Karyn E Alexander

Barriers and enablers to delivery of the Healthy Kids Check: an analysis informed by the Theoretical Domains Framework and COM-B model

BackgroundMore than a fifth of Australian children arrive at school developmentally vulnerable. To counteract this, the Healthy Kids Check (HKC), a one-off health assessment aimed at preschool children, was introduced in 2008 into Australian general practice. Delivery of services has, however, remained low. The Theoretical Domains Framework, which provides a method to understand behaviours theoretically, can be condensed into three core components: capability, opportunity and motivation, and the COM-B model. Utilising this system, this study aimed to determine the barriers and enablers to delivery of the HKC, to inform the design of an intervention to promote provision of HKC services in Australian general practice.MethodsData from 6 focus group discussions with 40 practitioners from general practices in socio-culturally diverse areas of Melbourne, Victoria, were analysed using thematic analysis.ResultsMany practitioners expressed uncertainty regarding their capabilities and the practicalities of delivering HKCs, but in some cases HKCs had acted as a catalyst for professional development. Key connections between immunisation services and delivery of HKCs prompted practices to have systems of recall and reminder in place. Standardisation of methods for developmental assessment and streamlined referral pathways affected practitioners’ confidence and motivation to perform HKCs.ConclusionApplication of a systematic framework effectively demonstrated how a number of behaviours could be targeted to increase delivery of HKCs. Interventions need to target practice systems, the support of office staff and referral options, as well as practitioners’ training. Many behavioural changes could be applied through a single intervention programme delivered by the primary healthcare organisations charged with local healthcare needs (Medicare Locals) providing vital links between general practice, community and the health of young children.

‘Can they really identify mental health problems at the age of three?’ Parent and practitioner views about screening young children’s social and emotional development

Objective: To report the views of parents, general practitioners and practice nurses on the proposed changes to incorporate social and emotional health checks of three-year-olds into the Healthy Kids Check, a one-off pre-school health assessment delivered through general practice. Method: Participants were recruited from three socio-culturally diverse urban areas of Melbourne for a qualitative study involving 28 parent interviews and six focus groups with a total of 40 practitioners. Participants discussed child social and emotional development, health-seeking and preventive health care for young children. Transcripts were thematically analysed. Results: Common themes showed: (i) Although both parents and practitioners were receptive to the idea of social and emotional screening, parents had limited knowledge about mental health issues for young children and the need for early intervention. (ii) All groups questioned the current capabilities of practice staff to identify problems, and practitioners expressed a need for further training and tools. (iii) Parents and practitioners cautioned that screening may increase parental anxiety and lead to unnecessary referrals. Practitioners countered this with examples of cases not recognised by parents. (iv) Participants questioned the value of earlier identification of problems without effective and accessible therapeutic pathways. Conclusions: For programmes to be effective, parents need to be reminded of the benefits of early intervention and encouraged to attend preventive health appointments. Practitioners require further training and tools specific to the primary care setting. Further investment in specialist and allied health services is considered essential to assure better outcomes for young children’s mental health following screening and referral. Practitioners welcome a more collaborative relationship with other professionals (e.g. early educators) in assessing children’s social and emotional development. General practice has the capability but requires a more structured approach to assessing the social and emotional health of young children.

Parents' decision making and access to preventive healthcare for young children: applying Andersen's Model

Implementing preventive health care for young children provides the best chance of improving health and changing a childs life course. In Australia, despite government support for preventive health care, uptake of preventive services for young children is low. Using Andersens behavioural model of health‐care utilization, we aimed to understand how parents conceptualized their childrens preventive health care and how this impacted on access to preventive health‐care services.

Preventive healthcare for young children: A systematic review of interventions in primary care

High rates of preventable health problems amongst children in economically developed countries have prompted governments to seek pathways for early intervention. We systematically reviewed the literature to discover what primary care-targeted interventions increased preventive healthcare (e.g. review child development, growth, vision screening, social-emotional health) for preschool children, excluding vaccinations. MEDLINE, EMBASE, CINAHL, and Cochrane databases were searched for published intervention studies, between years 2000 and 2014, which reflected preventive health activities for preschool children, delivered by health practitioners. Analysis included an assessment of study quality and the primary outcome measures employed. Of the 743 titles retrieved, 29 individual studies were selected, all originating from the United States. Twenty-four studies employed complex, multifaceted interventions and only two were rated high quality. Twelve studies addressed childhood overweight and 11 targeted general health and development. Most interventions reported outcomes that increased rates of screening, recording and recognition of health risks. Only six studies followed up children post-intervention, noting low referral rates by health practitioners and poor follow-through by parents and no study demonstrated clear health benefits for children. Preliminary evidence suggests that multi-component interventions, that combine training of health practitioners and office staff with modification of the physical environment and/or practice support, may be more effective than single component interventions. Quality Improvement interventions have been extensively replicated but their success may have relied on factors beyond the confines of individual or practice-led behaviour. This research reinforces the need for high quality studies of pediatric health assessments with the inclusion of clinical end-points.

Scrapping the Healthy Kids Check: a lost opportunity

The HKC was introduced into general practice in 2008, policy that reflected advances in neuroscience (eg, the evolution of brain architecture, critical time points for development and the benefits of early intervention) and significant health shifts towards prevention. Uptake of the health assessment was slow (16% of eligible children in its first year) and beset by argument about a lack of evidence for some of its mandatory components and by scaremongering about labelling 3-year-olds with mental health diagnoses. In the ensuing negative debate, it was easy to forget major barriers to preventive health care before the HKC: sick child consultations, poor remuneration, lack of time, resources and training, and the ever-increasing demands of chronic disease management in an ageing population. Nevertheless, over the next 7 years, uptake of the HKC climbed to 50%, as practice nurses were upskilled and parents were incentivised by tax benefits. Our research with practitioners, 3 years after its introduction, indicated that in some circumstances, the HKC had acted as a catalyst for general practitioner and practice nurse (PN) role development, and in some cases promoted an entire practice shift towards preventive health care for young children. The important contribution made by PNs, in particular, has been overlooked by the government in its statement that GPs can continue to provide health assessments as part of Medicare-funded general GP attendance items, because PNs are excluded from those services.

Identified health concerns and changes in management resulting from the Healthy Kids Check in two Queensland practices.

Objectives: To determine how many children had health problems identified by the Healthy Kids Check (HKC) and whether this resulted in changes to clinical management.

The challenges of trying to increase preventive healthcare for children in general practice: results of a feasibility study

BackgroundIn Australia, general practice, the linchpin for delivery of preventive health care to large segments of the population, provides child-immunisation and preventive health alongside government services. Despite this, less than half of eligible children complete a Healthy Kids Check (HKC), a preschool preventative health assessment available since 2008. Using a rigorous theoretical process, the barriers that affected delivery and reduced general practitioner and practice nurse motivation to provide HKCs, were addressed. The resulting multifaceted intervention, aimed at increasing the proportion of children receiving evidence informed HKCs from general practice, was piloted to inform a future randomised controlled trial.MethodsThe intervention was piloted in a before and after study at three sites located southeast of Melbourne, between February and October 2014. The HKC-intervention involved: 1) Delivery of training modules that motivated reception and clinical staff by delivering key messages about local prevalence rates and the “Core Story of Child Development” 2) Practical advice to prepare clinics for specific HKC-examinations 3) Workflow advice regarding systems that included all staff in the HKC process, and 4) Provision of a “Community Resources Folder” that enabled decision making and referrals. A major component of the intervention incorporated the promotion of structured developmental screening by the practice team using Parents’ Evaluation of Developmental Status.ResultsTwenty of 22 practitioners and practice managers agreed to join the study. Post-training questionnaires showed participants had developed their skills working with young children as a result of the training and all respondents believed they had successfully implemented standardised HKC services. Post intervention proportions of children completing HKCs significantly increased in two of the practices and quality improvements in HKC-processes were recorded across all three sites.ConclusionThis pilot study confirmed the feasibility of delivering a multi-faceted intervention to increase HKCs from general practice and demonstrated that significant quality improvements could be made. Future studies need to extend the intervention to other states and research the health outcomes of HKCs.