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New Zealand dental therapists’ beliefs regarding child maltreatment

New Zealand dental therapists’ beliefs regarding child maltreatment I n 2003, UNICEF reported that deaths among children due to abuse and neglect were six times greater in New Zealand than similar developed countries. 1 Hospital admissions due to injuries arising from assault, neglect or maltreatment of children aged 0–14 years stood at 17 per 100,000 in 2012. On average, in 2000–12, eight children per year died in NZ as a result of these forms of abuse. 2 In Australia, the total number of substantiated abuse and neglect cases has nearly doubled since 2001. In 2011–2012 there were 48,420 substantiations across Australia, concerning 37,781 children. 3 In recent years, NZ's Child Youth and Family Services (CYFS) has reported an increase in the number of child abuse cases detected. This could, in part, be due to better awareness and/or a willingness to report cases directly to CYFS. 4 Of the reports that required action, more than 80% involved children under 14 years. 4 Dental therapists are potentially in a position to recognise and report suspected cases of child abuse and/or neglect because this is the main age group they treat. NZ legislation defines child abuse as the “harming (whether physically, emotionally or sexually), ill‐treatment, neglect or deprivation of any child or young person”. 5 The term ‘child maltreatment’ can be used as it encompasses these forms of abuse as well as neglect. 6 These definitions reflect, in part, societal views of actions that are viewed as improper or unacceptable. 7 Although dental neglect is not defined within the NZ legislation, the American Academy of Pediatric Dentistry defines it as “the wilful failure of parent or guardian to seek and follow through with treatment necessary to ensure a level of oral heath essential for adequate function and freedom from pain and infection”. 8 In NZ, child abuse and neglect cases are handled by CYFS (part of the Ministry of Social Development) and Child Protection Services (mandated and funded by the Ministry of Health but operated by District Health Boards); as well as the Social Work Service of District Health Boards. Most District Health Boards employ Child Protection Officers and have a Violence Prevention Service. Internationally, research has consistently shown a discrepancy between the number of cases of child maltreatment suspected and the number reported by dental professionals. 9–14 In a Greek study, 13% of dentists had suspected abuse and 35% had suspected neglect of child patients during their careers. However, only 1.6% had reported their suspicions to an appropriate authority. A major barrier was doubt over their diagnosis. 11 A wide variety of barriers to reporting have been described by previous international studies (Table ). A comparison of international studies of suspicion and reporting of child maltreatment in dental practice. Author & Year Country of study Type of practitioners Number of participants Percent of participants who suspected child maltreatment Percent of participants who reported child maltreatment Main barrier identified to reporting child maltreatment McDowell, Kassebaum 22 USA (Colorado) 79% dentists 21% specialists 407 29 14 Lack of history Ramos‐Gomez, Rothman 13 USA (California) 83% dentists 17% specialists 2,005 16 6 Lack of adequate history John, Messer 23 Australia Dentists 347 28 8 Uncertainty diagnosis Kilpatrick, Scott 24 Australia Dentists and members of the Australia New Zealand Society of Paediatric Dentistry 67/55 24/58 10.4/36.4 Confidentiality Cairns, Mok 9 Scotland Dentists 375 29 8 Fear of litigation affecting referrals Chadwick 10 UK Dental therapists 396 34 Unclear a Lack of certainty Owais, Qudeimat 12 Jordan Dentists 342 42 20 Lack of history Harris, Elcock 20 UK Dentists & dental care professionals b 789 67 29 Lack of certainty about diagnosis Uldum, Christensen 14 Denmark Dentists & hygienists 1,145 38.3 33.9 Uncertainty about observations Sonbol, Abu‐Ghazaleh 25 Jordan Dentists 256 50 12 Fear re anger of parents El Sarraf, Marego 26 Brazil Paediatric Dentists 69 36 12 Lack of information on identifying and reporting Laud, Gizani 11 Greece Dentists 368 13 (abuse) 35 (neglect) 1.6 Doubt over diagnosis a 83% recorded in file but not necessarily reported to authority b dental therapists and hygienists In NZ, slightly more 1–14 year‐old children visited a dental professional (78%) than a medical practitioner (75%) in the years 2011/2012, 15 and they do so more frequently. Since dental therapists focus on the oral cavity, they can potentially recognise dental neglect. Physically and/or sexually abused children are significantly more likely to have higher levels of caries than the general population, 16,17 so further investigation of child's social situation may be appropriate in cases where an unusually high caries rate is observed. The aims of this study were to describe: 1) dental therapists’ perceptions of child maltreatment in NZ; 2) dental therapists’ participation in, and demand for, relevant training courses; 3) how frequently dental therapists suspect and report maltreatment; and 4) barriers that prevent the reporting of suspected child maltreatment cases. Methods Ethical approval was obtained from the University of Otago Human Ethics Committee. The study population included all registered dental therapists with current annual practising certificates and valid NZ‐based addresses (n=643). Questionnaire Pre‐testing of a self‐administered postal questionnaire for validity and ease of completion was carried out by several dental therapists at the Faculty of Dentistry, University of Otago. This led to improvements in wording, clarity, and relevance. The 22‐question survey used questions constructed with either a multiple‐choice or Likert‐scale format and was divided into two sections. The first covered demographic details such as age, ethnicity, years in practice and practice region; the second focused on: perceptions of child maltreatment in NZ past training experiences in the recognition of child abuse (undergraduate and postgraduate courses) number of child maltreatment (physical abuse, child neglect, dental neglect) cases suspected and reported in the past year and in their career actions after suspecting maltreatment and any barriers that prevent reporting personal considerations of the characteristics of child abuse and dental neglect perceptions of strategies that may decrease the incidence of maltreatment. A participant information sheet was sent with all the questionnaires. It gave a brief description of the study and informed participants that answering the questionnaire would imply consent. A reply‐paid envelope for return of the completed questionnaire was included in each pack. A reminder questionnaire and participation information sheet was posted to dental therapists who had not responded following the first mail‐out. Participating therapists were entered into a random prize draw. Statistical analysis Data were double‐entered in an electronic database and checked to ensure accuracy. Data were cleaned, managed, and analysed in IBM Statistical Package for the Social Sciences (SPSS Version 20.0). The chi‐square test was used to test for significance of observed associations, and the level of statistical significance was set at p <0.05. Results Participation The response rate was 49.8% (n=320 of 643). The majority of participants were NZ European (247, 77.4%) females (312, 97.5%). Proportionally more dental therapists were employed by District Health Boards (240, 75.2%) than private dental clinics (69, 21.6%). One in every five dental therapists was dual‐qualified as both a dental therapist and dental hygienist (n=63, it was unknown whether two dental therapists were dual‐qualified or not). Of those employed in private dental clinics, 79.4% (n=50) were dual‐qualified. About one in every three was from the Auckland region (100, 31.3%). Most (230, 72.1%) worked in the city, while 86 (27.0%) worked in rural areas. Three of every four respondents (267, 84.0%) were members of the NZ Dental Therapists Association. The characteristics of participants were similar to those reported in the 2010 survey of the NZ dental therapy workforce (Table ). Sex, age and practice type of participants compared to those of dental therapists in 2010. This study (%) New Zealand N (%) a χ 2 statistic, p value Australia N (%) b χ 2 statistic, p value Practice type Public practice c Private practice Educational institute d Other/Unknown 241 (75.3) 69 (21.6) 5 (2.0) 4 (1.2) 556 (75.0) 96 (13.0) 9 (1.4) 79 (10.6) e 8.463, 0.015 724 (69.3) 203 (19.4) 31 (3.0) 86 (8.2) 2.362, 0.307 Sex Females Males 312 (97.5) 8 (2.5) 715 (96.6) 25 (3.4) 0.028, 0.867 1,014 (97.1) 30 (2.9) 0.126, 0.722 Age <35 35–44 45–54 55+ Unknown 67 (21.6) 48 (15.0) 77 (24.1) 120 (37.5) 6 (1.9) 158 (21.4) 116 (15.7) 177 (23.9) 289 (39.1) 0.086, 0.993 114 (10.9) 268 (25.7) 513 (49.1) 149 (14.3) 134.833, <0.001 Mean age 47.0 49.3 46.3 a Data source 2010/2011 NZ Dental Council Workforce dataset . b Data source 2011 c New Zealand – District Health Boards, Iwi, government department; Australia – community health care services, hospitals, schools, or government departments or agencies (1 double‐counted practitioner excluded from Australian statistics) . d Tertiary/other educational institutes e Dental therapists who are also qualified as dental hygienists often indicate other/unknown type of practice in the NZ Dental Council dataset; however we asked for more complete data on this point. The variation in the way the question was asked is the likely explanation for the difference . Participant perceptions Ninety‐six per cent of participants believed that child abuse and neglect were important social issues in NZ, while 77.1% of respondents believed that the rates of death due to child maltreatment were higher in NZ than in other countries. Almost all (94.6%) the participants stated feeling a responsibility to report suspected cases of abuse, while 75.8% believed that it should be mandatory for dental professionals to report all suspected cases of child abuse. Many (71.1%) of the participants were aware that child abuse occurs throughout the whole population, irrespective of socioeconomic status. Most (85.3%) believed a child missing several appointments was a sign of neglect, while 70.2% of participants considered untreated dental caries of a severity requiring referral for treatment under general anaesthetic, and pain, to also be features of dental neglect. Training experiences Of the dental therapists who responded, 38.9% could not recall having received training in managing cases of child abuse as undergraduate students, while a further 43.1% could remember very little from their undergraduate training. Only 3.1% stated that child protection was covered well in their undergraduate training. In total, 73.7% of participants felt there should be more undergraduate training on the topic. Proportionally more of those participants who graduated more than 20 years ago stated that their undergraduate training did not cover child protection issues. After graduating, 58.8% of participants had participated in a Continuing Professional Development (CPD) course on this topic. A further 82.4% were interested in learning more about child maltreatment, while 81.8% felt that more CPD courses about child protection should be available. Fewer than one in three participants (30.9%) believed that they could easily recognise the signs and symptoms of child abuse. Features of child abuse Dental therapists were asked to list and describe the features of child abuse, based on their own opinions. The most commonly cited features were physical injuries and child behavioural patterns. Most therapists named a visible physical injury or obvious debilitation of the child due to a hidden injury as indicative of abuse. Many also described intra‐oral trauma such as bruises on the palate as a sign of abuse. Behavioural patterns such as ‘social withdrawal’ or ‘cowers away from parents when they try to touch the child’ indicated abuse for many therapists. Other factors mentioned were that an ‘unkempt child’ would raise concern and that ‘urine‐smelling’ children would catch their attention. Dental therapists noted that some parents do not bring their child in for treatment despite being told about the child's need for dental treatment. Neglect of medical problems was also mentioned by some dental therapists. Suspicion and reporting of maltreatment In the past year, more than one in every two participants had suspected child dental neglect, one in three had suspected child neglect, and one in five had suspected child physical abuse (Table ). Around 15% of participants had never suspected a case of child abuse or neglect. Number of participants who suspected and reported child maltreatment. 1 to 10 N (%) 11 to 30 N (%) 31+ N (%) Overall 1+ N (%) Physical abuse Suspected past year Reported past year Suspected career Reported career 55 (17.7) 33 (10.6) 130 (41.8) 81 (26.0) 1 (0.3) 0 12 (3.9) 6 (1.9) 0 0 1 (0.3) 1 (0.3) 56 (18.1) 33 (10.6) 142 (46.0) 89 (28.6) Child neglect Suspected past year Reported past year Suspected career Reported career 87 (28.0) 40 (12.9) 86 (27.7) 59 (19.0) 1 (2.3) 1 (0.3) 25 (8.0) 5 (1.6) 3 (1.0) 0 13 (4.2) 3 (1.0) 97 (31.2) 41 (13.2) 124 (39.9) 67 (21.5) Dental neglect Suspected past year Reported past year Suspected career Reported career 101 (32.5) 68 (21.9) 75 (24.1) 66 (21.2) 40 (12.9) 9 (21.9) 42 (13.5) 17 (5.5) 23 (7.4) 7 (2.3) 61 (19.6) 16 (5.1) 164 (52.7) 84 (27.0) 178 (57.2) 99 (31.8) Seventy‐eight per cent of all participants stated they would discuss concerns about a child patient with a colleague, while 66.5% would discuss it with a dentist who is their professional agreement colleague (Figure ). In NZ, a professional agreement is a signed written document that outlines the professional relationship and responsibilities between two individual oral health practitioners. It is usually between a dentist (or dental specialist) and another oral health practitioner. The Dental Council codes of practice on professional working relationships for oral health practitioners require that a professional agreement must be in place for dental therapists and dentists, and dental hygienists and dentists. Actions taken after suspecting abuse. Only 12.5% said they would refer the case to a paediatric dentist while 37.6% said they would directly notify CYFS (though about one in three therapists reported a lack of confidence in child protection services). Most participants (68.6%) felt the biggest barrier was a fear of mistakenly reporting a non‐abuse case (Figure ). Barriers to reporting of child maltreatment, as perceived by NZ Dental Therapists. Child abuse prevention strategies Many believed that decreasing illicit drug use (89.3%) and alcohol abuse (88.7%) would help in the prevention of child abuse. A high proportion (87.5%) felt that increasing the knowledge and awareness of the general population would decrease the problem of abuse, while 77.7% believed improving the knowledge of health professionals would make a difference. Discussion Almost all participants (96.1%) felt that child abuse and neglect are important issues in NZ. Many (77.1%) felt that death rates due to abuse in NZ are among the worst in the developed world. Most (94.6%) perceived a responsibility to aid early detection of abuse and 75.8% thought it should be mandatory for dental practitioners to report suspected cases. Despite this knowledge and a willingness to be involved in early detection, not all suspected cases were reported. The most common action participants reported they would take was to discuss the case with a colleague (78.1%). Only 37.6% of respondents would consider reporting suspected cases to CYFS, and about one in every three therapists reported a lack of confidence in child protection services, but the major barrier was a fear of reporting a non‐abuse case (68.6%). The NZ Ministry of Health funds and mandates Child Protection Services within each District Health Board, whose role is to partner with health professionals to prevent and respond to child abuse and neglect. There appears to be little engagement at present between Dental Therapists and these Child Protection Services. Generalisability of study findings Participant characteristics were similar to those of non‐participants and the officially reported NZ and Australian dental therapist workforce demographics. A large majority of the dental therapy workforce in NZ are females, and most are employed by District Health Boards, 18 and this is mirrored in the respondents. The Australian dental therapy public system differs somewhat from NZ system, but similar proportions of dental therapists were working in the public versus private sectors (recognising that some dual‐qualified dental therapist/hygienists split their time between public and private practice). NZ dental therapists do tend to be older than Australian dental therapists and this is mirrored in our sample. It is likely that the study participants are representative of NZ and Australian dental therapists and that the study findings are relevant in the broader Australasian context. Strengths and weaknesses The perceptions and role of dental therapists in the early detection of child abuse in NZ were previously unknown. As questionnaires were sent to all dental therapists who currently hold a practicing certificate, sampling errors were eliminated. One of the weaknesses of the study was a relatively low response rate. This could be because the questionnaires were sent out during the annual school holiday period when many dental therapists were on leave. Recall bias is another factor which plays a role in a questionnaire study. Therapists were asked to remember how many abuse cases they have suspected, not only in the past year, but in their careers. Recall bias is also possible with regards to dental therapists’ recollections of their past education in the area of child maltreatment. Practitioners who have been in practice for an extended period of time would be less likely to recall all details of their undergraduate education or cases of abuse or maltreatment from early on in their careers. International comparisons As in many other countries, this study found a difference between the number of cases suspected and the number reported. 9–14 Although most studies have involved dentists, a 2009 United Kingdom (UK) study was conducted among dental therapists. 10 This study investigated training in child protection, suspicion of abuse and the number reported, as well as further actions taken. Knowledge of referral guidelines and barriers present when reporting a case were also investigated. 10 As the aims and the target population of the UK study are similar, comparisons can be made. A noted difference is that half (49.4%) of participants in the UK study were recent graduates who had practised for less than 10 years. 10 In this study, there is an even distribution among the participants, with only 28.0% practising for less than 10 years. Other differences include the recall of undergraduate training (UK 63.1%, NZ 38.7%) and the therapists’ interest in further training (UK 62.6%, NZ 82.4%). The most common action taken after suspecting abuse was similar in both studies, with 48.2% of respondents in the UK study discussing the case with their “principal dentist or other dental colleague”, 10 while in NZ, 78.1% of dental therapists would discuss the case with a colleague. Seventy per cent of dental therapists in the UK would not report a case if there was a “lack of certainty over their diagnosis”. 10 In NZ, a fear of mistakenly reporting a non‐abuse case was the major barrier for 68.6% of dental therapists. Dental neglect Previous research has shown that child dental neglect frequently accompanies other forms of maltreatment. 17 The majority of dental therapists in this study (86%) believed that a child missing several appointments was a sign of the parent(s) neglecting the dental needs of the child. In Sweden, 68% of public sector dentists assumed parental negligence when children missed several appointments. 19 Some researchers have asked “Do paediatric dentists neglect child dental neglect?” 20 They found that more than 80% of UK paediatric dentists saw cases of dental neglect at least once a week. However, referring to social services was the least favoured option used by only 4.1% of paediatric dentists. The same authors suggested that this could be as a result of lack of knowledge or awareness that a relationship exists between general neglect and dental neglect. Paediatric dentists with postgraduate child protection training were more likely to report cases to social services. 20 It would appear that child protection training increases awareness and reporting of dental neglect by dental professionals. International policy statements on dealing with child dental neglect have previously been produced to provide guidance on dealing with these issues in clinical practice. 21 Recommendations for action As frontline health professionals who care for children on a daily basis, dental therapists in NZ are in a unique position for early detection of child abuse. For those employed by DHBs (72.5% of respondents), the DHB Child Protection Officers could serve as a valuable sounding board providing support in making a decision regarding notification to CYFS. The results of this research highlight the willingness of dental therapists to help reduce cases of abuse. They also highlight the need for better national guidelines and a clearer referral procedure for dental therapists in NZ. Child Protection Services from within each District Health Board and the Dental Therapy Services should engage with each other more effectively with regard to education about child abuse and also to facilitate appropriate action where there are any concerns about a particular child. There also appears to be a gap in the availability of Social Work Services to child dental therapists and their clients. Conclusions Dental therapists understand that they can play an important role in decreasing the incidence of child abuse. Many have observed signs of child maltreatment among the young patients they treat, yet only about half of the cases they suspect are reported to authorities. A fear of mistakenly reporting non‐abuse cases may be reduced with increased training, knowledge and support. Acknowledgements The study was conducted while D Tilvawala was the recipient of a Child Injury Prevention Foundation Summer Research Scholarship. This study would not have been possible without the support of the Sir John Walsh Research Institute and Colgate. We also thank all the participants. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

New Zealand dental therapists’ beliefs regarding child maltreatment

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Publisher
Wiley
Copyright
© 2014 Public Health Association of Australia
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/1753-6405.12238
pmid
25168913
Publisher site
See Article on Publisher Site

Abstract

I n 2003, UNICEF reported that deaths among children due to abuse and neglect were six times greater in New Zealand than similar developed countries. 1 Hospital admissions due to injuries arising from assault, neglect or maltreatment of children aged 0–14 years stood at 17 per 100,000 in 2012. On average, in 2000–12, eight children per year died in NZ as a result of these forms of abuse. 2 In Australia, the total number of substantiated abuse and neglect cases has nearly doubled since 2001. In 2011–2012 there were 48,420 substantiations across Australia, concerning 37,781 children. 3 In recent years, NZ's Child Youth and Family Services (CYFS) has reported an increase in the number of child abuse cases detected. This could, in part, be due to better awareness and/or a willingness to report cases directly to CYFS. 4 Of the reports that required action, more than 80% involved children under 14 years. 4 Dental therapists are potentially in a position to recognise and report suspected cases of child abuse and/or neglect because this is the main age group they treat. NZ legislation defines child abuse as the “harming (whether physically, emotionally or sexually), ill‐treatment, neglect or deprivation of any child or young person”. 5 The term ‘child maltreatment’ can be used as it encompasses these forms of abuse as well as neglect. 6 These definitions reflect, in part, societal views of actions that are viewed as improper or unacceptable. 7 Although dental neglect is not defined within the NZ legislation, the American Academy of Pediatric Dentistry defines it as “the wilful failure of parent or guardian to seek and follow through with treatment necessary to ensure a level of oral heath essential for adequate function and freedom from pain and infection”. 8 In NZ, child abuse and neglect cases are handled by CYFS (part of the Ministry of Social Development) and Child Protection Services (mandated and funded by the Ministry of Health but operated by District Health Boards); as well as the Social Work Service of District Health Boards. Most District Health Boards employ Child Protection Officers and have a Violence Prevention Service. Internationally, research has consistently shown a discrepancy between the number of cases of child maltreatment suspected and the number reported by dental professionals. 9–14 In a Greek study, 13% of dentists had suspected abuse and 35% had suspected neglect of child patients during their careers. However, only 1.6% had reported their suspicions to an appropriate authority. A major barrier was doubt over their diagnosis. 11 A wide variety of barriers to reporting have been described by previous international studies (Table ). A comparison of international studies of suspicion and reporting of child maltreatment in dental practice. Author & Year Country of study Type of practitioners Number of participants Percent of participants who suspected child maltreatment Percent of participants who reported child maltreatment Main barrier identified to reporting child maltreatment McDowell, Kassebaum 22 USA (Colorado) 79% dentists 21% specialists 407 29 14 Lack of history Ramos‐Gomez, Rothman 13 USA (California) 83% dentists 17% specialists 2,005 16 6 Lack of adequate history John, Messer 23 Australia Dentists 347 28 8 Uncertainty diagnosis Kilpatrick, Scott 24 Australia Dentists and members of the Australia New Zealand Society of Paediatric Dentistry 67/55 24/58 10.4/36.4 Confidentiality Cairns, Mok 9 Scotland Dentists 375 29 8 Fear of litigation affecting referrals Chadwick 10 UK Dental therapists 396 34 Unclear a Lack of certainty Owais, Qudeimat 12 Jordan Dentists 342 42 20 Lack of history Harris, Elcock 20 UK Dentists & dental care professionals b 789 67 29 Lack of certainty about diagnosis Uldum, Christensen 14 Denmark Dentists & hygienists 1,145 38.3 33.9 Uncertainty about observations Sonbol, Abu‐Ghazaleh 25 Jordan Dentists 256 50 12 Fear re anger of parents El Sarraf, Marego 26 Brazil Paediatric Dentists 69 36 12 Lack of information on identifying and reporting Laud, Gizani 11 Greece Dentists 368 13 (abuse) 35 (neglect) 1.6 Doubt over diagnosis a 83% recorded in file but not necessarily reported to authority b dental therapists and hygienists In NZ, slightly more 1–14 year‐old children visited a dental professional (78%) than a medical practitioner (75%) in the years 2011/2012, 15 and they do so more frequently. Since dental therapists focus on the oral cavity, they can potentially recognise dental neglect. Physically and/or sexually abused children are significantly more likely to have higher levels of caries than the general population, 16,17 so further investigation of child's social situation may be appropriate in cases where an unusually high caries rate is observed. The aims of this study were to describe: 1) dental therapists’ perceptions of child maltreatment in NZ; 2) dental therapists’ participation in, and demand for, relevant training courses; 3) how frequently dental therapists suspect and report maltreatment; and 4) barriers that prevent the reporting of suspected child maltreatment cases. Methods Ethical approval was obtained from the University of Otago Human Ethics Committee. The study population included all registered dental therapists with current annual practising certificates and valid NZ‐based addresses (n=643). Questionnaire Pre‐testing of a self‐administered postal questionnaire for validity and ease of completion was carried out by several dental therapists at the Faculty of Dentistry, University of Otago. This led to improvements in wording, clarity, and relevance. The 22‐question survey used questions constructed with either a multiple‐choice or Likert‐scale format and was divided into two sections. The first covered demographic details such as age, ethnicity, years in practice and practice region; the second focused on: perceptions of child maltreatment in NZ past training experiences in the recognition of child abuse (undergraduate and postgraduate courses) number of child maltreatment (physical abuse, child neglect, dental neglect) cases suspected and reported in the past year and in their career actions after suspecting maltreatment and any barriers that prevent reporting personal considerations of the characteristics of child abuse and dental neglect perceptions of strategies that may decrease the incidence of maltreatment. A participant information sheet was sent with all the questionnaires. It gave a brief description of the study and informed participants that answering the questionnaire would imply consent. A reply‐paid envelope for return of the completed questionnaire was included in each pack. A reminder questionnaire and participation information sheet was posted to dental therapists who had not responded following the first mail‐out. Participating therapists were entered into a random prize draw. Statistical analysis Data were double‐entered in an electronic database and checked to ensure accuracy. Data were cleaned, managed, and analysed in IBM Statistical Package for the Social Sciences (SPSS Version 20.0). The chi‐square test was used to test for significance of observed associations, and the level of statistical significance was set at p <0.05. Results Participation The response rate was 49.8% (n=320 of 643). The majority of participants were NZ European (247, 77.4%) females (312, 97.5%). Proportionally more dental therapists were employed by District Health Boards (240, 75.2%) than private dental clinics (69, 21.6%). One in every five dental therapists was dual‐qualified as both a dental therapist and dental hygienist (n=63, it was unknown whether two dental therapists were dual‐qualified or not). Of those employed in private dental clinics, 79.4% (n=50) were dual‐qualified. About one in every three was from the Auckland region (100, 31.3%). Most (230, 72.1%) worked in the city, while 86 (27.0%) worked in rural areas. Three of every four respondents (267, 84.0%) were members of the NZ Dental Therapists Association. The characteristics of participants were similar to those reported in the 2010 survey of the NZ dental therapy workforce (Table ). Sex, age and practice type of participants compared to those of dental therapists in 2010. This study (%) New Zealand N (%) a χ 2 statistic, p value Australia N (%) b χ 2 statistic, p value Practice type Public practice c Private practice Educational institute d Other/Unknown 241 (75.3) 69 (21.6) 5 (2.0) 4 (1.2) 556 (75.0) 96 (13.0) 9 (1.4) 79 (10.6) e 8.463, 0.015 724 (69.3) 203 (19.4) 31 (3.0) 86 (8.2) 2.362, 0.307 Sex Females Males 312 (97.5) 8 (2.5) 715 (96.6) 25 (3.4) 0.028, 0.867 1,014 (97.1) 30 (2.9) 0.126, 0.722 Age <35 35–44 45–54 55+ Unknown 67 (21.6) 48 (15.0) 77 (24.1) 120 (37.5) 6 (1.9) 158 (21.4) 116 (15.7) 177 (23.9) 289 (39.1) 0.086, 0.993 114 (10.9) 268 (25.7) 513 (49.1) 149 (14.3) 134.833, <0.001 Mean age 47.0 49.3 46.3 a Data source 2010/2011 NZ Dental Council Workforce dataset . b Data source 2011 c New Zealand – District Health Boards, Iwi, government department; Australia – community health care services, hospitals, schools, or government departments or agencies (1 double‐counted practitioner excluded from Australian statistics) . d Tertiary/other educational institutes e Dental therapists who are also qualified as dental hygienists often indicate other/unknown type of practice in the NZ Dental Council dataset; however we asked for more complete data on this point. The variation in the way the question was asked is the likely explanation for the difference . Participant perceptions Ninety‐six per cent of participants believed that child abuse and neglect were important social issues in NZ, while 77.1% of respondents believed that the rates of death due to child maltreatment were higher in NZ than in other countries. Almost all (94.6%) the participants stated feeling a responsibility to report suspected cases of abuse, while 75.8% believed that it should be mandatory for dental professionals to report all suspected cases of child abuse. Many (71.1%) of the participants were aware that child abuse occurs throughout the whole population, irrespective of socioeconomic status. Most (85.3%) believed a child missing several appointments was a sign of neglect, while 70.2% of participants considered untreated dental caries of a severity requiring referral for treatment under general anaesthetic, and pain, to also be features of dental neglect. Training experiences Of the dental therapists who responded, 38.9% could not recall having received training in managing cases of child abuse as undergraduate students, while a further 43.1% could remember very little from their undergraduate training. Only 3.1% stated that child protection was covered well in their undergraduate training. In total, 73.7% of participants felt there should be more undergraduate training on the topic. Proportionally more of those participants who graduated more than 20 years ago stated that their undergraduate training did not cover child protection issues. After graduating, 58.8% of participants had participated in a Continuing Professional Development (CPD) course on this topic. A further 82.4% were interested in learning more about child maltreatment, while 81.8% felt that more CPD courses about child protection should be available. Fewer than one in three participants (30.9%) believed that they could easily recognise the signs and symptoms of child abuse. Features of child abuse Dental therapists were asked to list and describe the features of child abuse, based on their own opinions. The most commonly cited features were physical injuries and child behavioural patterns. Most therapists named a visible physical injury or obvious debilitation of the child due to a hidden injury as indicative of abuse. Many also described intra‐oral trauma such as bruises on the palate as a sign of abuse. Behavioural patterns such as ‘social withdrawal’ or ‘cowers away from parents when they try to touch the child’ indicated abuse for many therapists. Other factors mentioned were that an ‘unkempt child’ would raise concern and that ‘urine‐smelling’ children would catch their attention. Dental therapists noted that some parents do not bring their child in for treatment despite being told about the child's need for dental treatment. Neglect of medical problems was also mentioned by some dental therapists. Suspicion and reporting of maltreatment In the past year, more than one in every two participants had suspected child dental neglect, one in three had suspected child neglect, and one in five had suspected child physical abuse (Table ). Around 15% of participants had never suspected a case of child abuse or neglect. Number of participants who suspected and reported child maltreatment. 1 to 10 N (%) 11 to 30 N (%) 31+ N (%) Overall 1+ N (%) Physical abuse Suspected past year Reported past year Suspected career Reported career 55 (17.7) 33 (10.6) 130 (41.8) 81 (26.0) 1 (0.3) 0 12 (3.9) 6 (1.9) 0 0 1 (0.3) 1 (0.3) 56 (18.1) 33 (10.6) 142 (46.0) 89 (28.6) Child neglect Suspected past year Reported past year Suspected career Reported career 87 (28.0) 40 (12.9) 86 (27.7) 59 (19.0) 1 (2.3) 1 (0.3) 25 (8.0) 5 (1.6) 3 (1.0) 0 13 (4.2) 3 (1.0) 97 (31.2) 41 (13.2) 124 (39.9) 67 (21.5) Dental neglect Suspected past year Reported past year Suspected career Reported career 101 (32.5) 68 (21.9) 75 (24.1) 66 (21.2) 40 (12.9) 9 (21.9) 42 (13.5) 17 (5.5) 23 (7.4) 7 (2.3) 61 (19.6) 16 (5.1) 164 (52.7) 84 (27.0) 178 (57.2) 99 (31.8) Seventy‐eight per cent of all participants stated they would discuss concerns about a child patient with a colleague, while 66.5% would discuss it with a dentist who is their professional agreement colleague (Figure ). In NZ, a professional agreement is a signed written document that outlines the professional relationship and responsibilities between two individual oral health practitioners. It is usually between a dentist (or dental specialist) and another oral health practitioner. The Dental Council codes of practice on professional working relationships for oral health practitioners require that a professional agreement must be in place for dental therapists and dentists, and dental hygienists and dentists. Actions taken after suspecting abuse. Only 12.5% said they would refer the case to a paediatric dentist while 37.6% said they would directly notify CYFS (though about one in three therapists reported a lack of confidence in child protection services). Most participants (68.6%) felt the biggest barrier was a fear of mistakenly reporting a non‐abuse case (Figure ). Barriers to reporting of child maltreatment, as perceived by NZ Dental Therapists. Child abuse prevention strategies Many believed that decreasing illicit drug use (89.3%) and alcohol abuse (88.7%) would help in the prevention of child abuse. A high proportion (87.5%) felt that increasing the knowledge and awareness of the general population would decrease the problem of abuse, while 77.7% believed improving the knowledge of health professionals would make a difference. Discussion Almost all participants (96.1%) felt that child abuse and neglect are important issues in NZ. Many (77.1%) felt that death rates due to abuse in NZ are among the worst in the developed world. Most (94.6%) perceived a responsibility to aid early detection of abuse and 75.8% thought it should be mandatory for dental practitioners to report suspected cases. Despite this knowledge and a willingness to be involved in early detection, not all suspected cases were reported. The most common action participants reported they would take was to discuss the case with a colleague (78.1%). Only 37.6% of respondents would consider reporting suspected cases to CYFS, and about one in every three therapists reported a lack of confidence in child protection services, but the major barrier was a fear of reporting a non‐abuse case (68.6%). The NZ Ministry of Health funds and mandates Child Protection Services within each District Health Board, whose role is to partner with health professionals to prevent and respond to child abuse and neglect. There appears to be little engagement at present between Dental Therapists and these Child Protection Services. Generalisability of study findings Participant characteristics were similar to those of non‐participants and the officially reported NZ and Australian dental therapist workforce demographics. A large majority of the dental therapy workforce in NZ are females, and most are employed by District Health Boards, 18 and this is mirrored in the respondents. The Australian dental therapy public system differs somewhat from NZ system, but similar proportions of dental therapists were working in the public versus private sectors (recognising that some dual‐qualified dental therapist/hygienists split their time between public and private practice). NZ dental therapists do tend to be older than Australian dental therapists and this is mirrored in our sample. It is likely that the study participants are representative of NZ and Australian dental therapists and that the study findings are relevant in the broader Australasian context. Strengths and weaknesses The perceptions and role of dental therapists in the early detection of child abuse in NZ were previously unknown. As questionnaires were sent to all dental therapists who currently hold a practicing certificate, sampling errors were eliminated. One of the weaknesses of the study was a relatively low response rate. This could be because the questionnaires were sent out during the annual school holiday period when many dental therapists were on leave. Recall bias is another factor which plays a role in a questionnaire study. Therapists were asked to remember how many abuse cases they have suspected, not only in the past year, but in their careers. Recall bias is also possible with regards to dental therapists’ recollections of their past education in the area of child maltreatment. Practitioners who have been in practice for an extended period of time would be less likely to recall all details of their undergraduate education or cases of abuse or maltreatment from early on in their careers. International comparisons As in many other countries, this study found a difference between the number of cases suspected and the number reported. 9–14 Although most studies have involved dentists, a 2009 United Kingdom (UK) study was conducted among dental therapists. 10 This study investigated training in child protection, suspicion of abuse and the number reported, as well as further actions taken. Knowledge of referral guidelines and barriers present when reporting a case were also investigated. 10 As the aims and the target population of the UK study are similar, comparisons can be made. A noted difference is that half (49.4%) of participants in the UK study were recent graduates who had practised for less than 10 years. 10 In this study, there is an even distribution among the participants, with only 28.0% practising for less than 10 years. Other differences include the recall of undergraduate training (UK 63.1%, NZ 38.7%) and the therapists’ interest in further training (UK 62.6%, NZ 82.4%). The most common action taken after suspecting abuse was similar in both studies, with 48.2% of respondents in the UK study discussing the case with their “principal dentist or other dental colleague”, 10 while in NZ, 78.1% of dental therapists would discuss the case with a colleague. Seventy per cent of dental therapists in the UK would not report a case if there was a “lack of certainty over their diagnosis”. 10 In NZ, a fear of mistakenly reporting a non‐abuse case was the major barrier for 68.6% of dental therapists. Dental neglect Previous research has shown that child dental neglect frequently accompanies other forms of maltreatment. 17 The majority of dental therapists in this study (86%) believed that a child missing several appointments was a sign of the parent(s) neglecting the dental needs of the child. In Sweden, 68% of public sector dentists assumed parental negligence when children missed several appointments. 19 Some researchers have asked “Do paediatric dentists neglect child dental neglect?” 20 They found that more than 80% of UK paediatric dentists saw cases of dental neglect at least once a week. However, referring to social services was the least favoured option used by only 4.1% of paediatric dentists. The same authors suggested that this could be as a result of lack of knowledge or awareness that a relationship exists between general neglect and dental neglect. Paediatric dentists with postgraduate child protection training were more likely to report cases to social services. 20 It would appear that child protection training increases awareness and reporting of dental neglect by dental professionals. International policy statements on dealing with child dental neglect have previously been produced to provide guidance on dealing with these issues in clinical practice. 21 Recommendations for action As frontline health professionals who care for children on a daily basis, dental therapists in NZ are in a unique position for early detection of child abuse. For those employed by DHBs (72.5% of respondents), the DHB Child Protection Officers could serve as a valuable sounding board providing support in making a decision regarding notification to CYFS. The results of this research highlight the willingness of dental therapists to help reduce cases of abuse. They also highlight the need for better national guidelines and a clearer referral procedure for dental therapists in NZ. Child Protection Services from within each District Health Board and the Dental Therapy Services should engage with each other more effectively with regard to education about child abuse and also to facilitate appropriate action where there are any concerns about a particular child. There also appears to be a gap in the availability of Social Work Services to child dental therapists and their clients. Conclusions Dental therapists understand that they can play an important role in decreasing the incidence of child abuse. Many have observed signs of child maltreatment among the young patients they treat, yet only about half of the cases they suspect are reported to authorities. A fear of mistakenly reporting non‐abuse cases may be reduced with increased training, knowledge and support. Acknowledgements The study was conducted while D Tilvawala was the recipient of a Child Injury Prevention Foundation Summer Research Scholarship. This study would not have been possible without the support of the Sir John Walsh Research Institute and Colgate. We also thank all the participants.

Journal

Australian and New Zealand Journal of Public HealthWiley

Published: Oct 1, 2014

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