Volume 31, Issue 2 (3-2021)                   JHNM 2021, 31(2): 104-113 | Back to browse issues page


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Tohidi Noroodi H, Mirhadyan L, Mosaffa Khomami H, Kazemnezhad Leili E. Risk of Child Abuse and Its Predictors in Mothers with Children Under 5 Years Old. JHNM 2021; 31 (2) :104-113
URL: http://hnmj.gums.ac.ir/article-1-1596-en.html
1- Nursing (MSN), School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
2- Ph.D candidate, Department of Nursing, Instructor, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran , lm30075@yahoo. Com
3- Instructor, Department of Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
4- Associate Professor, Social Determinants of Health Research Center (SDHRC), Biostatistics, Guilan University of Medical Sciences, Rasht, Iran
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Introduction
he ages 1-5 years are a crucial period in forming a child’s personality in the future. The basis of a human personality is developed during this golden age [1]. One of the most devastating childhood events with long-term consequences is abuse and neglect [2]. Abuse is a significant public health problem that has direct and indirect adverse effects on children’s physical and mental health [3].
Child abuse is a broad term that includes maltreatment and neglect of the child. According to the 2020 World Health Organization report, child maltreatment is the abuse and neglect of children under 18 years of age. It includes all types of physical and or emotional ill-treatment, sexual abuse, neglect, negligence, and commercial or other exploitation, which results 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 [4].
Physical, emotional, sexual abuse, and neglect, which can occur alone or in combination, are different types of child abuse. Physical abuse refers to behaviors that lead to any kind of injuries to the child (e.g. hair pulling, hitting); emotional abuse, including behaviors that lead to a feeling of being unloved, unvalued, and unwanted (e.g., insulting, shouting); sexual abuse and enforcing children to engage in sexual activities such as genital or oral contact, exhibitionism and child pornography, and neglect, including poor physical and emotional care [56789]. Children, regardless of age, gender, race, or socioeconomic status, may be victimized by child abuse [10]. Various individual and environmental factors are associated with child abuse that increases its risk. These factors can be family size, poverty, unemployment, parents’ mental status and level of education, the divorce of parents, being young mother, parenting skills, parental addiction, social support network limitations, child’s age and gender, child’s mental and physical disability, residential area, family disputes, homeless children, and history of child abuse of parents [10, 11]. 
It is difficult to determine the prevalence of child abuse due to different definitions of child abuse and also not being reported or misreported in many cases [12]. According to the 2020 World Health Organization report, it is estimated that up to 1 billion children aged 2–17 years have experienced physical, sexual, or emotional violence or neglect in the past year around the world [13]. Child abuse is complex and challenging to study. Nonetheless, international studies reveal that nearly 3 in 4 children aged 2-4 years regularly suffer physical punishment and or psychological violence at the hands of parents and caregivers [4]. Every year, there are an estimated 40150 homicide deaths in children under 18 years of age, some of which are likely due to child abuse. This number almost certainly underestimates the true extent of the problem. In Iran, a study in Yazd City reported the frequency of physical abuse, neglect, and emotional abuse as 62.6%, 15.9%, and 23.7%, respectively [14], and another study showed that the prevalence of emotional abuse, physical abuse, and neglect in Zanjan City in Iran were 78%, 56%, and 39%, respectively [15].
Whereas cultural beliefs are useful in defining child abuse [16], it is essential to identify and change these misconceptions about child-rearing issues [17]. Physical punishment and violence are widely accepted as a norm and acceptable parenting behavior by a large part of society. Some families believe that physical punishment is necessary for nurturing children [18]. Since the mothers have a significant responsibility to take care of the children under 5 years old, it is essential to study the risk of child abuse and identify its predictors. Besides the health, social and educational consequences of child abuse, there is an economic impact, including costs of hospitalization, mental health treatment, child welfare, and longer-term health costs. At the same time, many future psychological, social, and economic problems will be significantly reduced by primary prevention. To maximize the effects of prevention and care, defining the problem and identifying causes and risk factors of child abuse are necessary. Therefore, the present study was conducted to determine the risk of child abuse and its predictors in mothers with children under 5 years old referred to comprehensive health service centers in Rasht.
Materials and Methods
This cross-sectional study was conducted from June to September 2019. The study population included mothers referred to 16 comprehensive health service centers in Rasht City, Iran. The samples were estimated at 450 based on the mean and standard deviation of the overall score obtained for the variable of child abuse risk (69.60±7.28) in the study of Cheraghi et al. [1], with a 95% confidence level and considering the margin error of 0.05.
The inclusion criteria were having an active health care file for children under 5 years old, lacking physical or mental illness to affect answering the questionnaire, and ability to read and write.
A questionnaire collected the study data. The first part of the questionnaire included demographic characteristics, including age, education, occupation, family income, current accommodation status, residency before marriage, marital status and duration of the marriage, marital satisfaction, history of spousal violence, number of children, age, and gender of the last child, history of illness and disability in the child, addiction status and history of abuse during childhood. The second part was the adult-adolescent parenting inventory form (AAPI-2 form A), including 40 items developed and standardized by Bavolek and Keene [1920]. The older version of this questionnaire with 32 items has already been used in Iran [21]. 
In this study, the new version of this questionnaire with 40 items evaluates mothers’ attitudes toward child abuse. It can determine the risk of child abuse in three levels of low, medium, and high risk. This questionnaire has 5 subscales, including “expectations of children”, “parental empathy towards children’s needs”, “use of corporal punishment”, parent-child family roles”, and “children’s power and independence”. It is scored on a Likert scale questionnaire, and participants were asked to rate their agreeability to each of the 40 items. The responses range from strongly agree (score 1), agree (score 2), no opinion (score 3), disagree (score 4), and strongly disagree (score 5). Items 1, 2, 9, 10, 21, 23, and 35 of the questionnaire had a reverse score. To accurately equalize and compare attitude scores, the aligned scores range for each subscale was calculated from a minimum of 1 to a maximum of 5. The higher scores indicated less risk of child abuse. The scores were categorized by risk for child abuse, including “low risk” (score of 4-5), “moderate risk” (score of 2-3.9), and “high risk” (score of 1-1.9) of child abuse. The response time of the questionnaire was 10 to 15 minutes approximately [1920].
The questionnaire was validated by the opinions of 10 faculty members of the Nursing Department. The measured Content Validity Ratio (CVR) was ranged from 0.6 to 1. The Content Validity Index (CVI), in terms of relevancy, simplicity, and clarity was ranged from 0.8 to 1 that confirmed the validity of the AAPI-2 form A questionnaire with 40 questions. The reliability of AAPI-2 form A was evaluated in a pilot study by 20 eligible examples. The Cronbach alpha coefficient for subscales was obtained as 0.89 for “expectations of children”, 0.72 for “parental empathy towards children’s needs”, 0.77 for “use of corporal punishment”, 0.77 for “parent-child family roles”, 0.72 for “children’s power and independence” and totally as 0.92, which indicated the appropriate reliability of the questionnaire.
The collected data were analyzed in SPSS v. 21 and using descriptive statistics and Friedman test to investigate the relationship between subscales and stepwise multiple linear regression to determine the predictors of child abuse risk, at the 0.05 level of significance.
Results
The findings showed that mean±SD age of samples was 30.6±5.2. Most of them had high school diplomas (41.78%), were housewives (79.33%), and all of them were married. Also, the majority of them expressed their satisfaction with their marital life (94.12%) and did not experience domestic violence (82.03%) by their spouse (Table 1). 






The results also showed that the highest mean score was obtained from “children’s power and independence” (3.64±0.58), and the lowest mean score from “parent-child family roles” (2.84±0.74). Also, the mean±SD of the total score of attitude towards child abuse is equal to 3.18±0.56. According to the Friedman test, there is a significant difference (P =0.001) between the attitude score towards the child abuse risk in 5 subscales (Table 2). 


The results of stepwise multiple linear regression analysis to predict the child abuse risk through individual-family variables indicated that education (β=0.161, 95%CI; 0.076-0.247, P =0.001), being an employee (β=0.223, 95%CI; 0.059-0.387, P=0.008), spouse’s education (β=0.128, 95% CI; 0.046-0.209, P=0.002), family income (β=0.092, 95% CI; 0.006-0.179, P=0.037) and addiction status of spouse (β=0.236, 95% CI; 0.006-0.466, P=0.044) were predictors of child abuse risk (Table 3). 


Discussion
The current results indicated that studied mothers have a moderate risk of child abuse. In a study by McKelvey et al. using the same questionnaire, the mean and standard deviation of the total score of parents’ attitudes showed a low risk of child abuse [22]. Also, the study of Asadollahi et al. aimed to determine the attitudes of fathers towards child abuse in health centers in Tabriz City, Iran, indicated that the mean and standard deviation of the total score obtained from the same questionnaire was significantly higher than average. This finding showed a negative attitude of fathers towards child abuse and a low risk of child abuse [23]. The different results probably are due to varying samples in terms of gender. This difference may be because fathers spend less time with their children than mothers. Also, this study was conducted in Tabriz, so different settings and cultures can lead to different findings.
Based on the aligned average scores of child abuse risk in the 5 subscales and total, the lowest risk of child abuse was related to the “children’s power and independence” subscale. Then there was “parental empathy towards children’s needs”, “inappropriate parental expectations”, and “use of corporal punishment”, respectively. The highest risk of child abuse was related to “parent-child role reversal”. Also, the findings of Cheraghi et al.’s study aimed to examine the effect of parental role education on the attitude of mothers of 1-5 years old children towards child abuse showed that the lowest score of mothers’ attitudes is related to the parent-child role reversal subscale [1], which indicated a higher risk of child abuse. In this regard, the findings of the present study were consistent with the results of Cheraghi et al. Whereas in McKelvey’s research, the highest mean score was related to the “parent-child role reversal” subscale, and the lowest mean score was related to the children’s power and independence subscale [22]. This inconsistency can be the result of different research settings. Because the study of  McKelvey was conducted in South America, a high percentage of mothers in the study were single and unemployed and of diverse races with cultural differences with the studied samples. After the “parent-child role reversal” subscale, “use of corporal punishment” had the highest score. In the study of Jabraeili et al. aiming to determine the attitude towards child abuse in mothers referring to Tabriz health centers, also the majority of mothers were opposed to corporal punishment of children [24].
Based on this study’s results, which indicated the highest risk of child abuse related to “parent-child role reversal”, this subscale refers to expect children to be responsible for the happiness and well-being of their parents. Such parents expect their children to do parental roles and responsibilities [19], and most of them are not aware of their child’s abilities and needs. On the other hand, to some extent, this problem is rooted in the culture and misconceptions about children’s growth and development. Abusive parents usually expect their children to behave beyond their developmental stages by pushing them. These parents’ expectations arise from the lack of knowledge about the children’s abilities at different developmental stages. Since most mothers were undergraduate, there is a possibility of not having enough knowledge about parenting skills and believe in inaccurate traditional parenting methods that have been passed down through generations.
The findings of the multiple linear regression test showed that education, being an employee, family income, spouse’s education, and addiction status of a spouse were identified as predictors of child abuse risk among the studied mothers. Boloorsaz et al. conducted a study to assess the relationship of demographic variables with the experience of child abuse among families in Karaj City, Iran. The findings indicated that male gender, family history of psychiatric disorders, education, occupation, smoking and addiction of parents, family income, and the number of family members were predictors of child abuse [10], the findings of the present study mostly consistent with that study.
The study of Doidge was conducted to identify the economic predictors of child maltreatment in Australia. The results showed that economic factors were the predictor of all types of child abuse and domestic violence except emotional abuse and neglect [25]. While in Anderson’s study, which aimed to determine the predictors of potential child abuse among women residing in domestic violence shelters in northeastern Ohio, USA, factors such as a history of childhood abuse, mental disorders, especially posttraumatic stress disorder, and history of spousal violence were identified as the predictors of child abuse risk [26]. The findings of the present study are not consistent with the results of Anderson’s study. This difference may be due to differences in research samples because, in Anderson’s study, the women who were victims of domestic violence were selected. In contrast, in the present study, most samples did not have a history of domestic violence.
Previous studies have shown that factors such as family size, low educated parents, being a young mother, poverty, parenting skills, parental addiction, parental occupation, social support network, age and gender of the child, physical and mental disability, and homelessness increase the risk of child abuse [2728]. The results of the present study also confirmed that the mother’s education and occupation, the spouse’s occupation and addiction status of the spouse, and the family income could predict the risk of child abuse. 
One of the limitations of this study is that the findings cannot be generalized to all families with children under 5 years old. Child abuse can be happened by other family members such as a father, older siblings, or other members of some families. In this study, the risk of child abuse was not considered based on physical, sexual, and emotional categories of abuse and neglect. Although some items in the questionnaire could be related to some types of child abuse, the risk of child abuse was considered in general. Using a self-report questionnaire to collect data can be another limitation of the present study. Therefore, it is suggested that future studies examine the various dimensions of child abuse considering all family members. Based on the findings, it can be recommended to assess the effects of educational interventions on mothers who had a high risk of child abuse.
The findings of the study showed that most mothers had a moderate risk of child abuse and the mother’s education and occupation, family income, spouse education, and addiction status of the spouse are child abuse predictors. Although mothers are the first refuge for children, especially in the early years of life, some characteristics of the mother, child and family can increase child abuse potential by mothers. Therefore, identifying high-risk cases can help health care providers, especially community health nurses, to take appropriate measures for preventing child abuse among children under 5 years old. Consequences of child maltreatment include impaired lifelong physical and mental health, and the social and occupational outcomes can ultimately slow a country’s economic and social development. Preventing child maltreatment before it starts is possible and requires a multi-sectoral approach. Supporting parents and teaching positive parenting skills can reduce child abuse risk reoccurring and minimize its consequences.

Ethical Considerations
Compliance with ethical guidelines

All ethical principles are considered in this article. The participants were informed of the purpose of the research and its implementation stages. They were also assured about the confidentiality of their information and were free to leave the study whenever they wished, and if desired, the research results would be available to them. This research has been registered with the ethical code IR.GUMS.REC.2019.099 in the Ethics Committee of Guilan University of Medical Sciences.

Funding
Guilan University of Medical Sciences funded this study.

Authors contributions
Conceptualization: Homa Tohidi Noroodi, Leila Mirhadyan, and Homa Mosaffa Khomami; Manuscript draft preparation: Leila Mirhadyan and Homa Tohidi Noroodi; Statistical analysis: Homa Tohidi Noroodi and Ehsan Kazemnezhad Leili; Review and editing: All authors.

Conflict of interest
The authors declared no conflicts of interest.

Acknowledgements
The authors would like to appreciate the Deputy of Research and Technology of Guilan University of Medical Sciences, the Nursing and Midwifery Faculty of Rasht, and the staff of studied health centers.


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Article Type : Applicable | Subject: Special
Received: 2021/03/7 | Accepted: 2021/03/20 | Published: 2021/03/20

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