Design and Assessment of a Multidisciplinary Training Programme on Child Abuse and Child Protection for Medical Students Comprising Coursework and a Seminar

Abstract

Child abuse affects millions of children globally. Comprehensive training is essential to promote its recognition and trigger appropriate responses to prevent missed opportunities for intervention. We describe a child abuse and child protection training programme for University of Ghana Medical School students and the cross-sectional survey of student assessment at the end. The programme comprised a lectures, dissertations, community surveys, case reports, public health advocacy topics, and poster designs. These were carried out as part of regular coursework in community health, using individual and group—methods. It culminated in a one-day whole-class seminar after their final examinations with completion and analyses of self-administered student assessment questionnaires. The seminar comprised nineteen 10-min oral presentations, twelve poster presentations on community surveys and dissertations, nine educative posters, three leaflets and a question-and-answer session. The training involved 208 students, and 126 completed the questionnaires. The majority of the students had good knowledge (80–100%). They correctly identified the types (91%), risk factors (87%), and gained clarity in selected areas. Added benefits were awards, a book of abstracts and summaries, policy brief and continuous professional development points for doctors. This training programme exemplifies the establishment of medical education in the context of the needs of the population to—be served.

1. Introduction

Recent happenings in Ghana, such as bullying in a senior high school and the assault of a child on social media that went viral, as well as a report of a ritual murder by minors at Kasoa and the exposure of a baby-stealing syndicate, highlight the urgent need for a robust child protection service in the country [1,2,3,4,5]. Child abuse occurs when there is harm done to a child as a result of acts of commission or omission [6]. The action may be deliberate, careless, and perpetrated by the family, community members or an institution. Common types of abuse children face are physical abuse, sexual abuse, emotional abuse, neglect, and exploitation. Additionally, modern forms of abuse have emerged, such as cyber abuse through the internet [6,7,8]. Child abuse affects a child’s development, physical and mental health and ability to learn in the short term, and it also impacts their transition to adulthood with adverse consequences in later life in the long term [7,9]. Given the gravity of the problem and attention it receives from the media in Ghana, it is important that the subject is reflected in training programmes of medical schools.

According to WHO, globally, nearly three in four children aged 2 to 4 years regularly suffer physical punishment and/or psychological violence; and one in five women and one in thirteen men report having been sexually abused as a child [10]. In 2015, the Domestic Violence and Victims Support Unit (DOVVSU), Ghana recorded 1198 cases of defilement nationally and reported that non-maintenance of one’s children was the most common form of abuse [8]. Child abuse costs the nation from GHS 926 million to GHS 1.442 billion per year [11]. Failure to recognise abuse and trigger an appropriate response and intervention can be extremely costly, as some children may die from unrelenting abuse or suffer physically, psychologically, and emotionally for life. Recent studies have shown that training medical students improves clinical reasoning and ability to identify and report childhood maltreatment which can make a difference by enhancing the capacity of medical practitioners to be well-versed in child protection [9,12].

In the clinical setting, children who are being abused may present to paediatric outpatient units as cases of marasmus, kwashiorkor or late in the course of disease due to neglect. They may remain on the ward after discharge due to unsettled bills or fail to attend appointments. They can also present to the casualty department, the family physician, the orthopaedic surgeon, or radiologist with fractures, or other injuries, or present to the Burns Unit with burns or to the eye clinic with an eye injury. Children who are abused may present to the surgeon with an acute abdomen or to the gynaecological clinic with a discharge or as a case of defilement or rape: they may present to the paediatrician, psychiatrist or internist with pseudo-seizures or non-epileptic attack disorder and to the dermatologist with a skin rash. Thus, child protection must be approached and taught as a multidisciplinary endeavour [13]. Pre-service training provides an opportunity for doctors to learn about the multidisciplinary nature of child protection early, before they choose their specialties. This will equip them to consider child abuse in whatever setting they find themselves.

Understandably, child protection is a difficult area of practice for doctors as it involves making decisions that are emotionally challenging, unpopular, and complex, which may have to be defended in court [13,14]. Therefore, medical students, as future doctors, require specially designed training on the subject. However, pre-service training of health personnel on child abuse is limited in many institutions due to competing pressures to deliver other aspects of the curriculum [15].

We sought to provide updated knowledge about child abuse and child protection using topics generated for Public Health Advocacy, Community Surveys and Dissertations within the context of the Community Health curriculum of the University of Ghana Medical School (UGMS). These topics were presented together in a one-day whole-class seminar at the end of the course. Seminars are presentations that enable students to collect, organise and present data on an assigned topic according to conventional outlines within a given time frame [16]. The study reports an intervention, a training programme comprising learning activities in child abuse and child protection which occurred throughout the final-year course in 2022 and culminated in a one-day whole-class seminar, together with the student assessment that took place after the course.

2. Materials and Methods

2.1. Study Design

The study was a descriptive study that provided a description of an intervention, a training programme comprising coursework on child abuse and child protection, a concluding seminar and a cross-sectional survey of student assessment of the programme. The assessment comprised an assessment of student knowledge about the subject and their opinion of the seminar. Learning activities based on the curriculum occurred throughout the final school year, culminating in the one-day whole-class seminar which was held in 2022, after the final-year examinations.

2.2. Study Area

The study was carried out at the University of Ghana Medical School (UGMS). The Medical School was established in 1962 as the premier medical school in Ghana [17]. It is located at the Korle Bu campus of the University of Ghana along the southern border of the capital city of Accra. It currently graduates approximately 200 students each year through two programmes, the Regular Undergraduate Programme and Graduate Entry Medical Programme (GEMP). The school has seventeen (17) departments and centres including Anaesthesia, Anatomy, Chemical Pathology, Community Health, Haematology, Medical Biochemistry, Medical Microbiology, Medical Pharmacology, Medicine and Therapeutics, Obstetrics and Gynaecology, Pathology, Paediatrics/Child Health, Physiology, Psychiatry, Radiology, Surgery and the Centre for Tropical Clinical Pharmacology and Therapeutics. Most of the clinicians of the school also work as consultants at Korle Bu Teaching Hospital, and some are heads of clinical departments of the hospital. In 2020, representatives from UNICEF Ghana met with the Dean at the time and clinicians and expressed a desire to support UGMS to carry out yearly seminars for medical students on child abuse and child protection for 3 years and research on the subject. Subsequently, concept notes were designed and the learning activities were commenced.

2.3. Sample Size and Sampling

All 208 final-year medical students of the final-year class in 2022 at the University of Ghana Medical School from both the regular undergraduate programme and Graduate Entry Medical Programme (GEMP) participated in the training programme. The final year is the 6th year of training for regular students and the 4th year of training for GEMP students. The students participated as part of regular learning activities in the final year either as presenters or listeners or by providing critiques.

2.4. Study Population

The study population consisted of students attending the University of Ghana Medical School (UGMS) in their final year in 2022. All the students were eligible and invited to participate in the study. Students who attended the seminar had to give consent and complete the student assessment questionnaires at the end. Thus, the inclusion criteria involved being a medical student of the UGMS and belonging to the final-year Class of 2022. Students who did not attend the seminar or provide consent were excluded from the student assessment.

2.5. Data Collection Instruments and Methods

2.5.1. The Intervention—Child Abuse Child Protection Training Programme Coursework in Community Health

To avoid disruption to the regular coursework of the students, maximize learning through a variety of learning methods and implement the training programme close to its application in clinical practice, the final-year course in Community Health was chosen as the best place to situate the training. It start after the second clinical year during which students receive a formal lecture on child abuse while studying paediatrics, which has gone on for the past 10 years, with another lecture in final year to reinforce this learning. Community Health is part of the final-year course of the medical school together with Medicine, Surgery and specialty subjects such as Anaesthesia, Orthopaedics and Trauma, Genito-Urinary Surgery and Neurosurgery. It is accomplished through ten-week rotations of four (4) groups of fifty (50) final-year students, grouped as A, B, C, D in the class. Normally, as part of the course, students in Community Health carry out a dissertation. They also conduct a community diagnosis survey in a rural or peri-urban area, present a case report from a rotation in a district hospital usually outside Accra andcarry out 10 min presentations on public health advocacy topics. Results from these three activities, included as part of the learning experience, are usually presented in smaller groups of the 50 students. With the exception of the community diagnosis surveys, all these activities contributed marks towards the final examination.

Aim and Objectives of the Training Programme

The aim of the training programme was to provide medical students with an overview of the clinical features and management of child abuse, as well as the services available for preventing abuse and protecting children, to equip them with information for safeguarding children. This information was part of coursework involving all students and delivered as oral and poster presentations at a seminar at the end of the course. Thus, by the end of the training programme, students should be able to describe the epidemiology, types, nature and consequences of child abuse and present this as a poster, oral presentation, essay or dissertation; identify symptoms and signs of abuse and report on these in a case report, an oral presentation or essay; and explain the process of child protection and steps to be followed when there are concerns that a child has been abused in an oral presentation and an essay. In addition, students will be able to describe the multidisciplinary nature of child protection in an oral presentation and in a written form that will distinguish between the roles and responsibilities of the different agencies involved in managing child abuse. Finally, students should be able to relate community perspectives and principles underlying prevention in oral presentations, essays and poster displays.

Selection of Topics and Posters for the Seminar

The selection of the topics for oral presentation during the concluding seminar was based on the aims and specific objectives of the programme. These were grouped into six (6) main themes, consisting of basic concepts such as definition types, the public health significance, epidemiology and effects of child abuse, child rights and legislation; sociocultural causes of child abuse, such as culture and traditions, domestic violence, developmental conditions and child abuse in Ghana; diagnosing child abuse, including physical abuse, sexual abuse and neglect, and case reports on these; guidelines and management of child abuse including management in hospital, management in the community and role of social welfare, forensic medicine and infectious diseases; the importance of multidisciplinary work and prevention of child abuse, with an emphasis on agencies involved in safeguarding children such as DOVVSU, CHRAJ, Social Welfare and the Ministry of Gender, Children and Social Protection.

The topics were given to students as public health advocacy topics during the course work and later modified for presentation to suit the context of the seminar. The advocacy topics were shared through a ballot. Each group of 50 students balloted for advocacy topics and among them were the 4 to 6 topics on child abuse. Students were also encouraged to present case reports from the district rotation on child abuse for oral presentation, and those with an interest in child abuse and child protection were encouraged to choose dissertation topics related to the subject. These were presented as poster presentations during the seminar together with the reports of the community surveys. The community surveys investigated community attitudes towards child abuse and child protection using pre-designed questionnaires. The questionnaire included questions on the demographic characteristics of respondents, frequency of child abuse in the community, types, risk factors and what is carried out when there is abuse. An interview guide meant to be administered to a key informant, was also used to inquire about child abuse in the community. The questions were along similar themes and on sociocultural factors affecting reporting and management. This was included as a pet topic for the community diagnosis surveys in different communities. In addition to the seminar topics, students were encouraged to create educative posters for display. Slogans suggested for a health day on child abuse and child protection proposed during a tutorial on world days of health importance were used to make posters with support from the graphics team and displayed along with posters solely designed by the students.

Tutoring and Outputs

All the groups of students received a lecture on child abuse delivered by the programme coordinator, a paediatrician with a background in community paediatrics and an interest in community health. Further guidance and direction were provided by lecturers within the UGMS and Korle Bu Teaching Hospital. They included consultants in community health, paediatrics, internal medicine, paediatric surgery and a professor of clinical psychology. For some of the topics, particularly the clinical topics, students were assigned a consultant from the outset. In addition, all the presentations were appraised by consultants at the Department of Community Health, residents and their peers during in-course presentations on the district experience, community diagnosis surveys, public health advocacy and supervision of dissertations. The written version was also appraised by the programme coordinator and additional modifications were recommended as necessary for students to make before the concluding seminar.

Orientation for the field work and supervision of community work was performed by research assistants and residents in the department, while support for the case presentation was obtained from a clinic nurse of the child protection unit in the paediatric department of the hospital -all of whom were either pursuing postgraduate programmes or holding postgraduate qualifications. Assigned consultants and consultant in charge of the Child Protection Unit also offered immense support to the students. The necessary correspondence was provided for students who needed to see external facilitators from the Department of Social Welfare and the Department of Children of the Ministry of Gender, Children and Social Protection (MoGCSP); the Commission on Human Rights and Administrative Justice (CHRAJ); and the Domestic Violence and Victims Support Unit (DOVVSU). These facilitators were mostly graduates in their respective fields and included two lawyers from CHRAJ. The Microsoft Word versions of the seminar topics were presented as essays, and together with the dissertations and community surveys, edited and converted into a book of abstracts and summaries.. The surveys were also summarised into posters and a policy brief for the Ministry of Gender, Children and Social Protection. Residents and research assistants at the Department of Community Health assisted with making poster presentations out of the community surveys and dissertations. An application was made to the Medical and Dental Council for continuous professional development credits to be awarded to doctors who attended the concluding seminar.

Structure of the Concluding Seminar

The concluding seminar was delivered after the student’s final examination using the oral presentations developed during the coursework. An exhibition showing the poster presentations of the community surveys, dissertations, educative leaflets and posters was displayed concurrently during the seminar. In addition to this, an address was given to the students by the Head of the Child Protection Unit of UNICEF Ghana, and a question-and-answer session was held with UGMS consultants who had training in community paediatrics in the UK with experience in the field. Students were informed ahead that there would be six (6) prizes for the best six (6) presentations; two (2) for the seminar (advocacy) presentations, one (1) each for the community surveys, dissertations, educational posters and leaflet; thus, an award ceremony was held at the end. The figure below (Figure 1) shows a summary of the activities undertaken.

2.6. Student Assessment

A semi-structured questionnaire was used to collect information on the student’s knowledge about child abuse and child protection and their opinion about the seminar. The questionnaires were self-administered by the students. The questions covered questions on knowledge about child abuse, recognition of types of abuse, prevalence, risk factors for abuse, prevention and their opinion of the training programme, participation and suggestions to improve the seminar. Answers were agreed by two experts before they were applied. Although it was expected that the same set of questions would be used for a pre-seminar and post-seminar assessment of the level of knowledge among students at the beginning and end of the course, the pre-seminar assessments were not carried out. If this had been done then any improvement in scores observed could have been attributed to the seminar alone. The questions were pre-tested among house officers at Korle Bu Teaching Hospital and modified accordingly.

2.7. Data Handling and Analysis

The topics students worked on during the coursework and presented at the seminar were compiled and summarised into tables. Data from the student assessment questionnaire were entered into a Microsoft Excel (version 16.77.1, 2023) spreadsheet and analysed with Statistical Package for Social Sciences (SPSS) version 22. Descriptive statistics, such as frequencies and percentages, were computed and presented in the tables. The mean age and standard deviation were also computed.

Assessment of the level of knowledge of child abuse among the students was carried out using Bloom’s cut-off point classification [18]. Students’ scores for the answers to each question were graded as good, moderate, and poor using Bloom cut-off categorisation criteria, where a good score referred to a score of 80–100%, a moderate was 60–79.9% and poor was less than or equal to 59.9%.

2.8. Ethical Consideration

Ethical Clearance was obtained from the Korle Bu Teaching Hospital Scientific and Technical Committee and Institutional Review Board, protocol number KBTH-STC/IRB/000149/2022. Consent for completion of the questionnaires was obtained in writing from the students.

3. Results

3.1. The Concluding Seminar

The concluding seminar attracted a total of 544 participants comprising 167 students, 344 doctors (25 in person and 319 online), and thirty-three (33) guests and staff. A total of twenty-four (24) students worked on seminar topics, with some working in groups; thus, altogether, nineteen (19) 10 min oral presentations were produced and carried out during the seminar. There were seven (7) poster presentations on community surveys, five (5) dissertations on child abuse/protection, nine (9) educative posters and three (3) leaflets.

Table 1. List of oral presentations carried out during the seminar.

No.	Seminar Topics
1	The definition, types and public health significance of child abuse
2	* The epidemiology of child abuse
3	The health and psycho-social effects of child abuse
4	Culture and child abuse
5	Domestic violence and child abuse
6	* Developmental conditions and child abuse
7	Diagnosing physical abuse
8	Diagnosing sexual abuse
9	Diagnosing neglect
10	A case report on physical abuse
11	A case report on sexual abuse
12	A case report on neglect
13	Guidelines and procedures for managing child abuse in the hospital
14	Guidelines and procedures for managing child abuse in the community and the role of social welfare services
15	Forensic medicine, infectious diseases and sexual abuse
16	Multidisciplinary working and agencies involved in child protection
17	The Domestic Violence and Victims Support Unit (DOVVSU)
18	Commission on Human Rights and Administrative Justice (CHRAJ)
19	Prevention of child abuse

* Award winners.

and

Table 2. List of poster presentations at the exhibition.

	Dissertations
1	* A Study of the Knowledge and Response to Child Abuse Among Healthcare Workers in Ghana
2	Child Abuse and Health Challenges Facing Street Children in Accra
3	Perceptions of child abuse among Junior High School pupils of St Mary’s Roman Catholic Girls Basic School
4	# Knowledge Attitudes and Practices of Adolescent School Girls Attending St Mary’s Senior High School Regarding Child Abuse and Child Protection
5	Knowledge and Attitudes Towards Child Abuse and Adoptive Measures among students at Ebenezer Senior High School, Accra
	Community Surveys
1	Knowledge, prevalence and positive parenting skills relating to Child Abuse Among residents of New Adoteiman
2	Child Abuse in Oyarifa: A Survey of the Knowledge, Prevalence and Positive Parenting Skills
3	* An Assessment of the Knowledge, Attitudes And Practices (KAP) Towards Child Abuse in The Peri-urban Town of Old-Adoteiman
4	Assessing the Knowledge, Prevalence and Positive Parenting Skills Among The People of Danfa South Concerning Child Abuse
5	Child Abuse in Danfa North: A Survey of The Knowledge, Prevalence and Positive Parenting Skills.
6	Knowledge of Child Abuse, Prevalence and Positive Parenting Skills in Otinibi, Greater Accra Region
7	Child Abuse in Kweiman: A survey of the knowledge prevalence and positive parenting skills
	Posters and leaflets
1	* 4 posters (fully self-designed by students)
2	5 posters (words provided by students)
3	* 3 leaflets

* Award winners. It includes one leaflet and one poster. ^# A late presentation.

provide a summary of learning activities displayed during the seminar.

3.2. Awards and Outputs

An exhibition was carried out to display the posters which were viewed during the break period. These oral and poster presentations were assessed by assigned faculty members, and awards were presented for the best two oral presentations, the best poster, the best leaflet, the best community survey report and the best dissertation. The main outputs from the project have been summarized in

Table 3. Awards and Outputs.

	Outputs
1.	Concluding Seminar
2.	Exhibition
3.	Awards
4.	Book of Abstracts and Summaries (This was given to majority of the students when they became house officers)
5.	Policy brief for the Minister of Gender, Children and Social Protection
6.	Posters and a leaflet used during celebration of the child health week in a public hospital in 2023
7.	Continuous Professional Development (CPD) points given to doctors who attended the event
8.	A video and teaching-aid for teaching child abuse/child protection

.

3.3. The Student Assessment

Analysis of the student assessment questionnaire revealed that, altogether, 126 respondents completed the evaluation forms out of the 167 who attended the seminar and 208 in the class. The mean age of respondents was 24.6 years (SD 2.3). The respondents consisted of 69 (54.8%) females and 56 (44.4%) males and 1 (0.8%) with no response. Five (5) respondents were married and two (2) had two (2) children each. A majority of the students demonstrated knowledge about the components of child abuse and the forms of child abuse correctly, as shown in

Table 4. Questions and statements used for student assessment and their responses.

* Questions and Statements	Frequency of Correct Answers	Percentage
Recognition of Child Abuse
Which of the following regarding child abuse is true?
Child abuse occurs when there is harm done to a child as a result of acts of commission or omission	111	88.8
The action may be intentional, reckless, and inflicted by the family, community or institution or another child	116	92.8
Harm is ill-treatment or the impairment of health or development	87	69.6
Boys are often the victims of beatings	86	68.8
Girls are prone to sexual abuse, forced prostitution	114	91.2
Girls are often victims of education and nutrition neglect	78	62.4
Respondents: 125 out of 126 respondents answered this question.
2. Which of the following suggests child abuse?
Inflicting pain on a child is a form of child abuse	120	96.0
Inflicting hunger on a child is a form of child abuse	116	92.8
Depriving a child of education is a form of child abuse	114	91.2
Overworking a child is a form of child abuse	114	91.2
Overprotecting a child	9	7.2
Respondents: 125 out of 126 respondents answered this question.
3. Which of the following suggests child abuse?
Repetitive injuries	118	95.2
Injuries not consistent with the story	116	93.6
Vague or inconsistent story	108	87.1
Previous evidence of abuse	105	84.7
Unique pattern of injuries	100	80.7
Delay in seeking medical help	100	80.7
A child with sexualized behaviour	87	70.2
Allowing a child to overeat and become obese	18	14.5
Respondents: 124 out of 126 respondents answered this question
Recognition of Different Forms of Child Abuse
4. Which of the following is a recognized form of child abuse?
Physical abuse	121	98.4
Sexual abuse	119	96.8
Emotional abuse	117	95.1
Neglect	112	91.1
Exploitation	92	74.8
Respondents: 123 out of 126 respondents answered this question
5. Which of the following falls into the category of child physical abuse?
Shaking	92	73.6
Throwing	111	88.8
Rape or oral sex involving a child	32	25.6
Burning	116	92.8
Choking	115	92.0
Making an under-age person or child pregnant	25	20.0
Asking a child to do hard work	67	53.6
Carrying heavy loads	81	64.8
Respondents: 125 out of 126 respondents answered this question
Epidemiology of Child Abuse
6. Which of the following statements regarding the epidemiology of child abuse are true?
Child abuse can have a multigenerational impact	96	85.0
Nearly 3 in 4 or 300 million children aged 2–4 years regularly suffer physical punishment and/or psychological violence at the hands of parents and caregivers	76	67.3
One in 5 women and 1 in 13 men report having been sexually abused as a child 0–17 years	51	45.1
120 million girls and young women under 20 years of age have suffered some form of forced sexual contact	36	31.9
Child abuse costs Ghana GHC 926 million to GHC 1.442 billion/year	22	19.5
Respondents: 113 out of 126 respondents answered this question
Risk Factors And Preventive Measures
7. Risk factors for child abuse that apply to caregivers include:
Poverty	124	99.2
Alcoholism	123	98.4
Drug abuse	120	96.0
A great number of unwanted children	117	93.6
Lack of support	108	86.4
Promiscuity	88	70.4
Respondents: 125 out of 126 respondents answered this question
8. Which of the following is a measure to prevent child abuse?
Creating awareness and dialogue with chiefs, religious leaders, and prayer camp leaders to modify customs and practices within their communities and churches	116	95.1
Increasing girl child enrolment and retention in school	115	94.3
Reducing risk factors such as alcohol and drug abuse in the society	113	92.6
Child welfare clinic interventions and home visiting	111	91.0
Negative parenting	12	9.8
Respondents: 122 out of 126 respondents answered this question
Students’ Opinion of the Programme
Aspects of child abuse that have become clearer to you through the programme:
Where to report abuse	100	82.0
Agencies that protect children and what they do	100	82.0
Risk factors for child abuse	95	77.9
Types of child abuse	94	77.1
Child protection procedures	85	69.7
Properly reporting all the information about the child	61	50.0
Alternative ways to discipline children	53	43.4
None	1	0.8
Respondents: 122 out of 126 respondents answered this question

* Multiple responses applied.

. Although some of the options on the epidemiology of child protection were answered accurately, a few were poorly answered.

In all, about 82.0% of respondents felt that the programme had made aspects of child protection clearer to them. Knowledge of where to report abuse, risk factors for child abuse, types of child abuse and child protection procedures had become clearer to the majority of respondents; however, proper reporting of child abuse became clearer to only about half of the respondents, and alternate forms of disciplining children were clearer to less than half of the respondents. There were also several suggestions for improving the programme, but the recurring themes were, involving all clinical-year students, adding video programmes, adding role-play or drama, repeating the programme, and broadening the viewership to include parents, high school students, media, national TV, and adding a quiz programme.

Table 5. Level of knowledge of child abuse among UGMS final-year medical students.

	Level of Knowledge
Domain	Good (80–100)	Moderate (60–79.0)	Poor (≤59.0)
	n, (%)	n, (%)	n, (%)
Recognition of Child Abuse
Knowledge of recognizing child abuse (Q2)	85 (68.0)	18 (14.4)	22 (17.6)
Knowledge of suggested presentations of child abuse I (Q3)	103 (82.4)	12 (9.6)	10 (8.0)
Knowledge of suggested presentations of child abuse II (Q6)	66 (53.2)	41 (33.1)	17 (13.7)
Recognition of Different Forms of Child Abuse
Knowledge of recognized types of child abuse (Q4)	112 (91.0)	5 (4.2)	6 (4.9)
Knowledge of the different categories of child physical abuse (Q5)	35 (28.0)	62(49.6)	28 (22.4)
Epidemiology of Child Abuse
Knowledge on the epidemiology of child abuse (Q1)	23 (20.4)	25 (22.1)	65 (57.5)
Risk Factors and Preventive Measures of Child Abuse
Knowledge of risk factors for child abuse that apply to caregivers (Q7)	109 (87.2)	11 (8.8)	5 (4.0)
Knowledge of measures to prevent child abuse (Q8)	99 (81.1)	15 (12.3)	8 (6.6)

depicts the answers to the questions that assessed the level of knowledge on child abuse and child protection, classified according to Bloom’s cut-off categories. It shows that the majority of the students displayed a good knowledge of most of the questions asked except for the epidemiology question, which was generally not well answered, and the question on the recognition of physical abuse, which was mostly moderately well answered.

Table 6. Comments and suggestions of ways the programme can be modified to improve it.

Comments and Suggestions of Ways the Programme Can Be Modified to Improve It	Frequency	Percentage
# More students must be encouraged to participate. More frequent programmes involving other classes. Could be open to all students in the clinical years. Programme should be carried out early in the academic year so that most students will be involved. It is a very good and informative program and students will be involved; should be held every year.	5	3.9
Including other stakeholders Programme was well planned and implemented well. Since only the soon-to-be doctors were present, I suggest it should be carried out every year to equip every batch of medical doctors. Involve media houses to help project the message. Introductory quiz and national television streaming of the seminar. Such programmes should be held at the national level in schools and then medical seminars such as this. Inviting Senior High School students, since they are also at risk of child abuse. Invitation of representatives from child protection agencies and other stakeholders to also make presentations at the seminar. Subsequent seminars should be organized on this same subject for traditional and religious leaders to ensure this campaign gets across to everyone .	7	5.5
Excellent program. Maybe next time we can make a video documentary. This was an amazing program. A video documentary would be lovely. Addition of videos to the seminar. Addition of videos and payment of students who do the fieldwork. Inclusion of videos. The use of more videos.	6	4.7
Should be more interactive. There can be breakout sessions with moderators. A breakout session can be added, and presenters should compare slides to avoid the repetition of some slides.	3	2.4
Add role-play. Add a role-play event to involve more students. Add other forms of education such as drama and role-play.	3	2.4
More publicity in the future. Improved publicity. Early publicity.	3	2.4
Reduce the number of presenters. Reduce the number of presenters.	2	1.6
Presentations should be shorter. Shorter presentations, video interlude on child abuse stories.	2	1.6
Start on time. Better time management and ushers should be present early.	2	1.6
Organizing it before the final exam.	1	0.8
Child abuse survivors can be contacted to have them share their personal stories if they are in psychologically sound space to do so.	1	0.8
Getting volunteers to undertake a field trip to one of the places where child abuse is reported, e.g., DOVVSU.	1	0.8
A different venue with better sound. There was some difficulty hearing presentations.	1	0.8
Slides of presenters should be less wordy.	1	0.8
For the presenters, some of the slides were not changed; such technicalities should be dealt with better.	1	0.8
Prior notice of the evaluation would have been appropriate.	1	0.8
Indicators must be created to help in the delineation of discipline and child abuse. This must be carried out by representatives of UNICEF in collaboration with the Ghana Health Service.	1	0.8
* Total	41	32.5

* A total of 41 (32.5%) out of 126 respondents answered this question. ^# Two respondents made this statement.

shows student suggestions to improve the programme. Four broad themes emerged from an open-ended question on ways to improve the programme, as displayed in Table 5. They included the following: 1. Broadening the reach of the course. 2. Including videos. 3. Using role-play and other interactive sessions. 4. Improving the technical aspect and organization of the seminar presentations. There were several single suggestions, such as creating indicators that will delineate discipline and physical abuse and the possible invitation of child abuse survivors who are willing to come and share their survival stories.

4. Discussion

According to Bannon and Carter [13], child protection training should be considered as a crucial component of training doctors, delivered to doctors who have contact with children, adapted to suit the level of participants and cover core competencies. These programmes should also address local and emerging concerns and embrace evidence-based educational interventions. Guidance on training programmes on child protection for medical students is limited [9,12]. However, it is generally recommended that they also need training along similar lines as doctors but in less detail [9,19]. This was what this study sought to do, as shown in Table 1.

The training programme provided students with updated knowledge about child abuse and child protection, including definitions, types, presentation, and risk factors for abuse as well as its recognition, management and prevention. A variety of teaching methods were used during the course work, including a lecture, public health advocacy, essays, community surveys and dissertations, as well as individual and group work which were later presented to the whole class as a seminar. Several outputs were obtained, as shown in Table 2. Being the first seminar, our focus was to provide an overview of the subject and build on the principles they had learnt in an earlier lecture, and we believe we achieved this. The structure and topics are also in consonance with some essential topics recommended for current training in child protection for trainees of the Royal College of Paediatrics and Child Health (RCPCH), [20]. The RCPCH recommends that training programmes should include training on the recognition of pointers of child maltreatment, vulnerable children and the effects of Adverse Childhood Experiences (ACEs). It also recommends that there should be training, on making appropriate referrals and knowing what to do when there are concerns about a child, and guidance on sharing information and multiagency working. This has been captured in Table 2.

Overall, their performance on the knowledge questions using Bloom’s classification was good (80–90%) in the majority of students. However, it appears that factual knowledge on the epidemiology of child abuse was not well learned, as it was the only question in which the majority of students received a poor score on some components; thus, it requires more attention. It also appears the students may have found some questions confusing, such as differentiating between physical abuse and child labour, which is classified as exploitation; hence, the low scores on those questions. Thus, converting these questions into a matching question in subsequent seminars may improve clarity. Some students wanted medical students in other classes to join the seminar, and others wanted other stakeholders to join so that the knowledge could be shared with a broader audience.

A study of medical and dental undergraduates and interns in Riyadh Saudi Arabia did not find any statistically significant difference in knowledge between those with previous training and those without previous training on the subject. It was felt that this observation might be because most of the training occurred in the classroom setting rather than the clinical setting or using scenarios and seminars. Additionally, the majority of participants felt that they needed additional training to deal with cases of the condition [21]. On the contrary, a study on child abuse training and knowledge of emergency medicine, family medicine and paediatric residents in the US found that paediatric residents outdid the other residents on a knowledge quiz, and superior performance was associated with larger centres, having a specialized child abuse physician or faculty responsible for child abuse as well as a curriculum and a rotation in paediatric child abuse. Although this study was carried out among residents, it highlights the importance of structured training [22]. Thus, we believe that providing a comprehensive overview of child abuse and child protection, such as that reported in this study, is likely to ensure that these medical students will be able to recognise and protect children when they encounter abuse in their future practice. Embedding the course within the regular coursework makes the sustainability of the course more likely. It is noteworthy that final-year and 6th-year medical students participated in some studies like our study [21,23].

Though seminars have been successfully used to teach medical students [16,24,25]; other ways of teaching child abuse and child protection have been explored [12,23]). Pelletier et al. studied the effect of a modified form of the Child Advocacy Studies Training programme on child maltreatment among first-year medical students in the US and found better vignette accuracy among those who took the programme than those in the comparison group [12]. The programme involved a total of 8 h of didactic lectures spread across 9 months, 4–8 h of group discussions about child maltreatment issues and cases with faculty as well as studying a case of child maltreatment. It also involved patient observation in a child and adolescent psychiatry ward to study the effect of adverse life events on children. Pretest and post-test vignettes were used to assess learning and they demonstrated learning in the intervention group when compared with the scores of a comparison group. The study exposed students to both clinical and theoretical aspects and a variety of consultants and multidisciplinary personnel who engage in child protection. However, it lacked random assignment. We also used a multidisciplinary approach with consultants from community health, medicine, paediatrics, and psychology as well as facilitators from the police, social services, CHRAJ and the Department of Children but we lacked pre-test scores for comparison.

Some students in our study requested role-play, video presentations, and more interactive sessions. This was not surprising, as a study by Giannakas et al. using interactive methods involving 2 h workshops with role-play, manikins and peer education to train medical students on child abuse and neglect found significant improvement in knowledge [23]. However, there were limitations, such as the lack of a control group, a milieu to practice communication skills, and the inability to engage a multidisciplinary team. Role play has also been used to improve the communication skills of medical students in Botswana [26]. Another study found from its pre-and post-test assessments that both creative drama and in-class teaching could be useful in changing attitudes towards violence against women among nursing students, and neither appeared superior to the other [27]. We have used role-play and drama on occasion to engage communities when giving them feedback after community surveys in the lower classes of the school. Given the time constraints, including role-play using student actors, would be more appropriate for students in the lower classes with a more flexible timetable. Drama could also be used to teach communication skills, especially if external actors are engaged, but it require funding.

Digital games and virtual reality are reported to be emerging tools, for medical education. A scoping review found that simulations from these applications in the form of scenarios of child maltreatment can be used to assess student knowledge and performance [28]. However, such simulations need to be driven by policy makers and other stakeholders and designed together with them. A study on the effectiveness of an interactive case-based e-learning module on non-accidental injury for medical students found a significant increase in the mean score between tests carried out before and after the modules [9]. Students with previous child protection training had lower pre-module test scores but higher scores after the training, whereas those in the higher years of training had higher pre-module test scores but minimal improvement after the course compared with students in lower years, indicating more benefit for those in lower years. The authors concluded that the training increased clinical reasoning leading to recognition and management more than knowledge about the subject, a recognised attribute of case-based learning [9]. Since starting the training in earlier classes also makes a difference, in this setting, case-based training can be linked to the prior training in paediatrics.

This seminar emphasized important points in history-taking and clinical examination and how to synthesize this information to make a diagnosis of child abuse. Some of the challenging issues regarding this were dealt with during the question-and-answer session by experts. What it was unable to provide was the practical environment to gain practical skills in communication with patients, parents and professionals, documentation and decision making. This was reflected in the observation that only half of students reported that properly reporting all the information about the child had become clearer to them. Though we used the lecture, case reports and presentations on the major forms of abuse and clinical management, our students lacked active training on clinical cases, according to the case-based learning principles. Furthermore, as adult learners, they demanded more active learning experiences, and case-based learning is one of the ways this need can be met [29]. Another way is to use clinical electives. A study used structured 2–4-week clinical electives to improve recognition and mandatory reporting of child abuse [30]. Our students may have gained some clinical exposure during their rotation in paediatrics in the 2nd year. Interestingly, we had an elective student from another country join one of the groups and participate in the coursework during the second year of the project.

Case-based learning is a teaching tool consisting of live, computer or web-based cases. Currently, it is used frequently in medicine to bridge the gap between theory and practice [29]. It involves the application of knowledge as well as using an inquiry-based learning approach in which groups of students are given a clinical case, a problem to be solved or questions to be answered and guided by a facilitator with learning objectives who ensures that these objectives are met. It involves self-directed learning and allows clinical reasoning, problem-solving and decision-making skills to be developed as solutions are found to a hierarchy of problems or questions, and repeated examples of cases of varying complexities are practiced. It induces deeper learning by stimulating critical thinking. It has been applied through e-learning with promising results [9].

What was unique about this seminar was that it included an emphasis on socio-cultural factors influencing child abuse and child protection as well as community attitudes and views. This provided an understanding of important beliefs and practices relevant to this setting that influence behaviour toward child protection [31]. For instance, in contrast to the finding that some cultural norms have been reported to have a positive influence on child protection [32], the community survey revealed that child abuse was not frequently reported to authorities due to barriers such as cultural norms, fear of broken marriages or divorce, and stigmatisation by society [33]. This suggests that sexual abuse may be occurring in communities, and custodians of culture must be engaged.

There were some limitations. We were unable to conduct a pre-seminar assessment of the knowledge and opinions about child abuse and child protection among the students as originally planned hence we cannot attribute the high knowledge to the seminar alone. Though all students participated in the lecture and community diagnosis, not all of them had public health advocacy topics, and not all of the students registered during the seminar and completed the questionnaires. Altogether, 126 students completed the assessment form out of the 167 students who attended the seminar and the 208 in the class. It would have been ideal to obtain the views of all the students. A comparison group was lacking.

5. Conclusions

Medical schools as gatekeepers of what medical students learn need to be sensitive to the major issues affecting society today and contribute solutions that are reflected in teaching programs of future doctors. Thus, locating this child abuse and child protection seminar in community health and obtaining input from other departments provided a unique opportunity to employ a variety of teaching methods and a multidisciplinary approach to deliver this pre-service training, a major issue in Ghana. It also enabled several outputs to be obtained. The students demonstrated high knowledge scores. The majority of students also reported that selected aspects of child abuse and child protection had become clearer to them, suggesting that this model could be used for training in child abuse and child protection in other similar settings or on similarly important subjects. Further studies to determine the impact of the seminar on their work as doctors need to be carried out.