Virtual emergency care in Victoria: Stakeholder perspectives of strengths, weaknesses, and barriers and facilitators of service scale-up.

BACKGROUND: Virtual emergency services have been proposed as an alternative service model to conventional in-person emergency department attendance. METHODS: Twenty participants were interviewed: 10 emergency medicine physicians, 4 health care consumers, and 6 other health care professionals. Conventional content analysis was performed on the interview transcriptions to identify perceived strengths and weaknesses of the VED, and barriers and facilitators to scaling-up the VED. RESULTS: VEDs are perceived as a convenient approach to provide and receive emergency care while ensuring safety and quality of care, however some patients may still need to attend the ED in person for physical assessments. There is currently a lack of evidence, guidelines, and resources to support their implementation. Most of the potential and existing barriers and facilitators for scaling-up the VED were related to their effectiveness, reach and adoption. Broader public health contextual factors were viewed as barriers, while potential actions to address resources and costs could be facilitators. CONCLUSIONS: VEDs were viewed as a convenient service model to provide care, can not replace all in-person visits. Current policies and guidelines are insufficient for wider implementation. Most of the barriers and facilitators for its scaling-up were related to VED effectiveness and delivery.

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.

Will a fee-for-service payment for a young people's health assessment in general practice increase the detection of health risk behaviours and health conditions? Protocol for a cluster randomised controlled trial (RAd Health Trial).

INTRODUCTION: Adolescence is a period of major transition in physical, cognitive, social and emotional development, and the peak time for the onset of mental health conditions, substance use disorders and sexual and reproductive health risks. Prevention and treatment during this time can improve health and well-being now and into the future. However, despite clinical guidelines recommending annual preventive health assessments for young people, health professionals cite lack of consultation time and adequate funding as key barriers. This trial aims to determine whether a specific fee-for-service ('rebate payment') for a young person's health assessment, is effective and cost-effective at increasing the detection and management of health risk behaviours and conditions among young people. METHODS AND ANALYSIS: This cluster randomised controlled trial will be conducted in Australian general practice. 42 general practices (clusters) will be randomly allocated 1:1 to either an intervention arm where general practitioners receive a rebate payment for each annual health assessment undertaken for 14-24-year-olds during a 2 year study period, or a control arm (no rebate). The rebate amount will be based on the Medical Benefits Schedule (Australia's list of health professional services subsidised by the Australian Government) currently available for similar age-based assessments. Our primary outcome will be the annual rate of risk behaviours and health conditions recorded in the patient electronic health record (eg, alcohol/drug use, sexual activity and mental health issues). Secondary outcomes include the annual rate of patient management activities related to health risks and conditions identified (eg, contraception prescribed, sexually transmitted infection tests ordered). A process evaluation will assess acceptability, adoption, fidelity and sustainability of the rebate; an economic evaluation will assess its cost-effectiveness. Analyses will be intention-to-treat. ETHICS AND DISSEMINATION: Ethics approval has been obtained from University of Melbourne Human and Research Ethics Committee (2022-23435-29990-3). Findings will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12622000114741.

Emotional work of getting help: a qualitative analysis of caregiver-perceived barriers to responding to childhood adversity.

OBJECTIVE: To explore caregivers' experiences and challenges of accessing help for adversity across both health and social care sectors. DESIGN: Qualitative study design using semistructured interviews to explore how caregivers accessed services across health and social care. Interviews were audio recorded, transcribed verbatim and analysed using reflexive thematic analysis. SETTING: Families living in the city of Wyndham, Victoria, Australia. PARTICIPANTS: 17 caregivers of children aged 0-8 years. RESULTS: Five main themes emerged. (1) Emotional work of getting help. Caregivers described that getting help for life challenges was both emotionally taxing and effortful. (2) Trusting relationships are key. Engagement was related to the degree of relational practice and whether they felt judged or demeaned. (3) Wanting to manage on your own. There was a strong desire by caregivers to be independent and to only seek help when it was absolutely necessary. (4) Importance of knowing help was available and how to access it. (5) Overcoming service access barriers including long waiting times, restricted service criteria, transport issues and out-of-pocket expenses. CONCLUSIONS: Caregivers highlighted a multitude of barriers to getting help for life challenges. Addressing these barriers will require services to become more flexible and codesign best approaches with families in ongoing partnership. Improving community knowledge of available services and building trusting relationships is the first step to overcoming these barriers.

A systematic review of health state utility values and psychometric performance of generic preference-based instruments for children and adolescents with mental health problems.

AIMS: This paper aims to systematically identify reported health state utility values (HSUVs) in children and adolescents with mental health problems (MHPs) aged less than 25 years; to summarise the techniques used to elicit HSUVs; and to examine the psychometric performance of the identified multi-attribute utility instruments (MAUIs) used in this space. METHODS: A systematic review was conducted following PRISMA guidelines. Peer-reviewed studies published in English, reporting HSUVs for children and adolescents with MHPs using direct or indirect valuation methods were searched in six databases. RESULTS: We found 38 studies reporting HSUVs for 12 types of MHPs across 12 countries between 2005 and October 2021. Attention deficit hyperactivity disorder (ADHD) and depression are the most explored MHPs. Disruptive Behaviour Disorder was associated with the lowest reported HSUVs of 0.06 while cannabis use disorder was associated with the highest HSUVs of 0.88. Indirect valuation method through the use of MAUIs (95% of included studies) was the most frequently used approach, while direct valuation methods (Standard Gamble, Time Trade-Off) were only used to derive HSUVs in ADHD. This review found limited evidence of the psychometric performance of MAUIs used in children and adolescents with MHPs. CONCLUSION: This review provides an overview of HSUVs of various MHPs, the current practice to generate HSUVs, and the psychometric performance of MAUIs used in children and adolescents with MHPs. It highlights the need for more rigorous and extensive psychometric assessments to produce evidence on the suitability of MAUIs used in this area.

Considerations for conducting a young person's health assessment in the general practice setting: Insights from key informants in Victoria.

BACKGROUND AND OBJECTIVES: There have been calls for a Medicare Benefits Schedule rebate to support a young person's health assessment in general practice. The aim of this study was to understand Victorian providers' needs and perspectives about implementing young people's health assessments in general practice. METHOD: Focus groups and interviews were conducted over Zoom with current general practitioners (GPs), practice nurses (PNs) and practice managers (PMs). A qualitative descriptive approach and conventional content analysis were used. RESULTS: Two focus groups and five interviews were conducted between September and November 2021. Participants (11 GPs, nine PNs and three PMs) represented metropolitan (n = 11), regional (n = 10) and rural (n = 2) Victoria. Key facilitators to implementing a young person's health assessment included established clinic systems and staff roles as well as the potential to empower young people. Key barriers included scheduling logistics and billing structures. DISCUSSION: Key informants generated substantive stakeholder perspectives to aid planning and implementing young people's health assessments in general practice.

An evaluation of existing text de-identification tools for use with patient progress notes from Australian general practice.

INTRODUCTION: Digitized patient progress notes from general practice represent a significant resource for clinical and public health research but cannot feasibly and ethically be used for these purposes without automated de-identification. Internationally, several open-source natural language processing tools have been developed, however, given wide variations in clinical documentation practices, these cannot be utilized without appropriate review. We evaluated the performance of four de-identification tools and assessed their suitability for customization to Australian general practice progress notes. METHODS: Four tools were selected: three rule-based (HMS Scrubber, MIT De-id, Philter) and one machine learning (MIST). 300 patient progress notes from three general practice clinics were manually annotated with personally identifying information. We conducted a pairwise comparison between the manual annotations and patient identifiers automatically detected by each tool, measuring recall (sensitivity), precision (positive predictive value), f1-score (harmonic mean of precision and recall), and f2-score (weighs recall 2x higher than precision). Error analysis was also conducted to better understand each tool's structure and performance. RESULTS: Manual annotation detected 701 identifiers in seven categories. The rule-based tools detected identifiers in six categories and MIST in three. Philter achieved the highest aggregate recall (67%) and the highest recall for NAME (87%). HMS Scrubber achieved the highest recall for DATE (94%) and all tools performed poorly on LOCATION. MIST achieved the highest precision for NAME and DATE while also achieving similar recall to the rule-based tools for DATE and highest recall for LOCATION. Philter had the lowest aggregate precision (37%), however preliminary adjustments of its rules and dictionaries showed a substantial reduction in false positives. CONCLUSION: Existing off-the-shelf solutions for automated de-identification of clinical text are not immediately suitable for our context without modification. Philter is the most promising candidate due to its high recall and flexibility however will require extensive revising of its pattern matching rules and dictionaries.

Changes in mental health across the COVID-19 pandemic for local and international university students in Australia: a cohort study.

PURPOSE: Previous research has indicated that university students experienced substantial mental health issues during the global COVID-19 pandemic, but few studies have considered changes relative to pre-pandemic levels across population groups. Hence, the aim of this study was to compare changes in mental health and associated stressors across the pandemic for international and local university students studying in Australia. METHODS: In a cohort of 4407 university students, we assessed depression (Patient Health Questionnaire 2), anxiety (Generalized Anxiety Disorder-2), social support (Medical Outcomes Study-Social Support Survey), inability to afford food, fear of partner, and experiences of discrimination, both pre-pandemic (April-May 2019) and during the pandemic (September-October 2020). Change in prevalence between local and international students were estimated with logistic regression, adjusting for baseline factors. RESULTS: Compared to local students, international students experienced an increase in probable major depression (odds ratio (OR) 1.43, 95% Confidence Interval (CI) 1.23, 1.66), low social support (OR 2.63, 95% CI 2.23, 3.11), inability to afford food (OR 5.21, 95% CI 3.97, 6.83) race-based discrimination (OR 2.21, 95% CI 1.82, 2.68) and fear of partner (OR 3.46, 95% CI 2.26, 5.13). Interaction analyses indicated that these issues were more likely to be experienced by students living outside their country of origin, inclusive of international students based in Australia (depression p value interaction term 0.02). CONCLUSION: The pandemic had a substantial negative impact on international students, particularly those living outside of their country of origin during the pandemic. The inequalities exacerbated by the pandemic were present prior to the pandemic and are likely to continue post-pandemic without action. Interventions to build the supports for international students need to be urgently explored.

Identifying Public Healthcare Priorities in Virtual Care for Older Adults: A Participatory Research Study.

There has been increasing adoption and implementation of virtual healthcare in recent years, especially with COVID-19 impacting the world. As a result, virtual care initiatives may not undergo stringent quality control processes to ensure that they are appropriate to their context and meet sector needs. The two objectives of this study were to identify virtual care initiatives for older adults currently in use in Victoria and virtual care challenges that could be prioritised for further investigation and scale-up and to understand why certain virtual care initiatives and challenges are prioritised over others for investigation and scale-up. METHODS: This project used an Emerging Design approach. A survey of public health services in the state of Victoria in Australia was first carried out, followed by the co-production of research and healthcare priorities with key stakeholders in the areas of primary care, hospital care, consumer representation, research, and government. The survey was used to gather existing virtual care initiatives for older adults and any associated challenges. Co-production processes consisted of individual ratings of initiatives and group-based discussions to identify priority virtual care initiatives and challenges to be addressed for future scale-up. Stakeholders nominated their top three virtual initiatives following discussions. RESULTS: Telehealth was nominated as the highest priority initiative type for scaling up, with virtual emergency department models of care nominated as the highest priority within this category. Remote monitoring was voted as a top priority for further investigations. The top virtual care challenge was data sharing across services and settings, and the user-friendliness of virtual care platforms was nominated as the top priority for further investigation. CONCLUSIONS: Stakeholders prioritised public health virtual care initiatives that are easy to adopt and address needs that are perceived to be more immediate (acute more so than chronic care). Virtual care initiatives that incorporate more technology and integrated elements are valued, but more information is needed to inform their potential scale-up.

A Qualitative Exploration of Parenting Adolescents in Indonesia.

OBJECTIVE: To explore how parents of Indonesian adolescents conceptualize adolescence and to identify the challenges faced in parenting adolescents, focusing on parents from different sociodemographic backgrounds. METHOD: Focus group discussions (FGD) were undertaken with parents of adolescents aged 10-18 years old from different sociodemographic backgrounds (urban high socioeconomic; urban low socioeconomic; rural low socioeconomic) using a semi-structured interview guide. Content and thematic analysis were assisted by Nvivo version 12.6.0. RESULTS: Forty-three parents participated in four FGD. All parents recognized that adolescence was a distinct developmental stage, reflected in changing behaviors, escalation of peer influences and sexual development. Parents from poor, rural backgrounds had relatively limited understanding of the emerging capabilities of adolescents and had a narrow repertoire of responses to challenging behaviors, with heavy reliance on religious rules and punishment. Parents from higher socioeconomic backgrounds displayed a wider range of warmer, more engaging approaches that they reported using to shape their children's behaviors. CONCLUSION FOR PRACTICE: These findings highlight opportunities to enhance parenting skills, which appear most warranted in parents of adolescents from disadvantaged backgrounds. Embedding basic adolescent parenting information within community programs appears indicated, and enhancing religious leaders' understanding of different approaches to parenting could be helpful in more religious communities.

"What is already known on this subject? Parenting practices play an important role in adolescent health, development, and well-being. Parenting practices are influenced by socio-economic, demographic and cultural determinants. The evidence for how Indonesian parents conceptualize adolescence and how parenting practices might differ across diverse sociodemographic contexts is scarce."What this study adds? While parents from different sociodemographic groups had a common conceptual understanding of some aspects of adolescence, there were substantial differences in their approaches to parenting. There are opportunities to enhance parenting skills, especially in more disadvantaged regions.

Assessment of a primary care e-support package of automated case finding, simplified treatment algorithm and decision support to increase hepatitis B treatment uptake in primary care clinics in Australia (SIMPLY-B Study): protocol for a pilot evaluation.

INTRODUCTION: Despite the availability of effective, subsidised hepatitis B treatment, linkage to care and treatment rates remain very low globally. In Australia, specially trained primary care physicians (general practitioner, GPs) can prescribe hepatitis B treatment, however, most hepatitis B care occurs in specialist clinics. Increasing hepatitis B management by GPs in primary care clinics is essential to achieve national hepatitis B linkage to care and treatment targets by 2030.This pilot study determines the feasibility, acceptability and effectiveness of Simply B, a novel GP hepatitis B e-support package designed to increase hepatitis B management by GPs in primary care clinics. METHODS AND ANALYSIS: This study will be conducted in three parts:Part A: A prospective open-label pilot intervention study, comparing the proportion of people with hepatitis B who are managed by their GP in primary care clinics before, 12 months and 24 months after implementation of the Simply B electronic hepatitis B support package.Part B: A nested qualitative health services feasibility study using semistructured interviews and thematic analysisPart C: Cost-effectiveness analysis. ETHICS AND DISSEMINATION: This study has received ethics approval by St Vincent's Hospital. Data management and analysis will be centralised through the Department of Gastroenterology, St Vincent's Hospital. TRIAL REGISTRATION NUMBER: NCT05614466.

The mental health of international university students from China during the COVID-19 pandemic and the protective effect of social support: A longitudinal study.

BACKGROUND: During the COVID-19 pandemic Chinese international students were reported to experience racism, food security issues and social isolation. However, no study has investigated the prevalence of these issues and the potential for worsening mental health in this population group during the pandemic. Therefore, this study aimed to examine the effect of this pandemic on the mental health of Chinese international students living in Australia and China, and the protective effect of social support. METHODS: Data were extracted from a survey of Australian university students (April-June 2019) and follow-up during the pandemic (Sept-Oct 2020). The prevalence of anxiety, major depression and pandemic-related stressors was reported. Multivariable logistic regression was used to assess the association between country of residence, social support (baseline/follow-up), and follow-up self-reported mental health. RESULTS: With the pandemic, there was a substantial increase in the prevalence of anxiety (24.7 % vs 45.7 %) and major depression (22.1 % vs 43.8 %). Major depression was less likely to be reported by international students in China (34.8 %) than in Australia (46.3 %). Students with high social support during the pandemic were less likely to report major depression (Adjusted OR:0.15 [95 % CI 0.06,0.34]), although this effect was not observed longitudinally (Adjusted OR:1.03 [95 % CI 0.58,1.83]). LIMITATION: Post pandemic improvement in mental health cannot be assessed. CONCLUSION: The pandemic appeared to have had a strong negative effect on Chinese international university students' mental health. Those living in Australia were more likely to experience poorer mental health, highlighting the need for increased support to this group.

Primary health care utilization and hospital readmission in children with asthma: a multi-site linked data cohort study.

OBJECTIVES: To (1) describe primary health care utilization and (2) estimate the effect of primary care early follow-up, continuity, regularity, frequency, and long consultations on asthma hospital readmission, including secondary outcomes of emergency (ED) presentations, asthma preventer adherence, and use of rescue oral corticosteroids within 12 months. METHODS: An Australian multi-site cohort study of 767 children aged 3-18 years admitted with asthma between 2017 and 2018, followed up for at least 12 months with outcome and primary care exposure data obtained through linked administrative datasets. We estimated the effect of primary care utilization through a modified Poisson regression adjusting for child age, asthma severity, socioeconomic status and self-reported GP characteristics. RESULTS: The median number of general practitioner (GP) consultations, unique GPs and clinics visited was 9, 5, and 4, respectively. GP care was irregular and lacked continuity, only 152 (19.8%) children visited their usual GP on more than 60% of occasions. After adjusting for confounders, there was overall weak indication of effects due to any of the exposures. Increased frequency of GP visits was associated with reduced readmissions (4-14 visits associated with risk ratio of 0.71, 95% CI 0.50-1.00, p = 0.05) and ED presentations (>14 visits associated risk ratio 0.62, 95% CI 0.42-0.91, p = 0.02). CONCLUSIONS: Our study demonstrates that primary care use by children with asthma is often irregular and lacking in continuity. This highlights the importance of improving accessibility, consistency in care, and streamlining discharge communication from acute health services.

Exploring gaps and opportunities in primary care following an asthma hospital admission: a multisite mixed-methods study of three data sources.

OBJECTIVE: Explore gaps and opportunities in primary care for children following a hospital admission for asthma. DESIGN: Exploratory mixed-methods, using linked hospital and primary care administration data. SETTING: Eligible children, aged 3-18 years, admitted to one of three hospitals in Victoria, Australia between 2017 and 2018 with a clinical diagnosis of asthma. RESULTS: 767 caregivers of eligible children participated, 39 caregivers completed a semistructured interview and 277 general practitioners (GPs) caring for 360 children completed a survey. Over 90% (n=706) of caregivers reported their child had a regular GP. However, few (14.1%, n=108) attended a GP in the 24 hours prior to index admission or in the 7 days after (35.8%, n=275). Children readmitted for asthma (34.2%, n=263), compared with those not readmitted (65.8%, n=504), were less likely to have visited a GP in the non-acute phase of their asthma in the 12 months after index admission (22.1% vs 42.1%, respectively), and their GP was more likely to report not knowing the child had an asthma admission (52.8% vs 39.2%, respectively). Fewer GPs reported being extremely confident managing children with poorly controlled asthma (11.9%, n=43) or post-discharge (16.7%, n=60), compared with children with well-controlled asthma (36.4%, n=131), with no difference by child readmission status. CONCLUSIONS: Given the exploratory design and descriptive approach, it is unknown if the differences by child readmission status have any causal relationship with readmission. Nonetheless, improving preventative patterns of primary care visits, timely communication between hospitals and primary care providers, and guideline concordant care by GPs are needed.

Modifiable factors associated with pediatric asthma readmissions: a multi-center linked cohort study.

OBJECTIVES: To (a) identify rates of hospital readmission and emergency department (ED) re-presentation for asthma within a 12-month period, (b) estimate the effects of modifiable hospital, general practitioner (GP) and home environmental factors on hospital readmission, ED re-presentations and rescue oral corticosteroid use. METHODS: We recruited 767 children aged 3-18 years who were admitted to 3 hospitals in Victoria, Australia between 2017 and 2018 with a validated diagnosis of asthma on chart review. Primary outcome was hospital readmission with asthma within 12 months of index admission. Secondary outcomes were ED re-presentation for asthma and rescue oral corticosteroid use. All outcomes were identified through linked administrative datasets. Their caregivers and 277 nominated GPs completed study surveys regarding the home environment and their usual asthma management practices respectively. RESULTS: Within 12 months of an index admission for asthma 263 (34.3%) participants were readmitted to a hospital for asthma, with participants between the ages of 3-5 years accounting for 69.2% of those readmitted. The estimated effect of GP reported guideline discordant care on the odds of readmission was OR 1.57, 95% CI 1.00-2.47, p = 0.05. None of the hospital or home environmental factors appeared to be associated with hospital readmissions. CONCLUSIONS: Hospital readmissions among Australian children with asthma are increasing, and linked datasets are important for objectively identifying the health services burden of asthma. They also confirm the important role of the GP in the management of pediatric asthma.

Factors impacting COVID-19 vaccine decision making in older adults and people with underlying conditions in Victoria, Australia: A cross-sectional survey.

Australia's COVID-19 vaccine rollout included prioritizing older adults and those with underlying conditions. However, little was known around the factors impacting their decision to accept the vaccine. This study aimed to assess vaccine intentions, information needs, and preferences of people prioritized to receive the COVID-19 vaccine at the start of the Australian vaccine rollout. A cross-sectional online survey of people aged ≥70 years or 18-69 with chronic or underlying conditions was conducted between 12 February and 26 March 2021 in Victoria, Australia. The World Health Organization Behavioural and Social Drivers of COVID-19 vaccination framework and items informed the survey design and framing of results. Bivariate logistic regression was used to investigate the association between intention to accept a COVID-19 vaccine and demographic characteristics. In total, 1828 eligible people completed the survey. Intention to vaccinate was highest among those ≥70 years (89.6%, n = 824/920) versus those aged 18-69 years (83.8%, n = 761/908), with 91% (n = 1641/1803) of respondents agreeing that getting a COVID-19 vaccine was important to their health. Reported vaccine safety (aOR 1.4, 95% CI 1.1 to 1.8) and efficacy (aOR 1.9, 95% CI 1.5 to 2.3) were associated with intention to accept a COVID-19 vaccine. Concerns around serious illness, long-term effects, and insufficient vaccine testing were factors for not accepting a COVID-19 vaccine. Preferred communication methods included discussion with healthcare providers, with primary care providers identified as the most trusted information source. This study identified factors influencing the prioritized public's COVID-19 vaccine decision-making, including information preferences. These details can support future vaccination rollouts.

Towards a health promoting university: descriptive findings on health, wellbeing and academic performance amongst university students in Australia.

BACKGROUND: Universities are increasingly recognised as institutions where health and wellbeing can be promoted to maximise academic outcomes, career transitions, and lifelong positive health behaviours. There is concern about the mental health of university students and other factors which affect academic outcomes particularly for subgroups such as international students. There are few cohort studies of the breadth of issues that can impact on mental health and academic outcomes for both local and international students. We conducted a baseline prevalence survey of students at a large Australian university covering health, academic, and social determinants of wellbeing. The purpose was to inform the university's new student health and wellbeing framework with a view to follow-up to determine predictors of mental ill-health and academic outcomes in the subsequent year. In this paper we present the baseline prevalence data and report on selected mental health and health care access issues for local and international students. METHODS: The entire university population as of April 2019 of over 56,375 students aged 18 or above were invited to complete the online survey. Questions explored eight domains: demographic characteristics, general health and wellbeing, mental health, risk taking behaviours, psychosocial stressors, learning and academic factors, social and cultural environment, and awareness of and access to health and wellbeing services. Records of academic results were also accessed and matched with survey data for a large subset of students providing consent. RESULTS: Fourteen thousand eight hundred eighty (26.4%) students commenced our survey and were representative of the entire student population on demographic characteristics. Three quarters were aged between 18 to 25 years and one third were international students. Eighty-five percent consented to access of their academic records. Similar proportions of local and international students experienced symptoms of a depression or anxiety disorder, however international students were less aware of and less likely to access available health services both inside and external to the university. We also reported on the prevalence of: general lifestyle factors (diet, exercise, amount of daily sleep); risk-taking behaviours (including alcohol, tobacco and other drug use; unprotected sexual activity); psychosocial stressors (financial, intimate partner violence, discrimination, academic stressors, acculturative stress); subjects failed; resilience; social supports; social media use; and health services accessed online. CONCLUSIONS: This rigorous and comprehensive examination of the health status of local and international students in an Australian university student population establishes the prevalence of mental health issues and other psychosocial determinants of health and wellbeing, along with academic performance. This study will inform a university-wide student wellbeing framework to guide health and wellbeing promotion and is a baseline for a 12-month follow-up of the cohort in 2020 during the COVID-19 pandemic.

Strengthening Care for Children (SC4C): protocol for a stepped wedge cluster randomised controlled trial of an integrated general practitioner-paediatrician model of primary care.

INTRODUCTION: Australia's current healthcare system for children is neither sustainable nor equitable. As children (0-4 years) comprise the largest proportion of all primary care-type emergency department presentations, general practitioners (GPs) report feeling undervalued as an integral member of a child's care, and lacking in opportunities for support and training in paediatric conditions. This Strengthening Care for Children (SC4C) randomised trial aims to evaluate a novel, integrated GP-paediatrician model of care, that, if effective, will improve GP quality of care, reduce burden to hospital services and ensure children receive the right care, at the right time, closer to home. METHODS AND ANALYSIS: SC4C is a stepped wedge cluster randomised controlled trial (RCT) of 22 general practice clinics in Victoria and New South Wales, Australia. General practice clinics will provide control period data before being exposed to the 12-month intervention which will be rolled out sequentially each month (one clinic per state) until all 22 clinics receive the intervention. The intervention comprises weekly GP-paediatrician co-consultation sessions; monthly case discussions; and phone and email paediatrician support, focusing on common paediatric conditions. The primary outcome of the trial is to assess the impact of the intervention as measured by the proportion of children's (0-<18 years) GP appointments that result in a hospital referral, compared with the control period. Secondary outcomes include GP quality of care; GP experience and confidence in providing paediatric care; family trust in and preference for GP care; and the sustainability of the intervention. An implementation evaluation will assess the model to inform acceptability, adaptability, scalability and sustainability, while a health economic evaluation will measure the cost-effectiveness of the intervention. ETHICS AND DISSEMINATION: Human research ethics committee (HREC) approval was granted by The Royal Children's Hospital Ethics Committee in August 2020 (Project ID: 65955) and site-specific HRECs. The investigators (including Primary Health Network partners) will communicate trial results to stakeholders and participating GPs and general practice clinics via presentations and publications. TRIAL REGISTRATION NUMBER: Australia New Zealand Clinical Trials Registry 12620001299998.