Assessing wellness in the well-child check

Design

This 3-part mixed-methods study included the following: a measure of national rates of well-child assessments for the 4-to-6 age group; chart reviews of the content of such assessments in a large academic family practice; and interviews with parents to gather qualitative information about experiences of well-child care. Ethics approval was received from the Queen’s University Research Ethics Board.

Setting

Prevalence data were from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN), while charts for reviews and parents for interviews were randomly selected from 1 large family practice with 20 family physicians in the medium-sized city of Kingston, Ont.

Interventions or exposures

Well-child checks were identified in CPCSSN by the ICD-9 (International Classification of Diseases, version 9) codes V20 (health supervision of a child) and V20.2 (routine child health check).²²

Data extracted from the 110 full charts included age, evidence of a well-child check for the 4-to-6 age group, and documentation of 4- to 6-year immunizations, physical illnesses, behavioural or speech concerns, or any resources, advice, or follow-up offered.

The qualitative portion of the study included in-person or telephone parent interviews conducted by 2 authors (M.J., R.L.), with each interview being conducted by only 1 of the 2 authors, to examine the phenomenon of social or behavioural developmental assessments of children. We standardized this process, then reviewed it after every 2 to 4 interviews. Parents completed the 36-item PERIK social and emotional development assessment just before the interview (Figure 1).²³ This previously validated scale was developed for teachers to record the behaviour and well-being factors aligned with resilience of children aged 4 to 6. It has 6 questions about each of social performance, self-control or thoughtfulness, assertiveness, emotional stability or coping with stress, task orientation, and pleasure in exploration; these characteristics that are aligned with resilience are further described in Box 1.²³ Parents were then asked questions (Box 2), shown how the PERIK would be interpreted, and offered relevant resources. Responses were not audiorecorded. Interviewers (M.J., R.L.) made extensive and often verbatim notes during the interview. These were coded, then analyzed for common themes by 3 authors (S.P.P., M.J., and R.L.), first independently and then together. What emerged was the essence of parents’ experiences, that is, what they experienced and how they experienced it.

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Figure 1.

The PERIK questionnaire

PERIK—Positive development and resilience in kindergarten.

Adapted from Mayr and Ulich.²³

Outcomes

Our population-level outcome was the proportion of children aged 4 to 6 in the CPCSSN data set who received a well-child check. The nature of that check was determined via the random chart reviews of 20 physicians in an academic family practice. Finally, individual-level assessments of parents’ recollections of whether their child’s behaviour patterns and social and emotional development were explored in well-child checks was ascertained using the PERIK as the “door opener” to further discussion.

Prevalence of well-child checks in Canadian family practices.

Of the 21 876 children aged 4 to 6 in CPCSSN (2015 to 2016), 24% had had a visit coded as health supervision of a child, and 11% (n = 2 475) (95% CI 10.89% to 11.73%) of them had been seen specifically for a well-child check. This proportion was similar for boys and girls and for the time frame 2014 to 2015.

Nature of audited well-child checks.

As detailed in the methods section, randomly selected charts for 12% (N = 110) of those born between 2008 and 2011 and patients of 20 different physicians in one teaching practice were selected for review. Most of these patients had had the well-child check for children aged 4 to 6 (83 of 110; 75%), and it was performed by family physicians, residents, or nurse practitioners. Of the remaining 27, 16 had received age-specific immunizations, 2 had refused these, and 9 had no record of this vaccination.

Among the 83 children who had had the well-child check, there was documentation of the following concerns: physical (30%), speech (8%), or behaviour (11%). Social and family context issues, whether positive (parent reads to child) or negative (child protection services involved), were recorded for 37 (45%) children.

At least 1 of the PERIK’s 6 dimensions of social and emotional well-being was charted for 34 of 83 (41%) children. This documentation was sometimes minimal (“in school”) but occasionally detailed (“does not speak up in class”; “perfectionistic tendencies”; “has friends”; “teacher concerns about speaking out of turn”). Some chart entries spoke to aspects of resilience not addressed by the PERIK tool, such as “perfectionist tendencies” or “talkative, constantly walking around room, climbing on chair during interview, but very cooperative for exam.”

Parent interviews.

Telephone invitations to parents of 83 children resulted in 65 (78%) agreeing to participate in the semistructured interview, to complete the PERIK questionnaire before the interview, and to discuss the questionnaire and their previous experiences with well-child care. After 20 interviews we did an initial thematic analysis. Although themes were generally being repeated, we proceeded with another 22 interviews to guarantee saturation.

Themes: The 3 themes that emerged from these qualitative interviews were as follows: well-child care’s focus is physical health and growth; social, behavioural, and emotional development are not presented as medical or health matters by family physicians; and parents are keen to talk about development and resilience. In general, parents reported that their recollection of well-child checks was that they had focused on physical development. None of the parents recalled discussing aspects of child resilience with a primary care provider, and few recalled being questioned about their child’s behaviour, interactions, or social and emotional development.

Parents’ opinions about the PERIK questionnaire: Parents found the PERIK questionnaire useful for starting discussions about their child’s development. They appreciated questions about social interaction, emotional stability, coping with stress, attention span, and self-assertiveness, but had difficulty generalizing about something as context-dependent as task orientation. Questions requiring a teacher’s familiarity with their child’s group interactions (eg, assertiveness) were also challenging. Parents noted that the PERIK missed some important domains such as family stability and communication skills. Nevertheless, using the questionnaire as a door opener signaled that behaviour, social, and emotional development, as well as interactions with others, were relevant to health and, therefore, part of a well-child assessment. Whether the outcome of such a discussion was receiving reassurance or validation of, as well as referral for, concerns, or direction to resources to foster healthy development, parents welcomed such conversations.

Limitations

The actual proportion of children receiving the well-child check for the 4-to-6 age group in Canada might deviate from what we report. As CPCSSN excludes patients who were not seen in the preceding 2 years, this could underestimate the denominator in our calculations. The ICD-9 codes capture visits beyond well-child checks and therefore might have distorted estimates. The difference in proportions receiving this checkup nationally and locally suggests an inability to identify all such visits in CPCSSN, a possible lack of documentation by the family physician when a child receives care elsewhere, or a higher standard of care in the audited practice than nationally. In some parts of Canada and among some providers, the Rourke record might not be the standard. Further, CPCSSN data only track care by family physicians and therefore miss well-child visits provided by pediatricians or public health nurses.

Although there is no evidence that those studied differ from the Canadian population, we are cautious about generalizing findings. Despite a high response rate, we cannot rule out selection bias in our parental survey and are particularly reluctant to claim external validity for the qualitative component of this study.

Relying on charting to determine what occurred during encounters might miss the depth of discussions. Conversely auditing Rourke Baby Record check boxes for behavioural assessment might overestimate whether topics were discussed. Although it is one of the more feasible screening tests available for resilience, the PERIK questionnaire was developed for use by teachers and not parents, includes some questions parents can only speculate about, and excludes others of relevance. Finally, parents’ reports of care experienced might be subject to recall bias in either direction.