Parents’ Knowledge and Perception of Child Abuse and Neglect in the Eastern Province of Saudi Arabia

Abstract

Background:

Child maltreatment is a crucial issue worldwide that has negative consequences for children and their families. Inability to distinguish between traditional corporal punishment and abuse is part of the problem.

Objectives:

To assess parents’ knowledge and perception of child maltreatment and investigate the factors that influence their awareness.

Materials and Methods:

This cross-sectional study recruited parents with at least one child aged <18 years. Data were collected using a self-administrated online questionnaire. Participants were categorized into two groups based on the median knowledge score.

Results:

A total of 447 participants completed the questionnaire, of which 62% were female and the average age was 37 years. Almost two-thirds of the respondents (60.6%) consider child abuse and neglect (CAN) to be a common problem in Saudi Arabia. Only 53% had good knowledge of CAN, and more than one-third were unaware of the hotline number available to report any CAN. Almost half of the participants did not consider refusing childhood immunization or smoking in front of children to be a form of CAN. Logistic regression showed that higher education and family income levels were significantly associated with good knowledge (P = 0.013 and 0.003, respectively).

Conclusions:

While most parents consider CAN to be a common problem in Saudi Arabia, they do not have adequate knowledge of what constitutes emotional abuse and neglect. These findings highlight the need for community-based education programs to increase parents and caregivers’ awareness of child rights.

INTRODUCTION

Child maltreatment refers to abuse and neglect of children aged <18 years.[1] According to the Child Abuse Prevention and Treatment Act, which is the major federal legislation addressing child abuse and neglect (CAN) in the United States, CAN is defined as “any act, or failure to act, by a parent or caregiver, which leads to serious harm or death.”[2] It encompasses all forms of physical, emotional, and sexual abuse and/or neglect.[1]

According to a recent report from the Centres for Disease Control and Prevention (CDC), 1 in 7 children is a victim of CAN.[3] Furthermore, the rate of case reporting varies among countries and demographic areas, and is frequently linked to culture, religious beliefs, and moral values.[4] Children in the Arabian Peninsula are exposed to different forms of CAN.[5] In Saudi Arabia, the first officially reported CAN case was in 1990 and it was followed by a series of subsequently recognized cases.[5,6]

CAN is a crucial public concern that has health, social, and educational consequences on children, families, and communities.[1] Recent studies have shown that abused children are at a higher risk of low academic achievement, mental health diseases, suicide, and sexually transmitted infections.[1,7-10] In addition, CAN causes negative economic impacts on the community, for example, by way of hospitalization and treatment costs.[1]

Depending on the social and cultural contexts, several factors are responsible for CAN such as parents’ ages, socioeconomic statuses, number of children, awareness of child rights, relationship within the family, alcohol or drug abuse, and mental illnesses.[1,11,12] In addition, according to recent studies, some risk factors for child maltreatment were magnified during the COVID-19 pandemic, including an increase in domestic violence, financial stress, family instability, and poor mental health.[13]

A multisectoral strategy is required to prevent CAN, and earlier intervention in a child’s life is better to achieve this goal.[1] In Saudi Arabia, different policies and laws have been developed to address CAN. The National Family Safety Program was established in 2005 as the first specialized quasi-governmental agency against CAN for raising public awareness.[14] Throughout the country, 38 hospitals were accredited with the status of Child Protection Centers.[15] Moreover, there is strong evidence that family training programs and behavioural interventions can lower the rate of CAN.[16]

Several cross-sectional studies have been conducted in Saudi Arabia to assess knowledge and perception regarding CAN among health professionals, who are thought to be more knowledgeable due to their training.[17-19] Despite the vital role of parents and caregivers in detecting and preventing CAN, only few studies from Saudi Arabia have identified their perception of CAN;[20,21] to the best of the authors’ knowledge, such studies have only been carried out in Riyadh. Therefore, this study aims to assess parents’ knowledge and perception of child maltreatment and investigate the factors that influence their awareness in the Eastern Province of Saudi Arabia.

MATERIALS AND METHODS

Study design, setting, and participants

This descriptive cross-sectional study recruited parents and primary caregivers in the Eastern Province of Saudi Arabia with at least one child aged <18 years. The study was conducted after obtaining approval from the Ethical Committee of King Faisal University.

A convenience sampling technique was used to select participants for the study. Assuming a standard 50% probability of poor knowledge of CAN among parents in our population, using the (n = z2.[p*q]/d2) formula and a margin of error of 5%, the required sample size was calculated to be 384. Another 10% was added to this to compensate for non-responses and missing data, which resulted in a total sample size of 422.

All participants were informed that participation is voluntary. They were also assured of data confidentiality and anonymity. All participants provided informed consent before proceeding to complete the survey.

Questionnaire development and data collection

Data were collected using a self-administered questionnaire prepared using Google Forms. Between January and March 2022, the authors used a mall and children’s hospital intercept method across the Eastern Province of Saudi Arabia. To those who agreed to participate and resided in this region, the link to the questionnaire was shared through email and/or instant messaging platforms (WhatsApp).

The survey comprised 32 questions and took an average of 7 minutes to complete. It was categorized into three sections. The first section included questions pertaining to the parents’ sociodemographic data (age, gender, marital status, educational level, employment status, number of children, smoking status, and history of exposure to CAN). The second section elicited data regarding parents’ knowledge of CAN and the current Saudi regulations for CAN response and prevention. Finally, the third section determined the participants’ knowledge of the risk factors of CAN and their perception toward different types of child abuse. The questionnaire was developed considering previous studies carried out in the Middle East.[18,19,21,22] Participants’ knowledge was classified into three response categories (agree, disagree, or don’t know), and their perception was recorded using a 5-point Likert scale (1 = strongly disagree; 5 = strongly agree).

The questionnaire was reviewed by two experts in the field of child abuse and piloted among 20 individuals outside the sample to test its validity and reliability (Cronbach’s alpha >0.7).

The usability and technical functionality of the questionnaire was tested before it was fielded. Participants were able to review their responses before submission. The questionnaire was not designed to be adaptive, and response to all questions was mandatory for inclusion in the current study. To avoid duplicates, the “Limit to 1 response” feature was activated in Google Forms.

Data analysis

Data from Google Forms were automatically transferred onto MS Excel sheets. Data analysis was done using the Statistical Package for the Social Sciences (SPSS) version 28.[23] The median and interquartile ranges, as well as frequencies and percentages, were used for continuous and categorical variables, respectively. Participants were categorized into two groups (good and average/poor knowledge) based on their median knowledge score, where good knowledge was defined as a score >70%. The Wilcoxon rank sum test was used to measure the association between the knowledge score and demographic data, and P < 0.05 was considered statistically significant.

RESULTS

Characteristics of the participants

A total of 500 questionnaires were distributed, from which, 447 responses were received (89.4%). Of these, 62% were female and the average age was 37 years. The majority (95.5%) were married with a mean number of children 3 ± 1 (SD). Around one-fifth (18.1%) of the sample reported a personal exposure to CAN during childhood [Table 1].

Table 1.

Sociodemographic characteristics of the participants (N=447)

Variables	n (%)
Age, median (IQR)	37 (7)
Number of children, median (IQR)	3 (1)
Gender
Male	170 (38)
Female	277 (62)
Marital status
Currently married	427 (95.5)
Divorced or widowed	20 (4.5)
Education
High school or less	112 (25.1)
Higher education	335 (74.9)
Income (Saudi Riyals/month)
≤5000	90 (20.1)
>5000	357 (79.9)
Employment
Employed	272 (60.9)
Unemployed	175 (39.1)
Smoking status
Never smoked	80 (17.9)
Current or former smoker	367 (82.1)
History of childhood abuse
Yes	81 (18.1)
No	366 (81.9)

IQR: Interquartile range

Participants’ knowledge and perception

The majority (95%) of parents were familiar with the term CAN and stated that their main sources of information were either internet search engines or family and friends (74% and 68%, respectively). Further, around one-fourth of the respondents got their information through the government platforms or educational efforts, and only 12% reported receiving education on CAN from their healthcare providers.

Based on participants’ perceptions, the most common form of child maltreatment in the Kingdom of Saudi Arabia is neglect, followed by emotional abuse (40.5% and 32.4%, respectively) [Figure 1].

Figure 1.

Most common type of child abuse and neglect in Saudi Arabia based on participants’ perception

Figure 2 provides the percentage of risk factors for CAN based on parents’ perceptions; substance abuse was ranked the highest (60%), followed by low income (57.5%). Only 14.5% of parents believed that children under the age of 4 years were at higher risk of CAN, and none of them considered that having more children increased the risk of CAN.

Figure 2.

Percentage of considered child abuse and neglect risk factors based on participants’ perception. CAN: Child abuse and neglect

Regarding participants’ knowledge, around half of them (53%) showed a good level of knowledge based on the median knowledge score (70). Approximately two-thirds (60.6%) of the parents agreed that abuse is a common problem in Saudi Arabia, while more than one-third were unaware that a hotline number and laws exist in Saudi Arabia to protect children from CAN. Almost half of the parents (49.9%) did not consider refusing child immunization as a form of CAN, and more than one-fifth (22.4%) believed that only strangers can engage in sexual abuse. Nevertheless, the majority (95%) agree that CAN has an impact on both mental and physical wellbeing [Table 2]. Finally, >60% of the parents viewed slapping on the face, telling children they do not love them, and public shaming as CAN. Only half of the participants believed that smoking in front of children is abuse [Figure 3].

Table 2.

Distribution of parents according to their knowledge about child abuse and neglect (N=447)

Question	Correct responses, n (%)	Incorrect responses, n (%)
CAN is common in KSA	271 (60.6)	176 (39.4)
Laws are there in KSA to protect children under the age of 5 years	221 (49.4)	226 (50.6)
Physical violence that does not require medical attention is not CAN	312 (69.8)	135 (30.2)
There are laws in KSA to protect against CAN	288 (64.4)	159 (35.6)
There is a hotline for CAN reporting in KSA	281 (62.9)	166 (37.1)
CAN affects children’s mental and physical wellbeing	428 (95.7)	19 (4.3)
Refusal to vaccinate is considered CAN	224 (50.1)	223 (49.9)
Refusal to send to school is considered CAN	358 (80.1)	89 (19.9)
Sexual child abuse only occurs from strangers	347 (77.6)	100 (22.4)
Sexual child abuse only counts when penetration occurs	286 (64)	161 (36)

CAN: Child abuse and neglect, KSA: Kingdom of Saudi Arabia

Figure 3.

Parents’ perception toward different types of child abuse and neglect. CAN: Child abuse and neglect

Table 3 shows the association between participants’ characteristics and their knowledge. There was a statistically significant association between knowledge and parents’ education, as well as family income. Higher education level and a family income of >5000 SR/month were significant factors for having good knowledge of CAN (P = 0.013 and 0.003, respectively). Other demographic factors such as age, gender, and having been abused in childhood did not have a significant impact on knowledge scores.

Table 3.

Median knowledge score and its association with sociodemographic characteristics

Variables	Median score (IQR)	P
Gender
Male	70 (22)	0.991
Female	70 (30)
Marital status
Currently married	70 (20)	0.329
Divorced or widowed	60 (45)
Education
High school or less	70 (30)	0.013*
Higher education	80 (30)
Income
≤5000	60 (20)	0.003*
>5000	70 (20)
Employment
Employed	60 (30)	0.056
Unemployed	70 (20)
Smoking status
Never smoked	70 (20)	0.122
Current or previous smoking	65 (30)
History of childhood abuse
Yes	70 (25)	0.460
No	70 (30)

*= Statistically significant; IQR: Interquartile range

DISCUSSION

Child maltreatment in Saudi Arabia had previously been an unrecognized and ignored phenomenon; however, recently its scope has been acknowledged.[15,20,21] Rather than only responding to the occurrence of CAN, it is possible to avoid it by implementing effective measures. For example, cultural attitudes and family dynamics have a significant role in CAN.[16] This study sheds light on parents’ knowledge and perception of child maltreatment and investigates factors that influence their awareness.

The current study revealed that two-thirds of parents consider CAN to be a common problem in Saudi Arabia, which is in line with another national study among healthcare professionals.[24] Further, 18.1% of the participants in the current study disclosed having been a victim of abuse during their childhood, while in the study of Alreshidi et al., 28.6% of the parents were victims of CAN.[25] This relatively low figure might be attributed to the community’s inability to distinguish between traditional corporal punishment and abuse. Although child safety is a high priority for caregivers, different cultures have varied standards for acceptable parenting practices.[26] According to our study, only slightly more than one-third of the parents viewed hitting on the hand as maltreatment, and less than half thought that violently shaking a child is abuse; in contrast, slapping on the face was considered abuse by almost two-thirds of participants. This unsafe attitude might place young children in danger.

Most of the parents concurred that CAN affects both the physical and mental health of their children; however, less than half of them considered shouting, yelling, and threatening their children as abuse. This underestimation of non-physical abuse is consistent with the findings of Hendaus et. al., which found that the majority of Qatari parents thought that screaming is less harmful than striking.[22] A possible reason is that the definition of verbal abuse is very difficult, as it is strongly influenced by cultural factors, and its consequences are likely to differ widely depending on the situation and the child’s age.[26]

The World Health Organization (WHO) defines child neglect as the parent’s failure to support the development of the child in one or more of the following areas: health, education, emotional development, nutrition, shelter, and safe living conditions.[27] Based on the literature, child neglect is the most common form of maltreatment in Saudi Arabia.[28] A considerable percentage of our sample did not consider the following to be a form of maltreatment: exposure to second-hand smoke, lack of vaccination, or refusal to send children to school. In another study that analysed 1770 child abuse-related deaths, neglect was recorded in 72.8% of the cases, and of those, 8.1% were linked to medical neglect.[28] Moreover, based on a recent Saudi study, the worsening of underlying diseases and a lack of immunization were the most common prevalent manifestation of medical neglect.[28] According to Temsah et al.,[29] an educational campaign for caregivers had a significant impact on their overall knowledge and attitudes to childhood and adolescents’ safety. This finding emphasizes the urgent need to alter societal norms, educate the public about child rights, and take steps to reduce risk in the future.

In our study, parents believed that neglect and emotional abuse are the most common types of CAN in Saudi Arabia. However, in a study conducted in Riyadh city, emotional and physical abuse were reported as the most prevalent forms of abuse.[21] On the other hand, sexual assault was the CAN type most frequently reported to the legal authorities based on studies conducted in Saudi Arabia, Egypt, and Tanzania.[30-32] This discrepancy between public beliefs and authorities’ reported cases is predictable, as the definition of neglect and emotional abuse vary depending on cultural factors and regulations on reporting abuse.[26]

The multifactorial increase in the chance for children to be abused must be acknowledged and addressed. CAN roots are complex and vary depending on social and cultural circumstances; certain risk factors are unique to a specific type of abuse.[33] In the current study, parents believed that substance abuse is the greatest risk factor (60%) followed by low income (57.5%). A similar finding was reported by Alnasser et al. among paediatricians and medical students; conversely, Alqurashi et al. found that psychiatric disease and a low educational level were the most cited risk factors.[21,24] Furthermore, only 14.5% of our sample thought that children younger than four years were at higher risk, and none of them cited having more children as a factor predisposing to CAN. Conversely, the WHO report on violence and health states that a child’s age is frequently cited as a risk factor and that families with ≥4 children are three times more likely to suffer from CAN.[34]

The majority of the participants were cognizant of the term CAN, which is consistent with the findings of other studies published in Arab countries.[20,23,35] However, only around half (53%) of our participants had good knowledge about CAN. Surprisingly, more than one-third of the participants did not know that Saudi Arabia has a hotline number and laws to protect children from abuse. Such a lack of knowledge about the relevant authorities has been reported previously by local studies concerning parents and health-care providers.[20,24] As a result, victims do not have the opportunity to access intervention services, which will ultimately worsen their maltreatment and its negative effects.

Despite the various sources of information for CAN, our participants cite the internet, family, and friends as the primary ones. Nevertheless, only a small proportion obtained their information from official sources such as government websites and healthcare providers. This outcome points to the need to increase public knowledge of the reliable, primary sources of information through social media and educational program campaigns.

Unsurprising, there was a statistically significant association between parents’ good knowledge and higher education and family income level. This finding is in partial agreement with studies carried out in Saudi Arabia and elsewhere. In Riyadh, Saudi Arabia, male parents and those with high academic achievement were more likely to have good knowledge of child maltreatment, while Yekta et al.’s study from Tehran only found a correlation between education level and adult attitudes to CAN.[20,36] This association was predictable, as having a higher level of education increases the likeliness of employment/work, financial security, and better standard of living, all of which decrease the prevalence of CAN and improve its awareness.[33]

Strengths and limitations

This is the first study that has assessed the knowledge and perception of parents toward CAN in the Eastern Province of Saudi Arabia. However, the study has some limitations. First, it concerns a sensitive issue that can influence how certain questions are answered. Second, reporting biases may have been introduced as the measure utilized in this study was self-reported. Finally, due to convenience sampling, the results cannot be generalized.

CONCLUSIONS

Parents in the Eastern Province of Saudi Arabia consider CAN a common problem in Saudi Arabia, but they have a poor perception of what constitutes emotional abuse and neglect. These findings highlight the need for a universally accurate definition of maltreatment. Moreover, community-based education programs are needed to increase parents and caregivers’ awareness of child rights.

Ethical considerations

This study was approved by the Ethical Committee of King Faisal University, Al Ahsa, Saudi Arabia (Ref. no.: KFU-REC-2022-JAN-EA000350; date: January 04, 2022). All participants provided informed consent before completing the questionnaire. The study adhered to the principles of the Declaration of Helsinki, as revised in 2013.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Peer review

This article was peer-reviewed by four independent and anonymous reviewers.

Author contributions

Conceptualization: Z.A. and J.T.; methodology: Z.A. and J.T.; data collection: A.B., A.A., M.A., R.A., B.A; data analysis, Z.A. and J.T.; Writing – original draft preparation: A.B., A.A., M.A., R.A., B.A; Writing – review & editing: Z.A.; Supervision: Z.A.

All authors have read and agreed to the published version of the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.