Identifying and intervening in child maltreatment and implementing related national guidelines by public health nurses in Finland and Japan

Resea ch A icle Iden i ying and In e ening in Child Mal ea men and Implemen ing Rela ed Na ional Guidelines by Public Heal h Nu ses in Finland and Japan Kayoko Suzuki,1Eija Paa ilainen,2Mika Helminen,3Aune Flinck,4Na suko Hi oyama,5 Taiko Hi ose,5No iko Okubo,5and Mo oko Okami su5 1School o Nu sing, Tokyo A iake Uni e si y o Medical and Heal h Sciences, Tokyo, Japan 2School o Heal h Sciences, Uni e si y o Tampe e, E el¨ a-Pohjanmaa Hospi al Dis ic , Tampe e, Finland 3School o Heal h Sciences, Uni e si y o Tampe e and Science Cen e , Pi kanmaa Hospi al Dis ic , Tampe e, Finland 4School o Heal h Sciences, Uni e si y o Tampe e, Na ional Ins i u e o Heal h and Wel a e, Depa men o Go e nmen Se ices, Tampe e, Finland 5G adua e School o Heal h Ca e Sciences, Tokyo Medical and Den al Uni e si y, Tokyo, Japan Co espondence should be add essed o Kayoko Suzuki; suzukik@ au.ac.jp Recei ed 6 Oc obe 2016; Accep ed 28 Decembe 2016; Published 6 Feb ua y 2017 Academic Edi o : Lesley Wilkes Copy igh © 2017 Kayoko Suzuki e al. This is an open access a icle dis ibu ed unde he C ea i e Commons A ibu ion License, which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed. Aim. This s udy aimed o in es iga e how public heal h nu ses iden i y, in e ene in, and implemen he guidelines on child mal ea men in Finland and Japan and o compa e he da a be ween he wo coun ies. Me hod. This s udy employed a c oss- sec ional design. Public heal h nu ses’ knowledge and skills wi h espec o child mal ea men p e en ion we e assessed using a ques ionnai e consis ing o h ee ca ego ies: iden i ica ion, in e en ion, and implemen a ion o guidelines. Public heal h nu ses wo king in he a ea o ma e nal and child heal h ca e in Finland (𝑛 = 193)andJapan(𝑛 = 440) we e he pa icipan s. Resul s.A signi ican ly highe pe cen age o Japanese public heal h nu ses iden i ied child mal ea men compa ed o Finnish public heal h nu ses, while Finnish nu ses in e ened in child mal ea men be e han hei Japanese coun e pa s. In bo h coun ies, public heal h nu ses who had ead and used he guidelines deal wi h child mal ea men be e han hose who did no . Conclusion. The esul s sugges ha e ec i e aining on child mal ea men and he use o guidelines a e impo an o inc ease public heal h nu ses’ knowledge and skills o iden i ying and in e ening in child mal ea men . 1. In oduc ion The si ua ion wi h espec o child well-being has apidly imp o ed in mos de eloped coun ies including Finland and Japan du ing he las ew decades. Finland and Japan a e op anked coun ies in he in e na ional compa ison su ey on child well-being in aspec s such as heal h, sa e y, educa ion, and en i onmen [1]. Awa eness o child mal ea men and i s consequences on he u u e well-being and de elopmen o child en has also inc eased du ing las decades. Conside able esou cesha ebeendeployed o ackle hep oblembu no always o he maximum e ec [2]. The numbe o child mal ea men cases has con inued o inc ease in Japan. In 2013, 73,802 cases we e epo ed o he Child P o ec ion Se ice in Japan. The numbe was 2.8 imes as many as ha epo ed in 2003 (26,569) [3]. The con ex is simila in Finland, whe e he numbe o child en in eme gency placemen has been g owing o e he las decade. A o al o 4,192 o child en we e aken in o eme gency placemen in 2013 in Finland. The numbe inc eased 3.3 imes in 10 yea s as compa ed o ha epo ed in 2003 (1,267) [4]. Child mal ea men is he e o e a social issue in bo h coun ies. Pa en s o mal ea ed child en a e o en known o a ange o p o essionals, and i is c ucial o p o essionals o be ale o signals o mal ea men , because child en who a e abused a e unlikely o exp ess he need o o seek help di ec ly om Hindawi Publishing Co po a ion Nu sing Resea ch and P ac ice Volume 2017, A icle ID 5936781, 7 pages h ps://doi.o g/10.1155/2017/5936781 2Nu sing Resea ch and P ac ice s a u o y agencies; u he mo e, hei pa en s a e likely o be ill-equipped o seek and make use o in o mal suppo se ices [5]. Childhood mal ea men is associa ed wi h a a i- e y o changes in b ain s uc u e and unc ion and in s ess- esponsi e neu obiological sys ems [6–8]. In addi- ion, ad e se expe iences in ea ly childhood can ha e long- e m heal h consequences, bo h physical and psychological [8]. Consequences o child mal ea men include impai ed li elong physical and men al heal h such as pos auma ic s ess diso de o dep ession, and he social and occupa ional ou comes can ul ima ely slow he economic and social de el- opmen o he coun y [9, 10]. The e o e, ea ly childhood is a c i ical ime o he p omo ion o heal hy de elopmen and he p e en ion o men al diso de s in adul li e. The e a e public heal h ca e sys ems in place o suppo child en and hei amilies in Finland and Japan. Public heal hnu ses(PHNs)wo kingwi hchild enand hei amilies p o ide p e en i e heal h ca e se ices and play an impo an ole as on wo ke s in iden i ying, in e ening in, and p e en ing child mal ea men . I is impo an o nu ses o de ec signs o child en and amilies being a a isk o mal ea men . P e en i e in e en ion in child mal- ea men is p ac iced based on guidelines in bo h coun ies. In Finland, he Na ional Nu sing Guideline o iden i ying and in e ening in child mal ea men based on sys ema ic e iew was published by he Nu sing Resea ch Founda ion in 2008.Themainpu poseo heguidelinewas o indme hods wi h which i is possible o iden i y child mal ea men cases and, ollowing ha , con inue o help child en and amilies by inding ways ou o hei si ua ion [11, 12]. In Japan, he guideline o child mal ea men p e en ion was designed by Minis y o Heal h, Labou and Wel a e in 1999 and e ised se e al imes [13]. The con en s o he guideline a e mainly he de ini ion o child mal ea men , p e en ion, and in e en ion in child mal ea men and child p o ec ion. The na ional guideline was a anged by each heal h ca e cen e and u ilized. Howe e , iden i ying and in e ening in child mal ea men is ex emely di icul and complex. Child mal ea men is mos ly iden i ied when child en al eady ha e se ious consequences and he sensi i i ies and speci ici y o ools a e inadequa e. Failu e o conside he possibili y o mal ea men will mean ha app op ia e diagnosis is no made and he child is e u ned o an abusi e en i onmen [14]. The e o e, esea ch o imp o e he assessmen o child mal ea men is needed o p e en i e nu sing in e en ion. The aims o his s udy we e o in es iga e how PHNs iden i y, in e ene in, and implemen guidelines on child mal ea men in Finland and Japan and o compa e he esul s be ween he wo coun ies. The indings will be help ul o inc ease PHNs’ knowledge and skills o p e en child mal ea men . 2. Me hods 2.1. Design and Pa icipan s. This s udy employed a c oss- sec ional design o in es iga e how PHNs iden i y, in e ene in, and implemen guidelines on child mal ea men in Finland and Japan. The knowledge and skills o PHNs wi h espec o child mal ea men we e assessed using a sel - assessmen ques ionnai e. Pa icipan s in his s udy we e PHNs wo king in he a ea o ma e nal and child heal h ca e in bo h coun ies. Finland. Pa icipan s we e ec ui ed om he egis e o he Finnish Union o Public Heal h Nu ses. An elec onic ques ionnai e was sen o PHNs who had an e-mail add ess andwo kedinchild- ela edclinics(𝑛 = 800)inFeb ua y 2012, among whom 367 nu ses comple ed he ques ionnai e, esul ing in a esponse a e o 46%. The su ey was app o ed by he boa d o he Public Heal h Nu se Union. A le e s a ing he aim and de ails o his s udy was a ached o he ques ionnai e and emphasized ha he esponden s would emain anonymous. Replying o he elec onic ques ionnai e indica ed in o med consen . Japan. The su ey was conduc ed om Sep embe o Oc obe in2012.TheJapanesepublicheal hca esys emwasclas- si ied in o 5 ypes acco ding o he popula ion size o he municipali y. A o al o 700 heal h ca e cen e s we e selec ed using a s a i ied sampling me hod acco ding o he numbe o PHNs wo king in 5 ypes o heal h ca e cen e s in 2011. Simila ly, 486 heal h ca e cen e s in small municipali ies we e selec ed by s a i ied sampling based on he numbe o PHNs wo king in he municipali ies o he 47 p e ec u es. Resea ch andomize was used o he s a i ied sampling. Two se s o ques ionnai es we e sen by mail o he PHNs who wo ked wi h p egnan women, child en, and hei amilies in a o al o 700 heal h ca e cen e s (𝑛=1,400), o which 453 nu ses comple ed he ques ionnai e ( esponse a e: 32.4%). A co e le e was a ached o he ques ionnai e o explain he aim and de ails o he s udy. I was emphasized ha pa icipa ion in he s udy was olun a y and pa icipan s would emain anonymous. Replying o he ques ionnai e indica ed in o med consen . This s udy was conduc ed wi h he app o al o he E hics Commi ee o Tokyo Medical and Den al Uni e si y. 2.2. Measu es. A ques ionnai e o assess PHNs’ knowledge and skills wi h espec o child mal ea men was de eloped basedon he esea cho Paa ilainene al.[15]basedon he Finnish Na ional Guideline. The con ex o he Finnish Guideline was sui able also o he Japanese con ex . The ques ionnai e consis ed o 3 ca ego ies: iden i ica ion (8 s a e- men s), in e en ion (31 s a emen s), and implemen a ion o guidelines (8 s a emen s) on child mal ea men . Pa icipan s we e asked o a e, on a 6-poin Like scale anging om 1 ( o ally disag ee) o 6 ( o ally ag ee), he ex en o which hey ag eed wi h he s a emen s. The ques ionnai e included demog aphic ques ions (age, gende , wo k expe ience as a PHN, and cu en job) and ques ions conce ning whe he PHNs knew abou he exis ence o guidelines on child mal ea men and had ead hem. Be o e conduc ing his su ey, 10 Finnish PHNs pa icipa ed in a pilo es o he elec onic e sion o he ques ionnai e, and subsequen ly a pa was modi ied. Nu sing Resea ch and P ac ice 3 Table 1: Backg ound o he pa icipan s. Va iables Finland (𝑛 = 193)Japan(𝑛 = 440) Mean (SD) Age 42.1 (11.2) 37.3 (9.1) Wo king yea s as a nu se 12.5 (10.3) 12.1 (9.1) 𝑛(pe cen ages) Gende (male/ emale) 1 (0.5%)/192 (99.5%) 5 (1%)/434 (99.0%) PHNs knowing he exis ence o he guidelines 156 (80.8%) 417 (95.4%) PHNs who had ead he guidelines 104 (53.9%) 383 (88.0%) Table 2: Iden i ica ion o child mal ea men . Va iables Finland (𝑛 = 193)Japan(𝑛 = 440)𝜒2(1) Φ Disag ee Ag ee Disag ee Ag ee PHNs mee mal ea ed child en o en 164 (85%) 29 (15%) 290 (67%) 145 (33%) 22.37∗∗∗ .19 PHNs ecognize child mal ea men based on Child- ela ed isk ac o s 88 (46%) 105 (54%) 25 (6%) 413 (94%) 114.99∗∗∗ .48 Pa en s- ela ed isk ac o s 58 (30%) 135 (70%) 21 (5%) 418 (95%) 78.26∗∗∗ .35 Family- ela ed isk ac o s 62 (32%) 131 (68%) 28 (6%) 411 (94%) 72.77∗∗∗ .34 The child’s beha io 117 (61%) 76 (39%) 140 (32%) 299 (68%) 45.87∗∗∗ .27 The pa en s’ beha io 130 (67%) 63 (33%) 131 (30%) 308 (70%) 77.84∗∗∗ .35 PHNs ecognize physical signs su icien ly well 88 (46%) 105 (54%) 73 (17%) 366 (83%) 59.25∗∗∗ .31 PHNs ecognize men al signs su icien ly well 120 (62%) 73 (38%) 111 (25%) 327 (75%) 78.32∗∗∗ .35 Es ima e signi icance: ∗∗∗𝑃< 0.001. In Japan, he same ques ionnai e ansla ed in o Japanese wasusedin hesu ey.Japanesepa icipan swe easked o a e hei ag eemen wi h he s a emen s using a 4- poin Like scale anging om 1 ( o ally disag ee) o 4 ( o ally ag ee). A ques ionnai e using 4-poin Like scale is widely used in Japan. A scale which had wide ange o choices was di icul o answe and unsui able o Japanese pa icipan s. The e o e 4-poin Like scale was adap ed o he Japanese ques ionnai e ins ead o 6-poin scale. One i em abou in e en ion in child mal ea men was excluded om heJapaneseques ionnai ebecausei wasdi icul oanswe in Japanese. 2.3. Da a Analysis. To make he g oups as compa able as possible, da a om PHNs wo king in ma e ni y, amily planning, o child clinics in Finland (𝑛 = 193)andda a om Japanese pa icipan s who wo ked wi h p egnan women, child en, and hei amilies (𝑛 = 440)we eused o he analysis. The answe s o each i em on he ques ionnai e we e classed as ei he “disag ee” (answe s o 1–3 poin s in Finland and 1-2 poin s in Japan) o “ag ee” (answe s o 4–6 poin s in Finland and 3-4 poin in Japan). Using chi-squa e es s, we examined whe he he e we e signi ican di e ences be ween Finnish and Japanese pa icipan s. S a is ical analyses we e conduc ed using SPSS. 3. Resul s 3.1. Demog aphic Cha ac e is ics. The demog aphic cha ac- e is ics o he pa icipan s a e shown in Table 1. Mos pa ic- ipan s we e emale in Finland and Japan. App oxima ely 80% o Finnish pa icipan s knew abou he guidelines; howe e , only 53.9% o hem had ead hem. On he o he hand, abou 95% o Japanese pa icipan s knew abou he guidelines and 88% o hem had ead hem. The e we e signi ican di e ences be ween hese answe s om Finnish and Japanese PHNs (𝑃 < 0.001). 3.2. Iden i ica ion o Child Mal ea men . On all o he i ems ega ding he iden i ica ion o child mal ea men , he pe cen age o Japanese PHNs wi h “ag ee” answe s was signi ican ly highe han Finnish PHNs (Table 2). Mo e han 90% o Japanese pa icipan s esponded ha hey ecognized isk ac o s o child mal ea men ela ed o child en, pa en s, and amilies. Finnish esponden s ag eed ha hey ecognized child mal ea men based on pa en s- ela ed isk ac o s and amily- ela ed isk ac o s mode a ely well, al hough mo e han 60% o esponden s p o ided “disag ee” answe s on h ee i ems; PHNs ecognized child mal ea men basedon hechild’sbeha io and hepa - en s’ beha io , and hey ecognized men al signs su icien ly well. 4Nu sing Resea ch and P ac ice Table 3: In e en ion o suppo child en and hei amilies. Va iables Finland (𝑛 = 193)Japan(𝑛 = 440)𝜒2(1) Φ Disag ee Ag ee Disag ee Ag ee PHNs discuss su icien ly well wi h amilies Risk ac o s in amilies 54 (28%) 139 (72%) 203 (47%) 233 (53%) 19.13∗∗∗ −.17 The child’s ca e 35 (18%) 158 (82%) 140 (32%) 297 (68%) 12.90∗∗∗ −.14 P oblems in he couple's ela ionship 70 (36%) 123 (64%) 258 (59%) 179 (41%) 27.81∗∗∗ −.21 P oblems in hei daily li e 17 (9%) 176 (91%) 132 (30%) 304 (70%) 34.10∗∗∗ −.23 The child’s de elopmen 21 (11%) 172 (89%) 92 (21%) 345 (79%) 9.41∗∗ −.12 P oblems in he child’s de elopmen 22 (11%) 171 (89%) 93 (21%) 343 (79%) 8.83∗∗ −.12 PHNs ad ise pa en s su icien ly well o Seek help when needed 9 (5%) 184 (95%) 117 (27%) 319 (73%) 41.05∗∗∗ −.26 Deal well wi h he child’s an ums 22 (11%) 171 (89%) 112 (26%) 324 (74%) 16.29∗∗∗ −.16 Ac well when he child does no mee pa en s’ expec a ions 31 (16%) 162 (84%) 148 (34%) 289 (66%) 20.55∗∗∗ −.18 Ac well when he child has special needs o illness 52 (27%) 141 (73%) 143 (33%) 293 (67%) 2.14NS −.06 Ac well when he child c ies 26 (13%) 167 (87%) 112 (26%) 323 (74%) 11.75∗∗ −.14 Discuss hei consis en nu u e 35 (18%) 158 (82%) 135 (31%) 300 (69%) 11.27∗∗ −.13 Es ima e signi icance: NS = no signi ican ; ∗∗𝑃<0.01;∗∗∗𝑃< 0.001. Table 4: In e en ion when suspec ing child mal ea men . Va iables Finland (𝑛 = 193)Japan(𝑛 = 440)𝜒2(1) Φ Disag ee Ag ee Disag ee Ag ee When suspec ing child mal ea men PHNs Ask abou i di ec ly 48 (25%) 145 (75%) 247 (57%) 189 (57%) 54.26∗∗∗ −.29 Always make a child wel a e no i ica ion 16 (8%) 177 (92%) 133 (31%) 303 (69%) 36.52∗∗∗ −.24 Help he mal ea ed child su icien ly well 86 (45%) 107 (55%) 265 (61%) 170 (39%) 14.51∗∗∗ −.15 Help he amily su icien ly well 88 (46%) 105 (54%) 282 (65%) 154 (35%) 20.11∗∗∗ −.18 Documen he mal ea ed child 17 (9%) 176 (91%) 41 ( 9%) 396 (91%) 0.05NS −.01 Guide o ollow-up ea men 17 (9%) 176 (91%) 176 (40%) 259 (60%) 62.91∗∗∗ −.32 Lis en o he amily unde suspicion 14 (7%) 179 (93%) 96 (22%) 341 (78%) 20.11∗∗∗ −.18 Es ima e signi icance: NS = no signi ican ; ∗∗∗𝑃< 0.001. 3.3. In e en ion in Child Mal ea men . Conce ning he in e en ion o suppo child en and hei amilies, he pe - cen age o Finnish pa icipan s who esponded wi h “ag ee” was highe han Japanese pa icipan s o all i ems. The e we e signi ican di e ences be ween answe s o Finnish and Japanese PHNs in all he i ems excep one i em ega ding suppo when he child has special needs o illness (Table 3). Fo mos i emsabou in e en ionwhensuspec ingchild mal ea men , he a e o pa icipan s who esponded wi h “ag ee” was signi ican ly highe o Finland han Japan. Mo e han 90% o Finnish PHNs esponded ha hey always made a child wel a e no i ica ion, documen ed he mal ea ed child, guided o ollow-up ea men , and lis ened o he amily unde suspicion. Mo e han 90% o Japanese PHNs esponded wi h “ag ee” o an i em abou documen a ion. The pe cen age o PHNs epo ing ha hey helped he mal ea ed child and he amily su icien ly well was less han 40% in Japan (Table 4). Rega ding he i ems on in e en ion, collabo a ion, and suppo om o he p o essionals, he pe cen age o Finnish PHNs who esponded wi h “ag ee” was signi ican ly highe han Japanese PHNs in 5 i ems: collabo a ion wi h o he p o essionals, suppo om pee s, suppo om physicians, clea ins uc ions on how o make a child wel a e no i ica ion, and wo king acco ding o he child mal ea men guidelines. The a e o Finnish PHNs who esponded wi h “ag ee” was signi ican lylowe hanJapanesePHNs o 2i emsabou suppo omsupe io sandins uc ions ohandlechild mal ea men cases. O e 90% o PHNs in bo h coun ies epo ed ha hey knew who o con ac when suspec ing child mal ea men , and he e we e no signi ican di e ences be ween he wo coun ies o his i em (Table 5). In addi ion, mo e han 80% o PHNs in Finland and Japan epo ed ge ing enough suppo om pee s when child mal ea men was suspec ed, and he a es we e he highes o suppo om o he p o essionals in bo h coun ies. Al hough 78% o Finnish PHNs epo ed ecei ing enough suppo om physicians, his a e was only 29% o Japanese PHNs. 3.4. Implemen a ion o Guidelines. Answe s ega ding he implemen a ion o guidelines a e shown in Table 6. The pe cen age o Finnish pa icipan s who esponded wi h Nu sing Resea ch and P ac ice 5 Table 5: In e en ion, collabo a ion, and suppo om o he p o essionals. Va iables Finland (𝑛 = 193)Japan(𝑛 = 440)𝜒2(1) Φ Disag ee Ag ee Disag ee Ag ee When suspec ing child mal ea men PHNs Collabo a e su icien ly well wi h o he p o essionals 9 (5%) 184 (95%) 103 (24%) 331 (76%) 33.11∗∗∗ −.23 Think mul i-p o essional collabo a ion wo ks well in he municipali y 73 (38%) 120 (62%) 151 (35%) 285 (65%) 0.59NS .03 Think mul i-p o essional collabo a ion wo ks well in hei o ganiza ion 46 (24%) 147 (76%) 131 (30%) 305 (70%) 2.55NS −.06 Know who o con ac 17 (9%) 176 (91%) 22 (5%) 415 (95%) 3.28NS .07 When suspec ing child mal ea men PHNs ge enough suppo om Supe io s 85 (44%) 108 (56%) 92 (21%) 345 (79%) 35.02∗∗∗ .24 Pee s 17 (9%) 176 (91%) 70 (16%) 366 (84%) 5.90∗−.10 Physicians 43 (22%) 150 (78%) 307 (71%) 128 (29%) 126.39∗∗∗ −.45 Child p o ec ion 52 (27%) 141 (73%) 139 (32%) 298 (68%) 1.50NS −.05 In he o ice/clinic PHNs ha e join ins uc ions o deal wi h child mal ea men 75 (39%) 118 (61%) 128 (29%) 309 (71%) 5.61∗.09 PHNs ha e clea ins uc ions how o make a child wel a e no i ica ion 45 (23%) 148 (77%) 179 (41%) 257 (59%) 18.36∗∗∗ −.17 I is possible o wo k acco ding o he guidelines 58 (30%) 135 (70%) 181 (42%) 250 (58%) 8.05∗∗ −.11 Es ima e signi icance: NS = no signi ican ; ∗𝑃<0.05;∗∗𝑃<0.01;∗∗∗𝑃< 0.001. Table 6: Implemen a ion o guidelines on child mal ea men . Va iables Finland (𝑛 = 193)Japan(𝑛 = 440)𝜒2(1) Φ Disag ee Ag ee Disag ee Ag ee The guidelines a e an impo an ool 20 (10%) 173 (90%) 196 (45%) 237 (55%) 71.96∗∗∗ −.34 The guidelines lead my wo k 65 (34%) 128 (66%) 223 (52%) 210 (48%) 17.07∗∗∗ −.17 The guidelines change my wo k ou ines o comply wi h he ecommenda ions 13 (7%) 180 (93%) 372 (87%) 56 (13%) 362.97∗∗∗ −.77 PHNs ha e had enough aining on he con en s o he guidelines 147 (76%) 46 (24%) 376 (87%) 57 (13%) 11.06∗∗ −.13 PHNs ha e amilia ized hemsel es wi h he con en s o he guidelines 96 (50%) 97 (50%) 355 (82%) 78 (18%) 68.92∗∗∗ −.33 PHNs discuss he con en s o he guidelines in he o ice 144 (75%) 49 (25%) 373 (86%) 60 (14%) 12.35∗∗∗ −.14 PHNs suppo each o he o ac in acco dance wi h he guidelines in he o ice 90 (47%) 103 (53%) 321 (74%) 112 (26%) 44.78∗∗∗ −.27 The e a e su icien esou ces o implemen he guidelines in he o ice 110 (57%) 83 (43%) 394 (91%) 38 (9%) 100.00∗∗∗ −.40 Es ima e signi icance: ∗∗𝑃<0.01;∗∗∗𝑃< 0.001. “ag ee” was signi ican ly highe han Japanese pa icipan s o all i ems ega ding he implemen a ion o guidelines. Al hough mo e han 40% o Finnish PHNs had no ead he guidelines, 90% o hem epo ed ha he guidelines we e an impo an ool. Al hough 90% o PHNs had ead he guidelines in Japan, only 55% o hem ecognized hem as an impo an ool. The pe cen age o Japanese esponden s who epo ed ha ing amilia ized hemsel es wi h he con en s o he guidelines (18%) was signi ican ly lowe han Finnish esponden s (50%). Da a om he PHNs in each coun y we e di ided in o wo g oups acco ding o he answe gi en o he i em on ha ing amilia ized hemsel es wi h he con en s o he guidelines. PHNs’ answe s o he 8 i ems in he iden i ica ion sec ion and he 31 i ems in he in e en ion sec ion we e analyzed using a chi-squa e es o explo e he di e ences be ween he answe s om PHNs in he wo g oups. The esul so hecompa ison,o heJapanese esponden swho we e amilia wi h he con en s o he guideline wi h hose who we e no , showed signi ican di e ences in he esponses 6Nu sing Resea ch and P ac ice o7o heiden i ica ioni emsand27o hein e en ioni ems ( he o me g oup had a highe pe cen age o PHNs who esponded wi h “ag ee”). Likewise, signi ican di e ences we e obse ed in he Finnish esponden s’ answe s o 4 o he iden i ica ion i ems and 12 o he in e en ion i ems, when compa ing hose who we e amilia wi h he con en s o he guideline wi h hose who we e no . Thus, he pe cen age o pa icipan s who esponded wi h “ag ee” was signi ican ly highe in he g oup o PHNs who we e amilia wi h he con en s o he guideline, compa ed wi h he g oup o PHNs who we e no . 4. Discussion 4.1. Iden i ica ion and In e en ion in Child Mal ea men . The cu en su ey was conduc ed o in es iga e PHNs’ knowledge and skills ega ding child mal ea men p e- en ion and da a om Finnish and Japanese PHNs we e compa ed. The esul s indica e ha Japanese PHNs iden i y child mal ea men be e han hei Finnish coun e pa s, whileFinnishPHNsin e eneinchildmal ea men be e han Japanese PHNs. This may be due o he di e ences in he public heal h ca e sys ems o he wo coun ies. In Finland, as a No dic coun y, child heal h ca e se ices a e p o ided o all child en and hei amilies, who can access hese se ices 16 imes be o e en e ing school. The se ices a e ee o cha ge and hei a e o use is ex emely high [16]. The e o e, PHNs in Finland can suppo all child en and hei amilies based on hei needs. In Japan he e is a public heal h ca e sys em, bu he equencyo useo heuni e salchildheal hca e se ices is ex emely lowe han in Finland. I is he e o e an impo an ole o Japanese PHNs o iden i y mal ea ed child en and o connec hem wi h addi ional heal h ca e and wel a e se ices, as he oppo uni ies o PHNs o mee child en and hei amilies a e limi ed [17]. I seems ha his sys em migh p omo e Japanese PHNs skills o iden i y child mal ea men . Japanese PHNs e alua ed hei knowledge and skills o iden i ying child mal ea men mo e posi i ely han o in e ening in child mal ea men . This esul is simila o ha o an ea lie s udy conduc ed on pedia ic hospi al s a [18].Theknowledgeandskillso FinnishPHNs oin e ene in child mal ea men we e highe han hose epo ed in ha esea ch [18]. I has al eady been epo ed ha Finnish PHNs who had pa icipa ed in aining on child mal ea men in e ened well in child mal ea men [15]. In Finland, PHNs’ aining was p omo ed in he con ex o he Ea ly Eu opean P omo ion P ojec (EEPP). The EEPP was conduc ed in i e Eu opean coun ies including Finland du ing he i s hal o he 2000s, wi h he aim o p omo ing pa en -in an ela- ionships and hence in an men al heal h and o p e en ing emo ional and beha io al p oblems by p o iding a uni e sal se ice a ailable o all amilies wi h small child en. T aining in he EEPP was in ended o p omo e PHNs p e en i e wo k o young child en and hei amilies [19–21]. I seems ha his aining migh ha e inc eased Finnish PHNs’ knowledge andskills oin e eneinchildmal ea men .The e o e, i is sugges ed ha e ec i e PHNs’ aining, such as he EEPP aining, is also needed o Japanese PHNs o inc ease hei knowledge and skills ega ding child mal ea men in e en ion. 4.2. Implemen a ion o Guidelines on Child Mal ea men . Al hough mos Japanese PHNs had ead he guidelines on child mal ea men , mos o hem did no ag ee wi h he ques ionnai e s a emen s ega ding he implemen a ion o he guidelines. This inding shows ha , ega dless o he guidelines, he e a e some issues in he p ocess o hei in oduc ion and implemen a ion. In addi ion, he Japanese PHNs who we e amilia wi h he con en s o he guidelines iden i ied and in e ened in child mal ea men be e han he PHNs who did no . These esul s sugges ha de eloping s a egies o u ilizing he guidelines a e equi ed in o de o inc ease PHNs’ knowledge and skills o iden i ying and in e ening in child mal ea men in Japan. In his s udy, Finnish PHNs who amilia ized hemsel es wi h he con en s o he guidelines deal wi h child mal- ea men be e han PHNs who did no . The impo ance o guidelines has been shown in ea lie esea ch ega d- ing child mal ea men [22]. The e o e, i is sugges ed ha unde s anding he con en s o guidelines is also impo an in o de o inc ease he knowledge and skills o iden i ying and in e ening in child mal ea men in Finland as well as in Japan. 4.3. Limi a ions o This S udy. The knowledge and skills o PHNs o iden i y and in e ene in child mal ea men we e assessed using a sel - epo ques ionnai e in his s udy. I is conside ed ha e alua ing PHNs’ knowledge and skills accu a ely o p e en child mal ea men in his way is di icul and his is a limi a ion o his s udy. The su ey was conduc ed using ques ionnai es, in he o m o a web-based su ey in Finland and a mail su ey in Japan. The di e ence in he su ey me hods may ha e con- ibu ed o he di e ences in he answe s o he esponden s be ween he wo coun ies. Da a om Finnish and Japanese PNHs we e compa ed and discussed in his s udy. Howe e , he ac o s associa ed wi h e ec i e nu sing in e en ions we e no conside ed in de ail. Fu he discussion abou hese ac o s is needed in o de o p omo e PHNs’ skills wi h espec o child mal ea men in e en ion. 5. Conclusion The cu en s udy ound ha Japanese PHNs iden i ied child mal ea men be e han Finnish PHNs, and Finnish PHNs in e ened in child mal ea men be e han hei Japanese coun e pa s. I was shown ha e ec i e aining on child mal ea men is needed o inc ease PHNs’ knowledge and skills o iden i ying and in e ening in child mal ea men . In addi ion, u ilizing guidelines is also equi ed in o de o e ec i ely in e ene in child mal ea men in Finland and Japan. Nu sing Resea ch and P ac ice 7 Compe ing In e es s The au ho s ha e no con lic o in e es s di ec ly ele an o he con en o his a icle. Acknowledgmen s The au ho s wish o acknowledge he con ibu ion o Finnish andJapanesePHNswhopa icipa edin hiss udy, heboa d o he Public Heal h Nu se Union in Finland, he heal h ca e cen e s ha ex ended hei coope a ion o his s udy in Japan, and he s a is ical assis ance o D . Takahide Omo i. Re e ences [1] UNICEFO iceo Resea ch,“Childwell-beingin ichcoun ies, Compa ing Japan,” UNICEF O ice o Resea ch, Decembe 2013, h p://www.unice -i c.o g/publica ions/709. [2] B. Daniel, J. Taylo , and J. Sco , “Recogni ion o neglec and ea ly esponse: o e iew o a sys ema ic e iew o he li e a u e,” Child and Family Social Wo k, ol.15,no.2,pp.248–257,2010. [3] Heal h, Labou , and Wel a e S a is ics Associa ion, “T ends in public wel a e and nu sing ca e,” Jou nal o Heal h and Wel a e S a is ics, ol.62,no.10,pp.100–106,2015. [4] Na ional Ins i u e o Heal h and Wel a e, “Child wel a e 2013,” Na ional Ins i u e o Heal h and Wel a e, No embe 2014, h ps://www. hl. i/en/web/ hl i-en/s a is ics/s a is ics-by- opic/ social-se ices-child en-adolescen s-and- amilies/childwel a e. [5]C.A.Fa e ,S.L.C aw o d,andT.Combs-O me,“Se ices o child mal ea men : challenges o esea ch and p ac ice,” Child en and You h Se ices Re iew, ol.21,no.2,pp.89–109, 1999. [6] C. Heim, M. Shuga , W. E. C aighead, and C. B. Neme o , “Neu obiological and psychia ic consequences o child abuse and neglec ,” De elopmen al Psychobiology, ol.52,no.7,pp. 671–690, 2010. [7] M. H. Teiche , “Sca s ha won ’s heal: he neu obiology o child abuse,” Scien i ic Ame ican, ol.286,no.3,pp.68–75,2002. [8] R. F. Anda, V. J. Feli i, J. D. B emne e al., “The endu ing e ec s o abuse and ela ed ad e se expe iences in childhood: a con e gence o e idence om neu obiology and epidemiology,” Eu opean A chi es o Psychia y and Clinical Neu oscience, ol. 256, no. 3, pp. 174–186, 2006. [9] Wo ld Heal h O ganiza ion, “Fac shee on child mal ea men ,” WHO Media cen e, Decembe 2014, h p://www.who.in / mediacen e/ ac shee s/ s150/en/. [10] Wo ld Heal h O ganiza ion and In e na ional Socie y o P e- en ion o Child Abuse and Neglec , “P e en ing child mal- ea men : a guide o aking ac ion and gene a ing e idence, Chap e 1. The na u e and consequences o child mal ea men ,” WHO, pp. 7–16, 2006, h p://www.who.in / iolence inju y p e en ion/publica ions/ iolence/child mal ea men /en/. [11] E. Paa ilainen and A. Flinck, Iden i ica ion o and In e - en ion in Child Mal ea men : A Clinical P ac ice Guide- line, Nu sing Resea ch Founda ion, Helsinki, Finland, 2008, h p://www.ho us. i. [12] E. Paa ilainen and A. Flinck, E icien Me hods o Iden i ying Child Mal ea men in Social and Heal h Ca e, Upda ed Ve sion, Nu sing Resea ch Founda ion, Helsinki, Finland, 2015, h p://www.ho us. i/sys em/ iles/SUOSITUS las en kal oinkoh elu ENGLANTI%20%282%29.pd . [13] Minis y o Heal h, Labou , and Wel a e, “Guideline o child mal ea men ,” Minis y o Heal h, Labou and Wel a e, 2013, h p://www.mhlw.go.jp/seisakuni sui e/bunya/kodomo/kodomo kosoda e/d /130823-01.h ml. [14] C. Keane and R. Chapman, “E alua ing nu ses’ knowledge and skills in he de ec ion o child abuse in he eme gency depa men ,” In e na ional Eme gency Nu sing, ol.16,no.1,pp. 5–13, 2008. [15] E. Paa ilainen, A. Flinck, and L. Leh om¨ aki, “How public heal h nu ses iden i y and in e ene in child mal ea men based on he na ional clinical guideline,” Nu sing Resea ch and P ac ice, ol.2014,A icleID425460,7pages,2014. [16] Minis y o Social A ai s and Heal h, Finland’s Family Policy, Minis y o Social A ai s and Heal h, 2016. [17] K. Suzuki, M. Okami su, T. Hi ose, and N. Okubo, “Pa en ing suppo o p e en ing child abuse in Finland: ocusing on nu ses’ ole,” The Jou nal o Child Heal h, ol.74,no.3,pp.447– 452, 2015. [18] S. Glasse and W. Chen, “Su ey o a pedia ic hospi al s a ega ding cases o suspec ed child abuse and neglec ,” Is ael Medical Associa ion Jou nal, ol.8,no.3,pp.179–183,2006. [19] H. Da is and J. Tsian is, “P omo ing child en’s men al heal h: he Eu opean Ea ly P omo ion P ojec (EEPP),” In e na ional Jou nalo Men alHeal hP omo ion, ol.7,no.1,pp.4–16,2005. [20] E. Layiou-Lignos, J. Tsian is, H. Da is e al., “T aining o p ima y heal h ca e p ac i ione s,” In e na ional Jou nal o Men al Heal h P omo ion, ol.7,no.1,pp.41–53,2005. [21] K. Papadopoulou, C. Dimi akaki, H. Da is e al., “The e ec s o he Eu opean Ea ly P omo ion P ojec aining on p i- ma y heal h ca e p o essionals,” In e na ional Jou nal o Men al Heal h P omo ion, ol.7,no.1,pp.54–62,2005. [22] D. A. Wol e and C. McIsaac, “Dis inguishing be ween poo / dys unc ional pa en ing and child emo ional mal ea men ,” Child Abuse and Neglec , ol.35,no.10,pp.802–813,2011. 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