Using Participatory Methods to Engage Diverse Families in Research about Resilience in Middle Childhood.

BACKGROUND: Resilience entails drawing on resources to navigate adversity; few measures exist to explore how children cope with adversity in varying cultural contexts. PURPOSE: We aimed to develop a socially-inclusive measure of child resilience by (1) co-designing methods to engage diverse families, and (2) identifying resilience factors. METHODS: We used a community-based participatory research (CBPR) approach to recruit Aboriginal families, refugee families, and families from hospital outpatient clinics. To triangulate findings and codesign methods, we held discussion groups with 21 service providers. Codesigned group-based visual methods were employed in discussion groups with 97 parents and 106 children (5-12 years). FINDINGS: Participants identified culturally-meaningful resilience factors such as loving family, speaking their home language (for families of Non-English speaking backgrounds). We discuss differences and commonalities across participant groups. CONCLUSION: Co-designing research that is both rigorous and inclusive is critical for gleaning culturally-meaningful data from diverse families.

OPTIMISE: a pragmatic stepped wedge cluster randomised trial of an intervention to improve primary care for refugees in Australia.

OBJECTIVES: To examine whether primary care outreach facilitation improves the quality of care for general practice patients from refugee backgrounds. DESIGN: Pragmatic, cluster randomised controlled trial, with stepped wedge allocation to early or late intervention groups. SETTING, PARTICIPANTS: 31 general practices in three metropolitan areas of Sydney and Melbourne with high levels of refugee resettlement, November 2017 - August 2019. INTERVENTION: Trained facilitators made three visits to practices over six months, using structured action plans to help practice teams optimise routines of refugee care. MAJOR OUTCOME MEASURE: Change in proportion of patients from refugee backgrounds with documented health assessments (Medicare billing). Secondary outcomes were refugee status recording, interpreter use, and clinician-perceived difficulty in referring patients to appropriate dental, social, settlement, and mental health services. RESULTS: Our sample comprised 14 633 patients. The intervention was associated with an increase in the proportion of patients with Medicare-billed health assessments during the preceding six months, from 19.1% (95% CI, 18.6-19.5%) to 27.3% (95% CI, 26.7-27.9%; odds ratio, 1.88; 95% CI, 1.42-2.50). The impact of the intervention was greater in smaller practices, practices with larger proportions of patients from refugee backgrounds, recent training in refugee health care, or higher baseline provision of health assessments for such patients. There was no impact on refugee status recording, interpreter use increased modestly, and reported difficulties in refugee-specific referrals to social, settlement and dental services were reduced. CONCLUSIONS: Low intensity practice facilitation may improve some aspects of primary care for people from refugee backgrounds. Facilitators employed by local health services could support integrated approaches to enhancing the quality of primary care for this vulnerable population. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12618001970235 (retrospective).

Response to language barriers with patients from refugee background in general practice in Australia: findings from the OPTIMISE study.

BACKGROUND: Language is a barrier to many patients from refugee backgrounds accessing and receiving quality primary health care. This paper examines the way general practices address these barriers and how this changed following a practice facilitation intervention. METHODS: The OPTIMISE study was a stepped wedge cluster randomised trial set within 31 general practices in three urban regions in Australia with high refugee settlement. It involved a practice facilitation intervention addressing interpreter engagement as one of four core intervention areas. This paper analysed quantitative and qualitative data from the practices and 55 general practitioners from these, collected at baseline and after 6 months during which only those assigned to the early group received the intervention. RESULTS: Many practices (71 %) had at least one GP who spoke a language spoken by recent humanitarian entrants. At baseline, 48 % of practices reported using the government funded Translating and Interpreting Service (TIS). The role of reception staff in assessing and recording the language and interpreter needs of patients was well defined. However, they lacked effective systems to share the information with clinicians. After the intervention, the number of practices using the TIS increased. However, family members and friends continued to be used to interpret with GPs reporting patients preferred this approach. The extra time required to arrange and use interpreting services remained a major barrier. CONCLUSIONS: In this study a whole of practice facilitation intervention resulted in improvements in procedures for and engagement of interpreters. However, there were barriers such as the extra time required, and family members continued to be used. Based on these findings, further effort is needed to reduce the administrative burden and GP's opportunity cost needed to engage interpreters, to provide training for all staff on when and how to work with interpreters and discuss and respond to patient concerns about interpreting services.

Evaluation of systems reform in public hospitals, Victoria, Australia, to improve access to antenatal care for women of refugee background: An interrupted time series design.

INTRODUCTION: Inequalities in maternal and newborn health persist in many high-income countries, including for women of refugee background. The Bridging the Gap partnership programme in Victoria, Australia, was designed to find new ways to improve the responsiveness of universal maternity and early child health services for women and families of refugee background with the codesign and implementation of iterative quality improvement and demonstration initiatives. One goal of this 'whole-of-system' approach was to improve access to antenatal care. The objective of this paper is to report refugee women's access to hospital-based antenatal care over the period of health system reforms. METHODS AND FINDINGS: The study was designed using an interrupted time series analysis using routinely collected data from two hospital networks (four maternity hospitals) at 6-month intervals during reform activity (January 2014 to December 2016). The sample included women of refugee background and a comparison group of Australian-born women giving birth over the 3 years. We describe the proportions of women of refugee background (1) attending seven or more antenatal visits and (2) attending their first hospital visit at less than 16 weeks' gestation compared over time and to Australian-born women using logistic regression analyses. In total, 10% of births at participating hospitals were to women of refugee background. Refugee women were born in over 35 countries, and at one participating hospital, 40% required an interpreter. Compared with Australian-born women, women of refugee background were of similar age at the time of birth and were more likely to be having their second or subsequent baby and have four or more children. At baseline, 60% of refugee-background women and Australian-born women attended seven or more antenatal visits. Similar trends of improvement over the 6-month time intervals were observed for both populations, increasing to 80% of women at one hospital network having seven or more visits at the final data collection period and 73% at the other network. In contrast, there was a steady decrease in the proportion of women having their first hospital visit at less than 16 weeks' gestation, which was most marked for women of refugee background. Using an interrupted time series of observational data over the period of improvement is limited compared with using a randomisation design, which was not feasible in this setting. CONCLUSIONS: Accurate ascertainment of 'harder-to-reach' populations and ongoing monitoring of quality improvement initiatives are essential to understand the impact of system reforms. Our findings suggest that improvement in total antenatal visits may have been at the expense of recommended access to public hospital antenatal care within 16 weeks of gestation.

Afghan families and health professionals' access to health information during and after pregnancy.

BACKGROUND: Having a baby in a new country can be challenging, especially if unable to communicate in a preferred language. The aim of this paper is to explore the provision of health information for Afghan women and men during pregnancy, childbirth and the first year after birth in Melbourne, Australia. METHODS: Community engagement underpinned the study design. Qualitative study with bicultural researchers conducting semi-structured interviews. Interviews and focus groups were also conducted with health professionals. RESULTS: Sixteen Afghan women and 14 Afghan men with a baby aged 4-12 months participated. Thirty four health professionals also participated. Verbal information provided by a health professional with an interpreter was the most common way in which information was exchanged, and was generally viewed favourably by Afghan women and men. Families had limited access to an interpreter during labour and some families reported difficulty accessing an interpreter fluent in their dialect. Availability of translated information was inconsistent and health professionals occasionally used pictures to support explanations. Women and men were unsure of the role of health professionals in providing information about issues other than pregnancy and infant wellbeing. CONCLUSION: Both individual and health system issues hinder and enable the availability and use of information. Consistent, understandable and 'actionable' information is required to meet the needs of diverse families. Health professionals need to be supported with adequate alternatives to written information and access to appropriate interpreters. Inconsistent provision of information is likely to contribute to low health literacy and poor maternal and child health outcomes.

The OPTIMISE project: protocol for a mixed methods, pragmatic, quasi-experimental trial to improve primary care delivery to refugees in Australia.

BACKGROUND: Australia is one of many nations struggling with the challenges of delivering quality primary health care (PHC) to increasing numbers of refugees. The OPTIMISE project represents a collaboration between 12 organisations to generate a model of integrated refugee PHC suitable for uptake throughout Australia. This paper describes the methodology of one component; an outreach practice facilitation intervention, directed towards improving the quality of PHC received by refugees in Australian general practices. METHODS: Our mixed methods study will use a cluster stepped wedge randomised controlled trial design set in 3 urban regions of high refugee resettlement in Australia. The intervention was build upon regional partnerships of policy advisors, clinicians, academics and health service managers. Following a regional needs assessment, the partnerships reached consensus on four core areas for intervention in general practice (GP): recording of refugee status; using interpreters; conducting comprehensive health assessments; and referring to refugee specialised services. Refugee health staff trained in outreach practice facilitation techniques will work with GP clinics to modify practice routines relating to the four core areas. 36 general practice clinics with no prior involvement in a refugee health focused practice facilitation will be randomly allocated into early and late intervention groups. The primary outcome will be changes in number of claims for Medical Benefit Service reimbursed comprehensive health assessments among patients identified as being from a refugee background. Changes in practice performance for this and 3 secondary outcomes will be evaluated using multilevel mixed effects models. Baseline data collection will comprise (i) pre-intervention provider survey; (ii) two surveys documenting each practices' structure and approaches to delivery of care to refugees. De-identified medical record data will be collected at baseline, at the end of the intervention and 6 and 12 months following completion. DISCUSSION: OPTIMISE will test whether a regionally oriented practice facilitation initiative can improve the quality of PHC delivered to refugees. Findings have the potential to influence policy and practice in broader primary care settings. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12618001970235 , 05/12/2018, Retrospectively registered. Protocol Version 1, 21/08/2017.

Enhancing general practice referrals for women of refugee background to maternity care.

This paper presents the findings from a quality improvement project implemented by a maternity hospital located in a region of high refugee settlement. The project was designed to improve the completeness of general practice referral information to enable triage to maternity care that would best meet the needs of women of refugee background. Referral information included four data items - country of birth, year of arrival in Australia, language spoken and interpreter required - used in combination to provide a proxy measure of refugee background. A communication strategy and professional development activity engaged general practitioners (GPs) in the rationale for collecting the four data items on a new referral form. Audits of referrals to the maternity hospital before, and at two time points following the quality improvement activity, indicated that very few referrals were completed on the new form. There were modest improvements in the recording of two items - country of birth and interpreter required. Overall, two-thirds of referrals did not contain information on interpreter requirements. Changing practice will require a more cohesive approach involving GPs in the co-design of the form and development of the quality improvement strategy.

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.

Compromised communication: a qualitative study exploring Afghan families and health professionals' experience of interpreting support in Australian maternity care.

INTRODUCTION: Difficulties associated with communication are thought to contribute to adverse perinatal outcomes experienced by refugee background women living in developed countries. This study explored Afghan women and men's experience of language support during pregnancy, labour and birth, and health professionals' experiences of communicating with clients of refugee background with low English proficiency. METHODS: Interviews were conducted with (1) Afghan women and men in the first year after having a baby in Australia, by multilingual, bicultural researchers and (2) midwives and medical practitioners providing care to families of refugee background. Analysis was conducted thematically. RESULTS: Sixteen Afghan women, 14 Afghan men, 10 midwives, five medical practitioners and 19 community-based health professionals (refugee health nurses, bicultural workers, counsellors) providing maternity or early postnatal care participated. Midwife and medical informants concurred that accredited interpreters are generally booked for the first pregnancy visit, but not routinely used for other appointments. Very few Afghan participants reported access to on-site interpreters. Men commonly interpreted for their wives. There was minimal professional interpreting support for imaging and pathology screening appointments or during labour and birth. Health professionals noted challenges in negotiating interpreting services when men were insistent on providing language support for their wives and difficulties in managing interpreter-mediated visits within standard appointment times. Failure to engage interpreters was apparent even when accredited interpreters were available and at no cost to the client or provider. CONCLUSIONS: Improving identification of language needs at point of entry into healthcare, developing innovative ways to engage interpreters as integral members of multidisciplinary healthcare teams and building health professionals' capacity to respond to language needs are critical to reducing social inequalities in maternal and child health outcomes for refugee and other migrant populations.

Fatherhood in a New Country: A Qualitative Study Exploring the Experiences of Afghan Men and Implications for Health Services.

BACKGROUND: Fathers of refugee background are dealing with multiple, interrelated stressors associated with forced migration and establishing their lives in a new country. This has implications for the role of men in promoting the health and well-being of their families. METHODS: Afghan community researchers conducted interviews with 30 Afghan women and men who had recently had a baby in Australia. Interviews and focus groups were conducted with health professionals working with families of refugee background. RESULTS: Fourteen men, 16 women, and 34 health professionals participated. Afghan men reported playing a major role in supporting their wives during pregnancy and postnatal care, accompanying their wives to appointments, and providing language and transport support. Although men embraced these roles, they were rarely asked by health professionals about their own concerns related to their wife's pregnancy, or about their social circumstances. Perinatal health professionals queried whether it was their role to meet the needs of men. CONCLUSION: There are many challenges for families of refugee background navigating maternity services while dealing with the challenges of settlement. There is a need to move beyond a narrow conceptualization of antenatal and postnatal care to encompass a broader preventive and primary care approach to supporting refugee families through the period of pregnancy and early years of parenting. Pregnancy and postnatal care needs to be tailored to the social and psychological needs of families of refugee background, including men, and incorporate appropriate language support, in order to improve child and family health outcomes.

Bridging the Gap: using an interrupted time series design to evaluate systems reform addressing refugee maternal and child health inequalities.

BACKGROUND: The risk of poor maternal and perinatal outcomes in high-income countries such as Australia is greatest for those experiencing extreme social and economic disadvantage. Australian data show that women of refugee background have higher rates of stillbirth, fetal death in utero and perinatal mortality compared with Australian born women. Policy and health system responses to such inequities have been slow and poorly integrated. This protocol describes an innovative programme of quality improvement and reform in publically funded universal health services in Melbourne, Australia, that aims to address refugee maternal and child health inequalities. METHODS/DESIGN: A partnership of 11 organisations spanning health services, government and research is working to achieve change in the way that maternity and early childhood health services support families of refugee background. The aims of the programme are to improve access to universal health care for families of refugee background and build organisational and system capacity to address modifiable risk factors for poor maternal and child health outcomes. Quality improvement initiatives are iterative, co-designed by partners and implemented using the Plan Do Study Act framework in four maternity hospitals and two local government maternal and child health services. Bridging the Gap is designed as a multi-phase, quasi-experimental study. Evaluation methods include use of interrupted time series design to examine health service use and maternal and child health outcomes over a 3-year period of implementation. Process measures will examine refugee families' experiences of specific initiatives and service providers' views and experiences of innovation and change. DISCUSSION: It is envisaged that the Bridging the Gap program will provide essential evidence to support service and policy innovation and knowledge about what it takes to implement sustainable improvements in the way that health services support vulnerable populations, within the constraints of existing resources.

Promoting the inclusion of Afghan women and men in research: reflections from research and community partners involved in implementing a 'proof of concept' project.

INTRODUCTION: With mounting evidence that poor maternal and child health outcomes are related to the social determinants of health, researchers need to engage with vulnerable and isolated communities to gather the evidence that is essential to determine appropriate solutions. Conventional research methods may not ensure the degree and quality of participation that is necessary for meaningful study findings. Participatory methods provide reciprocal opportunities for often excluded communities to both take part in, and guide the conduct of research. METHOD/DESIGN: The Having a baby in a new country research project was undertaken to provide evidence about how women and men of refugee background experience health services at the time of having a baby. This two year, multifaceted proof of concept study comprised: 1) an organisational partnership to oversee the project; 2) a community engagement framework including: female and male Afghan community researchers, community and sector stakeholder advisory groups and community consultation and engagement. DISCUSSION: Inclusive research strategies that address power imbalances in research, and diversity of and within communities, are necessary to obtain the evidence required to address health inequalities in vulnerable populations. Such an approach involves mindfully adapting research processes to ensure that studies have regard for the advice of community members about the issues that affect them. Researchers have much to gain by committing time and resources to engaging communities in reciprocal ways in research processes.

How do Australian maternity and early childhood health services identify and respond to the settlement experience and social context of refugee background families?

BACKGROUND: Refugees have poor mental, social and physical health related to experiences of trauma and stresses associated with settlement, however little is known about how refugee families experience maternity and early childhood services. The aim of this study was to explore the responsiveness of health services to the social and mental health of Afghan women and men at the time of having a baby. METHOD: Participatory methods including community engagement and consultation with the Afghan community and service providers in Melbourne, Australia. Bicultural researchers conducted interviews with Afghan women and men who had recently had a baby. Interviews and focus groups were also conducted with health professionals working in the region. RESULTS: Thirty interviews were conducted with Afghan women and men who had recently had a baby. Thirty-four health professionals participated in an interview or focus group.Afghan women and men reported significant social hardship during the period before and after having a baby in Australia, but were rarely asked about their social health by maternity and early childhood services.Most health professionals recognised that knowledge and understanding of their client's migration history and social circumstances was relevant to the provision of high quality care. However, inquiring about refugee background, and responding to non-clinical needs of refugee families was challenging for many health professionals. Factors that made it more difficult for health professionals to engage with Afghan families in pregnancy included limited understanding of the context of migration, dependency of many Afghan women on their husband for interpreting, short appointments, and the high likelihood of seeing different health professionals at each antenatal visit. Community-based maternal and child health nurses had more scope to work with interpreters, and build relationships with families, providing a stronger foundation for identifying and responding to complex social circumstances. CONCLUSION: There are significant challenges in providing comprehensive, high quality primary health care for Afghan families accessing Australian maternity and early childhood services. The limited capacity of public maternity services to identify families of refugee background and provide tailored service responses are contributing to inequitable maternal and child health outcomes for families of refugee background.

Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.

BACKGROUND: Often new arrivals from refugee backgrounds have experienced poor health and limited access to healthcare services. The maternal and child health (MCH) service in Victoria, Australia, is a joint local and state government operated, cost-free service available to all mothers of children aged 0-6 years. Although well-child healthcare visits are useful in identifying health issues early, there has been limited investigation in the use of these services for families from refugee backgrounds. This study aims to explore experiences of using MCH services, from the perspective of families from refugee backgrounds and service providers. METHODS: We used a qualitative study design informed by the socioecological model of health and a cultural competence approach. Two geographical areas of Melbourne were selected to invite participants. Seven focus groups were conducted with 87 mothers from Karen, Iraqi, Assyrian Chaldean, Lebanese, South Sudanese and Bhutanese backgrounds, who had lived an average of 4.7 years in Australia (range one month-18 years). Participants had a total of 249 children, of these 150 were born in Australia. Four focus groups and five interviews were conducted with MCH nurses, other healthcare providers and bicultural workers. RESULTS: Four themes were identified: facilitating access to MCH services; promoting continued engagement with the MCH service; language challenges; and what is working well and could be done better. Several processes were identified that facilitated initial access to the MCH service but there were implications for continued use of the service. The MCH service was not formally notified of new parents arriving with young children. Pre-arranged group appointments by MCH nurses for parents who attended playgroups worked well to increase ongoing service engagement. Barriers for parents in using MCH services included access to transportation, lack of confidence in speaking English and making phone bookings. Service users and providers reported that continuity of nurse and interpreter is preferred for increasing client-provider trust and ongoing engagement. CONCLUSIONS: Although participants who had children born in Melbourne had good initial access to, and experience of, using MCH services, significant barriers remain. A systems-oriented, culturally competent approach to service provision would improve the service utilisation experience for parents and providers, including formalising links and notifications between settlement services and MCH services.

Cost losses associated with the "PICC, stick, and run team" concept.

Covenant Healthcare System is a 500-bed facility in Saginaw, Michigan. A peripherally inserted central catheter (PICC) program was instituted there in 1990 when it was St. Lukes Hospital. Over the course of 17 years, 30 nurses had been trained to place PICCs in their spare time. A "PICC, stick, and run team" was established in 1998 but was unsuccessful. After a merger with Saginaw General Hospital, Covenant Healthcare created two full-time vascular access specialty positions. This nursing-based PICC program with full-time staffing has revitalized vascular access at Covenant Healthcare System. Currently, PICCs are placed proactively at the beginning of hospital stays. Peripheral catheter restarts have been replaced with reliable PICC access sites. Delayed discharge for PICC insertion is no longer an issue.