Primary Health Care Physicians' Knowledge, Attitudes, Practices of Screening for Adverse Childhood Experiences (ACEs) in Qatar and barriers to implementation: a Cross-Sectional Study

Primary Health Care Physicians' Knowledge, Attitudes, Practices of Screening for Adverse Childhood Experiences (ACEs) in Qatar and barriers to implementation: a Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Primary Health Care Physicians' Knowledge, Attitudes, Practices of Screening for Adverse Childhood Experiences (ACEs) in Qatar and barriers to implementation: a Cross-Sectional Study Usra Elshaikh, Hafiz Ahmed Mohamed, Hanan F. Abdul Rahim This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8861367/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Adverse Childhood Experiences (ACEs) profoundly affect lifelong health, yet primary care screening remains underutilized globally. As the first study in Qatar examining this issue, we assessed knowledge, attitudes, practices (KAP) and barriers regarding ACEs screening among Primary Health Care Corporation (PHCC) physicians. Methods A cross-sectional survey was conducted in January 2024 among family medicine and well-baby clinic physicians across all PHCC centers. The validated questionnaire assessed demographics, KAP, and barriers, analyzed through the Theoretical Domains Framework. Statistical analyses included descriptive statistics and cluster-adjusted regression models. Results Of the 205 participating physicians, most lacked formal training on ACEs, with 66% unfamiliar with the ACE questionnaire. Knowledge increased significantly with PHCC experience (p = 0.043). Attitudes were generally positive with a mean score of 37.2, with 91% believing ACEs should be addressed in primary care. However, only 59% had screened within PHCC settings, primarily using symptom-triggered approaches (67%) rather than routine screening (5%). Major barriers included insufficient time (78%), absence of response protocols (53.7%), and inadequate mental health resources (33.2%). Most physicians (83%) supported universal screening across age groups, with 75% expressing interest in further education. Conclusion Despite positive attitudes toward ACEs screening, significant knowledge gaps and implementation barriers limit practice in Qatar's primary care settings. Prioritizing trauma-informed education, standardized protocols, and resource allocation may enhance screening implementation. These findings provide a foundation for Qatar and similar healthcare systems to integrate ACEs screening into preventive care, aligning with global best practices. Further research should evaluate culturally adapted interventions and long-term outcomes. Adverse Childhood Experiences primary care screening barriers trauma-informed care Qatar Introduction Adverse Childhood Experiences (ACEs) represent a critical global public health challenge with profound implications for health. Defined by Centers for Disease Control and Prevention as potentially traumatic events occurring before age 18, ACEs encompass abuse, neglect, and household dysfunction [ 1 ]. Globally, adverse childhood experiences are highly prevalent. A recent systematic review estimated that nearly half (48%) of children experience at least one ACE [ 2 ]. While regional data are limited, a study in Saudi Arabia indicated high prevalence of psychological abuse (74.9%), physical abuse (57.5%), and exposure to violence (50.7%) among adolescents [ 3 ]. The lifelong health consequences of ACEs are profound. Exposure to childhood adversity increases the risk of chronic diseases in adulthood, including cardiovascular disease, chronic lung disease, and premature mortality [ 4 , 5 ]. The neurobiological impact manifests early, with studies demonstrating associations between ACEs and decreased brain volume, altered functional connectivity, and elevated cortisol levels in children [ 6 , 7 ]. Additionally, exposure to ACEs predispositions individuals to anxiety disorders, depression, post-traumatic stress disorder, substance use disorders, and suicidal behaviors [ 8 , 9 ]. The economic burden is significant, with CDC estimating lifetime cost of child maltreatment cases in the United States at $ 124–585 billion, with ACEs-related costs exceeding 1% of GDP in many countries [ 10 , 11 ]. Primary health care is uniquely positioned to address ACEs through different levels of prevention. Screening for ACEs fulfills established criteria for evidence-based screening programs: high prevalence, reliable identification methods, and available early interventions [ 12 ]. Health policy has evolved to include ACEs screening, with leading US and UK health organizations now recommending it and California establishing the first universal screening requirement for children under the age of 18 [ 13 ]. Despite the value of incorporating ACEs screening into routine primary care, where it creates opportunities for patients to discuss early adversity, reflect on its health impacts, and receive empathetic clinical support, implementation remains inconsistent [ 14 ]. Research reveals significant gaps in physician screening practices globally. In the United States, fewer than 30% of family physicians routinely screen adult patients for ACEs, despite 79% acknowledging it as part of their role [ 15 ]. Similarly, Canadian family medicine residents screen less frequently than practicing physicians, with both groups disproportionately screening female patients [ 16 ]. Screening rates also vary substantially by specialty, with psychiatrists reporting higher rates than family physicians [ 17 ]. Regional studies reveal similar gaps. Among Saudi pediatricians, one-third had no child sexual abuse training, and nearly half had never examined a child for abuse [ 18 ]. Another study found suboptimal knowledge of reporting procedures [ 19 ]. In Kuwait, while half of pediatricians encountered maltreatment cases, over 80% were unaware of mandatory reporting laws [ 20 ]. Understanding ACEs screening implementation requires a theoretical framework that systematically examines factors influencing clinical behavior. The Theoretical Domains Framework (TDF), developed by behavioral scientists and implementation researchers, provides a comprehensive approach to identifying determinants of practice change [ 21 ]. Applying the TDF to ACEs screening can assist in systematically identifying and informing targeted implementation strategies. The State of Qatar's healthcare system, with primary care centralized under the PHCC, presents a critical, unstudied context for ACEs screening. No data exist on physician KAP and barriers in this setting. To address this gap, this study aims to comprehensively examine PHCC physicians' KAP regarding ACEs screening in Qatar. The specific objectives are to evaluate physicians' knowledge of ACEs and their health consequences, assess attitudes toward ACEs screening, including perceived importance and feasibility, determine the prevalence of current screening practices, characterize screening approaches, and identify barriers to implementation. Methods Study design and population A cross-sectional survey was conducted among all eligible family medicine and well-baby clinic physicians employed across Qatar's PHCC centers. The study was designed and reported in accordance with the STROBE guidelines. The survey attempted a census approach, including all physicians in the target population. Survey instrument A structured questionnaire was developed to assess PHC physicians' demographics, knowledge, attitudes, practices, and barriers regarding ACEs screening. The instrument was informed by a literature review and adapted from validated tools, including the Adverse Childhood Experiences International Questionnaire (ACE-IQ)[ 22 ], the Physician Experiences with ACEs questionnaire (PEA-Q)[ 23 ], and a barriers instrument from a preexisting study[ 16 ]. The ACE-IQ's validated, comprehensive domains ensured broad coverage of ACEs[ 22 ]. The PEA-Q provided a framework for assessing physician attitudes and experiences across five key categories[ 23 ]. The final survey instrument was organized into six thematic sections as shown in Appendix A. The first section captured demographic characteristics, including sex, age, nationality, professional experience, practice setting, and patient load. The second section assessed knowledge of ACEs, covering familiarity, prior training, and understanding of health impacts. The third section evaluated attitudes using a 10-item scale adapted from the PEA-Q and mapped to TDF constructs. Additionally, the survey addressed screening context, clinical practices, and implementation barriers. Pilot test The questionnaire was pilot-tested with 11 community medicine residents to assess face and content validity, including clarity, structure, and acceptability. Feedback indicated the questions were generally clear and the length appropriate. Suggested improvements included refining question wording and expanding response options for greater comprehensiveness. The instrument was revised to incorporate the feedback. Questionnaire implementation A questionnaire was administered across all PHCC health centers in January 2024. Hard copies of questionnaires, accompanied by an information sheet and a mandatory consent form, were distributed. The research team visited all centers to disseminate questionnaires in clinics or during meetings to maximize reach. The lead physician at each center was contacted for support, and the total number of eligible physicians was recorded to track the response rate. Anonymity was maintained to minimize response bias by not collecting names and by having questionnaires returned anonymously via a drop-off box at each center. Follow-ups were conducted at centers with low response rates to address non-response bias and questionnaires were collected after a two-week period for data entry. Primary outcomes The primary outcomes were physicians' KAP regarding ACEs. Knowledge was assessed using a 4-item scale, with a total score calculated from assigned point values. Attitudes were measured via a 10-item scale, with the aggregate score reflecting perspectives on ACEs screening. Practices were evaluated using a 7-item scale, where the total score quantified engagement in screening behaviors. Secondary outcomes Secondary outcomes included: 1) the prevalence of ACEs screening, determined by a binary (yes/no) response to whether a physician conducts screening; and 2) reported barriers to implementation, identified through a structured survey quantifying predefined obstacles and an open-ended question for additional unlisted barriers. Ethical approval and confidentiality Ethical approval was obtained from the PHCC ethics committee (BUHOOTH-D-23-00031) and Qatar University Institutional Review Board (QU-IRB 1920-E/23). The survey posed minimal risk, as participants were not asked to disclose personal experiences with ACEs but rather their professional screening practices. The questionnaire length was optimized to minimize participant burden, and contact information was provided for any inquiries. All responses were anonymized to ensure confidentiality. Statistical analysis Descriptive statistics summarized physician responses. Continuous data were reported as mean ± standard deviation (SD) and median with interquartile range (IQR). Categorical variables were presented as frequencies and percentages. Missing data were minimal (< 5% for nationality, which was excluded from analysis due to interpretive limitations). An attitudes score (range: 10–50) was computed from ten 5-point Likert-scale questions, with negatively worded items reverse-scored. The score's distribution was characterized using measures of central tendency and variability. A random-effects model estimated the intraclass correlation coefficient (ICC) to quantify within-health-center clustering. The association between attitudes scores and predictors (sex, experience, knowledge) was assessed using linear regression, adjusted for health center clustering. The relationship between knowledge and predictor variables was examined using cluster-adjusted chi-square tests and univariate logistic regression. Results Participant demographics and characteristics A total of 205 physicians participated in this survey, constituting a 34% overall response rate that varied between health centers. Demographic and professional characteristics are summarized in Table 1 . Participants had a median age of 45 years and were predominantly male (64%). The participant’s nationalities were diverse, primarily from Europe (40%), North Africa (26%), and the Middle East (21%). The median post-graduation experience among physicians was 11 years. Experience within the PHCC system was distributed evenly with 37% having less than 5 years of experience, 35% had 6–10 years, and 28% had 11 or more years. Most physicians (56%) reported a daily patient load exceeding 26 patients. The vast majority (93%) practiced in family medicine outpatient clinics, with many also working in well-baby (40%) or other specialized clinics (18%). Table 1 Participant demographics and characteristics of study participants (n = 205) Respondent Characteristic Sex, n (%) Female 73 (35.61%) Male 132 (64.39%) Age (years) Median (IQR) 45 (40, 49) Nationality, n(%) Europe 82 (40.00%) North Africa 54 (26.34%) Middle East 43 (20.98%) North America 7 (3.41%) Asia 7 (3.41%) Australia & Oceania 2 (0.98%) Total years of experience post grad Median (IQR) 11 (6, 18) Years of experience at PHCC, n(%) ≤ 5 76 (37.07%) 6–10 72 (35.12%) 11–15 26 (12.68%) > 15 31 (15.12%) Number of patients daily, n(%) < 15 12 (5.85%) 15–25 78 (38.05%) ≥ 26 115 (56.10%) Practice setting, n(%) Family medicine 191 (93.17%) Well baby clinic 83 (40.48%) Others (CDC, Emergency clinic, Triage, NCD, etc) 38 (18.53%) IQR: interquartile range; SD: Standard deviation; CDC: Communicable diseases center; NDC: Non-Communicable Disease Physicians' knowledge of ACEs screening Knowledge of ACEs was limited among surveyed physicians. Approximately two-thirds (66%) were unfamiliar with the ACE questionnaire, and 70% reported no formal education/training on the topic during their medical education or professional development. Awareness of health conditions linked to ACEs varied substantially, with more detailed in Appendix B. Most physicians recognized associations with mental health disorders, including generalized anxiety (85%) and depression (80%). Awareness of physical health consequences was markedly lower. Fewer than 21% identified connections to chronic diseases such as diabetes, or asthma, and less than 13% were aware of links to stroke or cancer. Knowledge was not significantly associated with gender (p = 0.548), age group (p = 0.239), or practice setting (p = 0.472). However, a significant association emerged with years of PHCC experience (p = 0.029). Univariate mixed-effects logistic regression analyses, adjusted for health center clustering, are presented in Table 2 . Years of experience at PHCC was a significant predictor (p = 0.043). Compared to physicians with ≤ 5 years of experience, those with 6–10 years (OR = 2.08), 11–15 years (OR = 2.97), and > 15 years (OR = 2.85) demonstrated significantly higher odds of ACEs knowledge. Due to the limited sample size, a multivariate model adjusting for potential confounders was not feasible. Table 2 Predictors of physician’s knowledge on ACEs. Physician’ knowledge* Variable OR‡ 95% CI P-value Gender Female Male Ref 1.20 - 0.65–2.20 0.5536 Age 30–39 40–49 50–59 60+ Ref 1.40 1.74 3.16 0.66–2.96 0.66–4.57 0.96–10.46 0.2750 Years of experience at the PHCC ≤ 5 6–10 11–15 > 15 Ref 2.08 2.97 2.85 1.01 – 4.27 1.16–7.62 1.17–6.95 0.0432 PHCC setting FM/WB/Others FM and WB Others only FM only FM and others WB only WB and others 2.12 0.98 0.53 Ref 1.59 2.12 1 0.73–6.14 0.49–1.94 0.05–4.93 - 0.51–4.95 0.40–11.07 (empty) 0.6051 *Binary outcome (knowledge yes/no) ‡Adjusted odds of knowledge accounting for clustering of health centers Physicians' attitudes towards ACEs screening For the questionnaire section assessing attitudes reliability analysis indicated questionable internal consistency (Cronbach’s α = 0.57). As shown in Table 3 physicians demonstrated generally positive attitudes toward ACEs screening. Most physicians (91%) agreed on the importance of addressing ACEs in primary care. Attitude scores ranged from 26 to 50 (mean = 37.2, SD = 4.094). A cluster-adjusted linear regression examined associations between attitude scores and physician characteristics in Table 4 . No significant associations were observed between attitude scores and gender (p = 0.934) or age (p = 0.959). A marginal association was found with years of PHCC experience (p = 0.050). Table 3. Physician’s attitudes regarding ACEs screening Please indicate your level of agreement with the following statements n(%) Statement Strongly Agree Agree Neutral Disagree Strongly disagree Median (IQR) My medical experience prepared me to understand the effect of adverse childhood experiences on patient health 48 (23.4%) 110 (53.7%) 40 (19.5%) 4 (2.0%) 3 (1.5%) 4 (4,4) I lack confidence in asking about families’ stressful experiences 3 (1.5%) 27 (13.2%) 42 (20.5%) 104 (50.7%) 29 (14.1%) 4 (3,4) It is important in primary health care to pay attention to adverse childhood experiences 105 (51.2%) 81 (39.5%) 15 (7.3%) 2 (1.0%) 2 (1.0%) 5 (4,5)_ I believe that stressors at home have no impact on the health of my patients 10 (4.9%) 8 (3.9%) 8 (3.9%) 61 (29.8%) 118 (57.6%) 5 (4,5) There are resources in my hospital/clinic to help families manage life stressors 13 (6.3%) 62 (30.2%) 83 (40.5%) 33 (16.1%) 14 (6.8%) 3 (3,4) I do not ask about adverse childhood experiences because I am unable to prevent them 7 (3.4%) 10 (4.9%) 42 (20.5%) 119 (58.0%) 27 (13.2%) 4 (3,4) There is not enough time to screen for adverse childhood experiences in primary health care 47 (22.9%) 81 (39.5%) 36 (17.6%) 37 (18.0%) 4 (2.0%) 2 (2,3) It is appropriate to discuss adverse childhood experiences with patients and their families 43 (21.0%) 118 (57.6%) 33 (16.1%) 6 (2.9%) 5 (2.4%) 4 (4,4) It is not a physician’s role to ask about private family stressors 1 (0.5%) 8 (3.9%) 24 (11.7%) 89 (43.4%) 83 (40.5%) 4 (4,5) The PHCC management would approve of routine screening for adverse childhood experiences. 23 (11.2%) 89 (43.4%) 80 (39.0%) 9 (4.4%) 4 (2.0%) 4 (3,4) Practice setting was significantly associated with attitudes (p < 0.001). Physicians in combined Family Medicine (FM), Well-Baby (WB), and other clinics showed more positive attitudes than those in FM-only settings, while those in WB-only or partial-combination settings showed less positive attitudes. Significantly more positive attitudes were observed among physicians who had previously inquired about ACEs within PHCC (p = 0.019) and those with greater ACEs knowledge (p = 0.049) Table 4 Univariate linear regression of attitudes scores Physician’s attitudes Variable Coefficient‡ 95% CI* P-value Gender Female Male Ref -0.51 - -1.29–1.19 0.9338 Age -0.001 -0.06–0.06 0.9587 Years of experience at the PHCC ≤ 5 6–10 11–15 > 15 Ref 1.07 -0.14 -1.21 -0.23–2.37 -2.32–2.03 -3.09–0.65 0.0503 PHCC setting FM/WB/Others FM and WB Others only FM only FM and others WB only WB and others 2.22 1.76 1.81 Ref -1.29 -0.74 -1.58 -0.66–5.12 0.51–3.01 1.02–2.61 - -3.48–0.88 -4.65–3.15 -2.27 – -0.88 < 0.001 Knowledge of ACEs Yes No 1.45 Ref 0.006–2.90 35.99–37.41 0.0491 † Cluster adjusted coefficient; *95% Confidence interval; Ref, Reference, ; FM, Family medicine clinic; WB, Well Baby clinic; others, other clinics Physician practices regarding ACEs screening Current ACEs screening practices among PHCC physicians varied. While 59% reported having asked a patient about ACEs within PHCC settings, this proportion was higher (68%) while working outside the PHCC. Screening was primarily symptom-triggered, with 67% asking about adversity when clinically relevant, and only 5% conducting routine screening. Most physicians (86%) reported screening patients equally regardless of sex. However, female physicians were more likely than male colleagues to screen women more frequently (20% vs. 3%). 55% supported incorporating ACEs screening into routine visits, while 34% were undecided, and 11% opposed. Preferred screening frequencies included: when symptoms are present (43%), annually (20%), or at every visit (17%). A strong majority (75%) expressed interest in further education on ACEs. ACEs screening context Physicians expressed clear preferences regarding the implementation of ACEs screening. The vast majority (85%) agreed that any trained healthcare provider is qualified to perform screenings. Support was strong for universal approaches: 67% favored universal screening over targeted screening for high-risk individuals, and 83% supported screening individuals of any age, with minimal support for restricting screenings to only adults (7%) or only children (8%). Opinions were divided on screening location, with 41% supporting screenings outside healthcare settings and 25% opposing this approach. Barriers to ACEs screening among physicians in primary care Barriers to ACEs screening, analyzed through the TDF, are presented in Table 5 . The most frequently cited barrier fell within the 'Environmental Context and Resources' domain of the TDF, with 78% of physicians identifying insufficient time as a major constraint. Table 5 Barriers endorsed by physicians’ with TDF lens Domain/Barrier N (%) Knowledge Lack of professional education on topic 65 (31.9%) Not considering childhood traumas a medical problem 24 (11.7%) Beliefs about Capabilities Not feeling confident about how to ask 34 (16.6%) Feeling embarrassed or uncomfortable asking questions 38 (18.5%) Beliefs about Consequences Asking about ACEs will not change how I treat the patients 21 (10.2%) Asking about ACEs will cause distress to patients and/or their parents 65 (31.7%) Concern that patients/their parents will find the question irrelevant 88 (42.9%) Concerns that the process of screening could potentially impact the relationship between the patient and their parents 64 (31.2%) Concern that asking might impact my relationship with the patient and/or their parents 51 (24.9%) Environmental Context and Resources Not having mental health resources to refer patients to if they reveal problems 68 (33.2%) Not having enough time to screen patients 160 (78.0%) Unsure how to respond if events are identified (No clear guidelines or laws) 110 (53.7%) Discussion This study aimed to explore physician’s knowledge, attitudes, practices, and barriers regarding ACEs screening. Our study found that most physicians supported universal screening across all age groups in healthcare settings. However, they face major challenges in implementing ACEs screening due to time constraints and absence of clear protocols. Notably, physicians with greater clinical experience demonstrated higher ACEs knowledge, and both knowledge and prior screening experience were positively associated with more favorable attitudes toward screening. Only one-third of physicians in Qatar were familiar with the ACE questionnaire, mirroring low awareness rates among US physicians and residents [ 24 ]. This gap persists globally among family medicine residents [ 16 ] and pediatricians [ 25 ], indicating a systemic failure in medical education regarding childhood trauma. The low rate of formal ACEs training among Qatari physicians contrasts sharply with higher training rates elsewhere [ 16 ]. Our findings reveal a critical disconnect that while physicians readily identified mental health consequences of ACEs, recognition of physical health links like heart disease or diabetes was poor. This pattern aligns with Canadian research showing limited awareness of ACEs' physical health impacts [ 17 ]. Experienced physicians demonstrated significantly greater ACEs knowledge, a correlation supported by other studies [ 26 ]. This suggests knowledge accumulates through clinical practice, yet it should not replace foundational training. Evidence confirms that targeted education, like the Child Advocacy Studies Training program, effectively builds physician confidence in ACEs screening [ 27 , 28 ]. While regional studies from Saudi Arabia show higher child abuse awareness [ 29 , 30 ], the reasons remain unclear. One study in Egypt suggests undergraduate education serves as physicians' primary knowledge source [ 26 ], underscoring the need to strengthen medical school curricula. As primary care physicians are often the first to encounter affected children, integrating trauma-informed care into medical education is crucial for early identification and intervention [ 31 ]. Physicians in Qatar demonstrated strongly positive attitudes toward ACEs screening, with a large majority believing it falls within their professional role a perspective also observed among physicians in Egypt [ 26 ], though considerably less common in Poland, where only a small minority of clinicians endorsed this [ 23 ]. This variation highlights how cultural and professional norms shape perceptions of clinical responsibilities. Notably, over half of physicians in this study believed their management would support routine screening a notably more optimistic outlook, contrasting with significant physician uncertainty about administrative support found in Poland [ 23 ]. This important divergence suggests a unique policy opportunity within Qatar's healthcare system. Direct engagement with healthcare leadership could capitalize on this distinctive perceived openness, potentially accelerating the development of organizational cultures that systematically support trauma-informed care. A concerning gap exists between physician screening practices and opportunity. While most physicians ask about ACEs, screening occurs less frequently within Qatar's primary health centers than elsewhere, suggesting organizational barriers limit implementation. Globally, screening rates vary widely, from minimal to common practice [ 15 , 25 , 32 ]. Most physicians preferred targeted over universal screening, contrasting with settings where routine screening is established [ 17 ]. This may reflect practical constraints or unfamiliarity with preventive models. Although physicians agreed gender should not determine screening, female physicians screened female patients more frequently, a pattern seen in different studies [ 16 , 25 ]. This is relevant given Qatar's gender-specific maltreatment patterns across age groups [ 33 ]. Screening protocols must balance epidemiological awareness with unbiased implementation. Our findings reveal a paradox in screening implementation. While physicians supported universal, interdisciplinary ACEs screening across all age groups, many believed it might be better conducted outside healthcare settings. This contrasts with evidence positioning ACEs screening as fundamental to primary care [ 23 ]. Furthermore, physicians endorsed screening by any trained health professional, not just doctors or nurses. This collaborative view aligns with research showing teachers, for instance, can be crucial detectors of childhood adversity [ 34 ]. A multi-sector approach, combining clinical screening with broader community awareness [ 26 ], may offer the most effective path toward comprehensive early detection and intervention. The primary was barrier time constraints, which appears more perceptual than practical. U.S. studies demonstrate that ACEs screening typically adds under five minutes to appointments [ 35 ], suggesting workflow integration is feasible. This discrepancy highlights a critical knowledge gap in implementing efficient screening processes. Beyond time constraints, physicians identified critical structural barriers including uncertainty about how to respond when ACEs are identified, stemming from absent clear protocols and referral pathways. This echoes challenges documented in other settings where ambiguous reporting procedures hinder effective response [ 26 , 30 ]. Qualitative responses highlighted cultural and linguistic obstacles, including stigma, as significant barriers. As research from Saudi Arabia demonstrates, cultural and religious contexts profoundly shape the recognition and reporting of adversity [ 36 ]. These findings underscore that effective implementation requires more than clinical guidelines. It demands culturally-informed protocols developed with community stakeholders, ensuring screening initiatives are both medically sound and socially resonant. Policy and practice recommendations To address ACEs effectively within Qatar's primary care system, a multi-level approach is essential. At the policy level, this includes mandating trauma-informed care training through continuing medical education, a strategy supported by evidence that such training, when integrated throughout medical education and reinforced in specialized sessions, optimally prepares clinicians to address the consequences of trauma [ 37 ]. This foundational policy effort should be coupled with integrating ACEs screening into national preventive health guidelines and establishing quality metrics for accreditation. To effectively operationalize these policies, parallel development of clinical infrastructure and workforce capacity is essential. A cornerstone of this effort is the enhancement of electronic health records (EHRs), which can be transformed from passive repositories into active clinical tools. By integrating structured ACEs documentation and automated referral pathways, EHRs can serve as teleprompters that guide assessment and planning, with software facilitating auto-documentation, referral generation, and secure information sharing through patient portals [ 38 ]. This technological backbone must be supported by robust regional networks that seamlessly connect primary care to mental health services and community resources, while also ensuring that screening for ACEs is paired with an assessment of protective factors to guide intervention. Research priorities Future research should focus on critical areas. First, implementation science should build upon successful pilot trials. For example, one study demonstrated that multifaceted strategies can increase screening rates from 0% to over 11% [ 39 ]. This foundation should be expanded to systematically evaluate screening models' real-world feasibility and effectiveness, while simultaneously assessing how training impacts both patient outcomes and provider wellbeing, and conducting rigorous cost-effectiveness analyses. Second, culturally-specific adaptations are essential not only for Qatar but for the broader region. Evidence suggests that culturally adapted instruments ensures that assessments are both appropriate and effective within their specific context [ 40 ]. This foundational work should extend to investigating local protective factors and resilience mechanisms, ultimately enabling the development of family-centered interventions that align with regional values and social structures. Finally, longitudinal research is essential to evaluate the sustained impact of trauma-informed care. Such studies should track long-term health outcomes to determine if screening and subsequent interventions yield lasting benefits, investigate whether these practices can disrupt intergenerational cycles of trauma, and assess the neurodevelopmental effects of early identification and support. Limitations and strengths This study provides the first comprehensive analysis of physician knowledge, attitudes, and practices regarding ACEs screening within Qatar's primary healthcare system. By employing a theoretical framework to examine barriers across multiple domains, the research offers systematic insights into implementation challenges. The findings establish crucial baseline data to inform clinical protocol development and educational initiatives, while identifying specific targets for intervention to enhance trauma-informed care capacity. This foundational work creates an essential evidence base for developing effective strategies to address childhood adversity in similar healthcare contexts. Several limitations should be considered when interpreting these results. The cross-sectional design and reliance on self-reported data may introduce social desirability bias and limit causal inference between physician characteristics and screening behaviors. While the sample size was adequate for initial analysis, the low response rate may affect generalizability across all healthcare settings in Qatar. Additionally, the exclusive focus on public primary care physicians’ limits applicability to private practice or specialized clinical environments. Conclusion In conclusion, this study marks a significant step towards understanding the current state of ACEs screening among physicians in Qatar. By uncovering the extent of knowledge, attitudes, practices and barriers related to ACEs screening, it highlights the critical areas for improvement and the need for comprehensive educational and policy interventions. This research not only adds to the limited literature on ACEs screening in the region but also sets the stage for future studies to build upon these findings, aiming to enhance the identification and support mechanisms for individuals impacted by ACEs. Abbreviations ACEs Adverse childhood experiences PHCC Primary Health Care Corporation KAP Knowledge, attitudes, and practices TDF Theoretical domains framework ACE-IQ Adverse childhood experiences international questionnaire PEA-Q Physician’s experiences with ACEs questionnaire Declarations Compliance with Ethical Standards Conflict of interests : Usra Elshaikh, Hafiz Ahmed Mohammed, and Hanan F. Abdul Rahim, declare that they have no conflict of interest. Consent to participate: Informed consent was obtained from all participants prior to their participation in the study. Consent to publish: Not applicable. Ethics approval and consent to participate: Ethical approval was obtained from the Primary Health Care Corporation (PHCC) ethics committee (BUHOOTH-D-23-00031) and Qatar University Institutional Review Board (QU-IRB 1920-E/23). Funding: This research was funded by Qatar University student grant QUST-2-CHS-2023-1532. Author Contribution H.A.R. conceptualized the study and supervised data collection and analysis. U.E. conducted data collection and analysis and drafted the main manuscript text. H.A.M. contributed to drafting the manuscript. All authors critically reviewed and approved the final manuscript. Acknowledgement We would like to acknowledge the Primary Health Care Corporation, including its dedicated physicians and administrators. Special appreciation is extended to Al Wajba, West Bay, Rawdat Al Khail, and Al Daayen health centers. We also sincerely thank Dr. Alia A. Al-Ruwaili, Dr. Amani Alyafei, and Dr. Mahasin Idris. Data Availability The data supporting the findings of this study are available within the article. Individual-level data are available from the corresponding author upon reasonable request. References Fast Facts: Preventing Adverse Childhood Experiences |Violence Prevention|Injury Center|CDC. 2021. https://www.cdc.gov/violenceprevention/aces/fastfact.html Madigan S, Thiemann R, Deneault A-A, Fearon RMP, Racine N, Park J, et al. Prevalence of Adverse Childhood Experiences in Child Population Samples: A Systematic Review and Meta-Analysis. JAMA Pediatr. 2025;179:19–33. https://doi.org/10.1001/jamapediatrics.2024.4385 . Al-Eissa MA, AlBuhairan FS, Qayad M, Saleheen H, Runyan D, Almuneef M. Determining child maltreatment incidence in Saudi Arabia using the ICAST-CH: A pilot study. 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J Psychiatr Res. 2010;44:732–40. https://doi.org/10.1016/j.jpsychires.2010.01.004 . Hughes K, Ford K, Bellis MA, Glendinning F, Harrison E, Passmore J. Health and financial costs of adverse childhood experiences in 28 European countries: a systematic review and meta-analysis. Lancet Public Health. 2021;6:e848–57. https://doi.org/10.1016/S2468-2667(21)00232-2 . Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse Negl. 2012;36:156–65. https://doi.org/10.1016/j.chiabu.2011.10.006 . Watson P. How to screen for ACEs in an efficient, sensitive, and effective manner. Paediatr Child Health. 2019;24:37–8. https://doi.org/10.1093/pch/pxy146 . California has begun. screening for early childhood trauma, but critics urge caution | Science | AAAS. https://www.science.org/content/article/california-has-begun-screening-early-childhood-trauma-critics-urge-caution . Accessed 19 Jul 2023. Finkelhor D. Screening for adverse childhood experiences (ACEs): Cautions and suggestions. Child Abuse Negl. 2018;85:174–9. https://doi.org/10.1016/j.chiabu.2017.07.016 . Weinreb L, Savageau JA, Candib LM, Reed GW, Fletcher KE, Hargraves JL. Screening for childhood trauma in adult primary care patients: a cross-sectional survey. Prim Care Companion J Clin Psychiatry. 2010;12. https://doi.org/10.4088/PCC.10m00950blu . PCC.10m00950. Tink W, Tink JC, Turin TC, Kelly M. Adverse Childhood Experiences: Survey of Resident Practice, Knowledge, and Attitude. Fam Med. 2017;49:7–13. Maunder RG, Hunter JJ, Tannenbaum DW, Le TL, Lay C. Physicians’ knowledge and practices regarding screening adult patients for adverse childhood experiences: a survey. BMC Health Serv Res. 2020;20:314. https://doi.org/10.1186/s12913-020-05124-6 . Aleissa MA, Sultana K, Saleheen HN, Aldihan DA, Al-Omar RH, Alharbi RO, et al. Attitude of pediatricians toward suspected cases of child sexual abuse (CSA) in Saudi Arabia. Int J Pediatr Adolesc Med. 2022;9:125–30. https://doi.org/10.1016/j.ijpam.2021.10.005 . Habib HS. Pediatrician knowledge, perception, and experience on child abuse and neglect in Saudi Arabia. Ann Saudi Med. 2012;32:236–42. https://doi.org/10.5144/0256-4947.2012.236 . Al-Moosa A, Al-Shaiji J, Al-Fadhli A, Al-Bayed K, Adib SM. Pediatricians’ knowledge, attitudes and experience regarding child maltreatment in Kuwait. Child Abuse Negl. 2003;27:1161–78. https://doi.org/10.1016/j.chiabu.2003.09.009 . Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N, et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implement Sci. 2017;12:77. https://doi.org/10.1186/s13012-017-0605-9 . Adverse Childhood Experiences International Questionnaire (ACE-IQ). https://www.who.int/publications/m/item/adverse-childhood-experiences-international-questionnaire-(ace-iq) . Accessed 19 Jul 2023. Mejia CL, Telega G, Wilson SL, Nagorska M. Screening for adverse childhood experiences within paediatric patients in Rzeszów, Poland. Pediatr Pol -. Pol J Paediatr. 2018;93:306–11. https://doi.org/10.5114/polp.2018.77995 . Stork BR, Akselberg NJ, Qin Y, Miller DC. Adverse Childhood Experiences (ACEs) and Community Physicians: What We’ve Learned. Perm J. 2020;24:19099. https://doi.org/10.7812/TPP/19.099 . Kerker BD, Storfer-Isser A, Szilagyi M, Stein REK, Garner AS, O’Connor KG, et al. Do Pediatricians Ask About Adverse Childhood Experiences in Pediatric Primary Care? Acad Pediatr. 2016;16:154–60. https://doi.org/10.1016/j.acap.2015.08.002 . Saeed N, Sultan EA, Salama N, Galal M, Ghanem M. Child maltreatment: knowledge, attitudes and reporting behaviour of physicians in teaching hospitals, Egypt. East Mediterr Health J Rev Sante Mediterr Orient Al-Majallah Al-Sihhiyah Li-Sharq Al-Mutawassit. 2021;27:250–9. https://doi.org/10.26719/emhj.20.126 Pelletier HL, Knox M. Incorporating Child Maltreatment Training into Medical School Curricula. J Child Adolesc Trauma. 2017;10:267–74. https://doi.org/10.1007/s40653-016-0096-x . McBain RK, Levin JS, Matthews S, Qureshi N, Long D, Schickedanz AB, et al. The effect of adverse childhood experience training, screening, and response in primary care: a systematic review. eClinicalMedicine. 2023;65:102282. https://doi.org/10.1016/j.eclinm.2023.102282 . Alnasser Y, Albijadi A, Abdullah W, Aldabeeb D, Alomair A, Alsaddiqi S, et al. Child maltreatment between knowledge, attitude and beliefs among Saudi pediatricians, pediatric residency trainees and medical students. Ann Med Surg. 2017;16:7–13. https://doi.org/10.1016/j.amsu.2017.02.008 . Alsaleem SA, Alsaleem MA, Asiri AM, Alkhidhran SS, Alqahtani WSS, Alzahrani MS, et al. Knowledge and attitude regarding child abuse among primary health care physician in Abha, Saudi Arabia, 2018. J Fam Med Prim Care. 2019;8:706–10. https://doi.org/10.4103/jfmpc.jfmpc_442_18 . Piszczor R, Barry C, Gundacker C, Wallace C, Shibuya J, Perle J. Medical Students’ Knowledge, Attitudes Toward, and Identification of Adverse Childhood Experiences and Trauma-Informed Care. Perm J. 2024;28:91–9. https://doi.org/10.7812/TPP/23.108 . Alhowaymel FM, Izahrani NS, Alharbi HF, Almarwani AM. Healthcare providers screening for childhood abuse among adult patients in Saudi Arabia: A cross-sectional study. J Nurs Scholarsh. 2023;55:1154–63. https://doi.org/10.1111/jnu.l2897 . Salem M, Dargham SR, Kamal M, Eldeeb N, Alyafei KA, Lynch MA, et al. Effect of gender on childhood maltreatment in the state of Qatar: Retrospective study. Child Abuse Negl. 2020;101:104314. https://doi.org/10.1016/j.chiabu.2019.104314 . Hynniewta B, Jose TT, Anjali KG. Knowledge and attitude on child abuse among school teachers, in selected urban English medium schools of Udupi District. Manipal J Nurs Health Sci MJNHS. 2017;3:32–6. Glowa PT, Olson AL, Johnson DJ. Screening for Adverse Childhood Experiences in a Family Medicine Setting: A Feasibility Study. J Am Board Fam Med JABFM. 2016;29:303–7. https://doi.org/10.3122/jabfm.2016.03.150310 . Alharbi HF, Moussa FL. Knowledge and Attitude of Pediatric Nurses in Saudi Arabia Regarding Child Abuse. J Multidiscip Healthc. 2023;16:2057–69. https://doi.org/10.2147/JMDH.S421210 . Steen M, Raynor J, Baldwin CD, Jee SH. Child Adversity and Trauma-Informed Care Teaching Interventions: A Systematic Review. Pediatrics. 2022;149:e2021051174. https://doi.org/10.1542/peds.2021-051174 . Dubowitz H, Finkelhor D, Zolotor A, Kleven J, Davis N. Addressing Adverse Childhood Experiences in Primary Care: Challenges and Considerations. Pediatrics. 2022;149:e2021052641. https://doi.org/10.1542/peds.2021-052641 . Jolles MP, Mack WJ, Rubio S, Helmkamp LJ, Saldana L, Aarons GA, et al. Testing a multi-faceted strategy to support the implementation of ACEs screenings in primary care: results of a stepped-wedge pilot trial. Implement Sci Commun. 2025;6:92. https://doi.org/10.1186/s43058-025-00771-4 . Elshaikh U, Hassan DA, Daher-Nashif S, Khaled SM, Abdul Rahim HF. Adverse childhood experiences (ACEs) measurement tools among children and adolescents in the Arab world: a scoping review. BMC Public Health. 2026. https://doi.org/10.1186/s12889-026-26312-9 . Additional Declarations No competing interests reported. Supplementary Files AppendixA.pdf AppendixB.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 19 Apr, 2026 Reviewers agreed at journal 18 Apr, 2026 Reviewers invited by journal 15 Apr, 2026 Editor invited by journal 16 Feb, 2026 Editor assigned by journal 12 Feb, 2026 Submission checks completed at journal 12 Feb, 2026 First submitted to journal 12 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8861367","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":625819236,"identity":"dec416c9-6255-4b3d-a532-6ca15a7d57a9","order_by":0,"name":"Usra Elshaikh","email":"","orcid":"","institution":"Qatar University","correspondingAuthor":false,"prefix":"","firstName":"Usra","middleName":"","lastName":"Elshaikh","suffix":""},{"id":625819237,"identity":"7fbb412e-a128-4ce5-94b2-2c4f7f6f6df0","order_by":1,"name":"Hafiz Ahmed Mohamed","email":"","orcid":"","institution":"Primary Health Care Corporation","correspondingAuthor":false,"prefix":"","firstName":"Hafiz","middleName":"Ahmed","lastName":"Mohamed","suffix":""},{"id":625819239,"identity":"bc917565-ae2d-4deb-b7a6-c88c7c5b3908","order_by":2,"name":"Hanan F. Abdul Rahim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYBACAzhLgrGB4QOYlUCCFsYZJGphYGDmIUaLOfvZg58LGOzy+Wc3t262KTvMwM+eY8Dwpga3FsuevGTpGQzJljPuHGy7nXPuMINkzxsDxjnH8DjsQI6BNA8DswHDjcS227lthxkMbuQYMPOw4dFy/o3xbx6GegN5kBZLoBZ7sJZ/eLTcyDED2nLYwACkhRFkiwRQC28bPi1vzKx5DI4bGAK13Ow5l84jceZZwcG5ffgclmN8m6ei2kDuRvqzGz/KrOX425M3PnjzDbcWqEYYg40BHDUHeAjpQABYQJGgZRSMglEwCoY/AAAkgU95EupRlwAAAABJRU5ErkJggg==","orcid":"","institution":"Qatar University","correspondingAuthor":true,"prefix":"","firstName":"Hanan","middleName":"F. Abdul","lastName":"Rahim","suffix":""}],"badges":[],"createdAt":"2026-02-12 11:13:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8861367/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8861367/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107658498,"identity":"a96e9e79-f4b2-4b46-9ed4-4e2b3e1ae3e6","added_by":"auto","created_at":"2026-04-23 16:25:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":430568,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8861367/v1/d6d3609d-4718-4ffb-b3d5-025bcec178f5.pdf"},{"id":107658428,"identity":"e8413f98-c5f7-4dd4-a74b-198137899927","added_by":"auto","created_at":"2026-04-23 16:25:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":224584,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixA.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8861367/v1/38708d303d21cbd4e67e036e.pdf"},{"id":107658429,"identity":"45a0a9bc-a6d0-4acf-bca1-2b87acfbaecd","added_by":"auto","created_at":"2026-04-23 16:25:15","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":23225,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixB.docx","url":"https://assets-eu.researchsquare.com/files/rs-8861367/v1/e8f7db5b1254e8794a428e47.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Primary Health Care Physicians' Knowledge, Attitudes, Practices of Screening for Adverse Childhood Experiences (ACEs) in Qatar and barriers to implementation: a Cross-Sectional Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAdverse Childhood Experiences (ACEs) represent a critical global public health challenge with profound implications for health. Defined by Centers for Disease Control and Prevention as potentially traumatic events occurring before age 18, ACEs encompass abuse, neglect, and household dysfunction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Globally, adverse childhood experiences are highly prevalent. A recent systematic review estimated that nearly half (48%) of children experience at least one ACE [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While regional data are limited, a study in Saudi Arabia indicated high prevalence of psychological abuse (74.9%), physical abuse (57.5%), and exposure to violence (50.7%) among adolescents [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe lifelong health consequences of ACEs are profound. Exposure to childhood adversity increases the risk of chronic diseases in adulthood, including cardiovascular disease, chronic lung disease, and premature mortality [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The neurobiological impact manifests early, with studies demonstrating associations between ACEs and decreased brain volume, altered functional connectivity, and elevated cortisol levels in children [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Additionally, exposure to ACEs predispositions individuals to anxiety disorders, depression, post-traumatic stress disorder, substance use disorders, and suicidal behaviors [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The economic burden is significant, with CDC estimating lifetime cost of child maltreatment cases in the United States at \u003cspan\u003e$\u003c/span\u003e124\u0026ndash;585\u0026nbsp;billion, with ACEs-related costs exceeding 1% of GDP in many countries [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrimary health care is uniquely positioned to address ACEs through different levels of prevention. Screening for ACEs fulfills established criteria for evidence-based screening programs: high prevalence, reliable identification methods, and available early interventions [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Health policy has evolved to include ACEs screening, with leading US and UK health organizations now recommending it and California establishing the first universal screening requirement for children under the age of 18 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Despite the value of incorporating ACEs screening into routine primary care, where it creates opportunities for patients to discuss early adversity, reflect on its health impacts, and receive empathetic clinical support, implementation remains inconsistent [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Research reveals significant gaps in physician screening practices globally. In the United States, fewer than 30% of family physicians routinely screen adult patients for ACEs, despite 79% acknowledging it as part of their role [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Similarly, Canadian family medicine residents screen less frequently than practicing physicians, with both groups disproportionately screening female patients [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Screening rates also vary substantially by specialty, with psychiatrists reporting higher rates than family physicians [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegional studies reveal similar gaps. Among Saudi pediatricians, one-third had no child sexual abuse training, and nearly half had never examined a child for abuse [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Another study found suboptimal knowledge of reporting procedures [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In Kuwait, while half of pediatricians encountered maltreatment cases, over 80% were unaware of mandatory reporting laws [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUnderstanding ACEs screening implementation requires a theoretical framework that systematically examines factors influencing clinical behavior. The Theoretical Domains Framework (TDF), developed by behavioral scientists and implementation researchers, provides a comprehensive approach to identifying determinants of practice change [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Applying the TDF to ACEs screening can assist in systematically identifying and informing targeted implementation strategies.\u003c/p\u003e \u003cp\u003e The State of Qatar's healthcare system, with primary care centralized under the PHCC, presents a critical, unstudied context for ACEs screening. No data exist on physician KAP and barriers in this setting. To address this gap, this study aims to comprehensively examine PHCC physicians' KAP regarding ACEs screening in Qatar. The specific objectives are to evaluate physicians' knowledge of ACEs and their health consequences, assess attitudes toward ACEs screening, including perceived importance and feasibility, determine the prevalence of current screening practices, characterize screening approaches, and identify barriers to implementation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eStudy design and population\u003c/h2\u003e\n\u003cp\u003eA cross-sectional survey was conducted among all eligible family medicine and well-baby clinic physicians employed across Qatar's PHCC centers. The study was designed and reported in accordance with the STROBE guidelines. The survey attempted a census approach, including all physicians in the target population.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eSurvey instrument\u003c/h3\u003e\n\u003cp\u003eA structured questionnaire was developed to assess PHC physicians' demographics, knowledge, attitudes, practices, and barriers regarding ACEs screening. The instrument was informed by a literature review and adapted from validated tools, including the Adverse Childhood Experiences International Questionnaire (ACE-IQ)[\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e], the Physician Experiences with ACEs questionnaire (PEA-Q)[\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e], and a barriers instrument from a preexisting study[\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. The ACE-IQ's validated, comprehensive domains ensured broad coverage of ACEs[\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. The PEA-Q provided a framework for assessing physician attitudes and experiences across five key categories[\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThe final survey instrument was organized into six thematic sections as shown in Appendix A. The first section captured demographic characteristics, including sex, age, nationality, professional experience, practice setting, and patient load. The second section assessed knowledge of ACEs, covering familiarity, prior training, and understanding of health impacts. The third section evaluated attitudes using a 10-item scale adapted from the PEA-Q and mapped to TDF constructs. Additionally, the survey addressed screening context, clinical practices, and implementation barriers.\u003c/p\u003e\n\u003ch3\u003ePilot test\u003c/h3\u003e\n\u003cp\u003eThe questionnaire was pilot-tested with 11 community medicine residents to assess face and content validity, including clarity, structure, and acceptability. Feedback indicated the questions were generally clear and the length appropriate. Suggested improvements included refining question wording and expanding response options for greater comprehensiveness. The instrument was revised to incorporate the feedback.\u003c/p\u003e\n\u003ch3\u003eQuestionnaire implementation\u003c/h3\u003e\n\u003cp\u003eA questionnaire was administered across all PHCC health centers in January 2024. Hard copies of questionnaires, accompanied by an information sheet and a mandatory consent form, were distributed. The research team visited all centers to disseminate questionnaires in clinics or during meetings to maximize reach. The lead physician at each center was contacted for support, and the total number of eligible physicians was recorded to track the response rate. Anonymity was maintained to minimize response bias by not collecting names and by having questionnaires returned anonymously via a drop-off box at each center. Follow-ups were conducted at centers with low response rates to address non-response bias and questionnaires were collected after a two-week period for data entry.\u003c/p\u003e\n\u003ch3\u003ePrimary outcomes\u003c/h3\u003e\n\u003cp\u003eThe primary outcomes were physicians' KAP regarding ACEs. Knowledge was assessed using a 4-item scale, with a total score calculated from assigned point values. Attitudes were measured via a 10-item scale, with the aggregate score reflecting perspectives on ACEs screening. Practices were evaluated using a 7-item scale, where the total score quantified engagement in screening behaviors.\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eSecondary outcomes\u003c/h2\u003e\n\u003cp\u003eSecondary outcomes included: 1) the prevalence of ACEs screening, determined by a binary (yes/no) response to whether a physician conducts screening; and 2) reported barriers to implementation, identified through a structured survey quantifying predefined obstacles and an open-ended question for additional unlisted barriers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eand confidentiality\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval\u0026nbsp;was obtained from the PHCC ethics committee (BUHOOTH-D-23-00031) and Qatar University Institutional Review Board (QU-IRB 1920-E/23). The survey posed minimal risk, as participants were not asked to disclose personal experiences with ACEs but rather their professional screening practices. The questionnaire length was optimized to minimize participant burden, and contact information was provided for any inquiries. All responses were anonymized to ensure confidentiality.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003eStatistical analysis\u003c/h2\u003e\n\u003cp\u003eDescriptive statistics summarized physician responses. Continuous data were reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) and median with interquartile range (IQR). Categorical variables were presented as frequencies and percentages. Missing data were minimal (\u0026lt;\u0026thinsp;5% for nationality, which was excluded from analysis due to interpretive limitations). An attitudes score (range: 10\u0026ndash;50) was computed from ten 5-point Likert-scale questions, with negatively worded items reverse-scored. The score's distribution was characterized using measures of central tendency and variability. A random-effects model estimated the intraclass correlation coefficient (ICC) to quantify within-health-center clustering. The association between attitudes scores and predictors (sex, experience, knowledge) was assessed using linear regression, adjusted for health center clustering. The relationship between knowledge and predictor variables was examined using cluster-adjusted chi-square tests and univariate logistic regression.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipant demographics and characteristics\u003c/h2\u003e\n \u003cp\u003eA total of 205 physicians participated in this survey, constituting a 34% overall response rate that varied between health centers. Demographic and professional characteristics are summarized in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Participants had a median age of 45 years and were predominantly male (64%). The participant\u0026rsquo;s nationalities were diverse, primarily from Europe (40%), North Africa (26%), and the Middle East (21%). The median post-graduation experience among physicians was 11 years. Experience within the PHCC system was distributed evenly with 37% having less than 5 years of experience, 35% had 6\u0026ndash;10 years, and 28% had 11 or more years. Most physicians (56%) reported a daily patient load exceeding 26 patients. The vast majority (93%) practiced in family medicine outpatient clinics, with many also working in well-baby (40%) or other specialized clinics (18%).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eParticipant demographics and characteristics of study participants (n\u0026thinsp;=\u0026thinsp;205)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRespondent Characteristic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73 (35.61%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e132 (64.39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (40, 49)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNationality, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEurope\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82 (40.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNorth Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54 (26.34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMiddle East\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 (20.98%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNorth America\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (3.41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (3.41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAustralia \u0026amp; Oceania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0.98%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal years of experience post grad\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (6, 18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYears of experience at PHCC, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026le;\u0026thinsp;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76 (37.07%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u0026ndash;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72 (35.12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u0026ndash;15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (12.68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (15.12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of patients daily, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (5.85%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u0026ndash;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e78 (38.05%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e115 (56.10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePractice setting, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFamily medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e191 (93.17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWell baby clinic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83 (40.48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers (CDC, Emergency clinic, Triage, NCD, etc)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (18.53%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003eIQR: interquartile range; SD: Standard deviation; CDC: Communicable diseases center; NDC: Non-Communicable Disease\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003ePhysicians\u0026apos; knowledge of ACEs screening\u003c/h2\u003e\n \u003cp\u003eKnowledge of ACEs was limited among surveyed physicians. Approximately two-thirds (66%) were unfamiliar with the ACE questionnaire, and 70% reported no formal education/training on the topic during their medical education or professional development. Awareness of health conditions linked to ACEs varied substantially, with more detailed in Appendix B. Most physicians recognized associations with mental health disorders, including generalized anxiety (85%) and depression (80%). Awareness of physical health consequences was markedly lower. Fewer than 21% identified connections to chronic diseases such as diabetes, or asthma, and less than 13% were aware of links to stroke or cancer. Knowledge was not significantly associated with gender (p\u0026thinsp;=\u0026thinsp;0.548), age group (p\u0026thinsp;=\u0026thinsp;0.239), or practice setting (p\u0026thinsp;=\u0026thinsp;0.472). However, a significant association emerged with years of PHCC experience (p\u0026thinsp;=\u0026thinsp;0.029).\u003c/p\u003e\n \u003cp\u003eUnivariate mixed-effects logistic regression analyses, adjusted for health center clustering, are presented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Years of experience at PHCC was a significant predictor (p\u0026thinsp;=\u0026thinsp;0.043). Compared to physicians with \u0026le;\u0026thinsp;5 years of experience, those with 6\u0026ndash;10 years (OR\u0026thinsp;=\u0026thinsp;2.08), 11\u0026ndash;15 years (OR\u0026thinsp;=\u0026thinsp;2.97), and \u0026gt;\u0026thinsp;15 years (OR\u0026thinsp;=\u0026thinsp;2.85) demonstrated significantly higher odds of ACEs knowledge. Due to the limited sample size, a multivariate model adjusting for potential confounders was not feasible.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePredictors of physician\u0026rsquo;s knowledge on ACEs.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003ePhysician\u0026rsquo; knowledge*\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOR\u0026Dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003cp\u003e1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e0.65\u0026ndash;2.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.5536\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e30\u0026ndash;39\u003c/p\u003e\n \u003cp\u003e40\u0026ndash;49\u003c/p\u003e\n \u003cp\u003e50\u0026ndash;59\u003c/p\u003e\n \u003cp\u003e60+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003cp\u003e1.40\u003c/p\u003e\n \u003cp\u003e1.74\u003c/p\u003e\n \u003cp\u003e3.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.66\u0026ndash;2.96\u003c/p\u003e\n \u003cp\u003e0.66\u0026ndash;4.57\u003c/p\u003e\n \u003cp\u003e0.96\u0026ndash;10.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.2750\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears of experience at the PHCC\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026le;\u0026thinsp;5\u003c/p\u003e\n \u003cp\u003e6\u0026ndash;10\u003c/p\u003e\n \u003cp\u003e11\u0026ndash;15\u003c/p\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003cp\u003e2.08\u003c/p\u003e\n \u003cp\u003e2.97\u003c/p\u003e\n \u003cp\u003e2.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.01 \u0026ndash; 4.27\u003c/p\u003e\n \u003cp\u003e1.16\u0026ndash;7.62\u003c/p\u003e\n \u003cp\u003e1.17\u0026ndash;6.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.0432\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHCC setting\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eFM/WB/Others\u003c/p\u003e\n \u003cp\u003eFM and WB\u003c/p\u003e\n \u003cp\u003eOthers only\u003c/p\u003e\n \u003cp\u003eFM only\u003c/p\u003e\n \u003cp\u003eFM and others\u003c/p\u003e\n \u003cp\u003eWB only\u003c/p\u003e\n \u003cp\u003eWB and others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003cp\u003e1.59\u003c/p\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.73\u0026ndash;6.14\u003c/p\u003e\n \u003cp\u003e0.49\u0026ndash;1.94\u003c/p\u003e\n \u003cp\u003e0.05\u0026ndash;4.93\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e0.51\u0026ndash;4.95\u003c/p\u003e\n \u003cp\u003e0.40\u0026ndash;11.07\u003c/p\u003e\n \u003cp\u003e(empty)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.6051\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e*Binary outcome (knowledge yes/no)\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u0026Dagger;Adjusted odds of knowledge accounting for clustering of health centers\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003ePhysicians\u0026apos; attitudes towards ACEs screening\u003c/h2\u003e\n \u003cp\u003eFor the questionnaire section assessing attitudes reliability analysis indicated questionable internal consistency (Cronbach\u0026rsquo;s \u0026alpha;\u0026thinsp;=\u0026thinsp;0.57). As shown in Table\u0026nbsp;3 physicians demonstrated generally positive attitudes toward ACEs screening. Most physicians (91%) agreed on the importance of addressing ACEs in primary care. Attitude scores ranged from 26 to 50 (mean\u0026thinsp;=\u0026thinsp;37.2, SD\u0026thinsp;=\u0026thinsp;4.094). A cluster-adjusted linear regression examined associations between attitude scores and physician characteristics in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e. No significant associations were observed between attitude scores and gender (p\u0026thinsp;=\u0026thinsp;0.934) or age (p\u0026thinsp;=\u0026thinsp;0.959). A marginal association was found with years of PHCC experience (p\u0026thinsp;=\u0026thinsp;0.050).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003eTable\u0026nbsp;3. Physician\u0026rsquo;s attitudes regarding ACEs screening\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"5\" align=\"left\"\u003e\n \u003cp\u003ePlease indicate your level of agreement with the following statements\u003c/p\u003e\n \u003cp\u003en(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStatement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStrongly Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAgree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeutral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDisagree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStrongly disagree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMy medical experience prepared me to understand the effect of adverse childhood experiences on patient health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48 (23.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e110 (53.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 (19.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (1.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (4,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI lack confidence in asking about families\u0026rsquo; stressful experiences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (1.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (13.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42 (20.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e104 (50.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (14.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (3,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIt is important in primary health care to pay attention to adverse childhood experiences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e105 (51.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e81 (39.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (4,5)_\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI believe that stressors at home have no impact on the health of my patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (3.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (3.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61 (29.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e118 (57.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (4,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThere are resources in my hospital/clinic to help families manage life stressors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62 (30.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83 (40.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (16.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (6.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (3,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI do not ask about adverse childhood experiences because I am unable to prevent them\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (3.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42 (20.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e119 (58.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (13.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (3,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThere is not enough time to screen for adverse childhood experiences in primary health care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47 (22.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e81 (39.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (17.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 (18.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIt is appropriate to discuss adverse childhood experiences with patients and their families\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 (21.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e118 (57.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (16.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (4,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIt is not a physician\u0026rsquo;s role to ask about private family stressors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (3.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 (11.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89 (43.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83 (40.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (4,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe PHCC management would approve of routine screening for adverse childhood experiences.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (11.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89 (43.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80 (39.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (4.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (3,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003ePractice setting was significantly associated with attitudes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Physicians in combined Family Medicine (FM), Well-Baby (WB), and other clinics showed more positive attitudes than those in FM-only settings, while those in WB-only or partial-combination settings showed less positive attitudes. Significantly more positive attitudes were observed among physicians who had previously inquired about ACEs within PHCC (p\u0026thinsp;=\u0026thinsp;0.019) and those with greater ACEs knowledge (p\u0026thinsp;=\u0026thinsp;0.049)\u0026nbsp;\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eUnivariate linear regression of attitudes scores\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003ePhysician\u0026rsquo;s attitudes\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCoefficient\u0026Dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003cp\u003e-0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-1.29\u0026ndash;1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.9338\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.06\u0026ndash;0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.9587\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears of experience at the PHCC\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026le;\u0026thinsp;5\u003c/p\u003e\n \u003cp\u003e6\u0026ndash;10\u003c/p\u003e\n \u003cp\u003e11\u0026ndash;15\u003c/p\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003cp\u003e1.07\u003c/p\u003e\n \u003cp\u003e-0.14\u003c/p\u003e\n \u003cp\u003e-1.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.23\u0026ndash;2.37\u003c/p\u003e\n \u003cp\u003e-2.32\u0026ndash;2.03\u003c/p\u003e\n \u003cp\u003e-3.09\u0026ndash;0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.0503\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHCC setting\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eFM/WB/Others\u003c/p\u003e\n \u003cp\u003eFM and WB\u003c/p\u003e\n \u003cp\u003eOthers only\u003c/p\u003e\n \u003cp\u003eFM only\u003c/p\u003e\n \u003cp\u003eFM and others\u003c/p\u003e\n \u003cp\u003eWB only\u003c/p\u003e\n \u003cp\u003eWB and others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.22\u003c/p\u003e\n \u003cp\u003e1.76\u003c/p\u003e\n \u003cp\u003e1.81\u003c/p\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003cp\u003e-1.29\u003c/p\u003e\n \u003cp\u003e-0.74\u003c/p\u003e\n \u003cp\u003e-1.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.66\u0026ndash;5.12\u003c/p\u003e\n \u003cp\u003e0.51\u0026ndash;3.01\u003c/p\u003e\n \u003cp\u003e1.02\u0026ndash;2.61\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-3.48\u0026ndash;0.88\u003c/p\u003e\n \u003cp\u003e-4.65\u0026ndash;3.15\u003c/p\u003e\n \u003cp\u003e-2.27 \u0026ndash; -0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnowledge of ACEs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.45\u003c/p\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.006\u0026ndash;2.90\u003c/p\u003e\n \u003cp\u003e35.99\u0026ndash;37.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0491\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u0026dagger; Cluster adjusted coefficient; *95% Confidence interval; Ref, Reference, ; FM, Family medicine clinic; WB, Well Baby clinic; others, other clinics\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003ePhysician practices regarding ACEs screening\u003c/h2\u003e\n \u003cp\u003eCurrent ACEs screening practices among PHCC physicians varied. While 59% reported having asked a patient about ACEs within PHCC settings, this proportion was higher (68%) while working outside the PHCC. Screening was primarily symptom-triggered, with 67% asking about adversity when clinically relevant, and only 5% conducting routine screening.\u003c/p\u003e\n \u003cp\u003eMost physicians (86%) reported screening patients equally regardless of sex. However, female physicians were more likely than male colleagues to screen women more frequently (20% vs. 3%). 55% supported incorporating ACEs screening into routine visits, while 34% were undecided, and 11% opposed. Preferred screening frequencies included: when symptoms are present (43%), annually (20%), or at every visit (17%). A strong majority (75%) expressed interest in further education on ACEs.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eACEs screening context\u003c/h2\u003e\n \u003cp\u003ePhysicians expressed clear preferences regarding the implementation of ACEs screening. The vast majority (85%) agreed that any trained healthcare provider is qualified to perform screenings. Support was strong for universal approaches: 67% favored universal screening over targeted screening for high-risk individuals, and 83% supported screening individuals of any age, with minimal support for restricting screenings to only adults (7%) or only children (8%). Opinions were divided on screening location, with 41% supporting screenings outside healthcare settings and 25% opposing this approach.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eBarriers to ACEs screening among physicians in primary care\u003c/h2\u003e\n \u003cp\u003eBarriers to ACEs screening, analyzed through the TDF, are presented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e. The most frequently cited barrier fell within the \u0026apos;Environmental Context and Resources\u0026apos; domain of the TDF, with 78% of physicians identifying insufficient time as a major constraint.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBarriers endorsed by physicians\u0026rsquo; with TDF lens\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDomain/Barrier\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eKnowledge\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLack of professional education on topic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65 (31.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot considering childhood traumas a medical problem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 (11.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBeliefs about Capabilities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot feeling confident about how to ask\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (16.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFeeling embarrassed or uncomfortable asking questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (18.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eBeliefs about Consequences\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsking about ACEs will not change how I treat the patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (10.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsking about ACEs will cause distress to patients and/or their parents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65 (31.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConcern that patients/their parents will find the question irrelevant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConcerns that the process of screening could potentially impact the relationship between the patient and their parents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e64 (31.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConcern that asking might impact my relationship with the patient and/or their parents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 (24.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eEnvironmental Context and Resources\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot having mental health resources to refer patients to if they reveal problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68 (33.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot having enough time to screen patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e160 (78.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnsure how to respond if events are identified (No clear guidelines or laws)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e110 (53.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to explore physician\u0026rsquo;s knowledge, attitudes, practices, and barriers regarding ACEs screening. Our study found that most physicians supported universal screening across all age groups in healthcare settings. However, they face major challenges in implementing ACEs screening due to time constraints and absence of clear protocols. Notably, physicians with greater clinical experience demonstrated higher ACEs knowledge, and both knowledge and prior screening experience were positively associated with more favorable attitudes toward screening.\u003c/p\u003e \u003cp\u003eOnly one-third of physicians in Qatar were familiar with the ACE questionnaire, mirroring low awareness rates among US physicians and residents [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This gap persists globally among family medicine residents [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and pediatricians [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], indicating a systemic failure in medical education regarding childhood trauma. The low rate of formal ACEs training among Qatari physicians contrasts sharply with higher training rates elsewhere [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Our findings reveal a critical disconnect that while physicians readily identified mental health consequences of ACEs, recognition of physical health links like heart disease or diabetes was poor. This pattern aligns with Canadian research showing limited awareness of ACEs' physical health impacts [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eExperienced physicians demonstrated significantly greater ACEs knowledge, a correlation supported by other studies [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This suggests knowledge accumulates through clinical practice, yet it should not replace foundational training. Evidence confirms that targeted education, like the Child Advocacy Studies Training program, effectively builds physician confidence in ACEs screening [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. While regional studies from Saudi Arabia show higher child abuse awareness [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], the reasons remain unclear. One study in Egypt suggests undergraduate education serves as physicians' primary knowledge source [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], underscoring the need to strengthen medical school curricula. As primary care physicians are often the first to encounter affected children, integrating trauma-informed care into medical education is crucial for early identification and intervention [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePhysicians in Qatar demonstrated strongly positive attitudes toward ACEs screening, with a large majority believing it falls within their professional role a perspective also observed among physicians in Egypt [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], though considerably less common in Poland, where only a small minority of clinicians endorsed this [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This variation highlights how cultural and professional norms shape perceptions of clinical responsibilities.\u003c/p\u003e \u003cp\u003eNotably, over half of physicians in this study believed their management would support routine screening a notably more optimistic outlook, contrasting with significant physician uncertainty about administrative support found in Poland [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This important divergence suggests a unique policy opportunity within Qatar's healthcare system. Direct engagement with healthcare leadership could capitalize on this distinctive perceived openness, potentially accelerating the development of organizational cultures that systematically support trauma-informed care.\u003c/p\u003e \u003cp\u003eA concerning gap exists between physician screening practices and opportunity. While most physicians ask about ACEs, screening occurs less frequently within Qatar's primary health centers than elsewhere, suggesting organizational barriers limit implementation. Globally, screening rates vary widely, from minimal to common practice [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost physicians preferred targeted over universal screening, contrasting with settings where routine screening is established [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This may reflect practical constraints or unfamiliarity with preventive models. Although physicians agreed gender should not determine screening, female physicians screened female patients more frequently, a pattern seen in different studies [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This is relevant given Qatar's gender-specific maltreatment patterns across age groups [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Screening protocols must balance epidemiological awareness with unbiased implementation.\u003c/p\u003e \u003cp\u003eOur findings reveal a paradox in screening implementation. While physicians supported universal, interdisciplinary ACEs screening across all age groups, many believed it might be better conducted outside healthcare settings. This contrasts with evidence positioning ACEs screening as fundamental to primary care [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, physicians endorsed screening by any trained health professional, not just doctors or nurses. This collaborative view aligns with research showing teachers, for instance, can be crucial detectors of childhood adversity [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. A multi-sector approach, combining clinical screening with broader community awareness [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], may offer the most effective path toward comprehensive early detection and intervention.\u003c/p\u003e \u003cp\u003eThe primary was barrier time constraints, which appears more perceptual than practical. U.S. studies demonstrate that ACEs screening typically adds under five minutes to appointments [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], suggesting workflow integration is feasible. This discrepancy highlights a critical knowledge gap in implementing efficient screening processes.\u003c/p\u003e \u003cp\u003eBeyond time constraints, physicians identified critical structural barriers including uncertainty about how to respond when ACEs are identified, stemming from absent clear protocols and referral pathways. This echoes challenges documented in other settings where ambiguous reporting procedures hinder effective response [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Qualitative responses highlighted cultural and linguistic obstacles, including stigma, as significant barriers. As research from Saudi Arabia demonstrates, cultural and religious contexts profoundly shape the recognition and reporting of adversity [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. These findings underscore that effective implementation requires more than clinical guidelines. It demands culturally-informed protocols developed with community stakeholders, ensuring screening initiatives are both medically sound and socially resonant.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003ePolicy and practice recommendations\u003c/h2\u003e \u003cp\u003eTo address ACEs effectively within Qatar's primary care system, a multi-level approach is essential. At the policy level, this includes mandating trauma-informed care training through continuing medical education, a strategy supported by evidence that such training, when integrated throughout medical education and reinforced in specialized sessions, optimally prepares clinicians to address the consequences of trauma [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. This foundational policy effort should be coupled with integrating ACEs screening into national preventive health guidelines and establishing quality metrics for accreditation.\u003c/p\u003e \u003cp\u003eTo effectively operationalize these policies, parallel development of clinical infrastructure and workforce capacity is essential. A cornerstone of this effort is the enhancement of electronic health records (EHRs), which can be transformed from passive repositories into active clinical tools. By integrating structured ACEs documentation and automated referral pathways, EHRs can serve as teleprompters that guide assessment and planning, with software facilitating auto-documentation, referral generation, and secure information sharing through patient portals [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. This technological backbone must be supported by robust regional networks that seamlessly connect primary care to mental health services and community resources, while also ensuring that screening for ACEs is paired with an assessment of protective factors to guide intervention.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eResearch priorities\u003c/h2\u003e \u003cp\u003eFuture research should focus on critical areas. First, implementation science should build upon successful pilot trials. For example, one study demonstrated that multifaceted strategies can increase screening rates from 0% to over 11% [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This foundation should be expanded to systematically evaluate screening models' real-world feasibility and effectiveness, while simultaneously assessing how training impacts both patient outcomes and provider wellbeing, and conducting rigorous cost-effectiveness analyses.\u003c/p\u003e \u003cp\u003eSecond, culturally-specific adaptations are essential not only for Qatar but for the broader region. Evidence suggests that culturally adapted instruments ensures that assessments are both appropriate and effective within their specific context [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. This foundational work should extend to investigating local protective factors and resilience mechanisms, ultimately enabling the development of family-centered interventions that align with regional values and social structures.\u003c/p\u003e \u003cp\u003eFinally, longitudinal research is essential to evaluate the sustained impact of trauma-informed care. Such studies should track long-term health outcomes to determine if screening and subsequent interventions yield lasting benefits, investigate whether these practices can disrupt intergenerational cycles of trauma, and assess the neurodevelopmental effects of early identification and support.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and strengths\u003c/h2\u003e \u003cp\u003eThis study provides the first comprehensive analysis of physician knowledge, attitudes, and practices regarding ACEs screening within Qatar's primary healthcare system. By employing a theoretical framework to examine barriers across multiple domains, the research offers systematic insights into implementation challenges. The findings establish crucial baseline data to inform clinical protocol development and educational initiatives, while identifying specific targets for intervention to enhance trauma-informed care capacity. This foundational work creates an essential evidence base for developing effective strategies to address childhood adversity in similar healthcare contexts.\u003c/p\u003e \u003cp\u003eSeveral limitations should be considered when interpreting these results. The cross-sectional design and reliance on self-reported data may introduce social desirability bias and limit causal inference between physician characteristics and screening behaviors. While the sample size was adequate for initial analysis, the low response rate may affect generalizability across all healthcare settings in Qatar. Additionally, the exclusive focus on public primary care physicians\u0026rsquo; limits applicability to private practice or specialized clinical environments.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study marks a significant step towards understanding the current state of ACEs screening among physicians in Qatar. By uncovering the extent of knowledge, attitudes, practices and barriers related to ACEs screening, it highlights the critical areas for improvement and the need for comprehensive educational and policy interventions. This research not only adds to the limited literature on ACEs screening in the region but also sets the stage for future studies to build upon these findings, aiming to enhance the identification and support mechanisms for individuals impacted by ACEs.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACEs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdverse childhood experiences\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrimary Health Care Corporation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKAP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKnowledge, attitudes, and practices\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTDF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTheoretical domains framework\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACE-IQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdverse childhood experiences international questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePEA-Q\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePhysician\u0026rsquo;s experiences with ACEs questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompliance with Ethical Standards\u003c/h2\u003e \u003cp\u003e \u003cb\u003eConflict of interests\u003c/b\u003e: Usra Elshaikh, Hafiz Ahmed Mohammed, and Hanan F. Abdul Rahim, declare that they have no conflict of interest.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to participate:\u003c/strong\u003e \u003cp\u003e Informed consent was obtained from all participants prior to their participation in the study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to publish:\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003e Ethical approval was obtained from the Primary Health Care Corporation (PHCC) ethics committee (BUHOOTH-D-23-00031) and Qatar University Institutional Review Board (QU-IRB 1920-E/23).\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis research was funded by Qatar University student grant QUST-2-CHS-2023-1532.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eH.A.R. conceptualized the study and supervised data collection and analysis. U.E. conducted data collection and analysis and drafted the main manuscript text. H.A.M. contributed to drafting the manuscript. All authors critically reviewed and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to acknowledge the Primary Health Care Corporation, including its dedicated physicians and administrators. Special appreciation is extended to Al Wajba, West Bay, Rawdat Al Khail, and Al Daayen health centers. We also sincerely thank Dr. Alia A. Al-Ruwaili, Dr. Amani Alyafei, and Dr. Mahasin Idris.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data supporting the findings of this study are available within the article. 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Adverse childhood experiences (ACEs) measurement tools among children and adolescents in the Arab world: a scoping review. BMC Public Health. 2026. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12889-026-26312-9\u003c/span\u003e\u003cspan address=\"10.1186/s12889-026-26312-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adverse Childhood Experiences, primary care, screening barriers, trauma-informed care, Qatar","lastPublishedDoi":"10.21203/rs.3.rs-8861367/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8861367/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAdverse Childhood Experiences (ACEs) profoundly affect lifelong health, yet primary care screening remains underutilized globally. As the first study in Qatar examining this issue, we assessed knowledge, attitudes, practices (KAP) and barriers regarding ACEs screening among Primary Health Care Corporation (PHCC) physicians.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional survey was conducted in January 2024 among family medicine and well-baby clinic physicians across all PHCC centers. The validated questionnaire assessed demographics, KAP, and barriers, analyzed through the Theoretical Domains Framework. Statistical analyses included descriptive statistics and cluster-adjusted regression models.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 205 participating physicians, most lacked formal training on ACEs, with 66% unfamiliar with the ACE questionnaire. Knowledge increased significantly with PHCC experience (p\u0026thinsp;=\u0026thinsp;0.043). Attitudes were generally positive with a mean score of 37.2, with 91% believing ACEs should be addressed in primary care. However, only 59% had screened within PHCC settings, primarily using symptom-triggered approaches (67%) rather than routine screening (5%). Major barriers included insufficient time (78%), absence of response protocols (53.7%), and inadequate mental health resources (33.2%). Most physicians (83%) supported universal screening across age groups, with 75% expressing interest in further education.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDespite positive attitudes toward ACEs screening, significant knowledge gaps and implementation barriers limit practice in Qatar's primary care settings. Prioritizing trauma-informed education, standardized protocols, and resource allocation may enhance screening implementation. These findings provide a foundation for Qatar and similar healthcare systems to integrate ACEs screening into preventive care, aligning with global best practices. Further research should evaluate culturally adapted interventions and long-term outcomes.\u003c/p\u003e","manuscriptTitle":"Primary Health Care Physicians' Knowledge, Attitudes, Practices of Screening for Adverse Childhood Experiences (ACEs) in Qatar and barriers to implementation: a Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-23 16:25:04","doi":"10.21203/rs.3.rs-8861367/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"309446385559038567508133060059041850794","date":"2026-04-19T19:03:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"153062769817528529449017228747012081708","date":"2026-04-18T15:51:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-15T20:39:28+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-16T07:12:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-12T22:28:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-12T22:27:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2026-02-12T10:59:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"be5633ce-2e77-4395-8483-abc541e454b2","owner":[],"postedDate":"April 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-23T16:25:05+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-23 16:25:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8861367","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8861367","identity":"rs-8861367","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}