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| Home / College Guide / Developing a framework for community childcare doctors to support community-base |
| Posted on Friday, December 06 @ 00:00:11 PST |
Article Text
Abstract
Objective Unintentional injuries are a major threat to children’s health. Community-based health management services, which include the prevention of unintentional injuries among children aged 0–6 years, are important basic national public health services. However, deficiencies exist at this stage, such as community childcare doctors not being motivated to provide guidance. Previous studies have explored the impact of the underlying reasons; however, few studies have considered the supporting factors from a social perspective. This study explored the elements supporting community childcare doctors in conducting parental health education and sought to generate a framework capable of providing recommendations.
Design A qualitative study was conducted to analyse data collected through semistructured interviews and used the grounded theory method.
Setting Interviews were conducted at eight health institutions, health management departments, hospital and universities in four regions of eastern China (Shanghai, Zhejiang, Anhui and Liaoning) and recorded on audio. Interviews were conducted face to face or online.
Participants Key informant interviews were conducted with 39 adults (15 parents of children, 11 direct providers of child healthcare and 13 health department managers or experts).
The information obtained through interviews included the current situation and difficulties faced by community childcare doctors providing parental health education, the attitudes and perceptions of parents regarding receiving health education and the degree of service acceptance. The independent transcription of interview results was performed by two coders.
Results A total of 39 interview transcripts from healthcare service providers, managers and demanders were analysed. Many factors affect the provision of parental health education by community childcare doctors, including the macrodimension and microdimension. Supplier, demander, direct support and indirect support were summarised and reported as both facilitators and barriers to active provision of health services, including 18 subdomains under these four main domains.
Conclusions A theoretical model of parental health education based on community childcare doctors was constructed to explain the factors influencing the implementation of education by community childcare doctors. These include individual and socialised behaviours requiring cooperation among individuals, families, governments, the general public and all workers in the healthcare sector.
For demanders, it is essential to evoke their beliefs, and for suppliers, it is necessary to improve their skills and stimulate their motivation, both of which cannot be separated from macrolevel support. This model can be used to guide intervention designs aimed at enhancing the enthusiasm of community childcare doctors and further enhancing parental literacy, ultimately achieving the goal of improving children’s health.
- Health Education
- Caregivers
- Health & safety
- Child protection
- Community child health
- Primary Health Care
Data availability statement
Data are available on reasonable request.
http://creativecommons.org/licenses/by-nc/4.0/
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The use of grounded theory made us aware of the factors affecting the motivation of community childcare doctors.
This study systematically summarises the supportive factors that enable community childcare doctors to deliver parental health education from a microlevel to macrolevel and develops a framework for the provision of recommendations.
Some interviews were conducted remotely, which limited our ability to observe non-verbal information.
The parental health education model remains a theoretical model in qualitative research. Future research should quantitatively validate the model at a theoretical level through randomised controlled trials in selected areas.
Background
Injury is the leading cause of death and disability in children worldwide, posing a serious threat to their safety.[1](#ref-1) In China, injuries account for nearly 50% of deaths among young children.[2](#ref-2) An analysis of the mortality trends among Chinese children aged under 5 years revealed an increase in the proportion of unintentional injuries as a cause of death[3](#ref-3) indicating the need to focus on preventing unintentional injuries in this age group.
The National Basic Public Health Service Standards (Third Edition) identify unintentional injury prevention for children aged 0–6 years as a key focus area. Community childcare doctors are required to provide childcare services, including unintentional injury prevention through the child health management service platform.
[4](#ref-4) Currently, the rate of registered health management for children aged 0–6 years exceeds 90%.[5](#ref-5) Owing to the inherent vulnerability of children aged 0–6, parental supervision is deemed necessary.[6–8](#ref-6) This suggests that the community-based child health services network offers a formal and practical platform to guide parents in preventing unintentional injuries among children, with wide coverage, high frequency and institutional guarantees. Community-based parental prevention of unintentional injuries for children aged 0–6 years is a feasible approach, and the positive impact of health education has been demonstrated.[9 10](#ref-9)
Community childcare doctors are aware that their primary duty is preventing unintentional injury in children aged 0–6 years; however, implementation of child health services is inconsistent and often limited to basic oral education. This limitation hinders parents from significantly improving their knowledge, beliefs and behaviours related to the prevention of unintentional injuries in children, making it challenging to maintain effective prevention. Potential reasons include (1) the insufficient allocation of community childcare doctors and (2) the lack of detailed content regulations in the existing assessment system and operational instruction manuals during the guidance process have led to a lack of motivation among community childcare doctors to provide guidance.
Addressing the inertia of community childcare doctors in implementing guidance for parents is important for improving the effectiveness of community-based parental health education for the prevention of unintentional injuries among children aged 0–6 years.
Most existing studies have explored the impact of individual reasons, focusing on parents[11](#ref-11) or community childcare doctors,[12](#ref-12) emphasising the importance of abilities from an individual viewpoint. However, few studies have considered the supporting factors for individual-level problems from a social perspective. A systematic framework for supporting community-based parental health education to prevent unintentional injuries in children is lacking. There is a need to develop a systematic framework that incorporates individual and social analyses to support community-based parental health education and prevent unintentional injuries in children from the perspective of community childcare doctors.
In this study, we used a grounded theory approach to develop a supporting factor model to understand, analyse and solve the implementation challenges of parental health education faced by community childcare doctors regarding unintentional injury prevention.
This model considers the essential elements to support community childcare doctors in actively delivering parental health education, along with the relationships among these elements from multiple perspectives. We constructed theoretical models to provide recommendations to enhance the motivation of community childcare doctors, ultimately improving parental literacy through health education, reducing the occurrence of unintentional injuries in children and ensuring child safety.
Methods
Study aims and setting
This study, based on the grounded theory, uses key informant interviews to understand the current implementation status of community-based parental health education on unintentional injury prevention in children in four eastern regions of China (Shanghai, Zhejiang, Anhui and Liaoning). The aim was to identify the problems faced by community childcare doctors in implementing health education for children’s parents and analyse the influencing factors. Based on the above, a systematic framework, including ‘supplier-demander-direct support-indirect support,’ was proposed to support community-based parental health education on unintentional injury prevention among children under 6 years of age to enhance its effectiveness.
The report of this study follows the Standards for reporting qualitative research (SRQR) checklist for qualitative research ([online supplemental appendix 1](#DC1)).
Supplemental material
The development of the eastern region of China is at the forefront of the country. According to the 2023 China Statistical Yearbook, Shanghai is the economic centre of China and the most developed city in China with the second highest gross domestic product per capita in the country, followed by Zhejiang Province in 5th place, Anhui Province in 13th place and Liaoning Province in 19th place.
Community childcare doctors are the main providers of child health services, while parents of children aged 0–6 years are the direct beneficiaries of child health services. The Health Commission, Maternal and Child Health Care Center and Centers for Disease Control and Prevention (CDC) are managers or technical support parties that guide community childcare doctors in providing child health services. Therefore, we conducted interviews at eight health institutions and health management departments (three community health service centres, one health commission, one maternal and child healthcare institute, one CDC, one hospital and one universities).
The study period was from October 2021 to March 2023.
Grounded theory
The grounded theory method (GTM)[13](#ref-13) is a qualitative research approach that employs systematic procedures to develop and inductively derive grounded theories based on a specific phenomenon, with the main purpose of establishing theories based on empirical data. This method asserts that concepts in a theory must be generated from the material within the substantive field being explored and related to the research object rather than focusing on verifying a theoretical hypothesis. The core of grounded theory involves coding data hierarchically, which includes three levels of coding.
The GTM is recognised in both Glaser and Strauss versions. This study adopts the Glaser version of the GTM, as the Strauss version presupposes a theoretical coding to frame the data and no longer awaits the presentation of theoretical coding from the data analysis.[14](#ref-14) The research method in this study emphasises the natural presentation of theory through three-level coding.
Study design and participants
Following the principle of theory saturation, we aimed to understand the current status of parental health education provided by community childcare doctors, parents’ attitudes towards receiving health education, community work mechanisms related to the prevention of unintentional injuries in children and the institutional relationship between the community and other institutions through multiple rounds of key informant interviews.
Understanding these issues requires the participation of children’s parents, community childcare doctors, clinicians, managers from various health service institutions and university professors in related fields.
The inclusion criteria for respondents other than parents were as follows: (1) understanding the research topics and issues related to unintentional injuries in children; (2) research expertise in health management, child healthcare and other relevant fields, which includes scholars from colleges, universities and research institutes or practical expertise in unintentional injury prevention in children and child healthcare services, which includes professionals from hospitals, healthcare committees, disease prevention and control centres, community health service centres and other relevant departments.
The inclusion criteria for parents were as follows: (1) being parents of children aged 0–6 years old and (2) being the primary guardians of their children or living together.
Three rounds of semistructured interviews were conducted until no new theory appeared, starting with direct providers and recipients of child health management services and selecting respondents from the bottom up.
The first round of interviews aimed to understand the operational mechanisms of the current child health service network and the utilisation of unintentional injury prevention in child healthcare. We invited four childcare doctors and one manager of a community health service centre, one department director of the Shanghai Health Promotion Center, five parents of children aged 0–6 years, one member of the maternal and child healthcare centre management team, one CDC director and four experts as participants for the first round of interviews from October to December 2021.
After organising the results of the first round of interviews, the second round of interviews was conducted to understand the implementation biases of community childcare doctors, information asymmetry, conflicts of interest of all the parties involved, problems and influencing factors in implementing parental health education on preventing children’s unintentional injuries in the community at the practical level, and the reasons for the inactive behaviour of community childcare doctors in preventing unintentional injuries in children. We invited the following as participants: two childcare doctors of the community health service centre, seven parents of children aged 0–6 years, one member of the maternal and child healthcare centre management team, two members of the CDC injury department and two members of the Health Commission.
The second round of interviews was conducted between September and November 2022.
Based on the findings of the first two rounds of interviews, the third round explored the understanding of the problems and influencing factors related to the prevention of children’s unintentional injuries at the community level. Furthermore, the third round of interviews explored the reasons for the inactive behaviours of the community childcare doctors in preventing unintentional injuries in children and involved further interviews with higher-level institutions to provide potential solutions and suggestions. We invited two childcare doctors of the community health service centre, three parents of children aged 0–6 years, one member of the maternal and child healthcare centre management team, one clerk from the CDC injury department and one clerk from the health commission as participants. The third round of interviews was conducted from February to March 2023, and after the end of this round, the information reached saturation. A flow chart of the three rounds of interviews is presented in [figure 1](#F1).
Data collection
For the semistructured interview materials, the researchers uniformly drafted an interview outline ([online supplemental appendix 2](#DC2)), which was discussed by team members and reviewed by experts in the field of child healthcare before sending it to the interviewees in advance, followed by consultations and interviews.
Supplemental material
Before the interview, the interviewees were informed that the entire interview would be recorded, subject to their consent. The recording was transcribed and reviewed immediately after the interview. The key points of the interview were summarised to avoid information omission or errors caused by the Hawthorne effect. The interview manuscripts were summarised by the researchers and provided to other researchers in the team for verification. Once the verification was completed, the manuscripts were labelled with the time and location of the interview, participants, compiler of the manuscript and verifier to ensure the authenticity and completeness of the information. Semistructured interviews were conducted between October 2021 and March 2023. Each interview lasted for approximately 60–90 min. The interview recording was transcribed into text by two members of the research team to ensure accuracy. The research team for this study consisted of professor and graduate students in child health research, and doctors and experts in maternal and child health. These individuals had a thorough understanding of the research questions and possessed the skills to effectively analyse the data obtained.
Data saturation was completed at the end of the second round of interviews, as we found that no new topics emerged during the third round of interviews.
Data analysis
Guided by the grounded theory, the data of this study were analysed and refined according to the three levels of coding, and relevant elements and models were constructed.[15](#ref-15)
First, open coding was performed.[16 17](#ref-16) The researchers established the theme as parental health education by community childcare doctors related to preventing unintentional injuries in children. The collected data were broken down and reassembled by reading and analysing the original interview records. The phenomena mentioned by the interviewees were marked and assigned preliminary concepts, which were named and categorised to create new concepts under the research theme and coded to form domains. Abstracting and generalising the rich and fragmented interview data generated a preliminary list of concepts mentioned by the interviewers that may have affected the engagement of community childcare doctors in parental health education.
The second stage of axial coding further refined the domains initially formed by open coding, identified various organic connections between the main and secondary concept domains and clarified the internal relationships and logic between them to reorganise the scattered data and summarise the main domains.
Researchers organised various concepts based on a list of concepts obtained through open coding and identified key concepts as axes to form the main domains of this study, extracting the final elements used for model construction.
The third stage of selective coding focused on analysing the path relationships and relational structures between the main domains, serving as the process of building a model. It analysed how the elements interacted with each other and jointly influenced childcare doctors to conduct parental health education related to preventing unintentional injuries in children.
For quality control of data analysis in this study, to prevent error coding and other errors, the author initially encoded the data. Subsequently, other members of the research team selected a portion of the content for repeated coding and calculated the reliability coefficient to ensure the reliability and objectivity of the content analysis results.
Patient and public involvement
None.
Results
Basic information of interviewees
In total, 39 participants were included in three rounds of interviews ([online supplemental appendix 3](#DC3)). Among them, 15 were parents of children (38.46%), 8 were community childcare doctors (20.
51%), 12 were clerks or managers of healthcare delivery departments or health management departments (30.77%) and 4 were experts from hospitals or universities (10.26%). Among the parents of the children, 8 were mothers and 7 were fathers; 10 parents had a graduate degree or above, 5 had a bachelor’s degree and the average age was 32 years. Among the 24 experts, the average work experience was more than 10 years, and over half held a graduate degree or above.
Supplemental material
Data coding
In the open coding stage, we analysed the essential meaning of the interviewees’ discourse sentence by sentence and group the common concepts to extract 18 initial categories ([table 1](#T1)).
Parental health education model
Barriers and facilitators to providing parental health education for preventing unintentional injuries in children were identified from the perspective of community childcare doctors. Analysis of the interview data yielded four major domains that formed a set of elements, explored the relationships among them and formed the final theoretical model.
The elements that influence community childcare doctors to actively conduct parental health education for preventing unintentional injuries in children include four major domains: supplier-related factors, demander-related factors, direct support and indirect support.
The inner circle primarily consists of the suppliers and demanders of children’s health-related services. The interaction between suppliers and demanders is influenced and guided by parental health education intervention programmes. Their work environment influences the motivation of providers to provide parental health education intervention services, while their family environment influences the motivation and effectiveness of parents in accepting health education. The middle circle consists of the direct support required to ensure that community childcare doctors provide parental health education, which affects the elements related to suppliers in the inner circle, such as technical training and performance evaluation. The outer circle is an indirect influencing element for community childcare doctors to provide parental health education, often considered at the macro level, including aspects such as social culture, publicity and fundraising. The construction of the parental health education model (PHEM) for community childcare doctors related to the prevention of unintentional injuries in children mainly considers the support from various stakeholders required in the service provision process from the individual to the social level.
Supplier
Value
Value refers to the recognition of community childcare doctors towards parental health education. Community childcare doctors are responsible for many tasks and require genuine recognition of their work value to stay motivated in their guiding roles. As grassroots organisations, most of the work of higher-level health organisations is left to community health service centres, burdening them with undertaking multiple tasks, with remuneration and incentives unable to reflect their labour value. Many doctors expressed that they were concerned about and aware of the importance of their role in preventing unintentional injuries in children, ‘B01: Because I have a pediatrician background, unintentional injuries are a concern for me, as we have seen too many regrettable things in pediatric clinical practice, such as drowning.’ However, resistance to providing guidance arises due to overwork, underpayment and inadequate incentives, which do not fully reflect the labour value of medical personnel. ‘B10: Working as a doctor in the field of child healthcare is indeed very difficult, with limited funding and complicated tasks. Salary and incentives cannot reflect their labor values, so it will be very contradictory in terms of concepts.
’
Skill
Skill refers to the professional knowledge and competence of community childcare doctors, which is a prerequisite for effective parental health education. Professional competence and responsibility are lacking, with a limited number of child healthcare doctors, which constrains the implementation of guidance work. ‘B01: Many communities only have 1–2 doctors; they cannot cope with so many children in a limited time. Moreover, some of them may still have problems with their business skills and responsibility.’
Behaviour motivation
Community childcare doctors face many concerns when performing their duties, such as heavy workload, inability to balance various tasks, and potential risks in guiding against unintentional injuries in children. Therefore, relieving physicians’ concerns and motivating them to provide guidance is necessary. Community childcare doctors undertake multiple collaborative tasks such as physical examinations, health screening and health guidance, all of which aim at promoting children’s health. However, the number of doctors is usually insufficient, with heavy tasks affecting their motivation. ‘B01: I think the biggest problem should be that there are too few childcare doctors and not enough time.
’ ‘B07: Community childcare doctors have a heavy workload and may not have time to guide parents in preventing unintentional injuries.’ Time and energy constraints have led them to devote more time and energy to tasks that can be highly supervised, such as physical examinations, objective data filling, and mandatory assessment indicators.
Some community childcare doctors who used to be clinical doctors are concerned about the serious consequences of unintentional injuries in children; therefore, they consider preventive measures to be important. However, they all stated that they had to make choices concerning their work owing to the unreasonable planning of work content because they lacked the behavioural motivation to educate parents in preventing unintentional injuries in children. ‘B01: There are no specific requirements or specific implementation measures within our system. Since there is no specific content, we will plan the work ourselves, but we are reluctant to say too much and will only briefly mention this issue.’
Community childcare doctors have cited the potential risks involved in instructing parents on children’s unintentional injury-related content as a key reason for weakening their motivation.
If parents follow the guidance of a doctor in the event of an accident, the doctor may be held legally responsible if problems arise. This fear may lead doctors to hesitate in providing guidance, ultimately neglecting their work on preventing unintentional injuries in children. ‘B07: If the guidance is unsatisfactory and some parents with worse attitude will say, ‘That is how the community childcare doctor taught me, and our child had problems. which is actually difficult to deal with. Community childcare doctor may accidentally take responsibility, so they are not willing to take the initiative to guide parents.’
Work environment
Working environment refers to the mutual influence and working atmosphere of community childcare doctors. During the interview, community childcare doctors generally indicated that they work in an environment where people do not pay enough attention to guiding parents in preventing unintentional injuries in children. They will not actively provide health education, but if a doctor starts to initiate such efforts, they will be influenced, ‘A04?Nobody will do it. The current work atmosphere is like this, but someone may casually mention it; if I hear that when parents come to ask, I will also remind them in the meantime.
’
Demander
Beliefs
Parents’ beliefs are reflected in two aspects: they realise that preventing unintentional injuries in children is an important part of ensuring their healthy growth; however, they realise that they are primarily responsible for keeping their children safe and can ensure their safety. Learning, growth and development of children are considered the primary responsibilities of parents, while the prevention of unintentional injuries is not. ‘B03: I think the cognitive and physical development of children, as well as their moral character and learning, are my main responsibilities.’
In addition, parents fail to recognise the risks of unintentional injuries, such as underestimating the likelihood and severity of injuries. Some parents lack responsibility for or attribute unintentional injuries to fate, resulting in their inability to identify risk factors and take measures against injuries proactively. Many parents do not realise that they are the first person responsible for the safety of their children. When parents are not around them, they assume that whoever is around the child is responsible if the child is injured in an accident. ‘B03: If an accident occurs when a grandparent or babysitter takes a child out and I am not present, it must be the responsibility of the person with the child because I may have advised him at the beginning.
’
Interaction
Interaction refers to the positive give-and-take between community childcare doctors and parents rather than the unidirectional knowledge output from community childcare doctors or inquiries from parents when guiding child injury prevention. From the parents’ perspective, they wish to receive more guidance from community childcare doctors and learn more about scientific parenting, including the prevention of children’s unintentional injuries and how to provide first aid after injuries occur. However, community childcare doctors need information about the occurrence of child injuries and parents’ knowledge and behaviours, to provide them with the necessary guidance. This interactive process requires periodic reciprocation, akin to a spiral progression. However, community childcare doctors often leave the content of their guidance to parents’ discretion and lack interaction with parents in practice owing to time constraints and insufficient guidance materials. An example of such guidance is, ‘1-year-old children are prone to falls; parents should pay attention.’ Interactions with parents are more focused on traditional topics, such as feeding, with little mention of injury prevention.
‘A01: Nowadays, parents ask more questions about their children’s illnesses, for example rashes, or about feeding, such as whether their children have lost weight or gained weight. But parents rarely ask about the injuries.’
Learn
Learning refers to the process through which parents acquire the knowledge and skills they need from community childcare doctors. The current problem is that parents usually do not take the initiative to learn about preventing their children’s unintentional injuries. Therefore, preventive measures are usually based on common sense and life experiences or knowledge gained from communication with colleagues and friends. Learning about the prevention of unintentional injury is passive. ‘B03: We seldom take the initiative to study because, in our opinion, accidental injury is a small probability event. In addition, we are also busy at work, so we do not have time to learn. Knowledge of prevention also includes some experience in life or common sense, or communicating with colleagues or friends, which is also a kind of passive learning. Another possibility is that sometimes I may receive some push or video on the phone, which can also be considered passive learning.
’
Custody
Custody refers to a change in the behaviour of parents after receiving health education, which is one of the direct outcomes that community childcare doctors focus on when providing guidance and subsequent follow-up. The current challenge is the absence of parents in the upbringing of children, ‘B05: Nowadays, people’s lives are so stressful and fast-paced that the caregiving responsibilities of many parents are transferred to babysitter elderly people.’ When parents are not direct caregivers, they should be encouraged to participate in preventing unintentional injuries to their children.
In addition, attention should also be paid to the problem of ‘custody without caring.’ Parents are often by their children’s side at the time of the occurrence of some high-risk behaviours. However, momentary distraction or inattention may lead to accidents, ‘B03: Sometimes I may look down to reply to a message, but as soon as I look up, the child runs away and disappears. Fortunately, there were no accidents.’ Therefore, special attention should be paid to the simultaneous existence of parent custody and caring in the process of health education. The direct purpose of conducting parental health education is to ensure changes in parental behaviour.
Family environment
The family environment implies that parents who have received health education are expected to influence the behaviours of their children, such as reducing child-initiated high-risk behaviours. Additionally, they are expected to influence the custody behaviours of other child caregivers to form a positive family atmosphere. The most prominent feature of the eastern cities is that children have more than one caregiver. In the process of caring, how grandparents or babysitters take care of children is unclear because the parents are not around. ‘A07: It is not the same in different cities. After the birth of a child in Shanghai, grandparents may come to take care of them, which may lead to a weaker responsibility of the parents.’
Communication between parents and other caregivers is lacking. They do not specifically explain the prevention of unintentional injuries when transferring their children to other people for care. They will ask about the child’s situation at the end of the day, but they will not communicate in detail if nothing serious has happened, and parents are accustomed to ignoring prevention. ‘B03: When the grandparents take care of the child, I may advise them to give the child more opportunities and space for activities.
For his age group, I may focus on the scope and frequency of activities, but I will not be particularly accountable for unintentional injury prevention.’
Direct support
Training
Training aims to improve the professional skills required by community childcare doctors to provide parental health education, including knowledge related to the prevention of children’s unintentional injuries, first-aid skills, personal role recognition and other aspects. Community childcare doctors undergo various types of training; however, few specialised training programmes are related to the prevention of unintentional injuries in children. ‘B02: The Maternal and Child Health Care Center will provide training for us, but not all of the content can be covered during the training program because there are too many topics, some of which are done in conjunction with the research projects, and some of which are routine. When unintentional injuries occur, special meetings will be held to discuss them, but there will be no special lectures related to children’s unintentional injuries.’ Community childcare doctors should be regularly provided with specialised training in unintentional injury prevention.
Experts in relevant fields or clinical doctors with professional knowledge can be invited to increase community childcare doctors’ awareness of the value of their role, increase their knowledge of child injury prevention, and reduce the avoidance of providing guidance owing to fear of guidance errors.
Cooperation
Cooperation refers to the collaboration between community childcare doctors and other department workers within the community or support department workers outside the community, including optimising children’s health electronic systems and improving cooperation efficiency through information technology. Community childcare doctors receive work instructions from their superiors in different lines of the department; however, a lack of communication between the different lines of work leads to work conflicts. ‘B10: when I carry out my project in the community, the doctor will feel that there is one more thing. The work of coordinating with hospitals is already very complicated, and doctors also need to coordinate with the CDC, in addition to undertaking the work of national monitoring and Shanghai municipal monitoring. As far as I know, there are duplicate indicators in the work of doctors that need to be reported several times.
’ This indicates that a lack of communication and cooperation between different departments leads to confusion in the work of community childcare doctors. This may result in insufficient time to repeat work, resulting in a significant loss of work efficiency. Therefore, establishing a unified electronic system for child healthcare, especially for reducing unintentional injuries, is crucial.
Incentive
To increase the motivation of community childcare doctors in providing parental health education, managers need to implement corresponding incentive measures to ensure the sustainability of education, such as setting reasonable assessment standards, forming assessment indicators and setting reward and punishment mechanisms based on assessment indicators. Parental health education is not a priority at this stage. No objective or mandatory assessment indicators exist, and the assessment results are not linked to salary, which, in their opinion, increases their workload and wastes time. Therefore, community childcare doctors devote less time and energy to tasks with low marginal returns. ‘B01: We will assess the rates of certain diseases, such as malnutrition rates, obesity rates, and anemia rates, and physical examination will be based on objective indicators.
The assessment of unintentional injury depends only on whether the doctor guides it; there are no corresponding objective and mandatory assessment indicators.’ ‘B10: The assessment is not related to the doctor’s salary, and theoretically, there will not be any situation of the deduction of salary due to poor performance, but we will organize our competitions on health education material for community doctors to provide appropriate incentives, but not penalties.’
Intervention programme
Parental health education provided by community childcare doctors should be guided by a clear intervention programme that includes the overall goal of the intervention, target population, intervention design, intervention content, intervention tools (such as providing reference materials for community childcare doctors), intervention timing and frequency, implementation of the intervention and evaluation of the intervention. Professional injury prevention departments should design intervention programmes to guide community childcare doctors. Community childcare doctors only inquire about the occurrence of unintentional injuries when guiding parents to prevent them and provide a general description of the prevention of individual types of unintentional injuries, lacking specificity.
As a result of the lack of guidelines for preventing unintentional injuries in children, doctors do not know how to provide guidance to parents or whether their guidance is correct, particularly in terms of first aid skills, ‘B02: There are detailed and authoritative policies or guidance materials on physical examination, health screening, and feeding guidance, as well as clear evaluation indicators, follow-up systems, and instruction manuals, so we will become more proficient by using these materials to support our work; however, guidance materials on unintentional injuries seem to be non-existent’. The intervention programme, a blueprint for community childcare doctors to provide parental health education, is an essential auxiliary tool in practice.
Indirect support
Culture and publicity
Chinese parenting has attached great importance to feeding, diseases, belittling injuries and disease prevention. The importance of preventing unintentional injuries in children is gradually being recognised; however, official guidance is still lacking, and the overall approach remains unchanged. Failure to effectively promote the role of child healthcare to parents results in them being unaware that child healthcare includes guidance on unintentional injury prevention, leading to a lack of parental supervision.
The lack of awareness among parents of their entitlement to guidance on this aspect of child healthcare limits the transmission of guidance to parents, even when the necessary condition and intentions for parental health education are in place. ‘A12: Overall, in fact, parents still do not have a complete awareness or concept of unintentional injuries, not as obvious as the obsession with food or milk formula. It may be because of the issue of opportunity for unintentional injuries to occur. In contrast, calcium deficiency is more likely to happen.’ ‘B03: For the doctors’ advice, I actually pay more attention to scientific feeding as it is related to the growth and development of children. What I may want to know more about is some knowledge about children’s growth and development.’
Evaluation system
From a macroperspective, higher-level managers must evaluate and supervise various institutions and organise timely supervision and inspections. The interview results revealed that the director of the maternal and child healthcare centre district lacked understanding and supervision of the operation of community health service centres and was unable to fully grasp all information on how community childcare doctors guide parents to prevent unintentional injuries in children.
The district maternal and child healthcare centre supervise the work of community childcare doctors every 6 months, with long intervals and low frequency, and no actual impact on the results of the evaluation, ‘B01: At present, there is no corresponding reward and punishment mechanism for the evaluation results of various types of child health care work. The child health care work was ranked by 13 communities; however, those individuals involved in delivering child health care worked very hard and the rigid ranking results were discouraging.’
The existing evaluation system only focuses on whether parents are provided guidance on preventing unintentional injuries in children and does not assess the quality of the guidance, ‘B10: In our information system, it is not mandatory to provide guidance on unintentional injuries.’ Each district ranks community health service centres for their work on child healthcare; however, because of the lack of strict and reasonable evaluation indicators for guidance on unintentional injury prevention in children, the ranking results naturally do not affect work motivation, leading to a perfunctory attitude towards this aspect of the work. Guidance results are usually filled in subjectively, and the authenticity must be examined.
‘B10: This evaluation result is not linked to the doctor’s salary because the community is managed by each unit individually. Our Maternal and Child Health Care Center only provides guidelines for work precautions, and there is no additional financial support or punishment for doctors.’
Legal system
The legal system refers to the legislative framework protecting children’s safety and preventing unintentional injuries. Strengthening legislation and law enforcement efforts in the field of child injury prevention and control is necessary. China’s current legal system suffers from the problem of being ‘too abstract, emphasizing principles excessively and overlooking practical applicability.’ When parents fail to fulfil the necessary care and supervision responsibilities, resulting in injuries to children, they are usually not penalised, and parents also lack knowledge of the relevant laws. ‘A16: I think taking care of children should be more of a parental responsibility and obligation. As for legal regulations, intentionally hitting a child and causing serious consequences or abandoning the child is definitely illegal. But I do not think there is such a detailed legal regulation on taking care of children, and it is also impossible to regulate it.
’ ‘A17: The national traffic laws are inadequate. They do not require children to sit in safety seats on highways, or specify the consequences of not ensuring that children do so, and I do not force him if he does not want to sit in it.’
There is no connection in community parental health education between legislation, the community and the target intervention objects. This results in a lack of implementation of national legislation in the community with a disconnect between the legal provisions and the content of community practice. What the community does is spontaneous or based on relevant policies that are distinct from the law. ‘A04: Our work will be promoted according to some operational norms or policies, but not yet at the legal level. There may be some macro legal provisions in the country, but there are still differences with the specific work content we implement.’
Financing
Financing refers to the level of fundraising across community institutions and the internal allocation of funds to ensure sufficient financial support for related work. At the present stage, the financing sources for community health education are mostly subject funds or funds from higher level management units, which introduces the challenge of education being task-oriented and often transient, and the implementation unstable and unsustainable, ‘A12: When there are funds allocated from the higher unit or conducting research projects, the requirements for education are relatively high, and even doctors will be sent to control quality.
However, once the project is completed, practice may not be sustained.’ ; ‘A12: If I can remember, I will send a pamphlet to parents while the subject is in progress, but there will be no other funds to support this work if the pamphlets run out.’
Injury surveillance
The surveillance of unintentional injuries in children is relevant to the focus of community childcare doctors in parental health education. The results of the surveillance indicate the current trends in unintentional injuries in children to provide targeted interventions. Owing to the different characteristics and risk factors of different types of injuries, differences inevitably exist in the intervention programmes, skills required by doctors and parents, and other aspects. Surveilling, reporting and evaluating unintentional injury events during the child’s growth and development, promoting standardisation of data and strengthening personalised guidance are potential future development trends. ‘A02: The current focus of our work is still on the surveillance of children’s growth and development, such as scientific feeding, physical examination, and so on. Regular follow-ups will also be conducted, including follow-up of subjects keeping dietary records.
However, there is no systematic record or regular follow-up of unintentional injuries. I think it can be strengthened in this regard.’
Discussion
This study examined the elements necessary for community childcare doctors to provide parental health education related to preventing unintentional injuries in children and constructed a model to provide a theoretical basis for improving the motivation of community childcare doctors.
In the prevention of unintentional injuries in children, we already known through existing studies that the knowledge and behaviours of parents or guardians play a key role, and we can provide relevant health education or interventions to parents to improve their basic health knowledge and promote their adoption of positive behaviours.[18](#ref-18) However, there is a lack of systematic summary of the barriers and facilitators to the effectiveness of health education or interventions. We found that the effectiveness of health education varies among individual parents, and that their beliefs, learning abilities and objective custody conditions influence the effectiveness of health education. The effectiveness of health education is also related to the individual characteristics of community childcare doctors who provide health education, including their values, skills and working conditions.
In addition, external factors such as training, incentive measures, social culture also have a direct or indirect impact on the effectiveness of health education.
We discovered that providing parental health education based on stakeholder findings requires consideration of the first level of elements related to suppliers and demanders and other support elements at higher levels. It involves higher-level managers and partners with the same work content in other lines. A study based on evidence from the WHO in the European region[19](#ref-19) highlighted the importance of promoting multisectoral collaboration to develop a national water safety plan to advance drowning prevention for children under 5 years. However, the goal of emphasising higher-level support elements remains to focus on community childcare doctors and assist them in performing their work and providing support.
We discovered that to conduct parental health education actively, the immediate internal elements of suppliers and demanders, which are relatively internalised parts of the equation, should be considered. Inner identity is a significant internal element of both the supplier and demander, manifested as a sense of value in the supplier and belief in the demander.
Ablewhite et al
[20](#ref-20) proposed a major theme for individual parents from the demand side perspective that would hinder or promote children’s unintentional harm in the family, including risk awareness. Based on research conducted in the USA, Moon et al
[21](#ref-21) reported that only 55% of caregivers received correct advice on preventing accidental suffocation in children during healthcare visits, indicating that even professional healthcare professionals lack awareness regarding the prevention of unintentional harm to children. Second, the model emphasises the importance of competency elements, whereby professional skills are required to provide health education, whereas the demander needs to possess the learning ability to receive health education. The supplier’s professional skills ensure that the guidance content conveyed to the parents is correct and useful. Providing guidance is a manifestation of a supplier’s skill. The complexity of the work content tests the efficiency of childcare doctors, and they must master how to provide guidance services efficiently. These skills are objective competencies that community childcare doctors must possess. Based on research in low-income South African communities, Schwebel[22](#ref-22) found that effective communication with caregivers is essential for preventing unintentional injuries in children under 7 years of age.
The author suggested that studies on health professionals is also necessary, as they are important information sources for parents and also often lack knowledge regarding child injuries. Parents’ learning must occur with sufficient frequency and intensity to be effective. Objective differences exist between the perceptions of parents and those of community childcare doctors; therefore, if parents are only given casual instructions, such as ‘Pay more attention when the child rolls over’ and ‘Do not make the bath water too hot,’ it can lead to problems as parents may lack genuine concern due to insufficient emphasis on the importance of these actions. We need to recognise this objective factor, which can affect parents’ learning behaviours. Additionally, the need for the supplier to be motivated to provide guidance corresponds to the need for the demander to communicate actively. The environment is also an element that affects both suppliers and demanders; the work environment of community childcare doctors can serve as an important tool for education,[23](#ref-23) and the family environment is a significant influencing factor for child safety. Finally, parent supervision measures, as an external manifestation of internal elements, have always been considered important.
[24 25](#ref-24)
The elements of direct support that we emphasise have a direct impact on the implementation of health education services on the supply side. At this level, the elements we propose are not restricted to the intrinsic nature of one type of subject but rather we consider how to approach other subjects and provide external element support to influence the intrinsic elements of health education providers. We propose training as an element of direct support to improve the skills of community childcare doctors, incentives as an element to enhance the sense of value and behavioural motivation, an intervention programme as an element of security to ensure that parental health education is conducted in a planned and organised manner, and cooperation as an element to improve the efficiency of health education by connecting departments with similar work content to achieve information sharing, provide support to each other and increase communication and cooperation. A study by Morrongiello in the USA[26](#ref-26) concludes that intervention targeting adult supervisors are critical, proposing existing ways to improve the intensity, frequency and quality of adult supervision of children.
The indirect support elements we emphasise affect the suppliers and demanders of health education at the macrolevel, primarily based on a social perspective. The cultural and policy environments cannot be ignored in guiding our work. A wealth of clinical research exists; however, there is a lack of public awareness about these studies. Therefore, increasing public awareness campaigns through official channels is urgently required to raise awareness among parents of the importance of preventing unintentional injury in children and the currently available services. The improvement of the evaluation system is conducive to forming good competition among communities, encouraging them to learn from each other and make progress together, establishing a feedback mechanism for public surveillance results and forming a positive social environment conducive to public surveillance. The development of a legal system allows the enforcement of the operations of community childcare doctors. In developed countries, laws have operational rules that have a binding effect on parents, doctors and other parties.[27 28](#ref-27) China must explore the promotion of practical work at the national legislative level.
Legal requirements and prohibitions can promote changes in the environment and behaviour of parents and community childcare doctors to provide a legal basis for the development of parental health education. A study by Nazif-Munoz et al
[29](#ref-29) in Israel demonstrated the effectiveness of legal/legislation and infrastructure modification in reducing traffic-related injuries and falls. Community childcare doctors must follow them at the institutional level to promote the protection of child safety. Financing is an important material support,[30 31](#ref-30) and community childcare doctors need stable and long-term financial support to provide parental health education. We discovered that injury surveillance is an important part of the closed-loop implementation of health education work, as the guidance content can be adjusted based on surveillance results and continuously improved. A study conducted in Ethiopia[32](#ref-32) also concludes that it is necessary to develop an injury surveillance system at health facilities.
Limitations
In terms of methodology, this study used key informant interviews and grounded theory in qualitative research. It must be acknowledged that the final conclusion of qualitative research may be affected by subjective tendencies of both the researcher and the interviewee.
Although we have interviewed as many different individuals as possible, the PHEM obtained in this study needs to be further validated through quantitative investigation and analysis to verify the relationships and pathways between different dimensions.
In addition, the source of participants for this study was limited to the eastern region of China. However, the eastern region is in a leading position nationwide in terms of development, so the results of this study may not be representative of the whole country.
Conclusions
This study contributes to the understanding of the factors affecting the motivation of community childcare doctors by examining the elements affecting their delivery of parental health education related to the prevention of unintentional injuries in children. We constructed a theoretical model of the elements required to deliver parental health education which identified the factors affecting the effectiveness of parental health education at the individual and social level, suggesting practical insights into considerations for real-world realistic interventions. For suppliers, professional skills are the fundamental guarantee for childcare doctors to provide parental health education, but skills alone insufficient, they also need to be motivated, both are indispensable.
For demanders, holding the belief that preventing unintentional injuries to children is a top priority, and parents need to fully recognise its importance in order for education to be meaningful. In practice, we must consider not only individual factors, such as personal skills, but also the influences on individual factors, such as the willingness of suppliers to be influenced by their performance evaluation, which require macrolevel intervention measures. Thinking logically from individual to social level is necessary and valuable. We believe that the PHEM can guide intervention designs to enhance the enthusiasm of community childcare doctors for providing parental health education. Designs of both self-intervention and external intervention are encouraged, and more attention should be paid to factors that may hinder change, as informed by the PHEM. Future research will focus on the PHEM model to conduct a series of studies, such as health education interventions to enhance parental literacy and training interventions for community caregivers.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved (IRB#2021-10-0921) by the Medical Research Ethics Committee, School of Public Health, Fudan University (IRB00002408 and FWA00002399) on 14 October 2021.
Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors would also like to acknowledge the participants of this study for generously sharing their time and opinions on the provision of parental health education by community childcare doctors. We also thank all the residents for their participation. We thank Editage (www.editage.cn) for English language editing.
Footnotes
Contributors All authors made substantial contributions to the conception and design of the study, acquisition of data, and analysis and interpretation of data. KC contributed to data acquisition, analysis, interpretation, drafting and revision of the manuscript. QZ contributed to data acquisition, analysis, interpretation and the conception, design, drafting and revision of the manuscript. JX contributed to data acquisition. YF, QX and JZ contributed to the revision of the manuscript. JL contributed to the study design. XL contributed to data acquisition and interpretation, and conception, design, and revision of the manuscript. XL acted as guarantor.
Funding The project was supported by the National Natural Science Foundation of China (nos. 71974037 and 71573049), the National Social Science Foundation of China (no.
17ZDA078).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
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