European Journal of Dental Education ISSN 1396-5883

Assessment of knowledge and attitudes of dental students in

regard to child abuse in Turkey
E. Hazar Bodrumlu1, A. Avsßar2 and S. Arslan3
1
Department of Pediatric Dentistry, Faculty of Dentistry, Bulent Ecevit University, Zonguldak, Turkey,
2
Department of Pediatric Dentistry, Faculty of Dentistry, Ondokuz Mayıs University, Samsun, Turkey,
3
Department of Biometry, Faculty of Veterinary Medicine, Ondokuz Mayıs University, Samsun, Turkey

keywords Abstract
child abuse; child neglect; dental students.
Introduction: Child abuse is a serious public problem. Signs of abuse are often pre-
Correspondence sent in the oro-facial region and dentists are in a strategic position to recognise and
Ebru Hazar Bodrumlu report suspected cases. The aim of this study was to investigate dental students’ knowl-
Department of Pediatric Dentistry edge about and attitudes towards child abuse.
Faculty of Dentistry
Bulent Ecevit Universty
Material and methods: This study was performed at the Faculty of Dentistry of the
Zonguldak/Turkey
Ondokuz Mayis University. The data were collected through a self-report questionnaire
Tel: +903722613659
administered to dental students (137 female/111 male) in three different dental classes
Fax: +903722613603
e-mail: hazarebru@yahoo.com
(third, fourth and fifth study years) and grouped by considering those students who
have been training in the school year of 2013. The definition of physical and social
Accepted: 20 September 2016 indicators of abuse, awareness regarding legal and ethical responsibilities, students’
experience and requests made by students were evaluated by the students’ response to
doi: 10.1111/eje.12242 questions put in the questionnaire. Descriptive statistics and chi-square tests were per-
formed to analyse the questionnaire data.

Results: The questionnaire completion rate was 100%. About 67.74% of the third
year, 40.71% of the fourth year and 16.67% of the fifth year believed that they could
detect child abuse cases. However, results indicated a major lack of knowledge of social
indicators, signs of physical abuse and reporting procedure amongst all respondents.
The assessment of the total correct answers exhibited significant differences amongst
third-, fourth- and fifth-year students’ answers. Fifth-year students had the highest rate
of correct responses (P < 0.05). Most students wanted to receive more knowledge
about this topic.

Conclusion: Dental students in Turkey are not sufficiently prepared for their role in
diagnosing suspected cases of child abuse.

which he/she is unable to give informed consent, for which the

Introduction
Child abuse is a serious problem that exists amongst all cultural
and socio-economic groups. Child abuse includes various con-
ditions that are threatening or harmful to children. Child abuse
presents as physical, sexual, emotional or psychological trauma.
Physical abuse is defined as any non-accidental injury inflicted
or allowed to be inflicted by a parent or caretaker. Child sexual
abuse and exploitation is defined as the involvement of a child
in sexual activity that he or she does not fully comprehend, to
child is not developmentally prepared, or an activity that vio-
lates the laws or social taboos of society. Psychological mal-
treatment of children is defined as acts of abuse, neglect or
both that convey to a child that he or she is worthless, flawed,
unwanted or unworthy of attention and affection (1, 2). The
World Health Organization stated that approximately 53,000
children were murdered globally in 2002 (3). The National
Society for the Prevention of Cruelty to Children (NSPCC),
which is a large nationwide children’s charity in the United

40 ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Eur J Dent Educ 22 (2018) 40–46
Hazar Bodrumlu et al.
Kingdom and Channel Islands, found that child maltreatment
has affected 5.9% of children under 11 years of age, and 18.6%
of 11- to 17-year-olds in the UK (4). According to an investiga-
tion amongst 7- to 18-year-old children in Turkey, performed
by UNICEF and the Ministry of Social Security, 45% of chil-
dren have experienced physical abuse, 50% of children have
experienced emotional abuse and 25% of children have suffered
from neglect (5). Another study that investigated child abuse
evaluated 16,100 children between four and 12 years in Turkey.
It was reported that the frequency of child abuse was higher in
children of preschool age. Amongst these children, 34.6% of
girls and 32.5% of boys suffered child abuse (6). The study of
Agirtan et al., which evaluated the studies related to child abuse
in Turkey, found that physical or emotional abuse was
observed in 36% of children in a hospital setting and that sex-
ual abuse was observed in 11% of 1,500 high school students
and in 13% of 1,871 female high school students. Although
physical discipline of children is culturally accepted, several
field studies revealed that up to one-third of children in Turkey
are probably physically abused. Intrafamilial sexual abuse
remains highly under-reported to authorities due to social
taboos. Similarly it can be assumed that emotional abuse and
neglect are quite common, considering high rates of domestic
violence, poverty and low educational levels. Overall, public,
professional and government awareness of child abuse and
neglect is low in Turkey (7).
Valente et al. (8) reported that in 2010 and 2011, respec-
tively, 58% and 65% of physical abuse cases involving a family
member presented head and neck injuries in a Southern Brazil-
ian metropolis. This study pointed out the importance of
detecting these injuries by health professionals. Dentists are in
a key position to notice the child abuse, with observable signs
in the head and/or neck area being discernable in the course of
a dental examination (9, 10). In addition, dentists can observe
the characteristic properties of the family because they have a
continued relationship with paediatric patients and their fami-
lies (11).
Because of the excellent position dentists have to detect signs
of child abuse, dental students need to be well trained with
respect to this issue (12).
In Turkey as well as other countries of the world, child abuse
is a very important issue. According to our knowledge, this is
the first study which reports the attitudes and knowledge level
of the dental students about child abuse cases in Turkey.
Hence, the aim of this study was to assess dental students’
knowledge about and their attitudes towards child abuse in
Turkey.
Material and methods
Study design
This research was performed between February and May of
2013, after approval by the dean’s office of the Faculty of Den-
tistry at Ondokuz Mayis University (protocol number:
05.02.2012/000.99-110). The data were collected through a self-
report questionnaire administered to dental students from 3rd
to 5th class (n = 248). Of 248 dental students, 93 were in the
third, 113 in the fourth and 42 in the fifth year of their studies
ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Eur J Dent Educ 22 (2018) 40–46
Knowledge of dental students about child abuse
in the Faculty of Dentistry at Ondokuz Mayis University.
Before handing out the questionnaire, the students were
informed that their participation was voluntary and being
unwilling to participate would not influence their grades. Per-
sonal information was not collected. The questionnaires were
distributed to the students at the end of their lectures. The
average time required to answer the questions was 10 min. The
questionnaire was composed of 29 questions, and it was based
on similar previous studies (12–20).
Questionnaire
The questionnaire consisted of ‘true’ – ‘false’ – ‘I don’t know’
questions or multiple-choice format questions and divided into
the following five parts:
• Part one collected characteristics and demographic informa-
tion of students including gender and year of dental class.
• Part two addressed participants’ knowledge of social and
diagnostic indicators of child abuse.
• Part three assessed students’ attitudes and knowledge related
to legal and ethical responsibilities.
• Part four determined their experience with child abuse.
• The last part of the questionnaire recorded requests by stu-
dents (these requests were mainly about what additional
training they wished to receive).
Statistical analysis
The data were grouped according to the study year of the stu-
dents. All questionnaires answered by the students were coded
numerically and recorded. This was done according to the sec-
tion of individual questions such as gender and year of study
in the survey; responses were coded numerically and classified
(gender classifications coded as male = 1, female = 2; year of
class was coded as follows: third year = 1, fourth year = 2, fifth
year = 3). The reliability of the answers to awareness questions
was determined via estimating the Cronbach a coefficient for
all subjects. Spearman–Brown prediction formula: this formula
was utilised to predict the reliability of test scores which can be
expressed as the ratio of the true-score and total-score vari-
ances. The theoretical value of alpha varies from 0 to 1, because
it is the ratio of two variances. Therefore, higher alpha values
are more desirable. In this study, Cronbach a was estimated as
0.80 or higher for all subjects. For the multiple-choice ques-
tions, subjects were expected to mark more than one option.
Therefore, calculations of the scores for these subjects were
compared with control scores for similar questions. In this
study, all statistical calculations and analyses were performed in
SAS (2009) (SAS Institute Inc., SAS Campus Drive, Cary,
North Carolina 27513, USA). The data were evaluated by group
in all questionnaires and chi-square test was performed to com-
pare groups. Descriptive statistics and frequencies were pre-
sented within the groups (21, 22).
Results
Two hundred and forty-eight dental students answered the
questionnaires, and the response rate was 100%. Table 1 shows
the distribution of respondents according to year of education
41
Knowledge of dental students about child abuse Hazar Bodrumlu et al.

and gender. The answers regarding students’ knowledge of signs major deficiencies in their knowledge of signs of child abuse.
of child abuse associated with year of study are shown in The attitudes of the students are shown in Table 3.
Table 2. In this part, the highest rate of correct answers was The proportion of the students who answered that they knew
given by fifth-year students (P = 0.042). About 67.74% of the the law in Turkey mandates dentists to report cases of child
third-year students, 40.71% of the fourth-year students and abuse is 43.1%, 58.41% and 90.48% for third-, fourth- and
16.67% of the fifth-year students stated ‘I can detect these fifth-year students, respectively. The response to the question
cases’. However, the results showed that students had in fact concerning the legal responsibilities can be seen in Table 4.
About 37.4% of third-year students, 43.5% of fourth-year stu-
dents and 50% of fifth-year students knew where to report
TABLE 1. Distribution of gender and the year of the education of
child abuse, whereas 19% of third-year students, 15% of
students
fourth-year students and 9% of fifth-year students said they did
Year of education not know where to report child abuse.
When the students were asked ‘have you ever had formal
3rd year 4th year 5th year Total training about child abuse’, 2.17% of third-year, 13.27% of
Gender n (%) n (%) n (%) n (%) fourth-year and 21.43% of fifth-year students answered posi-
Female 49 (52.69) 61 (53.98) 27 (64.29) 137 (55.30)
tively.
Male 44 (47.31) 52 (46.02) 15 (35.71) 111 (44.70)
In the fourth part of the questionnaire assessing students’
Total 93 (37.50) 113 (45.56) 42 (16.90) 248 (100) experience of child abuse, 38% of the third year, 6.19% of the
fourth year and 16.67% of the fifth year stated that they had
Statistics: Descriptive statistics and frequencies. suspected child abuse in one or more of their patients.

TABLE 2. Knowledge of the students about physical and social signs of abuse in relation to year of study, presented by percentage of correct responses
to the statement

3rd class 4th class 5th class Total correct

Correct Total Total Total answer
Question response n (%) n (%) n (%) n (%) P value

Bruises on the cheek may indicate slapping or grabbing of the face True 72 (77.42) 78 (69.91) 35 (83.33) 190 (76.8) 0.625
Repeated injury to the dentition resulting in avulsed teeth True 40 (43.01) 80 (70.80) 33 (78.57) 160 (64.15) <0.001
or discoloured teeth may indicate repeated trauma from abuse
Bruises noted around the neck are usually associated False 33 (35.48) 31 (27.43)* 18 (42.86) 87 (35.25) 0.613
with accidental trauma
Child abuse is primarily associated with the stresses of False 27 (29.03) 31 (27.43) 8 (19.05) 62 (25.26) 0.281
poverty and rarely occur amongst middle or high-income earners
Children who have been abused usually tell someone soon after the abuse False 60 (64.52) 66 (58.41) 30 (71.43) 160 (64.78) 0.141
If a child readily states that an adult has caused harm, True 91 (97.85) 92 (82.30) 42 (100) 231 (93.38) 0.005
the accusation should be addressed
Child abuse may be indicated if a parent describes a child’s True 34 (36.56) 54 (47.79) 28 (66.67) 125 (50.34) 0.040
injury as a self-inflicted injury
Child abuse may be indicated if a parent reports a child’s True 41 (44.09) 48 (44.25) 27 (64.29) 126 (50.87) 0.412
injury as a sibling inflicted injury
Child abuse may be indicated if a parent delays seeking True 54 (58.06) 69 (61.06) 33 (78.57) 163 (65.89) 0.231
medical attention for a child’s injury
Child abuse is one of the most relevant cause of paediatric mortality True 8 (8.60) 24 (22.12) 15 (35.71) 55 (22.14) 0.014
Child abuse prevalence is less than Down syndrome prevalence False 19 (20.43) 39 (34.51) 16 (38.10) 77 (31.01) 0.001
Dentists can detect child abuse during their clinical practice True 70 (75.27) 80 (70.80) 39 (92.86) 197 (79.64) 0.035
Additional bruises usually occur in areas overlying False 6 (6.45)* 14 (12.39) 4 (9.52) 70 (28.36) 0.096
bony prominences in abuse victims
The abuser in most cases is someone the child knows well True 61 (65.59) 75 (66.37) 34 (80.95) 176 (70.97) 0.176
The best way to deal with suspected cases of child abuse is False 72 (77.42) 74 (65.49) 37 (88.10) 190 (77) 0.424
to confront the parents and accuse them directly of the abuse
Emotional and psychological signs of abuse may include True 87 (93.55) 92 (81.42) 41 (97.62) 225 (90.86) 0.049
fear of going home or of the parents
A history that is vague and differs every time the parent True 86 (92.47) 89 (78.76) 42 (100) 224 (90.41) 0.003
tells it is a possible indicator of abuse
Total correct answer 50 (54.46) 61 (54.19) 28 (67.50) 0.042

*(P < 0.05).

Statistics: Chi-square analysis.

42 ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Eur J Dent Educ 22 (2018) 40–46
Hazar Bodrumlu et al. Knowledge of dental students about child abuse

TABLE 3. The attitudes of the students regarding child abuse

Question Response 3rd year (%) 4th year (%) 5th year (%)

Health workers should be trained with respect to child abuse Agree 95.85 79.65 97.62
Disagree 1.08 11.50 0
No idea 1.08 8.85 2.38
Dentists should be legally responsible to report child abuse Agree 80.65 75.22 100
Disagree 6.45 9.73 0
No idea 12.90 15.04 0
Dentists have an ethical duty to report child abuse Agree 91.40 88.50 100
Disagree 1.08 3.54 0
No idea 7.53 7.96 0
Professionals failing to make a report when child abuse Agree 74.19 66.37 80.95
is suspected may allow that child to be continuously injured Disagree 16.13 18.58 16.67
No idea 9.68 15.04 2.38

Statistics: Chi-square analysis.

TABLE 4. The knowledge of the students about reporting procedure of formal training about this issue. Consistent with the results of
child abuse in Turkey** the present study, Hashim and Al-Ani reported dental students’
knowledge and experience regarding child abuse in United Arab
Year of study
Where to report child Emirates, and in that study, 91.2% of students stated that they
abuse in Turkey? 3rd (%) 4th (%) 5th (%) P value had not received enough formal education dealing with child
abuse (26). In another study which investigated Croatian dental
Family 33 28 11 0.044 students’ knowledge and education about child abuse, 66.4% of
Family protection department* 37 43 50 0.335 the students reported that they have not come across the topic
Local police 67 62 78 0.201 of child abuse during their university education (27). Thomas
The nearest hospital 15 22 23 0.625 et al. evaluated the knowledge of dental students about child
Don’t know 19 15 9 0.654 abuse, and they reported that 70.5% of dental students learned
*True answer (P < 0.05).
about this issue in classroom settings (12). Although this rate is
**Respondents can multiple choice this question. more than that found in the present study, it still indicates that
Statistics: Chi-square analysis. the knowledge of the students about child abuse is deficient.
According to researchers (12, 27), the reason could be that
Additionally, 5.3% of the fourth year and 4.76% of the fifth although the students learned about child abuse in classrooms,
year stated that they had ignored a suspected case. In this this knowledge was not reinforced under clinical conditions.
study, the level of the knowledge about child abuse increases Students are informed about child abuse for the first time in
along with increasing length of time being trained. The rate of the lessons on paediatric dentistry in the 3rd class curriculum
correct answers is higher amongst the fifth-year students than of the faculty where the present study was conducted. This sub-
for the other classes. Table 5 presents the reasons for not ject is important especially in paediatric dentistry. However, the
reporting child abuse. Table 6 presents the requests by the stu- curriculum should provide dental students with comprehensive
dents for dealing with the issue of child abuse in the future. training in both classroom and clinical settings to detect, report
The topics requested most are ‘information about signs and and manage suspected cases of child abuse throughout their
symptoms’ and ‘information about reporting procedure and careers (28).
legal aspects’ about child abuse. In the present study, when the knowledge of the students
about the physical and social signs of abuse was assessed, it
became clear students lacked information. For example, 25.26%
Discussion
of the students were aware that child abuse can occur amongst
Child abuse is a public health problem, and systematic, science- high-income earners. Child abuse is one of the largest causes of
based, multidisciplinary and sustainable approaches are the best paediatric mortality. About 22.14% of the students in our study
ways for protection from abuse as with other damages and dis- approved this association. Additionally, 35.25% of the respon-
eases. It is found that 61% of the deaths caused by child abuse dents were aware that the bruises noted around the neck are
were preventable (23). If the sufferers of abuse were sent home usually not related to accidental trauma. Similar findings were
without proper evaluation, it was observed that 5—10% of reported by Al-Ani and Hashim, which found that there was a
them were murdered, whereas 35—50% of them had suffered lack of knowledge about the physical and social signs of child
serious damage (24, 25). abuse amongst all respondents (26). Jordan et al. also found
Identifying child abuse is the first and most essential step for less than half of the students responded correctly to the ques-
helping children who are being abused. In the present study, tions regarding their knowledge of signs of child abuse (27). In
2.17% of third-year students, 13.27% of fourth-year students studies from other countries, it was revealed that dental stu-
and 21.43% of fifth-year students stated that they had received dents had insufficient knowledge about child abuse and they

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Eur J Dent Educ 22 (2018) 40–46
Knowledge of dental students about child abuse Hazar Bodrumlu et al.

TABLE 5. The opinions of the students about the reasons for not report- Turkish law requires all healthcare workers, including den-
ing suspicions of child abuse** tists, to report abuse cases. According to the law of Turkey,
healthcare workers are obligated to report suspected cases to a
Year of study
competent authority. If they do not execute these obligations
3rd (%) 4th (%) 5th (%) P value or delay to undertake this action, they can be punished (30).
Hashim and Al-Ani in their research found the majority of
Fear of anger from 63 62 66 0.458 dental students reported that they were legally required to
parents and family report abuse cases (26). Other studies in the literature have
Lack of knowledge regarding 68 54 69 0.127 reported similar findings amongst students (12, 16, 20, 29). In
referral procedure
our study, 43.1% of third-year, 58.41% of fourth-year and
Uncertainty about diagnosis 63 43 54 0.037
90.48% of fifth-year students were aware that they had to
Possible effects on child’s family 13 30 23 0.025
report all suspected cases. Although most of the students were
No legal obligation or 35 34 23 0.585
aware of their legal responsibility, they did not know where
authority to report
they must report cases. About 37.4% of third-year students,
Possible effects on dentist’s 16 29 26 0.231
practice
43.5% of fourth-year and 50% of fifth-year students (close to
Fear of litigation 35 35 42 0.743 50% overall) answered the question correctly stating that sus-
No reason given 5 13 21 0.113 pected cases must be reported to the family protection depart-
ment. The findings of the current study are consistent with
**Respondents can multiple choice this question (P < 0.05). these other studies (12, 20, 26, 29). It is similar to the findings
Statistics: Chi-square analysis. of Hashim and Al-Ani, in which only 36.2% of the students
knew where to report child abuse. Approximately a quarter of
TABLE 6. The requests by the students in the future** the students reported that they did not know the answer (26).
In addition, dental professionals were not always aware of their
Year of study legal obligations to report child abuse, according to the studies
3rd (%) 4th (%) 5th (%) P value of Ramos-Gomez et al. (31) and Deshpande et al. (32). In a
study performed by Al-Dabaan et al. (33) amongst dental prac-
Information about signs 82 62 90 0.001 titioners in Saudi Arabia, it was found that a large proportion
and symptoms (59%) had experienced a case of child abuse in their practice,
Information about reporting 82 63 90 0.005 but only about 10% of these were reported. Their reasons for
procedures not reporting suspected cases were fear of family and lack of
Legal aspects 87 63 92 <0.001 precision about the diagnosis. Cukovic-Bagic et al. (34) sur-
Written form of information 58 41 66 0.018 veyed dentists in Croatia, and they found that 26.27% of the
required dentists reported getting suspicious of child abuse throughout
Verbal information 56 41 66 0.021
their career, and 5.1% of them reported their suspected cases.
Nothing 11 10 0 0.242
Only 11.4% of the dentists knew the procedure. Dalledone
**Respondents can multiple choice this question (P < 0.05). et al. (35) stated that 35.67% of the dentists reported suspected
Statistics: Chi-square analysis. cases to authorities in Brazil. There are many studies from all
over the world which reported similar findings (17, 34–37). In
did not feel ready for their role of protecting children (12, 16, the present study, most of the students stated the reasons for
29). not reporting child abuse were fear of anger from parents and
In the present study, fifth-year students demonstrated more family, lack of knowledge regarding the referral procedure and
knowledge about child abuse when their results were compared uncertainty about the diagnosis.
with the results of third- and fourth-year students. It is con- The limitations of this study include using the declarative
cluded that the upper classes are more interested in the subject. questionnaire and assessing the attitudes of low-level experi-
Similarly, Jordan et al. investigated the educational experiences ment students towards clinical conditions. However, remark-
and knowledge of Croatian dental students about child abuse able results have been obtained. The findings of this study
for all six years of study and they reported that students from revealed that legal knowledge of students should be improved.
more senior years of study had more information than those in It can be presumed that students who are not well trained
more junior years of the study. This can be attributed to the about their legal responsibilities might be less likely to respond
fact that until the fourth year, students are not taught about appropriately when they encounter a case of child abuse. The
clinical conditions in detail (27). students requested more information about the signs and
In the present study, the majority of the students were aware symptoms, reporting procedures and legal aspects of child
of their ethical responsibility towards protecting children from abuse. The willingness of the students in this regard is hopeful
child abuse. They thought that health workers should be for the future.
trained about child abuse and that dentists should be legally
responsible to report child abuse. These results indicate that
Conclusion
future dentists in Turkey are willing to undertake the role of
protecting children against abuse. Al-jundi et al. reported simi- This study discovered a lack of knowledge concerning child
lar findings for dental students in Jordan (16). abuse issues amongst Turkish dental students at Ondokuz

44 ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Eur J Dent Educ 22 (2018) 40–46
Hazar Bodrumlu et al.
Mayis University. The knowledge level of dental students varied
and needs to be improved. The students were not sufficiently
prepared to make the right decisions when they encounter this
problem in their professional careers. The greater proportion of
these students is not well prepared for their crucial role in pro-
tecting children. To provide better care for children who are
abused, dental schools’ curricula should be modified to focus
on improving education of students about detecting and
reporting child abuse using practical educational experiences.
Acknowledgements
This manuscript has been proofread by the BEU (Bulent Ecevit
University) Article Proofreading-Editing Office and professional
editing service.
Conflict of interest
The authors declare no conflict of interest.
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