Child health promotion and its challenge to medical education

Doctors need practical preventive skills they can use in clinical settings

The recently published recommendations for a national programme of child health promotion1 provide a structured framework for addressing the primary prevention of many of the major causes of illness and disability in preschool children. This is the latest in a series of important statements from the British Paediatric Association (now the Royal College of Paediatrics and Child Health) working party on child health surveillance.2 3 It repeats earlier calls for a targeted programme of secondary prevention measures, selected on the basis of evidence of efficacy, together with a greater emphasis on health promotion. Taken together, these reports represent a major change in the role of community child health services away from mechanistic attempts at early detection of developmental and other problems towards a more holistic approach to child health. They also have important implications for the way that clinicians are trained.

Perhaps the most radical departure is the suggestion that the term child health promotion is a more appropriate title for the programme than child health surveillance, which would be that part of the programme concerned with secondary prevention by early detection.1 The report emphasises the need for more resources for primary prevention and the opportunities for health education which could be given by doctors at various stages of the life cycle, beginning in pregnancy (and preferably before conception) and continuing throughout childhood. Examples include giving advice about immunisation, reducing the risk of cot death, encouraging breast feeding, dental prophylaxis, avoiding passive smoking, avoiding behaviour problems, and accident prevention. If accepted by the relevant professionals the proposed child health promotion programme will require those working in community child health services to develop skills in individually oriented health promotion techniques, notably health education, along with the more familiar forms of clinical prevention such as immunisation and screening. Inevitably this has implications for the content of undergraduate and postgraduate medical education.

In most medical schools health promotion is covered, to a greater or lesser extent, in the public health course. In Britain and many other countries this teaching tends to be self contained, with few points of contact with other disciplines. Indeed, public health has become so separated from clinical instruction that its relevance in the medical course has been questioned.4 As a result most medical students are unlikely to acquire the knowledge and skills necessary to apply epidemiological and preventive principles to clinical settings such as child health promotion. As postgraduates too, doctors have few opportunities to undertake training which includes a strong element of clinical prevention. To date the input of public health disciplines to the training programmes of community based clinical specialties (including community child health and general practice) has been minimal.

The General Medical Council (GMC) appears to have recognised the need to reinforce the role of public health in the training of tomorrow's doctors.5 The main challenge facing medical educationalists is one which the GMC may have underestimated: to provide students with practical preventive and health promotional skills that they can use in clinical settings, rather than merely theoretical knowledge of epidemiology and related fields.6 This is a difficult task that calls for an injection of ingenuity and innovation into the teaching of both public health and clinical practice to emphasise their interdependence as well as their differing perspectives. Role models are few, but the integration of epidemiological and public health teaching with clinical instruction has been achieved successfully at schools in Canada,7 the United States,8 Israel,9 and elsewhere.

With few exceptions, British medical schools have been reluctant to accord public health a central presence in the clinical curriculum. Part of the blame may lie with public health teachers themselves, many of whom regard their subject as exclusively population based and therefore outwith the clinical domain. These attitudes must change urgently if all British children being born in the 1990s are to benefit from the range of preventive, educational, and clinical skills that will be required of doctors to meet the objectives of child health promotion and other preventive programmes. The first step is for those responsible for developing undergraduate and postgraduate teaching in paediatrics, general practice, and public health to recognise the necessity to work together to help students acquire these new clinical skills. The GMC's initiative presents a rare opportunity for curriculum planners to respond positively and imaginatively to the challenge.