Transcript Module 1: General Introduction to Quality Improvement Programs

National Family Safety Program, NGHA
January 28th and 29th 2013
Presentation 3. Step 1 of the Public Health
Approach to Child Maltreatment Prevention:
The Magnitude and Distribution
of Child Maltreatment
Presented by
Alaa Sebeh, MD Ph.D.
Independent International Consultant,
Child Protection & Disability.
[email protected]
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Objectives
The core learning objective of this module is to provide a basic
understanding of the second part of step 1 of the public health
model as applied to child maltreatment prevention by focusing on
data on the magnitude and distribution of child maltreatment and
sources for, and problems with, these data.
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Outline
1. Data Sources for Estimating the Magnitude and Distribution of
Child Maltreatment and Difficulties Collecting Data
2. Existing Data on the Global Burden of Child Maltreatment and
Gaps within These Data
3. Presenting Data to Convince Policy-Makers
4. Summary and Conclusion
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Data Sources for Estimating the Magnitude and Distribution
of Child Maltreatment and Difficulties Collecting Data
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Main Sources of Data
The main sources of data for estimating the magnitude of child
maltreatment and its distribution can be divided into two main
types:
• Epidemiological information
• Case-based information
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Epidemiological Information
Epidemiology is the study of how often diseases occur in
different groups of people and why.
Incidence – Measures the number of new cases arising in
a defined population within a specified time period.
Prevalence – Measures all cases within a defined
population occurring at a point or period in time.
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Worldwide Epidemiological Information
In many parts of the world, epidemiological information
about child maltreatment is lacking.
Consequently, decision-makers and the general public often
refuse to accept that child maltreatment is a serious issue in
their society.
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Epidemiological Information on Child
Maltreatment and Its Consequences
Epidemiological information can contribute directly to preventing the phenomenon by:
• Providing a quantitative definition of the problem
• Providing ongoing and systematic data on the incidence and prevalence, causes and
consequences of child maltreatment at local, regional and national levels
• Enabling the early identification of emerging trends and problem areas in child maltreatment
• Suggesting priorities for prevention among those at high risk of either experiencing or
perpetrating child maltreatment
• Providing a means to evaluate the impact of prevention efforts
• Monitoring seasonal and longitudinal changes in the prevalence and characteristics of child
maltreatment and its associated risk factors
• Giving an overview of the geographic distribution of child maltreatment cases
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Sampling Strategies
Few cases of child maltreatment are reported; therefore, it is essential to conduct
population-based surveys using representative samples to get an accurate estimate of the
size of problem.
Probability sampling – Some form of random selection is used in choosing the elements,
and each element in the population has an equal and independent chance of being
selected.
Non-probability sampling – The elements that make up the sample are selected by nonrandom methods.
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Ethical Considerations
Surveys that question children and adults about events in the present and
recent past should be considered only where there are adequate resources to
guarantee a resolution of the situation or to bring it to the attention of the
relevant authorities.
Surveys should in every case be conducted in such a way that a respondent’s
situation is not made worse by answering the questionnaire.
The design of studies, therefore, should always be reviewed by an ethics
committee.
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Case-Based Information
Only a small proportion of all child maltreatment cases ever come to the attention of
service providers.
Case information refers to the information collected from individuals and families where
maltreatment has already occurred and who are currently receiving services to deal
with the effects of maltreatment.
Case-based information collected can never be used to measure the overall extent of
the problem of non-fatal child maltreatment.
Despite these limitations, facility-based information does serve two important
purposes:
1. Helps ensure a continuity of information about individual cases over
time and between the different agencies involved in case management
2. Helps plan the provision of services, such as what the peak demand
times are, what staff are required, or where the users come from
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Cased-Based Information and
Surveillance of Reported Cases
Surveillance of reported cases of child maltreatment can point to trends in service
provision and service utilization, but it cannot give a proper overview of the
problem.
Routine data collection on child maltreatment must be based on accepted,
standardized definitions so that categories are uniform and sets of data can be
effectively compared.
Surveillance systems should build on existing systems where possible and, ideally,
coordinate existing systems used by various sectors if they are independent of
each other.
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Reporting Child Maltreatment
Countries have taken different approaches to the issue of reporting suspected
child maltreatment, including:
• Mandatory reporting
• Confidential reporting
• Reporting as the accepted norm
Many countries however have no system for reporting or responding to
suspected or actual child maltreatment.
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Mandatory vs. Voluntary Reporting
of Child Maltreatment Cases
There are advantages and disadvantages to mandatory and voluntary reporting of child
maltreatment cases.
Mandated reporting creates an adversarial relationship between families and child
protection authorities. The fear of reporting and its consequences can be a powerful
deterrent for families.
There is extensive evidence that the public as well as professionals are reluctant to act on
knowledge or suspicions of maltreatment.
Without reporting laws, children in need of protection may not be identified ,and systems
will not be put in place to prevent further maltreatment.
Whichever approach is chosen, it should be founded in a public health and social support
context rather than being primarily punitive.
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Suspected Child Maltreatment
Children at risk of experiencing maltreatment, and the parents and other family
members of those children, frequently interact with a number of service
agencies.
Each of these interactions provides an opportunity to detect maltreatment and
to intervene.
Whenever a family or child encounters a service agency and child maltreatment
is either confirmed or suspected, basic information on the case should be
documented.
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Complete Understanding of Child Maltreatment
in a Particular Location
For non-fatal maltreatment:
• Population-based epidemiological surveys
• Case information on individual cases and communication about the cases within
and between agencies
• Routine data collection of cases seen by emergency medical care facilities, child
protection services, and other services
For fatal maltreatment:
• Systems for the medico-legal investigation of all known and suspected deaths
from external causes and all unexpected deaths in young children
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Gathering Information about Deaths
from Child Maltreatment
Fatal cases of child maltreatment cannot be easily measured through
population-based surveys or service-based case systems that record
information.
Accurate information about deaths from child maltreatment can be
obtained only in settings where:
• There is a legal obligation to report such deaths.
• This obligation is enforced.
• Systems exist for the medico-legal examination of all known and
suspected deaths from injuries or external causes.
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Main Difficulties Related to
Collecting Data on Child Maltreatment
Some of the main difficulties include:
• Existence of many different potential data sources generating different estimates
• Availability and quality of data
• Ethical problems
• Taboo and shameful nature of child maltreatment and the belief that it is "a private
affair”
Despite the difficulties of collecting data on child maltreatment, enough is known to
confirm that child maltreatment affects substantial numbers of children around the world.
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Existing Data on the Global Burden of Child
Maltreatment and Gaps within These Data
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Child Maltreatment and the
Global Burden of Disease and Injury
WHO’s Global Burden of Disease (GBD) project is a consistent and comparative
description of the burden of diseases and injuries.
The GBD project quantifies the health effects of more than 100 diseases and
injuries for eight regions of the world.
Data on child maltreatment within the GBD project are however quite limited.
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Child Maltreatment Mortality Rates (Ages 0–9) by
WHO Region and Country Income Level, 2004
Source of data: Global burden of disease database: 2004 update. WHO, 2008
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Misclassification of Child Homicides
It is possible for child deaths due to maltreatment to be missed, and for this
reason, these estimates underestimate the true number of deaths from child
maltreatment.
Many child deaths are not routinely investigated and post-mortem examinations
are not carried out.
In 2004, there were an estimated 22,320 deaths attributed to homicide among
children under 10 years of age and an estimated 31,000 among children under
15 years of age.
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Global Child Homicide Risks
Infants and pre-school children are at the greatest risk of fatal maltreatment as a result
of their dependency, vulnerability, and relative social invisibility.
The risk of fatal abuse is two to three times higher in low- and middle-income countries
than it is in high income countries.
It is also greater in societies with large economic inequalities than in those where
wealth is more evenly distributed.
The most common cause of death is head injury, followed by abdominal injuries and
intentional suffocation.
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Homicide Rates per 100,000 Population among 0-4
Year Olds by Region and Sex, 2002
4.5
4
3.5
3
Males
2.5
Females
2
Both
1.5
1
0.5
0
Africa
Asia
Aus./NZ
Europe
LAC
North
America
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Global Burden of Child Maltreatment
Studies suggest that members of the family are responsible for the majority of
homicides in children aged 0–14 years.
Deaths represent only a small fraction of the problem of child maltreatment.
Every year millions of children are victims of non-fatal abuse and neglect.
Some international studies have shown that, depending on the country,
between a quarter and a half of all children report physical abuse.
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Sexual Abuse of Children Worldwide
The reluctance of many cultures to openly discuss sexuality in general and sexual
abuse in particular, renders it extremely difficult to quantify this form of child
maltreatment.
WHO estimates that 20% of women and 5%–10% of men report being sexually
abused as children.
Approximately 150 million girls and 73 million boys under the age of 18 experienced
sexual violence, including rape, during 2002.
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Lifetime Prevalence of Child Sexual Abuse in High
Mortality Developing Regions of the World
Sub-region
Female %
Male %
Africa (high mortality)
21.3
9.6
Africa (very high mortality)
42.7
29.8
Latin America/Caribbean
13.3
20.0
Eastern Mediterranean
28.0
11.5
Southeast Asia (high mortality)
67.7
35.0
Source of data: Andrews et al., Child sexual abuse, WHO, 2004
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Child Maltreatment Trends in the US, 1990-2004
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Explanations of Child Sexual Abuse
Reduction in the US, 1990s
The 40% decline in CSA in the 1990s in the United States is due to four main
explanations consistent with the timing and breadth of the trends:
1. The economic boom, job growth, and economic optimism of the 1990s
2. An increase in the number of police, child protection workers, and other
agents of social intervention
3. Enhanced efforts to identify, arrest, prosecute, and incarcerate offenders
4. The widespread diffusion of new psychopharmacology, starting in the early
1990s, to deal with depression, anxiety, hyperactivity, and aggressive
behaviour in both children and adults
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Presenting Data to Convince Policy-Makers
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Child Maltreatment Data Determining Policy
It is vital that data on child maltreatment are presented in reports dealing exclusively
with the problem.
Reports should use simple language and clear charts and tables so the issue can be
clearly visible for policy-makers and others.
Dedicated reports on child maltreatment should also be made readily available to
the media and civil society organizations.
To protect the anonymity of individuals, all data presented in these reports must be
stripped of the case identification numbers and any other information that could
possibly allow individuals to be identified.
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Using Data to Inform Policy
For policy-makers to be convinced of the need for strong action on child maltreatment,
the analysis and reporting of data should include three important elements:
1. The size of the problem in relation to other issues. The scale of child maltreatment in
the given country can be highlighted by comparing it with:
o The magnitude of other public health threats
o The scale of child maltreatment in other countries
o The human cost of disasters and collective tragedies covered in the media
2. The relationships between child maltreatment and socioeconomic and environmental
factors.
3. The possibility of preventing maltreatment. Showing the considerable gains that good
prevention programmes can achieve is important for convincing policymakers
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Summary and Conclusion
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Summary and conclusion
This module reviewed:
• Data sources for estimating the magnitude and distribution of child
maltreatment and difficulties collecting data
•Existing data on the global burden of child maltreatment and gaps within
these data
•Presenting data to convince policy-makers
Despite the difficult nature of collecting reliable data on child maltreatment,
enough is known to confirm that child maltreatment affects substantial numbers
of children around the world.
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References
Andrews, G. Corry, J. Slade, T. Issakidis, C. Swanston, H. (2004). Child Sexual Abuse. In Ezzati, M Lopez, A. Rodgers, A.
Murray C. (Eds.), Comparative Quantification of Health Risks: Global and Regional Burden of Disease Attributable to
Selected Major Risk Factors Volume 1. (pp. 1851-1940). Geneva, World Health Organization.
Butchart, A. Phinney, A. and Furness, T. (2006). Preventing child maltreatment: A guide to taking action and
generating evidence. Geneva, World Health Organization.
Child Maltreatment. TEACH-VIP E-Learning. Retrieved March 17, 2010, from http://teachvip.edc.org/course/view.php?id=23
Finkelhor, D. Jones, L. (2006). Why Have Child Maltreatment and Child Victimization Declined? Journal of Social Issues.
62(4), 685--716
Gilbert, R. Widom, C. Browne, K. Fergusson, D. Webb, E. Janson, S. (2009). Burden and consequences of child
maltreatment in high-income countries. Child Maltreatment 1. 373 (9667), 1-14.
Global burden of disease database: 2004 update. (2008), Geneva, World Health Organization.
The Future of Children. (2009) Preventing Child Maltreatment. 119(2), 3-21.
Krug, E. et al. (2002). World report on violence and health. Geneva, World Health Organization.
Pinheiro, P.S. (2006). World report on violence against children. Geneva, World Health Organization.
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Activity: Reviewing Child Maltreatment Data
In small groups review the data provided and discuss implications and trends this
information may indicate, including:
• The strengths and weaknesses of
the data from different sources
• The differences between oneyear and lifetime prevalences
• The regional factors which may
influence these findings
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