The Childhood Resilience Study: Resilience and emotional and behavioural wellbeing experienced by Australian Aboriginal and Torres Strait Islander boys and girls aged 5-9 years.

BACKGROUND: Resilience is a process of drawing on internal or external strengths to regain, sustain or improve adaptive outcomes despite adversity. Using a child resilience measure co-designed with Aboriginal and Torres Strait Islander communities, we investigate: 1) children's personal, family, school and community strengths; 2) gender differences; and 3) associations between resilience and wellbeing. METHODS: 1132 parent/caregivers of children aged 5-12 years were recruited to the Childhood Resilience Study, including through the Aboriginal Families Study. The Aboriginal Families Study is a population-based cohort of 344 mothers of an Aboriginal and/or Torres Strait Islander child. This paper focuses on the wave 2 survey data on child resilience at age 5-9 years (n = 231). Resilience was assessed with the Child Resilience Questionnaire-parent/caregiver report (CRQ-P/C), categorised into tertiles of low, moderate and high scores. Child emotional/behavioural wellbeing and mental health competence was assessed with the parent-report Strengths and Difficulties Questionnaire. All Tobit regression models adjusted for child age. OUTCOMES: Aboriginal and Torres Strait Islander girls had higher resilience scores compared to boys (Adj.ß = 0·9, 95%CI 0·9-1·4), with higher School Engagement, Friends and Connectedness to language scale scores. Resilience scores were strongly associated with wellbeing and high mental health competence. A higher proportion of girls with low resilience scores had positive wellbeing than did boys (73.3% versus 49.0%). High resilience scores were associated with lower SDQ total difficulties score after adjusting for child age, gender, maternal age and education and family location (major city, regional, remote) (Adj.ß = -3.4, 95%CI -5.1, -1.7). Compared to the Childhood Resilience Study sample, Aboriginal Families Study children had higher mean CRQ-P/C scores in the personal and family domains. INTERPRETATION: High family strengths can support Aboriginal and Torres Strait Islander children at both an individual and cultural level. Boys may benefit from added scaffolding by schools, family and communities to support their social and academic connectedness.

Development of a multidimensional culturally and socially inclusive measure of factors that support resilience: Child Resilience Questionnaire-Child report (CRQ-C)-a community-based participatory research and psychometric testing study in Australia.

OBJECTIVE: Development and testing of a comprehensive and social and culturally inclusive child-report measure of resilience factors supporting positive outcomes in the face of adversity. DESIGN: The measure is based on a socioecological model of resilience and was developed and revised using community-based participatory research methods with Aboriginal and refugee background communities. Pilot testing and validation of the child-report version (Child Resilience Questionnaire-Child report (CRQ- C)) is described in this paper. SETTING: Australia. PARTICIPANTS: Children aged 7-12 years from culturally and socially diverse backgrounds completed the CRQ- C in the pilot (n=387) and validation study (n=775). Families recruited via hospital clinics, Aboriginal and refugee background communities and nested follow-up of participants in an existing cohort study. ANALYSIS: The factor structure and construct validity of CRQ-C scales were assessed using exploratory and confirmatory factor analyses. Preliminary assessment of criterion validity was conducted usinghe Strengths and Difficulties Questionnaire (SDQ). Internal consistency of final scales was assessed using Cronbach's alpha. RESULTS: Conceptually developed CRQ-C was over inclusive of resilience factors and items. Exploratory factor analyses and confirmatory factor analyses supported 10 subscales reflecting personal resilience factors (positive self/future, managing emotions) and connectedness to family, school and culture. Excellent scale reliability (α=0.7-0.9) for all but one scale (Friends, α=0.6). Significant negative correlation between CRQ-C and SDQ total difficulty score supporting criterion validity (rs=-0.317, p<0.001). CONCLUSION: The CRQ-C is a new culturally and socially inclusive self-report measure of resilience factors in childhood, with demonstrated content, construct and scale reliability. Further testing of criterion validity required. Availability of child and parent report CRQ supports broad applications in clinical, research and intervention work. Socially inclusive and culturally appropriate tools are fundamental to create the evidence needed to assess and guide intervention efforts.

Development and validation of a multidimensional, culturally and socially inclusive Child Resilience Questionnaire (parent/caregiver report) to measure factors that support resilience: a community-based participatory research and psychometric testing study in Australia.

OBJECTIVE: Develop a comprehensive socially inclusive measure to assess child resilience factors. DESIGN: A socioecological model of resilience, community-based participatory research methods and two rounds of psychometric testing created the Child Resilience Questionnaire (parent/caregiver report, child report, school report). The parent/caregiver report (CRQ-P/C) is the focus of this paper. SETTING: Australia. PARTICIPANTS: Culturally and socially diverse parents/caregivers of children aged 5-12 years completed the CRQ-P/C in the pilot (n=489) and validation study (n=1114). Recruitment via a large tertiary hospital's outpatient clinics, Aboriginal and refugee background communities (Aboriginal and bicultural researchers networks) and nested follow-up of mothers in a pregnancy cohort and a cohort of Aboriginal families. ANALYSIS: Exploratory and confirmatory factor analyses conducted to assess the structure and construct validity of CRQ-P/C subscales. Cronbach's alpha used to assess internal consistency of subscales. Criterion validity assessed with the Strengths and Difficulties Questionnaire (SDQ) parent report. RESULTS: Conceptually developed CRQ comprised 169 items in 19 subscales across five socioecological domains (self, family, friends, school and community). Two rounds of psychometric revision and community consultations created a CRQ-P/C with 43 items in 11 scales: self (positive self, positive future, managing emotions), family (connectedness, guidance, basic needs), school (teacher support, engagement, friends) and culture (connectedness, language). Excellent scale reliability (α=0.7-0.9), except basic needs scale (α=0.61) (where a highly endorsed item was retained for conceptual integrity). Criterion validity was supported: scales had low to moderate negative correlations with SDQ total difficulty score (Rs= -0.2/-0.5. p<0.001); children with emotion/behavioural difficulties had lower CRQ-P/C scores (ß=-14.5, 95% CI -17.5 to -11.6, adjusted for gender). CONCLUSION: The CRQ-P/C is a new multidomain measure of factors supporting resilience in children. It has good psychometric properties and will have broad applications in clinical, educational and research settings. The tool also adds to the few culturally competent measures relevant to Aboriginal and refugee background communities.

Two-year follow up of a cluster randomised controlled trial for women experiencing intimate partner violence: effect of screening and family doctor-delivered counselling on quality of life, mental and physical health and abuse exposure.

OBJECTIVES: This was a 2-year follow-up study of a primary care-based counselling intervention (weave) for women experiencing intimate partner violence (IPV). We aimed to assess whether differences in depression found at 12 months (lower depression for intervention than control participants) would be sustained at 24 months and differences in quality in life, general mental and physical health and IPV would emerge. DESIGN: Cluster randomised controlled trial. Researchers blinded to allocation. Unit of randomisation: family doctors. SETTING: Fifty-two primary care clinics, Victoria, Australia. PARTICIPANTS: Baseline: 272 English-speaking, female patients (intervention n=137, doctors=35; control n=135, doctors=37), who screened positive for fear of partner in past 12 months. Twenty-four-month response rates: intervention 59% (81/137), control 63% (85/135). INTERVENTIONS: Intervention doctors received training to deliver brief, woman-centred counselling. Intervention patients were invited to receive this counselling (uptake rate: 49%). Control doctors received standard IPV information; delivered usual care. PRIMARY AND SECONDARY OUTCOME MEASURES: Twenty-four months primary outcomes: WHO Quality of Life-Bref dimensions, Short-Form Health Survey (SF-12) mental health. SECONDARY OUTCOMES: SF-12 physical health and caseness for depression and anxiety (Hospital Anxiety Depression Scale), post-traumatic stress disorder (Check List-Civilian), IPV (Composite Abuse Scale), physical symptoms (≥6 in last month). Data collected through postal survey. Mixed-effects regressions adjusted for location (rural/urban) and clustering. RESULTS: No differences detected between groups on quality of life (physical: 1.5, 95% CI -2.9 to 5.9; psychological: -0.2, 95% CI -4.8 to 4.4,; social: -1.4, 95% CI -8.2 to 5.4; environmental: -0.8, 95% CI -4.0 to 2.5), mental health status (-1.6, 95% CI -5.3 to 2.1) or secondary outcomes. Both groups improved on primary outcomes, IPV, anxiety. CONCLUSIONS: Intervention was no more effective than usual care in improving 2-year quality of life, mental and physical health and IPV, despite differences in depression at 12 months. Future refinement and testing of type, duration and intensity of primary care IPV interventions is needed. TRIAL REGISTRATION NUMBER: ACTRN12608000032358.

Healing the Past by Nurturing the Future-co-designing perinatal strategies for Aboriginal and Torres Strait Islander parents experiencing complex trauma: framework and protocol for a community-based participatory action research study.

INTRODUCTION: Child maltreatment and other traumatic events can have serious long-term physical, social and emotional effects, including a cluster of distress symptoms recognised as 'complex trauma'. Aboriginal and Torres Strait Islander (Aboriginal) people are also affected by legacies of historical trauma and loss. Trauma responses may be triggered during the transition to parenting in the perinatal period. Conversely, becoming a parent offers a unique life-course opportunity for healing and prevention of intergenerational transmission of trauma. This paper outlines a conceptual framework and protocol for an Aboriginal-led, community-based participatory action research (action research) project which aims to co-design safe, acceptable and feasible perinatal awareness, recognition, assessment and support strategies for Aboriginal parents experiencing complex trauma. METHODS AND ANALYSIS: This formative research project is being conducted in three Australian jurisdictions (Northern Territory, South Australia and Victoria) with key stakeholders from all national jurisdictions. Four action research cycles incorporate mixed methods research activities including evidence reviews, parent and service provider discussion groups, development and psychometric evaluation of a recognition and assessment process and drafting proposals for pilot, implementation and evaluation. Reflection and planning stages of four action research cycles will be undertaken in four key stakeholder workshops aligned with the first four Intervention Mapping steps to prepare programme plans. ETHICS AND DISSEMINATION: Ethics and dissemination protocols are consistent with the National Health and Medical Research Council Indigenous Research Excellence criteria of engagement, benefit, transferability and capacity-building. A conceptual framework has been developed to promote the application of core values of safety, trustworthiness, empowerment, collaboration, culture, holism, compassion and reciprocity. These include related principles and accompanying reflective questions to guide research decisions.

The physical and mental health problems of refugee and migrant fathers: findings from an Australian population-based study of children and their families.

OBJECTIVES: The aim of this study was to report on the physical and mental health of migrant and refugee fathers participating in a population-based study of Australian children and their families. DESIGN: Cross-sectional survey data drawn from a population-based longitudinal study when children were aged 4-5 years. SETTING: Population-based study of Australian children and their families. PARTICIPANTS: 8137 fathers participated in the study when their children were aged 4-5 years. There were 131 (1.6%) fathers of likely refugee background, 872 (10.7%) fathers who migrated from English-speaking countries, 1005 (12.4%) fathers who migrated from non-English-speaking countries and 6129 (75.3%) Australian-born fathers. PRIMARY OUTCOME MEASURES: Fathers' psychological distress was assessed using the self-report Kessler-6. Information pertaining to physical health conditions, global or overall health, alcohol and tobacco use, and body mass index status was obtained. RESULTS: Compared with Australian-born fathers, fathers of likely refugee background (adjusted OR(aOR) 3.17, 95% CI 2.13 to 4.74) and fathers from non-English-speaking countries (aOR 1.79, 95%CI 1.51 to 2.13) had higher odds of psychological distress. Refugee fathers were more likely to report fair to poor overall health (aOR 1.95, 95% CI 1.06 to 3.60) and being underweight (aOR 3.49, 95% CI 1.57 to 7.74) compared with Australian-born fathers. Refugee fathers and those from non-English-speaking countries were less likely to report light (aOR 0.25, 95% CI 0.15 to 0.43, and aOR 0.30, 95% CI 0.24 to 0.37, respectively) and moderate to harmful alcohol use (aOR 0.04, 95% CI 0.10 to 0.17, and aOR 0.14, 95% CI 0.10 to 0.19, respectively) than Australian-born fathers. Finally, fathers from non-English-speaking and English-speaking countries were less likely to be overweight (aOR 0.62, 95% CI 0.51 to 0.75, and aOR 0.84, 95% CI 0.68 to 1.03, respectively) and obese (aOR 0.43, 95% CI 0.32 to 0.58, and aOR 0.77, 95% CI 0.61 to 0.98, respectively) than Australian-born fathers. CONCLUSION: Fathers of refugee background experience poorer mental health and poorer general health than Australian-born fathers. Fathers who have migrated from non-English-speaking countries also report greater psychological distress than Australian-born fathers. This underscores the need for primary healthcare services to tailor efforts to reduce disparities in health outcomes for refugee populations that may be vulnerable due to circumstances and sequelae of forced migration and to recognise the additional psychological stresses that may accompany fatherhood following migration from non-English-speaking countries. It is important to note that refugee and migrant fathers report less alcohol use and are less likely to be overweight and obese than Australian-born fathers.

Who is holding the baby? Women's experiences of contact with their baby immediately after birth: An Australian population-based survey.

BACKGROUND: Seeing and holding their baby immediately after the birth is the pinnacle of the childbearing process for parents. Few studies have examined women's experiences of seeing and holding their baby immediately after birth. We investigated women's experiences of initial contact with their newborns using data from an Australian population-based survey. METHODS: All women who gave birth in September/October in 2007 in two Australian states were mailed questionnaires six months following the birth. Women were asked three questions about early newborn contact including where their baby was held in the first hour after birth and whether they were able to hold their baby as soon and for as long as they liked. We examined the association between model of maternity care and early newborn contact stratified by admission to SCN/NICU. RESULTS: The majority (92%) of women whose babies remained with them reported holding their babies as soon and for as long as they liked in the first hour after birth. However, for women whose babies were admitted to SCN/NICU only a minority (47%) reported this. Women in public models of care (with the exception of primary midwifery care) whose babies remained with them were less likely to report holding their babies as soon and for as long as they liked compared to women in private care. CONCLUSION: Our findings suggest that there is potential to increase the proportion of mothers and fathers who get to hold their baby immediately after the birth by modifying birth suite and operating room practices.

Improving Aboriginal women's experiences of antenatal care: findings from the Aboriginal families study in South Australia.

BACKGROUND: Aboriginal and Torres Strait Islander families experience markedly worse maternal and child health outcomes than non-Aboriginal families. The objective of this study was to investigate the experiences of women attending Aboriginal Family Birthing Program services in South Australia compared with women attending mainstream public antenatal care. METHOD: Population-based survey of mothers of Aboriginal babies giving birth in urban, regional, and remote areas of South Australia between July 2011 and June 2013. RESULTS: A total of 344 women took part in the study around 4-9 months after giving birth; 93 percent were Aboriginal and/or Torres Strait Islanders, and 7 percent were non-Aboriginal mothers of Aboriginal babies. Of these, 39 percent of women lived in a major city, 36 percent in inner or outer regional areas, and 25 percent in remote areas of South Australia. Compared with women attending mainstream public antenatal care, women attending metropolitan and regional Aboriginal Family Birthing Program services had a higher likelihood of reporting positive experiences of pregnancy care (adjOR 3.4 [95% CI 1.6-7.0] and adjOR 2.4 [95% CI 1.4-4.3], respectively). Women attending Aboriginal Health Services were also more likely to report positive experiences of care (adjOR 3.5 [95% CI 1.3-9.4]). CONCLUSIONS: In the urban, regional, and remote areas where the Aboriginal Family Birthing Program has been implemented, the program has expanded access to culturally responsive antenatal care for Aboriginal women and families. The positive experiences reported by many women using the program have the potential to translate into improved outcomes for Aboriginal families.

Why are young women less likely to breastfeed? Evidence from an Australian population-based survey.

BACKGROUND: Younger mothers are less likely to continue breastfeeding compared with older mothers. However, few studies have explored this finding. The aim of this study was to investigate breastfeeding initiation and duration among women aged under 25 and 25 years or older, and assess the extent to which any differences associated with maternal age were explained by other factors. METHODS: All women who gave birth in September and October 2007 in two Australian states were mailed questionnaires 6 months after the birth. Women were asked about infant feeding, maternity care experiences, sociodemographic characteristics, and exposure to stressful life events and social health issues. We examined the association between maternal age, breastfeeding initiation, and breastfeeding at 6 months, while adjusting for a range of social and obstetric risk factors. RESULTS: While younger women were just as likely to initiate breastfeeding as older women (AdjOR 1.13; 95% CI 0.63-2.05), they had almost twice the odds of not breastfeeding at 6 months (AdjOR 1.76; 95% CI 1.34-2.33). Several psychosocial factors may explain why young women are less likely to breastfeed for longer periods. CONCLUSIONS: Given the complexity of young childbearing women's lives, supporting them to breastfeed will require a multisectorial approach that addresses social disadvantage and resulting health inequalities.

Women's experience of discrimination in Australian perinatal care: the double disadvantage of social adversity and unequal care.

BACKGROUND: Discrimination in women's health care, particularly perinatal care, has received minimal attention. The aim of this study is to describe women's experience of discrimination in different models of maternity care and to examine the relationship between maternal social characteristics and perceived discrimination in perinatal care. METHODS: A population-based postal survey was mailed 6 months postpartum to all women who gave birth in two Australian states in September and October 2007. Perceived discrimination was assessed using a five-item measure designed to elicit information about experiences of unequal treatment by health professionals. RESULTS: A total of 4,366 eligible women completed the survey. Women attending public models of maternity care were significantly more likely to report perceived discrimination compared with women attending a private obstetrician (30.7% vs 19.7%, OR 1.79, 95% CI 1.5-2.1). Compared with women reporting no stressful life events or social health issues in pregnancy, those reporting three or more stressful life events or social health issues had a twofold increase in adjusted odds of perceived discrimination (41.1% vs 20.4%, adj OR 2.27, 95% CI 1.8-2.8). Young women (< 25 yr) and women who were smoking in pregnancy were also at increased risk of experiencing perceived discrimination. CONCLUSIONS: Discrimination is an unexplored factor in how women experience perinatal care. Developing approaches to perinatal care that incorporate the capacity to respond to the needs of vulnerable women and families requires far-reaching changes to the organization and provision of care.

In-hospital formula supplementation of breastfed babies: a population-based survey.

BACKGROUND: In-hospital formula supplementation of breastfed newborns is commonplace despite its negative association with breastfeeding duration. Although several studies have described the use of formula supplementation, few have explored the factors that may be associated with its use. The aim of this study was to explore factors associated with in-hospital formula supplementation using data from a large Australian population-based survey. METHODS: All women who gave birth in September and October 2007 in two Australian states were mailed questionnaires 6 months after the birth. Women were asked how they fed their baby while in hospital after the birth. Multivariable logistic regression was used to explore specified a priori factors associated with in-hospital formula supplementation. RESULTS: Of 4,085 women who initiated breastfeeding, 23 percent reported their babies receiving formula supplementation. Breastfed babies had greater odds of receiving formula supplementation if their mother was primiparous (adj. OR=2.16; 95% CI: 1.76-2.66); born overseas and of non-English-speaking background (adj. OR=2.03; 95% CI: 1.56-2.64); had a body mass index more than 30 (adj. OR=2.27; 95% CI: 1.76-2.95); had an emergency cesarean section (adj. OR=1.72; 95% CI: 1.3-2.28); or the baby was admitted to a special care nursery (adj. OR=2.72; 95% CI: 2.19-3.4); had a birthweight less than 2,500 g (adj. OR=2.02; 95% CI: 1.3-3.15) or was born in a hospital not accredited with Baby-Friendly Hospital Initiative (BFHI) (adj. OR=1.53; 95% CI: 1.2-1.94). CONCLUSIONS: The number of factors associated with in-hospital formula supplementation suggests that this practice is complex. Some results, however, point to an opportunity for intervention, with the BFHI appearing to be an effective strategy for supporting exclusive breastfeeding.