Prevalence and factors associated child neglect in a Brazilian state

ABSTRACT

Objective

To quantify the prevalence of neglect against the child and identify its associated factors, based on the cases reported in the state of Espírito Santo between 2011 and 2018.

Methods

Cross-sectional study with data reported in the Notifiable Diseases Information System (SINAN) with all reported cases of child neglect from 2011 to 2018 in the state of Espírito Santo, Brazil. The characteristics of the victim, author, and aggression were studied, and the associations were analyzed by Poisson regression.

Results

The frequency of neglect was 31.3%, being more prevalent in males (PR: 1.48; 95%CI: 1.34-1.63); for the age group of zero to two years (PR: 3.05; 95%CI: 2.65-3.51); among female aggressors (PR: 16.20; 95%CI: 9.98-26.32), and regarding the bond to the victim, we note the highest prevalence of parents/stepfathers (PR: 6.69; 95%CI: 4.16-10.74), both parents (PR: 4.41; 95%CI: 2.84-6.85) and mothers/stepmothers (PR: 2.94; 95%CI: 2.20-3.93).

Conclusions and Implications for the practice

The magnitude of child neglect in Espírito Santo was significant, showing the need to advance in the understanding of this phenomenon and in the implementation of expanded intersectoral public policies aimed at ensuring adequate conditions for growth and development in childhood.

Keywords:
Child; Cross-Sectional Studies; Mandatory Reporting; Prevalence; Violence

RESUMO

Objetivo

Quantificar a prevalência da negligência contra a criança e identificar seus fatores associados, a partir dos casos notificados no estado do Espírito Santo no período entre 2011 e 2018.

Métodos

Estudo transversal com dados notificados no Sistema de Informação de Agravos de Notificação (SINAN) com todos os casos notificados de negligência contra a criança no período de 2011 a 2018 no Espírito Santo, Brasil. Foram estudadas as características da vítima, do autor e da agressão e as associações foram analisadas por meio da Regressão de Poisson.

Resultados

A frequência de negligência foi 31,3%, sendo mais prevalente no sexo masculino (RP: 1,48; IC95%: 1,34-1,63); na faixa etária de 0 a 2 anos (RP: 3,05; IC95%: 2,65-3,51); entre agressores do sexo feminino (RP: 16,20; IC95%: 9,98-26,32), e, em relação ao vínculo nota-se a maior prevalência de pais/padrastos (RP: 6,69; IC95%: 4,16-10,74), ambos os pais (RP: 4,41; IC95%: 2,84-6,85) e mães/madrastas (RP: 2,94; IC95%: 2,20-3,93).

Conclusões e Implicações para a prática

A magnitude de negligência contra crianças no Espírito Santo foi expressiva, demonstrando a necessidade de avançar no entendimento deste fenômeno e na implementação de políticas públicas intersetoriais ampliadas que visem garantir condições adequadas para o crescimento e desenvolvimento na infância.

Palavras-chave:
Criança; Estudos transversais; Notificação de Abuso; Prevalência; Violência

RESUMEN

Objetivo

Cuantificar la prevalencia del abandono infantil e identificar sus factores asociados, a partir de los casos notificados en el estado de Espírito Santo entre 2011 y 2018.

Métodos

Estudio transversal con datos notificados en el Sistema de Información de Enfermedades de Declaración Notificable (SINAN) con todos los casos reportados de negligencia infantil entre 2011 y 2018 en Espírito Santo, Brasil. Se estudiaron las características de la víctima, del agresor y de la agresión y se analizaron las asociaciones mediante Regresión de Poisson.

Resultados

La frecuencia de abandono fue del 31,3%, siendo más prevalente en el sexo masculine (RP: 1,48; IC95%: 1,34-1,63); en el grupo de edad de 0 a 2 años (RP: 3,05; IC95%: 2,65-3,51); entre las mujeres agresoras (RP: 16,20; IC95%: 9,98-26,32), y en relación al vínculo hay mayor prevalencia de padres/padrastros (RP: 6,69; IC95%: 4,16-10,74), ambos padres (RP: 4,41; IC95%: 2,84-6,85) y madres/madrastras (RP: 2,94; IC95%: 2,20-3,93).

Conclusiones e Implicaciones para la práctica

La magnitud del abandono de los niños fue expresiva, demostrando la necesidad de avanzar en la comprensión de este fenómeno y en la implementación de políticas públicas intersectoriales ampliadas que tengam como objetivo garantizar condiciones adecuadas para el crecimiento y desarrollo en la infancia.

Palabras clave:
Niño; Estudios Transversales; Notificación Obligatoria; Prevalencia; Violencia

INTRODUCTION

According to the Convention on the Rights of the Child, every infant is considered a subject of rights, who needs special care and assistance and, to develop properly, needs a family environment, happiness, love, and understanding.¹ Regarding this, the World Health Organization (WHO) argues that well-being in childhood is dependent on factors such as good health and nutrition; appropriate relationships; a safe, clean, and supportive environment; education, and achieving autonomy and personal resilience.²

However, children do not always have their needs met, characterizing the situation of neglect. This type of violence can be conceptualized as the omission of caregivers to provide the basic needs for the healthy growth and development of the child, meeting their needs in areas such as health, education, emotional development, nutrition, and safe living conditions.^3-5 Negligent acts can manifest themselves in food deprivation, lack of hygiene and health care, school absenteeism, lack of supervision and care regarding environment weather, exposure to violent situations and drugs, lack of affective and psychological support, and may culminate in total abandonment.^3,4

Situations of neglect may constitute isolated situations or a pattern of continuous failure in meeting the needs of the child.^6-8 Regardless of its intensity and constancy, this situation negatively influences child growth and development, involving not only physical aspects, but also psychological and emotional aspects, with manifestations even in adulthood. Neglected children are more likely to present deficits in their brain development, difficulties in relating to the external environment, aggressive and antisocial behavior, anxiety, and depression problems, learning difficulties and violent and delinquent behavior in adulthood.^3,8-12

Poverty is pointed out as the main factor associated with neglect, affecting the families’ access to basic social rights such as health, education, transportation, and adequate housing, which end up influencing the parents’ ability to provide the necessary care to the child.^3,6,8,13-15 Other associated factors related to parental characteristics are low self-esteem, difficulty in socializing and the use of social support resources, passivity, use of illicit substances, mental health problems, and difficulties related to planning their lives.^3,16-19 Adolescent parents and those who suffered adverse experiences during their childhood are also more likely to be negligent with their children.^8,18

Regarding the magnitude of this problem, Moody et al.,²⁰ based on a systematic review, found few studies addressing neglect, mainly for the regions of South America, Africa, and Oceania. The mean prevalence of lifetime neglect for the South American region was 6.6% (from data from two studies), while for Europe and North America, it was 30.1 and 27%, respectively. For Brazil, Rates et al.,²¹ when analyzing data from cases reported by the health sector in 2011, found a prevalence of 47.5%, and neglect was the main reported type of violence against children, which agrees with the findings of Malta et al.²² from the data from the 2014 Viva Survey.

Note that the lack of data on neglect may be due to the difficulty of conceptualizing and, therefore, identifying it.^5,23 In this sense, the importance of intersectoral public policies that guarantee the rights of the child becomes more evident, and the health sector gains a fundamental prominence. In addition to health being one of the areas in which childcare is neglected, the performance of health professionals, especially those in Primary Care, alongside families, makes it possible to know family dynamics and identify early risk situations for the occurrence of violent situations.⁴

Adding to the care of children and their families, the health sector is one of the responsible for reporting cases of violence, including neglect. Notification is a powerful instrument to trigger the care network, besides being an important data source for understanding the phenomenon and for developing effective public policies.^4,24 Therefore, this study aimed to quantify the prevalence of neglect against the child and identify its associated factors, based on the cases reported in the state of Espírito Santo, Brazil, between 2011 and 2018.

METHODS

This research is an epidemiological, analytical, cross-sectional study, in which data on mandatory reports of violence against children in the state of Espírito Santo from 2011 to 2018 were analyzed.

Located in the southeastern Brazilian region, the state of Espírito Santo has an population of 3,514,952 inhabitants for 2010, of which 509,102 are children from zero to nine years of age (14.5%). It is divided into 78 municipalities and three health regions. It has a Human Development Index (HDI) of 0.740, considered high, and an average per capita income of R$1,477.00.²⁵ In the period studied, there were 439,422 births in the state, which corresponds to a birth rate of 125.02 births/1000 inhabitants for the period.²⁶

The data were generated by health services from the Notification Form of Interpersonal and Self-Inflicted Violence, registered in the Notifiable Diseases Information System (SINAN) and an integral part of the continuous component of the Violence and Accident Surveillance System (VIVA-Continuo).²⁴ The study period chosen considered the inclusion of violence as a compulsory notification problem in 2011, from the enactment of Ordinance No. 104.²⁷ The Epidemiological Surveillance Sector of the State Department of Health of Espírito Santo provided the database.

All data from individuals aged between zero and nine years old and who had the type of violence suffered identified were included. This age group was chosen since it was the one adopted by the Ministry of Health.²⁴ Before the analysis, a data qualification process was performed to minimize possible errors and inconsistencies, following the guidelines of the Instruction of Interpersonal and Self-Inflicted Notification.²⁴

The outcome analyzed in this study was cases of violence of the type of neglect (no; yes), and the category “no” is constituted of cases that suffered other types of violence. The independent variables were grouped as follows: a) characteristics of the victim: sex (male; female); age group (0 to 2 years; 3 to 5 years; 6 to 9 years); ethnicity/color (white; black/mixed race); presence of disabilities and/or disorders (no; yes); and area of residence (urban/periurban; rural); b) characteristics of the aggressor: age group (0 to 19 years; 20 years or more); sex (male; female; both); bond to the victim (father/stepfather; mother/stepmother; both parents; acquaintance); and suspected alcohol use (no; yes); c) characteristics of the event: number of involved (one; two or more); occurrence in the residence (no; yes); shift of occurrence (morning/afternoon; night/dawn); history of recurrence (no; yes); and referral to other services (no; yes). The blank or ignored data in each of the variables were disregarded, so the total number of individuals may vary.

Analyses were performed in the Stata 14.1 program. We estimated absolute and relative frequencies of the variables and their 95% confidence intervals. Pearson’s Chi-Square Test was used in the bivariate analysis; the variables with p-value lower than 0.20 in this analysis were included in the multivariate model, except for the variable “referral” since we considered that this occurred after the outcome. Poisson regression was used with estimation of prevalence ratios (PRs) in the multivariate analysis. The input of the model variables was performed on two levels: first, the characteristics of the victim were included and in the second level, the characteristics of the aggressor and event; the permanence of the variables in the model respected the criterion of a p-value lower than 0.05.

The Research Ethics Committee of the Federal University of Espírito Santo approved this study under CAAE no. 88138618.0.0000.5060 and opinion number 2.819.597 of August 14, 2018.

RESULTS

From 2011 to 2018, 968 cases of child neglect were reported in Espírito Santo, which corresponds to 31.3% of all the 3,127 reported cases of violence (95%CI: 29.7-33.0). Prevalence in boys was 39.1% (95%CI: 36.5-41.7) and in girls was 25.4% (95%CI: 23.4-27.5).

The data show that the victims are mostly male (54%), aged between zero and two years (57.7%), black or mixed ethinicity/color (74.2%), without disabilities and/or disorders (97.1%) and residents of the urban area (91.7%). Regarding the aggressor, 90.5% were over 20 years of age, 50.7% were women, 47.5% were mothers or stepmothers of the victims and there was no suspicion of alcohol use in 76% of the cases. Neglect, in general, involved only one aggressor (54.4%), occurred in the residence (80.4%), in the morning or afternoon shifts (67.4%) and on a recurrent basis (53.5%). Referral to other services was performed in 78% of the reported cases (Table 1).

Table 1
Characteristics of reported cases of neglect against the child according to characteristics of the victim, the aggressor, and the aggression. Espírito Santo, 2011 to 2018.

Variables	n	%	95%CI
Sex
Male	523	54.0	50.9-57.2
Female	445	46.0	42.8-49.1
Age group
0 to 2 years	554	57.7	54.6-60.8
3 to 5 years	218	22.7	20.2-25.5
6 to 9 years	188	19.6	17.2-22.2
Ethnicity/Color
White	204	25.8	22.9-29.0
Black/Mixed race	587	74.2	71.0-77.2
Disabilities/Disorders
No	909	97.1	95.8-98.0
Yes	27	2.9	2.0-4.2
Area of residence
Urban/Periurban	857	91.7	89.7-93.3
Rural	78	8.3	6.7-10.3
Age group of the aggressor
0 to 19 years	33	9.5	6.8-13.1
20 years or more	315	90.5	86.9-93.2
Sex of the aggressor
Male	65	6.9	5.5-8.8
Female	475	50.7	47.5-53.9
Both	397	42.4	39.2-45.6
Bond to the victim
Father/Stepfather	61	6.6	5.1-8.4
Mother/Stepmother	442	47.5	44.3-50.8
Both parents	379	40.7	37.6-44.0
Acquaintance	48	5.2	3.9-6.8
Suspected use of alcohol
No	341	76.0	71.8-79.7
Yes	108	24.0	20.3-28.2
Number of involved
One	510	54.4	51.2-57.6
Two or more	427	45.6	42.4-48.8
Occurred in the residence
No	172	19.6	17.1-22.3
Yes	707	80.4	77.7-82.9
Shift of Occurrence
Morning/Afternoon	327	67.4	63.1-71.5
Night/Dawn	158	32.6	28.5-36.9
History of recurrence
No	208	46.5	41.9-51.2
Yes	239	53.5	48.8-58.1
Referral
No	211	22.0	19.5-24.7
Yes	750	78.0	75.3-80.6

• ^*
  Absolute frequency totals differ due to the missing data (blank or ignored in notification sheets).

Based on the bivariate analysis, we found that the neglect was related to the sex and age group of the child, the age group and sex of the aggressor, the bond between the aggressor and the victim, the number of people involved in the aggression and the referral (p < 0.05) (Table 2).

Table 2
Bivariate analysis between neglect and the characteristics of the victim, the aggressor, and the aggression. Espírito Santo, 2011 to 2018.

Variables	n	%	95%CI	p-value
Sex
Male	523	39.1	36.5-41.7	<0.001
Female	445	25.4	23.4-27.5
Age group
0 to 2 years	554	52.1	49.1-55.1	<0.001
3 to 5 years	218	24.8	22.1-27.8
6 to 9 years	188	16.8	14.8-19.1
Ethnicity/Color
White	204	28.0	24.8-31.3	0.078
Black/Mixed race	587	31.5	29.4-33.6
Disabilities/Disorders
No	909	31.9	30.2-33.6	0.103
Yes	27	24.6	17.4-33.5
Area of residence
Urban/Periurban	857	31.2	29.5-33.0	0.714
Rural	78	30.1	24.8-36.0
Age group of the aggressor
0 to 19 years	33	10.2	7.3-14.0	<0.001
20 years or more	315	30.7	28.0-33.6
Sex of the aggressor
Male	65	4.4	3.5-5.6	<0.001
Female	475	61.6	58.1-65.0
Both	397	75.2	71.3-78.7
Bond to the victim
Father/Stepfather	61	9.8	7.7-12.5	<0.001
Mother/Stepmother	442	70.2	66.5-73.6
Both parents	379	79.5	75.6-82.9
Acquaintance	48	5.0	3.8-6.6
Suspected use of alcohol
No	341	31.0	28.3-33.8	0.547
Yes	108	32.7	27.9-38.0
Number of involved
One	510	25.2	23.4-27.2	<0.001
Two or more	427	57.4	53.8-60.9
Occurred in the residence
No	172	33.7	29.7-37.9	0.559
Yes	707	32.3	30.4-34.3
Shift of Occurrence
Morning/Afternoon	327	35.2	32.2-38.3	0.135
Night/Dawn	158	31.3	27.4-35.5
History of recurrence
No	208	26.1	23.1-29.2	0.291
Yes	239	23.9	21.4-26.7
Referral
No	211	58.6	53.4-63.6	<0.001
Yes	750	27.8	26.1-29.5

In the multivariate analysis, neglect was associated with the sex and age of the victim, the sex of the perpetrator and the bond to the child. Boys had a 48% higher frequency of being victims of neglect (PR: 1.48; 95%CI: 1.34-1.63). Children aged zero to two years old suffered 3.05 times more neglect than those aged between six and nine years old (95%CI: 2.65-3.51) and, among children aged three to five years old, the frequency was 50% higher (PR: 1.50; 95%CI: 1.26-1.78). The frequency of female perpetrators was 16.20 times higher (95%CI: 9.98-26.32) when compared with males; for the category of both sex, the frequency was 11.97 times higher (95%CI: 7.23-19.81). In general, the aggressors were mainly those with maternal/paternal bonds with children: the frequencies were 2.94 times higher for the mother or stepmother (95%CI: 2.20-3.93), 4.41 times higher for both parents (95%CI: 2.84-6.85) and 6.69 times higher for the father or stepfather (95%CI: 4.16-10.74), when compared with the victim’s acquaintances (p < 0.05) (Table 3).

Table 3
Crude and adjusted analysis of the effects of the characteristics of the victim, the aggressor, and the aggression with the neglect perpetrated against children. Espírito Santo, 2011 to 2018.

Variables	Crude analysis			Adjusted analysis
	PR	95%CI	p-value	PR	95%CI	p-value
Sex
Male	1.54	1.39-1.71	<0.001	1.48	1.34-1.63	<0.001
Female	1.0			1.0
Age group
0 to 2 years	3.09	2.68-3.57	<0.001	3.05	2.65-3.51	<0.001
3 to 5 years	1.47	1.24-1.75		1.50	1.26-1.78
6 to 9 years	1.0			1.0
Ethnicity/Color
White	1.0		0.081	1.0		0.143
Black/Mixed race	1.13	0.99-1.29		1.10	0.97-1.24
Disabilities/Disorders
No	1.3	0.93-1.81	0.122	1.02	0.71-1.45	0.928
Yes	1.0			1.0
Age group of the aggressor
0 to 19 years	1.0		<0.001	1.0		0.931
20 years or more	3.02	2.16-4.23		0.99	0.83-1.19
Sex of the aggressor
Male	1.0		<0.001	1.0		<0.001
Female	14.03	10.99-17.91		16.20	9.98-26.32
Both	17.12	13.43-21.82		11.97	7.23-19.81
Bond to the victim
Father/Stepfather	1.95	1.36-2.81	<0.001	6.69	4.16-10.74	<0.001
Mother/Stepmother	13.93	10.52-18.44		2.94	2.20-3.93
Both parents	15.78	11.93-20.86		4.41	2.84-6.85
Acquaintance	1.0			1.0
Number of involved
One	1.0		<0.001	1.0		0.966
Two or more	2.28	2.07-2.51		0.99	0.69-1.42
Shift of Occurrence
Morning/Afternoon	1.13	0.96-1.32	0.139	1.08	0.98-1.20	0.137
Night/Dawn	1.0			1.0

• ^*
  PR: Prevalence Ratio

DISCUSSION

Approximately one third of the reports of violence against children in Espírito Santo were by neglect, mainly against boys, under the age of five years, and had as main perpetrator those with maternal/paternal bond.

In Brazil, violence of the neglect type presents with varied prevalence among studies, according to the scope and location of the data. Most reports of neglect came from the state of Paraíba between 2010 and 2013, reaching an 81% frequency.²⁸ In the municipalities of Porto Alegre, state of Rio Grande do Sul,²⁹ and in Rio das Ostras, Rio de Janeiro,³⁰ neglect reached frequencies of 41% and 36.8%, respectively, with magnitudes only lower than those of sexual violence. These frequencies were closer to that found for the state of Espírito Santo. In cities in the north of the state of Minas Gerais³¹ and in the city of Ribeirão Preto, São Paulo,³² this was the least reported type of violence against children.

Our study showed a higher prevalence of neglect against boys than girls, which agrees with another study.³³ Alternatively, a systematic review found that this problem was more frequent with female children in North America, whereas Europe and Asia showed no gender difference.²⁰ This difference is believed to be due to the gender violence rooted in Brazilian society.³⁴ In this sense, women are understood as the “fragile gender” and, therefore, would need more care, whereas the experience of adverse situations during childhood would be a preparation for adulthood in males.^3,35

The younger the child, the more dependent they are to meet their physical, psychological, and emotional needs, which makes them more vulnerable to situations of neglect, as demonstrated in this study, where the prevalence were higher the younger the child. Egry et al.,³³ analyzing notification data from the city of Curitiba, Paraná, found that 27.3% of the notifications occurred with children under one year of age. Note that childhood is an essential period of human growth and development, and that the child needs an adult who can guarantee the appropriate conditions and stimuli also considering that this age group has a difficulty in verbalizing their needs.^8,21 Moreover, during the period between conception and two years of age, known as the 1000-day window, guaranteeing the best living conditions for the child is essential, since the changes that occur at this development window can influence the quality of life and the predisposition of diseases in adulthood, which can impact society and future generations.^36-38

Historically and culturally, women are the main caregivers of children and, therefore, among the main perpetrators of neglect, which agrees with this study findings regarding the variable gender of the aggressor. Today, in addition to the role of responsible for the home and family, women also have an increasing insertion in the labor market, configuring a double journey that can be difficult and stressful.³⁹ According to data from the last Brazilian census, conducted in 2010, 37.3% of households had women as the main responsible.⁴⁰ This new conformation can lead to the occurrence of situations of neglect, especially if the mother lacks the support of a partner or other people, a situation aggravated by the culture that domestic work should be exclusively female.³³

Also, according to the data of our study, fathers or stepfathers were the main perpetrators of neglect, with prevalence higher than mothers and both parents. Many parents, although present, do not provide the attention and support necessary to their partner in the care of children and the home; in more extreme situations fathers abandon their families and the children are raised only by their mother. Culturally, fathers have the role of provider of financial conditions of the house, and this role is considered sufficient in the family dynamics.³³ Dubowitz et al.⁴¹ found in their study that greater involvement of fathers in family life decreases the risk of neglect against the child. This neglect of men in childcare is ratified by the society that considers their absence in health and education-related care as natural, a situation reinforced by the posture of services that end up not involving fathers in situations concerning children, such as medical consultations and meetings between parents and teachers.^33,41

Note the difficulty in defining the intentionality of the act of neglect compared to other types of violence.⁶ Parents are often negligent due to lacking another choice or having inadequate knowledge of the child’s needs and not understanding that such situations constitute neglect, such as leaving their children alone at home to go to work due to lacking access to daycare, school, or other caregivers.^3,5 When looking at the problem of child neglect, we also must consider the distinct cultural patterns of what should be the behavior of parents towards their children and what are the principles that should govern care for children.^3,14

Another issue of note is the role of the health sector in preventing and tracking neglect, considering its proximity to families and communities, which facilitates the understanding of the different social, economic, and cultural dynamics that involve them, providing mechanisms not only for identifying situations that trigger violence, but also those necessary for overcoming them.⁴

Situations that may be consequences of the neglect can be identified during pediatric and childcare consultations, such as low weight or short stature, poor hygiene care, non-attendance to the vaccination schedule, absence of consultations, among others.⁴ Therefore, health professionals should be aware and investigate the causes of these situations and make the notification to trigger the network of protection services, even in the face of suspected violence.²⁴ This simple attitude will contribute to breaking the cycle of violence and to minimizing the negative effects of the neglect that the child may be suffering. In this context, broadening the view of health professionals beyond the biological issue and strengthening the network of intersectoral articulation is essential to make actions really effective regarding guaranteeing the rights and protection to the children and the Brazilian family.³⁹

Our study limitations are those related to underreporting of cases and the use of secondary data. Since the data used in this study come from the health sector, the registered cases refer to individuals who have access to these services and who are identified and notified by health professionals; therefore, cases of neglect that did not reach the health service are outside the analyzed universe. In addition, we highlight the gaps involving the quality and the completion of the filled notification forms; we minimized this limitation with the database qualification process. In this sense, the need for permanent education policies for health professionals on the theme of violence is evident, thus qualifying the process of identification and notification of cases of violence against children.

CONCLUSION

Neglect proved to be a problem with a significant magnitude among children of Espírito Santo, mainly affecting males and those under five years of age. Those with maternal/paternal bonds who should be the main caregivers presented themselves as the main perpetrators of this type of violence.

This study allowed including elements for a greater understanding of neglect, given the gaps in the literature. Thus, it is important to highlight the role of health professionals, including nurses, in identifying and monitoring victims and their families. The information collected in this study provides subsidies for these situations to be identified in clinical care and in the day-to-day of multidisciplinary teams.

Note that the context in which neglect occurs is fundamental for its understanding, identification, and for planning interventions. We cannot stigmatize families as good or bad, instead help them find solutions. Only with an expanded view of this phenomenon and with the involvement of various sectors, especially those related to the fight against poverty and social inequalities, will we be able to guarantee the necessary conditions for the growth and development of all children to protect them from situations of neglect. This is a responsibility that the whole society and the State must share.

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Edited by

ASSOCIATED EDITOR

SCIENTIFIC EDITOR

Publication Dates

• Publication in this collection
  19 Dec 2022
• Date of issue
  2023

History

• Received
  08 Apr 2022
• Accepted
  20 Aug 2022