What factors increase Dutch child health care professionals' adherence to a national guideline on preventing child abuse and neglect?

Expert consensus on multilevel implementation hypotheses to promote the uptake of youth care guidelines: a Delphi study

BACKGROUND

The implementation of youth care guidelines remains a complex process. Several evidence-based frameworks aid the identification and specification of implementation determinants and strategies. However, the influence of specific strategies on certain determinants remains unclear. Therefore, we need to clarify which active ingredients of strategies, known as behaviour change techniques (BCTs), elicit behaviour change and improve implementation outcomes. With this knowledge, we are able to formulate evidence-based implementation hypotheses. An implementation hypothesis details how determinants and in turn, implementation outcomes might be influenced by specific implementation strategies and their BCTs. We aimed to identify (1) determinants relevant to the implementation of youth care guidelines and (2) feasible and potentially effective implementation hypotheses.

METHODS

A four-round online modified Delphi study was conducted. In the first round, experts rated the implementation determinants based on their relevance. Next, experts formulated implementation hypotheses by connecting BCTs and implementation strategies to determinants and were asked to provide a rationale for their choices. In round three, the experts reconsidered and finalised their hypotheses based on an anonymous overview of all formulated hypotheses, including rationales. Finally, the experts rated the implementation hypotheses based on their potential effectiveness and feasibility.

RESULTS

Fourteen experts completed the first, second, and third rounds, with 11 completed the final round. Guideline promotion, mandatory education, presence of an implementation leader, poor management support, knowledge regarding guideline use, and a lack of communication skills were reported as most relevant determinants. In total, 46 hypotheses were formulated, ranging from 6 to 9 per determinant. For each determinant, we provide an overview of the implementation hypotheses that were most commonly deemed feasible and potentially effective.

CONCLUSION

This study offers valuable insights into youth care guideline implementation by systematically identifying relevant determinants and formulating hypotheses based on expert input. Determinants related to engagement and to knowledge and skills were found to be relevant to youth care guideline implementation. This study offers a set of hypotheses that could help organisations, policymakers, and professionals guide the implementation process of youth care guidelines to ultimately improve implementation outcomes. The effectiveness of these hypotheses in practice remains to be assessed.

Optimizing implementation: elucidating the role of behavior change techniques and corresponding strategies on determinants and implementation performance: a cross-sectional study

INTRODUCTION

Behavior change techniques (BCTs) are considered as active components of implementation strategies, influencing determinants and, ultimately, implementation performance. In our previous Delphi study, experts formulated 'implementation hypotheses', detailing how specific combinations of BCTs and strategies (referred to as BCT-strategy combinations) might influence determinants and guideline implementation within youth care. For example, educational meetings providing instructions on guideline use were hypothesized to enhance practitioners' knowledge and, consequently, guideline implementation. However, these hypotheses have not been verified in practice yet.

METHOD

We conducted a cross-sectional study involving practitioners and management professionals from youth (health)care organizations. Using questionnaires, we obtained data on the presence of BCT-strategy combinations and their perceived influence on determinants and implementation performance. Chi-squared tests and regression analyses were employed to determine the influence of specific BCT-strategy combinations on determinants and implementation performance.

RESULTS

Our analyses included data from 104 practitioners and 34 management professionals. Most of the management professionals indicated that the BCT-strategy combinations positively influenced or had the potential to influence their implementation performance. At the practitioner level, half of the combinations were perceived to have a positive influence on determinants and implementation performance. Furthermore, practitioners who reported the absence of BCT-strategy combinations were more skeptical about their potential influence on determinants and implementation performance.

CONCLUSION

Several BCT-strategy combinations were perceived to improve or potentially improve implementation performance of both practitioners and management professionals. In the development and evaluation of implementation efforts, we advocate for clearly describing the implementation effort's objective and using frameworks that detail the BCTs inducing behavior change, the strategy employed, and the processes driving the observed changes. Understanding these interconnected processes is important in designing targeted, evidence-based behavior change interventions. This understanding optimizes resource allocation and contributes to the overall success of implementation efforts in youth care.

Judgements of physicians, nurses, and social workers regarding suspected Child maltreatment in community health care services

This study investigated how physicians, nurses, and social workers in community health care services make judgements about possible child maltreatment in ambiguous situations. We examined the influences of social biases (i.e., perceptions linking ethnicity, gender, and family socioeconomic status to child maltreatment) and belonging to distinctive occupational groups (i.e., physicians, nurses, and social workers) on professionals' assessment of suspected child maltreatment, intention to consult with others, and reporting. We used an experimental survey design including vignettes presenting a child's history inspired by real-life clinical cases. Data were collected from 397 health care professionals-170 physicians, 179 nurses, and 48 social workers-employed at community health care clinics in northern Israel. Findings show that the child's gender and family socioeconomic status had significant effects on assessment of possible child maltreatment. Also, professionals' occupational group had significant effects on assessment of child maltreatment and intention to pursue consultation. Another key finding was the significant effects of judgements about child maltreatment assessment, consultation, and reporting on one another. The study reinforces efforts to improve health care professionals' management of suspected child maltreatment that include the development of clinical decision support systems that use routinely collected electronic medical record data.

Pediatricians' Attitudes Toward Child Sexual Abuse in the Republic of Srpska

Child sexual abuse (CSA) affects all cultures and sociodemographic sections. As health professionals, pediatricians are often the first line of defense when it comes to CSA identification and reporting. Our previous study examined encounters, competence, beliefs, and reporting regarding CSA among pediatricians in countries of the former Yugoslavia, Serbia, and Montenegro. Following up on this work, we expanded our research to another neighboring country, the Republic of Srpska (RS). Sixty pediatricians were surveyed in 2020, comprising 30% of all practicing pediatricians in the Republic of Srpska. Compared to their colleagues from Serbia and Montenegro, RS pediatricians revealed an increased perception that children are often abused by someone they do know well, were more confident in their abilities to detect CSA, reported a higher number of CSA cases, and were more interested in further trainings on the subject of CSA. Despite this, the level of underreporting remained high (40%). To our knowledge, this is the first study to both assess and compare CSA-related attitudes in this part of the world. Key differences between RS, other two neighboring countries as well as from other countries worldwide are likely to stem from the level of pediatricians' training and education, as well as from the socio-cultural and legislation context. Although encouraging, our data indicate a need for further research in the countries of the former Yugoslavia.

How child health care physicians struggle from gut feelings to managing suspicions of child abuse

Aim

We examined how gut feelings of child health care physicians’ (CHCPs) contribute to the development of a suspicion of child abuse, how they act upon this suspicion and what barriers they experience in their management. To gain insight into the youth health care chain, we compared the diagnostic reasoning and management regarding this issue by CHCPs and family physicians (FPs).

Methods

Three focus groups, 20 CHCPs, thematic content analysis.

Results

A gut feeling acted as an early alert to look for the triggering cue(s), by observing more closely and asking relevant questions. CHCPs struggled to distinguish whether the situation involved child abuse or a lack of parenting skills, and how to communicate their concerns with parents. They tried to motivate parents to improve the situation, avoiding the term child abuse and considered involving the Child Abuse Counselling and Reporting Centre (CACRC) a measure of last resort only.

Conclusion

As with FPs, gut feelings support CHCPs in becoming attentive to child abuse and to situations which can lead to child abuse. The next step, discussing their suspicion with the parents, is a difficult one, and the CACRC might actually help to make this step easier.

Mandatory reporting between legal requirements and personal interpretations: Community healthcare professionals' reporting of child maltreatment

BACKGROUND

Healthcare professionals working at community-based services have a crucial position in raising concerns about possible child maltreatment. Yet, barriers exist to healthcare professionals adhering to mandatory reporting rules and regulations.

OBJECTIVE

The current study investigated the various forms by which healthcare professionals working in community services manage mandatory reporting, their reasoning and experience with formal requirements. The study has utilized the decision-making-ecology model as a conceptual framework.

PARTICIPANTS AND SETTING

The study was carried out in the largest district of the largest health-management organization in Israel, across fourteen sites located at seven cities. Eighteen healthcare professionals of various occupational groups participated in in-depth semi-structured interviews.

RESULTS

The results reveal that out of the of 52 recent cases that have been suspected for possible child maltreatment, only 58 % were reported as legally required. Yet, about half were reported in delay. Practitioners were more likely to report after additional evidence accumulated and increased the level of suspicion or after failing to manage the issue by other means of support. The analysis identified multiple factors that combined to impact the decision-making regarding reporting. Those were clustered around the individual case, healthcare professional, organizational setting, and external context.

CONCLUSIONS

Our results emphasize the importance of workplace-environmental conditions in promoting optimal reporting behaviors, including working in multi-disciplinary teams, availability of rapid expert consultation, provision of emotional-support, and reciprocal exchange of information with child-protection-services.

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

Background

Healthcare professionals’ adherence to guidelines on child protection is not self-evident. This study assessed the effects of a computerised support tool on child healthcare professionals’ adherence to the seven recommended guideline activities, and on time spent seeking information presented in this guideline.

Methods

A community-based intervention trial design was applied, comparing access to a paper-based guideline (control) with access to a paper-based guideline supplemented with a computerised guideline support tool (intervention). A total of 168 child healthcare doctors and nurses working in one large Dutch organisation were allocated to an intervention or control group. Outcomes were professionals’ performance of seven recommended guideline activities and the amount of time spent seeking information presented in the guideline. Professionals’ adherence was measured using two methods: health record analysis and a self-report questionnaire. The questionnaire was also used to collect data on the amount of time spent seeking guideline information.

Results

In total, 152 health records (102 in the intervention group and 50 in the control group) were available for analysis. The tool was registered in 14% of the records in the intervention group. Performance of activities, corrected for intentional non-adherence, was except for one activity, high (range 80–100%); no differences were found between the control and intervention groups. Forty-nine questionnaires (24 in the intervention group and 25 in the control group) were analysed. Sixty-three percent of the questionnaire respondents (15/24) claimed to have used the tool. No differences in guideline adherence were found between the two groups. Respondents in the intervention and control groups spent, on average, 115 and 153 min respectively seeking relevant information presented in the guideline.

Conclusions

The results regarding use of the tool were inconclusive as the outcomes differed per method. In contrast to expectations, performance of guideline activities was high in both groups. The support tool may decrease the amount of time spent on seeking guideline information. However, given the high adherence scores and small number of questionnaire respondents, the outcomes failed to reach statistical significance. Future research should focus on studying the effects of the tool after a longer period of availability.

Electronic supplementary material

The online version of this article (10.1186/s12911-019-0884-y) contains supplementary material, which is available to authorized users.

The Healthy Primary School of the Future: A Contextual Action-Oriented Research Approach

Background: Schools can play an important role in promoting children’s health behaviours. A Dutch initiative, ‘The Healthy Primary School of the Future’, aims to integrate health and well-being into the school system. We use a contextual action-oriented research approach (CARA) to study the implementation process. Properties of CARA are its focus on contextual differences and the use of monitoring and feedback to support and evaluate the process of change. The aim of this article is to describe the use of the approach. Methods: Four schools (each with 200–300 children, aged 4–12 years) were included; all located in low socio-economic status areas in the south of the Netherlands. Data collection methods include interviews, observations, questionnaires, and health and behavioural measurements. Research contributions include giving feedback and providing schools with a range of possibilities for additional changes. The contextual data we examine include schools’ health promoting elements, practices of teachers and parents, dominating organisational issues, and characteristics of the student population; process data include the presence of potential barriers to changes. Discussion: CARA is an adaptive research approach that generates knowledge and experiences on how to deal with health promotion in complex systems. We think this approach can set an example for research efforts in comparable initiatives.

Screening for social determinants of health in clinical care: moving from the margins to the mainstream

Background

Screening for the social determinants of health in clinical practice is still widely debated.

Methods

A scoping review was used to (1) explore the various screening tools that are available to identify social risk, (2) examine the impact that screening for social determinants has on health and social outcomes, and (3) identify factors that promote the uptake of screening in routine clinical care.

Results

Over the last two decades, a growing number of screening tools have been developed to help frontline health workers ask about the social determinants of health in clinical care. In addition to clinical practice guidelines that recommend screening for specific areas of social risk (e.g., violence in pregnancy), there is also a growing body of evidence exploring the use of screening or case finding for identifying multiple domains of social risk (e.g., poverty, food insecurity, violence, unemployment, and housing problems).

Conclusion

There is increasing traction within the medical field for improving social history taking and integrating more formal screening for social determinants of health within clinical practice. There is also a growing number of high-quality evidence-based reviews that identify interventions that are effective in promoting health equity at the individual patient level, and at broader community and structural levels.

Walking Children Through a Minefield: How Professionals Experience Exploring Adverse Childhood Experiences

Understanding the challenges of professionals in addressing child adversity is key to improving the detection, protection, and care of exposed children. We aimed to synthesize findings from qualitative studies of professionals' lived experience of addressing child adversity. Through a systematic search, we identified eight qualitative studies and synthesized them using metaethnography. We generated three themes, "feeling inadequate," "fear of making it worse," and "facing evil," and one overarching metaphor, "walking children through a minefield." The professionals felt that they lacked the means necessary to explore child adversity, that they were apprehensive of worsening the child's situation, and that their work with child adversity induced emotional discomfort. This metasynthesis indicated that the professionals' efficiency in exploring abuse relied upon their ability to manage emotional and moral distress and complexity. To support children at risk, we propose developing professionals' ability to build relationships, skills in emotion regulation, and proficiency in reflective practice.

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

This study examined the presence and strengths of determinants associated with consultation of an in-house expert on child abuse and neglect (CAN) by preventive child health care professionals who suspect CAN. This study also assessed the relationship between in-house CAN expert consultation and professionals' performance of six recommended activities described in a national guideline on preventing CAN for preventive child health care professionals. A total of 154 professionals met the study's inclusion criteria. They filled in a questionnaire that measured in-house consultation practices and twelve determinants associated with the professional, the in-house expert, and the organizational context. Bivariate and multivariate regression analyses were performed. Almost half of the participants (46.8%) reported to consult the in-house expert in (almost) all of their suspected CAN cases. Professionals who reported better recollection of consulting the in-house expert (i.e. not forgetting to consult the expert) (p=.001), who were more familiar with consultation (p=.002), who had more positive attitudes and beliefs about consultation (p=.011) and who reported being more susceptible to the behavior (p=.001) and expectations/opinions (p=.025) of colleagues regarding in-house expert consultation were more likely to consult the in-house expert. Furthermore, in-house expert consultation was positively associated with two of six key guideline activities: consulting the regional child protection service and monitoring whether support was provided to families. The implications of these results for improving professionals' responses to CAN are discussed.