Details of Thesis

Title Open access community child health services: A three-phase evaluation
Author Kearney, Lauren Naomi
Institution Australian Catholic University
Date 2010
AbstractDespite significant evidence of the importance of the early years of life, to date limited research has evaluated how health services best support and assist families during this crucial time.  One important service through which infant and children’s health are promoted and monitored in Australia are the government-based community child health nursing services (CCHNS).  Traditionally, child health surveillance and health promotion are provided through CCHNS via individual appointment-based clinics.  In recent years, resource allocation and workload within CCHNS has changed, requiring the development of contemporary approaches to service delivery.  One novel approach, which was examined in this study, was an Open Access Clinic (OAC), which provided a group-based, appointment-free clinic where parents could attend with their infant for child health nurse support and health care, based on parental needs and convenience. The objective of this research study was to investigate the efficacy, quality and perceived value of the OAC approach to universal child health surveillance in one urban community child health service.  A three-phase study, using method triangulation was conducted. It comprised a retrospective documentary analysis of pre- and post-OAC healthcare outcomes; a phenomenological inquiry into the lived experience of those directly involved with the OAC; and an 18-month prospective cohort study, tracking health care-seeking behaviours and child care practices of families who accessed the OAC.

The key findings from the retrospective documentary analysis (phase one) demonstrated that the OAC performed  favourably when compared with the traditional individual appointment approach, specifically in the areas of infant nutrition (including breastfeeding and the introduction to solids), referral rates, health promotion (including immunisation and SIDS prevention strategies), and assessing for postnatal mood disorders.  There was also a statistically significant increase in families receiving unemployment benefits (thus were from a relatively low socio-economic demographic) in the OAC cohort, when compared with the individual appointment approach.  However, a statistically significant decrease was noted in the developmental assessment documentation in the OAC cohort when compared with the individual appointment cohort, which was further investigated in the prospective cohort study (phase three). The second phase of the overall study was a phenomenological inquiry into the everyday experience of the OAC.  The purpose of phase two was to understand what the OAC meant to those involved with it, and to gain insight into the everyday experience of the OAC.  The methodology used for this phase was a North American phenomenological inquiry approach, which sought to describe and interpret the everyday experience of multiple participants’ lived experiences of the phenomenon - the OAC.  New knowledge and understanding has been generated through this inquiry.  According to the participants the OAC represented a place where support and reassurance could be accessed flexibly and provided in a non-judgemental manner.  The emerging themes described a busy and bustling clinic. It was a place where parents felt safe and supported. They enjoyed the flexibility, the appointment-free structure and valued the accessible location of the both the urban clinics, where shops were close by and public transport available. However, for working parents, services offered in extended hours would be of benefit. The service had a clear role definition and according to the participants achieved this purpose through the working of the OAC, in conjunction with other support services (such as the breastfeeding clinic and the early intervention specialists). Furthermore, parents often shared experiences of feeling lonely and socially isolated. They valued the consistency of seeing the same child health nurse within the OAC, and the child health nurses valued this for reasons of continuity. The parents reported the benefits of the group approach, and overall preferred it to individual appointments. The mothers identified their use of other service providers, for example their general practitioner if sensitive or confidential issues required attention. The information discussed during the clinics was offered in a non-judgemental way, however the findings indicate that it is essential that the child health nurse’s advice and practice is consistent with the latest evidence-based guidelines. The child health nurses sometimes found the clinic stressful and busy, without enough time to perform thorough family assessments. The parents did not percieve this busyness to be a problem, neither did they identify waiting as an issue.  Through reflective interpretation some areas for quality improvement have been generated by these experiences.  Therefore, this second study has yielded new and greater understanding of the Open Access Approach to child health surveillance and parent support, as perceived by those with real life, direct experiences of it.

The prospective cohort study (phase three) involved the follow up of 72 families with a new born infant for a period of 18 months.  Six questionnaires were administered during the 18 month period, collecting data in areas of service usage and attendance patterns; parent information and support; infant nutrition, growth and development; parental coping and well-being; and, health promotion, specifically immunisation, SIDS awareness and oral health.  Through prospectively following this cohort insightful contemporary information has been gathered from local Queensland families. More specifically, clear trends of usage, such as increased visit frequency and use of breastfeeding clinics in the early weeks, provided helpful evidence to assist in service planning. Through understanding where parents access information, such as family and friends, health services may target these sources with health promotion activities. “The real challenge lies in ensuring sustained policy effort to achieve long-term measurable change in outcomes for children – to improve their health and well being, to modify the effects of social determinants, and to minimise the inequalities already apparent in early childhood” (Goldfeld & Oberklaid, 2005, p. 209). This final phase affirmed that parents have varied patterns of attendance within the OAC, based on their immediate needs, and that these change with the age of the infant.  Important data was also found detailing patterns of usage for other child health service providers, such as access of general practitioners and child health nurses for routine well-baby assessments.  Potentially, parents could be provided with clearer service pathways prior to discharge from maternity units, informing them regarding which services are helpful for specific infant health issues. There is also potential for increased collaboration between Queensland Health and general practitioners and practice nurses, to ensure that services are streamlined and thus reduce unnecessary burden on the health care system.  This may also be helpful in ensuring consistency of health care information provided to parents between different providers. Whilst this phase was limited by the small sample size, and a context specific group of families, it does provide new information in key areas, such as why parents introduce solids early, when they consider prevention for childhood obesity, where they are attending for their infants’ developmental assessments, and health care needs at different stages between 0-eighteen months. These findings will provide Child Health Services, with valuable information to more efficiently and effectively plan services to meet parental and infant health needs. Overall, the key findings from the combined phases found the OAC compared favourably to the traditional individual-appointment method of child health surveillance in the areas of parent and health care professional satisfaction, infant growth and nutrition, immunisation status and key health promotion areas such as Sudden Infant Death Syndrome prevention.  However, areas for quality improvement were also found, specifically in the areas of consistent evidence-based information, documentation in areas such as developmental assessment attendance, health care provider duplication and collaboration and timely discussion of parent-infant attachment. 
This study has generated new knowledge and understanding regarding the effectiveness and quality of an OAC approach to community child health nursing services, specifically in the delivery of group-based, appointment-free universal child health surveillance services.
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