Research-related activities in community-based child health services
Title. Research-related activities in community-based child health services.
Aim. This paper is a report of a study to describe current research-related activities within community-based child health services in a large urban health service.
Background. In recent years, increased participation in research-related activities has accompanied implementation of evidence-based practice in hospital-based services. Little is known about participation in these activities in community-based health services.
Methods. We undertook a descriptive study of current research-related activities by staff working in community-based child health services in an urban setting in Australia in 2006–2007. Research-related activities were defined as reflective practice, quality improvement, evaluation and research.
Results. Staff reported that research-related activities usually comprised reflective practice or quality improvement. These activities worked best when there were sufficient staff within teams and a stable environment. Evaluation was confined to activities closely related to quality improvement. Participation in research was limited. Our consultation revealed a need for sustained investment to build organizational and workforce capacity, and resource support and infrastructure to encourage participation in research-related activities.
Conclusion. Increased focus on evidence-based practice has created expectations that community-based child health service staff will utilize and contribute to research evidence. Whilst there is interest among community-based child health service staff in participating in research-related activities, investment in leadership, skill development, infrastructure, resource and novel ways to enhance research output within these services are needed to increase participation in research-related activities, and the evidence base for community-based child health services.
What is already known about this topic
- •There is an expectation that staff working in community-based child health services will participate in research activities and contribute to building a research evidence base for this sector.
- •Current levels of participation in research-related activities and the opportunities and barriers for increased participation within a large urban health service have not been explored.
What this paper adds
- •There was limited participation in research-related activities in the community-based child health services.
- •Barriers to participation include structural changes within services, skills and co-ordination and sharing of information.
- •The evidence-based practice movement has had limited influence in this setting.
Evidenced-based practice (EBP) is a term that is applied to the use of research findings by healthcare professionals in their clinical practice to inform clinical decisions, actions and interactions with clients. EBP emerged in the acute medical care setting in the early 1990s as a tool for clinicians to enable them to use expanding research evidence effectively to address issues of clinical concern (Sackett et al. 1996, Sackett & Wennberg 1997, Christakis et al. 2000). In practice, EBP is a method of collating the best available scientific evidence, supplementing this with a consensus of clinical expertise, and taking into account patient preferences and available resources, to determine the ‘best’ approaches to clinical care (Sackett et al. 1996, DiCenso et al. 1998, Kerridge et al. 1998, Kitson 2001). Uptake in clinical settings has been supported by the development and dissemination of training packages in EBP, conduct of an increasing number of research summaries and systematic reviews to support EBP through local, national and international organizations including the Cochrane Collaboration and the Joanna Briggs Institute, and development of EBP guidelines to guide the management of common clinical conditions (Sackett et al. 1996, Ring et al. 2006). EBP is particularly suited to acute care, where treatment is often based on defined procedures or medication regimes followed up over relatively short-time frames. In clinical settings, interest in EBP has also contributed to a rapid increase in research-related activities, including randomized trials of treatments in nursing practice (Kitson 2001, Winch et al. 2002, Cleary et al. 2005, Jones 2005).
The adoption of EBP has been accompanied by a debate about the types and sources of evidence on which practice should be based, and how knowledge is generated and used. There is increasing recognition of the value of multiple types of knowledge, including technical and propositional knowledge associated with research; ‘internal evidence’ from systematically obtained performance, quality and evaluation activities and non-propositional knowledge from clinical experience, including critical reflection, externalization and exploration of practice (Rycroft-Malone et al. 2004). In areas of healthcare practice where the technical and propositional research base is traditionally low, there is a need to increased activity to develop these multiple forms of evidence to inform EBP.
Community-based child health services (CBCHS) in Australia are a part of public health services and are responsible for providing nursing and allied health care to infants and children within the community. They largely operate separately from the hospital (inpatient) system and provide a range of services to infants, children and their families, including well-baby screening, physical and psychological health care and parenting advice. Whilst much is known about the utilization of research and barriers to this (see, e.g. Estabrooks et al. 2003, Meijers et al. 2006), in these settings there is little information about research-related activities occurring within the day-to-day work of CBCHS, how or in what circumstances research and other evidence-generating activities are being undertaken, or the impact of the EBP movement on implementation of research-related activities within CBCHS. In healthcare services, it is generally assumed that strategies used to implement EBP in acute settings would be taken up in community-based settings and that there would be adequate investment in resources in these settings to support implementation.
However, changing practice in relation to EBP has been slow (Roberts 1998, Wallin et al. 2003). Barriers to implementation include the lack of a positive research culture, skills and experience in research among practitioners (Gething et al. 2001, Eller et al. 2003, Roxburgh 2006); inadequate skills, experience and confidence in the use of EBP techniques; and underlying fears that research evidence will be used as a tool to further rationalize community-based services and promote ‘cookbook’ practice (DiCenso et al. 1998), especially in services addressing psychosocial rather than physical aspects of health care.
In Australia, where the study report here was conducted, both state and central governments have invested in initiatives to expand the research capacity of community-based health services including CBCHS to participate in these activities [Families First, 2004 (New South Wales Office of Children and Young People and New South Wales Department of Community Services 2005), CDHAC 2005]. Information indicating how research-related activities and EBP have been implemented in CBCHS is needed to understand barriers and opportunities and develop strategies to demonstrate the role and value of these techniques (Winch et al. 2002).
The aim of this study was to describe current research-related activities within CBCHS in a large urban healthcare service.
We undertook a qualitative descriptive study of current research-related activities by clinical services in CBCHS during late 2006 using a mixed method strategy of enquiry (Sandelowski 2000, Creswell 2003). The overall study method was developed in association with senior managers of CBCHS, and information on research-related activities was gathered during a consultative process undertaken with CBCHS team leaders.
For the purpose of this research, CBCHS refers to services provided to children in community settings through community health services, and the term ‘research-related activities’ is used to refer collectively to the range of research activities that might be undertaken in this setting: reflective practice, quality improvement, evaluation and research. Interest in understanding what research-related activities were occurring in CBCHS was initiated by senior health service managers, who were interested in how well policies relating to EBP had been implemented in this sector.
We were specifically interested in research-related activities among clinicians working in CBCHS. Based on our extensive experience in working with these services to implement our research programmes and on the views of senior managers, we used a broad definition of research-related activities. This definition recognized that clinicians may participate in research activities and generate evidence in different ways and valued the use of research findings through reflective practice and quality improvement, even though these are not traditionally considered as ‘research’. Consequently, we categorized research-related activities as reflective practice, quality improvement, evaluation or research. For this purpose, we defined reflective practice as a technique to reflect on events, experiences and outcomes relating to one’s clinical practice and incorporate the knowledge gained into future activity (Bolt 1991); quality improvement as an activity designed to monitor, evaluate or improve the quality of health care delivered by a provider (individual, service or organization) (NHMRC 2003); evaluation as a type of research designed to determine the effectiveness of a programme, treatment, practice or policy (Polit et al. 2001); and research as a systematic inquiry using orderly, disciplined methods to answer questions or solve problems and to expand knowledge about topics of interest (Polit et al. 2001).
This study was implemented in three steps using a combination of sampling and data collection methods, feedback and discussion. First, a structured, open-ended response survey form was develop and distributed by email by senior staff to all team leaders and the results were collated. We used snowballing techniques to distribute the survey throughout CBCHS. Senior service managers and senior team leaders working in CBCHS were emailed copies of the form and asked to circulate it to team leaders within their service. Twenty-four CBCHS team leaders returned the completed form. These included a range of healthcare professionals and teams including nurses, allied health professionals (physiotherapists, occupational therapists, speech pathologists and psychologists) and other healthcare professionals and health research groups within the area (Table 1). In the survey, we sought information about the person completing the form (usually the team leader) and the identity of the person responsible for quality improvement activities within the service or team; a description of the service or team for which the form was completed; and information on clinical data collection and management systems used. Information was sought on current of previous research-related activities within the particular team or service and on the opportunities and barriers to implementation of such activities.
Table 1. Brief description of community-based child health services (CBCHS) teams participating in the study
| Early childhood service||3||0–5||Nurses, liaison officers, social worker||Parenting, breast feeding, home visits, health surveillance, assessment, referral|
| Child and family team||2||0–5||Nurses*|
| Child and family team ||1||0–16||Nurses*|
| Child, adolescent and family teams ||1||0–5 ||Medical and allied health||Assessment and management of child health problems not dealt with by other agencies|
|1||0–12||Psychology||Assistance with behavioural and emotional problems in childhood|
|2||0–18||Medical, nursing, counselling||Assessment and management of child health problems not dealt with by other agencies|
| Child development service||1||0–14||Multidisciplinary team not specified||Children with learning difficulties and mild developmental delay|
| Rainbow cottage||1||0–14||Medical and allied health||Developmental delays and learning difficulties|
|Allied health teams|
| Speech pathology||1||0–18||Speech pathologists||Communication, eating assessment, support and intervention|
| Paediatric allied health ||1||0–18 (rehab)|
|Multidisciplinary, allied health||Developmental problems, acute rehabilitation or early intervention|
| Occupational therapy team||1||3–7||Occupational therapists||Individual assessment, class programmes, community development|
| Paediatric physiotherapy ||1||0–18||Physiotherapy||Therapy for children with physical conditions|
| Orthoptics||1||0–10||Orthopticians||Vision problems, assessment and treatment|
| Nutrition and dietetics ||1||–||Dieticians, nutritionists||Health promotion, and public health nutrition, community development|
| Community ambulatory paediatics||1||0–18||Paediatricians||Assessment and management|
|Mental health counselling services|
| Counselling team ||1||0–12||Psychologists, social workers||Counselling and behavioural management|
| Early childhood social work || ||0–5||Social workers|| |
| Perinatal infant mental health ||1||Mothers||Psychologists, psychiatrist, nurses||Support, information and counselling|
Next, the survey results were discussed at meetings with team leaders and further information sought. A number (eight) of people were interviewed and two focus groups with team leaders of CBCHS were held (20 participants). The eight people were selected because they occupied positions with specific responsibility for research and quality improvement activities or expressed specific interest in the study. During these face-to-face interviews and focus groups, we asked participants to comment on their agreement with our conceptualization of research-related activities for CBCHS, whether, in their opinion, our interpretations of activities and opportunities and barriers were correct and what other issues should be raised.
Finally, a draft report was circulated to all personnel who had completed the survey form or who were nominated as having responsibility within the team for research-related activities such as quality improvement (n = 62). Comments on the draft report were actively sought and further consultations were held with selected participants (senior managers and interested volunteers) to confirm the study findings.
The research was registered as a quality improvement activity with a health service human research ethics committee. All participants participated voluntarily.
Qualitative content analysis (Sandelowski 2000) was undertaken to identify and draw out major activities and barriers and opportunities to participating in research-related activities. The coding was undertaken independently by the authors, who then met to discuss their findings, reassign research-related activities (e.g. a journal club was reassigned to quality improvement rather than research as presented in the data collection form), and to agree categories for barriers and opportunities for participation in research-related activities.
Twenty-four CBCHS team leaders completed the structured, open-ended response survey form (Table 1), 28 participated in further discussion either individually or in a focus group and 62 people were invited to make comments on the draft report. Participants came from nursing, allied and mental health services attached to CBCHS. The following findings are grouped according to our categories of research-related activities. Within each category we describe issues that were raised by participants in relation to participation in each research-related activity.
Reflective practice activities are summarized in Table 2. Most teams reported that arrangements were in place for clinical supervision, case discussion and team meetings. While case discussion and case conferences were mentioned, usually these occurred as a part of regular intake meetings held to distribute new clients. A number of participants mentioned a journal club, but were unclear about whether this comprised reflective practice or research.
Table 2. Types of reflective practice activities reported by community-based child health services staff
|Clinical supervision (individual or group)|
|Case discussion, case review, case conferences, intake meetings|
|Team meetings with team leader or other healthcare professionals|
|Ad hoc meetings to discuss specific issues|
|Australian Confederation of Paediatric and Child Health Nurses competencies|
|In-service training usually led by a team member|
|Journal clubs usually led by a team member|
The extent to which reflective practice occurred as part of routine activities or periodically was unclear. For example, use of words such as ‘have access to’ suggested that these activities were more likely to occur in an ad hoc way rather than as a core activity of the service or team. Activities were generally organized within teams, with no standardization of approaches between teams. For example, clinical supervision varied in frequency between teams, sometimes occurring regularly, for example monthly, or as needed; and it occurred individually or as a group activity according to team policy. These findings suggest that there was no strong organizational expectation that CBCHS workers would participate.
Participants indicated that reflective practice activities worked best when there were adequate staffing levels within the team and a stable environment. Understaffing, uncertainty and change, and other stressors within services and teams resulted in reduced participation and implementation of reflective practice activities.
Participants indicated concern about how services were organized and about client satisfaction and achievement of client goals. There was also interest in developing new approaches to identifying and addressing issues in service delivery, particularly waiting lists. A range of quality improvement activities was reported (Table 3). These included activities within teams, such as management of waiting lists, and between teams, such as the standardization of records and clinics within community health centres. Some CBCHS teams were working to implement Australian Confederation of Paediatric and Child Health Nurses competencies among nursing staff (ACPCHN 2006). A number of teams were also participating in the Evaluation and Quality Improvement Program (EQuIP) activities within the health service. EQuIP accreditation is conducted by The Australian Council of Healthcare Standards (2003) and the Australian healthcare industry to assist organizations to establish effective quality improvement programmes and is being undertaken within the health service (EQuIP, 2007) The accreditation process requires services to use standards and self-assessment processes to identify and implement opportunities for service improvement.
Table 3. Types of quality improvement activities reported by staff of community-based child health services
|Quality improvement meetings; staff member with responsibility for quality improvement|
|Standardization of clinics, records and files|
|Participation in Evaluation and Quality Improvement Program (EQuIP) activities|
|Examination of workloads and compliance with policies across the area|
|Development of ‘secondary’ services|
|Implementation of Australian Confederation of Paediatric and Child Health Nurses competencies|
|Development of orientation and preceptor packages|
|Client satisfaction surveys|
|Clinical indicators working party|
Limited evidence of standardization of approaches to quality improvement activities or evidence of organizational leadership across the health service was provided. Many teams reported that there was a member with responsibility for quality improvement activities, most notably meeting the EQuIP accreditation requirements, and production of reports for area quality improvement activities; however, many of these positions were vacant at the time of the consultation because of staff shortages, absence and service imperatives:
None recently due to staff shortages. In the past the team has looked at innovative ways to manage waiting lists using a parent orientation meeting; increasing referrals of younger children; the effectiveness of group programmes etc.
A few examples of quality improvement activities were produced, for example:
Multidisciplinary assessment project
Children with multiple disabilities may require access to several CBCHS, e.g. counselling, medical, speech, OT, physiotherapy, etc. Currently these children may be on serial waiting lists for assessment and treatment. The aim of this project is to identify these clients at intake, to co-ordinate appointments, and ensure that all assessments are completed within 3 months of intake.
Participants indicated a need to develop among team members a more positive understanding of the role of quality improvement activities in supporting the development of services. Important barriers to the implementation of quality improvement activities were a lack of understanding about the scope of quality improvement activities, lack of skills to undertake these activities, need for staff with responsibility for quality improvement, funding and other infrastructure needs and absence of methodology and tools to support the development and implementation of quality improvement activities. Participants mentioned that staff shortages, health service restructuring and other pressures on service provision had an impact on participation in quality improvement activities and staff compliance with agreed activities.
Research and evaluation
Limited participation in research and evaluation activities was reported. Process evaluation activities were reported as a part of the quality improvement cycle. These included satisfaction surveys of staff, clients, parents and school staff, needs assessments, chart audits and evaluation of training programmes. Research and evaluation of the impact or outcome of programmes or treatments were infrequently reported. Where they were reported, activities were led by team members or external organizations with a specific interest in a particular topic or project. Consequently, if projects did not actively engage other team members, they lapsed if the interested team member was absent or left the team. Projects being undertaken by external agencies such as universities involved limited participation of team members, frequently did not include feedback to the CBCHS team involved and included few opportunities to build research-related capacity within the team.
Team leaders who participated in the consultation were interested in increasing their involvement in research and evaluation. They regarded research that was generated and led by external organizations such as universities as a way to do this, and recognized that these had the potential to contribute to the research base underpinning CBCHS. However, they also indicated that team engagement varied from limited involvement, for example providing access to research participants, to considerable interaction during all stages of the research. Where there was active engagement of CBCHS services in the research and opportunities to discuss its results in relation to implications for development of CBCHS, the research contributed to the research capacity of the team and development of services (Kemp et al. 2006–2007). Participants indicated that there were also issues about interesting external researchers in undertaking research that was of clinical relevance to CBCHS if this was not also of interest to the researchers concerned.
Participants agreed that there was a need to develop the research base for CBCHS, but they were unclear about how to go about doing this. They indicated that the current work climate/situation and focus on delivery of clinical services did not support increased engagement or reward participation in these activities. As many team members were focussed on their core business, there was limited willingness or capacity to engage in or comply with activities that were not seen as consistent with this. They indicated that strategies were needed to demonstrate the role of research-related activities in informing clinical care and to provide opportunities for participation in these activities. Of particular concern were current financial arrangements within the health service, which made it very difficult for CBCHS to quarantine-specific funding for research projects.
The aim of this research involving team leaders of CBCHS in a large urban health service was to describe research-related activities within these services and to identify opportunities and barriers to increased participation in research-related activities. We documented systematically what was already suspected, namely that there were currently few research-related activities within CBCHS in this large health service. The research went further to document system and service factors that affected attitudes to and participation in research-related activities within this sector. The discussion below presented in three sections, addressing CBCHS interest in participating in research-related activities, opportunities and barriers to participation, and the need for clearer organizational leadership and support.
We employed a descriptive methodology of research-related activities within clinical CBCHS in a large healthcare service and did not attempt to validate the descriptive results using other observational or objective methods. Although the study was undertaken in one area and may not relate to what happens in similar services elsewhere, the findings may assist in considering the research-related activities of other services.
Participation in research-related activities
Team leaders reported considerable interest in developing and implementing research-related activities within CBCHS, particularly activities with direct implications for the development of their service and addressing aspects of clinical care such as clinical standards and new approaches to service delivery. This interest was reflected in the finding that the majority of research-related activities reported were concerned with reflective practice and quality improvement. This is an important finding in the context of the EBP focus on outcomes rather than process research (Kerridge et al. 1998, Paley 2006), and is evidence of the need for EBP to include broader understandings of the nature of evidence to support non-‘cookbook’ approaches to service delivery (DiCenso et al. 1998, Rycroft-Malone et al. 2004). In this context, clinicians working in CBCHS may not want to undertake their own research but may have a strong interest in evidence generation and research utilization through reflective practice and quality improvement activities. This is not to suggest that research to build a strong evidence base to underpin and inform CBCHS is not valued, but rather that different strategies may be needed to build sustainable research capacity (Wallin et al. 2003). This is consistent with observations elsewhere (McCance et al. 2007).
Our findings also highlight the need to clarify expectations about the types of research-related activities that should be undertaken in CBCHS settings, and to identify the organizational leadership, resource support and infrastructure, and workforce development needed to ensure participation in research-related activities that are of a high standard, contribute to knowledge and are accepted as core business. These discussions need to engage CBCHS staff actively in building their capacity for participation.
Participation in research-related activities by clinicians working in CBCHS settings requires recognition of the scope of research-related activities most frequently undertaken, valuing of the research methods used to support these activities and development of capacity to become active participants. To increase capacity in this area, investment in developing skills, confidence and resources to effectively access, synthesize and utilize the current research evidence through reflective practice and quality improvement are indicated (Gething et al. 2001). Where these issues have been addressed, professional development and implementation of EBP have been observed (Wallin et al. 2003).
Opportunities and barriers to participation
In talking about reflective practice and quality improvement, participants identified opportunities and barriers to participation in research-related activities. We have grouped these as structural changes, support and co-ordination and sharing of information. Significant structural changes were occurring within the wider healthcare service at the time of the consultation. These included the merging of two previously independent area health services and redevelopment and redeployment of team structures. Within the CBCHS, there were ongoing changes in demand for and delivery of services that were driven externally by the shift in care provision from hospital to community settings, and internally by the introduction of new programmes and policies. These often required new ways of providing care within the existing resource base. Together, these structural changes were both barriers and opportunities to participation in research-related activities. While the restructuring process meant that many activities not perceived as central to core business, including research-related activities, had stopped, the restructuring also provided opportunities to think about how best to incorporate research-related activities within new team structures.
The second barrier concerned the capacity of CBCHS management confidently to support research-related activities. During our consultation, we observed that team leaders were unclear about the scope of activities that comprised research-related activities. This is not surprising, as many of these services have not had a strong academic base. Nurses’ lack of knowledge about which activities are considered to be research-related has been previously identified (Roxburgh 2006). Investment in education and support is needed to build capacity in this area. Finally, we observed limited coordination of research-related activities across the different teams within CBCHS, and limited evidence of sharing activities, information or instruments and other materials. Related to the lack of coordination of activities, there was limited documentation and a reluctance to formalize activities through an approval or registration system. The organization did not provide a repository of standard methods, materials, instruments or other resources that would assist in research-related activities. Further, reports of activities were not available and there was no system to reward those who participated in research-related activities or education. Many of the projects that we identified were unsustainable because of their dependence on the enthusiasm of single staff members. If the person leading the activity left, the activity often lapsed and details of what had been undertaken were lost.
In the short term, the findings of this consultation suggest that different strategies may be needed to increase evaluation and research activities in CBCHS. This may require development of partnerships with external organizations, such as research groups or academic units with capacity to undertake research and evaluation. It would also require sustained investment over time, and involvement of organizations external to CBCHS that have expertise in design and implementation of evaluation and research (Eller et al. 2003). While participants gave examples where these relationships already occurred, they also identified some practical issues. First, the relationship most often developed around a particular project of interest to the external organization and was not sustained beyond the project. Team leaders from CBCHS who participated in our consultation had not had success when they tried to interest external researchers in research that was of clinical relevance to their service. There were examples of the use of CBCHS to facilitate the research, for example to access CBCHS clients, which did not provide opportunities for transfer of the results to CBCHS. While participants were keen to work with and support external researchers, there is a need to develop models in which CBCHS who ‘host’ research have greater opportunities to contribute to the development of the research, to comment on the implications of the results for services and to build their own capacity to undertake research-related activities.
In recent years, interest in research has increased rapidly and, at a health service level, has paralleled the implementation of EBP. In part this has been driven by policy and planning initiatives to increase the efficiency, effectiveness and accountability of acute care services. In this regard, acute care settings such as hospitals have led the way and CBCHS and other community-based services have been slow to follow. Our consultation indicated that there is a need for sustained investment in the development of organizational capacity within CBCHS to participate in research-related activities, particularly reflective practice and quality improvement, and to demonstrate the role of these activities in informing clinical practice (Rycroft-Malone et al. 2004). These investments include organizational capacity and support and investment in personnel, education and infrastructure to support research-related activities. Cummings et al. (2007) identified the importance of a responsive administration, providing opportunities for staff development and collaboration, and sufficient staffing and support services in increased utilization of research. Our consultation also indicated a need for a responsive administration and area-wide approach to research-related activities that includes specifying responsibility for research-related activities within performance contracts at all levels of the service, development of governance arrangement to support and coordinate research-related activities across the service, and clarification of organization expectations about participation in research-related activities. It indicated that there is a need to build positions and resource persons with responsibility for some research-related activities, particularly those relating to reflective practice and quality improvement, and to provide professional support and mentoring of staff with specific responsibility for these activities. We identified noted that education was needed to ensure that activities are undertaken at a satisfactory standard, including increasing understanding of and skills in undertaking these activities and an expansion of resources such as ‘how to’ packages to ensure that there is adequate coordination of activities between different teams. Of particular concern for participants were the limited opportunities to present work and attend peer-related meetings and professional development activities that were external to the health service. This could be addressed by ensuring that there are funds to support attendance at conferences and other meetings.
We found that, although there were increasing expectations that CBCHS would participate in research-related activities, there had been limited investment in these activities. While there is a continuing perception that these are additional activities, other activities, conflicting priorities and the lack of skilled staff will distract attention from them. Building confidence through development of standardized methods and encouraging sharing of experience will address the poor image of research-related activities among some clinicians that results in reluctance to participate, negative attitudes to implementation of research-related activities within teams and poor compliance with and engagement in research-related activities.
Our findings indicate that there is a need for further debate about the role of EBP within clinical services. A focus on non-propositional knowledge and internal evidence and greater investment developing skills and confidence to better access and use research results to inform clinical practice through reflective practice and quality improvement are needed. New strategies are also needed to encourage development of applied research activities to increase the research evidence for CBCHS activities.
EJC & LK were responsible for the study conception and design. EJC & LK performed the data collection. EJC & LK performed the data analysis. EJC & LK were responsible for the drafting of the manuscript. EJC & LK made critical revisions to the paper for important intellectual content. EJC provided statistical expertise. EJC obtained funding. EJC & LK provided administrative, technical or material support. EJC & LK supervised the study.
This work was supported by the Division of Population Health, Sydney South West Area Health Service. Garth Alperstein, John Eastwood and Chris Rissel contributed to the conceptualization of the work. We would like to thank the staff of Child and Family Services for their participation.