Counting culturally and linguistically diverse (CALD) children in Australian health research: Does it matter how we count?

OBJECTIVE

To describe how culturally and linguistically diverse (CALD) children are identified and enumerated in routine data collections and in child health research in Australia.

METHODS

Descriptive analysis, where different definitions of CALD were applied to the 2021 Australian Census to measure the size of the CALD population of Australian children aged 0 to 17 years. Narrative review of the Australian child health literature to examine how CALD children were defined.

RESULTS

Applying various definitions to the 2021 Census, the estimated proportion of CALD children aged 0 to 17 ranged from 6.3% to 43%. The most commonly applied CALD indicators were language background other than English and being born overseas.

CONCLUSIONS

There is no consensus on how CALD is defined in Australian child health research. Application of different CALD indicators can generate up to seven-fold differences in estimates of who counts as being a CALD child.

IMPLICATIONS FOR PUBLIC HEALTH

If we are to advance health and well-being equity for CALD children, we need a more consistent approach to understanding which children are counted as CALD.

Excess Hospital Burden Among Young People in Contact With Homelessness Services in South Australia: A Prospective Linked Data Study

PURPOSE

Youth homelessness remains an ongoing public health issue worldwide. We aimed to describe the burden of emergency department (ED) presentations and hospitalizations among a South Australian population of young people in contact with specialist homelessness services (SHS).

METHODS

This whole-of-population study used de-identified, linked administrative data from the Better Evidence Better Outcomes Linked Data (BEBOLD) platform on all individuals born between 1996 and 1998 (N = 57,509). The Homelessness2Home data collection was used to identify 2,269 young people in contact with SHS at ages 16-17 years. We followed these 57,509 individuals to age 18-19 years and compared ED presentations and hospital separations related to mental health, self-harm, drug and alcohol, injury, oral health, respiratory conditions, diabetes, pregnancy, and potentially preventable hospitalizations between those in contact and not in contact with SHS.

RESULTS

Four percent of young people had contact with SHS at ages 16-17 years. Young people who had contact with SHS were 2 and 3 times more likely to have presented to an ED and hospital respectively, compared to those who did not contact SHS. This accounted for 13% of all ED presentations and 16% of all hospitalizations in this age group. Excess burden causes included mental health, self-harm, drug and alcohol, diabetes, and pregnancy. On average, young people in contact with SHS experienced an increased length of stay in ED (+0.6 hours) and hospital (+0.7 days) per presentation, and were more likely to not wait for treatment in ED and to self-discharge from hospital.

DISCUSSION

The 4% of young people who contacted SHS at ages 16-17 years accounted for 13% and 16% of all ED presentations and hospitalizations respectively at age 18-19 years. Prioritizing access to stable housing and primary health-care services for adolescents in contact with SHS in Australia could improve health outcomes and reduce health-care costs.

Child protection contact among children of culturally and linguistically diverse backgrounds: A South Australian linked data study

AIM

To describe the cumulative incidence of child protection (CP) system contact, maltreatment type, source of reports to age 7 years, and socio-demographic characteristics for culturally and linguistically diverse (CALD) Australian children.

METHODS

We used CP, education, health, and birth registrations data for children followed from birth up to age 7 from the South Australian Better Evidence, Better Outcomes, Linked Data (SA BEBOLD) platform.

PARTICIPANTS

SA born children enrolled in their first year of school from 2009 to 2015 (n = 76 563). CALD defined as non-Aboriginal or Torres Strait Islander, spoken language other than English, Indigenous or Sign, or had at least one parent born in a non-English speaking country.

OUTCOMES MEASURES

For CALD and non-CALD children, we estimated the cumulative incidence (risk) of CP contacts up to age 7, relative risk and risk differences for all levels of CP contact from notification to out-of-home care (OOHC), primary maltreatment type, reporter type, and socio-economic characteristics. Sensitivity analyses explored different population selection criteria and CALD definitions.

RESULTS

By age 7, 11.2% of CALD children had 'screened-in' notifications compared to 18.8% of non-CALD (risk difference [RD] 7.6 percentage points (95% confidence interval: 6.9-8.3)), and 0.6% of CALD children experienced OOHC compared to 2.2% of non-CALD (RD 1.6 percentage points (95% confidence interval: 1.3-1.8)). Emotional abuse was the most common substantiated maltreatment type for CALD and neglect for non-CALD. Among both groups, the most common reporter sources were police and education sector. Socio-economic characteristics were broadly similar. Sensitivity analyses results were consistent with primary analyses.

CONCLUSION

By age 7, CALD children had lower risk of contact with all levels of CP. Estimates based on primary and sensitivity analyses suggested CALD children were 5-9 percentage points less likely to have a report screened-in, and from 1.0 to 1.7 percentage points less likely to have experienced OOHC.

Using linked administrative data to move from an individual unit to family units: An example from child protection policy to better inform family focused interventions

ObjectiveTo describe turning an incident based child protection system contacts and data (e.g. number of notifications) into child specific experiences and then into patterns of family experiences with child protection (CP) to inform family focused interventions and policy. ApproachData was drawn from Better Evidence Better Outcomes Linked Data (BEBOLD), a whole-of-population linked de-identified administrative data platform for all children in South Australia born from 1991-2016 (n~500,000) as well as their families and carers. Data linked included birth registrations, perinatal statistics, child protection services, family health services, education, justice, hospitalisation, and welfare payments. Families have been defined in BEBOLD based on mother-child relationships identified via birth registrations. The mother is the index family member, and all children registered with the same mother are grouped into one family. We analysed family experiences of the child protection system over ten years from 2006 to the end of 2016 and described their sociodemographic characteristics. ResultsAlmost 1 in 4 families had contact with CP 10 years after the birth of their first child. Two-thirds of families in contact with CP had one or two children, but larger families are more likely to have contact (57.1% of families with five or more children compared to 21.9% for families with one child).  Of the families that had CP contact, 56.5% had contact when they only had one child, 32.9% first had contact after birth of their second child, and 9% had contact had birth of third child. Families with only one child at first CP contact had a generally higher risk profile across a range of characteristics at birth than families who first had contact with two, or three or more children. ConclusionUnderstanding CP contact for family units more closely reflects how services seek to address CP risk by working with families. Describing how families interact with CP and identifying families at high risk of CP involvement can inform how agencies design and deliver services to target the most vulnerable families.

The hospital burden of intergenerational contact with the welfare system: A whole-of-population liked data study

ObjectivesIntergenerational welfare contact (IWC) is a policy issue due to personal and social costs of ‘entrenched disadvantage’ across generations, yet few studies have quantified the burden of IWC on health. We examine the proportion of children who experienced IWC and other welfare contact (WC) types; and estimate cause-specific hospital burden. ApproachA whole-of-population linked administrative data study of children in South Australia born 1991-1995 (n=94,358), followed from birth up to age 20 years and their parent/s (n=143,814). The study used de-identified data from the Better Evidence Better Outcomes Linked Data platform including data from Australian Government Centrelink (welfare payments), birth registration, perinatal birth records, and inpatient hospitalisations. Children were classified as: No WC, parent only WC, child only WC, or IWC. Cause-specific hospitalisation rates and cumulative incidence were estimated by age and WC group. ResultsUsing Australian Government Centrelink data, WC was defined as parent/s receiving a means-tested welfare payment (low-income, unemployment, disability or caring) when children were aged 11-15, or children receiving payment at ages 16-20. IWC was WC occurring in both parent and child generations. IWC affected 34.9% of children, who had the highest hospitalisation rate (133.5 per 1,000 person-years) compared to no WC (46.1 per 1,000 person-years), parent WC  (75.0 per 1,000 person-years), and child only WC (87.6 per 1,000 person-years). Of all IWC children, 43.0% experienced at least one hospitalisation between 11-20 years, frequently related to injury, mental health, and pregnancy. Conclusions and RelevanceChildren experiencing IWC represent a third of the population aged 11-20. Compared to children with parent-only WC, IWC children had 78% higher hospitalisation rates from age 11 to 20, accounting for over half of all hospitalisations in this age group. Frequent IWC hospitalisation causes were injuries, mental health, and pregnancy.

Linked administrative data can inform policy and practice: An academic - government research partnership in South Australia

ObjectiveTo describe how the Better Evidence Better Outcomes Linked Data (BEBOLD) platform has been used to partner with government agencies to generate evidence to support service reform that contributes to improving outcomes for children and families in contact with the child protection system. ApproachData was drawn from the BEBOLD platform, a whole-of-population linked de-identified administrative data platform for all children in South Australia born from 1991-2016 (n~500,000), as well as their parents. Data linked included birth registrations, perinatal statistics, child protection services, family health services, education, youth justice, housing and homelessness, emergency department presentations and hospitalisation, as well as adult drug and alcohol services. ResultsWe present case studies illustrating how the BEBOLD platform has been used to 1) investigate the descriptive epidemiology of child protection contact patterns with a focus on priority populations (e.g. young parents); 2) describe service interactions of child protection populations in a way that highlights prevention potential (e.g. the overlap between public housing and child protection); and 3) identify policy defined target populations to inform contracting of support services (e.g. estimate counterfactual reunification rates for a defined population to inform development of a Social Impact Bond). ConclusionUsing linked data to take an intelligent system view of potential priority populations can inform policy and service delivery in a resource restricted setting. Descriptive epidemiology of child protection contact patterns, population sizes, transitions, and characteristics can aid services to explore elements of service or system design including eligibility criteria.

The Hospital Burden Associated With Intergenerational Contact With the Welfare System in Australia

IMPORTANCE

Intergenerational welfare contact is a policy issue because of the personal and social costs of entrenched disadvantage; yet, few studies have quantified the burden associated with intergenerational welfare contact for health.

OBJECTIVE

To examine the proportion of individuals who experienced intergenerational welfare contact and other welfare contact types and to estimate their cause-specific hospital burden.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used a whole-of-population linked administrative dataset of individuals followed from birth to age 20 years using deidentified data from the Better Evidence Better Outcomes Linked Data platform (Australian Government Centrelink [welfare payments], birth registration, perinatal birth records, and inpatient hospitalizations). Participants included individuals born in South Australia from 1991 to 1995 and their parents. Analysis was undertaken from January 2020 to June 2022.

EXPOSURES

Using Australian Government Centrelink data, welfare contact was defined as 1 or more parents receiving a means-tested welfare payment (low-income, unemployment, disability, or caring) when children were aged 11 to 15 years, or youth receiving payment at ages 16 to 20 years. Intergenerational welfare contact was defined as welfare contact occurring in both parent and offspring generations. Offspring were classified as: no welfare contact, parent-only welfare contact, offspring-only welfare contact, or intergenerational welfare contact.

MAIN OUTCOMES AND MEASURES

Hospitalization rates and cumulative incidence were estimated by age, hospitalization cause, and welfare contact group.

RESULTS

A total of 94 358 offspring (48 589 [51.5%] male) and 143 814 parents were included in analyses. The study population included 32 969 offspring (34.9%) who experienced intergenerational welfare contact. These individuals were more socioeconomically disadvantaged at birth and had the highest hospitalization rate (133.5 hospitalizations per 1000 person-years) compared with individuals with no welfare contact (46.1 hospitalizations per 1000 person-years), individuals with parent-only welfare contact (75.0 hospitalizations per 1000 person-years), and individuals with offspring-only welfare contact (87.6 hospitalizations per 1000 person-years). Hospitalizations were frequently related to injury, mental health, and pregnancy. For example, the proportion of individuals with intergenerational welfare contact who had experienced at least 1 hospitalization at ages 16 to 20 years was highest for injury (9.0% [95% CI, 8.7%-9.3%]).

CONCLUSIONS AND RELEVANCE

In this population-based cohort study, individuals who experienced intergenerational welfare contact represented one-third of the population aged 11 to 20 years. Compared with individuals with parent-only welfare contact, individuals with intergenerational welfare contact were more disadvantaged at birth and had 78% higher hospitalization rates from age 11 to 20 years, accounting for more than half of all hospitalizations. Frequent hospitalization causes were injuries, mental health, and pregnancy. This study provides the policy-relevant estimate for what it could mean to break cycles of disadvantage for reducing hospital burden.

Examining the intersection of child protection and public housing: development, health and justice outcomes using linked administrative data

OBJECTIVE

We described development, health and justice system outcomes for children in contact with child protection and public housing.

DESIGN

Descriptive analysis of outcomes for children known to child protection who also had contact with public housing drawn from the South Australian (SA) Better Evidence Better Outcomes Linked Data (BEBOLD) platform.

SETTING

The BEBOLD platform holds linked administrative records collected by government agencies for whole-population successive birth cohorts in SA beginning in 1999.

PARTICIPANTS

This study included data from birth registrations, perinatal, child protection, public housing, hospital, emergency department, early education and youth justice for all SA children born 1999-2013 and followed until 2016. The base population notified at least once to child protection was n=67 454.

PRIMARY OUTCOME MEASURE

Contact with the public housing system.

SECONDARY OUTCOME MEASURES

Hospitalisations and emergency department presentations before age 5, and early education at age 5, and youth justice contact before age 17.

RESULTS

More than 60% of children with at least one notification to child protection had contact with public housing, and 60.2% of those known to both systems were known to housing first. Children known to both systems experienced more emergency department and hospitalisation contacts, greater developmental vulnerability and were about six times more likely to have youth justice system contact.

CONCLUSIONS

There is substantial overlap between involvement with child protection and public housing in SA. Those children are more likely to face a life trajectory characterised by greater contact with the health system, greater early life developmental vulnerability and greater contact with the criminal justice system. Ensuring the highest quality of supportive early life infrastructure for families in public housing may contribute to prevention of contact with child protection and better life trajectories for children.

838Thriving in adversity: positive child development despite early disadvantage in a whole-of-population data linkage study

Background

Experiencing socioeconomic disadvantage, poor health, or child maltreatment in early life has negative effects on child development. However, we know little about children who have good developmental outcomes despite experiencing adversity.

Methods

This study used de-identified, linked government administrative data from the South Australian Early Childhood Data Project: specifically Australian Early Development Census (AEDC) data for all South Australian born children in their first year of school in 2009, 2012 and 2015 (n = 47,179) and their corresponding birth, perinatal, school enrolment, hospital admission, emergency department presentation, public housing and child protection data. Latent class analyses constructed multidimensional measures of socioeconomic, health, and maltreatment adversities experienced from birth to age 5.

Results

Overall, 49.8% (95% CI 49.2-50.4) of children were on track on all five AEDC domains, but this ranged from 53.7% among children who did not experience high levels of adversity to 13.5% among children with high levels of all three adversities.

Conclusions

Among children who experienced high levels of two or three early adversity types, approximately 1 in 5 were developmentally on track. Understanding characteristics of these children who thrive, against the odds, will help identify intervention opportunities to improve child development.

Key messages

Compared with children who did not experience high levels of adversity, each additional adversity reduced the likelihood of being developmentally on track by approximately 10% to 15%. Children experiencing socioeconomic or maltreatment adversity were less likely to be developmentally on track than children experiencing health adversity.

844Considering child maltreatment in social inequalities of educational achievement: a whole-of-population data linkage study

Background

Strategies aimed at reducing health inequalities include a focus on improving education, a key determinant of health and labour market outcomes. Studies have demonstrated that both early life socioeconomic disadvantage and child maltreatment result in poorer educational outcomes, but have not examined the effect of the combination of these adversities.

Methods

This study used de-identified, linked government administrative data from the South Australian Early Childhood Data Project on children born in South Australia who completed Year 5 National Assessment Program—Literacy and Numeracy (NAPLAN) during 2008-2015 (n = 61,445), and their corresponding birth, perinatal, school enrolment and child protection system data.

Results

Overall, 23.7% (95% CI 23.4-24.1) had a poor NAPLAN outcome (at or below national minimum standard on three or more of the five domains - reading, writing, spelling, grammar and punctuation, numeracy). This proportion was approximately double for children who experienced substantiated maltreatment compared to children who did not experience contact with the child protection system, irrespective of the social circumstances (parental education, employment, housing and area-level disadvantage) in which the child lived.

Conclusions

Social advantage is not sufficient to protect children from poor educational outcomes if they experience substantiated maltreatment. Interventions and services will need to focus on child maltreatment, in addition to socioeconomic factors, to improve educational outcomes in the population.

Key messages

Within each social group, from advantaged to disadvantaged children, the risk of poor NAPLAN outcomes was greater for children who had contact with the child protection system.

Characteristics of paediatric frequent presenters at emergency departments: A whole-of-population study

AIM

To quantify the frequency of emergency department (ED) presentations and profile the socio-demographic, health and presentation characteristics of paediatric ED frequent presenters.

METHODS

A population-based data linkage study of 55 921 children in the South Australian Early Childhood Data Project aged 0-12 years with 100 976 presentations to public hospital EDs in South Australia. For each child, the total number of recurrent ED presentations during a 364-day period post-index presentation was calculated. Frequent presenters were children who experienced ≥4 recurrent ED presentations. We determined the socio-demographic, health and presentation characteristics by number of recurrent presentations.

RESULTS

Children with ≥4 recurrent presentations (4.4%) accounted for 15.4% of all paediatric ED presentations and 22.5% of subsequent admissions to hospital during the 12-month study period. Compared to children with no recurrent ED presentation, frequent presenters had higher proportions of socio-economic and health disadvantage at birth. One in two (49.3%) frequent presenters had at least one injury presentation and one (21.3%) in five had at least one presentation related to a chronic condition.

CONCLUSIONS

Children with ≥4 presentations do not represent the majority of ED users. Nevertheless, they represent a disproportionate burden accounting for 15% of all paediatric ED presentations in a 12-month period. Frequent presenters were characterised by early socio-economic and health disadvantage, and childhood injury. Strategies targeting social disadvantage and childhood injury may reduce the burden of ED presentations.

A public health approach to preventing child maltreatment: An intelligent information infrastructure to help us know what works

Researchers and policymakers have called for a shift from incident-driven statutory child protection responses to greater investment in coordinated system-wide child and family focused approaches to preventing child maltreatment. However, system-wide capacity to prevent maltreatment is limited without an intelligent information infrastructure that is able to routinely examine child and family focused outcomes, and overall system performance to increase our understanding of what works. The purpose of this article is to investigate the current state of indicators for child protection, health, development and wellbeing, and to propose indicator domains that are needed for an intelligent information infrastructure in a prevention-focused child protection system. A non-systematic narrative review was undertaken to explore commonly used indicators. Examples are drawn from high-income countries with well-developed child protection agencies. Our analysis shows that process indicators that measure within-agency activities are most commonly used. Indicators that measure outcomes in children are less common, and even less common are indicators linking system processes to child and family outcomes. Capacity to understand the success of system-wide prevention of child maltreatment is limited by siloed data collection and information systems. Three information indicator domains need to be routinely collected and linked. First, within-agency processes (what activities occurred); second, warm handover (referrals between agencies) and therapeutic dose of interventions; and third, child and family wellbeing outcomes. An intelligent information infrastructure spanning these domains would increase capacity to understand whole-of-system efforts to prevent child maltreatment.

The role of business size in assessing the uptake of health promoting workplace initiatives in Australia

BACKGROUND

Worksite health promotion (WHP) initiatives are increasingly seen as having potential for large-scale health gains. While health insurance premiums are directly linked to workplaces in the USA, other countries with universal health coverage, have less incentive to implement WHP programs. Size of the business is an important consideration with small worksites less likely to implement WHP programs. The aim of this study was to identify key intervention points and to provide policy makers with evidence for targeted interventions.

METHODS

The worksites (n = 218) of randomly selected, working participants, aged between 30 and 65 years, in two South Australian cohort studies were surveyed to assess the practices, beliefs, and attitudes regarding WHP. A survey was sent electronically or by mail to management within each business.

RESULTS

Smaller businesses (<20 employees) had less current health promotion activies (mean 1.0) compared to medium size businesses (20-200 employees - mean 2.4) and large businesses (200+ employees - mean 2.9). Management in small businesses were less likely (31.0 %) to believe that health promotion belonged in the workplace (compared to 55.7 % of medium businesses and 73.9 % of large businesses) although half of small businesses did not know or were undecided (compared to 36.4 and 21.6 % of medium and large businesses). In total, 85.0 % of smaller businesses believed the health promotion activities currently employed in the worksite were effective (compared to 89.2 % of medium businesses and 83.1 % of large businesses). Time and funding were the most cited responses to the challenges to implementing health promoting strategies regardless of business size. Small businesses ranked morale and work/life balance the highest among a range of health promotion activities that were important for their workplace while work-related injury was the highest ranked consideration for large businesses.

CONCLUSION

This study found that smaller workplaces had many barriers, beliefs and challenges regarding WHP. Often small businesses find health promotion activities a luxury and not a serious focus of their activities although this study found that once a health promoting strategy was employed, the perceived effectiveness of the activities were high for all business regardless of size. Tailored low-cost programs, tax incentives, re-orientation of work practices and management support are required so that the proportion of small businesses that have WHP initiatives is increased.

The use of a chronic disease and risk factor surveillance system to determine the age, period and cohort effects on the prevalence of obesity and diabetes in South Australian adults--2003-2013

Background

Age, period and cohort (APC) analyses, using representative, population-based descriptive data, provide additional understanding behind increased prevalence rates.

Methods

Data on obesity and diabetes from the South Australian (SA) monthly chronic disease and risk factor surveillance system from July 2002 to December 2013 (n = 59,025) were used. Age was the self-reported age of the respondent at the time of the interview. Period was the year of the interview and cohort was age subtracted from the survey year. Cohort years were 1905 to 1995. All variables were treated as continuous. The age-sex standardised prevalence for obesity and diabetes was calculated using the Australia 2011 census. The APC models were constructed with ‘‘apcfit’’ in Stata.

Results

The age-sex standardised prevalence of obesity and diabetes increased in 2002-2013 from 18.6% to 24.1% and from 6.2% to 7.9%. The peak age for obesity was approximately 70 years with a steady increasing rate from 20 to 70 years of age. The peak age for diabetes was approximately 80 years. There were strong cohort effects and no period effects for both obesity and diabetes. The magnitude of the cohort effect is much more pronounced for obesity than for diabetes.

Conclusion

The APC analyses showed a higher than expected peak age for both obesity and diabetes, strong cohort effects with an acceleration of risk after 1960s for obesity and after 1940s for diabetes, and no period effects. By simultaneously considering the effects of age, period and cohort we have provided additional evidence for effective public health interventions.

A comparison of Australian rural and metropolitan cardiovascular risk and mortality: the Greater Green Triangle and North West Adelaide population surveys

OBJECTIVES

Cardiovascular (CVD) mortality disparities between rural/regional and urban-dwelling residents of Australia are persistent. Unavailability of biomedical CVD risk factor data has, until now, limited efforts to understand the causes of the disparity. This study aimed to further investigate such disparities.

DESIGN

Comparison of (1) CVD risk measures between a regional (Greater Green Triangle Risk Factor Study (GGT RFS, cross-sectional study, 2004-2006) and an urban population (North West Adelaide Health Study (NWAHS, longitudinal cohort study, 2004-2006); (2) Australian Bureau of Statistics (ABS) CVD mortality rates between these and other Australian regions; and (3) ABS CVD mortality rates by an area-level indicator of socioeconomic status, the Index of Relative Socioeconomic Disadvantage (IRSD).

SETTING

Greater Green Triangle (GGT, Limestone Coast, Wimmera and Corangamite Shires) of South-Western Victoria and North-West Adelaide (NWA).

PARTICIPANTS

1563 GGT RFS and 3036 NWAHS stage 2 participants (aged 25-74) provided some information (self-administered questionnaire +/- anthropometric and biomedical measurements).

PRIMARY AND SECONDARY OUTCOME MEASURES

Age-group specific measures of absolute CVD risk, ABS CVD mortality rates by study group and Australian Standard Geographical Classification (ASGC) region.

RESULTS

Few significant differences in CVD risk between the study regions, with mean absolute CVD risk ranging from approximately 1% in the age group 35-39 years to 14% in the age group 70-74 years. [corrected]. Similar mean 2003-2007 (crude) mortality rates in GGT (98, 95% CI 87 to 111), NWA (103, 95% CI 96 to 110) and regional Australia (92, 95% CI 91 to 94). NWA mortality rates exceeded that of other city areas (70, 95% CI 69 to 71). Lower measures of socioeconomic status were associated with worse CVD outcomes regardless of geographic location.

CONCLUSIONS

Metropolitan areas do not always have better CVD risk factor profiles and outcomes than rural/regional areas. Needs assessments are required for different settings to elucidate relative contributions of the multiple determinants of risk and appropriate cardiac healthcare strategies to improve outcomes.