Our study aimed at identifying the knowledge, attitude and practice of Iranian medical physicians toward child maltreatment and evaluating the medical training system in this regard.
The results of our study indicated a satisfactory level of knowledge and attitude towards child maltreatment among physicians. 88.93% of the subjects received more than 70% of scores in the knowledge subscale and only 1.7% of subjects were on the poor level in the attitude section which is higher than reported in physicians in Egypt (41%)(44) and community health workers in Tabriz, Iran(38).
Unwanted pregnancies and young age of parents and the disability in children have been detected as child maltreatment risk factors by more than 90% of the participants. History of abuse in a parent reported as a risk factor by 80% of the participants, respectively. 68.5% of the participants agreed that child abuse can occur in high socioeconomic groups and is not primarily associated with poverty. These results are much higher than reported in family physicians in France(45).
98.3% of the participants successfully identified that the children who have been abused, usually delay telling someone about the abuse which is higher than reported in medical and dental residents in Gujarat, India (69.23%)(39), physicians in teaching hospitals in Egypt (70%)(44), and medical and dental doctors in Pakistan (74.1%)(46).
In diagnosing the sign and symptoms of child maltreatment, the knowledge of participants was sufficient in almost all questions. Although, 59.1% of participants detected the bruises over bony prominences as a sign of abuse and didn’t have the knowledge that most such injuries are in fact unintentional(47, 48). Even so, this number is much lower than reported in physicians in Egypt(44) and dentists in Jordan(49), Saudi Arabia(50) and United Arab Emirates(51).
96.6% of the participants admitted that physicians are morally responsible to report any sign of child maltreatment which is in agreement with reported in dentists in Germany(47), and physicians in Gujarat, India (39) and Egypt(44).
The total Attitude score mean was 69.9% which is higher than reported among dentists in Iran in 2017(37).
In the subscale of Attitude towards prevention of child abuse, near all of the participants (97.4%) strongly agreed/ agreed with the importance of child abuse education which is in agreement with results reported among physicians in USA(41), Sri Lanka(36), and higher than physicians in Gujarat, India(39).
86.4% of the participants wanted additional training in child maltreatment which is in agreement with results reported in dentists in Australia(52) and physicians in Sri Lanka(36).
The majority of the participants prefer to refer a case suspected of child abuse to an expert (52.8% to a pediatrician and 86.6% to a psychiatrist) which is in agreement with the results of the study Lane and Dubowitz(41).
The practice of child maltreatment was the most conflictual area among Iranian physicians. 63.4% of the participants have never diagnosed and 82.1% have never reported a case of child abuse which is higher than reported in physicians in Egypt(44) and Sri Lanka(36) and pediatricians in Kuwait(35). The main reasons for underdiagnosis and underreporting are the lack of knowledge or the negative attitude(44). These differences, despite the higher scores in attitude and knowledge, suggest other reasons. As reported in the result section, the main reasons for not reporting in our participants were: possible effect on the child (46.8% agreed), fear of anger from parents and family (41.3% agreed), no legal obligation or authority to report (29% agreed) and the possible effect on their practice (37.1% agreed).
The number of diagnosing and reporting a case of child abuse suggests that 18.6% of the participants diagnosed a case of maltreatment but did not report it. Although, 90.2% of the participants mentioned that they have no history of not reporting child abuse. It suggests that 8.8% of the participants were not completely sincere in answering the questionnaire. This matter and the lower rate of diagnosis and reporting (despite the satisfactory level of knowledge and attitude) suggest the stigma of child abuse among Iranian physicians. Reporting child maltreatment is not mandated in Iran and there is no fixed strategy for it. Some of the cases are referred to the police and some cases are reported to welfare organizations. In addition, social, cultural and religious contexts cause many challenges in reporting abuse cases(16).
In 235 medical students (with a mean age of 24.35 ± 0.76) at the start of the internship course, only 7 (3%) students formerly received any education about child maltreatment. This result is the same as the study of Li et al.(33) in China (3.19% of health-care professionals had ever received education on child maltreatment intervention) and the study of Pelletier and Knox in America(21) (4.5% of medical students had received more than 5 hours of training on child abuse). There are some differences between our study and the studies which report higher former education: the subjects of some studies are not physicians nor the participants are not medical students(39, 44, 46). In particular the study of Sahebihagh et al.(38) which was performed in Tabriz, Iran and has reported 26.99% of former education. The participants of this study are not physicians with a mean age of 39 ± 7.85 and 14 ± 8.14 years of work experience.
We have evaluated the change of knowledge, attitude and practice of medical students toward child maltreatment during the internship course (which is the last 18 months of the medical training in Iran and medical students work as interns in teaching hospitals) to examine the medical training system regarding child maltreatment.
There was no significant difference in five of eight knowledge and attitude subscales. The knowledge of diagnosis of the medical students improved significantly during the internship course. Although, the scores of attitudes towards diagnosis and reporting significantly decreased. In addition, the scores of the practice of prevention and general practice improved during the internship course.
In spite of the fact that the level of knowledge and attitude among medical students are satisfactory after the internship period, our results have shown that Iran’s medical training towards child maltreatment is not sufficient. It was successful in the knowledge area and identifying the sign and symptoms of child maltreatment but the fact that the attitude of medical students decreased is a concerning point. One of the possible reasons can be the difference and paradox that medical students encounter between what they theoretically have learned and what is actually happening in teaching hospitals. There are many ethical, legal and cultural challenges regarding child maltreatment that happen in the medical working places(16). Despite what medical students have learned in theory, they will face uncertainty about the child future, the results of reporting, the situation of welfare centers and the capability of welfare organizations(16).
On the other hand, despite significant improvement in two of five subscales of the practice of medical students, the score of the practice at the end of the internship course is not yet satisfactory. The main questions in the practice of prevention and general practice subscales are about the training courses regarding child maltreatment. The scores of the other subscales which mainly are about diagnosing, treatment and reporting (which are aspects that are actually happening in the practice of a physician) are not changed during the internship course.
In addition to what have been mentioned so far, legal problems are other difficulties in practicing and even educating the medical students regarding child maltreatment. According to the Iran’s law, children’s guardians are their fathers and fathers have the right to discharge the under 18years old children against medical advice (unless there is an urgent life-threatening matter)(53). In many cases the abusive father can discharge the child and as child maltreatment is not mandatory in Iran, the child abuse reporter is not supported by the law(53). On the other hand, in Iranian culture father or husband is the head of the family and the decision maker and the children grow with the value of being a good child for the parents(54).
All these obstacles and their paradox with what medical students learn theoretically before working in hospitals interfere with their education and practice.
There is a significant difference between the change of the scores of the subscale of the practice of prevention and reporting during the internship course in terms of the sex of participants (with better performance of female subjects). This result is congruent with the study of Sanyuz(55) which the majority of the physicians who made a child abuse diagnosis were females. This difference might be explained by the different role of females regarding children. Due to their conventional role, females are more concerned and involved with children(56).
There is a significant difference between the change of the scores of the subscale of the practice of treatment and reporting during the internship course in terms of the marital status of participants (with better performance of married subjects). In the study of Kara et al.(40) among physicians in Ankara, it has been shown that the knowledge of married physicians regarding child maltreatment is significantly higher than the single physicians but there is no examination of the level of practice of physicians regarding child abuse in terms of their marital status in other studies. This difference can have multiple reasons: the difference in involvement and preoccupation with children between married and single people, as the child baring is considered a value in Iranian culture(57), higher empathy in married people(58), and higher empathic skills (such as sharing and helpfulness, and internalizing the moral values) in married couples(59).