A critical review of child abuse and its management in Africa

Factors associated with access and utilization of sexual abuse emergency healthcare services among street children in Zomba, Malawi: a qualitative study

BACKGROUND

Sexual abuse among street children is a problem that renders a burden of sexually transmitted diseases, HIV infection, and early pregnancy. Literature shows that globally 95 million children experience sexual abuse with 1 in 5 girls and 1 in 7 boys exposed to sexual abuse before 18 years of age in Malawi. Malawi adopted the World Health Organization guidelines for providing emergency health services for victims of sexual abuse, which include HIV Post Exposure Prophylaxis (PEP) and Emergency Contraceptive Pills (ECP) within 72 h of exposure, Sexually Transmitted Infections (STI) treatment, and psychosocial services. However, there are challenges associated with the services that limit access and utilization among street children. This study explored the factors associated with access and utilization of sexual abuse emergency healthcare services among street children in Zomba.

METHODOLOGY

This was a cross-sectional phenomenological qualitative study conducted in Zomba City from 2022 to 2023 using in-depth and key informant interviews. We purposively selected street children between 10 to 17 years who have been exposed to sexual abuse on the streets and social actors working with street children. The study employed a thematic analysis approach.

RESULTS

The study found that street children did not utilize sexual abuse emergency health services. The major factors associated with utilization included the knowledge of sexual abuse, its associated health risks and sexual abuse emergency health services, and perceptions of utilizing sexual abuse emergency health services. The barriers to utilization of sexual abuse emergency health services included perceived shame, fear, discrimination, prolonged treatment process, and attitude of the health service providers.

CONCLUSION

Sexual abuse and its health risks continue to be a challenge among street children. The absence of adequate connections and secure environments for street children to report sexual abuse and seek help without facing judgment has created significant obstacles for them in accessing sexual abuse emergency health services. To curb this challenge it is crucial for successful interventions to specifically address the health needs of street children and involve them in the decision-making processes related to their interventions.

Burden, consequences and associate factors of childhood maltreatment in Ethiopia: A systematic review and meta-analysis

Introduction

Child maltreatment is any type of abuse or child negligence which results the concrete or prospective hurt for those under age of eighteen. It is a global issue which severely endangered children's physical, emotional, behavioral, developmental and mental well-being for immediate and later in life. Although, its magnitude and devastating burden are difficult to comprehend, much remains to be done to know its prevalence and comprehensive impact. This meta-analysis and comprehensive review will provide important light on the burden, consequences, and contributing factors for child maltreatment.

Methods

This meta-analysis and comprehensive review was coded at Prospero number of CRD42024503799. Universal online databanks including PubMed, Cochrane, Google, Google Scholar, SCOPUS, and Web of Science and Global Health were used to search for articles. Microsoft Excel was used for data extraction, and STATA17 was used to analyze this systematic review and meta-analysis. A random effect model exploration was employed when heterogeneity among included studies were evidenced.

Results

The pooled prevalence of childhood maltreatment was 57.0 % (95 % CI = 32.00, 83.00). Included studies revealed that childhood maltreatment has multiple child health-related consequences. Being female (AOR = 2.94, 95 % CI: 1.48, 4.41), being young (AOR = 1.22, 95%CI: 1.09, 3.35), paternal illiteracy (AOR = 2.16, 95%CI: 1.012, 3.302) and have an open family discussion about sexual matters (AOR = 0.381 (95%CI: 0.121, 0.884) were considerably associated with child maltreatment.

Conclusion

This finding publicized that the burden and multiple consequences of childhood maltreatment need much attention. Childhood maltreatment has both immediate and life time consequences for children later in life. Being female, being young, having illiterate fathers, and open family discussion about sexual matters were associated factors of child maltreatment.

Programs to Prevent Violence Against Children in Sub-Saharan Africa: A Systematic Review

Violence against children-which includes maltreatment (including physical, sexual, psychological and emotional violence, and neglect), bullying (including cyberbullying), youth violence (including physical assault with or without weapons), intimate partner violence (including exposure to domestic violence and direct involvement in teen dating violence), and sexual violence-continues to present itself as a significant public health crisis in Sub-Saharan Africa (SSA) leading to numerous short- and long-term deleterious outcomes. As such, the prevention of violence against children in SSA is a critical public health priority. In this systematic literature review, we identified 45 articles that reported on results from 22 programs that seek to reduce violence against children in SSA. Results suggested that programs that focus on (1) economic strengthening, (2) teachers schools, (3) entire families, (4) caregivers only, and (5) children only are generally effective in reducing violence against children by promoting focused action on the mechanisms of change (e.g., parenting skills, enhanced parent-child relationships, resistance skills for children). To date, no research in SSA has examined the impact of policy interventions on childhood victimization or community-level interventions to change norms and values that support violence against children. Future research is needed to examine the impacts of comprehensive efforts to prevent violence against children in SSA as well as factors that predict uptake and sustainability of such prevention efforts in SSA.

Building police capability in child protection in Kenya

BACKGROUND

Existing literature illustrates a high prevalence of child protection issues throughout Kenya. This is adjoined by additional research detailing issues of corruption, cultural rationalization and the potential lack of capability to deal with the problem in existing law enforcement practices. There is no specific research that investigates the establishment or operational function of a child protection department within law enforcement in Kenya.

OBJECTIVE

This study aims to directly address this research gap by exploring the establishment of an overseas initiative to support the development of a child protection function in the National Police Service of Kenya and to analyse the conditions in developing the project.

PARTICIPANTS, SETTING AND METHODS

The study, which took place in Kenya, consists of n = 15 face to face interviews, comprising of n = 10 Kenyan Police Child Protection Officers, and n = 5 National Crime Agency (NCA) officers who contributed to the development of the unit. The semi-structured interviews were based upon existing literature from developing overseas support and child protection in Kenya.

CONCLUSION

The results evidenced the need to focus in three key areas when building child protection capability overseas to create a successful function; the requirement to tailor context specific understanding of the culture and operating environment, the need to understand the current and potential capabilities within this context, and the importance of obtaining leadership and governance support from appropriate stakeholders both internally and externally. These themes begin to develop a base for the development of international practice for the establishment of overseas child protection policing functions.

As the Twig is Bent so the Tree is Inclined? Exploring the Associations of Adverse Childhood Experiences and Adult Relational Impairments in Ghana

Studies on adverse childhood experiences (ACEs), which have been conducted predominantly with samples from Western cultures have found ACEs to be associated with poor health outcomes and relational impairments in adulthood. This study sought to contribute to the ACEs literature by investigating the long-term consequences of ACEs on the interpersonal functioning of adult survivors in Ghana, a non-Western culture. In the current study, the associations of five ACEs (high parental conflict, physical abuse, sexual abuse, emotional abuse, and neglect) with four types of relational impairments (alienation, insecure attachment, egocentricity, and social incompetence) were examined using a community sample of 403 adults who retrospectively provided self-reports of ACEs. The most frequently reported ACE in this sample was high parental conflict, while sexual abuse was the least frequently reported ACE. Participants with ACE histories had significantly more relational impairments than those with no ACE histories, however multiple regression analyses revealed no significant relational impairments in adulthood following any ACE experience, whether alone or in any combination, suggesting that cultural values such as collectivism and religiosity may play a protective role against ACEs negative effects in the interpersonal domain. The study's limitations, and the implications of these findings for the Ghanaian and other similar contexts are discussed.

Physical, sexual, and psychosocial health impacts of child abuse: Evidence from Ghana

Child abuse is a significant global health problem. While data on child abuse in Ghana are scant, anecdotal evidence suggests the vast majority of Ghanaian children have experienced some form of physical or sexual abuse. This paper explores links between early childhood abuse and health outcomes using a life course perspective. Nationally representative cross-sectional data were collected from a sample of 2289 ever-married Ghanaian women in 2017. Women provided retrospective accounts of different types of violence in early childhood. Random-effects logit models were used to examine the impact of two dimensions of early childhood abuse (physical and sexual) on the physical, sexual, and psychosocial health outcomes of women in later years. Women who experienced childhood physical abuse, but not often, were significantly more likely to report physical disabilities in later years than women who did not experience it. Women reporting childhood sexual abuse were more likely to be depressed in later years than those who never experienced such abuse. They were also significantly more likely to report sexually transmitted diseases. Our findings provide support for the life course theory by showing abuse experienced in childhood could have a long-term impact. We therefore suggest the need for early interventions to address child abuse.

Understanding sibling violence and its impact over the life course: The case of Ghana

Sibling relationships are a significant part of family dynamics, and sibling violence may be manifested in these relationships. Sibling violence has rarely been examined in the domestic violence literature on sub-Saharan Africa, so little is known about its prevalence or consequences. This study used a life course perspective to examine the effects of sibling violence on Ghanaian women's intimate partner violence (IPV) victimization and perpetration in adulthood. Data were collected from about 1700 ever-married Ghanaian women aged 18 years and above between May and August 2022. Logit models were used to explore retrospective accounts of women's experience of various types of sibling violence in childhood and their later victimization and/or perpetration of IPV. Results showed sibling violence was prevalent in our sample: 51.2% experienced sibling emotional violence, 39.5% experienced physical violence, and 2.3% experienced sexual violence. Our findings generally supported the life course perspective. Women with experiences of sibling physical, sexual, and emotional violence were significantly more likely to perpetrate physical, sexual, and emotional IPV in adulthood. Similarly, women with experiences of sibling violence were more likely to report IPV victimization in later years. Domestic violence interventions should pay attention to sibling relationships in children's early years.

Clinical Decision Making in Forensic Nursing: A Cross-Sectional Study From an Emergency Nursing Perspective

BACKGROUND

Appropriate clinical decision making (CDM) is very important for emergency nurses when working with forensic patients with violence-related injuries and can improve patient outcomes. Therefore, it is essential for emergency nurses to have the basic skills to make the right clinical decisions when working with forensic patients.

AIM

The aim of this study was to evaluate the CDM of emergency nurses when caring for forensic patients.

METHODS

This study was conducted using a cross-sectional design. Nurses working in the seven emergency departments of Rasht hospitals, Guilan Province, Iran, were recruited to take part in the study. Data collection was performed via census sampling from September to November 2019. Data were collected via a two-part questionnaire developed by the researcher(s) that addressed (a) demographic characteristics and (b) simulated scenarios that assessed their CDM in caring for forensic patients.

FINDINGS

One hundred ninety-two emergency nurses participated in this study. The mean score of CDM in forensic nursing was moderate (56.46; 95% CI [54.49, 58.43]). Of the participants, 60.42% of the emergency nurses had moderate CDM knowledge related to forensic nursing, whereas only 2.8% had desirable knowledge of CDM. There was a statistically significant relationship between CDM in forensic nursing and the history of encountering forensic patients ( p = 0.008).

CONCLUSION

CDM scores regarding emergency nurses' knowledge of forensic nursing were moderate. Knowledge of and CDM in forensic nursing is very important and provides high-quality safe care for forensic patients.

IMPLICATIONS FOR CLINICAL FORENSIC NURSING PRACTICE

This study highlights the importance of additional education and professional development in forensic nursing, for emergency nurses, and should be considered further by nursing administrators and nursing educators.

Quality of life and well-being problems in secondary schoolgirls in Kenya: Prevalence, associated characteristics, and course predictors

BACKGROUND

Adolescents in sub-Saharan Africa often report low levels of quality of life (QoL) and well-being, but reliable data are limited. This study examines which sociodemographic, health, and behavioral risk factors and adverse adolescent experiences are associated with, and predictive of, QoL in Kenyan secondary schoolgirls.

METHODS AND FINDINGS

3,998 girls at baseline in a randomised controlled trial in Siaya County, western Kenya were median age 17.1 years. Subjectively perceived physical, emotional, social and school functioning was assessed using the Pediatric Quality of Life (QoL) Inventory-23. Laboratory-confirmed and survey data were utilized to assess sociodemographic, health and behavioral characteristics, and adverse adolescent experiences. We identified a group of girls with Low QoL (n = 1126; 28.2%), Average QoL (n = 1445; 36.1%); and High QoL (n = 1427; 35.7%). Significantly higher scores on all well-being indicators in the LQoL compared with HQoL group indicated good construct validity (Odds Ratio's (ORs) varying from 3.31 (95% CI:2.41-4.54, p < .001) for feeling unhappy at home to 11.88 (95%CI:7.96-17.74, p< .001) for PHQ9 defined possible caseness (probable diagnosis) of depression. Adverse adolescent experiences were independently statistically significant in the LQoL compared to the HQoL group for threats of family being hurt (aOR = 1.35,1.08-1.68, p = .008), sexual harassment out of school (aOR = 2.17,1.79-2.64, p < .001), and for menstrual problems like unavailability of sanitary pads (aOR = 1.23,1.05-1.44, p = .008) and stopping activities due to menstruation (aOR = 1.77,1.41-2.24, p < .001). After 2-years follow-up of 906 girls in the LQoL group, 22.7% persisted with LQoL. Forced sex (aOR = 1.56,1.05-2.32, p = .028) and threats of family being hurt (aOR = 1.98,1.38-2.82, p < .001) were independent predictors of persistent LQoL problems.

CONCLUSIONS

Persistent QoL problems in Kenyan adolescent girls are associated with adverse physical, sexual and emotional experiences and problems with coping with their monthly menstruation. A multi-factorial integral approach to reduce the rate of adverse adolescent experiences is needed, including provision of menstrual hygiene products.

TRIAL REGISTRATION

ClinicalTrials.gov:NCT03051789.

Exploration of factors influencing court outcomes in cases involving minors as victims in Ghana

BACKGROUND

The factors that influence positive court outcomes for cases of child sexual abuse (CSA) have been studied in other contexts but very few such studies exist for Sub-Saharan countries. Knowledge of how such cases fare in these court systems is, however, important for a global assessment of such outcomes.

OBJECTIVE

The study explored the predictive effect of the victim, complainant; offender and offence characteristics, and length of the trial on case disposition and dropout.

METHODS, PARTICIPANTS AND SETTING

Three hundred and eighty-nine (389) closed court files related to child sexual abuse in Ghana were reviewed and analyzed.

RESULTS

The findings show that the number of court sittings (length of trial) and complainant characteristics predict negative outcomes for CSA cases in Ghana. Specifically, convictions were less likely to occur where caregivers were the complainants (OR = 0.45), and when there were longer court sittings (OR = 0.95). Victim, offender, and offence characteristics, however, did not influence case outcomes.

CONCLUSIONS

This study is one of the first studies using actual court data to predict the outcome of cases in CSA in Ghana, and makes recommendations for the support of children and caregivers through the court process.

Circumstances and Consequences of Violence-Related Injuries Presenting at Hospital. A Study at the Pediatric Emergency and Forensic Medicine Units of Maputo Central Hospital, Mozambique

Rates of violence against children are high in Sub-Saharan Africa and information is scarce on the resulting injuries. This study investigates sex-related differences in the circumstances and consequences of sexual and physical violence in the Mozambican context. Hospital records from 2019 at the pediatric emergency and forensic medicine units of Maputo Central Hospital were scrutinized using a standardized form. Of the 321 cases identified, 60% resulted from sexual violence. Girls represented 86.4% of the victims of sexual violence and boys, 66.1% of those from physical violence. Being injured in a familiar environment and by a parent, a relative, or someone known was strikingly common. The injury pattern varied by form of violence and sex of the child. About half of the injuries sustained by physical violence were minor/superficial. Severe injuries requiring hospitalization (33% in total) and some specialized care (27% in total) were mainly sustained by girl victims of sexual violence. While circumstances and consequences of violence-related injuries have several similarities, being severely injured is more typical of girl victims of sexual violence. Besides medical care, hospital services in Mozambique must be prepared to offer pediatric victims of violence the necessary social care.

The management of childhood sexual abuse by midwifery, nursing and medical providers in Tanzania

BACKGROUND

Child sexual abuse (CSA) is a significant public health problem affecting one billion children aged 2 to 17 globally. The prevalence of CSA in Tanzania is one of the highest; however, how health care providers manage CSA cases has not been studied.

OBJECTIVES

This study investigated how medical, nursing, and midwifery professionals in Tanzania handle cases of CSA and identified the factors that facilitate or impede the provision of quality care to CSA victims.

METHODS

Participants were 60 experienced healthcare professionals and 61 health students working in Dar es Salaam, Tanzania. We conducted 18 focus groups stratified by profession (midwifery, nursing, or medicine) and experience (practitioners versus students).

RESULTS

Three main themes emerged. First, child abuse management involved using a multi-disciplinary approach, including proper history taking, physical assessment, treatment, and referral. Second, factors that enhanced disclosure of CSA included building rapport, privacy, and confidentiality. Third, factors that impeded care included fear of harm to the child if the abuse was reported, abuse reporting being perceived as a "waste of time" for providers, loss of evidence from the victim, family resistance, poverty, corruption and cultural dynamics.

CONCLUSIONS

Midwives, nurses and doctors were all experienced in and reported similar challenges in addressing CSA. At a structural level, the ratio of providers to patients in health facilities inhibits quality care. These findings have implications for strengthening CSA policy/guidelines and clinical practice in Tanzania. Mandated CSA training is necessary for midwifery, nursing, and medical students as well as in continuing education courses for more experienced providers.

Boys should not be overlooked: Sexual violence victimization and associated factors among school-going adolescents in urban Ghana

BACKGROUND

Adolescent sexual violence victimization is still less researched in countries within sub-Saharan Africa, including Ghana.

OBJECTIVES

To estimate the 12-month prevalence of sexual violence victimization and describe the differences and commonalities in the associated factors between school-going boys and girls in urban Ghana.

PARTICIPANTS AND SETTING

Students (n = 1692) aged 13-19 years attending Second Cycle Schools in the Greater Accra Region of Ghana participated in this study.

METHODS

This is a cross-sectional survey involving the use of a self-report anonymous questionnaire. Items measuring sexual violence victimization and correlates were adopted from the 2012 WHO-Global School-based Student Health Survey. Data analysis involved bivariable and multivariable approaches.

RESULTS

Overall, 17.6% (95% confidence interval [CI] 15.7, 19.4) adolescents (males = 10.4% [95% CI 8.3, 13.6]; females = 24.3% [95% CI 21.5, 27.3]) reported sexual violence victimization during the previous 12 months. Girls (compared to boys) were nearly three times more likely to report sexual violence victimization (aOR = 2.74, 95% CI 2.01, 3.74, p < 0.001). Breakup, sexual minority status, and conflict with parents were uniquely associated with sexual violence victimization among females. Regardless of gender, adolescents who were in a romantic relationship (aOR = 1.63, 95% CI 1.19, 2.24, p = 0.002) and reported physical abuse victimization (aOR = 1.84, 95% CI 1.36, 2.49, p < 0.001) were more likely to report sexual violence victimization.

CONCLUSIONS

The prevalence of sexual violence victimization among school-going adolescents in urban Ghana compares with estimates from sub-Saharan Africa, but also warrants the need for universal and targeted prevention regimes against the offence in both boys and girls.

Health knowledge and non-pharmaceutical interventions during the Covid-19 pandemic in Africa

Providing health information is a non-pharmaceutical intervention designed to reduce disease transmission and infection risk by encouraging behavior change. But does knowledge change behavior? We test whether coronavirus health knowledge promotes protective risk mitigation behaviors early in the Covid-19 pandemic in samples from four African countries (Ghana, Malawi, Sierra Leone, and Tanzania). Despite reputations for weak health sectors and low average levels of education, health knowledge of the symptoms and transmission mechanisms was high in all countries in the two months after the virus entered the country. Higher knowledge was associated with increased protective measures that would likely lower disease risk with one exception-knowledge was inversely correlated with social distancing. Respondents largely adhered to mask mandates and lockdowns, but continued coming into contact with others at small, informal gatherings, gatherings not affected by mandates. Knowledge alone did not reduce all risky activities, especially gatherings within other people's homes. Even early in the pandemic, income loss or stress were commonly reported. Our results suggest that early and consistent government provision of health information likely reduced the initial severity of the pandemic in Africa but was not a panacea.

Comparison of childhood household injuries and risk factors between urban and rural communities in Ghana: A cluster-randomized, population-based, survey to inform injury prevention research and programming

BACKGROUND

Childhood household injuries incur a major proportion of the global disease burden, particularly in low- and middle-income countries (LMICs). However, household injury hazards are differentially distributed across developed environments. Therefore, we aimed to compare incidence of childhood household injuries and prevalence of risk factors between communities in urban and rural Ghana to inform prevention initiatives.

METHODS

Data from urban and a rural cluster-randomized, population-based surveys of caregivers of children <5 years in Ghana were combined. In both studies, caregivers were interviewed about childhood injuries that occurred within the past 6 months and 200 meters of the home that resulted in missed school/work, hospitalization, and/or death. Sampling weights were applied, injuries and incidence rate ratios (IRRs) were described, and multi-level regression was used to identify and compare risk factors.

RESULTS

We sampled 200 urban and 357 rural households that represented 20,575 children in Asawase and 14,032 children in Amakom, Ghana, respectively. There were 143 and 351 injuries in our urban and rural samples, which equated to 594 and 542 injuries per 1,000 child-years, respectively (IRR 1.09, 95%CI 1.05-1.14). Toddler-aged children had the highest odds of injury both urban and rural communities (OR 3.77 vs 3.17, 95%CI 1.34-10.55 vs 1.86-5.42 compared to infants, respectively). Urban children were more commonly injured by falling (IRR 1.50, 95%CI 1.41-1.60), but less commonly injured by flame/hot substances (IRR 0.51, 95%CI 0.44-0.59), violence (IRR 0.41, 95%CI 0.36-0.48), or motor vehicle (IRR 0.50, 95%CI 0.39-0.63). Rural households that cooked outside of the home (OR 0.36, 95%CI 0.22-0.60) and that also supervised older children (OR 0.33, 95%CI 0.17-0.62) had lower odds of childhood injuries than those that did not.

CONCLUSIONS

Childhood injuries were similarly common in both urban and rural Ghana, but with different patterns of mechanisms and risk factors that must be taken into account when planning prevention strategies. However, the data suggest that several interventions could be effective, including: community-based, multi-strategy initiatives (e.g., home hazard reduction, provision of safety equipment, establishing community creches); traffic calming interventions in rural community clusters; and passive injury surveillance systems that collect data to inform violence and broader prevention strategies.

Characterizing the prevalence and contributing factors of sexual violence: A representative cross-sectional study among school-going adolescents in two East African countries

BACKGROUND

Sexual violence against minors is a global phenomenon with wide-ranging negative consequences. Global reports suggest that it is a particularly serious issue in East African countries, although research on prevalence and characteristics of violence in these countries is scarce.

OBJECTIVE

The aim of this study was to assess sexual violence and its circumstances among Tanzanian and Ugandan adolescents.

PARTICIPANTS AND SETTING

Two representative samples of secondary school students aged 12-17 from Tanzania and Uganda (N = 1402) were included in this study.

METHODS

Data assessed using standardized questionnaires were analyzed to determine prevalence, characteristics, and contributing factors of sexual violence among youth.

RESULTS

We found high levels of sexual violence (27.2 %) exceeding global average estimates of under 20 %. Significantly more sexual violence experiences were reported by boys (29.9 %) than girls (24.6 %) and by older compared to younger adolescents (30.2 % vs. 19.6 %). Peers were the most frequent perpetrator group, named by 47.6 % of those reporting abuse. Several potential contributing factors for victimization were identified, such as rural living area, external financial support, and being in a romantic relationship.

CONCLUSIONS

Sexual violence is a relevant issue among East African adolescents that occurs in a variety of settings but appears to be most prevalent between peers. Comprehensive sexual education approaches may help to improve the protection of adolescents and to enhance autonomous sexual development.

Anal/anogenital lesion revealing child sexual abuse: A case series of an unusual situation in a black African setting

INTRODUCTION

Child sexual abuse (CSA) remains a big taboo in black Africa with an underestimated prevalence. In our context, the majority of cases are known by revelations of the child at least one year after the facts.

PRESENTATION OF CASES

We report three cases of CSA revealed by an anal/anogenital lesion requiring surgery. All of these patients were female with ages ranging from 20 months to 8 years. The lesions encountered were: an anal abscess, a fissure-in-ano with permanent anal mucosal eversion and a complex perineal tear including partial anal sphincter rupture with partial section of the rectovaginal septum. The outcome was favorable in all cases after surgery. The abuser was subsequently able to be identified after the statements of two of these three children.

DISCUSSION

Detection of anogenital lesions during a pediatric consultation should make practitioners aware of the possibility of sexual abuse. Surgical repair of these lesions can be simple or complex, requiring major reconstructions. In such cases, it's important to listening to the child's voice.

CONCLUSION

Anogenital lesions discovered during pediatric consultation must evoke sexual abuse. The silence and the taboo surrounding these abuses in Africa must be break down.