Understanding the epidemiology and impact of the COVID-19 pandemic on domestic violence and child abuse in Saudi Arabia: A cross-sectional study

Abstract

Objectives

The purpose of this paper is to highlight the impact of a pandemic on the lives of vulnerable members of the community who have experienced or are ‘at risk’ of experiencing intimate family violence and child abuse in Saudi Arabia. By reviewing the experience in Saudi Arabia in the context of the international literature, the study explores similarities and differences in the impact of the pandemic on family violence.

Methods

The study investigated the impact of the COVID-19 pandemic on family violence and child abuse in Saudi Arabia by conducting a comparative analysis of the prevalence of cases, types of abuse, and geographical location of those experiencing violence between the years 2019 and 2020. Data were obtained from the Family Violence Reporting Center 1919 in Saudi Arabia.

Results

The study found that the risk of family violence and child abuse increased during the COVID-19 pandemic in Saudi Arabia, similar to findings in other countries. Conversely, there was a decrease in the number of reports due to factors associated with COVID-19.

Conclusions

The study highlighted the importance of ensuring that existing policies and services are sufficient to ensure the risks arising from the impact of COVID-19 responses and minimize the negative consequences.

1. Introduction

Violence in families has catastrophic impacts for both adults and children. Domestic violence, sometimes referred to as intimate partner violence or family violence, can be psychological, physical, and/or sexually abusive behavior of one partner to the other [1]. The World Health Organization (WHO) defines violence against women as “a major human rights violation as well as a widespread public health concern” [2]. Child abuse and maltreatment are defined by the WHO as follows “all types of physical and/or emotional ill-treatment, sexual abuse, neglect, negligence, and commercial or other exploitation, which results in actual or potential harm to the child's health, survival, development, or dignity in the context of a relationship of responsibility, trust, or power” [2].

The high prevalence of domestic violence was a pre-pandemic global concern across all continents [2]. Kazzaz et al. conducted eleven studies across six cities in Saudi Arabia - Riyadh, Jeddah, Medina, Taif, Arar, and Al-Ahsa to explore the prevalence, risk factors, and outcomes of domestic violence prior to the pandemic in 2019 [3]. In four of the studies, the authors utilized the WHO Multi-Country Study Questionnaire. They found that the “lifetime prevalence of domestic violence ranged between 39.3% and 44.5% in Saudi Arabia [3]. Key risk factors for domestic violence included both perpetrators' and victims' educational attainment, and perpetrators’ alcohol and drug abuse. Their pre-pandemic study concluded that one in three women in Saudi Arabia had experienced domestic violence [3].

Huecker et al. also found “an inverse relationship between education and domestic violence,” with poorer educational attainment correlating with a higher incidence of domestic violence in the United States of America (USA) [1]. A major public health issue in the USA, domestic violence was estimated to impact 10 million people in the country every year ^[1]. Similarly, in Australia, a survey by the Australian Bureau of Statistics Personal Safety in 2016 found that 2.2 million Australians had experienced physical and/or sexual violence from a partner, and 3.6 million Australians had experienced emotional abuse from a partner [4]. Multiple risk factors underpin the occurrence of violence.

Nduna et al. noted the role of power in 2020 as “a dynamic variable to work with in explaining violence” [5]. Noting the intersectional nature of violence, they identified contributing factors such as gender and educational level and argued that family violence stems from patriarchy and the lower status of women in families. The intersection of multiple risk factors was present in both understandings of child abuse and neglect, and domestic violence. Kazzaz et al. in their Saudi-based study found that there was an increased risk of child abuse and neglect where there was a parental history of criminal activity, drug and/or alcohol dependence, or psychiatric illness [3]. These risk factors when combined with low educational levels were strong predictors of child abuse and neglect. Other risk factors included poverty, disability, drug, and alcohol abuse, child abuse, and neglect [6,7].

1.1. Impacts of violence on children

Approximately, one billion children are estimated to experience violence and abuse worldwide [2]. The impact of violence on children can have lifelong consequences, affecting children's mental well-being and contributing to poor educational outcomes and a range of behavioral issues [8]. The WHO estimated in 2020 that nearly three in four children, aged 2–4 years, regularly suffer physical punishments considered abusive and psychological violence by their parents and/or caregiver [2]. Adverse childhood experiences (ACE) including exposure to family violence, maltreatment, poverty, interparental violence, and parental substance abuse can have wide-ranging impacts on children's health and well-being, which can extend into adulthood [9]. A systematic review conducted by Oh et al., in 2018 found that childhood adversity is associated with cognitive delay, asthma, altered immune responses, somatic complaints, and sleep disruption [10]. Another systematic review conducted by Brunton and Dryer in 2021 explored the effects of child abuse on pregnancy and childbirth. The study showed that women with child abuse histories have more adverse experiences including experiencing harmful behavior in pregnancy and childbirth than nonabused women [11]. A cross-sectional study that explored the relationship between health and risk behavior involving more than 10,000 participants in Saudi Arabia who had ACE was undertaken by Almuneef et al., in 2014 [12]. The study found that having just one ACE contributed significantly to the increased likelihood of developing diabetes mellitus (OR = 1.3), depression (OR = 1.32), or anxiety (OR = 1.79). Two ACEs increased the likelihood of developing hypertension (OR = 1.46), mental illness (OR = 1.93), smoking (OR = 1.17), alcohol use (OR = 1.75), and drug use (OR = 1.45). Coronary heart disease (OR = 1.94) and obesity (OR = 2.25) had the highest odds ratio for respondents who reported four or more ACEs ^[12]. Costs attributed to the presence of ACEs were estimated to be US$581 billion in Europe and US$748 billion in North America [13]. In the USA, the estimated annual economic cost to the community was US$2 trillion [14], and in Australia, the cost was estimated at AU$7.7 billion [15].

A study conducted for the Office of the Advocate for Children and Young People in New South Wales, Australia, in 2018, found that “violence against children and young people is associated with numerous long-term adverse outcomes for both the person who experienced violence and the wider community” [16]. The study found that this abuse and violence cost a total of $3.8 billion in New South Wales and $11.2 billion in Australia [16].

1.2. Impact of COVID on the incidence of child abuse and neglect

The novel coronavirus (COVID-19) was identified as a pandemic on March 11, 2020 [17]. The pandemic had a major impact to individual, community, and country levels. Globally, more than six million deaths were reported due to COVID-19 [18]. Such trauma extended to the subsequent emotional and financial costs of losing a family member or a loved one. In addition, the rapid community transmission forced many businesses to close leading to rising unemployment, with governments requiring households to isolate to avoid transmission. These social distancing and quarantine measures implemented in most countries contributed to the escalation of domestic violence [19,20].

Family violence during the pandemic has been associated with a range of factors including economic stress, disaster-related instability, increased exposure to exploitative relationships, and reduced options for support [21]. Due to the social isolation measures implemented across the globe to help reduce the spread of COVID-19, people who lived in volatile situations of family violence were often restricted to their homes, and for extended periods. In Australia, as stay-at-home orders came into force, police in some parts of the country reported a 40% drop in crime overall, but a 5% increase in domestic abuse call-outs [22]. At the same time in Australia, Google reported a 75% increase in internet searches relating to support for domestic abuse [19,23]. The responses from governments to contain the pandemic lockdown, social isolation, and limited social engagement increased the vulnerability of women and children to violence.

Reports of the increased incidence of domestic abuse and family violence since social isolation and quarantine measures came into force have been noted internationally. Recent, anecdotal evidence from the United States, China, and Brazil, indicated increases in intimate partner, women, and children violence due to isolation and quarantine [24,25]. China was the first country to impose mass quarantine in the Wuhan province, which saw reported domestic abuse incidents rise threefold in February 2020 compared to the previous year [26].

During such public health emergencies, women, children, and the elderly were recognized as particularly vulnerable to maltreatment. Vulnerability factors included gender, economic position, and disability [27,28]. The poor financial status of parents was reported as a risk factor for physical abuse and psychological maltreatment ^[28]. For example, historically economic crises, such as the Great Depression and Great Recession, were linked to family hardships to a change in parenting behavior and children's lives [29]. A systematic review conducted by Seddighi et al., in 2021 found that, in emergencies, parental history of exposure to violence, poverty, substance abuse, and child labor were predictors of parents' increased violence against children [30].

Furthermore, Nikolaidis highlighted the direct implications of the pandemic on the health of children [31]. This included grief from the death of parents, the death of children through COVID-19, malnutrition, and the impact of school closures, including uneven access to digital learning resources [31]. Studies from Australia, Spain, and China showed an increase in depressive symptoms and a decrease in life satisfaction [32]. Nikolaidis also highlighted that most of the devastating implications to children's fundamental rights during the pandemic era were inflicted not by virtue of the direct impact of COVID-19 on children but rather as “side effects” of emergency measures to respond to the pandemic taken by contemporary societies [31].

2. Methodology

This is an analytical cross-sectional study undertaken in Saudi Arabia, and it was written in accordance with STROBE guidelines for cross-sectional studies [33]. During 2019 and 2020, data were gathered about the reported cases of domestic violence, and child abuse and neglect. The key research questions that directed the study were as follows.

• i.What was the rate of reported domestic violence and child abuse and neglect in the Kingdom of Saudi Arabia for the years 2019 and 2020?
• ii.Did the COVID-19 pandemic have an impact on the rates of reported domestic violence and child abuse and neglect in the Kingdom of Saudi Arabia?
• iii.Was there a difference in domestic violence and child abuse rates based on gender, type of violence, and geographical location?

2.1. Data collection and statistical considerations

Since the goal of this study is to learn more about the prevalence of events in a specific population, a cross-sectional design was chosen because Yin (1994) concluded that exploratory studies do not require a minimum number of cases or a random selection [34]. Therefore, data regarding domestic violence and child abuse were collected monthly in 2019 and 2020 from the Family Violence Reporting Center 1919, which is an associate center for the Ministry of Labor and Social Development in Saudi Arabia, then analyzed in SPSS software (version 20.0.1 for Windows, SPSS Inc., Chicago, Il, USA). Descriptive statistics for the continuous variables were reported as means and standard deviations (SD). Categorical variables were summarized as frequencies and percentages. The student's t-test and linear graph were used to compare the number of reported cases in 2019 and 2020. A p-value less than 0.05 was considered significant.

3. Results

The rate of domestic violence and child abuse in Saudi Arabia for the year 2019 prior to the pandemic was 64,739 out of 34,268,529 incidents or 189 per 100,000 people. On the other hand, the rate of violence and abuse in the Kingdom of Saudi Arabia for the year 2020 was 64,739 out of 34,268,529 or 189 per 100,000 population. As shown in Fig. 1, there was a decrease in the number of reported cases for the months covering the partial lockdown due to COVID-19 (March, April, and May 2020). However, there was an increase in the number of reported cases in June 2020 (during the complete lockdown). Since August 2020, there has been an increase in the reported cases ranging between 12% and 25%.

Fig. 1.

Overall monthly reported cases in 2019 and 2020.

The pattern of reports in relation to gender, age groups, type and level of violence, and locations in 2019 and 2020 was similar across the two years. For both genders (males under 18) as shown in Fig. 2, there was a decrease in the number of reported cases of family violence or child abuse and neglect for the months covering the partial lockdown (March, April, and May), and an increase in the number of reported cases in June (during the complete lockdown). For November and December (2019 and 2020), there was a statistically significant result (P=<.05) for an increase in female cases from 4157 to 5163 (0.001) and 3936 to 5155 (<0.001), respectively.

Fig. 2.

Monthly reported cases in 2019 and 2020 by gender.

There is a significant increase in the number of domestic violence in all types except for witnessing violence. This increase was true during all months of the year except August and September (0.273) and (0.216), respectively. The average number of cases was higher in 2020, with a percentage change ranging from 19% for sexual violence cases to 58% for threats to kill (see Table 1).

Table 1.

Types of abuse reported in 2019 and 2020.

Type of cases	2019		2020		Difference		P-value
	Mean	SD	Mean	SD	Mean difference 2020–2019	Change (%)
Killing threat	482.3	146.9	761.3	95.8	278.9	57.8	<.001a
Negligence	852.7	214.5	1035.2	319.6	182.5	21.4	.005a
Physical	1705.3	355.1	2174.6	357.9	469.3	27.5	<.001a
Sexual	106.8	35.1	127.0	23.8	20.2	18.9	.005a
Witnessing violence	127.6	46.5	123.3	32.1	−4.3	−3.3	.831
Verbal	1434.1	296.4	1913.0	353.6	478.9	33.4	<.001a
Psychological	1748.4	383.3	2386.9	414.8	638.5	36.5	<.001a

^aP-values were reported using the student's t-test.

Table 2 shows paired comparison of the number of cases per region in both years. There is a significant increase in the numbers in the eastern region only. The average number of cases was higher in 2020 in the eastern region by a monthly average of 66 cases, representing a 10% increase. Moreover, for all months except January, April, September, and October 2020, there was a statistically significant difference in the distribution of cases by region.

Table 2.

Comparison of reported cases across regions in Saudi Arabia 2019–2020.

Region	2019		2020		Difference		P-value
	Mean	SD	Mean	SD	Mean difference 2019–2020	Change (%)
Central	1488.8	220.0	1605.3	394.1	116.6	7.8	.152
Eastern	656.2	131.2	722.0	150.4	65.8	10.0	.038a
Northern	412.7	66.6	443.2	83.6	30.5	7.4	.176
Southern	1094.3	155.8	1187.2	222.5	92.9	8.5	.097
Western	1568.7	186.6	1608.8	438.6	40.2	2.6	.655

^aP-values were reported using the student's t-test.

4. Discussion

The data and findings add to the knowledge of the phenomena of domestic violence and child protection in Saudi Arabia. The findings of this study suggested that the changes in the number of reported cases of family violence and child abuse in the KSA were approximately 6.4% higher in 2020 prior to the pandemic than in 2019, with a total of 4129 cases compared to 4432 cases in 2020. Comparing this finding with international research during the same period, the data showed concordance with the rapid increase in the shadow pandemic of family violence. This discussion highlights the initial results regarding the impact of COVID-19 on family violence in Saudi Arabia compared to the global experience.

Many countries reported that the impact of the pandemic demonstrated a significant increase in reports of domestic violence, for example, China, Argentina, the USA, and Singapore between 2019 and 2020 specifically at the times when countries were in lockdown and the movement of citizens was restricted [35]. There were similar findings in Australia. For example, it was observed that urgent applications filed for hearings in relation to family violence disputes in the Family Court of Australia and the Australian Federal Circuit Court in March and April 2020 increased by 39% and 23%, respectively [36]. In addition, the Australian National Domestic Violence Hotline; 1800 Respect, experienced a surge in calls after midnight when perpetrators were asleep and a 38% increase in the use of online chat tools between March and April [37]. In Victoria, Australia, family violence-related police callouts, ambulance attendances, and emergency department presentations were higher between 1 April 2020 and June 2020, compared to the same period in 2019 [38].

Additionally, the Men's Referral Service in Australia, a phone service providing referral pathways for men who use violence, also logged a 37% increase in calls in the last week of April compared to the same period in 2019 [39]. Moreover, an online survey of 15,000 Australian women in May 2020 during lockdown due to COVID-19 found that 4.6% of women had experienced physical or sexual violence in the three months prior to the survey, 5.6% had experienced coercive control, and 11.6% had experienced at least one form of emotionally abusive, harassing, or controlling behavior perpetrated by a current or former cohabiting partner [20,40].

While COVID-19 restrictions were implemented, the numbers for reported domestic violence cases in 2019 and 2020 in Saudi Arabia were compared. This study's findings suggested that the number of reported cases of domestic violence to services has decreased. There were 120 cases fewer in March 2020, which indicated a −2.5% in change. The negative results in the numbers continued for a couple of months. In April, the number of reported cases decreased by 1099 which reported a −23.3% change, and in May, 230 cases were less than in 2020 which was a −5.3% change. These initial outcomes appear to contradict international patterns. However, in Australia, the Victorian statewide family violence service Safe Steps initially found a 30% reduction in calls during stay-at-home orders in April 2020, while the state experienced its first significant lockdown [40].

Moreover, as reported by the United Nations Population Fund (UNFPA), “the pandemic also makes it more challenging for survivors of violence to seek help” [41]. Early in 2020 when little was known about COVID-19, some survivors were afraid to seek support because they were worried about contracting the virus [41]. This concern is felt by frontline gender-based violence service providers, as well. In Mongolia, focus group discussions with One Stop Service Center Mongolian staff revealed that fear, uncertainty, and feelings of unpreparedness about COVID-19 led to a heavy demand for services leading to fewer new clients being accepted for services, along with a drop in proactive community outreach [41]. Likewise, during the initial stages of the lockdown, several states in the USA reported double-digit percentage decreases in child maltreatment hotlines [42]. Similarly, in Saudi Arabia, the number of domestic violence cases in the early stages of the pandemic reduced as per January statistics that showed 538 cases less in 2020 than at the same time in 2019, which represented a - 9.2% in change.

4.1. Child protection systems

Up until 2006, no country met the desired adequacy level of child maltreatment protection services and systems [43]. In one study, it was claimed that Saudi Arabia showed low to intermediate levels of child maltreatment awareness among the general population [44]. This lack of awareness of child maltreatment in the community may have influenced the reduction in the reported case of child abuse during school lockdowns due to COVID. Schools in Saudi Arabia were closed from March 2020 and remained closed during all lockdowns until January 2022. These conditions were associated with a reduction in the number of calls for assistance. Similar lockdown actions were experienced internationally, and they were linked to the reduction in calls for assistance during this time. The shutdown of schools removed this place of protection for children. Schools were places more likely to report incidences of suspected child abuse observed in children and also provided a safe space for children during the day. Moreover, in 2019, the number of reported abuse cases increased when schools were not under lockdown. This may indicate an important role for school professionals who report suspected abuse and can provide for child safety.

Brooks et al. conducted a review of research into the ‘psychological impact of quarantine’ and found that there can be long-term, negative consequences of quarantining including anger, grief, anxiety, and fear [45]. They argue that “if quarantine is essential …. officials should take every measure to ensure that this experience is as tolerable as possible for people” [45]. UNICEF (2021) also expressed concerns that “the COVID-19 pandemic has raised concerns about the mental health of a generation of children” [46].

Internationally, some studies found that, for many women, “COVID-19 coincided with an increase in the frequency or severity of ongoing violence or abuse” [20,40]. Also, as reported by Gibbons et al. and Ragavan et al. who studied family violence during COVID-19 in Argentina, those at risk of violence became more vulnerable during COVID restrictions, as it was more difficult to find a safe place to make calls and seek help when an abusive partner or, in case of the child abuse, an abusive parent was present [47,48].

This research reports a higher rate of violence against women than men in both 2019 and 2020 as indicated by the number of reports to services. In 2019, the rate was up by 24,200 women while in 2020 it was 27,914, with total changes in the rate for women over men around 38.6% in 2019 and about 41.8% in 2020. The rate of change from 2019 to 2020 in the total number of women was 3921, which is around 9% change. During the period between June to December 2020, when the Saudi Arabia government decided that people should return to their usual routines, there was a noticeable rise in the rate of reports of violence observed. Starting in June 2020, however, the combined rates of domestic violence and child abuse cases rose by 11.0%, then in August the rate increased by 17.9% increasing again in September and October by 12.2% and 12.6% respectively, in November an increase by 19.4% and finally in December a 25.3% increase. However, by the end of 2020, considerable support for families was being provided, and families were in an improved situation that could reflect better relationships and less neglect or stress. Additional services available included tele-support services which became available to the community during the lockdown. A unique service that may have impacted the rate was the major community public education campaign about domestic violence that was launched in Saudi Arabia early in early 2020. This community campaign included a massive social media presence and included the Ministry of Human Resource and Social Development (HRSD) and affiliated web portals containing information about family violence. In addition, there were interviews with family violence activists and experts who promoted family safety and awareness of family violence in the community. All these factors played a strong role logically and systematically in addressing family violence.

4.2. Strengths and limitations

The data and findings of this study have added to the knowledge of domestic violence and child protection prevalence and responses in Saudi Arabia. However, the study results are limited to cases that approached authorities and do not take into account the unreported ones. Our findings can therefore be used to evaluate the impact of the COVID-19 health crisis on child abuse in Saudi Arabia for people who seek help. In addition, the current study compared the prevalence in 2019 and 2020 only, but the pandemic is not finished yet; long-term evaluation and more advanced research will help to address the issue of family violence and implement interventions.

5. Conclusion

The impact of COVID-19 on the prevalence of family violence and child abuse and neglect has been severe in Saudi Arabia, which is consistent with research undertaken in other countries. It was recognized that existing Saudi Arabia policies and programs were not adequate to support at-risk families during COVID-19. With the arrival of the pandemic in early 2020, governments worldwide implemented city-wide lockdowns and social distancing measures to curb the spread of the virus and ensure healthcare systems were not overloaded. However, vulnerable populations were not provided with ready access to support, and as has been shown, there has been an increased incidence of family violence and child abuse, and neglect worldwide. With increased awareness of the phenomena, policies and services were developed in Saudi Arabia to address these concerns. The major public education campaign about family violence showed promise. Whilst there was an increase in reports of family violence, this suggests that the community was more aware of the action which needed to be taken to address family violence.

In Saudi Arabia, the Ministry of Human Development and Social Affairs concentrates on community monitoring and reporting, while the Saudi National Family Safety Program is currently keeping an eye on cases that are presented to medical centers; therefore, it is recommended to improve agency collaboration to build a comprehensive system aimed at reporting domestic violence and child abuse. In addition, it is important to implement child-friendly reporting mechanisms to encourage children who are at risk of abuse to get assistance, and these tools must be specifically modified and customized to pandemic-like situations.

Ethical statement

The study was written in accordance with the Declaration of Helsinki. Data were analyzed anonymously to respect the anonymity and confidentiality of participants. IRB approval was obtained from the King Abdulaziz City for Science and Technology (KACST) (5-20-01-500-0004).

Funding

The Investigators acknowledge that this study was funded under the Fast Track Funding Path for Coronavirus (COVID-19) by the King Abdulaziz City for Science and Technology (KACST), Riyadh, Saudi Arabia (Grant number: 5-20-01-500-0004). Many thanks to all the people who have supported this project.

Author contributions

All individuals who fulfill the requirements for authorship are mentioned as authors, and so all authors confirm that they have contributed sufficiently to the work to assume responsibility for its content, including involvement in its conception, design, analysis, drafting, and revision.

Additionally, each author attests that before appearing in the International Journal of Pediatrics and Adolescent Medicine, this material or similar material has not been submitted to, and will not be submitted to, or published in any other journals.

Declaration of competing interest

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.