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Meesha Iqbal,¹ Zafar Fatmi,1 Kausar Khan¹ and Asaad Nafees¹

¹Department of Community Health Sciences, Aga Khan University Hospital, Karachi, Sindh, Pakistan (Correspondence to: Meesha Iqbal: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

Abstract

Background: Child labourers are exposed to an insecure environment and higher risk of violence. Violence among child labourers is an under-studied phenomenon which requires contextual assessment.

Aims: We applied Bronfenbrenner’s ecological model (micro-, exo- and macro-system) to understand the interplay of individual, community, societal and policy context fuelling violence.

Methods: Focus group discussions and family ethnographies of child-labourers working in common occupational sectors of suburban areas of Sindh were carried out to gain in-depth understanding of their immediate environment and abuse (micro-system). Frequency of emotional, physical and sexual violence (5–14 years; n = 634) was also determined. In-depth interviews with employers (exo-system, n = 4) and key-informant-interviews of prominent stakeholders in Pakistan (macro-system, n = 4) working against labour/violence were carried out Thematic-content analysis was performed using MAXQDA, version 8.0.

Results: We estimated that 21%, 19% and 9% of children suffered from emotional, physical and sexual violence respectively. Child labourers’ interviews indicated the existence of all forms of abuse at home and in the workplace; sexual violence by grandfathers was highlighted (micro-system). Children reported frequent scolding and insults in the workplace along with physical violence that could be fatal (exo-system). The legal environment of violence in Pakistan was considered deficient as it did not address the hidden forms (touching, kissing, etc.; macro-system).

Conclusion: We documented that all forms of violence were rampant among the child labourers, and improved efforts and comprehensive legislation is direly needed to alleviate the situation.

Key words: violence, child labour, sexual child abuse, physical maltreatment, Pakistan

Citation: Iqbal M; Fatmi Z; Khan K; Nafees A. Violence and abuse among working children in urban and suburban areas of lower Sindh, Pakistan. East Mediterr Health J. 2021;27(5):501–508. https://doi.org/10.26719/2021.27.5.501

Received: 14/01/20; accepted: 08/06/20

Copyright © World Health Organization (WHO) 2021. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo)

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Introduction

The World Health Organization (WHO) defines violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation” (1). Violence may include deprivation or emotional, physical or sexual harm to the victim (2). Violence against children is a significant public health concern globally (3): one billion children worldwide, aged 2–17 years, experience some form of violence annually (4). Every fourth adult underwent at least one form of violence during childhood, and about 12% of children were sexually abused in 2017 alone (5). About 90% of the global deaths due to violence occurred in low- and middle-income countries (5).

Violence is a complex process that occurs with the interplay of multiple factors: individual, personal relationships, community and societal factors (6). Proximal determinants of violence include the personal history and personality of the individuals; low socioeconomic household status; and exposure to violent families, friends and peers, whereas poverty, unemployment, cultural norms and the legal environment form some of the overarching factors (6).

Exposure of child labourers to an unprotected environment is greater compared with other children, putting them at a higher risk of violence (7). The global burden of abuse among child labourers is not readily available, however the International Labour Organization identifies violence as a specific hazard for domestic child labourers, migrants and children working in mines (8). Violence poses long-term emotional and physical effects on children. The emotional effects include depression, anxiety, insomnia, low self-esteem, social isolation and panic attacks (9). These children are more likely as adults to suffer from poor mental health, drug and alcohol abuse, risky sexual behaviour and criminality (10). Physical violence is the leading cause of injury and death among children (11).

Pakistan has a high frequency of violence, although this is grossly underreported (12). Recently, there has been substantial increase in the reporting of violence in Pakistan. In 2016 alone, 4139 child sexual abuse cases, an alarming 11 cases per day, were reported (12). A population representative survey (Multiple Indicator Cluster Survey, 2014) reported that 81% of the children in Punjab and Sindh provinces experienced violence in the form of aggression, punishment or violent behaviour by others (13,14).

Pakistan harbours more than 12.5 million child labourers and the number is steadily increasing (15). There is dearth of literature regarding the various forms of abuse that the child labourers face. We designed this study to estimate the proportion of violence in various sectors of child labour in urban and suburban parts of lower Sindh. We also conducted contextual assessment to understand the individual, community, societal and policy factors playing a role in violence among child labourers.

Methods

Background

The study was a part of a larger project to assess the health and social status of child labourers in suburban areas of lower Sindh, Pakistan, carried out from May to December 2017. It was based on Bronfenbrenner’s ecological framework, which considers the health of an individual to be affected by the environment in which he/she thrives, including his own attributes and lifestyle (micro-system), the working environment and the social support system (exo-system) and the policies of the government at the broad level (macro-system) (16). (Figure  1) Violence was assessed and explored at all 3 levels (as described above) to understand its existence and the environment in which it thrives.

The qualitative exploratory inquiry for violence was carried out according to Bronfenbrenner’s ecological model (16).

Micro-system

Focus group discussions (FGDs, n = 10) and family ethnographies (FEs, n = 9) for child labourers were conducted to explore their perspective regarding violence. Questions were asked pertaining to health, relationships with people, including neighbours, relatives and employers, and myths and fears of children. Direct inquiry about violence was not deemed suitable; thus, it was indirectly probed with tools, viz: sociogram, timeline and storytelling. The sociogram was used to explore the association of children with known people. Timelines assessed the daily routine of children, highlighting the window periods where they were vulnerable to violence. Storytelling (worst and best memory of life) provided snapshots of the children’s lives pointing towards any memories of violence.

We also conducted a quantitative survey to determine the proportion of violence. Children aged 5–14 years working in the agricultural sector, the manufacturing industry and hotels and restaurants along with domestic workers and migrants were recruited by respondent-driven sampling and interviewed (n = 634). The details of the sampling technique, sample size assumptions and methodology are specified elsewhere (17). A pictorial tool (sketches depicting violence) was created to represent emotional, physical and sexual abuse and tested for face validity. The tool was administered by trained interviewers.

Exo-system

In-depth interviews of the children’s employers helped gain insights into the exo-system. Four in-depth interviews of employers/caretakers of children were conducted to develop an understanding of their working relations and environment. All forms of violence were directly questioned and probed from the employers (Table 1).

The FGDs and the FEs with the children also helped gain insights into the working environment.

Macro-system

Key informant interviews with important stakeholders (n = 5) working against child labour and violence casted light on laws and policies against abuse and labour in Pakistan (Table 1). The purpose was to gain insights regarding the factors, experiences, challenges and gaps in the policies and programmes pertaining to presence of violence among child labourers. Nongovernmental organizations working in Pakistan for child labourers were contacted and the snowball technique was used for inclusion of further stakeholders. The representatives of the International Labour Organization, the Society for the Protection of the Rights of the Child (SPARC), the Pakistan Institute of Labour Education and Research (PILER) (working for the rights of the working class), and the representatives of Aahung and Sahil (working against violence) were included. The interviewees were questioned about the activities of the organization regarding child labour, their experiences, especially in the domain of violence against working children, the usual challenges in addressing labour and violence, the gaps present at the policy level and recommendations for improvement.

Analysis

The children were shown pictures of violence and asked to mark if they had experienced any such situation in the “past 1 month” for emotional abuse, “past 3 months” for physical and “ever” for sexual abuse (Figure 1). Any child with a single positive answer was considered a victim of violence. Proportions and frequencies of abuse were calculated. The Pearson chi-squared test was applied to determine the differences of the outcomes across the occupational groups. The data were analysed using SPSS, version 23 and Stata, version 8.

All qualitative interviews were developed as a semi-structured guide and were conducted by 2 trained research associates. They were audio-recorded and extra notes were taken where necessary. All the interviews were transcribed and translated, and thematic content analysis was done to synthesize the results (18). The qualitative data was analysed using MAXQDA, version 8.0.

Under the law of emancipation of minors, consent was obtained from the children prior to the interview. The Ethical Review Committee of the Aga Khan University approved the study (ERC number: 4591-CHS-ERC-16).

Results

Micro-system

The mean age of the study participants was 10.9 years [standard deviation (SD) 2.1] (Table 2). Most of the children working in hotels and restaurants were boys (98.5%), domestic workers were mostly girls (87.3%); the rest of the occupational groups had a fairly balanced distribution between the sexes. Most of the agricultural workers (87.5%) were of Sindhi ethnicity, whereas Punjabis dominated among the manufacturing, domestic and hotel and restaurant sectors. The mean income per month was highest among the migrants and lowest among domestic workers; Rs 5688 and Rs 3338 respectively. On average 8.3 (SD 3.5) people lived in a household, and 45.9% of the children lived in kacha houses. Around a quarter of the children reported currently going to school; however, almost half said that they had previously attended school at least for a month.

The children experienced high frequency of emotional (20.8%), physical (19.1%) and sexual abuse (8.5%) (Table 3). There was a statistically significant difference comparing violence among the occupational groups (P = 0.01), all forms of violence being highest among the agricultural workers (emotional 28.2%; physical 27.2%; sexual 19.0%). Emotional and sexual abuse were the least prevalent among children working in hotels and restaurants; 9.0% and 3.0% respectively. Physical abuse was lowest among domestic workers (12.7%). For emotional and sexual abuse, there was no difference between the sexes, but physical abuse was significantly more prevalent among boys (boys 23.3%, girls 14.7% P = 0.006) (Table 4).

The FGDs and FEs for the children indicated that the social support among the child labourers relied mostly on their parents and siblings, with less for friends and relatives. All the children expressed profound love and attachment for their mothers whereas they had a varied relationship with their fathers: some of them were loving and caring but some were physically abusive. Slapping and hitting with a stick were frequently reported. Most of the children lived in a joint family system and narrated an adverse affiliation with their grandfathers: “He curses me and hits me with a stick when I don’t work … (FGD, Migrant boy)”.

Children did not directly report sexual violence. They reported that they felt frightened to go alone outside their houses. One girl reported that she felt insecure from men when she went outside (bangle industry); another girl (agricultural sector) reported being scared of visitors coming to her house. One of the domestic workers revealed that she quit school as it was not a “safe” place to go.

Exo-system

The FGDs, FEs and in-depth interviews for the employers provided insights at the level of the exo-system; thist focused on the dealings, relationships and violence in the workplace or school. Verbal abuse, yelling and cursing children’s’ parents were frequently reported, with most common reasons being late and inefficient at work.

Physical abuse was reported in almost all sectors of child labour. The migrant children working in the vegetable market typically reported being hit with a metal stake by the supervisors for negligence at work.

“The shopkeepers at the vegetable market hit the kids with a metal stake (a steel rod) … when they steal vegetables … once a kid died … the man who killed him picked up his gun … he hit the kid on the back of his head with the back of the gun … which caused him to die … the owner believed that the kid was stealing from him … the killer then ran away, but he was later taken to the police … (FGD, migrant boys)”

Physical abuse was also expressed as a frequent reason for school drop-out: “They would pull my ears and slap me, so I ran away from school” (FE, agriculture).

Contrary to the reports from the children, the supervisors (farmers, landlords, factory owners) denied any sort of emotional, physical or sexual abuse against the children. They considered work as healthy for children as they supported their families and learnt a skill that would help them in future. They considered the working environment a secure place for all children.

Macro-system

The information pertaining to the environment of the child labourers at the macro level was organized into themes of landscape, barriers and recommendations to alleviate violence.

Landscape/situation with regard to violence: It was recounted by one of the stakeholders that the laws and policies in Pakistan were inadequate to protect children from all forms of violence. The Pakistan Penal Code (Section 509) addressed sexual harassment as an overarching law but failed to take account of the hidden forms of violence such as touching, kissing, oral sex, exhibitionism, voyeurism, etc. However, it was emphasized that the country’s judiciary had considerably improved in the past 2 decades as the judges were more sensitive to violence and quicker court decisions were being given, with cases resolving within a year (key informant interview, Sahil).

One of the respondents mentioned that talking about violence had always been difficult in the past, however with social media playing a pivotal role, the attitudes of people had started to change. It was no longer a distasteful topic to mention in front of the masses. Consequently, the reporting of violence also had increased considerably, however, only the worst forms of abuse such as rape and sodomy reached the courts.

“In 2003 or 2004 we had 2 to 3 cases of sexual abuse per year, today we have over a hundred cases annually. One major thing missing in our data, that can be massive, is pornography and oral sex, you would not find a single case! (key informant interview, Sahil)”

Barriers to eliminating violence: The biggest barrier to eliminating violence was that perpetrators were usually relatives, neighbours or people known to the children and it was challenging for children or their families to raise voice.

“Abuse is always a power game … they always had some sort of control; physical or positional, over the children … if it is the grandfather or even a father who has sexually abused the child, it creates a situation where the mother might feel helpless, she can’t do anything against them, where would she take her child?” (key informant interview, Sahil)”

Moreover, the shelter homes of the country (Dar-ul-aman) were generally not safe as there were growing reports of abuse in these asylums and the people had practically no place for sanctuary. For those who wanted to report violence, they were generally not aware of the intricacies of the legal process for reporting abuse. Even after reporting violence, the court proceedings were painful for the victim and the family. Many people withdrew their cases to escape the agony of repeatedly facing the perpetrator during court trials (key informant interview, Aahung).

Recommendations to alleviate violence: One of the stakeholders recommended revising the provincial legislation to form a comprehensive law addressing all forms of violence across the country. It was also advised that the court proceedings should be improved to make them less agonizing for the victims. It was proposed to put a screen between the perpetrator and the victim during court trials or to accept videos to spare the victim from going to the court.

The need to enhance community awareness regarding violence was strongly advocated by all stakeholders. It was proposed to add modules on violence into the curriculum of primary and secondary school children attending government or private schools. Schools should also incorporate educational videos on “good touch” and “bad touch”, to familiarize and sensitize the children during early childhood. It was emphasized that many nongovernmental organizations were working in Pakistan against labour and violence, but the government was not actively involved in the matter. The Ministry of Labour normally needed to be on board as the nongovernmental organizations served only as a “drop in the ocean” and could not alleviate the situation without the involvement of the government.

Discussion

We report a high burden of emotional (20.8%), physical (19.1%) and sexual violence (8.5%) among child labourers working in Pakistan. Physical violence was more prevalent among boys than girls (23.3% vs 14.7%, P = 0.006); no statistically significant difference was observed for emotional and sexual abuse. Sexual violence was alarmingly high among agricultural workers (19.0%), and least among the children working in hotels and restaurants (3.0%).

The varied manifestations of child labour and violence means there are no concrete operational definitions for comparison with other studies. There is dearth of literature for violence among child labourers in Pakistan. The International Labour Organization determined that violence among working children aged 5–14 years was 20%, 31% and 59% in the coal mines (n = 169; Chakwal, Nowshera), bangle industries (n = 527; Hyderabad) and tanneries (n = 152; Kasur) respectively (19–21). Validated tools were not used in these surveys and physical and sexual abuse were not separately assessed; however, the estimates strengthen our findings. Another study carried out in Turkey estimated similar results: 21% for physical and 25% for sexual violence among child labourers (n = 595) (22). The reason for the high proportion of sexual abuse among agricultural workers was not clearly understood. These children mostly worked as part of a family enterprise; we assume that the close relatives were the perpetrators in the majority of cases as is also evidenced by other reports from Pakistan (12,23,24). The authors are also of the view that the agricultural fields provide an environment favouring promiscuity, fewer witnesses and easy escape by the perpetrators, affecting girls and boys equally. Even with such high numbers, we consider these underestimates as some of the children would not have wanted to disclose information considering the fear and stigma associated with abuse. The real situation might be worse.

Our qualitative inquiry reinforced our quantitative assessment and provided insight into the holistic picture of violence among child labourers in Pakistan. Similar findings were reported by children in Jordan where the employers shouted and insulted them when they made mistakes or refused to do some work (25). Physical abuse such as slapping, kicking and sexual abuse by “elder boys” were also stated as a means of “teaching discipline” and “testing manhood” respectively.

The key stakeholders reported that the community awareness, laws and judiciary of the country had improved over time, but support mechanisms for the families of the victims, including reporting of violence, court trials and safe shelter homes, were not present. A lot of importance was given to having a comprehensive provincial legislature addressing all forms of violence. More extreme cases of abuse (rape and sodomy) were coming to light but the milder forms (touching, kissing, etc.) remained largely unreported. The interviewees believed that the legislature addressing the milder forms will lead to a trickling effect towards prevention of abuse. It was recommended that education on violence be included in the syllabi of the schools, starting in early classes and reiterating its importance in the older classes. Since the government has both the mandate and the responsibility for education of children, it must be taken on board to manifest an impact.

We believe that this is the first study to quantify violence among child labourers in Pakistan. Although not all sectors of child labour were included in our study, the major groups were represented. Respondent-driven sampling, considered a robust technique for hidden populations, was utilized. The stakeholders represented the conspicuous nongovernmental organizations in Pakistan working against violence or child labour. However with a sample size of 5, the level of saturation was not reached. The authors believe that increasing the number of interviewees via the snowball technique could have added valuable information. Furthermore, representatives of the government were not included; their opinion would have provided further insight and also highlighted the hurdles in the policy ecosystem. Furthermore, the geographical focus of data for the micro- and exo-systems was limited to urban and suburban areas of lower Sindh, thus, the generalizability of our findings to whole country is not appropriate. A pictorial tool was created to collect quantitative data for abuse; although the face validity of the tool was established, criterion validity would have further strengthened our findings.

We recommend further research to assess violence and its risk factors in diverse cadres of child labourers, especially children working in the agricultural fields. We assume working children are a vulnerable group for abuse and violence because of the absence of social protection at a very early age. The government needs to explore this particular group as they remain in silent suffering.

Funding: This research project received financial support from the World Health Organization Regional Office for the Eastern Mediterranean through the Research in Priority Areas of Public Health Grant Scheme, 2016/17.

Competing interests: None declared.

Violence et mauvais traitements parmi les enfants qui travaillent dans les zones urbaines et suburbaines du bas Sindh, Pakistan

Résumé

Contexte : Les enfants travailleurs sont exposés à un environnement précaire et à un risque accru de violence. La violence parmi ces derniers est un phénomène sous-étudié qui nécessite une évaluation contextuelle.

Objectifs : Nous avons appliqué le modèle écologique de Bronfenbrenner (micro- exo- et macro-système) pour comprendre l'interaction du contexte individuel, communautaire, sociétal et politique qui alimente la violence.

Méthodes : Des groupes de discussion thématique et des ethnographies familiales d'enfants travailleurs opérant dans des secteurs professionnels communs des zones suburbaines du Sindh ont été menés pour acquérir une compréhension approfondie de leur environnement immédiat et des abus (micro-système). La fréquence des violences émotionnelles, physiques et sexuelles (5 à 14 ans ; n = 634) a également été déterminée. Des entretiens approfondis avec des employeurs (exo-système, n = 4) et des entretiens avec des informateurs clés d'acteurs importants au Pakistan (macro-système, n = 4) œuvrant contre le travail/la violence ont été réalisés. Une analyse du contenu thématique a été mise en place à l'aide du logiciel MAXQDA, version 8.0.

Résultats : Nous avons estimé que 21 %, 19 % et 9 % des enfants respectivement souffraient de violences émotionnelles, physiques et sexuelles. Les entretiens avec les enfants travailleurs indiquaient l’existence de toutes les formes de mauvais traitements à domicile et sur le lieu de travail ; la violence sexuelle des grands-pères était mise en évidence (micro-système). Les enfants ont rapporté de fréquentes réprimandes et insultes sur le lieu de travail ainsi que des violences physiques qui pourraient être mortelles (exo-système). L'environnement juridique de la violence au Pakistan a été considéré comme déficient car il n'aborde pas les formes cachées (attouchements, baisers, etc. ; macro-système).

Conclusions : Nous avons documenté que toutes les formes de violence étaient répandues parmi les enfants travailleurs, et que de meilleurs efforts et une législation complète sont grandement nécessaires pour atténuer la situation.

العنف والإيذاء بين الأطفال العاملين في المناطق الحضرية والضواحي في السند السفلي، باكستان

ميشا إقبال، ظفر فاطمي، كوثر خان، أسعد نفيس

الخلاصة

الخلفية: يتعرض الأطفال العمال لبيئة غير آمنة ولخطر العنف بصورة أكبر من غيرهم. ويُعتبر العنف بين الأطفال العمال من الظواهر التي لم تُدرس بالقدر الكافي، مما يستلزم تقييمًا سياقيًا.

الأهداف: هدفت هذه الدراسة إلى تطبيق نموذج برونفنبرنر البيئي (النظام الجزئي والخارجي والكلي) لفهم التفاعل القائم بين الفرد والمجتمع والسياق المجتمعي والسياسي الذي يغذي العنف.

طرق البحث: أُجريت مناقشات المجموعات البؤرية ودراسات خصائص أسر الأطفال العاملين (الإثنوجرافيا) الذين يعملون في القطاعات المهنية الشائعة في ضواحي السند، وذلك لتكوين فهم متعمق لبيئتهم المباشرة والإيذاء الذي يتعرضون له (النظام الجزئي). كما تَحَدَّد أيضًا تواتر العنف الوجداني والبدني والجنسي (5-14 عامًا؛ العدد = 634). وأُجريت مقابلات متعمقة مع أصحاب العمل (النظام الخارجي، العدد الخارجي = 4) ومقابلات مع مقدمي المعلومات الرئيسيين لأصحاب المصلحة البارزين في باكستان (النظام الكلي، العدد = 4) الذين يناهضون عمل الأطفال/العنف ضد الأطفال. وأُجري تحليل المحتوى المواضيعي باستخدام الإصدار 8.0 من برنامج MAXQDA.

النتائج: قدَّرنا أن 21% و19% و9% من الأطفال كانوا يعانون من العنف الوجداني والبدني والجنسي على التوالي. وأوضحت المقابلات التي عُقدت مع الأطفال العاملين وجود جميع أشكال الإيذاء في المنزل ومكان العمل؛ كما أُلقي الضوء على العنف الجنسي الذي يرتكبه الأجداد (النظام الجزئي). وأبلغ الأطفال عن تعرضهم بصورة متكررة إلى التوبيخ والإهانات في مكان العمل إلى جانب العنف البدني الذي قد يكون مميتًا (النظام الخارجي). كما أن البيئة القانونية للعنف في باكستان كان يشوبها القصور، إذ أنها لم تعالج الأشكال غير الظاهرة (اللمس، والتقبيل، إلى ما غير ذلك) (النظام الكلي).

الاستنتاجات: لقد وثَّقنا أن جميع أشكال العنف كانت متفشية بين الأطفال العاملين، وهناك حاجة ماسة إلى تحسين الجهود ووضع التشريعات الشاملة للتخفيف من هذا الوضع القائم.

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