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Family Medicine and Community Health

is an open access journal focusing on the topics of family medicine, general practice and community health.

Impact Factor 6.1 Citescore 8.4 All metrics >>

FMCH  strives to be a leading international journal that promotes 'Health Care for All' through disseminating novel knowledge and best practices in primary care, family medicine, and community health.  FMCH  publishes original research, review, methodology, commentary, reflection, and case-study from the lens of population health.  FMCH 's Asian Focus section features reports of family medicine development in the Asia-pacific region.

FMCH  aims to serve a diverse audience including researchers, educators, policymakers and leaders of family medicine and community health. We also aim to provide content relevant for researchers working on population health, epidemiology, public policy, disease control and management, preventative medicine and disease burden.  FMCH  does not impose any article processing charges (APC) or submission charges.

FMCH was founded by the Beijing Huawei General Practice Research Institute (BHGPRI) as an internationally focused open access journal devoted to subjects that are common and relevant to family medicine, general practice and community health. FMCH is owned by BHGPRI

JOURNAL NEWS:  Family Medicine and Community Health  is now indexed in PubMed Central and Medline.

Access further content on the  journal blog . Follow the journal on  X  and Facebook. FMCH has a Citescore of 8.4 (2022) and an Impact Factor of 6.1 (2022).

Highlighted Articles

Family Medicine and Community Health accepts submissions of a wide range of article types, including Editorials, Original research, Focus on Asia Pacific, Review articles, Reflections, Case reports and Letters to the Editor.

The Author Information section provides specific article requirements to help you turn your research into an article suitable for FMCH.

Information is also provided on editorial and data policies .

Latest Articles

Original research :

18 May 2024

Perspective :

10 April 2024

4 April 2024

Most Read Articles

16 October 2023

13 October 2023

12 May 2023

Systematic review :

6 July 2023

10 May 2022

In the Journal

18 February 2022

Uncategorized

16 December 2021

26 November 2021

20 August 2021

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Family medicine and community health - our full story.

Listen to Editor-in-Chief of Family Medicine and Community Health, Prof. Li Li, talk about the journal's aims and scope, the advice he has for authors thinking about submitting to the journal, what the journal has to offer to readers, highlights from the journal and what the journal has planned for 2024.

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AFP Journal Case Studies CME

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The AFP Journal Case Studies CME course gives you access to a new engaging learning experience with branch case scenarios and interactive learning activities to reinforce learning. Maximize patient care through the delivery of evidence-based guidelines, recommendations, and resources on topics that include essential cannabis clinical practice tools, treatment of acute and chronic conditions, disease prevention, and more. Designed to take you from research to practice, this course includes:

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Cannabis Essentials: Tools for Clinical Practice Payam Sazegar, MD, FAAFP

Common Oral Lesions David Randall, MD

Evidence-based Contraception: Common Questions and Answers Scott Paradise, MD

Fever of Unknown Origin in Adults Jeffrey Quinlan, MD, FAAFP and Aisha David, MD

Onychomycosis:  Rapid Evidence Review Winfred Frazier, MD, MPH and Zuleica Santiago-Delgado, MD

Orthostatic Hypotension: A Practical Approach Michael J. Kim, MD, FAAFP

Parathyroid Disorders Jarrett Sell, MD, FAAFP and Sarah Ramirez, MD, FAAFP

Recent-onset Altered Mental Status Evaluation and Management Brian Veauthier, MD

Upon completion of this CME activity, you should be able to:

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• Develop evidence-based health promotion/disease prevention plans for patients across the lifespan, incorporating current AAFP and USPSTF recommendations.
• Consider strategies to address barriers to care and health equity for patients seen in primary care.
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Making the case for the study of symptoms in family practice

The evaluation and, when possible, alleviation of symptoms is a substantial portion of the work of family physicians. However, until recently, it has received relatively little research attention. 1 , 2 That is changing owing to 2 factors: large databases derived from anonymized, aggregated data from electronic medical records (EMRs), and a coding system that allows for recording the reason for encounters, including symptoms.

Role of symptoms and their frequency in practice

Evaluation of symptoms—the patient’s expression of their experience of illness—is a key part of the work of family physicians and others in primary care. Community studies show that, in any given month, 80% of people experience symptoms; 33% consider seeking care and 22% actually visit a physician. 3 , 4 In their role as first-contact practitioners, family physicians tend to see symptoms earlier in the process than is the case with referral-based practitioners, and, as a result, undifferentiated symptoms are a substantial part of the work in primary care, present in 50% to 60% of visits. 5 , 6 Symptoms, when combined with signs and investigations, might lead to a new diagnosis; they might represent a repeat presentation of a pre-existing diagnosis; or they might remain undiagnosed (medically undiagnosed symptoms). Nevertheless, even when a diagnosis is made, symptoms frequently continue. At least one-third of common symptoms do not have a clear-cut disease-based explanation, and although many improve over weeks to months, 20% to 25% will become chronic or recurrent. 6 Family physicians are challenged to make early diagnoses of serious illness, and when faced with unexplained symptoms, physicians tend to order more tests in pursuit of a diagnosis. 7 The ability to evaluate an undifferentiated symptom and make an early diagnosis of a serious illness is a hallmark of excellent clinicians and one of the ways in which family medicine improves health system functioning. 8 Symptoms are predictive of health care use, quality of life, work-related disability, and mortality. 6 In a world where multiple chronic diseases are the norm in clinical practice, 9 , 10 diagnoses are usually known and the role of symptoms goes beyond assisting in the diagnostic process, and symptoms require attention in their own right to address patient suffering. Therefore, evidence-informed evaluation of symptoms is critical to effective medicine improving 2 of the Triple Aim agenda items: the patient experience and being efficient with resources. 11

Why have symptoms not, in the past, received much attention?

In spite of their importance, research on symptoms dwindled during the first half of the 20th century. 1 , 2 Research has been hampered for several reasons. The first is the lingering effects of the dominant medical model that emerged in the late 19th century. In this model, illness was conceived of as being due to discrete disease entities that existed separate from the individual sufferer. This led to studies to identify and describe the natural history of various diseases in the 19th and early 20th centuries. 12 Combining the symptom with objective physical signs, bolstered by results of laboratory and imaging investigations, completed the diagnostic process. Over the 20th century, emphasis on the location of the disease “in the body” 13 and the emergence of increasingly powerful imaging and laboratory investigations heavily tilted the diagnostic process away from symptoms toward “objective” findings. This has added to the cost of medical care, as clinicians attempt to fit patients’ symptoms into known diagnostic categories. Diagnostic categories provide names for patients’ illnesses, thereby reducing anxiety and uncertainty, and, ideally, they provide direction to optimal treatment and prognosis and are part of the infrastructure of health care necessary for many bureaucratic and administrative purposes, as well as for epidemiologic research.

The second key barrier to doing research on symptoms is their inherently idiosyncratic nature. They can be highly nuanced and particular to the patient, and in any given medical practice will be present in too few patients to make systematic inquiry feasible.

Return to focus on symptoms

Since the late 20th and into the early 21st century, several developments have changed these dynamics. First, there has been an increased emphasis on patients’ illness experience, the subjective aspect of ill health. This has involved developing an understanding of illness in the context of the patient’s life and is one of the key elements of the patient-centred clinical method. 14 It has been argued that, rather than symptoms being seen as a derivative of disease, they should be recognized as a higher-order phenomenon, blending elements of disease and nondisease, and, therefore, “the most human expression of clinical medicine,” 6 deserving to be the focus of research in their own right. 15

Second, the widespread use of EMRs makes possible anonymized aggregations of many individual encounters in different medical practices, thus increasing the number of cases available for study. 16 – 19

However, to be useful for studying symptoms, such data must use standardized coding systems, such as the International Classification of Primary Care, 20 which includes codes for symptoms as well as diseases. When used in its entirety (coding all reasons for encounters and procedures, and all end-of-visit codes), it provides a more complete picture of activity in family practice than is available from health administrative data. The analytic power possible with the combination of large EMR databases and standardized coding holds the promise of providing new insights unique to family medicine. 21 Symptoms and the pathways they follow over time can be linked to patient characteristics and social variables to place illness in its full context.

Returning to our roots

Recently, it has been recommended that, in family and general practice, symptoms be accepted as equivalent to diagnoses when they are a more accurate description of the level of clinical certainty. 22 , 23 Knowledge of the prognosis of symptoms might reduce the imperative to initiate investigations, attempting to fit the patient into an abstract category of disease taxonomy. Symptom-based prognosis, in some ways, hearkens back to the traditional meaning of diagnosis , which referred to the person, rather than a disease label. 24 But if symptom-based prognoses are to be useful, there must be knowledge of the natural history of symptoms. Over years of practice, family physicians tend to acquire such knowledge tacitly, but younger physicians have no access to this experiential knowledge. Studies of natural history are needed, not just of diseases, but of symptoms.

Necessary elements of research on symptoms

A broad-based program of research on symptoms is recommended. 25 It needs to recognize that symptoms are often multiple, usually multifactorial in cause, and frequently occur in recognizable clusters. 26 , 27 Both patient characteristics (age, sex, demography, concurrent disorders, psychological and social factors) and symptom characteristics (severity, location, duration, accompanying symptoms) need to be taken into account. Broad prognostic categories of symptoms (self-limited, symptom disorder, recurrent or persistent) 23 have been suggested and might help to define a research program. For example, those symptoms that are chronic or recurrent hold greater interest for family physicians. Defining the pathways or natural history of recurrent, persistent symptoms is a necessary first step.

However, a moment’s reflection will make clear that not all of what is needed to be known about symptoms is contained in large, well-coded databases. There remains a need for studies closer to the lived world of the patient. Symptom studies are ideal for mixed-methods research including case studies, case series, qualitative studies, and linguistics. 28 – 30

In Canada, there is a long, but interrupted, history of studying the frequency of presenting symptoms in general in family practice 31 and of specific symptoms such as headache, 32 chest pain, 33 urinary symptoms, 34 and fatigue. 35 – 37

With the expansion of EMRs and the availability of coding systems that include symptoms, it is an opportune time to once again engage in symptom research that is uniquely relevant to daily family practice.

Acknowledgments

Dr Stewart was funded by the Dr Brian W. Gilbert Canada Research Chair in Primary Health Care Research (2003–2017) in the Schulich School of Medicine and Dentistry at Western University.

Hypothesis is a quarterly series in Canadian Family Physician (CFP) , coordinated by the Section of Researchers of the College of Family Physicians of Canada. The goal is to explore clinically relevant research concepts for all CFP readers. Submissions are invited from researchers and nonresearchers. Ideas or submissions can be submitted online at mc.manuscriptcentral.com/cfp or through the CFP website www.cfp.ca under “Authors and Reviewers.”

Competing interests

None declared

This article has been peer reviewed.

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Case Files: Family Medicine, 5e

Author(s): Eugene C. Toy; Donald Briscoe; Bruce Britton; Joel J. Heidelbaugh

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Case Reports

51-year-old woman • history of graves disease • general fatigue, palpitations, and hand tremors • dx.

► History of Graves disease ► General fatigue, palpitations, and hand tremors

55-year-old woman • myalgias and progressive symmetrical proximal weakness • history of type 2 diabetes and hyperlipidemia • Dx?

► Myalgias and progressive symmetrical proximal weakness ► History of unilateral renal agenesis, type 2 diabetes, and hyperlipidemia

52-year-old man • intermittent fevers • recently received second dose of COVID-19 vaccine • tremors in all 4 extremities • Dx?

► Intermittent fevers ► Recently received second dose of COVID-19 vaccine ► Tremors in all 4 extremities

24-year-old woman • large joint arthralgias • history of type 1 diabetes, seizures, migraines • Dx?

► Large joint arthralgias ► History of type 1 diabetes, seizures, migraines

49-year-old woman • headache and neck pain radiating to ears and eyes • severe hypertension • Dx?

► Headache and neck pain radiating to ears and eyes ► Severe hypertension

30-year-old woman • progressive dyspnea and peripheral edema • 35th week of gestation with a history of mild preeclampsia • Dx?

► Progressive dyspnea and peripheral edema ► 35th week of gestation with a history of mild preeclampsia

55-year-old woman • unilateral nasal drainage • salty taste • nasal redness • recent COVID-19 nasal swabs • Dx?

► Unilateral nasal drainage ► Salty taste ► Nasal redness ► Recent COVID-19 nasal swabs

64-year-old woman • hot flashes, facial flushing, excessive sweating, and palpitations • daily headaches • history of hypertension • Dx?

► Hot flashes, facial flushing, excessive sweating, and palpitations ► Daily headaches ► History of hypertension

23-year-old woman • fever, fatigue, and sore throat • scleral icterus and hepatosplenomegaly • Dx?

► Fever, fatigue, and sore throat ► Scleral icterus and hepatosplenomegaly

75-year-old man • recent history of hand-foot-mouth disease • discolored fingernails and toenails lifting from the proximal end • Dx?

► Recent history of hand-foot-mouth disease ► Discolored fingernails and toenails lifting from the proximal end

85-year-old woman • insomnia • abdominal discomfort • urge to move at night • Dx?

► Insomnia ► Abdominal discomfort ► Urge to move at night

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A Reflective Case Study in Family Medicine Advance Care Planning Conversations

Affiliations.

• 1 From the Family Medicine Residency Program, Natividad Medical Center, Salinas, CA (MT); Department of Family and Preventive Medicine University of Arkansas for Medical Sciences, Salinas, CA (WV). [email protected].
• 2 From the Family Medicine Residency Program, Natividad Medical Center, Salinas, CA (MT); Department of Family and Preventive Medicine University of Arkansas for Medical Sciences, Salinas, CA (WV).
• PMID: 30610149
• DOI: 10.3122/jabfm.2019.01.180198

Advance care planning conversations traditionally have been promoted using the Standard of Substituted Judgment and the Standard of Best Interests. In practice, both are often inadequate. Patients frequently avoid these conversations completely, making substituted judgment decisions nearly impossible. Surrogates are also often unable to make clinical decisions representing the best interests of family members as patients. Many physicians are unskilled at discussing these difficult and complex decisions with surrogates as well. Using an integrative family medicine ethics approach, we present a case study that demonstrates how skillful family physicians might introduce and conduct these conversations at routine office appointments, reconciling ethical theory with both patient-centered and physician-centered considerations in a practical and time-sensitive fashion. We believe 3 physician behaviors will help prepare patients to engage their surrogates and help empower surrogates to serve their role well, if and when that time comes: 1) thinking broadly about clinical issues and ethical considerations; 2) engaging in a mindful and contemporaneous deliberation with the patient-and surrogate when appropriate and possible-about these issues and considerations; and 3) cultivating a reflective responsiveness to these interactions, both when things go well and when they do not.

Keywords: Advance Care Planning; Ethical Theory; Family Physicians.

© Copyright 2019 by the American Board of Family Medicine.

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• Terminally Ill / psychology*

Announcing Over 100 New Case-Based Questions in NEJM Knowledge+ Family Medicine Board Review

At NEJM Knowledge+, we’re committed to ensuring that our products cover the breadth of knowledge that clinicians need for both clinical practice and board exam preparation. NEJM Knowledge+ Family Medicine Board Review , launched in February 2015, already contains more than 1500 case-based questions on the most relevant and important topics in family medicine today. We’re adding another 119 case-based questions to further expand that knowledge base.

Most of the new questions we’ve developed this year relate to three key areas:

• Child and adolescent care
• Patient safety in the hospital setting
• Ambulatory care across the organ systems

Each year, we plan to add at least 100 new questions to NEJM Knowledge+ Family Medicine Board Review — this is in addition to continually updating our content when guidelines change and in response to user feedback. Our goal is to become increasingly comprehensive in the learning we provide while remaining as clinically relevant and up-to-date as possible.

Case-Based Questions, Free from Outside Influence

All the questions we develop for NEJM Knowledge+ Family Medicine Board Review meet the same high-quality standards you’ve come to expect from NEJM Group. The content was written by more than 300 clinicians from academic programs across the country and was subjected to a rigorous editorial process that included review by highly respected professional educators, leading specialists in their fields, generalists, PAs, and NEJM Group editors . You can be sure that what you’re learning in NEJM Knowledge+ is accurate, evidence-based, and relevant to your daily practice.

NEJM Knowledge+ offers a comprehensive question bank that reflects the breadth of primary care cases that family medicine physicians and PAs encounter in their practices today.

Personalized Learning, Tailored to You

NEJM Knowledge+ uses adaptive learning technology that tailors your learning to your needs. This adaptive learning technology continuously assesses the subjects you know and identifies the areas where you need reinforcement. It then delivers questions based on what you know already, what you need to study more, what you are struggling to master, what you think you know better than you do, and what you might be forgetting.

With the addition of these 119 new questions, NEJM Knowledge+ Family Medicine Board Review now includes:

• more than 1620 case-based questions
• more than 4500 total questions tied to 2500 learning objectives

With the ability to earn:

• CME credits
• AAFP Prescribed credits
• AAPA Category 1 Self-Assessment CME credits

All in all, we are strengthening one of the most comprehensive solutions available for continuous learning and board exam preparation.

More on NEJM Knowledge+ Content:

Roadmap to Great Content Work Less and Learn More: Here’s How in NEJM Knowledge+ Our Family Medicine Board Review Questions Improve Your Recall for Medical Board Exams Content Updates

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Kindly update me for family medicine

greatly obliged if more on child & neonatal care.

Kindly update me on family medicine

requesting again for more in child & neonatal care

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In collaboration with:

Society of teachers of family medicine (stfm).

The 40 interactive virtual patient cases in Aquifer SM Family Medicine deliver on the learning objectives of the Society of Teachers of Family Medicine’s (STFM) clerkship curriculum, powered by Aqueduct SM , Aquifer’s teaching and learning platform.

Aquifer Family Medicine builds clinical competency, fills educational gaps, and helps instill the core values and attitudes of family medicine. The course fosters self-directed and independent study, develops clinical problem-solving skills, and teaches an evidence-based, patient-centered approach to patient care.

Now Available: Embedded Curricular Threads

New embedded threads provide consistent teaching on interdisciplinary Clinical Excellence topics throughout Aquifer’s core courses. Select Family Medicine cases include brief teaching to highlight key principles in palliative care, trauma-informed care, social determinants of health, high value care, diagnostic excellence, and foundations of telemedicine. Learn more…

Key Features

• Created for educators, by educators, to cover the full range of STFM curriculum
• Available for institutional subscription or for direct purchase by individual subscribers
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• Proven pedagogy that standardizes experiences —overcoming geography, seasonality, and accessibility
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• Self-assessment questions emphasize key content and enable students to test their knowledge and skills
• A wealth of source material, tools, and full references in each case
• Delivered via the Aqueduct teaching and learning platform, which includes user management options, easy reporting on student progress and course usage, plus tools for creating custom courses to match a specific curriculum

Course Content

This course covers the complete STFM Family Medicine Clerkship Curriculum. Course content includes five Aquifer Pediatrics cases and two Aquifer Internal Medicine cases to help cover the full range of family medicine learning objectives.

Curriculum Integration

Aquifer Family Medicine can be used by third-year medical students, PA students, and NP/DNP students as a complement to a clerkship or course on family medicine.

Aquifer Calibrate , an innovative system for formative assessments, is available for Aquifer Family Medicine. Calibrate combines the concepts of test-enhanced learning and distributed practice to facilitate efficient study planning and self-directed learning for students, and identify at-risk students and curricular gaps for faculty.  Calibrate is available with your 2023-24 institutional subscription to Family Medicine.

Family Medicine 01: 45-year-old female wellness visit

Family Medicine 02: 55-year-old male wellness visit

Family Medicine 03: 65-year-old female with insomnia

Family Medicine 04: 19-year-old female with sports injury

Family Medicine 05: 30-year-old female with palpitations

Family Medicine 06: 57-year-old female diabetes care visit

Family Medicine 07: 53-year-old male with leg swelling

Family Medicine 08: 54-year-old male with elevated blood pressure

Family Medicine 09: 50-year-old female with palpitations

Family Medicine 10: 45-year-old male with low back pain

Family Medicine 11: 74-year-old female with knee pain

Family Medicine 12: 16-year-old female with vaginal bleeding and UCG

Family Medicine 13: 40-year-old male with a persistent cough

Family Medicine 14: 35-year-old female with missed period

Family Medicine 15: 42-year-old male with right upper quadrant pain

Family Medicine 16: 68-year-old male with skin lesion

Family Medicine 17: 55-year-old post-menopausal female with vaginal bleeding

Family Medicine 18: 24-year-old female with headaches

Family Medicine 19: 39-year-old male with epigastric pain

Family Medicine 20: 28-year-old female with lower abdominal pain

Family Medicine 21: 12-year-old female with fever

Family Medicine 22: 70-year-old male with new-onset unilateral weakness

Family Medicine 23: 5-year-old female with sore throat

Family Medicine 24: 4-week-old female with fussiness

Family Medicine 25: 38-year-old male with shoulder pain

Family Medicine 26: 55-year-old male with fatigue

Family Medicine 27: 17-year-old male with groin pain

Family Medicine 28: 58-year-old male with shortness of breath

Family Medicine 29: 72-year-old male with dementia

Family Medicine 30: 27-year-old female labor and delivery

Family Medicine 31: 66-year-old female with shortness of breath

Family Medicine 32: 33-year-old female with painful periods

Family Medicine 33: 28-year-old female with dizziness

Pediatrics 01: Newborn male infant evaluation and care

Pediatrics 02: Infant female well-child visits (2, 6, and 9 months)

Pediatrics 03: 3-year-old male well-child visit

Pediatrics 04: 8-year-old male well-child check

Pediatrics 13: 6-year-old female with chronic cough

Internal Medicine 02: 60-year-old female with chest pain

Internal Medicine 16: 45-year-old male who is overweight

From Our Cases

Learn how Aquifer Family Medicine can benefit medical students and faculty in your program:

Testimonial

“In the first and second years of medical school, you learn a lot about physiology and diseases—usually by organ system. Aquifer Family Medicine gives you the opportunity to start thinking about the way that patients actually present—and begin to apply what you already know. The cases are a wonderful way to start turning medical facts into clinical judgment. I just wished I had used them earlier and more often.”

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Aquifer Family Medicine Course Board

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Due to current covid19 situation and as a measure of abundant precaution, our member services centre are operating with minimum staff, international journal of, eissn: 2577-8269, family & community medicine.

Mini Review Volume 8 Issue 2

An assessment of the inclusive early childhood development program (IncluDe) in Kandy district, Sri Lanka a case study

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1 Senior Registrar (Medical Administration), Office of DDG Laboratory Services, Ministry of Health 2 National Program Manager, Child Development and Special Needs - Family Health Bureau, Ministry of Health

Correspondence: Jayasundara KMPD, Senior Registrar (Medical Administration), Office of DDG Laboratory Services, Ministry of Health, Sri Lanka

Received: January 18, 2024 | Published: May 15, 2024

Citation: Jayasundara KMPD, Hewamalage A. An assessment of the inclusive early childhood development program (IncluDe) in Kandy district, Sri Lanka a case study. Int J Fam Commun Med . 2024;8(2):60-64. DOI: 10.15406/ijfcm.2024.08.00351

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Sri Lanka has identified the importance of providing quality and effective health care to all women, children, and families. In 1968, the Ministry of Health established the Family Health Bureau (FHB) to conduct the Maternal and Child Health (MCH) program nationally. The FHB's Inclusive Early Childhood Development Program (IncluDe), which will be phased across all districts, aims to systematically screen all Sri Lankan children to detect developmental delays and disabilities as early as possible and intervene through a multidisciplinary team approach to improve their quality of life. The purpose of this study is to evaluate the IncluDe program in the Kandy district and to prioritize the issues that need to be addressed to establish a comprehensive, sustainable program to serve the district's children with disabilities. Data collection was done by Key Informant Interviews, Focus Group Discussions, Team discussions, Observation visits to study settings, and review of secondary data. Numerous issues were identified across the program's service settings (Screening program of the children, Services of Child Development Intervention Center (CDIC), and specialized referrals at Tertiary Care Hospitals). Improving the comprehensiveness of care given at CDIC at rehabilitation hospital Digana, addressing the training needs of health staff, fulfilling the human resource requirement, and establishing a monitoring and evaluation mechanism of the program were among the priority problems. After conducting an in-depth analysis, recommendations were made to enhance the comprehensiveness of care provided at CDIC. The study reveals the importance of parallel development of all facets of the IncluDe program to provide adequate care to children with developmental delays and disabilities in the Kandy district. In conclusion, the Inclusive Early Childhood Development Program in Kandy District, Sri Lanka needs urgent attention in implementing measures to achieve its objectives successfully.

Keywords : early childhood development program, Kandy district, Sri Lanka

Introduction

Inclusive early childhood development program (IncluDe)

The Sri Lankan child health program focuses on activities to enhance the growth and prevent morbidities and mortalities of children. Until recently, the services for early child development and services for children with disabilities were not a priority. Around 15% of the world's population is estimated to have some form of disability. 1 Also, it is estimated that among 52.9 million children with disabilities under 5 years worldwide, 95% live in Low Middle-Income Countries. 2 There is no data on the prevalence of disabled children in Sri Lanka. Recent scientific evidence justifies that the insult to the developing brain during the antenatal or perinatal period causes most of the developmental disabilities in children. 3 , 4 Among them, Cerebral Palsy, Autism Spectrum Disorder, Dyslexia, and Intellectual Impairment are common. Early detection and intervention in managing these children through a multidisciplinary approach is the key to successfully addressing the developmental issues. Thus, identifying the importance of managing children with disabilities, the Family Health Bureau (FHB) of the Ministry of Health developed the Inclusive Early Childhood Development Program (IncluDe) with multi-stakeholder concurrence. The Child Care Development and Special Needs Unit (CDSNU) of the FHB is the focal point leading this program. 5 IncluDe program targets to systematically screen all children of Sri Lanka to identify developmental delays and disabilities as early as possible and to provide early intervention via a multidisciplinary team led by a Consultant Community Pediatrician or a Consultant Pediatrician.

There are three service delivery settings of the IncluDe program.

The three screening pathways are as follows,

• Systematic screening of all children by PHM
• Screening of high-risk neonates by institute base neonatal teams
• Screening by primary care physicians and general practitioners.

Referral pathways of the program

The program intends to establish a CDIC in a selected apex hospital in every district phase-wise. Currently, the program is functioning in the Colombo and Kandy districts.

IncluDe program in the Kandy District

The IncluDe program in the Kandy district was launched in March 2021, establishing the CDIC at Rehabilitation Hospital Digana (RHD) with the existing resources. This 60-bed health facility is located 15 kilometers from Kandy and is directly administered by the PDHS central province. It provides a range of rehabilitation services for patients, including Inward care, Outpatient care, Physiotherapy, Occupational therapy, Speech and Language Therapy, Counselling services, Vocational Training, Supply of disabled appliances (free of charge), and Training of relatives of disabled care. In addition, it provides medical, dental clinic services and, Emergency treatment services, and general OPD. RHD provides a conducive environment for disabled patients and has high accessibility. The dedicated administrative and clinical staff offers essential rehabilitation services to manage children with disabilities. PHMs of the district were trained online. All MOHs have commenced referring patients. Currently, the CDIC is caring for 153 disabled children under two consultant pediatricians.

The objective of the study

This study aims to assess the IncluDe program of the FHB in the Kandy district to identify the critical problems to be addressed and suggest practical recommendations to improve the quality of service delivery.

Data collection

Methods of data collection,

• Conducting Key Informant Interviews (KIIs) with the,
• The National Focal Point of the program, Central Provincial and Kandy Regional Directors of Health, Institutional Heads (National Hospital Kandy, Rehabilitation Hospital- Digana), Consultant Community Physician – Kandy, Consultant Community Pediatrician – Rehabilitation Hospital Digana, MOH
• Focus Group Discussions (FGDs)
• Discussions with Therapists at Rehabilitation Hospital Digana
• Observation visits
• Secondary data
• Literature Review – (Journal articles/Publications).

Problem analysis

The main problems were identified through a situational analysis that focused on three primary areas:

Screening program of the children

• Comprehensive care at CDIC at Rehabilitation Hospital – Digana
• Provision of specialized services at Tertiary Care Hospital.

The following issues have been identified:

At the community level

1.1 Inadequate and insufficient Training for PHMs/MOHs

Due to the prevailing COVID-19 situation, only an online training session has been held on screening, documentation (Filling the Child Health Development Record and Maintaining a register), and referral. However, no proper review has been done. In addition, no follow-up continuous training was conducted.

No formal training on a comprehensive assessment of referred children was provided to MOHs and staff.

1.2. Deficiencies in conducting Child Development Clinics at MOH offices and referring patients to CDIC

All MOH areas have started the screening though some have detected comparatively low cases. Since the staff was mobilized to participate in COVID-19 programs, they could not conduct regular child development clinics.

1.3. Deficiencies in parental awareness of the program

1.4. Low sensitivity of the screening

• Most patients referred already had significant developmental issues, with only a few new cases detected.
• The detection rate of young infants with disabilities was very low.

At tertiary Care Level – The Neonatal Screening

It is yet to commence at a tertiary care institute in the Kandy district.

At the Primary care Physician/General Practitioner – screening has not commenced yet

Lack of comprehensive care at CDIC at Rehabilitation Hospital – Digana

The analysis revealed multiple issues at RHD in providing continuous quality care to children referred by the community-based screening program.

• Deficiencies in the management processes at CDIC
• The waiting list for the first visit till the end of December 2021
• Due to COVID-19 staff regulations, the staff is attending to work in rotations. Specialized therapists (OT/PT/SLT) are allocated two days per week to manage pediatric patients, limiting the exposure time.
• Gaps in parental training and providing continuous guidance
• Gaps in arranging specialized referrals and investigations from tertiary care hospitals
• Transport issues of patients causing lapses in follow-up visits

Deficiencies in Infrastructure

There is no sufficient place to conduct the multidisciplinary clinical assessment. At the moment, the hospital Montessori building's limited space is being utilized. The toys and tools available are deficient and outdated.

Issues related to Human Resources.

Details of cadres

The main issues are,

• No designated trained medical officer to the CDIC
• There is no permanent therapist staff dedicated to the CDIC. Therefore, different therapists attend the multidisciplinary assessment, which affects the quality of developing individualized management plans and subsequent patient assessments and management.
• Lack of a proper training program to update the knowledge and skills of therapist staff in managing children with disabilities.

Inadequate Investigation Facilities

Only basic laboratory tests are available at RHD. Many patients needing Thyroid and Bone profiles have to be referred to National Hospital Kandy, or patients have to do them from the private sector.

X-Ray facilities are not available. Patients are referred to BH-Theldeniya, or they get it done from the private sector.

Provision of specialized services at Tertiary Care Hospital

Sirimavo Bandaranayke Specialized Children Hospital (SBSCH) Peradeniya, National Hospital Kandy (NHK), and Teaching Hospital Peradeniya (THP) are the Tertiary Care Referral centers for CDIC at DRH. Children who need Pediatric Neurology, ENT, Eye, and Child Psychiatric assessments are referred to SBSCH, and the orthopedic opinions are obtained from NHK or THP. However, the following gaps were identified in getting specialized services from these referral centers.

• There is no administratively agreed-upon system for appropriately referring children with disabilities detected through the program to tertiary care hospitals.
• Referrals are done in a conventional paper-based method where case discussions among clinical specialists are lacking between institutes
• No priority is given to these children with disabilities at the Tertiary care level
• The children are being assessed in the general clinics at tertiary settings most of the time, which may affect practical assessment due to inadequate time and a non-conducive environment for these referred children.
• Children who need multiple specialists' opinions had to visit different intervals to tertiary settings as the clinics were held on other days of the week.

Based on the findings, prioritization of the problems was done with discussions of RDHS-Kandy, Consultant Community Physicians in the PDHS office, and RDHS office Kandy and Matale.

Impact on the program, Practical feasibility, Financial feasibility, and Administrative leadership were the elements considered in selecting the " Lack of comprehensive care at CDIC " as the priority problem for further analysis using an Ishikawa diagram.

The CDIC is where most IncluDe program activities occur, including developing and implementing individualized management plans, progress monitoring, and intersectoral collaboration to deliver effective care. Thus, it is proposed to strengthen the CDIC at RHD, which is essential to provide comprehensive care to children with disabilities identified by the screening program.

Recommendations

Based on the findings of the in-depth analysis, the following suggestions are made for early implementation to strengthen the services provided at CDIC

• To discuss with the Regional, Institute administration and the clinical team conducting the intervention clinic at more spacious and convenient pediatric ward premises until a permanent place is provided. The other options are,
• Request to acquire the adjacent building of RHD, which belongs to Mahaweli Authority (This is a single-story, underutilized building that can be renovated with minimal financial resources to an ideal CDIC setting)
• Request donor support to construct a separate CDIC building
• Provision of adequate tools and toys to CDIC
• Assigned a medical officer to CDIC and arranged a two-week training at AYATHI center, Ragama, on managing disabled children
• Conduct a structured training program for therapists to update their knowledge and skills in managing children with disabilities
• Discuss with the therapist staff to arrange a practical roster for attending services at CDIC regularly
• The management team of CDIC to implement a system to achieve the program objectives focusing on,
• Developing a communication channel with screening teams and curative sector teams in preventive and tertiary care settings
• Appointment systems, registration, and follow-up plan of referred patients at CDIC
• Parental education and training on home base care
• Management of patient data
• Intersectoral collaboration – special education, social services
• Arranging outreach programs
• To provide a point-of-care analyzer to the medical laboratory to perform specialized onsite investigations (Thyroid profile)
• Form a monitoring and evaluation mechanism of the CDIC services by establishing an oversight committee with national and regional representatives.
• Request a permanent cadre of health staff for CDIC from the Human Resource Division of the Ministry of Health.

Plan of implementation

Detecting developmental delays is essential for early intervention in low to middle-income countries. 6 Sri Lanka has a well-organized preventive healthcare system focusing on delivering equitable care for all ages. The FHB of the Ministry of Health, Sri Lanka is the focal point of delivering community-level childcare comprehensively. However, it was identified that the detection of children with developmental defects at a very early age was not addressed sufficiently through the FHBs child development program. Thus, the Inclusive Early Childhood Development Program (IncluDe) was introduced by the Childcare Development and Special Needs unit of the FHB. 5 In India, the Integrated Child Development Service (ICDS) is a government program that provides nutritional meals, preschool education, primary healthcare, immunization, health check-ups, and referral services to children under 6 years of age and their mothers. However, it has been revealed that this program has been largely ineffective and needs major refurbishing. 7

Having a well-trained professional health staff is essential to conducting early childhood developmental screening programs, and managing and referring to other specialties. Thus, Primary care physicians play a significant role in the early identification of developmental delays, both through developmental screening and routine developmental surveillance. Hence, they must have the knowledge and skills to identify developmental delays and provide an appropriate management plan to the family, including counseling the parents if necessary. 8 Establishing and maintaining a Child Development Intervention Centre (CDIC) is the greatest challenge as the community-level specialists in pediatrics, physiotherapists, speech therapists, occupational therapists, etc., and other necessary services such as Radiological and laboratory services are incomplete in this case.

Data and evidence on Early Childhood Development are essential to identifying the children at greatest risk of not achieving their full potential, improving and targeting services, and making the case for adequate investments in young children and their families. 9 This study reveals the necessity of having appropriate infrastructure, human resources, and training and coordination among different levels of healthcare facilities to sustain the IncluDe program in the Kandy District.

The Family Health Bureau has identified the importance of a comprehensive program (IncluDe) to detect children with disabilities at a very early age. The objective is to implement a structured multidisciplinary approach to intervene early in management and arrange regular follow-ups. This program is a timely initiative to improve the quality of life of children with disabilities. To achieve an effective outcome, it is essential to strengthen all facets of the IncluDe program in the Kandy district (screening, CDIC facilities, and tertiary care referrals). Since CDIC is the center point of care, priority should be given to improving the facilities of CDIC at the rehabilitation hospital Digana.

Acknowledgments

Conflicts of interest.

The author declares there is no conflict of interest.

• WHO. World Report on Disability . 2021.
• Kamiya Y. Current situation of children with disabilities in low- and middle-income countries. Pediatr Int . 2021;63(11):1277–1281.
• Cioni G, D’Acunto G, Guzzetta A. Perinatal brain damage in children: Neuroplasticity, early intervention, andmolecular mechanisms of recovery. Prog Brain Res . 2021;189:139–154.
• Baxter C. Prenatal Risk Factors for Developmental Delay in Newcomer Children . Caring for Kids New to Canada. 2019.
• FHB. Child Care, Development & Special Needs Unit . Family Health Bureau. 2021.
• Abdoola S, Swanepoel D, van der Linde J, et al. Detecting developmental delays in infants from a low-income South African community: Comparing the BSID-III and PEDS tools. Early Child Development and Care . 2019;191(4):545–554.
• Kouser S, Popat D. Early childhood care and development in India . 2022;1:27–31.
• Choo YY, Agarwal P, How CH, et al. Developmental delay: Identification and management at primary care level. Singapore Med J. 2019;60(3):119–123.
• Early childhood development . UNICEF. (n.d.). 2024.

©2024 Jayasundara, et al. This is an open access article distributed under the terms of the, Creative Commons Attribution License ,--> which permits unrestricted use, distribution, and build upon your work non-commercially.

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