifying and reporting cases of child abuse were also addressed in other Brazilian studies. Health professionals' perception of child abuse, and responsibility to report cases according to past experience were analyzed through interviews (n=10) [10]. All professionals said that they discard organic hypothesis by examining the victims, and only then investigate "external causes". A third of interviewees said that when there are injuries suggesting abuse (such as bruises in a child admitted to the Hospital), it is difficult to confirm this diagnosis, as they fear committing "injustices". Whether or not the reporting occurred, feelings of frustration, powerlessness, and immobility were recurrent. In addition, in two reported cases, the police advised professionals to withdraw the notification. Psychological abuse was less valued than physical violence; as such acts were viewed as natural forms of child rearing. The study reports that mental health professionals tend to be silent about abuse, because "their training involves understanding and treating offenders and therefore do not consider reporting as

The perception of 17 health professionals was analyzed [11] in relation to attitudes regarding child abuse, by means of semi-structured interviews. A swing between belief and disbelief of solving cases was noticed by researchers, as well as fear and emotional insecurity. Problems associated to lack of professional training, and the reproduction of cultural patterns of non-involvement beliefs regarding family issues were also identified. The study also highlighted the disbelief in the effective action of Child Protection Services, and previous negative experiences as reasons for not getting involved in child abuse cases.

Studies in the U.S. [12] also indicate difficulties professionals face in reporting abuse, as well as negative experiences with the legal system, contributing to non-reporting. Another study in Australia identifies problems with services available to children and families where child abuse reporting is made, indicating the need for continuing education of health professionals to identify symptoms and signs of physical abuse, as well as the physicians'

This first author [14] sought to investigate problems found by pediatricians in identifying and reporting cases of abuse in a mid-size city of the State of São Paulo, Brazil. Main results pointed out that difficulties were related to lack of training, disbelief and doubts about CPS, fear of possible legal consequences, and fear of causing further trauma or discomfort in the family and/or the child. The study detected a general belief in the need to confirm the

role in multidisciplinary efforts to address child abuse [13].

suspicion of abuse as a prerequisite to reporting.

among different stakeholders of the child protection network.

their responsibility " (p.23).

Due to the complexity of child abuse, its close link with Public Health and the fact that mandated reporting is regulated in many countries, health professionals involvement with the topic has been the focus of several studies. In Brazil, the Child and Adolescent ACT (ECA – *Estatuto da Criança e do Adolescente* 1990) ,in Article 245, [3] regulates mandated reporting to proper authorities of any suspected or confirmed child abuse case. Failure to do so may receive a penalty involving from 3-20 minimal wage fines.

The Child and Adolescent Act was implemented in Brazil in 1990, guarantying special rights and full protection of children. In addition, the Ministry of Health developed guidelines in the document "*National Policy for Reduction of Morbidity and Mortality from Accidents and Violence",* in existence since 1998. Later, with the publication of another document ("*National Policy for Reduction of Morbidity and Mortality from Accidents and Violence in Childhood and Adolescence*"), in 2001, child abuse mandated report by Unified Health System professionals was enforced [4]. Despite this requirement, violence underreporting in all areas is a reality in Brazil. It is estimated that for every reported case, at least two others exist which have not been reported [5].

#### **1.1. Health professionals' role in dealing with child abuse**

Health professionals are under-qualified to deal with child abuse, in part due to a lack of awareness on how to proceed when cases arise. There is lack of regulations to guarantee appropriate technical procedures to deal with abuse cases in Brazil. In addition, there is an absence of legal mechanisms to protect those who do report cases. Failure in child abuse identification by health professionals, and fear of breaching client confidentiality, are barriers that also contribute to under–reporting [6]. Additionally, the difficulties may include lack of basic information to identify abuse, a topic not been addressed in undergraduate or graduate curricula. Lack of infrastructure and an excessive workload by Child Protection Services (CPS), and even its non-existence in some counties are also barriers to be mentioned. Another peculiarity is a culture which values family privacy and, Finally, threats made to professionals by abusers are also arguments responsible for nonreporting [6].

Child abuse reporting is extremely important because it is a tool to curb and prevent maltreatment, allowing interventions to take place at various levels. When child abuse becomes public, one may see that it is more common than expected. Needless to say that no type of violence should be considered ordinary or normal [7].

In spite of Brazil's mandatory reporting laws, there is a large gap between legislation and reality. Iossi [8] conducted interviews and document analysis in the municipality of Guarulhos, in the greater São Paulo area, observing that 23% of child abuse referrals health professionals made to treatment centers were made without the awareness of CPS, that is, without proper reporting. This situation may result in duplication of referrals to health services, resulting in false demands, illustrating , thus, the need for effective communication among different stakeholders of the child protection network.

118 Child Abuse and Neglect – A Multidimensional Approach

been reported [5].

reporting [6].

than most conventional medical procedures [1].

so may receive a penalty involving from 3-20 minimal wage fines.

**1.1. Health professionals' role in dealing with child abuse** 

type of violence should be considered ordinary or normal [7].

for increases in emergency assistance, and rehabilitation expenses, the latter more costly

Due to the complexity of child abuse, its close link with Public Health and the fact that mandated reporting is regulated in many countries, health professionals involvement with the topic has been the focus of several studies. In Brazil, the Child and Adolescent ACT (ECA – *Estatuto da Criança e do Adolescente* 1990) ,in Article 245, [3] regulates mandated reporting to proper authorities of any suspected or confirmed child abuse case. Failure to do

The Child and Adolescent Act was implemented in Brazil in 1990, guarantying special rights and full protection of children. In addition, the Ministry of Health developed guidelines in the document "*National Policy for Reduction of Morbidity and Mortality from Accidents and Violence",* in existence since 1998. Later, with the publication of another document ("*National Policy for Reduction of Morbidity and Mortality from Accidents and Violence in Childhood and Adolescence*"), in 2001, child abuse mandated report by Unified Health System professionals was enforced [4]. Despite this requirement, violence underreporting in all areas is a reality in Brazil. It is estimated that for every reported case, at least two others exist which have not

Health professionals are under-qualified to deal with child abuse, in part due to a lack of awareness on how to proceed when cases arise. There is lack of regulations to guarantee appropriate technical procedures to deal with abuse cases in Brazil. In addition, there is an absence of legal mechanisms to protect those who do report cases. Failure in child abuse identification by health professionals, and fear of breaching client confidentiality, are barriers that also contribute to under–reporting [6]. Additionally, the difficulties may include lack of basic information to identify abuse, a topic not been addressed in undergraduate or graduate curricula. Lack of infrastructure and an excessive workload by Child Protection Services (CPS), and even its non-existence in some counties are also barriers to be mentioned. Another peculiarity is a culture which values family privacy and, Finally, threats made to professionals by abusers are also arguments responsible for non-

Child abuse reporting is extremely important because it is a tool to curb and prevent maltreatment, allowing interventions to take place at various levels. When child abuse becomes public, one may see that it is more common than expected. Needless to say that no

In spite of Brazil's mandatory reporting laws, there is a large gap between legislation and reality. Iossi [8] conducted interviews and document analysis in the municipality of Guarulhos, in the greater São Paulo area, observing that 23% of child abuse referrals health professionals made to treatment centers were made without the awareness of CPS, that is, without proper reporting. This situation may result in duplication of referrals to health A survey [9] analyzed the child abuse reporting process with 359 family health team professionals in the city of Fortaleza, Northeast Brazil, showing that reporting by professionals happens sporadically, rather than systematically. In that sense, the development of programs for continuing education and the increase of professional network support may reduce insecurity, and increase the number of child abuse reported cases.

Insecurity and difficulties faced by health professionals in identifying and reporting cases of child abuse were also addressed in other Brazilian studies. Health professionals' perception of child abuse, and responsibility to report cases according to past experience were analyzed through interviews (n=10) [10]. All professionals said that they discard organic hypothesis by examining the victims, and only then investigate "external causes". A third of interviewees said that when there are injuries suggesting abuse (such as bruises in a child admitted to the Hospital), it is difficult to confirm this diagnosis, as they fear committing "injustices". Whether or not the reporting occurred, feelings of frustration, powerlessness, and immobility were recurrent. In addition, in two reported cases, the police advised professionals to withdraw the notification. Psychological abuse was less valued than physical violence; as such acts were viewed as natural forms of child rearing. The study reports that mental health professionals tend to be silent about abuse, because "their training involves understanding and treating offenders and therefore do not consider reporting as their responsibility " (p.23).

The perception of 17 health professionals was analyzed [11] in relation to attitudes regarding child abuse, by means of semi-structured interviews. A swing between belief and disbelief of solving cases was noticed by researchers, as well as fear and emotional insecurity. Problems associated to lack of professional training, and the reproduction of cultural patterns of non-involvement beliefs regarding family issues were also identified. The study also highlighted the disbelief in the effective action of Child Protection Services, and previous negative experiences as reasons for not getting involved in child abuse cases.

Studies in the U.S. [12] also indicate difficulties professionals face in reporting abuse, as well as negative experiences with the legal system, contributing to non-reporting. Another study in Australia identifies problems with services available to children and families where child abuse reporting is made, indicating the need for continuing education of health professionals to identify symptoms and signs of physical abuse, as well as the physicians' role in multidisciplinary efforts to address child abuse [13].

This first author [14] sought to investigate problems found by pediatricians in identifying and reporting cases of abuse in a mid-size city of the State of São Paulo, Brazil. Main results pointed out that difficulties were related to lack of training, disbelief and doubts about CPS, fear of possible legal consequences, and fear of causing further trauma or discomfort in the family and/or the child. The study detected a general belief in the need to confirm the suspicion of abuse as a prerequisite to reporting.

Difficulties in dealing with child abuse are present in other health related areas besides medicine: 84% of dentists (n = 70) in the city of Blumenau, Southern Brazil, [15] reported feeling unprepared to deal with child abuse. Difficulties associated in reporting were related to not being sure about confirming the abuse (42%), lack of knowledge, (32%), and fear of consequences (6%). Likewise, Australian dentists were unaware about child abuse issues, as shown by the high frequency of "*I don't know*" answers, when asked about procedures to be followed in child abuse cases [16].

Increasing Awareness of Brazilian Family Health Team Professionals on Reporting Child Abuse: A Case Study 121

routine, and in the organizational framework of welfare and educational services; 2) raising awareness and training health professionals and educators to understand the consequences of abuse to children's development, teaching professionals how to diagnose child abuse, how to report cases and make referrals when problems are found; and 3) building partnerships and alliances to ensure that reporting is only a first step of a much broader activity to support children, adolescents, their families or institutions working with them,

Researchers agree on the need to train professionals on child abuse, and to systematically evaluate such trainings in studies in order to overcome the difficulties mentioned [4,13,15- 16]. In addition, there is a need to insert the topic into curricula, as knowledge of child abuse is essential for healhcare [21]. The literature indicates that for physicians already in practice, training is more relevant in terms of case variables which are more difficult to observe, such as: a) the explanation given for the injury in case of physical abuse; and b) the time taken to bring the child for medical care, instead of restricting training to injury severity and its relationship to child abuse exclusively [21]. For medical students, it is necessary to develop skills of information gathering, and case deductions, and from the onset of training, students should actively be involved in the process of identification and child abuse reporting,

Moreover, it is important for professionals to become familiar with epidemiological data on child abuse, as this helps in making decisions to evaluate the information collected, especially in relation to the explanation given when child abuse is suspected, or in differential diagnosis [13, 21]. The literature also indicates that the difficulties in identification and reporting child abuse are found in several health related areas [14], thus it would be possible to start training from a broader topic such as what is child abuse, and subsequently direct the training to specific areas, such as types of treatment that a physician

The literature [22] has also recommended that for the training to be appropriate it should consider the ecological context of child maltreatment to understand risk factors present in the child, the family, the community and society. Researchers also say that the disparity in knowledge of health professionals who work at the same institution should be reduced by training all staff, with emphasis in the need for continuing education. The same conclusion was reached by scholars [23] who found an increase in the number of reported cases after training, but a decrease in subsequent months, indicating the need for ongoing education. Additionally, it is suggested [13] having regular case discussion meetings, stressing the investigative nature of protective services, and to educate physicians in the

Furthermore, it is recommended [24] that challenges faced by pediatricians in dealing with child abuse cases may be inserted into the training, such as: having the families, not just the children and mothers as the focus of attention; assessing routinely risk and protective factors associated with the child and the family; strengthening protective factors; and

and not simply an obligation as an end in itself.

working with experienced professionals as role models [22].

and a dentist may have to perform with an abused child [14].

multidisciplinary aspects of child abuse.

working to minimize or eliminate the risk factors.

## **1.2. Brazil's Family Health Program**

The *Family Health Program* (*Programa Saúde da Família* or PSF), was initiated, in Brazil, in 1994, as a strategy for reorienting the healthcare model, through the implementation of multidisciplinary teams in primary healthcare units. These teams are responsible for monitoring a number of families (up to 4.500 persons) located in a defined geographical area. The teams act on health recovery, health promotion, disease rehabilitation, and more frequent disorders, as well as maintaining the community's health level [17].

Each team is responsible for becoming aware of family demographics by taking pertinent data from each family, filling out information on different diagnoses for all individuals in a given family. Health professionals and the families create bonds, which in turn, facilitates the identification and assistance to community health problems [18].

The Family Health Program in the city of San Carlos, where this study was conducted, was established in 2001 with four Teams. Currently this program benefits 64.000 people, and 16 teams are in operation. The municipality has a goal of reaching 50% of the population by the end of 2012, as the city undergoes a health service remodeling process.

Another peculiarity about this city is the fact that the Medicine Faculty from *Universidade Federal de São Carlos* (Federal University of São Carlos) has partnered with the municipality in terms of developing an innovative project geared towards family health care. The project involves adopting a model with a strong interaction between the public healthcare system in which the medical student starts his/her practice in the Family Health Program.

Working in the Family Health Program exposes professionals to various types of violence, such as family and urban violence which may affect professionals' mental health [19]. In addition to violence, through home visitation, professionals notice other adversities, such as extreme poverty, which in its turn, may trigger feelings of helplessness. Other potential problems are the non-recognition of efforts, no delimitation between professional and personal boundaries; fear of exposure to risks; feelings of moral and physical integrity threats, and fear of retaliation. All this context and challenges must be considered when proposing any intervention with such professionals [19].

### **1.3. The training of health professionals on child abuse**

For Brazil's Ministry of Health [20], the development of a child abuse reporting system must overcome three challenges: 1) incorporating the reporting process in the healthcare activities routine, and in the organizational framework of welfare and educational services; 2) raising awareness and training health professionals and educators to understand the consequences of abuse to children's development, teaching professionals how to diagnose child abuse, how to report cases and make referrals when problems are found; and 3) building partnerships and alliances to ensure that reporting is only a first step of a much broader activity to support children, adolescents, their families or institutions working with them, and not simply an obligation as an end in itself.

120 Child Abuse and Neglect – A Multidimensional Approach

followed in child abuse cases [16].

**1.2. Brazil's Family Health Program** 

Difficulties in dealing with child abuse are present in other health related areas besides medicine: 84% of dentists (n = 70) in the city of Blumenau, Southern Brazil, [15] reported feeling unprepared to deal with child abuse. Difficulties associated in reporting were related to not being sure about confirming the abuse (42%), lack of knowledge, (32%), and fear of consequences (6%). Likewise, Australian dentists were unaware about child abuse issues, as shown by the high frequency of "*I don't know*" answers, when asked about procedures to be

The *Family Health Program* (*Programa Saúde da Família* or PSF), was initiated, in Brazil, in 1994, as a strategy for reorienting the healthcare model, through the implementation of multidisciplinary teams in primary healthcare units. These teams are responsible for monitoring a number of families (up to 4.500 persons) located in a defined geographical area. The teams act on health recovery, health promotion, disease rehabilitation, and more

Each team is responsible for becoming aware of family demographics by taking pertinent data from each family, filling out information on different diagnoses for all individuals in a given family. Health professionals and the families create bonds, which in turn, facilitates

The Family Health Program in the city of San Carlos, where this study was conducted, was established in 2001 with four Teams. Currently this program benefits 64.000 people, and 16 teams are in operation. The municipality has a goal of reaching 50% of the population by the

Another peculiarity about this city is the fact that the Medicine Faculty from *Universidade Federal de São Carlos* (Federal University of São Carlos) has partnered with the municipality in terms of developing an innovative project geared towards family health care. The project involves adopting a model with a strong interaction between the public healthcare system in

Working in the Family Health Program exposes professionals to various types of violence, such as family and urban violence which may affect professionals' mental health [19]. In addition to violence, through home visitation, professionals notice other adversities, such as extreme poverty, which in its turn, may trigger feelings of helplessness. Other potential problems are the non-recognition of efforts, no delimitation between professional and personal boundaries; fear of exposure to risks; feelings of moral and physical integrity threats, and fear of retaliation. All this context and challenges must be considered when

For Brazil's Ministry of Health [20], the development of a child abuse reporting system must overcome three challenges: 1) incorporating the reporting process in the healthcare activities

frequent disorders, as well as maintaining the community's health level [17].

the identification and assistance to community health problems [18].

end of 2012, as the city undergoes a health service remodeling process.

proposing any intervention with such professionals [19].

**1.3. The training of health professionals on child abuse** 

which the medical student starts his/her practice in the Family Health Program.

Researchers agree on the need to train professionals on child abuse, and to systematically evaluate such trainings in studies in order to overcome the difficulties mentioned [4,13,15- 16]. In addition, there is a need to insert the topic into curricula, as knowledge of child abuse is essential for healhcare [21]. The literature indicates that for physicians already in practice, training is more relevant in terms of case variables which are more difficult to observe, such as: a) the explanation given for the injury in case of physical abuse; and b) the time taken to bring the child for medical care, instead of restricting training to injury severity and its relationship to child abuse exclusively [21]. For medical students, it is necessary to develop skills of information gathering, and case deductions, and from the onset of training, students should actively be involved in the process of identification and child abuse reporting, working with experienced professionals as role models [22].

Moreover, it is important for professionals to become familiar with epidemiological data on child abuse, as this helps in making decisions to evaluate the information collected, especially in relation to the explanation given when child abuse is suspected, or in differential diagnosis [13, 21]. The literature also indicates that the difficulties in identification and reporting child abuse are found in several health related areas [14], thus it would be possible to start training from a broader topic such as what is child abuse, and subsequently direct the training to specific areas, such as types of treatment that a physician and a dentist may have to perform with an abused child [14].

The literature [22] has also recommended that for the training to be appropriate it should consider the ecological context of child maltreatment to understand risk factors present in the child, the family, the community and society. Researchers also say that the disparity in knowledge of health professionals who work at the same institution should be reduced by training all staff, with emphasis in the need for continuing education. The same conclusion was reached by scholars [23] who found an increase in the number of reported cases after training, but a decrease in subsequent months, indicating the need for ongoing education. Additionally, it is suggested [13] having regular case discussion meetings, stressing the investigative nature of protective services, and to educate physicians in the multidisciplinary aspects of child abuse.

Furthermore, it is recommended [24] that challenges faced by pediatricians in dealing with child abuse cases may be inserted into the training, such as: having the families, not just the children and mothers as the focus of attention; assessing routinely risk and protective factors associated with the child and the family; strengthening protective factors; and working to minimize or eliminate the risk factors.

Experiences with training other professionals on child abuse prevention are also worth mentioning. A quasi-experimental study was conducted by the second author to train preschool educators [25] to act as child sexual abuse primary prevention agents. 101 pre-school teachers, 2.918 children, and 2.732 family members of these children took part of the program, which was developed in partnership with the city of São Carlos' Board of Education. Teachers participated of 12 weekly meetings, for three months, in which they learned to develop practical activities with the children, and their family members on child sexual abuse prevention. The program had a very positive impact in all involved, and the sexual abuse cases reported in the community nearly doubled at the program's end.

Increasing Awareness of Brazilian Family Health Team Professionals on Reporting Child Abuse: A Case Study 123

Number of participants 11 11 22 Sex Female 8 9 17

10 months – 18 years

M = 29

M = 7.6 years

abuse is still considered by many a taboo, and often, a family secret.

**Table 1.** Demographic characteristics of participants in Groups A and B.

Age (years) 23 – 41

**2.2. Instruments used in data collection** 

Length of professional

experience

study.

Male 3 2 5

a) *Questionnaire on Hypothetical Cases,* [14] containing two vignettes with the aim of verifying which procedures the professional would adopt in the process of child abuse identification and reporting. The instrument was originally developed by the first author to pediatricians, and the vignettes were written based on reports from health professionals who had contact with suspected child maltreatment. For the present study, the instrument was adapted adding the context and routine of the Family Health Program. The first vignette involved a possible neglect case, and the second a suspected sexual abuse case. The choice of these two types of violence refers to the difficulty in identifying negligence by health professionals, in spite of being the most common type of abuse reported to CPS; as well as the fact that sexual

b) *Child Maltreatment in Pediatric Primary Care Evaluations* by Lane and Dubowitz [27].The instrument contains three parts: the first being a survey of cases of physical, sexual abuse and neglect reported or not reported; the second part is made of 38 sentences in which the professional responds according to a five point Likert Scale of agreement, where 1 corresponds to *strongly disagree* with the statement, and 5 with *strongly agree* with the statement. The statements address reporting consequences to the professional, evaluate need for training and support in making decisions, and assess knowledge on the subject. The third part of the instrument characterizes the professional (giving information on age, gender, ethnicity, work experience, number of courses on the subject). For the present study only 37 sentences of the second part of the instrument were used. The authors gave authorization to the translation and adaptation of this instrument to Portuguese for this

c) *Questionnaire on Family Violence against Children and Adolescents*, developed by Rossi [28] whose definitions of types of violence were adapted by Giusto [29]. This questionnaire aimed at investigating whether reporting was a procedure adopted by health professionals working in the public sector. In addition, the instrument was designed to assess the knowledge of professionals about the signs of abuse, to identify if there are personal and professional consequences to child abuse reporting, and to identify whether discussion of family violence was part of the professionals' training. The instrument provides a definition of each type of Violence (physical, sexual, psychological abuse and neglect,), giving information on

Group A Group B Total

24 – 47 M = 33

16 months – 21 years

M = 6.4 years

23-47 M= 31

10 months – 21 years

M= 6.9 years

Training teachers in child abuse prevention is highly recommended. Hazzard and Rupp [26] compared child abuse-related knowledge and attitudes of pediatricians, mental health professionals (social workers, psychiatrists and psychologists), teachers and University students who completed a questionnaire on definitions, characteristics, causes and effects of child abuse. Mental health professionals were better informed than pediatricians. In contrast, teachers and University students were the least knowledgeable. On the basis of this study results, additional abuse-related education was recommended for pediatricians and, particularly, for teachers.

The training of health professionals should aim at increasing awareness of children's rights and needs, in ways to also increase the skills in identifying child abuse, maximizing the commitment to child abuse notification to ensure compliance with the law [7]. Thus, the aim of this study was to increase awareness of Family Health Program professionals in preventing child abuse, by evaluating a training course to identify and report abuse. Professional child abuse awareness was here defined in terms of the ability to identify child abuse cases, as well as specifying its different modalities, and to comply with legal requirement of case notification, when child abuse is suspected or confirmed.

## **2. Method**

### **2.1. Participants**

Two Family Health Unit teams (Group A and B) of the mid-size city of São Carlos, in the State of São Paulo, Southeast Brazil, took part of the study, encompassing a total of 22 health professionals. Group A consisted of one physician, a nurse, two nursing aids, a dentist, a dental assistant and six community health agents. Group B had similar members, minus the dentist and dental assistant, as configuration of the teams varies according to practical demands. The groups were similar regarding the number of participants, gender distribution, average age and average length of professional experience. Table 1 below presents a description of both family health teams.

The teams were chosen based in communities with higher prevalence of child abuse in the year of 2008, as reported to CPS. The Protection Service had only started to have reports with number of reported cases per neighborhood as of the year 2008.


**Table 1.** Demographic characteristics of participants in Groups A and B.

### **2.2. Instruments used in data collection**

122 Child Abuse and Neglect – A Multidimensional Approach

particularly, for teachers.

**2. Method** 

**2.1. Participants** 

Experiences with training other professionals on child abuse prevention are also worth mentioning. A quasi-experimental study was conducted by the second author to train preschool educators [25] to act as child sexual abuse primary prevention agents. 101 pre-school teachers, 2.918 children, and 2.732 family members of these children took part of the program, which was developed in partnership with the city of São Carlos' Board of Education. Teachers participated of 12 weekly meetings, for three months, in which they learned to develop practical activities with the children, and their family members on child sexual abuse prevention. The program had a very positive impact in all involved, and the

sexual abuse cases reported in the community nearly doubled at the program's end.

Training teachers in child abuse prevention is highly recommended. Hazzard and Rupp [26] compared child abuse-related knowledge and attitudes of pediatricians, mental health professionals (social workers, psychiatrists and psychologists), teachers and University students who completed a questionnaire on definitions, characteristics, causes and effects of child abuse. Mental health professionals were better informed than pediatricians. In contrast, teachers and University students were the least knowledgeable. On the basis of this study results, additional abuse-related education was recommended for pediatricians and,

The training of health professionals should aim at increasing awareness of children's rights and needs, in ways to also increase the skills in identifying child abuse, maximizing the commitment to child abuse notification to ensure compliance with the law [7]. Thus, the aim of this study was to increase awareness of Family Health Program professionals in preventing child abuse, by evaluating a training course to identify and report abuse. Professional child abuse awareness was here defined in terms of the ability to identify child abuse cases, as well as specifying its different modalities, and to comply with legal

Two Family Health Unit teams (Group A and B) of the mid-size city of São Carlos, in the State of São Paulo, Southeast Brazil, took part of the study, encompassing a total of 22 health professionals. Group A consisted of one physician, a nurse, two nursing aids, a dentist, a dental assistant and six community health agents. Group B had similar members, minus the dentist and dental assistant, as configuration of the teams varies according to practical demands. The groups were similar regarding the number of participants, gender distribution, average age and average length of professional experience. Table 1 below

The teams were chosen based in communities with higher prevalence of child abuse in the year of 2008, as reported to CPS. The Protection Service had only started to have reports

requirement of case notification, when child abuse is suspected or confirmed.

presents a description of both family health teams.

with number of reported cases per neighborhood as of the year 2008.

a) *Questionnaire on Hypothetical Cases,* [14] containing two vignettes with the aim of verifying which procedures the professional would adopt in the process of child abuse identification and reporting. The instrument was originally developed by the first author to pediatricians, and the vignettes were written based on reports from health professionals who had contact with suspected child maltreatment. For the present study, the instrument was adapted adding the context and routine of the Family Health Program. The first vignette involved a possible neglect case, and the second a suspected sexual abuse case. The choice of these two types of violence refers to the difficulty in identifying negligence by health professionals, in spite of being the most common type of abuse reported to CPS; as well as the fact that sexual abuse is still considered by many a taboo, and often, a family secret.

b) *Child Maltreatment in Pediatric Primary Care Evaluations* by Lane and Dubowitz [27].The instrument contains three parts: the first being a survey of cases of physical, sexual abuse and neglect reported or not reported; the second part is made of 38 sentences in which the professional responds according to a five point Likert Scale of agreement, where 1 corresponds to *strongly disagree* with the statement, and 5 with *strongly agree* with the statement. The statements address reporting consequences to the professional, evaluate need for training and support in making decisions, and assess knowledge on the subject. The third part of the instrument characterizes the professional (giving information on age, gender, ethnicity, work experience, number of courses on the subject). For the present study only 37 sentences of the second part of the instrument were used. The authors gave authorization to the translation and adaptation of this instrument to Portuguese for this study.

c) *Questionnaire on Family Violence against Children and Adolescents*, developed by Rossi [28] whose definitions of types of violence were adapted by Giusto [29]. This questionnaire aimed at investigating whether reporting was a procedure adopted by health professionals working in the public sector. In addition, the instrument was designed to assess the knowledge of professionals about the signs of abuse, to identify if there are personal and professional consequences to child abuse reporting, and to identify whether discussion of family violence was part of the professionals' training. The instrument provides a definition of each type of Violence (physical, sexual, psychological abuse and neglect,), giving information on

professional demographic characteristics; on identification of signs and symptoms of child abuse; knowledge of laws; aspects of personal consequences of reporting child abuse; knowledge of the professional ethics code; training on child abuse and the responsibility to report.

Increasing Awareness of Brazilian Family Health Team Professionals on Reporting Child Abuse: A Case Study 125

The specific training involved that by the end of the course professionals should be able to: a) identify family violence as a phenomenon, b) identify different modalities of child abuse; c) identify the signs and symptoms associated with such violence; d) identify risk and protective factors for child abuse; e) analyze myths surrounding the subject; f) analyze appropriate ways to approach victimized children; g) identify the protective network in their community; h) identify and analyze factors that promote resilience; i) establish a dialogue with CPS, and j)

Training lasted 15 hours in total, divided into 10 biweekly meetings, lasting one and a half hour each, inserted into their regular four-hour staff meetings. Different activities to increase

Different activities to increase participation were used throughout the training. In meetings 2 and 6 there were discussions about written material compiled by the first author. In meetings 3 and 7 excerpts from the film "*Bastard Out of Carolina*" [33] were shown, as well as an animation *"Once upon a family*" [34] to facilitate group discussion. In addition, at meeting 7, local and national newspaper clippings on child abuse cases were given for analysis of risk factors and procedures involved. At meeting 4 there was role-playing of a fatal child abuse hypothetical case by participants, who were divided into pairs, and given different roles. In the meeting 9, two reporting forms were analyzed: one used by the State Department of Health and another by the Ministry of Health. In meeting 5, a representative of the local Child Protection Service made a presentation, and answered questions, and in meeting 8 a forensic psychologist

After each meeting, the first author took records of the main procedures and verbalizations. At the end of the training course, a questionnaire was administered to assess the degree of

This case study had a pre-experimental A-B design which allowed comparing differences in

In the *Questionnaire on Hypothetical Case* [14] data analysis is based on categories established by questions. The answers were analyzed qualitatively, enabling the creation of

The *Child Maltreatment Evaluations in Pediatric Primary Care* [27] uses a Likert scale of 5 points: *strongly disagree* (SD), *disagree* (D), *neutral (*N), *agree* (A) and *strongly agree* (SA). To verify if there were changes of opinion between the steps, the Wilcoxon test was used. The level of significance was set at 5%. Thus, the p-value obtained in each test rejected the hypothesis of equality groups and no change of opinion when the p-value is greater than

The *Questionnaire on Family Violence against Children and Adolescents* [29] has a predetermined set of response categories for each variable, thus the final score involved the frequency

subcategories, and a descriptive analysis of the responses was performed.

0.05. Data analyzes were performed using SPSS statistical software.

correctly complete the mandated child abuse health professional reporting form.

working in the Judiciary system made, likewise, a presentation.

scores on the pre-test and post-test in both groups [35].

participation were used throughout.

participant satisfaction.

responses of presented options.

**2.5. Data analysis** 

Data collection also involved monitoring child abuse reporting behavior to CPS by each team participant, prior to the training program (for one year) and afterwards.

## **2.3. Procedure**

The project was approved by the University's Ethics Committee, and participants signed Informed Consent explaining the study's objectives, risks and benefits associated with the research, and guarantee of anonymity. The initial contact with the health teams was made by telephone, followed by a letter sent by email, with the course proposal attached. After interest in participation was expressed, a meeting was held with the first author to provide further explanations.

The intervention initially took place exclusively with Group A, and two pre-intervention assessments were done with Group B prior to their respective training. The training took place at each Family Health Unit's office, in rooms designated for staff meetings. Each Unit office was located in different geographical areas.

Before starting training with Group A, the *Questionnaire on Family Violence against Children and Adolescents* was administered to both groups to evaluate the initial repertoire on the subject and previous group experience. The instruments *Questionnaire on Hypothetical Cases* and *Child Maltreatment in Pediatric Primary Care Evaluations* were applied at pre-test to evaluate the course, as well as at post-test for comparison.

## **2.4. The training procedure**

The training was aimed at overcoming the second challenge indicated by Brazil's Ministry of Health [20] which is to raise awareness, and train health professionals to understand the consequences of abuse to children's development, teaching professionals how to diagnose child abuse, how to report cases, and make referrals when problems are found.

The training contents were divided into four main themes:


The training relied on LAPREV's (The Laboratory for Analysis and Prevention of Violence) past experience in teaching the topic of child abuse to different professionals, such as, teachers [25], police [30], CPS [31] and institutional staff [32].

The specific training involved that by the end of the course professionals should be able to: a) identify family violence as a phenomenon, b) identify different modalities of child abuse; c) identify the signs and symptoms associated with such violence; d) identify risk and protective factors for child abuse; e) analyze myths surrounding the subject; f) analyze appropriate ways to approach victimized children; g) identify the protective network in their community; h) identify and analyze factors that promote resilience; i) establish a dialogue with CPS, and j) correctly complete the mandated child abuse health professional reporting form.

Training lasted 15 hours in total, divided into 10 biweekly meetings, lasting one and a half hour each, inserted into their regular four-hour staff meetings. Different activities to increase participation were used throughout.

Different activities to increase participation were used throughout the training. In meetings 2 and 6 there were discussions about written material compiled by the first author. In meetings 3 and 7 excerpts from the film "*Bastard Out of Carolina*" [33] were shown, as well as an animation *"Once upon a family*" [34] to facilitate group discussion. In addition, at meeting 7, local and national newspaper clippings on child abuse cases were given for analysis of risk factors and procedures involved. At meeting 4 there was role-playing of a fatal child abuse hypothetical case by participants, who were divided into pairs, and given different roles. In the meeting 9, two reporting forms were analyzed: one used by the State Department of Health and another by the Ministry of Health. In meeting 5, a representative of the local Child Protection Service made a presentation, and answered questions, and in meeting 8 a forensic psychologist working in the Judiciary system made, likewise, a presentation.

After each meeting, the first author took records of the main procedures and verbalizations. At the end of the training course, a questionnaire was administered to assess the degree of participant satisfaction.

#### **2.5. Data analysis**

124 Child Abuse and Neglect – A Multidimensional Approach

office was located in different geographical areas.

evaluate the course, as well as at post-test for comparison.

The training contents were divided into four main themes:

2. What is mandated reporting and its importance to society;

Network operate and some of the difficulties they face;

teachers [25], police [30], CPS [31] and institutional staff [32].

report.

**2.3. Procedure** 

further explanations.

**2.4. The training procedure** 

World Health Organization;

professional demographic characteristics; on identification of signs and symptoms of child abuse; knowledge of laws; aspects of personal consequences of reporting child abuse; knowledge of the professional ethics code; training on child abuse and the responsibility to

Data collection also involved monitoring child abuse reporting behavior to CPS by each

The project was approved by the University's Ethics Committee, and participants signed Informed Consent explaining the study's objectives, risks and benefits associated with the research, and guarantee of anonymity. The initial contact with the health teams was made by telephone, followed by a letter sent by email, with the course proposal attached. After interest in participation was expressed, a meeting was held with the first author to provide

The intervention initially took place exclusively with Group A, and two pre-intervention assessments were done with Group B prior to their respective training. The training took place at each Family Health Unit's office, in rooms designated for staff meetings. Each Unit

Before starting training with Group A, the *Questionnaire on Family Violence against Children and Adolescents* was administered to both groups to evaluate the initial repertoire on the subject and previous group experience. The instruments *Questionnaire on Hypothetical Cases* and *Child Maltreatment in Pediatric Primary Care Evaluations* were applied at pre-test to

The training was aimed at overcoming the second challenge indicated by Brazil's Ministry of Health [20] which is to raise awareness, and train health professionals to understand the consequences of abuse to children's development, teaching professionals how to diagnose

1. Definition of child abuse according to Brazilian law, Brazil's Ministry of Health and the

3. How do Child Protection Services, the Judiciary System and the Protection Support

The training relied on LAPREV's (The Laboratory for Analysis and Prevention of Violence) past experience in teaching the topic of child abuse to different professionals, such as,

4. Proper use of the child abuse mandated reporting form to health professionals;

child abuse, how to report cases, and make referrals when problems are found.

team participant, prior to the training program (for one year) and afterwards.

This case study had a pre-experimental A-B design which allowed comparing differences in scores on the pre-test and post-test in both groups [35].

In the *Questionnaire on Hypothetical Case* [14] data analysis is based on categories established by questions. The answers were analyzed qualitatively, enabling the creation of subcategories, and a descriptive analysis of the responses was performed.

The *Child Maltreatment Evaluations in Pediatric Primary Care* [27] uses a Likert scale of 5 points: *strongly disagree* (SD), *disagree* (D), *neutral (*N), *agree* (A) and *strongly agree* (SA). To verify if there were changes of opinion between the steps, the Wilcoxon test was used. The level of significance was set at 5%. Thus, the p-value obtained in each test rejected the hypothesis of equality groups and no change of opinion when the p-value is greater than 0.05. Data analyzes were performed using SPSS statistical software.

The *Questionnaire on Family Violence against Children and Adolescents* [29] has a predetermined set of response categories for each variable, thus the final score involved the frequency responses of presented options.
