How do general practices respond to a pandemic? Protocol for a prospective qualitative study of six Australian practices.

INTRODUCTION: The COVID-19 pandemic has transformed healthcare systems worldwide. Primary care providers have been at the forefront of the pandemic response and have needed to rapidly adjust processes and routines around service delivery. The pandemic provides a unique opportunity to understand how general practices prepare for and respond to public health emergencies. We will follow a range of general practices to characterise the changes to, and factors influencing, modifications to clinical and organisational routines within Australian general practices amidst the COVID-19 pandemic. METHODS AND ANALYSIS: This is a prospective case study of multiple general practices using a participatory approach for design, data collection and analysis. The study is informed by the sociological concept of routines and will be set in six general practices in Melbourne, Australia during the 2020-2021 COVID-19 pandemic. General practitioners associated with the Monash University Department of General Practice will act as investigators who will shape the project and contribute to the data collection and analysis. The data will include investigator diaries, an observation template and interviews with practice staff and investigators. Data will first be analysed by two external researchers using a constant comparative approach and then later refined at regular investigator meetings. Cross-case analysis will explain the implementation, uptake and sustainability of routine changes that followed the commencement of the pandemic. ETHICS AND DISSEMINATION: Ethics approval was granted by Monash University (23950) Human Research Ethics Committees. Practice reports will be made available to all participating practices both during the data analysis process and at the end of the study. Further dissemination will occur via publications and presentations to practice staff and medical practitioners.

Improving assessment of child development: Results of a quality improvement intervention in general practice.

AIMS: Parents' Evaluation of Developmental Status (PEDS) is a validated tool used to assess child development that has not previously been tested in Australian general practice. We examined the effect of a Quality-Improvement intervention in a single general practice in Melbourne, Australia, that aimed to use this tool to improve the documented assessment of child developmental surveillance during vaccination visits. METHODS: Mixed methods incorporated audits of clinical records of children aged 1-5 years, before and after intervention, written questionnaires and a focus group (informed by the theoretical domains framework and Capability, Opportunity, Motivation-Behaviour (COM-B model)) with clinical and non-clinical staff. RESULTS: After 6 months, developmental surveillance more than doubled and was documented in more than one in three visits (34.1%). Almost one in five (18.6%) vaccination visits included the PEDS tool. Overall, the tool was positively received with staff expressing high levels of comfort asking parents to complete it (92.8%), increasing development of professional skills (71.4% staff) and confidence (55% clinicians) detecting developmental delays. Thematic analysis of the focus group transcript revealed underlying barriers arising from the practice environment, staff capabilities and motivation. CONCLUSIONS: In a whole of practice Quality-Improvement intervention that applied PEDS training and implementation, including the receptionist in the medical team more than doubled documented rates of child developmental surveillance during vaccination visits. Solutions to underlying barriers could be incorporated into a revised training module. Future studies need to test the tool in more methodologically robust studies that include analysis of the outcomes of developmental surveillance.

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.

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

BACKGROUND: In 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. METHODS: The 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. RESULTS: Twenty 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. CONCLUSION: This 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.

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

BACKGROUND AND OBJECTIVE: Implementing preventive health care for young children provides the best chance of improving health and changing a child's life course. In Australia, despite government support for preventive health care, uptake of preventive services for young children is low. Using Andersen's behavioural model of health-care utilization, we aimed to understand how parents conceptualized their children's preventive health care and how this impacted on access to preventive health-care services. DESIGN: Semi-structured telephone interviews conducted between May and July 2011. SETTING AND PARTICIPANTS: Twenty-eight parents of children aged 3-5 years from three diverse socio-economic areas of Melbourne, Australia. RESULTS: Thematic analysis showed parents' access to child preventive health care was determined by birth order of their child, cultural health beliefs, personal health practices, relationship with the health provider and the costs associated with health services. Parents with more than one child placed their own experience ahead of professional expertise, and their younger children were less likely to complete routine preventive health checks. Concerns around developmental delays required validation through family, friends and childcare organizations before presentation to health services. CONCLUSIONS: To improve child preventive health requires increased flexibility of services, strengthening of inter-professional relationships and enhancement of parents' knowledge about the importance of preventive health in early childhood. Policies that encourage continuity of care and remove point of service costs will further reduce barriers to preventive care for young children. Recent reforms in Australia's primary health care and the expansion of child preventive health checks into general practice present a timely opportunity for this to occur.

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

BACKGROUND: More 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. METHODS: Data from 6 focus group discussions with 40 practitioners from general practices in socio-culturally diverse areas of Melbourne, Victoria, were analysed using thematic analysis. RESULTS: Many 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. CONCLUSION: Application 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.

The Healthy Kids Check - is it evidence-based?

OBJECTIVE: To assess whether the components of the Healthy Kids Check (HKC), a preschool screening check recently added to the Australian Government's Enhanced Primary Care Program, are supported by evidence-based guidelines or reviews. DATA SOURCES: Guideline and MEDLINE databases were searched for guidelines and systematic reviews published between 2000 and 2008 that were relevant to screening, prevention or well-child care in primary health care, and including children of preschool age. Search subjects reflected the HKC components: growth, weight, obesity, vision, hearing, oral health, enuresis, encopresis, allergic disease and food allergies. STUDY SELECTION: 34 relevant guidelines or reviews were retrieved. DATA EXTRACTION: For each component of the HKC, guidelines addressing the presumed rationale for screening, or the test or tool required to implement it, were reviewed. Relevant evidence-based and consensus-based guideline recommendations were assessed as either supporting or opposing components of the HKC, or stating that the evidence was insufficient to recommend screening of preschool children. DATA SYNTHESIS: Guidelines were often inconsistent in their recommendations. Most of the components of the HKC (eg, screening for chronic otitis media and questioning about toilet habits) are not supported by evidence-based guidelines relevant to the primary care setting, though a number of consensus-based guidelines are supportive. CONCLUSIONS: There is currently a dearth of evidence relevant to child health surveillance in primary care. The components of the HKC could be refined to better reflect evidence-based guidelines that target health monitoring of preschool children.