Paediatrics (RCH) - Research Publications
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ItemNurse home visiting to improve child and maternal outcomes: 5-year follow-up of an Australian randomised controlled trial(PUBLIC LIBRARY SCIENCE, 2022-11-28)OBJECTIVES: Nurse home visiting (NHV) is widely implemented to address inequities in child and maternal health. However, few studies have examined longer-term effectiveness or delivery within universal healthcare systems. We evaluated the benefits of an Australian NHV program ("right@home") in promoting children's language and learning, general and mental health, maternal mental health and wellbeing, parenting and family relationships, at child ages 4 and 5 years. SETTING AND PARTICIPANTS: Randomised controlled trial of NHV delivered via universal, child and family health services (the comparator). Pregnant women experiencing adversity (≥2 of 10 risk factors) were recruited from 10 antenatal clinics across 2 states (Victoria, Tasmania) in Australia. INTERVENTION: Mothers in the intervention arm were offered 25 nurse home visits (mean 23·2 home visits [SD 7·4, range 1-43] received) of 60-90 minutes, commencing antenatally and continuing until children's second birthdays. PRIMARY AND SECONDARY OUTCOMES MEASURED: At 4 and 5 years, outcomes were assessed via parent interview and direct assessment of children's language and learning (receptive and expressive language, phonological awareness, attention, and executive function). Outcomes were compared between intervention and usual care arms (intention to treat) using adjusted regression with robust estimation to account for nurse/site. Missing data were addressed using multiple imputation and inverse probability weighting. RESULTS: Of 722 women enrolled in the trial, 225 of 363 (62%) intervention and 201 of 359 (56%) usual care women provided data at 5 years. Estimated group differences showed an overall pattern favouring the intervention. Statistical evidence of benefits was found across child and maternal mental health and wellbeing, parenting and family relationships with effect sizes ranging 0·01-0·27. CONCLUSION: An Australian NHV program promoted longer-term family functioning and wellbeing for women experiencing adversity. NHV can offer an important component of a proportionate universal system that delivers support and intervention relative to need. TRIAL REGISTRATION: 2013-2016, registration ISRCTN89962120.
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ItemEconomic evaluation of an Australian nurse home visiting programme: a randomised trial at 3 years(BMJ PUBLISHING GROUP, 2021-12)OBJECTIVES: To investigate the additional programme cost and cost-effectiveness of 'right@home' Nurse Home Visiting (NHV) programme in relation to improving maternal and child outcomes at child age 3 years compared with usual care. DESIGN: A cost-utility analysis from a government-as-payer perspective alongside a randomised trial of NHV over 3-year period. Costs and quality-adjusted life-years (QALYs) were discounted at 5%. Analysis used an intention-to-treat approach with multiple imputation. SETTING: The right@home was implemented from 2013 in Victoria and Tasmania states of Australia, as a primary care service for pregnant women, delivered until child age 2 years. PARTICIPANTS: 722 pregnant Australian women experiencing adversity received NHV (n=363) or usual care (clinic visits) (n=359). PRIMARY AND SECONDARY OUTCOME MEASURES: First, a cost-consequences analysis to compare the additional costs of NHV over usual care, accounting for any reduced costs of service use, and impacts on all maternal and child outcomes assessed at 3 years. Second, cost-utility analysis from a government-as-payer perspective compared additional costs to maternal QALYs to express cost-effectiveness in terms of additional cost per additional QALY gained. RESULTS: When compared with usual care at child age 3 years, the right@home intervention cost $A7685 extra per woman (95% CI $A7006 to $A8364) and generated 0.01 more QALYs (95% CI -0.01 to 0.02). The probability of right@home being cost-effective by child age 3 years is less than 20%, at a willingness-to-pay threshold of $A50 000 per QALY. CONCLUSIONS: Benefits of NHV to parenting at 2 years and maternal health and well-being at 3 years translate into marginal maternal QALY gains. Like previous cost-effectiveness results for NHV programmes, right@home is not cost-effective at 3 years. Given the relatively high up-front costs of NHV, long-term follow-up is needed to assess the accrual of health and economic benefits over time. TRIAL REGISTRATION NUMBER: ISRCTN89962120.
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ItemThe feasibility and acceptability of a population-level antenatal risk factor survey: Cross-sectional pilot study(WILEY, 2017-06)AIM: Australian data on the prevalence and distribution of antenatal risk factors are scarce. This study aimed to investigate (i) the feasibility and acceptability of an antenatal risk factor survey collected in public settings and (ii) whether the survey risk factors co-occur with more sensitive risk factors that are privately asked by clinicians. METHODS: Design and setting: study-designed survey linked with clinician-collected risk factors. PARTICIPANTS: pregnant women attending antenatal clinics at two Victorian hospitals. MEASURES: (i) study-designed survey: young pregnancy, no support, poor/fair/good general health, anxious mood, not finishing high school, no income, long-term illness, living without another adult, not employed, never had a job and proxy poverty measures; (ii) Clinician-collected data: smoking, alcohol/marijuana/drug use, domestic violence, social issues, history of mental health problems and depression symptoms. ANALYSES: (i) feasibility and acceptability were assessed through survey completion. Each item was assessed for whether they discriminated risk; dichotomised into risk versus no risk; with a total count calculated. (ii) Co-occurrence was assessed by examining how the risk factor count agreed with clinician-collected items. RESULTS: One hundred and sixty-six of 186 (89%) eligible women completed the survey; 139 of 166 (84%) consented to linking clinician-collected data. The high response and zero missing data demonstrated feasibility and acceptability. Of women with linked data, 92 of 139 (66%) had ≥1 survey risk factor and 30 of 139 (22%) had ≥3; 36 of 139 (26%) had at least one co-occurring clinician-collected risk factor. CONCLUSIONS: This survey provides a simple, rapid approach to gathering antenatal risk data publicly. It may be a helpful addition to clinicians' standard history collection.
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ItemClinical, financial and social impacts of COVID-19 and their associations with mental health for mothers and children experiencing adversity in Australia(PUBLIC LIBRARY SCIENCE, 2021-09-13)BACKGROUND: Australia has maintained low rates of SARS-COV-2 (COVID-19) infection, due to geographic location and strict public health restrictions. However, the financial and social impacts of these restrictions can negatively affect parents' and children's mental health. In an existing cohort of mothers recruited for their experience of adversity, this study examined: 1) families' experiences of the COVID-19 pandemic and public health restrictions in terms of clinical exposure, financial hardship family stress, and family resilience (termed 'COVID-19 impacts'); and 2) associations between COVID-19 impacts and maternal and child mental health. METHODS: Participants were mothers recruited during pregnancy (2013-14) across two Australian states (Victoria and Tasmania) for the 'right@home' trial. A COVID-19 survey was conducted from May-December 2020, when children were 5.9-7.2 years old. Mothers reported COVID-19 impacts, their own mental health (Depression, Anxiety, Stress Scales short-form) and their child's mental health (CoRonavIruS Health and Impact Survey subscale). Associations between COVID-19 impacts and mental health were examined using regression models controlling for pre-COVID-19 characteristics. RESULTS: 319/406 (79%) mothers completed the COVID-19 survey. Only one reported having had COVID-19. Rates of self-quarantine (20%), job or income loss (27%) and family stress (e.g., difficulty managing children's at-home learning (40%)) were high. Many mothers also reported family resilience (e.g., family found good ways of coping (49%)). COVID-19 impacts associated with poorer mental health (standardised coefficients) included self-quarantine (mother: β = 0.46, child: β = 0.46), financial hardship (mother: β = 0.27, child: β = 0.37) and family stress (mother: β = 0.49, child: β = 0.74). Family resilience was associated with better mental health (mother: β = -0.40, child: β = -0.46). CONCLUSIONS: The financial and social impacts of Australia's public health restrictions have substantially affected families experiencing adversity, and their mental health. These impacts are likely to exacerbate inequities arising from adversity. To recover from COVID-19, policy investment should include income support and universal access to family health services.
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ItemHair cortisol as a measure of the stress response to social adversity in young children(WILEY, 2019-05)Hair cortisol has the potential to provide insight into young children's long-term stress response to social adversity. This study investigated associations between children's exposure to adversity from pregnancy to 2 years of age and their hair cortisol at 2 years, using a longitudinal cohort of children enriched for adversity risk, whose mothers were recruited during pregnancy through the "right@home" trial. Exposures were 18 maternal socioeconomic and psychosocial indicators of adversity, examined as concurrent, cumulative, and longitudinal exposure from pregnancy to 2 years. Hair samples were analyzed from 319/603 (53%) children participating at 2 years. Multivariable regression analyses for concurrent exposure showed three indicators of adversity were associated with higher hair cortisol (housing tenure of public rental, paying board or living rent free; not living in a safe place; higher maternal stress symptoms), one with lower hair cortisol (housing problems), and 14 indicators with no evidence of association. There was no evidence of association for the cumulative adversity count. Longitudinal exposure showed "intermittent" and "persistent" high maternal stress symptoms were associated with higher hair cortisol. The small number of associations identified suggests that hair cortisol is limited as a measure of stress response to social adversity in children at 2 years.
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ItemSurveying social adversity in pregnancy: The antenatal risk burden experienced by Australian women(WILEY, 2018-07)AIM: Many, varied, antenatal risk factors can adversely impact children's health, behaviour and cognition. Understanding the antenatal risk factors experienced by women can help identify which families are most likely to benefit from additional early supports; however, there is a dearth of published Australian antenatal risk data. This study aimed to determine the prevalence and co-occurrence of a broad range of risk factors in a community-based sample of pregnant Australian women. METHODS: A brief risk factor survey (10 items, including age, social support, health, smoking, stress or anxious mood, education, household income, employment) completed by pregnant women attending the antenatal clinic waiting rooms of 10 public maternity hospitals, which were selected for their provision of care to areas with fewer socio-economic resources in the states of Victoria and Tasmania, between May 2013 and August 2014. RESULTS: A total of 5586 women participated, with an average age of 29.0 years and gestation of 26.9 weeks. The most prevalent antenatal risk factors were poorer global health (38.9%), not finishing high school (33.5%) and smoking (14.9%), all proportions higher than the general population. Most women reported at least one risk factor (68.6%), with 21.5% reporting ≥3. There was a high degree of co-occurrence between risk factors, especially the three most prevalent. CONCLUSIONS: This study reveals the considerable and varied risk burden experienced by Australian women during pregnancy. By understanding where need is greatest and tailoring support accordingly, risk factor assessment provides an opportunity to address equity through health care, ultimately optimising the future developmental outcomes of all children.
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ItemNo Preview AvailablePatterns of maternal depression, anxiety, and stress symptoms from pregnancy to 5 years postpartum in an Australian cohort experiencing adversity(Springer, 2021-12-01)The objective of this study is to describe the longitudinal patterns of depression, anxiety, and stress symptoms from pregnancy to 5 years postpartum, in a cohort of Australian mothers experiencing adversity. Longitudinal data were drawn from the control group of a trial of nurse home visiting. Pregnant women experiencing adversity (≥ 2 of 10 adversity risk factors) were recruited from antenatal clinics across 2 Australian states (30 April 2013–29 August 2014). Women completed the Depression Anxiety and Stress Scales short-form (DASS-21) at 11 time-points from pregnancy to 5 years postpartum. DASS-21 scores were summarized at each time-point for all women and by level of adversity risk. Three hundred fifty-nine women (100%) completed the DASS-21 in pregnancy and 343 (96%) provided subsequent data. Mental health symptoms were highest in pregnancy and at 4 and 5 years postpartum. While this pattern was comparable across levels of antenatal adversity risk, women with greatest adversity risk had consistently higher mental health symptoms. In a cohort of mothers experiencing adversity, depression, anxiety, and stress symptoms were highest in pregnancy and at 4 to 5 years postpartum. The striking patterns of persistent, high, mental health symptoms, beyond the first year postpartum, can inform a more equitable and responsive health system.
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ItemPrevalence of language and pre-literacy difficulties in an Australian cohort of 5-year-old children experiencing adversity(WILEY, 2021-03)BACKGROUND: Early reading success is predicated on language and pre-literacy skills. Children who are behind their peers in language and pre-literacy development before formal schooling are less likely to be proficient beginner readers, and difficulties may persist throughout primary school and beyond. We know children experiencing adversity are at greater risk of early language and pre-literacy difficulties; we do not know the prevalence of these difficulties in an Australian adversity context. AIMS: To investigate the prevalence and co-occurrence of language and pre-literacy difficulties in a cohort of Australian 5-year-old children experiencing social adversity. METHODS & PROCEDURES: Data were drawn from a large Australian community-based trial of nurse home visiting (right@home), which aimed to support women experiencing social adversity from pregnancy until their child turned 2 years of age. Social adversity was determined by two of more risk factors: young pregnancy, not living with another adult, no support, poorer health, current smoker, long-term illness, anxious mood, not finishing high school, no household income and no previous employment. Children whose mothers were enrolled in the control group (receiving usual maternal and child healthcare) were included in the current study (n = 359). Language and pre-literacy skills were measured at age 5 using the Clinical Evaluation of Language Fundamental Preschool-Second Edition (CELF-P2) and the School Entry Alphabetic and Phonological Awareness Readiness Test (SEAPART). Language difficulties were defined as ≥ 1.25 standard deviations (SD) below the Australian normative mean on CELF-P2 Core Language scores. Pre-literacy difficulties were defined as children scoring in the Beginner (versus Developing or Competent) criterion-referenced level on the SEAPART First Sound Identification and/or Alphabet Letter Identification subtests. Co-occurrence of language and pre-literacy difficulties was also determined. OUTCOMES & RESULTS: At the 5-year follow-up, 201/359 (56%) children were assessed (mean age = 5.1 years, SD = 0.1). Mean Core Language score for this cohort (91.8, SD = 15.9) was 0.54 SD below the normative mean (100, SD = 15). The proportion of children presenting with language difficulties was 24.9%. Regarding pre-literacy skills, 43.8% of children were 'Beginner' for identifying first sounds and 58.6% for identifying alphabet letters/sounds. There was also considerable overlap whereby 76.7% of children with language difficulties also exhibited pre-literacy difficulties. CONCLUSIONS & IMPLICATIONS: This is the first empirical Australian-based study highlighting the high prevalence and co-occurrence of language and pre-literacy difficulties in preschool children experiencing social adversity. Clinicians should be aware of co-morbid language and pre-literacy difficulties in disadvantaged populations and consider both areas during assessment and intervention planning. What this paper adds What is already known on the subject The prevalence of language and literacy difficulties is substantially higher in cohorts experiencing social adversity when compared with more advantaged families. There is some evidence that adversity also contributes to pre-literacy difficulties, but less is known here. What this paper adds to existing knowledge This study presents new prevalence data showing high rates of language and pre-literacy difficulties for 5-year-old children experiencing adversity within an Australian context. It is the first to explore these skills in a large cohort of pre-schoolers recruited from community settings in Australia. What are the potential or actual clinical implications of this work? In this cohort experiencing adversity, most children who presented with language difficulties likewise exhibited pre-literacy difficulties. This concordance reflects how early oral language and pre-literacy skills develop together. Clinicians should assess both skills in preschool populations-especially those working with children experiencing adversity-to ensure all children have strong foundations to become proficient beginner readers.
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ItemExamining longitudinal associations between self-reported depression, anxiety and stress symptoms and hair cortisol among mothers of young children(ELSEVIER, 2021-03-01)BACKGROUND: Maternal mental health is critically important given its impacts on both women's and children's outcomes. Hair cortisol concentrations (HCC) may provide insight into physiological processes underpinning mental health. This study investigated associations between mothers' self-reported mental health symptoms and their HCC at 1, 2 and 3 years postpartum. METHODS: Longitudinal study of Australian mothers recruited for their experience of adversity in pregnancy ('right@home' trial, N=722). Mental health symptoms were self-reported using the Depression, Anxiety and Stress Scales (DASS). Associations between DASS total and subscale scores and HCC were estimated using linear regression and generalized estimating equation (GEE) models, examining associations: at each age; across all ages (multivariate GEE); and with persistence of high symptom severity. Missing data were addressed using multiple imputation. RESULTS: 546/722 (76%) women provided at least one hair sample (71% at 1, 61% at 2, 49% at 3 years). Associations between DASS total or subscale scores and HCC were not evident across time points. Only dichotomized high depression symptom severity was associated with higher HCC in the GEE models (β=0.12, p=0.04). There was no evidence of associations between persistence of high DASS symptom severity and HCC at 3 years. LIMITATIONS: The DASS measured self-reported symptoms for the preceding week whereas HCC captured average cortisol over three months. Associations amongst mothers experiencing adversity may not represent patterns in the general population. CONCLUSIONS: Considered in context with existing literature, these findings suggest that HCC provides limited insight into the mental health of mothers experiencing adversity across the early postpartum years.
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ItemNurse Home Visiting and Maternal Mental Health: 3-Year Follow-Up of a Randomized Trial(AMER ACAD PEDIATRICS, 2021-02)BACKGROUND: Poor mental health is recognized as one of the greatest global burdens of disease. Maternal mental health is crucial for the optimal health of mothers and their children. We examined the effects of an Australian Nurse Home Visiting (NHV) program (right@home), offered to pregnant women experiencing adversity, on maternal mental health and well-being at child age 3 years. METHODS: A randomized controlled trial of NHV delivered via universal child and family health services (2013-2016). Pregnant women experiencing adversity (≥2 of 10 risk factors) were recruited from 10 antenatal clinics across 2 states. Intervention comprised 25 home visits until child age 2 years. The outcomes assessed 1-year postintervention completion were maternal self-report of mental health symptoms (Depression Anxiety Stress Scales) and positive aspects of mental health (personal well-being and self-efficacy). RESULTS: Of the 722 women enrolled in the trial, 255 of 363 (70%) intervention and 240 of 359 (67%) control group women provided data at 3 years. Compared with controls, the intervention group reported better mental health (reverse Depression Anxiety Stress Scales scores): effect sizes of 0.25 (depression; 95% confidence interval [CI]: 0.08 to 0.32), 0.20 (anxiety; 95% CI: 0.05 to 0.30), 0.17 (stress; 95% CI: 0.09 to 0.37), and 0.23 (total score; 95% CI: 0.12 to 0.38); 0.16 (95% CI: 0.04 to 0.29) for personal well-being; and an odds ratio of 1.60 (95% CI: 1.19 to 2.16) for self-efficacy. CONCLUSIONS: An NHV designed to support mothers experiencing adversity can lead to later maternal mental health benefits, even after the program ends.