Knowledge and attitudes
Most DTs and OHTs participants considered CAN as significant health and social issue in NZ. Oral health practitioners hold the potential to be involved in the prevention and early intervention of CAN. However, it appears that DTs and OHTs may not be routinely reporting suspected cases. During the 2019 financial year, 82.1% of children aged 1–14 had at least 1 dental health care worker visit [
26]. Because roughly 10% of NZ children and adolescents get substantiated as CAN victims before they turn 18 years old [
5], oral health practitioners will likely encounter suspected CAN cases.
Even though the definition of CAN can vary among countries, oral health practitioners’ low reporting rates are observed worldwide [
18‐
20]. In Denmark, 38% of dentists and dental hygienists suspected CAN during their careers; among those who had suspected CAN, only 1 in 3 (34%) reported their concern for further investigation [
23]. The current study’s findings are also consistent with the previous NZ study of DTs conducted by Tilvawala et al. [
12], which indicated 46% had identified suspected physical abuse and 40% for suspected child neglect; however, 29 and 22% reported, respectively.
Low SES was mentioned most as an observed common feature for suspected CAN patients. Various studies have noted a relationship between the socioeconomically disadvantaged and CAN [
27,
28]. However, the association must be interpreted with caution, as socioeconomically disadvantaged families experience poverty, housing and food insecurity, and social and health inequalities, which often lead to parental depression and substance abuse. These conditions can contribute to abusive and neglectful behaviours. Apart from parental depression and substance abuse, other factors can diminish caregivers’ abilities.
Participants also identified CAN over-representation for Māori and Pacific Island children. The literature has indicated that identifying with particular ethnic and social groups can increase the likelihood of child protection concerns being detected and reported [
29]. In the NZ context, understanding the impact of colonisation and social and institutional racism on health and social inequalities is necessary to respond effectively [
30,
31]. Stereotyping can cause over-diagnosis for Indigenous Māori and Pacific Islander children and children from families with low SES [
29]. Providing family violence prevention and early intervention designed to suit Indigenous Māori and Pacific Islander families is most likely to achieve the best outcome for children and families [
31]. On the other hand, children from privileged families may receive less attention, with health practitioners missing the signs and symptoms of abuse and neglect and the opportunity to intervene. Further research is critical to understand how the pre-existing perception of DTs and OHTs towards patients with different SES affects their attitudes in the detection and reporting of CAN. Importantly, understanding the close association between intimate partner violence (IPV) and CAN will be beneficial to understanding the broad picture of family violence. Both IPV and CAN are different forms of family violence with shared risk factors that occur concurrently in a family [
32]. Increasing the understanding of IPV and its impacts on the child’s health and the potential harm can enable an integrated and effective response to victims and their families and contribute to a prevention and early intervention approach.
DTs and OHTs reported 2 dominant barriers to detecting and reporting CAN: 1) fear of causing harm to the patient and 2) a lack of knowledge to detect and report. The barriers indicate a necessity to improve oral health practitioners’ knowledge of child protection. Even though identifying oral manifestations of CAN and reporting procedures are part of undergraduate training, knowledge gaps and lack of confidence are evident among DTs and OHTs. These findings are consistent with other international studies. The fear of false reporting and further violence has been reported in many studies, including the NZ study by Tilvawala et al. [
12] (69% fear of false reporting), UK study by Harris et al. [
33] (78% lack of certainty about diagnosis, 53% fear of family violence), and Scotland study by Cairns et al. [
18] (88% uncertain about the diagnosis, 34% fear of family violence). Similarly, lack of knowledge was commonly reported elsewhere by Harris et al. [
33] (32% lack knowledge of referral procedures) and Cairns et al. [
18] (71% lack knowledge of referral procedures).
More than half (52%) of the current research participants were unwilling to confront families of potential victims. This behaviour may be linked with concerns about self-protection, confidentiality, or time restrictions. This study did not investigate participants’ more profound understanding of how those barriers have formed and how they influence current responses to CAN, which needs further attention. An increased understanding of the current low responsiveness toward CAN will help oral health professionals to enhance their knowledge and attitudes.
In the current study, participants provided potential facilitators to help DTs and OHTs in child protection. Seventy percent who attended courses or training found them beneficial. Responses to open-ended questions support the effectiveness and potential benefits of having child protection training to gain up-to-date information on reporting pathways and policies and connect with other health and social professionals to work as an interdisciplinary team. The New Zealand Dental Association [
13] guideline assists oral health practitioners with child protection and guides practitioners’ responsibilities. However, the guideline is from a professional dental association rather than a regulatory authority. DTs and OHTs usually do not belong to the New Zealand Dental Association which focuses on advocating for dentists and dental specialists, therefore, DTs and OHTs are unlikely to read the guideline. The study findings have implications for developing a comprehensive guideline that can be incorporated into the DCNZ professional standards framework and tertiary training programs. In a qualitative meta-synthesis, Hegarty et al. [
34] identified collaboration among health and social practitioners and being supported by the health system as the main themes to improve the readiness of health practitioners to address family violence. Evidence indicates that the multidisciplinary team approach is more effective in improving responses than stand-alone practices. Designing a training programme that guide practitioners to access multidisciplinary support and embedding this in the professional standards framework and tertiary education programmes would be essential. The actual availability and effectiveness of any child protection courses and training were not examined in this study, which might provide a better understanding of the practitioner’s training needs. Future studies on the current topic are therefore recommended.
Another issue highlighted was participants’ limited awareness of the Family Violence Act 2018 and its impact on their practices. The Act provides support and protection mechanisms, including 1) participants’ abilities to request, use, or disclose personal information for purposes related to CAN, 2) what to consider when disclosing personal information, and 3) necessary protection that participants can access when disclosing information. A majority of the participants were not aware of the Act, indicating a potential communication gap among the government, the professional and regulatory bodies and the frontline oral health practitioners. Providing accurate information on how the government can provide the necessary support has the potential to act as a facilitator to support both potential victims and practitioners by supporting oral health practitioners to detect and report potential cases more confidently.
Most participants (74%) agreed with mandatory reporting of suspected cases; however, there is an ongoing debate regarding its effectiveness [
35]. A mandatory reporting system may create a culture among health practitioners to report frequently within the legal boundaries. However, there are obvious barriers to implementing mandatory reporting, including health practitioners’ resistance and having no gold standard to diagnose and identify potential cases. Most importantly, lack of knowledge to adequately detect and report suspected cases would prevent the implementation of mandatory reporting as the mandatory reporting system would not work if practitioners do not know how to respond with the situation [
36]. Further investigation to assess the feasibility and efficiency of a mandatory reporting system would be necessary.
Strengths and limitations
A strength of the current study is that it included both dental and oral health therapy professions, which together provide most children with oral health care in various community settings. As a result, the participants had a high rate of involvement in children and adolescent oral health care. The findings reinforce a strong need to improve the knowledge and attitudes of DTs and OHTs for the future generations of the 2 professions.
This study’s limitations include the relatively low response rate (16%) and a greater representation of oral health therapists than dental therapists (Table
1). OHTs are a more recently established profession; therefore, most OHTs had their undergraduate training within the last 10 years, while most DTs would have had more clinical experiences. It is unclear how the 2 professions would respond differently to CAN in their practice. Additionally, there could be differences between those who responded, and those who did not. As the survey was sent out by email, it may have increased the accessibility and responsiveness to younger practitioners who are represented more in the oral health therapy workforce. It may be that non-respondents were either more or less likely to be engaged with child protection practices. The COVID-19 pandemic may have also impacted the response rate, as the survey was sent out soon after NZ’s first national lockdown, where the profession was focused on adapting to the new COVID regulations and practice standards. Given the low response rate, the outcome cannot be necessarily considered as wholly representative of NZ dental and oral health therapy professions. The focus of the study is to understand the knowledge and attitudes of DTs and OHTs in detecting and reporting child abuse and neglect, however, to fully understand the whole oral health profession, dentists and paediatric dentists could have been invited as some adolescents are also examined and treated by them.
In terms of the questionnaire, even though the study adopted a previously developed questionnaire and was further piloted by 2 DTs and 2 OHTs, it was not fully validated to evaluate the structure of the survey. Some questions in the second part of the survey generated skewed results as it is hard to disagree that child protection is an important social issue. Also, several questions included both child abuse and child neglect, however, signs of symptoms of the 2 issues are different [
9]. Asking specific questions on each issue would have provided further understanding of participants’ knowledge and attitudes. Another limitation was that competence in recognition of CAN was self-reported. Participants may have under- or over-recognised CAN cases, however, due to the limitation of the survey research, it was not possible to assess the accuracy of their reporting. Furthermore, some participants provided ranges for case numbers rather than a specific number which were converted into means. Using means increased the risks of losing outliers and underestimating the variance of responses.
Implications for public health and future research
A CAN identification process is highly reliant on health practitioners’ personal judgment and a clear understanding of their roles and responsibilities [
37]. This emphasises the need to improve oral health practitioners’ understanding in detecting CAN cases in early stages, provide the necessary support to children and their families, and report to the child protection agencies to provide safer environments to children and adolescents in need. Despite challenges to measuring the impact of early intervention approaches on child protection, McCarry et al. [
38] identified a perceived need and positive impact of the early interventions approach by children, mothers, and service providers to effectively safeguard children from family violence. Emphasising the need for evidence-based early intervention approach to prevent further harm to the child is equally crucial to detecting and reporting potentially imminent harm. The participants’ desire to improve their knowledge and attitudes toward child protection is promising. The consensus statement on future directions for the behavioural and social sciences in oral health research [
39] emphasises the need to address social and environmental determinants. Further study will be required to explore how proximal determinants are affecting the responsiveness of oral health practitioners to CAN and those factors can be addressed to improve practitioners’ responses. Understanding those determinants can enhance child’s safety and wellbeing by improving the responsiveness of oral health practitioners and facilitating early-intervention approaches to child protection.
Further research will be necessary to include other oral health practitioners such as paediatric dentists and community dentists, other relevant stakeholders, and community members to share their perspectives on CAN and the role of oral health practitioners in child protection. Investigating the impediments and associated impacts on the responsiveness of oral health practitioners to children’s safety and wellbeing needs would be required. Key findings can be translated into oral health practitioners’ early intervention approaches to child protection to achieve child safety and wellbeing.
Given the complexity of family violence, it is unlikely that a single guideline will suffice [
37]. Even so, having practical guidance from the regulatory authority can increase oral health practitioners’ confidence to take action. The guideline shouldbe easily accessible by practitioners and regularly updated to ensure current and relevant information. As oral health services are often provided in a school setting, information should incorporate an interprofessional approach to communicate with other health, education, and social professionals and share knowledge with each other. The guideline should provide information on how DTs and OHTs can support the family and the community, not just detecting and reporting the potential CAN cases. Providing necessary support helps as a part of holistic care to the family and the community across the continuum of needs that can protect children and adolescents from further harm from CAN [
38]. The government recently introduced Te Aorerekura (the national strategy to eliminate family violence and sexual violence), which includes a reformation of NZ healthcare to make it more equitable and better suited to meet the needs of all people [
40]. This will be a crucial moment to review oral health practitioners’ roles in child protection practices. Further consultations with DTs and OHTs will be required to provide ideal support.
Carefully designed courses to educate DTs and OHTs to improve understanding, knowledge, and attitude are required to improve responsiveness to child protection to detect suspected CAN cases and provide adequate support to affected children and families. Even for health professionals who have extensive prior experience in dealing with CAN cases, consistent engagement with continuing developments and training is beneficial to maintain a capability to detect and report suspected cases. The course should train practitioners to be able to access necessary resources when needed, seek professional advice from other health or social practitioners, and approach multi-disciplinary team support. The focus of the training should be based on the needs of oral health practitioners, stakeholders, communities, and service users. Additionally, this should be a valuable opportunity to engage with Māori and Pacific communities to understand structural racism in health and child protection practices and address those inequity issues in oral health practices in NZ.
Further investigation to understand the reasons for the under-reporting of child protection concerns by DTs and OHTs is required and should be addressed at both individual and professional levels. Currently, there are insufficient courses related to CAN available for oral health practitioners in NZ. Stakeholders should work collaboratively to design appropriate courses that can be delivered regularly, ensuring the educational material is readily accessible to all oral health practitioners.