Opening Pandora's box - key facilitators of practice change in detecting and responding to childhood adversity - a practitioner perspective.

BACKGROUND: Childhood adversities worsen physical and mental health across the lifespan. Health and social care practitioners play a key role in identifying and responding to childhood adversity, however, may be reluctant to do so due to a perceived lack of services to refer to, time pressures and a deficit of training and confidence. We aimed to (1) quantify changes in practitioner comfort and confidence to identify and respond to childhood adversity following a multimodal intervention within an integrated child and family health and social care hub and (2) to understand barriers and facilitators of practice change. METHODS: Hub practitioners were surveyed about their competence and comfort to directly ask about and confidence to respond to adversity at baseline and then at six and twelve months post training. Interviews were undertaken to explore practitioner barriers and enablers of practice change. Interviews were recorded, transcribed verbatim, and analysed using reflexive thematic analysis. The theoretical domains framework was used to identify the key drivers of practice change. RESULTS: Fifteen of 18 practitioners completed all three surveys and 70% reported increased competence and comfort to directly ask, and confidence to respond across a range of adversities over the 12-month intervention. Twenty-one practitioners completed interviews. Six themes were identified as either facilitators or barriers to practice change. Facilitator themes included (1) connection matters, (2) knowledge provides assurance, (3) confidence in ability and (4) choosing change. Barrier themes were (1) never enough time and (2) opening Pandora's box. Following analysis, key drivers of practice change were 'social influence', 'belief in capability', 'knowledge' and 'behaviour regulation' while barriers to practice change were 'environmental context and resources' and 'emotion'. CONCLUSIONS: Practitioners reported improved confidence in identifying and responding to adversity through a multimodal intervention delivered in an integrated Child and Family Hub. Changing practice requires more than just education and training. Opportunities for social connection and coaching to improve self-confidence and perceived competence are needed to overcome the fear of opening Pandora's box.

The protective measure for institutional care of children and adolescents from the perspective of national studies. / A medida protetiva de acolhimento institucional de crianças e adolescentes na perspectiva dos estudos nacionais.

This article aims to analyze the national scientific production on protective measures aimed at institutional care for at-risk children and adolescents in Brazil. By carrying out an integrative review, we seek to reflect on the main trends, themes, institutional actors, methodologies, and objectives of studies on the aforementioned measure and to analyze how the conditions and the right to health are presented and articulated in these references. Six thematic units were identified in the collection: Perceptions and roles of different actors in institutional reception processes; Processes of autonomy, dismissal, and causes of institutional care; Legislative aspects, evaluation of services, and identification of profiles; Family and community coexistence; Education and professional training; and Physical and mental health of sheltered children and adolescents. In Brazil, specifically, few studies investigate the concepts of the children and adolescents placed in shelters concerning protective measure processes or access to education. The link between poverty and institutionalization appears prominently and the scarcity of activities aimed primarily at family reintegration is evident. A large number of surveys point to the difficulties in implementing legislation.

O artigo tem como objetivo analisar a produção científica nacional sobre as medidas protetivas de acolhimento institucional para crianças e adolescentes em situação de risco no Brasil. Através da realização de uma revisão integrativa, busca-se refletir sobre as principais tendências, temas, atores institucionais, metodologias e objetivos dos estudos acerca da referida medida e analisar como se apresentam e se articulam as condições e o direito à saúde nessas referências. Seis unidades temáticas foram identificadas no acervo: percepções e papéis de diferentes atores nos processos de acolhimento institucional; processos de autonomia, desligamento e causas de acolhimento institucional; aspectos legislativos, avaliação de serviços e identificação de perfis; convivência familiar e comunitária; educação e formação profissional; e saúde física e mental de crianças e adolescentes acolhidos. No Brasil, especificamente, poucos estudos investigam as concepções dos acolhidos sobre os processos de medida protetiva, assim como o acesso à educação. O vínculo entre pobreza e institucionalização aparece com destaque e fica evidenciada a escassez de atividades visando a reintegração familiar de maneira prioritária. Um número alto de pesquisas aponta para as dificuldades de implementar legislações.

Hybrid approaches to allied health services for children and young people: a scoping review.

BACKGROUND: Hybrid models that integrate both in-person and remote health services are increasingly recognized as a promising approach. Nevertheless, research that defines and characterizes these models in children and young people is scarce and essential for establishing guidelines for implementation of hybrid allied health services. This scoping review evaluates four key aspects of hybrid allied health services in children and young people: 1. definitions, 2. service characteristics, 3. outcome measures, and 4. results of hybrid allied health services. METHODS: Six databases were searched: Medline (Ovid), Embase, CINHAL, Psycinfo, Cochrane CENTRAL, and Web of Science. Of the 9,868 studies potentially meeting the inclusion criteria, 49 studies focused on children and young people. Following full-text review, n = 21 studies were included. RESULTS: Terminology used for hybrid allied health services varied across studies which targeted diverse clinical populations and varied in study design, type and frequency of remote and in-person treatments. Over 75% of cases used custom-written software, limiting scalability. All interventions started in-person, possibly to establish a therapeutic alliance and solve technological issues. Most hybrid allied health services (67%) were in mental health, while only a minority involved physical, occupational or speech therapy. The most common outcomes were feasibility and satisfaction, but tools used to measure them were inconsistent. Although 57% of studies demonstrated effectiveness of hybrid allied health services, none measured cost-effectiveness. DISCUSSION: Despite the potential of hybrid allied health services for children and young people, the literature remains at a preliminary stage. Standardization of definitions and outcome measures, and clearer reporting of service characteristics and results would likely promote consolidation of hybrid allied health services in children and young people into clinical practice.

Characteristics and influencing factors of caregivers' healthcare preferences for young children under COVID-19 lockdown: a cross-sectional study in Shanghai, China.

BACKGROUND: Missed or delayed child healthcare caused by the COVID-19 lockdown has threatened young children's health and has had an unpredictable influence on caregivers' child healthcare preferences. This study investigated caregivers' child healthcare preferences and the factors that influence them among families with young children (0-3 years) during the lockdown in Shanghai. METHODS: Participants in this cross-sectional study were enrolled through random encounter sampling. Questionnaires were distributed online from June 1 to November 10, 2022, in Shanghai. A total of 477 valid questionnaires were received. The demographics of caregivers and their families, children's characteristics, COVID-19-related information, and caregivers' healthcare preferences were analyzed. The statistical analyses included frequency and percentage, chi-square tests, and multinomial logistic regression. RESULTS: Caregivers preferred child healthcare professionals in the community health service system (CHS; 47.6%) followed by hospital pediatricians (40.0%) during lockdown. Caregivers with the following characteristics preferred CHS: those with an annual household income of CNY 200,000-300,000, those whose youngest children were aged 8-12 months, and those who experienced early childhood physical development issues. Caregivers preferred hospitals if they had experienced healthcare-seeking-related difficulties in accessing professional guidance from hospital pediatricians. CONCLUSIONS: During pandemic lockdowns, policymakers should allocate more resources to CHS to meet caregivers' childcare demands. Moreover, special attention should be given to the healthcare needs for CHS among families with specific demographics. TRIAL REGISTRATION: Approval was obtained from the Ethics Committee of Shanghai Jiao Tong University School of Medicine School of Public Health (SJUPN-202,109; June 1, 2022).

'There was nothing, just absolute darkness': Understanding the needs of those caring for children and young people with complex neurodisability in a diverse UK context: A qualitative exploration in the ENCOMPASS study.

BACKGROUND: Children and young people (CYP) with complex neurodisability experience multiple physical, communication, educational and social challenges, which require complex packages of multidisciplinary care. Part of the holistic care required includes supporting the families and parents/caregivers. The aim of the wider study was to introduce a new programme ('Ubuntu') to parents/caregivers and healthcare professionals (HCPs) in order to test the feasibility and acceptability of the concept and content, with the goal of potential adaptation for the UK in mind. Data collection and analysis uncovered rich data on caregiving journeys, navigation of health services, and perceived service gaps. This paper focuses solely on these topics. Further papers will report on the feasibility and adaptation data. METHODS: Two rounds of semi-structured interviews were conducted with 12 caregivers of CYP with complex neurodisability and six HCPs from a variety of disciplines, recruited from a community child health service in London Borough of Newham, UK in 2020. The interviews included open-ended questions to explore caregiving journeys, experiences of navigating health services and perceived service gaps. Transcripts were analysed using a data-driven inductive thematic analysis. RESULTS: Three themes were identified that related to the aim of understanding caregivers' experiences and unmet needs relating to current service provision. These were (1) Caregiver Mental Health, (2) The Information Gap and (3) The Need for Holistic Support. Mental health difficulties were reported, particularly around the period of diagnosis. Priority needs included the provision of clear information about the diagnosis and services offered, opportunities to forge peer support networks and for services across the community to collaborate. CONCLUSIONS: The delivery of health services for CYP with neurodisability should encompass the broad needs of the family as well as meeting the clinical needs of the CYP.

Experiences of healthcare providers and caregivers regarding health system bottlenecks affecting child healthcare service delivery in a rural district: Empirical qualitative study.

AIM: To explore the experiences of nurses and caregivers about the health system bottlenecks to the delivery of child healthcare services in a rural district in Ghana. DESIGN: The study employed a qualitative approach using an exploratory, descriptive design. METHODS: Collection of data was through semi-structured, face-to-face interviews with 26 participants in the Nkwanta South Municipality, Ghana. Audio recordings of interviews were transcribed verbatim and analysed qualitatively. Inductive codes generated were organised into themes and sub-themes. RESULTS: The main health system bottlenecks that emerged were the poor state of in-patient facilities, inadequate basic logistics and persistent shortage of essential medicines needed for child healthcare delivery. CONCLUSIONS: Health system bottlenecks have the tendency to affect the treatment and hospitalisation outcomes of sick children and eventually impact the state of child healthcare negatively. Concerted efforts by government and local authorities to remove these barriers will help to improve child health and child health outcomes. PUBLIC CONTRIBUTION: A total of 26 participants comprising nurses and caregivers, agreed and participated in this study. Interviews with these participants were conducts either in the health facilities or in the communities where they live. Their responses contributed significantly to the content of this article.

A protocol for the formative evaluation of the implementation of patient-reported outcome measures in child and adolescent mental health services as part of a learning health system.

BACKGROUND: Mental health conditions affect one in seven young people and research suggests that current mental health services are not meeting the needs of most children and youth. Learning health systems are an approach to enhancing services through rapid, routinized cycles of continuous learning and improvement. Patient-reported outcome measures provide a key data source for learning health systems. They have also been shown to improve outcomes for patients when integrated into routine clinical care. However, implementing these measures into health systems is a challenging process. This paper describes a protocol for a formative evaluation of the implementation of patient-reported measures in a newly operational child and adolescent mental health centre in Calgary, Canada. The purpose is to optimize the collection and use of patient-reported outcome measures. Our specific objectives are to assess the implementation progress, identify barriers and facilitators to implementation, and explore patient, caregivers and clinician experiences of using these measures in routine clinical care. METHODS: This study is a mixed-methods, formative evaluation using the Consolidated Framework for Implementation Research. Participants include patients and caregivers who have used the centre's services, as well as leadership, clinical and support staff at the centre. Focus groups and semi-structured interviews will be conducted to assess barriers and facilitators to the implementation and sustainability of the use of patient-reported outcome measures, as well as individuals' experiences with using these measures within clinical care. The data generated by the patient-reported measures over the first five months of the centre's operation will be analyzed to understand implementation progress, as well as validity of the chosen measures for the centres' population. DISCUSSION: The findings of this evaluation will help to identify and address the factors that are affecting the successful implementation of patient-reported measures at the centre. They will inform the co-design of strategies to improve implementation with key stakeholders, which include patients, clinical staff, and leadership at the centre. To our knowledge, this is the first study of the implementation of patient-reported outcome measures in child and adolescent mental health services and our findings can be used to enhance future implementation efforts in similar settings.

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.

Current and preferred services of specialized professionals in childcare settings in Quebec, Canada: A descriptive survey of childcare administrators' perspectives.

BACKGROUND: Many challenges exist in promoting inclusion in childcare settings. Adequate support from specialized professionals is necessary to create inclusive childcare settings. Understanding which services are being delivered by specialized professionals in childcare contexts is an important first step. The aim of this study was to (1) describe the services currently being delivered by specialized professionals in childcare settings in Quebec (Canada) and (2) seek childcare administrators' perspectives on their preferred services. METHODS: An online province-wide descriptive survey was conducted with childcare administrators (n = 344). Questions focused on 11 service delivery dimensions (e.g. professionals involved, children served). Descriptive statistics were calculated. RESULTS: Childcare settings received services from a median of two specialized professionals (IQR [1-4]). Most services were delivered by early childhood special educators (61.3%), speech-language pathologists (57.6%), psycho-educators (43.6%) and occupational therapists (43.3%). Childcare administrators identified these four services as being particularly supportive. Professionals delivered a median of 0.4 h of service per week in each childcare setting (IQR [0.1-3.0]). A high percentage (91.2%) of administrators reported unmet needs for professional support in at least one developmental domain, with a high percentage (57.3%) of administrators identifying needs in the socio-emotional domain. Most (63.3%) expressed a desire to prioritize services for children without an established diagnosis but identified by early childhood educators as having needs for professional support. Most administrators (71.4%) also preferred in-context services. CONCLUSIONS: Childcare administrators perceive an important role for specialized professionals in supporting inclusion in their settings. Recommendations emerging are based on the four main professional service needs identified: (1) increasing the intensity and stability of services; (2) providing services for undiagnosed children identified by early childhood educators as having unmet needs; (3) ensuring that services encompassing all developmental domains with a focus on the socio-emotional domain; and (4) prioritizing of in-context services.

Tiny patients, huge impact: a call to action.

The continuation of high-quality care is under threat for the over 70 million children in the United States. Inequities between Medicaid and Medicare payments and the current procedural-based reimbursement model have resulted in the undervaluing of pediatric medical care and lack of prioritization of children's health by institutions. The number of pediatricians, including pediatric subspecialists, and pediatric healthcare centers are declining due to mounting financial obstacles and this crucial healthcare supply is no longer able to keep up with demand. The reasons contributing to these inequities are clear and rational: Medicaid has significantly lower rates of reimbursement compared to Medicare, yet Medicaid covers almost half of children in the United States and creates the natural incentive for medical institutions to prioritize the care of adults. Additionally, certain aspects of children's healthcare are unique from adults and are not adequately covered in the current payment model. The result of decades of devaluing children's healthcare has led to a substantial decrease in the availability of services, medications, and equipment needed to provide healthcare to children across the nation. Fortunately, the solution is just as clear as the problem: we must value the healthcare of children as much as that of adults by increasing Medicaid funding to be on par with Medicare and appreciate the complexities of care beyond procedures. If these changes are not made, the high-quality care for children in the US will continue to decline and increase strain on the overall healthcare system as these children age into adulthood.

Barriers to accessing and utilising under-five primary health care services in Vhembe District.

BACKGROUND:  Sub-Saharan Africa continues to be the region with the highest under-five mortality rate globally, with 74 deaths per 1000 live births. Even though under-five child primary health care (PHC) services are free in South Africa, accessing such services remains challenging. Children under 5 years reportedly die from common illnesses such as pneumonia, diarrhoea and malaria, which are treatable in PHC facilities. AIM:  The study explored the barriers to accessing and utilising under-five PHC services in the Vhembe District. SETTING:  The study was conducted in two PHC centres in Vhembe District among guardians accessing care for under-five child health services. METHODS:  An interpretative phenomenology design was followed using a semi-structured individual interview guide. Sixteen participants were purposively sampled for the study. Colaizzi's steps of data analysis were followed, and trustworthiness as well as ethical principles were ensured throughout the study. RESULTS:  Four themes emerged as health system barriers, health personnel-related behaviours, health facility infrastructure barriers and guardians-related barriers. Subthemes emerged as distance from the facility, lack of resources, long waiting times; poor time management, lack of commitment and work devotion, insufficient waiting space; challenges with water and sanitation, guardians' healthcare beliefs and the urgency of the illness. CONCLUSION:  It is imperative that an enabling professional and friendly environment is created to facilitate better access to PHC services for children under 5 years.Contribution: The study's findings brought insight into considering the context of the guardians in improving quality care for under 5 years.

"The Early Years are Like a Foundation for the Future" Perspectives, Facilitators, and Challenges of Anganwadi Workers in Supporting Early Child Development Interventions in Hyderabad, India: Qualitative Findings from a Scalable Program Incorporating Early Child Development Interventions.

BACKGROUND: Integrated Child Development Services (ICDS) scheme, a large public health program, addresses the needs of young children with Anganwadi Workers (AWWs) as frontline agents of delivery. A scalable program incorporating early child development interventions (ASPIRE) has been developed to complement the program and address some of its gaps. OBJECTIVES: This paper describes formative work done with AWWs, as part of ASPIRE to assess their understanding of early childhood development (ECD) and acceptability of a novel ECD intervention using digital technology. MATERIALS AND METHODS: Six focus group discussions (FGDs) were conducted with 31 AWWs, using a semi-structured guide. RESULTS: Framework analysis of their responses from FGDs led to the identification of three themes: (1) time use, (2) understanding of ECD, and (3) delivering messages using videos. The findings suggest that AWWs tight schedules often leave them feeling overburdened with work. They are aware of factors that can aid as well as hinder child growth and development, but their understanding of play is limited to games played by older children. They expressed acceptability in using a video intervention, specifying features that would increase relevance for families. CONCLUSION: Integration of novel ECD interventions delivered by frontline workers needs to take into account their existing work schedules and associated challenges. Training on ECD interventions will need to broaden AWWs understanding of the critical foundational experiences which responsive caregiving and early child stimulation can provide.

O uso do Facebook com pais de recém-nascidos: uma revisão integrativa / The use of Facebook with parents of newborns: an integrative review / El uso de Facebook con padres de recién nacidos: una revisión integradora

Investigar e analisar as evidências disponíveis na literatura sobre o uso do Facebook com os pais de recém--nascidos. Trata-se de uma revisão integrativa, realizada no segundo semestre de 2020, nas bases de dados Lilacs (Literatura Latino-Americana e do Caribe em Ciências da Saúde), SciELO (Scientific Electronic Li-brary Online) e Medline (Medical Literature Analysis and Retrieval System Online). Amostra composta por 11 artigos, divididos em duas categorias. Foi evidenciado o uso do Facebook como forma de recrutamento de participantes e como suporte de apoio e compartilhamento de informações entre os pais dos recém--nascidos. No recrutamento, a utilização do Facebook foi eficaz, podendo ser um método viável de contatar usuários. Como suporte de apoio e compartilhamento de informações, a rede social também foi efetiva, devido à troca de experiência, apoio mútuo entre os usuários, disseminação de informações, facilidade ao usar a plataforma e alto engajamento dos participantes.

To investigate and analyze the evidence available in the literature on the use of Facebook with parents of newborns. This is an integrative review, carried out in the second half of 2020, in the Lilacs databases (Literatura Latino-Americana e do Caribe em Health Sciences), SciELO (Scientific Electronic Library Online) and Medline (Medical Literature Analysis and Retrieval System Online). Sample composed of eleven articles, divided into two categories. The use of Facebook was evidenced as a way of recruiting participants and as support and information sharing between parents of newborns. In recruitment, the use of Facebook was effective and may be a viable method of contacting users. As support and information sharing, the social network was also effective, due to the exchange of experience, mutual support among users, dissemination of information, ease of use of the platform and the high engagement of participants.

Investigar y analizar la evidencia disponible en la literatura sobre el uso de Facebook con padres de recién nacidos, se trata de una revisión integradora, realizada en el segundo semestre de 2020, en las bases de datos Lilacs (Literatura Latino-Americana e do Caribe em Health Sciences ), SciELO (Biblioteca científica electrónica en línea) y Medline (Sistema de recuperación y análisis de literatura médica en línea). Muestra compuesta por once artículos, divididos en dos categorías. Se evidenció el uso de Facebook como forma de captación de participantes y como apoyo e intercambio de información entre padres de recién nacidos. En la contratación, el uso de Facebook fue efectivo y puede ser un método viable para contactar a los usuarios. Como apoyo e intercambio de información, la red social también resultó eficaz, debido al intercambio de experiencias, el apoyo mutuo entre los usuarios, la difusión de información, la facilidad de uso de la plata-forma y el alto compromiso de los participantes.

Monitoring children’s development in Europe and central Asia with a focus on primary health care: directions for policy and practice

This publication was developed by the United Nations Children’s Fund (UNICEF) Regional Officefor Europe and Central Asia and the World Health Organization (WHO) Regional Office for Europe. It aims to support policy makers, professionals, advocates and academics in introducing developmental monitoring as a part of routine child health services at the primary health care level. The publication provides guidance for professionals on the essentials of developmental monitoring, based on the available literature and findings regarding the currentstatus of developmental monitoring in the region.

Understanding barriers to well-child visit attendance among racial and ethnic minority parents.

OBJECTIVES: To assess racial and ethnic minority parents' perceptions about barriers to well-child visit attendance. METHODS: For this cross-sectional qualitative study, we recruited parents of pediatric primary care patients who were overdue for a well-child visit from the largest safety net healthcare organization in central Massachusetts to participate in semi-structured interviews. The interviews focused on understanding potential knowledge, structural, and experiential barriers for well-child visit attendance. Interview content was inductively coded and directed content analysis was performed to identify themes. RESULTS: Twenty-five racial and ethnic minority parents participated; 17 (68%) of whom identified Spanish as a primary language spoken at home. Nearly all participants identified the purpose, significance, and value of well-child visits. Structural barriers were most cited as challenges to attending well-child visits, including parking, transportation, language, appointment availability, and work/other competing priorities. While language emerged as a distinct barrier, it also exacerbated some of the structural barriers identified. Experiential barriers were cited less commonly than structural barriers and included interactions with office staff, racial/ethnic discrimination, appointment reminders, methods of communication, wait time, and interactions with providers. CONCLUSIONS: Racial and ethnic minority parents recognize the value of well-child visits; however, they commonly encounter structural barriers that limit access to care. Furthermore, a non-English primary language compounds the impact of these structural barriers. Understanding these barriers is important to inform health system policies to enhance access and delivery of pediatric care with a lens toward reducing racial and ethnic-based inequities.

Pediatric health service utilization at tertiary hospitals in Denmark 2000-2018.

Pediatric health service differs between and within countries. To prioritize limited resources, data-driven studies on pediatric tertiary hospital contacts are warranted. This population-based register study identified all contacts with four Danish tertiary hospitals 2000-2018 by 0-17-year-old patients. During 2000-2018, 2,496,001 individuals resided in Denmark while 0-17 years old, and the study described 829,562 inpatient and 3,932,744 outpatient contacts at tertiary hospitals by hospital, sex, age, diagnosis, department, and residence. Male patients accounted for more contacts overall (inpatient 55.51%, outpatient 52.40%) and more contacts with severe chronic disease (inpatient 56.24%, outpatient 54.41%). Median (interquartile range) patient age was 3.09 (0.26-9.96) and 8.48 (2.78-13.70) years for in- and outpatient contacts. Overall, 28.23% and 21.02% of in- and outpatient contacts included a diagnosis of a severe chronic disease, but the proportions differed across hospitals. A pattern of pediatric healthcare directed towards less severe diseases was observed: While the total number of outpatient visits at tertiary hospitals increased from 2000 to 2018, the proportion of these contacts which had a diagnosis of a severe chronic disease decreased. Future comparisons between hospitals regarding pediatric outcomes should consider potential differences in terms of uptake and diagnosis severity. Such findings may have implications for future pediatric organization, nationally and internationally.

Providing Compassionate, Evidence-Based Care for Refugee, Immigrant, and Migrant Children.

Immigrant children experience diverse migration paths to the United States facing unique challenges that impact their health and well-being. This article provides an overview of the pathways to health care and physical, mental, and behavioral health considerations for refugee and immigrant children. Health equity and cultural humility frameworks are reviewed. Approach to care guidance and clinical pearls are provided for the initial medical assessment in addition to medical screening, mental health, education, and developmental health. The importance of health literacy and advocacy are highlighted, emphasizing their ability to address health inequities and improve care.

Improving Outcomes for Regional Families in the Early Years: Increasing Access to Child and Family Health Services for Regional Australia.

Providing child and family health (CFH) services that meet the needs of young children and their families is important for a child's early experiences, development and lifelong health and well-being. In Australia, families living in regional and rural areas have historically had limited access to specialist CFH services. In 2019, five new specialist CFH services were established in regional areas of New South Wales, Australia. The purpose of this study is to understand the regional families' perceptions and experiences of these new CFH services. A convergent mixed-methods design involving a survey and semi-structured interviews with parents who had used the service was used for this study. Data collected include demographics, reasons for engaging with the service, perception, and experience of the service, including if the service provided was family centred. Triangulation of the quantitative and qualitative analysis uncovered three main findings: (i) The regional location of the service reduced the burden on families to access support for their needs; (ii) providing a service that is family-centred is important to achieve positive outcomes; and (iii) providing a service that is family-centred advances the local reputation of the service, enabling a greater reach into the community. Providing local specialist CFH services reduces the burden on families and has positive outcomes; however, providing services that are family-centred is key.