Regional Child Health Research Articles

Examining the feasibility of a brief parent intervention designed to promote positive food communication with infants

BackgroundFew prevention interventions exist focusing on supporting parents to use positive food communication at mealtimes, for the prevention of disordered eating. “Mealtime chatter matters (MCM)” is a brief intervention designed for parents of infants. The intervention was designed in collaboration with child health nurses (CHNs) to be embedded into usual care. The overall aim of this study was to test the feasibility of the intervention through examining the acceptability of the MCM content and resources and the potential impact of the intervention on parents.MethodsThis pilot study utilised a mixed methods approach and took place within a regional child health service in Queensland, Australia (October 2021 to June 2022). Participants were parents of infants attending child health education groups and CHNs. The intervention consisted of a brief education session (including accompanying resources), facilitated by a Paediatric Dietitian. The acceptability of MCM content and resources was assessed by both parents and CHNs via self-reported questionnaires and the potential impact on parents assessed via pre-/post-self-reported questionnaires.ResultsForty-six parents of infants (aged < 8 months) and six CHNs who hosted the intervention and observed the program’s delivery participated in the study. MCM content and resources were highly acceptable to parents and CHNs, as both qualitative and quantitative data concurred. How the program may have potentially impacted parenting practices was unclear from the survey results and further investigation is required to better understand these. Tangible lessons and opportunities to further test this intervention were clear from current results.ConclusionOverall, MCM was acceptable to both parents and CHNs, with the content and resources both being highly valued. Parents reported the content to be informative and engaging and CHNs were keen to have such an intervention available in the future. However, further modification and testing is required of MCM. This feasibility study is an essential first step in supporting parents and CHNs to access an evidence-based intervention with the aim of preventing disordered eating.Trial registrationGriffith University Human Research Ethics Committee (2021/577) and Gold Coast Hospital and Health Service Human Research Ethics Committee (QGC/76618).

Quality improvement dashboard for healthcare providers and targeted client communication to pregnant women to improve timely attendance and quality of antenatal care: A multi-arm cluster randomized trial (the eRegCom trial)

Abstract Background: Digital health interventions can strengthen coverage and quality of care. Our aim was to assess the effectiveness of targeted client communication (TCC) to pregnant women via text messages, health care provider communication via a quality improvement dashboard (QID) and the combination of TCC and QID—generated and delivered from a digital maternal and child health registry (MCH eRegistry), running on the District Health Information Software 2 (DHIS2) platform in West Bank and Gaza. The control was the regular MCH eRegistry. Methods: We included 137 clusters in a four-arm cluster randomized controlled trial. Primary outcomes were appropriate screening and management of anemia, hypertension and diabetes during pregnancy, and timely attendance to routine antenatal care (ANC). Results: The COVID-19 pandemic interrupted the trial, which failed to achieve the estimated sample size. Between 1 December 2019 and 23 March 2020, 4138 women attended ANC in the TCC, 3553 in the QID, 4223 in the TCC &amp; QID and 3324 in the control arm. In the TCC arm, 76.5% of the visits were attended timely versus 73.4% in the control arm, (adjusted odds ratio, 1.2; 95% confidence interval, 0.90–1.61). We found no difference between QID and control, or between TCC &amp; QID control in the proportion of visits where anemia, hypertension and diabetes were appropriately screened and managed. Conclusion: The routine individual-level data of the MCH eRegistry enabled the implementation of theory-driven TCC and QID. However, the COVID-19 pandemic interrupted this trial of TCC and QID, and we were unable to observe any significant effect. Trial registration: ISRCTN Registry, ISRCTN10520687.

Maturity Level of Digital Reproductive, Maternal, Newborn, and Child Health Initiatives in Jordan and Palestine.

While there is a rapid increase in digital health initiatives focusing on the processing of personal data for strengthening the delivery of reproductive, maternal, newborn, and child health (RMNCH) services in fragile settings, these are often unaccompanied at both the policy and operational levels with adequate legal and regulatory frameworks. The main aim was to understand the maturity level of digital personal data initiatives for RMNCH services within fragile contexts. This aim was performed by choosing digital health initiatives from each country (two in Jordan and three in Palestine) based on RMNCH. A qualitative study design was adopted. We developed a digital maturity assessment tool assessing two maturity levels: the information and communications technology digital infrastructure, and data governance and interoperability in place for the five selected RMNCH initiatives in Jordan and Palestine. Overall, the digital infrastructure and technological readiness components are more advanced and show higher maturity levels compared with data governance and interoperability components in Jordan and Palestine. In Jordan, the overall Jordan stillbirths and neonatal deaths surveillance initiative maturity indicators are somehow less advanced than those of the Electronic Maternal and Child Health Handbook-Jordan (EMCH-J) application. In Palestine, the Electronic Maternal and Child Health-registry initiative maturity indicators are more advanced than both Avicenna and EMCH-Palestine initiatives. The findings highlighted several challenges and opportunities around the application and implementation of selected digital health initiatives in the provision of RMNCH in Jordan and Palestine. Our findings shed lights on the maturity level of these initiatives within fragile contexts. The maturity level of the five RMNCH initiatives in both countries is inadequate and requires further advancement before they can be scaled up and scaled out. Taking the World Health Organization recommendations into account when developing, implementing, and scaling digital health initiatives in low- and middle-income countries can result in successful and sustainable initiatives, thus meeting health needs and improving the quality of health care received by individuals especially those living in fragile contexts.

Phenotypic characterization of a pediatric cohort with cystinuria and usefulness of newborn screening.

Cystinuria is an inherited metabolic disease involving the defective transport of cystine and the dibasic amino acids in the renal proximal tubules that causes the formation of stones in the urinary system. In our regional child health program, cystinuria is included in newborn metabolic screening. Our objectives are the phenotypic characterization of our cystinuric pediatric cohort and to present our experience in neonatal cystinuria screening. The study of clinical cases of pediatric patients diagnosed with cystinuria over a period of 32years. All patients were studied at demographic, clinical, laboratory, radiological, and therapeutic levels. We diagnosed 86 pediatric patients with cystinuria; 36% of them had the homozygous biochemical phenotype. 95.3% of the patients were detected by neonatal metabolic screening. We performed urine biochemical analyses of parents with additional diagnoses of 63 adult patients. The mean follow-up time was 16.8 ± 8.5years. 11.6% of patients developed one or more episodes of urinary tract infection during that period. Chronic kidney disease, proteinuria, and hypertension were uncommon (1.2%). 10.5% developed kidney stones at the mean age of presentation of 7.78 ± 7.6years; 33% were recurrent. The risk of developing lithiasis was higher for homozygous biochemical-phenotype patients. Hypercalciuria was a significant risk factor in the development of lithiasis. Our clinical data suggest that diagnosing cystinuria through neonatal screening could be a useful strategy for the detection of presymptomatic cases, in order to establish preventive measures, as well as for the detection of relatives at risk. A higher resolution version of the Graphical abstract is available as Supplementary information.

ERegTime-Time Spent on Health Information Management in Primary Health Care Clinics Using a Digital Health Registry Versus Paper-Based Documentation: Cluster-Randomized Controlled Trial.

BackgroundDigital health interventions have been shown to improve data quality and health services in low- and middle-income countries (LMICs). Nonetheless, in LMICs, systematic assessments of time saved with the use of digital tools are rare. We ran a set of cluster-randomized controlled trials as part of the implementation of a digital maternal and child health registry (eRegistry) in the West Bank, Palestine.ObjectiveIn the eRegTime study, we compared time spent on health information management in clinics that use the eRegistry versus the existing paper-based documentation system.MethodsIntervention (eRegistry) and control (paper documentation) arms were defined by a stratified random subsample of primary health care clinics from the concurrent eRegQual trial. We used time-motion methodology to collect data on antenatal care service provision. Four observers used handheld tablets to record time-use data during one working day per clinic. We estimated relative time spent on health information management for booking and follow-up visits and on client care using mixed-effects linear regression.ResultsIn total, 22 of the 24 included clinics (12 intervention, 10 control) contributed data; no antenatal care visits occurred in the other two clinics during the study period. A total of 123 and 118 consultations of new pregnancy registrations and follow-up antenatal care visits were observed in the intervention and control groups, respectively. Average time spent on health information management for follow-up antenatal care visits in eRegistry clinics was 5.72 minutes versus 8.10 minutes in control clinics (adjusted relative time 0.69, 95% CI 0.60-0.79; P<.001), and 15.26 minutes versus 18.91 minutes (adjusted relative time 0.96, 95% CI 0.61-1.50; P=.85) for booking visits. The average time spent on documentation, a subcategory of health information management, was 5.50 minutes in eRegistry clinics versus 8.48 minutes in control clinics (adjusted relative time 0.68, 95% CI 0.56-0.83; P<.001). While the average time spent on client care was 5.01 minutes in eRegistry clinics versus 4.91 minutes in control clinics, some uncertainty remains, and the CI was consistent with eRegistry clinics using less, the same, or more time on client care compared to those that use paper (adjusted relative time 0.85, 95% CI 0.64-1.13; P=.27).ConclusionsThe eRegistry captures digital data at point of care during client consultations and generates automated routine reports based on the clinical data entered. Markedly less time (plausibly a saving of at least 18%) was spent on health information management in eRegistry clinics compared to those that use paper-based documentation. This is likely explained by the fact that the eRegistry requires lesser repetitive documentation work than paper-based systems. Adoption of eRegistry-like systems in comparable settings may save valuable and scarce health care resources.Trial RegistrationISRCTN registry ISRCTN18008445; https://doi.org/10.1186/ISRCTN18008445International Registered Report Identifier (IRRID)RR2-10.2196/13653

SIMON WILE SYMPOSIUM: FOCUS ON DIVERSITY AND EQUITY THROUGH A PEDIATRIC COLLABORATIVE AND INTEGRATED CARE LENS

The goal of this year’s Simon Wile Symposium will be to focus on diversity, equity, and inclusion through the lens of pediatric collaborative and integrated care. National experts will share their experiences and perspectives in building systems to collaborate with pediatric primary care providers (PCPs), working within and improving regional child health and mental health systems to improve health equity. Given national trends of focus on systemic racism and on racial and ethnic disparities, our Center for Inclusive Child Care (CICC) committee discussed possible invitees who had developed innovative programs to target improved access to care for children in Black, Indigenous, and People of Color (BIPOC) and Latinx populations. The literature on child psychiatry access programs was also reviewed, resulting in the current Symposium submission. Presentations this year will focus on programs that are as follows: 1) evaluating the impact of social determinants on ADHD symptoms among a racially and ethnically diverse population of preschoolers in primary care settings; 2) implementing collaborative and integrated care through a Federally Qualified Health Center for a racially and ethnically diverse population of children; and 3) targeting improving health equity among racially and ethnically diverse populations including BIPOC and Latinx populations. As child and adolescent psychiatrists continue to work to address the significant child mental health needs in communities across the country, we have increasingly found child psychiatry collaborative and integrated care to be a valuable tool in helping pediatric PCPs care for children and families struggling with mental health issues. We believe that this can also be a valuable tool in improving health equity. Our speakers will share innovations in their access programs that have allowed them to reach new and underserved populations, better engage PCPs, and carefully build systems of collaborative care.

Gestational age recorded at delivery versus estimations using antenatal care data from the Electronic Maternal and Child Health Registry in the West Bank: a comparative analysis

BackgroundEstimated dates of delivery have important consequences for clinical decisions during pregnancy and labour. The Electronic Maternal and Child Health Registry (MCH eRegistry) in Palestine includes antenatal care data and birth data from hospitals. Our objective was to compare computed best estimates of gestational age in the MCH eRegistry with the gestational ages recorded by health-care providers in hospital delivery units. MethodsWe obtained data for pregnant women in the West Bank registered in the MCH eRegistry from Jan 1, 2017 to March 31, 2017. Best estimates of gestational age in the registry are automated and based on a standard pregnancy duration of 280 days and ultrasound-based pregnancy dating before 20 weeks’ gestation or the woman's last menstrual period date. Hospital recorded gestational ages are reported by care providers in delivery units and are rounded to the nearest week. We calculated proportions of gestational ages (with 95% CIs) from both sources that fell into the categories of term, very preterm (24–32 weeks’ gestation), preterm (33–37 weeks), or post-term (>42 weeks). Findings1924 women were included in the study. The median hospital recorded gestational age was 39 weeks (IQR 38–40 weeks) and according to MCH eRegistry estimates was 39 weeks and 5 days (IQR 38 weeks and 1 day to 40 weeks and 5 days). Proportions of very preterm, preterm, and post-term deliveries were higher based on MCH eRegistry estimates than on hospital recorded gestational ages (very preterm 3%, 95% CI 2–4 vs 2%, 1–2; preterm 6%, 5–7 vs 5%, 3–6 ; post-term 6%, 5–7 vs 1%, 1–2). InterpretationIn addition to clinical care, the proportions of term, very preterm, preterm, and post-term births can have implications for public health monitoring. The proportion of deliveries within the normal range of term gestation was calculated to be higher by care providers in delivery units than by MCH eRegistry estimates. Extending the access of hospitals to information from antenatal care in the MCH e-Registry could improve continuity of data and better care for pregnant women. FundingEuropean Research Council, Research Council of Norway.

Development of a targeted client communication intervention for pregnant and post-partum women: a descriptive study

BackgroundTargeted client communication using text messages can inform, motivate, and remind pregnant and postpartum women to use care in a timely way. The mixed results of previous studies of the effectiveness of targeted client communication highlight the importance of theory-based co-design with users. We planned, developed, and tested a theory-based intervention tailored to pregnant and postpartum women, to be automatically distributed via an electronic maternal and child health registry in occupied Palestinian territory. MethodsWe did 26 in-depth interviews with pregnant women and health-care providers in seven purposively selected public primary health-care clinics in the West Bank and Gaza to include clinics with different profiles. An interview guide was developed using the Health Belief Model to explore women's perceptions of high-risk conditions (anaemia, hypertension, diabetes, and fetal growth restriction) and timely attendance for antenatal care, as predefined by a national expert panel. We did thematic analyses of the interview data. Based on the results, we composed messages for a targeted client communication intervention, applying concepts from the Model of Actionable Feedback, social nudging, and enhanced active choice. We assessed the acceptability and understandability of the messages through unstructured interviews with local health promotion experts, health-care providers, and pregnant women. FindingsThe recurring themes indicated that most women were aware of the health consequences of anaemia, hypertension, and diabetes, but that they seldom associated these conditions with pregnancy. We identified knowledge gaps and low awareness of susceptibility to and severity of these complications and the benefits of timely antenatal care. The actionable messages were iteratively improved with stakeholder and end-user feedback after presenting the initial draft, and the messages deemed were understandable and acceptable based on reflections during unstructured assessment. InterpretationFollowing a stepwise iterative process by a theory-based approach and co-designing the intervention with users, we revealed elements critical to an efficacious targeted client communication intervention. A potential limitation of our study is that conducting in-depth interviews on several health conditions simultaneously might have reduced the depth of information we could have obtained. The strength of our study was that we assessed for, developed, and refined the intervention following recommended theoretical frameworks and best practices. The effectiveness of this intervention is under evaluation in a cluster-randomised trial (ISRCTN10520687). FundingEuropean Research Council and Research Council of Norway.

National Swedish survey showed that child health services and routine immunisation programmes were resilient during the early COVID-19 pandemic.

AimRoutine immunisation programmes are at risk of disruption due to the COVID‐19 pandemic. This study aimed to investigate the resilience of the Swedish national immunisation programme for children up to the age of five years during the early stages of the pandemic.MethodsThis was a cross‐sectional, web‐based survey of regional child health offices in Sweden between 10 September and 9 October 2020. It explored the organisation of child health services during the early stages of the pandemic, focusing on routine child immunisation.ResultsAll 21 Swedish regional child health offices responded. They stated that child immunisation had been prioritised, communication with families had been intensified and there was greater flexibility at all organisational levels of child health services. In addition, the vaccine supply was sustained and child health centres remained open. However, there were periodic staff shortages, increased numbers of health visits cancelled by parents and most parent education groups were paused.ConclusionThe Swedish immunisation programme was resilient during the early COVID‐19 pandemic, thanks to sustainable organisation co‐ordinated by Sweden's network of regional child health offices.

Development of a targeted client communication intervention to women using an electronic maternal and child health registry: a qualitative study

BackgroundTargeted client communication (TCC) using text messages can inform, motivate and remind pregnant and postpartum women of timely utilization of care. The mixed results of the effectiveness of TCC interventions points to the importance of theory based interventions that are co-design with users. The aim of this paper is to describe the planning, development, and evaluation of a theory led TCC intervention, tailored to pregnant and postpartum women and automated from the Palestinian electronic maternal and child health registry.MethodsWe used the Health Belief Model to develop interview guides to explore women’s perceptions of antenatal care (ANC), with a focus on high-risk pregnancy conditions (anemia, hypertensive disorders in pregnancy, gestational diabetes mellitus, and fetal growth restriction), and untimely ANC attendance, issues predefined by a national expert panel as being of high interest. We performed 18 in-depth interviews with women, and eight with healthcare providers in public primary healthcare clinics in the West Bank and Gaza. Grounding on the results of the in-depth interviews, we used concepts from the Model of Actionable Feedback, social nudging and Enhanced Active Choice to compose the TCC content to be sent as text messages. We assessed the acceptability and understandability of the draft text messages through unstructured interviews with local health promotion experts, healthcare providers, and pregnant women.ResultsWe found low awareness of the importance of timely attendance to ANC, and the benefits of ANC for pregnancy outcomes. We identified knowledge gaps and beliefs in the domains of low awareness of susceptibility to, and severity of, anemia, hypertension, and diabetes complications in pregnancy. To increase the utilization of ANC and bridge the identified gaps, we iteratively composed actionable text messages with users, using recommended message framing models. We developed algorithms to trigger tailored text messages with higher intensity for women with a higher risk profile documented in the electronic health registry.ConclusionsWe developed an optimized TCC intervention underpinned by behavior change theory and concepts, and co-designed with users following an iterative process. The electronic maternal and child health registry can serve as a unique platform for TCC interventions using text messages.

Review of Aboriginal child health services in remote Western Australia identifies challenges and informs solutions

BackgroundDespite a national focus on closing the gap between Aboriginal and non-Aboriginal child health outcomes in Australia, there remain significant challenges, including provision of health services in very remote communities. We aimed to identify and map child health services in the very remote Fitzroy Valley, West Kimberley, and document barriers to effective service delivery.MethodsIdentification and review of all regional child health services and staffing in 2013. Verification of data by interview with senior managers and staff of key providers in the Western Australian Country Health Service, Kimberley Population Health Unit, Nindilingarri Cultural Health Services and non-government providers.ResultsWe identified no document providing a comprehensive overview of child health services in the Fitzroy Valley. There were inadequate numbers of health professionals, facilities and accommodation; high staff turnover; and limited capacity and experience of local health professionals. Funding and administrative arrangements were complex and services poorly coordinated and sometimes duplicated. The large geographic area, distances, extreme climate and lack of public and private transport challenge service delivery. The need to attend to acute illness acts to deprioritise crucial primary and preventative health care and capacity for dealing with chronic, complex disorders. Some services lack cultural safety and there is a critical shortage of Aboriginal Health Workers (AHW).ConclusionsServices are fragmented and variable and would benefit from a coordinated approach between government, community-controlled agencies, health and education sectors. A unifying model of care with emphasis on capacity-building in Aboriginal community members and training and support for AHW and other health professionals is required but must be developed in consultation with communities. Innovative diagnostic and care models are needed to address these challenges, which are applicable to many remote Australian settings outside the Fitzroy Valley, as well as other countries globally. Our results will inform future health service planning and strategies to attract and retain health professionals to work in these demanding settings. A prospective audit of child health services is now needed to inform improved planning of child health services with a focus on identifying service gaps and training needs and better coordinating existing services to improve efficiency and potentially also efficacy.

BRIGHT Coaching: A Randomized Controlled Trial on the Effectiveness of a Developmental Coach System to Empower Families of Children With Emerging Developmental Delay.

Background: In preschool-aged children with, or at elevated risk for, developmental disabilities, challenges and needs arise from vulnerabilities linked to critical and newly emerging cognitive, speech, motor, behavioral, and social skills. For families, this can be a stressful period as they witness the gradual unfolding of their child's differences and await to receive care. Nationally and internationally, service delivery models during this critical period are not standardized nor are they nimble or sufficient enough, leading to long wait times, service gaps and duplications. Given these struggles, there is a need to examine whether “health coaching”, a structured educational program that is deliverable by different and more accessible means, can be effective in empowering families, by delivering information, providing social supports, and decreasing the demands on the overwhelmed health and developmental services. The primary objective is to evaluate the feasibility and the effectiveness of a coaching intervention (in comparison to usual and locally available care), for parents of children with emerging developmental delays.Method/Design: A multi-centered pragmatic randomized controlled trial design will be used. Families will be recruited from a representative sample of those awaiting publicly-funded regional child health services for children with developmental delays in four Canadian provinces. The target sample size is 392 families with children aged 1.5 to 4.5 years at recruitment date. Families will be randomly assigned to receive either the BRIGHT Coaching intervention (coach supported, hardcopy and online self-managed educational resources: 14 sessions, 2 sessions every 4 weeks for 6–9 months) or usual care that is locally available. In addition to the feasibility and acceptability measures, outcomes related to family empowerment, parental satisfaction and efficacy with caregiver competency will be evaluated at baseline, post-treatment (8 months), and follow-up (12 months).Discussion: This manuscript presents the background information, design, description of the interventions and of the protocol for the randomized controlled trial on the effectiveness of BRIGHT Coaching intervention for families of children with emerging developmental delays.Trial Registration: ClinicalTrials.gov, U.S. National Library of Medicine, National Institutes of Health #NCT03880383, 03/15/2019. Retrospectively registered.

Use of the national electronic maternal and child health registry (MCH eRegistry) in primary care clinics in occupied Palestinian territory: a pilot time-motion study

BackgroundIn primary care maternal and child health clinics in occupied Palestinian territory, documentation and reporting consume considerable time for care providers. An electronic maternal and child health registry (MCH eRegistry), with point-of-care clinical decision support, is being implemented nationally in governmental clinics. We conducted a pilot study of time spent by care providers on important tasks, in preparation for a trial to compare eRegistry and non-eRegistry clinics. MethodsWe conducted semi-structured interviews of ten nurse-midwives from six governmental clinics in the West Bank to map clinical workflows, and developed a data collection tool for time-motion observations. In May, 2017, observers recorded one workday in three eRegistry and three non-eRegistry clinics. For each consultation, we calculated the median time spent (in minutes) on each task, and then compared time spent in eRegistry and non-eRegistry clinics using Wilcoxon rank-sum tests. Ethics approvals were obtained from the Palestinian Health Research Council and Regional Ethics Committee, Norway. Informed consent was obtained from all pregnant women. FindingsTwelve antenatal consultations (four first booking visits, eight follow-up visits) were observed in eRegistry clinics and 39 (four first visits, 35 follow-up visits) in non-eRegistry clinics. The median duration of booking visits was 19·9 min (IQR 12·9) in eRegistry clinics and 22·1 min (24·9) in non-eRegistry clinics. In eRegistry clinics, the median duration of follow-up visits was 14·6 min (17·3), of which the median clinical examination time was 1·7 min (0·6) and median health information management time was 5·3 min (5·8). In non-eRegistry clinics, the median duration of follow-up visits was 8·8 min (8·7), of which the median clinical examination time was 2·5 min (2·9) and health information management time was 4·6 min (2·0). This pilot study was not sized for comparisons; health information management time was not statistically different between groups (p=0·1). InterpretationHealth information management constituted large parts of limited antenatal consultation time. The pilot provided data to estimate that the upcoming trial must include a sample of 24 clinics and 210 observations, with similar proportions of booking and follow-up consultations in both arms, to observe meaningful differences in time consumption with sufficient statistical power. FundingEuropean Research Council and Research Council of Norway.

Maternal and child health and care provision in Palestine: data from the national electronic maternal and child health registry (MCH eRegistry)

BackgroundGood quality data from health systems can benefit several stakeholders, including policy makers, care providers, clients, and researchers. Conventional data collection methods for maternal and child health, such as household surveys, may not be suitable to assess processes of service delivery. The electronic maternal and child health registry (MCH eRegistry) has been implemented in 182 governmental primary care clinics in Palestine. Here we present the data in the MCH eRegistry. MethodsWe processed the raw data in the MCH eRegistry from the West Bank, and documented validation rules for crude data points (time of entry, values allowed). Definitions and appropriate categorisations were created for core process indicators. Data from the MCH eRegistry and the electronic health information system in governmental hospitals were linked using statistical software. FindingsAs per the second quarter of 2018, the MCH eRegistry contained raw data on 69 793 antenatal care visits, 27 304 postpartum care visits and 40 264 newborn care visits. From antenatal care, data on core process indicators were available for screening of anaemia (n=48 542), hypertension (n=66 814), diabetes (n=18 013), asymptomatic bacteriuria (n=31 757), as well as antenatal ultrasound (n=55 453). Distributions of raw data on haemoglobin and blood pressures had no extreme outliers. Links had been established between antenatal care and delivery data in governmental hospitals for 51% of births. InterpretationThe MCH eRegistry contains data from antenatal to postpartum and newborn care. These data have been successfully linked with delivery data, resulting in a large data set on continuity of care and birth outcomes. Furthermore, the data are accessible, of good quality, and can be used for studies of quality of care and maternal and newborn epidemiology, among others. Researchers are invited to use this resource in working towards improving the health system and the health of Palestinians. FundingEuropean Research Council and Research Council of Norway.

Governance guidance for an eRegistry for maternal and child health: lessons from the occupied Palestinian territory

BackgroundThe eRegistry for maternal and child health is an electronic registry system developed for the collection, analysis, retrieval, storage, and dissemination of information on health determinants and outcomes for women and children. The purpose of the eRegistry is to improve health-care provision and public health surveillance in the occupied Palestinian territory. Given the highly sensitive nature of reproductive health information, however, careful attention to ethical and legal considerations is essential. The aim of this study was to map the legal, regulatory, and ethical landscape using a situation analysis tool tailored for the Palestinian context and to identify gaps, opportunities, and actions necessary to ensure an ethical and lawful framework for an eRegistry. MethodsWe used an exploratory situation analysis tool (SAT) to map the current legislative, regulatory, and governance environment in the occupied Palestinian territory. The primary objective was to assess, document, and analyse the legal and ethical landscape. Specific focal topics addressed by the SAT included identifying relevant legislation (eg, civil registration, data privacy, health registries, public health law), existing governance structures, accountability, and oversight bodies (ie, ethical review committees, data protection authorities), and data quality and security policies. The Palestinian National Institute of Public Health (PNIPH) completed the SAT and held workshops for relevant stakeholders, including staff from the ministry of health's legal affairs department, PNIPH staff, and other legal experts. No ethical approval was required because data were collected from public documents. FindingsThe findings from the SAT reflect the current situation in the occupied Palestinian territory with respect to existing laws, accountability and oversight bodies, and data collection protocols and policies concerning data privacy and security. Existing Palestinian legislation relevant to health registries includes Article 4 of the General Statistics Law (2000), which honours data confidentiality and the privacy of individuals. The Penal Law number 16 of 1960 addresses the disclosure of confidential information, whereas Article 355 specifically states that disclosure of official confidential information to unauthorised persons is unlawful and could result in imprisonment. Furthermore, the Public Health Law (2004) addresses general maternal and child health issues in Articles 4 and 5. We investigated relevant oversight and accountability bodies (eg, ethical review board) that might be relevant to an electronic maternal and child health registry. Finally, in a review of existing data privacy protocols and policies, we noted that few formal protocols (ie, privacy manual) or policies regulate data collection and access practices. InterpretationSpecific areas within the legal and regulatory framework of the occupied Palestinian territory could be strengthened. The eRegistry Governance Guidance Toolkit, predicated on the SAT content, outlines responsible data stewardship practices and provides assistance in developing protocols and policies in lieu of specific laws by providing a framework to ensure the protection of women and children's privacy. Effective governance that protects women and children's privacy and confidentiality is essential for maintaining public trust and ensuring the long-term success of an eRegistry. FundingEuropean Research Council and the Norwegian Agency for Development Cooperation (Norad).

20.0 Simon Wile Symposium: Super-Powered Child Psychiatry Access Programs! Adding Value From System-Wide Integration, Early Childhood Interventions, and Quality Improvement Initiatives

The goal of this year’s Simon Wile Symposium will be to examine innovative practices in child psychiatry access programs (CPAPs) that improve access to quality mental health care for children, adolescents, and families across the nation. National experts will share their experiences and perspectives in building systems to reach pediatric primary care providers (PCPs), work within and improve regional child health and mental health systems, and continually innovate beyond the core of regional telephone consultation lines.

Task-shifting impact of introducing a pilot community health worker cadre into Zambia's public sector health workforce.

BackgroundThe Zambia Ministry of Health (MOH) recruited and trained a new cadre of Community Health Assistants (CHAs) as part of its National Community Health Strategy. The inaugural class of 307 CHAs completed one year of training in July 2012 and deployed to their communities.MethodsThe impact of the CHA program on the volume and type of health services provided at health posts and their respective referral health centers was measured with a non-randomized difference-in-differences design. Monthly health service provision data was collected for 12 months before and after CHA deployment at 8 health posts along with 8 referral health centers. The analysis controlled for seasonality, changes in non-CHA staffing, and periodic regional child health campaigns, and used facility-level fixed effects.ResultsDeploying two CHAs to a health post did not lead to a statistically-discernible increase in services at the intervention facilities. Health services provided at referral health centers increased by 697.9 services per month (95% CI: 131.4 to 1,264.3, p = .016), and combined services (at health posts and referral health centers) increased by 848.6 services per month (95% CI: 178.2 to 1,519.1, p = .013).ConclusionIn this pilot, the addition of CHAs in rural areas increased health service provision at referral health facilities and at facilities overall, shifting the burden of basic health services away from more highly trained health workers. Shifting tasks to lesser-trained, less-expensive cadres like the CHAs, policymakers can rapidly improve access to care with constrained budgets. Evaluations measuring the direct impact of lower level cadres without accounting for task-shifting may underestimate their contribution to the health workforce.

'Doing Better Together': Developing a cross-agency regional child health and wellbeing plan

In 2013, the alignment of the geographic boundaries of the regional Local Health District, Family and Community Services and the Medicare Local/Primary Health Network presented a strategic opportunity to form a high-level strategic partnership and planning group. This group provided an ideal platform for collaboration. The Local Health District had already identified the need for a five-year child health plan and proposed that this was completed collaboratively and that it covered both health and broader wellbeing. The emergence of integrated care as a focus area for the New South Wales (NSW) Ministry of Health was an additional driver for developing a shared plan. Membership of the Senior Partnership and Planning Group was expanded to include representatives from the child and family non-government sector and the Department of Education. Whilst each organisation involved are working towards child health and wellbeing in many ways every day, the Plan focuses on the ‘additionality’ that comes from cross-agency collaboration and integration. A stakeholder consultation workshop with over one hundred service providers informed the determination of strategic priorities and related actions for inclusion in the Plan. The Plan provides a framework for shared governance, collaboration and a common vision for child health and wellbeing outcomes over a five year period. The mission for the Child Health and Wellbeing Plan is for the children of Inner West Sydney region to be healthy, safe, respected, valued and happy, living in supportive families, and nurtured in strong inclusive communities. The Plan is based on the important idea that agencies working together, in collaboration with communities, can do more and can achieve meaningful change, particularly when vulnerable children and families are involved. Vulnerable children include those living in poverty, at risk of violence, abuse and neglect, newly arrived refugees and migrants, living with parents or carers who have mental health and/or substance abuse issues, and whose chances of reaching their potential are reduced or at risk. The ‘Inner-West Child Health and Wellbeing Plan: Doing Better Together’ was launched by the NSW Minister for Health in November 2015. 'Healthy Homes and Neighbourhoods' is a three-year integrated care initiative funded through a NSW Ministry of Health Integrated Care Planning and Innovation Fund. 'Healthy Homes and Neighbourhoods' is a demonstration project of the Child Health and Wellbeing Plan and provided an immediate and significant opportunity to extend and test the collaborative partnership. The program addresses the complex health and social needs of the most vulnerable families in our community who may be disconnected from key services and who require multi-agency assistance. Approximately 170 individuals have enrolled for care coordination since program implementation in June 2015. All the needs of identified families are in scope for the intervention, including housing, employment, income support and legal advice. Geospatial mapping identified clusters of extreme family disadvantage, where additional community projects are being implemented. Scoping papers have been completed for the Child Health and Wellbeing Plan high priority initiatives with oversight, support and quality assurance from an Implementation Sub-Committee with cross-agency representation.

A Multi-Institutional Medical Educational Collaborative

Educational collaboratives offer a promising approach to disseminate educational resources and provide faculty development to advance residents' training, especially in areas of novel curricular content; however, their impact has not been clearly described. Advocacy training is a recently mandated requirement of the Accreditation Council for Graduate Medical Education that many programs struggle to meet.The authors describe the formation (in 2007) and impact (from 2008 to 2010) of 13 California pediatric residency programs working in an educational collaboration ("the Collaborative") to improve advocacy training. The Collaborative defined an overarching mission, assessed the needs of the programs, and mapped their strengths. The infrastructure required to build the collaboration among programs included a social networking site, frequent conference calls, and face-to-face semiannual meetings. An evaluation of the Collaborative's activities showed that programs demonstrated increased uptake of curricular components and an increase in advocacy activities. The themes extracted from semistructured interviews of lead faculty at each program revealed that the Collaborative (1) reduced faculty isolation, increased motivation, and strengthened faculty academic development, (2) enhanced identification of curricular areas of weakness and provided curricular development from new resources, (3) helped to address barriers of limited resident time and program resources, and (4) sustained the Collaborative's impact even after formal funding of the program had ceased through curricular enhancement, the need for further resources, and a shared desire to expand the collaborative network.

Using routinely collected data to improve immunisation histories.

Immunisation is one of the most effective health interventions in existence yet outbreaks of vaccine-preventable diseases continue to occur in developed countries. High rates of cover are needed to provide adequate herd immunity and there is evidence that a significant proportion of paediatric inpatients are not up to date even in areas with high levels of community cover. A proportion of these children will have parents who consciously declined immunisation, however the remaining children represent a vulnerable cohort whose under-immunisation is not routinely identified.Two-hundred consecutive admissions to rural paediatric assessment unit had their routinely documented vaccination histories checked against their records on the regional Child Health Information System (CHIS). 30 children (15%) were not up to date on the CHIS, yet routine clerking only identified 5 of these children (17%). After introduction of a simple system whereby ward clerks and doctors were taught how to access and print full immunisation histories from the CHIS, a further 200 consecutive admissions were audited. A similar number were not up to date (29/200) but the proportion of children with missing immunisations correctly identified in the clerking documentation increased to 52% (15 children). This is a 35% improvement (95% CI; 12–58%).Access to routinely collected data can significantly improve identification of under-immunised children and contribute towards higher levels of individual and herd-immunity.