Inter-district and Wealth-related Inequalities in Maternal and Child Health Service Coverage and Child Mortality within Addis Ababa City.

In sub-Saharan Africa, urban areas generally have better access to and use of maternal, newborn, and child health (MNCH) services than rural areas, but previous research indicates that there are significant intra-urban disparities. This study aims to investigate temporal trends and geographic differences in maternal, newborn, and child health service utilization between Addis Ababa's poorest and richest districts and households. A World Bank district-based poverty index was used to classify districts into the top 60% (non-poor) and bottom 40% (poor), and wealth index data from the Ethiopian Demographic and Health Survey (EDHS) was used to classify households into the top 60% (non-poor) and bottom 40% (poor). Essential maternal, newborn, and child health service coverage was estimated from routine health facility data for 2019-2021, and five rounds of the EDHS (2000-2019) were used to estimate child mortality. The results showed that service coverage was substantially higher in the top 60% than in the bottom 40% of districts. Coverage of four antenatal care visits, skill birth attendance, and postnatal care all exceeded 90% in the non-poor districts but only ranged from 54 to 67% in the poor districts. Inter-district inequalities were less pronounced for childhood vaccinations, with over 90% coverage levels across all districts. Inter-district inequalities in mortality rates were considerable. The neonatal mortality rate was nearly twice as high in the bottom 40% of households' as in the top 60% of households. Similarly, the under-5 mortality rate was three times higher in the bottom 40% compared to the top 60% of households. The substantial inequalities in MNCH service utilization and child mortality in Addis Ababa highlight the need for greater focus on the city's women and children living in the poorest households and districts in maternal, newborn, and child health programs.

A higher proportion of children aged 4 years were referred to speech and language therapists after the introduction of a new language screening tool.

AIM: Language difficulties in children can have enduring impacts on their academic and emotional well-being. Consequently, early identification and intervention are critical. This study aimed to investigate the impact of introducing Språkfyran, a language screening tool, on the identification and referral rates for speech and language assessment compared to the previous method. METHODS: An observational study was conducted in Gotland, Sweden, using the medical records of 3537 children (53% boys) who were 3-4 years of age. The study period lasted between 5 January 2016 and 29 April 2022, encompassing data collection both before and after the introduction of Språkfyran. RESULTS: Following the introduction of Språkfyran, 15% failed the screening, compared to 20% with the previous speech test. However, referrals for assessment increased significantly with Språkfyran, rising to 7% compared to 3% with the speech test. CONCLUSION: The proportion of children who failed the Språkfyran screening was consistent with findings from previous studies. Children who failed the screening were more likely to be referred for speech and language assessment after the introduction of Språkfyran. This indicates that Språkfyran is a clinically relevant tool that promotes children's language development through increased referral rates.

First-Time Parents' Support Needs and Perceived Support From a Child Health Service With the Integrated New Families Home Visiting Programme.

The transition to parenthood is complex and influenced by interacting factors related to society, the parents and the child. Professional support is considered to be one of the societal factors affecting this transition by facilitating parents' sense of confidence and their competence as parents. In this study, we aimed to explore first-time parents' support needs and experiences of support from a child health service with the integrated New Families home visiting programme, in the context of their transition to parenthood in the first year postnatally. Interpretive description guided this qualitative study. Six couples and one mother, all well-educated and employed, were interviewed individually (N = 13). The parents were recruited from the research project 'New Families - Innovation and Development of the Child Health Service in Oslo'. We found that being a first-time parent is perceived as overwhelming and that defining support needs may be challenging, particularly in the first period postnatally. In addition, the support needs are constantly changing due to the complexity of interacting factors and the ongoing development of confidence in the parental role. Retrospectively, the parents were satisfied overall with the support from the child health service. The home visit during pregnancy facilitated management and relational and informational continuity. However, we identified a need for even more proactive information provision and communication to optimise the service's availability and efficiency postnatally. In addition, the importance of peers and of approaching both mothers and fathers must be acknowledged in facilitating parental confidence.

Difficulties experienced by health care professionals who performed home visits to screen for postpartum depression during the COVID-19 pandemic: a qualitative study in Japan.

BACKGROUND: Postpartum depression is a risk factor for suicide and maltreatment of children, and its early detection and appropriate intervention are issues to be resolved. In Japan, local governments are working to detect postpartum depression early by conducting home visits to families with infants within 4 months postpartum, but home-visit professionals have faced new difficulties due to the coronavirus disease 2019 (COVID-19) pandemic that started in 2020. The purpose of this study was to clarify the difficulties experienced by health care professionals who perform home visits to screen for postpartum depression. METHODS: Focus-group interviews were conducted during the COVID-19 pandemic with health care professionals (n = 13) who make postpartum home visits to families with infants within 4 months. Data were analyzed using thematic analysis. RESULTS: Four main categories were identified that describe the difficulties experienced by health care professionals: "Lack of support for partners," "Difficulty in talking face-to-face," "Inability to offer family assistance," and "Anxiety about being a source of infection." CONCLUSIONS: This study shed light on the difficulties faced by professionals in supporting mothers and children in the community during the COVID-19 pandemic. Although these difficulties were considered to have become apparent during the pandemic, the results may offer an important perspective for postpartum mental health support even after the pandemic ends. Accordingly, it may be necessary for these professionals to receive supported through multidisciplinary collaboration in order to improve postpartum care in the community.

Adapting group care to the postpartum period using a human-centered design approach in Malawi.

BACKGROUND: Responsive and resilient strategies to reduce high rates of maternal and infant mortality and clinician shortages are needed in low- and middle-income countries (LMICs). Malawi has some of the highest maternal and infant mortality rates globally. Group healthcare is a service delivery model that integrates these strategies. Although primarily implemented during the prenatal period, its potential for improving both maternal and infant health outcomes during the postpartum period has not been realized. The purpose of this study was to adapt and co-design the prototype for an evidence-based group care model for the postpartum period using a human-centered design approach with key stakeholders in Malawi. METHODS: We completed steps of a framework guiding the use of human-centered design: 1) define the problem and assemble a team; 2) gather information through evidence and inspiration; 3) synthesize; and 4) intervention design: guiding principles and ideation. Qualitative methods were used to complete steps 2-4. In-depth interviews (n = 24), and incubator sessions (n = 6) that employed free listing, pile sorting and ranking were completed with key stakeholders. Data analysis consisted of content analysis of interviews and framework analysis for incubator sessions to produce the integrated group postpartum and well-child care model prototype. The fifth step is detailed in a separate paper. RESULTS: All stakeholders reported a desire to participate in and offer group care in the postpartum period. Stakeholders worked collaboratively to co-create the prototype that included a curriculum of health promotion topics and interactive activities and the service delivery structure. Health promotion topic priorities were hygiene, breastfeeding, family planning, nutrition, and mental health. The recommended schedule included 6 sessions corresponding with the child vaccination schedule over the 12-month postpartum period. CONCLUSIONS: Using a human-centered design approach to adapt an evidence-based group care model in an LMIC, specifically Malawi, is feasible and acceptable to key stakeholders and resulted in a prototype curriculum and practical strategies for clinic implementation.

Clinical risk factors at 3 months of age for the development of bronchial asthma at 36 months of age.

BACKGROUND: We examined the associations between factors evident at the routine 3-month well-child visit (WCV) and the risk of developing 36-month parent-reported physician-diagnosed bronchial asthma (BA). METHODS: This longitudinal study was conducted in Nagoya City, Japan, and included 40,242 children who qualified for the 3-month WCVs in the city between April 1, 2016 and March 31, 2018. In total, 22,052 (54.8%) questionnaires linked to their 36-month WCVs were analyzed. RESULTS: The prevalence of BA was 4.5%. The multivariable Poisson regression model identified male sex (adjusted risk ratio [aRR], 1.59; 95% confidence interval [CI]: 1.40-1.81), born in autumn (aRR, 1.30; 95% CI: 1.09-1.55), having at least one sibling (aRR, 1.31; 95% CI: 1.15-1.49), wheeze history before 3-month WCVs, with clinic/hospital visit: aRR, 1.99; 95% CI: 1.53-2.56; hospitalization: aRR, 2.99; 95% CI: 2.09-4.12, eczema with itch (aRR, 1.51; 95% CI: 1.27-1.80), paternal history of BA (aRR, 1.98; 95% CI: 1.66-2.34), maternal history of BA (aRR, 2.11; 95% CI: 1.77-2.49), and rearing pets with fur (aRR, 1.35; 95% CI: 1.15-1.58) were independent risk factors for BA at 36 months of age. The combination of severe wheeze history (with clinic/hospital visit or hospitalization) and maternal and paternal BA could identify high-risk infants whose prevalence of BA was 20%. CONCLUSIONS: The combined assessment of important clinical factors enabled us to identify high-risk infants set to derive optimal benefit from health guidance provided to the parent or caregiver of the child or infant at WCVs.

Norwegian fathers' experiences with a home visiting program.

OBJECTIVE: To explore fathers' experiences with a Norwegian home visiting program during the prenatal period and the first-year postpartum. DESIGN: Qualitative design with interpretive description (ID) as the methodological approach. SAMPLE: Individual interviews with fathers (n = 13) who received home visits by a public health nurse (PHN) within the New Families home visiting program. MEASURES: Interviews were guided by a semi-structured interview-guide, which contained open-ended questions encouraging informants to reflect on their experiences with home visits. The analysis of the data was informed by content analysis. RESULTS: Two main themes that reflect the fathers' experiences emerged: (1) The importance of being on their home ground captures the fathers' experience of receiving home visits and building a trusting relationship with the PHN. (2) Including fathers in the home visit represents their thoughts about the content and focus of the home visits. CONCLUSIONS: Fathers experienced the universal New Families home visiting program as an important contribution towards a more available and tailored service, with the home environment as a suitable arena for developing a trusting relationship with the PHN. However, the fathers often felt insufficiently included in the home visits, with only scant attention towards them as independent caregivers, their emotional reactions, roles, and family relationships. Pre-birth home visits might contribute to strengthening preparations for fatherhood and increase fathers' engagement in the Child Health Service.

Factors associated with child health service delivery by female community health volunteers in Nepal: findings from a national survey.

BACKGROUND: Nepal has made a significant improvement in child survival in the last few decades and the involvement of female community health volunteers (FCHVs) has been crucial in such achievement. While there have been many studies on child health in Nepal however, rarely explored the status and factors associated with the child health service provided by these volunteers. This study aimed to identify the factors associated with the child health service delivery by FCHVs. METHODS: A national survey was conducted in 2014 in Nepal that included 4302 FCHVs using the structured questionnaire across the 13 geopolitical domains of the country. Factors associated with the use of child health services was examined using Chi-square test (χ2) followed by logistic regression. RESULTS: Overall, 62.6% of FCHVs provided at least one child health service. Those FCHVs who utilized money from the FCHV fund, conducted health mothers' group meeting, involved in local committees and those who supported antenatal care and outreach clinics related activities had higher odds of providing child health services. Similarly, FCHVs equipped with the stock of Cotrimoxazole tablet, Zinc tablet, Oral Rehydration Salt packets were more likely to provide child health services. The province-wise analysis showed that FCHVs from Province 5 and Sudur Paschim Province were more likely to provide child health services compared to their counterparts from province 1. Technology-wise, FCHVs who were using mobile were more likely to provide child health services. CONCLUSIONS: FCHVs are important human resource in providing child health services in Nepal. To improve child health service delivery by FCHVs; availability of key commodities, involvement of FCHVs in regular health mothers' group meeting, use of mobile phone, involvement in other public health programs and social networks, and utilization of the FCHV fund need to be taken into consideration.

Maternal and child health nurses work with refugee families: Perspectives from regional Victoria, Australia.

AIMS AND OBJECTIVES: To explore service provision for Victorian regional refugee families from the perspective of maternal and child health nurses. BACKGROUND: Increasingly, more families from a refugee background are resettling in regional Victoria. The refugee journey has significant effect on families. Refugee families with infants and young children can be provided with support by maternal and child health services; however, many families experience barriers to ongoing engagement with this service. DESIGN: This descriptive study used focus group and questionnaire. A purposive sample of 26 maternal and child health nurses was drawn from six municipalities throughout regional Victoria, where higher numbers of people from a refugee background resettle. Six focus groups were held in 2014. Audio-recorded narratives were transcribed, prior to inductive thematic analysis. METHODS: This descriptive study used focus group and questionnaire. A purposive sample of 26 Maternal and Child Health nurses was drawn from six municipalities throughout regional Victoria where higher numbers of people from a refugee background resettle. Six focus groups were held in 2014. Audio-recorded narratives were transcribed verbatim, prior to inductive thematic analysis. RESULTS: Participating nurses were experienced nurses, averaging 12 years in the service. Four major themes emerged from thematic analysis: "How to identify women from a refugee background"; "The Maternal and Child Health nurse role when working with families from a refugee background"; "Interpreting issues"; and "Access to other referral agencies." Nurses worked to develop a relationship with families, attending to a complex mix of issues which were complicated by language barriers. Nurses found their role in supporting refugee families required additional time and more home visits. CONCLUSIONS: To provide best practice, maternal and child health nurses need (i) ongoing professional development; (ii) time, flexibility and creativity to build relationships with refugee families and (iii) better access to services that enhance communication, such as interpreting services and translated resources. RELEVANCE TO CLINICAL PRACTICE: Nurses require ongoing professional development to help them address the multifaceted needs of families of refugee background. With limited resources available in regional areas, accessing further education can be challenging. Distance education models and organisational support could provide nurses with educational opportunities aimed at improving service provision and clinical practice.

Effects of nurse-led child health service in child-care centers: A survey study.

There are relatively few initiatives to promote children's health and prevent disease in Korean child-care centers. The purpose of this study was to describe the effects of the nurse-led child health service in Korean child-care centers. A total of 9664 parents and 3892 teachers at child-care centers and 49 nurses completed self-administered questionnaires. Parent satisfaction, teacher satisfaction, and nurses' self-evaluation were surveyed. Case-management reports of children were collected over 5 years. Dental problems were ranked high among children across 5 years in the study. Most parents perceived nurse-led child health service as being useful. Overall, teachers' satisfaction scores were statistically significantly higher for home child-care centers compared to public or private child-care centers. Increasing the need for the nurse-led child health service was ranked the highest item by nurses, whereas the health management of teachers was ranked the lowest. The nurse-led child health service in Korean child-care centers induced positive outcomes, including the satisfaction of parents, teachers and nurses.

Regular source of primary care and emergency department use of children in Victoria.

AIM: The aim of this paper was to study the prevalence of a regular source of primary care for Victorian children attending one of four emergency departments (EDs) and to determine associated characteristics, including ED use. METHODS: Responses were collected via an electronic survey from parents attending EDs with their child (≤9 years of age) for a lower-urgency condition. Single, multiple choice, and Likert scale responses were analysed using bivariate and logistic regression tests. RESULTS: Of the 1146 parents who provided responses, 80% stated their child has a regular source of primary care. Of these, care is mostly received by a general practitioner (GP) (95%) in GP group practices (71%). Approximately 20% have changed where their child receives primary care in the last year. No associations were observed between having a regular source of primary care and frequency of ED attendance in the past 12 months, although parents whose child did not have a regular source of primary care were more likely to view the ED as a more convenient place to receive care than the primary care provider (39% without regular source vs. 18% with regular source; P < 0.0001). Children were less likely to have a regular source of primary care if their parents were younger, had a lower household income, lower education, and were visiting a hospital in a lower socio-economic indexes for areas rank. CONCLUSIONS: Policy options to improve continuity of care for children may require investigation. Increasing the prevalence of regular source of primary care for children may in turn reduce ED visits.

Effects of the health insurance coverage extension on the use of outpatient services among small children in rural China.

A new public health insurance scheme has been gradually introduced in rural provinces in China since 2003. This would likely cause an increment in the use of health services. It is known that the association between health insurance coverage and health service utilization varies among different age groups. This study aims to examine the association between extending health insurance coverage and increment in outpatient service utilization of small children in rural China, and to identify other factors associated with the outpatient service utilization. A household survey was conducted in 2 counties in north China in August 2010, targeting 107 selected households with a child aged 12-59 months. The questionnaire included modules on demographic information such as ages of children and parents, enrollment status of health insurance, the number of episodes of illness as perceived by parents, month of incidence of episode and outpatient service utilization at each episode. Based on the utilization at each episode of illness, a random effects logistic regression model was employed to analyze the association. It was found that eligibility for the reimbursement of outpatient medical expenses was not significantly associated with decision to seek care or choice of health facility. This might be in part due to the low level of reimbursement which could discourage the use of insured, and to the close relationship with village clinic workers which would encourage the use of uninsured. Three other factors were significantly associated with increment in the outpatient service utilization; age of children, mother's education, and number of children in a household.

Impact of COVID-19 on the Utilization of Maternal and Child Health Services at a Regional Referral Hospital in Kenya.

Background and Objective: Pandemics, like COVID-19, disrupt healthcare, potentially reversing progress in various disease areas. The impact on maternal and child health (MCH) services in Kenya during the pandemic is yet to be determined. Recognizing this impact is crucial for formulating policies and programs that minimize disruptions in reproductive health services during future health crises. The purpose of this study was to determine the effect of COVID-19 on the uptake of MCH services at Thika Level V Hospital, a regional referral hospital in Kenya. Methods: In this cross-sectional mixed methods study, we reviewed antenatal clinic (ANC), MCH, and family planning (FP) registers for data on the uptake of the various services during the COVID-19 pandemic (July to October 2020) compared to a year before the COVID-19 pandemic (July to October 2019). MCH clients (N = 60) and healthcare workers (N = 19) were interviewed about the impact of the pandemic on MCH services at the hospital. Differences in clinic attendance before and during the pandemic were compared using the student t-test. Thematic analysis was conducted on the interview responses. Results: The number of MCH/FP clients dropped from 12,915 pre-pandemic to 7,429 during the pandemic. Significant differences were noted in ANC revisits (p = 0.026) and those completing the World Health Organization recommended minimum of four ANC visits (p<0.001) during the COVID-19 pandemic. The number of revisits at the child welfare clinic was also significantly lower (p = 0.004) during the COVID-19 lockdown period. MCH clients stated that the decline in the uptake of MCH services was attributable to the fear of contracting disease, financial difficulties, and strain on the healthcare workforce. Conclusion and Global Health Implications: This study found a decline in access to MCH/FP services during the COVID-19 crisis with the potential to reverse gains made in securing the safety of the pregnant mother and unborn baby.

Autism assessment: the Melton Health model.

AIM: The following paper describes the Autism Spectrum Assessment Clinic which operates at Melton Health, a publically funded health service in Melbourne's west. METHODS: A retrospective audit of 234 children assessed between 2007 and 2012 in the Autism Spectrum Assessment Clinic was undertaken. Characteristics of the children assessed (age, sex, locality, referral source) were examined along with characteristics of the clinic (clinicians, assessment outcome). RESULTS: A detailed description of the model is provided, including evident changes since the clinic began. Data were split between the 2007 to 2009 and 2010 to 2012 time periods to reflect changes in the operation of the clinic. Overall, 48 girls and 186 boys were assessed with a mean age of 71 months; the average waiting time between referral and assessment was 136.6 days. Across the two time periods, the proportion of children receiving a diagnosis of autism spectrum disorder increased from 43.1% to 66.3%. Changes are evident in the referral sources between the two time periods, and in the disciplines of clinicians involved in the assessment. CONCLUSIONS: The research illustrates an assessment model, within the Victorian public health context, which currently operates effectively according to best-practice guidelines. This research begins to fill a gap between localised clinical practice and the dissemination of this information to a wider audience, allowing for comparison for other assessment providers. It is hoped that we can contribute more broadly to future assessment processes becoming more consistent, reproducible and equitable for children suspected of having autism spectrum disorders.

Psychosocial health information in free text notes of Swedish children's health records.

BACKGROUND: High-quality documentation of children's health is an important priority in health care given trends of declining mental health and reduced well-being in children. There is a lack of information concerning psychosocial health in the standardized part of the national health record in the Child Health Service and the School Health Service in Sweden. Further, little is known if the free text notes in the health record, besides information on physical health, also include information on children's psychosocial health. The aim of this study was to describe what is recorded concerning children's health and development in free text notes. METHODS: The study was based on a retrospective analysis of text using an inductive approach for qualitative analyses of content. RESULTS: The analysis of the free text notes in the health records yielded seven categories: development, family, health problems, living habits, medical issues, preschool/school and leisure, and well-being. The categories mainly covered psychosocial aspects of health and were not only about health and development problems of the child but also what was covered during the visits. The information was unevenly distributed across the ages. A stronger focus on the youngest age groups within a family and preschool setting is needed. There was novel information in the free text notes such as pain, general health, emotions, mother's mental health and leisure activities, which was not covered in the standardized part of the health records. CONCLUSION: The free text notes mainly reflected a psychosocial perspective on health. The findings of this study suggest that requesting more information on children's psychosocial health in the standardized part of the health records could contribute to more comprehensive and informative health records in the Child health Service and the School Health Service in Sweden.

Growth Monitoring and Promotion Service Utilisation and Associated Factors among Children in Afar Region, Northeast Ethiopia.

The use of growth monitoring and promotion (GMP) services in the first two years of life can facilitate the early identification of common childhood health issues such as malnutrition and infections. It also creates an opportunity to promote education and nutritional counselling. This study is the first to investigate the use of GMP and its influencing factors among mothers in Ethiopia's pastoralist regions, including the Afar National and Regional State, where childhood malnutrition is a significant cause of morbidity and mortality. Between May and June 2021, a cross-sectional study was conducted within the Semera-Logia city administration. The study used a random sampling technique to select 396 children under two, and data were gathered using an interviewer-administered questionnaire. Multivariable logistic regression was used to analyse the influence of explanatory variables, which included socio-demographic, health service, and health literacy factors, on the utilisation of GMP services. The overall utilisation of GMP services was 15.9% (95% confidence intervals [CI]: 12.0%, 19.5%). Children whose fathers had college or higher education were more likely to utilise GMP services (adjusted odd ratios [AOR] = 7.75; 95% CI: 3.01, 19.99), whereas children living in households with more children were less likely to utilise GMP services (AOR = 0.11; 95% CI: 0.04, 0.28 for households with 3-4 children and AOR = 0.23; 95% CI: 0.08, 0.67 for households with 4+ children). Children who received postnatal care had higher odds of GMP service use (AOR = 8.09; 95% CI: 3.19, 20.50). GMP services are not being fully utilised to decrease infant and child morbidity and mortality caused by malnutrition in Ethiopia. We recommend strengthening GMP services in Ethiopia and taking targeted action to address the low attainment of parental education and poor postnatal care utilisation. Public health initiatives such as the implementation of mobile health (mHealth) approaches and education of mothers by female community healthcare workers on the significance of GMP services could be effective in increasing GMP service utilisation.

Average Time Spent in Referral Process and its Determinants Among Clients of Maternal and Child Health Service in 2 Districts of Jimma Zone, Ethiopia.

Background: The time spent between referring and receiving health facilities is an important determinant of the outcome of the referred patients/clients especially among women in low-income countries due to poor access to early and appropriate referrals. Thus, the aim of this study is to assess the average time spent between referring and service utilization at receiving health facility. Methods: A cross-sectional study was employed by using time and motion approach. Structured questionnaire and observation checklist were used for collecting data. SPSS 21 version was used for data analysis and binary and multivariable logistic regression analysis was carried out to identify a variable that has a significant association on the basis of OR, 95% confidence interval, and a P value of less than .05. Result: A total of 266 women participated in the study with the mean age of the study population is 24.65 (±5.03) years. The majority, (223 (83.8%)) of the participants came for maternal health services and more than half, (143 (53.8%)) of the respondents were self-referrals. Among the referred cases, the main reason for the referral was for further evaluation and management. Women spent a maximum of 540 min on the way to arrive at receiving health facility. Residence and distance were the predictor variables for average time spent. Conclusion: In general, women wait a maximum of one and half hours to contact health care providers for assessment and more than two-fifth of the women wait more than 3 h to get the service at receiving health facility.

Nurse Documentation of Child Weight-Related Health Promotion at Age Four in Sweden.

(1) Background: Overweight and obesity in children have increased worldwide and tend to persist into adolescence and adulthood. The Child Health Service (CHS) has an important role in providing health-promotive interventions, and such interventions are required to be documented in a child's health record. The aim of the study was to investigate Child Health Care (CHC) nurses' documentation of weight-related, health-promotive interventions in the Child Health Care Record (CHCR) regarding lifestyle habits in connection to the four-year visit. (2) Methods: A record review of 485 CHCRs using a review template was accomplished. Of the included CHS units, four used electronic records and two used paper records. Chi-square tests and Spearman's rank-order correlations were used to analyse data. (3) Results: The results showed that CHC nurses document interventions regarding lifestyle habits to a low extent, although children with overweight/obesity seemed to undergo more interventions. There was also a difference between electronic and paper records. (4) Conclusions: The consequences of not documenting the interventions in the CHCR make it difficult to follow up and demonstrate the quality of the CHC nurse's work. There is a need for more research to gain a deeper understanding of the reasons that the work of CHC nurses is not visible in children's health records.

The Australian Nurse-Family Partnership Program for aboriginal mothers and babies: Describing client complexity and implications for program delivery.

CONTEXT: The Australian Nurse-Family Partnership Program is a home visiting program for Aboriginal mothers and infants (pregnancy to child's second birthday) adapted from the US Nurse Family Partnership program. It aims to improve outcomes for Australian Aboriginal mothers and babies, and disrupt intergenerational cycles of poor health and social and economic disadvantage. The aim of this study was to describe the complexity of Program clients in the Central Australian family partnership program, understand how client complexity affects program delivery and the implications for desirable program modification. METHODS: Australian Nurse-Family Partnership Program data collected using standardised data forms by nurses during pregnancy home visits (n = 276 clients from 2009 to 2015) were used to describe client complexity and adversity in relation to demographic and economic characteristics, mental health and personal safety. Semi-structured interviews with 11 Australian Nurse-Family Partnership Program staff and key stakeholders explored in more depth the nature of client adversity and how this affected Program delivery. FINDINGS: Most clients were described as "complicated" being exposed to extreme poverty (66% on welfare), living with insecure housing, many experiencing domestic violence (almost one third experiencing 2 + episodes of violence in 12 months). Sixty-six percent of clients had experienced four or more adversities. These adversities were found challenging for Program delivery. For example, housing conditions mean that around half of all 'home visits' could not be conducted in the home (held instead in staff cars or community locations) and together with exposure to violence undermined client capacity to translate program learnings into action. Crises with the basics of living regularly intruded into the delivery of program content, and low client literacy meant written hand-outs were unhelpful for many, requiring the development of pictorial-based program materials. Adversity increased the time needed to deliver program content. CONCLUSIONS: Modifications to the Australian Nurse-Family Partnership Program model to reflect the specific complexities and adversities faced by the client populations is important for effective service delivery and to maximise the chance of meeting program goals of improving the health and well-being of Australian Aboriginal mothers and their infants.