Small beginnings: A systematic review of interventions to improve the delivery of preventive healthcare for young children in general practice

Problem

In developed countries like Australia, more than a quarter of preschool children suffer health, developmental or behavioural problems that progressively impact their lives. Twelve percent of GP visits are with children and prevention is a routine aspect of GP care, but it is rarely incorporated into child health consultations. Consequently, problems remain unidentified and children miss out on opportunities for early intervention. There is little research on interventions that increase the delivery of child preventive health care, despite appropriate tools becoming available for use in general practice.

Approach

This was a systematic review of intervention studies in primary care, using MEDLINE, EMBASE, CINAHL and Cochrane databases (2000-2014), that included preventive health or any domain of child development, nutrition, exercise or growth (inclusive of children age 2-5 years), published in English. Interventions in low or middle income countries, or that targeted professionals-in-training or parents were excluded. Risk of bias and quality of studies was rated by two researchers using the “Effective Public Health Practice Project Quality Assessment Tool”. Primary outcomes were assessed using a logic model of primary health care.

Findings

From 743 titles, 30 studies were identified, all from the United States (US). Participant numbers ranged from one to 2873, working across one to 164 sites, serving diverse communities. Seventeen of 30 studies were before-and-after studies and only one of five randomised controlled trials was of high quality. Twenty-four studies targeted either general development or childhood overweight. Three studies focussed on social and emotional health, two, vision screening and one, preventive dental health. Many studies (n=13) involved practice teams delivering multi-faceted, quality-improvement style interventions. Ninety per cent, or more, of interventions modified the practice environment and/or trained staff. Except for two studies, all encounters were in the context of “Well-Child Care”. Only three studies tracked children following intervention and no study reported improvements in clinical outcomes as the primary outcome measure. One trial of nurse home- visiting and structured practice change, recorded increased parent-satisfaction, a designated “desired” outcome, and 12 studies improved “intermediate outcomes” (e.g. earlier detection, treatment and referral of problems). The remainder enhanced various mechanisms or attributes of primary care (e.g. capacity, efficiency, physician learning). The heterogeneity of studies precluded meta-analysis.

Consequences

This is the first systematic review of preventive health interventions targeting professionals working with preschool children. In the context of well children attending primary care practices in the US, multi-faceted quality-improvement style interventions have attained modest improvements in service delivery and have gone on to be widely replicated. There is an urgent need to test interventions during routine GP-consultations. Support for interventions which change practice will likely require evidence of improved clinical outcomes for children.