Knowledge and Attitudes Towards Child Abuse and Neglect Among Dental Students from North Macedonia

Introduction

Children have the right to be protected from any form of abuse, neglect, physical and mental violence; they have the right to health care, treatment, and recovery from illness, drinking water, food, and a clean environment. The United Nations Convention on the Rights of the Child was adopted in 1989, and the Republic of North Macedonia has been a signatory to that international agreement since 1993. In 2003, following the ratification of the two optional protocols, the Government of the Republic of Macedonia committed itself to ensure the fulfilment and protection of children’s rights to develop strategies, policies, and practices for the promotion and protection of children’s rights. In 1989, Article 19 of the United Nations Convention on the Rights of the Child (UNCRC) defined violence as “all forms of physical or mental violence, injury and abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse” [1].

The World Health Organization (WHO) defined violence as “The intentional use of physical force or power, threatened or actual, against oneself, another person, or a group or community, that either results in, or has a high likelihood of resulting in, injury, death, psychological harm, maldevelopment, or deprivation” [2].

In 1999, at a consultation on the prevention of child abuse, the WHO compared definitions of “child abuse” in 58 countries and made the following definition - “Child abuse or bullying is all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting 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”.

In the Republic of North Macedonia, the Law covers legal regulations on protection of children’s rights by the Law on Healthcare, the Law on Prevention and Protection against Domestic Violence, and the Law on Family. However, no law obliges dentists in our country to report any child abuse they notice in their dental practice, as in Croatia with the Law on Dental Activity.

Child abuse and neglect are a major public health issue throughout the world, including North Macedonia [3]. According to statistics obtained from an epidemiological study on child abuse and neglect in 9 Balkan countries with 2, 586 children aged 11, 13, and 16 years, the rate of exposure to psychological violence was 64.6%, to physical violence - 50.6%, to sexual violence - 7.6%, to contact sexual violence - 3.8%, to feeling of being neglected - 27.47%. The past-year prevalence of schoolchildren’s exposure rate for psychological violence in North Macedonia was 60.21%, for physical violence - 42.40%, for sexual violence - 5.44%, for feeling of neglect - 24.90%, and for positive and non-violent parenting - 83.02% [3].

Training communication skills is very important for dental students handling with dental neglect when they have to educate patients about human papilloma virus as an etiological factor for the occurrence of oral cancer, as well as other difficult clinical situations [4]. Ignoring child (dental) neglect by healthcare workers can cause cognitive and social-emotional adverse events and can prevent the cessation of child abuse. In the literature, there is no definition that accurately describes how many teeth must be affected by caries or how many infections should be diagnosed for “dental neglect” [5]. Dentists play a very important role in identifying child abuse as they may be the first healthcare professionals to examine such victims [6].

Adequate education about child abuse and neglect is necessary for the development of social and communication skills of students as well. Moreover, it is associated with the course of forensic medicine in dental education.

As it has already been mentioned, child abuse remains a very important public health issue worldwide, including North Macedonia. To our knowledge, this is the first study which reports dental students’ knowledge and attitude towards child abuse and neglect in North Macedonia.

This study would like to point out the important role of dentists, especially pediatric dentists, in detecting and reporting child abuse and neglect as these injuries are often located in the orofacial region.

The aim of this cross-sectional survey was to investigate undergraduate dental students’ knowledge, attitudes, and behaviors towards child abuse and neglect.

Materials and Methods

Results

Of all 163 dental students who responded to the questionnaires, 117 (71.78%) were females, 46 (28.22%) were males, and the majority were senior students (Table 1).

Students’ attitudes about child abuse depending on the year of study are presented in Table 2. The summary of responses (based on Tables 1 and 2) to the statements exploring participants’ attitudes towards child abuse are presented in Table 3.

The difference depending on the year of study was observed only in the students’ attitude as to whether they would be able to report abuse (p=0.002) (Table 2). No difference depending on the year of study was observed between the attitudes of students who underwent child abuse prevention training (Table 2).

Students’ responses to the knowledge of signs of child physical abuse are listed in Table 4. Correct answers are marked with an asterisk. The questionnaire consisted of 10 questions, with a maximum possible score of 10 points.

The average number of points achieved by the student was 5.94 ± 2.40. According to Bloom’s classification, 48 (29.45%) students had good knowledge, 50 (30.67%) students demonstrated moderate knowledge, and 65 (39.88%) students had poor knowledge of recognizing signs of child physical abuse.

There was no difference in the knowledge between male and female students (p=0.829) or between the years of study (p=0.054).

In addition, there was no difference in scores between students who stated that they had received training on child abuse issues and whether they received any information on how to recognize and diagnose a possible case of abuse during their university education (p=0.659).

Discussion

Despite the high prevalence of child abuse and neglect in developing countries, many cases remain unreported. Therefore, the knowledge, attitude, and experience of dentists regarding child abuse and neglect is critical as they may need to be the first to recognize signs of abuse [11]. The present study is the first study on the dental aspects of child abuse and neglect conducted among dental students in North Macedonia.

In this study, 79.14% of dental students reported a lack of training programs, while 79.75% of students answered that they had never received any information on how to recognize and diagnose a possible case of abuse during their university education. Those results indicated the necessity of adding relevant child abuse content to the curriculum of our faculty. The percentage of students who reported completing training on this issue was 20.86% that was slightly higher than in other studies - 8% in a study of Jordan et al. [12] or 2.17% in that of Hazar et al. [9].

Several previous studies [8, 9, 12, 13, 14] have found that the training of students in this area is still deficient, including insufficient knowledge of the forms, indicators, and symptoms of abused children; therefore, it is necessary to consolidate the theoretical knowledge given during lessons. However, it is important that learning occurs through clinical practice. Dental neglect knowledge is essential for future dentists. In this study, 23.31% of students answered that they did not know what dental neglect was. During their university studies, prospective dental professionals must be trained for this entity and its timely detection.

Only 46.01% of dental students knew what steps to take to report a suspected abuse case. Yet, surprisingly, as many as 88.34% of students were aware of the legal consequences that would follow if a suspicious case was not reported. Child abuse and neglect comes in different forms [1]. For that reason, dental students must be well educated and able to recognize child abuse and neglect in its complexity and in all its varieties.

Dental neglect, as a special subgroup of medical neglect, is the intentional avoidance and/or refusal to provide oral and dental care to achieve non-inflammatory conditions and to establish satisfactory masticatory function [1, 2, 3]. Epidemiological findings of oral health status of primary school children from the two municipalities of Berovo and Pechcevo located in the Eastern region of the Republic of North Macedonia, where the decayed, missing, and filled teeth (DMFT) index was more than 6, while the percentage of untreated caries was 82.93%, suggested possible dental neglect [15]. The mean DMFT index of 4.97 among 15-year-old secondary school children from Veles city [16] and mean DMFT index of 3.47 among 12-year-old primary school children from the Eastern region indicated possible dental neglect as well [17]. In an epidemiological study conducted by Ambarkova in 2013, the percentage of untreated caries or the D/DMFT ratio in 396 primary school children was 0.5324 (53.24%) [17].

Compared to results of a study conducted by Al-Ani [18] among dental students from Hamburg, where more than two-thirds (69.6%) of students responded positively when asked whether a dentist was obligate to report a case of abuse, in our study, that percentage was 97.53%.

In a study conducted by Sulimany et al., 60% of dental students from Saudia Arabia had inadequate knowledge of child abuse and neglect and were not satisfied with child abuse and neglect education they received in dental schools [19]. In our study, 39.88% of students had poor knowledge of recognizing signs of child physical abuse; however, 69.80% of students believed they could re-identify abuse. A lot of studies have examined dentists’ knowledge and skills in recognizing child abuse and neglect, including dental neglect [14, 20, 21]. In a study conducted by Malpani et al. in India, only a small number of dentists identified all the signs of child abuse and neglect although there were many dentists who thought they could handle it [20].

According to Bloom’s classification, dental students in our study had insufficient knowledge of some signs of physical abuse. For example, less than half of respondents (41.72%) knew that bruises on the neck were not associated with accidental trauma. Lack of correct answers to questions about diagnostic indicators and signs of physical abuse shown in Table 4 could be the result of the absence of the topics related to child abuse and neglect in the undergraduate curriculum.

Limitations

There are some limitations to the study: firstly, the sample was not random, and the results could not be generalized to all the dental students from five dental schools in the Republic of North Macedonia; secondly, dental students could perceive questionnaires as examinations, with the possibility of searching the media, journals, or textbooks for correct answers, rather than giving their own experience related to child abuse education; finally, it was not possible to determine if the students were colluding when answering the questions, and we don’t know if the answers were honest.

Conclusions

According to Bloom’s classification, 29.45% of students had good knowledge, 30.67% of students demonstrated moderate knowledge, and 39.88% of students had poor knowledge of recognizing signs of child physical abuse. Almost 98% of participants indicated that dentists were required to report a case of abuse. Only 69.94% of respondents thought they could identify abuse. Furthermore, 88.34% of students agreed that not reporting a case of abuse had consequence. Therefore, the subject that will cover the topics related to recognizing and reporting abused and neglected children from a dental perspective should be part of the curricula at the Dental Faculties in undergraduate and postgraduate education.

By working together with child social protection services, law enforcement institutions, forensic physicians, medical and dental teams, child abuse can be prevented and eliminated.

Ethical Statement

An approval to conduct the study was obtained from the Ethics Committee of the Faculty of Dental Medicine, Saints Cyril & Methodius University.

Informed Consent

The informed consent was obtained from each participant before completing survey.