PROTOCOL: How Do Primary Care Providers Seek Advice Regarding Paediatric Care? Protocol for a Mixed Methods Systematic Review

Abstract

Despite their central role, Primary Care Practitioners (PCPs) encounter numerous challenges in providing primary care for children. Complex factors spanning all levels of the health system contribute to variability in the quality of paediatric primary care. Contextually informed strategies addressing these factors can deliver positive change. These strategies recognise healthcare as a complex adaptive system and leverage the interconnectedness of the health system and communication networks of healthcare providers. Evidence describing advice-seeking practices of PCPs related to paediatric care is limited. This protocol outlines a mixed methods systematic review that aims to examine how primary care practitioners seek advice regarding paediatric care. The resulting review will synthesise the structures and characteristics of the social networks through which PCPs seek advice regarding paediatric care, how networks are measured, the benefits of these networks, and factors PCPs encounter when seeking advice. The review will be guided by the Joanna Briggs Institute Mixed Methods Systematic Review manual and the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) statement. We will search English language publications in EMBASE, Ovid MEDLINE, and Web of Science. Relevant peer-reviewed articles published since 2013 will be included, encompassing randomised controlled trials (RCTs), non-RCTs, pre- and post-intervention studies, cross-sectional studies, qualitative studies, social network analysis, and mixed-methods studies. Data will be synthesised using a convergent integrated approach, transforming quantitative data into textual descriptions and aggregating where possible to produce integrated findings. PROSPERO Registration Number: CRD420251025798.

Plain Language Summary

Why is This Study Important?

Primary Care Practitioners, such as general practitioners and family physicians, have an important role in providing care for children. Despite the importance of their role, they face numerous challenges that impact the quality of care children receive. These challenges are often linked and occur across all levels of the health system, including the practitioner, clinic, and the broader health system. Primary care practitioners sometimes reach out to other healthcare providers for advice when they encounter these challenges, but we don’t know much about who they contact or how. If we want to improve care for children and better support primary care providers, we first need to understand how they get advice when they need it and what we can do to make it easier for them to get the advice they need.

What Will the Researchers Do?

In this paper, we outline our plan to review and analyse research on how primary care practitioners seek advice about care for children.

How Will the Researchers Identify and Analyse the Research?

The researchers will be guided by the Joanna Briggs Institute Mixed Methods Systematic Review manual and the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) statement. We will search English language publications in EMBASE, Ovid MEDLINE, and Web of Science. A range of study types, including trials, surveys, mixed-methods and qualitative studies, will be included if they are relevant, peer-reviewed, and published since 2013. We will analyse and combine the findings from the research studies we find by comparing the findings from different studies, and grouping the findings together into categories when we can to create key findings and overall results.

What Will the Researchers Do With Their Findings?

The researchers will publish a study that summarises their findings on the networks of people through which primary care practitioners seek advice about providing healthcare for children. It will also cover how these networks are measured, the benefits they provide, and the factors primary care practitioners encounter when seeking advice.

Keywords

general practitioners advice-seeking paediatric primary care

Background

Primary Care Practitioners (PCPs), which includes general practitioners (GP), family doctors, and primary care physicians, are central to a child’s medical care. They provide essential support for children and their families to maintain good health and well-being and are responsible for the delivery of several components of care. Primary care encompasses prevention, health promotion, diagnosis of conditions, prescribing and monitoring treatment(s), coordinating referrals to specialist care, and escalating care where appropriate (e.g., referring to emergency departments) (Braithwaite et al., 2018; Jeyendra et al., 2013; Royal Australian College of General Practitioners, 2019). Trust and strong clinical relationships that are maintained across a child’s lifespan are crucial to providing high-quality, patient-centred paediatric primary care and supporting children as they transition from paediatric to adult services (NSW Agency for Clinical Innovation, 2021; O’Brien et al., 2016; Transition From Children’s to Adults’ Services for Young People Using Health or Social Care Services, 2016).

Clinical practice guidelines are designed to support PCPs to deliver evidence-based care (Institute of Medicine, 2011). Yet, numerous challenge impede both the adoption of guideline recommendations, and the delivery of high-quality healthcare for children. These complex, often interacting, factors arise across multiple levels of the healthcare system and include patient health literacy and sociodemographic, time available for appointments, provider knowledge of specialist referral options and availability of tertiary health services, national funding structures, and even clarity regarding the scope of general practice care provision (Jeyendra et al., 2013; O’Brien et al., 2016; Wang et al., 2023). Caring for children adds further complexity; they have different clinical presentation patterns to adults and are often reliant on their families for communication.

These challenges, among others, contribute to variability in safety, quality, and cost of paediatric care. Clinical audits demonstrate that overall, only approximately 60% of healthcare provided for children in Australia (Braithwaite et al., 2018) and the United States of America (Mangione-Smith et al., 2007), aligns with quality indicators (Braithwaite et al., 2018; Mangione-Smith et al., 2007). Exacerbating this situation, evidence generated from research takes an average of 17 years to translate into routine, widespread practice (Morris et al., 2011), and not every study is taken up in the real world. Such delays or failures to translate evidence mean that many of today’s children will be adults before advances in paediatric research and medicine are routinely adopted into everyday practice (Morris et al., 2011; Westfall et al., 2007). This issue stimulates two fundamental questions: How do we overcome these complex challenges, and how do we do it quickly?

Conventional strategies have typically responded to these questions using a linear approach (Churruca et al., 2019; Westfall et al., 2007), often expressed as the pipeline model of evidence, moving from bench-to-bedside. This assumes that once a new drug or technique is developed, tested, and proven effective, publishing the results will catalyse change and findings will be unproblematically adopted into routine clinical practice. As a result, reinforcement strategies have tended to rely on didactic education, such as lectures or workshops. These often produce minor shifts in physician behaviour and insufficient improvements in patient outcomes (Barton et al., 2003; Dowling et al., 2018; Oxman et al., 1995; Shah et al., 2011; Sinclair et al., 2016; Thepwongsa et al., 2014). In contrast, strategies that consider the broader social, political and organisational context in which care is delivered can generate positive change (Oxman et al., 1995; Samuel et al., 2021; Thepwongsa et al., 2014). These contextually informed strategies combine linear tactics with more holistic approaches to change e.g. feedback-loop reminders, personalised academic shadowing, and reinforcement from opinion leaders. In one study in public health units in Canada, staff who were highly connected to their colleagues participated in a multifaceted intervention to improve evidence-informed decision making. Staff who were closely connected to the intervention participants showed significant improvements in evidence-informed decision making, despite not taking part in the intervention directly (Yousefi Nooraie et al., 2017). This may be more expensive than passive models of change but can be more effective in changing practice (Al-Haddad et al., 1997; Bernardes et al., 2019; Oxman et al., 1995; Samuel et al., 2021; Thepwongsa et al., 2014).

A contextually informed approach to evidence translation harnesses the connections between people and is underpinned by the assertion that healthcare is a complex adaptive system (CAS) (Braithwaite et al., 2017). CASs consist of individual agents (patients, clinicians, administration, support staff, etc.) who are interconnected, and influenced directly and indirectly by one another’s actions; They learn dynamically, and collectively adapt to achieve a common goal (Braithwaite et al., 2017; Plsek & Greenhalgh, 2001; Preiser, 2019); like a school of fish, finding food and avoiding a shark. If healthcare is conceptualised as a CAS, it follows that how communication flows across these networks of agents are key to how healthcare systems function. Despite the proliferation of guidelines and online knowledge resources, PCPs consistently rely on these network connections to seek information from others (Clarke et al., 2013). Leveraging communication networks through which advice is sought and shared presents a potential mechanism to enhance PCP performance and improve patient outcomes (Calciolari et al., 2017; Centola et al., 2023; Cunningham et al., 2012; Long et al., 2013; Nair et al., 2010; Scaioli et al., 2020). However, evidence describing PCPs advice-seeking practices related to paediatric care is limited (Cunningham et al., 2012; Long et al., 2013). Reviews conducted approximately a decade ago synthesised findings from social network research to explore how networks can improve healthcare practices found relatively little research detailing PCPs or findings that focused on care for children (Cunningham et al., 2012; Long et al., 2013). Persistence of this gap in evidence impedes our ability to design interventions that strengthens PCP’s access to timely and appropriate advice and in turn, limits our ability to improve care for children.

To address the identified gap in how PCPs seek advice about paediatric care, our systematic review aims to describe the advice-seeking networks used by PCPs, specific to paediatric care provision. We will use a mixed-methods approach to allow for an integrated synthesis of quantitative, qualitative and mixed-methods literature to provide a contemporary understanding of the literature (Lizarondo et al., 2020; Stern et al., 2020).

Objectives

Our overarching review question is: ‘how do primary care practitioners seek advice regarding paediatric care?’ (Lizarondo et al., 2020).

Our specific review questions are:

1. What are the structures and characteristics of social networks through which PCPs seek advice and share knowledge regarding paediatric conditions and care provision?

2. How does advice regarding paediatric care spread through a PCP’s social network?

3. How do PCPs benefit from accessing advice about paediatric care through network structures?

4. What factors do PCPs encounter when seeking advice regarding paediatric care?

Methods

Method

The proposed review will be conducted in accordance with the most recent guidance from the Joanna Briggs Institute Mixed Methods Systematic Review (MMSR) (Lizarondo et al., 2020, 2025; Stern et al., 2020). MMSRs allow for the examination of the degree of agreement and triangulation of results, the description of discrepancies between qualitative and quantitative data, the determination of whether qualitative and quantitative studies address different aspects of the research questions, and the exploration, contextualisation and explanation of other types of data (Lizarondo et al., 2020). The protocol has been written following the preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2015 guidelines (PRISMA-P) (Appendix 3 – PRISMA-P Checklist) (Moher et al., 2015). The review has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 13 May 2025 (registration ID CRD420251025798).

Inclusion and Exclusion Criteria

The review will include studies that describe advice-seeking by PCPs. Advice-seeking must be related to paediatric care. Advice can relate to any aspect of care including diagnosis, treatment, referral, and any condition. The review will consider qualitative, quantitative, and mixed methods studies if they report empirical evidence and are peer-reviewed and published in English. Studies not written in English will be excluded due to resource constraints and is a limitation of the review. Studies from any country or geographical region will be included. Studies that include a range of healthcare practitioners in which data specific to PCPs are not analysed and reported specifically will be excluded.

The search will be limited to studies that have been published after 2013. A literature review by Clarke et al. (2013) identified physicians and nurses seeking information have a preference to seek information from colleagues, whilst noting a rise in Internet usage. In the time since their review, there has been an exponential increase in technology, the ability to connect and communicate electronically, including asynchronous options such as message boards and online social media platforms (Facebook, YouTube, TikTok, etc.). Including studies published since 2013 will more closely reflect the current context. A summary is provided in Table 1, and the definitions associated with review screening criteria are provided in Appendix 1: Review definitions. Briefly, PCPs encompasses General Practitioners (GPs), family doctors, family medicine or primary care physicians. Nurses, including nurse practitioners, and allied health clinicians have been included in the search terms however, these professions are not included in the PCP concept for this review.

Table 1

Inclusion and Exclusion Criteria

Inclusion	Exclusion
- Primary care practitioners - Full text written in English - Care provision for children or conditions experienced by children - Studies that detail advice seeking through a network in which PCPs are involved.	- Studies reporting the perspectives of medical students where qualified doctors are not represented or analysed separately. - Studies that describe patient or health consumer perspectives. - Conference abstracts, opinion pieces and non-peer reviewed articles. - Systematic, scoping or narrative reviews - Published prior to 2013

Search Methods for Identification of Studies

A search strategy has been designed by the research team in collaboration with a clinical librarian (JC) from the healthcare discipline. We will search MEDLINE, EMBASE and Web of Science using medical subject headings (MeSH) and keywords. An initial limited search of MEDLINE was undertaken to identify key articles on our review topic. The text words contained in titles and abstracts of relevant articles and MeSH terms used to describe the articles was used to develop the full search strategy. The search strategy, including all identified keywords and index terms, was adapted to each database’s syntax and subject heading. A librarian from the healthcare discipline was consulted to refine the search strategy and adapt the search for each database. The search parameters of the sample population were expanded to include common healthcare providers from whom PCPs may seek advice. The search sample and Phenomenon of Interest was again expanded due scarcity of results during strategy refinement. Any study detailing a PCP seeking advice from another healthcare provider will be considered for inclusion. The SPIDER search tool (Sample, Phenomenon of Interest, Design, Evaluation, Research Type) was used to formulate the search strategy (Table 2). The search strategy can be found in full in Appendix 2: Search strategy.

Table 2

Search term categories mapped to the SPIDER Search Tool

Sample	Primary care practitioners
Phenomenon of interest	Sharing of knowledge or seeking advice regarding paediatric care provision
Design	Empirical studies: Interviews, surveys, randomised control trials, non-randomised community interventions, pre- and post-intervention studies, cross-sectional studies, qualitative studies, mixed methods studies, and social network analyses.
Evaluation	Knowledge or skill attainment, change in behaviour, patient outcomes, dissemination, implementation or translation of evidence, knowledge of clinical practice guidelines, description of an advice-seeking network.
Research type	Qualitative, quantitative, and mixed methods

Manual backward and forward tracking (snowballing) will be used to maximise the list of included literature. The reference list of all articles selected for data extraction will be screened for additional studies (backward tracking), The Lens platform (Jefferson et al., 2019; The Lens - Free & Open Patent and Scholarly Search, nd) will be used to screen articles that have cited the included articles (forward tracking) (Mohamed Shaffril et al., 2021). The first 100 results citing the included literature will be screened.

Screening

Following the search, all identified records will be uploaded to Rayyan Software (Ouzzani et al., 2016), an internet-based software program that facilitates collaboration among reviewers during the study selection process. Reviewers unfamiliar with Rayyan software will be provided with training before the start of the review.

Duplicate records will be removed in Covidence software and then imported into Rayyan prior to a collaborative screening meeting between four independent reviewers (TV, GF, LP and DG) Here, the three reviewers will collaboratively screen 20 records to ensure consistency of inclusion and exclusion criteria interpretation. Thereafter, the title and abstract of each record will be independently screened by two of these reviewers. Disagreements will be reviewed, and resolved via consensus, with arbitration provided by JB where needed.

Potentially relevant results will be retrieved in full and again imported into Rayyan for full-text review. The full text of each included record will be independently assessed against the review inclusion criteria by two of four reviewers (TV, GF, LP, DG). Disagreements will be reviewed, and resolved via consensus, with arbitration provided by JB where needed. Reasons for exclusion of full-text articles will be recorded.

The results of the search will be reported in full in the final report and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram (Page et al., 2021).

Data Extraction

Data will be extracted into a custom-built REDCap form (Harris et al., 2009). The review team (TV, GF, LP and DG) will pilot the form on two methodologically distinct articles and make any necessary amendments.

One reviewer (TV) will then independently perform data extraction to maintain consistency. Wherever possible data will be extracted verbatim, or [ ] will indicate data has been transformed during extraction. One of the three reviewers (GF, LP or DG) will independently check the extracted data for accuracy and completeness. Any disagreements will be noted and resolved by consensus among reviewers (TV, GF, LP and DG). Authors of papers will be contacted to request missing or additional data, where required.

Extracted data will include:

• Article characteristics: First author name and host country, year of publication.

• Study characteristics: Aim/objectives of the study, study design, recruitment procedures, outcome measures and primary care context.

• Participant characteristics: Age, gender, profession, location of practice, years working in profession.

• Network characteristics: Description of the network, Main findings from any social network analysis conducted (for example, measures of betweenness, centrality, and density), how advice was sought through the network.

• Benefits of accessing advice about paediatric care

• Description of factors influencing seeking advice regarding paediatric care

Data Analysis

Article, participant, and study characteristics will be reported descriptively, using summary statistics where appropriate. Then, a convergent data-based (integrated) approach to synthesis and integration will be used to synthesise data related to advice-seeking and knowledge-sharing networks. Figure 1 shows a representation of data synthesis (Lizarondo et al., 2020, 2025; Stern et al., 2020).

Figure 1

Data synthesis approach

During data extraction quantitative data will be ‘qualitized’, whereby quantitative data is converted into textual statements (Lizarondo et al., 2020, 2025; Stern et al., 2020).

For review questions one and two, two reviewers (TV and LP or GF) will examine textual statements and extracted data to identify similarities across the literature and combine them to form categories. Where possible, categories will then be aggregated to produce integrated findings related to the review questions (Figure 2).

Figure 2

Detailed approach to data aggregation and generation of integrated findings (Lizarondo et al., 2020; Stern et al., 2020)

Data relating to research question three will be analysed through inductive thematic analysis. Researchers (TV and LP or GF) will work together to generate initial codes from the extracted data, review codes to identify themes, and define and name themes (Saldaña, 2016). Any disagreements will be resolved by consensus among reviewers (TV, LP or GF). Codes and themes will be reviewed by a third reviewer (GF or LP) who will act as an adjudicator in the instance a conflict cannot be resolved. A summary of proposed data analyses according to review questions is reported in Table 3.

Table 3

Summary of proposed data analysis according to review questions

Review questions:	Analysis and report
1) What are the structures and characteristics of social networks through which primary care practitioners seek and share advice regarding paediatric conditions?	Graphic and/or tabulated (table), integrated findings and/or narrative summaries
2) How does information regarding paediatric care spread through a primary care practitioners social network?
3) How do PCPs benefit from accessing advice about paediatric care through network structures?
4) What factors do PCPs encounter when seeking advice and sharing information regarding paediatric care?	Inductive thematic analysis

Assessment of Methodological Quality

The quality of articles will be evaluated using the Mixed-Methods Appraisal Tool (Hong et al., 2018), widely used for systematic reviews (Hong et al., 2018). An electronic version of the form will be built into the REDCap tool to allow for electronic capture (Harris et al., 2009). Each article will be assessed by one of two reviewers (TV and GF, LP or DG) and checked by one of two reviewers (GF, LP or DG). Any disagreements will be noted and resolved through discussion among reviewers (TV, LP, GF and DG) until consensus is reached. All studies will be included regardless of quality. Quality appraisal ratings will be reported and considered in the interpretation of results.

Supplemental Material

Supplemental Material - PROTOCOL: How Do Primary Care Providers Seek Advice Regarding Paediatric Care? Protocol for a Mixed Methods Systematic Review

Supplemental Material for PROTOCOL: How Do Primary Care Providers Seek Advice Regarding Paediatric Care? Protocol for a Mixed Methods Systematic Review by Tina Vickery, Georgia Fisher, Lisa Pagano, Darran Foo and Jeffrey Braithwaite in Campbell Systematic Reviews.

Supplemental Material

Supplemental Material - PROTOCOL: How Do Primary Care Providers Seek Advice Regarding Paediatric Care? Protocol for a Mixed Methods Systematic Review

Supplemental Material

Supplemental Material - PROTOCOL: How Do Primary Care Providers Seek Advice Regarding Paediatric Care? Protocol for a Mixed Methods Systematic Review

Footnotes

Acknowledgements

The authors thank clinical librarian Jeremy Cullis at Waranara, the Macquarie University Library, for his support and help with designing the search strategy. The authors also thank Duha Gide who will join the review team to support screening, data extraction and analysis of the review.

Author Contributions

TV, GF, LP and JB conceptualised and designed the review. TV wrote the initial draft of the manuscript, created the first draft of images within the manuscript, and designed the library database search. GF and LP critically appraised and revised the search strategy. GF, LP, DF and JB critically appraised and revised the manuscript and associated images. All authors approved the final manuscript.

ORCID iDs

Tina Vickery

Georgia Fisher

Lisa Pagano

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Search strategies for each database with search strings, database names, access platforms, search fields and other limitations/settings are available in supplementary materials. Extracted data will be made available on reasonable request.*

Preliminary Timeframe

Screening the studies commenced after the protocol was registered in PROSPERO in May 2025. Data extraction should be completed by end of September 2025 such that analyses can be completed by December 2025.

Plans for Updating This Review

The authors will consider updating the review pending the findings and available resources.

Supplemental Material

Supplemental material for this article is available online.

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