An Australian study has built on effective strategies for providing First Nations care within Western health services, hoping to address current gaps in health outcomes for Aboriginal children impacted by chronic lung disease.
The co-designed and culturally secure intervention sought to improve medical follow-up for Aboriginal children hospitalised with acute chest infections, and its successful implementation resulted in higher follow-up rates and improved longer-term lung health outcomes for children.
The study, published 10 February 2023 in The Lancet Regional Health – Western Pacific, was co-led by Dr Pam Laird, a senior respiratory physiotherapist with the Wal-yan Respiratory Research Centre – a partnership between Telethon Kids Institute, PCH and the PCH Foundation – and UWA’s Associate Professor André Schultz, who heads the Respiratory Program at the Telethon Kids Institute.
Dr Laird explained that Australian Aboriginal children experience some of the highest rates of acute respiratory infections in the world, with higher severity and poorer outcomes than other Australian children.
“Almost one in five young Aboriginal children hospitalised for an acute chest infection is diagnosed with bronchiectasis within two years of being discharged,” Dr Laird said.
“While national guidelines recommend Aboriginal children receive medical follow-up a month following hospital discharge to ensure any ongoing cough can be treated, this is not widely known and there are not processes in place to facilitate this.”
Aboriginal children hospitalised with acute chest infections are at-risk of developing bronchiectasis, which among First Nations people is associated with early mortality as young as the third and fourth decade of life.
The earliest sign of chronic lung disease after hospitalisation is usually a wet cough for more than four weeks, but if the ongoing wet cough is managed early, bronchiectasis can often be prevented, making effective follow-up after being discharged from hospital essential.
“We conducted a search of the literature [including studies published between 16 September 2002 and 16 September 2022] to examine evidence for any interventions to facilitate medical follow-up for Aboriginal children hospitalised with acute chest infections,” Dr Laird explained.
“While there was good evidence for Aboriginal children being at-risk of developing bronchiectasis following hospital admission for bronchiolitis or pneumonia, there was little evidence for successfully implemented strategies to improve respiratory health outcomes in this at-risk group.
“Culturally secure care is a critical component to providing medical advice or instruction, such as the need for follow-up, [but] unfortunately, while medical follow-up post-hospitalisation is conceptually simple, the process is complex and includes multiple steps with many opportunities for derailment.”
In Aboriginal contexts, good health outcomes are predicated on culturally secure medical care – care that acknowledges Aboriginal families’ distinctive and diverse cultural needs – yet sustained implementation can be even more challenging due to failures to incorporate comprehensive and integrated Aboriginal-driven approaches.
“The implementation of evidence-based interventions within health systems has only been effective in Aboriginal contexts when strategies were based on barriers and facilitators identified by both Aboriginal consumers and their clinicians using combined participatory action research and implementation science methods,” the authors explained.
“In practical terms, this includes the provision of health information that is delivered in a way that resonates with and is understandable to parents and ensures parents feel safe and heard.
“Providing parents with disease-specific health information in a culturally secure way improves knowledge, medical help-seeking, and health outcomes for their children.”
Based on their review the team designed and evaluated the implementation of a hospital-based, culturally secure intervention to facilitate medical follow-up for Aboriginal children hospitalised with chest infections four weeks after discharge from Perth Children’s Hospital (PCH).
The intervention included hospital system changes, hospital staff training, and culturally secure health information with resources being provided for families and was implemented across all relevant departments in the hospital over 16 months.
The core components of the intervention were:
- Aboriginal lead
- Stakeholder engagement to identify and solve implementation barriers
- Training of health care providers (HCPs) to use new processes
- Educational resources for parents provided at admission and discharge
- Hospital processes (new patient admissions and discharge requirements), and,
- SMS text reminder sent to parents one-month post-discharge, to seek follow-up.
Health outcomes before and after the intervention were measured, with 181 children completing the study.
The follow-up rates one month after hospital discharge were significantly higher in those children after the intervention was implemented (50.7%) compared to the children who did not receive the intervention (13.6%), and the improved follow-up appeared to contribute to healthier kids.
After the intervention, the lung health-related quality of life of children with a chronic wet cough aligned with the increase in the percentage of children (57.9%) who received antibiotic treatment one month after being discharged, compared to only 13.3% of children receiving antibiotics in the pre-intervention group.
Dr Laird said the study demonstrates the urgent need for a national follow-up strategy for Aboriginal children who have been hospitalised for acute chest infections, to prevent more serious lung disease.
“This study has demonstrated an effective intervention for improving medical follow up for Aboriginal children hospitalised with acute chest infections, and most importantly, for improving the longer-term lung health of Aboriginal children,” she said.
“We demonstrated that in-hospital strategies to facilitate medical follow-up post-hospitalisation resulted in healthier children six weeks to three months after discharge from hospital.
“Our aim now is to collaborate to scale-up this study as a national clinical trial: we would like to facilitate implementation of a culturally secure follow-up strategy in other regions of Australia, to ensure that Aboriginal children around the nation are receiving effective medical follow-up and treatment.
“And if we can demonstrate wider success in respiratory health then perhaps this strategy can be adapted to address other key health issues for Aboriginal children.”