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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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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ItemNo Preview AvailableThe Impact of Nurse Home Visiting on the Use, Dose and Quality of Formal Childcare: 3-Year Follow-Up of a Randomized Trial(ELSEVIER SCIENCE INC, 2022-03)OBJECTIVE: We investigated whether nurse home visiting (NHV) affects the uptake and quality of formal early childhood education and care (ECEC) at child ages 2 and 3 years, and reasons for using ECEC at 3 years. METHODS: Design: Secondary analysis of the "right@home" randomized trial of NHV. PARTICIPANTS: 722 pregnant Australian, English-speaking women experiencing adversity recruited from antenatal clinics across 2 states. INTERVENTION: 25 nurse home visits to 2 years; Control: universal well-child nursing service. MEASURES: Parents reported formal ECEC use (government approved and subsidized), comprising long or family day care (LDC), and reasons for use. ECEC quality was classified using the Australian government's national ratings. Eighty-three percent of parents provided data at 2 years (306 intervention/290 control); and 69% at 3 years (255 intervention/240 control). ANALYSIS: Intention-to-treat analyses were conducted using adjusted regression models, addressing missing data using multiple imputation and inverse probability weighting. RESULTS: There was no evidence of group differences in ECEC uptake or quality, although control families may have used more LDC at 3 years (mean difference 2.8 hours, 95% confidence interval, -0.2 to 5.8 hours). Intervention parents reported using ECEC to support their children's social development more frequently than controls (48% vs 33%) but less for work/study (39% vs 46%). CONCLUSIONS: The right@home NHV program did not impact ECEC uptake or quality, although it may influence parents' reasons for using ECEC. If supported by policy and provision, there is an opportunity for NHV programs to promote the transition to high-quality ECEC and evaluate the synergistic benefit on children's development.
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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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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.