Perspectives of health service providers in delivering best-practice care for Aboriginal mothers and their babies during the postnatal period

BACKGROUND

Evidence suggests that Aboriginal babies in Western Australia are not receiving adequate primary health care in their first 3 months of life, leading to questions about enablers and constraints to delivering such care. This paper presents findings from a qualitative research project investigating health providers' perceptions and experiences of best and current practice in discharge planning, postnatal care and health education for Aboriginal mothers and their newborn babies.

METHODS

Constructivist grounded theory guided this research involving 58 semi-structured interviews conducted with health providers who deliver care to Aboriginal mothers and infants. Participants were recruited from hospital-based and primary health sites in metropolitan Perth, and regional and remote locations in Western Australia.

RESULTS

Structural factors enabling best practice in discharge planning, postnatal care, and health education for mothers included health providers following best practice guidelines and adequate staffing levels. Organisational enablers included continuity of care throughout pregnancy, birth and postnatally. In particular, good communication between services around discharge planning, birth notifications, and training in culturally respectful care. Structural and organisational constraints to delivering best practice and compromising continuity of care were identified as beyond individual control. These included poor communication between different health and social services, insufficient hospital staffing levels leading to early discharge, inadequate cultural training, delayed receipt of birth notifications and discharge summaries received by Aboriginal primary health services.

CONCLUSION

Findings highlight the importance of examining current policies and practices to promote best practice in postnatal care to improve health outcomes for mothers and their Aboriginal babies.

Spatial and Temporal Variability in Trihalomethane Concentrations in the Bromine-Rich Public Waters of Perth, Australia

High concentrations of trihalomethanes (THMs) in public water supplies potentially pose a health hazard, but exposure assessment remains a complex task. To interpret research findings and monitoring data for THMs, it is important to evaluate spatial and temporal variations in both total THM and the individual constituent compounds (including brominated species). We therefore aimed to determine the concentrations, and spatial and temporal variability of concentrations, of THMs public water supplies in Perth, Western Australia, which is known historically to have high brominated THM concentrations. We analysed water samples from 21 water distribution zones around Perth (including Busselton and Bunbury) across different seasons over a period of two years. A total of 250 samples provided a median total THM of 72 µg/L (range of 0-157 µg/L), which falls well within Australia's National Health and Medical Research Council guidelines. The concentration of all species, including brominated forms, also fell the World Health Organization's guidelines. Total THM concentrations were typically higher in spring and summer. A high degree of spatial variability was detected and appears to relate to the source water. Both the temporal and spatial variability in THM concentrations have implications for epidemiological studies, and monitoring.

Health service provider education and/or training in infant male circumcision to improve short- and long-term morbidity outcomes: A systematic review

AIM

To systematically review the effectiveness of education and/or training for traditional (informal) and formal health service providers in infant male circumcision on morbidity or mortality outcomes.

METHODS

We searched Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, Global Health, Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects and clinical trial registries in all languages from January 1985 to June 2018. Our primary outcomes were all-cause morbidity and all-cause mortality.

RESULTS

We identified 1399 publications. Only four non-controlled before and after studies from the USA and Uganda satisfied our criteria, all of which examined the effect of training on the skills and knowledge of medical doctors, midwives and clinical officers. No study involved informal traditional circumcision providers. All included studies were low quality.

CONCLUSIONS

High-quality studies of simple training packages to improve education and training of circumcision providers, especially informal non-medical providers in low income countries are needed.

Anemia in disadvantaged children aged under five years; quality of care in primary practice

Background

Anemia rates are over 60% in disadvantaged children yet there is little information about the quality of anemia care for disadvantaged children.

Methods

Our primary objective was to assess the burden and quality of anemia care for disadvantaged children and to determine how this varied by age and geographic location. We implemented a cross-sectional study using clinical audit data from 2287 Indigenous children aged 6–59 months attending 109 primary health care centers between 2012 and 2014. Data were analysed using multivariable regression models.

Results

Children aged 6–11 months (164, 41.9%) were less likely to receive anemia care than children aged 12–59 months (963, 56.5%) (adjusted odds ratio [aOR] 0.48, CI 0.35, 0.65). Proportion of children receiving anemia care ranged from 10.2% (92) (advice about ‘food security’) to 72.8% (728) (nutrition advice). 70.2% of children had a hemoglobin measurement in the last 12 months. Non-remote area families (115, 38.2) were less likely to receive anemia care compared to remote families (1012, 56.4%) (aOR 0.34, CI 0.15, 0.74). 57% (111) aged 6–11 months were diagnosed with anemia compared to 42.8% (163) aged 12–23 months and 22.4% (201) aged 24–59 months. 49% (48.5%, 219) of children with anemia received follow up.

Conclusions

The burden of anemia and quality of care for disadvantaged Indigenous children was concerning across all remote and urban locations assessed in this study. Improved services are needed for children aged 6–11 months, who are particularly at risk.

Improving developmental care in primary practice for disadvantaged children

Our primary objective was to assess if sustained participation in continuous quality improvement (CQI) activities could improve delivery of 'basic developmental care' to disadvantaged children in primary care settings. Secondary objectives were to assess if delivery of developmental care differed by age and geographic location.Data were analysed using multivariable logistic regression and generalised estimating equations. 109 indigenous primary care centres across Australia from 2012 to 2014 and2466 client files from indigenous children aged 3-59 months were included. Outcome measures were delivery of basic developmental care.We found that the proportion of children who received basic developmental care ranged from 55% (advice about physical and mental stimulation of child) (1279, 55.1%) to 74% (assessment of developmental milestones) (1510, 73.7%). Ninety-three per cent (92.6%, 88) of children received follow-up care. Centres with sustained CQI participation (completed three or more consecutive audit cycles) (508, 53.9%) were twofold more likely to deliver basic developmental care compared with centres without sustained CQI (completed less than three consecutive audit cycles) (118, 31.0%) (adjusted OR (aOR) 2.37, 95% CI 1.33 to 4.23). Children aged 3-11 months (229, 54.9%) were more likely to receive basic developmental care than children aged 24-59 months (151, 38.5%) (aOR 2.42, 95% CI 1.67 to 3.51). Geographic location had little effect (aOR 0.68, 95% CI 0.30 to 1.53). Overall our study found that sustained CQI can improve basic developmental care in primary care settings. However, many disadvantaged children are not receiving services. Improved resourcing of developmental care and CQI in primary care centres is needed.

Meningococcal Disease in Northern Ireland - Past, Present & Future: MeningoNI Forum

Meningococcal disease has had devastating consequences in Northern Ireland since its first description locally in 1859. The incidence of this disease has significantly declined in recent years, however it is important to understand reasons for this changing epidemiology and to acknowledge the diagnostic and clinical management developments that have been made locally. This review aims to examine the changing face of this disease in Northern Ireland over the years, with particular reference to local disease prevention, epidemiology, diagnosis, clinical treatment and management, post-disease sequelae and the role of meningitis charities locally, in terms of patient support and research.

Quality of social and emotional wellbeing services for families of young Indigenous children attending primary care centers; a cross sectional analysis

BACKGROUND

The quality of social and emotional wellbeing services for Indigenous families of young children is not known, in many settings especially services provided by primary care centers.

METHODS

Our primary objective was to assess delivery of social and emotional wellbeing services to the families of young (3-11 months) and older (12-59 months) Indigenous children attending primary care centers. Our secondary objective was to assess if delivery differed by geographic location. Two thousand four hundred sixty-six client files from 109 primary care centers across Australia from 2012 to 2014 were analysed using logistic regression and generalised estimating equations.

RESULTS

The proportion of families receiving social and emotional wellbeing services ranged from 10.6% (102) (food security) to 74.7% (1216) (assessment of parent child interaction). Seventy one percent (71%, 126) of families received follow up care. Families of children aged 3-11 months (39.5%, 225) were more likely to receive social and emotional wellbeing services (advice about domestic environment, social support, housing condition, child stimulation) than families of children aged 12-59 months (30.0%, 487) (adjusted odds ratio [aOR] 1.68 95% CI 1.33 to 2.13). Remote area families (32.6%, 622) received similar services to rural (29.4%, 68) and urban families (44.0%, 22) (aOR 0.64 95% CI 0.29, 1.44).

CONCLUSIONS

The families of young Indigenous children appear to receive priority for social and emotional wellbeing care in Australian primary care centers, however many Indigenous families are not receiving services. Improvement in resourcing and support of social and emotional wellbeing services in primary care centers is needed.

Sustained participation in annual continuous quality improvement activities improves quality of care for Aboriginal and Torres Strait Islander children

AIM

To determine whether participation in the continuous quality improvement (CQI) Audit and Best Practice for Chronic Disease programme improved care and outcomes for Indigenous children.

METHODS

Data were collected from 59 Australian primary health-care centres providing services to Indigenous people and participating in the programme (February 2008 and December 2013). Indigenous children aged less than 2 years and centres that completed three or more consecutive annual audits within the 6-year study period were included. Crude and adjusted logistic generalised estimating equation models were used to examine the effect of year of audit on the delivery of care. Odds ratio (OR) and 95% confidence interval (CI) were calculated. Outcomes were related to age-relevant health issues, including prevention and early intervention. These included administrative, health check, anticipatory guidance and specific health issues.

RESULTS

During the audit period, there were 2360 files from 59 centres. Those that had a recall recorded, improved from 84 to 95% (OR 2.44, 95% CI 1.44-4.11). Hearing assessments improved from 52 to 89% (OR 1.37, 95% CI 1.22-1.54). Improvement in anticipatory guidance, treatment and follow-up of medical conditions was almost universal.

CONCLUSION

We documented significant improvements in quality of care of Indigenous children. Outcomes and their corresponding treatment and follow-ups improved over time. This appears to be related to services participating in annual CQI activities. However, these services may be more committed to CQI than others and therefore possibly better performing.

Understanding the structure and processes of primary health care for young indigenous children

ABSTRACT INTRODUCTION Primary health care organisations need to continuously reform to more effectively address current health challenges, particularly for vulnerable populations. There is growing evidence that optimal health service structures are essential for producing positive outcomes. AIM To determine if there is an association between process of care indicators (PoCIs) for important young indigenous child health and social issues and: (i) primary health-care service and child characteristics; and (ii) organisational health service structures. METHODS This was a cross-sectional study of 1554 clinical child health audits and associated system assessments from 74 primary care services from 2012 to 2014. Composite PoCIs were developed for social and emotional wellbeing, child neurodevelopment and anaemia. Crude and adjusted logistic regression models were fitted, clustering for health services. Odds ratios and 95% confidence intervals were derived. RESULTS Overall, 32.0% (449) of records had a social and emotional wellbeing PoCI, 56.6% (791) had an anaemia PoCI and 49.3% (430) had a child neurodevelopment PoCI. Children aged 12–23 months were significantly more likely to receive all PoCIs compared to children aged 24–59 months. For every one point increase in assessment scores for team structure and function (aOR 1.14, 95% CI 1.01–1.27) and care planning (aOR 1.14, 95% CI 1.01–1.29) items, there was a 14% greater odds of a child having an anaemia PoCI. Social and emotional wellbeing and child neurodevelopment PoCIs were not associated with system assessment scores. DISCUSSION Ensuring young indigenous children aged 24–59 months are receiving quality care for important social and health indicators is a priority. Processes of care and organisational systems in primary care services are important for the optimal management of anaemia in indigenous children.

Healthcare seeking patterns of families of infants with circumcision-related morbidities from two population-based cohort studies in Ghana

OBJECTIVE

This study assessed healthcare seeking patterns of families of infants with circumcision-related morbidities and families of infants with acute illnesses in rural Ghana.

DESIGN

Two population-based cohort studies.

SETTING

Brong Ahafo Region of central rural Ghana.

PARTICIPANTS

A total of 22 955 infants enrolled in a large population-based trial (Neovita trial) from 16 August 2010 to 7 November 2011 and 3141 infants in a circumcision study from 21 May 2012 to 31 December 2012.

PRIMARY OUTCOME

Care seeking for circumcision-related morbidities and acute illnesses unrelated to circumcision.

RESULTS

Two hundred and thirty (8.1%) infants from the circumcision study had circumcision-related morbidities and 6265 (27.3%) infants from the Neovita study had acute illnesses unrelated to circumcision. A much lower proportion (35, 15.2%) of families of infants with circumcision-related morbidities sought healthcare compared with families of infants with acute illnesses in the Neovita study (5520, 88.1%). More families sought care from formal providers (24, 69%) compared with informal providers (11, 31%) for circumcision-related morbidities. There were no obvious determinants of care seeking for acute illnesses or circumcision-related morbidities in the population.

CONCLUSIONS

Government and non-government organisations need to improve awareness about the complications and care seeking needed for circumcision-related morbidities.

The influence of socioeconomic factors on choice of infant male circumcision provider in rural Ghana; a community level population based study

Background

The influence of socio-economic determinants on choice of infant male circumcision provider is not known in areas with high population coverage such as rural Africa. The overall aim of this study was to determine the key socio-economic factors which influence the choice of infant male circumcision provider in rural Ghana.

Methods

The study investigated the effect of family income, distance to health facility, and cost of the circumcision on choice of infant male circumcision provider in rural Ghana. Data from 2847 circumcised infant males aged under 12 weeks and their families were analysed in a population-based cross-sectional study conducted from May to December 2012 in rural Ghana. Multivariable logistic regression models were adjusted for income status, distance to health facility, cost of circumcision, religion, maternal education, and maternal age.

Results

Infants from the lowest income households (325, 84.0%) were more likely to receive circumcision from an informal provider compared to infants from the highest income households (260, 42.4%) even after adjusting for religious affiliation (adjusted odds ratio [aOR] 4.42, 95% CI 3.12–6.27 p = <0.001). There appeared to be a dose response with increasing risk of receiving a circumcision from an informal provider as distance to a health facility increased (aOR 1.25, 95 CI 1.30–1.38 P = <0.001). Only 9.0% (34) of families in the lowest socio-economic quintile received free circumcision services compared to 27.9% (171) of the highest income families.

Conclusions

The Government of Ghana and Non-Government Organisations should consider additional support to poor families so they can access high quality free infant male circumcision in rural Ghana.

Economic evaluation of interventions delivered by primary care providers to improve neurodevelopment in children aged under 5 years: protocol for a scoping review

BACKGROUND

Frequently cited benefit-cost ratios suggest that interventions to improve neurodevelopment have high economic returns when implemented during pregnancy and early childhood. However, there are many challenges when primary care providers implement these interventions at scale, and it is unclear how many research studies or programmes have examined cost-effectiveness and which methods were used. There are no current scoping or systematic reviews which have assessed economic evaluations of interventions delivered by primary care providers to improve child neurodevelopment.

METHODS/DESIGN

The aim of this review is to describe the economic evaluations of interventions delivered by primary care providers to improve neurodevelopment in children aged 0-4 years. Specific subgroup analyses will include income level of country (high, middle and low); population type (universal vs targeted); time period when intervention was implemented (antenatal vs infancy [0-11 months] vs early childhood [12-59 months]); and setting (research study vs programmes evaluation at scale). All study designs will be included. The primary outcomes of interest are cost per neurodevelopmental or cognitive health gain in children aged 0-4 years. All measures of cost, neurodevelopment or cognitive function that have been previously validated as an appropriate test in this domain will be included. Databases such as MEDLINE (OVID), PsycINFO (OVID), EMBASE (OVID), CINAHL, Cochrane Library (including CENTRAL, DARE, HTA and NHS EED), Paediatric Economic Database Evaluation (PEDE) and WHO databases and reference lists of papers will be searched for relevant articles. Five phases will be followed: identifying the research question, identifying relevant studies, study selection, charting data and collating, summarising and reporting results. We will present cost and effectiveness data descriptively.

DISCUSSION

This review appears to be the first to be conducted in this area. The findings will be an important resource for future systematic reviews on interventions that have a cost component. This information will be valuable for policy makers and programmers who work in public health or primary care settings.

Determinants of morbidity associated with infant male circumcision: community-level population-based study in rural Ghana

OBJECTIVE

Male circumcision services have expanded throughout Africa as part of a long-term HIV prevention strategy. We assessed the effect of type of service provider (formal and informal) and hygiene practices on circumcision-related morbidities in rural Ghana.

METHODS

Population-based, cross-sectional study conducted between May and December 2012 involving 2850 circumcised infant males aged under 12 weeks. Multivariable logistic regression models were adjusted for maternal age, maternal education, income, birthweight and site of circumcision.

RESULTS

A total of 2850 (90.7%) infant males were circumcised. Overall, the risk of experiencing a morbidity (defined as complications occurring during or after the circumcision procedure as reported by the primary caregiver) was 8.1% (230). Risk was not significantly increased if the circumcision was performed by informal providers (121, 7.2%) vs. formal health service providers (109, 9.8%) [adjusted odds ratio (aOR) 1.11, 95% CI 0.80-1.47, P = 0.456]. Poor hygiene practices were associated with significantly increased risk of morbidity: no handwashing [148 (11.7%)] (aOR 1.78, 95% CI 1.27-2.52, P = 0.001); not cleaning circumcision instruments [174 (10.6%)] (aOR 1.80, 95% CI 1.27-2.54, P = 0.001); and uncleaned penile area [190 (10.0%)] (aOR 1.84, 95% CI 1.25-2.70, P = 0.002).

CONCLUSION

The risk of morbidity after infant male circumcision in rural Ghana is high, chiefly due to poor hygiene practices. Governmental and non-governmental organisations need to improve training of circumcision providers in hygiene practices in sub-Saharan Africa.

Hospital Utilisation in Indigenous and Non-Indigenous Infants under 12 Months of Age in Western Australia, Prospective Population Based Data Linkage Study

Background

Indigenous infants (infants aged under 12 months) have the highest hospital admission and emergency department presentation risks in Australia. However, there have been no recent reports comparing hospital utilisation between Indigenous and non-Indigenous infants.

Methods

Our primary objective was to use a large prospective population-based linked dataset to assess the risk of all-cause hospital admission and emergency department presentation in Indigenous compared to non-Indigenous infants in Western Australia (WA). Secondary objectives were to assess the effect of socio-economic status (Index of Relative Socio-Economic Disadvantage [IRSD]) on hospital utilisation and to understand the causes of hospital utilisation.

Findings

There were 3,382 (5.4%) Indigenous and 59,583 (94.6%) non-Indigenous live births in WA from 1 January 2010 to 31 December 2011. Indigenous infants had a greater risk of hospital admission (adjusted odds ratio [aOR] 1.90, 95% confidence interval [95% CI] 1.77–2.04, p = <0.001) and emergency department presentation (aOR 2.15, 95% CI 1.98–2.33, p = <0.001) compared to non-Indigenous infants. Fifty nine percent (59.0%) of admissions in Indigenous children were classified as preventable compared to 31.2% of admissions in non-Indigenous infants (aOR 2.12, 95% CI 1.88–2.39). The risk of hospital admission in the most disadvantaged (IRSD 1) infants in the total cohort (35.7%) was similar to the risk in the least disadvantaged (IRSD 5) infants (30.6%) (aOR 1.04, 95% CI 0.96–1.13, p = 0.356).

Interpretation

WA Indigenous infants have much higher hospital utilisation than non Indigenous infants. WA health services should prioritise Indigenous infants regardless of their socio economic status or where they live.

Health service provider education and/or training in infant male circumcision to improve short- and long-term morbidity outcomes: protocol for systematic review

BACKGROUND

There has been an expansion of circumcision services in Africa as part of a long-term HIV prevention strategy. However, the effect of infant male circumcision on morbidity and mortality still remains unclear. Acute morbidities associated with circumcision include pain, bleeding, swelling, infection, tetanus or inadequate skin removal. Scale-up of circumcision services could lead to a rise in these associated morbidities that could have significant impact on health service delivery and the safety of infants. Multidisciplinary training programmes have been developed to improve skills of health service providers, but very little is known about the effectiveness of health service provider education and/or training for infant male circumcision on short- and long-term morbidity outcomes. This review aims to evaluate the effectiveness of health service provider education and/or training for infant male circumcision on short- and long-term morbidity outcomes.

METHODS/DESIGN

The review will include studies comparing health service providers who have received education and/or training to improve their skills for infant male circumcision with those who have not received education and/or training. Randomised controlled trials (RCTs) and cluster RCTs will be included. The outcomes of interest are short-term morbidities of the male infant including pain, infection, tetanus, bleeding, excess skin removal, glans amputation and fistula. Long-term morbidities include urinary tract infection (UTI), HIV infection and abnormalities of urination. Databases such as MEDLINE (OVID), PsycINFO (OVID), EMBASE (OVID), CINAHL, Cochrane Library (including CENTRAL and DARE), WHO databases and reference list of papers will be searched for relevant articles. Study selection, data extraction and synthesis and risk of bias assessment using the Cochrane risk of bias assessment tool will be conducted. We will calculate the pooled estimates of the difference in means and risk ratios using random effects models. If insufficient data are available, we will present results descriptively.

DISCUSSION

This review appears to be the first to be conducted in this area. The findings will have important implications for infant male circumcision programmes and policy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015029345.

Improving access to primary care for Aboriginal babies in Western Australia: study protocol for a randomized controlled trial

Background

Despite a decade of substantial investments in programs to improve access to primary care for Aboriginal mothers and infants, more than 50 % of Western Australian Aboriginal babies are still not receiving primary and preventative care in the early months of life. Western Australian hospitals now input birth data into the Western Australian electronic clinical management system within 48 hours of birth. However, difficulties have arisen in ensuring that the appropriate primary care providers receive birth notification and clinical information by the time babies are discharged from the hospital. No consistent process exists to ensure that choices about primary care are discussed with Aboriginal families.

Methods/Design

We will undertake a population-based, stepped wedge, cluster randomized controlled trial of an enhanced model of early infant primary care. The intervention is targeted support and care coordination for Aboriginal families with new babies starting as soon as possible during the antenatal period or after birth. Dedicated health professionals and research staff will consult with families about the families’ healthcare needs, provide information about healthcare in the first 3 months of life, offer assistance with birth and Medicare forms, consult with families about their choice for primary care provider, offer to notify the chosen primary care provider about the baby’s health needs, and offer assistance with healthcare coordination at the time of discharge from the hospital.

We will evaluate this model of care using a rigorous stepped wedge approach. Our primary outcome measure is a reduced hospitalization rate in infants younger than 3 months of age. Secondary outcome measures include completed Aboriginal and Torres Strait Islander child health screening assessments, immunization coverage, and satisfaction of the families about early infant primary care. We will also assess the cost effectiveness of the model of care.

Discussion

This study will be conducted over a 4-year period in partnership with birthing hospitals and primary care providers including Western Australian Aboriginal Community Controlled Health Services and the new Primary Health Networks. The results of our trial will be used to develop improved primary care models and to improve health outcomes for all Aboriginal infants. These are vital steps toward more equitable health service delivery for the Aboriginal and Torres Strait Islander children in Australia.

Trial Registration

Australian New Zealand Clinical Trials Registry

Registration number: ACTRN12615000976583 

Date registered: 17 September 2015