Violence against children in sub-Saharan Africa and Mozambique : burden and prevention mechanisms in Mozambique

<p dir="ltr">Background: Violence against children undermines children's rights and their development into autonomous people. Public health agendas must prioritise our understanding of this preventable health threat and inform its prevention. The Sub-Saharan African (SSA) region has some of the highest prevalences of child violence-related injuries globally. Yet, knowledge of its burden and prevention is scarce in the region, including in Mozambique.</p><p dir="ltr">Aim: The thesis aims are twofold: to increase knowledge of the burden of violence- related injuries among children in the SSA region and Mozambique and to shed light on whether the prerequisites are in place for Mozambican stakeholders to engage and succeed in the prevention of all forms of violence against children. Each aim is addressed by two complementary studies.</p><p dir="ltr">Methods: The first two papers are register-based, and the following two are based on primary data gathered through interviews. Paper I is a cross-country (SSA region), ecological study based on data from the Global Burden of Disease 2019 study (latest data available at the time of the study). The outcome was the trend in child violence-related death and DALYs and its correlation with risk factors. Descriptive statistics compiled trends over the past 30 years and Spearman's rank correlation test for the association with alcohol consumption per capita. Paper II was cross-sectional and hospital-based. Outcomes were forms of child violence-related injuries presented at the paediatric emergency and forensic unit of the Maputo Central Hospital in Mozambique. Data were extracted from medical records (2019) using a standardised Case Report Form. Descriptive analysis and chi-square tests were performed. Paper III addressed community readiness to prevent child maltreatment based on the WHO Readiness Assessment for the Prevention of Child Maltreatment-Individual questionnaire with stakeholders from national agencies and in Maputo. The questionnaire-specific scoring system and descriptive analysis were performed. Paper IV was qualitative descriptive research exploring frontline practitioners' experiences with the implementation and enforcement of child protection laws in local services in Maputo City. An inductive approach and thematic analysis by Braun and Clarke were used.</p><p dir="ltr">Results: The SSA region registered a decline in child violence-related deaths and DALYs rates between 1990 and 2019, 22.5% and 22.3%, respectively. In Mozambique, death and DALYs rates declined 22.7% and 25.3%, respectively, that the country in 2019 to match the regional average rates in 2019. A significant correlation was seen between alcohol consumption and child interpersonal violence for both death and DALYs in 2019 (r=0.446, p<0.001 and r=0.435, p<0.001, respectively) (Paper I). Among the 321 cases of child violence-related injuries treated at the hospital over one year, sexual violence was the most common form (59.5%), followed by physical violence (40.5%). While girls were the most common victims of the former (female-to-male ratio of 6.35), boys were of the latter (male- to-female ratio of 1.95). Children of both sexes sustained multiple injuries but not severe injuries due to physical violence, mainly bruises to the head or upper limbs. Girls who were victims of sexual violence suffered more serious injuries, of the kind that required surgery or intensive care (Paper II). Mozambique is at the preparation stage of prevention of child maltreatment, with a total average score of readiness of 5.4 (for a maximum of 10) according to information from professionals in the child protection sector at national and local levels. Low scores were observed in resources, scientific data, and programmes (Paper III). Through interviews with frontline practitioners, two themes were identified. The first related to barriers encountered in the implementation and enforcement of child protection laws: limited resources, a weak organisational system, legal gaps and constraints, and norms and attitudes. The second theme concerned the facilitators: resourceful support from NGOs and a favourable working environment (Paper IV).</p><p dir="ltr">Conclusion: Findings from this thesis indicate that, albeit declining, the rates of child violence-related injuries remain higher both in SSA and in Mozambique than the global average, despite the significant reduction in death and DALYs rates in the past three decades. Sexual violence, typically sustained by girls, was the most frequent form of violence among child victims seeking hospital care in Maputo Central Hospital. Mozambique is in early stages of readiness to prevent child maltreatment. Child protection services in Maputo lack the capacity to implement and enforce child protection laws to protect children from violence, mainly at the local level.</p><h3>List of scientific papers</h3><p dir="ltr">I. Trends and demographic differences in interpersonal violence against children in sub-Saharan Africa: findings from the 1990-2019 Global Burden of Disease Study. <b>Sergio Nhassengo</b>, Lucie Laflamme, Mathilde Sengoelge, GBD 2019 SSA Child Interpersonal Violence. BMJ Open. 2025;15:e083070. <a href="https://doi.org/10.1136/bmjopen-2023-083070">https://doi.org/10.1136/bmjopen-2023-083070</a></p><p dir="ltr">II. Circumstances and Consequences of Violence-Related Injuries Presenting at Hospital. A Study at the Pediatric Emergency and Forensic Medicine Units of Maputo Central Hospital, Mozambique. <b>Sérgio Keita </b><b>Nhassengo</b>, Stela Ocuane Matsinhe, Eunice Jethá and Lucie Laflamme. Int. J. Environ. Res. Public Health. 2021, 18, 12125. <a href="https://doi.org/10.3390/ijerph182212125">https://doi.org/10.3390/ijerph182212125</a></p><p dir="ltr">III. Community readiness to prevent child maltreatment in Mozambique: An investigation among key informants at country level and from Maputo city. <b>Sergio Nhassengo</b>, Lucie Laflamme, Mathilde Sengoelge. Children and Youth Services Review. 176 (2025) 108400. <a href="https://doi.org/10.1016/j.childyouth.2025.108400">https://doi.org/10.1016/j.childyouth.2025.108400</a></p><p dir="ltr">IV. Frontline practitioners' perspective of the implementation of child protection laws and prevention of violence against children in Maputo, Mozambique. <b>Sergio Nhassengo</b>, Stela Ocuane Matsinhe, Eunice Jetha, Mathilde Sengoelge, Lucie Laflamme and Asli Kulane. [Submitted]</p>