Bridging the Gap: using an interrupted time series design to evaluate systems reform addressing refugee maternal and child health inequalities.
BACKGROUND
The risk of poor maternal and perinatal outcomes in high-income countries such as Australia is greatest for those experiencing extreme social and economic disadvantage. Australian data show that women of refugee background have higher rates of stillbirth, fetal death in utero and perinatal mortality compared with Australian born women. Policy and health system responses to such inequities have been slow and poorly integrated. This protocol describes an innovative programme of quality improvement and reform in publically funded universal health services in Melbourne, Australia, that aims to address refugee maternal and child health inequalities.


METHODS
A partnership of 11 organisations spanning health services, government and research is working to achieve change in the way that maternity and early childhood health services support families of refugee background. The aims of the programme are to improve access to universal health care for families of refugee background and build organisational and system capacity to address modifiable risk factors for poor maternal and child health outcomes. Quality improvement initiatives are iterative, co-designed by partners and implemented using the Plan Do Study Act framework in four maternity hospitals and two local government maternal and child health services. Bridging the Gap is designed as a multi-phase, quasi-experimental study. Evaluation methods include use of interrupted time series design to examine health service use and maternal and child health outcomes over a 3-year period of implementation. Process measures will examine refugee families' experiences of specific initiatives and service providers' views and experiences of innovation and change.


CONCLUSIONS
It is envisaged that the Bridging the Gap program will provide essential evidence to support service and policy innovation and knowledge about what it takes to implement sustainable improvements in the way that health services support vulnerable populations, within the constraints of existing resources.
Healthy Mothers Healthy Families Research Group, Murdoch Children's Research Institute, Parkville, 3052, , VIC, Australia. jane.yelland@mcri.edu.au.|Department of General Practice and Primary Health Care Academic Unit, University of Melbourne, Parkville, VIC, Australia. jane.yelland@mcri.edu.au.
Jane
J
Yelland
Healthy Mothers Healthy Families Research Group, Murdoch Children's Research Institute, Parkville, 3052, , VIC, Australia. elisha.riggs@mcri.edu.au.|Department of General Practice and Primary Health Care Academic Unit, University of Melbourne, Parkville, VIC, Australia. elisha.riggs@mcri.edu.au.
Elisha
E
Riggs
Victorian Foundation for Survivors of Torture, Brunswick, VIC, Australia. szwarcj@foundationhouse.org.au.
Josef
J
Szwarc
Victorian Foundation for Survivors of Torture, Brunswick, VIC, Australia. caseys@foundationhouse.org.au.
Sue
S
Casey
Healthy Mothers Healthy Families Research Group, Murdoch Children's Research Institute, Parkville, 3052, , VIC, Australia. wendy.dawson@mcri.edu.au.
Wendy
W
Dawson
Healthy Mothers Healthy Families Research Group, Murdoch Children's Research Institute, Parkville, 3052, , VIC, Australia. dannielle.vanpraag@mcri.edu.au.
Dannielle
D
Vanpraag
Monash Women's Maternity Services, Monash Health, Clayton, VIC, Australia. christine.east@monash.edu.|School of Nursing and Midwifery, Monash University, Clayton, VIC, Australia. christine.east@monash.edu.|The Ritchie Centre, Monash University, Clayton, VIC, Australia. christine.east@monash.edu.
Chris
C
East
Monash Women's Maternity Services, Monash Health, Clayton, VIC, Australia. euan.wallace@monash.edu.|The Ritchie Centre, Monash University, Clayton, VIC, Australia. euan.wallace@monash.edu.|Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia. euan.wallace@monash.edu.
Euan
E
Wallace
Women's and Children's Services, Western Health, Sunshine, VIC, Australia. Glyn.Teale@wh.org.au.|Department Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia. Glyn.Teale@wh.org.au.
Glyn
G
Teale
Maternal and Child Health, City of Greater Dandenong, Dandenong, VIC, Australia. bernadette.harrison@cgd.vic.gov.au.
Bernie
B
Harrison
Maternal and Child Health, City of Wyndham, Wyndham, VIC, Australia. Pauline.Petschel@wyndham.vic.gov.au.
Pauline
P
Petschel
Department of General Practice and Primary Health Care Academic Unit, University of Melbourne, Parkville, VIC, Australia. j.furler@unimelb.edu.au.
John
J
Furler
Centre for Community Child Health, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia. sharon.goldfeld@mcri.edu.au.|Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia. sharon.goldfeld@mcri.edu.au.
Sharon
S
Goldfeld
Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia. fiona.mensah@mcri.edu.au.|Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Royal Children's Hospital, Parkville, VIC, Australia. fiona.mensah@mcri.edu.au.
Fiona
F
Mensah
School of Nursing and Midwifery, Monash University, Clayton, VIC, Australia. maryanne.biro@monash.edu.
Mary Anne
MA
Biro
School of Nursing and Midwifery, Monash University, Clayton, VIC, Australia. suzanne.willey@monash.edu.
Sue
S
Willey
South Eastern Melbourne Medicare Local, Dandenong, VIC, Australia. i.cheng@semml.com.au.|Southern Academic Primary Care Research Unit, Monash University, Dandenong, VIC, Australia. i.cheng@semml.com.au.
I-Hao
IH
Cheng
Judith Lumley Centre, La Trobe University, Melbourne, VIC, Australia. R.Small@latrobe.edu.au.
Rhonda
R
Small
Healthy Mothers Healthy Families Research Group, Murdoch Children's Research Institute, Parkville, 3052, , VIC, Australia. stephanie.brown@mcri.edu.au.|Department of General Practice and Primary Health Care Academic Unit, University of Melbourne, Parkville, VIC, Australia. stephanie.brown@mcri.edu.au.|School of Population Health, University of Melbourne, Parkville, VIC, Australia. stephanie.brown@mcri.edu.au.
Stephanie
S
Brown
D001315:Australia; D057191:Capacity Building / Q000458:organization & administration; D005260:Female; D006297:Health Services Accessibility / Q000458:organization & administration*; D054624:Health Status Disparities; D006801:Humans; D065186:Interrupted Time Series Analysis; D000068101:Maternal-Child Health Services / Q000458:organization & administration* / Q000592:standards; D011247:Pregnancy; D011256:Pregnancy Outcome; D017150:Public Sector; D058996:Quality Improvement / Q000458:organization & administration; D012036:Refugees; D012107:Research Design; D012307:Risk Factors