Studying the Rate of Physical and Emotional Abuse among Elementary School Students of Isfahan in 2014 and Its Relation with Some of the Cognitive Demographic Characteristics for Better Health Care

Aim: Determining the rate of physical and emotional abuse among elementary school students of Isfahan and its relation with demographic characteristics Place and Duration of the Study: The study was conducted in 12 elementary school of Isfahan in central Iran from November to January of 2014. Methods: In analytic descriptive 500 Samples multi-step random sampling. Data gathered using a some individual and family characteristics and physical and from 2014. Data was analyzed using SPSS software and by appropriate analytic descriptive statistics. Results showed that were forced to stand in the corner of the class” among choices for physical abuse (mean = +1.87, -0.96) and “you were shout at” among choices for emotional abuse (mean = +1.80, -0.98) gained the highest mean scores. There was a significant relation between the age and sex of student and their fathers’ job with the rate of physical and emotional abuse. But mothers’ education only had a statistically significant relation with emotional abuse. There was no significant relation between fathers’ education and mothers’ job with the rate of physical and emotional abuse. Conclusions: Since physical and emotional abuse does exist among elementary school students, and it is more in boys rather than girls and in older students rather than younger students, careful planning, supervisory actions and necessary educations regarding this field are essential.


INTRODUCTION
Elementary school students are the future of every society [1] and their health has a great importance [2]. At this age children have a slow physical development, while their social progress is very fast and complex and they are vulnerable in this field [3]. School has an important role in students' social development and their relation with their classmates [4] and teachers and school staff has an important role in creating a safe environment for students [5]. School nurses as care managers have an important role to create a safe environment school staff, students and their families [6]. Having care managers for providing health cares would increase satisfaction, control the problems better [7] cause better communications and enhance the health of students [8]. When school nurses play the role of care managers, it would enhance the participation of teachers, school staff, students and their families in creating a safe environment and better interactions and more attention would be paid to preventive operations [6]. But unfortunately for centuries students have been abused under the name of school regulation [9,10]. It has even been reported that some students experience their first emotional abuse at school [11,12]. This matter has been recognized as a universal complicated and persistent problem [8,13] which is increasing [14] but unfortunately it has not been studied decisively [15]. Abusing children at school is one of the universal public health concerns [16] which is affected by different factors [17,18] and could lead to different physical and mental health problems [18,19] ; also it is in conflict with goals of school [20]. Therefore it requires public health interventions [17] and special attention [21,22]. Results of a study in 37 countries showed that 86% of children aged 2 to 14 have at least once experienced physical, emotional or verbal abuse [7]. In Arabic countries sometime parents and teachers use physical punishment as a disciplinary method [23]. Also 37% of Tanzanian students would be exposed to a sort of physical or verbal abuse [24]. In schools of morocco 37% of teachers claimed that they have abused their students and 87% of students complained of being physically punished by a ruler or a twig [25]. On the other hand victims of abuse usually feel ashamed and believe they deserved to be punished and refuse to talk about it to others [26]. Also abuse at school could cause irrecoverable and permanent damages to students [27]. It could decrease physical, mental and social health of children, disturb students' learning, increase the rate of students' absence from school [28], disturb students' ability to concentrate and damage their ability to become a spouse or a parent in future [29]. On the other hand it would cause anti-social behaviors [9], detachment, nervousness and aggression, depression [30,31]. Pessimistic opinions, violent behaviors, obsession and personality disorders [32,33]. Therefore considering the extent of the problem and its consequences and not knowing the extent of physical and emotional abuse in elementary schools of Iran, this study was aimed to determine the rate of physical and emotional abuse among students of elementary schools of Isfahan and its relation with some demographic characteristics.

Research Design and Setting
This was a descriptive cross-sectional study conducted in 12 elementary schools (6 boy schools and 6 girl schools) from 2 nd and 4 th educational regions of Isfahan from November to January 2014. Isfahan is one of the major cities of Iran which is place in the center of Iran.

Sampling
Study population was all the students of 4 th , 5 th and 6 th grades of elementary schools that were studying at the time of this research. Samples were selected through multi-stage random sampling, meaning that first from 6 educational regions of Isfahan 2 nd and 4 th regions were selected randomly. Then from the list of elementary schools in each region 12 schools (6 girl schools and 6 boy schools) were randomly selected equally from both regions. In these 12 schools 1765 students were studying in three grades. A list of the students in the targeted grades was prepared and a code was assigned to each one of them. Then using a randomized table, 500 students (250 boys and 250 girls) were selected equally from both regions; all of the selected students filled the abuse questionnaire.

Instrumentation and Data Collection
Data was gathered using a researcher made questionnaire. Researchers, after studying articles related to the abuse of students at schools, designed this questionnaire in two parts. The first part was about some of the demographic data of students such as students' age and gender and their parents' education and job; the second part included 13 questions about physical abuse and 11 questions about emotional abuse. First every question was graded as (never, rarely, sometimes, often, always) based on the five point Likert scale. For content validity of the questionnaire, an expert team consisting of 6 nursing faculty members, 4 primary education faculty members and 2 child psychology faculty members reviewed the questionnaire and then the questionnaire was revised based on their opinions. Then for structure validity, in a pilot study the questionnaire was filled by 30 students from 4 th , 5 th and 6 th grade of an elementary school in the 2 nd educational region who were not a part of the present study and base on that pilot study grading of the questions was changed from (never, rarely, sometimes, often, always) to (never, rarely, often, always), because the pilot study showed that students did not differentiate between "rarely" and "sometimes". For scoring the questions always was assigned as 4 scores, often as 3 scores, rarely as 2 and never as 1. To determine the rate of physical and emotional abuse, all the scores that were gained from students' answers in each aspect were added up. Therefore the total score of physical abuse was between 13 and 52 and the total score of emotional abuse was between 11 and 44. The reliability of the questionnaire was 0.89 using Cronbach's α coefficient.

Ethical Consideration
All the procedures of the study were confirmed by the Ethical Committee of the Isfahan University of Medical Sciences. Also for entering the schools permission was gained from research center of Department of Education of Isfahan. For gathering the data, after showing the recommendation letter from Department of Education to school authorities and acquiring their consent, the aims of the study and the procedure for filling the questionnaire were explained for students and their parents and they were ensured that all of the information would remain confidential. Before filling the questionnaire students and their parents filled the written consent form. No ethical problem occurred during the study and data gathering.

Statistical Analysis
Data was analyzed using SPSS software. Descriptive statistics including frequency, percentage, mean and standard deviation (SD) and inferential statistics including independent samples t-test, analysis of variance (ANOVA) and parsons' corrlation were performed. The level of significance was considered as P < 0.05. Also to control the role of confounding factors on results, multivariable regression model was used.

Demographic Information
500 elementary school students, equal from both groups of girls and boys, participated in this study. The age with the highest frequency among girls and boys (38.8%, 42.4%) was 12. The highest frequency of educational degree in mothers of girls and boys belonged to diploma (37.2%, 44.4%) and in fathers of girls and boys also belonged to diploma (38.4%, 41.2%). Most of the mothers of girls and boys (72%, 78%) were housewives and most of the fathers of girls and boys (41.2%, 43.6%) were freelancers. According to Table 1, there was no significant difference between age, mothers' education, fathers' education, mothers' job and fathers' job of both groups.

Description of Abuse
Results showed that the choice of "you have been forced to stand in the corner of the class" among the questions for physical abuse had the highest mean score (1.87±0.96) and only 58.6% of students mentioned that they have never experienced this abuse; and 17% of students have demonstrated that they always experience this misbehavior. 96.2% of students said that they have never been "forbidden from eating as a punishment" and the mean score of this choice (1.05±0.25) was the lowest mean score among physical abuse choices. Among emotional abuse questions, the choice of "being shouted at" had the highest mean score (1.80±0.98) and only 54.8% of students mentioned that they have never been shouted at. 95.2% of students mentioned that they have never been "humiliated for being poor or not being able to provide some equipment" by their teachers and this choice gained the lowest mean score (1.08±0.41) among emotional abuse choices ( Table 2).

Relation between Demographic Characteristics and the Rate of Abuse
Results showed that there was a significant relation between the sex of students with physical (P = 0.01, t = 4.45) and emotional (P = 0.02, t = 3.08) abuse and according to Table 3, the rate of physical and emotional abuse was higher among boys than girls. Also there was a significant and direct relation between the age of students and the rate of physical (P = 0.02, r = 0.11) and emotional (P = 0.01, r = 0.20) abuse, meaning that as the students get older the rate of abuse would increase. Also results showed no significant relation between mothers' job and physical abuse (P = 0.16, F = 1.70) but it had a significant relation with emotional abuse (P =0.06, F =4.20) and according to Table 5 by increasing the education level of the mother, the rate of this kind of abuse would decrease. Also according to Table 9 and using multivariable regression results showed that students who their mothers had diploma were emotionally abused less than those with under diploma mothers at school. There was no significant relation between fathers' education and physical (P = 0.26, F = 1.31) and emotional (P = 0.15, F = 1.77) abuse. Also mothers' job had no significant relation with physical (P = 0.24, F = 1.42) and emotional (P = 0.15, F = 1.85) abuse. But With using one-way ANOVA there was a significant relation between fathers' job and physical (P = 0.01, F = 21.67) and emotional (P = 0.02, F = 4.20) abuse.          In this analysis categorized variables with more than 2 levels were defined as dummy Variables of K-1 level and entered the model. The undefined level in the model was assumed as the reference level While using multivariable regression model and controlling the role of confounding factors in results, it was revealed that father's job had no significant relation with emotional abuse but students who their fathers were laborers or employees experiences less physical abuse at school than students with unemployed fathers.

Principal Finding
Results showed that in most of the questions about physical and emotional abuse about 80% of students have demonstrated that they have never experienced this kind of abuse. Anyhow "being forced to stand in the corner of the class" had the highest rate among physical abuses and only 56.6% of students mentioned that they have never experienced it. 96.2% of students have never "been forbidden from eating as a punishment". Among emotional abuses "being shouted at"| had the highest rate and this choice not only gained the highest score but only 54.8% of students mentioned that they have never experienced it and other students have somehow been exposed to this behavior from their teachers. 95.2% of students have mentioned that they have never "been humiliated for being poor or not being able to provide some equipment". In this regard Chen et al. [32] studied the rate of students' abuse by their teachers and revealed that 56.6% of students have at least once experienced physical abuse. In their study the most common physical abuses were running, standing in a corner, kneeling, repeating homework and being punched, hit or kicked at and none of the students complained from being burned, cut or squeezing the neck as an attempt to suffocate. In another study conducted by El Bcheraoui et al. [5] by studying 1177 Lebanese students aged from 10 to 18 years old it was revealed that 54.4% of students have never experienced any kind of abuse at school. The most common physical abuse was hitting by a ruler and the least common ones were pouring pepper in their mouths, burning by cigarettes, hitting by belt, putting in hot or cold water and squeezing the neck. Also regarding emotional abuse, the most common abuse was shouting at students and the least common one was humiliating for being an orphan.
Shumba [34] showed that 80.4% of elementary students in Zimbabwe have been hit by whip, 10.9% were slapped and 4.3% were punched by their teachers. The differences in kinds of abuses could be due to the differences in educating and supervisory methods over teachers' functions. But in the present study the rate of abuse was less than other previous studies.
In regard to the relation between age and sex of students and the rate of abuse, results showed that the rate of abuse was significantly higher among boys rather than girls and as they get older in both groups the rate of abuse would increases. This difference in abuse has been observed in previous studies too. For example Okoza et al. [35] by studying 1537 high school students, boy students experienced more abuse than their peer girl students and older students in both groups experience more abuse than younger ones. Also El Bcheraoui et al. [5] concluded that Lebanese boys in elementary schools have experienced more abuse from their teachers than the girls. Gesinde et al. [20] also mentioned getting older as one of the effective factors on the rate of mental and psychological abuse among high school students. Deb et al. [36] in their study also mentioned that boys would experience more physical and mental abuse than girls; but girls are mostly become victims of sexual abuse. Khoury-Kassabri et al. [37] by studying 1014 students aged from 7 to 11 years concluded that as the students get older the rate of abuse would increase and boys would be abused more than girls. The results of all of these studies were in consistent with the present study. It could be said that higher rate of abuse among boys could be because they are more active and naughty than girls. Also one of the reasons for students' abuse is not obeying the laws and as students get older they would break the laws more [38] that could be an explanation for higher rate of abuse among older students.
In regard to the relation between educational degree of mothers and the rate of abuse by teachers, the study showed that there was no significant relation between mother's education and the rate of physical abuse but it had a significant relation with the rate of emotional abuse. Meaning that as mother's get higher educational degrees, the rate of emotional abuse would decrease. Also there was no significant relation between father's educational degree and the rate of physical and emotional abuse. In contrary, Khoury-Kassabri et al. [39] in their study on students of 7 th to 11 th grades concluded that the rate of abuse was higher among students who their parents had lower educational degrees. Also Benbenishty et al. [11] in studying 5472 students from 4 th to 6 th grades showed that students who their parents have lower educational degrees would experience more abuse from their teachers. In this regard the study of Ba-Saddik et al. [38] on 1066 elementary students concluded that boy students were abused more than girls and as the father's educational degree gets higher, the rate of abuse among students decreases. Finding no significant relation between father's education and abuse among students in the present study could be explained by this fact that in elementary schools usually mothers communicate with teachers and attend school events, while fathers' due to their businesses in the morning, have less communications with schools; therefore teachers usually are not aware of fathers' educational degree.
Also the results of the present study showed that there was no significant relation between mother's job and the rate of abuse among students by their teachers but there was a significant relation between father's job and physical abuse. Since in this study 71% of mothers were housewives therefore mothers' jobs had no significant effect on the economic status of families. But father's job was effective on the economic status of the family that could be effective on the rate of abuse. Because previous studies have mentioned that economic status of families were related to the rate of abuse among students. For example Benbenishty et al. [11] mentioned that students with lower economic status in their family would tolerate more abuse from their teachers. Also Khoury-Kassabri et al. [40] in their study on students of 4 th to 11 th grades revealed that economic and social status of students' families were related to the rate of abuse by teachers and as their social and economic status lowers, the rate of abuse by teachers increases.

Limitations
Since, in the present study, the questionnaires were filled by the students themselves, it could have affected the results and reported higher scores. Since data was gathered through questionnaires there might be some kinds of emotional and physical abuses that were not mentioned in this questionnaire and therefore were not considered in this study. Also mental and psychological condition of students and recent behaviors of school staff could have affected their answers. Therefore to increase the reliability of the study it is recommended to use other data gathering means such as observation and interview.

CONCLUSION
According to the results of this study abuse is an important health problem that exists in our schools and students are experiencing different kinds of physical and emotional abuses; meaning that school boys experience abuse more than school girls and older students experience it more than younger ones. Therefore accurate planning and supervision over teachers' and school staff's actions, especially in boys schools, are necessary. Also it is necessary to increase the knowledge of teachers and school staff about abuse and its adverse effects. Since abuse is more common among children of families with lower social and economic situations, more attention must be paid to planning and education in deprived areas. School nurses also as health care managers could prevent abuse and correct inappropriate behavior toward students and help to enhance their health condition in coordination with teachers and school staff and also psychiatrists and students' parents.