The healthcare needs of a cohort of kindergarten children in a rural New South Wales community: a medical record review

Introduction

The importance of a positive transition to school is well established.¹ Children’s initial adjustments to school are crucial to their development, wellbeing, and educational trajectories; however, children from low-socioeconomic backgrounds are at increased risk of health problems, school adjustment difficulties, and poorer academic outcomes.^2,3

The Australian National Framework for Universal Child and Family Health Services identifies school entry as a key time for health services to support children and families and advises that children receive health checks and vision screening before commencing primary school.⁴ These checks usually fall under the remit of child and family health services, which cover the period in a child’s life from birth to 5 years of age. Access to these services generally requires caregiver initiative, particularly after the infant stage when checks become less frequent. Less-advantaged families face a number of barriers that impact their ability to attend routine health checks and access services when further assessment or treatment is required.⁵ Recent reports from New South Wales (NSW) indicate that almost half of children starting school have not received all the recommended health and development checks.⁶

Health service provision at schools can overcome some of the barriers to accessing health checks and other services. In Australia, primary school attendance is compulsory, and various models of school-based and school-linked healthcare services exist, including school-based clinics,⁷ visiting school-nurse services,^8,9 and school-based nursing services.^10–12 Some school healthcare services provide universal school entry health checks,^8,9 whereas others do not.¹² The degree of integration of services with schools also varies; some act as an external visiting service, whereas others are integrated with education teams.^10–12

The School-Based Primary Health Care Service (SB-PHCS) is a nurse-led, school-integrated service that provides school entry health checks, care navigation, and health promotion to students and their families. The service’s Primary Health Care Registered Nurses (PHCRN) first conducted school entry health checks in 2019. The checks were completed alongside the NSW Best Start Kindergarten Assessment.¹³ In NSW, the first year of primary school is known as ‘kindergarten’. Children can start kindergarten between the ages of 4.5 and 6 years. The health checks were completed via face-to-face meetings with children and their carers, during which carers completed the 60-month Ages and Stages Questionnaire and the 60-month Ages and Stages Questionnaire: Social Emotional.¹⁴ Carers were also asked about their child’s medical history, health service usage, sleep habits, and preschool attendance, and children’s height and weight were measured. Care navigation was provided if further assessment or service access was required. Care navigation is an approach to improving service access in underserved communities and involves identifying and addressing barriers to care and linking patients to services.¹⁵ In addition to school entry health checks, kindergarten children were also identified for care navigation by referrals from teachers, carers, and service providers.

This paper describes the kindergarten population from a medical record review of SB-PHCS primary school clients. It quantitatively describes the healthcare needs of the kindergarten cohort and assesses the role of school entry health checks in identifying children in need of healthcare services.

Methods

Results

Eighty-four kindergarten students were referred to the SB-PHCS with health or developmental concerns; this represents 60% of 2019 kindergarten enrolments¹⁶ at the sample schools (Fig. 1).

Fig. 1.

Population, sample, and cases in the study of health needs of kindergarten children in a rural New South Wales community.

Of the children with identified health and development concerns, there was an even gender split (Table 2). Speech and language issues were the most frequently observed concern (43%), followed by metabolic/nutrition (26%). Evidence of challenges to accessing care was found in the records of 40% of the identified children.

Almost all children received basic navigation (95%), and most children (63%) were referred to another service (Table 3). Most referrals were made directly by a PHCRN, but for some children, a PHCRN assisted or prompted another person outside the family to make a referral. This included supporting school staff to make referrals to Child and Adolescent Mental Health Services, student-led school-based allied health services, or social-care services, and when a PHCRN felt a child needed a specialist referral and referred to a general practitioner (GP) to facilitate the referral. The PHCRNs coordinated communication for many children (52%), most frequently between schools and service providers. Fewer children received treatment support (14%).

Children with longstanding issues had more service interactions than those whose issues were more recently identified (Table 4). A smaller, but still substantial, percentage of those with longstanding issues were referred to other services. In total, 92 referrals were made for 53 children.

Discussion

We found that more than half of the kindergarten children in the study schools were supported by the SB-PHCS for health and developmental concerns. Most of these children were identified by school entry health checks. Half of the children identified had longstanding issues and 40% had challenges to accessing care. Direct comparisons with other data are difficult because of differences in collection methods, but overall, the evidence suggests significant health and support needs at school entry in this community.

The proportion of children identified in our study was higher than local (23–31%) and national (22%) estimates of developmental vulnerability by the two most recent Australian Early Development Censuses (AEDCs).²⁰ The AEDC is, however, designed for population surveillance, based on teacher observation, and has poor sensitivity and low correlation with parent reports and interviewer directly assessed measures.²¹ Evidence of high local need has been reported in previous developmental screening conducted by allied health professionals and students. This screening found that 71% of kindergarten children required support with mild to moderate delays.²² This data included nearby remote communities, which are known to experience higher rates of developmental vulnerability. This finding accords with our higher estimate of need in this group. Comparative data from NSW were not available, but the 2019 Victorian school entrant health questionnaire found that 22% of children screened were at high risk of developmental or behavioural problems²³ (language, motor skills, self-help, academic, behaviour, and social–emotional), and 15% reportedly had a speech and language difficulty. Both findings are lower than those of the current study.

The most frequently identified concerns in our cohort were about speech and language (42% of identified cases and 26% of kindergarten children in the sample schools). Speech and language skills underpin all areas of learning, and deficits are associated with future mental health difficulties, lower academic achievement, lower socioeconomic status, and behaviour and relationship problems.²⁴ Behaviour and learning concerns were also prevalent. Childhood behavioural problems have similarly been found to impact educational attainment and be associated with later contact with criminal justice systems.²⁵ The importance of early intervention for these issues is well documented.²⁶

For many children in the study, health and developmental concerns had only recently been raised. Ideally, these concerns would be identified and addressed before starting school, but children from disadvantaged families are less likely to access health services⁵ and early childhood education,²⁷ reducing the opportunities for problems to be identified. In socioeconomically disadvantaged communities, entry to primary education may be the opportune time for screening. Families may be difficult to access before this point, and if issues are left to be identified by teachers or parents, they may not become apparent until later in a child’s schooling. Later identification of problems may mean a greater impact on educational achievement and lower access to services. Due to workforce shortages, high demand, and the greater benefits of early intervention, some paediatric services necessarily limit services to younger children.²⁸ We have observed incidences of children missing out on allied health services because, by the time they reached the top of the waiting list, they were too old to meet the eligibility criteria.

Health checks in preschools may go some way to ameliorating issues of delayed identification. Funding structure reforms have increased access to preschool; however, attendance is not compulsory and enrolment rates are still lower for the least advantaged,²⁷ meaning at-risk children will still be missed. Preschool health check programs should also consider ensuring continuity of care through the transition to school for those who require additional support to access services and manage their condition at school. This could be achieved by extending their services to school age or coordinating with existing school-based services.

Fifty-one percent of children identified by the SB-PHCS had issues that were already known; however, more than half of these children were referred to another service by the SB-PHCS, suggesting that although concerns had been raised, there was a significant unmet need for services. Forty percent of records reviewed provided evidence that families had challenges accessing care, such as a lack of transport, money, or the skills to navigate the health system. In less-advantaged communities, simply screening and referring may not be enough, as families often need support to access assessments and ongoing care. The SB-PHCS was developed to respond to these challenges by addressing both the needs of families and the complexity of the healthcare system. The service provides ongoing support to families and is co-located in schools, while being funded and managed by the Local Health District. This embeddedness and longer-term engagement allow the SB-PHCS to develop relationships with families and schools to address family-related challenges, while maintaining links with the health system to facilitate service access for children.¹⁰ This three-way communication is key to the service model, and the current study found that the PHCRNs coordinated communication for most children in the cohort. Qualitative data from an associated study found that the school-embedded health check model and face-to-face information sharing enhanced teachers’ knowledge of students and helped them to monitor for, quickly identify, and address issues arising in the classroom.¹⁰ For the PHCRNs, the health checks established relationships with families. Screening and surveillance activities are important opportunities for health professionals to form therapeutic relationships with vulnerable families.²⁹ These relationships are integral to effectively supporting less-advantaged children’s transition to school and educational journey.

Conclusion

The National Framework for Universal Child and Family Health Services acknowledges that some families need additional support to access services. Most kindergarten children in this rural community had concerns raised about their health or development, and a substantial proportion of families had challenges accessing care. In disadvantaged communities, where children are more likely to have health and developmental concerns and are less likely to access early childhood education, school entry is an opportune time for screening. Preschool and school entry health check models in less-advantaged communities should facilitate the sharing of relevant information with schools and support families managing identified issues and accessing relevant services throughout their child’s transition to school and beyond.