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

14 Pages·2015·0.16 MB·English

doi:10.1111/hex.12100
Parents’ decision making and access to preventive
healthcare for young children: applying Andersen’s
Model
Karyn E. Alexander MB ChB, FRACGP, MPH,* Bianca Brijnath PhD† and Danielle Mazza MD,
MBBS, FRACGP, DRANZCOG, Grad Dip Women’s Health‡
*PhDCandidate,†NHMRCEarlyCareerPublicHealthFellowand‡Professor,Head,DepartmentofGeneralPractice,Schoolof
PrimaryHealthCare,MonashUniversity,NottingHill,Vic.,Australia
Abstract
Correspondence Background and objective Implementing preventive health care for
Dr.KarynE.Alexander,MBChB,
young children provides the best chance of improving health and
FRACGP,MPH
PhDCandidate changing a child’s life course. In Australia, despite government
DepartmentofGeneralPractice support for preventive health care, uptake of preventive services
SchoolofPrimaryHealthCare
for young children is low. Using Andersen’s behavioural model of
MonashUniversity
Building3,270FerntreeGullyRoad health-care utilization, we aimed to understand how parents con-
NottingHill ceptualized their children’s preventive health care and how this
Vic.3168 impacted on access to preventive health-care services.
Australia
[email protected] Design Semi-structured telephone interviews conducted between
Acceptedforpublication May and July 2011.
28May2013
Setting and participants Twenty-eight parents of children aged 3–
Keywords:Andersen’stheory,general
practice,parents,preventive 5 years from three diverse socio-economic areas of Melbourne,
healthcare,qualitativeresearch, Australia.
youngchildren
Results Thematic analysis showed parents’ access to child preven-
tive health care was determined by birth order of their child, cul-
tural health beliefs, personal health practices, relationship with the
health provider and the costs associated with health services. Par-
ents 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 devel-
opmental delays required validation through family, friends and
childcareorganizations before presentation to health services.
Conclusions To improve child preventive health requires increased
flexibility of services, strengthening of inter-professional relation-
ships and enhancement of parents’ knowledge about the impor-
tance 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 expan-
sion of child preventive health checks into general practice present
a timely opportunity for this to occur.
1256 ©2013JohnWiley&SonsLtd
HealthExpectations, 18, pp.1256–1269
ApplyingAndersen’sModel, KEAlexander,BBrijnathandDMazza 1257
In response to these figures, and as a means
Introduction
of containing the costs of an ageing population
It is increasingly recognized that the onset of with increasingly complex chronic diseases, the
chronic diseases, such as hypertension, cardio- Australian government has set targets for child
vascular disease, stroke and diabetes, is predes- preventive health on healthy eating, body
tined by events in utero and early childhood.1,2 weightandphysicalactivity,and,most recently,
Similarly, compelling associations link child- child mental health.14,15 Responsibility for
hood emotional experience with an increased much of this developmental surveillance rests
risk of adult mental and physical health.3 The withmaternalandchildhealthnurses(MCHN),
pre-school period is a critical transition point4 registered nurses and midwives with additional
where high-quality health interventions can qualifications in child and community health,
reap benefits, which may extend across the life located within local council areas, with services
course.5 Accordingly, timely and appropriate freeatthepointofcare.InthestateofVictoria,
delivery of preventive health services in early where this study was conducted, parents are
life, defined as activities to stop, interrupt or encouraged to make 10 key visits scheduled
slow the likelihood of developing a disease and from birth to three and half years, the first
its progression,6 has assumed great priority on seven of which are meant to occur before the
national health agendas and in health services child’s first birthday.16 Uptake of services is
delivery. excellent (90% of families complete the first
In Australia, where health care is both pri- fourvisits)butdropsofftolessthan60percent
vately and publically funded, maternal child for the final visit.17 Evaluation of MCHN ser-
health nurses, paediatricians and general prac- viceshasfocussedonmaternalratherthanchild
tice services intersect across the early years of health outcomes, including maternal emotional
life to provide relatively comprehensive immu- health,18 use of the Edinburgh Postnatal
nization, developmental surveillance and Depression Scale,19 maternal service engage-
screening services.7 Childhood immunization mentandratesofnormalvaginaldelivery.20
coverage is high (93 per cent of 2-year-olds), Internationally, health checks of young chil-
neonatal hearing screening programme partici- dren by physicians have demonstrated
pation is increasing, and exclusive breastfeed- increased detection of physical, developmental
ing to 6 months is widely promoted.8 A and behavioural problems.21–24 In 2008, to
snapshot of children’s development as they improve monitoring of children’s health, the
enter school shows that the majority (75%) are government introduced the Healthy Kids
doing well.9 However, health risks for Austra- Check (HKC) – a pre-school health assessment
lian children exist: currently, 22% of children aimed at 4-year-old children. HKCs are con-
are considered developmentally vulnerable and ducted in general practice, an appropriate set-
4.9 per cent have special needs.9 Immunization ting given that four of five Australians visit a
coverage at 6 years is lower than that at general practitioner (GP-equivalent to a family
2 years,10 one-fifth of pre-schoolers are over- physician) each year, and health promotion and
weight or obese,11 and dental caries affects half prevention are key activities in the provision of
of 6-year-olds.12 Additionally 11 per cent of 2- patient care.25 Delivered by GPs, general prac-
year-olds and 20 per cent of 5-year-olds suffer tice nurses or Aboriginal health workers, a
clinically significant behavioural problems.13 rebate can only be claimed once, and only
Moreover, different population groups within when pre-school vaccinations are completed.26
Australia experience widely varying levels of Although publically funded (a Medicare rebate
morbidity, with children living in remote or is available to parents for this item of care), ini-
low socio-economic areas and indigenous chil- tial uptake of the HKC was much lower than
dren the most disadvantaged.10 anticipated and only 16 per cent of 4-year-olds
©2013JohnWiley&SonsLtd
HealthExpectations, 18, pp.1256–1269
1258 ApplyingAndersen’sModel, KEAlexander,BBrijnathandDMazza
Environment Population characteristics Health behaviours Outcomes
Rural/urban Predisposing characteristics (age, Personal health and Health status
gender, socio-economic status, lifestyle behaviours
Healthcare
race/ethnicity, education, health
systems
beliefs) Consumer
Policies Use of health satisfaction
Enabling factors (family, friends, services
financial, employment, community)
Perceived need (health condition
or co-morbidities) Use of preventive health services
Figure1 Andersen’sModelofbehaviouraluseofhealthservices,andpreventivehealthservices.
completed a HKC in the first year, with wide resources that enable access. Environmental fac-
variation between and within states.27 Reasons tors (physical, economic and political compo-
for this discrepancy are not well understood in nents including the health-care system), health
the Australian context. Thus, the aim of this behaviours (health promoting behaviours and
study was to explore parents’ perceptions of use of services) and outcomes (consumer satis-
preventive health care for children. Using faction and health status) influence access to
Andersen’s behavioural model, we explain how health-care services and were added to later
parents acquire knowledge of ‘normal’ child phases of the model (Fig. 1).28
health and development, describe how they rec- For more than 30 years, Andersen’s model
ognize and deal with possible developmental has been empirically applied to multiple facets
problems, explain their intentions to undertake of medical care across diverse populations.29–31
preventive child health care and portray their Studies have shown that predisposing socio-
experiences of accessing services. We begin by demographic factors such as gender, young age
providing an overview of Andersen’s theory and ethnicity are barriers to accessing ser-
and our methods before presenting our find- vices32–34; specific health beliefs determined by
ings, discussion and key conclusions. culture, personal attitudes and values are pow-
erful predictors for health service use35; educa-
tional achievements, increased household
Theoretical framework
income and having health insurance enable
Andersen’s behavioural model is a well-estab- access;36–38 and perceived need is a significant
lished theoretical framework used to under- determinant for seeking care.37,39 Other compo-
stand individuals’ use of health services and nents of the model, health policy and health-
equitable access to health care. In the model, care safety-net services,40 and health behaviours
need for care determines how much an individ- (previous use of services)33,36 also impact on
ual with certain predisposing characteristics access to services.
(age, sex and culture) uses health services For children’s preventive health-care, predis-
according to their personal and community posing risk factors for non-participation have
©2013JohnWiley&SonsLtd
HealthExpectations, 18, pp.1256–1269
ApplyingAndersen’sModel, KEAlexander,BBrijnathandDMazza 1259
been found to be young parental age,41 family that their experience of accessing preventive
structure (particularly single parent fami- health care could be quite different.51
lies)41,42 and having older siblings.41 Language
barriers may be the underlying reason for
Recruitment strategy
reduced use of services according to ethnicity43
or may indicate wider disparities in health Parents were recruited from the community.
behaviours and use of health services.44 The study was advertised in kindergartens,
Research shows the mixed effect of parental playgroups, community centres, maternal child
health beliefs on access to preventive child health centres, libraries and supermarkets.
health-care services. US data showed that Additional participants were recruited through
mothers’ beliefs about their child’s health were snowballing. Potential participants were asked
not influential,45 but parents whose beliefs to contact the researchers and were selected if
matched local guidelines for the timing of they had at least one child between the age of
check-ups were more likely to follow through 3 and 5 years, lived in one of the three study
with care.46 Families that lack personal areas, spoke English and had resided in Aus-
resources (lower income, lower levels of educa- tralia for more than 12 months. Recruitment
tion) have been found to be less likely to was stopped when data saturation was
receive preventive services for their children.41 achieved.52
Outcomes for access were mixed with respect
to need (increased in US study where the child
Interviews
was reported sick in the past year46; decreased
in a Danish study with increasing number of Data were collected between May and July
hospitalizations41) and may reflect differing 2011. Telephone interviews were conducted by
opportunities for preventive care in different the first two authors, following receipt of
health environments. signed written consent. Interviews were tape-
Qualitative studies have successfully applied recorded and lasted approximately 45 min.
Anderson’s model to a diverse range of settings Respondents were offered an A$75 gift voucher
and health issues32,47,48, and quantitative stud- to participate in the study. A semi-structured
ies have utilized Andersen’s model to under- interview guide, informed by Anderson’s
stand access to child health services including model, was used to question parents on their
the use of emergency department for non- children’s preventive health (Table 1).
urgent care,49 asthma care50 and preventive
care.46 However, to the best of our knowledge,
Data analysis
Anderson’s model has not been qualitatively
applied to child preventive health-care services. Data were analysed using thematic framework
analysis comprising inductive and deductive
techniques. The first two authors read, re-lis-
Method
tened and re-read each transcript to familiarize
themselves with the data and check for accu-
Setting
racy. They independently coded the data, then
Three socio-economically diverse urban areas met to compare and discuss results and obtain
of Melbourne were chosen for the study: consensus. As more codes were discovered, pre-
‘Westgate’ (low socio-economic), ‘Bayside’ viously coded transcripts were checked to
(high socio-economic) and ‘Dandenong’ [cul- ensure that the codes still applied, in an itera-
turally and linguistically diverse (CALD)]. This tive process to maintain quality within the
third suburb was targeted to ensure the sample data.53,54 The third author was consulted to
included the opinion of parents living in Aus- review the codes, resolve differences and over-
tralia for less than 10 years, as it was expected see the linking of codes into categories. Data
©2013JohnWiley&SonsLtd
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1260 ApplyingAndersen’sModel, KEAlexander,BBrijnathandDMazza
Table1 Andersen’sBehaviouralModelofHealthServicesUseanddevelopmentofquestionsforsemi-structuredinterviewof
parents
Domains Majorconcepts Components Examplesofquestions
Environment Healthcare Personnel- Doyouhavearegulardoctor?
system Medicaland
other
Organisational- Whatservicesareavailabletoyouinyourcommunitytohelp
healthcare youmonitoryourchild’shealth,growthanddevelopment?
systemsinplace Whenconsideringvisitstothedoctor,howimportantisit
foryoutofindadoctorwhobulk-bills?
Haveyoueverreceivedaninvitationforyourchildtoattend
ahealthcheck?
Population Predisposing Demographic Couldyoutellmealittlebitaboutyouandyourfamily?
characteristics characteristics andsocial Whatlanguageisspokeninthefamilyhome?
Healthbeliefs Iaminterestedtohearyourviewsaboutyourchild’sgrowth,
developmentandbehaviour–Howdoyoumonitorthese
aspectsofyourchild’shealth?
Enablingresources Personaland Doyoueverdiscussissuesaboutroutinehealthcarewith
family yourfamilyorfriends?
Doyouhaveanyhealthinsurance?
Perceivedneed Couldyoutellmeaboutthehealthofyourchildingeneral
overthelast12months?
Haveyoueverbeenconcernedaboutyourchild’sgrowthor
development?Whatabouteatingandsleep?Whatabout
yourchild’semotionaldevelopmentandgettingalongwith
others?–Whatdidyoudo?
Healthbehaviour Personalhealthpractices Doyoueverpersonallyattendyourdoctorforahealthcheck?
Useofhealthservices HasyourchildhadaHealthyKidsCheckorapre-schoolcheck?
Howaboutcheck-upswithotherhealthprofessionals?for
example,dentistandoptometrist
Thinkbacktothelasttimeyouhadyourchildweighed/
measured?Canyoutellmeaboutthat?
Outcomes Consumersatisfaction Howsatisfiedareyouwithyourmaternalchildhealthnurse
services?
What’syourimpressionofthecareyouhavereceivedfrom
doctorsinthelastfewyears?
were finally imported into NVivo 8.55 Data region). Approximately half the sample could
were de-identified to ensure participant ano- be classified as low- to middle-income earners
nymity. Approval was obtained from Monash (based on receipt of family tax benefits and
University Human Research Ethics Committee. health insurance status). Eleven per cent of
the sample had not completed secondary
school, 64 per cent had an undergraduate
Results
degree, and 21% had a postgraduate qualifi-
Twenty-eight interviews were conducted. The cation.
mean age of participants was 40 years, and Four themes were identified within Ander-
only one participant was male (Table 2). Ten sen’s model: (i) the families’ need, health belief
participants were from CALD communities systems and enabling resources (Population
and had resided in Australia for less than characteristics), (ii) health behaviour and
10 years (eight resided in the Dandenong parents’ personal health practices, (iii) parents’
©2013JohnWiley&SonsLtd
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ApplyingAndersen’sModel, KEAlexander,BBrijnathandDMazza 1261
Table2 Characteristicsofparentsinterviewed(n=28) the age of the child. In the early weeks of
infancy, particularly for a first child, parents
Numberor
felt less confident managing feeding, growth
range
and sleep behaviours and sought guidance
Age(years)
from MCHN services. Contact with services
Mean 40
diminished as the child got older. With subse-
Range 30–47
quent children, parents were more confident,
Gender
Female 27 balancing the advice received from providers
Male 1 against knowledge gained from past experience.
Migrantlessthan10years They frequently prioritized experience over
UK 4
expertise.
India/Ceylon 2
China 1
Especially being the second time now, I listen to
Vietnam 1
the advice they give me about the feeding and
HongKong 1
thingslikethat,butIthinkalotofitisyouhave
Lebanon 3
to just sort of decide what you’re going to try
Iraq 2
yourself.(Belinda,40 years,Bayside,2children)
Maritalstatus
Married 25
Separated 3 Because she’s my third I’m like, ‘Well, if she
Numberofchildren wants a dummy I’ll do it’… It just seems it’s not
3–4 11 the pressure I think of your first one… it’s not
2 15 like I’m a bad mother, I’m doing it all wrong.
1 2 (Rebecca,38 years,Bayside,3children)
HealthInsurance
Parents were familiar with the schedule of
Yes 10
No 14 visits proposed by MCHN services and the
Unknown 4 immunization requirements for young children.
FamilyTaxBenefitPartA* However, between 12 and 18 months of age
No 10
(when primary vaccinations were completed),
Yes 16
parents re-evaluated the need for ongoing
Unknown 2
involvement with maternal and child health
Educationlevel
Notcompletedsecondaryschool 3 services. In our sample, one-quarter (7/28) had
Otherqualificationaftersecondaryschool 7 not completed a visit at three and a half years.
Undergraduate 12 Some parents felt confident they could recog-
Postgraduate 6
nize developmental problems and others stated
Recruited:12PlaygroupVictorianewsletter;4kindergarten;2 they were too busy managing their own or
communitycentre;1supermarketcommunitynotice;1maternal
another child’s health problems. CALD par-
childhealthcentre;8snowball.
*Agovernmentbenefitpayableforeachchildandadjusted ents also said they preferred to use a doctor
accordingtonumberofchildrenandtaxableincome.
who spoke their first language.
Other cultural factors also influenced contin-
satisfaction with the health service and continu- uation with preventive services. Parents from
ityofcareand(iv)financialbarriersexperienced overseas countries made positive comparisons
by families when seeking preventive health care favouring Australia’s child health services.
fortheirchildren. However, if advice conflicted with cultural
expectations, satisfaction diminished and led to
early discontinuation of services. Shada,
Families’ need, health belief systems and
(39 years, Dandenong, 4 children) for example,
enabling resources
decided she would wean her children according
Perceived ‘need’ for preventive health services to Lebanese practices and discontinued MCHN
was primarily determined by birth order and visits after 12 months:
©2013JohnWiley&SonsLtd
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1262 ApplyingAndersen’sModel, KEAlexander,BBrijnathandDMazza
Ihavehadchildrenfor15 years…Inmycountry Social influences played a significant role in
I start feeding my children at 3 months… But uncovering a developmental delay. Parents
here they are told, no you can’t do this, maybe
consulted books and searched Websites and
after 6 months or 8 months…. I feel like I have
blogs to determine the likelihood of a problem,
experience,youknowmorethannurse.
then corroborated their uncertainties with
Parents believed that a family history of other significant individuals before taking the
developmental or health problems constituted next step. However, parents were cognisant of
a genetic risk and meant they became watchful being labelled ‘overanxious’.
of their children’s health and development.
I had a friend over, and I said, ‘Does she look a
There were frequent references to a personal or
little bit cross-eyed?’ And we were looking at her
family history of vision problems such as
and it didn’t seem all that noticeable again. And
‘squint’ and ‘short sight’, height variations, then thenextdaymyhusbandandIwerewatch-
speech delay, dental health and medical condi- ingher,andshewouldlookcross-eyedfromtime
tions such as asthma. to time, but then it would sort of correct itself.
So I rang the maternal health nurse and got an
appointment for her. (Jenny, 32 years, Westgate,
I suppose in terms of having reduced hearing
2children)
through glue ear, both their dad and I have had
it, so I suppose I was fairly conscious and they
were both late talkers and with [my son] I was
talking about it at his 18 month maternal health
Health behaviour and parents’ personal
nurse check-up. (Alison, 37 years, Westgate, 2
health practices
children)
This group of parents was already engaged
Alongside family history, a culture of aware-
with preventive health services and recognized
ness for the timing of immunizations, maternal
the value of healthy lifestyles. Mothers (20/28)
child health checks and kindergarten requisites
stated that they attended their GP for pap
was created through social relationships. This
smears or blood tests, and two had undertaken
was an important personal resource that
personal health checks. All children had been
‘enabled’ parents to acquire knowledge of ser-
vaccinated, and parents talked about exercise
vices. Parents of young children sought rela-
and healthy eating as their responsibilities.
tionships with other families with similarly
They talked of difficulties counteracting a busy
aged children and consciously or instinctively
lifestyle and moderating fast food, and friend-
checked their child’s development against other
ships and peer groups were regarded as impor-
children. Parents also expected childcare agen-
tant for their child’s social and emotional
cies to help them with monitoring, and in this
well-being.
data set, professionals who flagged potential
How parents sought health care for them-
problems to parents were MCHNs (3), kinder-
selves influenced the choices they made on
garten teachers (3), primary school teachers (3)
behalf of their children. Six of seven parents
and childcare workers (1).
who used complementary and alternative medi-
I suppose because they’re at childcare 3 days a cine (CAM) administered it to their children,
week,seeingthemthere,andwegotoplaygroup, believing that the practice would ‘strengthen
and we interact with other children’s parents, their immune system’. Some parents used vege-
so I can sort of gauge that they’re doing okay.
tables or herbs familiar from their cultural
(Vanessa,39 years,Bayside,2children)
background. One parent who regularly received
acupuncture, chiropractic services and Chinese
Theyhadacoupleofhoursonceaweekatocca-
herbal medicines did not have a regular GP
sional care and then a couple of hours at kinder
and had chosen to ‘homoeopathically vacci-
so from that point of view their developmental
nate’ her children, terminating MCHN visits
levels were monitored from those sort of organi-
sations.(Justine,42 years,Bayside,3children) after 18 months:
©2013JohnWiley&SonsLtd
HealthExpectations, 18, pp.1256–1269
ApplyingAndersen’sModel, KEAlexander,BBrijnathandDMazza 1263
The information I was getting from them was more deeply. If parents felt that the check was
stuff that I could already see in my child and basic, they did not feel there was anything to be
we’re a tall family, so they were always at the
gainedbycontinuingtoattendMCHNchecks.
top end of the percentile and …I guess for me,
mybelief wasthat theyarejust aset offigures.I I’ve never ever felt that anything that they’ve
believed that they were well and growing well. asked wouldn’t be obvious, would highlight any-
(Natalie,39 years,Bayside,2children) thing anyway. I think that’s another reason I
probably don’t go back very often. I don’t sort
of think anybody tries too much if you like.
(Ella,39 years,Bayside,2children)
Parents’ satisfaction with the health
service and continuity of care Parents were also generally satisfied with
their GP but pointed out significant differences
Satisfaction with health services affected the
between GP and MCHN child health services:
likelihood of continued engagement. Mixed
practitioner availability of time and type of
results were obtained in relation to satisfaction
health care. Appointments with GPs were
with MCHN services. Many parents expressed
shorter and attendance usually involved a sick
high levels of satisfaction with the ‘light-
child with an acute health problem. Overall,
hearted’ environment and time allocated for
parents lacked knowledge of preventive services
appointments. Parents were comfortable asking
offered by GPs, except for immunization ser-
for advice and described nurses as helpful, sup-
vices (50 per cent of participants). They could
portive and caring. Those who retained MCHN
neither recall receiving routine preventive ser-
services through the preschool years alluded to
vices for children nor asking the GP for advice
the continuity of the relationship, the skill set
or support with developmental issues.
of the nurse and how she handled the children,
and the environmental ambience, including I’m fromthat generation thatkindofdon’t want
to bother the doctor in some respects… He’s lit-
rooms geared for children and availability of
erally on a needs must basis, when they’re sick
promotional materials such as books and CDs.
we go to the GP. I wouldn’t even seek advice
Parents expected that in return for the efforts from my GP… I wouldn’t go and say I’m really
they made to attend routine health checks, the struggling with my children, I’m not sure if I can
nurse would address their individual concerns cope with them. (Rebecca, 38 years, Bayside, 3
children)
and not just check developmental items. There
was significant dissatisfaction when this expec- When prompted to consider specific aspects
tation was not met. of preventive health care for children, parents
recalled their GP had measured their child, but
I’vealwaysbeenverycarefulwithmyfollow-ups.
thought this was to calculate a drug dose not
The last one I did probably last year, his four
yearoldfollow-up, andthatwasextremely basic. to monitor growth. Four parents said their
I was quite disappointed with it because I child had received a health check from the GP
remember taking my daughter…she had to build with their immunization at 4 years. Two fami-
blocks, she had to do this, she had to do that -
lies were offered HKCs by GPs, but declined
there was quite a few different steps that they
ran through with her…[This time]she said ‘Did I invitations as these clinics were not their regu-
have any concerns?’ and I said I’m just a bit lar point of care. Only one parent specifically
worried about his pronunciation. She said ‘Oh requested a health check for her child, although
no, that’ll come with time’. And basically it was her experience suggested the clinic doctor did
weigh him, measure him and out the door. (Vir-
not know about HKCs and included a blood
ginia,43 years,Westgate,2children)
test (not a routine part of the check).
The use of checklists was regarded as ‘superfi- As older siblings transitioned from the
cial’ and ‘base level stuff’, and one parent articu- MCHN to the GP, parents looked for conve-
lated that a ‘good’ MCHN should ask ‘curious nience with appointments and streamlined the
questions’toproberesponsesmadeonachecklist family’s health care.
©2013JohnWiley&SonsLtd
HealthExpectations, 18, pp.1256–1269
1264 ApplyingAndersen’sModel, KEAlexander,BBrijnathandDMazza
Then if there were any other kinds of issues they parents, most (20/28) actively sought ‘bulk-
would be able to deal with them on the spot billed’ services for their children. All families
rather than me having to be referred on …to see
from the Dandenong area (low socio-economic,
a doctor… You know, kill two birds with one
CALD community) were receiving health care
stone I suppose. And if there had to be prescrip-
that was direct billed. The four HKCs obtained
tions done or anything like that then you could
doit.(Angela,47 years,Bayside,3children) appeartohavebeenbilledinthismanner.Some
parents prioritized continuity of care over cost,
As a result, younger children were more
particularlyforchronichealth-careissues.
likely to miss preventive care visits.
Actually there are two [GPs] that I use, one does
Immunisation, I’ve been struggling with that for
bulk billing for children, they tend to be a bit
the last 6 months… It’s just a scheduling prob-
more inconsistent in terms of who the doctor is
lem, remembering to do it.… just for the third
there,butthat’sokayforstraightforwardsortof
child, I think it’s just life with three kids and it’s illnesses…. And then there is another one… that
quite challenging. (Julia, 41 years, Westgate, 3
I would probably categorise as the long-term
children)
treatment one. So that’s who I go to for [my
And as attendances for acute health issues daughter’s] asthma… She’s very good… very
approachable… and has a nice calm manner
accumulated, a feeling of continuity of care
about her. Yeah she’s great. But you know she’s
with the GP developed, as the scheduled
also $65 a visit. (Justine, 42 years, Bayside, 3
MCHN visits declined. children)
I’m familiar with the doctor, there’s a relation- Dental services, which are generally privately
shipthereandIhonestlydon’tknowwhoI’dsee billed and not rebated by Medicare, were a
if I went down to the maternal child health cen-
major source of financial anxiety to parents
tretomorrow.
across each study area. One parent lamented
that she could not afford to complete her
Financial barriers to preventive health daughter’s orthodontic work and could not
services access treatment for her 4-year-old son’s severe
dental caries. In contrast, optometrists were
Parents from all three socio-economic areas
well regarded for the fact that assessments were
cited cost and frequency of GP visits with
both comprehensive and ‘bulk billed’.
small children, including the cost of medica-
tions, specialist visits, pathology services, allied
Discussion and recommendations
and dental services, as potential barriers to
health care, including preventive services. Through the application of Andersen’s
Whilst parents prioritized their children’s behavioural theory, our study clarifies parents’
health care, privately billed services were fre- intentions to undertake health checks for their
quently beyond their reach, and resorting to children and presents the social context
public services meant children experienced through which parents recognize and act upon
delays accessing speech pathology, occupa- developmental concerns.
tional therapy and psychological services. Parents in this data set were personally
Maternal and child health services are free at engaged in a range of preventive services and
the point of service, whereas GP services are actively monitored their children’s health with
usually privately billed, with some of the costs regards to diet, exercise, growth and social well-
rebated by the Australian Government insur- being.Allparentshadimmunizedtheirchildren,
ance scheme, Medicare. Some practices offer and only one had not accessed maternal child
direct billed (bulk-billed) services, paid to the healthservices.Childpreventivehealthcarewas
practitioneratalowerratethanthegovernment influenced by health beliefs and personal health
scheduled fee, so that the patient does not incur practices. Considerable overlap between these
out of pocket expenses. Amongst this group of twodomainsexistedinrelationtoculturalback-
©2013JohnWiley&SonsLtd
HealthExpectations, 18, pp.1256–1269
ApplyingAndersen’sModel, KEAlexander,BBrijnathandDMazza 1265
ground. These findings resonated with earlier can refer to early intervention services.58 This
studieswhichshowedparentalbeliefsabout:the could be augmented by ‘Medicare Locals’, pri-
useofcomplementarymedicines,56thetimingof mary health-care organizations recently estab-
routine visits,46 and immunization,57 all affected lished in Australia to better respond to local
preventive health-care uptake for their children. health care needs and connect GPs and other
Our study also revealed the significance parents health services.59 These organizations are ide-
assignedtofamilyhistorywhenitcametoantic- ally placed to foster liaisons between GPs and
ipatingproblems. early childhood education and care, to inte-
Parents had good knowledge of the schedule grate services and streamline referral processes.
of maternal and child health visits. Neverthe- Ourstudyalsohighlightedtheabsenceofrou-
less, a quarter of our sample had ceased to visit tine preventive health services for children from
the MCHN by the child’s second year. Argu- general practice. Parents generally took their
ably the number of preventive visits – 16 in children to the doctors when they were sick, did
total – proved onerous for many families, espe- not realize GPs had a stake in preventive health
cially where there was more than one child and care for children and were reluctant to make
siblings were older. As older siblings switched appointments for non-specific concerns. Devel-
from the MCHN to the GP, parents sought to opmental problems were not presented to the
streamline health care, so that younger children GP, and although parents were aware that GPs
were less likely to complete MCHN visits. weighed children, they believed this was to cal-
These data correlate well with quantitative culate a drug dose and not to monitor growth;
studies which have shown that having older however, national guidelines suggest that GPs
siblings increases the risk of non-adherence to should measure BMI twice a year for their
the schedule of preventive child health examin- paediatric populations.60 Only one parent had
ations.41 Parent’s beliefs in their own capabili- specifically requested a HKC, despite them
ties influenced this transition as did the need beingavailableforthelast3 years,andfewpar-
for expediency. The GP administered HKC ents had even heard of them. The mismatch
goes some way towards increasing flexibility of between government expectations for the deliv-
preventive health-care services to children, with eryofpreventivecareandactualreceiptwasalso
practitioners ideally placed to tap into family a major finding with adult preventive care in
history and cultural beliefs. Future develop- general practice (where the focus of consulta-
ments could increase this service beyond the tionswasalsoacutecare)andholdsmajorimpli-
current single time point for its delivery. cationsforputtingpreventionintopractice.61
Anomalies in children’s health were initially Parentsregardedcontinuityofcare,bothwith
picked up in home, kindergarten, school and MCHN and GP services, as important. Parents
childcare settings. Having an environment in wereunlikelytoaccepthealthchecksfromprac-
which parents could compare their children’s tices that were not the regular source of health
development was an important determinant of care and considered that their child’s coopera-
parents’ help-seeking. Parents expected agen- tion was dependent upon familiarity with the
cies routinely involved with their children to practice and the practitioner. Adult patients
help them monitor development and often dis- whoregularly attend one practice report greater
cussed concerns with these professionals first. provision of preventive care.62 Continuity of
This hierarchy of information seeking serves as care may prove to be an important determinant
a reminder to health professionals to thor- of the quality of preventive health care for chil-
oughly evaluate parents’ concerns when they dren in Australia, as it has overseas63–65, and
are raised. A major goal of the Australian policies that encourage continuity (e.g.
Government is to have a more effective early increased insurance rebates for enrolment with
childhood development system with coordi- a nominated provider) have previously been
nated, interdisciplinary, flexible services that consideredforotherpopulationgroups.66
©2013JohnWiley&SonsLtd
HealthExpectations, 18, pp.1256–1269