Prevalence and determinants of childhood physical abuse in South Asia: a systematic review and meta-analysis of the studies

doi:10.21203/rs.3.rs-5295742/v1

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Systematic Review

Prevalence and determinants of childhood physical abuse in South Asia: a systematic review and meta-analysis of the studies

https://doi.org/10.21203/rs.3.rs-5295742/v1

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Background

Child physical abuse (CPA) is a significant public health issue in South Asia, yet regional data on its prevalence and contributing factors remain fragmented. This study aims to systematically review and analyze the prevalence of CPA across South Asia, focusing on geographic and period influences.

Methods

A systematic review and meta-analysis of studies published between 2000 and 2023 was conducted. Studies reporting on the prevalence of CPA in South Asia were included, and a random-effects model was used to calculate pooled prevalence estimates. Subgroup analyses was conducted based on country and publication years of the study. Meta-regression of the study was also performed according to age and publication years.

Results

A total of 23 studies were analyzed, revealing a pooled prevalence of 44%, with significant variation across countries, ranging from 2.3–72.7%. Conflict-affected regions, Afghanistan exhibited the highest prevalence (72%), while Pakistan had the lowest (27%). High heterogeneity (I²=99.84%) reflects the influence of cultural, socioeconomic, and legal factors on abuse rates across the region. Additionally, an increase in CPA prevalence was observed over time, with a 1.8% (p = 0.01) rise during the study period.

Conclusions

The findings emphasize the urgent need for improved child protection measures, legal enforcement, and further research to understand the underlying causes of abuse and regional disparities in South Asia.

Child physical abuse

Prevalence

South Asia

Temporal Change

Age

Child physical abuse (CPA) are serious public health concerns worldwide since these are attributed to violations of human rights and have considerable adverse impacts on person’s physical and psychosocial health [1, 2]. There is a great amount of research showing that there are strong enduring effects of physical abuse and other adverse childhood experiences on mental and/or physical health in adulthood [3–6].

The Federal Child Abuse Prevention and Treatment Act provides a clear definition of child abuse. It states that child abuse encompasses any recent action or neglect by a parent or caretaker that leads to the death, severe physical or emotional harm, sexual abuse, or exploitation of a child. It also includes any action or neglect that poses an immediate and significant risk of serious harm to the child [3]. Child abuse comprise both physical and mental harm inflicted upon a kid, arising from acts of neglect or deliberate activities. Typically perpetrated by individuals known to the child, such as parents, family members, caregivers, or close family friends [6]. Physically maltreated children can demonstrate aggressive and violent behaviors towards their peers [7, 8], experience a reduction in good connections and show disruptive and antisocial behavior [9]. Across the world, 25–50% of all children report being physically abused. Severe instances of child abuse are usually reported to the police or local religious and community figures, who sometimes possess insufficient knowledge in topics concerning children.

Although the South Asian countries were committed to the Sustainable Development Goals (SDGs) by eliminating all forms of violence against children, girls and women including harmful practices and discrimination, they are still far from achieving the targets. A meta-analysis study found that Asia reported the third-most CPA (11.6%, ranging from 7.5 to 22.3%) behind, Africa and North America [10]. Another systematic review showed that about 50% of children experienced some types of physical abuse in their entire life. The prevalence of severe physical abuse ranges from 27.8–47.6% in the region [11]. However, under-reporting of violence, abuse and maltreatment has been a serious concern in this region. The limited focus on child sexual and physical abuse (CSA and CPA) within Asian countries may be attributed, to some extent, to various circumstances. One potential element is the perception, held by certain individuals, that these difficulties are not substantial societal concerns among Asian people due to religious and cultural norms [11].

However, although a growing body of evidence has been generated on CPA, several countries, particularly countries from South Asia and Africa have little or no data. Studies reported many barriers including failure to recognize abuse or maltreatment and provide access to social and response support [12], stigma and perceived helplessness [13] and obstinate cultural belief and weak justice against perpetrators [14]. Therefore, this systematic review and meta-analysis aims to generate evidence through collating reported prevalence of physical abuse among children in South Asia. Our study would help policymakers design informed policies, intervention strategies and advocacy programs to prevent and control abuse in this region.

Literature search strategy

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-2020) guideline as illustrated in the [15]. The study protocol registered with PROSPERO (Registration number: CRD42024553672), an international registration forum for prospective systematic reviews [16]. We searched and identified relevant literature from major databases (PubMed, Web of Science, BanglaJol, Scopus, PsyclINFO, and other sources) with the combination of terminologies ‘Prevalence’, ‘Child physical abuse’, ‘Child physical assault’, ‘Child maltreatment’, ‘Child physical violence’ for each the South Asian country.

Eligibility criteria

We only searched studies on child physical abuse in South Asia countries. The inclusion criteria are (i) Studies published in only English language from January 2000 to December 2023, (ii) clear definition of children, and physical abuse/maltreatment/neglect (respondents aged 0 to 19 with experience of physical abuse), (iii) reported prevalence or determinants of CPA and (iv) published in peer-reviewed quantitative articles. We excluded (i) studies reporting CPA outside of South-Asia, (ii) non-original articles (systematic reviews, narrative reviews, commentary, opinion, case-report, or grey literature), (iii) lack clear definitions of terminologies mentioned above and qualitative studies,

Study screening and selection

We applied double-blind screening to identify relevant articles. Two authors (ZF and MMR) screened titles and abstracts and put them into an Excel sheet. Some uncertain studies based on the title and abstract were also included for further evaluation after removing duplicates. Then two authors (ZF and AAN) screened full text and applied the eligibility criteria to select studies. Any kind of disagreement that arose was discussed with the lead authors and included with reasons. We identified 381 studies from different databases on the prevalence of physical abuse of children in South Asia. After reviewing the titles and abstracts of selected studies, there were 264 studies are excluded because of duplications and irreverence with this research objective. After a series of screening, our study finally selected 23 articles and included for analysis (Fig. 1).

[Please insert Fig. 1 here]

Figure 1. Flow diagram for included studies in the meta-analysis.

Data extraction and analysis

We extract the following meta data from all the included studies: first author name, article published year, study design, age range of the respondents; sample size; response rate, residence (urban or rural), prevalence of physical abuse, prevalence based on gender and other risk factors.

Next, we estimated the pooled prevalence of CPA from individual studies in South Asian countries through forest plots. The plots illustrate pooled prevalence with 95% confidence intervals. We used random-effects models to combine studies, used τ² and I² Q statistics to estimate the heterogeneity, and used I² statistics to calculate the observed variance between studies. We examined publication bias with Egger's test and the aid of a funnel plot. Then, depending on the type of variable, we conducted comprehensive statistical analyses [17], specifically subgroup analysis and meta-regression, to identify and examine the moderating variables that cause differences in the global prevalence of child [18, 19].

Quality Assessment

Study quality was evaluated following Joanna Briggs Institute guidance on conducting prevalence and incidence reviews [20–22]. A set of eight criteria was applied. This evaluation confirmed that the studies were representative, and study participants were included appropriately. Sample size was sufficient in 15 (65%) studies. Study subjects and setting description for all were described elaborately. The identified sample studies justified a sufficient coverage of data analysis aside from two studies (8.70%) [23, 24]. A standard and objective criterion was applied to achieve a reliable measure in 15 (65%) studies. There were 18 (78.26%) studies took important confounding factors and subgroup into consideration (Supplementary Table S1).

Study characteristics

We included 23 articles in this systematic review comprising of 40696 study population with their age ranges from 0 to 18. Studies included samples from Afghanistan (n = 3) [25–27], Bangladesh (n = 5) [28–32], India (n = 4) [23, 24, 33, 34], Nepal (n = 4) [35–38] and Pakistan (n = 7) [39–45]. No studies were found in Maldives, Bhutan, and Sri Lanka (Fig. 1). All the studies except for three longitudinal studies were cross-sectional design [31, 42, 43]. The prevalence of CPA varied from 2.3–72.7%. Seven studies (31%) adopted International Society for the Prevention of Child Abuse and Neglect (ISPCAN) Child Abuse Screening Tool [27, 29, 31, 34, 39, 42, 43], and 8 studies (35%) used developed/pre-tested and structured questionnaire [26, 30, 32, 33, 40, 43–45]. Seventeen studies evaluated the socio-economic status of the study participants. Most of the studies used either probability sampling [26, 28, 33, 35–39, 42] or non-probability sampling [27, 29, 30, 40, 41, 45], albeit eight studies did not report sampling technique [23, 24, 31–34, 43, 44]. Supplementary Table S2 described the characteristics of studies included in the study.

Prevalence of Physical Abuse in South Asia

The weighted pooled prevalence of CPA regardless of gender, country, and year was 44.0% [95% CI: 31% -58%]. There was a large amount of heterogeneity in the prevalence of CPA (I² = 99.84%; Cochran Q-statistic p < 0.001) (Fig. 2).

Sub-group analysis of the prevalence of physical abuse according to time

These studies were segregated into two periods. The first period was comprised of studies conducted between 2000 and 2017 (48% of the total studies). The second period comprised of the studies from 2018 to 2023 (52% of the total studies). Random effect meta-analysis showed that prevalence of physical abuse was higher in 2018–2023 period (52%; 95% CI: 37–66%) compared to 2000–2017 period (34%; 95% CI: 14–57%). However, high degree of heterogeneity was observed in both time frame (I² value of 99.83% and 99.77% for first and second period respectively; p = 0.0001).

Subgroup analysis according to country

Afghanistan

The Random Effect meta-analysis showed that the pooled prevalence of physical abuse of child in Afghanistan was 72% [95% CI: 69–75%].

Bangladesh

The weighted pooled prevalence was 39% [95% CI: 0–98%] based on reported total prevalence. This analysis also identified a high degree of heterogeneity among the population (I² = 99.01%; Cochran Q-statistic p < 0.001) (Fig. 3).

India

A total of 4 cross-sectional studies comprised of 7910 participants was selected from India. The weighted pooled prevalence of CPA in India was 65% [95% CI: 45–83%]. A high degree of heterogeneity was observed (I² = 99.01%; Cochran Q-statistic p < 0.001) (Fig. 3).

Nepal

A total of 19548 study participation was included encompassing 4 cross-sectional studies. The weighted pooled prevalence of CPA in Nepal was 45% [95% CI: 34–57%] with a high degree of heterogeneity among the population (I² = 99.84%; Cochran Q-statistic p < 0.001) (Fig. 3).

Pakistan

The weighted pooled prevalence of CPA in Pakistan was 27% [95% CI: 17–39%] with a high degree of heterogeneity among the population (I² = 98.40%; Cochran Q-statistic p < 0.001) (Fig. 3).

Meta-regression analysis according to age of the study participants

Due to the variation in age group, we could not calculate the weighted pooled prevalence of CPA according to age. Therefore, the mean age group of the studies were considered to perform the meta-analysis. The mean age group was calculated for the studies that did not report the mean of the study population. The prevalence of CPA increases 0.4% (p = 0.06; Fig. 5) for every one-year increase in mean age of the study participants (Fig. 5.A).

Meta-regression analysis according to publication year

This study examined the temporal change in prevalence of physical abuse. Overall, there was a 1.8% increase (p = 0.01) in the prevalence of CPA during the study period (Fig. 5.B).

Publication Bias

The supplementary figure S1 represents the funnel plot which indicates asymmetry in the prevalence of physical abuse among the selected study (Supplementary Figure S1).

The goal of this systematic review and meta-analysis was to determine the prevalence of CPA in South Asia and investigate its relationship with age and geographic location. The data demonstrate that physical abuse is common throughout South Asia, with substantial differences depending on age, country, and publication years.

The pooled prevalence of CPA among the analyzed studies was 44%, ranging from 2.3–72.7% with substantial heterogeneity (I²=99.84%). This fluctuation demonstrates significant heterogeneity in the context of abuse among South Asian nations, indicating differences in cultural, socioeconomic, and legal elements shaping child safety [46]. The findings are comparable to an earlier systematic review that included studies between 2015 and 2020 and depicted that physical violence is the most prevalent violence against children in South Asia [11]. Additionally, children experienced more severe physical punishments ranging from 27.8–47.6% by caregivers/mothers. However, our study found a considerable high prevalence of physical abuse in South Asia compared to global and continental prevalence. For instance, a study reported that the prevalence of CPA globally, immediately after COVID-19 was 18 % (95 %CI: 1–29 %) [47]. Moeover, the study found the prevalence of CPA in Asia was only 16%. However, no continent except Africa had a similar prevalence of CPA (43 %, 95 % CI:40–46%) [47]. Even i a pre-pandemic meta-analysis, the global prevalence of CPA was found significantly lower than our findings, only 17.7 % (95 % CI: 13. % − 3.6 %) [48]. Hwever, n studies reported the prevalence of CPA in South Asia. This is likely because in the developed countries, mostly in Europe and North America, child protection laws are not enforced strictly, and corporal punishment is culturally accepted [49].

Among the five South Asian countries that were part of the analysis, there were notable differences in the prevalence of physical abuse. At 72%, Afghanistan had the highest prevalence, while Pakistan had the lowest at 27%. The occurrence of CPA differs significantly across countries and within the different areas of a country due to inconsistencies in definitions, differences in research methodologies, children's circumstances, and methods of reporting. Therefore, comparing the findings is challenging. Conflict-affected nations like Afghanistan had high rates of CPA. This was also observed in Palestine, where the occurrence of CPA was 34% [50]. The protracted conflict and instability in the area, which have undermined social institutions and made children more susceptible to abuse are attributed to Afghanistan's high prevalence [51]. This shows that social structures and constitutional protections decompose in conflict environments, making child abuse worse. We also found a high incidence of CPA in India with 65% [95% CI: 45–83%]. A study in North-eastern India reported the occurrence of CPA was only 21.9%, while a South Indian study in Kerala reported comparatively higher frequency with 78.5% of school-going reported experiencing physical abuse during their lifetime. However, our study revealed a comparatively lower prevalence of CPA in Pakistan, only 27% [95% CI: 17–39%] although we weighted seven studies. Hyder and Malik reported that CPA in workplaces ranges from 10 to 60. Numerous factors, such as differing degrees of social awareness, law enforcement, and child abuse reporting mechanisms, can be blamed for the glaring variations in prevalence between nations (WHO, 2020). Ahad MA et al., in their recent scoping review of child maltreatment in 4 South Asian countries, exhibit that the occurrence of physical maltreatment among child laborers was (15.14 %). Thesubgroup analysis revealed that the prevalence of physical abuse has increased over time. The pooled prevalence for studies undertaken between 2018 and 2023 was 52 and 34% for those between 2000 and 2017. Moreover, there was a 1.8% increase in CPA during the study period. It is supported by previous studies reported that the global prevalence of CPA before and after COVID-19 was 18 % [47] and 7.7 % [48]. The obsrved trend in child abuse reports and awareness may be attributed to recent improvements in socioeconomic conditions in certain regions of South Asia, which may also have contributed to an increase in actual abuse rates [52]. Due to lockdowns and economic hardships exacerbating family troubles and abuse, the COVID-19 pandemic has also been connected to an increase in child abuse worldwide [53]. However, studies conducted around the world over the past ten years have also shown an increase in reports of child abuse. It is crucial to remember that an increase in reports does not always mean that there is more abuse occurring; instead, it could be the result of better reporting and detection systems [54]. Both factors might be at work in South Asia, indicating the need for more research to determine what causes this temporal increase in physical abuse.

Limitations and future implications

When interpreting the review's observations, it is important to keep a few things in mind. The accuracy of the pooled prevalence estimates is reduced by the high heterogeneity among the studies, and bias may have been presented by variations in study design, data collection techniques, and reporting requirements. Furthermore, the results cannot be applied to the whole South Asian region because of the exclusion of nations like Bhutan, Sri Lanka, and the Maldives because there are not enough published articles.

Notwithstanding these drawbacks, the study emphasizes how critical it is for South Asia to implement more robust child protection laws and programs. In order to promote healthy parenting techniques and increase public awareness of the detrimental effects of physical abuse, governments and international organizations must collaborate. All forms of child abuse should be outlawed by law, and to ensure that those who commit these crimes are held accountable, enforcement procedures must be strengthened. In addition, addressing socioeconomic inequality and challenging harmful gender norms through culturally sensitive interventions is essential to lowering the incidence of physical abuse in South Asia.

The systematic review and meta-analysis on child physical abuse in South Asia reveals a concerning prevalence of physical abuse among the analyzed studies. This study clearly indicates that the prevalence in this region is considerably higher compared to many developed and least developed regions. Moreover, the frequency of physical abuse is increasing over time. However, we did not analyze the socio-economic characteristics including gender due to variations in definitions and contexts. The findings underscore the complexity of addressing child abuse across South Asia, necessitating tailored interventions that consider local contexts, improve reporting mechanisms, and enhance child protection laws and enforcement.

Ethics approval and consent to participate

Not Applicable.

Ethics approval and consent to participate

Not Applicable.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

Not Applicable.

Funding

This research received no grant from any funding agency in the public, commercial or not-for-profit sectors.

Zaki Farhana¹, Abdullah Al Noman², Fatema Tuj Johora Lima³, Safayet Jamil⁴, Anton Abdulbasah Kamil⁵, Mohammad Meshbahur Rahman^6*

Contributions

MMR conceived and directed the present study. ZF, AAN, FTJL, SJ, AAK, and MMR contributed to systematic searching. All the authors helped with article searches, review, and selection. ZF and MMR performed the analysis and interpreted the results. All authors contributed in drafting the manuscript. AAK and MMR worked as methodological advisors. All authors revised it critically for important intellectual content, read and approved the final manuscript.

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No competing interests reported.

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Prevalence and determinants of childhood physical abuse in South Asia: a systematic review and meta-analysis of the studies

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Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Methods

Literature search strategy

Eligibility criteria

Study screening and selection

Data extraction and analysis

Quality Assessment

Results

Study characteristics

Prevalence of Physical Abuse in South Asia

Sub-group analysis of the prevalence of physical abuse according to time

Subgroup analysis according to country

Afghanistan

Bangladesh

India

Nepal

Pakistan

Meta-regression analysis according to age of the study participants

Meta-regression analysis according to publication year

Publication Bias

Discussion

Limitations and future implications

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1