Physical child abuse Prevalence and its risk factors in Saudi Arabia - A review Update

Article Title: Physical child abuse Prevalence and its risk factors in Saudi Arabia – A review Update

Abstract:

Background: The aim of this overview to provide a summary overview of physical child abuse prevalence, its and its risk factors in Saudi Arabia.

Methods: A searching strategy for the included Studies were gathered by reviewing published articles from 1991 to 2020, in the PubMed and Google Scholar databases reporting the prevalence of Physical child abuse and Its risk factors in Saudi Arabia. Out of the total of 131 Articles that were searched 79 articles were excluded follows the article's title screening, out of 52 articles 37 excluded by abstract reading, out of 22 articles read as full text only 15 full-text articles met the inclusion criteria of the review. The data extraction from the review articles was done based on a selection form. The form has been used to summarize evidence of included studies, it includes the following categories: title, design of the study, demographic data, study population, year of publication, and conclusion.

Results: Most studies of child abuse have been published in Saudi Arabia were cross-sectional studies and case reports which consider the low level of evidence studies based on the hierarchy of research evidence, physical child abuse was the most prevalent reported form of child abuse its prevalence estimated to be 47 %. The significant risk factors associated with physical child abuse were parents' history of physical abuse during their childhood, young age parent, witness to domestic violence within family members, parents with poor self-control, and Parents who did not own a house compared to parents who live in a rented house.

Conclusions: Physical child abuse is the most commonly reported form of child abuse in Saudi Arabia, it has a high prevalence. Its risk factors are complex. However, many of these risk factors can be identified early. It is doable to initiate prevention programs, such as screening and counseling for parents of at-risk children and it can be implemented in all hospital service setting especially emergency department and primary health care.

Keywords: Child abuse; physical abuse; risk factors; Saudi Arabia

العنوان: نظرة عامة محدثة عن انتشار وعوامل الخطر للاعتداء الجسدي على الأطفال في المملكة العربية السعودية

الملخص:

تهدف هذه الدراسة إلى تقديم نظرة عامة وملخص عن انتشار وعوامل الخطر للاعتداء الجسدي على الأطفال في المملكة العربية السعودية.

طريقة البحث:

تم جمع إستراتيجية البحث للدراسات المشمولة من خلال مراجعة المقالات المنشورة من عام 1991 الى 2020 في قواعد بيانات PubMed و Google Scholar التي تشير إلى انتشار الإساءة الجسدية للأطفال وعوامل الخطر في المملكة العربية السعودية. من إجمالي 131 مقالة تم البحث في 79 مقالة تم استبعادها بعد فحص عنوان المقالة ، من أصل 52 مقالة تم استبعاد 37 مقالة بعد قراءة الملخص ، من أصل 22 مقالة تمت قراءة النص كامل ، استوفت 15 مقالة فقط معايير التضمين للبحث .تم تلخيص البيانات من المقالات في نموذج يشمل ملخص الدراسات على النحو الآتي : عنوان ونوع الدراسة ، بيانات مجتمع الدراسة، سنة نشر الدراسة، ملخص نتائج الدراسة.

النتائج:

معظم الدراسات التي تم نشرها عن إساءة معاملة الأطفال في المملكة العربية السعودية كانت عبارة عن دراسات استقصاء مقطعي وتقارير لحالات فردية ،والتي تعتبرذا مستوى متدني في التسلسل الهرمي للأدلة البحثية وكان الاعتداء الجسدي على الأطفال هو النمط الأكثرالمبلغ عنه لإساءة معاملة الأطفال حيث يقدر انتشاره بنسبة 47٪. عوامل الخطر المرتبطة بشكل كبير بالاعتداء الجسدي على الأطفال هي وجود تاريخ سابق لتعرض الآباء للاعتداء الجسدي ، الوالدين الاصغر عمرا ، مشاهدة العنف المنزلي ضد أحد أفراد العائلة ، وضعف التحكم في النفس والآباء الذين لم يكن لديهم تملك منزل مقارنة بالآباء الذين يسكنون في منزل مستأجر.

الاستنتاجات:

الاعتداء الجسدي على الأطفال هو الشكل الأكثرالمبلغ عنه لإساءة معاملة الأطفال في المملكة العربية السعودية ، حيث ينتشر بشكل كبير. حيث تعتبرعوامل الخطر له معقدة. ومع ذلك ، يمكن تحديد العديد من عوامل الخطر هذه في وقت مبكر. كما أنه من الممكن تطوير المبادرات والبرامج الوقائية مثل تقديم المشوره للآباء المعرضين لعوامل خطرالاعتداء الجسدي ضد الأطفال . كما يمكن تنفيذ هذه البرامج في أقسام المستشفى المختلفه وخاصة قسم الخدمات الطارئه والرعاية الصحية الأولية.

Background:

Child physical abuse is defined as actions or inactions, which result in actual or potential physical harm, that is within the control of or preventable by the parent, career, or authorized person such as a school teacher [1].

Unfortunately, we noticed that physical child abuse globally, as well as within Saudi Arabia is underreported, there have been limited reports about the prevalence of physical child abuse in Saudi Arabia.

Globally, many studies have been done to assess physical child abuse prevalence. A study has been done in the UK for almost there thousand adults reporting 21% they had physical abuse,11% they had sexual abuse (before age 16 years), 6% had neglected and 6% had emotional abuse. [2]

In 2002 the World Health Organization (WHO) recognized Child abuse and neglect as a global problem, manifested in different forms and deeply rooted in cultures. [3]

A cross-sectional study done in Yamen showed that the prevalence of physical child abuse is a common range from 50-80% [6]

King Abdul-Aziz Medical city in Riyadh belongs to the ministry of the Saudi National Guard health affairs established the national family safety program [8]. The establishment of this program has led to an improvement in the reporting system for physical child abuse cases attending to health care facilities. Nevertheless, recent papers published in Saudi Arabia have reported a continuous increase in the number of such cases annually. [9]

In 2008, the hospital-based child protection teams project proposed by the national family safety program has been approved by the Saudi National Health Council even after, 39 CPTs have been founded in major hospitals across the 13 provinces of Saudi Arabia. [10]

Our recent literature review showed that Risk factors of physical child abuse are multiple and complex, they include parent history of physical child abuse during their childhood, poor coping skill of parent, stressed parent, domestic violence in the family, less educated parent, smoker parent, poor parent impulse control, a child with attention deficit hyperactivity disorders. [11] [12]

This review aims to seek the contents of all relevant updated published articles and reports on physical child abuse in Saudi Arabia from scientific journals and to provide an overview of the extent of this issue and estimates of the prevalence of physical child abuse and its risk factors, identifying knowledge gaps for future research and prevention program development.

Methods:

Search Strategy:

This review was based on studies published in Saudi Arabia between 1991 to 2020. These were primarily observational, analytical studies (prevalence and incidence), case reports, and reviews from different Governmental hospitals.

Inclusion criteria:

1. Studies related to children less than 18- year-old of age

2. Prevalence studies of child abuse at home and in school in Saudi Arabia.

3. Studies on risk factors associated with physical child abuse.

4. Studies published in the English language only.

Electronic searches in the database were the main method of selecting the articles through the PubMed and google scholar. In addition to this, a manual search was also done on relevant books, journals, indexes, and abstracts to extract the required information.

Certain keywords defined the search criteria to make it more specific and accurate like child abuse, physical abuse, child maltreatment, corporal child abuse, risk factors, and Saudi Arabia.

PubMed Search with the following keywords: (child abuse) or (physical abuse) or (child maltreatment) or (corporal child abuse) and (risk factors) and (Saudi Arabia)

A total of 36 articles were reached out by PubMed, in which 19 articles were flawed and they rejected based on inconclusive findings. Again, out of these 17 articles, 5 articles were excluded to include 12 articles on physical child abuse or its risk factors in Saudi Arabia.

Google Scholar search, we search with the following keywords:

"physical child abuse" "risk factors" in "Saudi Arabia" sorted by relevance 95 articles were researched out by google scholar which 62 articles were considered flawed and thus rejected based on inconclusive findings in them. From these 33 articles again 17 articles were excluded to include 16 articles on child abuse which were from Saudi Arabia.

Out of the total of 28 Articles that were searched out by PubMed and Google Scholar 13 articles were excluded because of duplication thus 15 articles were included on physical child abuse and its risk factors in Saudi Arabia.

Articles fulfilling the above criteria were first selected and their abstracts scanned to ensure that it is suitable for inclusion in the study.

The data extraction from the review articles was done based on a selection form. Having categories like title and type of study, demographic data, study population, year of publication, and conclusion.

Finally, an overall assessment of each article was maintained depend on included studies, based on their relevance and appropriateness of each study design and methods which have been used to the stated objectives.

Results:

Physical child abuse is an international prevalent phenomenon. Saudi Arabia has begun to recognize the existence of such a problem and this would be a good beginning to make it a focal point of substantial public and governmental attention. [9]

It has been noticed that in 1990, reporting for the first case of child abuse and neglect occurred in Saudi Arabia [4] however, most child abuse and neglect cases in Saudi Arabia were underreported by health care professionals. [5]

In 1991, an article was published by AlEissa described seven children ranging from five months to seven years of age attending a teaching hospital in Saudi Arabia who had suffered from child abuse and neglect [19]

Eleven reports from all over Saudi Arabia reported 40 child abuse cases; 6 cases with neglect 24 with physical abuse, 4 with MSP cases, and 6 cases with sexual abuse. The fatal outcome was identified in 5 cases. [7]

In 1994, Kattan H, reported 3 physical child abuse cases, 4 cases of child neglect, and one case of sexual assault [7]

In 2007, Al-Mahroos FT, a study was done in Saudi Arabia, eleven case reports were reported, 40 child abuse cases,24 physical child abuse, 6 child neglect cases, and the same number of cases for sexual abuse and 4 Munchaian syndrome by proxy cases. Five children were with high fatal outcome. [6]

Furthermore, he noticed that the highest child abuse fatality rates in cases occurred among poor people pointing to a possible association between low income and child abuse. Less-educated parents, large families, and young parents' age and low family income have been suggested as probable risks. [6]

In 2010 Al Eissa reported that the most common form of child abuse in Saudi Arabia in the first (2000-2004) and second (2005-2006) period was physical abuse at 61% and 76%, respectively. It has been changed in the third (2007-2008) period to neglect 41.6%. perpetrators in most of the cases were Parents at 48.9%. Such a high case was due to mandatory reporting and data collection strategies. [18]

Osama et al, conducted a study in Dammam in 2012 to declare that the total of the child abuse case reports were 87 cases, including a majority of sexual abuse cases (74 cases) followed by other types of abuse like physical. The victim's mean age was 11.04 ±5 years. [20]

Al-Eissa et al, in the 2015 study included 2043 cases, they found the majority of cases of psychological abuse and neglect 1533 and 1021 cases respectively. They found 1175 physical child abuse cases. Lastly 287 sexual abuse cases. Thus, the incidence of physical abuse in this study was (57.5%,), exposure to violence (50.7%) [17]

Retrospectively chart review of case reports for files of the Child Protection Centre between 2009 and 2013 was published by Almuneef et al in 2016 in Riyadh showed the most common form of child abuse was Physical abuse (42%), which has been followed by child neglect (39%), however, child sexual abuse has been reported around (14%), and lastly child emotional abuse (4%) [13].

Nonworking fathers were 2.8 times as likely to use physical abuse toward their children. Besides, Children who live in single/step-parent households were 4 times more to suffer physical abuse [13]

Almuneef et al, conducted a cross-sectional study including all regions of Saudi Arabia in 2017 which showed that physical child abuse (42%) in this study. Witnessing domestic violence against any family member was the most common family dysfunction around (57%) and the least prevalent was living with a parent addicted to substance abuse around (9%) then Less parent's education level and lastly conflict in marital life. [16]

AlDosari et al conducted a study in Riyadh in 2017 which found that almost 18% of the parents used physical punishment for their children. [15]

Several risk factors were associated with physical child abuse, a parent's history of physical abuse during childhood, a witness of domestic violence, poor parent self-control, and a parent who did not own a home. Children will be more prone to physical child abuse child who has attention deficit hyperactivity disorders or child who is difficult to control. [15]

Another cross-sectional study was done in Al-Medina (Al Monawara) in 2017 which showed that children aged 12–16 years old estimated prevalence of physical abuse was estimated to be (72%). However, 42.5% of children (mean age: 9.67 years) were exposed to physical punishment. [14]

Table 1 showed a summary of all previous physical child abuse and its risk factors studies results conducted in Saudi Arabia.

Discussion:

This review summary showed that most child abuse studies that have been published in Saudi Arabia were cross-sectional studies and case reports, the most common form of child abuse was physical abuse, its prevalence estimated to be 47 %.[13] [17] The significant risk factors associated with physical child abuse were parents' history of experience of physical abuse during their childhood, the witness of domestic violence in household family members, poor parent self-control, and the parent who did not own a home and young parent. [13] [17]

Several methodological issues need to be discussed. Limitations for this review, it limited results to within Saudi Arabia and in English language only.

The studies in this review were done on the parent and their children in different regions of Saudi Arabia, who shared a similar background and socioeconomic status. So, we cannot generalize studies results to all other parents

Strength for this review to our knowledge, this study is the first review specifically about Physical child abuse & its risk factors in Saudi Arabia in the last two years. Searching in PubMed database which is one of the major Databases for a high quality of research in medicine and health sciences

When we compare our review, results reported percentage of physical child abuse in Saudi Arabia is similar to physical abuse prevalence reported by the National Longitudinal Study of Adolescent Health study from the United States that prevalence of physical assault and neglect (40.2%) [22]

A study conducted in England and Wales by Michelle Degli Esposti et al in 2019 showed that Physical abuse was the primary reason (8900 [33%] of 27 100 registrations) for a child being placed on a child protection register in 1988–99, then the primary reason became neglect in 2000–16 [23]

Interesting there was an association between the parent who did not own a house and corporal punishment of their children in a study in 2017 in Riyadh by AlDosari et al, it might be an indicator of the low income of the parent. [15]

Whipple et al., found that child physical abuse is associated with stressful life events, parenting stress, and emotional distress. [28] Besides, many stressful situations like anxiety, or depression, may exaggerate the emotional characteristics of the family members affected which may also increase the level of family conflict and abuse. [29]

The National Family Safety Program (NFSP) reported that Physical maltreatment and neglect were slightly more common among boys. [21]

Several risk factors for child abuse have been identified by (NFSP) based on their report in 2016 including 159 (26.3%) cases of divorced parents, 104 (17.2%) of family dysfunction, 66 (10.9%) large family size- more than 6 members, 51 (8.4%) young child's age, 33 (5.4%) poor parental skills, 32 (5.3%) drug abuse, 26 (4.3%) chronic illness/disability of the child, 24 (4%) domestic violence, 19 (3.1%) chronic illness/disability of parents. Also, there were 14 (2.3%) for false social beliefs, 13 (2.1%) young parents, 9 (1.5%) unemployment, 8 (1.3%)

parents' death, and 5 (0.8%) peer violence. There were 42 (6.9%) registered cases with unknown risk factors recognized by child protection teams. [21]

AlDosari M. et al study in 2017 in Saudi Arabia found that parent who using physical punishment toward their children were younger at least five years compared with who did not use physical punishment. [15]

Schumacher et al. study showed that inconclusive results about parent age as risk factors for physical child abuse (24) Several other studies showed younger mothers more prone to physical abuse their children compare with old mothers. [25] [26]

This review showed that parent's childhood history of physical abuse, they were more likely to use physical abuse toward their children. [15] It similar to the previous study in the United States of America that approximately 33% of those exposed to physical abuse during their childhood will expose their children to physical abuse [27]

Implications: as it was shown in the review physical child abuse is prevalent in Saudi Arabia and the causes of physical child abuse are complex. However, early identification of risk factors of physical child abuse can help to develop initiatives for prevention, for example, screening and counseling for the high-risk parent who might physically abuse their children and can be put in primary care practice. Risk factors of Physical child abuse include a wide range of services such as the promotion of community awareness, support of parent education, and home visit for audiences ranging from the general public to individuals who have abused or neglected a child.

It is recommended to have family education programs in primary health care for a newly married couple in addition to community support-based services.

It's advised that based upon this review special attention for those parents who have been physically abused during their childhood as it has been found it is a significantly associated risk factor for them to be hit or physically abuse their children. [15]

We support the idea of parents screening for child physical abuse risk factors in hospital-based (inpatient) or outpatient setting or any child with early sign of violence to have easy convenient access to the resource in healthcare setup or governmental sector to connect an at-risk individual with appropriate support services like social protection in the ministry of social affairs.

Our conclusions, physical child abuse is the most common type of child abuse in Saudi Arabia, it has a high prevalence. Its risk factors are complex. However, many of these risk factors can be identified early. It suggested to have prevention initiatives, like proper screening tools for parents at-risk children and it can be implemented in all hospital service setting especially emergency department and primary health care.

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