Change in health outcomes for Aboriginal children with chronic wet cough: a multi-centre implementation study

The intervention is implementation of a "strategy" to facilitate early recognition and management of chronic wet cough in First Nations children at the primary care level. The strategy has seven core components for each site. The core components of the strategy include: 1. First Nations Lead: appointed at each site to advise on all cultural components of project, ensure culturally secure operations with First Nations knowledge being privileged. A First Nations officer is available for all First Nations participants from recruitment to all participation components. Adherence is measured by a First Nations lead being appointed and employed for the duration of the study. 2. Stakeholder engagement - with healthcare providers (HCPs) in primary care and local hospitals, First Nations parents to generate buy-in and ascertain and address local barriers and facilitators to implementation. Engagement occurs with in-person focus groups and interviews for the purpose of identifying current state, barriers and facilitators to providing the strategy. Qualitative experts (content expert and First Nations cultural expert, who are research team members) will lead the interviews and focus groups. Focus groups will be scheduled for 30-60 minutes, and interviews will be scheduled for 10-30minutes, with an expected single attendance only by participants. There is no limit to the number of attendees for focus groups, but numbers are not expected to exceed 25 per group based on size of departments. Stakeholder engagement can occur during the pre-intervention period (approximately 12-months). Adherence is measured via a written, published report summarising the key findings, process map and tailored implementation of strategy for each site. 3. Training of HCPs (3-month period). Training via online modules, podcasts, in-person training. In-person (or virtual in-person) training (1-hour duration x 3 occasions) will be scheduled for relevant HCPs during preferred departmental time allocation by managers. The on-line module will be promoted to all staff throughout the intervention period. The module takes 45 minutes to complete and is only completed once. The 30-min podcast is intended for single listening and will be promoted throughout intervention period. The podcast is an additional resource, not primary form of teaching. In-person (or virtual) training is provided by a paediatric respiratory physician for doctors and/or paediatric respiratory clinician for other HCPs (e.g. physiotherapist or nurse). All trainers are part of the research team. Adherence is measured by metrics of completions at each site (electronic capture system) for online training and calculation of the percentage or proportion of HCPs trained out of the total number who could be trained at each site. 4. Practice changes: Easily accessible, clear clinical practice guidelines will be placed in each clinic (Source: CARPA manual p134, i.e., https://healthinfonet.ecu.edu.au/healthinfonet/getContent.php?linkid=592687&title=CARPA+standard+treatment+manual%3A+a+clinic+manual+for+primary+health+care+practitioners+in+remote+and+Indigenous+health+services+in+central+and+northern+Australia. Call-back option operational (ability to schedule follow-up with same clinician),i.e.(to be determined at each site as per need and coordinated with local Information technology department); Flow chart on wall in clinic to prompt clinicians (designed for study, source: supplementary File 3 of protocol); Electronic decision support, which includes pop-up reminder to ask about cough and link to cough guidelines within electronic medical records (designed during nil-intervention period if required and if feasible). Coordination will be facilitated by clinical practice manager. Adherence will be measured through record if booking option is operational and the total number of record flow chart placements in each clinic room per room available. Practice changes will be implemented anytime during the same 3-month period of the intervention, i.e., during the teaching period) 5. Educational resources for HCPs: (i)culturally secure Flipchart (developed with First Nations parents, consumer endorsed and used at Perth Children's Hospital (PCH) and Broome Regional Aboriginal Medical Service. https://www.telethonkids.org.au/globalassets/media/documents/research-topics/wet-cough-flipchart.pdf. The 10-page flip chart is written with simple language and pictures. Clinicians will use the tool to teach parents whose children suspected or at high risk of protracted bacterial bronchitis who attend primary care clinic. The flip chart explains a child's chronic wet cough and the risk of developing bronchiectasis and the need for medical care. It takes approximately 5-minutes to go through with the parent/carer. (ii)Animated film version of flip chart. (time: 3min 12 sec; https://www.youtube.com/watch?v=822rxbYIZcU; Use will be by choice of clinician and/or family - in addition to flip chart or instead of flip chart). Adherence will be measured by record of adaptions of materials if required for each site and record of whom resources are provided to at each site. 6.Information campaign (Same 3-month period as HCP training). Note all materials currently available (https://www.telethonkids.org.au/our-research/research-topics/wet-cough/) and can be used in current version or may be adapted for each site during nil-intervention phase) i) Posters in clinic (3-6 posters per clinic in high traffic areas such as family centre, waiting room and paediatric areas) and community (where agreed within the community, e.g., day care centres, library, local town noticeboard). Posters depict child coughing +/- sports hero: Copy states: "Lil one got wet cough long time? Get 'em to clinic'. Local clinic logo, phone and website with more information listed (ii) Social media- advertising and information page. The page contains links to the Flipchart, local video clips, film, wet cough audio file and information about chronic wet cough - relevance and need for health seeking. Messenger service is offered where community can ask questions, responses by respiratory clinician researcher who has manager rights on Facebook page. Information given will only advise on the health message to seek medical help for chronic wet cough and will not involve specific medical advice. Targeting advertising will be on Facebook only, as per posters, which pop up in news feed of community using social media. We will target the location of the sites in the project and the surrounding areas (within 100km radius), and expect daily pop-ups if a local person is using Facebook during the 3-month campaign. Facebook Ads Manager will be used to post targeted advertisements - with 6 "boosted" posts from the page, which run for a 28-day cycle. All analytics for reach of post are collected via Facebook Ads Manager. pagehttps://www.facebook.com/wetcough/); (iii) Health promotion discussions i.e. “yarning”. (at playgroups x3 sessions/site, 30-minutes; day-cares x1 30-min session per daycare (~2-3 centres per site); small groups in homes (for remote communities only with <600 population) ~15 home visits for 15 minutes each. Trained health promotion officers from local clinic provides sessions. Officers trained during the nil-intervention period by clinician researcher. (half day course with theoretical and practical component on chronic wet cough recognition and management); (iv) Advertising- radio (3 x 30sec), television (1x 30sec) (optional) on local Indigenous stations (topic chronic wet cough) (v) Other information materials and booklets (optional) A5 booklet version of Flipchart (and child version) can be provided to family during yarning sessions or during consultations with child with respiratory illness./chronic wet cough in local clinic. Members of the research team will coordinate campaign in liaison with local champions/stakeholders. Adherence is measured by (i) Check posters placed as required; (ii) Facebook page live and reach and engagement of ads recorded and (iii) Record of number of yarning groups and attendees for each community. 7. Local champions within primary care system identified and mobilised to improve uptake of systems changes and provide audit and feedback to staff. One or two local champions will be identified per primary care clinics (at least one clinician champion will be recruited per clinic). Champions will be recruited during the focus group sessions by invitation from the clinical lead at each site. The champions will provide feedback of audited clinician medical record entries of children presenting with respiratory illness if clinician asked about cough presence, quality and duration and metrics of online module completions within the clinic at monthly departmental meetings during the intervention stage of the project (3-months). The feedback is expected to take no more than 5-minutes and will be collated for the local champion by the local research leader. Adherence is measured through recording and reporting the number of champions and interactions recorded at each site. Timeline: The intervention components 1 and 2 commence prior to the implementation period to ensure appropriate tailoring for each site. This period will take approx 12-months. Once the intervention commences, core components 3-6 occur simultaneously. Please note there are two groups in the study. Nil-intervention controls do not receive any intervention. The second group is the post-intervention group who are recruited following the 3-month intervention period. This group have been exposed to the lung health promotion campaign and clinicians have received training and practices have implemented required changes. The stakeholder engagement and appointment of a First Nations lead and adaption of the implementation for each site occurs during the nil-intervention period.