Are Parent-Held Child Health Records a Valuable Health Intervention? A Systematic Review and Meta-Analysis

Parent-held child health record (PHCHRs), a public health intervention for promoting access to preventive health services and fostering communication and education around these services, have been in use in many developed and developing countries for decades. There are 2 main types of PHCHRs: the Child Personal Health Record (CPHR) and the Maternal and Child Health Handbook (MCHH). This review examines the value of these records in terms of parents' frequency of use/views of them, as well as their impact on parent health knowledge and health-related outcomes.

Common major themes across the PHCHRs include keeping up to date with immunisation, documenting diseases and health events, and monitoring growth changes and developmental milestones. The PHCHRs are given to all parents during pregnancy or at the birth of the baby, which enables periodic monitoring of children health and development. The central aim is to ensure optimum continuity of care, while at the same time serving as a means of communication between parents and professionals and as a public health education tool. The records can be in an electronic form that is accessible to parents or a hard-copy document that is kept by parents at home.

From April through June 2018, the researchers searched PubMed, PsycINFO, CINAHL, Cochrane Library and Google Scholar to identify relevant articles, of which 32 studies (31 of which were quantitative) met the inclusion criteria. The overall population size was 15,399 parents of children 0-5 years. Due to considerable heterogeneity, findings were narratively synthesised. Outcomes with sufficient data were meta-analysed using a random-effects model. Odds ratio (OR) was used to compute the pooled effect sizes at 95% confidence interval (CI).

Nineteen of the studies were conducted in high-income countries, or HICs (Australia, France, Germany, Norway, New Zealand, Singapore, United Kingdom (UK), United States), 4 in high-middle-income countries (Brazil, South Africa), 8 in low-middle-income countries (Vietnam, Bangladesh, Palestine, Mongolia, Kenya, Indonesia, Cambodia), and 1 in a low-income country (Uganda).

Selected findings:

• The pooled effect of the PHCHR on the utilisation of child/maternal healthcare was not statistically significant (OR = 1.31, 95% CI 0.92-1.88).
• Parents who use the record in low- and middle-income countries (LMICs) were approximately twice as likely to adhere to child vaccinations (OR = 1.93, 95% CI 1.01-3.70), utilise antenatal care (OR = 1.60, 95% CI 1.23-2.08), and practice better breastfeeding (OR = 2.82, 95% CI 1.02-7.82).
• Many parents (average of 72%) perceived the PHCHR as useful/important, and the majority (average of 84%) took it to child clinics. Young mothers are more likely to use/value the record than mothers with previous pregnancy experience.
• A qualitative account of some parents (34 women and 1 man) considers the child record as a foundation towards establishing a long-term relationship between them and nurses, as well as a means of positive attributes between the mother and the child.
• Qualitative interviews with 20 mothers indicated their satisfaction with the book due to its appearance, practical information, convenience, long-term value, size, and illustrations. However, some parents (average 48%, range 25.1%-59.3%, n = 3) in both LMICs and HICs favour adding more illustrations/pictures to aid understanding.
• A significant proportion of parents (average 40%, range 24%-56%, n = 2) indicated not being asked to present the PHCHR, while 89% think the PHCHR would be more useful if professionals showed interest.
• Health visitors and nurses/midwives were more likely to use the record than hospital doctors.
• PHCHR effect on parent-professional communication showed no significant overall effect in 2 studies, although one study reported better communication with health visitors (specialist community public health nurses in the UK) compared to general practitioners (GPs).
• While there are generally insufficient studies to conclude the effect of PHCHR on mother/parent knowledge, MCHH is likely to influence awareness on early rupture of the membrane and breastfeeding in LMICs.

In short, the overall findings indicated that the PHCHR is used and perceived by the majority of parents as an important document for child care. However, there was no significant effect of the PHCHR on the utilisation of child/maternal and child health (MCH) care nor communication with professionals. Beneficial effects of the record on knowledge and health outcomes were in LMICs, whereby a positive relationship was found with child immunisation uptake, vitamin A supplement uptake, child growth/development, knowledge and practice of both antenatal care (ANC) and breastfeeding, and awareness of pregnancy danger signs.

To look at one of these findings in more depth, the positive relationship between the use of the PHCHR and child immunisation uptake found in LMICs may be connected with the fact that resistance to immunisation in many HICs is quite low compared to LMICs. Accordingly, both studies that assessed the effect of the PHCHR on immunisation uptake in the HICs showed no overall effect. The positive association in LMICs could be the result of poor awareness about immunisation; the PHCHR is likely to educate parents about importance of immunisation. Although findings from this review indicated only one study that reported the effect of the PHCHR on parent knowledge of immunisation, the study showed a positive effect.

The finding that health professionals, particularly hospital doctors (GPs, paediatricians, casualty doctors) were less likely to ask for the record or make inputs during consultations suggests that there is need for proper orientation among the professionals to be more committed to using the record. This in turn should result in the proper use of the record by parents, as they tend to value health information that comes directly from their healthcare providers.

In conclusion, parents generally value the PHCHR, but its effect on child health-related outcomes has only been demonstrated in LMICs. However, the findings also have implications in HICs, where the record is valued and used by the majority of parents. The study thus recommends: more commitment of health professionals toward the use of the record, wide adoption with more studies to assess parent use/views of the record book in LMICs, and, finally, more studies that investigate cause-effect relationships in HICs.