Availability and implementation of guidelines in European child primary health care: how can we improve?

Abstract Background Clinical guidelines are important for providing high-quality child primary health care. We aimed to assess the availability, use and achieved delivery of guidelines in the European Union (EU). Methods We used a case study design to ascertain expert views on guidelines in six countries representing the EU. The experts completed an online questionnaire (response 49%), asking about their perception of guideline availability and implementation regarding three topics that represent prevention and care, i.e. vaccination, assessment of mental health and asthma care. Results According to the respondents all countries had guidelines available for asthma care. For vaccination and mental health assessment respondents agreed to a lesser degree that guidelines were available. Implementation of guidelines for vaccination was mostly perceived as intended, but implementation of the guidelines for mental health assessment and asthma care was limited. Notable barriers were complexity of performance, and lack of training of professionals and of financial resources. Important facilitators for guideline implementation were the fit with routine practice, knowledge and skills of professionals and policy support. We found no clear relationship of guideline availability and implementation with type of child primary health care system of countries, but strong governance and sufficient financial resources seemed important for guideline availability. Conclusions Availability and implementation of clinical guidelines in child primary health care vary between EU countries. Implementation conditions can be strongly improved by adequate training of professionals, stronger governance and sufficient financial resources as facilitating factors. This can yield major gains in child health across Europe.


Introduction
T he importance of high-quality primary care is vital, as it regards the first point of contact with health problems of children and young people. [1][2][3] A poor performance on quality indicators such as governance, accessibility and continuity of care by child primary health care in the European Union (EU), may be detrimental for the health outcomes of its young inhabitants. 4 Quality of care can be improved using clinical guidelines, which contribute to compliance with best care practices and to standardized delivery of care. 5 This, e.g. holds for guidelines on monitoring of asthma in children, issued by professional organizations, such as the European Respiratory Society and the Global Initiative for Asthma. [6][7][8][9] To affect outcomes in patients, guidelines need to be adopted or used by the professional health care workers, and carefully implemented with special attention to the achieved delivery in the intended way. [10][11][12][13][14] Literature on the quality of guidelines in treatment of paediatric diseases noted for instance tensions in the applicability of guidelines with lack of attention to facilitators and barriers of implementation. [15][16][17] Moreover, the use and delivery of guidelines is likely to differ between EU countries due to system factors which relate to implementation theory, such as the varying compatibility with values and daily practice of local care professionals, and the organizational and socio-political context. 18,19 Evidence is lacking on the implementation of guidelines in the practice of Europe's child primary health care systems, characterized by the lead professional, i.e. General Practitioner (GP) or Paediatrician, and regulation of access to specialized services. 4,20 We therefore aimed to assess the availability, use and achieved delivery of three guidelines regarding vaccination, mental health assessment and asthma care, and the factors affecting their implementation across the EU. The study was part of the Models of Child Health Appraised (MOCHA) project that systematized and appraised the types of models of child primary health care in all 30 EU/EEA countries (http://www.childhealthservicemodels.eu/ 22 August 2022, date last accessed). 4

Methods
We used a case study design to ascertain multiple stakeholders' perspectives on the topics of study, i.e. availability, use and delivery of guidelines. 21,22 Selection of guidelines We selected guidelines on three differing topics based on the following criteria that they: 1. were pivotal for child health in the European context, 2. covered the different stages of childhood from early age to adolescence, 3. represented the full range of the functions prevention, surveillance and diagnosis in primary care, including somatic and mental health care. Experts working in the MOCHA project eventually selected: (i) vaccination of children, (ii) identification or assessment of mental health problems in adolescents aged 10-18 years, and (iii) asthma care in children aged 6-18 years. In preparing our study we searched for international accepted standards and guidelines on the three selected topics, using literature and consultation of experts. Guidelines could also be formal procedures, laid down in documents by governmental bodies or expertise centres, to leave open the inclusion of such formally authorized procedures, e.g. vaccination schemes. We denote further in the text these formal procedures also as 'guidelines'.
Two-stage sampling: countries and experts within countries Experts were sampled following a two-stage procedure. First, we selected six countries that were exemplary of the types of primary care systems in the EU based on variation in: (i) the lead practitioner who is responsible for the primary care for the child, and (ii) the way the system can be accessed by the patient, i.e. gatekeeper or open access systems. 4 Combining these two characteristics led to the following types of country systems: (a) gatekeeper-GP led: countries with a gatekeeper and a GP-led primary care, i.e. Sweden and the Netherlands; (b) gatekeeper-mixed led: countries with a gatekeeper and either a paediatrician-led primary care, or a mixed paediatrician and GP-led primary care, i.e. Poland and Italy; (c) open access care: countries with care use without gatekeeping and lead practitioner, i.e. Germany and Cyprus. 4,20 The countries with the three system types vary on a continuum with at the one end a centralized regulated professional model organized around primary care (type a), and at the other end a decentralized regulated model with primary care less at the core of the health system and allowing for more professional autonomy in providing services (type c). 23 Second, we selected experts regarding the topics of the selected guidelines who also had a general view on child primary health care in the country concerned. The experts were recruited via members of the External Advisory Board of the MOCHA project or country agents. 24 The latter regarded a network of one agent per country who acted as informant for obtaining data from country sources. To ensure inclusion of a wide variety of professionals, we asked the agents and board to identify at least two experts in each country per field of the guidelines. The resulting number of approached experts per country varied: Italy 46, Germany 12, the Netherlands 9, Sweden 3, Cyprus 5 and Poland 19. These comprised varying backgrounds from care practice, policy making, expert and science centres, and from end users, i.e. patient or interest groups. All were selected because of their expertise on one or more of the selected topics of this study. All experts consented to the request of the country agent to participate in the questionnaire and were informed about the objectives of the questionnaire, details about the MOCHA research project, confidentiality of provided information by the experts and anonymous report of data by the researchers. According to the criteria of the Dutch Medical Research Involving Human Subjects Act, this study did not need to be submitted for ethical approval by a Medical Ethical Committee. The study was reviewed and approved by the ethical committee of the Faculty of Behavioural, Management and Social Sciences of the University of Twente under file number BCE17583, on 19 September 2017.

Procedure and measures
Data were collected end of 2017 and beginning of 2018. The experts filled in an online questionnaire comprising three sections on child vaccination, mental health problems or asthma care. The measures used for these three topics were similar, but the respondents could choose for which one of these health topics they gave their answers and opinions. Participation was on a voluntary and anonymous basis. We used the following measures.

Availability
We asked about availability of the guidelines and procedures for each topic, i.e.: (i) under-vaccination of children, (ii) asthma care in children aged over 6 years, and (iii) identification or assessment of mental health problems in adolescents aged 10-18 years (see table 1).

Use and achieved delivery
We asked how often primary care practitioners used the guidelines, ranging from use for all children with a significant likelihood of having the health problem concerned, to for hardly any children. This can also be understood as asking about coverage of the guideline, i.e. whether all the people who should be receiving the benefits of the guideline actually did so. 14 Next, we assessed the achieved delivery of the guidelines. 14 We did so by limiting questions to specific guideline actions professionals are commonly expected to perform. Therefore, we asked the extent to which the following guideline actions were implemented in the intended way: (i) communication with parents who are not inclined to vaccinate their child, 25 (ii) conduct of a risk assessment for mental health problems in adolescents aged 10-18 years, 26 and (iii) performance of spirometry for diagnosing asthma in children aged over 6 years [6][7][8][9] (see table 1).

Barriers and facilitators
A total of sixteen statements on barriers for and facilitators of implementation of the guidelines were asked per specific action mentioned above, i.e. communication with parents about having their child vaccinated, risk assessment for mental health problems, and spirometry (table 1). The items originate from the Measurement Instrument for Determinants of Innovation (MIDI) and were grouped into four categories of facilitating or hindering factors, 18 i.e. characteristics of the guidelines, the primary care practitioner, the organizational context, and the socio-political context.

Background characteristics
The questionnaire included questions on the type of organization where the experts were employed, their current position, their highest level of education, and their field of expertise.

Analysis
First, we described the characteristics of the sample of experts participating in the study per country. Second, we assessed the availability of guidelines for each health topic in six EU countries using crosstabs, with country as independent variable. Then, we assessed the use and achieved delivery per guideline using crosstabs, with country as independent variable. Questions on implementation barriers and facilitators with Likert-type scales ranging from 1 to 5 were pooled reverse when stated negative. Per item and per respondent, answer categories strongly agree and agree were scored as positive (þ), neither agree or disagree as neutral (0), and strongly disagree and disagree as negative (À). Per country these scores were compiled into schemes with items and categories. Next, at least two raters (P.L.K., N.M.C.v.K. and R.v.Z.) made total scores per category classified as positive (facilitator) or negative (barrier), as shown in Supplementary table S1. The SPSS package for statistical analysis was used. 27

Characteristics of the sample
We invited a total of 94 experts, of which 46 participated (response 49%, varying from 35% in Italy to 89% in the Netherlands). The respondents identified themselves predominantly as experts from practice or science (table 2). They considered themselves most knowledgeable on child vaccination and asthma care. The respondents' most common affiliations were research institutes and universities or community types of primary care organizations. The respondents were active as paediatricians or nurses in paediatrics (in total 14), child and adolescent psychiatrists or psychologists (12), medical doctors in leading positions (11), among them two GPs, researchers (4) or other professions (5).

Availability, use and achieved delivery of guidelines
For three countries the experts agreed about the availability of guidelines for vaccination, for all six countries about guidelines for asthma care, and for three countries about those for mental health assessment (see table 3). An overview of the guidelines mentioned by the experts per topic and per country is given in Supplementary table S2. Guidelines for child vaccination were used for nearly all children and achieved delivery was as intended in most countries as perceived by the respondents. Countries differed largely regarding use and achieved delivery of mental health assessment guidelines. Guidelines for asthma care were available according to most experts, but they were only used for all children at risk in Sweden and Poland. Implementation as intended of the asthma guideline, i.e. performance of spirometry, was poor in all countries, except Sweden.

Facilitators and barriers
Important facilitators in communicating with vaccination hesitant parents were the characteristics of the guideline, e.g. not too difficult to perform and fitting well within routine practice (table 4 and  Supplementary table S2). Also, the general acceptance by primary care practitioners and the socio-political context of support for child Table 1 Questionnaire items to measure guideline availability, use, achieved delivery and implementation

Constructs
Questionnaire item Guideline availability, use and delivery Availability In your country, is a guideline or formal procedure formulated for [best practicea] a Yes, at an international level, yes, at national level, yes, at regional level, yes, at international and national level, yes, at international and regional level, yes, at national and regional level, yes, at international, national and regional level, no Use In your country, how often do primary care practitioners use a guideline or formal procedure for [ (5) a: Guidelines address child vaccination of children, identification or assessment of mental health problems in adolescents aged 10-18 years, and diagnosis of asthma in children aged over 6 years. b: Health themes: parents who do not have their child vaccinated, adolescents with mental health problems, and children with asthma. c: Actions of guidelines: communication with parents who are not inclined to vaccinate their child, conduct of a risk assessment for mental health problems in adolescents aged 10-18 years, and performance of spirometry for diagnosing asthma in children aged over 6 years.
a: þ available, À not available, 6 answers varied. b: þ use for nearly all children, À sometimes or hardly for any children.
c : þ to a great or certain extent implemented as intended, À somewhat or very little implemented as intended, þ/answers varied. d: Missing value.
Guidelines in European child primary health care 673 vaccination from health care policy makers were mentioned as facilitators. Financial constraints and limited time available were mentioned as important barriers for use of vaccination guidelines. All country experts except those from Poland mentioned mainly facilitators for all implementation categories regarding this activity. For conducting a risk assessment of mental health problems in adolescents the experts brought forward the barriers lack of knowledge or skills of professionals, lack of time and funds, and lack of dedicated policies. Facilitators were training of professionals, options for referral, financial resources and legislation. Experts from the Netherlands mentioned almost only facilitators, whereas experts from Sweden and Cyprus mentioned mainly barriers, and experts from Germany, Italy and Poland both barriers and facilitators.
Concerning implementation of the asthma guideline, in particular spirometry, experts from almost all countries identified barriers related to practitioners' characteristics such as lack of knowledge and self-efficacy of doctors and nurses, and at organizational level such as limited financial resources and time available. Moreover, barriers existed at the level of the socio-political context, namely lack of fit with legislation and regulations and lack of policy support. Facilitators regarded a foundation in correct knowledge as characteristic of the guideline and its fit with legislation and regulations.
Availability, use and achieved delivery of guidelines regarding the three selected topics seemed to be fairly independent from the type of primary health care system. The experts from the Netherlands and Sweden, countries with gatekeeper GP-led systems, experienced facilitators for guideline implementation to a slightly greater extent and some less barriers, in the Netherlands particularly in risk assessment of adolescent mental health problems and in Sweden in use of spirometry.

Discussion
We conducted a qualitative case study on the availability of clinical guidelines, their use and achieved delivery by child primary health care professionals, and the facilitators and barriers of implementation of the guidelines in six European countries. According to most countries' experts, guidelines were generally available. Use of guidelines and achieved delivery as intended were favourable for child vaccination but relatively poor for mental health assessment and asthma care. Factors affecting the implementation of the guidelines differed, but barriers were notably found regarding mental health assessment and asthma care, i.e. risk assessment for mental health problems and performing spirometry. We found no clear relationship of use and achieved delivery of the guidelines with type of child primary health care system.
We found ample availability of guidelines for primary child health care which may be explained by strong governance, e.g. either state governance in centrally led countries such as observed in Sweden or the Netherlands, or strong clinical governance manifest in professional and organizational accountability as observed in less centrally led countries, such as Germany. 28 Another explanation for guideline availability may regard a country's financial resources and associated expenditures on health care. This could explain the advantaged position of Germany in guideline availability in comparison to Cyprus with a much lower Gross Domestic Product and lower health expenditure per capita than Germany, which both regard countries with open access care. Both governance and financial resources may thus be important factors for the availability of guidelines for child health care.
We found use and delivery of the guidelines mental health assessment and for asthma care to be much poorer than for child vaccination. A first explanation for this difference may regard the characteristics of the guideline. For child vaccination the good fit of the guidelines with daily routines added to the uptake in most countries according to the experts, whereas the complexity of carrying out the guideline for asthma care 29 may explain its poor delivery. This wide variation in guideline uptake per targeted health problem confirms previous findings, with uptake ranging from 28% for a guideline regarding sudden infant death to 100% for a guideline on congenital heart disorders. 11 These findings show that use and delivery of a guideline depends on the type of health problem addressed combined with characteristics of the guideline such as its complexity.
A second explanation for the differences in use and delivery of guidelines as found may regard the characteristics of practitioners in a specific country, like their attitudes, knowledge and skills. The general acceptance of the child vaccination guidelines explains its favourable implementation. The practitioners' knowledge and skills seemed to be important for the use and delivery of the high uptake of the asthma care guideline in Sweden. Research has shown the presence of specialized asthma nurses in primary health care clinics to add to performing spirometry tests in Sweden. 29 The large investment in obtaining evidence for best psychosocial assessment by primary health care physicians and nurses in the Netherlands, resulting in a broadly used guideline since 2000, is another example of the practitioners' role in guideline implementation. 30,31 However, the Dutch experts were still critical about the delivery as intended of that guideline. Our study here shows the importance of practitioners' characteristics attitude, knowledge and skills for use and delivery of guidelines. Finally, our findings show that professionals differ in what they consider to be suitable as guideline, e.g. Dutch and German experts varied regarding the reported availability of vaccination guidelines. Probably this variation may be understood as that some experts consider a child vaccination scheme with some additional information as a sufficient guideline whereas others do not.
We found that factors in the organizational and socio-political context facilitated or hampered guideline implementation, but that the occurrence of such factors had no clear relationship with type of primary child health care system in these six countries. The time and cost that experts mentioned as organizational barriers have been reported before 32,33 and the same holds for the importance of adequate training of professionals for guideline adherence. 32,34,35 Regarding the socio-political context, experts frequently mentioned lack of policy support as barrier for guideline implementation. However, this did not affect adherence to guidelines for child vaccination as these seem generally accepted by professionals and also the social-political context seems favourable in most countries. Such policy support for planned and structured guideline implementation will have to take into account the countries' epidemiological, sociocultural, socio-economic, ethical, legal, and political circumstances. [36][37][38] Organizational context and policy support should thus be addressed in the implementation of guidelines for child primary health care.

Strengths and limitations
A strength of this study is its case study approach in which we compared guidelines regarding three selected topics covering a broad range of age categories of children and adolescents, a range of service functions, i.e. prevention, surveillance and diagnosis in primary care, including somatic and mental health care, and a range of contexts and health care systems among EU countries, i.e. centralized or decentralized regulated models. In this way we got a fair representative picture of topics and health care systems, relevant for qualitative assessment of guideline use and implementation. A second strength is our use of a validated scale measuring implementation in child primary health care, 18 combined with qualitative data on the availability and use of guidelines.
A limitation is that experts mainly came from practice, expert centres, and science with only two representing patient organizations. We may thus not have gained full insight in the achieved delivery of guidelines from the perspective of patients. A second limitation is the small number of participating experts from Sweden, Germany and Cyprus relative to the numbers from the other countries. Our findings thus require confirmation for these relatively underrepresented countries. Moreover, we mostly obtained expert opinions from the field of paediatrics and relatively few from general practice. Future studies should also address more experts from the latter field.

Implications for practice
This study showed room for improvement of guideline availability, use and achieved delivery with variation in the health problem addressed and practitioners' characteristics. Education on the awareness of the usefulness of guideline recommendations and systematic postgraduate training of skills are advised to support the adherence to guidelines in routine daily practice, often tasks of great complexity. 29 Training of professionals enables them to use the guideline for the patient 'tailor-made' and provides the practitioner with substantiated arguments to use the guideline. Training of professionals, time and financial resources as part of the organizational context of primary child health care should facilitate guideline implementation.
Furthermore, our research shows a clear demand for policy support for structured implementation of guidelines for adolescents' mental health assessment and asthma care. Our findings suggest that strong governance, i.e. state regulation or clinical leadership, and sufficient health care expenditures are associated with better guideline availability and use. This may evidently lead to major gains in child and youth health. We therefore strongly recommend support from national governments and paediatric and public health associations for guidelines, embedded in a strong quality assurance system. Clear policy making and increase of resources could benefit such quality systems. 39

Implications for research
Availability, use and achieved delivery of guidelines varied largely, with variation only partially explained, showing a need for further research to better understand the way systems of child primary care influence the implementation of guidelines. First, this requires structured monitoring and evaluation of guideline implementation using standardized measurement instruments, such as the MIDI or the GuideLine Implementability Appraisal (GLIA) instrument. 18,40 Second, we need further research to increase our understanding of the effects of external factors on perceived facilitators and barriers of implementation, such as the influence of the availability of guidelines and degree of experience with guidelines in practice.

Conclusions
This study shows varying degrees of availability, use and achieved delivery of clinical guidelines in child primary health care in six EU countries. Adequate training of professionals, compatibility with daily routines, strong governance and sufficient financial resources seemed important facilitators for guideline implementation, though implementation conditions in the countries can be strongly improved. This can yield major gains in child and youth health across Europe.

Supplementary data
Supplementary data are available at EURPUB online.