Training and knowledge of professionals of the health family team on reporting mistreatment of children and adolescents

Objective: To analyze training and knowledge of professionals in the Family Health Team on reporting the mistreatment of children and adolescents. Methods: Cross-sectional study carried out in three municipalities of Ceará State, Northeast Brazil, from January to April 2012. The research included 51 professionals: physicians (9), nurses (26), and dentists (16) who worked in the Family Health Strategy. A questionnaire was used for data collection, which received descriptive statistical analysis with the Pearson’s chi-square test, being significant p≤0.05. Results: There was a predominance of professionals who had not participated in violence against children and adolescents training (86.3%); who knew the Child and Adolescent Statute (90.2%), and how to notify mistreatment (62.7%). Most interviewees said that the health unit had the form (70.5%), and they knew where to refer victims to Endereço para correspondência: Gracyelle Alves R. Moreira Rua Silva Jatahy, 1.140, apto. 903, Meireles CEP 60165-070 – Fortaleza/CE E-mail: gracyremigio@gmail.com Fonte financiadora: Fundação Cearense de Apoio de Desenvolvimento Científico e Tecnológico – FUNCAP (Edital de Segurança Pública 05/2008) Conflito de interesses: nada a declarar Recebido em: 2/8/2012 Aprovado em: 4/2/2013


Introduction
Violence against children and adolescents is a historical phenomenon, manifested as a public health problem due to the effect on the morbidity and mortality of the group, as well as the negative impact on the quality of life of the victims.It is estimated that, worldwide, about 3,500 children and adolescents die every year for physical abuse or neglect (1) .In Brazil, external causes (accidents and violence) are the leading cause of death in the population between 5 and 19 years (2) .
Reporting child and adolescent abuse stands out as a coping strategy in this context.In Brazil, a legal provision was introduced by the Child and Adolescent Act (Estatuto da Criança e do Adolescente -ECA), regulating mandated reporting of any suspected or confirmed abuse case by professionals in health care and education (art.13), establishing a penalty for those who fail to do so (art.245) (3) .
The act of reporting starts a process that aims to end violent attitudes and behavior within the family and by any aggressor, promoting socio-sanitary care aimed at the protection of children and adolescents in situations of violence (2) .For the Health System, this action also aims to generate reliable records of cases of abuse, enabling to scale the problem from an epidemiological point of view and develop public policies to tackle and prevent this situation (4) .This procedure is supported by Ordinance n. 1.968/2001, from the Brazilian Ministry of Health, which established mandatory reporting of abuse against children and adolescents, treated at the Brazilian public Unified Health System (Sistema Único de Saúde -SUS) (5) .Recently, the Secretariat of Health Vigilance, recognizing this demand, published in January 25th, 2011, the Ordinance n. 104 that established about domestic, sexual and/or other violence as the 45th event of mandatory notification, establishing flows, criteria, responsibilities, and duties to health care professionals and services (6) .
Despite all these legal apparatus, the literature (7,8) still demonstrates the underreporting of cases, indicating the existence of structural weaknesses and barriers in the process of notification.International and national studies (9)(10)(11) indicate the presence of technical difficulties in the act of reporting, making it impracticable to conduct systematic action.The type and the degree of severity of abuse, insufficient knowledge about the identification of cases and reporting procedures, the deficiency of the service network, cultural influences, distrust in child protective services and fear of legal involvement are some of the factors that interfere in the decision of the professional who is supposed to report (11)(12)(13) .
In this context, it is relevant to investigate the process of reporting violence against the child population, to determine the arrangements of primary care services and the experiences of the workers involved in this scenario.Thus, the study analyzed the amount of training and information of the Family Health Team professionals on reporting child and adolescent abuse.

method
This study is part of a wider investigation, continuing the research performed in other regions of the state of Ceará (12,14,15) , aiming to obtain a situational diagnosis about the report of abuse in children and adolescents in municipalities located in the state, within primary health care.
This was a cross-sectional study, conducted in the municipalities of Cascavel, Ocara, and Pindoretama, located in the Metropolitan Region of Fortaleza (MRF), state of Ceará, in the period of January-April 2012.Data from the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística -IBGE) revealed that the combined population in these municipalities is of approximately 108,832 inhabitants (16) .
Participants were physicians, nurses, and dentists who worked in Family Health Teams in the selected municipalities.The absent professionals, those who were on vacation or sick leave during the period of data collection were excluded.
Initially the study assumed a census character, because it intended to investigate the professionals that make up the population.The target population was estimated based on data provided by the Department of Primary Care (DPC) that, at the time of the research had 36 physicians, 36 nurses, and 32 dentists, totaling 104 professionals in the three municipalities.Because the percentage of adherence reached 49%, the authors assumed that the investigation was conducted from a convenience sampling, widely used in exploratory studies, which supports the importance of this research; however, it is recognized that the studied sample does not represent the population.
To guide data collection an anonymous questionnaire with 32 closed questions was used, tested, and validated in a previous research (12) .This instrument identifies variables related to the following characteristics: sociodemographic, training, knowledge, and professional conduct in cases of abuse in children and adolescents.In the operationalization of data collection, the research was first presented to the Municipal Health Administrators, and then questionnaires were administered to professionals through visits to the Basic Health Units of the municipalities.
Data were organized, coded, tabulated, and statistically analyzed using the Statistical Package for the Social Sciences -SPSS, version 16.0 for Windows.Descriptive statistical analysis and calculation of measures were performed through the Pearson correlation test (χ 2 ).Differences were considered statistically significant at a significance level of 5%.
It was established as an outcome the reporting of abuse in children and adolescents, and as independent variables: gender (male; female); occupation (physician; nurse; dentist), age (22-30 years, 31-40 years; >40 years), marital status (married, not married); time since graduation (less than 05 years; 05-10 years; above 10 years), post-graduation (none; specialized in public/collective health; specialized in specific areas, internship in specific areas), time serving the FHS (less than 05 years; 05-10 years, above 10 years), attended training (yes, no); knows the Child and Adolescent Act (yes; no); knows the report form (yes; no); health unit has the report form (yes; no); knows where to refer cases (yes; no); reads about the subject (yes; no); issue is discussed at work (yes; no); knows the institutions for assistance of victims of violence (yes; no).The variable age range obeyed stratification according to the economically active population (16) .
The research followed the ethical aspects of research involving human subjects in conformity with Resolution n. 196/96 by the National Health Council, participants' anonymity was guaranteed, and the Term of Consent was signed.The research was approved by the Research Ethics Committee of Universidade de Fortaleza, under opinion n. 072/2007.results Among the 104 selected professionals, 51 (49%) participated in the survey: nine physicians, 26 nurses, and 16 dentists.The mean age of participants was of 347±8.4years.When analyzed by professional category, the mean age of physicians was of 42.7±8.0,nurses, 33.5±7.4,and dentists, 32.1±8.2years.The sociodemographic characteristics and professional education indicate the predominance of: females (62.7%), the age group between 22 and 30 years (37.4%),unmarried participants (60.8%), time since graduation lower than 5 years (43.1%),professionals with expertise in the area of public/collective health (34.7%) and less than 5 years of service for the Family Health Strategy (51.1%).
Among the respondents, 86.3% did not attend training in the area of violence against children and adolescents, 90.2% knew the Statute of the Child and adolescent (SCA), 62.7% knew the abuse report form, 70.5% said the health unit had the report form and 82.3% knew where to refer victims (Table 1).Most professionals reported not having the habit of reading about the subject (86.3%) and that the subject was not discussed at the health facility (76.5%).Regarding knowledge of institutions for assistance of children and adolescents who are victims of violence, 88.2% did not have this information (Table 1).In relation to the identification and the decision-making in the face of cases of child and adolescent abuse, 62.8% said they did not come across situations of abuse in their professional practice.Among the 37.2% who had identified a case, 60% reported it and 40% did not perform this procedure (Table 1).
There was no association between the act of reporting and the sociodemographic and professional education variables (Table 2).Despite the lack of statistical association, it is important to mention that the characteristics of professionals that most reported cases of abuse were: nurses (40%), female participants (35%), age range 31-40 years (25%), time since graduation above 10 years (30%), specialization in specific areas (35%), and serving the Family Health Strategy from 5 and 10 years (25%).It is noteworthy that, regarding the variable marital status, the married (30%) and unmarried (30%) participants showed the same percentage.Table 3 highlights the statistical relationship between the reporting of abuse and the variables related to training and professional knowledge.It was observed that the variable "attended training" is associated (p=0.035) with the act of reporting, while the other variables were not significant.

Discussion
An important aspect highlighted in this research and that is in line with the literature (12,17) is the fact that most professionals did not attend training on the thematic of violence against children and adolescents.Several authors highlight the scarce knowledge about the issue as one of the main factors affecting the identification and reporting of maltreatment (11,13,17,18) .This issue does not present itself as an object of training in the continuing education of Family Health Teams.For this reason, many professionals are not prepared to handle cases and do not offer help that has real impact on the health of victims (19) .Despite the low percentage of professionals who attended specific training in the area, most showed a degree of adequate knowledge about the reporting of abuse in children and adolescents, demonstrating to know the Children and Adolescent Act, the report form, and where to refer cases.This fact was also observed by Pires et al (17) in a survey conducted with 92 pediatricians in southern Brazil.
It was also found that readings about the theme are not of interest to health professionals and that the subject is not usually discussed in health units.The distance is justified because violence is not a typical health problem, it extrapolates the biomedical model, and, therefore, it has not been addressed in most programs of graduations and post-graduation courses (18) .
Training professionals in understanding that violence is a health problem that requires committed attitudes is a widely recognized demand by public policies directed to face the phenomenon in Brazil.The National Policy for Reduction of Morbidity and Mortality from Accidents and Violence postulates as one of its guidelines the "training and mobilization of health professionals working at all levels of health care within SUS, in order to overcome problems related to the investigation and information on accidents and violence" (20) .
There was also a lack of knowledge about institutions for assistance to maltreated children and adolescents among health workers.This unawareness of the services that make up the protection network existing in municipalities constitutes a difficulty in dealing with violence at the local level and reflects the disarticulation of intersectoral actions and the lack of protocols that establish systematized actions and referral networks.
Another finding of the present study revealed the predominance of professionals who had not come across cases of abuse in their practice, similar to the work of Luna, Ferreira, and Vieira (12) and differently from the study by Pires et al (17) .However, some factors may have interfered with the detection of this fact: the existence of recall bias -because some workers performed their duties for many years, in more than one institution; the influence of cultural aspects; the lack of knowledge about the problem; and the training technically grounded in the biomedical sciences.Often, health professionals only identify a situation of violence when clinical signs evidence it, and this could hamper the discovery of the case, because victimization is not always revealed through physical injuries (13) .A professional look is necessary to reveal the implicit demand that the individual presents.However, finding the truth is no easy task, as it requires a differentiated analysis, based in a theoretical framework that guides it (21) .
Among professionals who had found cases of abuse, prevailed those who reported violent situations.This result goes against another investigation (22) , which portrayed a larger share of unreported cases.In the conception of Day et al (23) , heath professionals omit to report due to misinformation, denial, and fear.The idea that it is necessary to investigate and confirm a case with evidence generates doubt and feelings of insecurity, leading many professionals to fail to report (11) .
In this study, the sociodemographic and professional training characteristics were not statistically significant for the act of reporting.However, other studies have reported association between some of these aspects and the reporting of maltreatment in children and adolescents (12,15) .Luna, Ferreira and Vieira (12) found that the training years and the fact of having a post-graduation had a positive association with the act of reporting.Silva (15) , in addition to the items above, also found that marital status and working years in the Family Health Strategy significantly influenced the initiative to report.Although there was no statistical association, it is noteworthy that nurses, women aged between 31 and 40 years, professionals who were graduated for over 10 years, professionals with post-graduation in specific areas, and those who had between 5 and 10 years of FHS service, showed greater chances to report in the face of cases of maltreatment.Studies (12,14,15) indicate nursing, among the professional categories, as the one that most reports cases, denoting the proximity and sensitivity of these professionals with the demands of the health system.The strong presence of the nurse in the management process and the more accurate perception of community's subjectivity (15) may be associated with greater engagement of this professional category with the issue of identification and reporting of violence against children and adolescents.
These results also suggest that the personal and professional maturation provides greater experience, formation of bonds, communication skills, greater sensibility to the issue, and confidence, favoring the appropriation of skills laid out in the legislation and safety in the act of reporting.In contrast, one cannot infer that the experience will provide a better procedure in the face of cases of violence, because the initiative and interest to enforce the rules and ordinances in effect are independent of practice time, being related to the individual position of each professional.
Among the training and professional knowledge variables, only the variable "attended training" was positively associated with the act of reporting.This finding reinforces the assumption of the positive influence of information, access to training, and qualification of the training about the actions of reporting cases of violence against children and adolescents (12) .
A study undertaken with 419 professionals of Primary Health Care in Northern Ireland found that many workers failed to report for not knowing how to proceed in cases of abuse (24) .A Brazilian research also showed that the lack of information was associated with failing to report maltreatment (17) .Leite et al (25) investigating and intervening with intern physicians in the state of São Paulo, analyzed the number of reports of child abuse before and after the completion of a course on the subject.It was found that there was a considerable increase in the number of reports after completion of training.However, in the months following the course, there was a drop in the number of records.This fact suggests that offering a single course is not enough, so a process of continuing education is necessary, that addresses the issue involving all dimensions and fosters the development of professional skills for effective action on the issue.Some limitations of this study should be taken into consideration.The adherence to the survey was 49% of the studied population, and according to professional category, the adherence was of 72.2% among nurses, 50% among dentists, and 25% among physicians.Factors such as work overload, complexity of the object of research, lack of interest and training, and the lack of a compensation for participation in the study may be related with these rates.It is important to add that, when a convenience sampling is used, the results do not reflect the general behavior of professionals of the Family Health Strategy in relation to the act of reporting in the municipalities investigated.It is also possible that most of the associations between the dependent and the independent variables did not present statistical significance due to the limited percentage of professionals who reported abuse, which were those who come across some There are also limitations inherent to the cross-sectional design of the study that measures a particular phenomenon in a single moment, making it impossible to deepen it, which would be possible through qualitative research.
In summary, the presence of gaps in the training and knowledge on the reporting of child and adolescent abuse was verified among the 51 professionals of the Family Health Team.It was found that dealing with this procedure involves difficulties that do not appear on other types of report.For this reason, the approach of health services and professionals to minimize the problem must take into account these obstacles and complexities.
The present findings indicate that the educational institutions, the management, and the health services should get together to discuss the redirection of existing curricula to meet current demands, and the establishment of continuous training on violence against the child and its confrontation, involving the issue in discussions and lectures within the health services.

Table 1 -
Distribution of professionals according to information on training, knowledge, and behavior when faced with situations of child and adolescent maltreatment in the municipalities of Cascavel, Ocara, and Pindoretama, state of Ceará, Brazil, 2012 SCA: Statute of the Child and Adolescent.

Table 2 -
Relationship of sociodemographic data and professional training with reporting cases of child and adolescent abuse in the municipalities of Cascavel, Ocara, and Pindoretama, state of Ceará, Brazil, 2012 FHS: Family Health Strategy.

Table 3 -
Variables related to the reporting of abuse and neglect in children and adolescents.Cascavel, Ocara and Pindoretama, state of Ceará, Brazil, 2012 SCA: Statute of the Child and Adolescent.