Child maltreatment prevention strategies: Saudi youth perspectives.

BACKGROUND AND OBJECTIVES: Child maltreatment (CM) is a global problem that has long-term negative outcomes. The objective of this study is to explore the knowledge and perceptions of youth regarding CM prevention.
METHODS: The study was conducted in Saudi Arabia using International Child Abuse Screening Tool (ICAST). Answers to open-ended questions were analyzed and a list of CM prevention strategies was generated.
RESULTS: Participants identified a range of preventive strategies that were grouped into three main themes: 1) collective preventive efforts; 2) recognizing and responding to CM; 3) gaining closure. For each overarching theme, a list of subthemes were derived. Subthemes included raising awareness through the mass media; school professionals' capacity building and curriculum advancement; strengthening family relationships; enact CM preventive legislations and policies; monitoring media content and video games and limiting access to firearms for the first theme. The second theme comprised the subthemes reporting services and protective services. As for the third theme it included rehabilitation; punishment for CM crimes and connection to spirituality.
CONCLUSION: Gathering youth perspectives on CM prevention will help us in designing future prevention strategies.

Introduction

Child maltreatment (CM) is defined by the World Health Organization (WHO) as physical and/or psychological abuse, sexual abuse, neglect or commercial or other exploitation that result in actual or potential harm to the child's development, health, and survival [1]. Globally, a quarter of all adults report having been physically abused during their childhood [2]. Children who are exposed to psychological, physical, or sexual abuse are at greater risk of negative health consequences in adulthood [3]. The financial costs for victims and society are substantial. One year of confirmed cases of CM is associated with total lifetime cost of $124 billion [4]. Previous studies have shown that treating the consequences of CM is less effective and more costly than preventing it before it occurs [5]. Thus, CM prevention has become a global health priority. Preventing CM necessitates development of healthy and harmonious relationships in the family. Securing healthy relationships will protect the children against early adverse events and are essential to ensure the long-term physical and psychological well-being [6]. Internationally, a number of evidence-based strategies to prevent or reduce the risk factors for this public health problem were shown to be effective such as good care and education during childhood, and increase parenting skill to promote healthy development of the child [5,6].

In the Middle Eastern countries, CM is a common phenomena [7]. In the last two decades, increasing initiatives at country and regional levels are being directed towards improving the welfare of children through strengthening existing instruments or producing new ones. All countries in the Middle East and North Africa (MENA) region have enacted and passed the ‘Child Protection Law’ that is considered as a milestone in the CM prevention field. This law is a local translation and adoption of the international Convention on the Rights of the Child (CRC) [8]. However, the situation of the rights of children in the MENA region still need to be improved in a number of areas such as promoting norms and values that support pro-social, non-violent behavior and enforcement of enacted laws. In Saudi Arabia, CM is not uncommon. Al-Sehaimi, Barron, and Hodson conducted a meta-analyses assessing childhood physical abuse and the results showed that prevalence ranged between 32% and 69% [9]. Another meta-analysis on child sexual abuse in Saudi Arabia concluded that the prevalence ranges between 15 to 21% [10]. A recent national study that was conducted among 16,010 students between 15 and 18 years of age, found that 65% were psychologically abused, 50% were physically abused and 10% reported sexual abuse [11]. Another population based study in Saudi Arabia with 12,575 adolescents found that 25% of them experienced bullying in the past 30 days prior to participation in the study [12]. National efforts are being put together to prevent CM and neglect such as enacting laws (the “Law of Protection from Abuse” issued in 2013 and the “Child Protection Law” issued in 2014). Administration of these laws might help case management. According to a recent study that was implemented in 2011, the readiness of Saudi Arabia to implement large-scale preventive programs is moderately low [13]. Modest progress was observed when the same study was conducted again in 2016 (unpublished data). Although some dimensions still need to be improved, such as the attitude of people towards CM and the availability of human and technical resources; however, significant progress was reported in other dimensions such as the passage of laws and the implementation of CM prevention programs.

Children also have a right to be involved in the matters which influence them. Participation allows children to convey their opinions, affect decision-making and attain change. According to Article 12 of the CRC, children should be able to express their comments on any subject which affect them [14]. That is why international organizations that work in child welfare, such as Save the Children, have developed guides on children's participation detailing ways for professionals to support children's involvement in the observation, judgment, and action of their work [15]. In line with this, this study aims to explore the knowledge and perceptions of Saudi youth towards CM preventive methods in Saudi Arabia.

Materials and methods

Participants

The data for this paper was drawn from a larger study conducted among 16,010 adolescents (15–18 years of age) in Saudi Arabia that aimed to explore adolescents' exposures to CM.

Procedure

Multistage stratified sampling technique was used. A list of secondary high schools including public and private for boys and girls were obtained from the Ministry of Education (MoE). From each province, a weighted sample size of the student was identified based on students' population in each of the five provinces. Two cities were selected randomly from ‘urban’ and ‘rural’ list of cities for each of the provinces. Then, in every selected city, schools were divided based on four geographical areas to ensure differences of demographic characteristics of the students were captured. At least one school in each area was selected randomly. All students from each of the randomly selected schools were asked to participate in the study. Data collectors received standardized training on recruitment procedure, interviewing technique, and human subject protection issues. All students meeting the inclusion criteria were informed about the study. After obtaining informed parental/guardian consents and student assents, participants were distributed anonymous questionnaires (ISPCAN Child Abuse and Neglect Screening Tool- Child: Home version). The questionnaire distributed was in Arabic. In order to avoid any parental/guardian influence, the questionnaires were completed at school. It took 30–40 min for the participant to complete the questionnaire.

Measures

The International Society for Child Abuse and Neglect (ISPCAN) and UNICEF developed the validated self-administered questionnaire [16]. The questionnaire was translated to Arabic (www.ISPCAN.org/?page=ICAST). Two open-ended questions were added to the instrument to obtain in-depth information about the following: a) What do you think about the current CM prevention activities? and b) What are your suggestions to improve the CM prevention efforts? The data for the purpose of this analysis was based on the responses from these two open-ended questions.

Data analysis

The sample size in this study was 16,010 and 4177 (26%) of them responded to the open ended questions and were included in this analysis. All responses were entered into our database verbatim. Through a content analysis approach, all data was reviewed and emergent themes were identified by the researchers. They were thereafter grouped into categories. The emergent themes and categories were thereafter independently reviewed by three expert researchers in the field to ensure the validity of the qualitative data interpretation. The final themes were agreed upon through consensus and supported with participants' verbatim quotations (translated from Arabic to English for the purpose of this paper). Descriptive statistics were calculated for demographic data using Statistical Package for the Social Sciences (SPSS) version 20.0 [17].

Ethics

Institutional Review Board (IRB) of King Abdullah International Medical Research Center (KAIMRC) approved the study (RR11/008). The Ministry of Education (MoE) provided permission and support to conduct the study. School principals agreed to have their school participate and parental/guardian informed consent was obtained. Also prior to the start of data collection, the study was explained to the adolescent participants and their assent was obtained. If the participants chose not to continue, they could withdraw from the study without any negative consequences. They were asked to contact their school social worker or call the toll-free Child Helpline if they wished to disclose maltreatment or were distressed by the questionnaire.

Several measures were taken for human subject protection and data confidentiality. Training was provided to the data collectors regarding ethical conduct, human subject protection, and data confidentiality. Surveys were anonymous and all data were entered into a database with password. Hard copies of the questionnaires were stored in secured cabinets in a locked office.

Results

The participant's mean age was 16.8 years. Boys and girls were almost equally distributed and majority (84%) of the participants lived with both biological parents (Table 1).

Table 1

Demographic characteristics of the participants (n = 4177).

	Number (%)a
Age
Mean ± SD	16.8 (0.9)
Gender
Boys	1732 (41.5)
Girls	2445 (58.5)
Area
Urban	2523 (60.4)
Rural	1654 (37.2)
Caregivers
Both parents	3514 (84.1)
Single biological parent	273 (6.5)
Biological and step-parent	96 (2.3)
Missing	294 (7.0)
Living arrangements
Nuclear family	3545 (84.9)
Extended family	443 (10.6)
Missing	189 (4.5)

Percentages may not add to 100 due to missing data.

Three main themes emerged: collective preventive efforts, recognizing and responding to CM, and gaining closure (Table 2).

Table 2

Key themes and subthemes emerged from participants suggestions.

Key themes	Subthemes
1. Collective preventive efforts	1.1. Raising awareness through the mass media
	1.2. School professionals' capacity building and curriculum advancement
	1.3. Strengthening family relationships
	1.4. Enact CM preventive legislations and policies
	1.5. Monitoring media content and video games
	1.6. Limiting access to firearms
2. Recognizing and responding to CM	2.1. Reporting services
	2.2. Protective services
3. Gaining closure	3.1. Rehabilitation
	3.2. Punishment for CM crimes
	3.3. Connection to spirituality

Collective preventive efforts

Participants cited strategies that reflect collective and comprehensive efforts to prevent violence including raising awareness through the media, capacity building of school professionals' and curriculum advancement, strengthening family relationships, enactment of CM preventive legislations and policies, monitoring media content and video games and limiting access to firearms:

Raising awareness through the mass media

Over two-third (68%) of participants considered raising awareness the mainstay for CM prevention. Young participants suggested using the powerful social media to create innovative campaigns to help people learn more about the signs, consequences, and response to early violence. Social media has become an outlet for advocates to speak up and spread awareness messages. It also encourages everyone to get involved and be part of the solution:

“Everyone I know is engaged in social media. You can tell them about child rights and violence against children through it.” (Male, 16 years).

Another interesting suggestion proposed by participants was the development of mobile applications that broaden community knowledge on CM, and influence people's attitudes:

“Youth are spending long time on their smart phones nowadays. Why not develop an awareness application for them to download?” (Female, 15 years)

“I saw an advertisement about a sexual abuse awareness application developed in a neighboring country. It was useful and had much information.” (Male, 18 years)

Furthermore, participants noted the importance of organizing mass media programs on television and radio to prevent CM and promote child rights given the option to contact target groups of people:

“There has to be awareness in television, radio, and newspaper. Everyone should be informed about this problem.” (Female, 17 years)

“There aren't enough T.V. programs telling the community about child maltreatment and its consequences. People need to know it is a crime and there are penalties.” (Female, 18 years)

School professionals' capacity building and curriculum advancement

Additional potentially effective strategies cited by adolescents include school based prevention programs. They indicated the necessity to design programs in schools to increase children's knowledge and awareness of CM prevention and children's rights. Schools are also an important setting where CM can be detected. Therefore, participants claimed that teachers and other staff need to learn how to recognize CM cases and how to respond to children's disclosure of maltreatment. The youth expressed the need for teachers to be more attentive to children's concerns:

“I told a teacher about a friend who is sexually abused at home. She didn't do anything to help her!” (Female, 15 years)

“Teachers should be trained to identify abused children in order to help them.” (Male, 17 years)

“In schools, children have to be taught about their rights and how to protect themselves.” (Male, 16 years)

However, interestingly, participants indicated the need for having psychologists in all the schools to support the recognitions and management of CM cases. One adolescent reported:

“We need a psychologist in each school. Psychologists know how to recognize and treat abused children.” (Male, 18 years)

Strengthening family relationships

To reduce the risk of CM, participants indicated the importance of communication in the family. They stated that parents should encourage dialogue with children and give them their full attention so that children become comfortable with expressing their problems to parents. They also disclosed that parents should take children's disclosures seriously, as this would encourage children to communicate further with their parents. Relationship with parents should be stable and parents should invest more time in listening and talking to their children. Good communication can deepen the bond and the trust in the parent-child relationship:

“Family members should talk to each other; there has be dialogue within the family.” (Male, 16 years)

“Parents should spend more time with their children, surround them with love, and listen to them and satisfy their needs.” (Female, 18 years)

To also prevent childhood adverse experiences, participants stated that children should always be accompanied by adult caregivers in public places at all times. They should not be left unsupervised with domestic workers during extended family gatherings:

“Many people leave their young children with housemaids during family gatherings. Some abused them and some left them unsupervised.” (Female, 16 years)

Participants explained that abuse by domestic workers is not rare in the country and should be thought of in awareness campaigns.

Enact CM preventive legislations and policies

The youth expressed the need for effective national legislations and institutional policies to protect children's rights and criminalize violence against them have to be enacted:

“We need strong laws to protect children's rights.” (Female, 15 years)

“Unfortunately the laws we have are not effective enough to end violence against children.” (Male, 18 years)

Participants highlighted the significance of raising awareness of the public on these laws. The urgent need for stricter penalties for offenders was expressed by many participants. Furthermore, young participants reported the importance of passing laws that require from engaged couples who wish to get married to attend pre-marital courses that will increase their knowledge on the best methods and practices of raising children:

“There has to be pre-marital courses to teach future parents how to raise and discipline their children.” (Female 17 years)

Monitoring media content and video games

Approximately 16% of participants stated that violence children are exposed to on the Internet, television and video games encourages violence and aggressive behaviors among children. Participants clarified that parental involvement in monitoring children's media exposure can neutralize these influences. According to them, parents and caregivers should be careful in monitoring the types of programs that their children watch, the amount of time their kids spend watching television and gaming and selecting appropriate games for their ages. A participant reported:

“There are many violent videogames available in the market and any child can buy them. There has to be some restrictions.” (Male, 16 years)

Other participants also added the importance of the government's role in exerting more control on the content of TV programs in general and children's programs in specific. One youth stated:

“News, movies, and T.V. shows contain violence. No warning for the viewers or age limit. The authorities should enforce some rules.” (Male, 17 years)

Limiting access to firearms

Knowing that the majority of firearm victims in Saudi Arabia are youngsters below 30 years of age, adolescents raised the importance of imposing strict rules towards the availability and accessibility to firearms in Saudi households to prevent homicides, suicides, and unintentional injuries. Children should stay away from guns and be persuaded that gun violence is not an acceptable way to resolve conflicts. One adolescent stated:

“There are many people in our neighborhood who have guns in their houses. A classmate brought his father's pistol to school.” (Male, 16 years)

Recognizing and responding to CM

Fewer than a quarter (23%) of participants suggested implementation of effective programs for early recognition and detection of CM at home, schools, and community. They also criticized the delay in responding to CM cases and considered current reporting channels ineffective.

Reporting services

In this study, it was found that participants mentioned the importance of notifying the authorities when CM is suspected. Child friendly services should be readily available for all children, caregivers, and professionals across the country with free access. These locations should offer non-stressful places for the victims to be interviewed and examined:

“I suggest developing dedicated child protective services with a toll-free number for children to report maltreatment. These services should be accessible from anywhere in the country.” (Female, 18 years)

Protective services

The participants expressed their dissatisfaction with regard to quality of and speed of care in the country:

“My step-father was sexually harassing me. My mom approached protective services. They came after few days, but it was too late!” (Female, 16 years)

“Those who receive a complaint about child maltreatment should respond to it promptly with no delay.” (Male, 15 years)

Effective protective services with rapid response mechanism and strict accountability and quality assurance measures are highly required. Their main focus is the child's safety and prevention of further abuse. Participants stated that there should be safe placements or shelter for the abused child to separate him/her from the person suspected of abuse and prevent further harm:

“The abused child should be taken away from the offender to protect him. I suggest building shelters for those kids.” (Female, 18 years)

Gaining closure

Participants went on to express strategies reflective of gaining closure to CM. This included the importance of rehabilitating abused children.

Rehabilitation

Few (9%) participants specified that special rehabilitation programs need to be designed by experts and directed to abused children and their families. Other programs directed towards perpetrators' rehabilitation are also necessary and need to focus on behavioral modification:

“Abused children need to be rehabilitated to live within their family, regain their capacities and become productive.” (Male, 18 years)

“Unless rehabilitated, the offenders won't stop abusing children” (Female, 16 years).

Punishment for CM crimes

Along with CM criminalization; deterrent penalties have to be warranted to CM perpetrators. Suggested penalties included: imprisonment, fines and public disgrace. Participants reported that abusers should be closely monitored by legal or social services to prevent them from reiterating their acts:

“Child maltreatment is a crime and criminals should be punished.” (Female, 15 years)

“Those who abuse children should be punished and carefully watched. They have to stop hurting children.” (Male, 17 years)

Connection to spirituality

Knowing that in Saudi Arabia religion is widely considered as a foundation for coping with difficulties, participants suggested the involvement of religious leaders in the care of abused children and families. They explained that religious leaders could collaborate with social service providers to build communities committed to prevention of the initial occurrence of abuse and the healthy development of children. Interestingly, the youth also mentioned the role of religious leaders in rehabilitating and treating the perpetrators:

“Friday Prayer sermons, as well as neighborhood mosque lectures, should be employed to condemn child maltreatment. People here are spiritual and accept religious advice. Imams of mosques and religious leaders are expected to guide people.” (Male, 18 years)

Discussion

Our study provides insights to youth perspectives of CM prevention and response. Participants recognized many strategies to combat CM and their propositions focused on collective preventive efforts, recognizing and responding to CM and treating cases and perpetrators. Their responses highlight their awareness of CM prevention, as they cited strategies that have been proven to be effective in combating CM. In essence, their suggestions reflect a comprehensive public health model to the prevention of CM.

Unsurprisingly, a great percentage of young participants suggested the use of technology to spread awareness and knowledge on CM prevention. Media in all its forms including social media are currently among the first choices for awareness campaigns given the massive numbers it can reach. Previous studies [18,19] have shown that social media are effective in spreading knowledge to a very large number of audience. It is also found to increase the level of concern over addressed issues, draws attention to certain problems and spreads influential messages to the extent of turning vision into action. According to Saunders and Goddard, mass media for CM prevention are useful tools to advocate for children's rights, promote awareness, and prevent CM. However, the authors emphasize that campaign strategies may only be successful if combined with community education and direct support programs [20].

Although media has a positive role in disseminating useful information it can also be used to spread violent content. An additional suggested preventive measure by the youth was monitoring children's access to media and video games. Youth violence is related to movies and video games with increased levels of violent content. Over the past three decades, the association between exposure to violence in the media and aggressive behaviors have been widely studied and most of the studies support the relationship [21]. A recent study showed that watching aggression on TV was longitudinally associated with future relational aggression [22]. Violence in the internet (killing, shooting, fighting, etc.) was also found to be associated with a 50% increase in reports of aggressive behaviors [23]. Sargent and others, (2002) [24] surveyed 5456 middle school students, of which 28% watched extremely violent movies. A review of 600 studies has shown that aggression, desensitization, and fear were the main negative outcomes of exposure to TV violence. Changes in attitudes among youth regarding violence in interpersonal relationships have been found to be associated with exposure to violence in the media [25]. Carnagey, Anderson, and Bushman reported a physiological connection with diminished emotional responsiveness to violent video games [26]. For this reason, monitoring the types of programs is crucial for the prevention of violence. Strategies to decrease exposure to violence in the media include controlling the setting by parents or guardians and advanced technologies that block adult content from being watched by the children [27].

Another repeated youth recommendation to prevent CM was improving child parent relations. Participants mentioned the importance of communication between family members to decrease CM. It has been previously found that poor child parent relationships are strongly associated with adolescent exposure to bullying or physical violence in Saudi Arabia and as such, efforts to strengthen child parent relationships are needed [28]. Previous publications report that parenting programs that entail disciplinary action, parental monitoring and supervision, and knowledge on the consequences of CM provide essential raising skills to mothers for the promotion of harmonious family relationships [29]. The Mother and Child Education Program (MOCEP) is an international program that has been implemented in nine countries since 1993 and provides parents with pro-social behaviors and conflict resolution techniques that are practiced directly with young children. Results have shown that in the aftermath of participating in such programs, mothers experience less conflict and violence and greater harmony within their families, as well as greater female empowerment [30]. In Saudi Arabia, MOCEP has already been initiated and showed successful results [31]. Expanding such programs at the national level in Saudi Arabia will greatly assist in decreasing CM cases.

Participants in this study also indicated that school-based prevention programs are of primary importance to prevent CM and also support children who are exposed to CM. Teachers and other school staff are in daily contact with students and their role in identifying and preventing CM is substantial. Previous systematic reviews [32] on school based programs to prevent sexual abuse have revealed the effectiveness of such programs in increasing knowledge of participating children about abuse prevention as well as the skills in protective behaviors.

Young participants also proposed the need to have more accessible and child friendly systems for reporting cases of abuse. Saudi Child Help Line (SCHL) was initiated and a campaign was carried out in all public schools in order to inform the students to disclose all forms of maltreatment in addition to other problems they experience. This may relieve the pressure on youth by disclosing maltreatment and getting the direction to handle it. However, these services may be unheard of for some people and specifically children. For that reason, more awareness should be targeted for those groups to propagate such services. On the other hand, we do lack child friendly settings that can receive children and respond to suspected or alleged cases of abuse.

As for the rehabilitation of abused children and perpetrators, Saudi youth pointed out to the importance of religion and spirituality in the prevention of CM. It can also serve as a positive coping mechanism in reducing the tremendous stress caused by abuse. Religion is an important part of Saudi lives and supposedly, many would prefer to have it incorporated into their therapeutic processes. Recently many mental health researchers have investigated the beneficial role of religion in mitigating the impact of adversity on the wellbeing of individuals [33]. Thus, psychologists and social workers working with abused children should take into consideration the role of religion and possibly the aid of religious leaders in victims and offenders rehabilitation.

Considering the views and opinions of youth in any matter that concerns them, such as CM prevention strategies, is of paramount importance. Working in collaboration with children brings new perspectives and greater credibility and, possibly, better outcomes [15]. The Youth Safety Project, which is an NFSP initiative that aims at empowering young people and increasing their knowledge on the prevention of CM and domestic violence by promoting social leadership and raising community awareness, is such an example. Youth Safety members have the opportunity to plan and implement CM awareness programs and community activities that contribute to the safety of the Saudi family from all aspects of domestic violence.

Limitations

Although this study enabled us to explore the opinions and perceptions of adolescents regarding CM prevention, there are some limitations. First, the data that was used for this study was based on self-reported qualitative data to two open-ended questions. The study was not designed in a way to conduct focus groups or interviews and so probing and further in-depth information gathering was not attainable due to the nature of the data collection. Furthermore, though the responses were insightful, participants' responses may have been influenced by the preceding quantitative measures of the survey. Future qualitative studies involving focus groups are suggested to explore children' perspectives in-depth.

Conclusion

Insightful information on the prevention and response to CM have been shared by youth. The results from this study have implications for both public health practice and future research. More focused, specifically tailored, and culturally appropriate CM preventive strategies should be adopted in Saudi Arabia. Public health practitioners should optimize the use of more technologies to spread awareness among youth. Also, religion could be more widely used by professionals as a coping mechanism to rehabilitate abused children and perpetrators. Finally, youth should be given the opportunities to actively engage in designing new CM preventive strategies in the future.

Conflicts of interest

This is to declare that all authors have no conflict of interest.

Funding

The authors would like to thank King Abdullah International Medical Research Center (KAIMRC) for their financial support of this study with grant number: RR11/008.

Ethical statement

The study was approved by the Institutional Review Board (IRB) of King Abdullah International Medical Research Center (KAIMRC) (RR11/008). The Ministry of Education (MoE) provided permission and support to conduct the study. School principals' agreed to have their school participate and parental/guardian informed consent was obtained. Also prior to the start of data collection, the study was explained to the adolescent participants and their assent was obtained. Participants were allowed to withdraw from the study if they chose not to continue without any negative consequences. They were asked to contact their school social worker or call the toll-free Child Helpline if they wished to disclose maltreatment or were distressed by the questionnaire.

Data was collected only for research purposes. Several measures were adopted to ensure confidentiality of data and protect participants. Data collectors received training and continuous monitoring in areas related to ethical conduct, confidentiality protection, and other issues in human subject protection. Surveys were anonymous and all data were stored in a password-protected database on computers in locked offices. The hard copies of this information were stored in a locked cabinet.