Cultural Perceptions of Child Abuse in Terms of Parents Perspective a Qualitative Study in Indonesia

Background Child abuse (CA) is a serious problem and difficult to detect. According to World Health Organization (WHO), CA is responsible on 950,000 deaths in children aged below 18 every year. As many cultures as various of CA among parents inside. This research aims to determine the cultural perceptions of child abuse in terms of parents in Indonesia. Method A qualitative study using focus group discussions was conducted to thirty one parents that selected purposively. The discussion centered about CA definition, classification, and frequency, level of CA (mild, moderate, and severe), the difference between violence and discipline. The focus group discussions divided in to 3 groups level education, Elementary/Junior high school, senior high school, and bachelor’s degree. The process offocus group discussion were recorded, transcribed, and analyzed using manifest qualitative content analysis. Results Every cultures in Indonesia perceived that CA is a form of parents’ emotion which lead to injure children physically and mentally. Indonesian cultures were not familiar with neglect and exploitation. Participants’ opinion regarding level of violence can be categorized as severe if leaving wounds, need to be hospitalized, and visumed. The parents assumed as CA if occurred more than twice and/or leaving marks. The discipline’s ussualy purpose is not to mistreat, but for goods, character building, and educating the children. Conclusions Cultural perceptions of parents about CA is a form of parents’ emotion which lead to injure children physically and mentally. The community and health workers should be aware to decrease morbidity and mortality of CA Backgrounds

outsiders but by the citizens of the culture concerned [14]. Culture influences violence.
Perceptions towards violence are very subjective, are based on cultures, and depend on people's beliefs, perspectives, values, and norms [15,16]. The word culture came from the Sanskrit word bhudhayah, which is the plural form of budhi, which means budi (mind) or akal (sense) in Bahasa Indonesia. Culture is defined as the whole system of ideas, actions, and human creations in a human's life that came from humans themselves through learning [14,17,18]. Cultures contribute to defining the basic principle of nurturing and caring for children [19,20].
There is great cultural diversity in the world. For example, in Ecuador, mothers believe that female babies should be given breast milk for a shorter amount of time than male babies, and when babies have a fever or diarrhoea or cry excessively, parents do not take their child to the doctor; instead, they just hold the child's head in water. [21] In Cicinde village, Karawang, West Java, Indonesia, the traditional name for culture is name "ngayun budak". At 7 days old, babies are swung around, which may cause hypoxic ischaemic encephalopathy [22]. These cultural actions are part of traditional processes of child care but negatively influence behaviour and emotional problems in children [23].
Cultural practices must be reassessed if they are irrelevant [21]. Several cultures in Indonesia expect discipline to be enforced without violence. Violence and discipline overlap if performed incorrectly. Punishment can lead to physical and/or emotional abuse if performed with anger or desperation rather than to support children in learning how to behave. Most parents shape their children's behaviour through discipline. Physical punishment, such as hitting, is used as a form of discipline in almost every country [24][25][26]. The standards for parenting practices are still an issue, but authorities should analyse this practice with regard to whether it leads to emotional and/or physical disadvantages in children, in which case, such practices then should be punished. [21] The effort to detect CA is not an easy task. There are several questionnaires about CA, such as ISPCAN Child Abuse Screening Tool (ICAST); ICAST includes the ICAST-C (ISPCAN Child Abuse Screening Tool-Children's Version), which has been used in pilot projects with children aged 12-17 years old in 4 countries and has been translated into 6 languages. The ICAST-C questionnaire is able to screen and detect early signs of CA and has already been translated to Bahasa Indonesia; the validity and reliability have been measured [27,28]. However, the ICAST-C does not provide information on the frequency or degree of severity of violence (which is influenced by various Indonesian cultural aspects). This is expected to contribute to the reporting system and management of child abuse in Indonesia. The aim of this study is to define the cultural perceptions of child abuse among parents in Indonesia. This research is expected to identify cultural aspects that often act as obstacles to preventing CA so that people and health workers can become more aware of CA issues and morbidity and mortality due to CA can be avoided.

Study design
The study design is qualitative. Qualitative research is a means for exploring and understanding the meaning individuals or groups ascribe to a social or human problem.
The process of research involves developing questions and procedures, collecting data in the participants' own setting, analysing the data inductively while building from particulars to generate themes, and interpreting the meaning of the data. [29] This research, employing the focus group discussions (FGDs) technique and qualitative content analysis (QCA), was chosen for its potential to enable the identification and exploration of cultural perceptions of child abuse among parents in Indonesia. The term FGDs refers to a method of data collection in which people of similar backgrounds discuss a research topic [30,31].

Study setting
This study was performed between December 2018 and April 2019 in the village of Pamekaran, Soreang Sub-District, Bandung District, West Java Province, Indonesia. The subjects in the study were 31 participants who were purposively selected and divided into 3 groups based on education level: parents with education levels of elementary/junior high school, senior high school, and a bachelor's degree or equivalent; the participants were from Java (Central Java and East Java), Sundanese, Betawi, Batak, Padang, Palembang, Riau, Bangka, Lampung, Madura, Bali, Sulawesi, East Nusa Tenggara, and Papua. Each group was analysed at different times, and before starting, we obtained permission from local authorities, including the Badan Kesatuan Bangsa dan Politik (Kesbangpol) or the National and Political Unity Agency of West Java, Bandung District Health Office.

Participants
Focus group discussions (FGDs) were performed with 31 parents with 3 different levels of education: group 1 included 9 parents who had graduated from junior high school; group 2 included 11 parents who had graduated from senior high school; and group 3 included 11 parents who had graduated from college. The participants were between 29-57 years old, with 27 (87%) parents below 50 years old. There were 22 (71%) women and 9 (21%) men.
The number of children in the family ranged from 1 to 7 children. The majority (90.4%) of the participants had more than one sibling. The characteristics of the FGD participants are shown in Table 1. The participants (parents) originated from various ethnic groups ( Table 1). The majority of the participants were Muslim (77.4%). Twenty-eight participants (90.4%) grew up with their biological parents.

Focus group discussion
Sample perceptions were obtained using the FGD method [30]. Inclusion criteria were being literate, fluent in Bahasa Indonesia, and willing to be a respondent; having an education level of were elementary/junior high school, senior high school, or bachelor's degree or equivalent; and living in Soreang, Bandung District. Exclusion criteria were not being able to communicate well or not being cooperative. We obtained informed consent from all study participants.
This study variable was cultural adaptation from the Bahasa Indonesia version of the ICAST-C [32]. The FGD implementation used open-ended questions to encourage subjects to explain their answers. The facilitators directed the discussion using question guidelines.
FGDs were performed for 60 minutes. The FGD facilitators consisted of 3 people: a discussion guide (facilitator-moderator), note taker, and observer. The moderator played the role of a guide, listener, observer, and data analyser and had prior experience with similar group discussions. In this study, the moderators were from the public health master's degree science team of the Faculty of Medicine Universitas Padjajaran. The facilitator team provided FGD question guidelines according to the problems or topics that were to be discussed. The note taker recorded the process and discussion results. The researcher was an observer who did not affect the answers given by the subjects during FGDs [30].

Analysis
Data tabulation was performed using Microsoft Excel to convert data into information. The data-processing steps were as follows: transcription by writing down the FGD results into narrations that were tailored to be as similar as possible to the real discussion; editing by rechecking the data's validity; coding by assigning codes to materials or information obtained (numeral data) from data in sentences or words according to what was needed; data entry by inputting the coded data into a computer program based on similar categories or the uniformity of the information; and cleaning by rechecking the codes, theme organization, and data interpretation. Qualitative content analysis (QCA) was used to analyse the transcription [29,31]. The analysis process is shown in Table 2.

Ethical Considerations
The study topic of cultural perceptions is a sensitive subject. The participants received an oral explanation of the objectives and procedures of the study to obtain their informed voluntary participation. Considering that the study participants were human, some ethics were explained, and the participants were fully informed of the potential risks and benefits of their participation. The study obtained ethical clearance from the Research Ethics Committee of Universitas Padjajaran, registration number: 0318091294. Violence, in my opinion or words, that causes both physical and mental damage to children or that cause children to "get hurt" or "offended" is both emotionally and physically abusive.

Physically and mentally
Make an effort to hurt physically and mentally

Results
After the data were analysed, five key categories in the cultural perceptions of child abuse among parents in Indonesia were identified: 1) The definition of child abuse, 2)The classification of child abuse, 3) The frequency of the occurrence, which can cause it to be categorized as child abuse, 4) The level of child abuse (mild, moderate, and severe), and 5) The difference between violence and discipline.

Definition of Child Abuse
The perception of CA according to the FGDs was that violence happens because parents' unstable emotions cause physical and mental injury to children. Below are several FGD quotes from participants that clarify their definitions of CA. Exploitation occurs when children are asked to work out of economic need, but asking them to help their parents at home voluntarily for educational purposes so that the children can be independent is allowed; this help includes cleaning the house, washing dishes, ironing and sweeping the floor. This is the way parents teach children to be disciplined, and it does not equate to violence.

The Frequency of This Kind of Behaviour Can Determine Whether it is Described as Violence
Yes, once is enough if the children didn't do anything wrong. If the children didn't listen, you probably could beat them twice. However, beating doesn't mean leaving any marks, only as reminder. If we can see the marks, this can already be described as violence. (A9, female, Lampung) There were several opinions regarding the frequency of behaviours that could be described as violence. The participants did not describe the behaviours as violent if the physical contact only happened 1-2 times on the hand or foot, did not leave any marks or was performed only to remind the children to behave.

Level of Child Abuse (mild, moderate, and severe)
The participants described the level of child abuse in various ways: The participants regarded various types of violence as mild, moderate, or severe. These terminologies included mild-moderate physical abuse such as pinching, tweaking, hitting the hand or foot, or hitting with an object; emotional abuse such as scolding or bullying; and sexual abuse such as touching sensitive parts and hugging. Abuse was considered severe if it leaves wounds, the child needs to be hospitalized and examined, or if the abuse included having sex. Severe emotional abuse included shouting inappropriate words. Using a high-pitched voice was not violent, as this practice varies according to the culture and perceptions of each parent.

The Difference Between Violence and Discipline
The participants described the difference between violence and discipline in various ways: … hitting on the head and face are violence, but if performed on the hand, foot or elsewhere on the body… this is love… (P4, male, Palembang) … it is hard to ask them to pray, so we hit the soles of their feet and also tweak their ears but not to injure them… or beat their soles using stick. (A4, female, Sundanese) … pinching… sometimes hitting the thigh … but the objective is not to maltreat the children, but only to educate them so that they will be reticent and for character building.
(P3, female, Madura) Discipline and violence are quite similar, so we found some overlap between them.
According to the participants, the difference between violence and discipline is based on the location where the blows land; for example, it can be considered violence if the child is hit on the head or facial area. The difference between violence and discipline depends on the objective; discipline is not intended to hurt children but to ensure a better future by educating the children so that they can behave and build character. Discipline means the activity is performed out of love.

Definition of Child Abuse (CA)
Research has been conducted in the United States regarding cultural adaptations implemented to prevent CA, but parents' perceptions regarding how to educate and treat their children vary according to ethnicity and demographics. The current study is limited because of the specific adaptations of the local Latino community [33]. The cultures in Indonesia were described based on the participants' knowledge of violence. Indonesian people are aware of and understand the definition of CA. According to the FGDs, all cultures agree that child abuse occurs because of parents' unstable emotions resulting in the physical and/or mental injury of children. This conception is consistent with the definition of CA, which is all form of activity/treatment that hurts children physically, psychically, or sexually or through neglect that causes or leads to injury or real disadvantages to a child's health, quality of life, growth and development, or self-esteem [3,34].

Classification of Child Abuse (CA)
The classifications of CA consisted of physical abuse, emotional abuse, sexual abuse, neglect, and exploitation [3,4,34,35]. The classifications of child abuse according to the World Health Organization (WHO) consist of physical abuse, emotional abuse, sexual abuse, and neglect [36,37]. In the FGDs, some participants described CA as consisting of three types of abuse: physical, mental, and sexual abuse [38]. Other FGD participants classified CA into two main types: physical abuse and non-physical abuse or, as some described, physical abuse and psychological/mental abuse. People from many cultures in Indonesia are not aware of neglect and exploitation as types of child abuse. In some parts of the world, tradition and culture contribute to various aspects of violence that are sometimes still considered acceptable, although sometimes unreasonable and dangerous.

Physical Abuse
Physical abuse consisted of hitting, kicking, pushing, suffocating, scratching, throwing, pulling hair, poisoning, swinging, pouring hot water over, and throwing things. The participants' considered it physical abuse when hands were used, including hitting, kicking, stepping on, punching, throwing things, and tweaking ears. The terminology for using hands was quite wide, and Indonesian cultures are aware of physical abuse.
Previous research regarding "ngayunbudak" in Indonesian cultures has been conducted in the village of Cicinde, Karawang, West Java. This tradition is a ritual performed when a baby is 7 days old, and this practice is dangerous since it is a risk factor for hypoxic ischaemic encephalopathy (JIE) [22]. Shaking is a prevalent form of abuse experienced by a majority of children who are less than 9 months old. Most perpetrators of such abuse are men, who tend to apply greater force in shaking children than women do. Intracranial haemorrhages, retinal haemorrhages and small fractures at the major joints of a child's extremities can result from the very rapid shaking of an infant. They can also follow from a combination of shaking and the head hitting a hard surface [19]. The results from the FGDs show that Sumatera people mentioned that the tradition of swinging children is permissible because it is a sign of love.

Emotional Abuse
Participants considered emotional abuse to include shouting and scolding without any cause. If parents scare children, some agreed that this could be described as violence, while others did not. Emotional abuse can include blaming, belittling, degrading, intimidating, terrorising, isolating, or otherwise behaving in a manner that is harmful, and it can potentially damage a child psychologically or emotionally through threatening, insulting, ridiculing, and confining the child [36,37]. The results of the FGDs show that an understanding of emotional abuse is not widespread among the participants.

Sexual Abuse
Participants considered abuse to include touching sensitive, private body parts and having sex. Sexual abuse consists of penetration involving the mouth, penis, vulva, or anus of the child and another individual or contact, such as direct, intentional touching or touching of the genitalia, buttocks, or breasts through clothing (excluding contact required for normal care) [36,37]. In principle, all FGD participants were aware of the different types of sexual abuse.

Neglect
Most of the various cultures in Indonesia are not familiar with neglect as one of the types of CA, but they were able to explain examples of such a phenomenon. Participants considered it neglect if parents could not fulfil children's needs in accordance with their economic conditions, though participants recognized that parents only have so much control over these conditions. Neglect includes the failure to provide adequate food, clothing, or accommodation; not seeking medical attention when needed; allowing a child to miss a large amount of school; and failure to protect a child from violence in the home or neighbourhood or from avoidable hazards [36,37].

Exploitation
The exploitation of a child refers to the child engaging in work or other activities for the benefit of others, which includes child labour and child prostitution. These activities are to the detriment of the child's physical and mental health, education, and spiritual, moral, social, and emotional development [4,35]. The participants considered it exploitation if the children were asked to work to meet others' economic needs; however, asking children to help parents at home voluntarily, including cleaning the house, washing dishes, ironing and sweeping, is part of educating children to be independent and can be done to teach children discipline.

Described as Violence
Tools to screen child abuse, such as the International Society for the Prevention of Child Abuse and Neglect (ISPCAN)-Child Abuse Screening Tool (ICAST)-for Children (ICAST-C), do not investigate whether the frequency of this type of behaviour can determine whether it can be described as violence (the frequency is influenced by Indonesia's huge diversity) [32]. The participants believed that the frequency of this type of behaviour can determine whether it can be described as violence; for example, when the violence is inflicted only 1-2 times on the hand or foot and does not leaving marks and the objective is to correct not to maltreat, it is acceptable, but if it occurs more than that, then can be described as violence.

Level of child abuse (mild, moderate, and severe)
Overall, 33.3% of Asian-American parents educate their children by inflicting mild violence, and only 2.2% reported inflicting severe violence [24,25]. Tools to screen for child abuse, such as the International Society for Prevention of Child Abuse and Neglect (ISPCAN)-Child Abuse Screening Tool (ICAST)-for Children (ICAST-C), do not examine the severity of violence (which is also influenced by Indonesia's huge diversity) [32]. Participants' understanding regarding the level of violence, which can be categorized as mild, moderate, or severe, included mild-moderate acts of physical abuse (pinching, tweaking, hitting the hand or foot, hitting with things), emotional abuse (scolding, bullying), and sexual abuse (touching sensitive parts and hugging). Abuse is considered severe if it leaves wounds the child needs to be hospitalized and examined, or if, in sexual abuse, there is sex involved. Severe emotional abuse included shouting inappropriate words. Participants who came from Palembang, Batak, Betawi, East Nusa Tenggara explained that using a high-pitched voice is not violent because the practice varies with culture and perception.

The Difference Between Violence and Discipline
Discipline and violence are quite similar, so we found some overlap between the understandings of these concepts. However, there were also several differences between the two. Positive discipline strategies for children are done to improve their self-esteem and ability to behave correctly and to develop a positive relationship. Punishment through physical and/or emotional abuse usually reflects anger or despair and is not a good strategy for educating children to behave properly [26]. Children's education in every culture in the world may include a kind of child abuse and should be analysed directly to determine whether this leads to physical or emotional disadvantages, and cultural practices should be re-evaluated if found harmful [21]. The cultures of NTT and Madura still use the practice of pinching and confining as an act of discipline. The limits of violence and discipline must be clear. According to the participants' opinions about the difference between violence and discipline, the location on the body where the child is hit can determine whether an action can be considered violence, for example, if hit on the head or face. The difference between violence and discipline depends on the objective: it is not violence if the intention is not to harm the child but to ensure a better future for him or her, educating the child so that he or she can behave and build character. It is discipline when the activity is performed out of love.

Expectation and Management of Violence
Parenting practice standards are still an issue, and authorities should analyse these practices if they lead to emotional and/or physical disadvantages in children, in which case, the practices should be punished [21]. Other study results regarding cultural traditions have shown that children and women have difficulty finding help if they experience sexual abuse. Community campaigns, entertainment programs, education, and mass media play a huge role in preventing the abuse of children and women [39]. The global effort to prevent child abuse has been announced and is considered an important effort. Prevention efforts have been made through various approaches: a family approach, a healthcare approach, a treatment approach, constitutional and related programmes, efforts in the community, and a social approach, including programmes, national constitutional amendments, and international agreements [3,19,40]. Management approaches, including prevention, have been related to the family approach through religion because no religions support violence. Community-based efforts have been related to several strategies to prevent violence against children, including providing educational television programs and social approaches to improve the awareness of both people and the government. There must be cooperation and communication between the community and the government, with responsive efforts to report findings to neighbourhoods, neighbourhood chiefs, village officials, and police and to form localized definitions of child abuse.
Further studies are needed to completely determine the perception of CA in the 34 provinces in Indonesia. Future studies should measure the cost of prevention programs and the feasibility of implementing programs in each region. Based on these results, we hope that the family environment, community, Commission for the Protection of Women and Children (KPPA), social services, public health officers, and police will pay more attention and participate in managing and preventing CA.

Conclusions
The perceptions in various cultures in Indonesia regarding the definition of child abuse (CA) will centre around parents' unstable emotions causing injury to a child's physical or mental health. If such violence occurs only 1-2 times on the hand or foot and does not leave a mark and there is no intention to cause maltreatment, the act is not considered CA. In terms of severe violence that causes bruises and requires treatment in a hospital, this is considered CA. The differences between violence and discipline depend on the intention, as discipline is not intended to maltreat the child but is used to improve the child's future, educating him or her so that he or she behaves and builds character. People from the Papua, Kupang, Betawi, and Palembang cultures agree that using a loud voice is not violent but a habit that is not intended to cause harm. People from diverse cultures in Indonesia know and understand CA in principle, and therefore efforts to prevent CA have been associated with family approaches through religion, communication and cooperation between communities and the government.

Physically and mentally
Make an effort to hurt physically and mentally