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Balkan Epidemiological Study on Child Abuse and Neglect

Final Report Summary - BECAN (Balkan Epidemiological Study on Child Abuse and Neglect)

Executive summary:

The EU/FP-7 funded BECAN project (ID: 223478), is an epidemiological study aiming at shedding light to the magnitude and characteristics of the phenomenon of child abuse and neglect (CAN) in 9 Balkan countries (AL, BG, BH, HR, MK, GR, RO, RS and TK). It was coordinated by the Institute of child health (GR) and with participants organizations Children's human rights centre of Albania (AL), South-West University 'N. Rilski' (BG), University of Sarajevo (BH), University of Zagreb (HR), University of Skopje (MK), Babes-Bolyai University (RO), University of Belgrade (RS) and provincial health directorate of Izmir (TK), while it also involved Insituto deli Innocenti (IT) as an evaluator and University of Nottingham (UK) as a scientific consultant. It consists from two main threads of research, namely its epidemiological field survey and its case-based surveillance study.

Project context and objectives:

Issues concerning child abuse and neglect transcend national borders, affecting developing as well as developed countries. As the 2002 United Nations landmark study on violence against children stresses out, violence against children occurs in every country and cuts across social, cultural, religious and ethnic lines. However, the Executive Director of UNICEF, during her speech in the Parliamentary Assembly's ordinary session of the January 23 2007, argued that data and legislation on violence against children are often alarmingly weak, while she pointed out that child abuse and neglect (CAN) should be a priority area in the international co-operation agenda. The lack of data and legislation is associated with the inconsistencies of classification of child maltreatment and a lack of common research methodologies; consequently, little internationally comparable data are produced. WHO (1999) and UNICEF-IRC (2005) have both arrived to the same conclusions.

The discrepancy in methodologies used internationally to collect data on child maltreatment, as well as the inherent difficulty of collecting data on childhood have often led European governments and international organizations to base their policy-making decisions and prevention and intervention planning on statistical data concerning child fatality rates (e.g. UNICEF-IRC, 2003) and number of cases of CAN reported to governmental authorities. However, there is much more CAN in the world than the reported cases' statistics reveal, as all international organizations working on children's rights point out.

If limited data are available in industrialized countries, even less is known about child abuse and neglect in non-European and/or European countries with relatively lower standards of socioeconomic development, such as the majority of Balkan countries. With the exception of Greece and Slovenia that provided some limited data on child maltreatment (principally, child mortality rates) to the ChildONEurope Secretariat for the purposes of a survey concerning the evaluation of European national systems of statistics and registration on child abuse (2007) , we have no officially published data on CAN concerning the most of Balkan countries. Balkan countries have faced many political, social and financial changes during the last decades. Children in some of the Balkan countries have faced war, the effects of immigration, and the loss of their beloved ones, among other hardships. This makes them more prone to have witnessed, experienced, and be exposed to, one or other form of maltreatment. For example, a UNICEF opinion survey in 2001, conducted through interviews with 15.200 children from 9 to 17 years in 35 countries in Europe and Central Asia, indicated that 59% of children had experienced violent or aggressive behaviours within their families; of these children, 61% were residing in Eastern and Central Europe and Central Asia and 54% in Western Europe. In addition, Children's Human Rights Centre of Albania has argued that in 2004 Albania had no national authority for the rights of the child, while and at the same time it was estimated that the number of Albanian children trafficked in Europe for sexual and economical exploitation was between 3000 and 5000. In Bosnia and Herzegovina, more than 3000 registered cases of abuse in the family were identified, while 33.8% of children studied by UNICEF and 'Save the children' (2004) claimed that they know between one to three children that have suffered abuse in the family. These numbers are suspected to be much higher in the general population, as in many traditional cultures of Balkan countries there is a widespread belief that family is the sole responsible for the child, and consequently instances of child abuse and neglect stay most of the time unreported and private (Sicher, et al., 2000) .

The alarming rates of CAN in industrialized countries and the even higher suspected numbers in developing countries have led to the global will of creating a safer and more appropriate society for the children. The UN Convention on the rights of the child, which was entered into force on the 3rd of September 1990, is globally considered as the most specific and progressive human rights treaty ever adopted. Subsequently, the Council of Europe launched the campaign 'Building a Europe for and with children' aiming to promote children's rights across the wider Europe and, in 2006, the European Commission published a Communication entitled 'Towards a European strategy on the rights of the child', setting out its intention to lead the creation of the first-ever EU strategy on children's rights and committing itself to a number of actions to this end. Meanwhile, WHO (2005) declared injuries and violence as a top priority area for action unfolding subsequent initiatives.

In February 2012, the Council of Europe adopted a new strategy to protect and promote children's rights. The strategy is a response to the needs expressed by governments, professionals working with children, civil society and children themselves who ask for more efforts to be made in implementing existing standards. In order to achieve this, the Council will provide guidance and support to its 47 member states on how best to bridge gaps between the rights and the reality of children in Europe.

The strategy will focus on four main objectives:
1. promoting child-friendly services and systems (in the areas of justice, health and social services);
2. eliminating all forms of violence against children (including sexual violence, trafficking, corporal punishment and violence in schools);
3. guaranteeing the rights of children in vulnerable situations (such as those with disabilities, in detention, in alternative care, migrant or Roma children) and
4. promoting child participation.

Although such initiatives create the appropriate political circumstances for actions, reliable, compatible and comparable data on CAN are considered to be a necessary tool for implementing the Convention on the Rights of the Child, as they will constitute an important step towards integration and cohesion of national EU policies. However, in the European area, up to 2007 only five EU Member Countries and one EU Candidate Country have established specific instruments, programmes or bodies dealing with the collection of statistical data on children (ChildONEurope, 2007).

Therefore, considering the lack and the urgency of obtaining internationally comparable consistent data on CAN, the lack of relevant data in the Balkan area and the rapidly changing reality of the Balkan countries, the Balkan epidemiological study on child abuse and neglect (BECAN) has been carried out. In order to obtain comparable data, the study followed the ChildOnEurope's suggestions on how to solve problems of comparison of data coming from different countries . Namely, all partners agreed on the concepts and definitions to be used, followed the same methodology and applied the same –culturally validated- instruments for data collection and considered the relevant law in force in each country. Particularly, ICAST instruments that created by ISPCAN/UNICEF and recommended by WHO were used for data collection in all participating countries, while the existence of ethnic minorities has also being considered in the study's methodology. Knowing the rates of child abuse and neglect would:

- facilitate the implementation of the Convention on the Rights of the Child in the Balkan area;

- contribute to the necessary policy-making activities of the Balkan governments in order to comply with the suggestions of the aforementioned Convention;

- provide information on factors that might allow the prevention or the early identification of CAN;

- improve the assessment of effectiveness and efficiency of the health welfare practices related to the subject;

- allow a financial planning closer to reality concerning the acts that should be taken to combat CAN;

- allow a step towards unifying the diagnostic processes of CAN in the Balkan area allowing in such a way an easier and faster cooperation, with the option to extend these diagnostic processes to other countries in the European area;

- facilitate further harmonization and unification in issues of child health and protection services and relevant legislation;

Main objectives of the BECAN study

a) Mapping CAN in school-aged children (11 to 16 years-old) of the general population in the Balkan countries and,

b) Mapping CAN in children (11 to 16 years-old) that have dropped out school in the Balkan countries.

In order for the main objectives to be achieved, the following steps were made, as provisioned:

- National networks of experts and child services were created in order for the Consortium to have access to information available on CAN issues in each partner country, including national databases of identified cases of CAN.

- ICAST questionnaires that were used for the collection of epidemiological data, translated and culturally validated for all partner countries (considering also ethnic minorities residing in partner countries) before their application to national samples.

- Pilot studies were carried out before the starting of the main study in order to test the appropriateness of the translated and culturally validated instruments and the methodology planned for data collection.

- The data collected during the main epidemiological study, were cleaned and data analysis was planned in order to get the final results and arrive into conclusions.

Secondary objectives of the BECAN study

- To reveal a more realistic picture concerning the difference between reported and hidden incidence and prevalence of CAN cases in school-aged children in Balkan countries through the Consortium's access to national databases of identified cases of CAN and the obtaining of epidemiological data.

- To deliver comparable and compatible data on CAN for all participant countries facilitating common policy-making activities, future research and better understanding of CAN features.

- To achieve the unification of definitions related to CAN issues and relevant research tools among Balkan countries.

- To train a group of specialized scientists throughout Balkan countries in order to deliver appropriately the ICAST questionnaires. That will create a 'pool' of researchers able to repeat in the future such research on demand by government, academic or other stakeholder.

- To contribute to decision and policy-making activities related to CAN issues in Europe, and particularly in Balkan countries. The final results of the epidemiological studies allowed the development of a common strategic plan for all partner countries advocating follow up of CAN's level at an annual basis in order to provide a longitudinal view of the problem and therefore a better understanding of the effectiveness of intervention and prevention programs, permitting for corrective decisions.

BECAN Project responded to the European Committee's preoccupation concerning the promotion of healthy behaviour in children and adolescents (HEALTH-2007-3.3-1). Particularly, CAN is considered to be an important extrinsic factor that significantly influences behaviour and quality of life of children and adolescents. In addition, abuse and neglect is widely accepted to have a mediating influence on children's healthy behaviour by its impact on intrinsic factors characterizing each child. Moreover, in the context of the BECAN study the instruments applied to local societies were culturally validated and a multidisciplinary analysis of data was entailed. Therefore, BECAN study provide information on socio-economic and cultural determinants of CAN, which are expected contribute to a better prevention and intervention planning.

Project results:

One of the main components of the BECAN project was the design and realization of an Epidemiological field survey in the Balkan area, where there is great lack of reliable data regarding child abuse and neglect (CAN). The 9 Epidemiological Surveys, that were conducted (Albania, Bosnia and Herzegovina, Bulgaria, Croatia, F.Y.R. of Macedonia, Greece, Romania, Serbia and Turkey), aimed at investigating –among other things- the prevalence and incidence of CAN in representative randomized samples of the general population of pupils attending three grades (the grades attended mainly by children 11, 13 and 16 year-olds). Data were collected by two sources, namely by children and their parents in matched pairs, by use of two of the ICAST Questionnaires (the ICAST-CH and the ICAST-P) as modified for the purposes of the BECAN project (which is described in Chapter A.1.3 of the current Report).

Surveys' timeline. The timeline of the epidemiological studies was different among countries in terms of their starting and ending points as well as in terms of their duration (which were dependent on each survey's sample size, the human resources devoted and other factors that either facilitated or hindered the onset or the process of realizing the surveys).

Research teams. For the purposes of the data collection, each country assembled and trained (as described in Chapter A.1.4) its own National research team. Overall, the 9 research teams consisted of 267 professionals and, more specifically, of 222 researchers who were coordinated and supervised by 47 professionals. The composition of the research teams, in terms of their specialties, for each participating country is described in detail in their National Reports that are available at the project's website.

-.1. Organization of epidemiological surveys

The preparation phase of the epidemiological surveys in the 9 Balkan countries included the following core activities
a) obtainment of permission by the International society of the prevention of child abuse and neglect (ISPCAN) in order to translate and use the ICAST questionnaires and their corresponding manuals in each country,
b) obtainment of official permissions from national authorities to enter the schools,
c) preparation of the research tools and materials including the modification, translation and cultural validation of the research instruments,
d) development and translation of the 'Training manual and guidelines for researchers for the modified ICAST-CH and ICAST-P questionnaires' and
e) realization of a train-the-trainers workshop at Balkan level which was followed by 9 Field Researchers' Training Workshops at National level, in each country.

-.1.1. Permissions to access schools

All national teams applied to national authorities (e.g. Ministries of Education) and obtained official permission to access schools in order to conduct the epidemiological surveys. In some countries apart from the permission granted by the Ministry of Education it was also necessary national teams to obtain approval by local authorities (e.g. School Inspectorates). In some countries one permission was granted for all grade groups while in other countries separate permissions were granted for different grade groups or different geographical areas. Moreover, the research at schools was conducted upon approval of the schools' Principals. To this point it should be mentioned that the process of official permissions' obtainment was quite long for some countries (e.g. Albania, Bosnia and Herzegovina, Greece and Turkey) for several different reasons (e.g. elections, negotiations with officials about the kind of consent to be used, complexity of administrative procedures).

-.1.2. Research tools

The research tools selected to be used for this survey were two of the ISPCAN child abuse screening tools (ICAST) and more specifically the ICAST-CH and ICAST-P questionnaires, which were modified, translated and culturally adapted for use in the 9 Balkan countries.

With the support of the Oak Foundation, ISPCAN collaborated with UNICEF, the UN Secretary General's study on violence against children, the Office of the High commissioner of human rights, and the world health organization (WHO) to create the ICAST instruments. The tools were designed by international experts, reviewed by more than 100 professionals from different countries using a Delphi process, pilot tested in 8 countries, and refined. Since then, the ICAST instruments have been translated and tested in at least 20 languages.

The ICAST instruments is a set of three model questionnaires that are designed to collect data, on the extent of violence against children, by independent young adults [ICAST-R (retrospective)], parents [ICAST-P (parents)] and children over 11 years old [ICAST-C (child)]. The ICAST-C is further divided into an instrument to assess children's victimization in the home (ICAST-CH for home) and an instrument to assess victimization in the school or work place (ICAST-CI for institution).

-.1.3. Modification, cultural validation and pilot testing of the research tools.

The aforementioned ICAST-CH and ICAST-P questionnaires were modified for the purposes of the BECAN study. The main reason that rendered this modification necessary was the matched-pairs design of the epidemiological studies; more specifically, data was designed to be collected from matched pairs of children and their parent/guardian but, even though both ICAST-P and ICAST-CH tools measure the same topics, they differ in the way some of the items are stated as well as in the scales used.

-1.4. Research teams' capacity building

Training manual and guidelines for researchers. For the purposes of the National epidemiological studies, the BECAN 'Training Manual and Guidelines for the modified ICAST-CH and ICAST-P Questionnaires' (Petroulaki, Tsirigoti, Nikolaidis, 2010) was developed, aiming to offer useful guidelines to the trainers of the national research teams, the field research coordinators and the field researchers, with the ultimate goal being the conduct of the national epidemiological surveys at a best possible uniform way in all countries. The BECAN Manual was based on the principles of the accompanying Manuals of the ICAST instruments developed by ISPCAN (ISPCAN, 2006a,b), but it was also supplemented with specific entities in order to cover all methodological and educational needs of the field researchers that undertook the data collection in the context of the BECAN epidemiological studies in the 9 Balkan countries.

The target group of the BECAN Manual is two-fold as it targets both the trainers of field researchers and the field researchers themselves. Therefore, it consists of two, distinct, parts:
a) the first part (Training Manual) it was mainly developed in order to be used by the trainers of the national field research teams in order to provide a standardized training of field researchers in all participating countries, but it also includes guidelines for the field research coordinators that undertook the organization and supervision of the surveys while
b) the second part (Guidelines for Researchers), was developed in such a way so that is offering a ready-for-printing material to be distributed to the field researchers providing them with a useful guide for all aspects of the data collection and for handling problems that might emerge while being in the field.

Therefore, the BECAN 'Training Manual' is divided into various chapters, covering in detail all issues related to the preparation, organization and coordination of the epidemiological surveys, the methodology, the process to be followed for data collection via the two different methods (self-completed questionnaires and structured interviews), the steps to be followed after data collection (quality check, data entry and encoding), as well as ethical and safety issues. The BECAN 'Guidelines for Researchers', include the researchers' obligations and detailed description of the procedures they would follow prior, during and after data collection, the materials they needed during data collection, instructions about conducting the survey via self-completed questionnaires and structured interviews, actions to be undertaken after data collection and important ethical and safety issues they needed to take into consideration.

Train-the-Trainers Seminar. Before the onset of the national surveys, the project's coordinator (ICH-MHSW) conducted a two-day Train-the-Trainers Workshop (Tirana, 17-18 May 2010) aiming to the harmonization of the research activities (including National research teams' training) among the 9 Balkan countries. A total of 34 professionals, representatives of research organization as well as specialized professors and experts attended the training on the methodology of the epidemiological studies in order to be able to uniformly train their field researchers and supervise them while conducting the national surveys by using the same methodology.

National Research Teams' Training. The field researchers is the key to a successful study; 'they are the heart and soul' of a study and especially if the study deals with sensitive issues such as experiences of abuse and neglect or issues that are considered to be 'family matters' (ISPCAN, 2006a). Therefore, candidate researchers had to be very carefully chosen among professionals with specific qualifications and to be appropriately trained; in addition, they had to be able, but also willing, to strictly and unswervingly follow all of the rules that were set for the survey's conduct. Eligible field researchers to be trained were professionals of health or social sciences or other related sciences.

-. 2. Methodology

A.2.1. Sampling method and samples

According to the BECAN survey's design, the method of multi-stage stratified cluster sampling was to be used in each country for the selection of a representative sample of pupils from three grade-groups (the grades attended mainly by children 11, 13 and 16 year-olds) in both urban and rural areas of at least three different geographical areas in each participating country; a paired sample, including each child's (who had participated in the survey) parent/caregiver was also addressed .

The pupils' and their parents' samples' sizes in the 9 participating countries as well as the participation/response rates. The pupils sample size that the surveys in all countries aimed to reach were 63.250 pupils from the three grade groups; in total, 42.272 valid ICAST-CH questionnaires were collected. The parents' sample size was 46.526 parents of whom 26.287 valid ICAST-P questionnaires were collected in total.

A.2.2. Data collection Procedure

According to the survey's design, data were collected by matched pairs of child - parent/guardian. In order to achieve this pairing without endangering anonymity and confidentiality, prior to data collection each ICAST-CH had been matched with an ICAST-P by assigning to both of them the same, a unique Subject Number; this matching code consisted of the initials of the country, the initials of the area and a unique number per pair of questionnaires. The method of data collection was as follows:

- Pupils: administration of self-completed questionnaires to the pupils in the classroom by the trained field researchers (with the exception of children having learning or physical disability where the method of structured interview or guided completion was offered)

- Parents/guardians: self-completed questionnaires sent to the parents/guardians of the pupils who had participated in the survey (structured interview was planned to be offered only to parents that would request from researchers to help them with the completion).

The methods designed to be followed for the data collection and the field work process is described in detail in the 'Training Manual and Guidelines for Researchers for the modified ICAST-CH and ICAST-P Questionnaires', in which are also provided step-by-step instructions to the field researchers for the administration of the questionnaires via both methods. The process that was followed for the data collection per country can be found in details in the National Reports of each participating country, while the basic steps are described in brief below.

A.2.3. Ethical considerations related to the fieldwork process

Due to the fact that the subject matter of the research, namely CAN, is very sensitive, particular ethical and safety issues were taken under consideration during the planning and implementation phase of the epidemiological surveys in the 9 Balkan countries. More specifically, the issues related with the ethical Principals concerning participants' privacy, anonymity and confidentiality, informed consent, right to decline to participate and to withdraw, debriefing in terms of safeguarding their well being, as well as the reaction to CAN cases' disclose or suspicion, are described in detail in the Training Manual and Researchers' Guidelines; country-specific information on the way each National team handled the aforementioned issues are described in each country's training manual and researchers' Guidelines as well as in the National Report.

-.3. Main results

Due to the limited size of this summary report, only the main findings of children's exposure to violence will be presented, along with a few other interesting results revealed in all of the countries.

As it was previously described (in Chapter A.1.3) the modified ICAST-CH questionnaire comprised of 5 scales, aiming to measure the prevalence and incidence rates for pupils' exposure to three forms of violent behaviour (psychological, physical and sexual), their subjective feeling of being neglected as well as their experiences with positive and non-violent parenting behaviors; the 2 contact sexual items included in the sexual violence scale are treated as a subscale of contact sexual violence.

Of interest is to note the extremely high prevalence and incidence rates in all countries for all forms of violence as well as for the children's feeling of neglect; more specifically, the results show that among all countries the smallest percentage of children who report having experienced at least one psychologically violent act during their life time is 64.58% while the highest percentage is as high as 83.16%. The incidence rates are also high (ranging from 60-70%), showing that in different countries 6-7 in 10 children has been subjected to psychological violence during the past 12 months prior to their participation to the survey. The corresponding rates for the physical violence scale reveals that, in different countries, 5 – 8 in 10 children had such experience (rates were ranging from 51% to 76% for children's life time and from 42% to 51% for the past year); in regards to the sexual violence scale, it seems that, in different countries, 1 – 3 in 15 children had experienced sexual violence (rates were ranging from almost 8% to 19% for children's life time and from 5% to 14% for the past year); half of these children are reporting contact sexual experiences. As for the children's subjective feeling of neglect, it seems that 1 – 2 in 4 children are feeling this way in the different countries (rates were ranging from almost 23% to 48% for children's life time and from almost 17% to 40% for the past year). It is also interesting to note that almost all children reported that they are also experiencing positive and non violent parental behaviors only a very small percentage of children do not report only 2 children are also (rates were ranging from 84% to 98% for children's life time and from 83% to 96% for the past year).

An important note of caution must be made at this point in regards to the meaningless of making direct comparisons among countries due to methodological or other differences that were existent among the different studies, which are differently affecting its sample's representativeness and, therefore, the generalizability of its findings. In other words, it is worth stressing out for example that, even though most of the minimum percentages are appearing in FYRoM and in Romania and the maximum percentages in Greece and Bosnia and Herzegovina, this does not consist strong evidence that in these countries the specific forms of violent behaviors are the lowest or the highest in comparison with the remaining countries; in other words, before concluding that children are subjected to less violence in FYRoM (on the basis of the finding that this country appears having 6 of the 12 minimum rates) one must firstly take also into account that this was also the country with the lower children's participation rates, especially for the 11- and 13-year olds grades, (33% and 36%, respectively), a fact that could have affected the representativeness of the prevalence and incidence rates that were measured.

In contrast with most standard perceptions in prior respectful international literature (both scientific and 'grey'), in our research gender differences were not found to exhibit a clear gradient towards boys for exposure to physical and girls for exposure to sexual violence (as it should be anticipated based on the aforementioned standard perception of the CAN phenomenon). That is to say that even where differences are observed, they in general do not seem to represent a substantial diversity (with the remarkable exception of subjective feelings of neglect in which girls have a clear predominance in our results). However, some trends indeed exist also in our research; still not necessarily comprise a radical differentiation of the distribution of violence experiences to girls and boys. More specifically, in most of the participant countries physical violence's rates in boys exceed those of girls regarding both prevalence and incidence but only in 2 or 3 reached significance; this difference is even more notable in the case of sexual and especially contact sexual abuse where in most countries boys' rates of exposure exceed girls' ones pace the standard apprehension of child sexual abuse as occurring predominantly in girls with almost double frequency as in boys. On the contrary, exposure to psychological violence's rates seem in most countries to be higher in girls for both prevalence and incidence rates (but the difference reaches significance only in 1 or 2 countries). However, in the case of subjective perception of neglect, girls by far report in higher rates such exposure regarding both prevalence and incidence rates, a gender diversity which is probably the higher found in the particular research. Last but not least, in all participant countries, girls rates for history of experience of positive parental practices tend to be slightly higher than the respectful ones of boys although in general such rates are found to be in most countries exceeding 90% of the responders' sample, making, thus, such differentiation as less indicative of pinning down a real diversity in parental practice in real social life.

A.4. Becan survey in samples of children who have dropped-out of school

In addition to the epidemiological surveys, the BECAN project also included the design and realization of supplementary surveys with convenience samples of children that have dropped-out of school (and their parents) in countries where the drop-out rates are high.

Such surveys were conducted in Bulgaria, Former Yugoslav Republic of Macedonia, Romania, and Turkey. The reasons for not conducting such a survey in the rest of countries related either to low drop-out rates that were identified in most of the countries or to the incompleteness of available data on drop-out rates as well as to the inability to obtain information about their contact details for children that have dropped out of school due to personal data protection regulations and/or other difficulties faced in the effort to approach the target group of children that have dropped-out of school and their parents (more information about the obstacles faced can be found in the respective countries' reports as well as in the Balkan Report for the BECAN survey on CAN in samples of children who have dropped-out of school).

The suggested methodology to be followed for the organization and implementation of the drop-out surveys was also included, along with this for the conduct of the epidemiological field surveys, in the 'Training Manual and Guidelines for the modified ICAST-CH and ICAST-P Questionnaires'. Data collection was conducted via using the same tools used for the epidemiological studies (the modified ICAST-CH and ICAST-P), but the provisioned method of data collection for the drop-outs survey was structured interviews instead of self-completion. The research tools' cultural validation and pilot testing described in Chapter A.1.3; in addition, the ICAST-CH was also pilot-tested via focus groups with children that have dropped out of school that were also conducted in countries that planned to implement such surveys; more specifically, 4 focus groups were conducted with 28 children that have dropped out of school. Moreover, countries that planned to conduct such surveys included in their field researchers' training sessions about the methodology and the process to be followed for data collection from school dropped out children and their parents.

2.2 Case-based surveillance study (CBSS)

The case-based surveillance study (CBSS) aimed at identifying CAN incidence rates based on already existing data extracted from the archives of agencies involved in the handling of CAN cases (such as child protection, health, judicial and police-services and NGOs) in the same geographical areas and for the same time period as the epidemiological field survey. The collected data were related to the characteristics of individual cases such as child, incident, perpetrator(s), caregiver(s), and information concerning the family. At the same time, the CBSS targeted to map the existing surveillance mechanisms, where available, and to outline the characteristics of the surveillance practices in each participating country. Moreover, comparison at national level between inductance rates of CAN as found in field survey in one hand and in case based surveillance study on the other would produce evidence based estimates of the instantiation of the 'iceberg' phenomenon regarding CAN, viz. that actual rates of the phenomenon are substantially higher than the number of cases actually known or provided for by services in the participant countries.

Current situation in Balkan countries

National mechanisms of child maltreatment surveillance either capture data about specific behaviors known to place children at risk of maltreatment or describe children and families who have come to the attention of social services or legal authorities. Both types of data are collected in order to help the countries assess their needs with regards to the existence of a specific policy leading from prevention to intervention. Additionally, each country must fulfill its obligations as these have been described in the UN convention on the rights of the child (CRC) concerning data collection 'as a key tool in its monitoring efforts'.

As it was described in a series of comprehensive reports on current situation of child abuse and neglect in each one of the BECAN Participating countries, surveillance mechanisms and practices vary significantly among Balkan countries, as significant differences noted in both, the progress that each individual country has made in establishing CAN surveillance mechanisms and the methods each country uses in the monitoring of CAN.

Specifically, Albania lacks what would be considered according to international standards, a pro-active child protection system. The poor response to issues of child abuse and neglect is related to the lack of a unified law on violence and the appropriate implementation and supervision mechanisms. The National child strategy and the National Social Services Strategy are efforts to ameliorate the current situation, however, their action plans have yet to be implemented in practice. In Bosnia and Herzegovina, there is a governmental Institution, the Council for Children in BH, which is the advisory body to the government on child rights issues and maintains a CAN surveillance system at a national level. According to the Council's Report, it collects data from different sources, namely the education-, health-, social protection- and justice-sectors. However, it's published data reliability and completeness has been challenged as well as the diversity of information collected by different sources which is not always internally compatible. Therefore, there is a lack of unified database about the abuse or neglect victims, as well as database of abusers. In Bulgaria since 2001, the State Agency for Child Protection collects data about cases of abused children from regional departments for child protection, police, prosecutors' offices and related NGOs.

Aims and objectives of CBSS

The primary aim of the CBSS was to produce estimations on the number of children maltreated in a single year (2010), including substantiated, suspected, and unsubstantiated cases, based on already existing CAN surveillance practices in each one of the 9 Balkan countries. The second aim was a comparative consideration of the results of the CBSS to those of the epidemiological survey in order for some observations on whether the non-systematic recording of CAN cases in some of the participating countries and the more systematic surveillance in some others sufficiently depict the CAN incidence rates or not. Such a consideration of the results is expected to reveal a more realistic picture concerning the difference between reported and hidden incidence of CAN cases in school-aged children in the nine Balkan countries. As such, the results are to be used as a needs assessment for identifying potential weaknesses of the existing surveillance practices in each country, even for countries that have already established a CAN surveillance system. Furthermore, CBSS results would provide a basis enabling the discussion of fundamental issues about the variation between and within the nine Balkan countries. The identification of any differences between the epidemiological survey and the CBSS within each country and consequent comparison of these differences among countries could potentially indicate what works better and to assess the quality of the already existing CAN surveillance systems, given that different methodologies, tools and mechanisms are currently employed for the monitoring of CAN. Specific objectives of the CBSS were:

- To identify CAN incidence rates, namely to quantify the size of the problem based on already existing data in the same geographical areas and for the same time period that the epidemiological survey conducted in nine Balkan countries.

- To collect data on child maltreatment from a range of sources nationwide in each country about the characteristics of individual cases including case identity, child-, incident-, perpetrator(s)-, caregiver-, family- household, previous maltreatment-, agencies involved- and services provided-related information.

- To collect data related to characteristics of the existing surveillance practices targeting to outline the current situation in the participating countries and identify common patterns and differences in the methods and tools used. Towards this objective, data are going to be collected concerning the identity of the agencies keeping related records, their legal status, the sectors they belong to, their mission as well as information related to the characteristics of the records, such as their format and whether they are collected via specific 'CAN recording form' or not.


CBSS research toolkit

Protocol for extracting CAN information from archives/databases: CBSS Protocol includes all necessary information related to the need for CAN monitoring and the aim of a systematic effort of collecting data on reported and/or detected CAN cases already recorded in archives and/or databases of agencies and services involved in the administration of such cases (such as child protection services, health and mental health services, education-, justice– and public order-related services as well as related NGOs).

Capacity building

Train-the-trainers workshop

The 2nd train-the-trainers' Workshop dedicated to WP4 'Case-based Surveillance' was held on October 11th and 12th in Cluj, Romania. During this workshop an introduction to the WP4-Toolkit was made and trainees (lately trainers) attended a presentation including theoretical-methodological background information aiming to provide them with a clear insight and understanding of the CBSS protocol, technical guidance on the use of the extraction forms and instructions on how to use the Operations Booklet during the training of the national research teams and for administering the data (coding, entry into SPSS file, analysis and reporting). Other issues were also discussed such as the aim and the objectives of the study, a set of indicators to be explored, CBSS expected limitations, selection of agencies-data sources (eligibility criteria) and procedure to be followed for data collection, while mock CAN cases were applied for testing the usability of the extraction forms.

Seminars for training the national research teams

In total, 100 trainees (CBSS field researchers) were participated in the seminars that were realized in the nine Balkan countries and were facilitated by 23 trained-trainers. The structure, method and material used during these seminars were similar in all countries and followed with the process of the train-the-trainers workshop.


The organization and implementation of the CBSS in all nine countries was identical and made in five distinct steps according to what was provisioned by the contract and based on the protocol developed for the study along with the operations' guide.

Step 1: Identification of CAN related Agencies and Networking [WP1 activities related to WP4]. For the identification of eligible agencies taking into account country's specifics (existing monitoring systems or not), a set of pre-defined eligibility criteria were drafted (especially for countries where no existing official monitoring system) related to agencies' identities and specifically to their location, legal status and availability of data. Every agency that fulfilled the eligibility criteria listed in the respective national inventory and invited to participate in the national network and to provide further information in regards to their archives (compilation of long inventories).

Step 2: Identification of eligible agencies-data sources and Preparation of list of collaborating agencies.

Step 3. Development of WP4 toolkit and national versions of WP4 Toolkit. A protocol along with two extraction forms were developed by the Coordinator and finalized by the consortium during the 3rd MM. Moreover, following a suggestion made by the Coordinating team during the 1st MM, an Operations' Manual for the Researchers was developed over and beyond of any contractual obligation (see above 'CBSS Research Toolkit').

Step 4. Train-of-trainers and train-national research teams [WP2 Activities related to WP4] (see above 'Capacity Building')

Step 5. Implementation of CBSS in nine Balkan countries. Scheduling and realization of site visits from the national research teams in agencies who accepted the invitation; Conducting a structured interview on the basis of Form I for collecting information on agency's identity; Studying the archives/databases, identifying eligible CAN cases and extracting data for these cases from the archives on the basis of the pre-coded Form II; data entry in SPSS (all partners in a common file); data cleaning per country; data analysis (on the basis of common syntaxes); reporting of the results (on the basis of a common template).


CBSS results in 9 Balkan countries

In the following pages the incidence rates of CAN are illustrated per country along with information in regards to the agencies-sources of data for the CBSS. Further details are also provided on incidence rates per individual form of CAN, substantiation of maltreatment and the presence of single or multiple forms of abuse, as well as for the main characteristics of children-victims of CAN. Information, such as family- and household-related, perpetrators- and caregivers-related, services involvement (during the cases' investigation as well as referrals to services and services provided) is available in the national BECAN WP4 'Case-based Surveillance' Reports.

CBSS participating agencies

Following the process described above (steps 1 and 2), a total of 911 organizations/child services were identified in the eligible geographical areas. Out of these agencies 505 fulfilled the eligibility criteria set for the needs of the CBSS in each country respectively. Out of the eligible organizations that were invited to participate in the CBSS, finally 281 provided access to their archives. To be noted that in 5 out of the 9 countries, where a more or less official CAN monitoring system is available, participating agencies selected by sampling, reducing in this way the number of the eligible agencies that participated in the study and, on the other hand, reducing the human and financial resources needed for the conduction of the study. Given that the existing monitoring systems in these countries administrate all the CAN cases, it is expected that the sampling has not influenced the results.

CAN incidence in nine Balkan countries resulted by case-based surveillance study

To be noted that the estimations were calculated on the basis of the available data identified and collected during the CBSS from part only of the agencies administrating CAN cases per country, that were selected either by sampling in countries with available CAN monitoring systems (Bosnia-Herzegovina, Bulgaria, Croatia, Romania and Serbia) or in a opportunistic mode (agencies who accepted the invitation to participate in the study out of the total eligible identified agencies in Albania, Bulgaria, FYRoM, Greece and Turkey). Therefore, illustrated incidence rates are by definition biased due to selection process and underestimated. Moreover, for some countries, the estimation of the general population was calculated indirectly due to the lack of recent national census.

Given these limitations, CAN incidence rates range from 0,41 cases/1000 children in Romania to 6,05 and 6,8/1000 children in Greece and Croatia respectively. For the remaining countries, the rates for Bulgaria and FYRoM are 3,77/1000 and 3,45/1000 while for Serbia, Bosnia and Herzegovina, Albania and Turkey range between 1,94/1000 and 1,24/1000 children in the general population

CAN incidence rate per country /1000 children' CAN incidence rate per country /1000 children' in the attached .pdf version of this report.

CAN incidence rates by gender

In some of the countries CAN seem to be more frequent among girls (Albania, FYRoM, Croatia and Turkey) and in other countries more frequent among boys (Bosnia-Herzegovina, Greece, Romania and Serbia). The larger difference was noted in Turkey, where the CAN incidence for girls is more than twice the incidence of boys (1,720/00 vs 0,730/00), while the smaller difference is observed in Romania where CAN incidence rate for boys is 0,410/00 vs 0,400/00 for girls. For Bulgaria the respectful rates are not available as information for the general population by gender in the specific areas for the year 2010 was not available by the National Statistical Agency.

Single vs. multiple forms of CAN

On average, at the Balkan level, half of the identified CAN cases concerned single form of abuse and the other half the presence of more than one forms of maltreatment. Similar to the Balkan is the distribution in Serbia. In Romania, Croatia, Bulgaria, Bosnia-Herzegovina and Turkey cases with single forms of abuse are more than these with multiple forms of abuse and the rate single/multiple abuse ranges from approximately 80%-20% (Romania) to 65%-35% (Turkey). In three countries (Greece, FYRoM and Albania), however, the cases with multiple forms of abuse were by far more than these with single forms of abuse. There is a trend for countries with CAN monitoring systems to record mainly single forms of abuse (with the exception of Serbia) and for countries having no monitoring mechanism there is a trend to record mainly multiple forms of abuse.

As for the gender, on average, in Balkan level, cases of boys' maltreatment concerned more frequently a single form of abuse, while cases of girls' maltreatment involve frequently more than one forms of CAN. The same pattern is also valid for Greece, FYRoM, Serbia, Turkey, Bosnia-Herzegovina, Croatia and Romania, while the pattern is reversed for Albania and Bulgaria.

Substantiation status of child maltreatment

Children-victims characteristics


Nine case-based surveillance studies in the respectful Balkan countries in the context of the BECAN project have been made following similar methodology (namely identical tools and common data extraction processes) and their results provide a comprehensive picture of the current situation in each participating country along with a series of facts indicating strengths and weaknesses of CAN surveillance systems throughout the participant Balkan states. However, due to a series of limitations these results –as it was expected- should not be considered as complete regarding their validity, reliability and representativeness, and therefore international comparisons can only have limited feasibility mainly regarding inter-country evaluation of prevailing trends and overall qualitative characterises and profiles of national systems, while quantitative comparison of indicators per se should be constraint with appropriate cautiousness (as figures as such refer to diverse nature and type of data administratively collected by differentiated in scope and focus organizations and agencies).

Study limitations

Main limitations of the CBSS study concern the fact of underreporting CAN incidents which is a phenomenon observed globally as derived for a variety of bibliographically well-known reasons hindering the accurate estimation of the magnitude and the characteristics of CAN actually in the general population. In many countries information for CAN incidence and prevalence is not available due to lack of coordinated national CAN monitoring efforts. Even in countries where a CAN surveillance system exists, as all international organizations working on children's rights point out, there are much more CAN occurrences in real social world than the reported cases' statistics reveal. Furthermore, as noted in the WHO report (2006) 'access to and use of any particular service is always remarkably uneven between different groups in the population' and therefore case-based information collected from such services and facilities should not be used to measure the overall extent of the problem of non-fatal child maltreatment.

Moreover, restrictions of the particular case-based surveillance studies in the nine participant Balkan countries constraining comparisons among countries, over and beyond under-reporting for reasons mentioned above, concern mainly two broad issues: first, current state of affairs in those countries (existence or not of a CAN monitoring mechanism) and secondly selection of participating agencies per country (including sampling or not). Regarding the former issue, for countries having a CAN monitoring system, only agencies such as centers for social work provided data, while for the remaining countries CAN data derived from a variety of agencies involved in the administration of cases of child maltreatment (social services, health/mental health services, courts of law, police and education-related agencies). As for later, in some countries all CAN-related organizations in the indicated regions were invited to provide data for the study (which also implied an additional methodological perplexity, namely that response rates vary from country to country), while in other countries a sampling process was used on the basis of different criteria from country to country in virtue of the particularities of child protection system per country and the differentiated administrative structure of respectful services from which data should be retrieved from (more details are available in the CBSS national reports).

BECAN epidemiological surveys and case-based surveillance: issues for consideration

BECAN epidemiological surveys conducted in the participant nine Balkan countries investigated the prevalence and incidence of child abuse and neglect in representative randomized samples of the general population of pupils attending three grades (mainly children 11, 13 and 16 year-olds), while in countries where the drop-out rates are high for producing estimates of respectful CAN indicators at national level supplementary surveys were conducted to convenience samples of children that have dropped-out of school. Data were collected by matched pairs of children and their parents, by using modified for the purposes of the BECAN project versions of the ICAST-CH and the ICAST-P self-completed questionnaires. By filling-in the ICAST-CH questionnaires, children provided information in regards to their experiences of psychological, physical, sexual violence, their subjective feeling of being neglected as well as their experiences with positive parenting behaviors.

Potential impact:

Overall context, current state of the art, contemporary trends and challenges in CAN research

CAN and in general exposure of minors to violence has attracted gradually increasing clinical attention over the last decades. By its first reporting by the American Pediatrician Henry Kempe in the'60ties up to its recognition by WHO as a major public health issue in late'90ties , perspectives over the subject matter changes drastically. During the last two decades, the main paradigm under which the phenomenon is dealt with internationally is predominantly the one of evidence-based social policy and clinical practice while the so called public health perspective on the issue is also gaining ground among professionals. Reasons and causes of the phenomenon's increased visibility over the years should be ascribed in the documentation of the severe implications of early exposure of children to violence or deprivation. These implications have been sufficiently correlated with a number of mental health problems in childhood and in later adulthood of victims like anxiety and depression, increased rates of suicidal behavior, abuse of alcohol and substances, dissociation and personality disorders, as well as with wider psychosocial consequences related with adolescent delinquency, educational shortcomings, difficulties in relations and family roles in adulthood, criminal activity and reproduction of the 'circle of violence'.

Key results – progress beyond current state of the arts

In overall, findings of the BECAN research have illustrated a rather increased magnitude of minors' exposure to violence in countries of the Balkan Peninsula. Almost half children reported at least one experience of exposure to physical violence during the year prior to research in all participant countries while almost two out of three report such a history over their childhood. Rates of exposure to psychological violence appear even higher reaching in many of the participant countries almost two thirds of responding children for incidence and even three quarters at some occasions for prevalence. Such an image can be better understood combined with sex distribution figures: pace standard conceptualization and prior research reports that physical violence is concerning predominantly boys, this particular research advocates for a more equated distribution pattern with male to female ratios being almost equivalent to one and in some cases females' report exceeding male ones. Whether such a rather unusual pattern of physical violence experiences' distribution should be attributed to cultural factors of the particular geographical area or is indicative of a widespread practice underestimated insofar, remains to be inquired by further research.

Main dissemination activities

The project had from the very beginning set a wide dissemination strategy resulting in a number of publications in peer reviewed scientific journals and other relevant resources, oral and poster presentations at scientific conferences, booklets, leaflets and other respectful material for communicating its methodology and results . Throughout its lifespan, the project organized also a number of specifically designed scientific events for disseminating its results, from which the most distinguished was BECAN International Conference in Athens held at 13-14/09/2012.

Additionally, BECAN National Conferences were also organized in Tirana, Albania at 29/01/2013, in Sarajevo, Bosnia and Herzegovina, at 24/01/2013, Blagoevgrad, Bulgaria at 26/10/2012, in Zagreb, Croatia at 22-23/03/2012, in Skopje, FYRoM at 7/12/2012, in Athens, Greece at 9-10 2010, in Cluj-Napoca, Romania at 27-29/4/2012, in Belgrade, Serbia at 3/11/2013 and Izmir, Turkey at 14/01/2013.

Apart for its own scientific conferences, the BECAN project was presented in many other scientific events and in all International and Regional Conferences organized by the most prominent scientific association on the subject matter of CAN globally, namely ISPCAN, during the project's lifespan, holding oral and poster presentations as well as round tables and symposia specifically on the progress and results of the BECAN project in 18th (Honolulu, U.S.) and 19th (Istanbul, Turkey) International Congresses, 12th (Tampere, Finland) and the forthcoming 13th (Dublin, Ireland) European Regional Congresses. As a result of the project's outcomes, ISPCAN initial developer of the ICAST tools are in collaboration with the BECAN consortium disseminating their modified by BECAN versions of these questionnaires as well as their Operating Manuals and Guides throughout the world in various research groups seeking for conducting field research on CAN. Additionally, WHO-Europe has invited BECAN results to be included in the comprehensive publication under developments (anticipated to be published at the end of 2013) on European guidelines for the phenomenon on CAN, related evidence and optimum ways of eradicating violence against children. Qua dedicated to the overall principles of 'open science' the BECAN consortium has decided not only to make results available as widely as possible, but also to make original databases available to researchers willing to conduct further analyses after an exclusive period of the first 3 years after the project's official conclusion.

Wider societal impact

CAN research always bear some or other wider societal implication given the nature of the subject matter of inquiry. That is to say that on this particular topic, namely minors' exposure to violence, field research in itself, apart from bringing about new epidemiological evidence which could contribute to increased predicting and explanatory value of mental health sciences' discourses, has also an increased social utility function. Accordingly, by providing a robust evidence-base for the understanding of the phenomenon of children's victimization can ultimately facilitate effective social and child protection policy design and implementation. From this angle, current evidence brought into light by the BECAN study indicates new targets for social policies and awareness raising interventions that could tackle insofar invisible aspects of the phenomenon of children's exposure to violence. Further research is also invited in order to verify these findings, shedding more light to minors' victimization which apart from medical, mental and psycho-social concerns represents also a human rights' challenge for modern societies.

As a result, apart from its scientific appreciation, results and progress brought about by the BECAN study was apprehended also by civil society's stakeholders. It is not accidental that in most of the aforementioned BECAN national and its international conferences central government's representation had an upgraded presence (in some cases even 4 different members of the cabinet, viz. Ministers, Deputy Ministers and General Secretaries of Ministers, mainly from respectful Ministries of Justice, Social Affairs, Health and Education, addressed the audience). Moreover, in virtue of the project's comprehensive dissemination plan which was laid out from the very beginning of its implementation, key results were widely disseminated apart from respectful scientific communities nationally and internationally, also to mass media and other such resources addressing the general public. A number of press releases, interviews in newspapers, radio and TV stations were produced, contributing substantially to awareness raising for the subject of CAN and its necessities in the participant Balkan countries. Furthermore, at the international level, the BECAN consortium was able to expand its dissemination range by acknowledged and invited to participate and present its results and methods of work at important meetings such as the Stakeholders meeting organized by the EU's Fundamental Rights Agency in Vienna on 22-23/02/2011, in Council Europe's Regional Conference 'Stopping Sexual Violence against Children - ratifying and implementing the Council of Europe Convention on the Protection of Children against Sexual exploitation and sexual abuse (CETS No. 201)' for S.E. Europe in Zagreb on 27-28/10/2011, at Council of Europe's initiating Conference for its Strategy for the Rights of the Child 2012-2015 'Building a child-Friendly Europe: turning vision into reality' at Monaco in 20-21/11/2011 on the National Focal Points Network Meeting, at European Parliament's Special Committee on CAN's hearing regarding new evidence on CAN at Brussels on 11/10/2011 and various other instances related with child protection from all forms of violence and victimization.

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