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Thefirst18monthsParentalchoicesregardingtheirinfantshealthcareneeds.pdf
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Abstract In Australia, community child health services provide comprehensive primary health care to infants, children and their families with the goal of optimising infant and family health in the first five years of life. Child health surveillance clinics are one important aspect of this service which provide infant growth and development monitoring, and parent support.
This prospective cohort study investigated families (n=72) attending an open-access clinic with a newborn infant over an 18-month period. Six structured questionnaires were administered. Data were collected in areas of service usage and attendance patterns, parent information and support, infant nutrition, growth and development, parental coping and wellbeing, and health promotion.
Key findings were that parents had varied patterns of attendance within the open-access clinic (OAC), based on their immediate needs, and that these changed with the age of the infant. Important data were also collected regarding patterns of usage for other child health service providers, such as access to general practitioners (GPs) and child health nurses (CHNs) for routine well-baby assessments. Potentially, parents could be provided with clearer service pathways prior to discharge from maternity units, informing them about which services are helpful for specific infant health issues. There is also potential for increased collaboration between community child health services and GP services, subsequently decreasing the burden on the health care system, and ensuring consistency of health care information provided to parents between different providers.
Although this study investigated a context-specific group, it provides important information in key areas, such as why parents introduce solids early, where and why they are attending for their infants’ developmental assessments and health care needs at different stages from birth to 18 months. The information from this study will help children’s primary health care services to efficiently and effectively plan services to meet parental and infant health needs in Australia.
Keywords Child health surveillance; child health nurse; infant; parent support; breastfeeding; child health; postnatal care.
The first 18 months: Parental choices regarding their infant’s health care needs Lauren Kearney * Senior Research Fellow (Maternal & Child Health), University of the Sunshine Coast/Sunshine Coast Hospital & Health Service, Locked Bag 4, Maroochydore DC, Qld 4558, Australia Email [email protected]
Paul Fulbrook Professor of Nursing – Australian Catholic University; Nursing Director – Research and Practice Development, The Prince Charles Hospital, Queensland Health
*Corresponding author
• approved 9/6/14
What is known about this topic
• There is strong evidence supporting the importance of children’s early years of life in their future development across the life span.
• Adjustment to parenting can be overwhelming and stressful, and it is essential CHNs provide accessible services to meet family needs.
• Universal child health surveillance is valuable; however, it is unknown how best to deliver this primary health care service in Australia, and which services parents are accessing and why.
What this paper adds
• Parents have varied patterns of attendance within the clinic, based on their immediate needs, and these change with the age of the infant.
• Important data were collected regarding patterns of usage for other child health service providers, such as access of GPs and CHNs for routine well-baby assessments. Potentially, parents could be provided with clearer service pathways prior to discharge from maternity units, informing them about which services are helpful for specific infant health issues.
• The results suggest there is potential for increased collaboration between community child health services and GP services, subsequently decreasing the burden on the health care system, and ensuring consistency of health care information provided to parents between different providers.
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Declarations Competing interests Neither of the authors of this paper have any competing interests which would bias the publishing of this paper.
Funding This research study and subsequent manuscript was funded through a Regional Research Grant awarded to the authors by the Royal Children’s Hospital Foundation.
Ethical approval This research study was conducted with full ethical approval of the local Human Research Ethics Committee (Protocol number 4/05N) and University Human Research Ethics Committee (Approval number Q 200 607 9).
Guarantor LK is the main author who retains responsibility for the content and publication of the paper.
Contributorship LK — main composition of the manuscript; data collection and analysis; finding funding. PF — conceptualisation of the study; study design; finding funding; manuscript editing and composition.
Acknowledgements Thank you to Dr Pratt who co-supervised Lauren Kearney’s Doctor of Philosophy study and thesis, of which this paper is a result.
Introduction In Australia, community child health services (CCHS) provide comprehensive primary health care to families aiming to optimise infant and family health in the first five years of life. Child health surveillance clinics are one important nurse-led aspect of this service, providing infant growth and development monitoring and parent support. There is strong evidence supporting the importance of children’s early years of life in their future development across the life span1-5. Early identification and intervention, in the areas of child development6, infant nutrition7,8 and parenting5 demonstrate good return, both on an individual and community level9. Yet, it is known that in developed countries many parents find the adjustment to parenting stressful and overwhelming10 and struggle with fatigue11. While CCHS aim to support families during this important time, little is known about how parents utilise and experience the service, and what direct impact nursing support has on the health and wellbeing of their family.
Universal CCHS refer to an easily accessible, free health care service available to 100% of children and families9. Recently, a greater focus has been placed on universal child and family health services12, yet there is a paucity of research available to guide how best to deliver universal services.
Traditionally, in Australia, universal child health surveillance nursing services have been offered as individual, scheduled appointment consultations with a child health nurse (CHN). However, due to the increasing volume of resource-intensive programmes now provided by CHNs (such as home visiting vulnerable families), innovative models of care delivery have been implemented in some areas. One contemporary approach to the delivery of universal child health surveillance in Queensland is via an open-access clinic (OAC). The OAC represents a contemporary approach, employing a ‘drop-in’ style, group setting, where parents attend according to their own needs and convenience, between specific hours, without an appointment. Parents and their infants are seen individually by the nurse, in an open environment, thus information is often
shared and discussed between the CHN, parent and parents waiting to be seen. If a family requires a more in-depth consultation or privacy, individual appointments are available. Referrals may be made to more specialised services, such as paediatric physiotherapy or an early intervention parenting specialist. The OAC operates concurrently with an immunisation clinic, breastfeeding clinic, and a parent education and support group.
As part of a larger evaluation project, the aim of this study was to prospectively investigate key aspects of the OAC, including service usage, infant growth and development, and parental support. This article will present and discuss the findings from this prospective cohort study. The previous phases of this evaluation study examined differences in attendance patterns and outcomes between the traditional appointment-based approach and the OAC13, and the experiences of mothers accessing and nurses working in the OAC14. The site of this study was a metropolitan centre west of the capital city in South-East Queensland, Australia. The area is predominantly of a middle-income, Caucasian, English-speaking background, with Aboriginal and Torres Strait Islander Peoples contributing to 3.8% of the population15.
Methods The study employed a prospective cohort design, using structured questionnaires administered at specific times during an 18-month follow-up period.
Setting The setting for this study was a child health surveillance clinic in South-East Queensland, Australia, in which a group-based approach (OAC) was implemented as an alternative to the traditional one-to- one appointment-based model.
Sample A convenience sample of 72 clients (parents, predominantly mothers) was recruited over a three-month period, out of a possible 180 families who accessed the service during this recruitment time. The sample size was determined by the number of parents attending the clinic during the three-month recruitment period.
Data collection Participants were followed up for a total period of 18 months. Six questionnaires were administered during this period. Data were collected in the areas of: service usage and attendance patterns; parent information and support; infant nutrition, growth and development; parental coping and wellbeing; and health promotion, specifically immunisation, sudden infant death syndrome (SIDS) awareness and oral health.
The initial questionnaire was administered face-to-face, when the infant was less than six weeks old, and subsequent questionnaires were administered via telephone interviews. The intervals between data collection were timed to coincide with the routine immunisations and developmental assessments identified in the infant’s Personal Health Record16, that is, at two, four, six, 12 and 18 months of age.
Data analysis Quantitative data were obtained from an interview schedule of structured questions with a range of given responses. Some qualitative data were obtained initially, which were analysed thematically and coded numerically to enable quantitative analysis. All data were entered into an SPSS database (Statistical Package for Social Scientists, version 15) for analysis. Significance was set at
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p<0.05. However, although inferential statistical tests were applied to the data, no statistically significant differences were found.
All aspects of the study were conducted in accordance with Australian national ethical research guidelines17 and ethical approval was given by the Human Research Ethics Committee for the health care service where the study was conducted.
Results Sample The initial cohort (n=72) consisted predominantly of females (n=64; 88%) of Australian descent (n=59; 84%). The majority (n=53; 74%) had achieved a senior high school certificate or higher, with very few (n=6; 9%) having returned to work (full- or part-time) at the time of the initial questionnaire.
CCHS information The mean average number of family visits to the OAC over the 18-month period was 10.2, ranging from 1 to 30 visits. The predominant referral source was by staff from the local maternity unit (n=39; 56%). Figure 1 identifies the main reasons participants chose the OAC in preference to other child health surveillance services. A large number of participants gave ‘other’ reasons for their attendance, of which the most common reason was that they knew that they would be able to speak with a “qualified” CHN (Figure 1).
Initially participants’ attendance was determined by their concern about their infant’s growth. The focus on growth (baby’s weight) only, as a reason, decreased significantly from the age of four months onwards, and was replaced by concerns about growth and development (Figure 2).
By the age of one month most parents (n=45; 71%) had also visited a general practitioner (GP) regarding their infant. The most common reason cited was for a ‘general check-up’ (n=35; 49%). At the two- month follow-up, of those participants who had seen their GP and CHN, 23% (n=14) identified that conflicting advice had been given. Additionally, when asked about any other differences between the GP and the CHN consultation, 10% (n=6) of participants identified that the CHN had provided more thorough and holistic information regarding their infant’s health and wellbeing than their GP.
Parental information sources Parents' key sources of child health information changed with the age of the infant (Figure 3).
Infant nutrition
At each follow-up, parents were asked about their infant’s predominant feeding method. The breastfeeding rate declined steadily over the first 12 months, and was overtaken by formula feeding at around five months of age (Figure 4).
At the two-month follow-up, when a participant identified that they were breastfeeding they were also asked how long they intended to breastfeed. A quarter stated that they intended to breastfeed for six to 12 months, and another 18% indicated their intention to breastfeed for at least 12 months. Very few participants (n=7; 9%) identified the officially recommended breastfeeding duration of at least 12 months18, as influencing their intended duration of breastfeeding, with most citing their need to return to work (n=10; 14%), as the main reason. Low breast milk supply was cited most frequently (n=7; 10%) as the main difficulty with breastfeeding.
Most families (n=54; 77%) had introduced solids by six months. At the two-month follow-up, the majority of participants (n=51; 84%) identified that they were aware of the recommendations regarding the introduction of solid/complementary food. However, whilst the majority understood that the recommendation was to introduce solids at around six months, approximately half of the cohort had already introduced solid food at the four-month follow-up. The most frequently cited reason for early introduction of solid food (at two- and four-month follow-up) was that the infant was not satisfied with breast milk or artificial formula (n=20; 28%).
At several intervals (initial interview, and six-, 12- and 18-month follow-ups) participants were asked whether they had implemented strategies to prevent childhood obesity. Providing their child with a ‘healthy diet’ was cited most frequently as the main obesity prevention strategy at both the six-month (n=15; 21%) and 18-month (n=17; 24%) follow-ups. By 18 months, over half of the parents had implemented specific strategies to prevent childhood obesity.
Infant developmental assessment At each follow-up interval, participants were asked whether their infant’s developmental assessment (Queensland Health, 2010) had been performed. Figure 5 demonstrates that although the majority was completed by a child health clinic, a significant proportion was undertaken by a GP (Figure 5).
Forty-eight of the 72 participants remained in the study for the full 18 months. Participants withdrew at various time-points, with the largest number (n=8; 11%) lost at the two-month follow-up. Twenty-two participants (32%) were withdrawn because they could no longer be contacted by telephone and two participants were withdrawn for other reasons: one had changed her attendance to a different clinic, and another’s child was no longer in her care.
Discussion CCHS Participants identified that the main reason they chose the OAC for child health surveillance was due to convenient, local access (33%); ability to see a qualified CHN (23%); and the face-to-face contact (17%). These findings were similar to the parental experiences identified in phase two of this evaluation study14, where parents also valued the face-to-face consultation, and the flexible, easily
List of figures and tables
0 5 10 15 20 25
Convenient local access
Free service
Personal contact
Friend/family recommenda9on
No appointment necessary
Other
Missing data
Figure 1 Reasons for a/ending the OAC
Par9cipants (number)
List of figures and tables
0 5 10 15 20 25
Convenient local access
Free service
Personal contact
Friend/family recommenda9on
No appointment necessary
Other
Missing data
Figure 1 Reasons for a/ending the OAC
Par9cipants (number)
Figure 1: Reasons for attending the OAC
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accessible clinic times. Personal contact with a health professional for support and reassurance is a key reason for health care service attendance by Australian parents2,19. In the present study, over half (56%) of the participants stated they were informed about the service via their hospital maternity unit.
Within Australia, a variety of health care services provide child health surveillance services and support to parents with infants and children, including government-funded CCHS (this study’s setting), GPs, pharmacy baby clinics, and non-government organisations (such as the Australian Breastfeeding Association). Parents choose which health service to access with their infant/child, and there is little consistency in care pathways, types of services provided and by whom, and service accessibility. Many parents access multiple services or none at all20. It is important that parents know exactly where to access the most appropriate services to meet their need.
Initially most participants (80%) stated that infant growth monitoring was their main reason for attendance. This early focus on the infant’s weight measurement, however, became less important to parents over the 18-month period, with more developmental concerns arising as the infant’s age increased. This has important implications for service provision and addressing parent-led needs, at different times. For example, offering a clinic appointment or education session discussing ‘Introduction of solids’ at around six months, which is the current recommendation21, may not be the most opportune time for parents, as Australian literature indicates most babies have received solid foods prior to six months22,23. Additionally parents’ reasons for attendance in the neonatal period (0–4 weeks of age), was infant weight monitoring, yet with time parents became more interested in talking to the CHN about overall aspects of infant
development, rather than weight measurement alone. This confirms the importance of family-centred care and the clarification needed between the parent and nurse, ensuring the nurse is addressing the same health needs as those of concern to the parent24.
Alongside the OAC in this study, CCHS offer a specialist breastfeeding clinic and parent information sessions. The uptake of these complementary services was initially high in the first four months of the infant’s life and a quarter of the cohort accessed the breastfeeding clinic during this period. This has important implications for the timeliness and accessibility of breastfeeding support, demonstrating a high need for specialised lactation support indicated by the rate of access. In Australia, breastfeeding initiation rates are high; however, decline rapidly to around 30% by four months of age25. The strong evidence supporting the importance of exclusive breastfeeding in reducing infant mortality and
morbidity26,27 further justifies a universal health service being available to support and promote breastfeeding. It is well recognised that early postnatal support, from health professionals enhances infant and parental health and wellbeing, such as breastfeeding rates28. The Ten Steps to Successful Breastfeeding28 states that upon discharge, all mothers should be made aware of local breastfeeding support services and groups. There should be a quick and accessible service, as continuing to breastfeed with cracked nipples or low supply is unsustainable without help, for most women. There is a need to offer specialist breastfeeding clinics within the first few weeks of an infant’s life, as this is a very high-risk time for weaning29.
Consistent with other Australian research2, most of the families within the cohort, at the one- and two-month intervals, had also accessed their GP. A visit to their general practice was predominantly for a well-baby check-up. An infant’s first year of life is a period of high health service usage1. However, the need to visit multiple health professionals for similar services is questionable in the current fiscal and human resource-limited environment. Potentially, to reduce replication of services, more clarification could be provided to parents as to where it is best to access specific information regarding specific areas of infant health.
This study has demonstrated that in a universal health care system parents are able to access a number of services for their children. There is no evidence, however, of a coordinated approach to service delivery that could capture the opportunities presented by such high-frequency visits at a time when, developmentally, there is a great need for consistent, preventative and supportive advice and intervention1. A more coordinated, multi-service approach would ensure parents have a clear understanding of health care providers’ specialist roles and expertise in caring for their family in their infant’s early years, and potentially reduce excess service usage.
0
10
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0-‐4 week 6-‐8 week 4 month 6 month 12 month 18 month
Pa r7 ci pa
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Figure 2 Primary reason for a/ending the OAC
Infant growth monitoring
Infant development monitoring
Specific health issue/ques9on
Parental social contact
Immunisa9on
Infant growth, development and ques9ons
Parental reassurance
Not applicable / had not accessed service
Figure 2: Primary reason for attending the OAC
0
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Figure 3 Primary parental informa7on source
Family and friends
Community Child Health Service
Internet
Publica9ons
General Prac99oner
Other
Figure 3: Primary parental information source
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Infant development and growth monitoring In this study, the number of families accessing the OAC CHN was similar to those accessing the GP for the 18-month developmental assessment (CHN 28%; GP 30%). These figures predominantly reflected parental-preference and which service was more accessible at the time. Earlier in the infant’s life, more parents accessed the CHN for a developmental assessment. For example, at the four-month follow-up, 47% of participants attended the CHN, compared to 25% who accessed the GP. This is consistent with high health service attendance frequencies when infants are less than six months old; a time when parental need for information and support is high.
Parents are encouraged to attend regular developmental assessments for their infants concurrent with the immunisation schedule. There is mixed evidence regarding the effectiveness of routine developmental assessment on infants30. Throughout industrialised countries the frequency of recommended visits varies from two in New Zealand to six in the USA. Blank31 reviewed the available literature and found that there was no clear evidence to guide the number of health supervision visits. The lack of data and clear evidence available to health professionals does not provide sufficient information to enable the development of effective guidelines for this process, yet justification remains for health surveillance based on the severe health problems that are identified. Furthermore, in a Scandinavian study32 it was found that there was no evidence that health examinations carried out by nurses were of lower quality in detecting health problems that those carried out by physicians. The authors questioned the viability and need for physicians (already short and in demand) to carry out a routine health assessment at 18
months, when the nurses’ consultation was often more focused on parental concerns and child development and growth.
Breastfeeding rates In this study, the exclusive breastfeeding rate at two months of age was 47%, which reduced to 31% at six months. These rates are well below the Queensland Health targets of 60% of babies being exclusively breastfed at three months of age, and 50% at six months33. However, they are significantly better than the overall South-East Queensland rates reported by the Infant Nutrition Project34: 38% and 10% at two and five months of age, respectively. The overall Queensland rates are similar to those of other developed countries, such as Canada, where exclusive breastfeeding rates are around 39% at four months35.
The somewhat better exclusive breastfeeding rates found in this study may be due to mothers accessing the OAC receiving timely support, thus persisting with breastfeeding for longer. The wider literature36,37 suggests that families supported by a health professional in the early weeks of an infant’s life are more likely to persist with breastfeeding28. Approximately 25% of the cohort accessed the breastfeeding clinic in the first eight weeks of their infant’s life, which potentially would have
corrected early feeding problems.
The World Health Organization38 recommends exclusive breastfeeding as the optimal infant food source for the first six months of life, and to continue beyond two years in conjunction with complementary foods. Breastfeeding rates and duration provide a key indicator to assess infant and young child feeding practices39. In this study, returning to work was the most frequently cited reason for intended breastfeeding duration. Participants frequently noted their reason for weaning as due to a low supply of breast milk. Often, this is linked to the mother’s confidence in her ability to breastfeed, rather than often true low-supply or a knowledge deficit35,40.
Introduction of solid foods In this study, 12% of two-month-, 49% of four-month-, and 100% of six-month-old infants were eating solid foods. The most frequently cited reason given by parents for commencing solid/complementary foods was that their “baby was not full on breast milk/formula alone.”
For infants, after six months of age, it becomes increasingly difficult for them to meet their nutritional needs from breast milk alone27. Concurrent with this nutritional need, infants are developmentally ready for complementary foods, at around six months of age41. Despite this global recommendation, many families continue to introduce complementary foods earlier than six months22,42. Limited Australian research is available describing the incidence of early introduction to complementary foods.
Of the mothers in the OAC cohort, 84% stated they were aware of the recommendations regarding introduction of solids, with 75% able to identify ‘around six months’ as the specific recommendation.
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Figure 4 Infant feeding
Full/par9al breasReeding
Ar9ficial feeding
Figure 4: Infant feeding
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
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Figure 5 Developmental assessment a/endance by provider
Child health clinic General Prac99oner Other Did not aXend developmental assessment
Figure 5: Developmental assessment attendance by provider
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Despite this, around half of the cohort had introduced solid food at four months. It would appear that they have accurate knowledge regarding recommendations; however, there are other more influential factors affecting their infant feeding choices. Concerns regarding nutritional adequacy of exclusive breastfeeding until six months, and slowing of infant weight gain, influence parental choice for early introduction of solids43. Potential solutions for this are to consistently provide parents with evidence-based information, being proactive about informing them regarding the normal course of breastfeeding, situations they may encounter, and erroneous advice that may be given to them44.
Limitations The study design was descriptive and context-specific, and therefore it was not intended to generalise the findings to the wider population. However, the findings are relevant to other child health services in Australia, and theoretical generalisation45 is possible.
Implications for clinical practice This study aimed to prospectively investigate parents’ usage of universal child health care services with infants aged 0–18 months in South-East Queensland, Australia. Important information was gathered detailing patterns of attendance, timing and choice of various child health care providers (such as GPs and/or nurse-led services), infant growth and development needs and infant nutrition. Clinical implications from the study indicate there is potential for increased collaboration between CCHS and GP services to ensure that services are streamlined and thus reduce the burden on the health care system unnecessarily. This may also be helpful in ensuring consistency of health care information provided to parents between different providers. Further research is required to examine the broader population and their knowledge and access trends of universal community child health services in Australia, and to explore partnerships between CCHS and GP services.
Acknowledgement This study was funded through a Regional Research Grant from the Royal Children’s Hospital Foundation.
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