The Word Health Organization has defined child abuse or child maltreatment as parents or children's engagement or not engagement in any practice that violates the children's rights and put their decent life and dignity at risk. ¹ There are four types of child abuse:

Physical child abuse: It occurs when a child suffers or may suffer from a noticeable damage due to any harm from the parents or a guardian

Since the symptoms of child abuse and neglect often manifest in orofacial area, the dental team has a key role in identifying children subjected to abuse. Further, the child neglect is often followed by poor oral health. ⁴ , ⁵

According to the literature, a high percentage of child abuse occurs annually, which is not reported due to various reasons such as social and cultural factors. Hence, the oral treatment team needs to enhance their information in this regard, diagnose this abnormality, and report it consequently. This systematic review was aimed to explore the failure to take history as a barrier to reporting child abuse by dentists.

In this systematic review and meta-analysis, PubMed, Embase, Scopus, Google Scholar, ProQuest, Cochrane, and ISI databases were searched for the cross-sectional articles in English languages reporting the barriers to reporting child abuse by dentists since 1985 using Medical Subject Headings (MeSH) and free search based on P: Population and O: Outcome as well as terms “OR” and “AND”. Since the articles investigated were descriptive, only P and O components of the PICO model were analyzed (P: Dentists, O: Failure to report cases of child abuse).

PUBMED:

(OR (child* AND (abuse OR neglect) AND dent* “child abuse”)).

EMBASE:

#1. “Child abuse”

#2. “Child OR children OR abuse OR neglect”

#3. “Report OR not report”

#4. “Child OR children OR abuse OR neglect” AND “Barriers and report” AND “Failure to take history”

#5. Dental neglect

#6. Sexual child abuse

#7. Physical child abuse

#8. Emotional child abuse

#9. #2 OR #3 OR #4OR #5 OR #6 OR #7

#10. #1 AND #8

The extracted articles were first selected by two reviewer based on their title and abstract. The full text of relevant article were then obtained and studied separately by the main researchers and assessed and scored based on the Newcastle–Ottawa checklist. This checklist has 7 items with maximum score for the cross-sectional studies. Therefore, each article is scored from 0 to 10. Based on a point of distinction of 5, the articles with a score ≥5 were considered high quality articles. The first section of the checklist for cross-sectional studies consisted of 4 items with a total score of 5. The first item evaluated the adequacy of the sample size, the second item the correctness of sampling, the third item the adequacy of response percent, and the fourth item the quality of the measurement tool of the risk factors. The second section of the checklist included one item measuring comparability, with a score of 2. The third section of the checklist had two items with a total score of 3. The first item assessed the outcomes and the second item evaluated the statistical analyses Table 1.{Table 1}

The inclusion criteria consisted of the cross-sectional studies in English languages reporting the frequency of barriers to reporting child abuse by dentists.

The exclusion criteria included:

Articles not compatible in terms of Papulation and Outcome, i.e., articles with study population other than dentists and those not investigating our expected outcome and merely reporting child abuse not the barriers to reporting child abuse

Statistical analysis

Comprehensive Meta-Analysis software was used for the statistical analysis of data. Since the results of different studies do not have the same value, binominal distribution was used to estimate the variance of each study. Then, each study was given a weight inversely proportional to its variance. Heterogeneity of studies was determined by Q-test and I-square index. Given the significance of the I-square index and heterogeneity of studies, random effects model was used to combine the results. Publication bias was analyzed by funnel plot based on Begg and Egger's tests. In funnel plots, relative ratio versus inverse squared standard error is presented. In case of bias in results, the funnel plot is asymmetric in the wider part of the funnel.

Numerous studies on child abuse were retrieved from the domestic and international databases, but many of them were excluded from the study because they did not meet the inclusion criteria Figure 1. Figure 1

Selection procedure of studies included in the systematic review.

A total of 5 studies conducted in various countries were recruited in this meta-analysis. The findings showed the barriers to reporting child abuse by dentists included failure to take history and others such as diagnostic uncertainty, fear of family violence against child.

The results of other studies conducted on populations other than dentists indicated similar cases as the present study. For instance, Lee et al. performed a study in Korea on emergency nurses and reported inadequate knowledge about child abuse as the most important barrier for reporting child abuse, while those undergoing child abuse education were regularly more inclined to report child abuse. ¹⁰ In the present study, inadequate knowledge about child abuse was reported in four articles. ⁹ , ¹¹ , ¹² , ¹³

In the study of Herendeen et al. in the U.S. on pediatric nurses, the presence of vague history about child abuse was reported as a major factor involved in failure to report child abuse. It was also emphasized that nurses had to be trained sufficiently to be able to take a complete and clear history of their patients. ¹⁴ In the current study, five studies reported failure to take history as a barrier to reporting child abuse, failure to take history means the history of patients is not available which is different from communication skills. ⁴ , ⁶ , ⁷ , ⁸ , ⁹

Knowledge and attitudes among California dental care providers regarding child abuse and neglect the results have not shown this barrier ¹⁵ . In the research performed by Louwers et al., in the U.K. in the emergency department, practical problems, personal barriers, and insufficient communication skills were reported as barriers to reporting child abuse. ¹⁶ These problems were not reported in the 5 articles analyzed in this meta-analysis.

In the study of Tiyyagura et al. in the U.S. in the emergency department, inadequate time, fear of unfair judgment, and lack of sufficient communication skills were reported as barriers to reporting child abuse, ¹⁷ which were not reported in the 22 articles included in the present meta-analysis.

In a narrative review by Azizi among doctors and paramedics, the barriers to reporting child abuse were classified into four categories, including personal barriers, interpersonal barriers, organizational barriers, and situational barriers. The instance mentioned in the personal barriers such as inadequate knowledge and in interpersonal barriers like fear of violence were in line with the results of the present study. ¹⁸

Studies have shown that different groups of health-care providers, including nurses, pediatric doctors, family doctors, and general practitioners are located in different levels with respect to reporting child abuse so that pediatric specialists are more sensitive and responsible in reporting child abuse. ¹⁹ In studies conducted on dentists, very few cases of child abuse have been reported, which is justifiable considering the numerous barriers reported in the present study. ² , ³ , ⁵

In a study by Kilpatrick et al., 75% of dentists mentioned reporting child abuse was not part of their responsibility. ²⁰ Moreover, 63% of dentists in the study of Olatosi et al. ²¹ Studies have reported lack of clinical strategies and instructions as one of the barriers ahead of health-care providers. ³ This, however, was not found to be a barrier, which could be due to diversity of studies in different countries such as Denmark, Joran, Australia, England, and Scotland, most of which have clinical strategies for dentists to report child abuse.

The analysis of various studies revealed lack of information about referral procedures as an important barrier to reporting child abuse by dentists.

Suggestions

Enhancing the dentists' knowledge of correct diagnosis of child abuse cases, referral procedures of child abuse discovered, and dentists' responsibility in dealing with child abuse

A limitation of this study was that articles published in languages other than English were not included in the meta-analysis.

Acknowledgment

This work was supported by the Medical University of Isfahan research and ethics committee as an undergraduate doctorate thesis (Research and ethics code IR.MUI.RESEARCH.REC.1397.129).

Financial support and sponsorship

This work was supported financially by by the Medical University of Isfahan research and ethics committee as an undergraduate doctorate thesis (research and ethics code IR.MUI.RESEARCH.REC.1397.129).

Conflicts of interest

The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or non-financial in this article.