Cultural perceptions of child abuse in terms of parents’ perspective: a qualitative study in Bandung-Indonesia

Child abuse (CA) is a serious problem and difficult to detect. According to World Health Organization, CA is responsible for 950,000 deaths of children. Many various cultural norms may affect CA. This research aims to determine the cultural perceptions of child abuse in terms of parents in Indonesia. A qualitative study using focus group discussions (FGDs) was conducted with 31 parents who were selected purposively. The FGDs centered on the CA definition, classification, frequency, level of CA (mild, moderate, and severe), and the difference between violence and discipline. The FGDs were divided into three groups based on level of education completeed: elementary and junior high school, senior high school, and bachelor’s degree. The process of the FGDs was recorded, transcribed, and analyzed using manifest qualitative content analysis. This study was conducted from December 2018 to April 2019 in Pamekaran, Soreang Bandung. Every culture in Indonesia perceived that CA is a form of parents’ emotion that could injure children physically and mentally. Indonesian cultures were not familiar with neglect and exploitation. Participants’ opinions regarding level of violence can be categorized as severe if leaving wounds, and needing to be hospitalized. The parents assumed there was CA if it occurred more than twice and/or leaving marks. The discipline purpose is not to mistreat, but for protecting their children’s life, building characters, and educating the children. In conclusion, a cultural perception of parents about CA is a form of parents’ emotion which leads to injury of children physically and mentally.


Introduction
Child abuse (CA) is a serious problem and difficult to detect.][3][4] In the United States, as many as 4.3% of children younger than 18 years were reported to be victims of maltreatment.In 2019, a national estimate for maltreatment reported was 4.4 million (4,378,000).The national rate of screened-in referrals (reported) was 32. 2 per 1,000 children in the national population.Child fatalities are the most tragic consequence of maltreatment.It was estimated nationally that 1,840 children died caused by abuse and neglect with a rate of 2.50 per 100,000 children in the population. 5n the East Asia and Pacific region, the estimates show that violence against children is widespread across the region, with 17-35% prevalence for both boys and girls. 5A meta-analysis for prevalence of CA and neglect in the world showed that according to self-reports, 127/1000 cases came from sexual abuse, 226/1000 from physical abuse, and 363/1000 for emotional abuse. 6cording to the Child Protection Commission of Indonesia (KPAI) from 2011 to 2015 CA increased.Based on an Indonesian national survey in 2012, results showed that 91% children suffered from CA in their family, 87.6% in their school, and 17.9% in their community.West Java was one province with a high prevalence of CA.Therefore, the West Java Government in 2016 declared "Jabar Tolak Kekerasan" or "West Java No Violence".8][9] Bandung ranks second after Jakarta according to KPAI data in 20112016, with 4,605 cases. 10ild abuse is a significant problem which will influence all individuals from every culture. 11,12There are various and diverse cultures and ethnic groups in the world.Indonesia consists of five major islands (Sumatra, Java, Sulawesi, Borneo and Papua) and about 30 smaller groups, and has various ethnic groups, such as Sumatra (Aceh, Batak, Padang, Palembang), Java (Sunda, Central Java, East Java), Madura, Bali, Bugis, et cetera.Ethnic groups are a culture with a distinctive style, who are a group of people bound by awareness and identity of "cultural unity", whereas these are often (but not always) reinforced by the unity of language.The seven elements which are the main contents of each culture can be found in all nations of the world, namely: language, knowledge systems, social organizations, systems of living and technology, livelihood systems, religious systems and arts.Unity of culture is not something that is determined by outsiders, but by citizens of the culture concerned. 13lture influences violence.The perceptions towards the violence is very subjective, based on cultural norms, which depend on the people's beliefs, perspectives, values, or attitudes. 14,15Culture (budaya) came from Sanskrit, bhudhayah, which is the plural form of budhi which means budi (mind) or akal (sense) in Bahasa Indonesia.Culture is defined as the whole system of ideas submission, action, and human creation in human's life which came from the humans by learning. 13,16,17All cultures are influenced by normative customs in defining basic principles in nurturing and caring for children. 18,19ltural diversity exists in the world, for example in Ecuador, mothers believe that baby boys should be given breast milk for longer duration than baby girls.The babies who have fever, diarrhea, and excessive crying are not seen by a doctor, but undergo a submerging practice called "holding back" involving lowering the baby's head into water.Previous research regarding "ngayun budak" or the 'rocking slave' in Indonesian cultures in Cicinde village, Karawang, West Java, identified that this tradition was a ritual which is performed when the baby is 7 days after been born.Basically, this practice is dangerous since it poses a risk of hypoxic ischemic encephalopathy. 20search showed that childcare practices will influence the behavioral and emotional problems in children. 21ltural practices must be reassessed if they are irrelevant. 22Every culture in Indonesia is expected to enforce discipline without violence.Violence and discipline efforts could overlap if performed incorrectly.Punishment could lead to physical and/or emotional abuse, if performed with anger or desperation that does not support children to behave.Most parents shape children's behavior through discipline.[26] The International Society for the Prevention of Child Abuse and Neglect (ISPCAN) questionnaires about CA, include the ISPCAN Child Abuse Screening Tool (ICAST) and ICAST-C (ISPCAN -Children's version) which has been used in pilot projects in children aged between 1217 years old in 4 countries and translated into 6 languages.8] However, ICAST-C does not provide violence frequency and severe to mild violence grouping (which are influenced by the Indonesia cultural diversity).This is expected to contribute in the reporting system and management of CA in Indonesia.The aim of this study was to define the cultural perceptions of CA among parents in Indonesia.This research is expected to provide data for prevention programs of CA in a culturally diverse population.

Methods
The qualitative study was conducted by employing focus group discussions (FGDs) technique.The qualitative content analysis (QCA) was chosen for its potential to enable identification and exploration of cultural perceptions of CA among parents in Indonesia.1] This study was performed from December 2018 to April 2019 in the village office Pamekaran, Bandung District.The study setting was chosen because the prevalence of CA in the village is highest compared with other villages in the district and there are volunteers who were trained in prevention of CA.
The participants were 31 parents of an adolescent who were collected purposively and approached face-to-face by the researcher (RF).The number of respondents represents the various cultures of the existing society in the study setting.The participants were divided into 3 groups based on education level, such as elementary/junior high school, senior high school, and parents with bachelor's degree or equals.Grouping was done to ensure all participants could actively take part in conversations and to provide a more intimate setting, where no one felt their knowledge was better than the other participants and a secure atmosphere was conducive for discussions.
The participants were invited considering their cultural backgrounds such as Javanese (Central Java and East Java), Sundanese, Betawi, Batak, Padang, Palembang, Riau, Bangka, Lampung, Madura, Bali, Sulawesi, East Nusa Tenggara (ENT), and Papua.Each group was analyzed at a different time.The permission to conduct the research was granted from the authorities of National and Political Unity Agency of West Java, Bandung District Health Office.
Inclusion criteria were literate, fluent in Bahasa Indonesia, and willing to be a respondent.Exclusion criteria were parents who cannot communicate well and were not cooperative.Informed consent was obtained from all participants.The study was approved by the Research Ethics Committee of Universitas Padjadjaran, 1332/UN6.KEP/EC/2018.Three FGDs were performed using open questions which encourages the subjects to express their perceptions and views regarding CA.Each FGD was conducted for approximately 60 minutes duration and recorded.FGDs were performed in the community building.Facilitators for the FGDs consisted of moderators, note takers, and observers.The moderators (NA, KM) were trained in conducting FGDs.A list of questions for the interviews was developed based on the literature review.
Data were analyzed through transcription by writing interview results into narration; coding; inputting coded data into computer program based; cleaning by rechecking the codes, theme organization, and data interpretation.Qualitative Content Analysis (QCA) was used to analyze the transcription. 29,31Thematic analysis was applied to report the results of the study.
The data saturation was identified when theme saturation was reached and no further data collection was needed.The data trustworthiness was achieved by member checking, data triangulation and debriefing.The researcher's reflexivity was showed in the data collection and analysis process.Data, codes and theme were analyzed by all research members from different backgrounds such as doctorate in public health/ medical anthropology (KM), family physician (NA) and pediatrician (RF, SE, MD, VK, NS, EF).
Parents perspective of child abuse
After the data were analyzed, five key categories in the cultural perceptions of child abuse among parents in Indonesia were identified: (1) definition of child abuse; (2) classification of child abuse; (3) the frequency of behavior described as child abuse; (4) level of child abuse (mild, moderate, and severe); and (5) the difference between violence and discipline.

Definition of child abuse
The perceptions of CA according to FGDs were activity causing injury to children and occurred because of parents' unstable emotion.This is reflected in the description two participants indicated, Therefore, violence is … parents' unstable emotion.(P9, male, Bangka) Violence … injuring … children's physics and mental … (A5, male, Palembang)

Classifications of child abuse (CA)
Based on the classification of CA, the study explored the perception of parents regarding the classification as described below.

Physical abuse
The study found that participants perceived physical abuse as beatings, including hitting, kicking, stepping on, punching, throwing things, and tweaking.A participant from Sumatra mentioned that swinging their children is accepted and means showing love and affection to correct their children's behavior.
… hitting, kicking, stepping on, and 'God forbid', hopefully keep away from punching, until bleed.(P3, male, Madura) … if you just pinch it into physical violence, get beaten too… (A11, male, East Nusa Tenggara) … tweaking ears if done too hard could also mean physical violence.(A4, female, Sundanese) ... those who came from Sumatra maybe able to accept, and have been a tradition… to raise a child… this means love (P9, male, Bangka)

Emotional abuse
Participants' perceptions regarding emotional abuse were including yelling, and scolding without any reasons.Making the children scared is inconsistent since some said this can be included as violence, but some did not feel that way.The cultures of Papua, Kupang, Betawi, Palembang agree that a loud voice is not a form of violence, but a habit and not intended to hurt.… emotional abuse is when the violence occurs without a reason… (P1, male, Sundanese) … including their mental abuse because we make them scared… (A3, male, Sulawesi) Making the children scared, I think we do that as a reminder only… (P3, female, Madura) ... while being scolded is also actually a mental violence... (K5, female, Sundanese) This is the characteristic of people who came from Medan, Papua, Kupang.Our high pitch voice doesn't mean emotional abuse, but if we do something with the physics, that is violence.(A10, male, Papua)

Sexual abuse
Participants perceived sexual abuse including touching sensitive areas such as private areas and having sexual contact.Sexual harassment can occur even if the child does not understand.

Neglecting
Regarding definition of neglect, participants described it will happen if parents could not afford what the children needs.However, if this is in accordance to the economic condition, it cannot be forced."It's the parents' obligation to fulfil what the children need… However, if we can't afford then we can't force ourselves, this way it's not violence…" (A9, female, Lampung)

Exploitation
Exploitation means forcing the children to work for economic needs, but asking/helping parents at home voluntarily for educating purpose so that the children can be independent, such as cleaning the house, washing the dishes, ironing or sweeping the floor are allowed, and these are the way parents teach children to be disciplined and these are not seen as violence or CA.
If we ask them to work outside … this way, that's means we are abusing our children ... (A4, female, Betawi)

The frequency of behavior described as violence
It is important that parents understand and are aware of CA.This is often confusing if there is no clear definition about it.There were several perceptions regarding the frequency described as violence.Parents did not describe them as violence if it only happened for 1-2 times whether the location is on the hand or foot.They also stated if it does not leave any marks, but it is done to remind only.
Yes, once is enough if the children didn't do anything wrong.If the children didn't listen probably could beat them twice..However, beating doesn't mean until it left any marks, just only as reminder.If we can see the marks, this already can be described as violence.. (A9, female, Lampung)

Level of CA (mild, moderate, and severe)
Participants' opinion regarding the level of CA was described based on type of activities.The mild-moderate CA was described as pinching, tweaking, hitting the hand, foot parts, hitting with things for physical abuse and scolding, and bullying for emotional abuse.Touching sensitive parts and hugging are described as mild-moderate sexual abuse.
Severe physical abuse was described if the activity left wounds, needed to be hospitalized, and included having sex in sexual abuse.Severe emotional abuse was including shouting inappropriate words.The participants stated that high pitched voice was not violence, but is just done according to the cultures and the perceptions of each parents.… pinching is still mild for me.(P9, male, Bangka) … mild one … from hand, ...(P4, male, Palembang) The mild one is touching or "poking" … this is already a violence if touching the unnatural area.(P6, male, Palembang) … violence usually happens only to scold the kid … moderate abuse usually happens by tweaking, pinching … severe abuse means hitting with things or something that is leaving bruises…" (K1, female, Betawi) The most severe abuse is related to "having sex" … holding only is still mild … hugging is moderate… (A8, female, Central Java) … if they touch some part of the body and the owner doesn't allow this is already mild… touching private parts is moderate, and the severe one happens when impregnate and don't want to be responsible and killing the victim … (A4, male, Sundanese) … visum examination means severe abuse.(A11, male, East Nusa Tenggara) … the severe one is when they shout inappropriate words … ask once or twice and don't want to do something and the words come out… (A3, male, Sulawesi) … in Sumatera … Palembang people talk … harshly, with high pitch … just according to each person's perspectives.(A5, male, Palembang) Betawi people character is mostly hard, that's why when calling the children, it's normal to shout, I know that… (A1, female, Betawi)

The difference between violence and discipline
Discipline and violence are very similar so that we found some overlap.According to participants' opinions about the difference between violence and discipline, there were two definitions.First, it is based on the location of the hitting that occurred.For example, if the location is on the head and face area, it can be included as violence.
Second, it depends on the objective.If it does not intend to violate, but to educate the children and build good character.Discipline is defined when the activity is performed out of love.
… hitting on the head and face are violence, but if performed on the hand foot or body… this is love… (P4, male, Palembang) ...hard to ask them to pray so that we could hit their soles of the feet and also tweaking their ears but not injuring… and beating their soles using stick.. (A4, female, Sundanese) ...pinching… sometimes hitting the thigh.. but the objective was not to maltreat the children, but only to educate them so that they would be reticent and for character building.(P3, female, Madura)

Discussion
This study explored parents' perception on CA from different cultural background and generated five themes.

Definition of child abuse (CA)
A research in the United States of America regarding cultural adaptation to prevent CA found parents perceptions regarding how to educate and treat their children were varied according to the ethnic and demography, and the current adaptation and study were limited because of the specific adaptation to the local Latino community. 33Culture in Indonesia can be described based on the participants' knowledge of violence.Indonesian people had been aware and understand the definition of CA.
According to the FGDs, all cultures agree that CA happens due to the parents' unstable emotion, injuring the children's physical and mental condition.These are corresponding with the commonly used CA definition which is all form of activity/treatment which hurt physically, psychically, sexually or by neglecting, causing or can lead to injury or real disadvantage towards the child's health, quality of life, growth and development, or self-esteem. 3,34

Classification of child abuse (CA)
Classification of CA consisted of physical abuse, emotional abuse, sexual abuse, neglecting, and exploitation. 3,4,34,35Child abuse classifications according the World Health Organization (WHO) consisted of physical abuse, emotional abuse, sexual abuse, and neglecting. 36,37Some studies described CA consisting of three types according to the results of the FGDs, which were physical, mental, and sexual abuse. 38cording to some of the other FGDs participants, classification CA was divided into two main types, which were physical abuse and non-physical abuse or some described as physical abuse and psychological/ mental abuse.Cultures in Indonesia were not aware of child neglect and exploitation.In some parts of the Parents perspective of child abuse Dewi, et al.
world, tradition and culture norms usually contribute in various aspects of violence, which are sometimes still considered as acceptable, although they are unreasonable and dangerous.

Physical abuse
Physical abuse consisted of hitting, kicking, pushing, suffocating, scraping, throwing, pulling hair, poisoning, swaying, swinging, pouring hot water, and throwing things.While the participants' opinions regarding the physical abuse were physical abuse was when using hands, including hitting, kicking, stepping on, punching, throwing things, and tweaking.The terminologies of using hands were quite wide, while Indonesian cultures are generally aware of physical abuse.
Previous research regarding "ngayun budak" in Indonesian cultures in Cicinde village, Karawang, West Java.This tradition was a ritual which performed when the baby was 7 days after been born, and this practice is dangerous since it is a risk factor of hypoxic ischemic encephalopathy (JIE). 23Shaking is a prevalent form of abuse seen in the majority of cases who are less than 9 months old.Most perpetrators of such abuse are male, and tend to apply greater force to shake children.
Intracranial hemorrhages, retinal hemorrhages and small fractures at the major joints of the child's extremities can result from very rapid shaking of an infant.They can also follow from a combination of shaking and the head hitting a surface. 18According to the results from the FGDs, Sumatera people mentioned that the tradition to swing the children is allowed to be done, because this is seen as a sign of love.

Emotional abuse
Participants' opinions regarding emotional abuse included shouting and scolding without any cause.If parents make the children scared, some agreed to describe this as violence, while some did not.Emotional abuse can include blaming, belittling, degrading, intimidating, terrorizing, isolating, or otherwise behaving in a manner that is harmful, which can potentially damage the child psychologically or emotionally, by threatening, insulting, ridiculing, and confining. 36,37The results of the FGDs indicate that the participants do not widely know what is included in emotional abuse.

Sexual abuse
Participants' opinions regarding sexual abuse was including holding sensitive parts, such as touching private parts and having sex.Sexual abuse consists of penetration: in mouth, penis, vulva, or anus of the child and another individual and sexual contact: intentional touching directly or through clothing of genitalia, buttocks, or breasts (excluding contact required for normal care). 36,37In principle, all FGDs participants know the type of sexual abuse.

4.2.4.Neglect
Various cultures in Indonesia are not familiar with neglect as one of the CA classifications, but they were able to explain the examples.Participants' opinions regarding the examples of neglect included if parents could not fulfil their children's needs, in accordance to economic conditions and could not be forced.Neglect includes failure to provide adequate food, clothing, or accommodation; not seeking medical attention when needed; allowing a child to miss large amounts of school; and failure to protect a child from violence in the home or neighborhood or from avoidable hazards. 36,37

Exploitation
Exploitation of a child refers to use of the child in work or other activities for the benefit of others, which includes for child labor and child prostitution.These activities are to the detriment of the child's physical, mental health, education, or spiritual, moral, social, and emotional development. 4,35Participants' opinions about exploitation included asking the children to work to meet the economic needs whatever it is, but asking/helping parents at home voluntarily to educate children to be independent, such as cleaning the house, washing dishes, ironing or sweeping could be done, because this way parents could teach discipline.

The frequency of behavior described as violence
Tools to screen child abuse, such as the ICASTfor Children (ICAST-C), did not provide the frequency of this kind of behavior enough to be described as violence (influenced by Indonesia's huge diversity). 3articipants' opinions regarding the frequency of this kind of behavior until it can be described as violence included if the violence was only performed 12 times on the hand or foot, not leaving marks and the objective was to remind not for maltreatment, and if more than that then it can be described as violence.

Level of CA (mild, moderate, and severe)
Overall, 33.3% Asian-American parents educate their children by doing mild violence, and only 2.2% reported severe violence. 20,25Tools to screen child abuse, such as the ICAST-for Children (ICAST-C), have not provided the level of severe to mild violence (which also influenced by Indonesia's huge diversity). 32Participants' opinions regarding the level of violence which can be categorized as mild, moderate, and severe, indicated that these terminologies were including mild-moderate such as physical abuse: pinching, tweaking, hitting the hand, foot parts, and hitting with things, in emotional abuse: scolding, and bullying, while sexual abuse: touching sensitive parts and hugging.
Severe abuse happens if leaving wounds, needed to be hospitalized, and examined, including having sex in sexual abuse.Severe emotional abuse was including shouting inappropriate words.Participants who came from Palembang, Batak, Betawi, East Nusa Tenggara explained that a high-pitched voice is not violence, because it depends on each culture and their perception.

The difference between violence and discipline
Discipline and violence are very similar so that we found some overlap.However, there were several differences between the two.Positive discipline strategies in children were done to improve selfesteem, improve the ability to behave correctly, and develop a positive relationship.Punishments with physical abuse and/or emotional abuse were usually reflecting anger or despair and not as a good strategy to educate children to have a good behavior. 26ildren's education in every culture on earth which has even one kind of child abuse should be analyzed directly if this leads to physical or emotional harm or disadvantage, and the cultural practices should be re-evaluated if found irrelevant. 22The culture of NTT and Madura still use the practice of pinching and confining as an act of discipline.The limits of violence and discipline must be clear.
According to participants' opinion about the difference between violence and discipline, it was based on the location on which the hitting happened, so if the parent hit the head and face area this can be included as violence.The difference between violence and discipline are depending on the objective, not to violate, but to create a better future, and educate the children so that they can be obedient and reticent and for character building.Discipline is when the potentially abusive activity is performed 'out of love'.

Practice implication
The standard of parenting practice is still a dilemma, but the authorities should analyze any practice if it leads to emotional and/or physical harm or disadvantage in children which then should be punished by law. 22Other study results regarding the cultural tradition showed that sexual abuse in children and women faced trouble in finding help.Community campaigns, entertainment programs, education, and mass media play a huge role in preventing CA and women abuse. 39The effort to prevent CA has been announced universally and is considered as an important human right.
The effort of CA prevention was performed in family approach, healthcare approach, treatment approach, law and constitution and related programs, efforts in the community, and social approaches including intervention programs and international agreements. 3,18,40Participants' opinions regarding the expectation and management against CA was so that it does not happen again.The management efforts including prevention were related to the family approach from religion because no religion supports violence, community-based efforts were related to several strategies to prevent violence against children including providing educational television program, and then the social approach by improving the people and government's awareness.
Parents perspective of child abuse Dewi, et al.
There must be cooperation and communication between the community and the government, with responsive efforts to report to the neighborhood watch, neighborhood chief, village officials, police and to inform of incidents of CA.

Limitations of study
The study was conducted in one city of Indonesia.To have broader cultural perceptions, further study is needed to completely determine the perceptions of CA from all 38 current provinces in Indonesia.Research should measure the cost aspects and reachability of the region.Based on the results, CA prevention efforts need more attention from family, community and government members such as the Commission for the Protection of Women and Children (KPPA), social services, public health officers, and police to participate in managing and preventing CA.

Conclusions
From a variety of cultural perceptions, child abuse occurred because of the parents' unstable emotion and was described as causing injury to the children's physical and mental conditions.Mild-moderate child abuse occurred if it happened only 1-2 times, on the hand or foot part, did not leave marks, and was done with the intention to remind the children to be obedient and build character.Severe child abuse occurs when it results in bruises and requires hospitalization.The differences between abuse and discipline are depending on the intention and the cultural norms.Discipline is intended not to maltreat but for the children's behavior and to educate the children.Cultural diversity in Indonesia in principle reflects the knowledge and understanding about CA, which were related to the family approach from religion, communication and cooperation between communities and the government.