FraGile

FRAGILE Please Handle With Care

Understanding and supporting professionals’ response to suspicions of child abuse and neglect

Annemieke A. J. Konijnendijk

Fragile, please handle with care. Understanding and supporting professionals’ response to suspicions of child abuse and neglect. This thesis is part of the Health Science Series, HSS 18-21, department Health Technology and Services Research, University of Twente, Enschede, the Netherlands. ISSN 1878-4968. This research is part of the Academic Collaborative Centre Youth Twente. This study was funded by ZonMw, the Netherlands Organisation for Health Research and Development (grant number 159010003).

Cover design and lay-out: Kevin van Dijk (Graphic Design Twente) Printed by: Ipskamp Printing, Enschede, the Netherlands ISBN: 978-90-365-4504-4 DOI: 10.3990/1.9789036545044 © Copyright 2018: Annemieke Konijnendijk, Enschede, the Netherlands. All rights reserved. No parts of this thesis may be reproduced, stored in a retrieval system or transmitted in any form or by any means without permission of the author. Alle rechten voorbehouden. Niets uit deze uitgave mag worden vermenigvuldigd, in enige vorm of op enige wijze, zonder voorafgaande schriftelijke toestemming van de auteur.

FRAGILE, PLEASE HANDLE WITH CARE UNDERSTANDING AND SUPPORTING PROFESSIONALS’ RESPONSE TO SUSPICIONS OF CHILD ABUSE AND NEGLECT

DISSERTATION

to obtain the degree of doctor at the University of Twente on the authority of the rector magnificus, prof.dr. T.T.M. Palstra on account of the decision of the Doctorate Board, to be publicly defended on Thursday the 7th of June 2018 at 14:45 hours by

Annemieke Ariënne Johanneke Konijnendijk

born on the 19th of January 1985 in Almelo, the Netherlands

This dissertation has been approved by: Prof.dr. A. Need (supervisor) Dr. M.M. Boere-Boonekamp (supervisor) Graduation Committee Chairman/secretary Prof.dr. Th. A.J. Toonen

University of Twente

Supervisors Prof.dr. A. Need Dr. M.M. Boere-Boonekamp

University of Twente University of Twente

Referees Dr. S. Gijzen GGD Twente Dr. F.J.M. van Leerdam Health and Youth Care Inspectorate Committee Members Prof.dr. R. Torenvlied University of Twente Prof.dr. M.D.T. de Jong University of Twente Prof.dr. K. Hoppenbrouwers Catholic University of Leuven Prof.dr. S.A. Reijneveld University Medical Center Groningen/ University of Groningen

Paranymphs Cherelle van Stenus Sytske Wessels

CONTENTS Chapter 1

General introduction

Chapter 2

A qualitative exploration of factors that facilitate and impede adherence to child abuse prevention guidelines in Dutch preventive child health care

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Chapter 3

What factors increase Dutch child health care professionals’ adherence to guidelines on preventing child abuse and neglect?

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Chapter 4

In-house consultation to support professionals’ responses to child abuse and neglect: Determinants of professionals’ use and the association with guideline adherence

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Chapter 5

Professionals’ preferences and experiences with inter-professional consultation to assess suspicions of child abuse and neglect

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Chapter 6

Effects of a computerised guideline support tool on child healthcare professionals’ response to suspicions of child abuse and neglect: a community-based intervention trial

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Chapter 7

Conclusion and discussion

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Appendices

Appendices belonging to chapter 3 (A, B) Appendices belonging to chapter 4 (A, B, C, D) Appendices belonging to chapter 5 (A, B) Appendix belonging to chapter 6 (A)

129 138 160 169

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References

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Summary

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Samenvatting

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Dankwoord (Acknowledgements)

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Curriculum Vitae

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Publications and other contributions

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CHAPTER 1 General introduction


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GENERAL INTRODUCTION Child abuse and neglect Child abuse and neglect across the globe Abuse and neglect that occur to children under 18 years of age are serious public health concerns. Child abuse and neglect stand in sharp contrast with the United Nation’s Convention on the Rights of the Child. This convention states that children should grow up in a family environment, in an atmosphere of happiness, love and understanding for the full and harmonious development of their personality [1]. Across the world, different definitions exist as to what might constitute child abuse and neglect. In Europe for example, definitions vary between countries [2]. A definition that is commonly used is that of the World Health Organisation (WHO) [3, p 15.]: ‘Child abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power’ Child maltreatment traumatises millions of children across the globe [4]. A meta-analysis that included articles published between 1980 and 2008 on the prevalence of child abuse and neglect reported the following overall estimated rates for self-report studies that mainly assessed lifetime prevalence rates: 12.7% for sexual abuse, 22.6% for physical abuse, 36.3% for emotional abuse, 16.3% for physical neglect and 18.4% for emotional neglect. For studies using informants that mainly assessed one-year prevalence rates, the estimated prevalence rates were 0,4% for sexual abuse, and 0,3% for both physical and emotional abuse [4]. Child abuse and neglect in the Netherlands Child abuse and neglect remains a major societal problem in high-income countries, as a considerable number of children continue to be maltreated and exploited [5]. In the Netherlands, the following definition of child abuse and neglect is currently in use, officially documented in the Youth Act [6] ‘Every form of threatening or violent behavior towards minors of a physical, psychological or sexual nature. This behavior is forced on minors actively or passively by parents or other persons towards whom minors feel dependent and lack freedom. This behavior (threatens to) cause(s) serious harm in the form of physical or psychological damage’

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Chapter 1

A nation-wide prevalence study is performed approximately every five years in the Netherlands to estimate the one-year prevalence of child abuse and neglect in general and that of several subtypes. These prevalence studies make use of three information sources: informants (professionals), official registrations by the national Advice and Reporting Centre Child Maltreatment (Advies en Meldpunt Kindermishandeling, Veilig Thuis since 2015) on child abuse and neglect reports, and self-reports of students in secondary school. In 2016, the nation-wide prevalence study was limited to self-reports of secondary school students. In 2010, the overall estimated one-year prevalence was 3.4% based on the results of the informants study and the official registration of Veilig Thuis [7]. This prevalence rate is 0.4% higher than found in 2005 [8]. In 2003, the yearly report of the Dutch Advice and Reporting Centre [9] showed the organisation was consulted 47,000 times, and investigated 20,000 suspected cases (0.6% of all Dutch children in 2013 [10]). One-year prevalence rates based on self-report study alone remained stable between 2005 and 2010, 9.9% of students between eleven and seventeen years old reported to have experienced child abuse and neglect [7, 8]. The self-report study among secondary school students (in one of the first four years of secondary schools) performed in 2016 (6.5%) showed a decline of the one-year prevalence rate compared to 2005 and 2010 [11]. In 2010, the most prevalent types of child maltreatment were physical, emotional and educational neglect, i.e. not attending to children’s academic needs. Furthermore, the study concluded that almost a quarter of victims underwent sexual and/or physical abuse in 2010. Compared to 2005, emotional neglect (including being a witness of domestic violence) and educational neglect were reported more often, while sexual abuse and physical neglect were reported less often [7]. Causes and consequences In the last two decades, research has increased public knowledge about risk factors and protective factors of child abuse and neglect. It became evident that a complex interplay of multiple risks contributes to child abuse and neglect. These risks can be categorised into five categories: individual-level (parental) risk factors, individual-level (child) characteristics, family factors, contextual factors and macrosystem factors [12]. Parental risk factors include a history of abuse and/ or neglect (intergenerational transmission), early childbearing, and parental psychopathology, such as depression and substance use. A child characteristic that has been associated with greater risks of abuse and neglect is the presence of a physical or mental disability. Examples of family factors include family structure, deficient parenting skills, and social isolation. Contextual factors include for instance poverty, unemployment and low socioeconomic status. Finally, macrosystem factors concern social attitudes and norms within society towards violence or beliefs about discipline. Multiple studies have shown that the likelihood of child abuse and neglect increases when more risk factors are present [13, 14]. Thus far, relatively little is known about factors that protect children from abuse and neglect, and the interaction between protective factors and risk factors [12]. Protective factors that have been identified include biological predispositions, positive events that alleviate risk factors, parents that have secure and supportive relationships with others, and environmental conditions [12].


Understanding of the physical, psychological, and economic consequences of child abuse and neglect has expanded dramatically in the last twenty years [15]. It became clear that child abuse and neglect endangers and impairs the neurological, biological and behavioural development to varying degrees. The impact of child abuse and neglect depends on existing risk and protective factors. It also depends on characteristics of maltreatment, such as type, severity, chronicity, and timing [15]. Experiencing child abuse and neglect has been associated with behavioural problems, long-lasting psychological disorders, obesity, low educational employment, criminal behaviour [16], lower perceived quality of life [17], intergenerational transmission [18] and even child death [19, 20]. The negative outcomes of child abuse and neglect are also reflected in substantial costs in adulthood due to health service utilisation and productivity losses [21, 22]. The high burden of abuse and neglect makes clear that efforts are needed to prevent and end child abuse and neglect. Professionals’ responsibilities in tackling child abuse and neglect A growing appeal to professionals Increased knowledge about the high prevalence of child abuse and neglect and its impact on children’s lives and society as a whole has raised attention in politics for tackling the problem in the last two decades. Policy makers all over the world are increasingly challenged to develop strategies that are effective in safeguarding children from harm. As parents and maltreated children often do not seek help themselves [9, 23-25], governments strongly appeal to professionals who work with children and families to respond to suspicions of child abuse and neglect at an early stage [e.g. 2]. Child abuse and neglect is no longer seen as a problem ‘behind the front door’, but as a problem that professionals need to address. Especially professionals working in universal services, such as (pre)schools, day-care facilities and preventive child healthcare, have an important role in the secondary prevention of child abuse and neglect, i.e. the early detection of possible child abuse and neglect, and an early response to suspicions in order to prevent (further) maltreatment. Virtually all children make use of universal services that aim to optimise the healthy development and upbringing of children. As such, these places are important sites where abuse and neglect can be detected at an early stage. Supporting professionals in safeguarding children According to the WHO “a comprehensive response to child maltreatment involves putting into place measures and mechanisms to detect and intervene in cases of maltreatment” [26, p 4.] To stimulate professionals to respond to concerns about possible child abuse and neglect, governments across the world documented professionals’ roles, and responsibilities, and instructions on how to recognise, and respond to suspicions of child abuse and neglect in policies and laws. In many countries, such as Australia [27], Brazil [28], and South Africa [29], and in almost all European Union Member States [30], professionals are legally obliged to report suspicions of child abuse and neglect to child protection services. These services can further investigate reported concerns. In other countries, including the Netherlands, professionals working with children and families are not legally required to report suspicions, but need to follow specific guidelines when they suspect child abuse and neglect [31, 32].

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Chapter 1

In order for professionals to respond adequately to concerns about a child’s safety, it is critical that professionals are familiar with the aetiology of child abuse and neglect, are able to recognise abnormal patterns of injuries or behaviour, and are aware of the procedures on how to respond [33]. To support professionals’ knowledge and responses, (clinical) guidelines in the field of safeguarding children are becoming increasingly available world-wide [e.g. 26, 34, 35, 36]. In general, guidelines have become a familiar part of the daily practice of clinicians [37, 38], but also increasingly emerge in other fields of care and welfare services [e.g. 39]. Guidelines may have many benefits for professionals, children as well as children’s caregivers. They have the potential to improve the quality of critical decisions as they offer systematically developed recommendations on how to provide the best care based on evidence-based practice. Also, they facilitate the overturning of beliefs of professionals accustomed to outdated practices, they support professionals who are uncertain how to proceed and improve the consistency of care [37, 40]. Furthermore, guidelines assist professionals in managing the growing information flow of literature [40]. Supporting professionals in safeguarding children in the Netherlands Preventing child abuse and neglect has been particularly high on the Dutch political agenda since 2007. In that year, action plans were introduced in all municipalities to stimulate local policy makers and child-serving professionals working in the same region to develop more effective responses to suspicions of child abuse and neglect. Furthermore, collaborative youth and family centres were founded across the country. Moreover, new legislation on the prevention of child abuse and neglect was announced. In July 2013, the Mandatory Reporting Code (Domestic Violence and Child Abuse) Act came into force [31]. From that year on, organisations and independent professionals working with children and families in the fields of (youth) healthcare, youth care, education, child care, social justice support and criminal justice have been legally obliged to follow an action plan for responding to signs of domestic violence, child abuse and neglect [31, 32]. The reporting code consists of five steps that professionals are expected to take when concerns about child abuse and neglect arise: 1. 2.

3. 4. 5.

Identifying the signs. When a professional identifies signs of domestic violence or child abuse and neglect, (s)he is expected to make a record of these signs; Consultation of a colleague, and, if necessary, consultation with the regional child protection service: Advice and Reporting Centre for Child Maltreatment (‘Veilig Thuis’ since 2015), or an injury specialist. Discussing concerns with the child and/or the caregivers; Assessing violence and abuse, based on the information collected in the previous steps; Reaching a decision: providing or arranging assistance, or reporting to Advice and Reporting Centre if the professional believes that (s)he cannot protect the client sufficiently against the risk of domestic violence or child abuse and neglect.


The reporting code also recommends that professionals obtain relevant information from other professionals involved with the family when they suspect abuse and/or neglect, if deemed necessary and in principle with caregivers’ consent. This activity has been explicitly included in the national guideline on child abuse and neglect prevention for physicians [32, 41]. Veilig Thuis provides expert consultation on child abuse and neglect, and domestic violence. Currently, Veilig Thuis takes over the investigations of suspicions that are reported to this organisation. From January 1st 2019, every branch of professions will be obliged to develop and implement an assessment framework to support professionals’ decision making in the fifth step of the reporting code if suspicions persist: is it necessary to report suspicions to Veilig Thuis, ánd is it (also) possible to provide or arrange assistance? In the Netherlands, the Health and Youth Care Inspectorate, part of the Dutch Ministry of Health, Welfare and Sport, supervises and promotes good and safe care [42]. One of their activities concerns supervising whether organisations implemented the reporting code adequately and professionals’ use of the reporting code [43]. The role of Dutch preventive child healthcare in safeguarding children Preventive child healthcare has a unique position in the early recognition of and response to child abuse and neglect. In the Dutch healthcare system, teams of child-specialised physicians, nurses and assistants monitor the health and development of virtually all children in well-baby clinics and schools. They also support caregivers in their parenthood and provide vaccinations. Preventive child healthcare is free of charge [33, 44]. Preventive child healthcare professionals have frequent contact with caregivers and their children, and have been extensively trained to recognise health problems, psychosocial issues and parenting problems in early stages, including adverse child environments [44]. The frequent medical and psychosocial examinations and contact with caregivers provide preventive child healthcare professionals with the optimal opportunity to observe signs of child abuse and neglect. Moreover, the preventive child healthcare professional can take into account the information collected on the child’s health and psychosocial development, environmental circumstances and parenting skills since the child’s birth. Since 1998, approximately thirty systematically developed guidelines on various topics have become available for Dutch preventive child healthcare professionals to stimulate more uniform and evidencebased practice [45]. These guidelines all followed a rigorous approach to guideline development. This approach combined scientific evidence with expert opinion [38, 46]. Most guidelines in preventive child healthcare are not mandatory; they are however not optional. In case of a medical litigation, a judge needs to answer the question whether a professional has acted in a way that can be expected of a reasonably competent and reasonably acting professional in the given circumstances. The judge will then use guidelines as sources of information to determine the standard of care. Deviating from guidelines in individual cases is allowed when professionals have valid and justifiable argumentation,

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and when deviating is in the interest of good care [47, p 68,78]. In case of suspected child abuse and neglect, a judge will also use The Mandatory Reporting Code Act [31] to judge whether professionals responded correctly. This law contains room for professional consideration; it allows deviation from the mandatory five steps when these steps conflict with the provision of good care. Documentation of the decision to not follow guidelines is important to be able to demonstrate when and why the decision to not follow guideline recommendations was made. In 2002, national guidelines on early detection and response to child abuse and neglect were published aimed at professionals working with children [48]. In 2010, a new national guideline specifically for preventive child healthcare professionals was issued [49]. The key activities described in the guideline concur to a large extent with those in the reporting code. These activities are described below in the order in which the guideline on child abuse and neglect recommends preventive child healthcare professionals to perform them. 1. 2. 3. 4. 5. 6. 7.

Risk assessment based on protective and risk factors; Discussing suspicions with caregiver(s) and/or child; Consulting an in-house expert on child abuse and neglect; Consulting the national child protection service: Advice and Reporting Centre; Requesting information from professionals outside the preventive child healthcare organisation who are also involved with the family; Acting: providing support to caregivers, referring the family to other organisations for support or reporting suspicions to the Advice and Reporting Centre; Monitoring the support that is provided to the family and taking action again if the support is inadequate.

In 2016, an update of the guideline was issued that incorporated new legislation, i.e. the Mandatory Reporting Code Act, new scientific insights and consensus discussions among content experts [50]. The Dutch Health and Youth Care Inspectorate included child maltreatment as one of the main risky topics for supervision in the preventive child healthcare setting [42]. In the period 2016-2017, the Inspectorate monitored how preventive child healthcare organisations performed regarding four activities: professionals’ detecting, referring and monitoring of child abuse and neglect, training on the topic of child abuse and neglect, registrations of (suspected) child abuse and neglect and performed activities, and information exchange with other organisations involved with the care for children. Understanding why professionals do or do not follow guidelines The existence of guidelines does not guarantee that professionals follow their recommendations [51, 52]. It is a well-known phenomenon that innovations in health and other areas of professionals practice, are not automatically accepted by its prospective users [53]. Omachonu and Einspruch


defined a healthcare innovation as “the introduction of a new concept, idea, service, process, or product aimed at improving treatment, diagnosis, education, outreach, prevention and research, and with the long term goal of improving quality, safety, outcomes, efficiency and costs” [54, p 5]. Studying the effects of introducing innovations on professionals’ behaviour is a relatively new [55] and developing [53] research field. Eccles and Mittman [55, p 1] defined implementation science as “the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practice into routine practice, and, hence, to improve the quality and effectiveness of health services and care”. Nowadays many theories, models and frameworks have been used in implementation science to describe, understand and explain innovation processes, including determinant frameworks [53]. According to Nilsen [53], a determinant framework describes general categories of determinants that are hypothesised or have been found to influence the innovation process. Typically, each category of determinants includes a number of factors, impeding and/or facilitating, that have an impact on implementation outcomes, e.g. guideline adherence. According to Nilsen, “the overarching aim of a determinant framework is to understand and/or explain influences on outcomes, e.g. predicting outcomes or interpreting outcomes retrospectively” [53, p 3]. Studying the importance of a set of specific determinants, as perceived by (prospective) users, can provide insights into the relative importance of these determinants in relation to a specific innovation, such as new guidelines [53]. Providing insight into determinants of a particular innovation and an assessment of their relative importance are important activities to better target strategies to change these relevant determinants [53, 56, 57]. For example, when poor familiarity with the content of the guideline is identified as the most important barrier to guideline adherence, a strategy should be developed that aims to improve familiarity. In this example case, strategies that focus on other determinants will probably not be effective in changing behaviour. Several determinant frameworks have been developed that point to factors assumed or found to influence the innovation process of clinical guidelines. For example, Cabana et al. [58] described a variety of factors in their literature review on barriers to physician’s adherence to clinical guidelines. The determinants include external barriers (patient factors, guideline characteristics, and organisational factors), familiarity, awareness, outcome expectancy, the belief that he/she can or cannot perform guideline recommendations, agreement with guidelines in general or with a specific guideline, and inertia of previous practice. These factors greatly overlap with those described in the determinant framework by Fleuren, Wiefferink and Paulussen [56]. This framework (see Figure 1) relies on existing theories [e.g. 59, 60, 61], and on synthesised results from empirical studies on new practices, including guidelines in Dutch preventive child healthcare and education settings. Fleuren et al. [56] described the process from disseminating an innovation until continued use by its prospected users as the innovation process. The innovation process consists of four phases. The first phase, dissemination, refers to the active spread of new practices to the target audience using planned strategies [53]. Adoption is the phase in the innovation process in which people acquire and process

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Chapter 1

information about the innovation and make their decision about using it (behavioural intention) [57]. Implementation is the process of putting to use or integrating new practices within a setting (behaviour) [53, 57, 62, 63]. The final phase is the continuation phase: the decision of a person or organisation to (dis)continue using the innovation [56]. Fleuren et al. [56] identified 29 critical determinants that may affect the transition from one phase to the next phase, such as clarity of the innovation, social support, and personal benefits/drawbacks. These 29 determinants are divided over four categories of determinants: guideline factors (e.g. clarity, consistency with earlier work procedures), professional factors (e.g. self-efficacy, familiarity with the content, outcome expectations), organisational factors (e.g. limited time) and factors related to the socio-political context (rules and regulations). Innovation strategies, targeted to specific determinants, aim to facilitate desired behaviour.

Innovation determinants

Characteristics of the innovation strategy

Innovation process

Characteristics of the socio-political context

Dissemination

Characteristics of the organisation

Adoption

Characteristics of the adopting person (user)

Implementation

Characteristics of the innovation

Continuation

Figure 1. Framework representing the innovation process and related categories of determinants [56], reproduced with permission. Research question According to the WHO, little attention in terms of research and policy has been given to the prevention of child abuse and neglect [64, 65]. In 2013, the WHO called for increased investment in prevention and the need for increased intersectional cooperation in their European report [64]. In the Netherlands, further investments in research and policy are needed, as the one-year prevalence of child abuse and neglect did not decline between 2005 and 2010 [7]. Guidelines on safeguarding children aim to contribute to better prevention of (on-going) child abuse and neglect by making professionals more cautious to signs and capable of responding to their concerns. Guidelines, including those on handling suspicions of child abuse and neglect, are relatively new in the field of


preventive child healthcare [38, 66]. As active spreading of innovations to the target audience does not guarantee their implementation by professionals, the desired effects of introducing guidelines may not appear. Therefore, studying the effects of guidelines on professional practice is essential to be able to further improve the detection, protection and care for children who are exposed to child abuse and neglect [67]. Although guidelines on handling suspected child abuse and neglect become increasingly available, few studies thus far focused on adherence to guideline recommendations, and the factors that contribute to it. In particular, little is known about consultation, i.e. seeking advice or requesting client information from professionals to assess suspicions of child abuse and neglect, while these are critical activities. Careful consideration about further action is essential, as professionals can make better informed decisions that best suit the needs of the child. Furthermore, little is known about the specific factors that facilitate or impede the performance of guideline activities. Information on the relevant influences is useful to better target innovation strategies to support healthcare professionals in their responsibilities to keep children safe from abuse and neglect. The first aim of this thesis is to better understand if and why professionals do or do not (always) perform guideline activities when they suspect child abuse and neglect, and what factors contribute to their level of guideline adherence. Two guideline activities are investigated in more detail: in-house consultation and inter-organisational consultation. The second aim is to develop, implement and evaluate an intervention that aims to promote preventive child healthcare professionals’ guideline adherence and to decrease their time spent on seeking guideline information: this intervention was realised by developing a computerised guideline support tool in the child’s health record system. These aims correspond largely with the risky topics that the Health and Youth Care Inspectorate find important issues to supervise on in (health) care for children [42, 43]. The determinant framework provided by Fleuren et al. [56, 57] is used to guide the studies on adherence to guideline activities, to identify relevant determinants of guideline adherence and to provide insight in the relative importance of particular barriers and facilitators. The framework by Fleuren was chosen as it was developed and proved useful to study the implementation of guidelines in Dutch preventive child healthcare [56]. Furthermore, an aim was to identify determinants in addition to the determinants described in the framework that are particularly important in relation to guidelines on child abuse and neglect prevention. As such, next to practical and policy implications, this research also has theoretical relevance. The general research question is: Why do or don’t Dutch child-serving professionals, in particular preventive child healthcare professionals, follow guideline recommendations on the secondary prevention of child abuse and neglect, and how can preventive child healthcare professionals be supported in following these recommendations?

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Chapter 1

Outline The studies described in Chapters 2 – 4 and 6 focus on professionals in the preventive child healthcare setting. Chapter 5 takes a broader perspective including all child-serving professions. Chapter 2 describes the results of a qualitative study among preventive child healthcare professionals working in the Dutch region of Twente. This study answers the following question: a. What factors facilitate or impede professionals’ adherence to guidelines on the prevention of child abuse and neglect? In Chapter 3 the results of a nationwide study among preventive child healthcare professionals on guideline adherence are presented. The measurement instrument is a questionnaire based on the results of the qualitative study (Chapter 2). The following research questions will be answered: a. To what extent do child healthcare professionals adhere to key activities of the guideline on child abuse and neglect prevention? b. Which determinants associated with the guideline, the professional, the organisational context and the socio-political context, facilitate or impede professionals’ overall adherence to the guideline on child abuse and neglect prevention? In Chapter 4 the focus is on adherence to one specific key guideline activity: in-house consultation, i.e. consultation of an expert on child abuse and neglect prevention in the organisation. This study answers the following questions: a. What determinants facilitate or impede the extent to which Dutch preventive child healthcare professionals consult the in-house child abuse and neglect expert? b. To what extent is the degree of consultation with the in-house child abuse and neglect expert by preventive child healthcare professionals associated with the degree of performing the six other recommended activities described in the guideline on the prevention of child abuse and neglect? Chapter 5 focusses on child-serving professionals’ response in relation to one aspect of assessing child abuse and neglect suspicions: inter-professional consultation, i.e. seeking a professional’s opinion from professionals from other child-serving organisations. This chapter presents a case study in which interorganisational consultation preferences and experiences by professionals who provide in healthcare, social care and preschool services to children are studied. This study addresses the following questions with regard to suspected child abuse and neglect in children of up to four years of age: a. How many professionals intend to seek inter-organisational consultation? b. What types of children’s services do professionals prefer to consult? c. What factors can be identified as facilitators and barriers with regard to inter-organisational consultation, based on professionals’ experiences?


Chapter 6 presents the development, implementation and evaluation of a computerised tool for preventive child healthcare professionals to support their response according to the guideline on child abuse and neglect prevention, and to decrease their time spent on seeking guideline information. The research question addressed in chapter 6 is: a. What are the effects of having access to the paper-based guideline on child abuse and neglect prevention complemented with a computerised guideline support tool, compared to having access solely to the paper-based version, on child healthcare professionals’ adherence to the guideline and on the time spent on seeking relevant information provided by the guideline? In Chapter 7 the main findings are presented and discussed. Recommendations for policy, practice and further research are provided to better support future child-serving professionals’ response to suspicions of child abuse and neglect.

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CHAPTER 2 A qualitative exploration of factors that facilitate and impede adherence to child abuse prevention guidelines in Dutch preventive child health care

This chapter has been published as: Konijnendijk, A. A. J., Boere-Boonekamp, M. M., Haasnoot-Smallegange, R. M. E., & Need, A. (2014). A qualitative exploration of factors that facilitate and impede adherence to child abuse prevention guidelines in Dutch preventive child health care. Journal of Evaluation in Clinical Practice, 20(4), 417–424.

A qualitative exploration of factors that influence child healthcare professionals’ guideline adherence

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Abstract Rationale, aims and objectives - In the Netherlands, evidence-based Child Abuse Prevention (CAP) guidelines have been developed to support child health care professionals (CHPs) in recognizing and responding to suspected child abuse. The aim of this study was to identify factors related to characteristics of the guidelines, the user, the organization, and the socio-political context that facilitate or impede adherence to the CAP guidelines. Methods - Three semi-structured focus groups including 14 CHPs working in one large Dutch child health care organisation were conducted in January and February 2012. Participants were asked questions about the dissemination of the guidelines, adherence to their key recommendations and factors that impeded or facilitated desired working practices. The interviews were audiotaped and transcribed. Impeding and facilitating factors were identified and classified. An innovation framework was used to guide the research. Results - CHPs mentioned 24 factors that facilitated or impeded adherence to the CAP guidelines. Most of these factors were related to characteristics of the user. Familiarity with the content of the guidelines, a supportive working environment and good inter-agency cooperation were identified as facilitating factors. Impeding factors included lack of willingness of caregivers to cooperate, low self-efficacy and poor inter-agency cooperation. Conclusions - The results indicate that a broad variety of factors may influence CHPs’ (non-) adherence to the CAP guidelines. Efforts to improve implementation of the guidelines should focus on improving familiarity with their contents, enhancing self-efficacy, promoting intra-agency cooperation, supporting professionals in dealing with uncooperative parents, and improving interagency cooperation. Recommendations for future research are provided.

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Chapter 2

Introduction Child abuse is a considerable problem across the world [68-70]. In the Netherlands, approximately 1 in 30 children between the ages of 0 and 19 is abused every year [7]. Child abuse may cause longlasting physical and psychological damage to individual children (e.g. [71-73]) and may also results in economic costs for society [74]. Policy makers therefore agree that efforts should be made to stop child abuse. Professionals working with families play an important role in the prevention of child abuse. However, they do not always recognize child abuse [75], or do not respond adequately when they have suspicions [e.g. 76, 77]. As a result, vulnerable children and families may not get the support they need. Clinical guidelines may improve the quality of professional decision making [37, 78-80]. In 2010, The National Institute for Public Health and the Environment, and the Netherlands Centre for Youth Health introduced extensive evidence-based clinical guidelines on early detection of and responses to suspected child abuse in preventive child health care (henceforth: the Child Abuse Prevention (CAP) guidelines) [49]. Dutch preventive child health care professionals (CHPs), doctors and nurses, offer preventive child health care services in child health clinics and schools. CHPs are in an ideal position to recognize and respond to suspected child abuse, as they have contact with approximately 95% of Dutch children on a regular basis [33, 81]. Key recommendations in the CAP guidelines include registration of facts and observations that underpin suspicions, talking with parents and/or children about suspicions, consulting a colleague (preferably an expert on child abuse) and consulting the Dutch Child Protection Services (CPS). CHPs may also contact other professionals involved with the family if parents permit this. If suspicions persist, CHPs should organize a second meeting with parents and/or the child, provide support, refer the family to other organizations for support or report their suspicions to CPS. CHPs need to monitor the support that is provided to the family and act again if they feel that the support is insufficient. All their activities should be registered in the electronic child health care record. The CAP guidelines also includes background information and a time-phased decision tree. From July 2013, CHPs and other professionals working with families are obliged by law to follow the guidelines if their suspicions persist [82]. Despite efforts to improve implementation, professionals do not always adhere to clinical guidelines. To gain a better understanding of professional adherence to innovations in health care, including new guidelines, Fleuren, Wiefferink and Paulussen [56] developed a theoretical framework. This framework unites several theories and models [e.g. 59, 60, 61] and has been shown to be suitable for studying innovation in Dutch (child) health care [83, 84]. The framework distinguishes four stages of the innovation process (dissemination, adoption, implementation and continuation). It also lists four


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categories of factors, or so-called determinants, that may facilitate or impede the transition from one stage to the next: characteristics of the innovation, the adopting person, the organization and the socio-political context. Guidelines or protocols that aim to support professionals in responding to child abuse also exist in other countries [34-36, 85]. However, research on adherence to guidelines in relation to child abuse prevention is scarce. One study that did evaluate a set of guidelines on positive parenting and family violence prevention indicated multiple barriers to using the guidelines, related to guideline characteristics (complex structure) and organizational characteristics (lack of time and competing agency demands and priorities) [85]. Although little is known about adherence to child abuse prevention guidelines, numerous studies have focused on factors impeding professionals’ decision making in relation to reporting child abuse to child protection services. These factors include poor knowledge of the symptoms of child abuse [86, 87], feelings of loyalty towards the family [88], low perceived self-efficacy [89], poor knowledge of reporting laws and processes [90, 91], being threatened with a law suit or having testified in child abuse cases [90], and being in practice for longer [90]. Multiple studies have found that professionals feel reluctant to report suspected child abuse to CPS because of negative attitudes and low trust towards CPS, negative experiences, inadequate feedback or delayed investigations [75]. Insight into the relevant determinants for successful implementation allows health care organizations to develop strategies tailored to these determinants in order to achieve desired work practices [56]. It is as yet unclear whether and for what reasons CHPs do or do not adhere to the recommendations of the CAP guidelines. Therefore, the current study aims to identify factors that facilitate or impede CHPs’ adherence to the CAP guidelines. We used a qualitative design. The framework by Fleuren et al. [56] was used to guide the research.

Methods Study Design We conducted three focus groups of CHPs in January and February 2012. These CHPs all worked at one preventive child health care organization covering the Twente region in the Netherlands (henceforth: GGD Twente). According to the criteria of Dutch Medical Research Involving Human Subjects Act, this study didn’t need to be submitted for ethical approval by a Medical Ethical Committee [92]. Participants GGD Twente has been working with the CAP guidelines since 2010. During the study period, 54 child health care doctors and 125 child health care nurses were employed by GGD Twente. In 2012, these CHPs

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were providing preventive child health care services to approximately 152,000 children between the ages of 0 and 19. All 179 CHPs were invited to participate in a focus group interview via an email from their manager. Two weeks later, a reminder was sent to the target population. CHPs were asked to participate on a voluntary basis. They were reimbursed for travel expenses and received a €20 gift voucher. The invitation to participate in the study informed CHPs about the research objectives. Fourteen CHPs, six doctors and eight nurses, agreed to participate: three CHPs in focus group session 1, seven CHPs in focus group session 2 and four CHPs in focus group session 3. At the time of the focus groups, seven participants were working with children up to the age of four and seven were working with older children. All participants were women with experience as a CHP ranging from 1 year to over 20 years. In all the sessions, all the participants actively engaged in the group discussions. Interview schedule A semi-structured interview schedule was developed to guide the focus group discussion and to ensure comparability of the three sessions. A time schedule was included to ensure that every interview question received enough attention. The questions were developed by the authors and pilot-tested with a child health care doctor. Conduct of sessions Each session was guided by a different moderator: the first, second or fourth author. The sessions all started with introductions, followed by a 10-minute presentation to introduce the discussion topic, explain the study’s purpose and provide instructions. The moderator guaranteed both confidentiality and anonymity before the actual discussion started. A research assistant made detailed notes during the discussions. The first part of each focus group session focused on dissemination of the CAP guidelines. The main question was: ‘In what way or ways have you become familiar with the guidelines?’ The second part started with open questions to find out what kind of suspicions or what situations led participants to start using the guidelines. The sessions continued with questions about their experiences in performing key activities described in the guidelines. We asked the participants to elaborate on factors that facilitated or impeded them in adhering to the guidelines. The interview schedule can be found in Table 1. Each focus group session lasted approximately two hours, including the introduction and a 15-minute coffee break.


29

Table 1. Interview schedule. #

Interview questions

1

In what way or ways did you become familiar with the guidelines?

2

In what situations do you use the guidelines?

3

To what extent do you use the guidelines when you suspect child abuse?

4

The guidelines recommend talking to parents and/or children about your suspicions. What are your experiences with this recommendation?

5

The guidelines recommend consulting CPS when you suspect child abuse. What are your experiences with this recommendation?

6

The guidelines recommend collecting information from professionals who are involved with the family outside the child health care organization, when suspicions persist. What are your experiences with this recommendation?

7

The guidelines recommend consulting a child abuse expert in your organization when you suspect child abuse. What are your experiences with this recommendation?

8

The guidelines recommend providing support, referring the family to other organizations for support, or reporting suspicions to CPS when suspicions persist. What are your experiences with providing support? What are your experiences with referring a family to other organizations for support? What are your experiences with reporting suspicions to CPS?

9

The guidelines recommend requesting follow up information, in case other organizations do not provide information after CHPs have referred a family for support or reported the family to CPS. What are your experiences with this recommendation?

10 What are your experiences and perceptions about the recommended time scales which are contained in the guideline? 11 How do you evaluate the guidelines in general? To what extent do you think there is information missing from the guidelines? In what ways do you think the guidelines could be improved? What is the most important barrier that you experience in working with the guidelines? 12 Do you have any final questions or points you would like to add to the discussion?

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Data analysis Focus group interviews were audiotaped with consent of the participants and literally transcribed. The analysis [93] was carried out using the software program Atlas.ti [94]. Two assessors independently read each transcript and coded text fragments. The first author analyzed the transcripts first. A second assessor coded the same transcripts using the coding scheme provided by the first author. Impeding and facilitating factors were identified and classified using the revised taxonomy proposed by Fleuren, Paulussen, Van Dommelen and Van Buuren [84]. Text-fragments that did not correspond with any of the 29 factors in this taxonomy were given separate codes. Differences in classification were discussed between the two assessors until consensus was reached.

Results In total, 24 determinants that facilitated or impeded adherence to the recommendations in the CAP guidelines were identified, of which nine determinants were mentioned in all three focus group interviews or by seven participants or more. Nineteen of the 29 determinants presented by Fleuren et al. [84] were identified. Most of the determinants were identified in the category of characteristics of the user (10 out of 11). Five determinants were identified in addition to the set of 29 determinants: concreteness and feasibility in the category of characteristics of the innovation, attitudes and routine in the category of characteristics of the user, and inter-agency cooperation in the category of the socio-political context. Table 2 gives a description of the 29 determinants described by Fleuren et al. [84], the five extra determinants identified in this study and the number of participants that identified facilitating and impeding factors. Determinants related to characteristics of the innovation (CAP guidelines) Three participants mentioned that the guidelines promote a working method that largely reflects existing practice. The most salient changes to their working procedures included the recommendation to consult a child abuse expert in the organization and the time-phased decision tree in which the main recommendations are integrated. In general, participants had a positive attitude towards these changes. Therefore, these positively evaluated changes were not coded as impeding factors, although they were incongruent with their earlier work methods. Participants in one focus group interview discussed the feasibility of the recommended timeline. One participant claimed that, particularly in holiday periods, it is not always feasible to respond within the recommended time scale. In two focus group interviews, at least one element of the CAP guidelines was perceived as unclear. In one focus group, participants found the CAP guidelines to be incomplete. Three participants found the guidelines’ references to specific instruments for support in recognizing child abuse and decision making useful. One participant was quite negative about the CAP guidelines and had not adopted them. She perceived the guidelines as too rigid to apply in a wide variety of situations.

Description of the determinants

Extent to which the innovation is based on trusted knowledge

Extent to which the innovation contains the information and materials needed for its effective use

Extent to which the innovation is perceived as complex

Extent to which the innovation is perceived as consistent with existing work procedures

Extent to which the results of the innovation are observable to the health care professional

Extent to which the innovation has added value for the client

Extent to which the innovation is perceived as both realistic and achievable

Extent to which the innovation is concrete rather than abstract or imaginary

2. Correctness

3. Completeness

4. Complexity

5. Compatibility

6. Observability

7. Relevance client

Feasibility

Concreteness

2 3 3

1 -

2 4

2 12* -

Experienced or expected support of colleagues, professionals from other health care organizations, team

14. Descriptive norm

13. Social support

Perceived behavior of colleagues with respect to the use of the innovation

leaders, or higher management

innovation

the innovation

Extent to which the health care professional expects or experiences that the client will cooperate in the

12. Cooperation client

Extent to which the health care professional expects or experiences that the client will be satisfied with

11. Satisfaction client

11*

-

2

Extent to which the innovation fits in the perceived task orientation of the health care professional

10. Task orientation

plausible 3

2

3

-

1

-

1

3

-

Extent to which the health care professional perceives the outcomes of the innovation as important and

-

-

9. Outcome expectations

7

2

6*

factor (-)

factor (+)

Extent to which the innovation has (dis)advantages for the health care professional

Impeding

Facilitating

8. Personal (dis)advantage

Determinants related to the characteristics of the adopting person (user)

Extent to which the procedures/guidelines of the innovation are clear

1. Clarity

Determinants related to characteristics of the innovation

Determinants

Table 2. Number of participants identifying a factor as facilitating or impeding adherence to the CAP guidelines. A qualitative exploration of factors that influence child healthcare professionals’ guideline adherence 31

2

Confidence of the health care professional in the ability to perform the behavior needed to use the

16. Self-efficacy

Extent to which the health care professional is familiar with the content of the innovation

Expressions of affect towards the innovation in general, or its specific recommendations

Extent to which the use of the innovation is integrated into daily practice of the health care professional

18. Familiarity

Attitudes

Routine

Replacement of health care professionals who use the innovation and leave the organization

Staff capacity in the organization or department

Financial resources made available for implementing the innovation

Time available for health care professionals to integrate the innovation in daily practice

Resources and services made available for health professionals to use the innovation, e.g. equipment,

material or offices

One or more persons charged with coordinating the implementation of the innovation within the

20. Staff turnover

21. Staff capacity

22. Financial resources

23. Time

24. Availability of resources and

services

25. Coordinator

professional

Extent to which the organization provides feedback about the implementation to the health care

Availability of information about the use of the innovation

innovation, e.g. the implementation of multiple innovations simultaneously

Extent to which other (organizational) changes took place during the implementation of the

Perceptions about the cooperation with professionals from other organizations.

Inter-agency cooperation

* Factors identified in all three focus group sessions, or by seven participants or more.

Note. Italicized determinants are additional to the 29 determinants presented by Fleuren et al. [84]

Extent to which the innovation fits into existing rules and legislation

29. Rules and legislation

Determinants related to characteristics of the socio-political context

28. Feedback

innovation

27. Information about

impetuosity

26. Organization

organizational policies

management

organization

Formal reinforcement of the innovation by management, e.g. by integrating the innovation into

19. Formal reinforcement by

Determinants related to characteristics of the organization

Extent to which the health care professional has the knowledge needed to use the innovation

17. Required knowledge

innovation

The influence of important other professionals on the use of the innovation

15. Subjective norm

10*

-

-

-

-

9*

10*

-

-

-

-

2

2

7

11*

3*

3*

-

9*

-

-

-

3

3

6*

2

-

-

-

6

7*

1

7*

2

9*

-

32 Chapter 2


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Determinants related to characteristics of the user All participants were aware of the existence of the CAP guidelines and familiar with most of the main recommendations. However, familiarity with its more specific recommendations was poor. Four participants admitted to not having read the entire guidelines or to having only read the guidelines in preparation for the focus group interview. Overall, participants had positive attitudes towards the CAP guidelines, describing it as ‘very nice’, ‘important’, ‘sensible’, ‘useful’ and ‘an improvement’. Self-efficacy was identified in all focus groups as both a facilitating and an impeding factor. Participants found it difficult to recognize child abuse. They also experienced low self-efficacy when their suspicion of child abuse was primarily based on vague and ambiguous signals, in unusual situations about which the CAP guidelines do not provide information, when they need to talk to caregivers about their suspicions, when they need to plan follow-up meetings with caregivers and when they do not receive information from other child welfare organizations about suspected child abuse. Experience in responding to child abuse was mentioned as improving skills and self-efficacy, as this quote of a child health care doctor illustrates: ‘[…] then you will be become increasing skillful and tend to experience less fear of making poor decisions’. Poor willingness and/or ability of caregivers to cooperate was also identified as a barrier in all focus group interviews. In particular, participants found it difficult to meet the recommended time scales when caregivers did not attend appointments. Social support was mentioned positively in all focus group interviews, particularly regarding child abuse expert consultation. A child abuse expert is a child health care doctor with additional education in early detection of child abuse who colleagues can consult. GGD Twente has had five permanent child abuse experts in post since 2009. Child abuse expert consultation was evaluated as both supportive and valuable. It was mentioned that child abuse experts can strengthen CHPs’ confidence, can motivate CHPs to respond more quickly and can remind CHPs about other recommendations. However, child abuse experts were not consulted by the participants in all cases. Seven participants didn’t always think of it, consulted other colleagues instead, or just didn’t find child abuse expert consultation necessary. The telephone service for advice and consultation provided by the CPS was evaluated as accessible, personal, pleasant, supportive and guiding. Personal advantages of the guidelines were mentioned by six participants in three focus group sessions and included expertise on child abuse, support in dealing with suspicions of child abuse, more motivated to respond quickly and legal coverage. Legal coverage refers to being able to justify actions to the court if necessary. A child health care doctor said: ‘You are in a stronger position when you have discussed the case with professional colleagues, and this will also give you greater legal protection if your decisions are challenged’.

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Determinants related to characteristics of the organization The availability of resources and services was addressed in all focus group interviews, as both a facilitating and an impeding factor. In this study, this determinant refers to the availability and accessibility of the child abuse expert, registration options in the electronic child health care record and a safe working environment. Participants differed in their perceptions about the availability and accessibility of child abuse experts. Eight participants had positive reactions: child abuse experts have a flexible attitude, are approachable and easily accessible. However, three doctors found the availability and accessibility of the child abuse expert insufficient. Three participants mentioned the electronic child health care record as a supportive instrument for documenting their activities and important information. One doctor felt that the electronic child health care record has some flaws and that the system could be improved to better support professionals in responding to suspected child abuse. CHPs working with children up to the age of four sometimes visit caregivers at home. Two nurses stated that they feel less safe and find it more difficult to discuss suspicions of child abuse in a home setting, compared with a child health care clinic. In a home setting, no colleagues are available for back up if a situation escalates. Also, CHPs have less control over the situation during a home visit, as a child health care nurse illustrates: ‘This mother has an aggressive boyfriend […]. When I am at the mothers’ house, I hope that her boyfriend will not show up. When I mention the word CPS, they will burst with anger’.

Determinants related to characteristics of the socio-political context Inter-agency cooperation was mentioned in all focus group interviews, particularly with the CPS. Ten participants had good experiences: communication went smoothly, the action plan was clear and CHPs were informed about the CPS’ actions, such as research outcomes and referrals. However, nine participants had negative experiences: receiving no feedback or follow-up information from the CPS and feeling frustrated or not taken seriously when their report was rejected by the CPS. Difficulties in cooperating with other child welfare agencies concerned: not involving preventive child health care (by mental health care, police and schools), too much focus on the caregivers’ problems (by mental health care), receiving unlawfully obtained information (by schools), poor or slow action in response to suspected child abuse (by schools, child daycare), poor willingness to share information because of professional preciousness (by general practitioners), improperly delegating actions to CHPs (by schools), and no feedback (by the Child Protection Board).


35

Characteristics of innovation strategies Most participants knew which person in the organization was responsible for the coordination of the implementation of the CAP guidelines. Most participants learned about the CAP guidelines during a presentation given by the implementation coordinator for the CAP guidelines or by child abuse experts. Child abuse experts supported the coordinator in informing CHPs about the CAP guidelines and their role as child abuse experts.

Discussion The goal of this study was to examine which factors facilitate or impede the adherence of Dutch child health care professionals [CHPs] to the Child Abuse Prevention [CAP] guidelines two years after their introduction in preventive child health care. Facilitating and impeding factors relevant to (non-)adherence to guidelines Analysis of the three focus group discussions showed that a broad variety of both facilitating and impeding factors affect adherence to recommendations in the CAP guidelines. In total, 24 determinants were found that facilitated and/or impeded adherence to the CAP guidelines. Seventeen factors were identified that facilitated adherence to the CAP guideline. The results showed that most of the participants were pleased with the availability and quality of social support provided by child abuse experts and CPS. Child abuse expert consultation may be an important strategy in improving desired practice, as this may help CHPs to discuss their observations before they consider further action. Jones et al. [95] found that consultation may positively influence reporting behavior. Twenty-two factors that may hinder CHPs’ adherence to the CAP guidelines were identified. The most frequently identified factors include poor familiarity with the contents of the guidelines, low selfefficacy, poor cooperation with parents and poor inter-agency cooperation. Although all participants were aware of the existence of the CAP guidelines, some of the participants were only partly familiar with their contents. Familiarity is a crucial factor and the first step towards desired behavioral change. According to Cabana et al. [58], guidelines first affect knowledge, then attitudes and finally behavior. Rogers [96] and Fleuren et al. [56] also stated that an innovation needs to be disseminated before professionals can adopt it. Low confidence in the individuals’ ability to carry out the guidelines’ re was also mentioned frequently. Self-efficacy is present in different psychological models that aim to predict behavior, including the social cognitive theory by Bandura [97]. According to this theory, people avoid tasks when their self-efficacy is low and are more likely to perform tasks when their self-efficacy is high. A high self-efficacy is required to enable successful use of the guidelines. Nevertheless, despite training efforts, for most of the CHPs participating in the focus groups early detection of child abuse and

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communicating suspicions of child abuse to caregivers remained a challenge. Also, poor willingness or ability of caregivers to cooperate made it more difficult for professionals to respond within the recommended time scales. This factor was also identified by Saillour-Glenisson and Michel [98]. Responding to suspected child abuse can be a complex decision process and often requires the involvement of multiple organizations. Inter-agency cooperation was a dominant topic in all focus group interviews, especially in relation to CPS. In agreement with previous research [76, 89-91, 99-101], this study also demonstrates that poor cooperation with CPS can make professionals more hesitant to report their suspicions to CPS, Furthermore, the results suggest that cooperation with other child welfare organizations, including General Practitioners and teachers, can facilitate or impede professionals’ adherence to guidelines. Strengths and limitations This study made a contribution to the scant empirical research available on adherence to child abuse prevention guidelines from the perspective of the child health care professional. Given that no systematic research has been published on adherence to child abuse prevention guidelines, we needed a qualitative research method to explore hidden reasons for (non)adherence. Focus groups fit the purpose of our study best, as this method provides the best opportunity for developing an in-depth understanding of people’s viewpoints [102]. The results must be carefully interpreted in light of several limitations. First, one limitation of this study lies in the sampling bias, as the participants were self-selected. They may not be representative of the overall target population. Unfortunately, overall willingness to participate in the study was low. As a result, 14 instead of the desired 21 CHPs participated in the study. An advantage of a rather small group is that it gives each participant more time to raise facts and arguments [103]. Second, the retrospective self-report method is known for its validity problems. Participants may have been mistaken or may have misremembered relevant information. Nevertheless, the focus group approach has a high level of face validity. What participants say can be confirmed, reinforced or contradicted within the group discussion [104]. Third, the presence of other people can inhibit an individual and influence the way an answer is given, thus pushing participants to express more socially desirable and stereotypical answers [103, 105]. However, as questions were not sensitive or very personal, we believe that the results were not strongly biased by this limitation. We aimed to limit threats to validity and reliability by developing a standard interview schedule with specified interview questions, to ensure replicability. A time schedule was integrated into the interview schedule to ensure that all interview questions got enough attention. Finally, the findings may not be completely applicable to CHPs working in other Dutch child health care organizations. In particular, perceptions about characteristics of the organization and the sociopolitical context may differ from CHPs from different organizations. However, perceptions about the guidelines and characteristics of the user will probably be applicable to CHPs in other child health care organizations as well.


37

Future research The factors found in this study provide a basis for further research. Future research on adherence to the CAP guidelines should include CHPs from various preventive child health care organizations in the Netherlands, to validate and elaborate on the results from this study. To prevent misjudgment about the importance of particular determinants, both users and non-users should be included. The framework by Fleuren et al. [56] proved to be useful in studying adherence to the CAP guidelines. It could also be valuable in studying adherence to similar guidelines in other countries. The degree of inter-agency cooperation may be a particularly important extra factor to take into account when implementing guidelines on child abuse prevention, as this determinant was mentioned frequently in both the focus group interviews and in the literature [76, 86, 90, 99] . We found a broad variety of factors that impede or facilitate adherence to guidelines. To determine which factors should receive most attention in the development of innovation strategies, it is important to know which factors are crucial. Furthermore, some determinants, including familiarity, may influence adherence only indirectly as Cabana et al. [58] stated, or be particularly relevant to a specific stage in the innovation process [56, 79]. Future research should therefore examine which factors significantly predict adherence to child abuse prevention guidelines using quantitative research methods. Practical implications Insight into relevant determinants may help preventive child health care organizations in developing appropriate and effective innovation strategies which are tailored to these determinants [56]. Implementation should focus on improving familiarity with the contents of the guidelines, enhancing self-efficacy, promoting consultation of child abuse experts, supporting professionals in dealing with uncooperative parents, and improving inter-agency cooperation. Acknowledgements The authors would like to thank all 14 child health care professionals who participated in the focus group interviews. We would also like to thank Hilde Peters for contributing to the data-analysis and Wieteke Stooker and Judith Bakker for assisting at the focus group interviews. This study was funded by the Netherlands Organization for Health Research and Development (ZonMw).

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CHAPTER 3 What factors increase Dutch child health care professionals’ adherence to guidelines on preventing child abuse and neglect?

This chapter has been published as: Konijnendijk, A. A. J., Boere-Boonekamp, M. M., Fleuren, M. A. H., Haasnoot, M. E., & Need, A. (2016). What factors increase Dutch child healthcare professionals’ adherence to a national guideline on preventing child abuse and neglect? Child Abuse & Neglect, 53, 118–127.

Explaining child healthcare professionals’ guideline adherence

41

Abstract Guidelines to support health care professionals in early detection of, and responses to, suspected Child Abuse and Neglect (CAN) have become increasingly widely available. Yet little is known about professionals’ adherence to these guidelines or the determinants that affect their uptake. This study used a cross-sectional design to assess the adherence of Dutch Child Health Care (CHC) professionals to seven key activities described in a national guideline on preventing CAN. This study also examined the presence and strengths of determinants of guideline adherence. Online questionnaires were filled in between May and July 2013 by 164 CHC professionals. Adherence was defined as the extent to which professionals performed each of seven key activities when they suspected CAN. Thirty-three determinants were measured in relation to the guideline, the health professional, the organisational context and the socio-political context. Bivariate and multivariate regression analyses tested associations between determinants and guideline adherence. Most of the responding CHC professionals were aware of the guideline and its content (83.7%). Self-reported rates of full adherence varied between 19.5% and 42.7%. Stronger habit to use the guideline was the only determinant associated with higher adherence rates in the multivariate analysis. Understanding guideline adherence and associated determinants is essential for developing implementation strategies that can stimulate adherence. Although CHC professionals in this sample were aware of the guideline, they did not always adhere to its key recommended activities. To increase adherence, tailored interventions should primarily focus on enhancing habit strength.

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Chapter 3

Introduction Child Abuse and Neglect (CAN) is increasingly recognised as a serious worldwide public health concern. In The Netherlands, at least 3.4% of all children suffer from sexual, physical or emotional maltreatment every year [5]. CAN may result in long-lasting physical and psychological damage to individual children [15] and may also result in economic costs for society [74]. Attempting to decrease the prevalence of CAN is therefore essential. Professionals working with families play an important role in the prevention of CAN, as caregivers and maltreated children frequently do not seek help or support themselves [23, 24]. However, studies have demonstrated that nurses and doctors in various health care settings sometimes fail to recognise CAN [e.g. 75, 106, 107] or do not respond adequately when they have suspicions [e.g. 99, 106, 107]. As poor recognition and response to CAN concerns may leave children vulnerable to victimisation, health care professionals working with families need to be supported on these issues. Internationally, clinical practice guidelines on preventing CAN have become increasingly widely available [34-36]. Clinical guidelines may improve the quality of health care, help professionals who are uncertain how to proceed and improve the consistency of care [37]. However, very few studies have investigated professionals’ adherence to guidelines on CAN prevention or investigated factors that impede or facilitate their use. One study on the evaluation of guidelines on positive parenting and family violence prevention demonstrated that lack of time, the complex structure of the guidelines and competing organisational demands and priorities impeded integrating the guidelines in public health nurses’ practice [85]. In an earlier study, Konijnendijk, Boere-Boonekamp, Haasnoot & Need [108] identified poor self-efficacy, poor inter-organisational cooperation and poor caregiver willingness to cooperate as impeding factors for Child Health Care (CHC) professionals’ adherence to a guideline on CAN prevention. Although little research has focused on (determinants of) adherence to guidelines on preventing CAN, extensive research has focused on factors that explain non-adherence to one specific key activity in CAN prevention: reporting suspected CAN to child protection authorities. This activity is mandatory for health professionals in countries such as the United States of America, Canada, Australia, Italy and the United Kingdom [109, 110]. Impeding factors to reporting suspected CAN include for example poor knowledge of child abuse symptoms [e.g. 86, 87, 90, 99, 111], poor knowledge of reporting laws and processes [90, 91, 112], negative attitudes towards and low trust in child protection services due to negative experiences, inadequate feedback or delayed investigations [e.g. 76, 90, 99, 113]. Also, the potential loss of the relationship with the child and the family may also decrease the likelihood of professionals reporting CAN concerns [88, 114]. Some professionals prefer to address their concerns with the family rather than report their concerns to child protection authorities [95, 101], or they may not find their suspicions serious enough to make a report [115].


43

Reporting CAN to child protection authorities can be an important activity in preventing (ongoing) CAN and it is therefore important to understand this behaviour. However, other activities, including discussing CAN concerns with caregivers and seeking expert consultation, often precede the decision to report or not. Also, monitoring the support that is provided to the family after a referral or report is important to be able to safeguard vulnerable children. Far too little attention has been paid to understanding and explaining adherence to the broad spectrum of activities that professionals should perform when they suspect CAN. This study seeks to obtain data which will help to address this research gap. The present study assessed (determinants of) adherence of Dutch CHC professionals to key activities described in a clinical guideline on CAN prevention (further referred to as the CAN guideline). Insight into relevant determinants allows health care organisations to develop implementation strategies to stimulate desired work practices [57, 116]. We used an implementation framework that was developed to gain better understanding of professional adherence to innovations in health care, including new guidelines [56, 57]. This framework lists four categories of determinants that may facilitate or impede implementation of new practices: determinants associated with the innovation, the professional, the organisation context and the socio-political context. The research question is twofold: 1) To what extent do CHC professionals adhere to key CAN guideline activities; and 2) Which determinants associated with the CAN guideline – the professional, the organisational context and the socio-political context – facilitate or impede professionals’ overall adherence to the CAN guideline?

Methods Study Design This study used a cross-sectional design. An online survey was conducted among CHC professionals working in seventeen Dutch preventive CHC organisations. Data collection took place in 2013 between May 13 and July 5. Research context The CAN guideline One of the first clinical guidelines on preventing CAN in The Netherlands was developed specifically for preventive CHC professionals. This clinical guideline on early detection and responses to suspected CAN was published and implemented nationwide in 2010 [38, 49]. The CAN guideline was developed by the scientific institute TNO, in cooperation with CHC professionals with an evidence-based approach to guideline development [46, 117]. Details about the development, implementation and evaluation of Dutch guidelines in preventive CHC are described elsewhere [38]. The developers of the CAN guideline have explicitly indicated key activities which they believed are critical [38]. Box 1 displays the key activities in the CAN guideline, presented in the order in which the guideline recommends CHC professionals to

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Chapter 3

perform them. A suspected CAN case may sometimes require a CHC professional to perform an activity more than once.

Box 1. • Risk assessment based on protective and risk factors; • Discussing suspicions with caregiver(s) and/or child; • Consulting an intra-organisational professional specialised in child abuse and neglect; • Consulting the Advice and Reporting Centre; • Requesting information from professionals outside the child healthcare organisations who are also involved with the family; • Acting: providing support, referring the family to other organisations for support or reporting suspicions to the Advice and Reporting Centre; • Monitoring the support that is provided to the family and taking action again if the support is inadequate.

In the Netherlands, the Advice and Reporting Centre for CAN is responsible for investigating whether a child is a victim of CAN. In contrast to many other countries [109, 110], Dutch professionals are not legally required to report CAN concerns to the Advice and Reporting Centre. Since July 2013, CHC professionals and other professionals working with families have been obliged by law to follow CAN guidelines if their suspicions persist [118]. Preventive child health care In the Netherlands, teams consisting of a doctor, a nurse and an assistant provide preventive services to families with children (0-19 years) in well-baby clinics and schools. CHC is preventive care which concentrates on the optimal growth and development of a child, to prevent the child from suffering from severe health problems [44]. CHC doctors and nurses have a crucial and equal role in the identification and management of CAN for two reasons. Both disciplines have frequent contact with children and their caregivers, in comparison with other health disciplines. Frequent medical and psychosocial examinations provide CHC professionals with the optimal opportunity to observe signs of CAN. The CHC professional can take into account the historical information collected on the child’s health and psychosocial development, environmental circumstances and the caregivers’ parenting skills from the child’s birth onwards. Second, early detection of factors that endanger the healthy development of a child is the core task of CHC professionals. Therefore, they have been trained extensively to develop skills for screening and managing health, psychosocial and parenting problems.


45

Participants In April 2013, a total of 4,695 CHC professionals – 1,611 doctors (34.3%), and 3,084 nurses (65.7%) – were working in twenty well-baby clinics, eight school health care organisations and 21 organisations that provide services to children of all ages. In April 2013, the managers of these 49 CHC organisations were invited to allow their organisations to participate, which meant surveying half of the doctors and nurses employed in their organisation. Seventeen organisations (35%) spread throughout the Netherlands agreed to participate: seven child health clinics (35%), two school health care organisations (25%), and eight organisations that provided services to children of all ages (38%). Both urban and rural areas were represented and the areas were scattered across the Netherlands. A total of 1,058 CHC professionals were invited to fill in the questionnaire. Procedure Implementation coordinators from the seventeen participating organisations received a mail with an informative letter, the web-link to the online questionnaire and sampling instructions. Implementation coordinators are responsible for introducing CHC guidelines in their own organisation. The sampling instructions contained information on how to randomly select half of the doctors and nurses in the organisation in order to obtain a representative sample. The implementation coordinators were asked to forward the web-link, and a letter with information on anonymity and confidentiality to the selected CHC professionals. These coordinators were also instructed to send reminders to the selected professionals (prepared by the researchers), two and four weeks after the initial mailing. Measures A self-report online questionnaire was used as a measurement instrument. The questionnaire was digitalised using the program LimeSurvey. A pilot-test with four CHC professionals was performed, to assess the comprehensibility of the questionnaire and to assess the time required to fill it out (15-20 minutes). Participants had to answer each question before they could proceed to the next. Furthermore, participants were invited to elucidate their answers multiple times throughout the questionnaire. The full questionnaire is available on request. Dependent variable This study investigated the level of CHC professionals’ self-reported adherence to the seven key activities in the CAN guideline. CHC professionals indicated adherence to each key activity over the previous twelve months with one of seven possible responses: “with no children”, “with almost no children”, “with a minority of the children”, “with half of the children”, “with a majority of the children”, “with almost all children” and “with all children”. For each participant with valid scores on at least six out of seven activities, a composed score for adherence was obtained by calculating the average adherence score over the seven key activities. The Cronbach’s alpha of .66 indicates a sufficiently reliable scale.

3

46

Chapter 3

Determinants This study assessed 33 determinants of adherence to the CAN guideline. The selection and operationalisation of these determinants were largely based on the Measurement Instrument for Determinants of Innovations (MIDI) [119] and on results from a qualitative study on determinants of adherence to the CAN guideline in preventive CHC [108]. The MIDI is a generic survey-format that describes how determinants related to four categories of determinants (innovation, professional, organisational context and socio-political context), should best be measured. The questionnaire used Likert scale questions. Appendix A presents the determinants measured in this study by category, their descriptions, the operationalisation of each determinant, and Chronbach’s alpha values when determinants were measured with multiple items. Control variables Control variables used in this study included years in professional practice and the number of suspicions of CAN the CHC professionals had had in the twelve months preceding the questionnaire completion date. Data analysis Survey data was exported from the program LimeSurvey to the Statistical Program for the Social Sciences (IBM SPSS Statistics 20 for Windows). Participants were excluded from the database successively when they did not represent the target group, only answered questions about background characteristics, were not aware of the guideline or had not read it, did not have suspicions of CAN in the twelve months preceding their participation in the study or did not have valid answers on all variables relevant for the multivariate analysis. After cleaning the data, the following analyses were performed. First, all items were checked for extreme scores. These were found in relation to the number of suspicions participants reported. Two participants reported thirty suspicions and two participants reported respectively 25 and 17 suspicions. A new ordinal variable was created in which the number of suspicions was placed into one of seven categories (0, 1-2, 3-4, 5-6, 7-8, 9-10, >11 suspicions). Second, the items that were negatively formulated were recoded. As a result, higher scores indicate more positive answers for all items. Third, the distribution of the dependent variable guideline adherence was checked. This distribution was not different from normal, with Z-scores for skewness and kurtosis lower than 1.96 (p < .05). Fourth, reliability analyses were performed for determinants that were measured with multiple items. Analysis revealed respectable Cronbach’s alpha values ranging between .69 and .92 (see Appendix A). Next, frequencies and descriptives were calculated for background variables, all seven key activities, overall guideline adherence and all determinants. Due to the limited number of participants, a maximum of sixteen variables was allowed in the multivariate regression analyses [120 p. 48]. Therefore, several combined scales were created. All eight determinants associated with the CAN guideline were combined into one scale. The two determinants related to the parents (client satisfaction and client cooperation) were also joined. Next, the determinants about knowledge and skills were merged. Furthermore, eleven items related to attitudes and beliefs about


47

working in accordance with the guideline and professional obligation were integrated into one scale. Also the two determinants regarding caregivers (client satisfaction and client cooperation) were combined. Finally, all six organisational determinants were combined into one scale. All new scales had appropriate Cronbach’s alpha values, ranging between .76 and .87 (see Table 2 in the results section). Bivariate correlation analyses and multivariate regression analyses were performed with overall guideline adherence as the dependent variable. The analyses were performed following the procedures as described by Field [121 p. 262-356]. The results of the regression analysis were corrected for withincluster correlation using STATA (version 14) to control for the fact that participants worked in seventeen organisations. We also controlled for years in professional practice and the reported number of suspicions in the previous twelve months. For both the bivariate and multivariate analyses, p-values of

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