2.1. Phase 1: Barriers and Facilitators to Family Engagement

In Phase 1, three face-to-face community focus groups explored the barriers and facilitators to the uptake of health screening by families. Twelve parents and carers participated in the focus groups, none of these 12 families participated in later phases of data collection.

2.2. Phase 2: Parent Perspectives on CUBS

Phase 2 examined family perspectives on the outcomes of the CUBS program using data from 36 interviews with a parent or carer. The interview covered their experience of the CUBS program, following up referrals and accessing support, communication with and between services and expectations about their child’s school readiness. Most interviews were conducted by telephone due to COVID-19 restrictions. Of these 36, 25 also completed a demographic survey. Families completed the survey with researcher support. Ethics approval from the local health district to seek access to health data from families was not received until late in the process, so the number of health records accessed is low. Access to health data was provided for 24 children from 19 families: 4 of these families were also participants in the qualitative interviews, 15 of the 19 gave permission for the researchers to access their child’s health data only and did not participate in any other way.

2.3. Phase 3: The Role of CUBS in School Transition

Phase 3 explored service integration and school transition based on family case studies and interviews with service professionals. To understand the service integration issues, we conducted interviews with 7 service professionals comprising 3 community service professionals, 3 allied health professionals and a primary school educator. Case study interviews were conducted, after the child had started school, with 5 families and six educators, two of the educators were preschool educators and 4 were primary school educators. We invited families who had been interviewed in Phase 2 to participate in case study interviews, seeking a sample of children with different levels and types of support needs. The interviews covered the child’s experience of school transition, whether CUBS had an impact on this transition, and whether health and developmental information had been shared with the school to support transition. The children have been given the pseudonyms of Kiah, Levi, Caiden, Holly and Kyle. Quotes from service providers have been attributed as ‘educator’, ‘health’ or ‘community’.

2.4. The Participating Families

We collected demographic data from the survey respondents, who make up 40% of participating families. Of the respondents, 84% were mothers, 8% fathers and 8% other women kinship carers. Most of the participants had completed year 10 at high school (96%), 28% completed year 12 as their highest level of education, 36% studied at TAFE, and 4% achieved a University degree.

The mean number of children was 3, ranging from 1 to 6 children. The families responding to the survey included Anglo non-Indigenous Australians (40%), Indigenous Australians (28%) and families from non-Indigenous culturally diverse backgrounds (32%) including Tongan, Bangladeshi, French Polynesian, Timorese, Lebanese and Sudanese families. All households had internet access, although many families sought researcher support to fill in the online survey. Most of the families spoke only English at home (76%), 4% did not speak English at home, and 20% spoke English and another language at home. According to the ABS 2021 Census data for this postcode area, 53.2% of people speak only English at home, 8.2% of people are Indigenous or Torres Strait Islander, 30.2% had both parents born in Australia, 56.5% educational level greater than year 10, 13% achieved a bachelor’s degree [20]. This suggests that, compared to the community profile, our participants were more likely to have attained an education level greater than year 10, to be Indigenous and to speak only English at home, but less likely to have a University degree. The bias in the sample towards English-speaking people is unsurprising given that most data collection was carried out by telephone due to COVID-19 restrictions, and in English.

2.5. Analysis

The three phases of research provided data to examine integrated health screening for young children from parent, service provider and educator perspectives. Initially, the data were analysed separately for each of the three phases. For Phase 1, focus groups were transcribed and a thematic analysis was undertaken. Phase 2 had a mixed methods design with data linkage. Interview transcripts were transcribed and subject to a thematic analysis. The results of survey data were considered in the light of the themes identified in the interview data. The child health records were analysed to determine the prevalence and type of developmental support needs. The interview data gave us information on whether and how referrals were acted on. Phase 3 interviews were transcribed and thematically analysed as a set. In addition, five narrative case studies were compiled for the five individual children.

The author who did not participate in data collection or analysis in Phases 1 to 3 then reviewed the analysis to determine themes that were common across these phases. This meta-analysis was checked by the other authors for validity, based on their familiarity with the data, and refined through a collective writing process. This article reports on the meta-analysis rather than the individual findings from each phase and uses data from each phase to evidence and illustrate the meta-analysis.

3.1. Prevalence of Need

More than half of the children were referred to more than one service (58%), and 8% were referred to six services. New applications for funding from the National Disability Insurance Scheme (NDIS) were made for 17% of the children. Only four of the 24 children had neither emerging nor established needs, leaving 83% with emerging or established needs. This is extremely high compared to the prevalence of teacher-identified special health care needs in Australia at 23% [14].

Our sample size was small, so we can only indicate possible trends that need to be investigated further rather than draw any firm conclusions. However, there is no reason to expect that these records are not representative of the whole population in the suburb. It should be noted that the child health records accessed for this analysis were from children who had attended a CUBS check-up in a community setting, rather than at a preschool, due to COVID-19 restrictions and school lockdowns during this phase of our data collection. It is possible that nonattendance at preschool was associated with higher levels of developmental support needs than might have been the case otherwise. What we can say is that CUBS was successful in picking up developmental issues that may not have been identified without the CUBS program for 75% of children assessed in a community setting and highlights a need for future models to consider program delivery in non-early childhood education and care (ECEC) settings.

3.2. Place-Based Care

Service providers were of the view that place-based screenings can engage the families who would otherwise not engage with health services for child development checks. One reason given for this was that parents were ‘reluctant to engage in things offsite where they don’t know people’ (educator). Families in the focus groups reported a reluctance to visit the GP for a screening check when their child was not sick because they did not want to waste the GPs time, they were reluctant to pay for a GP visit, nor did they want to risk contagion. Families were positive about the possibility of screening services embedded in early childhood education and care services and concerned that all families had an opportunity for CUBS: ‘There needs to be a better hub … to target the children who are not in early education’ (parent).

Locating CUBS in early education settings worked well for families attending the service. Parents who were interviewed in Phase 2 valued the convenience of CUBS being located at their child’s preschool, saying ‘actually being at the school … makes it a lot easier’ (parent), particularly because ‘we don’t have a maternal health nurse here in this suburb’ (parent). Parents also valued the check-up being in a familiar environment for their child. Location in educational and community settings also broadened the perspective of service providers. One explained ‘I love the fact that Community Health see the value in coming to the service instead of the families coming to them’ (community). A need for CUBS in community settings outside of ECEC was expressed by the parents. They suggested a drop-in service in a shop front or local church, or a mobile service that visited homes.

Making appointments online or by telephone was a barrier for some families, so access to services at a place that is visited by families in their day-to-day lives is helpful. One parent said that ‘public transport is pretty bad here’, and this makes travel with young children difficult. Travelling to services in pandemic conditions was even harder, for one family an allied health appointment could not be attended during COVID-19 restrictions as it was out of the area where they could freely travel.

3.3. Amplify Family Agency

Our data indicated that the experience of developmental screening provided parents with the knowledge and the tools to act to support their child. In the initial focus groups, a prevailing discourse about children’s development was that ‘when you just let things happen on their own they tend to happen’. From this perspective, checking on child development was not a priority or concern for families, who assumed that children would develop in their own time. One service provider said that issues such as delayed speech and language were ‘almost normalised’ (educator) in the area, which reflects the parent discourse. Another noted that if children are not screened and the school picks up a disability or health issue ‘it comes as a shock to them (parents)’ (educator).

For many families that did attend a check-up, CUBS increased family knowledge of health and development needs and gave parents ways to support their child’s development at home. One parent told us that ‘I’ve got information on how to maintain their teeth and healthy eating, … stuff that I think I wouldn’t have got before’. Following CUBS, Kiah’s parent understood that Kiah’s motor skills were less developed than other children, so he spent time with her doing activities to develop these skills. As a result, when Kiah started school, Kiah’s teacher noted her confidence, strong fine motor skills and listening skills.

A third of parents in the Phase 2 interviews had received a referral and had attended or made an appointment, or were on waiting lists, although one parent chose not to use the referral. Parents in Phase 2 cited barriers to following up referrals that were similar to those to attending checkups: COVID-19 restrictions, cost, access to transport or technology, family circumstances and not understanding how it would be useful. COVID-19 restrictions had led to the check-ups happening very late in the school year. As a result, there was inadequate time for referrals to be acted upon and support to be in place before children started school.

The participating service providers observed that the agencies working together had ‘changed the experience’ (community) for parents, enabling them to better ‘navigate the system’ (community) which resulted in ‘empowering them to look for the solutions themselves or pointing them in the right direction’ (health). Parents appreciated service providers who took the time to explain their child’s CUBS report and suggest strategies to support their children. The nurse ‘really went out of her way to try and help us out with therapies’ (parent interview Phase 2). In the Phase 2 parent interviews, parents spoke about how the CUBS report was a useful tool to take to other appointments, as evidence, to highlight and legitimise any concerns.

These data demonstrate that for many parents, the CUBS assessment was an enabling process that increased their understanding and gave them the confidence to actively support their children’s health and development.

3.4. Relationship-Based Care

In the focus groups, held before families had experienced CUBS, families viewed CFHNs as supportive, but relevant only when children were infants. Although 80% of parents we surveyed perceived the GP as a source of child development information, we found from the focus groups that parents found it hard to build a relationship with a single GP. Parents in the focus groups explained that feeling a connection to the provider, when that was achieved, was powerful and led to participation and satisfaction. However, many families described facing dismissive attitudes from health professionals in previous encounters (focus groups).

In contrast, parents reported that CUBS builds good relationships (parent Phase 3). Some parents described feeling a rapport with the CFHN, another said ‘The CUBS team are really helpful’. Service providers recognised that many of the families they support are living with trauma, so family-friendly, relationship-based care is particularly important. Examples of helpful professional behaviour were provided in the parent interviews. These included that the nurse took time to explain what was happening and the results of the assessment and made follow-up calls to check in on progress. One service provider described flexibility demonstrated by the nurse to work in a family-centred way: ‘if a parent had made an appointment and didn’t show up, (the nurse) would come in on a different day or a different time to try and work in around that family’ (educator). The availability of brokerage funding to pay for postassessment appointments such as therapeutic or paediatric assessments meant support was accessed where it otherwise would not have been.

Service providers were conscious that care needed to be founded in relationships, and as a result, ‘we refer them on to non-judgemental professionals that are supportive’ (community). Families were referred on to carefully chosen professionals that are able to build relationships.

These data emphasise the scope of the CUBS program as a wrap-around service consisting of both screening and practical intervention to address identified needs and support families in an ongoing way. Supportive relationships between parents and CUBS team members were key factors in parents’ perceptions of the program’s effectiveness.

3.5. Flow of Information

Parents in the focus group expressed frustration with poor information flow from previous health services, which had led to having to tell their story to multiple people, and immunisation records being lost or delayed when they needed them to be provided to Centrelink (the government agency providing incentive payments for immunisations and welfare payments) or preschool. The service providers we interviewed explained that CUBS is intentional work, and these intentions include that information can flow freely between providers.

Cross-disciplinary information flow, for example, between CUBS and early learning services, means more issues are likely to be picked up by a professional. One service provider noted that ‘sometimes (the nurse) picked up things that we hadn’t picked up on and vice versa’ (educator). Participation in the CUBS program in ECEC settings included consent for the information to be used by early childhood educators to write an additional statement to accompany the transition to school document drawn up for each child prior to starting school and sent to the school. This addition reported any concerns about the child’s development. Service providers were enthusiastic that the CUBS report acts to share information in preparation for starting school, and that families and school get ‘a picture of where their child is and areas needing improvement or attention’ (educator).

Some parents reported delays in receiving CUBS information after the assessment (Phase 2 interviews). This is most likely due to assessments happening late in the school year, and the priority was to get children assessed when COVID-19 restrictions were lifted, resulting in a backlog in providing the report and waiting lists for referrals. Similarly, some CUBS assessments were not completed until after the transition to school statement was sent. Some teachers reported not receiving this statement. Sometimes this resulted in the teachers picking up on a child’s developmental needs. Caiden was on a waitlist for speech therapy as a result of CUBS. The kindergarten teacher did not know this, noticed that Caiden needed support, and flagged it up to the school executive.

In other instances, the lack of a report meant that the teacher was unaware of a child’s learning needs. Levi’s preschool teacher had been liaising with the health linker and his school to prepare an NDIS application as a result of the CUBS assessment, but the kindergarten teacher seemed to be unaware of this, believing from her own observations that Levi was ‘flourishing’.

The case studies in Phase 3 also paint a picture of how information sharing can work well. Kyle had received a CUBS assessment with no concerns identified. Kyle’s parents felt the CUBS assessment had confirmed his readiness for school. Kyle’s preschool teacher printed out the CUBS report and sent it to the parents and the school. Kyle’s parents and teacher reported a successful transition. Holly had already been under the care of a paediatrician before the CUBS screening, and the CUBS screening report had been a useful source of information for the kindy teacher to discuss progress with Holly’s carers, and access resources to support Holly’s hearing loss.