Moving from idea to reality: The barriers and enablers to implementing Child and Family Hubs policy into practice in NSW, Australia.

BACKGROUND: Adverse childhood experiences can impact physical and mental health throughout the lifespan. To support families experiencing adversity and improve child health and developmental equity, an integrated, multi-sector response is required. Child and Family Hubs (Hubs) are a feasible and acceptable approach to providing such a response. In the Australian context, a number of federal and New South Wales (NSW) state policies support an integrated, multi-sector response using Hubs to support families experiencing adversity. This study examined NSW policy stakeholder and health service manager perspectives on the barriers and enablers to translating policy into practice in the implementation of Child and Family Hubs. METHODS: Semi-structured interviews were conducted with 11 NSW government policy stakeholders and 13 community health service managers working in child and family policy and planning or child and family community-based services. Interviews were of 30-60 min duration and explored stakeholder knowledge, perspectives and experiences around childhood adversity, and barriers and enablers to operationalizing policies supporting Hubs. Analysis of barriers and facilitators to implementation of Hub models of care was undertaken using the Consolidated Framework for Implementation Research (CFIR). RESULTS: Key barriers that emerged included short-term and inconsistent funding, lack of resourcing for a Hub co-ordinator, limited support for evaluation and insufficient time to plan for Hub implementation. Key enablers included flexibility and adaptability of Hub models to meet local needs, formal change management processes, strong governance structures and engagement among Hub practitioners. Key insights included the importance of targeted strategies to support sustained individual practice change and the need for organization-wide commitment to enable the successful adoption and maintenance of the Hub model of care. CONCLUSIONS: This study provides valuable insights and contributes evidence around what is needed to strengthen and support the operationalization and scalability of the Hub model of care. Key recommendations for Hub practitioners include the importance of formal change management processes and establishment of strong governance structures, while key recommendations for policymakers include the need for sustainable Hub funding and a standardized, evidence-based framework to support Hub implementation and evaluation.

Do Australian policies enable a primary health care system to identify family adversity and subsequently support these families-A scoping study.

ISSUE ADDRESSED: To determine if Australian policies support a primary health care system to identify family adversity and subsequently support these families. METHODS: Two methodological approaches were used: (i) a scoping review of Australian federal and two states (Victoria and New South Wales) policies related to family adversity (e.g., childhood maltreatment or household dysfunction, such as parental mental illness); (ii) thirteen semi-structured interviews with Victorian Community Health Service (CHS) staff and government policy makers, recruited via snowball sampling to understand the context of policy making and service implementation. Data collected were subsequently discussed in relation to the Stages Model of policy analysis. RESULTS: One hundred and eighty-eight policies referenced family adversity. Of these, 37 policies met all eligibility criteria including a focus on early intervention within primary care and were included in the review. Most policies were developed within health departments (78%) and included a wide range of adversities, with the majority based within maternal and child health and CHS platforms. Most policy development included consultation with stakeholders. Although most policies received some level of funding, few included funding details and only a third included evaluation. CONCLUSIONS: There are many policies related to family adversity in Australia, with most focused within existing primary care platforms. Given these policies, Australia should be well positioned to identify and respond to family adversity. SO WHAT: More work needs to be done to ensure policies are adequately implemented, evaluated and transparently and appropriately funded. The co-occurrence of adversity should focus policy action; and potentially lead to more effective and efficient outcomes.

Identifying Service, Research and Policy priorities for preventing the impacts of family adversity on children's mental health: An Australian national resource allocation study with professional and lived experience experts.

OBJECTIVES: The objective of this study was to develop Service, Research and Policy priorities to prevent the impact of family adversity on child mental health and determine comparative priorities of diverse stakeholders to those with lived experience of adversity. METHODS: Value-weighting approach conducted in a staged process: (i) professionals and experts with lived experience from health, education, justice and social care sectors attended a national symposium to identify priorities for family adversity and mental health and (ii) a subsequent resource allocation survey gathered views from participants and external experts on symposium priorities. RESULTS: Consensus was reached on priorities. Service priorities included establishing intersectoral hubs for children and families and early childhood nurse home-visiting programs. Research priorities included scaling up evidence-based interventions and evaluating cross-sector, flexible funding models for services addressing childhood adversity. Policy priorities included developing evidence-based policies with evaluation and implementation plans and flexible funding models to support integrated care. CONCLUSIONS: Our results provide detailed and actionable clarity on next steps to address family adversities. IMPLICATIONS FOR PUBLIC HEALTH: The priorities call for a focus on cross-sectoral approaches to preventing or mitigating the effects of family adversity. The current Australian policy environment provides a timely opportunity to action the proposed interventions.

Identifying and responding to family adversity in Australian community and primary health settings: a multi-site cross sectional study.

Background: Unaddressed family adversity has potentially modifiable, negative biopsychosocial impacts across the life course. Little is known about how Australian health and social practitioners identify and respond to family adversity in community and primary health settings. Objective: To describe, in two Australian community health services: (1) the number of adversities experienced by caregivers, (2) practitioner identification of caregivers experiencing adversity, (3) practitioner response to caregivers experiencing adversity, and (4) caregiver uptake of referrals. Methods: Survey of caregivers of children aged 0-8 years attending community health services in Victoria and New South Wales (NSW). Analysis described frequencies of caregiver self-reported: (1) experiences of adversity, (2) practitioner identification of adversity, (3) practitioner response to adversity, and (4) referral uptake. Analyses were sub-grouped by three adversity domains and site. Results: 349 caregivers (Victoria: n = 234; NSW: n = 115) completed the survey of whom 88% reported experiencing one or more family adversities. The median number of adversities was 4 (2-6). Only 43% of participants were directly asked about or discussed an adversity with a practitioner in the previous 6 months (Victoria: 30%; NSW: 68%). Among caregivers experiencing adversity, 30% received direct support (Victoria: 23%; NSW: 43%), and 14% received a referral (Victoria: 10%; NSW: 22%) for at least one adversity. Overall, 74% of caregivers accepted referrals when extended. Conclusion: The needs of Australian families experiencing high rates of adversity are not systematically identified nor responded to in community health services. This leaves significant scope for reform and enhancement of service responses to families experiencing adversity.

The feasibility of a Child and Family Hub within Victorian Community Health Services: a qualitative study.

OBJECTIVES: Explore the feasibility of an integrated Child and Family Hub within Victorian Community Health Services (CHS) to identify and respond to family adversities as preventable determinants of child mental health problems. METHODS: Thirteen Victorian CHS staff and government policy makers (PMs), recruited via snowball sampling, participated in semi-structured interviews exploring: 1) barriers and facilitators for implementing a hub; 2) feasibility of a proposed integrated hub; and 3) resources needed to scale and sustain a hub. Transcripts were analysed employing framework analysis. RESULTS: 1) Barriers included inadequate and activity-based funding, inability to fund community paediatricians and inadequate workforce competencies. Facilitators included CHS engagement with vulnerable communities and readiness to act. 2) The proposed hub model was identified as feasible to implement. Local co-design, co-location, and virtual delivery would support hub implementation. 3) To sustainably scale a hub, clear policy leadership and workforce and funding model reviews are needed. CONCLUSIONS: A hub was perceived as feasible when based in CHS; however, local and system-wide issues need consideration to support its sustainable scaling. IMPLICATIONS FOR PUBLIC HEALTH: Findings will inform the scaling of hub models of care across Victoria and other states to potentially optimise broader child and family health outcomes.

Do Integrated Hub Models of Care Improve Mental Health Outcomes for Children Experiencing Adversity? A Systematic Review.

This review assesses the effectiveness of integrated primary health and social care hubs on mental health outcomes for children experiencing adversity and describes common integration dimensions of effective hubs. PubMed, OVID Medline and PyschINFO databases were systematically searched for relevant articles between 2006-2020 that met the inclusion criteria: (i) interventional studies, (ii) an integrated approach to mental health within a primary health care setting, (iii) validated measures of child mental health outcomes, and (iv) in English language. Of 5961 retrieved references, four studies involving children aged 0-12 years experiencing one or more adversities were included. Most children were male (mean: 60.5%), and Hispanic or African American (82.5%). Three studies with low-moderate risk of bias reported improvements in mental health outcomes for children experiencing adversity receiving integrated care. The only RCT in this review did not show significant improvements. The most common dimensions of effective integrated hubs based on the Rainbow Model of Integrated Care were clinical integration (including case management, patient-centred care, patient education, and continuity of care), professional integration, and organisational integration including co-location. These results suggest hubs incorporating effective integration dimensions could improve mental health outcomes for children experiencing adversity; however, further robust studies are required. Registered with Prospero: CRD42020206015.

Integrated Child and Family Hub models for detecting and responding to family adversity: protocol for a mixed-methods evaluation in two sites.

INTRODUCTION: Integrated community healthcare Hubs may offer a 'one stop shop' for service users with complex health and social needs, and more efficiently use service resources. Various policy imperatives exist to implement Hub models of care, however, there is a dearth of research specifically evaluating Hubs targeted at families experiencing adversity. To contribute to building this evidence, we propose to co-design, test and evaluate integrated Hub models of care in two Australian community health services in low socioeconomic areas that serve families experiencing adversity: Wyndham Vale in Victoria and Marrickville in New South Wales. METHODS AND ANALYSIS: This multisite convergent mixed-methods study will run over three phases to (1) develop the initial Hub programme theory through formative research; (2) test and, then, (3) refine the Hub theory using empirical data. Phase 1 involves co-design of each Hub with caregivers, community members and practitioners. Phase 2 uses caregiver and Hub practitioner surveys at baseline, and 6 and 12 months after Hub implementation, and in-depth interviews at 12 months. Two stakeholder groups will be recruited: caregivers (n=100-200 per site) and Hub practitioners (n=20-30 per site). The intervention is a co-located Hub providing health, social, legal and community services with no comparator. The primary outcomes are caregiver-reported: (i) identification of, (ii) interventions received and/or (iii) referrals received for adversity from Hub practitioners. The study also assesses child, caregiver, practitioner and system outcomes including mental health, parenting, quality of life, care experience and service linkages. Primary and secondary outcomes will be assessed by examining change in proportions/means from baseline to 6 months, from 6 to 12 months and from baseline to 12 months. Service linkages will be analysed using social network analysis. Costs of Hub implementation and a health economics analysis of unmet need will be conducted. Thematic analysis will be employed to analyse qualitative data. ETHICS AND DISSEMINATION: Royal Children's Hospital and Sydney Local Health District ethics committees have approved the study (HREC/62866/RCHM-2020). Participants and stakeholders will receive results through meetings, presentations and publications. TRIAL REGISTRATION NUMBER: ISRCTN55495932.

Prioritising interventions for preventing mental health problems for children experiencing adversity: a modified nominal group technique Australian consensus study.

BACKGROUND: Despite the well-established link between childhood adversity and mental health problems, there is a dearth of evidence to inform decision making about the most acceptable and feasible interventions for preventing mental health problems for children experiencing adversity. Expert consensus is an important input into evidence-informed policy and practice but is often employed at the national level which misses important local contextual factors shaping decision making. This study aimed to: (1) reach consensus on local priority interventions for preventing mental health problems for children living with adversity in Wyndham, Victoria; and (2) understand the enabling factors and barriers to implementing these interventions. METHODS: This study employed six online modified nominal group technique (NGT) workshops with 19 stakeholders; intersectoral service providers from health, social and education sectors and caregivers of children aged 0-8 years. RESULTS: Three interventions reached consensus among the mixed stakeholder groups as being a high or very high priority for implementation in Wyndham: nurse home visiting, parenting programs and community-wide programs. Key rationales were the ability for these interventions to act as a gateway for families to increase their knowledge about topics immediately relevant to them (i.e. parenting), increase their knowledge about available supports and build relationships with service providers. CONCLUSIONS: Local priorities for preventing mental health problems for children living with adversity emphasized relational approaches to service provision and were shaped by the availability of existing interventions and supports in the locality. The NGT was found to be an effective method for prioritising evidence-based practice interventions in health settings, engaging local stakeholders, and identifying enablers and barriers to implementation.

Evaluation of the childhood obesity prevention program Kids--'Go for your life'.

BACKGROUND: Kids--'Go for your life' (K-GFYL) is an award-based health promotion program being implemented across Victoria, Australia. The program aims to reduce the risk of childhood obesity by improving the socio-cultural, policy and physical environments in children's care and educational settings. Membership of the K-GFYL program is open to all primary and pre-schools and early childhood services across the State. Once in the program, member schools and services are centrally supported to undertake the health promotion (intervention) activities. Once the K-GFYL program 'criteria' are reached the school/service is assessed and 'awarded'. This paper describes the design of the evaluation of the statewide K-GFYL intervention program. METHODS/DESIGN: The evaluation is mixed method and cross sectional and aims to: 1) Determine if K-GFYL award status is associated with more health promoting environments in schools/services compared to those who are members only; 2) Determine if children attending K-GFYL award schools/services have higher levels of healthy eating and physical activity-related behaviors compared to those who are members only; 3) Examine the barriers to implementing and achieving the K-GFYL award; and 4) Determine the economic cost of implementing K-GFYL in primary schools. Parent surveys will capture information about the home environment and child dietary and physical activity-related behaviors. Environmental questionnaires in early childhood settings and schools will capture information on the physical activity and nutrition environment and current health promotion activities. Lunchbox surveys and a set of open-ended questions for kindergarten parents will provide additional data. Resource use associated with the intervention activities will be collected from primary schools for cost analysis. DISCUSSION: The K-GFYL award program is a community-wide intervention that requires a comprehensive, multi-level evaluation. The evaluation design is constrained by the lack of a non-K-GFYL control group, short time frames and delayed funding of this large scale evaluation across all intervention settings. However, despite this, the evaluation will generate valuable evidence about the utility of a community-wide environmental approach to preventing childhood obesity which will inform future public health policies and health promotion programs internationally. TRIAL REGISTRATION: ACTRN12609001075279.

Developing an award program for children's settings to support healthy eating and physical activity and reduce the risk of overweight and obesity.

BACKGROUND: This paper aimed to identify the best way to engage, motivate and support early childhood services (ECS) and primary schools (PS) to create policy and practise changes to promote healthy eating and physical activity. This information would be used to develop a suitable program to implement within these children's settings to reduce the risk of childhood overweight and obesity. METHODS: The Medical Research Council's (UK) framework for the design and evaluation of complex interventions was used to guide the development of the healthy eating and physical activity program suitable for ECS and PS. Within this framework a range of evaluation methods, including stakeholder planning, in-depth interviews with ECS and PS staff and acceptability and feasibility trials in one local government area, were used to ascertain the best way to engage and support positive changes in these children's settings. RESULTS: Both ECS and PS identified that they had a role to play to improve children's healthy eating and physical activity. ECS identified their role in promoting healthy eating and physical activity as important for children's health, and instilling healthy habits for life. PS felt that these were health issues, rather than educational issues; however, schools saw the link between healthy eating and physical activity and student learning outcomes. These settings identified that a program that provides a simple guide that recognises good practise in these settings, such as an award scheme using a health promoting schools approach, as a feasible and acceptable way for them to support children's healthy eating and physical activity. CONCLUSION: Through the process of design and evaluation a program - Kids - 'Go for your life', was developed to promote and support children's healthy eating and physical activity and reduce the risk of childhood overweight and obesity. Kids - 'Go for your life' used an award program, based on a health promoting schools approach, which was demonstrated to be a suitable model to engage ECS and PS and was acceptable and feasible to create policy and practise changes to support healthy eating and physical activity for children.

The Effects of Hormonal Therapy and Exercise on Bone Turnover in Postmenopausal Women: A Randomised Double-Blind Pilot Study.

INTRODUCTION: Hormone replacement therapy (HRT) and walking were investigated independently and in combination, to determine which treatment provided most effect on bone turnover in postmenopausal women. METHODS: Using a randomised double-blind pilot study, 10 subjects received HRT (transdermal estradiol, 50 µg/day and oral MPA 5 mg/day) and 12 received placebo for 20 weeks. Following a baseline period of treatment, both groups undertook a graduated walking regimen, which increased in intensity, duration and frequency parameters from weeks 8-20. Measurements of aerobic capacity, female sex hormones, bone formation markers [osteocalcin (OC) and bone alkaline phosphatase (BAP)] and bone resorption markers [deoxypyridinoline (DPD) and pyridinoline (PYR)] were measured at baseline (T1), week 8 (T2) and week 20 (T3). RESULTS: Age, time of postmenopause, weight or body mass index were no different between each groups. The HRT group had significantly higher estradiol levels compared with the placebo group at T2 and T3. FSH and LH levels were significantly reduced following HRT. DPD and PYR were significantly reduced from baseline levels at T2 and T3 with HRT. No significant changes occurred in OC or BAP levels with either HRT or walking. Walking did not change bone turnover markers in either the HRT or placebo group. CONCLUSION: HRT reduces bone resorption, however, walking alone at the intensity and duration prescribed, or the combination of HRT and walking, provided no additional benefit after menopause. Therefore, HRT, but not walking is an effective treatment in reducing bone turnover in postmenopause women.

Hormone Therapy Reduces Bone Resorption but not Bone Formation in Postmenopausal Athletes.

INTRODUCTION: Independently, hormone therapy and exercise have well-established protective effects on bone parameters. The combined effects of hormone therapy and exercise, however, are less clear. We, therefore, examined the effects of hormone therapy on bone turnover markers in postmenopausal women undergoing regular high intensity exercise. METHODS: In a randomised, double blind study, postmenopausal athletes competing at Masters level, received either hormone therapy (50 µg transdermal oestradiol, 5 mg MPA, n = 8) or placebo (n = 7) for 20 weeks. Women were tested before and after treatment for plasma concentrations of oestradiol, FSH, LH, and serum bone formation marker -osteocalcin (OC); and urine bone resorption markers-pyridinoline (PYD) and deoxypyridinoline (DPD). RESULTS: As a result of treatment with hormone therapy there were significant reductions in levels of FSH (73.3 ± 13.7 to 48.6 ± 10.5 mmol/L, p = 0.01) and bone resorption markers (PYD, 81.9 ± 7.7 to 57.8 ± 3.7 nmol/mmol Cr, p = 0.001, and DPD, 18.5 ± 3.1 to 11.8 ± 2.1 nmol/mmol Cr, p = 0.01). Oestradiol and bone formation markers were not significantly altered as a result of hormone therapy. There were no changes to any variables with placebo treatment. CONCLUSION: Hormone therapy reduced bone resorption, but not bone formation, in postmenopausal athletes. These favorable reductions in bone turnover; therefore, provide an effective treatment in combination with high intensity exercise to further reduce the subsequent risk of osteoporosis and associated fractures.

Differential effect of urotensin II on vascular tone in normal subjects and patients with chronic heart failure.

BACKGROUND: Urotensin II (U-II) is a novel vasoactive peptide that also has direct hypertrophic and profibrotic effects on the myocardium. Upregulation of U-II and its receptor has been observed within the heart of patients with chronic heart failure (CHF). Furthermore, plasma levels of U-II have been found to be elevated in some but not all studies in such patients. However, the functional consequences of activation of the U-II system in patients with CHF, assessed by direct administration of exogenous U-II, have not been previously determined. METHODS AND RESULTS: We compared the effect of iontophoresed U-II on skin microvascular tone in normal subjects and patients with CHF, assessed with the use of laser Doppler velocimetry. U-II mediated a dose-dependent vasodilator response in normal subjects (baseline, 137.9+/-52; U-II, 10(-12) mol/L, 145+/-134; U-II, 10(-9) mol/L, 712+/-179; U-II, 10(-7) mol/L, 943+/-139 arbitrary flux units [AFUs], P<0.0001). In contrast, a dose-dependent vasoconstrictor response was observed in patients with CHF (baseline, 336.1+/-129; U-II, 10(-12) mol/L, 317+/-131; U-II, 10(-9) mol/L, 129+/-137; U-II, 10(-7) mol/L, 22.4+/-130 AFUs, P<0.05). Differences in flow between normal subjects and patients with CHF were significant overall (P<0.001, 2-way ANOVA) and at the U-II 10(-9) mol/L and U-II 10(-7) mol/L dose level by Student's unpaired t test (P<0.05, P<0.0001, respectively). In contrast, there was no significant difference between baseline blood flux and any dose of U-II in either group (or between groups) when the opposite polarity was applied. CONCLUSIONS: In addition to direct effects on the myocardium, U-II may contribute to the increased peripheral vascular tone that is characteristic of human CHF. The present observations support the contention that the U-II system may be a potentially important target for pharmacological blockade in the treatment of this condition.

Hormone therapy impairs endothelial function in postmenopausal women with type 2 diabetes mellitus treated with rosiglitazone.

Diabetes and ovarian senescence are associated with impaired endothelial function and altered arterial mechanical properties. Alterations in normal vascular structure and functioning are the primary cause of mortality and morbidity with type 2 diabetes. Similarly, after menopause, women experience an increase in the rate of cardiovascular disease. Thiazolidinediones have exhibited a number of antiatherogenic actions in populations with type 2 diabetes. The effect of thiazolidinediones in combination with hormone therapy (HT) in postmenopausal women is, however, unknown. To assess whether HT (transdermal estradiol 50 microg and micronized progesterone (100 mg/d) affects vascular function, 21 women receiving rosiglitazone were randomly assigned to receive HT or placebo for 12 wk in a double-blind crossover design. Measures of glycemic control, lipids, blood pressure, flow-mediated dilation, and distensibility index were undertaken at baseline and after each treatment. As a result, flow-mediated dilation was significantly reduced (15.3 +/- 3.8 to 6.6 +/- 1.6%, P = 0.02) with HT, whereas lipids, blood pressure, and distensibility index were unchanged. Placebo had no significant affect on any variables. Thus, the addition of HT to rosiglitazone treatment attenuates endothelial function without altering other cardiovascular risk factors. Caution should, therefore, be exercised when considering combined treatment with thiazolidinedione and HT.

Progesterone does not influence vascular function in postmenopausal women.

BACKGROUND: The protective functions of oestrogen therapy alone on cardiovascular risk parameters are well established; however, the action of progesterone on vascular parameters in an oestrogen-deprived environment is less clear. OBJECTIVES: To examine the effects of progesterone alone on vascular function and hormone levels in postmenopausal women. DESIGN: In a randomized, double-blind, cross-over design study, 20 healthy postmenopausal women were tested before and after 6 weeks of treatment with micronized progesterone (100 mg/daily) and matching placebo. METHODS: Tests included measurement of sex hormones and gonadatropin levels, lipids and measures of surrogate markers of vascular function including, blood pressure, flow-mediated dilation of the brachial artery, systemic arterial compliance and cutaneous vascular reactivity. RESULTS: The mean (+/- SEM) age of subjects was 56.4 +/- 2.7 years and the average body mass index at the baseline visit was 27.1 +/- 1.0 kg/m2. Progesterone levels increased as a result of progesterone treatment (0.9 +/- 0.2 to 9.5 +/- 2.3 nmol/l, P = 0.001), whereas follicle-stimulating hormone levels decreased (75.1 +/- 11.4 to 67.6 +/- 10.0, P = 0.001). Systemic arterial compliance, flow mediated dilation, cutaneous vascular reactivity, blood pressure, body mass index, plasma levels of cholesterol, lipids and oestrogen were unchanged. CONCLUSIONS: We conclude that progesterone given without oestrogen does not adversely affect vascular function in postmenopausal women.

The anti-atherogenic effects of thiazolidinediones.

The thiazolidinediones (TZDs) rosiglitazone (ROS) and pioglitazone (PIO) are insulin-sensitising agents widely used to treat patients with type 2 diabetes mellitus (T2DM). Thiazolidinediones significantly improve glycaemic control in diabetics by reduced fasting glucose, insulin and glycated haemoglobin and they delay the progression of insulin resistance/impaired glucose tolerance into T2DM. It is well recognized that adequate glycaemic control and subsequent amelioration of hyperinsulinaemia and hyperglycaemia can delay the onset of vascular complications. TZDs, however, also have a number of anti-atherogenic effects independent of their influences on glucose and insulin metabolism. They improve lipid profiles, lower blood pressure, have anti-inflammatory properties, improve endothelial function and increase large artery compliance in patients with type 2 diabetes mellitus. When compared to rosiglitazone, pioglitazone has more favourable effects on the lipid profiles of patients with T2DM. The disease preventive actions of TZDs may be the result of their agonistic effects on peroxisome proliferator-activated receptors (PPARs), ligand-activated transcription factors that regulate the expression of numerous genes and affect metabolism and vascular parameters. Thiazolidinediones, provide an effective treatment for populations with insulin resistance which is at high risk of developing cardiovascular disease. This paper discusses the differences between ROS and PIO and explores their anti-atherogenic effects with particular focus on post-menopausal women with type 2 diabetes mellitus.