Fragile, please handle with care: Understanding and supporting professionals' response to suspicions of child abuse and neglect

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518903-L-sub01-bw-Konijnendijk 518903-L-sub01-bw-Konijnendijk 518903-L-sub01-bw-Konijnendijk 518903-L-sub01-bw-Konijnendijk Processed on: 19-4-2018 Processed on: 19-4-2018 Processed on: 19-4-2018

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PLEASE HANDLE

WITH CARE

FRAGILE

Annemieke A. J. Konijnendijk

Understanding and supporting professionals’

response to suspicions of child abuse and neglect

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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.

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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

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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 University of Twente

Dr. M.M. Boere-Boonekamp 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

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Chapter 1 General introduction 9

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 117

Appendices Appendices belonging to chapter 3 (A, B) 129

Appendices belonging to chapter 4 (A, B, C, D) 138

Appendices belonging to chapter 5 (A, B) 160

Appendix belonging to chapter 6 (A) 169

References 181

Summary 193

Samenvatting 201

Dankwoord (Acknowledgements) 209

Curriculum Vitae 217

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1 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 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]

‘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’

‘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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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].

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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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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. 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;

2. 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.

3. Discussing concerns with the child and/or the caregivers;

4. Assessing violence and abuse, based on the information collected in the previous steps;

5. 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.

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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 evidence-based 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. Risk assessment based on protective and risk factors;

2. Discussing suspicions with caregiver(s) and/or child;

3. Consulting an in-house expert on child abuse and neglect;

4. Consulting the national child protection service: Advice and Reporting Centre;

5. Requesting information from professionals outside the preventive child healthcare organisation

who are also involved with the family;

6. Acting: providing support to caregivers, referring the family to other organisations for support or

reporting suspicions to the Advice and Reporting Centre;

7. 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

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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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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.

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 Figure 1. Framework representing the innovation process and related categories of determinants [56], reproduced with permission.

INNOVATION DETERMINANTS INNOVATION PROCESS

Characteristics of the

socio-political context Dissemination

organisation Adoption

adopting person (user) Implementation

innovation Continuation

Characteristics of the innovation strategy

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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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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 inter-organisational 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

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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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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 facilitate and impede

adherence to child abuse prevention guidelines in

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2 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 inter-agency cooperation. Recommendations for future research are provided.

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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 long-lasting 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.

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# 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.

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Determinan

ts

Description of the det

erminan ts F acilita ting fac tor (+) Impeding fac tor (-) Determinan ts r ela ted to char ac

teristics of the inno

v a tion 1. Clarit y E x tent t o which the pr oc edur

es/guidelines of the inno

vation ar e clear 2 7 2. C o rr ec tness Ex te nt t o

which the inno

vation is based on trust

ed k n o wledge -3. C omplet eness Ex te nt t o

which the inno

vation c

o

ntains the inf

ormation and mat

e rials needed f or its eff ec tiv e use -3 4. C omplexit y E x tent t o

which the inno

vation is per ceiv ed as c omplex -1 5. C ompatibilit y E x tent t o

which the inno

vation is per

ceiv

ed as c

onsist

ent with existing w

o rk pr oc edur es 3 2 6. Obser vabilit y E x tent t o which the r

esults of the inno

vation ar

e obser

vable t

o

the health car

e pr of essional -7. Relevanc e client E x tent t o which the inno

vation has added value f

or the client -Feasibilit y Ex te nt t o

which the inno

vation is per

ceiv

ed as both r

ealistic and achievable

1 2 C oncr eteness Ex te nt t o

which the inno

vation is c

oncr

et

e r

a

ther than abstr

ac t or imag inar y -3 Determinan ts r ela

ted to the char

ac

teristics of the adopting person (user)

8. P ersonal (dis)advantage Ex te nt t o

which the inno

vation has (dis)advantages f

or the health car

e pr of essional 6* 3 9. Out come expec tations Ex te nt t o

which the health car

e pr

of

essional per

ceiv

es the out

comes of the inno

vation as impor tant and plausible 1-10. Task orientation Ex te nt t o

which the inno

vation fits in the per

ceiv

ed task orientation of the health car

e pr of essional -3 11. Satisfac tion client E x tent t o

e pr

of

essional

expec

ts or experienc

es that the client will be satisfied wit

h the inno vation 2-12. C ooperation client E x tent t o

e pr

of

essional

expec

ts or experienc

es that the client will c

ooperat e in the inno vation 2 11* 13. S ocial suppor t Experienc ed or expec ted suppor t of c olleagues , pr of essionals fr

om other health car

e or ganizations , t eam leaders , or higher management 12* 2 14. Descriptiv e norm P er ceiv ed beha vior of c olleagues with r espec t t

o the use of the inno

vation -4 T able 2. Number of par

ticipants identifying a fac

tor as facilitating or impeding adher

enc

e t

o

the CAP guidelines

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15. Subjec tiv e norm T he influenc e of impor tant other pr of

essionals on the use of the inno

vation -16. S elf-efficac y C onfidenc

e of the health car

e pr

of

essional in the abilit

y t

o per

form the beha

vior needed t o use the inno vation 3* 9* 17. Requir ed k n o wledge Ex te nt t o

e pr

of

essional has the k

n

o

wledge needed t

o

use the inno

vation 3* 2 18. F amiliarit y E x tent t o

e pr

of

essional is familiar with the c

o

nt

ent of the inno

vation 11* 7* Attitudes Expr essions of aff ec t t o war ds the inno vation in gener al , or its specific r e commendations 7 1 Routine Ex te nt t o

which the use of the inno

vation is int e g rat ed int o daily prac tic

e of the health car

e pr of essional 2 7 * Determinan ts r ela ted to char ac teristics of the or ganiza tion 19. F ormal r einf or cement b y management Fo rmal r einf or

cement of the inno

vation b y management, e .g . b y int e g

rating the inno

vation int o or ganizational policies 26 20. Staff turno v e r R eplac

ement of health car

e pr

of

essionals who use the inno

vation and lea

v e the or ganization -21. Staff capacit y S taff capacit y in the or ganization or depar tment -22. F inancial r esour ce s Financial r esour ces made a v ailable f

or implementing the inno

vation -23. T ime T ime a v ailable f or health car e pr of essionals t o int e g rat e the inno vation in daily pr ac tic e -2 24. A v ailabilit y of r esour ces and ser vic es Resour

ces and ser

vic es made a v ailable f or health pr of essionals t o

use the inno

vation, e .g . equipment, mat erial or offic es 10* 6* 25. C oor dinat o r One or mor e persons char ged with c oor

dinating the implementation of the inno

vation within the

or ganization 9* 3 26. Or ganization impetuosit y E x tent t o

which other (or

ganizational) changes t

ook plac

e during the implementation of the

inno

vation, e

.g

. the implementation of multiple inno

vations simultaneously -3 27. I nf ormation about inno vation A v ailabilit y of inf

ormation about the use of the inno

vation -28. F eedback Ex te nt t o which the or ganization pr o vides f

eedback about the implementation t

o

the health car

e pr of essional --Determinan ts r ela ted to char ac

teristics of the socio

-political c o n te x t

29. Rules and leg

islation

Ex

te

nt t

o

which the inno

vation fits int

o

existing rules and leg

islation -Inter -agenc y c o oper ation P e rc

eptions about the c

ooper ation with pr of essionals fr om other or ganizations . 10* 9* Note . I taliciz ed det erminants ar e additional t o the 29 det erminants pr esent ed b y F leur en et al . [84] * F a ct

ors identified in all thr

ee f ocus g roup sessions , or b y sev en par ticipants or mor e .

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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’.