Child abuse: current problems and key public health challenges
Introduction
The United Nations Convention on the Rights of the Child (CRC) (United Nations, 1996) may be considered as a key document supporting policies on child protection, and as a powerful instrument for primary prevention activities. A child is defined in the CRC as ‘Every human being below the age of 18 years unless under the law applicable to the child majority is attained earlier’ (United Nations, 1996). Article 19 of the CRC specifically addresses child abuse and recommends a broad approach for its identification, reporting, investigation, treatment, follow-up and prevention. Other Articles in the CRC emphasize the important role of the health-care community in monitoring and reporting child abuse, as a channel for advocacy and as direct technical support to countries. Related areas concerning disabled children, parental responsibilities, child exploitation, children in armed conflict, child rehabilitation and others are highlighted in the Articles in relation to survival, development and the right to health care. The CRC, in discussing multiple rights and responsibilities, emphasises that “rights” refers to the child’s “…social, spiritual and moral well being and physical and mental health and to achievement of fullest possible individual development in all areas”.
Child abuse1 has recently been recognized by the World Health Organization as a major health problem (WHO, WHA50.19, 1997) impairing the health and welfare of children and adolescents (Finkelhor & Korbin, 1988). Consequences are often immediate, impinging on the formative years, and long lasting, following victims throughout their lives (Fleming et al., 1999, Grimstad and Schei, 1999).
Given the many forms, circumstances and consequences of violence, measurement of the magnitude of damage from child abuse has until now been very unsatisfactory. Analyses of cause- and age-specific mortality statistics have been the most widely used approach (McClain, Sacks, Ewigman, Smith, Mercy & Sniezek, 1994), but deaths from violence are only the tip of the iceberg, merely hinting at the massive scale of the problem. Mortality data, besides defining only part of the phenomenon, is also underestimated because of the variability of recording methods, definitions used and health workers willingness and ability to recognize child abuse as the cause of death (Sanders, Colton & Roberts, 1999). Data on morbidity and other consequences, such as disabilities and socio-economic implications, are scarce and often unreliable; and existing surveillance systems do not always capture child abuse (Finkelhor and Dziuba-Leatherman, 1994, Ards and Harrell, 1993, Cappelleri et al., 1993, Bertolli et al., 1995, Pieterse and Van Urk, 1989; López, Carpintero, Hernandez, Martin and Fuerto, 1995; Sariola and Uutela, 1994, Sariola and Uutela, 1996, Goldman and Padayachi, 1997, Halpérin et al., 1996, MacMillan et al., 1997; Somander & Raminer, 1991; De Paul et al., 1995, Finkelhor, 1994, Lodico et al., 1996, Berrien et al., 1995). Thus there are inadequate data for solid policy development. To address this important issue, in March 1999 an Initiative on Child Abuse Prevention was launched jointly by the World Health Organization and the Global Forum for Health Research (WHO, 1999a). The initiative aims to ensure adequate implementation of The Plan of Action on Violence and Health endorsed by the World Health Assembly in 1997 to secure an operational framework for public health involvement in the prevention and control of violence.
This paper attempts to look at child abuse from a public health perspective, taking into account the vast cultural diversity in which children and adolescents live. Child abuse per se, children at risk of abuse and violence, while a very important topic of discussion and research in the last years, is a relatively recent one for public health professionals. Furthermore, most studies have been done in economically developed countries and are therefore of unproven relevance for other cultures. This paper must therefore be seen as an attempt to focus the issue of abuse and violence in a broader public health perspective and may serve to highlight greater attention on possible country-specific interventions.
Section snippets
Dimensions and health consequences of child abuse
Child abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power (WHO, 1999a).
Injuries, intentional and unintentional, are a large and neglected health problem in all regions, accounting for 16% of the global burden of disease
Risk factors and children at risk
The primary goal of a public health approach to child abuse is prevention. This approach combines prevention activities with interventions designed to promote early identification and care for victims, as well as preventing the reoccurrence of abuse and its intergenerational transfer. A multidisciplinary approach, which promotes responsibility for health at all levels of society, encourages communication between sectors and makes use of the strengths of all disciplines, while avoiding overlap
The need for a concerted response at country level
In many countries, the issue of child abuse has surfaced in a context of increased mobilization by associations and movements, non-governmental organizations (NGOs), children rights activists or local community struggles. These forces have helped to consolidate research, knowledge and activism around the issue.
Conclusion
By looking at child abuse from a public health perspective we have attempted to highlight some of the many factors that illustrate the complexities and difficulties in responding to the issue. The interconnection and the complexity of the issues underlying child abuse are reflected in the range of structural reforms that need to be developed in implementing a comprehensive response at country level. Child abuse is a significant health and social problem affecting all countries and societies.
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