Embedding Child Health Promotion and Preventive Care Within Primary Health Care: From Agenda to Action

Embedding behaviours that support adequate sleep, a nutritious diet, sufficient physical activity and reduced sedentary time are key health promotion and preventive care goals to support childhood growth, health and development. In Australia, the National Action Plan for the Health of Children and Young People 2020–2030, the National Preventive Health Strategy 2021–2030 and Australia's Primary Health Care 10 Year Plan 2022–2032 all support a stronger health system focused on promoting wellbeing [1-3] as well as treating illness. Maternal, Child and Family Health Nurses (MCFHNs) and general practitioners (GPs) are amongst the most commonly consulted Primary Health Care (PHC) providers for Australian children [4]. Furthermore, Aboriginal and Torres Strait Islander Health Practitioners are also important providers of PHC to First Nations children. Health promotion and the provision of preventive care are critical components of MCFHNs', GPs' and Aboriginal and Torres Strait Islander Health Practitioners' scope of practice [5-8]. Additionally, Australian MCFHNs and GPs acknowledge the important role of paediatric health promotion and preventive care activities in their service setting [9-11]. However, day-to-day practice may not reflect these ambitions adequately due to challenges faced by PHC practitioners. These include a lack of adequate time available in consultations, gaps in education and training and the sensitivity of topics such as body weight [9, 10, 12]. Thus, despite being one of five key actions of the Ottawa Charter for Health Promotion [13], the reorientation of health services towards health promotion remains an aspirational target across PHC in Australia. Indeed, global progress towards health service reorientation has been disappointing [14]. Nevertheless, there is reason for cautious optimism as policy momentum towards change continues to grow in Australia. At a state and territory level, work is currently underway to embed a health promotion and preventive focus into relevant policy and practice. In South Australia, the Preventive Health SA Bill was passed in November 2024, supporting the continued work of an agency dedicated to preventive health [15]. In Queensland, Health and Wellbeing Queensland is developing a Clinical Prevention Framework intended to support prevention within their health system [16]. Additionally, two prevention-focused clinical practice guidelines directly relevant to PHC were updated in 2024: Guidelines for preventive activities in general practice [5] and the National guide to preventive healthcare for Aboriginal and Torres Strait Islander people [17]. Specific to overweight and obesity, the National Obesity Strategy 2022–2032 [18] was released in 2022. This recent wave of policy changes and updates offers an exciting window of opportunity to actively strengthen the implementation of health promotion and preventive care across PHC. We—the authors—are a group of early-career researchers each leading research programmes exploring health promotion and preventive care in Australian PHC settings. Through our research, we all seek to positively impact the health of Australian children. In addition, we are all registered healthcare practitioners (dietitians [DD, EH], GP registrar [KW] and public health physician [MG]) with practical, real-world experience. Thus, in this Commentary, we combine our practical experience and academic knowledge with contemporary research to articulate how PHC in Australia can be supported to reorientate services towards a more health-promoting approach, referencing the Ottawa Charter to outline our thoughts. Finally, given their prominent role in paediatric health provision in Australia, this Commentary mainly focuses on MCFHNs and GPs. McLeroy's adaption of the ecological model [19] describes five ecological levels which influence behaviour. Challenges to the provision of preventive care and health promotion in Australian PHC settings may be addressed locally at the individual, intrapersonal and organisational levels of the ecological model [20]. However, upstream policy-based changes are critical for embedding health promotion and preventive care into day-to-day practice of healthcare providers [10, 21]. For example, ‘Health Assessment Items’ are Medicare-rebated opportunities for GPs to evaluate an eligible patient's health, including the need for individualised preventive care and health promotion [22]. However, consistent with cited barriers to childhood preventive care in Australian general practice such as lack of time and inadequate remuneration in standard Medicare-reimbursed consultations [10, 11], the availability of ‘Health Assessment Items’ in the paediatric setting is limited [22]. In a promising development, the Australian federal government has commissioned a number of reviews relevant to Medicare. A consultation for the Medicare Benefit Schedule Health Assessment Items Review was recently closed [23]. Other reviews published in the last 5 years include the Review of general practice incentives: Expert advisory panel report to the Australian government [24]; Unleashing the potential of our health workforce: Scope of practice review [25]; and the Medicare Benefits Schedule Review Taskforce Final Report to the Minister for Health [26]. The reviews determined that the current healthcare payment model disincentivises prevention [26] and limits the delivery of high-value, multidisciplinary care conducive to preventive care [25]. Prevention and health promotion efforts could also benefit from a more consistent and coordinated approach across PHC disciplines; however, MCFHNs and GPs are funded and thus operate independently of each other. Furthermore, a ‘Health-in-all policies’ approach [27] may facilitate cross-sectoral action by breaking down silos beyond health services into social care, education, and other community organisations. Such approaches can leverage other service touchpoints to engage harder-to-reach populations by considering all the places where children and families live, work, and play to achieve common goals [28, 29]. Currently, South Australia [30] is the only Australian state or territory to have pursued a Health-in-all policies approach. Implementation support is a critical part of creating a supportive environment for change. Clinical practice guidelines and other policies intended to impact practice should be accompanied by an enabling action plan and tangible implementation tools. However, a recent review of Australian PHC guidelines related to child health behaviours in the early years found a significant lack of guidance on how to conduct screening and other health promotion activities in routine practice [DD personal communication]. Furthermore, a systematic review of international clinical practice guidelines [31] found a need for practical implementation tools for childhood obesity prevention guidelines. These findings are consistent with a relative lack of appropriate tools pertaining to growth monitoring and healthy behaviour promotion available to Australian general practices [32]. To strengthen implementation amongst healthcare providers, inclusive and collaborative co-creation processes are needed to ensure that end-users' needs are met. Recent workshops with Australian healthcare practitioners have demonstrated that collaborative research is feasible and achievable, identifying practical interventions and implementation strategies to create a supportive prevention environment in PHC [20, DD personal communication]. Systematic methodologies that support programme planning, implementation, and evaluation through participatory action, for example, Intervention Mapping [33], should also be considered. The framing and discourse of how ‘health’ is discussed within a clinical setting may also be important for success. Australian PHC settings tend to prioritise seeking and treating illness [2], rather than promoting health and wellbeing. In part, this is a function of the deficit-framing inherent within healthcare settings [34]. In contrast, a strengths-based approach seeks to leverage a child and their family's qualities and capacities for the gain of health [34]. For example, in the context of obesity prevention, using a strengths-based approach can refocus care provision away from emphasising weight loss. This may help to address the sensitivity associated with conversations about weight, a cited barrier by PHC professionals in clinical practice [9, 10]. Australian mainstream health services can also learn from examples of Aboriginal and Torres Strait Islander peoples' strengths-based approach to health [35]. Working collaboratively with diverse and priority populations is critical for strengthening community actions. Tailoring health promotion programmes to specific communities' needs is both feasible and acceptable in the Australian PHC context [36]. PHC staff have identified a need for enhanced support to have culturally appropriate discussions of key health promotion issues [10]. Collaborative and inclusive approaches are also a critical step towards health equity. Given that health in Australia is closely tied to various social determinants such as socioeconomic status [37], an equity-forward approach must be a strong focus of preventive care and health promotion initiatives. In pursuing this, partnerships with priority populations and local communities can provide insights to overcome unique challenges and tailor messages to suit the target audience. Concepts such as co-ideation, co-design, co-implementation, and co-evaluation [38] can be embedded to ensure that the voices of children, caregivers, and practitioners are heard and their needs are met throughout the process. With reference to Australian PHC providers, there is a recognised need for further development of skills and knowledge [9, 12, 20, 39]. Health professional education initiatives support early childhood health promotion in PHC settings, however, funding availability can vary between jurisdictions. A nation-wide sustained investment in workforce development would benefit ongoing skill development more broadly and is particularly relevant to general practice, which is administered at a national level. The ‘Connecting the Dots’ programme is an example of a national programme focusing on delivering professional development for PHC practitioners to support healthy growth in early childhood [40], however, investment is required to sustain service delivery. There is a ‘missing middle’ when it comes to ensuring that policies and strategies are translated into practice. In other words, articulating what broad principles and approaches are needed to reorientate healthcare is not enough. Rather, tangible actions that focus on how to bridge the implementation gap are also needed. Drawing upon our own research and experience, and contextualised within each of the five Ottawa Charter of Health Promotion actions, Figure 1 outlines activities that we believe will support improved health promotion and preventive care delivery in Australian PHC settings. An exciting window of opportunity to strengthen health promotion and preventive care within Australian PHC is upon us. Recent and anticipated updates of key Australian policies and clinical practice guidelines have the potential to move childhood health promotion and preventive care from merely being ‘on the policy agenda’ to routine PHC practice. As the next generation of healthcare researchers, we call for urgent action to embed health promotion and preventive care in Australian PHC, to ensure the future health and wellbeing of Australian children. The authors would like to thank professor Helen Skouteris and associate professor Elizabeth Sturgiss for their review of the manuscript prior to submission. Open access publishing facilitated by Monash University, as part of the Wiley - Monash University agreement via the Council of Australian University Librarians. The authors declare no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

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