Integrating primary health care and education to improve outcomes for children

Welcome to this special issue of the Australian Journal of Primary Health, which focuses on school-based models of primary health care to improve health and education outcomes for children and young people. We have brought together a collection of research papers and a forum article that address innovations in providing primary health care to school children.

Childhood health and development are strong predictors of future health, educational, financial and social outcomes. The importance of supporting the healthy development of children is particularly pertinent for children from disadvantaged backgrounds, who are much more likely than their more advantaged peers to have health problems that may impact on their ability to engage effectively with education. There are now more students with complex health and developmental needs entering mainstream schools because education systems have moved towards more inclusive models of education in recent decades. At the age of school entry, just under one-quarter of all children entering school between 2009 and 2018 were described as developmentally vulnerable. However, when the data were separated by socioeconomic group this rose to 32% in the most disadvantage group compared with only 15% in the most advantaged group (AIHW 2020). Having a disability or being identified as developmentally vulnerable does not need to automatically result in poor outcomes. With additional support from both the education and health sectors to address the needs of these children and their families it is possible to maximise their health and educational outcomes, and the successful integration primary health care and education may be a potential solution.

Recent policy developments have occurred in Australia to support children in school by enabling primary healthcare services to operate in schools with their education counterparts. For example, in 2017 the Victorian government provided A$43.8 million to fund doctors in schools (https://www.education.vic.gov.au/Documents/about/programs/health/DoctorsinSecondaryFactSheet.pdf, accessed 12 April 2021) and in 2020 the New South Wales government provided A$46.8 million to fund Wellbeing Health and In-reach Nurses (WHIN; https://www.health.nsw.gov.au/news/Pages/20201116_00.aspx, accessed 12 April 2021) to identify and triage health needs of children and provide care co-ordination. Further developments in Victoria include the goal to increase the number of mental health professionals in schools, and there have been increases in the funding for school counselling services in other states. In 2019, the Australian Nursing and Midwifery Federation (ANMF 2019) published their national standards for school-based nursing services. However, formal evaluations of these programs are yet to occur, so it is still unknown whether these initiatives are effective at supporting the health, well-being and educational attainment of children in Australian schools.

This special issue brings together research and reports of innovation that have been undertaken in schools or with school-aged children. There are four papers that describe the implementation, experiences and outcomes of integrating primary healthcare services in public schools, mainly primary schools and one secondary school model. All were established to address inequity in access to health care for children from disadvantaged backgrounds, with the aim not only to improve health outcomes for the children and families but also to support engagement of children in education to reduce the impact of socioeconomic disadvantage. There are two papers that report on different aspects of an innovative program to embed primary healthcare nurses into public schools across Broken Hill, NSW. A forum paper explores the public health advocacy role of primary healthcare nurses based in this school, the challenges they face and the opportunities to effect and sustain change in this vulnerable school age population (Jones et al. 2021). A second paper reports the qualitative findings that explore the role of the primary health nurses and the experiences of the nurses and education staff working in the integrated learning support and nursing teams (Sanford et al. 2021). A different model of integrating primary healthcare professionals and education professionals is presented in the practice and innovation report of the Our Mia Mia (OMM) program in rural NSW (Mendoza Diaz et al. 2021). Again, this service targets a disadvantaged population of children, approximately half of whom identify as Aboriginal or Torres Strait Islander. This model consists of a bulk-billing multidisciplinary health hub located in a public primary school. The location of these services in public primary schools means children and their families can access the hub with minimal time away from the classroom. The final paper reports on the longer term experiences of the learning support education team and primary health nurses who have been working together in an integrated model in a high school serving a disadvantaged population in south-west Sydney for close to 10 years (Noon and Zadkovich 2021). This service started as a primary care nursing-led model of care that has become more multidisciplinary over time.

Providing education professionals with the skills and resources to identify and refer to appropriate services is another way of integrating health services with education to improve outcomes for vulnerable populations is to provide professionals. A study from Victoria describes an educational intervention for education professionals working in schools with high numbers of children from refugee backgrounds (Long et al. 2021). The education sessions focus on available health services for people from refugee backgrounds so that they can act as links between the educational and local health services.

Providing health care to adolescents is challenging as they are less likely to engage with health services. There is also the complex issue of ensuring privacy, especially with the use of electronic health records (Beaton et al. 2021). A qualitative study explored these issues from the perspectives of the adolescents, and school health staff from a high school in Victoria. Understanding the concerns and e-health literacy of the students is important to ensure that health services are responsive while also respecting privacy.

The development and evolution of school-based models of primary will continue with the roll out of funding in this area. Careful and timely evaluation of the impact of these policy initiatives and innovations in this area will be essential to identify the models and approaches that best meet the needs of the children and their families to address social determinants of educational achievement and health.

SD is an author on one of the papers in the Research Front but had no role in the peer review or acceptance of the paper.