- Email: [email protected]
Reporting child abuse cases by dentists working in the United Arab Emirates (UAE)
Journal of Forensic and Legal Medicine 40 (2016) 12e15
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j fl m
Original communication
Reporting child abuse cases by dentists working in the United Arab Emirates (UAE) Suhail H. Al-Amad a, *, Manal A. Awad a, Laila H. Al-Farsi b, Rawan H. Elkhaled b a b
College of Dental Medicine, University of Sharjah, United Arab Emirates University Dental Hospital Sharjah, United Arab Emirates
a r t i c l e i n f o
a b s t r a c t
Article history: Received 29 August 2015 Received in revised form 16 November 2015 Accepted 1 January 2016 Available online 22 February 2016
Reporting of suspicious cases of child abuse is a sensitive issue that is often hindered by uncertainty of diagnosis. This cross sectional study aimed to assess the UAE dentists' experiences in child abuse recognition, the factors that prevent them from reporting suspicious cases to authorities and their perceived training needs. A closed-ended, self-administered questionnaire was distributed to 350 dentists working in the UAE. Chi Square test was used to determine association between training needs on child abuse and its reporting rate. Logistic regression was used to determine the association between perceived training needs and other covariates. One hundred and ninety three respondents satisfied the inclusion criteria. Forty seven (25%) dentists reported encountering a suspicious child abuse case at least once in their career, but only 15 (32%) of those reported their suspicion. Fear of making the wrong diagnosis was the most frequent challenge hindering reporting and dentists who demonstrated a need for specialized training were more likely to express this fear (OR ¼ 5.88, 95% CI: 0.07, 0.45; P ¼ 0.00). The majority of UAE dentists do not report their suspicion to authorities and specialized training should be offered to build dentists' capacity in diagnosing and appropriately reporting suspicious child abuse cases. © 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Keywords: Child abuse Education Dentistry Reporting United Arab Emirates
1. Introduction Injuries (intentional and unintentional) are considered to be the most common cause of death in children.1 Frequently, nonaccidental injuries to children occur inside the child's house, and the perpetrator is often one or more of the child's guardians.2,3 The child's inability to independently self-report incidents of violence to authorities and the closed domestic scene of the abuse make early detection and intervention of abused children a challenging task. Studies from various countries showed that the majority of the physically abused children sustain injuries to the head and neck region, making this body part the most common site to manifest violence.4e6 Accordingly, dentists are anticipated to be among the healthcare providers most likely to encounter cases of physical abuse, which can manifest as bruises to the oral mucosa, dental
* Corresponding author. Room M28-132. College of Dental Medicine, University of Sharjah PO box 27272, Sharjah, United Arab Emirates. E-mail address: [email protected] (S.H. Al-Amad).
trauma and/or alveolar fractures. This is evident from surveys conducted in various countries, which showed that between 13%7 and 50%8,9 of dental practitioners see cases of suspected child abuse, but less than half of those actually report those cases to authorities (Table 1). To many dentists, reporting of suspicious child abuse cases is hindered by the fears of making the wrong diagnosis, litigation and other negative impacts on the dentist's practice or the dentist's relationship with their patients.7e10 In the United Arab Emirates UAE, healthcare providers are permitted to breach patient's confidentiality by reporting to the authorities cases of violence if this breach is believed to be necessary to prevent a crime according to a new law on medical responsibility which was introduced in late 2008.11 In fact, the country's Penal code obligates healthcare providers to report injuries, even when those injuries are merely suspicious.12 Despite those immunities from litigation, healthcare workers in the UAE expressed their reluctance to report injuries due to their confusion over the clinical signs of abuse, as well as the ambiguity of reporting pathways in this country.13 This indecisive attitude comes at the determent of the abused child, and infers a deficiency in the healthcare provider's training on the recognition and intervention
http://dx.doi.org/10.1016/j.jflm.2016.01.033 1752-928X/© 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
S.H. Al-Amad et al. / Journal of Forensic and Legal Medicine 40 (2016) 12e15
13
Table 1 Dentists' experiences with regards to suspecting and reporting child abuse in various countries. City/State
Scotland3 Greece7
Jordan8 Texas9 London10 Victoria18 Croatia19 Denmark20 California21 Nigeria22 KSA23 Jordan24
Sample size
375
368
256
383
105
347
29% Percentage of dentists who indicated suspecting a child abuse case Percentage of dentists who 8% reported their suspicion
13%
50%
50%
15%
28%
26.20%
1.60% 12%
25%
7%
8%
5.10%
of child abuse. Furthermore, healthcare in the UAE is being provided by medical and dental personnel coming from a diversity of educational backgrounds from multiple nations,14 resulting in a non-standard approach to such sensitive cases. Although dental practitioners are considered to be situated at the forefront of detecting cases of child abuse, the knowledge and experiences of UAE dentists in this regard have not been previously investigated. Therefore, the objectives of this cross sectional survey were to have an appreciation of the UAE's dentists' experiences with regards to child abuse, the reasons that would hinder them from reporting suspicious cases to authorities and their perceived training needs in this field.
2. Materials and methods 2.1. Study sample A cross sectional survey was conducted on dentists working in various clinics in the public and private sectors in the seven emirates of the UAE. The UAE is a developing country in the Arabian peninsula with an approximate population of 8.3 million, of whom 7.3 million are expatriates.14 Data from the UAE's National Bureau of Statistics shows that there are around 2500 dentists registered in the UAE. A convenience sample of 350 dentists from private and public sectors were invited to participate in this survey. To ensure diversity, the sample consisted of dentists working in the public and private sectors from the seven emirates.
2.2. Survey tool
510
1145 38.3%
11%
2005
2.3. Data analysis ®
®
IBM SPSS Statistics (version 22) (IBM Corporation) was used for statistical analysis. Chi Square test was used for categorical variables. Logistic regression test was used to determine the association between perceived training needs and other covariates. Pvalue was significant if <0.05.
122
340
16%
39.40%
47%
42%
6%
6.90%
10%
20%
Total 6131 Overall average 33% Overall average 10%
3. Results One hundred and fifty seven dentists were excluded from this survey either because they did not return a completed questionnaire (n ¼ 149) or because they indicated that they don't treat children (n ¼ 8). One hundred and ninety three dentists returned a completed questionnaire, and were considered the study sample (response rate 55%), the demographic characteristics of whom are shown in Table 2. Those showed diversity in terms of sex, age, sector and geographical location, and hence can be considered representative. Forty seven participants (25%) indicated that they have recognized a case of suspicious child abuse at least once during their career and less than one third of those did report the case(s), mostly to the parents (Table 3). Making the wrong diagnosis of the abuse was ranked as the most important challenge facing dentists when they encounter a suspicious case of child abuse, while getting in trouble with authorities and losing patients were the least important challenges (Table 4). Dentists' who indicated that they did not recognize cases of child abuse during their career were significantly more likely to indicate their need for specialized training in this field (p ¼ 0.006) (Table 5). On the other hand, dentists who ranked wrong diagnosis of child abuse as the most important challenge were 5.88 times more likely to express the need for training in child abuse compared to those who did not indicate the need for such training (95% CI: 0.07, 0.45) (Table 6). Furthermore, participants who Table 2 Characteristics of study participants. Variable
A self-administered, closed-ended questionnaire was developed to assess the dentists' experiences with child abuse and the reasons for reluctance in referring suspicious cases when such cases are encountered. The questionnaire was pilot-tested on a small sample for consistency and understandability, and modified accordingly. The questionnaire consisted of four sections. The first section enquired about the participants' demographic characteristics and professional profile. The second section enquired about the perceived training need on child abuse. The third and fourth sections enquired about previous experiences with child abuse, and the challenges related to child abuse reporting, respectively.
175
Sex Male Female Age 35 >35 Years of Dental Practice <10 years 10years Specialty General Practitioner Specialist Practice sector Private Public Both Practice location (Emirate) Abu Dhabi Dubai Sharjah Fujairah Ajman Um Al Quwain Ras Al Khaimah
N (%) 110 (58) 83 (42) 88 (46) 94 (54) 79 (41) 114 (59) 100 (52) 92 (48) 112 (58) 49 (26) 32 (16) 85 46 33 10 8 8 3
(44) (24) (17) (5) (4) (4) (2)
14
S.H. Al-Amad et al. / Journal of Forensic and Legal Medicine 40 (2016) 12e15 Table 3 Experiences with child abuse. Question
Table 6 Logistic regression analysis for the association between dentists' perceived need of training in child abusea and other participants' characteristics.
N (%)
Variable
Have you encountered a suspicious case of child abuse? Yes 47 (25) No 146 (75) If yes, have you reported it? Yes 15 (32) No 32 (68) Who did you report the case to? Parents 8 (56) Official 3 (22) Official abuse authorities 4 (22) Police 0 (0) Do you think you need training in child abuse? Yes 123 (65) No 70 (35)
Table 4 The strongest causes for not reporting child abuse, if a case is suspected. Reasons for not reporting
Ranking of each reason N (%)
I was afraid that my diagnosis of abuse is wrong I did not know to whom to report I did not know how to take history about the injury I was afraid I would get in trouble with the parents I was worried that reporting a suspicious case would lead to further violence I was worried about losing the patient and his/her family I was worried about getting in trouble with authorities
61 41 34 31 25
(32) (21) (17) (16) (13)
4 (2) 2 (1)
N: Number of dentists who choose this cause as the most important.
Table 5 Crosstab showing a significant association between the dentists' perceived needs for training on child abuse recognition and their experience in child abuse recognition. Do you feel you need training in child abuse recognition?
Have you ever recognized a suspicious case of child abuse? *
Yes No
OR
Sex Male 0.94 Femaleb Age <35 1.20 35b Number of years of dental practice <10 years 1.45 10 yearsb Sufficient undergraduate training No 6.04 Yesb Wrong diagnosis of abuse Most Important 5.88 Othersb
Yes (N; %)
No (N; %)
Total
22 (47.8%) 101 (70.1%)*
24 (52.2%) 43 (29.9%)
46 (100%) 144 (100%)
P ¼ 0.006.
indicated that they did not receive adequate undergraduate training in child abuse recognition were 6.04 times more likely to express the need for training on this topic (95% CI: 2.88, 12.69) (Table 6). The perceived need for child abuse training was independent from the participants' sex, age and number of years of clinical practice.
4. Discussion Domestic violence is a serious public health problem, which in some cases resulted in victim's severe morbidity or death. Healthcare providers are considered to be at a unique position to recognize and report cases of violence, particularly those inflicted on children. Authorities are unable to intervene early and to protect children from further harm unless suspicious cases are professionally detected and reported to them. Because the majority of childhood injuries are located in the head and neck area, including the mouth and face,4e6 it is plausible that dentists are among the healthcare providers most likely to encounter those injuries. Twelve surveys from various countries investigated a total of 6131 dental practitioners' experiences in recognizing cases of suspicious child abuse and the reasons for
95% CI
P-value
0.45, 1.96
0.86
0.40, 3.76
0.74
0.52, 4.04
0.47
2.88,12.69
0.00
0.07, 0.45
0.00
No: reference category. a Perceived need response. b Reference categories.
reluctance in reporting them. The overall results show that between 13% and 50% (overall average 33%) of dentists have suspected a case of child abuse during their practice, but only an overall average of 10% of them actually reported it (Table 1). This is similar to our findings in which 25% of our sample recognized a suspicious case and almost one third of those reported their findings. Reporting of suspicious cases to authorities is mandatory according to article 273 of the Federal Law No. 3 (penal code),12 which penalizes healthcare providers for not reporting injuries that they treat, if the injuries or the circumstances were suspicious. Additionally, healthcare providers have been given immunity from prosecution if they breach patient's confidentiality when reporting injuries, if the purpose of their reporting was to prevent a crime.11 Previous studies have shown that the reluctance in reporting suspicious cases by dentists is attributed to a number of factors, such as uncertainty about the diagnosis of abuse, fear of parental retaliation on the child and/or upsetting the parents.7e10 In our sample, almost three quarters ranked reasons attributed to insufficient training in this field as factors for not reporting, including: fear of making the wrong diagnosis (32%), not knowing whom to report to (21%), and lacking abuse-specific history-taking skills (17%) (Table 4). In order to enhance reporting of child abuse, dentists must become confident in detecting, documenting and knowing to where suspicious cases should be reported. This can only be achieved through specialized training. Sixty five percent of our sample indicated that they need training in child abuse detection and reporting. This perceived need for training was significantly associated with insufficient training on this topic during the dentists' undergraduate education (OR 6.04; 95% CI 2.88, 12.69; P ¼ 0.00). Deficiencies in the medico-legal aspects of dentistry have been recognized in dental curricula and efforts are needed to design and implement appropriate educational tools in this regard at least at the undergraduate level.16 Our sample's perceived need for training in child abuse reveals two interesting findings. Firstly, a positive relationship is seen between the dentists' perceived need for training and their experiences in recognizing a suspicious case of child abuse, in which insufficient training has been leading to less recognition of cases of child abuse, and hence less reporting (p ¼ 0.006) (Table 5). Secondly, the need for training was associated with the dentists' uncertainty of making the correct diagnosis of abuse. Dentists who feared making the wrong diagnosis were almost 6 times more likely to indicate their need for training in this field. This relationship was independent from age, sex and years of clinical
S.H. Al-Amad et al. / Journal of Forensic and Legal Medicine 40 (2016) 12e15
experience (OR 5.88; 95% CI 0.07, 0.45; P ¼ 0.00) (Table 6). Those findings highlight the importance of structuring child abuse training programs for dentists to build their professional capacity to diagnose and report suspected child abuse case with confidence, and hence improve the outcome for the abused child. Another interesting finding of this study is that more than half the dentists who reported their suspicion did so to the parents rather than to government or police authorities. This finding is of a particular concern, since the statistics from the Dubai Foundation for Woman and Children indicate that the vast majority of the abused children who were admitted to the foundation were abused by one of their parents.15 Reporting to the parents, who frequently happen to be the abusers, indicates that even dentists who were less reluctant in taking the action of reporting, were doing so to the wrong terminus. This highlights yet another challenge related to reporting child abuse by dentists, one that is related to the reporting authority. The diversity of educational backgrounds of healthcare providers in the UAE and the segregation of health licensing authorities in this country leave medical and dental practitioners divided with regards to their medico-legal obligations, specifically with regards to which injuries they should report to authorities. Furthermore, the UAE, being based on a federation of seven emirates, each with its own local government, has at least three organizations handling cases of child abuse. Medical practitioners in the UAE have expressed ambiguity as to whom they should be reporting a child abuse case when they suspect one.17 Whilst our study shows that a structured training program is both desired and essential to improve the detection and the reporting of child abuse, such programs would remain deficient in the absence of clear and precise reporting channels and a unified reporting authority dedicated to those types of cases. Among the invited dentists, only 55% responded and satisfied the inclusion criteria. Nevertheless, the study sample did represent the distribution of the dental community across the UAE by having dentists practicing in the private and public sectors from all of the seven emirates. That being said, the relatively low response rate can be a manifestation of bias in that dentists who had experience with cases of suspected child abuse would be more willing to participate in this survey than those who did not. Although this can be viewed as a limitation of this study, consistency was observed between the percentages of dentists who encountered and reported cases of suspected child in the UAE with those reported in various countries (Table 1). This research investigates the UAE dentists' experiences and educational needs in child abuse. Despite legal protection, the results of this study reveal a low rate of reporting suspected cases, which is mainly attributed to lack of confidence in diagnosing abuse and uncertainly of the reporting terminus. Although capacity building programs in the forms of improving undergraduate dental curricula and organizing continuing education programs are essential, ambiguity related to where cases should be referred to must be eliminated in order to manage those sensitive cases successfully. To the best of our knowledge, this is the first survey study conducted on dentists in the UAE on this topic. Acknowledgment The authors acknowledge the work of Dr. Afnan Ahmed, Dr. Aseel Latif, Dr. Mousa Ateyah, Dr. Nadine Ghattas and Dr. Rania Hassan who contributed to this study by collecting data. Conflict of interest The authors declare that they have no financial, economic or professional interests that may have influenced the design, execution or presentation of this study.
15
Funding None.
Ethical approval None.
References 1. Committee on Child Abuse and Neglect, Committee on Injury, Violence, and Poison Prevention, Council on Community Pediatrics, American Academy of Pediatrics. Policy statement-child fatality review. Pediatrics 2010;126(3): 592e6. 2. Naidoo S. A profile of the oro-facial injuries in child physical abuse at a children's hospital. Child Abuse Negl 2000;24(4):521e34. 3. Cairns AM, Mok JY, Welbury RR. Injuries to the head, face, mouth and neck in physically abused children in a community setting. Int J Paediatr Dent 2005;15(5):310e8. 4. Jessee SA. Physical manifestation of child abuse to the head, face and mouth: a hospital survey. ASDC J Dent Chil 1995;62(4):245e9. 5. Cavalcanti AL. Prevalence and characteristics of injuries to the head and orofacial region in physically abused children and adolescents. Dent Traumatol 2010;26(2):149e53. 6. da Fonseca MA, Feigal RJ, ten Bensel RW. Dental aspects of 1248 cases of child maltreatment on file at a major county hospital. Pediatr Dent 1992;14(3): 152e7. 7. Laud A, Gizani S, Maragkou S, Welbury R, Papagiannoulis L. Child protection training, experience, and personal views of dentists in the prefecture of Attica, Greece. Int J Paediatr Dent 2013;23(1):64e71. 8. Sonbol HN, Abu-Ghazaleh S, Rajab LD, Baqain ZH, Saman R, Al-Bitar ZB. Knowledge, educational experiences and attitudes towards child abuse amongst Jordanian dentists. Eur J Dent Educ 2012;16(1):e158e65. 9. Bsoul SA, Flint DJ, Dove SB, Senn DR, Alder ME. Reporting of child abuse: a follow-up survey of Texas dentists. Pediatr Dent 2003;25(6):541e5. 10. Al-Habsi SA, Roberts GJ, Attari N, Parekh S. A survey of attitudes, knowledge and practice of dentists in London towards child protection. Are children receiving dental treatment at the Eastman Dental Hospital likely to be on the child protection register? Br Dent J 2009, 28;206(4). 11. Benomran F. Medical responsibility in the United Arab Emirates. J Forensic Leg Med 2010;17(4):188e93. 12. Article 273, Federal Law No. 3 of 1987 on issuance of the penal code. https:// www.icrc.org/ihl-nat/6fa4d35e5e3025394125673e00508143/ e656047207c93f99c12576b2003ab8c1/$FILE/Penal%20Code.pdf. [accessed on 28.08.15]. 13. Nereim V. Doctors frustrated over abuse of children in the UAE. The National newspaper (28 September 2012). http://www.thenational.ae/news/uae-news/ health/doctors-frustrated-over-abuse-of-children-in-the-uae. [accessed 20.06.15]. 14. United Arab Emirates. National Bureau of Statistics. 2010. http://www. uaestatistics.gov.ae/ReportPDF/Population%20Estimates%202006%20-%202010. pdf [accessed 20.06.15]. 15. Dubai Foundation For Women And Children. DWAFC 2nd annual report. 2009. p. 25. http://www.dfwac.ae/en/?page_id¼655 [accessed 20.06.15]. 16. Ivanoff CS, Hottel TL. Comprehensive training in suspected child abuse and neglect for dental students: a hybrid curriculum. J Dent Educ 2013;77(6): 695e705. 17. National Editorial. Make it easier to report. The National newspaper; 25 December 2012. http://www.thenational.ae/thenationalconversation/editorial/ make-it-easier-to-report-child-abuse [accessed 20.06.15]. 18. John V, Messer LB, Arora R, Fung S, Hatzis E, Nguyen T. Child abuse and dentistry: a study of knowledge and attitudes among dentists in Victoria, Australia. Aust Dent J 1999;44(4):259e67. 19. Cukovic-Bagic I, Dumancic J, Kujundzic Tiljak M, Drvaric I, Boric B, Kopic V. Croatian dentists' knowledge, experience, and attitudes in regard to child abuse and neglect. Int J Paediatr Dent 2014;15. http://dx.doi.org/10.1111/ ipd.12151. 20. Uldum B, Christensen HN, Welbury R, Poulsen S. Danish dentists' and dental hygienists' knowledge of and experience with suspicion of child abuse or neglect. Int J Paediatr Dent 2010;20(5):361e5. 21. Ramos-Gomez F, Rothman D, Blain S. Knowledge and attitudes among California dental care providers regarding child abuse and neglect. J Am Dent Assoc 1998;129(3):340e8. 22. Bankole OO, Denloye OO, Adeyemi AT. Child abuse and dentistry: a study of knowledge and attitudes among Nigerian dentists. Afr J Med Med Sci 2008;37(2):125e34. 23. Al-Dabaan R, Newton JT, Asimakopoulou K. Knowledge, attitudes, and experience of dentists living in Saudi Arabia toward child abuse and neglect. Saudi Dent J 2014;26(3):79e87. 24. Owais AI, Qudeimat MA, Qodceih S. Dentists' involvement in identification and reporting of child physical abuse: Jordan as a case study. Int J Paediatr Dent 2009;19(4):291e6.
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j fl m
Original communication
Reporting child abuse cases by dentists working in the United Arab Emirates (UAE) Suhail H. Al-Amad a, *, Manal A. Awad a, Laila H. Al-Farsi b, Rawan H. Elkhaled b a b
College of Dental Medicine, University of Sharjah, United Arab Emirates University Dental Hospital Sharjah, United Arab Emirates
a r t i c l e i n f o
a b s t r a c t
Article history: Received 29 August 2015 Received in revised form 16 November 2015 Accepted 1 January 2016 Available online 22 February 2016
Reporting of suspicious cases of child abuse is a sensitive issue that is often hindered by uncertainty of diagnosis. This cross sectional study aimed to assess the UAE dentists' experiences in child abuse recognition, the factors that prevent them from reporting suspicious cases to authorities and their perceived training needs. A closed-ended, self-administered questionnaire was distributed to 350 dentists working in the UAE. Chi Square test was used to determine association between training needs on child abuse and its reporting rate. Logistic regression was used to determine the association between perceived training needs and other covariates. One hundred and ninety three respondents satisfied the inclusion criteria. Forty seven (25%) dentists reported encountering a suspicious child abuse case at least once in their career, but only 15 (32%) of those reported their suspicion. Fear of making the wrong diagnosis was the most frequent challenge hindering reporting and dentists who demonstrated a need for specialized training were more likely to express this fear (OR ¼ 5.88, 95% CI: 0.07, 0.45; P ¼ 0.00). The majority of UAE dentists do not report their suspicion to authorities and specialized training should be offered to build dentists' capacity in diagnosing and appropriately reporting suspicious child abuse cases. © 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Keywords: Child abuse Education Dentistry Reporting United Arab Emirates
1. Introduction Injuries (intentional and unintentional) are considered to be the most common cause of death in children.1 Frequently, nonaccidental injuries to children occur inside the child's house, and the perpetrator is often one or more of the child's guardians.2,3 The child's inability to independently self-report incidents of violence to authorities and the closed domestic scene of the abuse make early detection and intervention of abused children a challenging task. Studies from various countries showed that the majority of the physically abused children sustain injuries to the head and neck region, making this body part the most common site to manifest violence.4e6 Accordingly, dentists are anticipated to be among the healthcare providers most likely to encounter cases of physical abuse, which can manifest as bruises to the oral mucosa, dental
* Corresponding author. Room M28-132. College of Dental Medicine, University of Sharjah PO box 27272, Sharjah, United Arab Emirates. E-mail address: [email protected] (S.H. Al-Amad).
trauma and/or alveolar fractures. This is evident from surveys conducted in various countries, which showed that between 13%7 and 50%8,9 of dental practitioners see cases of suspected child abuse, but less than half of those actually report those cases to authorities (Table 1). To many dentists, reporting of suspicious child abuse cases is hindered by the fears of making the wrong diagnosis, litigation and other negative impacts on the dentist's practice or the dentist's relationship with their patients.7e10 In the United Arab Emirates UAE, healthcare providers are permitted to breach patient's confidentiality by reporting to the authorities cases of violence if this breach is believed to be necessary to prevent a crime according to a new law on medical responsibility which was introduced in late 2008.11 In fact, the country's Penal code obligates healthcare providers to report injuries, even when those injuries are merely suspicious.12 Despite those immunities from litigation, healthcare workers in the UAE expressed their reluctance to report injuries due to their confusion over the clinical signs of abuse, as well as the ambiguity of reporting pathways in this country.13 This indecisive attitude comes at the determent of the abused child, and infers a deficiency in the healthcare provider's training on the recognition and intervention
http://dx.doi.org/10.1016/j.jflm.2016.01.033 1752-928X/© 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
S.H. Al-Amad et al. / Journal of Forensic and Legal Medicine 40 (2016) 12e15
13
Table 1 Dentists' experiences with regards to suspecting and reporting child abuse in various countries. City/State
Scotland3 Greece7
Jordan8 Texas9 London10 Victoria18 Croatia19 Denmark20 California21 Nigeria22 KSA23 Jordan24
Sample size
375
368
256
383
105
347
29% Percentage of dentists who indicated suspecting a child abuse case Percentage of dentists who 8% reported their suspicion
13%
50%
50%
15%
28%
26.20%
1.60% 12%
25%
7%
8%
5.10%
of child abuse. Furthermore, healthcare in the UAE is being provided by medical and dental personnel coming from a diversity of educational backgrounds from multiple nations,14 resulting in a non-standard approach to such sensitive cases. Although dental practitioners are considered to be situated at the forefront of detecting cases of child abuse, the knowledge and experiences of UAE dentists in this regard have not been previously investigated. Therefore, the objectives of this cross sectional survey were to have an appreciation of the UAE's dentists' experiences with regards to child abuse, the reasons that would hinder them from reporting suspicious cases to authorities and their perceived training needs in this field.
2. Materials and methods 2.1. Study sample A cross sectional survey was conducted on dentists working in various clinics in the public and private sectors in the seven emirates of the UAE. The UAE is a developing country in the Arabian peninsula with an approximate population of 8.3 million, of whom 7.3 million are expatriates.14 Data from the UAE's National Bureau of Statistics shows that there are around 2500 dentists registered in the UAE. A convenience sample of 350 dentists from private and public sectors were invited to participate in this survey. To ensure diversity, the sample consisted of dentists working in the public and private sectors from the seven emirates.
2.2. Survey tool
510
1145 38.3%
11%
2005
2.3. Data analysis ®
®
IBM SPSS Statistics (version 22) (IBM Corporation) was used for statistical analysis. Chi Square test was used for categorical variables. Logistic regression test was used to determine the association between perceived training needs and other covariates. Pvalue was significant if <0.05.
122
340
16%
39.40%
47%
42%
6%
6.90%
10%
20%
Total 6131 Overall average 33% Overall average 10%
3. Results One hundred and fifty seven dentists were excluded from this survey either because they did not return a completed questionnaire (n ¼ 149) or because they indicated that they don't treat children (n ¼ 8). One hundred and ninety three dentists returned a completed questionnaire, and were considered the study sample (response rate 55%), the demographic characteristics of whom are shown in Table 2. Those showed diversity in terms of sex, age, sector and geographical location, and hence can be considered representative. Forty seven participants (25%) indicated that they have recognized a case of suspicious child abuse at least once during their career and less than one third of those did report the case(s), mostly to the parents (Table 3). Making the wrong diagnosis of the abuse was ranked as the most important challenge facing dentists when they encounter a suspicious case of child abuse, while getting in trouble with authorities and losing patients were the least important challenges (Table 4). Dentists' who indicated that they did not recognize cases of child abuse during their career were significantly more likely to indicate their need for specialized training in this field (p ¼ 0.006) (Table 5). On the other hand, dentists who ranked wrong diagnosis of child abuse as the most important challenge were 5.88 times more likely to express the need for training in child abuse compared to those who did not indicate the need for such training (95% CI: 0.07, 0.45) (Table 6). Furthermore, participants who Table 2 Characteristics of study participants. Variable
A self-administered, closed-ended questionnaire was developed to assess the dentists' experiences with child abuse and the reasons for reluctance in referring suspicious cases when such cases are encountered. The questionnaire was pilot-tested on a small sample for consistency and understandability, and modified accordingly. The questionnaire consisted of four sections. The first section enquired about the participants' demographic characteristics and professional profile. The second section enquired about the perceived training need on child abuse. The third and fourth sections enquired about previous experiences with child abuse, and the challenges related to child abuse reporting, respectively.
175
Sex Male Female Age 35 >35 Years of Dental Practice <10 years 10years Specialty General Practitioner Specialist Practice sector Private Public Both Practice location (Emirate) Abu Dhabi Dubai Sharjah Fujairah Ajman Um Al Quwain Ras Al Khaimah
N (%) 110 (58) 83 (42) 88 (46) 94 (54) 79 (41) 114 (59) 100 (52) 92 (48) 112 (58) 49 (26) 32 (16) 85 46 33 10 8 8 3
(44) (24) (17) (5) (4) (4) (2)
14
S.H. Al-Amad et al. / Journal of Forensic and Legal Medicine 40 (2016) 12e15 Table 3 Experiences with child abuse. Question
Table 6 Logistic regression analysis for the association between dentists' perceived need of training in child abusea and other participants' characteristics.
N (%)
Variable
Have you encountered a suspicious case of child abuse? Yes 47 (25) No 146 (75) If yes, have you reported it? Yes 15 (32) No 32 (68) Who did you report the case to? Parents 8 (56) Official 3 (22) Official abuse authorities 4 (22) Police 0 (0) Do you think you need training in child abuse? Yes 123 (65) No 70 (35)
Table 4 The strongest causes for not reporting child abuse, if a case is suspected. Reasons for not reporting
Ranking of each reason N (%)
I was afraid that my diagnosis of abuse is wrong I did not know to whom to report I did not know how to take history about the injury I was afraid I would get in trouble with the parents I was worried that reporting a suspicious case would lead to further violence I was worried about losing the patient and his/her family I was worried about getting in trouble with authorities
61 41 34 31 25
(32) (21) (17) (16) (13)
4 (2) 2 (1)
N: Number of dentists who choose this cause as the most important.
Table 5 Crosstab showing a significant association between the dentists' perceived needs for training on child abuse recognition and their experience in child abuse recognition. Do you feel you need training in child abuse recognition?
Have you ever recognized a suspicious case of child abuse? *
Yes No
OR
Sex Male 0.94 Femaleb Age <35 1.20 35b Number of years of dental practice <10 years 1.45 10 yearsb Sufficient undergraduate training No 6.04 Yesb Wrong diagnosis of abuse Most Important 5.88 Othersb
Yes (N; %)
No (N; %)
Total
22 (47.8%) 101 (70.1%)*
24 (52.2%) 43 (29.9%)
46 (100%) 144 (100%)
P ¼ 0.006.
indicated that they did not receive adequate undergraduate training in child abuse recognition were 6.04 times more likely to express the need for training on this topic (95% CI: 2.88, 12.69) (Table 6). The perceived need for child abuse training was independent from the participants' sex, age and number of years of clinical practice.
4. Discussion Domestic violence is a serious public health problem, which in some cases resulted in victim's severe morbidity or death. Healthcare providers are considered to be at a unique position to recognize and report cases of violence, particularly those inflicted on children. Authorities are unable to intervene early and to protect children from further harm unless suspicious cases are professionally detected and reported to them. Because the majority of childhood injuries are located in the head and neck area, including the mouth and face,4e6 it is plausible that dentists are among the healthcare providers most likely to encounter those injuries. Twelve surveys from various countries investigated a total of 6131 dental practitioners' experiences in recognizing cases of suspicious child abuse and the reasons for
95% CI
P-value
0.45, 1.96
0.86
0.40, 3.76
0.74
0.52, 4.04
0.47
2.88,12.69
0.00
0.07, 0.45
0.00
No: reference category. a Perceived need response. b Reference categories.
reluctance in reporting them. The overall results show that between 13% and 50% (overall average 33%) of dentists have suspected a case of child abuse during their practice, but only an overall average of 10% of them actually reported it (Table 1). This is similar to our findings in which 25% of our sample recognized a suspicious case and almost one third of those reported their findings. Reporting of suspicious cases to authorities is mandatory according to article 273 of the Federal Law No. 3 (penal code),12 which penalizes healthcare providers for not reporting injuries that they treat, if the injuries or the circumstances were suspicious. Additionally, healthcare providers have been given immunity from prosecution if they breach patient's confidentiality when reporting injuries, if the purpose of their reporting was to prevent a crime.11 Previous studies have shown that the reluctance in reporting suspicious cases by dentists is attributed to a number of factors, such as uncertainty about the diagnosis of abuse, fear of parental retaliation on the child and/or upsetting the parents.7e10 In our sample, almost three quarters ranked reasons attributed to insufficient training in this field as factors for not reporting, including: fear of making the wrong diagnosis (32%), not knowing whom to report to (21%), and lacking abuse-specific history-taking skills (17%) (Table 4). In order to enhance reporting of child abuse, dentists must become confident in detecting, documenting and knowing to where suspicious cases should be reported. This can only be achieved through specialized training. Sixty five percent of our sample indicated that they need training in child abuse detection and reporting. This perceived need for training was significantly associated with insufficient training on this topic during the dentists' undergraduate education (OR 6.04; 95% CI 2.88, 12.69; P ¼ 0.00). Deficiencies in the medico-legal aspects of dentistry have been recognized in dental curricula and efforts are needed to design and implement appropriate educational tools in this regard at least at the undergraduate level.16 Our sample's perceived need for training in child abuse reveals two interesting findings. Firstly, a positive relationship is seen between the dentists' perceived need for training and their experiences in recognizing a suspicious case of child abuse, in which insufficient training has been leading to less recognition of cases of child abuse, and hence less reporting (p ¼ 0.006) (Table 5). Secondly, the need for training was associated with the dentists' uncertainty of making the correct diagnosis of abuse. Dentists who feared making the wrong diagnosis were almost 6 times more likely to indicate their need for training in this field. This relationship was independent from age, sex and years of clinical
S.H. Al-Amad et al. / Journal of Forensic and Legal Medicine 40 (2016) 12e15
experience (OR 5.88; 95% CI 0.07, 0.45; P ¼ 0.00) (Table 6). Those findings highlight the importance of structuring child abuse training programs for dentists to build their professional capacity to diagnose and report suspected child abuse case with confidence, and hence improve the outcome for the abused child. Another interesting finding of this study is that more than half the dentists who reported their suspicion did so to the parents rather than to government or police authorities. This finding is of a particular concern, since the statistics from the Dubai Foundation for Woman and Children indicate that the vast majority of the abused children who were admitted to the foundation were abused by one of their parents.15 Reporting to the parents, who frequently happen to be the abusers, indicates that even dentists who were less reluctant in taking the action of reporting, were doing so to the wrong terminus. This highlights yet another challenge related to reporting child abuse by dentists, one that is related to the reporting authority. The diversity of educational backgrounds of healthcare providers in the UAE and the segregation of health licensing authorities in this country leave medical and dental practitioners divided with regards to their medico-legal obligations, specifically with regards to which injuries they should report to authorities. Furthermore, the UAE, being based on a federation of seven emirates, each with its own local government, has at least three organizations handling cases of child abuse. Medical practitioners in the UAE have expressed ambiguity as to whom they should be reporting a child abuse case when they suspect one.17 Whilst our study shows that a structured training program is both desired and essential to improve the detection and the reporting of child abuse, such programs would remain deficient in the absence of clear and precise reporting channels and a unified reporting authority dedicated to those types of cases. Among the invited dentists, only 55% responded and satisfied the inclusion criteria. Nevertheless, the study sample did represent the distribution of the dental community across the UAE by having dentists practicing in the private and public sectors from all of the seven emirates. That being said, the relatively low response rate can be a manifestation of bias in that dentists who had experience with cases of suspected child abuse would be more willing to participate in this survey than those who did not. Although this can be viewed as a limitation of this study, consistency was observed between the percentages of dentists who encountered and reported cases of suspected child in the UAE with those reported in various countries (Table 1). This research investigates the UAE dentists' experiences and educational needs in child abuse. Despite legal protection, the results of this study reveal a low rate of reporting suspected cases, which is mainly attributed to lack of confidence in diagnosing abuse and uncertainly of the reporting terminus. Although capacity building programs in the forms of improving undergraduate dental curricula and organizing continuing education programs are essential, ambiguity related to where cases should be referred to must be eliminated in order to manage those sensitive cases successfully. To the best of our knowledge, this is the first survey study conducted on dentists in the UAE on this topic. Acknowledgment The authors acknowledge the work of Dr. Afnan Ahmed, Dr. Aseel Latif, Dr. Mousa Ateyah, Dr. Nadine Ghattas and Dr. Rania Hassan who contributed to this study by collecting data. Conflict of interest The authors declare that they have no financial, economic or professional interests that may have influenced the design, execution or presentation of this study.
15
Funding None.
Ethical approval None.
References 1. Committee on Child Abuse and Neglect, Committee on Injury, Violence, and Poison Prevention, Council on Community Pediatrics, American Academy of Pediatrics. Policy statement-child fatality review. Pediatrics 2010;126(3): 592e6. 2. Naidoo S. A profile of the oro-facial injuries in child physical abuse at a children's hospital. Child Abuse Negl 2000;24(4):521e34. 3. Cairns AM, Mok JY, Welbury RR. Injuries to the head, face, mouth and neck in physically abused children in a community setting. Int J Paediatr Dent 2005;15(5):310e8. 4. Jessee SA. Physical manifestation of child abuse to the head, face and mouth: a hospital survey. ASDC J Dent Chil 1995;62(4):245e9. 5. Cavalcanti AL. Prevalence and characteristics of injuries to the head and orofacial region in physically abused children and adolescents. Dent Traumatol 2010;26(2):149e53. 6. da Fonseca MA, Feigal RJ, ten Bensel RW. Dental aspects of 1248 cases of child maltreatment on file at a major county hospital. Pediatr Dent 1992;14(3): 152e7. 7. Laud A, Gizani S, Maragkou S, Welbury R, Papagiannoulis L. Child protection training, experience, and personal views of dentists in the prefecture of Attica, Greece. Int J Paediatr Dent 2013;23(1):64e71. 8. Sonbol HN, Abu-Ghazaleh S, Rajab LD, Baqain ZH, Saman R, Al-Bitar ZB. Knowledge, educational experiences and attitudes towards child abuse amongst Jordanian dentists. Eur J Dent Educ 2012;16(1):e158e65. 9. Bsoul SA, Flint DJ, Dove SB, Senn DR, Alder ME. Reporting of child abuse: a follow-up survey of Texas dentists. Pediatr Dent 2003;25(6):541e5. 10. Al-Habsi SA, Roberts GJ, Attari N, Parekh S. A survey of attitudes, knowledge and practice of dentists in London towards child protection. Are children receiving dental treatment at the Eastman Dental Hospital likely to be on the child protection register? Br Dent J 2009, 28;206(4). 11. Benomran F. Medical responsibility in the United Arab Emirates. J Forensic Leg Med 2010;17(4):188e93. 12. Article 273, Federal Law No. 3 of 1987 on issuance of the penal code. https:// www.icrc.org/ihl-nat/6fa4d35e5e3025394125673e00508143/ e656047207c93f99c12576b2003ab8c1/$FILE/Penal%20Code.pdf. [accessed on 28.08.15]. 13. Nereim V. Doctors frustrated over abuse of children in the UAE. The National newspaper (28 September 2012). http://www.thenational.ae/news/uae-news/ health/doctors-frustrated-over-abuse-of-children-in-the-uae. [accessed 20.06.15]. 14. United Arab Emirates. National Bureau of Statistics. 2010. http://www. uaestatistics.gov.ae/ReportPDF/Population%20Estimates%202006%20-%202010. pdf [accessed 20.06.15]. 15. Dubai Foundation For Women And Children. DWAFC 2nd annual report. 2009. p. 25. http://www.dfwac.ae/en/?page_id¼655 [accessed 20.06.15]. 16. Ivanoff CS, Hottel TL. Comprehensive training in suspected child abuse and neglect for dental students: a hybrid curriculum. J Dent Educ 2013;77(6): 695e705. 17. National Editorial. Make it easier to report. The National newspaper; 25 December 2012. http://www.thenational.ae/thenationalconversation/editorial/ make-it-easier-to-report-child-abuse [accessed 20.06.15]. 18. John V, Messer LB, Arora R, Fung S, Hatzis E, Nguyen T. Child abuse and dentistry: a study of knowledge and attitudes among dentists in Victoria, Australia. Aust Dent J 1999;44(4):259e67. 19. Cukovic-Bagic I, Dumancic J, Kujundzic Tiljak M, Drvaric I, Boric B, Kopic V. Croatian dentists' knowledge, experience, and attitudes in regard to child abuse and neglect. Int J Paediatr Dent 2014;15. http://dx.doi.org/10.1111/ ipd.12151. 20. Uldum B, Christensen HN, Welbury R, Poulsen S. Danish dentists' and dental hygienists' knowledge of and experience with suspicion of child abuse or neglect. Int J Paediatr Dent 2010;20(5):361e5. 21. Ramos-Gomez F, Rothman D, Blain S. Knowledge and attitudes among California dental care providers regarding child abuse and neglect. J Am Dent Assoc 1998;129(3):340e8. 22. Bankole OO, Denloye OO, Adeyemi AT. Child abuse and dentistry: a study of knowledge and attitudes among Nigerian dentists. Afr J Med Med Sci 2008;37(2):125e34. 23. Al-Dabaan R, Newton JT, Asimakopoulou K. Knowledge, attitudes, and experience of dentists living in Saudi Arabia toward child abuse and neglect. Saudi Dent J 2014;26(3):79e87. 24. Owais AI, Qudeimat MA, Qodceih S. Dentists' involvement in identification and reporting of child physical abuse: Jordan as a case study. Int J Paediatr Dent 2009;19(4):291e6.