Research - (2021) Volume 9, Issue 10
Knowledge and Attitudes toward Child Abuse and Neglect (CAN) among Dental and Medical Practitioners in Saudi Arabia
Roaa Merwass1*, Khalid Aboalshamat2, Fatmh Bashkail3, Ahad Alsolami4, Rahaf Alqadi5, Bushra Al-Motairi6 and Rawan Alamoudi3
*Correspondence: Roaa Merwass, Dental Intern, College of Dentistry, Umm Al-Qura University, Saudi Arabia, Saudi Arabia, Email:
Introduction: Child abuse and neglect (CAN) is a serious and an increasing global problem. Aim: Our study aims to assess the knowledge and attitudes toward child abuse and neglect (CAN) among dental and medical practitioners in Saudi Arabia. Methods: This cross-sectional study was conducted among 371 participants recruited from medical and dental students, interns, and practitioners in Saudi Arabia. The data were collected using an online self-administrated questionnaire to measure the CAN level of knowledge, social indicators, attitudes, and barriers. Descriptive statistics included the mean, standard deviation, count, and percentage. Chi-square and t-tests were used for the data analysis. Results: The mean total score of knowledge was 7.51 ± 1.68 points. A range of 93.8% to 56.6% of the participants recognized the social indicators of CAN. Females (7.86 ± 1.29) and health practitioners in the governmental sector (7.65 ± 1.68) reported a higher level of CAN knowledge than males (7.044 ± 2, P?0.001) and those in the private sector (7.20 ± 1.62, P=0.015). A total of 41.51% had previous CAN training, but only 10.24% had experience reporting a CAN incident. A total of 65.2% believed that further training was needed to deal with CAN. The majority (72.5%) believed that uncertainty was the prime cause of not reporting CAN. Conclusion: Most participants demonstrated a high level of knowledge regarding the clinical presentation of CAN. Also, the majority of the participants recognized the social indicators for CAN and believed that they needed further CAN training. It is recommended that health educational entities and hospitals provide additional CAN sessions and training.
Child abuse and neglect, Child maltreatment, Dental practitioners, Medical practitioners, Attitudes
Child abuse and neglect (CAN), or “child maltreatment,” is a serious and an increasing global problem . CAN’s consequences and effects are tremendous and might cause disordered psychological development and serious behavioural problems in children . According to the World Health Organization (WHO), child maltreatment, which includes “all types of physical and/or emotional illtreatment, sexual abuse, neglect, negligence, and commercial or other exploitation,” results in harm, whether actual or potential, to the child’s well-being . The four known types of CAN are: (a) physical abuse, which is the intentional use of physical force that could result in harm to the child ; (b) sexual abuse, which includes any use of the child for the purpose of sexual gratification of an adult ; (c) emotional abuse, which includes forms of continuous behaviours of rejection, threatening, or demeaning of the child by a caregiver ;
Over the past few decades, CAN has received more attention from scientific and healthcare scholars globally . The responsibility of healthcare providers, including medical and dental practitioners, is undeniably crucial to identifying child maltreatment cases. For example, dentists could be the first to encounter physical abuse commonly manifested in the head, neck, and mouth, since these areas are routinely examined by such healthcare providers [10,11].
According to the Child Abuse Recognition Experience Study (CARES), primary care clinicians do not always report suspected child abuse cases to protective services . In fact, there are several barriers that prevent healthcare practitioners from reporting such cases. For instance, the ambiguity that a child has been abused is one of the main difficulties, along with having past negative experiences due to reporting [13-15]. As a result, these barriers have made healthcare providers reluctant to take appropriate measures for children in need [13-15]. Healthcare providers have been assessed for their knowledge and attitudes regarding the diagnosis and reporting of CAN cases in various studies all over the world.
According to studies conducted in Saudi Arabia, knowledge of child’s physical abuse signs and symptoms among dentists has been revealed to be insufficient [16,17]. For example, a study conducted in Jeddah city found that about half of the dentists were unable to identify the correct signs of CAN . Moreover, 52.2% of the dentists in a similar study reported not being confident in recognizing them . Another study that investigated nurses in Jeddah city found that 40.7% of participants scored 75% or higher for knowledge of CAN signs . However, a study conducted in Abha city found that 96.3-97.3% of primary healthcare physicians recorded a good awareness level regarding types of CAN . In another study in Riyadh city, dental students were proven to have lower knowledge about CAN compared to medical students .
It is believed that CAN cases are underreported in Saudi Arabia . The most common barriers to reporting CAN cases in previously mentioned studies were fear of consequences (68.5-82.4%) , insufficient knowledge of measures taken in referral procedures (60%) , fear of family violence toward the child (88%) , and lack of certainty about the diagnosis of CAN (80%) . All of these studies addressed and recommended the need for further training of all healthcare providers and the necessity of improving the topic coverage in their school curricula or undergraduate studies, as this is the main source of healthcare providers’ knowledge [13,16-19].
Finally, further research on the knowledge and attitude of Saudi healthcare providers towards CAN is required to attain an extended and more representative data sample for validating generalizability. Accordingly, the aim of our study is to assess the knowledge and attitudes toward child abuse and neglect (CAN) among dental and medical practitioners in Saudi Arabia.
This cross-sectional study explored the level of knowledge and attitudes toward child abuse and neglect among dental and medical practitioners in Saudi Arabia. The inclusion criteria for participants in this study were medical and dental undergraduate students, interns, and all practitioners working in private and governmental clinics. Furthermore, participants who did not sign the study consent form or did not meet the participant criteria were excluded from the study.
The study survey was based on a previously published validated survey with modifications . The survey was self-reported and administered in an online format created using Google Forms in English. Social media platforms, such as Twitter, Instagram, and official study groups on Telegram and WhatsApp’s, were chosen to deliver the survey to all participants. The study’s objectives and goals were presented at the beginning of the survey. The responses were anonymized, and all participants signed a consent form prior to filling out the survey. Answering the survey took three to five minutes. Participation was highly encouraged; however, it remained voluntary. This study was approved by Umm Al-Qura University, with institutional review board number (HAPO-02-K-012-2021-08-725).
The survey is composed of five main sections. Section one is about demographic data, including gender, age, region, nationality, specialty, current studying status, workplace, and studying place. This is followed by two questions about previous training and reporting for CAN cases, with a range of answers (Yes/No). Section two measures social indicators and risk factors of CAN via nine questions with a range of answers (Yes/No). Section three measures clinical presentations of CAN via nine questions with a range of answers (Yes/No). Each question in Section three will have one correct answer, interpreted according to a previous study . The sum of the correct answers gives a total knowledge score that ranges between 0 and 9, where the latter indicates the highest level of knowledge. Section four measures the opinions and attitudes of medical and dental participants toward CAN via seven questions with three Likert-type scales (agree, neutral, disagree). Finally, Section five consists of questions assessing the barriers to reporting CAN cases with a range of answers (Yes/No).
Statistical analysis was conducted using Statistical Package for the Social Science (SPSS) version 25 (IBM, Inc., Armonk, NY, USA) and Excel software. Descriptive statistics, such as the mean, standard deviation, count, and percentage, were used to summarize the data. Chisquare, t-test, ANOVA, and linear regression were used for the data analysis. A P-value of 0.05 was used as the statistical significance level.
A total of 371 participants completed the study questionnaire. The mean age of the participants was 26.43 years, with a standard deviation (SD) of 3.82 years, and the mean years of practice was 1.37, with an SD of 2.85 years. The participants’ demographic data are shown in Table 1.
|Current workplace (primary)||Student/intern||188||50.67|
|Where do/did you study/studied medicine/dentistry?||Governmental college||257||69.27|
|Region in Saudi Arabia||Western||208||56.06|
|Did you receive any training for child abuse and neglect (CAN)?||Yes||154||41.51|
|Have you previously reported child abuse and neglect (CAN)?||Yes||38||10.24|
Table 1: Demographic data.
Regarding training for CAN, 41.5% of the participants received previous training; 92.2% of them were in thedentistry specialty, which made a significantly higher difference compared to those in the medical specialty when we used the Chi-square test (Pvalue0.001). Furthermore, only 10.2% of the participants had previously reported a CAN case.
The participants were asked about social indicators and risk factors of CAN (Table 2). The risk factor “Parents are substance abusers/alcoholics” was the highest recorded (93.8%). However, 43.4% did not think that child disability or having chronic diseases was a risk factor for CAN.
|Increased family size||Yes||227||61.2|
|Low socioeconomic status||Yes||292||78.7|
|Marital and family problems||Yes||346||93.3|
|One or both parents suffering from mental illness||Yes||324||87.3|
|Parents are substance abusers/alcoholics||Yes||348||93.8|
|Child is disabled/has chronic disease (s).||Yes||210||56.6|
|Child is an orphan/adopted.||Yes||261||70.4|
Table 2: Knowledge about social indicators and risk factors of CAN.
Participants answered several questions about their knowledge of the clinical presentation of CAN (Table 3).
|Changing the child’s history of illness||Yes*||297||80.1|
|Signs of unaccountable fear of a specific place or person||Yes*||330||88.9|
|Delayed social and intellectual development||Yes*||279||75.2|
|Poor general hygiene||Yes*||312||84.1|
|Multiple bruises in different healing stages||Yes*||341||91.9|
|Bruises over bony prominences||Yes||271||73|
|Burn marks on palms||Yes*||312||84.1|
|Burn marks with sharply delineated margins||Yes*||333||89.8|
|Repeated injury to the dentition, resulting in avulsion or discoloration||Yes*||314||84.6|
Table 3: Knowledge about clinical presentation of CAN.
The most recorded correct answer was that multiple bruises in different healing stages were a clinical presentation of CAN (91.9%).
The mean total knowledge score was 7.51 (with a maximum possible score of 9), with an SD of 1.68 points. Using a t-test, there was no significant difference in knowledge scores between different specialties ornationalities. However, females (m=7.86, SD=1.29) scored significantly higher knowledge levels compared to males (m=7.044, SD=2, P-value 0.001). Also, healthcare practitioners who studied or are studying in governmental colleges (m=7.65, SD=1.68) scored higher knowledge levels compared to those in private colleges (m=7.20, SD=1.62, P-value=0.015).
As displayed in Table 4, when asked about their opinions about CAN, 67.4% agreed that there are governmental agencies to protect children from CAN. However, 65.2% believed that they needed further training to deal with CAN. Other attitude items are shown in Table 4.
|Abused children will usually tell someone immediately.||Disagree||235||63.3|
|In most cases of CAN, the perpetrators are parents.||Disagree||45||12.1|
|The best way to deal with CAN is to accuse the parents directly.||Disagree||179||48.2|
|There are governmental agencies to protect children from CAN.||Disagree||33||8.9|
|You have the ability to differentiate CAN from accidental injuries.||Disagree||42||11.3|
|Medical and dental schools provide good background about CAN.||Disagree||81||21.8|
|We need further training to deal with CAN.||Disagree||38||10.2|
Table 4: Attitudes toward CAN.
Table 5 exhibits barriers to reporting CAN. The majority of participants believe that uncertainty was the prime cause for not reporting CAN (72.5%), followed by a lack of formal guidelines to report CAN (57.5%). A small percentage (38.8%) considered fear of the family to be a barrier to reporting CAN.
|Fear of family||Yes||144||38.8|
|Fear of consequences||Yes||204||55|
|Lack of knowledge||Yes||198||53.4|
|Lack of confidence||Yes||179||48.2|
|There are no formal guidelines
to report CAN.
Table 5: Barriers to reporting CAN.
This study aimed to explore the level of knowledge and attitudes toward child abuse and neglect among dental and medical practitioners in Saudi Arabia. Most participants had high levels of knowledge regarding the clinical presentation of CAN. Also, the majority of the participants recognized the social indicators for CAN. Females and health practitioners in the governmental sector demonstrated higher levels of CAN knowledge than males and those in the private sector, but there was no significant difference in knowledge scores among dental and medical specialties. Around one-third of the participants had previous training for CAN, but only a limited number had previously reported CAN. However, more than half of the participants believed that further training was needed to deal with CAN. The majority of participants believed that uncertainty was the most common cause for not reporting CAN, followed by a lack of formal guidelines for reporting CAN. In this study, 41.5% of the participants had received previous training for
CAN. This was slightly lower than in a previous Saudi study, which reported that 61.3% of dental and 53.9% of medical participants had previous training for CAN . our results are also slightly lower than an Indian study that found that 49% of dental and medical residents had formal training in identifying child abuse . This discrepancy might be due to cross-cultural differences and the fact that our study was conducted all over Saudi Arabia, which includes many medical and dental faculties that teach different curricula.
For reporting suspected cases of CAN and social indicators, 93.8% of participants agreed that substance abusers/alcoholics were the likeliest to abuse or neglect their children. This observation aligns with another Saudi study that showed agreement among 91.9% to 100% of the participants regarding this risk factor . In our study, marital and family problems were the second highest social indicator, as 93.3% of participants believed that marital and family problems put the child at high risk for abuse and neglect. Similar observations were reported in studies conducted in Saudi Arabia (93%)  and Malaysia (93.6%) .
Upon assessment of knowledge of the clinical presentation of CAN, the most identifiable sign was the presence of multiple bruises in different healing stages, followed by the presence of burn marks with sharply delineated margins (with a participant agreement of 91.9% and 89.8%, respectively). These results are comparable to , who reported a participant agreement of 94% and 84% for multiple bruises and burn marks, respectively. Moreover, the majority of the participants (73%) considered bruises over bony prominences a sign of CAN, which is incorrect because these areas are commonly injured during regular activities of children . These results are higher than what was reported in Jordan (54%) , India (58.5%) , and Malaysia (44.4%) , in terms of participants who considered bruises over bony prominences as a CAN sign. These differences might be due to the higher academic level of the population selected by these studies [20,21,23], while our study chose a larger population with participants ranging from undergraduate students to specialists.
There was no significant difference in the mean knowledge scores between dental and medical specialties in our study, which is consistent with  conducted in India, but contradicted the previous study in Saudi Arabia , where the mean score of knowledge among medical students and interns were found to be higher than dental students and interns . This difference may be due to the fact that our study was conducted all over Saudi Arabia, while the previous study was conducted only in Riyadh, Saudi Arabia . In the present study, there was a statistically significant difference in the knowledge levels between healthcare practitioners who studied or are studying in governmental colleges and those in private colleges, with the former demonstrating higher knowledge levels. This could indicate the need to improve the educational programs regarding CAN in private colleges.
When it comes to participants' opinions about CAN, 63.3% of participants showed their disagreement that abused children will usually tell someone immediately. Similarly, 69.23% of the participants disagreed with that statement in India .
The results of this study revealed that only 11.3% showed their inability to differentiate CAN from accidental injuries, which, in fact, may indicate a good level of knowledge. However, a slightly higher percentage (22.1%) disagreed about being confident in recognizing signs of child abuse in , possibly because the sample in this study included only dentists.
A significantly higher number of participants (36.2%) who are in the medical field disagreed with the statement “Medical and dental schools provide good background about CAN” compared to those in the dentistry field (19.2%). These results are similar to  findings, in which a higher number of medical students and interns (33%) disagreed with a similar statement compared to participants from the dental field (19.7%) . This could suggest a lack of adequate training in the medical undergraduate curricula compared to dental curricula or indicate that medical students pay more attention to CAN and consider it an important subject that needs more emphasis in their curricula.
Our study showed that the main barrier to reporting CAN cases among healthcare providers is uncertainty (72.5%), and this finding is similar to previous studies in Jordan (73%)  and Denmark (about 80%) . A significantly higher number of healthcare practitioners who studied or are studying in private colleges (64%) recorded a “Yes” to “Lack of knowledge” barrier than those in governmental colleges (48.6%). Similarly, a significantly higher number of medical healthcare practitioners (69%) also recorded “Yes” to the same barrier compared to dental practitioners (50.5%).
The present study focuses on participants from the dental and medical fields at different undergraduate and postgraduate levels, since they are in a crucial position to detect and diagnose child abuse and neglect, thus justifying the importance of such a study. The sample was taken from all regions of Saudi Arabia, which makes the data more representative compared to previous local studies. However, this study encountered certain challenges, including an unequal sample size of dental and medical participants and the use of a convenience sampling method. Future national surveys might be more informative about such an important topic. It is recommended that health educational entities include CAN as an essential part of the educational curricula, especially for private colleges, and that advanced courses on CAN be given to graduated health practitioners.
Most participants had high levels of knowledge regarding the clinical presentation of CAN. Also, the majority of the participants recognized the social indicators for CAN. Females and health practitioners in the governmental sector reported higher levels of CAN knowledge than males and those in the private sector. However, there was no significant difference in the knowledge scores among the dental and medical specialties. Some participants had previous training for CAN, but only a limited number had previously reported a CAN incident. Many of the participants believed that further training was required to deal with CAN. The majority of participants believed that uncertainty was the prime cause of not reporting CAN, followed by a lack of formal guidelines for reporting CAN. Based on the study results, health educational institutions, especially private colleges, should include CAN as an essential part of the curricula, and advanced training should be provided for graduated health practitioners.
This project did not receive any external funding. The authors would like to thank participants for answering research questionnaire.
Conflict of Interest
The authors declare that there is no conflict of interest.
List of Abbrevations
• Child abuse and neglect (CAN).
• Child Abuse Recognition Experience Study (CARES).
• Statistical Package for the Social Science (SPSS).
• Standard deviation (SD).
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Roaa Merwass1*, Khalid Aboalshamat2, Fatmh Bashkail3, Ahad Alsolami4, Rahaf Alqadi5, Bushra Al-Motairi6 and Rawan Alamoudi31Dental Intern, College of Dentistry, Umm Al-Qura University, Saudi Arabia, Makkah, Saudi Arabia
2Dental Public Health Division, Preventative Dentistry Department, College of Dentistry, Umm Al-Qura University, Saudi Arabia, Makkah, Saudi Arabia
3Dental intern, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
4General dentist, Ministry of Health, Tabuk, Saudi Arabia
5General dentist, Ministry of Health, Yanbu, Saudi Arabia
6General dentist, Ministry of Health, Madinah, Saudi Arabia
Citation: Roaa Merwass, Khalid Aboalshamat, Fatmh Bashkail, Reham Alsalhi, Ahad Alsolami, Rahaf Alqadi, Bushra Al-Motairi, Rawan Alamoudi,Knowledge and Attitudes toward Child Abuse and Neglect (CAN) among Dental and Medical Practitioners in Saudi Arabia, J Res Med Dent Sci, 2021, 9(10): 43-50
Received: 07-Sep-2021 Accepted: 23-Sep-2021