Children in general practice: An exciting area for research. Reflections on the EGPRN meeting in Plovdiv, Bulgaria, May 2010

Abstract

The European General Practice Research Network organized an international research conference on ‘Children in General Practice’ in Plovdiv, Bulgaria, in May 2010. Two of the authors were keynote speakers at the workshop, tasked with summarizing the theme research presentations on each of the two days of the meeting. The theme of the meeting ‘Children in General Practice’ refers to the primary aim for timely and high quality health care for every child and the related general practitioners’ activities. The meeting was an important event, especially for young doctors and investigators from different countries, because they were informed of good practices from other European countries in preventive work with children. All participants shared and learned a lot of good ideas beyond the standards and quality management. Examples of ideas for new research questions that emerged were to study differences in routine check-ups during childhood between European countries; to study the effectiveness of advices given by GPs to (parents of) obese children; and to study adverse events of medication in general practice.

Conclusion: At a European level, the diversity of the ways health care systems deal with health problems in children is striking. We felt great enthusiasm to further develop this research area. Interested family doctors are invited to attend future conferences to develop collaborative research projects on this topic.

Key words::

• Children
• prevention
• primary care
• and research methods

Background

The European General Practice Research Network (EGPRN) is a network within Wonca Europe, which supports the development of research projects and research capacity in general practice/family medicine. In May 2010, the 70th EGPRN meeting of 2010 took place in Plovdiv, the second largest city in Bulgaria (1). The theme of the meeting was ‘Children in General Practice.’

Children are vital for the future strength and success of any society—they are our guarantee for the future. Healthy children become healthy adults. Many adult diseases have their origin in early life, and events in childhood and adolescence have long-term sequels that determine adult well-being. There are wide variations in young people's health in the European region.

The family physician looks after the family as a unit of care. His care includes not only curative care but also disease prevention and health promotion (2). Repeated contact of a child with a family physician can result in a relationship with greater potential for support and the promotion of positive health (3). Child health surveillance provides the family physician with a systematic way of monitoring the physical and developmental growth of children. It allows for early detection and timely intervention of abnormalities detected.

In this paper, we want to summarize the presentations and discussions of the EGPRN conference in Plovdiv.

Child healthcare and research in Bulgaria

In her keynote lecture, Valentina Madjova (Varna, Bulgaria) addressed the ‘challenges facing child healthcare in Bulgaria.’ The end of the twentieth century brought about dramatic changes in Bulgaria's political system, and a series of reforms in the healthcare system came along with them (4). In Bulgaria the onset of family medicine development is as late as 1997, when departments of General Medicine/Family medicine were established in all five medical universities throughout the country. Three years later, restructuring primary health care (PHC) transformed outpatient therapists and paediatricians into ‘general practitioners’ (5). While in the beginning of the healthcare reform there were 5800 GP practices, 10 years later there are a thousand less. Currently, the average number of patients served by one family physician is above 1500 people. Another tendency is the merging of solo practices into group practices, either private medical centres or larger healthcare structures (5,6).

All the above-mentioned features of family practice in Bulgaria led to serious challenges facing its child healthcare efforts. On the one hand, demographic processes everywhere in Europe demand a special focus on children's health (7). For several reasons this is of particular importance for Bulgaria: the birth rate is among the lowest in Europe, and abortions are frequent. These negative demographic trends lead to a gradual aging of the average population (8,9). On the other hand, however, child healthcare in Bulgaria has some important advantages:

• Many GPs have specialized in paediatrics, have specific knowledge and skills and use various approaches in their work with patients,

• Although conducting research with children is difficult because of specific characteristics—clinical, ethical and administrative—serious research has been made into childhood obesity, diabetes and diabetic nephropathy in children;

• Most preventive activities of Bulgarian GPs are directed towards children (4,5).

Recently, there have been new legislative measures adopted to foster child healthcare, school-based health centres and youth policy. Still, it is difficult to find the balance between prevalence of child diseases and the lifestyle of young Bulgarians (5). Managing such a balance is a challenge and one of our most important current goals.

Feasibility of research on primary health care for children

In his keynote presentation, Hans van der Wouden (Rotterdam, The Netherlands) discussed the challenges of primary care research among children. Childhood and adolescence are the most dynamic periods of life in terms of growth, exposure to new infectious agents, changes in the immune system, and physical and social maturation. The frequency of primary care consultations in the first years of life is high, and children show specific morbidity patterns (10,11). It is illusive to assume that recommendations for managing childhood disorders can be guided by either research performed in adults or research performed in secondary or even tertiary care settings. The proportion of primary care research devoted to children is, however, surprisingly small. A quick scan of original research papers in six primary care journals over the year 2009 showed that less than 10% of papers concerned children or adolescents. Several hypothetical reasons for this discrepancy can be thought of, for example:

• Research in children is hard to fund;

• Research in children in unethical;

• Research in children is too difficult;

• Research in children is hard to publish.

In general practice, if properly prepared and organized, performing successfully studies in children, which answer clinically relevant questions and are adequately powered, is entirely feasible. From a wider perspective (not exclusively focused on children), it is important to address the pitfalls of patient recruitment in general practice and give examples of study characteristics that are related to successful completion of studies (12). Taking these factors into account, research in children in general practice is perfectly feasible, and many peer-reviewed journals are available to disseminate the results.

Variety of topics and research methods

The spectrum of presentations by the conference participants was very broad: from preventive services to chronic disease, from home safety issues to challenges faced by caregivers for children with cancer. Many papers addressed management of diseases in children. Furthermore, the studies used a wide variety of methods, i.e. analysis of routinely collected data, descriptive and comparative quantitative studies, and qualitative designs using interviews with health care professionals and caregivers.

Several papers dealt with the issue of obesity in children, i.e. its impact on children, their parents and GPs, and especially with the consequent psychological problems. These topics were useful for the preventive work of GPs in neighbouring countries, because of similar life style and habits. Dimitris Adamidis et al., presented impressive results of a field campaign of preventive medicine in a Greek rural area among several cultural minorities (1).

The poster session covered a broad variety of medical problems in children: prevention and risk factors, nutrition, respiratory problems and antibiotics, psychological problems, and immigration. Most of the authors were young investigators, which was a good indicator for the significance of the EGPRN meeting in the development of research capacity among young physicians.

Discussion

The aim of the 70th EGPRN meeting was to promote, develop and advance research and care of children and offer an exchange of information, new ideas and strategies between GPs and health professionals. As a whole, the presentations showed that children are a specific group that is attended by GPs. Family physicians should have specific knowledge addressed during their Vocational Training and should be able to apply flexible approaches and techniques in their work with children. They also should perform their own research, addressing topics that are relevant for their clinical practice. Research among children was versatile and multi-oriented and included studies concerning not only pathology but also the socio-psychological aspects of care for children and their parents. General practitioners need to be well educated and trained in generating research in this area.

Diversity

It was refreshing to experience the diversity of countries, health care systems, cultures and health beliefs. Too easily we assume that findings in one place in the world can be generalized to all other places, but we should always be aware of the differences, which may involve determinants of health and of health care interventions but can also affect the implementation of new ideas.

Prevention

The family physicians’ involvement in the preventive care of children can result in improved immunization coverage rates, reduction in childhood injuries and healthy lifestyle. Child health surveillance provides the family physicians with a systematic way of monitoring the physical and developmental growth of children. The family physician is in a good position to offer guidance related to child development, behavioural problems and appropriate use of services.

Emerging research topics

During the conference, many ideas were presented on how to improve research on children in primary care and many other important issues like funding, ethical problems and difficulty in publishing were dealt with. Several new research questions emerged. Some examples:

• The huge difference in number of routine check-ups during childhood between European countries begs for a study comparing content and finding evidence for an optimal way of monitoring children's health and well being.

• Obesity in children is a problem throughout the world. Little is known about the effectiveness of advices given by GPs to (parents of) obese children.

• Adverse events of medication have been studied extensively in hospital settings, but in general practice the issue has seldom been addressed. A study assessing which methods are available and how they compare in terms of accuracy and workload is needed.

Interested family physicians are invited to attend future conferences to develop collaborative research projects on these topics.

Conclusion

Research on children in primary care has its specific challenges. At the European level, the diversity of the ways health care systems deal with health problems in children is striking.

Problems mainly related to funding, ethnicity and feasibility need to be better addressed.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.