Knowledge and attitude regarding child abuse among primary health care physician in Abha, Saudi Arabia, 2018.

BACKGROUNDS: Child abuse or child maltreatment is physical, sexual, or psychological maltreatment or neglect of a child or children, especially by a parent or other caregiver. Child abuse may include any act or failure to act by a parent or other caregiver that results in actual or potential harm to a child, and can occur in a child's home or in the organizations, schools, or communities the child interacts with. This study was conducted to assess the primary health care (PHC) centers' physicians' knowledge and attitude toward child abuse including its types, and child neglect with their behavior regarding reporting of abuse cases.
METHODS: A cross-sectional study was conducted in Abha which is the capital of Aseer Province, including all PHC physicians (about 475) working in PHC centers. Data regarding physicians' demographic characteristics, perception, and awareness regarding child abuse and neglect were collected by self-administrative questionnaire in the PHC center during their time between patients' consultation.
RESULTS: The study included 300 PHC physicians whose ages ranged from 25 to 50 years old with mean age of 28 years. About 65% of the physicians were males and 69% of them were married with about 73% having at least one child. Overall, 96.3% of the physicians recorded good awareness level regarding types of child abuse and 97.3% recorded good awareness level regarding child neglect patterns. Underreporting of child abuse cases was recorded by about 64% of physicians.
CONCLUSION: Regarding child abuse and neglect, PHC physicians have good knowledge, optimal attitude, and positive perception. There was also the problem of underreporting of suspected child abuse cases among PHC physicians in Saudi Arabia, with many barriers to report, such as community traditions; unclear reporting strategy was identified.

Introduction

Childhood and adolescence are critical phases of human life, during which personality features are developed.[1] Health status including mental and physical health largely depends on the quality of education and life in this period.[2] Therefore, a silent and safe transition requires the support of family and community.[3] Child abuse or child maltreatment is physical, sexual, or psychological maltreatment or neglect of a child or children, especially by a parent or other caregiver. Child abuse may include any act or failure to act by a parent or other caregiver that results in actual or potential harm to a child, and can occur in a child's home or in the organizations, schools, or communities the child interacts with.[4] The World Health Organization (WHO) defines child abuse and child maltreatment as “all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power.”[5]

Child abuse includes many harmful activities and procrastination in performing parental tasks and responsibilities, leading to physical or mental harm, physical abuse, sexual abuse, misbehaving or neglecting the child, and death of the child.[67] Evidence suggests that severity of child abuse tends to propagate, so early detection and intervention is now crucial in preventing victims from suffering severe abuses.[8] Child abuse may cause stress, leading to changes in the nervous, cardiovascular, and immune systems, and metabolism.[9] Child abuse would form inappropriate personality features and increase risk behaviors among children.[10] Doctors have moral and legal responsibilities to report these cases to relevant governmental authorities or social welfare organizations to provide early interventions for victims and perpetrators and prevent further abuse.[11]

In Saudi Arabia, physical abuse and neglect were shown to be the most prevalent forms of maltreatment against children in Saudi Arabia.[12] The awareness about child abuse and neglect is less in Saudi Arabia, but is improving.[13] Consequently, the prevalence of detecting and reporting such cases is increasing, which might help in further improvement of actions.[14] More large-scale studies and recording of all available data at the national-level registry are recommended.[15]

The aim of this study is to assess the primary health care (PHC) centers’ physicians’ knowledge and attitude toward child abuse including its types, and child neglect with their behavior regarding reporting of abuse cases. It is crucial for safety and protection of children. No previous study assessed this regard at a PHC center level which is a cornerstone of delivering health care in Saudi Arabia.

Method

A cross-sectional study was conducted in Abha which is the capital of Aseer Province, including all PHC physicians (about 475) who were working in PHC centers. An English questionnaire was developed by researchers after intensive literature review and expert consultation for any suggestions, amendment, or modifications and to avoid any translation bias. The questionnaire consisted of five parts, namely, demographic data, concept, perception, professional experience, and reporting in Saudi Arabia the exploration of some situations representing forms of child abuse and/or neglect. Responses are reported on a Likert-type scale with responses ranging from 1 to 5: 1 (strongly disagree), 2 (disagree), 3 (not known), 4 (agree), and 5 (strongly agree). A pilot study was conducted on 15 physicians to test the questionnaire regarding comprehensiveness, applicability, validity, and reliability as well as time required for the interview. In accordance with the participants’ feedback, some modifications were undertaken to fit the objectives of the study and within the cultural context of Saudi Arabia. The participants of the pilot study were excluded from the main study. Data were collected by a self-administrative questionnaire in the PHC center during their time between patients’ consultation. Confidentiality and anonymity was maintained all through the research steps. The study was approved by the ethical committee. Prior to interview, verbal consent was taken from the respondents, and they will be informed about the aim and methodology of the study.

After data were extracted, revised, coded, and fed to statistical software IBM SPSS version 20. Statistical analysis was done using two-tailed tests with an alpha error of 0.05. P value less than or equal to 0.05 was considered to be statistically significant. Frequency and percent distribution were done for all data variables. The composite score for each domain (abuse and neglect constructs) items was calculated that ranged from 1 to 5, and it was considered to have good awareness if the composite score was between 4 and 5 points; otherwise, poor awareness was considered. Pearson's Chi-square test or exact tests were used to assess the significance of association between physicians’ characteristics and their awareness level.

Results

The study included 300 PHC physicians whose age ranged from 25 to 50 years old with a mean age of 28 years. About 65% of the physicians were males and 69% of them were married with about 73% having at least one child. Residents constituted 86.3% of the physicians while only 4.7% were consultants. About 61% of the physicians were family physicians while others were general practitioners (GPs). As for experience years, 69.7% of the physicians had experience less than 5 years while 9.7% had experience more than 10 years [Table 1].

Table 1

Personal data of primary health care physician in Abha, Saudi Arabia, 2018

Personal data		No	%
Age in years	25-29	170	56.7
	30-39	108	36.0
	40-49	22	7.3
Gender	Male	195	65.0
	Female	105	35.0
Marital status	Non-married	93	31.0
	Married	207	69.0
No. of children (n=207)	No	57	27.5
	1	58	28.0
	2	53	25.6
	3	26	12.6
	4+	13	6.3
Nationality	Saudi	277	92.3
	Non-Saudi	23	7.7
Job	Resident	259	86.3
	Specialist	27	9.0
	Consultant	14	4.7
Specialty	GP	116	38.7
	Family medicine	184	61.3
Years of practice	<5 years	209	69.7
	5-9	62	20.7
	10-20	29	9.7

Table 2 illustrates physicians’ agreement rate regarding general perception of child abuse. About 67.7% of the physicians agreed on the need to redefine child abuse and neglect in Saudi Arabia, according to our culture and religion. Also 64.3% of them recorded agreement regarding their willingness to report child abuse cases. About 62% of the participating physicians recorded their good training capability to deal with child abuse case. Also 64% of them agreed on that child abuse in Saudi Arabia is underreported. Only 7.7% of the physicians preferred limiting reporting of child abuse to life threatening injuries.

Table 2

Agreement rate regarding general perception of child abuse as recorded among primary health care physician in Abha, Saudi Arabia, 2018

General perception items	Agreement rate
	No	(%)
I have enough training to deal with child abuse and neglect	187	(62.3)
We need to redefine child abuse and neglect in Saudi Arabia according to our culture and religion	203	(67.7)
The present supportive services to deal with child abuse and neglect in Saudi Arabia are adequate	107	(35.7)
I prefer resolving a case of child abuse myself rather than reporting it to police	62	(20.7)
I am aware of the reporting persuader of child abuse in my hospital in Saudi Arabia	140	(46.7)
I am willing to report all suspected child abuse cases	193	(64.3)
I prefer limiting my reporting of child abuse to life threatening injuries	23	(7.7)
Child abuse is underreported in Saudi Arabia	192	(64.0)

With regard to reasons of underreporting as recorded by the study physicians [Figure 1], unclear reporting procedure was the most recorded reason (43.7%) followed by community barriers to report cases (40.7%) and fear of parent's response (38.7%), while illegality to mandate reporting child abuse was the least frequent reason (16%).

Figure 1

Reasons of underreporting of child abuse in Saudi Arabia as recorded by primary health care physician in Abha, Saudi Arabia, 2018

As for PHC physician's awareness regarding child abuse types [Table 3], 91% of the physicians recorded burning for child misbehavior followed with smoking at presence of child (89.7%), severe beating with marks (88.7%), leaving child alone at home (84.7%), and throwing different objects at the child on anger (84.3%). Considering neglect types, refusing medical treatment of surgery necessary for the child was the most identified neglect type (89.3%) followed by refusing to send the child to school (87.3%), while paying no attention for child cleanliness was the least identified neglect type (65%). Overall, 96.3% of the physicians recorded good awareness level regarding types of child abuse and 97.3% recorded good awareness level regarding child neglect patterns [Figure 2].

Table 3

Descriptives of primary health care physician awareness regarding child abuse and neglect forms, Abha, Saudi Arabia, 2018

Domain	Abuse forms	Agreement rate
		No	(%)
Child abuse	Burning the child for miss behaviors	273	(91.0)
	Locking the child alone at home	254	(84.7)
	Severe beating that leaves marks on the child body	266	(88.7)
	Parents throwing different object at the child when angry	253	(84.3)
	Parents who smoke at the presence of the child	269	(89.7)
Child neglect	Parents refused sending the child to school	262	(87.3)
	Parents refused medical treatment or surgical intervention necessary for their child	268	(89.3)
	Child with severe dental problems, which are not treated	247	(82.3)
	Parents pay no attention to the child cleanness	195	(65.0)
	Child fails to thrive due to social deprivation	226	(75.3)

Figure 2

Overall awareness level regarding child abuse and neglect of primary health care physicians, Abha, Saudi Arabia, 2018

Finally, on relating level of awareness regarding child abuse with the physicians’ characteristics [Table 4], all physicians aged above 40 years had good awareness level compared with 95.9% of younger age physicians. As for the gender, about 96% of both male and female physicians had good awareness level and nearly the same for married and unmarried physicians (96.6% and 95.7%). With regard to number of children, the awareness level was positively trended with having more children. All consultants recorded good awareness level compared with 96.5% of residents. Family physicians recorded higher awareness level regarding child abuse compared with GPs (97.3% vs. 94.8%, respectively). Also, years of experience was positively related to awareness level.

Table 4

Distribution of primary health care physician awareness regarding child abuse by their personal characteristics, Abha, Saudi Arabia, 2018

Personal data		Abuse awareness level				MCP
		Poor		Good
		No	%	No	%
Age in years	25-29	7	4.1	163	95.9	0.626
	30-39	4	3.7	104	96.3
	40-49	0	0.0	22	100.0
Gender	Male	7	3.6	188	96.4	0.923
	Female	4	3.8	101	96.2
Marital status	Non-married	4	4.3	89	95.7	0.695
	Married	7	3.4	200	96.6
No. of children	No	2	3.5	55	96.5	0.416
	1	4	6.9	54	93.1
	2	1	1.9	52	98.1
	3	0	0.0	26	100.0
	4+	0	0.0	13	100.0
Nationality	Saudi	11	4.0	266	96.0	0.330
	Non-Saudi	0	0.0	23	100.0
Job	Resident	9	3.5	250	96.5	0.443
	Specialist	2	7.4	25	92.6
	Consultant	0	0.0	14	100.0
Specialty	GP	6	5.2	110	94.8	0.271
	Family medicine	5	2.7	179	97.3
Years of practice	<5 years	8	3.8	201	96.2	0.507
	5-9	3	4.8	59	95.2
	10-20	0	0.0	29	100.0

MCP: Mont Carlo exact probability

Discussion

Childhood is a golden and enjoyable period of life. Protection of a child during this period is the responsibility of the professionals who care for the child. Beside the parents, teachers and physicians play a very important role. Child abuse and child neglect have negative psychological effect on children. This study aimed to focus on the role of the physician in this regard, mainly primary health practitioner or family physicians. In our research, we did not find such study in Saudi that studied the level of primary care physicians. In this study, child abuse and child neglect awareness were mostly good among physicians (96.3% and 97.3%, respectively). It is very important to raise such awareness because primary and family physicians are considered as the first and continuous contact with the child through their life. A study done by Mogaddam et al.[16] concluded that the awareness of child abuse and neglect was improving in Saudi Arabia. This was also noticed by Chang and his colleague.[17]

Kraus and Jandl-Jager[18] found that the majority of physicians recognized the most common symptoms of child abuse. Alnasser et al.[19] found that the Saudi medical students, pediatrics trainees, and pediatricians have good basic knowledge. Another study by Habib[20] concluded that the overall knowledge of participants about some important aspects of child abuse and negligence was adequate. In China, Li et al.[21] reported that there was insufficient knowledge of the health provider toward child abuse. This difference, it may be including all health professions in that study.

Yadav and his colleague[22] observed that most of the family physicians had inadequate knowledge about the identification and management of cases of child abuse. Other studies, such as Hynniewta et al.,[23] that explore awareness among other important persons like teachers make a sense in the detection and prevention of child abuse and neglect. It found that the majority (84%) of the schoolteachers had average knowledge on child abuse and 10% and 6% of them had good and poor knowledge, respectively. These findings reflect the importance of raising awareness among physicians and teachers as caregiver and contact caregiver with child.

The present study recorded that 64% of primary physicians agreed that child abuse is underreported in Saudi Arabia. AlMadani et al.[24] said that there was an increasing pattern of reports over recent years. Preidt[25] stated that the reporting of child abuse cases among primary care providers showed that 21% of suspected cases were not reported. Moreover, Eads[26] concluded that “Underreporting child abuse has become an epidemic.” A lot of reasons are mentioned for this; this study determined that the reasons of underreporting child abuse and neglect as recoded by physicians were unclear reporting procedures (43.7%), and it was the most common reason perceived by primary care physicians. In contrast to this, another study reported by Walsh et al.[27] indicated that different or clearer policies or procedures represent only 11% of all needs to improve reporting while the need to improve screening process represented 29%. A total of 38.7% of participants report fear of parents or child's family's response toward the child as a reason to not report in our study; this reflects the cultural beliefs and interferes to hidden issues about child abuse and neglect making the highlight very important.

Conclusions and Recommendations

After reporting results, researchers found that, regarding child abuse and neglect, PHC physicians have good knowledge, optimal attitude, and positive perception. There is also the problem of underreporting of suspected child abuse cases among PHC physicians in Saudi Arabia, with many barriers to report, such as community traditions; unclear reporting strategies were identified. More support and clearer guidelines should be provided for PHC physicians to address this issue. Further training on child abuse can be another option to increase awareness and knowledge in reporting and such training should be made mandatory. It is an important role of PHC physicians to identify and report child abuse cases; it is essential that the knowledge of health care professionals be improved and practical plans for dealing with cases of child abuse and neglect or suspected child abuse be established.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.