
==== Front
Glob Pediatr
Glob Pediatr
Global Pediatrics
2667-0097
Elsevier Inc

S2667-0097(24)00062-9
10.1016/j.gpeds.2024.100194
100194
Article
Improving primary health care for children and adolescents in Europe
Weber Martin W. weberm@who.int
⁎
Jullien Sophie
Redlich Cassie
Hall Jennifer
Carai Susanne
WHO regional office for Europe, Office for Quality of care and patient safety, Ploutarchou 3, Athens, Greece
⁎ Corresponding author. weberm@who.int
1 9 2024
9 2024
9 NoneNone
18 4 2024
31 5 2024
© 2024 Published by Elsevier Inc.
2024

https://creativecommons.org/licenses/by-nc-nd/3.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
Primary health care for children in Europe is often not optimal. Primary care providers might not have been trained adequately in dealing with common conditions affecting children and adolescents, and outdated practices often persist. To address these problems, WHO developed the Pocket Book of Primary Health Care for Children and Adolescents. It is for use by doctors, nurses and other health workers who are responsible for the care of children and adolescents at the primary health care level. It summarizes guidance on how to manage – and when to refer – children and adolescents presenting with common complaints and conditions. It includes information to enable primary health care providers to coordinate the continued care of children and adolescents with long-term conditions and diseases managed by specialists. Preventive and promotive measures from the newborn period to adolescence include advice on the timing and content of well-child visits, the promotion of early childhood development and health messages for adolescents.

The recommendations of the Pocket Book apply across the WHO European Region and may be adapted by countries to suit their specific circumstances. A mobile APP for Android and IOS phones is available to facilitate uptake and dissemination. The Pocket Book and APP aim to improve quality of care for children and adolescents at the primary health care level. Quality of care is at the core of the comprehensive European Child and Adolescent Health Strategy that is being developed by Member States supported by WHO and partners to refocus attention on child and adolescent health after the COVID-19 pandemic had scooped attention and resources away from this age group. Countries are encouraged to adapt Pocket Book and Strategy to improve the situation of child and adolescent health and well-being in their settings and monitor progress.

Keywords

Adolescent health
Child health
Primary health care
Pocket book
WHO
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pmcIntroduction

Primary health care for children in Europe is often not optimal. Many primary health care providers have limited knowledge of problems affecting children and adolescents: they have not been trained to address these problems.1, 2, 3, 4, 5 Sometimes, primary care providers have had very limited clinical practice under supervision after graduation.6 This is often leading to what they believe to be a cautious approach to young patients: unnecessary referrals and over treatment with too many drugs.7, 8, 9 Equipment and tests necessary to be able to diagnose and provide one-stop care are also often not available at primary health care level. Patients experience this and tend to bypass primary care; they have limited trust in primary care providers and go directly to hospitals or specialists. Guidelines which are embedded in national laws and decrees might not be up-to-date and not reflect the current status of evidence-based practise. In addition, there may be financial incentives for over-treatment and referral.

Over the past years, the WHO regional office for Europe has undertaken a series of applied health systems assessments using a tracer methodology.6 Tracers were selected to gain an insight into the overall functioning of the health system. The selected tracers included: the management of cough/pneumonia in children, vaccination, neonatal transport and adolescents’ access to sexual health services. The applied health systems assessments were undertaken in nine countries in Eastern Europe and Central Asia. The first step was a desk review of protocols, guidelines and national legislation, followed by in-country work to assess the scope of services provided in reality, the population coverage, and finally the quality of services provided. Interviews were undertaken with MoH staff, healthcare providers and patients and parents and the information triangulated. The applied health systems assessments gave a good insight into some of the problems hindering the delivery of good quality care. Health systems dysfunctions such as underfinancing of the health sector, low salaries, resource drain from public to private sector and weak governance need to be addressed through a wider health systems reform and are the scope of quality improvement initiatives in the countries reviewed.

The Pocket Book of primary care for children and adolescents

Outdated protocols were often found and interviewed health care providers underpaid and without access to continuing medical education leading to major knowledge gaps . To address these knowledge related issues, the WHO Regional Office for Europe developed the Pocket Book of primary care compiling WHO and other evidence-based guidelines.10 The Pocket Book is available in a pocket-sized format so that it can be carried easily and is always accessible to healthcare workers during their daily work. The target audience are primary care providers caring for children and adolescents including paediatricians, general practitioners or family doctors, as well as nurses such as community health workers and health visitors. The content of the guidelines is applicable across the European Region.

What is in the pocket book?

The content supports primary health care providers in the diagnosis, treatment and management of conditions occurring in childhood and adolescence. It shows them how to manage health conditions and when to refer, based on presenting complaints such as fever, cough, and abdominal pain. It also provides information on conditions which are usually managed by specialists, to enable primary health care providers to fulfil their coordination role. In addition, it contains chapters on health promotion and disease prevention such as information on timing and the components of well child visits from the newborn period to adolescence, the promotion of early childhood development and preventive and promotive measures such as vaccinations and screening tests. It also contains over 40 counselling boxes with messages on a healthy diet, physical activity, sleep and breastfeeding and other important topics.

The pocket book contains 9 chapters dealing with healthcare issues and the provision of care and 10 annexes, which give detailed guidance on practical procedures, growth monitoring and drug dosages (see Fig. 1). Chapter 6 is the core chapter of the book. It deals with the child or adolescent presenting with a specific complaint or symptom. This will be the most-used reference chapter in daily practice for the provider. It is symptom based. After the presenting symptoms such as cough or difficulty in breathing, the health care provider is led through steps in history, examination, possible investigations and the differential diagnosis, leading to a diagnosis. It includes the main features in favour of the diagnosis or tests required; the classification of severity is done where necessary, and advice is provided on treatment, referral and possible follow-up.Fig. 1 The Table of Contents of the Pocket Book and its annexes.

Fig 1

Like in the pocket book of hospital care for children,11 its sister publication, categories are colour coded with a blue square for diagnostic signs or symptoms and a red triangle for treatment recommendation or action points. Counselling boxes are highlighted with a call out sign.

The text is complemented by a wealth of illustrations which give a visual clue to the individual section and highlight specific features such as the distribution of rashes in specific childhood infections or how to perform procedures. There are boxes with important messages, red flags and counselling messages, which stand out from the text. The counselling messages are directly addressed to the parents, caregivers or the child and adolescent themselves, so they can be reproduced easily for handing them to patients or care takers.

The book flaps contain important information for quick access such as information needed for managing emergencies. Paediatric life support is following the ABCDE approach, dosages for emergency drugs are highlighted (Fig. 2).Fig. 2 Life-saving information in the front flap: the paediatric life support algorithm.

Fig 2

An annex provides guidance how to perform practical procedures which might be needed in primary care. Another annex provides the drug dosages for common drugs in primary health care for children with formulations and weight categories already calculated. Injectable drugs are highlighted with an underlying pink background.

How is the pocket book being used in countries?

The pocket book was launched in March 2022 and has been distributed in hard copy. Since then, translations have been undertaken and are available already in Ukrainian and Russian, and on the way in French, Spanish, Italian, Armenian, and several other languages. Country specific adaptations are underway. The pocket book may be adapted to countries to suit their specific circumstances. This is for example happening in Central Asia: Tajikistan, Kazakhstan, Kyrgyzstan, Turkmenistan; and in Balkan countries such as Serbia, Romania, and Greece. A global adaptation is being undertaken which will include diseases not common in Europe, such as Dengue and malaria.

A mobile app version is available in IOS and Android versions since April 2024. It contains additional features such as a weight-based drug calculator which will make drug dose calculations easier, plotting the growth measurements into growth charts, and tools for the classification of severity of diseases such as asthma. The counselling messages addressed to the children, adolescents and their families can be downloaded in PDF and directly sent to them by their health care providers through the mobile app.

A training course for primary health care providers based on the pocket book material is also being developed. We build on the paediatric associations in countries to use and run this training course.

The pocket book provides standards for quality of care for children and adolescents at primary health care level. It is, as such, a backbone for quality improvement approaches and can help with strengthening health systems. Preservice training and postgraduate training for GPs and family doctors, paediatricians, paediatric nurses, community nurses and home visitors should be built on this content. It is therefore also a useful source for continuous medical education. With this combination of approaches the pocket book can help improve the care for children and adolescents in the European region.

Disclaimer

MWW, CR and JH are WHO staff members. The opinions expressed are theirs and do not necessarily reflect the policies and positions of the World Health Organization.

CRediT authorship contribution statement

Martin W. Weber: Conceptualization, Writing – original draft. Sophie Jullien: Conceptualization, Writing – review & editing. Cassie Redlich: Writing – review & editing. Jennifer Hall: Writing – review & editing. Susanne Carai: Conceptualization, Writing – review & editing.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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References

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