|Year : 2020 | Volume
| Issue : 1 | Page : 38-46
Knowledge and attitudes toward child abuse and neglect among medical and dental undergraduate students and interns in Riyadh, Saudi Arabia
Vidyullatha Gopalakrishna1, Bahija Basheer1, Afnan Alzomaili2, Atheer Aldaham2, Ghaida Abalhassan2, Hend Almuziri2, Maha Alatyan2, Mona AlJofan2, Reem Al-Kaoud2
1 Department of Preventive Dental Sciences, College of Dentistry, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 Dental Intern, College of Dentistry, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
|Date of Submission||27-Aug-2019|
|Date of Acceptance||06-Oct-2019|
|Date of Web Publication||30-Dec-2019|
Dr. Atheer Aldaham
College of Dentistry, King Saud bin Abdulaziz University for Health Sciences, Riyadh
Source of Support: None, Conflict of Interest: None
Background: Child abuse and neglect (CAN) is a major problem around the world including Saudi Arabia. According to National Family Safety Program registry, most of cases of CAN in Saudi Arabia are detected in hospitals. Hence, healthcare professionals play an important role in identifying and reporting suspected cases of CAN. The purpose of the study is to assess knowledge and attitudes toward CAN among medical and dental undergraduate (UG) students and interns in Riyadh.
Materials and Methods: This cross-sectional study distributed a self-administrated structured questionnaire to 351 medical and dental UG students and interns in different public and private medical and dental colleges in Riyadh. Participants were recruited using convenient sampling. The data were entered using IBM SPSS version 22 software. Descriptive statistics (frequency distribution), Chi-square test, and t-test were used to perform the statistical analysis. The significance level (P value) was set at <0.05.
Results: About 57.5% of the participants reported having formal training on CAN during their UG study. Mean knowledge score related to CAN was 6.81 ± 1.17 for medical participants and 6.35 ± 1.35 for dental participants, and the difference was statistically significant (P = 0.001). Majority of the participants believed that the main barrier for not reporting a suspected case of CAN is the fear of consequences (medical = 82.4%, dental = 68.5%, P = 0.01). About 77% of the participants agreed to the need for further training in dealing with suspected cases of CAN.
Conclusion: This study showed that dental participants had relatively less knowledge about the clinical presentation of CAN than medical participants. Improvements in the educational system are still needed to raise awareness about this issue. Inclusion of case scenarios and problem-based learning may help retain knowledge acquired during training. To increase awareness about the diagnosis and referral procedures, academic institutes should consider continuous educational courses and seminars.
Keywords: Child abuse and neglect, dental students, knowledge and attitude, medical students
|How to cite this article:|
Gopalakrishna V, Basheer B, Alzomaili A, Aldaham A, Abalhassan G, Almuziri H, Alatyan M, AlJofan M, Al-Kaoud R. Knowledge and attitudes toward child abuse and neglect among medical and dental undergraduate students and interns in Riyadh, Saudi Arabia. Imam J Appl Sci 2020;5:38-46
|How to cite this URL:|
Gopalakrishna V, Basheer B, Alzomaili A, Aldaham A, Abalhassan G, Almuziri H, Alatyan M, AlJofan M, Al-Kaoud R. Knowledge and attitudes toward child abuse and neglect among medical and dental undergraduate students and interns in Riyadh, Saudi Arabia. Imam J Appl Sci [serial online] 2020 [cited 2021 Nov 27];5:38-46. Available from: https://www.e-ijas.org/text.asp?2020/5/1/38/274294
| Introduction|| |
Child abuse and neglect (CAN) is a major problem of concern in the world including Saudi Arabia. Child maltreatment in Saudi Arabia started to attract the attention of healthcare professionals after a number of cases were reported in the media in the early 1990s. Between 1986 and 1992, ten cases of maltreated children under the age of five were presented at King Faisal Specialist Hospital and Research Centre. Physical abuse and neglect among children were the most prevalent types of maltreatment in the years 2000–2008. As per the statistics given by the National Family Safety Program, in 2016, the prevalence of child neglect in Saudi Arabia was 51.5%, physical abuse was 33.7%, sexual abuse was 27.4% and emotional abuse was 16.8%. According to National Family Safety Program registry, most of cases of CAN in Saudi Arabia are detected in hospitals. Hereby, healthcare professionals' knowledge, attitudes, and beliefs play a major role in recognizing victims of CAN. However, the clinicians may fail to recognize or manage such cases due to uncertainty in diagnosis, fear of involvement in the family matter, legal procedures, and other causes. Internationally, several studies have been conducted in the past to assess knowledge and attitudes related to CAN among health-care providers including medical and dental practitioners, dental hygienists, and nurses.,, A study conducted in Brazil revealed that most dentists (78%) were able to detect cases of child abuse. However, majority of them (76%) who suspected the cases of CAN did not report the cases to legal authorities. In another study from Australia, nearly most dentists (88%–100%) identified emotional and physical abuse as a form of child abuse. In Saudi Arabia, few studies have been reported in relation to the knowledge and attitude toward CAN among healthcare professions.,, Apart from these, there are no known studies conducted in the past that assessed the differences in knowledge and attitudes toward CAN among medical and dental undergraduate (UG) students and interns.
A cross-sectional study was conducted in Brazil with a sample size of 276 working dentist concluded that 78.7% of the participants believe they can detect child abuse. However, 85.7% of them have never suspected a case in their clinic yet. Furthermore, 76% of the dentist who faced a CAN case did not officially report it. Among the dentists who suspected cases of CAN, statistically higher proportion are working at university. Unfortunately, the study did not mention the major manifestations their subjects consider as child abuse.
In Malaysia, health-care providers who attended a pediatric dentistry conference were asked to participate in a survey about child physical abuse. Dentists were mainly asked about the risk factors, occurrence frequency, diagnosis, and case reporting. It was shown that two-thirds of the respondents are not satisfied with their current knowledge about child physical abuse, and most of them wanted to receive sufficient information regarding diagnosis and reporting.
Furthermore, a study was performed in Australia to assess the knowledge and attitudes of dentists in Victoria toward CAN; Almost all the dentists were able to identify signs of emotional and physical abuse, but only 20% of them consider neglect as a form of abuse. Most of the respondents (79%) wanted to have educational sessions regarding CAN; furthermore, the majority knew they are legally required to report suspected cases. Generally, multiple drawbacks were found in this study.
A cross-sectional survey was distributed on 400 Jordanian dentists to assess their knowledge and attitudes toward CAN. Interestingly, 42% have had educational training regarding this subject, and almost half of the participants suspected a CAN case in their clinic. Unfortunately, only 12% reported these cases. The major reason not to report was fear of parents' anger. It was concluded that dentists with postqualification courses and training had significantly higher probability of reporting CAN cases.
In addition, a self-administered questionnaire was distributed on Jordanian UG and postgraduate dental students to assess their knowledge and attitude. It was shown that the majority of the sample manifested lack of knowledge regarding social indicators, signs of CAN as well as reporting methods. The participants' main source of knowledge was generally in their dental schools. Moreover, some of the postgraduate samples have attended few courses, and they believe attending conferences and educational courses improved their knowledge. It was indicated that Jordanian UGs and postgraduate dental students are not well prepared to apply their role in child protection.
In Jeddah, Saudi Arabia, a study was conducted on pediatric dentists, residents, and dental interns to evaluate their knowledge and attitudes toward CAN. Regarding the signs of child abuse, only half of the respondents answered all the questions about physical abuse signs correctly. Moreover, almost half of the respondents believe they have not had sufficient information from their dental schools. In relation to the subjects' attitudes toward the cases they face in the clinic, lack of knowledge about the referral procedure was the most reported reason for underreporting. It is worth to mention that only 3% of 11% suspected cases of CAN were reported, which indicates the need of more attention to CAN.
Another cross-sectional study applied on 122 dentists in the Saudi Dental Society by a self-administered, web-based questionnaire found that 27% of dentists who treat children in a daily basis see at least one case of child with neglected dentition every day. Also, 84.3% of the participants showed the intention to report CAN cases if they face them in the clinic. On the other hand, 18.7% did not report. Furthermore, the main barrier from reporting was fear of family violence toward the child (88%). One important drawback of this study was that most of the respondents were academics; so, the results might not be representative for working dentists.
Finally, a study that was carried out in King Saud University Medical City included pediatricians, pediatric trainees, and medical students in Saudi Arabia. In this study, 80% of the sample did not know of the existence of National Saudi protective system. In addition, the most common abuse to be reported by the participants was sexual abuse (96.9%); however, emotional abuse was the least likely to be reported (57.5%).
Therefore, the aim of the present study is to assess the knowledge and attitudes regarding CAN among medical and dental UG students and interns in Riyadh.
| Materials and Methods|| |
A cross-sectional study was conducted at different public and private medical and dental schools in Riyadh, Saudi Arabia. The ethical clearance was obtained from the Institutional Review Board of King Abdullah International Medical Research Centre. The sample size for this study after the power calculation was 351 individuals. A convenient sampling technique was used to recruit the individuals. The participants were informed about the study and a written consent was obtained. UG medical and dental students in the final year of their academic study and interns in Riyadh were included in this study. The students who were included in the study are those who study in one of these universities King Saud bin Abdulaziz University for Health Science, King Saud University, Princess Noura University, Al-Imam University, Riyadh Elm University, Almaarefa University, Prince Sultan university, or Alfarabi private college. However, UG medical and dental students in the first, second, and third year of their academic study were excluded from the study. Individuals who were not willing to give informed consent were also excluded from the study. The data were collected through a self-administrated structured questionnaire which was designed based on previous studies that assessed the knowledge, attitude, and beliefs of medical and/or dental practitioners regarding CAN.,,,,, However, they have been modified to meet the objectives of the current study. All participants were approached personally at the end of the scheduled lectures or clinical sessions at their respective colleges, and questionnaires were distributed after briefly stating the purpose of the study. The questionnaire used in the study comprised of four sections as follows: section one: participants' sociodemographic and background details including age, gender, and field of professional education. Section two: participants' knowledge about the social indicators and risk factors. Section three: participants' knowledge about clinical presentations associated with CAN. Section four: participants' attitudes and opinion on CAN. A pilot study was conducted to 20 participants to check the feasibility of the questionnaire, and necessary corrections were done accordingly. The data collection was collected during a period of 2 months. The data were entered using IBM SPSS (Statistical Package for the Social Sciences) version 22 software (Armonk, NY: IBM Corp.). Demographic data and the training status were analyzed using descriptive statistics (frequency distribution). Chi-square test was used to find the association between the field of professional education and previous training on CAN. To assess the knowledge of the participants, eight questions were chosen from the knowledge section of the questionnaire and scores were assigned to these questions. A score of 0 was assigned to the wrong answer and a score of 1 was assigned to the correct answer. The interpretation of these scores was based on a previous study. (A total score of ≥6.4/8 indicates good knowledge while a total score of <6.4/8 indicates poor knowledge). Using t-test, the mean score of knowledge for: (1) the medical and dental fields, (2) UG students and interns, and (3) students and interns who had training and those who had not had training were calculated and compared. Finally, Chi-square test was utilized to compare between the medical and dental participants' opinions and attitudes toward CAN. The significance level (P value) was set at <0.05.
| Results|| |
The total number of the participants was 403. After applying the inclusion and exclusion criteria, 52 individuals were excluded. The number of participants included in this study is 351. [Table 1] presented frequency distribution of demographic and background details of the participants. Among the 351 participants who met the inclusion criteria, 179 (51%) were males and 172 (49%) were females. These participants comprised of medical UG students (42.5%), dental UG students (32.5%), medical interns (8.2%), and dental interns (16.8%) as shown in [Table 1]. Only 57.5% of the respondents received formal training on CAN during their UG study while 42.5% did not.
|Table 1: Frequency distribution of demographic and background details of the participants|
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[Table 2] presented the association between the field of professional education and formal training on CAN during UG study. It showed that 61.3% of the dental UG students and interns and 53.9% of medical UG students and interns reported to have had formal training on CAN during their UG study period. There was no statistically significant association between the field of professional education and formal training on CAN (P = 0.164).
|Table 2: Association between the field of professional education and formal training on child abuse and neglect during undergraduate study|
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[Table 3] majority of the medical and dental students believe that increase in family size and density is a risk factor for child abuse. 81.9% of medical and 78.9% dental students answered that level of parents' education is risk factor for CAN; however, there was no statistically significant difference observed between the groups. All of medical UG students and interns (100%) considered parents being substance abusers or alcoholics as a risk factor for CAN as compared to 91.9% of the dental UG students and interns, which was statistically significant (P < 0.05). About 84.2% of medical students and 75.4% of dental students considered low socioeconomic status, while 96.6% of medical students and 89.6% of dental students considered marital and family problems as the risk factors of CAN, and the difference was statistically significant (P < 0.05). However, there was no statistically significant association between field of professional education and knowledge on majority of the other risk factors assessed in the present study.
|Table 3: Participants' knowledge about social indicators and risk factors of child abuse and neglect|
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[Table 4] summarizes the knowledge of the medical and dental students and interns about the clinical presentation of CAN. Majority of medical and dental students and interns correctly recognized that changing the child history of illness and CAN were related (medical = 89.3%, dental = 82.1%). In addition, most of the medical and dental students and interns correctly identified child fear of specific place or person as a clinical presentation of CAN (medical = 90.4%, dental = 90.2%). Many of the participants could identify that delayed social and intellectual development is a presentation of CAN (medical = 63.3%, dental = 59.6%). There was a statistically significant difference in assessing poor general hygiene (medical = 86.4%, dental = 73.8%, P = 0.003) and multiple bruises in different stages of healing (medical = 97.7%, dental = 91.8%, P = 0.01). Majority of the participants (63.8%) could not recognize that bruises over bony prominences do not indicate CAN. Furthermore, only 79% of the participants could correlate the burn marks on palms as clinical signs of CAN. Medical and dental students and interns were comparably able to recognize that burn marks with sharply delineated margins were indicative of CAN (medical = 93.7%, dental = 90.1%). Likewise, repeated injury to the dentition resulting in avulsion or discoloration was identified as a sign of CAN (medical = 79.5%, dental = 76.2%).
|Table 4: Summary of the knowledge of the medical and dental students and interns about the clinical presentation of child abuse and neglect|
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[Table 5] showed the differences in the mean score of knowledge related to CAN among medical and dental students and interns. Mean knowledge score related to CAN is 6.81 for medical UG students and intern (n = 176), and 6.35 for the dental UG and intern student (n = 169), and the difference was statistically significant (P = 0.001). In addition, the difference in the mean knowledge scores of the participants with or without the formal training on CAN during UG study was assessed, and the results are presented in [Table 5]. The difference observed was not statistically significant (P = 0.173).
|Table 5: The differences in the mean score of knowledge related to child abuse and neglect among medical and dental students and interns|
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[Table 6] presents association between field of professional education and knowledge related to CAN. It shows that 67.4% of medical UG students and interns compared to 50.3% of dental UG students and interns have adequate knowledge on CAN. The results showed that there is a statistically significant association between the field of professional education and knowledge related to CAN (P = 0.005).
|Table 6: Association between field of professional education and knowledge related to child abuse and neglect|
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[Table 7] summarized the opinions and attitudes of medical and dental students and interns toward CAN. Few of the medical and dental students and interns (medical = 15.4%, dental = 21.4%) believe that the abused child usually will not tell anyone about the abuse. However, only few dental students believe that the perpetrators are the parents in majority of CAN cases (medical = 48.9%, dental = 20.1%). More of the medical students and interns think accusing the parents about the abuse is not the best way to deal with it which was statically significant (medical = 67.6%, dental = 55.8, P = 0.05). Furthermore, both medical and dental students and interns agree that there are governmental agencies that protect CAN (medical = 73.9%, dental = 75.2%). In contrast to medical students and interns, dental students and interns are more confident to differentiate CAN cases from accidental injury cases (medical = 50.5%, dental = 58.4%, P = 0.02). Similarly, dental students agree that medical and dental schools provide good background about CAN (medical = 33.5%, dental = 47.4%, P = 0.01). In addition, 84.6% of the medical students and interns believe they need more training to deal with CAN cases. On the other hand, only 69.2% of the dental students and interns believe they need further training to deal with such cases which was significantly different (P = 0.01).
|Table 7: Summary of the opinions and attitudes of medical and dental students and interns toward child abuse and neglect|
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[Table 8] demonstrates opinion of medical and dental students and interns regarding the barriers to report CAN cases. Both medical and dental students and interns agreed that being uncertain of the diagnosis of CAN cases is one of the major barriers to report such cases (medical = 69.2%, dental = 76.2%). Furthermore, fear of family and their response was considered as a barrier by 57.9% of medical and 54.6% of dental students and interns. Only few subjects felt that lack of knowledge could be a reason for not to report CAN cases (medical = 32.8%, dental = 30.7%) Interestingly, more medical students and interns will not report a case of CAN due to the fear of the consequences (medical = 82.4%, dental = 68.5%, P = 0.01). Moreover, less dental students and interns thought lack of confidence as a barrier to report suspected cases of CAN (medical = 73.8%, dental = 62.2%, P = 0.042).
|Table 8: Summary of the opinion of medical and dental students and interns regarding the barriers to report child abuse and neglect cases|
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| Discussion|| |
Formal training on CAN during UG study period or later enhances the ability of health care professionals to detect and report suspicious cases. In the present study, 57.5% of the respondents have had educational training on CAN during UG studies [Table 1]. It was observed that a higher number of the dental participants (61.3%) had formal training during their UG study compared with the medical participants (53.9%) though this result was not statistically significant [Table 2]. These findings were similar to these of the study done by Deshpande et al. which showed that 46.1% medical and 56.1% dental residents had formal education on child abuse. In contrast, the studies which were conducted by Laud et al. and Kaur et al. indicated that 21% and 45.9% of the dentists, respectively, received educational training on CAN at their UG level.
Knowledge about social indicators and risk factors of CAN is an essential prerequisite for reporting suspected cases. Among the parental factors which deemed to subject the child to abuse and neglect, unemployment was considered as a risk factor by majority of the participants (71.9%) [Table 3]. This is in accordance with Gillham et al. who found an association between parent unemployment and CAN. This was later substantiated by a study conducted by Al-Dabaan et al. who reported that 74.6% of the participants agreed that unemployed parents were associated with child abuse. Further, all medical students and interns (100%) and majority of dental students and interns (91.9%) agreed to the fact that substance abusers and alcoholics are most likely to abuse their children [Table 3]. This was in accordance with the study conducted by Hussein et al. Similarly, parents with mental illness are more likely to be abusive as reported by Hussein et al. which was also reflected in the response by the participants of the current study (89.4%) [Table 3]. Moreover, low socioeconomic status was considered as a risk factor for CAN by Hussein et al.; and Gillham et al. and was also determined as a risk factor in the present study by majority of participants (79.8%) [Table 3]. However, several studies question the role of low economic status as a risk factor for CAN.,,, Furthermore, 93% of participants in the current study [Table 3] recognized marital and family problems as a risk factor for CAN similar to the study conducted by Hussein et al. In a study by Al-Dabaan et al., 66.4% of participants agreed that overcrowded household is a risk factor for CAN which is comparable to the results (63%) of the current study [Table 3].
Evaluation of knowledge of clinical presentations of CAN among the participants revealed that multiple bruises in different healing stages was considered as a sign of CAN by majority of them (medical = 97.7%, dental = 91.8%) [Table 4]. The second most identifiable sign was the presence of burn marks with sharply delineated margins (medical = 93.7%, dental = 90.1%) [Table 4]. Interestingly, these results are consistent with what was reported by Hussein et al., and Mogaddam et al., Furthermore, poor oral hygiene was considered a sign of CAN by majority of medical participants (86.4%), rather than dental participants (73.8%) and this difference was statistically different (P = 0.003) [Table 4].
Regarding opinions related to CAN, many of the subjects disagreed with the statement “abused children will usually tell someone immediately” (medical = 68%, dental = 60.7%) [Table 7]. On the other hand, in a Jordanian study by Sonbol et al., it was found that most of the participants incorrectly assumed that abused children would tell somebody immediately after the incidence. Significantly higher number of medical students (medical = 67.6%, dental = 55.8%. P =0.05) disagree with accusing the parents directly as a way of dealing with CAN. Moreover, almost half of the individuals of both groups believe that they can differentiate CAN from accidental injuries, and few of both groups are confident of their abilities to detect the cases of CAN [Table 7]. These results contradict many other studies by Mogaddam et al., Owais et al., and Al-Dabaan et al.,, This difference may be attributed to the higher level of professional education and experience of the participants in these studies compared to the interns and final year UG students in the current study.,, In addition, in the current sample, less of them are dissatisfied with CAN background provided by the medical or dental school when comparing with the previous studies., This finding suggests that the new educational curriculums pay more attention to important issues such as CAN.
Interestingly, more of medical students and interns believe they need more training on how to deal with CAN cases (medical = 84.6%, dental = 69.2%, P = 0.01) [Table 7]. Hence, even though dental and medical students and interns agreed on receiving good background on CAN, more training regarding this subject is advisable.
Both dental and medical students and interns agreed that being uncertain of the CAN case is one of the major reporting barriers (medical = 69.2%, dental = 76.2%) [Table 8]. Uncertain diagnosis by dentists was identified as the most common reason for not reporting suspected cases by Malecz; Al-Dabaan et al.; and John et al.,, Perhaps, dentists need to be more aware about children's unexplained physical wounds or emotional behaviors. However, dental practitioners are not required to diagnose a case before making a referral. Diagnosis is a shared responsibility of the child protection team. Fear of violence or unknown consequences to the child and lack of knowledge were the reason when medical and dental professionals fail to report suspected cases of CAN [Table 8]. The results were relatively similar to a study which was done by Al-Dabaan et al. Uncertainty about referral procedures was reported by Sonbol et al., as a major concern that prevented dentists from reporting suspected cases of CAN [Table 8]. Similarly, most participation of both groups admit that they are not aware of the referral protocols.
The mean score of knowledge among medical students and interns was higher than dental students and interns, which was statistically significant (P = 0.001) [Table 5]. The result was similar to a study that compared medical and dental residents by Deshpande et al. However, when the mean scores of knowledge were assessed between the participants who had prior training on CAN to those who did not, it showed that there was no statistically significant difference between the groups [Table 6]. Deshpande et al. opinioned that the reason for such observation could be due to the nature of training which was mostly limited to classroom setting, rather than clinical setting, scenarios or seminars.
The limitation of this study includes: (1) unequal sample size of dental and medical UGs and interns and (2) some of the participant might have not considered the didactic component as a formal training on CAN. This could be the probable reason for the lower percentage of training among medical students as revealed in the results.
| Conclusion|| |
This study demonstrated that dental students and interns have less knowledge about the manifestations of CAN than medical students and interns. Although more than half the participants had formal training on CAN, there was no significant correlation between having previous training and the level of knowledge. Moreover, most of the participants in this study believe that they need more training on how to deal with CAN cases. It was shown that the main barrier for not reporting CAN cases is fear of consequences after reporting abuse or neglect cases. Furthermore, most participants believe that uncertainty about the diagnosis of a CAN case is also a barrier to reporting them. Finally, in order to raise awareness about this issue, modifications are needed in the educational system regarding CAN lectures and seminars.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]