A meta-analysis of child physical abuse prevalence in China.

G Model CHIABU-2887; No. of Pages 12

ARTICLE IN PRESS Child Abuse & Neglect xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

Child Abuse & Neglect

A meta-analysis of child physical abuse prevalence in China Kai Ji, David Finkelhor ∗ Crimes against Children Research Center, University of New Hampshire, Durham, NH, USA

a r t i c l e

i n f o

Article history: Received 2 September 2014 Received in revised form 15 November 2014 Accepted 18 November 2014 Available online xxx Keywords: Physical assault Child victimization Systematic review International

a b s t r a c t This study estimated the prevalence of child physical abuse in China, compared Chinese prevalence with international and Asian estimates, and ascertained whether some differences in sample characteristics and methodological factors (e.g., time prevalence, definitional or regional difference) help explain variations in Chinese rates. Based on a metaanalysis of 47 studies found in English- and Chinese-language peer-reviewed journals that involved general populations of students or residents reporting child physical abuse prior to age 18, the life time prevalence of any child physical abuse in China was estimated at 36.6% (95% CI: 30.4–42.7), which was significantly higher than either the international or the Asian estimate in Stoltenborgh et al.’s (2013) study. Chinese prevalence was estimated at 43.1% (95% CI: 36.6–52.5) for minor physical abuse, 26.6% (95% CI: 21.4–31.8) for severe physical abuse, and 7.8% (95% CI: 5.0–10.5) for very severe physical abuse. Subgroup analysis found a significant difference between lifetime and 12-month or less prevalence only for minor physical abuse. The prevalence of any and minor child physical abuse in mainland China was significantly higher than that in non-mainland China. The mainland and non-mainland difference was significant even controlling for definitional and methodological factors as well as sample characteristics. The findings suggested the need to develop educational programs to promote non-violent parenting particularly in mainland China. © 2014 Published by Elsevier Ltd.

Introduction Physical abuse of children is a widespread global phenomenon (Runyan, Wattam, Ikeda, Hassan, & Ramiro, 2002; Sadowski, Hunter, Bangdiwala, & Munoz, 2004; Stoltenborgh, Bakermans-Kranenburg, van Ijzendoorn, & Alink, 2013; United Nations Children’s Fund, 2012). An international meta-analytic study of 157 samples from six continents (Africa, Asia, Australia, Europe, North America, and South America) estimates the world-wide prevalence of child physical abuse at 22.6% (95% CI: 19.6–26.1) (Stoltenborgh, Bakermans-Kranenburg, van Ijzendoorn, et al., 2013). Although Stoltenborgh et al. (2013) acknowledge that the tolerance of corporal punishment in Asia might lead to a higher prevalence of child physical abuse, they do not find a significant difference between Asia and other geographical areas. A closer look at the Asian samples shows that only one study (Ross et al., 2005) published in English is from mainland China, the home of Confucian values. Filial piety is at the heart of Confucian values, which endows parents with power to control and punish children. Physical discipline is also believed beneficial to children’s future because it teaches them how to be obedient to and respect authority (Qiao & Chan, 2005). Although the influence of Confucian values is waning in modern China, corporal punishment is still prevalent in parenting (K. Chan, 2012; Shen, 2009). Ross et al.’s (2005) study as the only mainland Chinese study included in Stoltenborgh et al.’s meta-analysis is unlikely to reflect the overall prevalence of child physical abuse in mainland China.

∗ Corresponding author at: Crimes against Children Research Center, University of New Hampshire, 125 McConnell Hall, Durham, NH 03824, USA. http://dx.doi.org/10.1016/j.chiabu.2014.11.011 0145-2134/© 2014 Published by Elsevier Ltd.

Please cite this article in press as: Ji, K., & Finkelhor, D. A meta-analysis of child physical abuse prevalence in China. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.11.011


ARTICLE IN PRESS K. Ji, D. Finkelhor / Child Abuse & Neglect xxx (2014) xxx–xxx

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In fact, a much larger number of Chinese studies were published in the past three decades (United Nations Children’s Fund, 2012), but the majority of them were published in Chinese and stored in Chinese databases. These Chinese studies were missing from Stoltenborgh et al.’s study because Stoltenborgh et al. limited their literature search to English language and English databases. Additionally, no systematic review has ever been conducted to synthesize findings from Chinese studies and provide directions for future research. To fill the gap in Stoltenborgh et al.’s literature search and systematic review in China, this study endeavors to do a meta-analytic review of all the qualified studies published in both English and Chinese. An additional reason to focus on China is that the pattern of child physical abuse in mainland China might be different from Hong Kong and Taiwan due to a different cultural and political environment. Exposed to Western culture for a much longer time, Hong Kong and Taiwan parents could be influenced less by punishment-oriented parenting and more by the advocacy of non-violent parenting in Western countries. The advanced child protection system in Hong Kong may also protect more children from physical abuse. The Child Protection Registry in Hong Kong keeps suspected child abuse and physical abuse records. However, the system for tracking and handling child abuse cases has not been established in mainland China. Therefore, no official data on prevalence of child physical abuse is currently available for mainland China and Hong Kong as a nation. This first comprehensive meta-analytic review of Chinese studies on child physical abuse has several goals. First of all, it estimates the prevalence of child physical abuse in China based on a meta-analysis of available studies published in English and Chinese. Secondly, it compares the prevalence of child physical abuse in China with Stoltenborgh et al.’s (2013) international estimate and their estimate for Asia. Thirdly, it examines the moderating of study location (i.e., mainland vs. Hong Kong and Taiwan studies) and other sample characteristics (e.g., small vs. large sample) and methodological factors (e.g., lifetime prevalence vs. 12-month or less prevalence) on the prevalence of child physical abuse. Methods Literature Search The key words search was conducted in the Chinese National Knowledge Infrastructure (CNKI) database. “qu ti nue dai (physical abuse)” and “er tong nue dai (child abuse)” were used as key words. The key words search generated 869 results, including journalistic reports, clinical studies and case studies. The primary goal of this study was to estimate the prevalence of child physical abuse in China based on a meta-analysis of rates reported in individual studies; therefore, only survey studies reporting a rate of child physical abuse in a community sample were collected. Qualified studies were manually selected according to the following criteria: (1) The study was published in a scholarly peer-reviewed journal or major conference symposium. (2) The subjects of the study must have been recruited from a general population (i.e., not exclusively clinical, justice system or other special samples). (3) The study used quantitative methods to estimate the prevalence of physical abuse before 18 years of age, whether the participants were children or adults at the time of data collection. (4) The prevalence was reported by victims, rather than perpetrators of child physical abuse (e.g., parents, teachers, etc.). A citation search was also conducted later by checking the references of qualified studies collected from the key words search. The reference lists of United Nations Children’s Fund’s (2012) and Stoltenborgh et al.’s (2013) systematic review on child abuse and neglect were searched. The search was completed in December 2013, collecting studies that met the above criteria and published from 1990 to 2013. The key words and citation search yielded 47 qualified studies. Thirty-eight studies used mainland Chinese samples; five studies used Hong Kong samples; and four studies used Taiwanese samples. One study used a female sample only (Qiu & Ma, 2010); the other studies used both female and male samples. One study used a structured interview to collect data (J. Wang, Liu, Meng, Xu, & Cheng, 1994); the other studies used anonymous questionnaires. Validated instruments, such as the Conflict Tactics Scale (CTS)/Parent–Child Conflict Tactics Scale (CTSPC) and the short version of Childhood Trauma Questionnaire (CTQ-SF) were used in some Chinese studies. Definition of Child Physical Abuse The third National Incidence Study (NIS-3) in the United States, a periodic sentinel survey to estimate incidence of child abuse and neglect, provides an operationalized definition of child physical abuse as “nonaccidental physical assault with or without an implement (weapon, foreign object or substance), including slapping, spanking with hand, hitting with fist, biting, kicking, shoving, shaking, throwing, nonaccidental dropping, stabbing, choking, permitting of physical assault, and semi-accidental injuries foreseeably resulting from physical assault” (Sedlak, 2001). Slapping, spanking with hand and other acts such as shoving, ear twisting, and pinching, which intend to cause bodily pain, but not injury, for purpose of the correction or control of the children’s behavior are often defined as “corporal punishment” (Straus & Donnelly, 2001). Corporal punishment without bodily injury is culturally and legally accepted, although some Please cite this article in press as: Ji, K., & Finkelhor, D. A meta-analysis of child physical abuse prevalence in China. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.11.011



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researchers advocate that children should never, ever, be spanked no matter what circumstance (Straus, 2005). But nonaccidental physical injury to a child, ranging from minor bruises to severe fractures or death as a result of punching, beating, kicking, biting, shaking, throwing, stabbing, choking, hitting, burning, is not legally acceptable in the United States, the United Kingdom, Hong Kong and many other countries in the world (Child Welfare Information Gateway, 2013; National Society for the Prevention of Cruelty to Children, 2009; Runyan et al., 2002; Social Welfare Department, 2007). For example, the Procedural Guide for Handling Child Abuse Cases (2007) provided by Social Welfare Department in Hong Kong defines child physical abuse as “physical injury or physical suffering to a child (including non-accidental use of force, deliberate poisoning, suffocation, burning, Munchausen’s Syndrome by Proxy, etc.), where there is a definite knowledge, or a reasonable suspicion that the injury has been inflicted non-accidentally.” Child physical abuse has not been clearly defined in mainland China (K. Chan, 2012). The majority of Chinese studies on child physical abuse in our collection did not differentiate corporal punishment from legally unacceptable forms of physical abuse. Therefore, severity of child physical abuse was chosen as a way to classify various measurements of child physical abuse in Chinese studies. The severity measurement in the CTSPC, a widely used scale estimating the prevalence of parent-to-child physical abuse in the general population (Sadowski et al., 2004), was used as a reference. CTSPC classifies assaultive acts into three severity levels: minor, severe, and very severe (Straus, Hamby, Finkelhor, Moore, & Runyan, 1998). Minor is also called “corporal punishment,” and includes spanking on the bottom with a bare hand, hitting the bottom with objects, slapping on the hand, arm or leg, pinching, and shaking. Severe includes slapping on the face, head or ears, hitting on the other parts of body besides the bottom with objects, throwing or knocking children down, and hitting with a fist or kicking hard. Very severe includes beating up, grabbing around neck and choking; burning or scalding on purpose, and threatening with a knife or gun (Straus et al., 1998). We adopted these classifications for purposes of this analysis. Variables and Coding The first author’s last name and the year of publication were used to identify studies. 1. Prevalence of Child Physical Abuse (1) Any physical abuse To make the prevalence of any physical abuse in this study comparable to Stoltenborgh et al.’s (2013) study, the prevalence of any physical abuse referred to the percent of respondents who experienced any physical abuse, regardless of the variation of severity levels, definitions, time frames and other methodological factors in individual studies. The rates of any physical abuse reported by thirty-seven studies were recorded. But ten studies only reported rates at certain severity levels (e.g., minor, severe, very severe). The highest available rate of minor, severe or very severe physical abuse was used to replace the missing rate of any physical abuse for these studies. (2) Severity of child physical abuse Several Chinese studies using CTSPC as the measurement of child physical abuse reported the rate of minor, severe and very severe physical abuse separately. If the rate of minor, severe or very severe physical abuse was reported in a study, these original rates were coded and used for analysis. For studies which did not report a separate rate for minor, severe and very severe physical abuse, the least severe item in that study was compared to minor, severe and very severe physical abuse items in CTSPC. If the least severe question in a study was comparable to minor physical assault items in CTSPC, the any physical abuse rate reported by this study was classified as a minor physical abuse rate. Similarly, if the least severe question in a study was comparable to severe physical assault items in CTSPC, the any physical abuse rate reported by this study was classified as a severe physical abuse rate. The equivalent was done for very severe physical abuse items. (3) Gender-specific rates for any physical abuse If a study reported rates for each gender separately, the rates of any physical abuse were coded for females and males. If the study did not report separate rates, the rates for females and males were coded as missing values. 2. Moderators Combining moderators that have often been examined in international meta-analytic reviews (Pereda, Guilera, Forns, & Gomez-Benito, 2009; Stoltenborgh, Bakermans-Kranenburg, & Ijzendoorn, 2013; Stoltenborgh, Bakermans-Kranenburg, Alink, & Van Ijzendoorn, 2012; Stoltenborgh, Bakermans-Kranenburg, van Ijzendoorn, et al., 2013; Stoltenborgh, van Ijzendoorn, Euser, & Bakermans-Kranenburg, 2011) with those that were unique to Chinese studies on child abuse and neglect (Ji, Finkelhor, & Dunne, 2013), the following moderators were tested in this study.



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(1) Sample characteristics a. Sample size. Twenty-four studies that included more than 1,000 respondents were coded as 1 (large sample size), whereas 23 studies that included less than 1,000 respondents were coded as 0 (small sample size). b. Response rate. The median response rate for all the studies was 94.24%. Twenty-two studies with a response rate higher than 94.24% were coded as 1 (high response), whereas 20 studies with a response rate lower than 94.24% were coded as 0 (low response). Five studies which did not report a response rate were coded as missing. c. Age cohort. Sixteen studies with adult respondents were coded as 1 (older age cohort), whereas 31 studies with respondents under the age of 18 years old were coded as 0 (younger age cohort). d. Probability sample. Twenty-eight studies with probability samples (e.g., utilization of random sampling, multi-stage random sampling) were coded as 1 (probability sample). Nineteen studies using convenience samples and studies that did not introduce their sampling procedures were coded as 0 (non-probability sample). (2) Methodological factors a. Prevalence period. Not all studies specified a prevalence period. Eighteen studies with a referred period equal to or less than one year were coded as 0 (12-month or less prevalence). Twenty-nine studies asking about the prevalence before a certain age (e.g., 14, 16 or 18) or not specifying a time period were coded as 1 (lifetime prevalence). b. Single or multiple sites. Thirty studies that included samples from multiple sites were coded as 1 (multiple sites), and 17 studies that included respondents from a single site were coded as 0 (single site). c. Mainland China. Thirty-eight studies that used a sample from mainland China and were coded as 1 (mainland study); and 9 studies that used a sample from Hong Kong or Taiwan were coded as 0 (non-mainland study). d. Urban or rural studies. Nine studies conducted in rural area were coded as 0 (rural study) and 34 studies conducted in urban area were coded as 1 (urban study). Four studies which did not specify study locations were coded as missing values. e. Family perpetrators. Twenty-five studies that defined perpetrators of child physical abuse exclusively as parents or family members were coded as 1 (perpetrators exclusively parents); 22 studies that did not specify perpetrators and a few studies that included other perpetrators (i.e., peers, teachers) were coded as 0 (other perpetrators). f. Validated instruments. Twenty-five studies that used validated instruments were coded as 1 (validated instruments); 22 studies that used self-created instruments that have not been validated were coded as 0 (instruments not validated). g. Type of instruments. Six studies that used the CTQ-SF were coded as 1; 10 studies that used CTS or CTSPC were coded as 2; and 31 studies using other instruments were coded as 3. The category of “other” not only included self-created instruments by Chinese researchers, but also referred to some validated instruments used by a few studies, such as the Juvenile Victimization Questionnaire, the Adverse Childhood Experience questionnaire, the Personal Report of Child Abuse. h. National Incidence Study (NIS) definition. The definition and measurement of child physical abuse in each study was compared to the NIS-3 definition. The NIS-3 definition of child physical abuse included minor physical abuse (e.g., slapping, spanking with hand, biting, kicking, and shaking) as well as very severe physical assault (e.g., assault with weapon, scalding, burning, poisoning, suffocating, and drowning). Thirty-six studies that adopted a definition that was stricter than or equal to the NIS definition were coded as 1; 8 studies that adopted a definition that was broader than the NIS definition were coded as 2. Three studies that did not provide a definition were coded as missing values. i. Confinement/non-contact corporal punishment. Confinement refers to confining victims in a small space with or without ropes/chains. “Non-contact” corporal punishment includes withdrawing food, water or shelter from victims, and/or demanding victims to complete excessive academic or physical work (e.g., standing, running). Although NIS-3 considered close confinement as a form of child emotional abuse (Sedlak, 2001), confinement was considered as “physical abuse” rather than “emotional abuse” in many Chinese studies (Chen, 2005; Chen, Ma, & Liang, 2008; Ding et al., 2007). Including these atypical categories of child physical abuse might inflate the prevalence of child physical abuse in China, relative to other countries. Therefore, four studies that included confinement or non-contact corporal punishment were coded as 1; and 43 studies that did not include these categories were coded as 0. j. Repeated abuse assessment. Forty-three studies that defined child physical abuse as a repeated pattern (e.g., “often” or “3 times a year”) were coded as 1 (repeated abuse assessment), and four studies that defined child physical abuse as the occurrence of any physical abusive event were coded as 0 (any abuse assessment). k. Specific questions. Thirty-six studies that asked about specific abusive acts toward victims (e.g., slapped on the hand, arm, or leg, spanked on the bottom with bare hand) were coded as 1 (specific questions); 9 studies that used general terms (e.g., hitting, beating, or corporal punishment) in the question without any explanation were coded as 0 (questions not specific); 2 studies that did not provide details on the survey questions were coded as missing values. l. Percent of questions on corporal punishment. The percent of questions on corporal punishment was calculated by dividing the number of questions on corporal punishment by the total number of questions asked in each study. The minor assault questions (also named as “corporal punishment”) in CTSPC were used as the reference. The percent of questions on corporal punishment ranged from 0 to 100% with a median of 38%. 22 studies with a percent of questions




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Fig. 1. The forest plot of any child physical abuse. *PR is the abbreviation of “prevalence rate”; CI is “confidence interval.”

on corporal punishment higher than 38% were coded as 1; and 22 studies with a percent lower than 38% were coded as 0. Three studies without any information about the questions were coded as missing values. m. Percent of questions on very severe physical abuse. The percent of questions on very severe physical abuse was calculated by dividing the number of questions on very severe physical abuse by the total number of questions asked in each study. The very severe questions in CTSPC were used as the reference. The percent of questions on very severe physical abuse ranged from 0 to 78% with a median of 33%. Twenty-one studies with a percent of questions on very severe physical abuse higher than 33% were coded as 1; and 23 studies with a percent lower than 33% were coded as 0. Three studies were coded as missing values. Statistical Analysis The meta-analyses were performed using meta-commands in STATA 13.0. Results from the random effects model were used instead of the fixed effects model to avoid the domination of studies with large sample sizes. In the first step, the estimated prevalence of any, minor, severe, and very severe child physical abuse was calculated. The confidence intervals of estimated prevalence were compared to determine whether there was a significant difference between minor, severe and very severe child physical abuse. Non-overlap between the confidence intervals indicated statistical significance (Higgins & Green, 2011). In the second step, all the studies were divided into subgroups according to the sample characteristics and methodological factors. Meta-analysis was conducted in each subgroup for any, minor and severe child physical abuse separately. Subgroup analysis was not performed for very severe child physical abuse because of very few cases. The confidence intervals between subgroups were compared to test significant difference. Finally, the meta-regression analyses were conducted to identify significant predictors of any and minor child physical abuse. Only significant moderators in subgroup analysis were entered into the meta-regression model. Meta-regression analysis of severe child physical abuse was not conducted because no significant moderator was found in the subgroup analysis. Step-wise meta-regression analysis was used to create a most parsimonious model. Results The Estimated Prevalence for Child Physical Abuse Based on the meta-analysis of 47 studies, the estimated prevalence for any child physical abuse was 36.6% (95% CI: 30.4–42.7). Significant heterogeneity was found for any child physical abuse (Q = 53,000, df = 46, p < 0.001). The central dotted line in Fig. 1 shows the estimated prevalence. The prevalence of any child physical abuse ranged from 4.1% (Lau et al., 2005) to 88.04% (Ding et al., 2007) (see Y axis for a list of studies in Fig. 1). The area of boxes in Fig. 1 shows the sample size and the mid-point shows the prevalence estimate for each study. Twenty-two studies reported the prevalence of any child physical Please cite this article in press as: Ji, K., & Finkelhor, D. A meta-analysis of child physical abuse prevalence in China. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.11.011


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Fig. 2. The forest plot of minor child physical abuse. *PR is the abbreviation of “prevalence rate”; CI is “confidence interval.”

abuse for women; 21 studies reported the prevalence for men. The prevalence of any child physical abuse was 35.2% (95% CI: 26.9–43.6) for women and 43.8% (95% CI: 31.9–55.6) for men. The prevalence was higher for men than women, but not significantly. Significant heterogeneity was also found for female (Q = 11,000, df = 21, p < 0.001) and male (Q = 21,000, df = 20, p < 0.001) child physical abuse. Based on 25 studies (see Fig. 2), the estimated prevalence for minor physical abuse was 43.1% (95% CI: 36.6–52.5). Based on 29 studies (see Fig. 3), the prevalence for severe physical abuse was 26.6% (95% CI: 21.4–31.8). Based on 6 studies, the prevalence for very severe physical abuse was 7.8% (95% CI: 5.0–10.5). There was a significant difference in prevalence between minor, severe, and very severe physical abuse. The prevalence for minor physical abuse was the highest, followed by severe physical abuse. The prevalence of very severe physical abuse was the lowest. Significant heterogeneity was found

Fig. 3. The forest plot of severe child physical abuse. *PR is the abbreviation of “prevalence rate”; CI is “confidence interval.”




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Table 1 Subgroup analyses of any child physical abuse by sample characteristics and methodological factors. Any child physical abuse N

Prev

95% CI Lower

Upper

Large sample size Small sample size

24 23

0.324 0.410

0.243 0.298

0.404 0.521

High response rate Low response rate

22 20

0.374 0.376

0.273 0.274

0.475 0.477

Older cohort Younger cohort

16 31

0.426 0.334

0.301 0.262

0.551 0.407

Probability sample Non-probability sample

28 19

0.340 0.403

0.269 0.309

0.412 0.497

Lifetime prevalence 12-month or less prevalence

29 18

0.384 0.335

0.321 0.243

0.447 0.427

Multiple sites Single site

30 17

0.322 0.444

0.250 0.322

0.393 0.565

Mainland China Non-mainland

38 9

0.406a 0.195a

0.338 0.072

0.474 0.318

Urban study Rural study

34 9

0.376 0.337

0.295 0.230

0.458 0.444

Perpetrators exclusively parents Perpetrators including others

25 22

0.288a 0.454a

0.225 0.382

0.350 0.526

Validated instruments Instruments not validated

25 22

0.304 0.436

0.242 0.321

0.366 0.550

CTQ CTS/CTSPC Other

6 10 31

0.258 0.352 0.391

0.181 0.266 0.308

0.336 0.437 0.473

Stricter or equal to NIS def Broader than NIS def

36 8

0.299a 0.593a

0.247 0.441

0.350 0.745

Including confinement/non-contact corporal punishment Excluding confinement/non-contact corporal punishment

4 43

0.616 0.342

0.348 0.280

0.885 0.405

Repeated abuse assessment Any abuse assessment

4 43

0.202a 0.381a

0.157 0.312

0.247 0.449

Specific questions Questions not specific

36 9

0.387 0.261

0.323 0.179

0.451 0.342

More than or equal to 38% questions on minor physical abuse Less than 38% questions on minor physical abuse

22 22

0.465a 0.260a

0.361 0.184

0.569 0.336

More than or equal to 33% questions on very severe physical abuse Less than 33% questions on very severe physical abuse

21 23

0.287 0.431

0.208 0.336

0.367 0.527

a

CIs do not overlap between contrast categories.

for minor (Q = 29,000, df = 24, p < 0.001), severe (Q = 9871.6, df = 28, p < 0.01) and very severe (Q = 588.2, df = 5, p < 0.01) physical abuse. Subgroup Analyses All the studies were coded into subgroups according to sample characteristics and methodological factors. The metaanalysis was performed for each subgroup to calculate the pooled estimate and 95% confidence intervals. Non-overlapping confidence intervals between subgroups indicated significant difference. The subgroup analyses were conducted for any, minor, and severe physical abuse. Very severe physical abuse was excluded from subgroup analyses due to limited cases. Subgroup analyses found lower rates of any child physical abuse in studies from non-mainland provinces, defining perpetrators exclusively as parents, adopting a definition that was stricter or equal to the NIS definition, using repeated abuse assessment of physical abuse, and asking less than 38% of the questions on minor physical abuse (see Table 1). There was no difference between studies using large and small sample, with high and low response, based on older and younger cohort, using probability and non-probability sample, reporting lifetime and 12-month or less prevalence, using single and multiple sites, conducted in rural or urban area, using validated and not validated instrument, using CTQ, CTS/CTSPC and Please cite this article in press as: Ji, K., & Finkelhor, D. A meta-analysis of child physical abuse prevalence in China. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.11.011



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Table 2 Subgroup analyses of minor and severe child physical abuse by sample characteristics and methodological factors. N

Minor child physical abuse Prev

N

95% CI Lower

Upper

Severe child physical abuse Prev

95% CI Lower

Upper

Large sample size Small sample size

11 14

0.356 0.489

0.231 0.333

0.482 0.646

17 12

0.280 0.245

0.211 0.184

0.350 0.306

High response rate Low response rate

15 9

0.440 0.418

0.302 0.237

0.577 0.599

12 12

0.219 0.309

0.154 0.248

0.284 0.369

Older cohort Younger cohort

7 18

0.620 0.357

0.426 0.259

0.814 0.455

9 20

0.275 0.262

0.172 0.199

0.378 0.325

Probability sample Non-probability sample

12 13

0.418 0.442

0.306 0.333

0.530 0.550

19 10

0.268 0.262

0.203 0.184

0.334 0.339

Lifetime prevalence 12-months or less prevalence

10 15

0.592a 0.324a

0.440 0.218

0.743 0.429

18 11

0.278 0.247

0.215 0.174

0.340 0.320

Multiple sites Single site

13 12

0.364 0.503

0.248 0.350

0.480 0.656

22 7

0.263 0.277

0.205 0.113

0.320 0.441

Mainland China Non-mainland

21 4

0.497a 0.072a

0.391 0.052

0.603 0.093

23 6

0.270 0.252

0.218 0.132

0.322 0.372

Urban study Rural study

20 4

0.416 0.474

0.312 0.367

0.520 0.581

21 5

0.275 0.227

0.212 0.113

0.337 0.341

Perpetrators exclusively parents Perpetrators including others

14 11

0.311a 0.583a

0.223 0.463

0.398 0.703

19 10

0.230 0.334

0.183 0.260

0.277 0.408

Validated instruments Instruments not validated

8 17

0.378 0.455

0.252 0.323

0.503 0.588

23 6

0.241 0.363

0.183 0.234

0.299 0.491

CTQ CTS/CTSPC Other

– 7 18

– 0.331 0.469

– 0.204 0.340

– 0.457 0.599

6 10 13

0.258 0.240 0.289

0.181 0.183 0.182

0.336 0.297 0.396

Stricter or equal to NIS def Broader than NIS def

16 7

0.319a 0.614a

0.242 0.415

0.395 0.813

–

–

–

–

Including confinement/non-contact corporal punishment Excluding confinement/non-contact corporal punishment

3 22

0.718a 0.392a

0.525 0.297

0.911 0.487

–

–

–

–

–

–

–

4 25

0.202 0.277

0.157 0.213

0.247 0.340

Repeated abuse assessment Any abuse assessment

–

Specific questions Questions not specific

17 7

0.494a 0.244a

0.373 0.158

0.616 0.329

27 2

0.262 0.319

0.207 0.160

0.318 0.479

More than or equal to 38% questions on minor physical abuse Less than 38% questions on minor physical abuse

20 4

0.470a 0.177a

0.356 0.053

0.585 0.300

8 20

0.291 0.252

0.221 0.175

0.360 0.329

More than or equal to 33% questions on very severe physical abuse Less than 33% questions on very severe physical abuse

8 16

0.310 0.477

0.202 0.365

0.417 0.589

15 13

0.239 0.292

0.174 0.210

0.303 0.373

a

CIs do not overlap between contrast categories.

other instrument, including and excluding questions on confinement/non-contact corporal punishment, asking specific and not specific questions, and asking more than/equal to and less than 33% questions on very severe physical abuse. Significantly lower rates of minor child physical abuse were found in studies reporting the 12-month or less prevalence, from non-mainland provinces, defining perpetrators exclusively as parents, adopting a stricter or equal to NIS definition, excluding questions on confinement/non-contact corporal punishment, asking not specific questions, and asking less than 38% questions on minor physical abuse (see Table 2). There was no difference between studies using large and small sample, with high and low response, based on older and younger cohort, using probability and non-probability sample, using single and multiple sites, conducted in urban and rural areas, using validated and not validated instrument, using CTS/CTSPC and other instrument, and asking more than/equal to and less than 33% questions on very severe physical abuse. No significant difference between subgroups was found for severe child physical abuse. Meta-regression Analyses Significant moderators for any and minor physical abuse in subgroup analyses were entered as independent variables in a meta-regression model to identify significant predictors for each type of child physical abuse. Step-wise meta-regression was performed to create a most parsimonious regression model. The results showed that mainland study and repeated abuse Please cite this article in press as: Ji, K., & Finkelhor, D. A meta-analysis of child physical abuse prevalence in China. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.11.011



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Table 3 Meta-regression analyses of any and minor child physical abuse. Variables Mainland study (mainland = 1, non-mainland = 0) Repeated abuse assessment (repeated = 1, any = 0) Prevalence period (lifetime = 1, within the past year = 0) * **

Any child physical abuse 0.230** −0.218*

Minor child physical abuse 0.329** 0.180*

p < 0.05. p < 0.01.

assessment were two significant predictors of any child physical abuse (see Table 3). Mainland studies yielded a significantly higher rate of any child physical abuse than studies that were conducted in Hong Kong and Taiwan. Also, studies that used repeated abuse assessment yielded a significantly lower rate of any child physical abuse than studies using any abuse measurement. Mainland study was also a significant predictor of minor child physical abuse. Prevalence period, rather than repeated abuse assessment, was the other predictor of minor child physical abuse. Studies reporting lifetime prevalence yielded a significantly higher rate of minor child physical abuse than studies reporting prevalence within the past year. Discussion The prevalence of any child physical abuse in China was estimated at 36.6% (95% CI: 30.4–42.7), based on a meta-analysis of 47 Chinese studies involving a total number of 200,547 participants in mainland China, Hong Kong and Taiwan. There was tremendous variability in rates: the rate of any child abuse ranged from 4.1% (Lau et al., 2005) to 88.04% (Ding et al., 2007). Similar to Stoltenborgh et al.’s (2013) definition of child physical abuse prevalence, the prevalence of any child physical abuse in this meta-analysis is a mixture of different definitions, time frames, severity levels and other sample and methodological features in individual studies. Because the majority of samples were lifetime estimates, and no significant differences were found between lifetime and 12-month or less estimates, this overall estimate should be considered in effect a lifetime estimate. Our estimate of child physical abuse prevalence for China was significantly higher than Stoltenborgh et al.’s (2013) international estimate (PR = 22.6, 95% CI: 19.6–26.1) and also their estimate for Asia (PR = 16.7%, 95% CI: 10.6–25.3). The current meta-analysis included a much larger proportion of studies from mainland China (38/47) than Stoltenborgh et al.’s meta-analysis of Asian studies (1/20), but a smaller proportion of studies from non-mainland China (9/47) than Stoltenborgh et al.’s meta-analysis (11/20). The subgroup and meta-regression analyses showed that the prevalence of any child physical abuse in non-mainland China was significantly lower than that in mainland China even controlling for other definitional and methodological factors as well as sample characteristics. A comparison between one Hong Kong (Tang, 1996) and one mainland (Kim et al., 2000) study using similar methodologies illustrates this difference. Tang’s study used a Hong Kong student sample and Kim et al. used a student sample from mainland China. The Hong Kong and mainland Chinese students were asked the same set of questions on the CTS. The referent period was the past year in both studies. But the results showed that the rate of minor assault was 13.2% reported by Hong Kong students and 42.2% reported by mainland Chinese students. The rate of severe assault was 8.5% in the Hong Kong and 22.5% in the mainland student sample (the rate of any physical abuse was not compared because the rate was not reported in Tang’s study). The comparison of individual studies showed a much lower rate of child physical abuse in Hong Kong than in mainland China. The results from the current meta-analysis combined with the comparison of individual studies suggest that the true prevalence of child physical abuse is very likely lower in Hong Kong and Taiwan than in mainland China. Corporal punishment, such as spanking and slapping, are culturally accepted within Chinese society (Lau et al., 2005; Shen, 2009). The Confucian philosophy of parenting, which endorses parents’ authority and filial piety, is still prevalent in the minds of Chinese parents and children. A well-known proverb “gun bang di xia chu xiao zi” (also translated as “spare the rod, spoil the child”) indicates that the filial piety is achieved by strict physical discipline of children. In contrast to punishment oriented Chinese parenting, parenting advice in the United States, the United Kingdom and some other Western countries, has been advocating a style that emphasizes closeness and warmth, reasoning and negotiation in the parent-child relationship (Chao & Tseng, 2002; Van Campen & Russell, 2010), avoidance of violence under the influence of research on “battered children,” (Kempe, Silverman, Steele, Droegemueller, & Silver, 1984) “spanking,” and the generational transmission of violence (Straus, 2005), and the implementation of child physical abuse prevention strategies and policies (Child Welfare Information Gateway, 2013). The advocacy of non-violent child rearing in Western countries may have had a larger impact on parents and children in Hong Kong and Taiwan, which have both had more Western influence, than those in mainland China. Therefore, parents and children in Hong Kong and Taiwan may not endorse parents’ authority and physical punishment as much as mainland parents and children do (S. M. Chan, Bowes, & Wyver, 2009). Additionally, child abuse advocacy and intervention is a much more active enterprise in Hong Kong than in mainland China. The Procedural Guide for Handling Child Abuse Cases (2007) issued by the Social Welfare Department of Hong Kong provides a complete guideline from identifying possible child abuse to multi-disciplinary involvement of social service units to protect children from the alleged abuse. The availability of child protection services in Hong Kong may reflect a social attitude and effort to eradicate physical abuse of children and therefore deter the perpetrators of physical abuse. However, in mainland China, when a suspected child abuse case is reported, there are no official guidelines concerning which social Please cite this article in press as: Ji, K., & Finkelhor, D. A meta-analysis of child physical abuse prevalence in China. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.11.011


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institution is responsible for handling the case, how the investigation should be conducted, and how to protect children from the suspected abuse. The advanced child protection system in Hong Kong may work to better protect children from abuse and promote a lower prevalence of child abuse than in mainland China. Moreover, according to available data, women in Hong Kong and Taiwan are better educated than those in mainland China. Research has identified mother’s lower education and younger age as risk factors for child physical abuse (Connelly & Straus, 1992). The educational attainment expectancy is 15 years for Hong Kong women and 16.4 years for Taiwanese women compared to 13 years for women in mainland China (Taiwan Ministry of Education, 2012; The World Fact Book, 2013–14, 2013). Women’s gross enrollment ratio in tertiary education is 61% in Hong Kong and 87.01% in Taiwan compared to 27% in mainland China (Taiwan Ministry of Education, 2012; United Nations Statistics Division, 2012). In terms of maternal age, Hong Kong has a much lower adolescent fertility rate than mainland China (4.2 vs. 9.1 per 1,000 women in the age group of 15–19 years) (United Nations Statistics Division, 2012). Adolescent women are at greater risk of child abuse because a number of characteristics are associated with early child bearing, such as single parenthood, inadequate support systems, insufficient knowledge of and experience in child rearing, inadequate education, and poverty (Connelly & Straus, 1992). Although the adolescent fertility rate (in 2010) was not available for Taiwan, the 2010 total fertility rate in Taiwan was the lowest in the world (Sui, 2011), suggesting that adolescent child bearing is also likely low. In sum, the results of the current study as well as available data on other family indicators strongly suggests that children in mainland China are at greater risk of physical abuse than children in Hong Kong and Taiwan. Higher rates of physical abuse are concerning in part because of the known associations between physical abuse and long term negative outcomes. Physical abuse of children is significantly related to poor mental health and harmful behaviors, such as depressive disorders, anxiety disorders, eating disorders, childhood behavioral disorders, suicide attempts, drug use, and risky sexual behavior (Norman et al., 2012). Studies in mainland China also found that physical abuse in childhood was associated with depression, anxiety and other forms of mental disorder (Ma et al., 2005; Tao et al., 2006), smoking (Lau, Chan, Lam, Choi, & Lai, 2003; Lau et al., 2005), problem drinking (H. G. Cheng, Huang, & Anthony, 2011), illicit drug use (Lau et al., 2005), and self-harming behaviors (Xiao, Tao, Xu, Su, & Huang, 2008). Evidence exists that educational programs directed at parents can reduce the occurrence of physical abuse (Institute of Medicine & National Research Council, 2014). Therefore, educational programs are highly recommended to promote non-violent child rearing practices especially in mainland China, where the prevalence of child physical abuse was found to be significantly higher than the international rate. The educational programs should target Chinese parents as well as pregnant women and high school students. To change the punishment-oriented child rearing practices derived from Confucian values, it is important to start from policies within the context of Confucian values. Family harmony is another core value in Confucian philosophy, which emphasizes the physical and emotional closeness and a lifelong bond in family relationships (K. Chan, 2012). The targeted populations need more exposure to models of parenting that emphasize Confucian values of family harmony and reasoning and negotiation in the parent–child relationship. Finally, it should be a priority for the Chinese government to build a child protection system to protect children from suspected abuse. An effective child protection system on child abuse can set the norms about child rearing and help more children grow up in a non-violent environment. There are limitations of this study and the need for caution in interpreting results must be acknowledged. First of all, there was tremendous variability in the rates of any, minor and severe child physical abuse in the studies aggregated in this analysis. The rate of any and minor child physical abuse ranged from 4.1% (Lau et al., 2005) to 88.04% (Ding et al., 2007) and the rate of severe child physical abuse ranged from 4.4% (P. Cheng et al., 2010) to 59.4% (Y. Wang & Chen, 2012). The sample characteristics and methodological factors examined in this study cannot account for all the variability of the rates. Secondly, the subgroup analysis of any, minor and severe child physical abuse between mainland and non-mainland China was based on relatively few Hong Kong and Taiwan studies. Limited studies in a subgroup may have made the estimate from this subgroup less reliable than the subgroup with plenty of studies. Therefore, readers should be aware that the estimate of prevalence in non-mainland China was based on fewer studies when interpreting the striking difference in the rate of child physical abuse between mainland and non-mainland studies. Thirdly, not every study reported the rate of minor, severe, and very severe rate of child physical abuse separately. The missing rates were substituted with the available rates at the same severity level to enable the comparison in/between each severity level. It is evitable that some substituted rates might deviate from the actual rates. Fourthly, this meta-analysis only collected studies on prevalence of child physical abuse reported by victims, rather than perpetrators, although perpetrator-reported rates in Chinese studies were as valid and reliable as victim-reported rates (Finkelhor, Hamby, Ormrod, & Turner, 2005; Straus et al., 1998). An analysis using perpetrator reported rates may come to a different conclusion. Additionally, because many Chinese studies did not specify the perpetrators, it is possible that these studies had actually been counting peers as the perpetrators of child physical abuse. This is not consistent with the international literature on child physical abuse which tends to define perpetrators as adults and older person (Child Welfare Information Gateway, 2013) and might lead to an overestimation of the prevalence of child physical abuse in China. Future Chinese studies should be more careful in defining perpetrators. Finally, the estimates in this study were based on victim reported prevalence of child physical abuse, which may exclude the experience of young children who were too young to report and whose experiences were not remembered by older respondents. But the NIS found that the incidence of maltreatment among the younger children (0–2 years old and 0–5 years old) were lower than that among older children (Sedlak & Broadhurst, 1996). And the rates of children with serious Please cite this article in press as: Ji, K., & Finkelhor, D. A meta-analysis of child physical abuse prevalence in China. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.11.011



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