Identifying Challenges in Implementing Child Rights Instruments in Nigeria: A Nationwide Survey of Knowledge, Perception, and Practice of Child Rights among Doctors and Nurses

Abstract

Context:

After thirty years of ratifying the child rights convention and nineteen years of the Child Rights Act, implementing child rights instruments remains challenging in Nigeria. Healthcare providers are well positioned to change the current paradigm.

Aim:

To examine the knowledge, perception, and practice of child rights and the influence of demographics among Nigerian doctors and nurses.

Materials and Methods:

A descriptive, cross-sectional online survey was done using nonprobability sampling. Pretested multiple-choice questionnaire was disseminated across Nigeria's six geopolitical zones. Performance was measured on the frequency and ratio scales. Mean scores were compared with 50% and 75% thresholds.

Results:

A total of 821 practitioners were analyzed (doctors, 49.8%; nurses, 50.2%). Female-to-male ratio was 2:1 (doctors, 1.2:1; nurses, 3.6:1). Overall, knowledge score was 45.1%; both groups of health workers had similar scores. Most knowledgeable were holders of fellowship qualification (53.2%, P = 0.000) and pediatric practitioners (50.6%, P = 0.000). Perception score was 58.4% overall, and performances were also similar in both groups; females and southerners performed better (59.2%, P = 0.014 and 59.6%, P = 0.000, respectively). Practice score was 67.0% overall; nurses performed better (68.3% vs. 65.6%, P = 0.005) and postbasic nurses had the best score (70.9%, P = 0.000).

Conclusions:

Overall, our respondents’ knowledge of child rights was poor. Their performances in perception and practice were good but not sufficient. Even though our findings may not apply to all health workers in Nigeria, we believe teaching child rights at various levels of medical and nursing education will be beneficial. Stakeholder engagements involving medical practitioners are crucial.

INTRODUCTION

The emergence of international child rights treaties in the early 20^th century was crucial to child protection globally. The United Nations Convention on the Rights of the Child (UNCRC) of 1989 and the African Charter on the Rights and Welfare of the Child (ACRWC) of 1991 provided a comprehensive framework that gave voice to every child.[1,2] In 2003, Nigeria domesticated these documents by signing the Child Rights Act (CRA) into law.[3] Knowledge gaps, reservations, and concerns are central to weak implementation of child rights laws and policies globally.[4,5,6,7,8,9,10,11]

Despite numerous child protection laws and policies in Nigeria, child labor, female circumcision, early marriage, sexual violence, unregistered births, out-of-school children, under-age criminal charges, and physical punishment of children still abound in the country.[12,13,14,15] Sociocultural and religious concerns and inconsistent statutes have been linked to nonadoption, partial adoption, and poor implementation of child centred laws in Nigeria.[16,17,18] Doctors and nurses are well positioned not only to address medical consequences of child maltreatment, but also to protect and advocate for children.[19,20] Healthcare workers (HCW) can only play such roles effectively if they sufficiently know and comply with relevant provisions of rights instruments.

Studies on knowledge, perception, and practice of child rights are sparse globally. To the best of our knowledge, no nationwide survey on the subject exists in Nigeria. We hoped this study would reveal the depth of HCW's knowledge of and compliance with child rights instruments. We aimed to determine the respondents’ knowledge of child rights, the extent of their compliance (in perception and practice), and the influence of demographic variables on performance.

MATERIALS AND METHODS

Study design, site, and population

This was a descriptive cross-sectional online study of Nigerian doctors and nurses practicing at home and abroad.

Nigeria comprises more than 250 ethnic groups living in two main geographical regions – the north and the south.[21] The regions are further divided into six geopolitical zones: north-central, north-west, north-east, south-south, south-east, and south-west. As of 2021, Nigerian doctors and nurses were estimated to be 106,291 and 281,586, respectively.[22,23]

Included in this study were Nigerian doctors and nurses registered with the Medical and Dental Council of Nigeria (MDCN) or the Nursing and Midwifery Council of Nigeria (NMCN), as appropriate.

Sample size estimation

Using finite population correction of the Cochran's formula,[24] the minimum sample required for the study was estimated with:

N is the estimated finite population size (doctors – 106,291 and nurses – 281,586). We presumed 50% (p) in each group have sufficient knowledge of children's rights and sufficient compliance with child rights laws, assuming a 5% margin of error (d) at 95% confidence interval (z = 1.96).

Thus, 383 and 384 were estimated for doctors and nurses, respectively.

Questionnaire development, sampling, and data collection

A structured multiple-choice nonleading questionnaire was prepared on Google form. Knowledge, perception, and practice of specific child rights were examined based on the UNCRC, ACRWC, CRA, and relevant laws on child labor, child adoption, criminal responsibility, female circumcision, and physical punishments.[1,2,3,12,13,25] All but one question had mutually exclusive options from which respondents were expected to select their answers. In all, there were 13 knowledge, 31 perception and 10 practice questions. Details of responses are shown in Appendices 1-3.

Appendix 1.

Distribution of correct responses to knowledge questions

	All respondents		Doctors		Nurses		P
	TVR	n (%)	VR	n (%)	VR	n (%)
1. Heard of Convention on the Rights of the Child	813	554 (67.5)	406	291 (71.1)	407	263 (63.8)	0.035†
2. Heard of African Charter on the Rights and Welfare of the Child	817	413 (50.3)	407	202 (49.4)	410	211 (51.2)	0.625
3. Heard of Nigeria’s Child Rights Act	815	764 (93.1)	407	381 (93.2)	408	383 (93.0)	0.886
4. Aware of the following rights in the Child Rights Act: Survival and development; A name; freedom of speech; adequate nutrition; participation; immunization; free primary education; compulsory primary education; freedom of association; dignity; health services; privacy; freedom of movement; cultural activities; freedom of thoughts, conscience and religion; leisure and recreation; nondiscrimination	821	60.8*	409	60.0	412	61.5	0.319
5. Aware a child is <18 years old in Nigeria	821	387 (47.1)	409	247 (60.4)	412	140 (34.0)	0.000†
6. Aware the minimum age of criminal responsibility in Nigeria is 7 years	821	15 (1.8)	409	12 (2.9)	412	3 (0.7)	0.020†
7. Aware the minimum marriageable age in Nigeria is 18 years	815	259 (31.5)	406	132 (32.3)	409	127 (30.8)	0.707
8. Aware Nigeria does not have a policy that allows children 10 to 17 years old free and easy access to contraceptives in schools and hospitals	817	390 (47.5)	409	188 (46.0)	408	202 (49.0)	0.327
9. Aware the minimum employable age in Nigeria is 12 years	816	4 (0.5)	407	3 (0.7)	409	1 (0.2)	0.373
10. Aware Nigeria does not have a law that bans all forms of physical punishment	814	311 (37.9)	405	158 (38.6)	409	153 (37.1)	0.665
11. Aware Nigeria has a law that bans all forms of female circumcision	808	377 (45.9)	403	170 (41.6)	405	207 (50.2)	0.011†
12. Aware Nigeria has a law regarding child adoption	807	601 (73.2)	403	312 (76.3)	404	289 (70.1)	0.063
13. Aware Nigeria’s law recognizes both parents as the owners of a child even if born out of wedlock	809	217 (26.4)	404	82 (20.0)	405	135 (32.8)	0.000†

*Mean of individual percentage scores from a total of “17” obtainable score, ^†Significant difference (at P<0.05) between doctors and nurses. n=Number of respondents with correct responses, TVR=Total valid responses, VR=Valid responses

Appendix 2.

Distribution of compliant responses to perception questions

	All respondents		Doctors		Nurses		P
	TVR	n (%)	VR	n (%)	VR	n (%)
1. Agreed children should have rights	815	800 (97.4)	406	399 (97.6)	409	401 (97.3)	1.000
2. Agreed child rights should begin before birth	803	287 (35.0)	400	188 (46.0)	403	99 (24.0)	0.000†
3. Supported the enforcement of full immunization for every child in Nigeria	818	761 (92.7)	407	379 (92.7)	411	382 (92.7)	1.000
4. Child rights laws are not in tension with personal belief	817	575 (70.0)	408	284 (69.4)	409	291 (70.6)	0.646
5. Supported <18 years as the age of a child in Nigeria	821	329 (40.1)	409	214 (52.3)	412	115 (27.9)	0.000†
6. Supported free and compulsory primary education for male children in Nigeria	817	792 (96.5)	406	399 (97.6)	411	393 (95.4)	0.040†
7. Supported free and compulsory primary education for female children in Nigeria	818	799 (97.3)	407	403 (98.5)	411	396 (96.1)	0.018†
8. Supported education as a fundamental human right for children in Nigeria	817	811 (98.8)	406	402 (98.3)	411	409 (99.3)	0.449
9. Supported ≥15 years as the minimum age of criminal responsibility in Nigeria‡	814	730 (88.9)	407	369 (90.2)	407	361 (87.6)	0.420
10. Supported 18 years as the minimum marriageable age in Nigeria	817	174 (21.2)	407	106 (25.9)	410	68 (16.5)	0.001†
11. Supported 18 years as the minimum age of consent for sexual intercourse	808	185 (22.5)	401	114 (27.9)	407	71 (17.2)	0.000†
12. Supported a policy that gives children (10-17 years old) in Nigeria free and easy access to contraceptives in schools and hospitals	812	229 (27.9)	406	111 (27.1)	406	118 (28.6)	0.640
13. Supported the introduction of sex education in Nigeria’s primary schools	818	627 (76.4)	409	277 (67.7)	409	350 (85.0)	0.000†
14. Supported the introduction of sex education in Nigeria’s secondary schools	817	772 (94.0)	407	376 (91.9)	410	396 (96.1)	0.009†
15. Supported 14-18 years as the minimum employable age in Nigeria§	818	418 (50.9)	407	245 (59.9)	411	173 (42.0)	0.000†
16. Agreed the intention to correct a child does not justify physical punishment even if applied with caution	814	92 (11.2)	406	42 (10.3)	408	50 (12.1)	0.439
17. Agreed the intention to correct a child does not justify scolding even if it’s with caution	810	38 (4.6)	402	13 (3.2)	408	25 (6.1)	0.067
18. Agreed that nonphysical measures are sufficient to train a child	810	393 (47.9)	404	133 (32.5)	406	260 (63.1)	0.000†
19. Supported a complete ban on all forms of physical punishment at home	812	169 (20.6)	404	65 (15.9)	408	104 (25.2)	0.001†
20. Supported a complete ban on all forms of physical punishment in schools	811	373 (45.4)	406	197 (48.2)	405	176 (42.7)	0.159
21. Did not support female circumcision by qualified nurses	808	751 (91.5)	402	368 (90.0)	406	383 (93.0)	0.132
22. Did not support female circumcision by qualified doctors	808	738 (89.9)	402	355 (86.8)	406	383 (93.0)	0.003†
23. Supported a complete ban on all forms of female circumcision	807	708 (86.2)	402	344 (84.1)	405	364 (88.3)	0.068
24. Supported child adoption	809	743 (90.5)	403	380 (92.9)	406	363 (88.1)	0.014†
25. Agreed that biological parents should transfer all their rights and responsibilities to adoptive parents	752	535 (65.2)	380	278 (68.0)	372	257 (62.4)	0.228
26. Supported both parents as the owners of a child even if born out of wedlock	804	399 (48.6)	401	216 (52.8)	403	183 (44.4)	0.020†
27. Agreed if children are allowed to freely sue their parents to court for rights violation	806	287 (35.0)	400	137 (33.5)	406	150 (36.4)	0.462
28. Supported a law that allows the court to take decisions on his/her child’s behalf even if such decisions may be contrary to his/her (the respondent) belief or opinion	799	271 (33.0)	397	139 (34.0)	402	132 (32.0)	0.550
29. Would allow child to choose a career respondent is totally against	801	457 (55.7)	396	222 (54.3)	405	235 (57.0)	0.617
30. Would allow child the freedom to practice a religion different from what respondent practices	803	144 (17.5)	397	57 (13.9)	406	87 (21.1)	0.010†

^†Significant difference at P<0.05, ^‡The African Union sets the minimum age of criminal responsibility at 15 years, ^§The International Labour Organization Convention sets the minimum age of employment at 14 years for developing countries. n=Number of respondents with compliant responses, TVR=Total valid responses, VR=Valid responses

Appendix 3.

Distribution of compliant responses to practice questions

	All respondents		Doctors		Nurses		P
	TVR	n (%)	VR	n (%)	VR	n (%)
1. Could stand as a child rights advocate	816	757 (92.2)	406	370 (90.5)	410	387 (93.9)	0.080
2. Had never employed a person <18 years old as a domestic worker	821	643 (78.3)	409	296 (72.4)	412	347 (84.2)	0.000†
3. If “no” to item 2, the age at the time of employment was 14-17 years	188	138 (73.4)	110	80 (72.7)	78	58 (74.4)	0.868
4. Had never employed a person <18 years old for business or trade	821	757 (92.2)	409	389 (95.1)	412	368 (89.3)	0.003†
5. If “no” to item 4, the age at the time of employment was 14-17 years	67	56 (83.6)	18	16 (88.9)	49	40 (81.6)	0.714
6. If “no” to item 4, the employee (12-13 years old) returns to the parents/guardian on a daily basis||	4	1 (25.0)	1	1 (100)	3	0 (0.0)	0.250
7. Had never applied physical punishment on his/her child or any child before	812	232 (28.3)	409	92 (22.5)	403	140 (34.0)	0.000†
8. Had never scolded his/her child or any child before	813	57 (6.9)	405	18 (4.4)	408	39 (9.5)	0.006†
9. No female child under his/her care/authority had been circumcised	627	607 (96.8)	328	317 (96.6)	299	290 (97.0)	0.825
10. Had never performed female circumcision	809	795 (96.8)	403	397 (97.1)	406	398 (96.6)	0.789

^†Significant difference at P<0.05, ^||Nigeria’s law requires children 12-13 years old in employment to return to their parents/guardians each day. n=Number of respondents with compliant responses, TVR=Total valid responses, VR=Valid responses

After a pilot test of 14 respondents and minor adjustments, participants were recruited using a nonprobability sampling technique. The link to the questionnaire was sent through WhatsApp and E-mail. Potential respondents were reached in the six geopolitical zones through personal contacts and professional groups, including Nigerian Medical Association, National Association of Nigerian Nurses and Midwives, Association of Resident Doctors, medical guilds, Alumni associations, and specialty groups. To possibly guarantee the most honest responses, no identifying information was required. Respondents were required to fill the form once; the re-submission link was also disabled. Data were collected between September 2021 and January 2022.

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki. Approval was obtained from the health research ethics committee of the Federal Capital Territory, Abuja, Nigeria (FHREC/2021/01/106/07-09-21). The first page of the questionnaire contained information about the survey, and respondents were required to consent before they could proceed.

Data analysis

Each correct or compliant response was awarded a score of 1. One question was excluded from the perception score – personal belief considered in tension with child rights instruments. Three questions were excluded from the practice score due to scanty valid responses – child's age at the time of employment for domestic work, child's age at the time of employment for business/trade, and child's place of abode. Thus, a total of 13 knowledge, 30 perception and 7 practice questions were analyzed.

The data were analyzed using IBM SPSS Statistics, Version 25.0. Armonk, NY, USA: IBM Corp. Descriptive statistics were used to analyze the demographic profile, the distribution of responses, and the mean scores. Chi-square was used to compare the proportions. Individual total scores show normal distribution in each domain of assessment [Figures 1-3].

Figure 1.

Distribution of knowledge scores

Figure 3.

Distribution of practice scores

Figure 2.

Distribution of perception scores

Mean scores were compared against contrived thresholds (50% and 75%) using one-sample Student t-test. Scores comparable to at least 50% were considered good performance, those comparable to at least 75% were considered sufficient performance, and those significantly below 50% were considered poor performance. Student t-test and analysis of variance were used to analyze the influence of dichotomous and polychotomous demographic variables, respectively. Post hoc analysis was done with Tukey honest significant difference to identify pairs that truly differ. Statistical significance was set at P < 0.05.

RESULTS

Participants and sociodemographic profile

A total of 821 respondents were analyzed; medical doctors accounted for 49.8% while nurses represented 50.2% [Figure 4]. Most respondents hail from the south, but majority practice in the north [Table 1]. Each geopolitical zone (as place of origin) accounted for between 15% and 23% except for north-east with 4.9%. Female-to-male ratio was 2:1 (1.2:1 for doctors, and 3.6:1 for nurses). Majority were between 21 and 50 years old with a preponderance of 31–40 years old respondents.

Figure 4.

Flow chart showing the number of excluded and included participants

Table 1.

Demographic characteristics by profession

Variable	Doctors, n (%)	Nurses, n (%)	Total
Region of origin
North	187 (45.7)	151 (36.7)	338 (41.2)
South	222 (54.3)	261 (63.3)	483 (58.8)
Total	409 (100.0)	412 (100.0)	821 (100.0)
Zone of origin
North-central	78 (19.1)	96 (23.3)	174 (21.2)
North-west	81 (19.8)	43 (10.4)	124 (15.1)
North-east	28 (6.8)	12 (2.9)	40 (4.9)
South-south	55 (13.4)	64 (15.5)	119 (14.5)
South-east	59 (14.4)	131 (31.8)	190 (23.1)
South-west	108 (26.4)	66 (16.0)	174 (21.2)
Total	409 (100.0)	412 (100.0)	821 (100.0)
Region of practice
North	253 (61.9)	239 (58.0)	492 (59.9)
South	115 (28.1)	142 (34.5)	257 (31.3)
Diaspora*	33 (8.1)	22 (5.3)	55 (6.7)
Total	401 (98.1)	403 (97.8)	804 (97.9)
Zone of practice
North-central	163 (39.9)	167 (40.5)	330 (40.2)
North-west	80 (19.6)	64 (15.5)	144 (17.5)
North-east	10 (2.4)	8 (1.9)	18 (2.2)
South-south	17 (4.2)	42 (10.2)	59 (7.2)
South-east	12 (2.9)	30 (7.3)	42 (5.1)
South-west	86 (21.0)	70 (17.0)	156 (19.0)
Total	368 (90.0)	381 (92.4)	749 (91.2)
Religion
Islam	201 (49.1)	106 (25.7)	307 (37.4)
Christianity	203 (49.6)	305 (74.0)	508 (61.9)
Others†	5 (1.2)	1 (0.2)	6 (0.7)
Total	409 (100.0)	412 (100.0)	821 (100.0)
Sex
Female	227 (55.5)	323 (78.4)	550 (67.0)
Male	182 (44.5)	89 (21.6)	271 (33.0)
Total	409 (100.0)	412 (100.0)	821 (100.0)
Age (years)
<21	1 (0.2)	1 (0.2)	2 (0.2)
21-30	78 (19.1)	168 (40.8)	246 (30.0)
31-40	186 (45.5)	164 (39.8)	350 (42.6)
41-50	98 (24.0)	52 (12.6)	150 (18.3)
51-60	35 (8.6)	26 (6.3)	61 (7.4)
61-70	8 (2.0)	1 (0.2)	9 (1.1)
>70	3 (0.7)	0	3 (0.4)
Total	409 (100.0)	412 (100.0)	821 (100.0)
Marital status
Married	310 (75.8)	263 (63.8)	573 (69.8)
Single	92 (22.5)	135 (32.8)	227 (27.6)
Others‡	7 (1.7)	14 (3.4)	21 (2.6)
Total	409 (100.0)	412 (100.0)	821 (100.0)
Number of children
0	103 (25.2)	115 (27.9)	218 (26.6)
1	49 (12.0)	59 (14.3)	108 (13.2)
2	66 (16.1)	76 (18.4)	142 (17.3)
3	77 (18.8)	67 (16.3)	144 (17.5)
4	48 (11.7)	41 (10.0)	89 (10.8)
5	22 (5.4)	25 (6.1)	47 (5.7)
>5	44 (10.8)	29 (7.0)	73 (8.9)
Total	409 (100.0)	412 (100.0)	821 (100.0)
Field of practice
Pediatrics	154 (37.7)	56 (13.6)	210 (25.6)
AMS§	77 (18.8)	51 (12.4)	128 (15.6)
SGS||	84 (20.5)	90 (21.8)	174 (21.2)
Others¶	94 (23.0)	215 (52.2)	309 (37.6)
Total	409 (100.0)	412 (100.0)	821 (100.0)
Number of years in practice
<1	19 (4.6)	22 (5.3)	41 (5.0)
1-5	106 (25.9)	154 (37.4)	260 (31.7)
6-10	91 (22.2)	121 (29.4)	212 (25.8)
11-15	90 (22.0)	47 (11.4)	137 (16.7)
16-20	38 (9.3)	19 (4.6)	57 (6.9)
21-25	33 (8.1)	18 (4.4)	51 (6.2)
26-30	10 (2.4)	14 (3.4)	24 (2.9)
31-35	12 (2.9)	7 (1.7)	19 (2.3)
>35	9 (2.2)	0	9 (1.1)
Total	408 (99.8)	402 (97.6)	810 (98.7)
Highest qualification
Basic nurse	-	124 (30.1)	124 (15.1)
PBN	-	82 (19.9)	82 (10.0)
BSc (Nursing)	-	182 (44.2)	182 (22.2)
MBBS/BDS	182 (44.5)	-	182 (22.2)
PBD	21 (5.1)	23 (5.6)	44 (5.4)
Member	68 (16.6)	-	68 (8.3)
Fellow	138 (33.7)	1 (0.2)	139 (16.9)
Total	409 (100.0)	412 (100.0)	821 (100.0)

*Australia (2), Canada (2), Egypt (1), Liberia (1), Netherlands (1), Niger (1), North Korea (2), Oman (1), Saudi Arabia (6), Sweden (2), The Gambia (2), UAE (3), UK (29), USA (2); ^†African traditional religion (4), grail message (1), none (1); ^‡Co-habiting (1) divorced (13), widow (5), widower (2); ^§Emergency medicine (27), family medicine (28), internal medicine (20), pathology (14), psychiatry (39); ^||Anesthesia (10), dental surgery/family dentistry (4), ear, nose and throat (5), obstetrics and gynecology (62), ophthalmology (36), radiology (7), surgery (50); ^¶Basic medical sciences (11), general practice (267), public health (31). Member=Senior registrar cadre, Fellow=Fellow of the Medical College (Nigeria), Fellow of the West African College of Physicians, Fellow of the West African College of Surgeons and their equivalents abroad. PBN=Postbasic nurse, BSc (Nursing)=Bachelor of science in nursing, MBBS=Bachelor of medicine, Bachelor of surgery, BDS=Bachelor of dental surgery, PBD=Postbachelor degree (master’s degree, doctor of philosophy), AMS=Adult medical specialty, SGS=Surgical specialty

Distribution of knowledge responses

At least 50% of respondents were aware of UNCRC, ACRWC, CRA, and existence of child adoption laws in Nigeria [Appendix 1]. Exceedingly small proportions (<2%) knew that minimum age of criminal responsibility (MACR) in Nigeria is 7 years, and the minimum employable age is 12 years.

Distribution of perception responses

Seventy percent believed there is no friction between their personal beliefs and child rights laws. At least 50% supported child rights, free and compulsory education for boys and girls, education as a fundamental human right, childhood immunization, recommendation on MACR and employable age, child adoption, sex education in primary and secondary schools, complete transfer of parental rights from biological to adoptive parents, children's freedom to choose a career, and a complete ban on female circumcision regardless of who performs it [Appendix 2].

Only 11% and 5% agreed physical punishment and scolding, respectively, are not justifiable. Meanwhile, 21% and 45% supported a complete ban on physical punishment at home and in school, respectively.

Distribution of practice responses

At least 70% of respondents were ready to be child rights advocates, had not employed persons <18 years old and had neither circumcised a female child nor had their daughters been circumcised [Appendix 3]. Only 7% had never scolded a child.

Overall performance

Respondents’ knowledge of child rights was below average and both groups of HCW had similar scores [Table 2]. Performances in perception and practice were above average, with nurses scoring much higher in the practice domain. Average cumulative scores were significantly <75% in all domains.

Table 2.

Overall performance in knowledge, perception, and practice of child rights

Domain (OS)	Participants	Mean score (%)	SD	tDN (P)	t50% (P)	t75% (P)
Knowledge (13)	All respondents	5.86 (45.1)	1.999	1.162 (0.246)	−9.207 (0.000)	−55.780 (0.000)
	Doctors	5.94 (45.7)	2.080		−5.455 (0.000)	−37.052 (0.000)
	Nurses	5.78 (44.5)	1.915		−7.666 (0.000)	−42.111 (0.000)
Perception (30)	All respondents	17.52 (58.4)	3.332	0.938 (0.349)	21.704 (0.000)	−42.795 (0.000)
	Doctors	17.63 (58.1)	3.415		15.596 (0.000)	−28.825 (0.000)
	Nurses	17.42 (58.7)	3.248		15.092 (0.000)	−31.777 (0.000)
Practice (7)	All respondents	4.69 (67.0)	0.953	−2.795 (0.005)	35.692 (0.000)	−16.930 (0.000)
	Doctors	4.59 (65.6)	0.832		26.586 (0.000)	−15.937 (0.000)
	Nurses	4.78 (68.3)	1.052		24.679 (0.000)	−9.085 (0.000)

t^50%=Score compared with 50% threshold, t^75%=Score compared with 75% threshold. OS=Obtainable score, SD=Standard deviation, DN=Doctors-nurses pair

Influence of demographics

South-southerners, married respondents, Christians, pediatric HCW, and medical fellows were the most knowledgeable about child rights [Tables 3 and 4]. Also, respondents’ knowledge improved with age, number of children, and years in medical practice. However, region of origin, place of practice and sex did not influence how much they knew about child rights.

Table 3.

Performance by demographic variables

Variable	Knowledge mean score (%)	t/F (P)	Perception mean score (%)	t/F (P)	Practice mean score (%)	t/F (P)
Region of origin
North	5.71 (43.9)	−1.806 (0.071)	17.01 (56.7)	−3.573 (0.000)	4.70 (67.1)	0.357 (0.721)
South	5.96 (45.8)		17.88 (59.6)		4.68 (66.9)
Zone of origin
North-central	5.93 (45.6)	3.005 (0.011)	17.34 (57.8)	5.350 (0.000)	4.71 (67.3)	0.787 (0.559)
North-west	5.46 (42.0)		16.57 (55.2)		4.63 (66.1)
North-east	5.53 (42.5)		16.95 (56.5)		4.88 (69.7)
South-south	6.39 (49.2)		17.94 (59.8)		4.76 (68.0)
South-east	5.87 (45.2)		18.35 (61.2)		4.68 (66.9)
South-west	5.78 (44.5)		17.32 (57.7)		4.61 (65.9)
Region of practice
North	5.79 (44.5)	1.284 (0.277)	17.42 (58.1)	0.535 (0.586)	4.65 (66.4)	0.667 (0.514)
South	6.00 (46.2)		17.68 (58.9)		4.72 (67.4)
Diaspora	5.64 (43.4)		17.65 (58.8)		4.78 (68.3)
Zone of practice
North-central	5.85 (45.0)	1.285 (0.262)	17.81 (59.4)	2.84 (0.010)	4.67 (66.7)	0.390 (0.886)
North-west	5.66 (43.5)		16.50 (55.0)		4.65 (66.4)
North-east	5.78 (44.5)		16.67 (55.6)		4.44 (63.4)
South-south	6.47 (49.8)		17.83 (59.4)		4.75 (67.9)
South-east	5.90 (45.4)		17.74 (59.1)		4.69 (67.0)
South-west	5.85 (45.0)		17.60 (58.7)		4.71 (67.3)
Diaspora	5.64 (43.4)		17.65 (58.8)		4.78 (68.3)
Religion
Muslims	5.51 (42.4)	7.857 (0.000)	16.34 (54.5)	34.095 (0.000)	4.65 (66.4)	0.346 (0.708)
Christians	6.07 (46.7)		18.25 (60.8)		4.71 (67.3)
Others	5.50 (42.3)		16.83 (56.1)		4.67 (66.7)
Sex
Male	5.94 (45.7)	0.813 (0.417)	17.07 (56.9)	−2.480 (0.014)	4.71 (67.3)	0.444 (0.657)
Female	5.82 (44.8)		17.75 (59.2)		4.68 (66.9)
Age (years)
<21	4.50 (34.6)	9.575 (0.000)	17.00 (56.7)	0.657 (0.684)	5.00 (71.4)	1.365 (0.226)
21-30	5.39 (41.5)		17.57 (58.6)		4.74 (67.7)
31-40	5.68 (43.7)		17.64 (58.8)		4.71 (67.3)
41-50	6.67 (51.3)		17.47 (58.2)		4.64 (66.3)
51-60	6.61 (50.8)		16.98 (56.6)		4.48 (64.0)
61-70	7.11 (54.7)		16.11 (53.7)		4.22 (60.3)
>70	6.00 (46.2)		18.33 (61.1)		5.33 (76.1)
Marital status
Married	6.07 (46.7)	11.413 (0.000)	17.34 (57.8)	3.180 (0.042)	4.71 (67.3)	3.552 (0.029)
Single	5.37 (41.3)		18.00 (60.0)		4.69 (67.0)
Others	5.19 (39.9)		17.48 (58.3)		4.14 (59.1)
Number of children
None	5.34 (41.1)	4.801 (0.000)	17.84 (59.5)	1.232 (0.287)	4.72 (67.4)	1.496 (0.177)
1	5.70 (43.8)		17.69 (59.0)		4.85 (69.3)
2	5.85 (45.0)		17.28 (57.6)		4.63 (66.1)
3	6.15 (47.3)		17.67 (58.9)		4.58 (65.4)
4	6.29 (48.4)		17.44 (58.1)		4.63 (66.1)
5	6.09 (46.8)		16.66 (55.5)		4.89 (69.9)
>5	6.38 (49.1)		17.16 (57.2)		4.62 (66.0)
Field of practice
Pediatrics	6.58 (50.6)	13.996 (0.000)	17.90 (59.7)	2.291 (0.077)	4.70 (67.1)	0.331 (0.803)
AMS	5.88 (45.2)		17.23 (57.4)		4.65 (66.4)
SGS	5.57 (42.8)		17.10 (57.0)		4.64 (66.3)
Others	5.51 (42.4)		17.62 (58.7)		4.72 (67.4)
Years in practice
<1	5.29 (40.7)	9.493 (0.000)	16.83 (56.1)	1.346 (0.217)	4.71 (67.3)	1.505 (0.152)
1-5	5.33 (41.0)		17.37 (57.9)		4.77 (68.1)
6-10	5.60 (43.1)		17.98 (59.9)		4.77 (68.1)
11-15	6.36 (48.9)		17.27 (57.6)		4.56 (65.1)
16-20	7.00 (53.8)		17.54 (58.5)		4.56 (65.1)
21-25	6.61 (50.8)		18.02 (60.1)		4.47 (63.9)
26-30	6.38 (49.1)		16.46 (54.9)		4.50 (64.3)
31-35	6.47 (49.8)		17.74 (59.1)		4.58 (65.4)
>35	7.78 (59.8)		17.22 (57.4)		4.33 (61.9)
Highest qualification
Basic nurse	5.45 (41.9)	10.862 (0.000)	17.23 (57.4)	1.099 (0.361)	4.73 (67.6)	2.611 (0.016)
PBN	5.95 (45.8)		17.44 (58.1)		4.96 (70.9)
BSc (Nursing)	5.90 (45.4)		17.47 (58.2)		4.74 (67.7)
MBBS/BDS	5.25 (40.4)		18.03 (60.1)		4.69 (67.0)
PBD	5.68 (43.7)		17.68 (58.9)		4.61 (65.9)
Member	5.96 (45.8)		17.15 (57.2)		4.60 (65.7)
Fellow	6.91 (53.2)		17.37 (57.9)		4.47 (63.9)

t/F=Statistic for dichotomous/polychotomous variables. Member=Senior registrar cadre, Fellow=Fellow of the Medical College (Nigeria), Fellow of the West African College of Physicians, Fellow of the West African College of Surgeons and their equivalents abroad. AMS=Adult medical specialty, SGS=Surgical specialty, PBN=Postbasic nurse, BSc (Nursing)=Bachelor of science in Nursing, MBBS=Bachelor of medicine, Bachelor of surgery, BDS=Bachelor of dental surgery, PBD=Postbachelor degree (master’s degree, doctor of philosophy)

Table 4.

Demographic variables with true difference in performance after post hoc analysis

Domain	Variable	PWTD	Mean difference	P
Knowledge	Zone of origin	SS versus NW	0.927	0.004
	Religion	Christians versus Muslims	0.565	0.000
	Age (years)	41-50 versus 21-30	1.279	0.000
		41-50 versus 31-40	0.996	0.000
		51-60 versus 21-30	1.212	0.000
		51-60 versus 31-40	0.929	0.010
	Marital status	Married versus single	0.699	0.000
	Number of children	3 versus none	0.809	0.003
		4 versus none	0.948	0.003
		>5 versus none	1.040	0.002
	Field of practice	Pediatrics versus AMS	0.698	0.008
		Pediatrics versus SGS	1.006	0.000
		Pediatrics versus others	1.066	0.000
	Years in practice	11-15 versus 1-5	1.023	0.000
		11-15 versus 6-10	0.754	0.011
		16-20 versus <1	1.707	0.001
		16-20 versus 1-5	1.665	0.000
		16-20 versus 6-10	1.396	0.000
		21-25 versus <1	1.315	0.032
		21-25 versus 1-5	1.273	0.001
		21-25 versus 6-10	1.004	0.025
		>35 versus <1	2.485	0.014
		>35 versus 1-5	2.443	0.006
		>35 versus 6-10	2.174	0.027
	Highest qualification	BSc (Nursing) versus MBBS/BDS	0.648	0.024
		Fellow versus basic nurse	1.455	0.000
		Fellow versus PBN	0.955	0.007
		Fellow versus BSc (Nursing)	1.005	0.000
		Fellow versus MBBS/BDS	1.654	0.000
		Fellow versus PBD	1.225	0.005
		Fellow versus member	0.951	0.016
Perception	Zone of origin	SE versus NC	1.008	0.042
		SE versus NW	1.780	0.000
		SE versus SW	1.031	0.034
		SS versus NW	1.369	0.016
	Zone of practice	NC versus NW	1.312	0.002
	Religion	Christians versus Muslims	1.909	0.000
	Marital status	Single versus married	0.657	0.032
Practice	Marital status	Married versus others	0.562	0.021
		Single versus others	0.549	0.031
	Highest qualification	PBN versus fellow	0.489	0.004

Member=Senior registrar cadre, Fellow=Fellow of the Medical College (Nigeria), Fellow of the West African College of Physicians, Fellow of the West African College of Surgeons and their equivalents abroad. AMS=Adult medical specialty, SGS=Surgical specialty, PBN=Postbasic nurse, BSc (Nursing)=Bachelor of science in Nursing, MBBS=Bachelor of Medicine Bachelor of Surgery, BDS=Bachelor of Dental Surgery, PBD=Postbachelor degree (master’s degree, doctor of philosophy), PWTD=Pair with true difference, SS=South-south, NW=North-west, SE=South-east, NC=North-central, NW=North-west, SW=South-west

In the perception domain, southerners and female respondents were more compliant with child rights instruments. Singles, Christians, and south-easterners recorded the best scores. Respondents practicing in the north-central and south-south geopolitical zones also had the best scores, even though a true difference was only observed between north-central and north-west. However, region of practice, age, number of children, field of practice, years in practice, and highest qualification were not influential in this domain.

In the practice domain, married and single respondents recorded comparable scores. Postbasic nurses earned the best score and significantly so when compared to doctors with fellowship qualification. Other demographic variables did not significantly impact on respondents’ practice of child rights.

DISCUSSION

Extensive literature search did not return population-based surveys involving all fields of medical practice to appropriately compare our findings with. Notwithstanding, our results have areas of similarities to those of previous studies that examined the same subject.

Knowledge of child rights

In the present study, 68% of respondents were aware of the UNCRC, and most could identify specific rights in the CRA. In Malaysia, up to 62% of 102 pediatric doctors were aware of the UNCRC, but only 19% could identify specific rights.[26]

On the ratio scale, our respondents’ performance in the knowledge domain was poor overall; doctors and nurses had similar scores, and only pediatric practitioners had a good score. In a similar Pakistani study involving 183 pediatric doctors and nurses, 85% of respondents were aware of child rights, and doctors performed better.[27] Since ratio scales are more informative and precise compared to frequency scale,[28] our results are likely more reflective of respondents’ performance. Nonetheless, the performances of pediatric practitioners in both studies suggest that regular contact with children is associated with better knowledge of child rights.

Although the scores were below average, region of origin and religion appear to have influenced our respondents’ knowledge of child rights – southerners and Christians scored higher than their northern and Muslim counterparts. The reason for this difference is not exactly clear from our study. Most southerners are Christians while most northerners are Muslims, a picture that was also observed in our study where southerners were 84% Christians and northerners were 69% Muslims. It is possible that adoption of the CRA in the entire Christian-dominated southern Nigeria has created considerable awareness about child rights – as of August 2022, all 17 southern states have signed the Act into law compared to 14 of the 19 northern states.[29]

Knowledge of child rights improved with age, marriage, number of children, years in medical practice, and advanced medical qualification. Such influence on knowledge could be considered intuitive. Chin et al.,[26] in the Malaysian study, similarly reported that respondents’ knowledge about the UNCRC improved with their years of experience in medical practice. In the Pakistani study, however, knowledge was not significantly influenced by age and years of experience.[27] The contrast in outcome between the Pakistani study and ours could be explained by the fact that our sample size was four times larger.

In the current study, the sex of respondents did not impact on how much they knew about child rights and child rights instruments. Although the striking female predominance in our study may have obscured any influence of sex, the outcome may still not be a surprise since knowledge acquisition in Nigeria is not gender restrictive.

Previous studies have also demonstrated poor knowledge of child rights among Nigerian non-HCW. First, among 121 Nigerian graduates in a multi-national survey that also involved Americans and Ghanaians.[5] Second, among 260 Nigerian parents with mostly primary and secondary education in Ilorin, Kwara state, north-central Nigeria.[30] Although samples in these studies are smaller, the similarity to our findings suggests that, regardless of social status, knowledge of child rights is generally poor in the Nigerian population.

Perception of child rights

Doctors and nurses in this study recorded good and comparable performances in their perception of child rights. However, their perception was not sufficiently compliant with provisions of relevant child rights laws and policies. In specific terms, fewer HCW were compliant in areas of marriageable age, age of sexual consent, reproductive health, physical punishment, family court, and freedom of religion. Poor knowledge of child rights could partly explain why compliance in this domain was not sufficient.

Only 10% of respondents in our study agreed physical punishment is not justifiable, while 21% and 45% supported a total ban in homes and schools, respectively. Apparently, a section of HCW, who perhaps believe that “reasonable” physical punishment has a role in child upbringing, would still prefer it banned completely. The reasons for and implications of such discordance could be investigated in the future. Similar studies in the US, UK, and Turkey show that 40−75% of health workers and the general population would not want physical punishment of children banned outrightly.[31,32,33] These may suggest that the practice (of physical punishment) transcends nationality, culture, educational attainment, profession, and medical specialty. It is worthy of note that recent studies in the US show a steady decline in the prevalence of corporal punishment in the last three decades.[34] The decline could be the impact of effective child rights advocacy and strong enforcement policies noticeable in developed countries.

The vast majority of respondents in our study did not know that Nigeria's MACR is 7 years. Meanwhile, a similar majority – around 90% aligned with at least 15 years (a recommendation of the African Union)[12] to be the MACR in the country. Such overwhelming support for recommended benchmark, despite poor knowledge of what is obtainable, may indicate that Nigerian HCW would likely endorse a legislative push for an upward review.

Healthcare workers in this study, irrespective of cultural or religious affiliations, demonstrated good albeit insufficient compliance in perception of child rights. Their good compliance shows that child rights instruments are not entirely in contention with religion or culture in Nigeria. This is consistent with the fact that majority of respondents (70%) in the current study believe that child rights laws do not contradict their belief system. The reason for insufficient compliance may not be clear from our study; yet it could be related to reservations often expressed by religious faithful. For example, some Christians have challenged the concept of adolescent sexual rights,[35] the ban on corporal punishment of children,[17] and the “undue interference” of child rights instruments in sensitive domestic matters.[36] Furthermore, some Muslim writers have disagreed with the definition of a child,[18] the minimum marriageable age,[18] the legitimacy of a child born out of wedlock,[37] the complete transfer of parental rights to adoptive parents,[37,38,39] the role of family courts,[18] and the complete ban on corporal punishment of children.[18,37]

Like in the knowledge domain, more compliance in perception by southerners and Christians may be attributed to domestication of the CRA in the entire southern part of the country. Meanwhile, the pattern of perception was different when respondents were grouped into their geopolitical zones of practice – those practicing in the north-central were most compliant with child rights laws. This may be because the zone is the seat of power and where child rights campaign was officially launched in Nigeria.

It is not precisely clear why female respondents in our study conformed better in their perception of child rights. Again, unequal distribution of sex in our study may have exaggerated this observation. Even then, the putative notion that women are more children-friendly may have played a role. On the other hand, married respondents, despite better performance in knowledge, scored less in perception than singles. The reason for this paradox becomes less clear when we consider the fact that married respondents are more likely to have children under their care than single respondents. How domestic experience with children influences perception of child rights could be explored in future studies.

Practice of child rights

In this survey, the performance of HCW in the practice of child rights was good but not sufficient, and why nurses performed better is hardly evident. Even though sex did not have a significant influence, we may be tempted to relate nurses’ performance to the preponderance of women (78%) among nurses compared to their population (56%) among doctors. A number of studies have shown that women are less likely than men to violate children's rights.[40,41,42]

Our study shows that physical discipline of children is still prevalent in Nigeria – 72% of HCW had applied physical punishment. This is even higher than the 52% reported by Nuhu et al.[30] in the Ilorin study. The sample size in the Ilorin study was smaller, physical punishments other than beating were not examined and the respondents were parents from lower socioeconomic class. These areas of differences may account for the apparently higher prevalence of the practice (of physical punishment) among Nigerian doctors and nurses. Both outcomes may nonetheless indicate that, despite increasing child rights campaigns globally and locally, enforcement is not yet pervasive in Nigeria.

Doctors with fellowship qualification, despite a good knowledge of child rights, obtained the lowest score in the practice domain, and significantly so compared to nurses with postbasic qualification. Such counterintuitive relationship between knowledge and practice among fellows may indicate that awareness of child rights laws and policies does not necessarily translate into compliant practices.

Strengths and limitations

A noteworthy strength of this study is the adequacy of sample size for both groups of health workers. Also, we consider the spread of respondents, especially across geopolitical zones (of origin), good enough to make meaningful interpretations. Furthermore, evaluation on ratio scale gives the true individual and collective performances of respondents.

One limitation is that the nonprobability sampling used may have introduced unintended bias. The method was, however, the most feasible for the researchers considering Nigeria's huge population and size; this also ensured that virtually all geopolitical zones (of origin) were represented. Second, two-thirds of respondents were practicing in the northern part of the country. Such unintended skewed distribution calls for caution when interpreting our findings, particularly with respect to place of practice.

CONCLUSIONS

In our study, knowledge of child rights was poor among Nigerian doctors and nurses. Their performances in perception and practice were good but not sufficient.

Inclusion of child rights into medical and nursing curricula at both undergraduate and postgraduate levels would not only equip HCW with the requisite knowledge, but would also enhance optimal compliance with child rights instruments. A mandatory prelicensure refresher training, organized by the MDCN and NMCN, would give doctors and nurses a sense of responsibility towards protecting children's rights. In addition, engagement of critical stakeholders is most crucial to implementing child rights instruments in Nigeria; medical professionals should feature prominently in such engagement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.