INTRODUCTION
Exposure to sexual harassment or abuse, particularly among school students, is a major public health issue owing to its potential negative impact on the students' physical and mental health. Exposure to sexual abuse is known to increase the risk of the victims to depression, violence, substance abuse, and various psychological comorbidities.[1 2 1 3 4 5
In an Islamic country like Saudi Arabia where sexual abuse is religiously prohibited, victims of sexual abuse may not report their abuse for fear of bad reputation and social stigma, particularly if they were young students. Sexual abuse in Islamic countries is considered a critical issue that may not be self-reported to responsible authorities and forensic bodies. Victims would tend to conceal the event of sexual abuse and subsequently will be prone to depression, violence, or even suicide.[6 7
Furthermore, both school educators and the vast majority of parents fail to provide adequate scientific knowledge regarding sexual abuse for young individuals. Schools in Saudi Arabia are deficient in education programs about sexual health, and teaching self-protection from sexual assault might be the first introduction to the children about this issue.[8 9
In a recent study, the participants mentioned the bullying or physical violence in Saudi Arabia and importance of communication between family members to decrease child maltreatment.[10
Thus, it was fundamental to conduct a large-scale population survey to study the prevalence of sexual harassment among Saudi students and to explore their awareness and knowledge about sexual abuse. To the best of our knowledge, there is no large-scale population study in Saudi Arabia that was carried out to address this potentially critical issue. Hence, the aim of this research was to assess knowledge and attitude toward sexual harassment and to create awareness among middle and secondary school students in Makkah, Jeddah, and Al-Madinah in the Kingdom of Saudi Arabia (KSA).
SUBJECTS AND METHODS
Study design
This is a descriptive cross-sectional study conducted at selected middle and secondary schools in Makkah, Jeddah, and Al-Madinah based on educational administration official approval in the period of 3 months from January to March 2018.
Sampling
The target population: Students in all levels (from the first, middle, to third secondary year) who accepted to participate in the study from both sexes
The exact number of all students in all middle and secondary public schools was obtained from official websites of related General Departments of Education (http://www.medu.sa, http://www.makkah.gov.sa/page/jeddah)
Online sample size calculator (http://www.surveysystem.com/sscalc.htm) Table 1 ].
Table 1: Sample size of the studied groups in Makkah and Al-Madinah Provinces, 2018
Study participants
Inclusion criteria: Saudis, students in middle and secondary public schools
Exclusion criteria: Non-Saudi, students in Quran recitation schools.
Ethical approval
Ethical approval was obtained at Taibah Medical College Ethical Committee, Al-Madinah
Official approval was obtained from each of the General Departments of Education, Ministry of Education, in the three regions. The corresponding departments selected the participating schools representing different regions in each city.
Informed consent was offered for all participants guardians before conducting the survey as most of the students were less than 18 years old after explaining the aim and nature of the study.
Data collection tool
Data were collected through a predesigned self-administered face-to-face questionnaire
The validity and reliability of the questionnaire were tested through a pilot study, in which fifty students from all levels were randomly selected to explore if there is any ambiguity or items leading to misunderstanding in the questionnaire in order to reach its current final form.
Methods
Nearly fifty medical students, from the 5th and 6th years in corresponding cities, distributed the questionnaire to approximately 27,000 students at selected schools. As data collectors and active field members, they received a lecture from the authors in areas related to ethical conduct, confidentiality protection, performing of anonymous questionnaire, methodology and aim of the current study.
An introductory ten-minutes pre-questionnaire presentation was presented by data collectors to students to define sexual harassment, followed by questionnaire administration.
Social supervisors in the involved schools were invited to provide postquestionnaire awareness and clarifications of misnomers for some forms of harassment
Participants were allowed to withdraw from the study if they chose not to continue without any consequences
Postquestionnaire Ministry of Health pursue for harassment awareness (in the form of descriptive flyers) was distributed to all participants to ensure the proper delivery of needed information and conveying proper modes of reporting to authorities.
Statistical analysis
Data analysis was carried out using statistical package for the social sciences (IBM SPSS®, IBM Corporation, USA). Descriptive analysis were expressed as frequency, percentages and standard deviations. Categorical variables were tested using Chi square and Student's t test.
RESULTS
The response rate was 99.4% from all the 27,000 distributed questionnaires. The participants from middle and secondary schools were nearly equal as they represented 49.8% and 50.2%, respectively. In addition, the sample was almost even distribution between both sexes as shown in Table 2 .
Table 2: Sociodemographics, knowledge, and attitudes of all participants
As for residency, 34.6%, 32.9%, and 32.5% of the respondents were from Jeddah, Makkah, and Al-Madinah, respectively [Table 2 ]. Regarding the educational level, students at first-, second-, and third-grade middle schools constituted 12.5%, 21.4%, and 16.1% of the sample, respectively. First-, second-, and third-grade secondary school students constituted 15.1%, 17.2%, and 17.9%, respectively [Table 2 ].
Studying the students' knowledge and awareness about sexual harassment, the vast majority reported that the scientific papers (38.7%) and their friends' experience (35.2%) were their main sources of information. On comparing data from the three studied cities and among all studied groups [Tables 2 and 3 ], the source of knowledge about sexual harassment was significantly different. Students in Al-Madinah reported that they got information mainly from scientific papers (58.81%), whereas students in Jeddah and Makkah got their information mainly from their friends (51.88% and 46.44%, respectively) (P < 0.001). Students' age was a significant determinant for the source of knowledge about sexual harassment. For instance, it was obvious from the results that the higher the age, the more the percentage of students getting information from scientific papers (44.4% of students aged 14–18 years and 71.3% of students aged above 18 years). Gender was another determinant of the source of knowledge. Of note, females were more likely to get their knowledge from friends (38.9%), whereas males were more likely to get information from scientific magazines (59.8%) (P < 0.001).
Table 3: Sociodemographics, knowledge, and attitudes among participants according to their city of residency
Knowledge of all three major categories of sexual harassment came first among both sexes at all ages and for all residencies, followed by sexual, verbal, and nonverbal forms (11.6%, 8.7%, and 4.7%, respectively) [Tables 2 -4 ]. Choice of others revealed the need for clear definitions of types and subtypes of harassments as many of the mentioned types were other names for the major types.
Table 4: Sociodemographics, knowledge and attitudes among participants according to their age groups
Astonishingly 47.66% of the respondents gave no response for whether they should tell their parents if they were exposed to harassment or not, whereas 41% of the respondents thought they could not tell their parents. Al-Madinah respondents were the highest by 92.6% refusal to inform their parents, 87.8% of them attributed that to their ignorance of the problem's magnitude, whereas 82.66% saw that harassment should be reported to authorities of which 37.9% thought that reporting to authorities is by calling police at 999 [Tables 2 and 3 ].
DISCUSSION
To the best of our knowledge, this is the first large-scale population study conducted in Saudi Arabia to explore knowledge and awareness of middle and secondary school students about sexual abuse in three of the largest cities in KSA (Jeddah, Makkah, and Al-Madinah).
The results from this study showed a significant lack of knowledge and awareness about sexual harassment among Saudi students and a generally negative attitude toward this issue. For instance, more than one-third of the studied students (35.2%) were getting their information from their friends. This was evident among female students from Jeddah and Makkah. This is of particular importance to health-care authorities, and it prompts the necessity of an urgent implication of a health education program that targets these populations. Older male students in Makkah seemed to be more aware of sexual abuse and to have a correct source of information about this issue unlike many of the middle (preparatory) students.
Students in Eastern countries unlike those from developed countries get their knowledge about sex and sexual harassment from school and parents.[11 12 13 et al . in their study of Vietnamese high school students, they reported that the main sources of information about sex were school (62%) parents (37%).[14
On the contrary, reports from different countries like India, Iran, and China stated that friends, internet, and siblings were the main sources of sexual knowledge among students.[15 16 17 18 19
Moreover, 11% of the students reported that they would confess exposure to sexual harassment to their parents. This result is very critical because it reflects a significant lack of communication between the students and their parents and the need for attitude change and modification. Such a result may be attributed to the fact that parents in KSA and different Islamic countries set cultural prohibitions on discussing sexual-related issues and harassment is considered a stigma.[20 21 22 23
Moreover, the results of this study threw light on importance of raising scientific-educational campaigns on sexual harassment knowledge and awareness. In addition, it was noted that the source of knowledge gained varied significantly among cities. Al-Madinah students were the most likely to receive information from media and scientific sources, whereas students from Jeddah and Makkah had their knowledge mainly from friends. This is important when considering implying health education problem because, despite the necessity of adopting an extensive health education program in all cities, health-care authorities should also be aware that in Makkah and Jeddah, the educational programs are fundamental.
CONCLUSION
The results of this study revealed a significant lack of knowledge and awareness about sexual harassment among school students in Saudi Arabia, associated with a negative attitude toward reporting or confessing the harassment.
Age, gender, and residency were significant determinants of the level of awareness and the variable attitudes toward sexual harassment.
Recommendations
Health-care, media, and social authorities are highly recommended to adopt health education strategies as illustrated posters, pursuers, and organization of media events that target those vulnerable students and their parents to improve their knowledge about sexual harassment, to modulate their attitudes toward this problem, and to change the parents' cultural prohibitions on discussing sexual-related issues.
Improvement of national antisexual harassment policy is highly recommended, according to the needs of different age groups, as discussed in the current work. It is necessary to expand quantitative and qualitative research on sexual harassment. A nationwide survey is needed to assess the whole problem in different regions, to measure the needed psychological, to evaluate the progress of social support services, and to adopt social change culture toward reporting of these events and dealing with its consequences.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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