Parent-child communication and preventive practices for child sexual abuse among the general population: A community-based study.

OBJECTIVES: This study was conducted to investigate parent-child communication and preventive practices centred on child sexual abuse among a cohort of Saudi population.
METHODS: A cross-sectional descriptive study was carried out at a single primary health care centre (PHC) in Dammam city, KSA. Parent-child communication and preventive practice were measured by a Self-Reporting Questionnaire with binary answers (yes/no). A total of 400 subjects were selected using a stratified random sampling method.
RESULTS: This study found that 82.5% (n = 329) of parents talked with their children about the latter's bodily privacy. With regard to supervision, most parents (91.7%) said that their children were under their direct supervision all the time. Other variables wear wearing appropriate clothes (94.7%), supervision (93.5%), and teaching a child about their bodily privacy (93.2%). A majority of the respondents (76.2%) were achieved a good preventive practice score, while 95 (23.8%) were observed to have poor communication practice. Logistic regression analyses for gender (p < 0.020; odds ratio 3.031; 95% CI), marital status (p < 0.026; odds ratio 0.081; 95% CI), and family size of more than one wife (p < 0.041; odds ratio 0.081; 95% CI) were significantly associated with good preventive practice.
CONCLUSION: The study showed that parent-child communication practices in KSA seem to be reasonably good. Further parental supervision of children with respect to sexual abuse needs attention. Parents are advised to communicate with their children and to provide them with information and material on the prevention of sexual abuse.

Introduction

Child sexual abuse (CSA) is a crime or serious offence that involves a child in sexual activity that he or she does not fully understand and for which the child is unable to give informed consent. It is a violation of a child's basic human rights.1, 2 CSA is often surrounded by silence, which can occur for many reasons, ranging from the family's omission to the child's fear that reporting the incident will result in further punishment, as well as difficulties in diagnosis of CSA and notifying of parents and the lack of standardised and effective tools for the proper handling of cases in the health system.

Studies on CSA are difficult to carry out for both ethical and legal reasons. Previous studies from different countries have evaluated the prevalence of CSA and its long-term consequences.4, 5, 6 Prior studies published in the US and other western societies have estimated that 1 in 5 girls and 1 in 12 boys have experienced some form of childhood maltreatment.5, 6 Studies from developing countries have indicated that 1 in 15 children aged below 18 years are subject to maltreatment annually, and this rate can be regarded as being higher than the estimates for the US and European countries.7, 8, 9, 10 In a recent meta-analysis, Pereda et al. found that the prevalence of sexual victimisation among boys was 7.9% and among girls it was 19.7%, with a significant difference between boys and girls.

The prevalence of CSA is on the rise around the world. However, individually, the prevalence of CSA varies between countries because of cultural differences. The prevalence of CSA in Morocco was 9.2%, while it was 9.2% in Europe, 10.1% in Asia, 15.8% in the US, and 23.9% in Oceania. Several studies have indicated that the highest prevalence of CSA is in Africa (34.4%). Recently, Al-Eissa et al. measured the prevalence of CSA among school students in KSA and reported a prevalence of CSA of 16%. Similarly, a retrospective study in 2009 recognised several cases of CSA in KSA in a paediatric surgery unit between 1987 and 2007. On the other hand, a cross-sectional survey conducted by Alquaiz et al. among 419 teenage girls in two schools in the capital city of KSA reported that 10% of the girls had been exposed to some form of sexual violence. A study from Turkey identified 101 cases of CSA and found that 66.3% of the victims had been abused by an acquaintance. A recent population-based survey of 1028 Lebanese children (54% boys, 46% girls) documented CSA in 249 (24%) of them. It is advisable for a broad literature review to identify the prevalence and the health consequences of CSA, for the improvement of prevention programmes and the provision of appropriate support.

This study examined parent–child interactions in the context of CSA awareness and strategies addressing these interactions. The findings of this study should be considered when developing a comprehensive strategy for the prevention of CSA in the Saudi community.

Materials and Methods

This cross-sectional descriptive study was conducted in the primary health care centre (PHCC) of Imam Abdurrahman Al-Faisal Hospital in the city of Dammam, KSA. Parents of children younger than 18 years who visited the PHCC were included in the study. Parents of children who were aged 18 years and above, parents with no children, and parents with children who had some form of psychiatric disability were excluded.

The minimum sample size was calculated using the Raosoft Sample Size Calculator. A sample size comprising 374 subjects is enough to produce a 95% confidence interval with a 5% accepted margin of error when the estimated proportion of CSA is 50.0%. About 10% was added to the sample size to compensate for rejected and/or incomplete questionnaires, to produce a total sample size of 411. Of these, 11 questionnaires were excluded because of incomplete major data.

To explore parent–child communication and preventive practices with respect to CSA, a new questionnaire was developed by a research team that comprised four professional members who had prior experience in the development and validation of questionnaires, based on the items covered by previously used and published questionnaires.18, 19

The questionnaire consisted of six sections with binary answers (yes or no). The first part covered demographic and family data and consisted of multiple-choice fill-in-the-blanks questions. The second part dealt with parent–child communication practices and consisted of six items (talking with children about their private parts; advising children not to go with others, even with grown-ups they are familiar with, to any place without parental permission; encouraging children to talk with their parents about sexual issues, etc.). The third part asked for information about the patterns of child supervision. The fourth part asked about preferred actions in the event that CSA had indeed taken place, and there were eight questions to address it. The fifth section dealt with parents’ suggestions for the prevention of CSA. The last part of the questionnaire contained questions to identify the experience of CSA in both parents and children, and consisted of two questions, asking “Have you been sexually assaulted while growing up?” and “Have any of your children been sexually assaulted?” Answers to these questions were recorded as “yes” or “no”. If the answer was yes, the participants were asked to specify the relation. Once the research tool was developed, it was sent to four reviewers, namely, a consultant and a family doctor with considerable experience in handling child maltreatment cases to provide their opinions and suggestions on the suitability of the questions; a nurse who was active in patient counselling and education; and a researcher working in the field of the social and behavioural sciences.

A pilot study was conducted at the PHCC under the supervision of an investigator to evaluate the responses of subjects to measure the validity of the questionnaire and to test the study tools. Furthermore, it was important to use the pilot to understand the best method of data collection and management. The pilot study was completed in 2 weeks and involved 44 subjects. All necessary additions or changes in the study tools were made. The results of the pilot study have not been included in the main study.

Data were collected by using a simple random sampling technique in which each sample had an equal probability of being chosen. This process was conducted under the supervision of the primary investigator and two pre-trained PHCC staff nurses. The objectives of the study and the content of the questionnaire were explained clearly. The investigator and the assistants were available to help the participants if they faced any difficulties and if they needed any clarifications.

Parent–child communication practices were measured using the CSA Prevention Education Scale, which consists of a total of six items. The CSA Prevention Education Scale was previously published and found reliable; a Cronbach's alpha of 0.65 was obtained by another author. The Reliability for the CSA Prevention Education Scale in our study was measured and found to be 0.63. The good preventive practice score and poor preventive practice score was assessed by assuming that a correct response scored one point and an incorrect response scored zero. All the elements were added up. The median (= 5) was considered the cut-off point that divided the results into good scores above the median and poor scores below. Parents' suggestions for the prevention of CSA and their preferred actions in the case of CSA were also assessed. Each questionnaire was translated into Arabic, which is the local language, and then back-translated into English to ensure consistency of meaning before data collection.

Statistical Package for Social Science version was used for data entry and statistical analysis. A significance level of less than 0.05 and a 95% confident interval were considered indicative of statistical significance. Frequency distribution tables were constructed, and the appropriate test was applied. The Chi-square test was used to assess the significance of the difference between categories. Significant variables were subject to multiple logistic regressions to identify relationships between the qualitative variables and the parents’ scores.

Results

A detailed description of demographics and family characters is presented in Table 1. Of the 411 participants, about 400 questionnaires were received with completely answers, giving a response rate of 97%. The remaining 11 questionnaires were incompletely answered by the respondents and were excluded from the study. About half of the respondents, 201, were middle-aged (50.6%), 185 (46.6%) were young, and only 11 (2.8%) were old. Males constituted slightly over half the sample, at 231 (57.8%) and the remaining 169 (42.2%) comprised females. As many as 140 (42.6%) were employed in the military, 100 (30.4%) were unemployed, and 81 (24.6%) were engaged in some form of civilian employment.

Table 1

Demographic and family characteristics of parents in the primary health care centre of Imam Abdulrahman Bin Faisal Hospital (N = 400).

Variables	Number	(%)
Age (Years)a
Young age (18–34)	185	(46.6)
Middle age (35–54)	201	(50.6)
Old age (55+)	11	(2.8)
Gender:
Male	231	(57.8)
Female	169	(42.2)
Employment statusa
Not employed	100	(30.4)
Military employee	140	(42.6)
Civilian employee	81	(24.6)
Retired employee	8	(2.4)
Level of Educationa
Low level	42	(10.7)
Average level	286	(73.0)
High level	64	(16.3)
Economic status
<9999 SAR	66	(16.6)
10000-19999)	224	(56.4)
>20000	107	(27.0)
Marital status
Married	366	(91.5)
Divorced	24	(6.0)
Widowed	10	(2.5)
Number of Wives:a
One	218	(84.5)
More than one	40	(15.5)
Number of male children:a
>5	369	(93.2)
<5	27	(6.8)
Number of female children:a
>5	370	(93.4)
<5	26	(6.6)

Missing values.

About 224 (56.4%) had an average family status (whose income in terms of Saudi riyals was between 10,000 and 19,999) while 107 (27%) had a high family status (whose income in terms of Saudi riyals was above 20,000). A majority of the participants were married (366, 91.5%), and most of the families comprised one wife (84.5%). As many as 93% of the families had more than five male and female children.

Table 2 presents the details of the prevailing parent–child communication practices. When asked about parent–child communication practices concerning the occurrence of sexual abuse and informing children that parents or other trustworthy adults should be told if such incidents happened, a majority of the children, 359 (90%) answered correctly. About 357 (89.5%) of the parents responded by saying that they had advised their children that if anyone asked to see or touch their private parts, they should definitely say no and leave the location immediately.

Table 2

Parent–child communication practices.

Variables	Number Correct (%)
Talks with children about their private parts	329 (82.5)
Tells child that if someone wants to see or touch their private parts, they should definitely say no and leave at once	357 (89.5)
Tells child that if sexual abuse happens, parents or other trustworthy adults should be told	359 (90.0)
Tells child not to go with others, even familiar grown-ups, anywhere without parental permission	349 (87.7)
Tells child not to accept gifts from strangers unless they have parental permission	356 (89.2)
Encourages child to talk with parents about sexual issues	252 (63.3)

Most parents (89.2%) had warned their children against accepting gifts from strangers or had told them not to go to places with either familiar adults or strangers without their parents' prior permission. A total of 349 parents (87.7%) had told their children not to go with others, even if they were familiar grown-ups, to any place without their parents' prior permission. A total of 329 (82.5%) reported that they had talked with their children about their bodily privacy. Communication specifically addressing sexual issues took place on fewer occasions than communication that specifically pertained to the children's protection from abuse (63.3%). With regard to the frequency of parental communication practices about CSA, 305 parents (76%) had a good score, while 95 (24%) followed poor communication practices.

Figure 1 indicates a pattern of child supervision as reported by parents. In response to the question about who supervises the child (ren) when they are not in school, almost all (91.7%) parents stated that their children were under their direct supervision all the time, while (33%) reported supervision by the children's older siblings, followed by grandparents (22%), relatives (18%), neighbours or friends (12%), and housemaids (9%). The values in this form field do not add up to 100% because of overlaps, with some children being looked after by more than one category of person.

Figure 1

Patterns of child supervision, as reported by parents.

With respect to the actions that a parent would prefer to take in the event of CSA, a majority (83.7%) preferred to report the matter to the police, while 66.8% preferred severe punishment for the perpetrator. Less than half (32.4%) preferred to opt for a hospital examination, 24.4% preferred going to a religious leader, and 11.1% preferred to turn to their family members. Very few (11.1%) said that they would discuss the issue with their friends and 2% with their father.

Parents offered the following suggestions for CSA prevention: wearing appropriate clothes (94.7%), supervision and guidance (93.5%), and teaching children about their bodily privacy (93.2%). Most of them (92.2%) suggested campaigns and events or audiovisual campaigns, most of them (92%) thought about separation, and about (86.7%) suggested sex education.

The Chi-square test was used to assess the significance of the differences between categories. There were statistically significant differences among parents who were not working, female, and had a low income, who had a good preventive practice score (P < 0.001 < 0.001 and <0.001; respectively) (Table 3). Families that consisted of more than one wife and where the parents were married had a good preventive practice score (P < 0.001 and <0.003, respectively) (Table 4).

Table 3

Effect of socio-demographic features of parents on preventive practice score.

Variables	Total	Good N (%)	Poor N (%)	χ 2 (P value)
Age in Years:*
Young age	184	148 (80.4)	36 (19.6)
Middle age	199	146 (73.4)	53 (26.6)	>.05
Old age	11	8 (72.7)	3 (27.3)
Total	394	302 (76.6)	92 (23.4)
Sex:*
Male	228	158 (69.3)	70 (30.7)
female	169	144 (85.2)	245 (14.8)	<0.001
Total	397	302 (76.1)	95 (23.9)
Occupation:*
Not working	100	86 (86.0)	14 (14.0)
Military	138	84 (60.0)	54 (39.1)
Civilian	81	68 (84.0)	13 (16.0)	<0.001
retired	7	4 (57.1)	3 (42.9)
Total	326	242 (74.2)	84 (25.8)
Education Level:*
Low	42	28 (66.7)	14 (33.3)
Average	284	220 (77.5)	64 (22.5)	>.05
High	63	49 (77.8)	14 (22.2)
Total	389	297 (76.3)	92 (23.7)
Income:*
Low	65	40 (61.5)	25 (38.5)
Average	222	184 (82.9)	38 (17.1)	0.001
High	107	77 (72.0)	30 (28.0)
Total	394	301 (76.4)	93 (23.6)

p = Chi-square test; * = missing value; PNS = P value not significant.

Table 4

Effect of family features of participants on preventive practice score.

Variables	Total	Good N (%)	Poor N (%)	χ 2 (P value)
Marital status:*
Married	366	285 (78.5)	113 (30.9)
Divorced	24	12 (50.0)	12 (50.0)	0.001
Widowed	10	5 (50.0)	5 (50.0)
Total	397	302 (76.1)	95 (23.9)
Number of Wives:*
One	216	177 (81.9)	39 (18.1)
More than one	40	24 (60.0)	16 (40.0)	0.003
Total	256	201 (78.5)	55 (21.5)
Number of male children:*
>5	366	281 (76.8)	85 (23.2)
<5	27	19 (70.4)	8 (29.6)	>.05
Total	393	300 (76.3)	93 (23.7)
Number of female children*
>5	367	279 (76.0)	88 (24.0)
<5	26	21 (80.8)	5 (19.2)	>.05
Total	393	300 (76.3)	93 (23.7)

Note. Chi-square test; * = missing value; PNS = P value not significant.

A total of 43 parents (10.8%) reported having experienced CSA in their early years; of these, 58.2% were males (n = 25) and 41.8% were females (n = 18). A total of 14 parents (32.5%) who had been abused themselves said that they did not know their perpetrators, whereas the rest were abused by their maternal or paternal uncles, cousins, drivers, neighbours, or friends.

As many as 33 parents (8.2%) reported that their children had experienced CSA. Of these, the offender was unknown in 34% of the cases. The rest had been abused by their maternal uncles, paternal or maternal cousins, neighbours, or friends.

Table 5 presents the logistic regression analysis of the variables associated with good preventive practice scores. The preventive practice score is considered a dependent variable, while sex, occupation, income, marital status, and number of wives were considered to be independent variables (P < 0.001, P < 0.001, P < 0.001, P < 0.001, and <0.003, respectively). The logistic regression shows that sex, marital status, and families with more than one wife were significantly associated with good preventive practices (P < 0.020, P < 0.026 and P < 0.041, respectively) with an odds ratio of 3.031, 0.081, and 0.427, respectively.

Table 5

Logistic regression analysis of variables associated with good preventive practice score.

Variables	B	S.E.	Odds ratio	Significant	95% CI (Minimum–Maximum)
Income	−0.056	0.261	0.946	0.830	(0.567–1.578)
Number of wives	−0.851	0.416	0.427	0.041	(0.189–0.965)
Sex	1.109	0.478	3.031	0.020	(1.189–7.730)
Occupation	0.015	0.278	1.015	0.957	(0.589–1.750)
Marital status	−2.519	0.802	0.081	0.026	(0.017–0.388)

Note. CI: confidence interval for odds ratio.

Discussion

Before discussing the results of the present study, we should understand the nature of the Saudi community, which is conservative and protective, and where sexual relationships before marriage are prohibited by religious law, with no exception.14, 20 CSA is a serious issue that requires significant attention. This study aimed to assess parent–child communication and preventive practices pertaining to CSA and to detect the gaps that need further attention. The present study found that 10.8% of the parents had a prior history of sexual abuse while growing up, and 8.2% of the parents reported that their children had been sexually abused. In a Nigerian study, 3.9% of the parents reported having experienced CSA while growing up, and 2.1% reported that their children had experienced CSA.

The estimated prevalence of sexual abuse of children has increased worldwide. This could be due to an increase in the reporting of incidents and a rise in parents’ awareness and in social awareness of the issue, which have helped to expose the problem better. This trend may be a warning of the danger that lies ahead in the form of the growing incidence of CSA. A study conducted by Ibrahim et al. in 2008 among female college students in Jeddah reported that 68.3% of the students had been exposed to some form of sexually inappropriate behaviour during childhood. Siblings were the commonest offenders of both physical and emotional abuse. The results also revealed that relatives and extra-familial persons were the main offenders in sexual violence. Similarly, another study conducted by Chen et al. in 2007 among Chinese parents in China showed that 13.6% of the children in the study had been exposed to unwanted sexual contact.

To defend children from sexual assault, it is essential for parents to have sound knowledge of CSA and to teach their children how to protect themselves. This study showed that 76% of the respondents had good parent–child communication practices in place. As in other studies,19, 22 the current study showed that most parents communicate with their children about their private parts, and most had also warned their children not to go with or accept gifts from strangers or familiar adults without prior permission from their parents. They also spoke with their children about their bodily safety, but only relatively few respondents had talked to their children about sexual issues. Parental communication with children is a good practice that has to be encouraged.

This study found that parents who were previously sexually abused and parents with a sexually abused child were better at recognising the signs of CSA. This could be the result of familiarity with the indicators of abuse. Another important finding is that parents with a prior history of being sexual abused and parents of abused children shared the same misconceptions about perpetrators and believed that boys were not at risk for sexual abuse. However, all the subjects in the study completely agreed that females could also sexually abuse children. This is an area of concern that calls for the comprehensive education of parents. Culturally appropriate CSA prevention programmes in the National Guard Community Hospital in KSA need to be developed. Health care providers, such as physicians and clinicians, should emphasise teaching parents about disclosing details of sexual abuse. They also need to be equipped with appropriate knowledge on CSA and should be encouraged to connect with children.

In response to the harmful outcomes reported by many studies on CSA, it is necessary to implement prevention initiatives to address CSA by developing various resources for survivors and promoting awareness among the community on the issue.23, 24 The community health approach recommends that risk factors, such as social norms supportive of sexual violence, must be identified and resolved to prevent CSA from occurring. CSA is a very sensitive and entirely forbidden issue, in that it is not uncommon in our society but is neglected and purposely ignored in most cases in order to avoid shaming and harassment, as well as the taboo nature of speaking about CSA. There has not been enough research in KSA to estimate the magnitude of this problem. Only very few studies have focused on the prevalence and impact of CSA, while others have examined the effect of the child protection system in place and its implementation.

This study has a few limitations. First, the study was a cross-sectional one, thus making it difficult to draw causal inferences. Second, the study focused on the attendees of one PHCC for a short period of time (only one month). This may have introduced a referral bias, and may have made it difficult to generalise our findings to the general population. Furthermore, the data collection tool was a self-administered questionnaire. It may have been subject to a recall bias and/or the answering of questions without proper reflection. The sensitive nature of the subject of the study may have affected the parents’ answers. They may have submitted false answers out of shame, embarrassment, or fear.

Conclusions

The results revealed that parents’ communication practices and their ability to detect the signs of abuse were not very strong. This needs further attention and reorientation. Myths around CSA should be clarified for parents, and their misconceptions around perpetrators should also be corrected. Future research is necessary to test the extent of knowledge children have, as well as their ability to protect themselves and to detect abnormal risky behaviour.

Recommendations

We recommend the establishment of national and comprehensive studies of violence and sexual abuse, which will indicate the true size of the problem. In addition, an educational programme is needed that targets children to teach them about their rights and bodily privacy. For further improvement in parental communications, better parental supervision of children also needs to be addressed. Nationwide surveys of the general population are required for better empirical understanding of CSA prevention in KSA.

Source of funding

The authors received no financial support for the research or preparation of this article.

Conflict of interest

The authors have no conflict of interest to declare.

Ethical approval

Ethical approval was obtained from the King Abdullah international medical research center (KAIMRC) to carry out the study and an informed written consent was taken from all participants in the study. All the participants were informed that the survey responses were treated anonymously and confidentially.

Authors' contributions

AAA and SSS conceived and designed the study, conducted research, and provided research materials. SMG and AAKM collected and organised data. AGEB and HHS analysed and interpreted the data. SW and SSS wrote and reviewed the manuscript. All authors contributed in every step of the article and provided logistical support. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.