Submission

Inquiry into child development services in WA

7 November 2022

Select Committee Inquiry into child development services in WA

The Western Australian Council of Social Service Inc. (WACOSS) welcomes the opportunity to contribute a submission to this inquiry.

WACOSS is the peak body for the community services sector in Western Australia and works to create an inclusive, just and equitable society. We advocate for social and economic change to improve the wellbeing of Western Australians, and to strengthen the community services sector that supports them. WACOSS is part of a network consisting of National, State and Territory Councils of Social Service, who advance the interests of people on low incomes and those made vulnerable by the systems that have been put in place.

WACOSS regularly convenes the Children’s Policy Advisory Council (CPAC), which brings together member organisations to ensure a cohesive whole of sector response is developed around children’s policy in Western Australia. Input and insights from attendees at the regular consultative forums are used to directly shape WACOSS policy agenda, engagement with key decision makers, and advocacy to improve outcomes for children, young people and families in Western Australia.

CPAC recently convened a public forum that may be of interest to the committee on Early Childhood Development, Disadvantage and Wellbeing with the WA Social Research Network and the Life Course Centre, Telethon Kids Institute. The forum discussed the latest evidence in early childhood development, disadvantage and wellbeing in Western Australia. Speakers included Prof. Fiona Stanley AC, UNICEF; Jacqueline McGowan-Jones, Commissioner for Children and Young People WA; Dr. Rosemary Cahill, Principal Senior Research Fellow, Telethon Kids Institute; and Gail Clark, AEDC Coordinator, Department of Education. Presentations can be found on the WACOSS website at: https://www.wacoss.org.au/networks/childrens-policy-advisory-council/

Attachments:

WACOSS (2013) Integrating services to support the mental health of infants & young children: Developing the Concepts, Western Australian Council of Social Service: Perth, Western Australia.

WACOSS (2014) Integrating services to support the mental health of infants & young children: Applying the Concepts, Western Australian Council of Social Service: Perth, Western Australia.

Priddis, L.E., Matacz, R.A., Kiely, D., Bayes, S., Barratt-Pugh, C., Pooley, J.A., Lauren, C., Thornton, J., Fitzgerald, H.E. (2018), Better Together: Supporting Perinatal and Infant Mental Health Services. Bankwest Curtin Economic Centre.

Cassells R., Dockery M., Duncan A., Kiely D., Kirkness, M., Nguyen T., Seymour, R., and Twomey C., (2020), The Early Years: Investing in Our Future, Focus on Western Australia Report Series, No. 13, August 2020.

Zubrick, S. (2018) Presentation to WACOSS Early Development Forum. Telethon Kids Institute. Note a version of these slides were part of the Commissioner for Children and Young People WA’s 2018 Early Vulnerability Series. See CCYP (2019) Improving the Odds for WA’s vulnerable children and young people.

Recommendations

• Commission an independent report on child development services in WA that specifically addresses the issues of:
  • Current and future population need & service planning
  • Service models, costs and outcomes in comparison to other jurisdictions
  • Wait times and waiting lists, and what alternative support should be offered in the interim
  • Access and outcomes for at risk population groups (eg low SES areas, Aboriginal, CALD, regional & remote) relative to population need.
• Develop outreach strategies and priority referral pathways for families in crisis or recovering from trauma, including family violence, child protection and homeless services.
• Review screening and referral pathways for early developmental delay, including child health nurses, child and parent centres, and early education and care services. Include simplified referral pathways to speech pathologists and occupational therapists for confirmation and treatment.
• Develop principles and practices for active outreach and effective communication with parents of children experiencing developmental delay to enable them to be part of a sustainable and effective solution.
• Review rates of intellectual disability and neurodiverse diagnoses within WA schools by location in comparison to school services & resources and referral pathways.
• Develop programs for young people whose needs were not identified earlier and no longer fit the priority age range for child development services.
• Increase access to maternal, child and youth mental health services.
• Develop policies and incentives to retain existing skilled early education and care staff, including greater job certainty and improved employment conditions.
• Prioritise the development and provision of childcare services in regional areas as a key support for regional development outcomes.
• Address barriers to childcare access for parents seeking work, particularly single mothers.
• Progress universal access to quality education and care as an economic development priority.

The importance of early child development

The early years are the most critical time in our life. It is when our bodies and brains are developing at their fastest rate and laying the foundations for lifelong development and wellbeing.

Early investment in healthy development is the best way we can ensure our children thrive. Happy, healthy, safe and connected kids grow into well-balanced and resilient young people and into productive and caring adults with fewer health and mental health problems, barriers to social and economic participation. Early development is critical to lifelong capability and potential, and the evidence is very clear that early disadvantages can accumulate to have an impact through the life-course. The sooner we are able to identify and address developmental concerns the better the developmental outcomes.1

We contributed to the development of the report The Early Years: Investing in Our Future released by Bankwest Curtin Economic Centre in August 2020 (attached) which provides a demographic profile of the number and share of children in WA from pregnancy through infancy and toddlerhood to preschool. It covers health and mental health outcomes for mothers and children as well as language development and access to early education and care to develop and present an Early Learning Disadvantage Index.

Table 1 – Within State variation in BCEC Early Learning Disadvantage index

The report highlights the incidence and depth of child poverty within WA, revealing how poverty increases the risk of early developmental delay and creates barriers to access to early learning opportunities and early development services.

1 William Teager, Stacey Fox and Neil Stafford, (2019) How Australia can invest early and return more: A new look at the $15b cost and opportunity. Telethon Kids Institute. See also BCEC (2020) The Early Years (attached), CCYP WA (2019) Improving the Odds for WA’s vulnerable children and young people.

Children living in the most disadvantaged areas in Western Australia are less likely to be accessing the benchmark of 15 hours of preschool each week in their year before school, than the national average. Around one-third of enrolled children are not attending preschool for 15 or more hours each week, compared to only 12.3 per cent of children in the most advantaged areas. Children in the most disadvantaged areas in WA also have high rates of developmental vulnerabilities, with 1 in 3 children assessed as developmentally vulnerable on one or more domain and 1 in 5 developmentally vulnerable on two or more domains.

The report found that 16% of toddlers in WA had socio-emotional competence problems, 24% had behavioural problems and 20% had delayed language development. These numbers increased to 44%, 44% and 40% respectively if the infant was growing up in an environment with limited parental affection or engagement. Approximately 30% of toddlers from households living in severe poverty were estimated to have delays in language development, which is twice the rate of those not living in poverty. 50% of children living in the most disadvantaged areas in Western Australia are developmentally vulnerable on two or more domains, compared with national average of 11%.

Figure 1 – Early learning disadvantage in WA

Table 2 – Most and least disadvantaged areas in early learning in WA

The 2022 BCEC report Behind the Lines: Poverty and disadvantage in Australia adds to this analysis by showing the impacts that growing up in poverty has on adult outcomes. The research shows a strong association between persistent poverty and psychological distress (Figures 2 & 4) and that childhood experience of poverty leads to much poorer employment and financial security outcomes in later life (Figures 3 & 5).

In 2020 in Australia 750,000 children were living in families below the income poverty line, with over 190,000 experiencing severe poverty. People who experience childhood poverty are up to 8 percentage points more likely to remain in poverty in adult life. The chances of securing future employment after a poverty in childhood are up to 11 percentage points lower compared to those who did not come from a poor childhood background, and they are significantly more likely to suffer from nervousness or feel unhappy with their lives for up to 10 years after leaving home.

Figure 2 – The relationship between persistent poverty and psychological distress

Figure 3 – Adult employment rates (age 17 to 30) vs persistent family poverty in childhood

Figure 4 – Impact of childhood poverty on adult outcomes after leaving the family home

Figure 5 – Number of years in poverty and prevalence of psychological distress by gender

Families living in poverty experience a wider range of vulnerabilities and experience much higher rates of social isolation.

Research by Telethon Kids Institute also highlights the effects of poverty. Monks (2017) report The impact of poverty on child development2 finds that poverty in the first five years of life is particularly harmful to children’s development, highlighting children in single parent families are three times more likely to be at risk. It aligns with other TKI analysis (eg Zubrick 2018, attached) that concludes that it is not so much poverty but the impacts that depravation has on early relationships and experiences on young children’s health and development. ‘Working poor’ households for example, where there is both limited access to developmental opportunities and resources, and where parents are time poor and stressed are of particular concern. This analysis suggests that intervening during the early years can break the cycle of disadvantage, if we are able to assist parents to cope effectively with disadvantage to provide consistent and responsive care. Parents under stress are likely to try to shield their children from their negative emotions out of concern, however the risk is that they can then become emotionally unavailable and withdrawn, rather than finding positive ways to engage.

There are some important issues to note here. The relationship with the parent or parents (or primary carer or carers) is the most significant for the developing child. It is the one in which they are most emotionally and developmentally invested and in which they spend the majority of their time. Hence effective interventions to assist developmentally at-risk children also need to include and support the primary carer. It can be helpful to provide other opportunities to connect and socialise with other adults and other children, however the child’s ability to engage and benefit from these activities may be limited by these fundamentals.

The biology and neurobiology of development suggests that early experiences can get ‘under the skin’ in a way that shapes lifelong health. Growing up in chaotic, unpredictable environments where children experience toxic stress can limit early brain development and mean the child is constantly vigilant or easily triggering survival reactions. Children starting early education and socialisation who are less ready and able to engage can be increasingly left behind – early development is a cumulative process and early disadvantages can quickly accumulate. (Shanker)

Monks (2017) also highlights the interaction between socio-economic status and developmental mobility in AEDC data in relation to the capacity of children with poor school readiness to be able to catch up on educational outcomes over time, concluding “despite poor school readiness, children of med-high SES can catch up within the first few years of starting school, but children of low SES do not demonstrate this same level of developmental mobility, and continue on a poor educational trajectory.” Conversely, the data also shows that good school readiness helps children from a low SES background to do well at school, saying “…if a low-SES child starts school with a good level of school readiness (high scores on the AEDC) then this appears to act as a protective factor, and they continue to achieve at an average level of academic achievement throughout school.”

2 H Monks (2017) The impact of poverty on the developing child, Telethon Kids Institute.

Efforts to develop more integrated early childhood services in WA

WA’s current approach to providing support to mothers and children in the early years of life is fragmented and inconsistent – meaning that whether or not those at risk are able to get timely access to advice and support depends on where they live and their capacity to navigate health and social services across multiple government and NFP agencies

Better Together: Supporting Perinatal and Infant Mental Health Services (BCEC 2019 attached) found that parents of infants seeking support struggled to engage with professional services to get meaningful and useful advice they could understand and act on, felt judged and disrespected, and were often frustrated by the lack of simple access and referral pathways.

Service system design needs to put the child and the parents at the centre, taking a wrap around and no-wrong-door approach to ensure that developmental needs and risks are identified early and dealt with effectively in a way that parents can understand and own.

WACOSS, the Mental Health Commission, the City of Cockburn and local child and family services undertook a project in 2012-13 to develop a model for integrating services to support the mental health of infants and young children. This led to the production of two reports Integrating services to support the mental health of infants and young children: Developing the concepts (WACOSS 2013, attached) followed by Applying the concepts (WACOSS 2014, attached).

Around this time, we also helped to establish the Connecting Communities for Kids project in the Cockburn and Kwinana local government areas through the Partnership Forum Early Years Working Group. The project has continued to have a significant impact on children and families in its’ local area by better connecting services and families through an integrated place-based model. However, we were unsuccessful in securing funding for ongoing monitoring and evaluation of the project, so were unable to progress the project’s original intent to pilot a model where the learnings could be shared in partnership to assist other local and regional areas with poor child development outcomes to adopt and adapt similar integrated place-based approaches.

There remains an opportunity to learn from and extend this model elsewhere, and to look more closely at the remaining barriers to family engagement and early child development in this local area, as seen in recent AEDC results for the Cockburn/ Kwinana region.

Addressing the Terms of Reference

We commend the WA Parliament for establishing this inquiry.

Select Committee terms of reference:

• a) the role of child development services on a child’s overall development, health and wellbeing;
• b) the delivery of child development services in both metropolitan and regional Western Australia, including paediatric and allied health services;
• c) the role of specialist medical colleges, universities and other training bodies in establishing sufficient workforce pathways;
• d) opportunities to increase engagement in the primary care sector including improved collaboration across both government and non-government child development services including Aboriginal Community Controlled Organisations; and
• e) other government child development service models and programs operating outside of Western Australia and the applicability of those programs to the State.

As the peak body for the community services sector in WA, our membership includes community-based child and family services and not-for-profit early education and care services, a well as those in areas such as child protection and out-of-home care, youth crisis service and the like. We have less direct insight into child development services in the paediatric health and allied health space, although many of our members interact with and refer to these services to coordinate the support of children in their care. We strongly support the role of Aboriginal Community Controlled Organisations in the delivery of services to Aboriginal children, families and communities, supported the development of the Noongar Family Safety and Wellbeing Council, and continue to work with the Aboriginal Health Council of WA to support the establishment of a state-wide Aboriginal community service peak body. We are currently leading work with the Department of Health to develop a partnership framework and increase collaboration between health services and social services to improve community-based prevention, early intervention and recovery as part of the Sustainable Health Review.

In relation to the terms of reference, we highlight the role of child development services (a) within the broader context of the critical role of the relationship with the parent(s) or primary carer(s) in early child development and wellbeing. We note the importance of the child’s early environment and experiences to healthy early development, including access to quality early education and care services. Universal access to quality education and care should be our starting point, with integration of early development screening for all children into these services, with targeted outreach and support to those families and communities most at risk. We need to have clear referral pathways alongside appropriate and effective parental communications and support.

Timely access to specialist child development services can play a critical role in addressing early development problems and developmental delay, hence issues of equity in access, affordability and waiting lists are of major concern. We want to see greater availability of these services and reduced wait times, particularly in those areas and regions where children are most at risk. These services should work in complement with universal health and education services, and the risk is that gaps in primary care can mean developmental risks are not identified early enough and developmental issues compound to make the task of specialist services more complex, the outcomes less promising, and the costs much greater.

We cannot offer much data or insight in relation to the availability of specialist child development services in metro and regional areas (b), other than reflecting the concerns raised by our members that services are hard to access and waiting lists are long, and that there few services and increasing access barriers for those in regional and remote areas. We have attached some analysis of access to early learning services, preschool enrolment and attendance and child health check data from the BCEC (2020) The Early Years report.

Child and Adolescent Health Service WA (CAHS 2022) data shows increasing demand for discipline referrals, which rose 8% in the last year and 24% over the last 3 years. Demand for autism assessment rose by 12% last year and by 82% in the last 5 years, increasing to 550 formal referrals in 2021-22. Allied service provision also increased by 9%.

WACOSS have little insight to offer specifically in relation to workforce pathways and training of professional staff for specialist development services (c). We draw the committee’s attention to our recent submissions on Delivering a Skilled Workforce for WA, and the Senate Inquiry on Work and Care in relation to the broader workforce attraction and retention crisis in the early education and care sector. There is strong evidence that poor pay and conditions for early childhood educators is limiting access to early education and care services, with many services forced to restrict enrolments, shut rooms or close premises due to a lack of staff, particularly in regional areas and on the urban fringe.

The early education and care workforce is projected to increase by over 10% nationally between 2020 and 2025, requiring an additional 154,000 workers nationally and around 16,000 in WA. Higher rates of workforce development will be needed if we are to increase the workforce participation rate of women within the WA labour market (now up to 64.5%, vs 74.8% for men) and to increase the proportion of women working fulltime (51.5%, vs 82.6% for men).3 Recent member survey data from the United Workers Union indicated that 46% of current workers are burnt out and considering leaving the sector within the next 1-2 years. 4

While the WA Government has announced a program to offer subsidised VET courses for early educators, more is needed to improve retention of existing staff and address the very high dropout rate of new graduates. Skilled staff are needed to provide on-the-job training, mentoring and supervision and to meet legislated standards.

Contact Details

For further enquiries on this submission please contact:

Chris Twomey, Leader Policy & Research, WACOSS Email: chris@wacoss.org.au

3 WA Women’s Report Card 2022. BCEC & Department of Communities. 4 Exhausted, undervalued and leaving: The crisis in early education. United Workers Union, August 2022

Western Australian Council of Social Service
Whadjuk Boodja
Level 2
3 Loftus Street
Boorloo (West Leederville) 6007
Western Australia
08 6381 5300
info@wacoss.org.au\

WACouncilofSocialService
WACOSS
wacouncilofsocialservice
Western Australian Council of Social Service
www.wacoss.org.au

Integrating services to support the mental health of infants and young children:

Developing the Concepts

April 2013

About WACOSS

The Western Australian Council of Social Service (WACOSS) is the leading peak organisation for the community sector in WA, and represents around 300 member organisations and individuals, and over 800 organisations involved in the provision of services to individuals, families and children in the community.

WACOSS advocates for social change that promotes the wellbeing of all Western Australians — particularly disadvantaged and vulnerable people — and has been at the forefront of policy development and advocacy work relating to the early years, and the need for better integrated services in WA. WACOSS has drawn upon its existing policy and advocacy work in preparing this document. For more information, visit http://www.wacoss.org.au/.

About the Mental Health Commission

The Western Australian Mental Health Commission (the Commission), the first to be established in Australia, is responsible for strategic policy, planning, purchasing and monitoring of mental health services. Raising public awareness of mental wellbeing and addressing stigma and discrimination affecting people with mental illness are also part of the Commission’s functions. The Commission’s reform agenda is set out in Mental Health 2020: Making it personal and everybody’s business (Mental Health 2020). The Commission acknowledges that mental health issues have a unique impact on certain groups of people requiring specialised responses and infants, children and youth are a priority population. The engagement of vulnerable infants, children and their families during the formative early years is a high priority for Mental Health 2020. A specific Action Area in Mental Health 2020 is Services Working Together and the Commission is cognisant of the need for agencies and organisations to work together at policy, program and service delivery levels required for prevention, early intervention, treatment and recovery and is continuing to support initiatives to achieve this. For more information, visit http://mentalhealth.wa.gov.au/.

Acknowledgements

In 2012/13, the Mental Health Commission provided the Western Australian Council of Social Service with funding to develop a model for integrating services to support the mental health of infants and young children.

While responsibility for the content of this document rests with WACOSS, we are grateful to the Mental Health Commission’s Infant and Child Mental Health Planning Group members for assisting in the planning of, and for their contributions to, this project. In particular, we wish to acknowledge:

Kate Civitella, Debra Clements, Eric Dillon, Julie Dixon, Dr Caroline Goossens, Alice Gould, Annie Mullan, Ayla Potts, Lynn Priddis, Dr Jonathan Rampono, Elizabeth Seah and Rosemary Woodward.

Suggested Citation: WACOSS (2013) Integrating services to support the mental health of infants & young children: Developing the Concepts, Western Australian Council of Social Service: Perth, Western Australia.

Contents

• 1. Introduction
• 2. What do we mean by the ‘early years’?
• 3. What do we mean by mental health (in the early years)?
• 4. Can an infant have a mental health disorder?
• 5. Why is mental health in the early years important?
• 6. What factors contribute to mental health in the early years?
  • 6.1 Secure attachment between infant and caregiver
  • 6.2 Sound maternal and perinatal health
    • 6.2.1 Perinatal and Infant Mental Health Model of Care & Service Delivery (WA)
  • 6.3 Knowledgeable, skilled and competent caregivers
• 7. How can the mental health of infants be assessed?
  • 7.1 Individual infant-caregiver assessment
  • 7.2 Population assessment
    • 7.2.1 Community Health Nurses
    • 7.2.2 The Australian Early Development Index
• 8. What kinds of services support mental health in the early years?
  • 8.1 Cultural considerations relating to service provision
• 9. What types of models are used for service provision?
  • 9.1 Universal services
  • 9.2 Targeted services
  • 9.3 Intensive services
  • 9.4 Proportionate universal services
• 10. What does service integration mean?
• 11. What does service integration look like in practice?
  • 11.1 The Platforms approach
  • 11.2 The journey towards service integration
• 12. What factors help/hinder service integration?
• 13. How can the effectiveness of integration be measured?
• 14. What would it mean to integrate infant mental health services?
• 15. Conclusion

• 16. References

                                                                         3
      

Please note: For the purpose of brevity in this report, the mental health of infants and young children (those under the age of 5), is sometimes referred to simply as infant mental health. Please keep this in mind as you read this document.

1. Introduction

In 2010, the recently appointed WA Commissioner for Mental Health established the Infant and Child Mental Health Planning Group. The planning group was established to provide a think tank around infant and child mental health that would inform the Mental Health Commission’s strategic thinking on contemporary ways to address need in infant and child mental health. Representatives were invited from the Departments of Health, Communities, Child Protection and the Australian Association for Infant Mental Health West Australian Branch Incorporated (AAIMHI WA). One of the Planning Group’s current projects is exploring the need for an integrated services model to address the mental health needs of children in the early years (up to five years of age, including the perinatal period), as well as their families and carers.

It is recognised that families, especially those with complex and multigenerational mental health difficulties, often require a complex and intensive level of intervention involving a number of different government agencies and organisations to affect positive change and address their interdependent needs.

There are a number of excellent examples of collaborative work occurring in the early childhood and infant and child mental health sectors in Western Australia, however there are also issues such as gaps in services and no common referral pathways. In addition, there is only piecemeal joint-planning between government and non-government agencies and organisations regarding the supports and services required for those infants, children and their families with mental health needs — these are all issues which need to be addressed.

The Western Australian Council of Social Service (WACOSS) has been funded by the Mental Health Commission to develop a model of integrated infant mental health services. The City of Cockburn has agreed to be a partner in this project — providing the location to explore this approach.

A series of documents will be produced by WACOSS as part of this project. The first of these: Integrating services to support the mental health of infants & young children: Developing the Concepts pulls together a collection of existing work across a range of disciplines, including the early years, mental health and community development.

This report is intended to lay the foundation for the more detailed application of the concepts to the Cockburn area, which will be addressed in the second report. A third report, detailing the more operational aspects of the implementation of the approach, will also be produced.

                                                                            4

2. What do we mean by the ‘early years’?

A good beginning to life is well recognised as the foundation for future development, health and wellbeing, not only in the early years, but also throughout life (Elliott, 2006, p. iii).

Today, there is broad acceptance of how critical the phase from birth to the age of three for brain development is for children. This is the phase which “sets the base for competence and coping skills that will affect learning, behaviour and health throughout life” (McCain & Mustard, 1999, p. 1). As a result we have seen growing political and social commitment to investing in the early years, to ensure strong early childhood development, health and education outcomes.

The policies and strategies of federal and state governments in Australia typically define the “early years” as the period from birth to between 5 and 8 years. Current policy debates in Australia are marked by a considerable degree of concern about children’s and young people’s development, and what can be done to “ensure that they grow to be productive adults who achieve their full potential” (ARACY, 2010, p. 1). A range of state and federal government policies and strategies are listed below, alongside their definition of early years:

Table 1: Australian (state and federal) policies and strategies relating to the early years

The Western Australian Perinatal Mental Health Unit (part of the Women’s Health Clinical Care Unit, Western Australian Department of Health) are currently coordinating the development of the

                                                                            5

Perinatal and Infant Mental Health Model of Care. Within this model of care, infant mental health services and needs are being considered within two age brackets — 0-2 years and 2-4 years1.

For the purpose of this project (which focuses on the provision of mental health services in the early years), “under 5” will be used as the definition of early years. This definition has been selected as it provides for consideration of:

1. The provision of mental health services to children prior to the beginning of compulsory education2; and
2. The provision of perinatal mental health services — in recognising the importance of the wellbeing of the mother (and other family members) for an infant3.

The management and treatment of mental and socio-emotional health issues across this age period will have a strong impact on a child’s school readiness (in terms of their capacity for learning, developing positive peer relationships and managing their emotions), as well as longer-term outcomes.

3. What do we mean by mental health (in the early years)?

The Mental Health Commission of Western Australia describes good mental health as

… a sense of wellbeing, confidence and self-esteem. It enables us to fully enjoy and appreciate other people, day-to-day life and our environment. When we are mentally healthy we can:

• form positive relationships
• use our abilities to reach our potential
• deal with life’s challenges (Mental Health Commission, 2010a).

The KidsMatter Early Childhood Development Mental Health Initiative4 describes mental health (in children) as follows:

Mental health is about having a healthy mind and body, and influences how we feel about ourselves, what we do, how we think, and how we relate to others. Good mental health helps us to form positive relationships with others, handle ups and downs and generally enjoy life. With good mental health, children can

1 For more about the Perinatal and Infant Mental Health Model of Care, see section 6.2.1 Perinatal and Infant Mental Health Model of Care & Service Delivery (WA). 2 In Western Australia, schooling is compulsory from the beginning of the year in which the child reaches the age of 6 years and 6 months — in this year the child must be enrolled in Year 1. From 2013, a child’s enrolment in pre-primary education (in the year they reach the age of 5 years and 6 months) is compulsory. 3 Perinatal mental health is defined as the “emotional and psychological wellbeing of women, encompassing the influence on infant, partner and family, and commencing from preconception through pregnancy and up to 36 months postpartum” (State Perinatal Reference Group (2003) in Department of Health WA, 2012). 4 KidsMatter Early Childhood is a national mental health promotion, prevention and early intervention initiative specifically developed for early childhood services. “It involves all the people who make a significant influence on young children’s lives -families, early childhood professionals along with a range of community and health professionals - in making a positive difference for young children’s mental health during this important developmental period” (Beyond Blue, 2012).

                                                                            6

feel good about themselves and be more open to trying and learning new things. Good mental health in early childhood lays the foundations for positive mental health and wellbeing now and into the future (KidsMatter, 2012b).

Infant mental health has also been described as follows:

In its simplest terms it’s about relationships - promoting and supporting nurturing relationships for all infants [and young children]. It’s about having the first relationship be a solid base for the next one and all the ones in the future. It’s about learning to trust that our physical and emotional needs will be met. And it’s about being able to use those trusting relationships to become healthy, productive adults. After all, it’s because of healthy relationships that we desire to please our parents and become socialized beings. It’s because of relationships that we care about our neighbours. So Infant Mental Health is about prevention and early intervention in assuming positive growth and development (Michigan Association for Infant Mental Health, 1993, in Minnesota Infant Mental Health Project, 2002).

ZERO TO THREE: The National (US) Centre for Infants, Toddlers and Families, has provided another popular definition of infant mental health. They describe infant mental health as being a young child’s ability to:

… experience, regulate and express emotions; form close and secure interpersonal relationships; and explore the environment and learn all in the context of family, community and cultural expectations for young children. Infant mental health is synonymous with healthy social and emotional development (ZERO TO THREE: Infant Mental Health Task Force, 2002).

The ZERO TO THREE definition above also draws an important link between the phrases “infant mental health” and “social and emotional development.” These are two terms which are often used interchangeably, as explained below:

While the term ‘mental health’ is relatively new in early childhood education and care, it is closely connected to children’s ‘emotional and social wellbeing’, which have long been seen as core aspects of quality provision. Skilled early childhood practitioners are aware that all aspects of a child’s development and welfare are interrelated and that, as significant adults in young children’s lives, they play a crucial role in establishing the foundations for current and future wellbeing and resilience (ECA & SNAICC, 2007, p. 17).

The social and emotional well-being of young children is directly tied to the emotional functioning of their caregivers and the families in which they live.

When these relationships are abusive, threatening, chronically neglectful, or otherwise psychologically harmful, they are a potent risk factor for the development of early mental health problems. In contrast, when these relationships are reliably warm, responsive, and supportive, they can actually buffer young children from the adverse effects of other stressors. It is essential to treat young children’s mental health problems within the context of their family,

                                                                            7

home, and community environments. Stated simply, addressing the stressors affecting a child requires addressing the stressors on his or her family in order to ensure that the critical environment of relationships can be maximally supportive (National Scientific Council on the Developing Child, 2008, p. 5).

4. Can an infant have a mental health disorder?

There is some community resistance to the idea that mental health problems can be present in childhood, and particularly in the early years. As Zeanah et al (2005b, p.5) explain, this discomfort comes from several sources, including:

… a negative association of “mental health” with major mental illness, the belief that early childhood is essentially a happy time makes it difficult to imagine that infants can have mental health problems, as well as general and cultural biases about mental health…

For this reason, the Centre for Community Child Health (2012, p.4) argues that education is needed to build community understanding about mental health in the early years:

Community education about mental health and mental illness, including its occurrence in early childhood, is needed in order to increase the knowledge and capacity of both parents and professionals. This can be supported by continuing to provide and enhance opportunities to understand child development.

While it may seem difficult at first to entertain the idea that infants can have a mental health disorder, there is growing clinical experience and growing data that shows that, as a result of a number of factors, infants may have diagnosable disorders which require mental health treatment (Zeanah, Stafford, Nagle, & Rice, 2005b). As the National Scientific Council on the Developing Child explains:

Contrary to popular belief, young children can and do experience serious emotional problems that are comparable in severity to what we observe in older children and adults, and can have lasting effects. Although young children are not as psychologically sophisticated as adults, research on early childhood development shows that they are capable of experiencing peaks of joy and elation as well as depths of grief, sadness, hopelessness, intense anger, and rage. Contrary to traditional views, highly negative emotional experiences in early childhood are not “forgotten” — they are built into the architecture of the developing brain and can have a sustained impact that extends well into the adult years, especially when they are severe, persistent, and uncontrollable. Aversive family and community environments can have a similarly enduring emotional impact on young children when they are experienced as toxic stress and not buffered by supportive relationships (National Scientific Council on the Developing Child, 2008, p. 5).

Much of the work in the area of infant mental health relates to the prevention of mental health problems and related-developmental vulnerabilities — ensuring infants and young children have

                                                                            8

quality early relationships and experiences. However, for young children who show clear characteristics of mental health problems such as anxiety disorders, attention-deficit/hyperactivity disorder, conduct disorder, depression, post-traumatic stress disorder at a very early age, it is important to ensure appropriate services are available to them (and to their families) (National Scientific Council on the Developing Child, 2008).

The notion of intervention in infant mental health has broad reach when a public health approach to infant mental health is applied, having a community- or population-level focus… All infants and toddlers could benefit from public health efforts to create health-promoting communities. Children at risk (especially those children affected by prenatal health challenges, family trauma or disruption, parental depression or mental illness, poverty, abuse, or exposure to violence) need a safety net of infant mental health services (Nelson & Mann, 2011, p. 131).

5. Why is mental health in the early years important?

The human brain is a “work in progress”, beginning before birth and continuing through the lifespan. However, neuroscientists have found that the first three years are the period of the most rapid growth, during which there are specific sensitive periods for optimal learning in particular areas (MCEECDYA, 2010). The early years are a time of rapid development of the brain, and the quality of development in this window has lifelong consequences (Human Early Learning Partnership, 2011; Centre for Community Child Health, 2012a; Bayer, et al., 2009).

What happens in the early years has an impact on outcomes later in life. In Australia, inequalities emerge very early in life, evident from birth. By the time children begin school, they are already distributed along a social gradient and the window of opportunity for making a difference has narrowed. Both early disadvantage and advantage continues to accumulate, widening the gap and increasing inequality (Goldfeld, 2012, p. 9).

James J. Heckman, the 2000 Nobel Prize winner in Economic Sciences (with Daniel McFadden), has written extensively on the productivity argument for investing in children when they are young. He contends that “an accumulating body of evidence suggests that early childhood interventions are much more effective than remedies that attempt to compensate for early neglect later in life” (Heckman & Masterov, 2004, p. 1).

A large body of empirical work at the interface of neuroscience and social science has established that fundamental cognitive and non-cognitive skills are produced in the early years of childhood, long before children start kindergarten. The technology of skill formation developed by economists shows that learning and motivation are dynamic, cumulative processes. Schooling comes too late in the life cycle of the child to be the main locus of remediation for the disadvantaged. Public schools focus only on tested academic knowledge and not the non-cognitive behavioural components that are needed for success in life. Schools cannot be expected to duplicate what a successfully functioning family gives its children.

                                                                            9

Parental environments play a crucial part in shaping the lives of children (Heckman & Masterov, 2007, p. 34).

Heckman’s work indicates that the effects of disadvantage appear early and accumulate over time. He also argues that remedying the effect of such disadvantage at later ages is expensive, and often cost prohibitive:

Skill begets skill; learning begets learning. Early disadvantage, if left untouched, leads to academic and social difficulties in later years. Advantages accumulate; so do disadvantages. Another large body of evidence shows that post-school remediation programs like public job training, GED certification and the like cannot compensate for a childhood of neglect for most people. Moreover, early investment is far more cost effective, in that it can achieve the same results, but at a lower cost (Heckman & Masterov, 2007, p. 3).

To keep young children healthy and happy, and to contribute to their longer-term development, attention must be paid to both their physical and mental health. Children’s mental health is important because “(s)ocial and emotional skills support virtually every other aspect of a child’s development, including learning, school readiness and cognitive and language development” (KidsMatter, 2012a, p. 8). This is because throughout life, learning happens within and through relationships and as a result, infants who experience poor social and emotional development may have negative experiences with regards to learning, development, mental health and wellbeing (KidsMatter, 2012a).

Social and emotional development encompasses a number of skills that children need to develop in order to succeed at school, and in life in general. These include the ability to identify and understand one’s feelings, accurately read and comprehend emotional states in others, manage strong emotions and their expression, regulate one’s behaviour, develop empathy for others, and establish and sustain relationships. These skills form the basis for self-regulation, enabling children to withstand impulses, maintain focus and undertake tasks regardless of competing interests (AIHW, 2009, p. 60).

As Nelson & Mann (2011, p. 129) explain:

The infant and toddler years are far from being a period of transitory challenges and reversible effects, and conditions in those years can lay the groundwork for lifetime mental wellness.

The significance of social and emotional wellbeing in the early years — and, as such, the need for communities to pay attention to and ensure adequate investment in services supporting infant mental health — couldn’t be more clear.

                                                                          10

6. What factors contribute to mental health in the early years?

An infant’s development is affected by both intrinsic factors (including biological, genetic, and constitutional make-up), and extrinsic factors (including the infants’ environment and relationships). These factors are dynamic, interact with each other, and all of these factors need to be considered when developing and administering infant mental health programs and services (Zeanah P. , Stafford, Nagle, & Rice, 2005b).

While genetic predisposition increases the likelihood of a young child experiencing mental health problems, genes are not destiny. As the Center on the Developing Child explain:

Our genes contain instructions that tell our bodies how to work, but the environment leaves a “signature” on the genes that authorizes or prevents those instructions from being carried out — or even speeds up or slows down genetic activity. Thus, the interaction between genetic predispositions and sustained, stress-inducing experiences early in life can lay an unstable foundation for mental health that endures well into the adult years (Center on the Developing Child, 2012).

The fact that genetics alone will not cause mental health problems in a young child is why this project’s focus is on the extrinsic factors, rather than the intrinsic (or genetic) factors which contribute to a young child’s social and emotional wellbeing. These are the factors over which caregivers and service providers can have some influence.

In her 2011 Report of the Inquiry into the mental health and wellbeing of children and young people in Western Australia, the Commissioner for Children and Young People identified long lists of risk and protective factors which impact the social and emotional wellbeing in children and young people. The report divides the risk and protective factor lists into five groups: individual factors, family factors, school context, life events and situations, and community and cultural factors (CCYP, 2011, pp. 35-37). While some of the factors identified do not relate to the under 5 age-range of this report, many relate to the major factors described in more detail below.

Some of the major environmental (or extrinsic) factors which can influence an infant or young child’s social and emotional wellbeing (and which help to prevent mental health problems and mental disorders later in life) include:

• Secure attachment between infant and caregiver

• Sound maternal and perinatal health, and

• Knowledgeable, skilled and competent caregivers who have access to support services and networks (Department of Health & Ageing, 2000, p. 74).

                                                                          11
  

6.1 Secure attachment between infant and caregiver

Attachment theory was introduced by psychoanalyst John Bowlby in the late 1950’s. Attachment theory states that:

… a child’s first relationship is a love relationship that will have profound long- lasting effects on an individual’s subsequent development. Closeness to the attachment figure provides protection and a psychological sense of security… A caregiver who is reliably available and responsive to a baby’s needs forms the basis for secure attachment, for competence in exploring the environment and forming other relationships, and for developing self-esteem (Colin, 1991).

As Onunaku, (2005, p.4) describes:

Babies are hardwired to develop strong, emotional connections, or attachment, with their primary caregivers. The ability to attach to a significant adult allows young children to become trusting, confident, and capable of regulating stress and distress. The most important part of attachment is the quality of attachment formed, as it predicts later development. Ideally, children develop secure attachment (a healthy emotional bond) with caregivers. Infants who develop secure attachment with a primary caregiver during the early years of life are more likely to have positive relationships with peers, be liked by their teachers, perform better in school, and respond with resilience in the face of adversity as pre- schoolers and older children.

Attachment is integral to the emotional development of the young child; babies need to become attached to at least one close, trusting adult. In fact, the innate need to attach is so strong that an infant will even develop an emotional connection with inconsistent and insensitive caregivers if optimal care is unavailable.

An infant’s style of attachment can be categorised as secure, insecure or disorganised. The table below provides a brief description of each attachment style, the kind of responses you might see from caregivers, and infants’ behaviour:

Table 2: Infant attachment relationship styles (Bunston & Sketchley, 2012, p. 16)

                                                                          12

| | to the infant’s signals and emotional needs. | controlled emotions; avoidance of affection; focus on exploration of the environment to avoid closeness. | | Insecure (ambivalent) | Inconsistent or unpredictable emotional availability and response to the infant’s attachment behaviours and emotional needs (for example, at times over-protective or over-stimulating and at other times rejecting or ignoring). | Overly engaged with attachment figure and may feel too anxious about the caregiver’s emotional availability to freely explore the environment. | | Disorganised | Unresponsive, intrusive, hostile or violent; some parents are frightening to their infants, others may be frightened due to past or continuing trauma. | Responses to the caregiver look chaotic and contradictory; the infant is trying to reconcile the impulse to approach for care with their need to avoid seeing the caregiver as a source of fear; observable reactions and behaviours may include hyper-vigilance, freeze or fear when the parent appears, dissociative behaviours such as a dazed expression, appearing emotionally numb or cut off, or not crying when distressed or hurt. |

In a review of 80 studies on disorganised attachment done over a period of approximately 10 years in the United States, it was concluded that approximately 15% of infants in middle class families in the United States develop disorganised attachment behaviour (van Ijzendoorn, Schuengel, & Bakersmans-Kranenburg, 1999, p. 225). For children of mothers with alcohol or drug abuse issues, the percentage of disorganised infants was 43%. Similarly, 48% of children with maltreating parents were found to have a disorganised attachment style (van Ijzendoorn, Schuengel, & Bakersmans-Kranenburg, 1999, p. 223).

While secure attachment can predict positive outcomes in a child’s socio-emotional development, insecure and disorganised attachment can predict future problems (Onunaku, 2005, pp. 4-5). Early disturbances in a child’s attachment experiences (resulting in insecure or disorganised attachment) have been shown to lay the foundations for psychopathology in adolescence (Sroufe, Carlson, Levy, & Egeland, 1999, p. 10). Research has also indicated that an infant who develops an insecure attachment to their primary caregiver is more likely to be at risk of developing learning delays, relationship dysfunction, difficulty expressing emotions, and future mental health disorders (Onunaku, 2005, pp. 4-5).

6.2 Sound maternal and perinatal health

There is an increasing body of evidence which shows that the physical and mental health and wellbeing of the mother in the perinatal period can directly impact the health of the infant.

If a mother experiences poor physical or mental health in the postnatal and antenatal periods, this can have a significant impact on the child’s

• Antenatal refers to the period during pregnancy, and prior to birth.

• Postnatal refers to the period immediately following birth.

• Perinatal refers to the period which commences after 20 completed weeks (140 days) of gestation and ends 28 completed days after birth. (This period encompasses parts of both the antenatal and postnatal periods.)

                                                                          13
  

development. A child can be adversely affected during this time by factors including the physical and mental ill-health of the mother; poor nutrition; poor antenatal care; exposure to nicotine, alcohol and illicit substances; exposure to stress and trauma; and poor emotional attachment to the developing foetus/infant. Such factors put the health, growth and development of the foetus and/or infant at risk (Queensland Health 2012). If issues relating to the caregiver’s health means that they fail to “respond to the baby’s needs in a nurturing manner, the child’s development can be compromised” (Minnesota Infant Mental Health Project, 2002).

6.2.1 Perinatal and Infant Mental Health Model of Care & Service Delivery (WA)

A Perinatal and Infant Mental Health Model of Care and Service Delivery (the Model of Care) is currently being developed in Western Australia. The Model of Care both aligns with, and is informed by, key state and national health and mental health frameworks and policies, such as the WA Perinatal and Infant Mental Health Strategic Framework5.

The aim of the Model of Care is to define evidence-based, best practice service delivery — including prevention, treatment and management — across the perinatal and infant continuum of care6. Central to the model is the aim of ensuring that people receive the right care, at the right time, from the right team in the right place. The Model of Care seeks to provide a foundation on which to plan and deliver services which contribute to optimal emotional health and wellbeing for women, infants and families in Western Australia. The Model of Care is built on the knowledge, service delivery models, and capacity of existing programs, services and strategies, and will be used to identify gaps in service provision, and make recommendations on how to address these.

The development of the Model of Care is being overseen by a multi-disciplinary, cross-sector agency working group. A range of government, non-government and consumer representatives (with perinatal and infant mental health expertise) have been consulted with, and sub-groups have worked collaboratively on the writing of the Model of Care. It is anticipated the Model of Care will be available by June 2013.

The guiding principles of the Model of Care are congruent with this document. It is expected that the two documents will complement each other and be an invaluable blue print for services into the future.

6.3 Knowledgeable, skilled and competent caregivers

Both the wellbeing and life circumstances of a child’s caregivers can have a profound effect on the quality of the infant/caregiver relationship (ZERO TO THREE: Infant Mental Health Task Force, 2002). The quality of the infant/caregiver relationship is critical to a child’s development, because :

Through relationships with parents and other caregivers, infants and toddlers learn what other people expect of them and what they can expect of other people. Nurturing, protective, stable, and consistent relationships are essential to young children’s mental health (ZERO TO THREE: Infant Mental Health Task Force, 2002).

5 The strategic framework for Perinatal and Infant Mental Health in Western Australia was developed in 2011 to provide direction for the Model of Care. 6 This continuum of care includes the pre-conception, antenatal, intrapartum, postnatal and infant periods.

                                                                          14

Factors identified as increasing the risk of mental health problems in young children include:

• the lack of a warm, positive relationship with parents;
• insecure attachment between carers and infants;
• harsh, inflexible or inconsistent discipline;
• inadequate supervision of, and involvement with, children;
• marital conflict and breakdown; and
• parental psychopathology (particularly maternal depression and high levels of parenting stress) (Sanders, 2002).

These factors increase the risk of young children developing major behavioural and emotional problems in later childhood, including conduct problems, substance misuse, antisocial behaviour and participation in delinquent activities (Sanders 2002, p. 87).

Studies have found that up to 80% of the time an infant’s style of attachment (discussed earlier in 6.1 Secure attachment between infant and caregiver) can be predicted based on their parent’s attachment style (Fonagy, 1999). That means that parents who experienced insecure attachment in their own infancy and early childhood are more likely to build an insecure attachment relationship with their own child. This happens because new mothers’ and fathers’ knowledge of parenting tends to come from their own experiences of being parented as young children.

The introduction in the 1980s of the Adult Attachment Interview (AAI) by Mary Main and her colleagues provided a tool for examining the relationship between parental and infant attachment styles. The AAI is

…a semi-structured interview that probes [adults] alternately for general descriptions of attachment relationships, specific supportive memories, and descriptions of current relationships with parents and other attachment figures. Participants are asked to retrieve attachment-related autobiographical memories from early childhood and to evaluate these memories from their current perspective (Bakermans-Kranenburg & van IJzendoorn, 2009, p. 224).

Like an infants’ style of attachment can be categorised as secure, insecure (avoidant), insecure (ambivalent) or disorganised, an adult’s attachment style can be categorised as secure (autonomous), insecure (dismissing), insecure (preoccupied) or disorganised (unresolved) (Miles & James, 2009).

The development of the AAI has expanded understanding of intergenerational patterns of attachment, and the transmission of intergenerational trauma. An individual’s earliest relationship experiences provide a lens through which they view, experience and shape all of their future relationships. Parents who experienced insecure or disorganised attachment may need access to specialised infant mental health interventions to assist them to unhook their past experiences from both their own, and their child’s, future experiences.

While the skills and competencies of parents and caregivers are a key contributor to a child’s mental health, it is also important to remember that the caregiver’s broader circumstances affect both their ability to parent well, and their ability or willingness to access services which may improve their parenting skills:

                                                                          15

Because infants are so dependent on their parents or primary caregivers, whatever affects the adult has an effect on the child. Families without financial and social supports are at greater risk for negative outcomes. If an adult is experiencing a life situation that prevents them from parenting well, such as depression, poverty, family or community violence, homelessness, chemical dependency, or social isolation, there can be a profound impact on the wellbeing of the child (Minnesota Infant Mental Health Project, 2002).

7. How can the mental health of infants be assessed?

The monitoring and assessment of mental health in the early years can be undertaken at both individual and population levels.

7.1 Individual infant-caregiver assessment

A wide range of people and organisations have (or may potentially have) a role to play in the monitoring and assessment of the mental health of infants and young children (and their families). The role each person or organisation may play in the assessment varies considerably, and may include clinical/diagnostic services, child-specific support services, or services which support the physical and/or mental wellbeing of a parent or family. Others may just be individuals who, through the course of their work have regular contact with a family, providing opportunities to observe the behaviour and wellbeing of a child, and their relationship with their caregiver(s).

Such people and organisations include (but are not limited to):

Table 3: People & organisations with a role in monitoring and assessing infant mental health in Western Australia

                                                                          16

There are many challenges involved in the screening, assessment and evaluation of the mental health of infants and toddlers compared with older children and adults. These challenges include the fact that:

• Young children have no or limited expressive language skills and can’t “tell” you what they know or think;
• Each area of development is influenced by every other area of development and it is difficult to tease apart where a problem may occur;
• Young children are changing at an incredible rate;
• Children’s behaviour reflects the values and culture in which they are raised and any judgment about child development must be done with sensitivity to cultural influences;
• Developmental problems in young children can be subtle and it takes much experience and knowledge of infant development to build acute observation and interpretation skills (Early Head Start National Resource Center, 2000).

Even though infants and young children may not be able to communicate verbally, signs that a child is experiencing difficulties in their relationships with their caregivers may be indicated by: “persistent difficulties for the infant with sleeping, settling and eating; tantrums or inconsolable crying; persistent separation anxiety; failure to thrive with no organic basis; significant sustained behaviour changes such as infants who become withdrawn, sleep too much or who are unusually quiet and/or disinterested in people” (AAIMHI WA, Undated).

From a clinical perspective, diagnosing mental health problems in adults and older children is very different to diagnosing infants and young children. Clinicians working with adults and older children

…rely on the symptoms reported by patients and their own observations to make a diagnosis. Clinicians can compare the patent’s symptoms with the standardised lists of symptoms and criteria contained in diagnostic manuals such as the [Diagnostic and Statistical Manual of Mental Disorders] (Fitzgerald, 2012).

Clinicians working with infants and young children rely on direct observations of the child and their family, symptoms reported by parents, and observation and collection of data about the child in differing environments, for example: day care, extended family and preschool.

While the Diagnostic and Statistical Manual of Mental Disorders (DSM)7 is relevant to the diagnosis of mental health problems in infancy and early childhood, for clinicians working with infants and young children, the DSM is complemented by the DC:0-3 diagnosis guidelines developed by ZERO TO THREE (published in 1994). These guidelines were developed specifically to “address the need for a systematic, developmentally based approach to the classification of mental health and developmental disorders in the first four years of life” (ZERO TO THREE, 2012).

7 The Diagnostic and Statistical Manual of Mental Disorders (DSM) is one of the key resources used by clinicians and psychiatrists to diagnose psychiatric illnesses.

                                                                          17

7.2 Population assessment

7.2.1 Community Health Nurses

Community health nurses in Western Australia offer all children aged 0-6 years universal child health and developmental assessments:

Acknowledging that parents are the best source of information about their own children, the Parent Evaluation of Developmental Status (PEDS), a parent completed screening tool, is offered to all parents and caregivers of children at the 3-4 months, 8 months, 18 months and three year old child health assessments, and again at school entry (4 to 6 year olds) (Department of Health, 2013).

Depending on the results of the PEDS, parents may be encouraged to complete a more detailed child development questionnaire (the Ages and Stages Questionnaire) which has a separate section addressing the infant and young child’s social and emotional development.

However, access to community health nurses — and thus use of the PEDS — is an ongoing issue in Western Australia. The 2009 Education and Health Standing Committee report Healthy Child—Health State: Improving Western Australia’s Child Health Screening Programs found that:

… the Inquiry reinforced early research findings dating back to 1999 that child development services are inadequately staffed. This is currently more noticeable in metropolitan primary schools. In 2008 the Department of Health prepared a business case for the previous government seeking an additional 126 full-time equivalent (FTE) in the Child Development Service, 105 FTE Community Child Health Nurses and 135 FTE for School Nurses (Parliament of Western Australia, 2009, p. xi).

In 2010, the Auditor General of Western Australia found that “while 99 per cent of newborns in the metropolitan area received recommended child health checks in 2009-10, only 30 per cent of 18 month olds and nine per cent of 3 year olds received the recommended checks” (Office of the Auditor General, 2010).

In its 2012-13 State Budget, the Western Australian State Government committed $59 million over four years for non-government organisations to employ an additional 100 community health nurses (Government of Western Australia, 2013). However, the growing numbers of births in Western Australia, the escalation in migration to the State, and the historical shortfall of nurses identified by the Education and Health Standing Committee, mean access to universal child health and developmental assessments is an ongoing concern.

7.2.2 The Australian Early Development Index

The Australian Early Development Index (AEDI) is a current, population-based measure of young children’s development. The AEDI is based on the Canadian Early Development Instrument (EDI), and has been adapted for use in Australia.

In Australia, the Canadian EDI checklist was first trialled in the northern metropolitan suburbs of Perth in 2002 and 2003, with around 4,300 children. In 2003, Australia began the adaption of the EDI - now called the Australian EDI, or

                                                                          18

AEDI. This adaptation was carried out by The Centre for Community Child Health in

partnership with the Telethon Institute for Child Health Research, Perth.

The AEDI was then piloted in 60 communities across Australia between 2004 and 2008. Following the successful pilot of the AEDI, the Australian Government provided $21.9 million for national implementation in 2009.

In 2010, a follow up data collection occurred in some small areas and the Australian Government increased funding to $24.5 million to incorporate the AEDI Local Champions program (Royal Children’s Hospital, 2010).

When undertaking the AEDI measurements, teachers complete a checklist for children in their first year of full-time school, and report on five key areas of early childhood development:

• Physical health and wellbeing — whether a child is healthy, independent, ready for school each day;
• Social competence — looks at how a child plays, gets along with others and shares, is self-confident;
• Emotional maturity — whether a child is able to concentrate, help others, is patient, not aggressive or angry;
• Language and cognitive skills — whether a child is interested in reading and writing, can count and recognise numbers and shapes; and
• Communication skills and general knowledge — whether a child can tell a story, communicate with adults and children, articulate themselves (DEEWR, 2011).

Two of the areas which the AEDI measures — social competence and emotional maturity — are directly related to a child’s mental health in the early years. A child’s mental health affects their capacity to learn and to explore their environment — factors critical to school readiness.

AEDI vulnerability (in a child’s first year of schooling) has been shown to be a strong predictor of poor school outcomes (measured by NAPLAN results in year 7)8, as illustrated in Figure 1:

8 In an early years seminar for the Western Australian Commissioner for Children and Young People in 2012, leading Canadian child development researcher Prof Clyde Hertzman described findings which showed Canada’s EDI results to be a similarly strong predictor of success in Grade 4 (Hertzman, 2012, p. 33).

                                                                          19

Figure 1: AEDI vulnerability predicts school outcomes (Brinkman, 2012)

The 2009 AEDI survey found that in Western Australia:

• 7.7% of children were considered developmentally vulnerable (below the 10th percentile) in the social competence domain; and
• 8.8% of children were considered developmentally vulnerable (below the 10th percentile) in the emotional maturity domain (Telethon Institute for Child Health Research, 2011).

While the AEDI does not identify individual children with specific developmental vulnerabilities, it does provide communities with evidence which can be used to inform a community’s policy and planning related to early childhood development. That is, communities can use AEDI data to determine what’s working well and/or what needs to be improved or developed in their community to better support young children and their families.

8. What kinds of services support mental health in the early years?

As discussed in section 7.1, a wide range of people and organisations have (or may potentially have) a role to play in the monitoring and assessment of the mental health of infants and young children (and their families). There exists considerable variability in the current delivery of infant mental health services. This variability can be seen in the range of:

• Intervention sites — ie. clinic, home, child care setting;

• Type of provider — ie. nurse, paraprofessional, mental health clinician;

• Severity of problem — ie. no problem/prevention, parenting or family problems or severe child behaviour/emotional problems. (Zeanah, Stafford, & Zeanah, 2005a, p. 3)

                                                                          20
  

There is also variability in whom different services target — whether this be the infant, toddler, parent, or the wider family. Some service providers also offer different services to young children based on the age of the child, or their disability (such as autism, intellectual delay or cerebral palsy). The National Scientific Council on the Developing Child (2008, p. 7) argues that:

• Because young children’s emotional well-being is tied so closely to the emotional status of their parents and non-family caregivers, the emotional and behavioural needs of infants, toddlers, and pre-schoolers are best met through coordinated services that focus on their full environment of relationships.
• Therapeutic help for a young child with emotional or behavioural problems can be provided through a combination of home- and centre-based services involving parents, extended family members, home visitors, providers of early care and education, and/or mental health professionals.
• Mental health services for adults who are parents of young children would have broader impact if they routinely included attention to the needs of the children as well.

However, as Nelson & Mann (2011, p. 130) have identified, traditionally mental health policies and funding has

… focused primarily on providing mental health treatment for older children and adults — often ignoring or minimizing important opportunities to promote, prevent, and treat the mental health needs of infants and toddlers. An emerging public health approach to infant mental health recognizes that strengthening social-emotional health in the early years can support life-long mental wellness.

The provision of funding for mental health services in Western Australia has typically been no different. Similarly, in recognising the importance of early intervention, in July 2012, the Stokes Report into public mental health facilities/services in Western Australia included a recommendation from the Commissioner for Children and Young People that:

Funding to the State’s Infant, Child Adolescent and Youth Mental Health Service be increased so it is able to provide comprehensive early intervention and treatment services for children and young people across WA, including meeting the needs of those with mild, moderate and severe mental illness (Stokes, 2012, p. 19).

Balanced investment — that is, providing a full range of support and services from promotion, prevention and early intervention to treatment and recovery — is one of the three key reform directions in Mental Health 2020: Making it personal and everybody’s business, the Mental Health Commission’s ten-year strategic policy document (Mental Health Commission, 2010b).

                                                                          21

8.1 Cultural considerations relating to service provision

In planning and delivering services, it is also important to consider the needs of both Aboriginal and culturally and linguistically diverse (CaLD) children and families. It is particularly important for staff to be aware of the fact that they

…bring their own cultural norms to their interactions with clients, other services and staff colleagues. It is incumbent on all staff to be aware of how one’s own cultural norms are similar or different to those of others, and how those similarities and differences can be played out in everyday tasks, roles and responsibilities. The development of one’s own and the organisation’s cultural competence is a responsibility that rests with all (Department for Child Protection, 2010, p. 2).

The cultural-sensitivity, accessibility, and sense of inclusivity and welcoming that services offer are all factors which are likely to influence whether or not CaLD and Aboriginal families will access services.

The higher rates of social and emotional vulnerability amongst Aboriginal children in Western Australia warrant particular consideration. The Western Australian Aboriginal Child Health Survey (published in 2005) identified a range of environmental factors which impact disproportionately upon Aboriginal children:

Compared to the general population, carers of Aboriginal children have lower levels of education. About one third of carers of Aboriginal children left school prior to the completion of ten years of compulsory education. Carers are more likely to have serious chronic illnesses and conditions that compromise their capacity to care. Amid a significantly higher rate of unemployment, employment that is available and undertaken is generally at a lower level of occupational skill and qualification (Zubrick, et al., 2005, p. 549).

Significantly, Aboriginal children are also more likely than non-Indigenous children to be born to mothers under the age of 20 years, and children aged 0-3 years are less likely to be cared for by either biological parent (Zubrick, et al., 2005, p. 549).

This combination of circumstances not only creates impoverishment of the financial wherewithal to raise children, but also compromises the very basis of human, psychological and social capital which forms the wider pool of resources essential for child growth and development, including their social and emotional wellbeing. The impoverishment across all of these resource domains is accompanied by a reduction in the choice, capacity and flexibility of carers, families and communities to meet the demands and challenges of daily living. This is a recipe for cumulative stress (Zubrick, et al., 2005, pp. 549-550).

The services and supports needed by CaLD and Aboriginal children and families may need to be given specific consideration when undertaking service planning and provision, to ensure the needs of the whole community are being met.

                                                                          22

9. What types of models are used for service provision?

Traditionally, discussions about the provision of child development services tend to set universal services against targeted services.

9.1 Universal services

Primary prevention, or universal approaches are aimed at improving child development, parenting knowledge and behaviour, and infant mental health for all families within their service range. These approaches can take place in any setting, but primarily in health care, early childhood education and child care, and family support settings. Strategies generally include promotion, screening and assessment, education and guidance, and referral for more intensive services when needed (Zeanah, Stafford, Nagle, & Rice, 2005b, pp. 11-12).

(Universal services) are available to the whole of the population and are designed to promote positive functioning and decrease the likelihood of specific problems or disorders developing. Such services are truly universal if they are not only available to the whole population but also accessible to and accessed by most people. Factors affecting accessibility include location, cost, opening hours, and inclusiveness (Centre for Community Child Health, 2009, p. 1).

The disadvantage of universal services is that while there is the potential to improve things for infants and young children in all Socio-Economic Status (SES) ranges, in practice, children in higher SES ranges tend to benefit more than those in lower SES ranges. That is, children in lower SES ranges are more likely to be prevented from accessing services as a result of barriers such as cost, transportation and language (Human Early Learning Partnership, 2011).

Figure 2: The weakness of universal programs (Human Early Learning Partnership, 2011, p. 3)

Examples of universal infant health services (which may or may not address infant mental health) include pre- and postnatal care (including maternal and child health nurses), child care and early

                                                                          23

childhood education, and healthy infant development promotion campaigns (Jordan & Sketchley, 2009).

9.2 Targeted services

Focused, or targeted approaches are aimed at specifically identified groups considered at risk for developing potentially serious social or emotional problems. These approaches may be generated from any setting that serves individuals at risk. Examples include early intervention for premature or low birth weight babies, home visiting services for first time mothers, or preventive interventions for abused or neglected children. Family support interventions include income assistance, adult basic and secondary education, parenting education to promote positive parent child interaction and interventions that address environmental risk factors like poverty (Zeanah P. , Stafford, Nagle, & Rice, 2005b, p. 12).

(Targeted services) are available to selected groups or individuals who are known to be at risk of developing a particular health or developmental problem, and designed to reduce the likelihood of the problem developing (Centre for Community Child Health, 2009, p. 1).

The disadvantage of targeted services is that by targeting infants and young children in low SES ranges, the largest number of vulnerable children are in the middle SES ranges are missed. In addition, targeting services at children in low SES ranges can lead to the stigmatisation of services (Human Early Learning Partnership, 2011).

Figure 3: The weakness of targeted programs (Human Early Learning Partnership, 2011, p. 3)

The Centre for Community Child Health has explained this dilemma in relation to access to childhood mental health services:

The majority of childhood mental health issues occur in the middle socio-economic brackets, since this is where Australia’s population density is concentrated. There are higher rates of childhood mental health concerns among Aboriginal and Torres

                                                                          24

Strait Islander children, children in out-of-home care and among children with a

learning disability. However, focusing only on prevention and treatment for these ‘at risk’ children and families will miss the majority of children with mental health problems and may also lead to stigmatisation of some families (Centre for Community Child Health, 2012a).

Examples of targeted infant health services (which may or may not address infant mental health) include home visiting services, therapeutic services and infant-sensitive adult support services for parents. These sorts of specialist services are designed to address specific risk factors that compromise parenting in vulnerable families (Jordan & Sketchley, 2009).

9.3 Intensive services

The other important service type to consider are intensive services which, rather than focusing on preventative or early intervention measures, tend to be designed to meet the needs of clients currently experiencing problems. As Zeanah, Stafford, Nagle, & Rice (2005b, p. 12) explain,

(Intensive services) are for infants and caregivers experiencing current difficulties, and also attempt to prevent or lessen future problems. These services are most likely to come out of mental health programs, and may be provided for those infants currently experiencing suffering, such as those who have experienced significant trauma, or for whom there are significant parent-infant relationship problems.

The purposes of universal, targeted and intensive services tend to exist along a spectrum — from prevention through to treatment. At one end of the spectrum are universal services, which focus on the prevention of difficulties. Intensive services are at the opposite end, focusing on treatment of identified difficulties/disorders. Targeted services exist in the centre — they work with vulnerable communities to prevent difficulties, but treatment may also be provided if problems become apparent.

A continuum of services—from promotion of positive relationships (between infant and caregiver) to intervention and treatment for relationships at risk—will ensure that our system for infant mental health meets the needs of all infants and caregivers (NMIMHCC, 2003, p. 5).

9.4 Proportionate universal services

As a means of addressing the disadvantages of the universal and targeted service approaches, Sir Michael Marmot introduced the concept of proportionate universalism in the report Fair Society, Healthy Lives (the Marmot Review), published in February 2010. The Marmot Review was an examination of the health inequalities in England, and recommended a range of strategies to address the social determinants of these inequalities.

Inequalities in health arise because of inequalities in society – in the conditions in which people are born, grow, live, work, and age. So close is the link between particular social and economic features of society and the distribution of health

                                                                          25

among the population, that the magnitude of health inequalities is a good marker of progress towards creating a fairer society (Marmot, 2010, p. 16).

In the Review, Marmot identifies a social gradient in health — “the lower a person’s social position, the worse his or her health” (Marmot, 2010, p. 15). As Marmot explains:

It is tempting to focus limited resources on those in most need. But… we are all in need – all of us beneath the very best-off. If the focus were on the very bottom and social action were successful in improving the plight of the worst-off, what would happen to those just above the bottom, or at the median, who have worse health than those above them? All must be included in actions to create a fairer society.

We are unlikely to be able to eliminate the social gradient in health completely, but it is possible to have a shallower social gradient in health and wellbeing than is currently the case for England…

To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. We call this proportionate universalism. Greater intensity of action is likely to be needed for those with greater social and economic disadvantage, but focusing solely on the most disadvantaged will not reduce the health gradient, and will only tackle a small part of the problem (Marmot, 2010, p. 16).

In response, the Marmot Review recommends the introduction of “actions of sufficient scale and intensity to be universal but also proportionately targeted to reduce the steepness of the gradient”9 (Marmot, 2010, p. 41). Marmot termed this approach “proportionate universalism.”

Two leading Canadian experts in childhood development who visited Western Australia in 2012 — Professor Clyde Hertzman10 and Dr Stuart Shanker11 — also advocated locally for the introduction of a proportionate universal approach. The 2009 report 15 by 15 (of which Professor Hertzman was one of the authors) draws similar conclusions to the Marmot Review:

… the social gradient reveals that vulnerable development is not concentrated among “the poor.” This is the case when examining both individuals and neighbourhoods. While the highest risk of vulnerability is found in the poorest neighbourhoods, the largest number of children with developmental vulnerabilities are found across neighbourhoods that are home predominantly to the middle- class. Research indicates that population health is advanced when jurisdictions “flatten” the social gradient by providing equitable access to the conditions that support healthy child development for all, not just for those at the highest end of the socioeconomic spectrum (Kershaw, Anderson, Warburton, & Hertzman, 2009, p. 13).

9 There is a social gradient in health – the lower a person’s social position, the worse his or her health. Action should focus on reducing the gradient in health. 10 Professor Clyde Hertzman made these comments in an Early Years seminar sponsored by the Commissioner for Children and Young People, in May 2012. 11 Dr Stuart Shanker was the Commissioner for Children & Young People’s Thinker in Residence in June 2012.

                                                                          26

Neither the provision of universal or targeted services alone will be able to substantially flatten the social gradient in such a way as to maximise mental health outcomes in the early years.

Key to reducing vulnerability in the early years is a universal platform of supports and services available to all children. This platform needs to be accompanied by additional targeted services for highly vulnerable children and children in low SES ranges or geographical areas. Key also is the elimination, as far as possible, of barriers to access (Human Early Learning Partnership, 2011, pp. 3-4).

Furthermore, ensuring coordination and collaboration between universal, targeted and intensive services will be a key to ensuring a successfully integrated approach to infant mental health services in Western Australia.

10. What does service integration mean?

Service integration means different things to different people. With regards to integrated (health) services, The World Health Organisation has written that:

Integration is best seen as a continuum rather than as two extremes of integrated/not integrated. Integration is about the organisation of various tasks which need to be performed in order to provide a population with good quality health services.

An overall working definition of integrated service delivery is “The management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system” (World Health Organisation, 2008, p. 1).

This definition can also be applied to the management and delivery of infant mental health services.

Most communities already have a range of early childhood organisations providing a range of services to support the care, education, health and wellbeing of infants and young children. However:

Integration of services and increased collaboration is increasingly important to policy and practice for a range of reasons, including recognition of the complex, multidimensional nature of people’s needs and the notion that ‘joined up problems’ require ‘joined up solutions’ (Valentine, Katz, & Griffiths, 2007, p. 3).

The World Health Organisation has also provided a useful explanation of what integrated (health) services might mean from the perspective of a user, a provider or senior managers and policy-makers:

For the user, integration means health care that is seamless, smooth and easy to navigate. Users want a coordinated service which minimizes both the number of stages in an appointment and the number of separate visits required to a health facility. They want health workers to be aware of their health as a whole (not just

                                                                          27

one clinical aspect) and for health workers from different levels of a system to communicate well. In short, clients want continuity of care.

For providers, integration means that separate technical services (and their management support systems) are provided, managed, financed and evaluated either together, or in a closely co-ordinated way.

At the macro level of senior managers and policy-makers, integration happens when decisions on policies, financing, regulation or delivery are not inappropriately compartmentalized. This means bringing together different technical programmes, but also considering the whole network of public, private and voluntary health services, rather than looking at the public sector in isolation (World Health Organisation, 2008, p. 5).

Broadly, integrated services refers to the process of building connections between services of different types so as to create a system that is more comprehensive and cohesive, as well as ensuring services are more accessible and more responsive to the needs of young children and their families (Prichard, Purdon, & Chaplyn, 2010). Ultimately, the purpose of service integration is to form:

…a unified and comprehensive range of services in a geographic area, where the intent is to enhance the effectiveness of the delivery of services and optimise the use of limited resources (King and Meyer 2006, p. 476 in Siraj-Blatchford and Siraj- Blatchford 2009, p. 16).

The following are some expected direct outcomes that should result from greater service integration:

• Families will be better informed about services and find them more accessible.
• Service providers will also be better informed and the services themselves will do more joint planning and service delivery.
• Children’s developmental problems will be identified earlier, and referrals to specialist services will be more prompt.
• Problems with parenting and family functioning will be recognised earlier, and appropriate help will be provided more promptly.
• Families will receive help that addresses all aspects of their needs in a cohesive fashion.
• There will be fewer families who are socially isolated or who are not making use of appropriate child and family support services. (Centre for Community Child Health, 2009, p. 2)

Other arguments for integrating service delivery are:

• Collaborative and integrated work should be more efficient, simultaneously serving multiple needs through one service and saving labour for staff as well as time and effort for families.

                                                                          28
  

• Expanded roles for significant and trusted family workers such as nurses, teachers and social workers should improve the quality and accessibility of services for families.
• Improved integration and communication between agencies should stop families ‘falling through the cracks’, as has happened in several catastrophic failures of services systems associated with child deaths or near deaths. (Valentine, Katz, & Griffiths, 2007, p. 3)

The projected impact of improving families’ access to (and the coordination of) infant mental health services — is improvements in child and family outcomes. As the Royal Australian and New Zealand College of Psychiatrists (RANZCP) stated in a submission to the National Women’s Health Policy:

Providing well integrated services to a population with widely differing and complex needs is inherently difficult and resource intensive. However, the alternative is likely to be a set of interventions that focus on symptomatic rather than causal factors, perpetuates service gaps, cost shifting pressures and ineffective commitment of resources (RANZCP 2012:10 in Evans, 2013).

Ultimately though, it is important to remember that service integration is not a panacea:

Evaluations of integrated services mostly indicate that the main influence on outcomes is the quality of the actual service delivered. Service integration will only benefit children and families if it results in higher quality interventions (Valentine, Katz, & Griffiths, 2007, p. 2).

11. What does service integration look like in practice?

As stated in the previous section, service integration means different things to different people. In part, this is because integrated services do operate differently in different situations/places.

Supporting integrated services does not mean that everything has to be integrated into one package. In reality, there are many possible permutations (World Health Organisation, 2008, p. 1).

In 2011, the Western Australian Department for Communities prepared the Integrated service models and community hubs background working paper, which gave consideration to the use of community hubs as a vehicle for integrated service development. However, as will be shown, there is no single picture of a “community hub.” This is reflected in the Department for Communities definition of community hubs:

(A community hub is) a mechanism facilitating collaborative and integrated service delivery between different organisations across a local area or region. The exact character of a community hub is flexible so as to adapt to local needs, circumstances and available resources (Department for Communities, 2011a).

The Department’s working paper identified a range of different types of location-defined community hubs, representing different levels and methods of service integration:

                                                                          29

Table 4: Types of Community Hubs (adapted from Department for Communities, 2011a)

11.1 The Platforms approach

The Platforms Service Redevelopment Framework (the Platforms approach), is a framework developed by the Centre for Community Child Health (CCCH) to help communities undertake work to support children’s development. The Platforms approach is based on the compelling research (discussed in section 5) about the importance of the early years. CCCH argue that communities are well placed to, and have a vested interest in supporting their children’s development. In order to do this, they need:

• Services that work together;
• Services that are engaged with and respond to the needs of their community;
• Services that plan and evaluate their work with the intended outcomes in mind; and
• Local leadership (Centre for Community Child Health, 2012b).

The Platforms approach involves four key phases: raising awareness; community engagement and planning; implementing; and monitoring and evaluating. Platforms training is “designed to equip those working in the early years sector with the knowledge and skills required to implement each phase of the Platforms framework” (Centre for Community Child Health, 2012b).

                                                                          30

The Platforms approach is already being utilised in Western Australia. In 2011, Child Australia coordinated the provision of formal training in the Platforms approach to a range of state government, local government and community sector staff in Perth.

11.2 The journey towards service integration

In 2010, the Centre for Community Child Health also published Moving Forward Together: A guide to support the integration of service delivery for children and families (Prichard, Purdon, & Chaplyn, 2010). This report is considered to be a key resource relating to the integration of early years services.

In the Moving Forward Together report, Prichard, Purdon, & Chaplyn describe the changing context within which early childhood services in Australia are currently being provided. These comments underpin the need to begin the journey towards integrated early years services here in Western Australia:

A mounting body of evidence points to the changing nature of children and families requiring new and distinctly different service responses. Families in many communities in Australia still only have access to early childhood and family support services that were designed to cater for family structures that were more common in past generations. Given that many services may still function in isolation from one another, there is an ever increasing number of families that miss out, or don’t fit into these traditional service structures. Now, more than ever before, more flexible and inclusive service options are required for Australian families. For the benefit of our children, it is undeniable that the most helpful change would be reflected by services working in far more connected ways (Prichard, Purdon, & Chaplyn, 2010, p. 8).

                                                                          31

Figure 4 (below) illustrates “the journey towards early childhood service integration with the key ingredients of partnership underpinning the process to ensure genuine integration.”

Figure 4: A journey towards early childhood service integration (Prichard, Purdon, & Chaplyn, 2010, p. 9)

                                                                          32

It is also worth noting that this illustration of the journey towards early childhood service integration was included in the Western Australian Department of Education’s 2012 tender request documentation relating to the establishment of the first ten Child and Parent Centres across the state. The tender documents described the Child and Parent Centres as bringing “together a range of government and non-government programs and services in a coordinated and integrated way.” Ngala (one of the successful Child and Parent Centre bidders) has also taken the lead in facilitating further professional development in 2013 relating to the Platforms approach.

Prichard, Purdon, & Chaplyn’s description of the process of establishing integrated services as a “journey” cannot be overstated. This is because “the journey towards integrated service delivery is challenging and will take a significant level of commitment from government, services and communities” — it cannot be achieved overnight, or without a significant amount of work. However, as the authors contend, “…the rewards of our collective efforts can create incredible opportunities for babies, young children, their families and entire communities (Prichard, Purdon, & Chaplyn, 2010, p. 26).

12. What factors help/hinder service integration?

There are a significant number of studies and papers which have examined the factors which assist in bringing about effective service integration, for early years-specific services (Prichard, Purdon, & Chaplyn, 2010; Valentine, Katz, & Griffiths, 2007; Department for Communities, 2011; Siraj-Blatchford & Siraj-Blatchford, 2009; Cameron, Lart, Bostock, & Coomber, 2012; KPMG, 2011). Through the review of such papers, the following factors have been identified as being beneficial to integration:

Table 5: Factors which assist early years’ service integration

                                                                          33

While the factors that hinder service integration are in essence, the opposite to those described above, a number of additional issues can also be identified. For example, the inclusiveness and effectiveness of committees is an ongoing challenge in service integration. To build successful service integration, committees responsible for integration initiatives need to be inclusive (including providing opportunities for participation by client representation); to reduce the burden of attending meetings (as a means of ensuring quorums and appropriate stakeholder representation is achieved); and to manage the potential for varying levels of autonomy for decision-making amongst committee members.

It is also critical to remember that service integration will never be a cure for inadequate resources (World Health Organisation, 2008). In fact, inadequate resources, lack of joint budgets and financial uncertainties have all been identified as impediments towards integrated service delivery.

A survey on integrated services carried out by the Western Australian Department for Communities also identified competitive tendering and funding arrangements as one of the key barriers to service integration. As one survey respondent explained:

                                                                          34

Services will not work together in an environment which exists at the moment which is very supportive of competitive tendering. If ideas and programs are shared then agencies believe that the intellectual property which they perhaps have spent years developing will be copied and will empower larger agencies to tender against them (Department for Communities, 2011b, p. 14).

Another survey respondent described how a “lack of funding can also prevent organisations working together as working collaboratively is time consuming and can cost more in wages…” (Department for Communities, 2011b).

13. How can the effectiveness of integration be measured?

Another important consideration relates to how the success of service integration is measured.

The quality rather than the type of integration is what matters in terms of improving outcomes. We therefore need to have clear, shared understandings of what we mean by ‘quality’ in integrated delivery of early years services and ensure that services adopt agreed quality standards (Siraj-Blatchford & Siraj-Blatchford, 2009, pp. 44-45).

As Brown & White (2006) explain, while there is much evidence based on the perceptions of professionals — such research tends to focus on the process of service provision rather than outcomes for children and families. Research has found that through service integration:

… organisations and professionals have much to gain from inter-professional working such as wider expertise, knowledge of the skills of other professionals, opportunities to contribute to other developments, reducing the duplication of work and improved communication in organisations (Rushmer and Pallis, 2002 in Brown & White, 2006, p. 14).

Improvements in staff retention, job satisfaction and professional development are all potentially positive outcomes to come from integrating services. However, there is an obvious difference between these types of measures of success and the primary purpose of integrating services — that is, to enhance the effectiveness of the delivery of services.

[M]easuring partnership success using an output, such as the number of children receiving a service, provides little information about the benefits for service users. What is more child focused is using an outcome measure, such as collating information about the effects of the service on children using the service (Horwath & Morrison, 2007, p. 58).

While there are significant challenges in determining methods to measure the effectiveness of integrated service provision from a user’s point of view — the value in being able to do so is clear. The Western Australian Department of Health has recently been awarded funding to undertake research into the evaluation of the integrated service initiatives targeting the early years in Western Australia.

                                                                          35

14. What would it mean to integrate infant mental health services?

Infant mental health services cannot be viewed alone — the supports and services required to maintain and develop mental health in young children depend on a wide range of other factors which may not focus specifically on mental health.

Figure 5: Levels of Infant Mental Health Care (Zeanah P. , Stafford, Nagle, & Rice, 2005b, p. 12)

The Strategic Plan for Infant Mental Health in New Mexico (published in 2003) clearly explained, in answering the question “Who will provide infant mental health services,” that:

Implementing infant mental health strategies in New Mexico does not require a wholesale remaking of early childhood programs throughout the state.

Workers from a number of disciplines, including social workers, psychologists, early childhood specialists, and others, can use a range of infant mental health strategies to foster healthy development. These strategies include providing families with assistance to meet their basic needs (food, housing, employment, physical and emotional safety, and medical care), as well as emotional support, developmental guidance, early relationship assessment and support, and infant- parent psychotherapy

Training, education and support materials can bring a critical understanding to all early childhood, behavioural health and medical settings, including the family home, day care, early intervention and education programs, community mental health centres, paediatrician’s offices and social service programs. Consolidation and collaboration among existing programs also will go a long way towards creating a cohesive system for infant mental health (NMIMHCC, 2003, p. 5).

                                                                          36

In the context of this project, it is the integration of infant mental health services within the broader provision of services for young children and their families that will be the focus.

15. Conclusion

This report has sought to develop a conceptual foundation for ongoing work relating to the provision of services to optimise socio-emotional wellbeing and mental health outcomes for infants and young children in Western Australia. To this end, work from across a range of disciplines: the early years, mental health, community development, has been pulled together to provide an understanding of why further consideration needs to be given, and further action undertaken, to improve both short and longer term outcomes for young children, parents and families.

The early years, are a critical period in a child’s brain development, and the quality of a child’s development in the early years has lifelong consequences. This report, which works from a definition of the early years as being under 5 years of age, has provided an overview of the importance of the early years, and the benefits of investing in children in the early years, rather than attempting to remedy the effects of disadvantage (experienced in the early years) later in life.

The report has also considered how the mental health of infants and young children can be assessed, the types of services which support mental health in the early years, and the need for education to reduce community resistance to the idea that mental health problems can be present in childhood. This led to discussion of traditional models of service provision — universal, targeted and intensive —and the emerging interest in what is known as proportionate universal services.

This report has outlined the advantages which can be derived by improving the coordination, collaboration and integration of services which support the mental health of infants and young children. In this context, specific reference has been made to the Platforms approach to early years service integration (which is already being implemented in some communities in Western Australia), and the importance of viewing the move towards service integration as a journey, rather than an end in itself. A significant number of studies have been examined to develop a set of key factors which assist in the integration of early years services. These factors will be explored further in the second report of this project.

Central to the next stage of this project is the application of the conceptual foundation (described in this report) to the City of Cockburn, a local government area located within metropolitan Western Australia. Through consultations with a range of parties in the City of Cockburn, an understanding will be sought of both the opportunities for and hindrances to the integration of mental health services for those under 5 years, in that regional area. The actions undertaken and findings of this second stage will be explored in a subsequent report.

Further information about the Integrating services to support the mental health of infants & young children: Developing the Concepts report (and, the project more broadly) can be obtained from:

Helen Creed, Policy Manager (Vulnerable People), WACOSS
helencreed@wacoss.org.au (08) 9420 7222
(Note: email address displayed in document text as helen@wacoss.org.au)

Sarah Mummé, Policy Officer (Vulnerable People), WACOSS

                                                                          37

sarah@wacoss.org.au (08) 9420 7222

Rosemary Woodward, A/Assistant Director Strategic Policy, Mental Health Commission
Rosemary.Woodward@mentalhealth.wa.gov.au (08) 6272 1270

16. References

AAIMHI WA. (Undated). Information sheet: What is Infant Mental Health.

AIHW. (2009). A Picture of Australia’s Children 2009. Canberra: Australian Institute of Health and Welfare. Retrieved April 5, 2013, from http://www.aihw.gov.au/publications/phe/phe-112-10704/phe-112-10704.pdf

ARACY. (2008). The Wellbeing of Young Australians: Report Card. Australian Research Alliance for Children & Youth. Retrieved April 5, 2013, from www.aracy.org.au/documents/item/104

ARACY. (2010). Conceptualisation of social and emotional wellbeing for children and young people, and policy implications. Sydney: Australian Research Alliance for Children and Youth and the Australian Institute of Health and Welfare. Retrieved April 5, 2013, from http://goo.gl/A5y2G

Bakermans-Kranenburg, M. J., & van IJzendoorn, M. H. (2009). The first 10,000 Adult Attachment Interviews: distributions of adult attachment representations in clinical and non-clinical groups. Attachment & Human Development, 11(3), 223–263.

Bayer, J., Hiscock, H., Scalzo, K., Mathers, M., McDonald, M., Morris, A., . . . Wake, M. (2009). Systematic review of preventive interventions for children’s mental health: what would work in Australian contexts? Australian and New Zealand Journal of Psychiatry, 43(8), 695-710 .

Beyond Blue. (2012). Programs: Early Childhood and Primary Schools. Retrieved December 3, 2012, from Beyond Blue: The National Depression Initiative: http://www.beyondblue.org.au/index.aspx?link_id=4.1355&print=true

Brinkman, S. (2012). Translational science fostering integration. Presentation by Sally Brinkman to WACOSS Sector Briefing: Child & Parent Centres, 20 November, 2012, Perth.

Brown, K., & White, K. (2006). Exploring the evidence base for Integrated Children’s Services. Edinburgh: Scottish Executive Education Department. Retrieved April 5, 2013, from http://www.scotland.gov.uk/Resource/Doc/90282/0021746.pdf

Bunston, W., & Sketchley, R. (2012). Refuge for babies in crisis: How crisis accommodation services can assist infants and their mothers affected by family violence. The Royal Children’s Hospital Integrated Mental Health Program.

Cameron, A., Lart, R., Bostock, L., & Coomber, C. (2012). Research Briefing: Factors that promote and hinder joint and integrated working between health and social care services. London: Social Care Institute for Excellence. Retrieved April 2013, 5, from http://www.scie.org.uk/publications/briefings/files/briefing41.pdf

CCYP. (2011). Report of the Inquiry into the mental health and wellbeing of children and young people in Western Australia. Perth: Commissioner for Children and Young People Western Australia. Retrieved April 5, 2013, from http://www.ccyp.wa.gov.au/files/MentalWellbeingInquiry/CCYP%20Mental%20Health%20Inquiry%20-%20Report%20to%20Parliament.pdf

Center on the Developing Child. (2012). In Brief: Early Childhood Mental Health. Harvard University. Retrieved April 5, 2013, from http://developingchild.harvard.edu/index.php/download_file/-/view/1263/

Centre for Community Child Health. (2009). Policy Brief: Integrating Services for Young Children and their Families. Melbourne, Australia: Royal Children’s Hospital Melbourne. Retrieved April 5, 2013, from www.rch.org.au/emplibrary/ccch/PB_17_FINAL_web.pdf

Centre for Community Child Health. (2012a). Policy Brief: Children’s Mental Health. Melbourne: The Royal Children’s Hospital, Melbourne. Retrieved April 5, 2013, from http://www.rch.org.au/ccch/resources.cfm?doc_id=10885

Centre for Community Child Health. (2012b). Platforms: Introduction to Platforms. Retrieved April 5, 2013, from Royal Children’s Hospital Melbourne: http://www.rch.org.au/ccch/consultancy/Platforms/

                                                                          38

Colin, V. L. (1991). Infant Attachment: What We Know Now. U.S. Department of Health and Human Services. Retrieved December 7, 2012, from http://aspe.hhs.gov/daltcp/reports/inatrpt.htm

Commonwealth Department of Health and Aged Care. (2000). Promotion, prevention and early intervention for mental health: a monograph. Canberra: Mental Health and Special Programs. Retrieved April 5, 2013, from http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-pubs-p-prommon

DEEWR. (2011). National Rollout of the Australian Early Development Index. Retrieved March 21, 2013, from Department of Education, Employment and Workplace Relations: http://www.deewr.gov.au/Earlychildhood/Policy_Agenda/AEDI/Pages/home.aspx

Department for Child Protection. (2010). Culturally and Linguistically Diverse Services Framework 2010-2012. Perth: Government of Western Australia. Retrieved March 15, 2013, from http://www.dcp.wa.gov.au/Organisation/Documents/CaLD%20Services%20Framework.pdf

Department for Communities. (2011a). Integrated Service Models and Community Hubs: Background Working Paper. Perth, Australia: Government of Western Australia.

Department for Communities. (2011b). Integrated service delivery and community hubs: Report of a survey of centres funded by the WA Department for Communities. Perth, Australia: Government of Western Australia. Retrieved April 5, 2013, from http://www.communities.wa.gov.au/childrenandfamilies/ISD/Documents/Integration%20Survey%20Report-Final%20Report%202011.pdf

Department of Health & Ageing. (2000). Promotion, prevention and early intervention for mental health: a monograph. Canberra, Australia: Mental Health and Special Programs Branch, Commonwealth Department of Health and Aged Care. Retrieved April 5, 2013, from http://www.health.gov.au/internet/main/publishing.nsf/content/A32F66862E8894ABCA25723E00175229/$File/pro5.pdf

Department of Health. (2013). Child and Adolescent Community Health: Our Services. Retrieved February 20, 2013, from Government of Western Australia: Department of Health: http://pmh.health.wa.gov.au/general/CACH/services.htm

Department of Health WA. (2012). King Edward Memorial Hospital: About Perinatal Mental Health. Retrieved December 3, 2012, from Women and Newborn Health Service Health Professionals: http://www.kemh.health.wa.gov.au/health_professionals/WA_perinatal_mental_health_unit/perinatal.php

Early Head Start National Resource Center. (2000). Developmental Screening, Assessment, and Evaluation: Key Elements for Individualizing Curricula in Early Head Start Programs. Washington DC, USA: Head Start Bureau, US Department of Health and Human Services. Retrieved April 5, 2013, from http://www.zerotothree.org/child-development/mental-health-screening-assessment/thepowerofplay-1.pdf

ECA & SNAICC. (2007). COAG Mental Health Early Intervention Measure – Early Childhood Component: Study to Scope Potential Service Delivery. Early Childhood Australia & Secretariat of National Aboriginal and Islander Child Care. Retrieved April 5, 2013, from http://www.health.gov.au/internet/main/publishing.nsf/content/F4C084E76EE2CD62CA25754D007A21F9/$File/earsco.pdf

Elliott, A. (2006). Early Childhood Education: Pathways to quality and equity for all children. Camberwell, Australia: Australian Council for Educational Research. Retrieved April 5, 2013, from http://research.acer.edu.au/cgi/viewcontent.cgi?article=1003&context=aer

Evans, A. (2013). Women’s Ten Point Plan of Action: Project Report. Women’s Health & Family Services (WA).

Fitzgerald, P. (2012). Explainer: what is the DSM and how are mental disorders diagnosed? Retrieved October 24, 2012, from The Conversation: http://theconversation.edu.au/explainer-what-is-the-dsm-and-how-are-mental-disorders-diagnosed-9568

Fonagy, P. (1999). The transgenerational transmission of holocaust trauma. Attachment & Human Development, 1:1, 92-114. Retrieved from http://dx.doi.org/10.1080/14616739900134041

                                                                          39

Goldfeld, S. (2012). Community: a universal platform of vital importance. Place-based Initiatives Transforming Communities: Proceedings from the Place-based Approaches Roundtable (pp. 9-10). Melbourne, Australia: Centre for Community Child Health, The Royal Children’s Hospital Melbourne.

Government of Western Australia. (2013). 2012-13 State Budget. Retrieved February 14, 2013, from http://www.ourstatebudget.wa.gov.au/

Heckman, J. J., & Masterov, D. V. (2007a). The Productivity Argument for Investing in Young Children. National Bureau of Economic Research. Retrieved April 15, 2013, from http://www.nber.org/papers/w13016

Heckman, J. J., & Masterov, D. V. (2007b). The Productivity Argument for Investing in Young Children. Review of Agricultural Economics, American Agricultural Economics Association, vol. 29(3), pp. 446-493.

Hertzman, C. (2012). The case for investing in the early years: lessons from Canada. Perth: Early Years Seminar for the Commissioner for Children & Young People (WA). Retrieved April 5, 2013, from http://www.ccyp.wa.gov.au/files/Dr%20Hertzman%20early%20years%20presentation.pdf

Horwath, J., & Morrison, T. (2007). Collaboration, integration and change in children’s services: Critical issues and key ingredients. Child Abuse & Neglect(Issue: 31), 55-69. Retrieved from http://www.parliament.wa.gov.au/parliament/commit.nsf/%28Evidence+Lookup+by+Com+ID%29/B43A495F260C4109482578310040CF30/$file/Sub+42+South+Metro+Area+Health+Internet+Ver.pdf

Human Early Learning Partnership. (2011). Policy Brief: Proportionate Universality. Canada: UBC. Retrieved April 5, 2013, from http://earlylearning.ubc.ca/media/publications/proportionate_universality_brief__-_final.pdf

Jordan, B., & Sketchley, R. (2009). A stitch in time saves nine: Preventing and responding to the abuse and neglect of infants. Child Abuse Prevention Issues(No. 30). Retrieved April 5, 2013, from http://www.aifs.gov.au/nch/pubs/issues/issues30/issues30.html

Kershaw, P., Anderson, L., Warburton, B., & Hertzman, C. (2009). 15 by 15: A Comprehensive Policy Framework for Early Human Capital Investment in BC. Vancouver: Human Early Learning Partnership, University of British Columbia. Retrieved January 14, 2013, from http://earlylearning.ubc.ca/media/uploads/publications/15by15-full-report.pdf

KidsMatter. (2012a). Literature Review, Component 2: Developing children’s social and emotional skills. Kids Matter: Australian Early Childhood Mental Health Initative, Commonwealth of Australia. Retrieved April 5, 2013, from http://goo.gl/dKKn0

KidsMatter. (2012b). Understanding mental health in early childhood. Retrieved September 6, 2012, from KidsMatter: Australian Early Childhood Mental Health Initiative: http://www.kidsmatter.edu.au/sites/default/files/public/KMEC_201109_C4_02-Understanding.pdf

KPMG. (2011). Child FIRST and Integrated Family Services: Evaluation Summary Report. Department of Human Services (Victoria). Retrieved April 5, 2013, from http://www.dhs.vic.gov.au/__data/assets/pdf_file/0007/646828/childFIRSTandIntfamservices-evalsummreport_09082011.pdf

Marmot, M. (2010). Fair society, healthy lives : the Marmot Review : strategic review of health inequalities in England post-2010. Retrieved March 21, 2013, from http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report

McCain, M., & Mustard, J. F. (1999). Reversing the Real Brain Drain: Early Years Study, Final Report. Ontario, Canada: Government of Ontario Children’s Secretariat. Retrieved October 24, 2012, from http://www.cfuwontcouncil.ca/Reports/REVERSING%20THE%20REAL%20BRAIN%20DRAIN,%20Mustard,McCain,%201999.pdf

MCEECDYA. (2010). Engaging Families in the Early Childhood Development Story. Ministerial Council for Education, Early Childhood Development and Youth Affairs. Retrieved April 5, 2013, from http://www.mceecdya.edu.au/verve/_resources/ECD_Story-Neuroscience_and_early_childhood_dev.pdf

Mental Health Commission. (2010a). What is mental health? Retrieved October 24, 2012, from Government of Western Australia: Mental Health Commission: http://www.mentalhealth.wa.gov.au/mental_illness_and_health/mh_whatis.aspx

                                                                          40

Mental Health Commission. (2010b). Mental Health 2020: Making it personal and everybody’s business. Perth: Mental Health Commission of Western Australia. Retrieved April 5, 2013, from http://www.mentalhealth.wa.gov.au/Libraries/pdf_docs/Mental_Health_Commission_strategic_plan_2020.sflb.ashx

Miles, B., & James, A. (2009). Your Effect on Your Child’s Attachment. Retrieved March 21, 2013, from AboutKidsHealth: http://www.aboutkidshealth.ca/En/ResourceCentres/PrematureBabies/AtHome/Attachment/Pages/Your-Effect-on-Your-Childs-Attachment.aspx

Minnesota Infant Mental Health Project. (2002). What is Infant Mental Health? Minneapolis, USA: University of Minesota, Center for Early Education & Development. Retrieved October 24, 2012, from University of Minesota: Center for Early Education & Development: http://www.cehd.umn.edu/ceed/projects/imh/resources/whatisimh.pdf

National Scientific Council on the Developing Child. (2008). Mental Health Problems in Early Childhood Can Impair Learning and Behavior for Life: Working Paper #6. Center on the Developing Child at Harvard University. Retrieved April 5, 2013, from http://developingchild.harvard.edu/index.php/resources/reports_and_working_papers/working_papers/wp6/

Nelson, F., & Mann, T. (2011, February-March). Opportunities in Public Policy to Support Infant and Early Childhood Mental Health: The Role of Psychologists and Policymakers. American Psychologist, 66(2), 129–139. Retrieved October 24, 2012, from http://www.apa.org/pubs/journals/releases/amp-66-2-129.pdf

NMIMHCC. (2003). A Strategic Plan for Infant Mental Health in New Mexico. New Mexico Infant Mental Health Collaborative Committee. Retrieved April 5, 2013, from http://www.nmaimh.org/NM_IMH%20Strategic%20Plan%2003.pdf

Office of the Auditor General. (2010, November 24). Children missing out on important health checks. Retrieved April 5, 2013, from http://www.audit.wa.gov.au/reports/pdfreports/media2010_11.pdf

Onunaku, N. (2005). Improving Maternal and Infant Mental Health: Focus on Maternal Depression. Los Angeles, CA: National Center for Infant and Early Childhood Health Policy at UCLA. Retrieved April 5, 2013, from http://goo.gl/nVWBq

Parliament of Western Australia. (2009). Healthy Child—Health State: Improving Western Australia’s Child Health Screening Programs. Perth: Education and Health Standing Committee. Retrieved April 5, 2013, from http://www.parliament.wa.gov.au/parliament/commit.nsf/%28Report+Lookup+by+Com+ID%29/C03031FD0022E6D548257831003E97D1/$file/Report+2-+Child+Health+Screening.pdf

Prichard, P., Purdon, S., & Chaplyn, J. (2010). Moving Forward Together: A guide to support the integration of service delivery for children and families. Melbourne, Australia: Murdoch Children’s Research Institute. Retrieved March 20, 2013, from http://www.rch.org.au/uploadedFiles/Main/Content/ccch/Moving_Forward_Together.pdf

Queensland Health. (2012, July 2). Perinatal and Infant Mental Health. Retrieved September 6, 2012, from Queensland Health: http://www.health.qld.gov.au/qcpimh/pimh.asp

Royal Children’s Hospital. (2010). Development of the AEDI. Retrieved March 20, 2013, from Australian Early Development Index: http://ww2.rch.org.au/aedi/about.cfm?doc_id=13190

Sanders, M. H. (2002). Parenting interventions and the prevention of serious mental health problems in children. Medical Journal of Australia, Vol. 177(7 October 2002), 87-92. Retrieved from http://www.gptt.com.au/Exam%20preparation%20CK%20Khong/RACGP/CLINICALS/Childhood%20behavioural%20management%20-%20tripleP.pdf

Siraj-Blatchford, I., & Siraj-Blatchford, J. (2009). Improving development outcomes for children through effective practice in integrating early years services. London, UK: Centre for Excellence and Outcomes in Chlidren and Young People’s Serviecs. Retrieved April 5, 2013, from http://www.c4eo.org.uk/themes/earlyyears/effectivepractice/files/c4eo_effective_practice_kr_3.pdf

Sroufe, L., Carlson, E., Levy, A., & Egeland, B. (1999). Implications of attachment theory for developmental psychopathology. Development and Psychopathology, 11, 1–13.

Steele, H., & Steele, M. (2008). Clinical Applications of the Adult Attachment Interview. New York: The Guildford Press. Retrieved from http://goo.gl/9HkjK

                                                                          41

Stokes, B. (2012). Review of the admission or referral to and the discharge and transfer practices of public mental health facilities/services in Western Australia. Perth, Australia: Government of WA : Mental Health Commission & Department of Health. Retrieved from http://www.amawa.com.au/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=1476&PortalId=0&TabId=132

Telethon Institute for Child Health Research. (2011). Australian Early Development Index: Community Profile (Sitrling, Western Australia). Retrieved April 5, 2013, from http://www.stirling.wa.gov.au/Resident/Services/Services-for-families/Families/Australian%20Early%20Development%20Index%20Community%20Profile.pdf

Valentine, K., Katz, I., & Griffiths, M. (2007). Early Childhood Services: Models of Integration and Collaboration. West Perth, Australia: Australian Research Alliance for Children and Youth (ARACY). Retrieved April 5, 2013, from http://www.sprc.unsw.edu.au/media/File/Report_ARACY_EarlyChildhood.pdf

van Ijzendoorn, M., Schuengel, C., & Bakersmans-Kranenburg, M. (1999). Disorganized attachment in early childhood: Meta-analysis of precursors, concomitants, and sequelae. Development and Psychopathology, 11, 225–249.

WA Perinatal Mental Health Unit. (2011, June). Perinatal Mental Health: Reference Guide. Retrieved April 5, 2013, from WA Perinatal Mental Health Unit: http://www.wnhs.health.wa.gov.au/health_professionals/WA_perinatal_mental_health_unit/documents/Reference_document.pdf

World Health Organisation. (2008). Integrated Health Services - What and Why? World Health Organisation. Retrieved April 5, 2013, from http://www.who.int/healthsystems/service_delivery_techbrief1.pdf

Zeanah, P. D., Stafford, B., & Zeanah, C. H. (2005a). Clinical Interventions to Enhance Infant Mental Health: A selective review. National Centre for Infant and Early Childhood Health Policy. Retrieved April 5, 2013, from http://www.eric.ed.gov/ERICWebPortal/contentdelivery/servlet/ERICServlet?accno=ED496852

Zeanah, P., Stafford, B., Nagle, G., & Rice, T. (2005b). Addressing social-emotional development and infant mental health in early childhood systems. UCLA. National Centre for Infant and Childhood Health Policy. Retrieved April 5, 2013, from http://www.nursefamilypartnership.org/assets/PDF/Journals-and-Reports/National-Center-for-Infant---Early-Child-Jan-2005

ZERO TO THREE. (2012). DC: 0-3R. Retrieved October 24, 2012, from ZERO TO THREE: National Centre for Infants, Toddlers, and Families: http://www.zerotothree.org/child-development/early-childhood-mental-health/diagnostic-classification-of-mental-health-and-developmental-disorders-of-infancy-and-early-childhood-revised.html

ZERO TO THREE: Infant Mental Health Task Force. (2002, January). What is infant mental health? Retrieved September 6, 2012, from UCLA Center for Healthier Children, Families & Communities: http://www.healthychild.ucla.edu/First5CAReadiness/Conferences/materials/InfantMH.definition.pdf

Zubrick, S., Silburn, S., Lawrence, D., Mitrou, F., Dalby, R., Blair, E., . . . Li, J. (2005). The Western Australian Aboriginal Child Health Survey: The Social and Emotional Wellbeing of Aboriginal Children and Young People. Perth: Curtin University of Technology and Telethon Institute for Child Health Research. Retrieved April 5, 2013, from http://aboriginal.childhealthresearch.org.au/media/394189/western_australian_aboriginal_child_health_survey_main_volume.pdf

                                                                          42

Published: April 2013

For further copies of this report, please contact:

Western Australian Council of Social Service
City West Lotteries House
2 Delhi St
WEST PERTH WA 6005

Phone: (08) 9420 7222
info@wacoss.org.au
www.wacoss.org.au

43

WwW

WaCOss

Western Australian Council of Social Service inc

Ways to make
a difference

Integrating services to support the mental health of infants and young children:

Applying the Concepts

May 2014

The Western Australian Council of Social Service (WACOSS) is the leading peak organisation for the community sector in WA, and represents around 300 member organisations and individuals, and over 800 organisations involved in the provision of services to individuals, families and children in the community.

WACOSS advocates for social change that promotes the wellbeing of all Western Australians — particularly disadvantaged and vulnerable people — and has been at the forefront of policy development and advocacy work relating to the early years, and the need for better integrated services in WA. WACOSS has drawn upon its existing policy and advocacy work in preparing this document. For more information, visit http://www.wacoss.org.au/.

The Western Australian Mental Health Commission (the Commission), the first to be established in Australia, is responsible for strategic policy, planning, purchasing and monitoring of mental health services. Raising public awareness of mental wellbeing and addressing stigma and discrimination affecting people with mental illness are also part of the Commission’s functions. The Commission’s reform agenda is set out in Mental Health 2020: Making it personal and everybody’s business (Mental Health 2020). The Commission acknowledges that mental health issues have a unique impact on certain groups of people requiring specialised responses and infants, children and youth are a priority population. The engagement of vulnerable infants, children and their families during the formative early years is a high priority for Mental Health 2020. A specific Action Area in Mental Health 2020 is Services Working Together and the Commission is cognisant of the need for agencies and organisations to work together at policy, program and service delivery levels required for prevention, early intervention, treatment and recovery and is continuing to support initiatives to achieve this. For more information, visit http://mentalhealth.wa.gov.au/.

In 2012, the Mental Health Commission provided the Western Australian Council of Social Service with funding to develop a model for integrating services to support the mental health of infants and young children.

While responsibility for the content of this document rests with WACOSS, we are grateful to the Mental Health Commission’s Infant and Child Mental Health Planning Group members for assisting in the planning of, and for their contributions to, this project, as well as Gail Bowman, Barbara Freeman and the City of Cockburn for their involvement in, and support of, this work.

Particular thanks also go to the service providers who gave so generously of their time to participate in the interviews we conducted and those who attended the community forum.

WACOSS (2014) Integrating services to support the mental health of infants & young children: Applying the Concepts, Western Australian Council of Social Service: Perth, Western Australia.

2

Contents

1.0 Introduction …………………………………………………………………………………………….. 4

2.0 An overview of the City of Cockburn …………………………………………………………….. 6

2.1 About the City of Cockburn …………………………………………………………………………….. 6

2.2 Socio-economic measures………………………………………………………………………………. 8

2.3 Health & wellbeing measures …………………………………………………………………………. 9

3.0 Early years mental health service delivery in the City of Cockburn …………………… 11

4.0 Methodology …………………………………………………………………………………………. 15

5.0 Factors that help or hinder integration ……………………………………………………….. 17

6.0 Discussion ……………………………………………………………………………………………… 20

6.1 Observations relating to partnerships & working collaboratively ………………………. 20

6.2 Observations relating to relationships ……………………………………………………………. 27

6.3 Observations relating to infant & early childhood mental health service delivery .. 31

6.4 Concluding observations ……………………………………………………………………… 42

7.0 Collaborative work initiatives ……………………………………………………………………. 43

8.0 Conclusion …………………………………………………………………………………………….. 47

9.0 References …………………………………………………………………………………………….. 49

10.0 Appendices ……………………………………………………………………………………………. 53

10.1 Appendix One: Interview schedule ……………………………………………………….. 53

10.2 Appendix Two: Interviewees ……………………………………………………….. 56

10.3 Appendix Three: The Integration Journey …………………………………………. 57

3

1.0 Introduction

Social and emotional wellbeing in the early years — and the need for communities to pay attention to and ensure adequate investment in services supporting infant mental health — is vitally important. Social and emotional skills support virtually every other aspect of a child’s development, including learning, school readiness and cognitive and language development.

This report is the second to be prepared by the Western Australian Council of Social Service (WACOSS) as a part of a project funded by the Mental Health Commission. The aim of the project is to consider the means and challenges to integrating services to support the mental health of infants and young children.

Report One: Developing the Concepts

Our first report, titled Integrating Services to Support the Mental Health of Infants and Young Children: Developing the Concepts, was published in June 2013. In preparing Report One, we pulled together existing work from across a range of disciplines — including the early years, mental health and community development. A significant number of studies and papers were drawn upon to explain why mental health among infants and young children is so important, as well as to identify a range of factors which assist in bringing about effective service integration for early years services.

Report Two: Applying the Concepts

WACOSS was pleased to undertake the second stage of the project in partnership with the City of Cockburn, a local government authority located in the southern suburbs of the Perth metropolitan region. In Report Two we consider the concepts and factors which assist the integration of infant and early years mental health services through their application to the City of Cockburn.

The primary focus of Report Two is the process of service integration — but it does not seek to provide a ‘gold standard model’ or ‘masterplan’ outlining how to integrate services in your community.

In Report Two, some of the factors considered are specific to the City of Cockburn, for example the City’s commitment to the early years, and their role in service delivery. However, it was WACOSS’ intention for both the research methodology and the discussion in Report Two to be relevant to people in other local government areas, or people working in fields other than infant and early childhood mental health.

One of the big challenges with service integration is that it can mean a lot of different things to different people and their organisations. To some, ‘service integration’ might mean establishing a central location where multiple organisations operate from whilst others

4

might view it as looking for ways to centrally coordinate access and referrals to services. Yet others might consider it to mean improving the ways and regularity with which organisations are in contact with one another. Integration is going to differ depending on which organisations, services and issues are part of the process.

We have focussed this report on understanding the journey of integration and identifying and exploring the factors that may assist or hinder that journey in a geographic area.

We hope that this report provides food for thought and guidance to communities and organisations interested in exploring the opportunities to build service integration at a local level.

5

2.0 An overview of the City of Cockburn

2.1 About the City of Cockburn

Location and suburbs

The City of Cockburn covers approximately 170 square kilometres, and is situated approximately 22km south of the Perth city, and 8km south of Fremantle. The City of Cockburn local government area shares boundaries with the City of Kwinana, City of Melville, Town of East Fremantle and City of Canning.

The City of Cockburn is made up of 21 suburbs:

• Atwell
• Aubin Grove
• Banjup
• Beeliar
• Bibra Lake
• Cockburn Central
• Coogee
• Coolbellup
• Hamilton Hill
• Hammond Park
• Henderson
• Jandakot
• Leeming
• Munster
• North Coogee
• North Lake
• South Lake
• Spearwood
• Success
• Wattleup
• Yangebup

Suburbs such as Bibra Lake, Leeming and North Lake are long-established, whereas suburbs such as Atwell, Beeliar and Success, are just reaching full development. On the other hand, suburbs such as Aubin Grove and Hammond Park were only approved in 2003 and 2002 respectively, so are still in the development stage, and as a result have experienced significant population growth in recent years. The level of development, and new housing opportunities available within different suburbs are factors which traditionally influence where households with particular demographics (i.e. retirees, young families, older families, young adults) are more likely to reside, and which services are going to be in greatest demand in that area as a result.

Population

At the time of the 2011 census, the City of Cockburn had 89,683 residents (representing an increase of 20.8 per cent since 2006) (NGAA, 2013a). Over the same period, the Western Australian population grew 14.3 per cent (ABS, 2013b).

According to the 2011 census, 1.8% of the population are Aboriginal or Torres Strait Islander and 32.4% of the City of Cockburn residents were born overseas. Almost 18% are from non-English speaking backgrounds.

6

Table 1: City of Cockburn population by age (ABS, 2012) (ABS, 2008)

[Chart showing population by age groups for 2006 and census people numbers]

Transportation

While the City of Cockburn offices are located in the coastal suburb of Spearwood, the growing centre of the City, known as ‘Cockburn Central’, is located in the suburb of Success. Cockburn Gateway is a large (and growing) shopping centre complex beside the Kwinana Freeway, and close to the Cockburn Central train/bus station on the Mandurah train line1. Facilities such as the Cockburn Youth Centre are also located very near to the shopping centre; the Cockburn GP Super Clinic is in a development nearby; and in 2012 the Fremantle Dockers announced their decision to establish a new training and administration facility as a part of a state-of-the-art regional aquatic and recreation centre in the same area (Fremantle Dockers, 2012).

1 For more on the Cockburn Central Town Centre development, visit http://www.cockburncentral.com.au/.

7

2.2 Socio-economic measures

Income

The median weekly income for individuals and households in the City of Cockburn are 4.4 per cent and 9.8 per cent higher than the median incomes for individuals and households in Western Australia (ABS, 2012).

Socio-Economic Indexes for Areas (SEIFA)

The Socio-Economic Indexes for Areas (SEIFA) is the ranking of geographic areas in Australia according to relative socio-economic advantage and disadvantage. The indexes are calculated based on Census data. The index is “derived from attributes that reflect disadvantage such as low income, low educational attainment, high unemployment, and jobs in relatively unskilled occupations” (NGAA, 2013b).

As Table 2 shows, based on the SEIFA Index the City of Cockburn has a low level of disadvantage, particularly in comparison to its southern neighbour, the City of Kwinana. However, it is worth noting that the SIEFA index is an average level of disadvantage across the local government area — as such, some suburbs within the area will have higher (or lower) levels of disadvantage.

Table 2: 2011 SEIFA Indexes for Cockburn and surrounding local government areas (NGAA, 2013c)

8

2.3 Health & wellbeing measures

Public health programs

The rate of childhood immunisation within the city of Cockburn is comparable to the rest of the State; however a City of Cockburn resident is 10 per cent more likely to receive their immunisation from a general practitioner (GP) than the average Western Australian (Department of Health, 2012).

In 2010, the birth rate amongst 15-44 year old women in the City of Cockburn was significantly higher than the overall Western Australian rate with a birth rate of 74.5 per 1,000 women in the City of Cockburn compared with the overall Western Australian rate of 63.4 per 1,000 (Department of Health, 2012).

Mental health

The table below shows the estimated number of people in the City of Cockburn with a current mental health problem — that is, the number of people diagnosed with depression, anxiety, stress-related or other mental health problem in the past 12 months.

These figures indicate that the City of Cockburn has a higher rate of mental health problems than Western Australia as a whole. However, a higher proportion of City of Cockburn residents (9.6%) also reported having accessed mental health services during the previous 12 months (from 2008 – 2011), compared with the State average of 6.1% (Department of Health, 2012).

Table 3: Estimated prevalence of mental health problem (Department of Health, 2012)2

2 These figures were cited as having come from the WA Department of Health Epidemiology Branch’s Health and Wellbeing Surveillance System (HWSS), January 2008 to December 2011.

9

Australian Early Development Index (AEDI)

The Australian Early Development Index (AEDI) is a current, population based measure of young children’s development. The AEDI is a measure of how well a community is raising their children to school age. Two of the areas which the AEDI measures — social competence and emotional maturity — are directly related to a child’s mental health in the early years.

In 2012, AEDI checklists were completed on 1,363 five year old residents of the City of Cockburn. On average, five year olds in the City of Cockburn were found to be above or in-line with State/National averages in the domains of physical health and wellbeing; social competence; and communication skills and general knowledge. They were found to be in-line with or slightly below on the domains of emotional maturity; and language and cognitive skills (AEDI, 2012). These are summarised in the following table of Developmental Vulnerability.

Table 4: AEDI Results: Developmentally vulnerable on one or more and two or more domain/s (AEDI, 2012)

The AEDI also found that:

Overall teachers reported 97.9 per cent of children in Cockburn have experienced some form of regular non-parental early childhood education and/or care in the year before entering formal full-time school (such as family day care, preschool or kindergarten, or care by a grandparent) (AEDI, 2012, p. 13).

This is above the average for both Australia (94.8%) and Western Australia (97.1%).

10

3.0 Early years mental health service delivery in the City of Cockburn

In Report One: Developing the Concepts, a range of people and organisations with a role in monitoring and assessing infant and early childhood mental health in WA were identified, as shown in Table 5:

Table 5: People & organisations with a role in monitoring and assessing infant mental health in Western Australia

The types of organisations and professions listed above have at least some presence either within the City of Cockburn, or in surrounding regions. It is important to remember that a family living within one local government area is not limited to accessing services within that area — they may also (or alternatively) choose/have access to services in surrounding regions, or even further afield. However, it is also worth noting that families with limited transportation options may struggle to access services not located near their residence.

All the organisations and/or individuals listed above provide services to City of Cockburn residents which seek to directly or indirectly support infant and early childhood mental health. Such support is provided through a range of universal, targeted and intensive services — as described briefly below.

11

Specialist infant and early childhood mental health services

Intensive infant mental health services

… are for infants and caregivers experiencing current difficulties, and also attempt to prevent or lessen future problems. These services are most likely to come out of mental health programs, and may be provided for those infants currently experiencing suffering, such as those who have experienced significant trauma, or for whom there are significant parent-infant relationship problems (Zeanah, Stafford, Nagle, & Rice, 2005).

The Fremantle Child & Adolescent Mental Health Service (CAMHS) and Raphael Centre are two organisations which provide specialist, intensive mental health services to infants and young children. Given the young age of the children involved, the services provided often include the identification of caregiver vulnerabilities that can significantly impact on child-parent attachment and parenting ability.

Targeted services addressing vulnerabilities in the early years

(Targeted services) are available to selected groups or individuals who are known to be at risk of developing a particular health or developmental problem, and designed to reduce the likelihood of the problem developing (Centre for Community Child Health, 2009, p. 1).

Targeted services are important because:

Children at risk (especially those children affected by prenatal health challenges, family trauma or disruption, parental depression or mental illness, poverty, abuse, or exposure to violence) need a safety net of infant mental health services (Nelson & Mann, 2011, p. 131).

A range of targeted programs and services are provided by organisations to parents and young children in the City of Cockburn. Such services include:

• The Department for Child Protection & Family Support’s Best Beginnings program is a home visiting service which targets vulnerable families with new infants (DCPFS, 2012).
• The Department for Local Government and Communities Best Start program is targeted at Aboriginal families with children up to five years of age (DLGC, 2013a).
• The StrongFamilies program is a coordinated planning process for consenting families with highly complex needs already in contact with two or more agencies (Government of Western Australia, 2013).
• The Child Development Service (CDS) provides a range of support services for children, with or at risk of developmental difficulties, and their families.

12

Developmental difficulties may relate to speech/language, coordination/movement, behaviour, learning or social/emotional skills (Department of Health, 2013).

While not described or positioned as specifically supporting infant mental health, such programs undoubtedly play a role in supporting the social and emotional wellbeing of infants and young children (and their families).

Universal early years services

(Universal services) are available to the whole of the population and are designed to promote positive functioning and decrease the likelihood of specific problems or disorders developing. Such services are truly universal if they are not only available to the whole population but also accessible to and accessed by most people. Factors affecting accessibility include location, cost, opening hours, and inclusiveness (Centre for Community Child Health, 2009, p. 1).

A wide range of universal early years and parenting services are also available within the City of Cockburn, including health services (such as Child Health Nurses and GPs), parenting support services (such as counselling and education), early childhood education and care services (such as child care and playgroups).

The State Government’s Child Health Services (including Child Health Nurses) is one of the key universal early years services provided in the City of Cockburn. The role of the Child Health Nurse is to assess children’s health and development as well as provide information about many aspects of parenting, maternal and family health and healthy lifestyles (Stokes, 2012). In addition, all Child Health Nurses are trained in using the Edinburgh Postnatal Depression Scale (EPDS), a set of 10 screening questions that can indicate whether a woman “has symptoms that are common in women with depression and anxiety during pregnancy and in the year following the birth of a child” (BeyondBlue, 2013).

Early childhood education and care service providers also play a role in monitoring the behaviour and wellbeing of children in their care. Their contact with parents can also provide them with the opportunity to recognise concerning behaviour in parents and possibly lead them to suggest support services which may assist a parent, and by extension, their child.

13

The role of the City of Cockburn in universal service delivery

Compared with many other local government authorities in metropolitan WA, the City of Cockburn is involved in providing a wide range of services to children and families on a universal basis.

The City is seen as a substantial provider of children’s services, and families view the City positively as standing out from other local government bodies in the provision of highly valued services (City of Cockburn, 2010, p. 3).

The City of Cockburn developed a 10 year plan for its Children’s Services – Our Children, Our Future, in 2001, and followed this up with the development of a Children Services Strategic Plan 2010-2015. At the time of developing their Strategic Plan, the City was already a significant provider of children’s services, employing around 37 full and part time staff (City of Cockburn, 2010, p. 4).

The City of Cockburn operates three different types of Child Care Services - Family Day Care, Outside School Hours Care including Vacation Care, and In Home Child Care. They also provide a number of services to parents, children and families including short term counselling, information sharing, parenting workshops and referrals to support networks. Programs and services including Froggy’s Fun on the Green, the Cockburn Early Years program, Atwell 3 Year Old Playclub, the Family Support Service, as well as a range of early years programs run through the City’s library service. The City also runs a number of free community events each year providing parenting information and entertainment for parents and their children.

The City of Cockburn is well regarded by other service providers for its commitment to the early years, and it is common for workshops to be run in partnership with other service providers, and for Cockburn to seek the participation of service providers at their larger events targeted at parents and children. Significantly, the City of Cockburn has also been seen to step in when a community group has been unable to continue providing a service (to ensure the service isn’t suddenly lost in the area). They have provided not only a level of financial stability and governance, but are also seen as neutral rather than being linked to an organisation with, for example, a particular religious affiliation.

14

The limited presence of community service organisations in service delivery

Compared with the strong presence of the City of Cockburn in the provision of children’s services, it was surprising to note just how few community service organisations are physically located within the City of Cockburn. While there is no reason why residents would not or could not access community sector services outside the City of Cockburn’s boundaries (for example, in the nearby Cities of Fremantle, Melville or Kwinana), the number of community service organisations in the local government area is very low compared to other areas of the Perth metropolitan region. The potential impact of this on the process of integration was not explored in the consultations undertaken as part of this project, having only emerged as a potential factor during the period of analysis.

4.0 Methodology

On mapping & gapping

Prior to the start of this project, the City of Cockburn had already undertaken considerable work assessing the provision of children’s services within their region, as seen in their 2010-2015 Children’s Services Strategic Plan. The strategic plan document outlines both the City’s “gap and needs” analysis, proposed outcomes and strategies to address the identified gaps and needs. As such, it was unnecessary for a further gaps and needs analysis regarding infant and early childhood mental health supports in the region to be undertaken as a part of this project.

This project is designed to be complementary to the work previously undertaken by the City of Cockburn — with our project focusing on further exploring partnerships, collaboration and relationships. As the former Department for Communities’ Resource Kit for starting and sustaining early year’s networks explains, any service mapping exercise:

… is more than just an audit of resources. The fundamental purpose of the mapping is to find connections and relationships between assets (Department for Communities, 2011, p. 18).

It is against this background of recognising the importance of relationships that WACOSS sought to engage a number of key stakeholders and existing services within the City of Cockburn in conversation about:

• How well is the mental health of infants and young children in the City of Cockburn being supported at present?
• What are the strengths of existing services and structures which support infant and early childhood mental health?
• Are there opportunities to improve service delivery through the integration of services? What factors might be barriers to service integration within the City of Cockburn?

15

A semi-structured interview approach was chosen because it would allow for focused, conversational, two-way communication between the interviewer and interviewee(s). An interview schedule was prepared [Appendix One] and distributed via email to interviewees prior to the interview. However, it was explained to interviewees in the accompanying email that the schedule would be

… adapted to suit each interviewee/group, and that you should consider it to be an indication of the sorts of things we are interested in talking about, rather than a list of questions that will be asked.

The semi-structured interview provided the interviewer with the flexibility and opportunity to probe for details or discuss issues.

A total of eleven interviews were undertaken between May and July 2013. A total of 28 people participated in an interview, with most interviews being conducted with a group of people from the same organisation.

The researchers sought to achieve a balance between State Government, local government, and community sector organisations when scheduling interviews. A list of organisations that were represented in the interviews can be found in Appendix Two.

The semi-structured interviews were complemented by an open forum, targeted at a wider range of early years’ service providers working in or around the City of Cockburn. Invitations to this event were distributed widely through the mailing lists of WACOSS, the City of Cockburn, organisations that had been interviewed previously, and other local agencies and contacts. A number of people who had previously been interviewed were among the 35 people who attended, but most who attended had not previously been involved.

Consulting with parents, families and community

The views of families about accessing services and the kind of services they need is an integral part of any proposal to develop an actual service. It was felt that it would not be appropriate to build up expectations of parents and families in Cockburn through formal engagement with this project, which is focussed on developing a model for service integration rather than delivering an integrated and ongoing service.

In Report One we described the Platforms Service Redevelopment Framework (the Platforms approach), a framework developed by the Centre for Community Child Health (CCCH) to help communities undertake work to support children’s development. One of the key strengths of the Platforms approach is that it can help practitioners work in partnership with community members to design, develop, implement and evaluate services that are truly responsive to the needs of children and families (Centre for Community Child Health, 2012). The Centre has also undertaken work specifically focused on engaging marginalised families (Centre for Community Child Health, 2010).

16

5.0 Factors that help or hinder integration

As part of the work developing Report One, a range of studies and papers which primarily addressed the issue of the early years service integration were reviewed. Table 12 provides a summary of the factors identified as being beneficial to integration.

Table 6: Factors which assist early years service integration

17

18

During the interviews, another factor clearly emerged. ‘Service capacity’ as defined by lack of (human, resource and/or financial) capacity was identified as a factor which provided a significant hindrance to the willingness of individuals or organisations to participate in integrated or collaborative working.

While the data gathering process did not involve strict and detailed consideration of each factor in turn, it did generate a wealth of information about how such factors translate and can be applied in practice.

19

6.0 Discussion

In this section, the key observations from the interviews and community forum are summarised and organised into the four key themes which emerged through these discussions:

1. Observations relating to partnerships & working collaboratively;
2. Observations relating to relationships;
3. Observations relating to infant & early childhood mental health service delivery; and
4. Location-specific observations.

In addition, blocks have been placed alongside each of the observations to provide a quick reference point to indicate which factor(s) that assist service integration we believe that observation relates to. A short concluding discussion relating to the relevance and application of each factor can be found in section 6.4.

Observations relating to partnerships & working collaboratively

In this section, the observations relating to partnerships and collaborative working arrangements are outlined. It was observed that:

1. Partnerships can be either formal or informal in nature. However there are relatively few examples of formal partnership arrangements between more than two organisations within the City of Cockburn at present.
2. Partnerships are established for a range of reasons. For example:
   • Support (in the form of a partnership) may be essential to the ongoing existence or establishment of a service;
   • Partnerships may help organisations direct people to the most appropriate service based on their needs; and/or
   • Partnerships may be established to help spread the service workload when capacity is an issue.
3. Networking meetings such as the Purely Early Years meetings are seen as valuable, but lack of capacity was the reason most organisations gave for non-attendance.
4. Competitive tendering arrangements can have a negative impact on:
   • Government/community sector partnerships — due to the requirement for regional government agency staff to distance themselves from the tendering process to avoid perceptions of bias in the awarding of tenders; and

20

• Community sector partnerships — due to the need for organisations to protect their intellectual property, and their own interests.

Existing partnership/collaboration arrangements

Interestingly, with the exception of the Department for Child Protection & Family Support coordinated Strong Families program, most examples of partnership identified through the interviews were partnerships between only two organisations.

The organisation for whom a commitment to working in partnership with others came across most strongly was Meerilinga. Meerilinga staff identified themselves as seeking out a partnership “on every tender” they prepare. When identifying opportunities for working in an area they ask:

“… where does there seem to be sufficient growth for Meerilinga to add service delivery, not duplicate what exists, but enhance and support what exists and fill in gaps? … [W]here is there also capacity that we could work collaboratively and in partnership either with local government, State Government, or other agencies in diminishing the operational costs so that we actually can concentrate on the service delivery and ensure and maintain a high quality of service….”

The Meerilinga CEO reflected that the organisation’s commitment to partnering with other organisations is well known and, as a result she regularly has other organisations come to her proposing they get involved in a project they are running, or proposing that Meerilinga prepare joint funding applications.

Partnerships which help services exist

Meerilinga has an arrangement with the City of Cockburn for the use of its recently refurbished Winterfold Road facility for a nominal rent.

*I think when [Meerilinga] approached us for the lease of the building we… met a few times and we said, “Look we’ve got a children’s plan we would like to work with you in relation to our children’s plan to not duplicate what we’re doing but complement what we’re doing so that we can all achieve better outcomes for the Cockburn community.

Partnerships designed to help spread the service workload

The Raphael Centre (having opened in December 2012) and Fremantle Medicare Local (the Healthy Minds for Children service began in 2013) have both recently begun providing specialist Fremantle-based infant and childhood mental health services. These two organisations have established an arrangement whereby the Raphael Centre gets referred 0-3 year old clients, but refers 4-12 year olds to the Healthy Minds for Children service. As such, the Raphael Centre is focused on providing a “more expert look at the infant age group.” The Raphael Centre staff identified the development of partnerships and working in partnership with other services (like the Multicultural Centre and Fremantle Medicare Local) as a central part of their planned model of working in the area.

Joining Together is a program run in partnership between Child and Adolescent Mental Health Service (CAMHS) and Child Development Service (CDS) at the Southwell Child Development Centre in Spearwood. The evolution of, and need for, the partnership was described by one of the interviewees as follows:

*The Joining Together Program started in 2007 and it’s essentially a joint program between CAMHS and CDS, so there are two or three people from CAMHS and two or three people from CDS that got together and said,

We know that we have kids in common here.” In fact, if anything, CAMHS is saying “we’re not getting the kids we need to service from an infant mental health point of view because of the stigma around infant mental health and the lack of recognition of what infant mental health looks like.” The CDS is saying “we’ve got enormous numbers of infant mental health kids on our case load but we’re not really mandated for that per se — we’re supposed to be doing more development but those things all kind of link in together so why don’t we combine forces?”*

A small, multidisciplinary team of CAMHS and CDS staff come together once a week to jointly triage a limited number of referrals. Joining Together referrals usually come via the CDS service, where the CDS team has identified a “relationship struggle in a child under three” that the team thinks might be impacting on the child’s development outcomes. Such an observation may lead to a referral being considered by the Joining Together team who then come together to decide which service — CAMHS, CDS, or even groups run by organisations such as Meerilinga — will best serve the identified needs of that client/family.

The interviewees from CAMHS and CDS identified many strengths of the Joining Together program. However, despite these strengths, the interviewees described the precariousness of the program. The interviewees felt, that while the services they were delivering in the Fremantle region were improved as a result of their working together more closely, the program’s sustainability was reliant upon individual advocacy rather than being an initiative embraced at a system level. Therefore, the Joining Together program is vulnerable to termination should it lose management support. The Joining Together circumstances illustrate the need for service integration to be supported at all levels within organisations seeking to integrate their services.

Partnerships designed to help people access services

Meerilinga also run an outreach parenting support service (MOPSS) in partnerships with local pharmacies in the City of Cockburn (which was especially interesting as an example of a community sector/private partnership). MOPSS provides a baby-weighing service, and parenting support to people in a small number of local pharmacies a few hours a week. In noting that CAMHS and CDS have waiting lists, and Child Health Nurses were struggling to keep up with the workload locally, the pharmacy partnership was sought by Meerilinga as it provided an opportunity for them to make contact with parents visiting the pharmacy and engage with them in “preventative work.”

*We’re not the service that fixes [health or mental health concerns] but we can identify with families that may have a concern and to say to that family,

Assert yourself and get yourself to a service, or referral. The worst case is you can be assured that someone who has that professional expertise has seen the child, assessed where they’re at and say there is no immediate need to intervene or there is and this is what we’re going to do.

Local early years networking

Building the awareness of available services — either making sure others are aware of your service(s), and/or building one’s own awareness of other services in the region — was valued and seen as important by most interviewees.

The Department of Local Government and Communities’ Children’s Services Officer (CSO) currently coordinates bi-monthly meetings of the Purely Early Years (PEY) group, made up of early years services and workers across the south west metropolitan region (encompassing the Cockburn, Melville, Fremantle and East Fremantle regions).3

Speakers on relevant topics are regularly invited to present at PEY meetings. The PEY group was established in 2010, through the amalgamation of a number of other (often overlapping and duplicative) early years networks and groups. The PEY group is now an important network for information sharing between local agencies (DLGC, 2013b).

A number of the interviewees (or other staff from their organisation) had attended PEY meetings and/or receive the PEY monthly newsletter by email — and identified value in doing so:

I’ve attended [PEY meetings]… I haven’t missed any, except when I was away. I’ve gone to every one of them. That’s how I started off promoting our (new) service — just with that little network. That’s how it started. And from there people get to know us.

When people get to know what we offer and they put it out there to their contacts, and then people come to us and explore [our services]. They call us and they come in and have a look at what we’ve got, what we offer.

3 In 2014 the Department announced that the role of CSO’s would change with all CSO being brought under the auspices of the Education and Care Regulatory Authority, and all being located in East Perth. The impact of this change on activities such as PEY is still to be seen, however indications are that the CSO is unlikely to be available to continue coordinating and hosting the PEY meetings.

25

However, it was also clear that while some organisations make a point of regularly attending the meetings, the attendance of others is less regular. The most commonly given reason for not attending relates to organisational capacity — if the staff member feels too busy at the time of the regularly scheduled meeting, it is common for them to send their apologies and not attend.

Government funding of/for community sector services

A number of the agencies interviewed are the providers of (primarily) grant-based funding to other organisations in the region. Such funding tends to be managed centrally rather than regionally, and funding decisions usually have only limited involvement by regionally-based departmental staff. Government departments provide funding to support a number of programs in the region, but little of the funding identified had partnership building or collaborative working at its core. One-off grants were the type of funding most commonly identified in the interviews.

The City of Cockburn explained that they tended to partner up with/support other local organisations and groups “on a fairly small scale usually, project by project basis, using existing resources, or maybe a bit of grant money.” Such funding tends to provide short-term assistance rather than necessarily contributing to the long-term sustainability of programs and services.

The challenge of competitive tendering

Competitive tendering can also be a challenge to partnerships between non-government organisations, with one community service organisation reflecting that when working in “non-integrated areas” (meaning locations without strong, supportive relationships between service providers)

*… it’s like copying homework at primary school,

can include providing information about available venues, providing information about playgroup structure and activities, through to providing recipes for how to make playdough!

The Cockburn GP Super Clinic, being built alongside the major Cockburn Gateway Shopping Centre is not yet operational, so is not yet part of any partnerships or collaborative work practices. The GP clinic describes itself as a:

A state-of-the-art, integrated medical centre with a team of dedicated doctors, nurses, allied health professionals and specialists working together to deliver quality, coordinated health care services to the community (Cockburn GP Super Clinic, 2013).

The project seeks to have multidisciplinary health and well-being professionals working together. Plans are in place to hold quarterly meetings of the “service provider committee” to discuss collaborative practice.. Thus far, limited planning appears to have been undertaken to build relationships throughout the community.

6.2 Observations relating to relationships

In this section, observations relating to relationships are outlined. It was observed that:

1. Organisational capacity is one of the key factors preventing or limiting participation in activities or processes supporting service integration. The development of relationships and sharing of knowledge is not usually considered to be “core business” for service providers, and as such staff can often find it difficult to justify the time required to effectively participate.
2. Positive, existing relationships between staff at different organisations can create expectations, and make staff seek to avoid disappointing one another. However, the danger of relying too heavily on personal relationships between small numbers of staff is that people leave jobs, and it can take time for new relationships to be formed when this happens.
3. Personal relationships are valuable, but are difficult to quantify. The informality of these relationships makes it difficult to apply a monetary value to them — but their value should be reflected in funding models, and organisational budget processes.
4. Formally and collectively defining the value of relationships and service integration will assist organisations embarking on a service integration journey to build both ownership and appropriate expectations of the integration process.

27

Is integration core business?

Despite the acknowledged value of attending and participating in networking meetings/events, it was clear that lack of organisational capacity is often the key hindrance to service integration. The development of relationships and knowledge is — despite its acknowledged value and positive contribution to service delivery — not usually considered to be “core business” for service providers. The core business for most organisations interviewed is typically direct service provision — often face to face contact with clients. With the establishment of KPIs or contractual obligations, and/or if demand for services are particularly high, the amount of time staff feel they can spend on activities related to relationship-building is reduced. As one interviewee reflected:

… I belong to the early years group in this area and I’m finding it harder and harder to get to the meetings myself. The pressures of work actually tend to pull you in a direction, and unfortunately it’s not always about the collaboration or meshing yourselves with other services — although you know that they’re there and you know that they’re a backup and a support to you…

Justifying your time

Related to the need for organisations to consider relationship-building as part of their core business, is the need for people to be able to justify their participation in networking meetings and the current difficultly many find in doing so. This was a particular challenge for clinical staff who are required to “stat” their work time in numbers. By participating in network meetings and putting effort into building relationships with, and knowledge of, other service providers in the local area, staff develop a body of knowledge which can be of great benefit to their clients particularly through the referral process. One interviewee explained that when you’re able to give the client the name of the individual(s) who work at the service provider you’re referring them to, it makes them a “person”, rather than an impersonal service, and the client tends to be more receptive.

However, the problem acknowledged was that relationship and knowledge building work is difficult to “stat” within the existing departmental reporting processes. Equally, the extent to which this work is directly linked to service integration (as opposed to more generally improving service delivery) may also be difficult to quantify.

28

Expectations of one another

Personal relationships can also help build better services, because those personal relationships can heighten the expectations service providers have of one another.

I was helping a young person make some phone calls recently to organise some debt repayments and the person on the phone was being quite rude to them. When I got on the phone as the advocate, the person’s attitude changed completely — and that was an unknown [to me] faceless, government person.

*If [a client] rings to speak to Lee [at service X] because Maggie sent her, it changes that because it’s not all unknown any more. It’s not a faceless person, it’s like,

Do relationships need to be formalised?

In both the interviews and at the forum there was discussion about the need to formalise relationships. For example, when a staff member leaves or goes on extended leave, it was suggested that there needs to be a (mandatory) requirement for that staff member’s contacts/relationships to be included as part of the handover process so as to limit working relationships being restricted to individuals. As such, it was suggested that organisations need to recognise the value of this organisational knowledge, and implement procedures to ensure that as little information about working relationships as possible is lost. This is of benefit to all the organisations involved — both as the receiver of referrals, or as the organisation needing to do the referring.

Assigning monetary value to relationship-building activities

The other reason it was suggested relationship building/partnerships would benefit from being formalised, is so that it can be incorporated into funding models, and organisational budget processes.

The formality [means] that it is then incorporated into funding. It becomes an expectation. So CEOs can come and go, staff can come and go however the contracts are there for a period of time and everyone must honour it. So the formality then is around removing it purely based on relationships, which works really well, however can easily fall over if those relationships stop.

The challenge of working collaboratively (when your model of work doesn’t formally assign value to the work involved in building relationships) was described by one of the State Government service providers:

One of the challenges is actually how we state what it is that we do. For example we’ve just spent two hours today talking about all of this, which could be potentially, incredibly useful from a service development point of view, but there’s been no activity that’s happened as a result of it. When I go out and talk to Best Beginnings and King Edward that’s another example of exactly the same thing.

… when you do [collaboration and community networking], and it works well, then you’re actually working more seamlessly for families and there’s increased flow through when you can actually do what it is that they’re asking — which is “let’s pick up people sooner, see them less long, have them seen by tier two services”, knowing that we can pick them up again if needs be. That’s the ideal world but we’re just stuck shifting from one model to the next.

30

The interviewee explained that when it comes to reporting on their work, it comes down to “the number of people that you see” — when you’re completely focused on reporting “those that come in through the door… all of that collaboration and community networking goes out the window.”

Formally defining the value & expectations of integration

For organisations interested in undertaking the service integration journey, there needs to be a common understanding amongst all parties involved of the value of relationships and shared knowledge — why do you want to work together, what value/benefits are you expecting to achieve through an integration process? The development of a common understanding will benefit from being developed collaboratively, and being formally articulated in the early stages of the integration process. This is the measuring stick and part of an evaluation tool for the process — it is how the organisations involved can determine whether they are achieving the value/benefit they wanted to through the process, and if not, potentially propose improvements/alternatives.

Formally and collectively defining the value of relationships and service integration will likely contribute to the building of both the expectations and ownership of the process by the parties involved.

6.3 Observations relating to infant & early childhood mental health service delivery

In this section we outline our observations relating to the delivery of infant and early childhood mental health services. It was observed that:

1. All interviewees were familiar with the concept of infant and early childhood mental health, but there remains a reluctance to use the term given the stigma attached to it and concern regarding parents’ expected reactions to the term.
2. Interviewees and forum participants consistently linked infant mental health to attachment theory. There was also reluctance from some participants to be required to attend further training on infant mental health without their existing knowledge such as attachment theory and skills first being recognised and acknowledged.
3. There existed notable hesitation amongst interviewees to describe their service as being “child-centred.” However we believe all interviewees would agree that it is important to both work with, and build the capacity of, the whole family in order to ensure the wellbeing of the child.
4. The Child Health Nurse is one of the services (if not the service) whose participation in effective service integration is considered to be critical. This is due to the contact they have with parents and young children, and the role they play in both receiving referrals, and making referrals to other services.

31

5. The extent to which the service capacity issues of one or more agencies is likely to undermine the opportunities for integrating services is a key question which needs to be thoughtfully and realistically addressed by parties interested in pursuing a service integration agenda. However, this may also provide the opportunity to ask a related question — is service integration/collaborative working a driver or enabler which could help to address service capacity issues in this region?

Talking about infant mental health

The underlying issue raised in Report One — relating to whether an infant can have a mental illness — was the key component of discussions around building a common language and the preference for many to refer to emotional health and well-being as less stigmatising and avoiding the medical/sickness connotations. Reluctance to label interventions as “mental health interventions” was also apparent.

As one group at the forum explained:

Mental health is seen as a specialist service so the workforce in contact with infants and their families (ie. child health nurses, child care services) tend to steer clear of those issues.

Identifying common knowledge and experiences

The concept which most interviewees and forum members seemed to be familiar and comfortable with was “attachment theory.” Being able to build any future training from an attachment theory starting point — and thus recognising the existing knowledge and experience of the workforce —would be a positive move.

The provision of joint training is often also posited as a very good way of building relationships. Participants at the forum were keen to see such a discussion expanded to recognise the importance of measures such as peer supervision and reflective practice, as well as the benefits of embedding specialist workers in more universal services. Such measures would provide additional pathways both for people to access services, and for opportunities for “on the job” training (designed to build on the existing skills of the other staff) to be provided.

32

Wanslea Children’s Services, for example, has recently commenced a project aimed at developing sustainable and ongoing research and learning practices that support and enhance research capacity and culture at all levels of the services, based on the following key principles:

• Ongoing learning and reflective practice;
• Build educators professional knowledge and develop learning communities;
• Encourage a culture of professional inquiry, where educators are engaged in an ongoing cycle of review through which current practices are examined, outcomes reviewed and new ideas generated;
• Practices to occur at the individual, team and organisational level, as well as in partnership with parents (Wanslea Family Services, 2013).

On being child-centred vs. parent- or family-centred

Through the interviews, a variety of viewpoints were expressed regarding the extent to which the child’s needs, as distinct from the parent or family needs were given priority. As a result, different organisations had different perspectives on who their client is — the child, the parent, the child-parent interaction (often referred to as the “dyad”). Some interviewees were particularly conscious about the impact a lack of parenting skill/knowledge or mental health issues can have on people’s ability to parent (including meeting the social-emotional needs of their child) when explaining why they would not consider their service to be “child centred.” As one of the interviewees remarked — “the babies don’t walk into child health by themselves!”

The reliance of infants and young children on their parents certainly was not an issue lost or ignored by those organisations who confidently described their work as being child-centred. However, amongst those organisations who describe their work in this way, there was still not a clear understanding about what it means to be child-centred. For one interviewee, having a child-centred approach related strongly to the concept of “child rights” and the importance of the voice of the child being heard:

…with child-centred, when we are working with families it’s always bringing it back to the child and their perspective and their views, so yes, we are working with families to understand things from the [child’s point of view], so we’re also facilitating families to understand the child-centred approach.

33

For another interviewee, being child-centred focused more heavily on the assignment of priorities:

I mean you can’t just work with the child and not with the parents and the family but I guess it about the level of priority that is given to the child’s needs instead of maybe being overtaken by the families priorities and other sorts of issues —more family support/social working type of stuff about financial management or other sorts of relationship issues or something else that might then take up the worker’s whole time — and then you’re looking at the relationship between the child and the parents and the attachment theory…

The hesitation many interviewees had towards describing their service as child-centred related to the perception that being child-centred meant under-playing the role of parents. However, as the quotations above indicate, to be child-centred does not mean to ignore the role of parents and family in the child’s life.

We believe all interviewees would agree that it is important to both work with, and build the capacity of, the whole family (and even community) in order to ensure the wellbeing of the child. This need is well described in the “ecological systems theory” work of American developmental psychologist Urie Bronfenbrenner4, and more recently in the early years services integration work of Iram Siraj-Blatchford and John Siraj-Blatchford.

If we accept that it is the child that lies at the heart of these family and social initiatives, then ecological models of integration focused on child outcomes like the one framed by Bronfenbrenner (1986, 1994) and Bronfenbrenner and Morris(1998) are seminal in identifying immediate and more distant factors that shape children’s developmental outcomes. Bronfenbrenner’s theory provides a familiar framework by which the child is located at the centre of a series of concentric circles, surrounded and influenced first by the family, then the community (including pre-schools) and finally the national and socio-cultural frameworks within which all families and pre-schools are embedded. (Siraj-Blatchford & Siraj-Blatchford, 2009, pp. 44-45).

Participants also reflected that the importance of having the child at the centre should not just apply to early years services, but should also apply equally to adult services. Concern was expressed at the community forum about adult services (in particular, mental health

4 Refer to Urie Bronfenbrenner, The Ecology of Human Development: experiments by nature and design, published in 1979. Also available online: http://goo.gl/S44qFq.

34

services) which focus solely on the adult as the client. Numerous service providers reported having found such service providers focused on the adult’s needs, often to the exclusion of considering the impact the adult or parent’s experience and family interactions may be having on their children.

Just how far we have to go to bring such a concept to fruition however, was really brought home to me at the forum when one of the groups was discussing their concern that in some funding arrangements, staff can only count time spent with the child (if the child is the client), not time involved in following up/through with whole family issues.

Smooth transitions between services (referrals)

Through the interviews there emerged clear differences in service referral practices between organisations. There was, for example, a clear distinction between referrals to medical/allied health services and referrals to other services. Medical/allied health services, unsurprisingly, tend to have very formal referral processes in place such as limitations on who is able to refer to services (for example, some services require parents to obtain a referral from their GP) and privacy restrictions on the sharing of information about a client with other services (even if that organisation is providing concurrent services or supports to the same client). While there are important reasons why such restrictions are in place, when looking for opportunities to improve service integration, it is important to be cognisant of the impact such restrictions can have on relationships between early years service providers.

Less formal referral processes tended to be favoured by non-medical/allied health service providers.

There was also a clear distinction between organisations which provide active as compared to passive referrals.

• A passive referral is one in which a staff member typically provides a pamphlet or phone number for a different organisation to a client and suggests that they get in contact with them. The other organisation is unlikely to be aware of why that person is contacting them (presuming the person takes the initiative and makes contact), and the client may be frustrated that they have to re-tell their story. It is also possible that the client may not communicate their needs in a way that allows the other service to understand why the client has been referred to their service.
• An active referral is one in which the staff member makes personal contact with the other service, often in the presence of the client being referred. This provides an open and transparent process, reduces the need for the client to

35

repeat all of his/her story, and any issues can be quickly addressed. However, such a referral process is highly reliant on the available capacity of both organisations to be able to allow the additional time to make or take a phone call.

Examples of both passive and active referrals were given, but there were also a number of other situations which fall along what could be regarded as a “referral continuum.” For example:

• Personal passive referral — It was explained by one interviewee that parents tend to respond more positively to (passive) referrals when they’re able to say “It would be good for you to speak to Name A at Service B, she’s really great at working with people on thing of concern.” Here, the personal relationships and knowledge staff members have with one another are critical to informal referral processes.
• Impersonal active referral — One service explained how because they have a relationship with a child health nurse, they can call the nurse and say,

*I’ve been talking to Mrs X. She’s been to see you before. I’m a little bit worried about x, y and z. Can she come in to see you, or can you give her a call?

The value of common referral and assessment processes has been highlighted in the work undertaken by the Armadale Family Support Network (AFSN). As the first of the Department for Child Protection & Family Support’s secondary family support networks to be implemented in WA, the AFSN is led by Parkerville Children and Youth Care, and operates with 13 partner agencies who are providers of secondary family support services. Partner agencies have signed memoranda of understanding which bind them to an agreed approach to service provision.

The recent Evaluation Report of the AFSN undertaken by KPMG sets out the key elements of the AFSN operating framework, including:

• common entry point into the local service network, with partner agencies to adopt a ‘no wrong door’ philosophy to connect clients with services;
• client screening where initial client information is collected by either the Common Entry Point or the partner agency;
• common approach to assessment so that the risk and need of each client can be effectively identified and addressed;
• allocation of cases based on greatest risk and need, and capacity of partner agencies to provide a response;
• ‘active holding’ rather than a traditional waitlist response;
• coordinated demand management where the lead agency has oversight of district level demand for both child protection and family support services;
• differential service intensity based on the assessment and case planning process (KPMG, 2013, p. 10).

The idea behind the “no wrong door” approach to accessing services is to enable clients

… to present themselves at any agency in the network. Should any client be better served elsewhere, it is the responsibility of the agency where the client presents themselves to make a referral and keep liaising with the family until they are receiving assistance from the other agency (KPMG, 2013, p. 40).

Waiting lists and “scaffolding support”

It was explained that when a child gets put on a service waiting list, they are in a “holding pattern”, and often benefit from support in the meantime. Some interviewees noted the valuable role the City of Cockburn play in providing what was described by one as “scaffolding support” to children and their families while they waited to access services. The term “scaffolding” is used to indicate that the support provided is intended to be temporary.

37

The importance of Child Health Nurses

Child health nurses were commonly identified through both the interviews and the forum as playing a key role in monitoring the developmental outcomes of young children. They were also identified as being both a key referrer to other services, as well as a key recipient of referrals from other organisations — especially (though not exclusively) universal service providers. However it became clear that, while many people expect child health nurses to be providing a range of services, as a result of service capacity issues, the primary focus of child health nurses has shifted to screening. 5 While the training and skills of child health nurses brings the opportunity to “provide a very holistic approach to maternal and infant mental health”, unfortunately limited capacity makes undertaking this work quite unrealistic for many child health nurses at present.

Location-specific observations

In this section we outline our observations specific to the City of Cockburn. It was observed that:

1. Funding has been made available by both State and Federal Government agencies for programs supporting service coordination in Western Australia. However, to-date, no such program funding has been made available within the City of Cockburn. It is assumed that this has not occurred because Cockburn has not been identified as “vulnerable”.
2. Lack of consistency amongst the geographic boundaries assigned to metropolitan Perth by different State Government departments hinders the ability of agencies (State Government departments, local government authorities and community sector organisations) to work together in an effective, coordinated manner.
3. Given the central role the City of Cockburn plays in delivering early years services, the proposed amalgamation of local government authorities across the Perth metropolitan region may have a significant impact on the delivery of early years services in the area. There are many as yet unanswered questions regarding the potential impact of combining multiple local government authorities (which have, for example, historically played very different roles in the delivery of early years and other community services).

5 While the wider service provision role of child health nurses has decreased, some do still play a role in the provision of services such as parent support groups.

38

Inequity in the funding for co-ordination

One of the State Government’s high profile and most recent early years initiatives has been the establishment of Child & Parent Centres (CPC). Of the 16 CPCs to be located on school sites in the metropolitan area, none are located within the City of Cockburn. Similarly, Communities for Children (C4C) was a major early years initiative by the Federal Government6, but no C4C has been established within the City of Cockburn. So, whereas other locations have been the site for government programs providing service coordination funding (and in some cases, multiple programs), Cockburn has missed out.

When you consider how some communities have used this funding — for example Communicare allocates a proportion of its funding under C4C in Armadale to the coordination of the Early Years Network, the inequity becomes even more significant.

The CPC & C4C programs are both focused on service coordination. However, as a community not often identified as being highly vulnerable based on SEIFA and AEDI measures, it means the City of Cockburn misses out on opportunities for service coordination funding. The lack of any funding to support or encourage early years service integration or collaboration in the City of Cockburn is highly inequitable at present.

It is tempting to focus limited resources on those in most need. But… we are all in need — all of us beneath the very best-off. If the focus were on the very bottom and social action were successful in improving the plight of the worst-off, what would happen to those just above the bottom, or at the median, who have worse health than those above them? All must be included in actions to create a fairer society.

We are unlikely to be able to eliminate the social gradient in health completely, but it is possible to have a shallower social gradient in health and wellbeing than is currently the case for England…

To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. We call this proportionate universalism. Greater intensity of action is likely to be needed for those with greater social and economic disadvantage, but focusing solely on the most disadvantaged will not reduce the health gradient, and will only tackle a small part of the problem (Marmot, 2010, p. 16).

6 Communities for Children was an initiative initially funded by the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA). For more on the initiative, see: http://goo.gl/5MG3FO.

39

Departmental boundaries

The variation between local and State Government departments’ regional boundaries can be a significant challenge to the ability of organisations to work together in a coordinated manner. Lack of consistency between local government and (multiple) departmental boundaries is challenging because it complicates the assignment of resources, and involvement in shared work because of conflicting work locations.

Departmental regions are typically operated and managed by separate regional offices, and the extent to which different regional offices coordinate their work across boundaries varies significantly. Importantly, each regional office has its own service targets which need to be achieved.

The final report of the Metropolitan Local Government Review Panel (published in 2012) found

… variation in the way State Government agencies organise their administrative districts or sub-regions, including varying definitions of ‘metropolitan’ and ‘regional’ (concerning local governments within the Peel Region). While there may be valid reasons for these variations, they may contribute to the complexity of State and local government relationships…

The report found, for example, that:

The Western Australian Police utilises seven metropolitan districts. The Department of Education operates four metropolitan regions and the Department of Health has two metropolitan service regions. The Department of Housing operates three metropolitan districts.7

The Panel believes a redefinition of local government structures will provide an opportunity for a more consistent alignment of boundaries for State Government agencies as well (Metropolitan Local Government Review Panel, 2012).

This brings particular challenges for a Local Government Authority seeking to actively and effectively engage State Government agencies work towards improved service integration in their area. At present it is unlikely that the boundary of a local government will coincide neatly with the boundaries of a single State Government department (or vice versa). This means that the LGA may need to negotiate the involvement of a State Government department with multiple regional offices whose areas of work cross the LGA’s boundaries. This creates repetitive work and inefficiencies for the LGA, as well as creating additional

7 The report includes a complete list of regional arrangements at the State Government level as an appendix to the report. (Metropolitan Local Government Review Panel, 2012).

work for the multiple regional offices that may need to negotiate their involvement with one another. The difficulty in undertaking such negotiations across (potentially) multiple regional offices of multiple departments and other stakeholders is undoubtedly a challenge and hindrance to service integration.

One of the advantages enjoyed by the City of Cockburn is that boundary inconsistency is not a significant issue for them at present. However, we have raised the issue given the relevance of this to other areas or regions.

Local government amalgamations

At the time of writing this report, local government authorities in the Perth metropolitan region are currently negotiating the establishment of new, amalgamated local governments. The aim of the changes to the local government arrangements is

… not simply about saving money (although there is the potential for savings), but about getting better value for the community. Given the extent of duplication in the current system, there is huge potential to mobilise public resources for more efficient purposes, such as better community facilities, or more consistent planning leading to increased local economic development (Metropolitan Local Government Review Panel, 2012, p. 26).

The State Government’s original proposal was to amalgamate the City of Cockburn and the City of Kwinana. At this stage it remains unclear as to what will ultimately emerge.

Currently early years services to residents of the City of Cockburn, tend to be located within formal service delivery boundaries stretching out through the City of Melville and over to the City of Fremantle. Service delivery boundaries which incorporate the City of Kwinana often (but not always) tend to head south and incorporate the City of Rockingham.

There are a couple of key differences between the City of Kwinana and City of Cockburn when it comes to early years service delivery:

1. Kwinana tends to receive more targeted early years funding from both the State and Federal Governments.
2. As a result of 1), Kwinana has a much larger community sector presence than the City of Cockburn.
3. The City of Kwinana is much less involved in direct provision of early years services than the City of Cockburn.

Given the lack of clarity about the future of the amalgamations, it remains unclear as to what role any newly amalgamated Cockburn/Kwinana (or other) local government authority may play in the early years. Similarly, it remains unclear what impact new boundaries will have on organisational referrals and relationships, and the existing early years networks. For

example, at present the Purely Early Years group includes Cockburn, Melville, Fremantle and East Fremantle, whereas Kwinana has its own early years network.

Information gained in the interviews conducted suggested that most organisations had a tendency to refer northwards (i.e. to Fremantle/Melville based services), rather than southward to Kwinana-based services. It is unclear at this stage to what extent this relates to factors including a) departmental boundaries; b) relationships with existing service providers; and c) stigma leading organisations to avoid referring people to services within a lower socio-economic area. If the Kwinana/Cockburn amalgamation were to proceed, it will be interesting to see whether referrals and relationships between service providers will remain similar to how they exist now, or whether they will shift to reflect new boundaries.

Concluding observations

While all of the factors identified as assisting service integration in Report One featured in the interviews and forums examining their application within the City of Cockburn, it became clear that some of the factors were more significant than others. There may be a number of explanations for this, but one of the main explanations observed was that the importance of the factor depends on which stage of the integration journey participants were at. Cockburn is considered to be quite early on the journey at present. For example:

• While clearly articulated governance arrangements are critical to any service integration work, governance is a factor which would be central to planning and implementation only after a collective decision to pursue an integration agenda has been made. Similarly, this may also explain why the need to establish a common evaluation framework, and the appointment of a project officer to oversee the implementation of an integrated model (resourcing) were not key factors raised in these discussions.
• In addition, the need for integration activities to be inclusive, especially of smaller organisations, was a factor relating to implementation which had not yet been considered by most of the larger organisations, as many of the organisations were focused on the capacity and resource limitations which they saw as likely to affect their own participation.

It is also worth noting that the emphasis placed on different factors varied depending on the professional roles of the interviewees and forum participants. For those involved in direct service provision, the factors of greatest interest or relevance to them tended to be those factors relating to relationships and communication, and often had very practical considerations and application:

• The need to have a good understanding and awareness of services provided by other organisations (information gathering and sharing), and the need for clear, frequent and transparent communication in order to overcome differences and build trust

and rapport were considered highly valuable factors which positively contribute to the ability of service providers to best support their clients.

• As understanding and awareness are built through communication, this can make a positive contribution towards the development of mutual respect and trust between organisations.
• Participants were often also concerned about the conflict they saw between the value in building quality relationships and partnerships, and the fact that activities supporting this work were typically not considered to be part of their core business. It was reported that, as a result of this, participation in activities intended to build or maintain relationships despite their value often end up being compromised or abandoned by organisations when they “get busy.”

Compared with staff involved in direct service provision, interviewees or forum participants in senior management roles, tended to have a more strategic view of service integration:

• For organisations seeking to establish strategic partnerships or collaborative working arrangements, confirmation of whether those organisations have shared values (such as whether or not the organisation considers itself to be child-centred) and goals is important. While early conversations between senior management staff can provide an indication as to whether or not those organisations’ values are complementary, ultimately it will always take some time for organisations to build the trust required for sustainable and effective arrangements for shared work. The current funding and contracting environment (including competitive tendering processes) makes achieving this particularly challenging, but the interest of most organisations interviewed in avoiding the unnecessary duplication of the work of others is positive.

Collaborative work initiatives

It has also been reassuring to observe the consistency between the observations outlined in this report, and the growing interest in exploring and applying models of collaborative work (between government, non-government and private sector organisations) both in Western Australia and across Australia.

Partnership Forum

A major initiative designed to encourage and support partnership between State Government and community sector agencies in Western Australia is the Partnership Forum launched in 2011:

The mission of the Partnership Forum is to bring together leaders from State Government agencies and the not-for-profit community sector to improve outcomes for all Western Australians through a genuine partnership in the

policy, planning and delivery of community services in Western Australia. (Department of Premier & Cabinet, 2013)

The Partnership Forum has provided a valuable channel for the community sector to work collaboratively with the State Government to progress improved approaches to funding and contracting processes. Policy and partnership, and service design and delivery, have been identified as two areas for further work in the coming year. In addition, three strategic priorities have recently been identified for this term of Government; one of which is the early years.

South West Metropolitan Partnership Forum

The South West Metropolitan Partnership Forum (SWMPF, not affiliated with the Partnership Forum described above) is a three year, State Government-funded social innovation project (DLGC, 2013). The SWMPF is described as responding to

…the growing body of evidence that joined-up services and placed-based approaches, in which all stakeholders are engaged, produce more effective, sustainable outcomes.

The [SWMPF] project is concerned with building on and strengthening existing partnership structures to better respond to the needs of the most disadvantaged and vulnerable members of the community.

It is anticipated that the [SWMPF] project will provide new models and lessons on innovative, localised and client-centred service delivery that can be translated elsewhere in Australia and beyond (South West Metropolitan Partnership Forum, October 2013).

The project covers the local government areas of Fremantle, Melville and Cockburn, and is auspiced by St Patrick’s Community Support Centre.8 While still in the early stages, the project represents an exciting opportunity for State Government agencies, community sector organisations, local governments and the wider community to participate in the exploration and implementation of initiatives to improve outcomes in their local area.

8 St Patrick’s Community Support Centre is a non-government organisation which has worked “to provide immediate and holistic care for the homeless, those at risk of being homeless and the disadvantaged in Fremantle and the wider south west metropolitan area of Perth” (St Patrick’s Community Support Centre, 2013).

One particular model of collaborative working which is also gaining some traction in Western Australia is known as collective impact9. The notion of collective impact was introduced by John Kania and Mark Kramer in the winter 2011 issue of Stanford Social Innovation Review, and fits neatly alongside the service integration agenda. Collective impact was described as

… the commitment of a group of important actors from different sectors to a common agenda for solving a specific social problem. Collaboration is nothing new. The social sector is filled with examples of partnerships, networks, and other types of joint efforts. But collective impact initiatives are distinctly different. Unlike most collaborations, collective impact initiatives involve a centralized infrastructure, a dedicated staff, and a structured process that leads to a common agenda, shared measurement, continuous communication, and mutually reinforcing activities among all participants (Kania & Kramer, 2011).

Collective impact is described in contrast to what the authors describe as “isolated impact.”

[Isolated impact is] an approach oriented toward finding and funding a solution embodied within a single organization, combined with the hope that the most effective organizations will grow or replicate to extend their impact more widely. [Many organisations] try to invent independent solutions to major social problems, often working at odds with each other and exponentially increasing the perceived resources required to make meaningful progress (Kania & Kramer, 2011).

Kania and Kramer’s paper also describes several examples of highly structured collaborative efforts that have achieved substantial impact on large scale social problems.

9 The first Collective Impact Forum in Perth was hosted by the Centre for Social Impact (UWA), Collective Impact Australia, Child Australia and WACOSS in August 2013.

Through this work they identified five conditions behind successful collective impact initiatives:

Table 7: The five conditions behind successful collective impact initiatives

As illustrated in the table above, the five conditions behind successful collective impact initiatives align very clearly with most of the factors identified as assisting service integration.

Conclusion

This project came about as a result of both the Mental Health Commission’s Infant Mental Health Planning Group’s recognition that mental health issues have a unique impact on infants and young children (and require specialised responses), and the Commission’s broader interest in government and non-government agencies working together at policy, program and service delivery levels. Combined with WACOSS’ long history of policy and advocacy work on behalf of the community services sector in WA — in particular relating to both the early years and the benefits to be achieved from better integrated services in WA — this project has provided a valuable insight into some of the personal, organisational and bureaucratic dynamics which can create, support or limit opportunities for service integration, and deliver optimal mental health outcomes for infants and young children.

With the identification of key factors which assist service integration in Report 1, we sought to build a common language of readily understood concepts. In Report 2 (this report) we applied these factors to the relationship and partnership experiences of service providers within the City of Cockburn. It is our hope that together, Reports 1 and 2 can provide a starting point for service providers within the City of Cockburn to further their consideration of opportunities to delivering services which — through improved service integration — will provide even better ways and means of supporting the mental health of infants and young children.

The key finding of this project comes down to the importance of putting a value on service integration. The interviewees universally acknowledged that there is real or potential value in better integrated services. For example, all agreed that attending and participating in meetings and events where they meet and interact with other service providers from the local area is of value to both them and their clients. This is because the relationships which often eventuate from such interactions, provide ongoing opportunities to share information, knowledge and contacts which can help them better serve their clients (potentially in a new or more holistic manner than they may have been able to achieve previously).

Unfortunately many interviewees, described “work” as getting in the way of activities which emphasise relationship-building. In this definition, “work” is equated with meeting KPIs or contractual obligations such as the numbers of clients seen. It does not necessarily evaluate how efficiently or effectively targets are met or the quality and sustainability of outcomes. Both government and community sector staff indicated that their current reporting processes and/or contracting arrangements do not adequately reflect the time, effort and value to their organisation of building and maintaining relationships. This makes it difficult for staff to justify the time needed to build and maintain the relationships which are at the core of better integrated services, and better service delivery.

As long as service integration is not identified as a part of an organisation’s core business, (adequate) resources are unlikely to be allocated to the integration journey. Our findings indicate that there is a clear need to further explore means of ensuring the value of service integration (in particular relationship/partnership building) is reflected in both government funding models, and organisations’ planning and budgeting processes.

Ultimately, we hope that the work of this project — through the identification of key issues that need to be considered by organisations which are working towards a greater integration — will be of use to a number of the initiatives currently occurring within the City Cockburn (such as the GP Super Clinic and the work Meerilinga). We also hope that this work will be useful to organisations in other localities who are considering moving along this journey towards integration.

While specific recommendations have not been proposed, it is hoped that the content of both reports and in particular our discussion around the key observations will form the basis for further consideration by the members of the Infant Mental Health Planning Group, and the City of Cockburn.

1. WACOSS (2013) Integrating services to support the mental health of infants and young children: Developing the Concepts.
2. Department for Communities (2011) Resource kit for starting and sustaining Early Years networks.
3. Edith Cowan University — Centre for Research in Early Childhood & Social Justice Research Centre, (2013) Child and Parent Centres on public school sites in low socioeconomic communities in Western Australia: A model of integrated service delivery.
4. KPMG (2013) Evaluation of the Armadale Family Support Network: Final Evaluation Report.
5. KPMG (2013) The Integration Imperative: reshaping the delivery of human and social services.
6. John Kania & Mark Kramer (2011) Collective Impact.

9.0 References

ABS. (2008). 2006 Census Community Profile Series : Cockburn (C) (Local Government Area), Basic Community Profile. Retrieved November 29, 2013, from Australian Bureau of Statistics: http://www.censusdata.abs.gov.au/ABSNavigation/prenav/ViewData?&action=404

&documentproductno=LGA51820&documenttype=Details&tabname=Details&area code=LGA51820&issue=2006&producttype=Community%20Profiles&&producttype =Community%20Profiles&textversion=false&na

ABS. (2012). 2011 Census of Population and Housing: Basic Community Profile. Retrieved November 26, 2013, from Australian Bureau of Statistics: http://www.censusdata.abs.gov.au/CensusOutput/copsub.NSF/AllI%20docs%20by% 20catNo/2011Community%20ProfileLGA51820/SFile/BCP_LGA51820.zip?OpenEl ement

ABS. (2013). Socio-Economic Indexes for Areas. Retrieved December 6, 2013, from Australian Bureau of Statistics: http://www.abs.gov.au/websitedbs/censushome.nsf/home/seifa

ABS. (2013b). 2011 Census Quick Stats: Western Australia. Retrieved December 2, 2013, from Australian Bureau of Statistics: http://www.censusdata.abs.gov.au/census services/getproduct/census/2011/quic kstat/5

AEDI. (2012). Australian Early Development Index: Community Profile 2012, Cockburn. Retrieved November 21, 2013, from http://reports.aedi.org.au/community- profile/wa/2012/51820.pdf

BeyondBlue. (2013). Edinburgh Postnatal Depression Scale. Retrieved November 21, 2013, from BeyondBlue: http://www.beyondblue.org.au/resources/for-me/pregnancy-

and-early-parenthood/edinburgh-postnatal-depression-scale

Centre for Community Child Health. (2009). Policy Brief: Integrating Services for Young Children and their Families. Retrieved December 6, 2013 from Royal Children’s Hospital Melbourne: http://www.rch.org.au/uploadedFiles/Main/Content/ccch/PB 17 FINAL web.pdf

Centre for Community Child Health. (2010). Policy Brief: Engaging Marginalised and Vulnerable Families. Retrieved December 6, 2013, from Royal Children’s Hospital Melbourne: http://www.rch.org.au/uploadedFiles/Main/Content/ccch/PB18 Vulnerable famili es.pdf

Centre for Community Child Health. (2012). Platforms: Introduction to Platforms. Retrieved April 5, 2013, from Royal Children’s Hospital Melbourne: http://www.rch.org.au/ccch/consultancy/Platforms/

City of Cockburn. (2010). Children’s Services Strategic Plan: 2010-2015. Retrieved November 20, 2013, from http://www.cockburn.wa.gov.au/documents/CommunityServices/Children_Health/ FINAL_WORKING_DRAFT_childrens_plan_July_26th_2010.pdf

Cockburn GP Super Clinic. (2013). Cockburn GP Super Clinic: Home. Retrieved November 19, 2013, from http://www.cockburngpsuperclinic.com/

DCPFS. (2012). Best Beginnings. Retrieved December 2, 2013, from Department for Child Protection & Family Support: https://www.dcp.wa.gov.au/SUPPORTINGINDIVIDUALSANDFAMILIES/Pages/BestBe ginnings.aspx

Department for Communities. (2011). Resource kit for starting and sustaining Early Years networks. Retrieved November 15, 2013, from Department for Local Government & Communities: http://www.communities.wa.gov.au/communities-in- focus/parenting_and_children/earlyyears/Pages/Starting-and-sustaining-Early- Years-Networks.aspx

Department of Health. (2012). General Health Profile for Cockburn Local Government Area. Perth: Epidemiology Branch: Department of Health, WA.

Department of Health. (2013). Child and Adolescent Community Health: Our Services. Retrieved February 20, 2013, from Government of Western Australia: Department of Health: http://pmh.health.wa.gov.au/general/CACH/services.htm

Department of Premier & Cabinet. (2013). Government of Western Australia: Partnership Forum. Retrieved March 10, 2014, from Partnership Forum: http://www.partnershipforum.dpc.wa.gov.au/Pages/Default.aspx

DLGC. (2013). Social Innovation Grants Recipients - September 2012 and January 2013. Retrieved March 10, 2014, from Department of Local Government & Communities: http://www.communities.wa.gov.au/Documents/Grants%20and%20funding/Social %20Innovation%20Grants%20Receipient_Round%205%20and%206.doc

DLGC. (2013a). Aboriginal and Torres Strait Islander families. Retrieved December 2, 2013, from Department of Local Government & Communities: http://www.communities.wa.gov.au/communities-in- focus/parenting_and_children/aboriginalbeststart/Pages/default.aspx

DLGC. (2013b). Purely Early Years - South West Metropolitan Early Years Interest Group. Retrieved November 19, 2013, from Department of Local Government & Communities: http://www.communities.wa.gov.au/communities-in-focus/parenting_and_children/earlyyears/early-years-networks-metro/Pages/Purely-Early-Years---South-West-Metropolitan-Early-Years-Interest-Group.aspx

Fremantle Dockers. (2012). Freo’s New Elite Training and Administration Facility. Retrieved December 1, 2013, from Fremantle Football Club: http://www.fremantlefc.com.au/news/2012-12-21/etaf-announcement

Government of Western Australia. (2013). Strong Families. Retrieved November 20, 2013, from http://www.strongfamilies.wa.gov.au/About

Kania, J., & Kramer, M. (2011). Collective Impact. Retrieved December 5, 2013, from Stanford Social Innovation Review: http://www.ssireview.org/articles/entry/collective_impact

KPMG. (2013, June). Evaluation of the Armadale Family Support Network: Final Evaluation Report. Retrieved November 18, 2013, from http://whereto.org.au/images/KPMG%20Evaluation%20Report%20-%20AFSN.pdf

KPMG. (2013). The Integration Imperative: reshaping the delivery of human and social services. Retrieved November 18, 2013, from http://www.kpmg.com/global/en/issuesandinsights/articlespublications/pages/int egration-imperative.aspx

Marmot, M. (2010). Fair society, healthy lives : the Marmot Review : strategic review of health inequalities in England post-2010. Retrieved December 12, 2013, from UCL Institute of Health Equity: http://www.instituteofhealthequity.org/projects/fair- society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report

Metropolitan Local Government Review Panel. (2012). Metropolitan Local Government Review: Final Report of the Independent Panel. Retrieved November 25, 2013, from Department of Local Government & Communities: http://metroreform.dlg.wa.gov.au/Content/Reports/Metropolitan-Local- Government-Review-Panel-Final-Report.pdf

Nelson, F., & Mann, T. (2011, February-March). Opportunities in Public Policy to Support Infant and Early Childhood Mental Health: The Role of Psychologists and Policymakers. American Psychologist, 66(2), 129–139.

NGAA. (2013a). Community Profile: City of Cockburn. Retrieved November 25, 2013, from National Growth Areas Alliance (NGAA) Profile.id: http://profile.id.com.au/ngaa/birthplace?BMID=38&WebID=250

NGAA. (2013b). Community Profile: SEIFA - disadvantage. Retrieved November 25, 2013, from National Growth Areas Alliance (NGAA) Profile.id: http://profile.id.com.au/ngaa/seifa-disadvantage?es=2&WebID=250

NGAA. (2013c). Community Profile: SEIFA - disadvantage. Retrieved November 25, 2013, from National Growth Areas Alliance (NGAA) Profile.id: http://profile.id.com.au/ngaa/seifa-disadvantage?es=2&WebID=250

Prichard, P., Purdon, S., & Chaplyn, J. (2010). Moving Forward Together: A guide to support the integration of service delivery for children and families. Retrieved March 10, 2014, from Murdoch Children’s Research Institute: http://www.rch.org.au/ccch/resources_and_publications/Training_and_practice_r esources/#bm_6

Siraj-Blatchford, I., & Siraj-Blatchford, J. (2009). Improving development outcomes for children through effective practice in integrating early years services. London, UK: Centre for Excellence and Outcomes in Chlidren and Young People’s Serviecs.

South West Metropolitan Partnership Forum. (October 2013). An Introduction to the South West Metropolitan Partnership Forum. Fremantle, WA.

St Patrick’s Community Support Centre. (2013). Overview. Retrieved March 10, 2014, from St Patrick’s Community Support Centre: http://www.stpats.com.au/about/overview/

Stokes, B. (2012). Review of the admission or referral to and the discharge and transfer practices of public mental health facilities/services in Western Australia. Perth, Australia: Government of WA : Mental Health Commission & Department of Health.

WACOSS. (2013). 2014-15 WACOSS Pre Budget Submission. Retrieved March 10, 2014, from WA Council of Social Service: http://www.wacoss.org.au/policy_and_advocacy/pre_budget_submission.aspx

Wanslea Family Services. (2013). Developing Research Capacity and Culture in Wanslea Children’s Services. Presentation by C. Baker at the 2013 WA Early Childhood Education & Care Conference “Wheels in Motion”.

Zeanah, P., Stafford, B., Nagle, G., & Rice, T. (2005). Addressing social-emotional development and infant mental health in early childhood systems.

Appendices

Appendix Interview

Introduction: Mental Health Commission has provided WACOSS with funding to explore the integration of infant and young children’s mental health services in WA. As part of this project, we’re talking specifically to existing services within the City of Cockburn to figure out:

• How well things are operating at present (re: supporting infant and young children’s mental health); for example the strengths of existing services and structures, and what opportunities there might be for improvement (with regards to integrating services)?
• What things might be barriers to service integration within the City of Cockburn?

Service integration can mean a lot of things. It might mean establishing a central location which multiple organisations operate from, but then again, it might not. It might mean looking for ways to centrally coordinate access and referrals to services, but it might not. It might mean improving the ways and regularity with which organisations are in contact with one another. But ultimately, what we’re seeking to do is to find ways to make sure infants and young children in the City of Cockburn receive the support they need in order to optimise their short and long term (mental health and wellbeing) outcomes.

Interview Questions

Organisational information

1. Can you tell me a little about your organisation and the services it provides to children in their early years?
   • What would you say your organisation’s core business is?
   • Why does your organisation believe that providing this service is so important? [values]
2. Does your organisation provide a ‘universal’ or ‘targeted’ service?
   • What sorts of people access your service?
   • Do you know of any groups of people who don’t currently access your service (but could or perhaps should)? [inclusion]
   • (How) Do you collect feedback from people who access your service? [evaluation]
3. Does your organisation work only in the Cockburn area, or does it have a much broader coverage. (How significant is the work in Cockburn in the context of the whole agency?)
4. What’s the demand like for your service in the Cockburn area?

• Are there other organisations in the area that provide the same or similar service to you?

5. Can you tell me a little about how your work is funded?
   • Do you access funding through competitive tendering arrangements? Does this process impact your relationship with other organisations in the area? [relationships] [information sharing]
   • Would you say that your organisation struggles to remain financially viable? [resourcing]
6. Can you tell me about the building your service operates from?
   • Who owns it?
   • Do you share it with anyone else? If so, what’s the sharing experience been like?
   • Is there any plan/desire for your organisation to move premises in the short-medium term?
7. Some organisations would describe their work as being ‘child-centred’, others as ‘family-centred’ or ‘parent-centred’. How would you describe your organisation?
   • What does it mean for your organisation to be [XX-centred]?
8. How do measure success or effectiveness of the services your organisation delivers? [evaluation]
   • Is this evaluation an important part of your work?
9. How would you describe the effectiveness of communication within your organisation?

Partnership history

10. The purpose of this project is to consider ways we can improve infant mental health outcomes by looking for opportunities to integrate services within the Cockburn area:
    • But first, can I ask you what you understand “service integration” to mean?
    • When we talk about service integration, we consider it to be a journey, as illustrated by this diagram. Where would you place your organisation on this diagram at present?
11. What/how much contact do you have with other organisations in Cockburn who do work supporting the mental health of infants & young children? [communication]
    • For example, what’s the process if you notice a child having a particular difficulty and believe they need to be referred to another (specialist) service?
    • Is there something you’d like to see improved here?
12. Does your organisation currently have any formal/informal partnerships/sharing arrangements with other organisations delivering early years mental health services in the Cockburn area? [relationships]
    • What’s the purpose of the partnership?

• Is your organisation one of the leaders in the partnership? Or would you say you’re not an active participant?
• How does the partnership work? What do you share? [shared work] [governance]
• What benefit do you get from the partnership?
• How do you think the partnership could be improved?

13. Have you worked for organisations which have had positive or negative experiences relating to partnerships or the integration of their and other organisations’ services?

Appendix Two: Interviewees

Table 8: Organisations represented in the interview process

10 Child Health Nurses work at a range of locations including Success, Atwell, Yangebup, Spearwood and South Lake in the City of Cockburn. 11 The development of the Cockburn GP Super Clinic is supported by financial assistance from the Australian Government under the GP Super Clinics Program, and the City of Cockburn (Cockburn GP Super Clinic, 2013). 12 Community Midwifery WA are scheduled to move into the Cockburn GP Super Clinic in Success upon its completion. 13 As of July 1 2013, the Department for Communities is now the Department of Local Government & Communities.

Appendix Three: The Integration Journey

A journey towards early childhood service integration (Prichard, Purdon, & Chaplyn, 2010, p. 9)

INDIVIDUALLY

• Each program/service has developed their individual philosophy, vision and values.
• Each program/service has separate funding arrangements.
• Little communication occurs between each program/service.

CO-LOCATION

• Some joint planning has taken place but each service maintains their individual philosophy, vision and values.
• Services have engaged the community and are responding to community need separately.
• Each program/service has separate funding arrangements.

COLLABORATION

• A common culture, values and actions between multiple organisations sharing the same vision.
• All organisations have an open dialogue, have engaged the community and are responding collectively.
• Some joint programming has required shared funding arrangements.

INTEGRATION

• A shared philosophy and vision has been developed and formally agreed by all.
• Primary focus is the shared outcomes responding in a way that is meaningful to the community and reflective of partnership.
• Pooled funding is administered for common early learning and care programs.

Many children miss out on access to services. Families have improved access to services but little enhanced benefit for children due to poor inter-service collaboration. Children benefit through increased inter-service collaboration. Families will receive support that addresses all aspects of their needs in a cohesive fashion

Published: May 2014

For more information, contact:

Helen Creed, Policy Manager (Vulnerable People), WACOSS helen@wacoss.org.au (08) 9420 7222

Sarah Mummé, Policy Officer (Vulnerable People), WACOSS sarah@wacoss.org.au (08) 9420 7222

Gail Bowman, Manager Human Services, City of Cockburn gbowman@cockburn.wa.gov.au (08) 9411 3444

BETTER TOGETHER: SUPPORTING PERINATAL AND INFANT MENTAL HEALTH SERVICES

PIMH in the City of Joondalup and the City of Wanneroo, WA March 2019

Supported by WA Primary Health Alliance phn PERTH NORTH, PERTH SOUTH, COUNTRY WA

About Edith Cowan University

Edith Cowan University was established in 1991. The name of the university is derived from Edith Dircksey Cowan OBE, best known as the first Australian woman to serve as a member of parliament. As a social reformer Edith Cowan worked for the rights and welfare of women and children. Edith Cowan University is guided by values of integrity, respect, rational inquiry and personal excellence. The focus of the university is on teaching and research inspired by engagement and partnerships with those in the many communities it was established to serve. Research at ECU seeks to extend knowledge and improve the quality of life for Australians and people across the globe. ECU’s research priorities focus on solving real world problems across social, economic, physical and environmental domains.

About ECU Transdisciplinary Child Research Collaboration

This collaboration developed in response to a growing awareness of the benefits of transdisciplinary research in the fields of Perinatal and Infant Mental Health. In particular students from diverse disciplines who came together to study in the Edith Cowan postgraduate programme of Infant Mental Health were required to complete a research project as part of their degree.

The ECU Transdisciplinary Child Research Collaboration comprise academics and clinicians from various branches of psychology, nursing and midwifery and early childhood education who have expertise and interest in applied research that supports the social and emotional wellbeing of infants, infants, young children and their families across a range of settings and continuum of care.

About the WA Primary Health Alliance

WA Primary Health Alliance is a federally funded commissioning organisation that oversees the state’s three Primary Health Networks; Perth North, Perth South and Country WA. It works across the WA health system to improve the coordination of care for people who are at risk of poor health outcomes and to facilitate a more effective and efficient health system. To achieve this, WAPHA is focused on improving health equity and access, commissioning services in the areas of greatest need and developing person-centred models of care.

About Bankwest Curtin Economics Centre

The Bankwest Curtin Economics Centre is an independent economic and social research organisation located within the Curtin Business School at Curtin University. The centre was established in 2012 through the generous support of Bankwest (a division of the Commonwealth Bank of Australia), with a core mission to examine the key economic and social policy issues that contribute to the sustainability of Western Australia and the wellbeing of WA households.

The centre is able to capitalise on Curtin University’s reputation for excellence in economic modelling, forecasting, public policy research, trade and industrial economics and spatial sciences. Centre researchers have specific expertise in economic forecasting, quantitative modelling, micro-data analysis and economic and social policy evaluation. The centre also derives great value from its close association with experts from the corporate, business, public and not-for-profit sectors.

Contents

List of figures iii List of tables v Foreword vi Acknowledgements vii Executive Summary viii Key Findings ix Recommendations xii Chapter 1: Introduction 1

• Introduction 2
• Scientific Background 3
• Conceptual Model 7
• Research Team 12 Chapter 2: Economic and Social Context 15
• Introduction 16
• Demographics 17
• Socio-economic Indicators 23
• Culture, Language and Religion 29 Chapter 3: Service Mapping 33
• Introduction 34
• Government Health and Mental Health Services 35
• Early Childhood Education and Care, Community Services and Libraries 36
• Universal Services 37 Chapter 4: Provider Survey Results 39
• Introduction and Characteristics of Survey Respondents 40
• Agency/organisation Success 42
• Agency/organisation Source of Funding and Staffing Resources 45
• Training – Agency/organisation Respondents 47
• Client Characteristics 50
• Referral Pathways 51
• Conclusion 52 Chapter 5: Consumer Survey Results 53
• Introduction and Characteristics of Survey Respondents 54
• Point of Contact 55
• Level of Difficulty in Accessing Services 56
• Communication 58
• Success of Agencies/organisations, Support Systems and Sources of Information 59
• Conclusion 64 Chapter 6: Participatory Action Research Findings 65
• Introduction 66
• Summary of Reference Group Meetings 67
• Consumer Focus Group Findings 75

i

Contents (continued)

Chapter 7: Interventions 83

• Introduction 84
• Primary Health Training and Evaluation: General Practitioners (GP) 85
• Primary Health Training and Evaluation: Pharmacists 87
• PIMH Community Training 89 Chapter 8: Social Network Analysis 93
• Introduction 94
• Method 95
• Perceptions of Success 96
• Perceptions of Barriers 97
• Contribution of Agencies/Organisations to Network 98
• Density, Degree of Centralisation, and Dimensions of Trust 99
• Overall Value and Trust Measure 100
• Partnership Intensity 103
• Referred Clients 107
• Implications and Recommendations 109 Chapter 9: Summary and Discussion 111 Chapter 10: Appendix 115 Chapter 11: Glossary 117 Chapter 12: References 119

ii

List of figures

Figure 1 Conditions of systems change 5 Figure 2 The nested environments of Relational Developmental Systems 6 Figure 3 Conceptual model 10 Figure 4 Team Leads 12 Figure 5 Total Population by SA2 region, City of Joondalup and City of Wanneroo, 2016 19 Figure 6 0-4 Year Old Population by SA2 region, City of Joondalup and City of Wanneroo, 2016 20 Figure 7 0-4 Year Olds as a percentage of total population, 2016 21 Figure 8 15-39 Year old Female Population by SA2 region, City of Joondalup and City of Wanneroo, 2016 22 Figure 9 Median Weekly Income by SA2 region, City of Joondalup and City of Wanneroo, 2016 27 Figure 10 Unemployment rates by SA2 region, City of Joondalup and City of Wanneroo, 2016 28 Figure 11 Government Health and Mental Health Services, 2018 35 Figure 12 Early Childhood Education and Care, Community Services and Libraries, 2018 36 Figure 13 Universal Services, 2018 37 Figure 14 General Practitioner Services per 1,000 of the Population of 0-4 Year olds, City of Joondalup and City of Wanneroo 38 Figure 15 Proportion of Respondents by Service Category 40 Figure 16 Length of Time Working in Current Category 41 Figure 17 Number of services or programs provided by the Agency/organisation 41 Figure 18 Self-reported Agency/organisation Success in supporting the needs of children aged 0-3 and their families 42 Figure 19 Self-reported Agency/organisation Success in supporting the needs of children aged 0-3 and their families, by Service Category 42 Figure 20 Aspects of Network Contributing to Agency/organisation Success 43 Figure 21 Barriers to Network Success 44 Figure 22 Expected benefits if greater cohesion of services existed 44 Figure 23 Main source of funding 45 Figure 24 Proportion of Agency/Organisation funding allocated to services for children aged 0-3 years 46 Figure 25 Proportion of Agency/Organisation staff providing services to 0-3 year olds 46 Figure 26 Availability of Training in IMH and PIMH for Agency/organisation Staff 47 Figure 27 Availability of Training in IMH and PMH for Staff, by Agency/organisation Category 48 Figure 28 Areas where agency/organisation would benefit from further training 49 Figure 29 First point of contact if difficulty during pregnancy or raising 0-3 year old child, 2018 55 Figure 30 Source of Difficulty in Accessing Services, 2018 56 Figure 31 Communication between services when two or more services/agencies/organisations accessed by the client, 2018 58

iii

List of figures (continued)

Figure 32 Success of Agencies/Organisations in supporting the needs of children aged 0-3 and their families, 2018 59 Figure 33 Success of Informal Supports towards emotional and social needs of 0-3 year old children 60 Figure 34 Source of Information regarding Parental well-being during pregnancy and after baby is born 61 Figure 35 Source of Information regarding social, emotional and/or behavioural concerns in 0-3 Year old 62 Figure 36 Areas where additional information would have benefitted during pregnancy and early years 63 Figure 37 Types of Agency/Organisation that participated in the SNA survey 95 Figure 38 Perceptions of Success 96 Figure 39 Contributing Aspects of Collaboration Success 96 Figure 40 Barriers to Success 97 Figure 41 Agencies/organisations Most Important Contribution to the Network 98 Figure 42 The Relative Value of Organisations 100 Figure 43 The Relative Trust of Organisations 101 Figure 44 Perceptions of Value 102 Figure 45 Dimensions of Trust 102 Figure 46 Partnership Intensity: None/Awareness only 105 Figure 47 Partnership Intensity: Cooperative Only 105 Figure 48 Partnership Intensity: Coordinated Only 106 Figure 49 Partnership Intensity: Integrated Only 106 Figure 50 Referred Clients 107

iv

v List of tables

Table 1 Transdisciplinary Team for Better Together 9 Table 2 Population, Births and Fertility Rates, City of Joondalup, 2016 17 Table 3 Population, Births and Fertility Rates, City of Wanneroo, 2016 18 Table 4 Socio-economic Indicators, Education and Need for Assistance, City of Joondalup, 2016 23 Table 5 Lone Parents by Gender, City of Joondalup, 2016 24 Table 6 Socio-economic Indicators, Education and Need for Assistance, City of Wanneroo, 2016 25 Table 7 Lone Parents by Gender, City of Wanneroo, 2016 26 Table 8 Culture, Language and Religion, City of Joondalup, 2016 29 Table 9 Immigrant Population by Region of Origin, City of Joondalup, 2016 30 Table 10 Culture, Language and Religion, City of Wanneroo, 2016 31 Table 11 Immigrant Population by Region of Origin, City of Wanneroo, 2016 32 Table 12 Summary of Better Together Reference Group Meetings 67 Table 13 Network Scores: Density, Centrality and Dimensions of Trust 99 Table 14 Definitions of Partnership Intensity 103

v

Foreword

As higher education strives to meet the challenges of UNESCO’s Global University Network for Innovation’s challenge to re-define its social responsibility, it increasingly is building partnerships with community that embrace collaborative inquiry, shared knowledge, and co-creative ingenuity in efforts to tackle and solve many of the world’s most wicked problems. Wicked problems involve networks of interacting systems, and increasingly it is clear that theories and approaches of the past are insufficient to unravel or transform problems that are embedded in social, economic, political and racial inequalities.

As a result, new paradigmatic views have given rise to theories and methods that are anchored in relational developmental systems frameworks. One such framework, Perinatal Infant Mental Health (PIMH), has emerged from nearly 40 years of systematic trans-disciplinary research on the biopsychosocial organisation of the human being from conception through the first five postnatal years of life. No other period of human development has generated the level of research intensity from the aggregate developmental sciences during the last 50 years of the 20th century to the present.

The PIMH framework targets systems that currently focus on interventions and support services for individuals who experience adverse childhood experiences (ACES), beginning at conception and encompassing infancy and the very early childhood years. Emboldened by knowledge of the impact of epigenetic influences on gene expression, and the organisation of neurobiological and hormonal regulatory systems, PIMH rejects isolated impact approaches to prevention and intervention, in favour of dynamic systems models that better reflect the realities of human development.

Those realities of human development require a deeper understanding of the adverse experiences that negatively affect nearly 20 per cent of children in every world society surveyed thus far. When children experience four or more adverse childhood experiences, from conception to age five, they are primed for developmental pathways that can lead to difficult physical and mental health problems, poor cognitive development, poor interpersonal relationships and high risk for psychopathology. Parents, relatives, teachers, faith leaders, neighbours, elected officials and all members of society share responsibility for optimizing the quality of child development and working to eliminate adverse childhood experiences. The good news is that change is possible!

Simply put, Better Together is an effort to transform how human beings relate to one another. It is an effort to encourage cross system integration, organisational cooperation, community empowerment, and reasoned approaches to resource sharing that can provide opportunities for every child to succeed, be free of serious mental health issues, become educated, and apply her or his unique view of the world to efforts to solve relationship problems that separate people, rather than fuelling efforts to be Better Together.

Hiram E. Fitzgerald

vi

vii ## Acknowledgements

Better Together: Supporting perinatal and infant mental health services was initiated after a professorial visit to Edith Cowan University (ECU) by Distinguished Professor Hiram Fitzgerald from Michigan State University (MSU). Distinguished Professor Fitzgerald provided the inspiration and vision of working to engage a whole community in the principles of Perinatal Infant Mental Health (PIMH) practice rather than the more restrictive approach of achieving change one dyad at a time. Transdisciplinarity was already part of the project team framework with the core research group representing nursing and midwifery, community psychology, clinical psychology and education. Edith Cowan University School of Arts and Humanities along with an anonymous and visionary philanthropist support the ECU Pregnancy to Parenthood clinic from which ideas for the project were conceived and from which the network of service providers and consumers developed.

The team of research assistants, Celeste Lauren, Olivia Marshall, Divyah Sreevardhanan and Jenna Thornton were unequivocally exceptional. Together, their professionalism, organisational skills and commitment to this project was outstanding and brought seamlessness to the complex organisation and data collection in the many concomitant arms of the project.

The contributions of stakeholders and consumers informed every stage of this project. Participation involved four reference group meetings as well as completion of lengthy questionnaires and contributions to focus group sessions. A testament to the importance of this topic and to the principles of community participation is that the collective group has voted to continue to meet beyond the life of the project.

The project would not have been possible without the financial support of the WA Primary Health Alliance (WAPHA), and their recognition of the importance of the PIMH field. Nor would it have been possible without collaboration with our project partner Bankwest Curtin Economic Centre and support of the Consumer and Community Health Research Network.

Finally, Better Together team and participants’ and ECU respectfully acknowledge the Noongar people, both past present and future, the traditional owners of the land on which we work. We especially recognise and respect Aboriginal beliefs about pregnancy, birth and childrearing and affirm our commitment to strengthening relationships in order to provide culturally sensitive services for Aboriginal people.

vii

Executive Summary

The well-being and social emotional development of infants, young children and their caregivers is critical to the future social fabric of society. To be effective the system of services supporting infants and young children in their families and communities must be integrated across levels of service delivery as well as across sectors. It must also be dynamic and responsive to the changing individual, family, community and environmental contexts. This project known as Better Together reports on research conducted on the System of Care for Perinatal Infant Mental Health (PIMH) in the Cities of Joondalup and Wanneroo in Western Australia and captures initial layers of information about this system.

Better Together mapped the population density of each of the cities with respect to where families with 0-4 age children resided. We also used GIS mapping to locate all of the System of Care agencies/organisations within each city. Training programs based on the Australian Association for Infant Mental Health West Australian Branch (AAIMHI WA) Competency Guidelines for culturally sensitive, Relationship Focused Practice Promoting Infant Mental Health® were conducted with agency/organisation personnel. A Social Network Analysis (SNA) was designed to assess a wide range of issues related to the degree to which the System of Care, in fact, operated as an integrated system with respect to services for infants, young children and their families. Focus group and interview approaches were used to assess community perspectives about the quality of care provide by the System. At the agency/organisation level, SNA was used to assess perinatal and infant mental health services that are provided, barriers to network success, expected benefits of an integrated service, proportion of funds focused on families (prenatal to age 3), the interconnections of agencies/organisations, their degree of trust and value of one another, and a wide variety of functions provided by the agencies/organisations. Personnel training and experience in relation to inter-agency/organisation connectivity was also assessed.

The findings from Better Together are the result of analyses of multiple sources of data from over 110 workers from 78 agencies/ organisations across a wide range of groups that provide services in these cities as well as from 53 consumers of those services (families with infants, young children 0-3 years who reside in the cities).

The key findings show that the System of Care collectively has 2,460 relationships and a low to moderate level of interconnectivity with only 44 per cent receiving service referrals. Relationships between agencies/ organisations are built mostly from referral pathways and educational programming (38%). Developing new initiatives, training needs and service delivery also underpin agency/organisation relationships (20-25%). Factors contributing to relationship development included, developing relationships with specific individuals (36%), practice efforts leading to connections with other individuals (31%), and participation in service related committee (48%). Social Network Analysis data indicated that the level of trust between agencies/ organisations was low to moderate, as was the degree to which they valued one-another. Data suggests many more connections are possible and there is room to improve system cohesiveness.

Agency/organisation personnel had very little knowledge of services provided by other services within the System of Care. There were sharp contrasts between perceptions of success and quality of service between service personnel and families, which was highlighted through consumer themes and subthemes in the focus groups. Parent concerns focused on the impersonal attitudes of agency/organisation personnel, lack of understanding what services are actually available to them, lack of assistance actually making a referral within the system, issues with culturally appropriate personnel, difficulties for vulnerable families to gain access to services, and differences they felt with respect to power relationships related to SES and vulnerability. These along with other key findings from the report are presented as follows.

viii

ix ## Key findings

SOCIO-ECONOMIC PROFILE AND SERVICE MAPPING: A Tale of Two Cities

• The two cities of Wanneroo and Joondalup are both northern metropolitan cities of Perth in Western Australia and they each have 14 SA2 regions within their borders. In 2016, Joondalup had a total population of 155,000, and a land mass of 99 sq kms; Wanneroo had a population of 188,000, land mass 685 sq kms. The 0-4 age population of Joondalup is 5.7 per cent; whereas that of Wanneroo is 8.0 per cent.
• The two cities are vastly different in their demographics. Joondalup is geographically and social advantaged (SEIFA = 9; lowest individual locality SEIFA = 6) with a declining population (-1.5%). Wanneroo has high levels of disadvantage in many of its localities (SEIFA= 5; 3 localities SEIFA 1-3), with a rapidly growing population up 24 per cent from 2011 including of children aged 0-4 years (+16%) and young women of birthing age (+18.7%).
• The two cities have a higher percentage of migrants than is average for WA, mostly from Europe (66.1%; 54.4%), Asia (13.4%; 24.3%) and Africa (17.4%; 19.0%). In Joondalup most young migrant women of birthing age are English speaking whilst in Wanneroo there are three localities with large percentages (6-10%) of young women of birthing age who have no or poor spoken English.

NETWORK CHARACTERISTICS AND FUNCTIONING: Social Network Analysis, Survey and Focus groups

• Collectively, Service providers were mostly female (86%) and 81 per cent identified as Australian or European; 6 per cent as African and none as Asian. Consumers in the survey identified as European or Australian (91%) and were mostly university educated. Consumers in the focus groups were from more diverse backgrounds including representation from hard to reach families.
• The agencies/organisations surveyed indicated that over 30 per cent of their clients are from culturally and linguistically diverse backgrounds. However, most agencies/organisations (93.5%) did not have an ethnic advisor. Furthermore, 65 per cent of agencies/organisations surveyed did not have an Aboriginal and Torres Strait Islander Liaison Officer, while 30 per cent of those surveyed had between 1 and 5 Aboriginal and Torres Strait Islander Liaison Officers.
• Consumer representatives identified that more Aboriginal staff are needed within agencies/organisations and this was in line with some service providers highlighting a need for cultural sensitivity as an area for improvement. Gaps in services for Culturally and Linguistically Diverse (CaLD) communities were also identified.
• Within the network, half of the organisations relate to each other at a level of awareness only with a limited understanding of the services offered by each other (58%). Twenty three percent of agencies/organisations connect at a cooperative level, where they exchange information, attend meetings together and inform each other of available services. Coordinated activities between agencies/organisations, where planning occurs together, data is shared and trainings are collaborative occur in twelve percent of cases. Only 7 per cent of the network connect through integrated activities that include shared funding and joint program development, combine services and have shared accountability.
• Within the system the interconnectivity or density (percentage of ties in the network) is moderate (20%); the degree of centralization is 43 per cent indicating that relationships are dispersed across the network rather than held by a few agencies/organisations; and the level of trust i.e. where communication is open and respondents feel agencies/organisations are reliable and open to discussion is moderate (35%).
• 83 per cent of service providers identified their agencies/organisations as being ‘successful’ to ‘completely successful’ in supporting the needs of children aged 0-3 years and their families, whilst only 64 per cent of families reported such success from providers they accessed. The main difference was in the category of ‘somewhat successful’ with 15 per cent service providers reporting this level of success and 34 per cent of consumers noting a ‘somewhat successful’ level for those agencies/organisations with whom they engage.

ix

• While many consumers were positive about accessing services, those who reported difficulties named waitlists (25%), not having private health insurance (18%), financial constraints (15%), insufficient services (12%) and transport, quality and flexibility of service availability (10%) as barriers to access. In the focus groups consumers reported more negative experiences of accessing and using PIMH services, lacking knowledge and awareness of those available. One interesting finding from both survey and focus group data was that consumers had few expectations that services they accessed would communicate with each other.
• Agencies/organisations believed that exchanging knowledge, creating informal relationships and meeting regularly contributed to successful collaborations between them. Collective decision making was viewed by a few but not the majority as important in developing partnerships. This may be a new concept for agencies/organisations in WA.
• In surveys, focus groups and social network analysis data, consumers reported that when they had difficulty in pregnancy or the early years their first point of contact is typically the General Practitioner (GP).
• Consumers and service providers agreed that important community and informal supports for the social and emotional wellbeing of young families are Child Health Nurses, local library programmes and playgroups. Local day care and parenting workshops were also nominated as useful sources with the proviso that not all consumers could afford these or access them. Consumers also nominated pharmacies as sources of knowledge and support.
• With regards to the functioning of the System of Care the primary factor contributing to its success was seen to be the ‘bringing together of diverse stakeholders’, with 68 per cent of respondents pointing to this factor. More than half (52%) of respondents felt that staff turnover was the greatest barrier to network success. This emphasises the importance of relationships in building the success of the network, and related trust.
• The majority of respondents felt that were the network to become more cohesive, benefits would include improved health outcomes (26%), together with an improved understanding of mental health issues (26%).
• Referral pathways both informal and formal are poorly defined and system data and agency/organisation level data on referrals that are actioned is unclear, suggesting that the System of Care lacks a coordinated and systematic process for referrals.
• While the workforce is experienced in their professional discipline/category, 58 per cent of workforce respondents reported being in their current role for less than 4 years. This has implications for network development and sustainability.

FUNDING and CONTINUITY OF CARE

• The main source of funding reported by the agencies/organisations surveyed (74%) was public (government) and very little of this directly reaches the service to 0-3 year olds and their families. Only 16 per cent of agencies/organisations surveyed reported allocating over 90 per cent of their funding specifically to the services of 0-3 year old age groups; 37.5 per cent do not allocate any funding to this age group and 34 per cent allocate between 1-20 per cent of their funding to this age group. The lack of allocated funding specific to infant mental health was reflected in the most recent State Budget for mental health (WA Mental Health and Alcohol and Other Drugs budget 2017/2018), which revealed an emphasis on youth mental health as preventative care, rather than drilling down to the earliest possible point of entry (pregnancy and infancy).
• With regards to the functioning of the System of Care
• The reference group identified that PIMH services tend to have short life spans and this creates difficulties for consumers in terms of experiencing continuity of care, but also keeping track of what services are available to them. More home visiting for vulnerable families was an identified gap.
• Focus group participants reported disappointment when services were discontinued or changed due to funding cuts.

x

BUILDING WORKFORCE CAPACITY: Intervention and Training

• In primary care only 7.7 per cent of staff reported having access to IMH related training within their organisations, and almost 31 per cent reported having no access to training or were not aware of training opportunities. Those who received most training were in the fields of Education (73%), Health (65%), and Community (50%). The figures are similar for PIMH for the primary care sector (23%) but much less for those in Education (33%) and less too for health (50%) and the community sector (31%).
• With regards to training, providers expected that more PIMH and IMH specific training might lead to increased awareness of referral sources for agencies/organisations as well as earlier screening and detection of problems in the perinatal period. When training was conducted with GPs and with pharmacists, an increased awareness was evident. Specifically GPs demonstrated greater awareness of the implications of challenges in the perinatal period and the transition to motherhood, as well as a capacity to notice and consider different aspects of the parent-child relationship and activate more targeted referral pathways. Pharmacists demonstrated a greater acknowledgement and awareness of mental health challenges and a greater awareness of aspects of the child-parent relationship.
• The need for consumer training about what to expect from the agencies/organisations they deal with was highlighted by the finding from both survey and focus group data that consumers had few expectations that services they accessed would communicate with each other.
• Consumers (73%) turn to the agencies/organisations they are already connected to for information regarding parental wellbeing during pregnancy and the early stages of a newborn’s life as well as social, emotional and/or behavioural concerns for their 0-3 year old suggesting that as they build trusting relationships with the staff of the service they turn to them for information. Many consumers (58%) said they would have liked further information about services they might turn too as well as more information on each of these topics.
• A community training workshop focussed on the following:
  • Green public space: Transforming existing physical spaces into places for infants, young children to play and explore nature, and for their caregivers to meet and rest.
  • Mobility for families: Making it possible for caregivers and infants, young children to walk and cycle to healthcare, childcare, a safe place to play and a place to get fresh food.
  • Data-driven decision-making: Collecting neighbourhood-level data on infants, young children and caregivers and using it to better target resources and facilitate coordination across sectors.
  • Parent coaching: Combining coaching on early childhood development for parents and other caregivers with services that meet families’ basic needs.

Outcomes from this workshop included a collective vision of fostering a community in which children can thrive and feel safe, and promoted a deeper and broader understanding of the context in which the PIMH system exists within the two cities of Wanneroo and Joondalup. Actions that might be achievable in 100 days and 1,000 days were brainstormed and discussed.

xi

Recommendations

Better Together has generated the most comprehensive analysis of system level factors influencing PIMH services in Western Australia and probably Australia that we are aware of. The information gathered to date can be used and extended to enhance integration of Systems of Care and to build stronger system knowledge about the importance of infant mental health relationships during the early years of development.

At the conclusion of this first year the system is well prepared to work towards meeting the following recommendations for next steps in Better Together and the wider West Australian community:

1. Continue engaging stakeholders and consumer representatives in capacity building opportunities to harness the established connections and to create innovative ways of funding engagement and capacity development across the PIMH System of Care.
2. Use the SNA data and build upon the existing Reference Group to identify key agencies/organisations and develop an implementation leadership team, that includes consumer representation, with newly agreed terms of reference underpinned by principles of collaborative enquiry, co-design and a relationship based framework.
3. The leadership implementation team continuously engage with the wider PIMH community to create a culture of learning and exploration of multiple perspectives that contribute to an authentic understanding of key leverage points, effective engagement strategies and barriers within the system.
4. Align SNA and service mapping data to determine the extent to which geographical location accounts of the degree of connectedness to other agencies/organisations within the System of Care and use this information to develop specific strategies targeting this potential barrier to system engagement.
5. Use the SNA data to identify and support agencies/organisations on the periphery to become more connected within the System of Care through membership in the implementation leadership team and participation in capacity building activities and system based interventions.
6. Explore the role technology can play in engaging stakeholders and consumers and increasing system cohesiveness through:
   • Offering an on-line communication platform that requires less time and resources than face to face interaction.
   • Pilot implementation and evaluation of the Person-Centred Network (PCN) App to link consumer families and service providers to appropriate services and supports (formal and informal) across the continuum of care in real time.
7. Explore multiple strands of enquiry to further develop more responsive referral pathways to ensure families access the appropriate care at the right time and in the most suitable locations. These include:
   • Use of the SNA data and relationships built within the reference and leadership groups, consumers and the existing networks in the Cities of Wanneroo and Joondalup to research and learn more about case examples of clear and responsive referral pathways that lead to a stepped care approach across the continuum of care in the Cities of Wanneroo and Joondalup.
   • Co-design and develop a whole System of Care approach to formalising referral pathways through building more in-depth analysis of current processes, piloting the ECSII and considering ways of utilising Health Pathways as part of this process.

xii

xiii

• Developing a shared database that incorporates outcome measures across agencies/organisations and the continuum of care to determine the effectiveness of clearer and more defined referral pathways across the System of Care.

8. Connect agencies/organisations within the System of Care around activities and interventions that increase trust and value among organisations which can lead to a more cohesive and integrated System. The following factors require consideration:
   • What infrastructure is in place for agencies/organisations to work together?
   • What understanding is there in agencies/organisations that working together will enhance creativity and innovation in design and delivery of services?
   • What commitment is there to working together to achieve better outcomes for families with infants, young children and understanding that this likely to be more successful than working in isolation or in limited partnerships?
9. Deliver the PIMH Primary Health Care training package to a wider set of service providers, specifically, offer this to child health nurses, and a broader group of GPs and pharmacists. Further develop this package to contain multiple levels of learning for all service providers.
10. PIMH Primary Health Care training packages are integrated with other PIMH trainings and embedded in a capacity building strategy across the PIMH System of Care and aligned with the AAIMHI WA Competency Guidelines and Endorsement framework.
11. Consider ways of creating a more diverse workforce to meet the need of families from culturally and linguistically diverse backgrounds which is steadily growing.
12. Design and deliver better communications to inform the public about services for prenatal to antenatal and to age three years, and to assess the relationship between service agency/organisation location and population density with regards to access to services.
13. Plan future evaluation of the system that includes reassessment using SNA to measure the impact of interventions going forward and to analyse whether and how the system has been impacted and shifted in way it relates, functions.
14. The research design for Better Together may be used to understand the system of PIMH throughout other localities in Western Australia. This will build a comprehensive platform for rigorous understanding and evaluation of PIMH System of Care across the state.

xiii

xiv

Chapter 1:

Introduction

Introduction

‘Better Together: Building Perinatal and Infant Mental Health Services’ is an applied research project conducted in the Cities of Wanneroo and Joondalup in Perth, Western Australia over 2017-2018. In this document the project is referred to as ‘Better Together’.

The purpose of Better Together was to map how services in the cities of Wanneroo/Joondalup interact to enhance the quality of prenatal and infant mental health services for the community. Collaborative inquiry or participatory action research method was used to draw multiple perspectives to bear on understanding the System of Care. Consumers and service providers were invited to work with the research team over 12 months to design, implement and evaluate the network of services that families with infants and infants, young children access. Together with community stakeholders, the research team planned to improve system responsiveness to the social wellbeing and mental health needs of families with infants and infants, young children, from both prevention and intervention perspectives. This was to be done by identifying three sets of factors that influence system functioning: (a) factors that help or hinder system networking, (b) factors related to workforce development, training pathways and resource availability, and (c) factors that could increase awareness of perinatal and infant mental health (PIMH) referral pathways, good practices, and interventions.

As the principles of collaborative inquiry and emergent design took hold, efforts to create and engage a more cohesive system took a different path to that originally planned and preconditions to meeting the aspirational goals were identified. These were:

1. The need to better understand the complexity of the current PIMH system
2. The need to have a deeper understanding of the factors that contribute to creating and sustaining problems within the system
3. The need to build the infrastructure necessary for producing meaningful and sustainable positive transformation of the PIMH system.

As the dynamic functioning of the system (through mapping, social network analysis, collecting extensive qualitative and quantitative data) became clearer, Better Together became well placed to understand the problems and the types of interventions needed to contribute to transformative change in the PIMH system.

At the conclusion of the first year we are now prepared to work toward specific objectives related to system change. The following objectives were generated from analysis of the data collected during Year 1, and comprise specific aims for any future work on Better Together:

1. Identify key agencies/organisations and develop an implementation leadership team with agreed terms of reference
2. Define and map the current service parameters for PIMH in the Wanneroo/Joondalup Region, including referral pathways, inclusion and exclusion criteria, existing collaborations, knowledge of PIMH principles and practice and identify gaps
3. Develop clear and responsive referral pathways with an aim to adopting a stepped care approach where (i) PIMH needs and risks are recognised and responded to in a timely manner and (ii) implementation factors which help and/or hinder the networked approach are identified
4. Create a robust local, across agency/organisation workforce development plan that identifies training for all relevant practitioners to increase awareness of PIMH, good practice and interventions
5. Develop a training package using existing resources and skills to build workforce competency in PIMH
6. Evaluate the effectiveness of implementation and practice outcomes in relation to specific training experiences noted above, designed to introduce perturbations to nudge system change.

2

3 ## Scientific Background

Infant Mental Health

Infant Mental Health (IMH) covers the healthy social and emotional development of a child from conception to age three years. It encompasses the developing capacity of the infant to experience, manage and express a full range of emotions, to form close and secure relationships, to explore the world and to learn (Zero To Three, 2012). The interdisciplinary field of IMH that has emerged over the past 41 years has at its core that the developing child is considered in the context of his/her System of Caregiving relationships and that understanding this context is important. The term was coined by Selma Fraiberg (1975) as she and her colleagues considered and intervened to address clinical disturbances in early parent-infant relationships.

The field of IMH has grown rapidly and is underpinned by theoretical frameworks that include developmental psychology, attachment theory, developmental neurobiology, psychoanalytic theory, and systems theory (Fitzgerald & Barton, 2000). Study of IMH has provided significant clinical and research contributions towards understanding social and emotional development in infancy and toddlerhood and the critical role this developmental stage plays in biopsychosocial development throughout the lifespan.

Advances in research on the developing brain have shown that infancy is a critical period that is ‘experience-dependent’ relying on sufficient and appropriate stimulation of the caregiving environment to ensure optimal development. Epigenetic research has identified that as early as the prenatal period; the intrauterine environment influences the foetal experience and can have both positive (e.g., good prenatal nutrition) and negative (e.g., maternal alcohol consumption) effects. Where the environmental context is toxic, the structural and functional organisation of the foetus can be compromised. To the extent that adverse childhood experiences (ACES) persist, their cumulative effects can lead to a lifetime of health and mental health issues, including drug and alcohol abuse, antisocial behaviour, depression, and suicide attempts. Clinical interventions have been designed to effectively target infant-caregiver relationships and caretaking systems, including marital conflict. More recently the works of economists have provided clear evidence of the cost benefit to society of investing in the social and emotional wellbeing of infants and toddlers, with estimates of returns on investments ranging from 7:1 to 20:1 (Elango, et al., 2015). In keeping with research and the principles of IMH the promotion of healthy social and emotional development, the prevention of mental health problems and treatment of problems in the infant and very young child are all best considered in the context of family, community, society and cultural relationships; in short, considered within a biopsychosocial systems perspective.

The first relationship between the infant and mother begins at conception. The PIMH systemic preventive-intervention framework is informed by the rapid advances in scientific understanding of experiential effects on gene expression (epigenetics). It provides a framework for prevention or intervention of adverse childhood experiences (ACES). Within this framework, attention to the parent-child relationship, the child, and parent require intensive and comprehensive treatment services that include attention to ACES, including child maltreatment and family dysfunction (including separation/divorce, family alcohol/drug problems, family mental illness, domestic violence, and parental incarceration). Additional indicators of risk, particularly when measured in childhood, have also been included, such as economic insecurity, homelessness, exposure to neighbourhood violence, racial discrimination, and parent loss through death. Moreover, PIMH interventions are design to reduce dosage effects so that infants and very young children exposed to ACES can be shifted to life-course pathways that enable generation of resilience through positive relationships with their parents and other carers (McKelvey et al., 2016, 2017). The PIMH framework infused into Western Australia’s System of Care, provides an avenue to promote or intervene in relationship issues within a system of social and health support.

3

Systems Change

PIMH is designed within the context of relational developmental systems (RDS: Overton, 2015). RDS systems are open systems, which simply mean that they change. A place-based service delivery system that is not dynamic becomes bounded, closed, and rigid, falling back on isolated impact approaches to service. Isolated impact approaches to service are based on the concept of changing one individual, one couple, or one family at a time. Prevalence rates of Adverse Childhood Experiences [ACES] reported to WHO by nearly every country in the world fall in the range of 17 - 21 percent of the population, with significant numbers of infants and young children exposed to 3 or more ACES (the cut point for predicting significant negative outcomes Felitti, Anda, et al., 1998). For Australia, this means roughly 5 million individuals with one type of ACES or another. The intervention work force necessary to provide isolated impact services cannot possibly exist or be sustained. The alternative is to change the system to maximize integration of services, cohesive preventive-intervention networks, and implementation of community engagement approaches to involve citizens more actively in efforts to enhance individual, family, and community well-being. Relational developmental systems change efforts, such as PIMH, strive to improve human service and community systems in order to create better and more equitable outcomes for consumers (Foster-Fishman, Nowell, & Yang, 2007). The strategies underlying PIMH are anchored by an extensive body of literature, which, in aggregate, indicates that changing a system has greater and more lasting impact than do efforts to “fix” one component of the system in isolation. Even so, creating and sustaining positive change in a system remains challenging, as Kania, Kramer & Senge (2018) illustrate with the following water analogy:

‘A fish is swimming along one day when another fish comes up and says “Hey, how’s the water?” The first fish stares back blankly at the second fish and then says “What’s water?”’ (p. 2)

This metaphor is particularly apt for the field of PIMH where identifying the workforce and building collaborative networks can be a challenge (Matacz & Priddis, 2015). PIMH is comprised of people from diverse disciplines who are often fluid within organisations and who work within traditional siloed (boundaried, closed system) departments delivering specific mandated services. The Australian context is no exception with a Western Australian report highlighting gaps that exist in knowledge, skills and policy whilst recognising preliminary steps that have been taken to create awareness of the system and to build workforce competency (Matacz & Priddis, 2015). Until now, no systems lens has been applied to understand the forces at play that bind the Western Australian PIMH system within the status quo, promoting silos and isolated impact services.

Kania et al offer six interdependent conditions that impede or enable system change and which include both those that are explicit and implicit (Figure 1). Beginning at an explicit level of structural change, policies, practices and flow of resources provide insight into the structural factors that constrain collaborative systems networking. In an Australian context, an example of system intervention at this level was the recognition of mental health as a significant political issue in 2010. In Western Australia a Mental Health Commission was established to lead reforms of the mental health system throughout the state. In the first mental health strategy published by this office, pregnant women, infants and children were recognised for the first time as a population with specific needs (Mental Health Commission, 2012), giving hope to the PIMH community that systems change would follow. A planning group was established, an inquiry into the mental health and wellbeing of children and young people was completed and recommendations made to improve outcomes for infants and children (Commissioner for Children and Young People Western Australia, 2011), as did another important review of the health system (Stokes, 2012). A number of strategic projects to investigate the best service options and workforce strategies for perinatal, infants, children and their families were initiated. Policy change accompanied by resources for the PIMH field appeared possible.

In the Kania et al., model, for systems change to be effective it also requires a second level of change which is semi-explicit. This involves consideration of the quality of relationships and connections as well as of power dynamics amongst both individuals and agencies/organisations involved. Key to achieving change is at the semi-explicit level or development of high levels of trust among system constituents, commitment to a common mission (ultimate goal), and shared resource to achieve community system change. In our example, the subsequent Mental Health plan (Western Australian Mental Health Commission, 2015) saw the term infants almost disappear. From a systems perspective it might be argued that new relationships needed to be forged, new alliances made and a shared vision created, but the mindset of bounded siloes prevailed.

The final level required for transformative change is implicit change. Implicit change refers to changes in the mindsets of individuals in the system; how they think, talk and act and their underlying beliefs. In the final analysis, individual relationships matter and system change is not possible unless all stakeholders can coalesce around a shared vision - that is, collectively working to enhance individual, family and community well-being. In the PIMH field there is growing awareness that “lifelong positive mental health begins in pregnancy and is crucial for the healthy development through early childhood, childhood and adolescence” (Commissioner for Children and Young People WA, 2015), however, considerable gaps in knowledge and understanding remain, both within the field and by consumers. Moreover, there is insufficient knowledge that individual well-being is always nested within broader systems (Figure 2).

Figure 1 Conditions of systems change

Source: Kania et al., 2018.

For structural change to occur relationships between people, agencies/organisations, and groups working in the same space require connection in meaningful and collaborative relationships, and a common vision and shared strategy for positive and equitable change must be developed. Systems change models give us the tools to intentionally and methodically alter status quo closed systems to bring about improvements in outcomes for targeted populations, such as vulnerable families with infants and infants, young children.

In recent times communication scientists have contributed to transformative change at the level of changing mental models by translating and sharing scientific knowledge with the public in ways that the public understands. By investigating and researching the communication challenges of a particular issue and creating alternative ways that people might understand that issue, via media and education campaigns, policy makers, consumers and individuals are enabled to change their mindsets concerning the issue (Center on the Developing Child at Harvard University, 2014), and to envision innovative approaches to systems change.

Figure 2 The nested environments of Relational Developmental Systems

Source: H. E. Fitzgerald, 2018.

6

Conceptual Model

Better Together is underpinned by the evidence based practice framework of community engagement scholarship (CES), which involves creating university and community partnerships in order to effect dynamic social systems change (Fitzgerald & Zientek, 2015; McNall, Barnes-Najor, Brown, Doberneck, & Fitzgerald, 2015). The boundary of the system identified for Better Together is the Perinatal and Infant Mental Health (PIMH) System of Care in the Cities of Wanneroo and Joondalup.

The key principles of CES are systems thinking, collaborative inquiry, support for ongoing learning, emergent design, multiple strands of inquiry and action and transdisciplinarity. Key aspects in CES to effecting transformative and lifelong sustainable change in a system are co-creation of knowledge, data driven decision making, and collective impact metrics that provide the evidence base for change.

1. Systems thinking (Place-based)

Systems change in Better Together refers to the idea that improvements for families with infants and infants, young children in the Cities of Wanneroo and Joondalup are most likely to come about by investigating “what worked for who?” in the broader system, rather than by investigating whether and how an individual project is working. It is place-based in that it aims to embed the PIMH relationship framework into all components of the System of Care available to families with infants and very young children, and to enhance referrals to integrate services across major components of the System of Care.

Members of the research team initially set out to collect outcome data for the newly established Edith Cowan University’s (ECU) Pregnancy to Parenthood clinic. While ECU is located in the City of Joondalup, the ECU Pregnancy to Parenthood clinic is located in the City of Wanneroo. What we discovered was a system of complex interacting problems or “messes” (Ackoff, 1999) that had developed in the system over time. To evaluate outcomes for the isolated and single case of the ECU Pregnancy to Parenthood clinic and even to implement interventions in the place-based system that might effect change in one or two aspects of the system was to ignore the complexity of contextual factors that had perpetuated the problem. This first order approach was unlikely to result in any change for PIMH system in these two cities.

Taking a systemic approach we identified that our focus would be best placed on what systems dynamics refers to as second order change. That is, we aimed to create a paradigm shift in understanding what was required in the system to best support the social and emotional wellbeing of infants and infants, young children in the communities (Foster-Fishman et al., 2007). We would explore the system from multiple perspectives in order to better understand the degree to which the component parts of the System of Care were interrelated and interdependent. The extent to which system components were siloed and system integration was not in service of families, we planned to introduce the PIMH systems framework to break down silos and enhance referral communications among the component entities providing care.

Place-based systems thinking recognises that engagement is mutual and becomes possible as community institutions and agencies/organisations discover how to respond when families and neighbourhoods seek to engage them. Furthermore, it starts in the community where families who are active community change makers take the lead.

2. Collaborative Inquiry

With the aim of Better Together now focussed on change to the dynamic functioning system of PIMH in the Cities of Wanneroo and Joondalup then relationship based approaches to gathering data and generating strategies for change were required. Collaborative inquiry, participatory action research, and social networking approaches are all suited to engagement of the community which has have a stake in improving

7

the system and to levering change. These approaches share a commitment to involving the community in all phases of the project and to co-creating an understanding of the system that incorporates new and diverse perspectives.

Better Together intentionally put the community at the centre of the change process through inclusive involvement of a broad spectrum of system stakeholders in the PIMH field in a Reference Group, composed of diverse stakeholders (see appendix…). Early stages of the project were devoted to identifying and mapping the stakeholders in the two cities, a process that facilitated inclusion of individuals rarely engaged in decision processes related to government-sponsored service delivery, particularly at the local level. Careful thought and adoption of a transdisciplinary team approach at all levels and stages of the project led to the creation of opportunities to authentically engage the diverse group of stakeholders at each stage of the project.

Having the family voice heard was essential to Better Together. Consumers gave input on how to evaluate and understand the current working of the system around the needs and capacities of families with infants and infants, young children; what questions to ask the community; how to collect data and how and what to think about the findings. The project included a group of consumer representatives who remain part of the Reference Group and play a key role across multiple domains of the project.

In creating a broader constituency for change, Better Together had more possibility of accurately understanding the PIMH system and in disrupting or attempting to change the system where needed.

3. Support for Ongoing Learning

Systemic change using collaborative inquiry and participatory action research approaches involves an ongoing cycle of investigation, shared data gathering and subsequent use of data in decision making, a part of ongoing change to system connectivity related to practice.

Through Better Together the research team provided ongoing feedback and learning opportunities to stakeholders; the reference group meetings gave opportunities for stakeholders within the System of Care to use data driven decision making processes to inform changes to the system.

Opportunity to fully engage families, developed though capacity to pay for their time. To engage ‘vulnerable’ and ‘hard to ‘reach families’ Better Together research team developed specific criteria to define these families and sourced representatives from this group of families to capture their experiences as part of the project.

Families informed Better Together team that pharmacists were often their first point of contact when they are having emotional difficulties related to adjustment to parenthood and/or concerns relating to their infant’s distress or emotional experience. This information led to:

• Inclusion of pharmacists’ in the Reference Group as a key stakeholder group
• Development and implementation of a pilot training model for pharmacists in PIMH.

4. Emergent Design

Better Together design was initially identified in broad and aspirational terms and then altered to incorporate new learning. In this way the design emerges from the cycles of the collaborative inquiry.

In Better Together input from consumers led to changes in questionnaire design, to changes to the Reference Group membership and to reference group activities as well as to specific training and evaluation of PIMH principles and practice.

Another example of emergent design in Better Together occurred when agencies/organisations in the Reference Group came together to co-fund and resource a workshop on translating the Bernard Van Leer organisation’s Global Approach, called ‘Urban 95,’ presented to the broader community of those interested in PIMH.

A third example, involved the recognition by Better Together that not all services are in a position to make changes and so an evaluation of service readiness for implementation of change was piloted by Reference Group members.

5. Multiple strands of inquiry and action

In order to maximise effectiveness of change process, multiple strands of inquiry and action are used to address complex problems with different teams involved in considering different angles within the system.

Within Better Together, teams were created to work on the different strands of the emergent design. For example, teams were created to consider and maximise the input and collaboration of vulnerable consumers, to focus on PIMH training programmes for primary health practitioners, to work on the global approach of the Bernard Van Leer foundation and to consider implementation strategies for agency/organisation change as well as the different strands of the research, such as the economic profile of the cities of Wanneroo and Joondalup and social networking.

6. Transdisciplinarity

According to McNall et al., (2015) transdisciplinarity involves researchers working jointly on a common problem using a shared conceptual framework that draws from multiple disciplines and it is this approach that holds the greatest promise for addressing complex systems issues.

At ECU we began by creating a Transdisciplinary Child Research Consortium to build research in perinatal infant and early childhood mental health. This consortium consisted of the research team pictured in Figure 4. The focus of this group was to bring transdisciplinary perspectives on how to achieve infant early child social and emotional well-being. Better Together revolved around the ECU Pregnancy to Parenthood clinic which was establishing itself in the local community and which had a very clear PIMH identity. Table 1 illustrates the transdisciplinary nature of both the research team and reference group in by its inclusion of a diverse range of disciplines and agencies/organisations

The broad base of Better Together minimised the negative consequences of holding a narrowly framed agenda that only looks at one specific component of PIMH. Indeed the first step in the project was to define and identify the principles of PIMH.

Table 1 Transdisciplinary Team for Better Together

Figure 3 Conceptual model

ECU Better Together Project: Supporting

Network Development Access Across Continuum of Care

PRINCIPLES GUIDING RESEARCH PROGRAM:

1. Perinatal and Infant Mental Health
2. Systems Change
3. Social Networking
4. Community Engagement Scholarship

TASKS AND GOALS:

• Coordination and project management
• To help create network mapping and assessment framework
• Facilitate collaboration and continuous communication
• Relationship building
• Connecting and engaging stakeholders through a range of activities
• Defining and creating different entry points to the network
  • Families (Consumer Representatives)
  • Reference Group
  • Consultation with state and local PIMH groups and initiatives
  • Pilot trainings with primary healthcare providers
• Continued evaluation of project frequently and from multiple fronts

RESEARCH TEAM (backbone structure of project)

BCEC TCRC P2P

Socio-Economic Mapping

POTENTIAL OUTCOMES AND RECOMMENDATIONS:

1. Ongoing collection of shared data across network and continuum of care and use of data as part of ongoing change to practice:
   • Implement Early Childhood Services Intensity Instrument (ECSII)
   • Extensive in-depth mapping and deep dive into suburb level, green spaces, and mobility
   • Create a shared vision for PIMH system in cities of Wanneroo and Joondalup
2. Social networking and authentic transdisciplinary partnerships:
   • Build enduring trust and reciprocal positive connections
   • Grow the diversity of the network

Source: Matacz, Priddis and Lauren, 2018.

Perinatal and Infant Mental Health Services

GOAL OF THE RESEARCH Transformational sustainable change to the dynamic system of place based PIMH services

INTERNATIONAL Health Government

CONSULTANTS Education

REFERENCE GROUP

Cities Participatory Action Providing structure Research Method:

• to enable unique contributions from diverse groups
• common goal: to know the network

Continuous communication through qualitative analysis - to identify common goals and themes needed to knit the network

3. Sustainable workforce development:

• Develop and pilot PIMH training for primary health professionals
• Implement PIMH training program across primary healthcare (GPs, Pharmacists and Child Health Nurses]

4. Collaborative inquiry and engagement design process to ensure continual evaluation of network dynamics and development, workforce training and consumer experiences of the system.

Community Services

Property Development

Primary Health

Guiding research

Hospitals

Parents & Caregivers of young children (Pregnancy -> 3yrs)

Data Visualisation: SNA process and outcomes, along with intangibles (trust, reciprocity, collaboration]

Questionnaires and Focus Groups to assess family’s experiences of system

Research Team

The coordinating body of the Better Together project comprises the transdisciplinary ECU Child Research Team (Education, Community Psychology, Clinical Psychology, Infant Mental Health and Nursing and Midwifery), Bankwest Curtin Economic Research Centre (BCEC) and the ECU Pregnancy to Parenthood Clinic and Developmental Psychology consultants from Michigan State University.

The purpose of this group was to oversee the day to day work of the collaboration, guide the design and evaluation framework of the PIMH System of Care. The group guided the creation of a shared collective strategy which was driven by shared measurement and was dedicated to supporting the network in increasing levels of resources, responsibility and capacity.

Refer to the Appendix for a full list of the members of the Reference Group for Better Together.

Figure 4 Team Leads

Edith Cowan University

Associate Professor Lynn Priddis

Ms Rochelle Matacz

Associate Professor Sara Bayes

Professor Caroline Barratt-Pugh

Professor Julie Ann Pooley

Bankwest Curtin Economics Centre

Dr Daniel Kiely

Professor Alan Duncan

Dr Kenneth Leong

Michigan State University

Distinguished Professor Hiram Fitzgerald

Dr Jessica Barnes Najor

Reference Group Chair

Ms Fiona Reid

Research Assistants

Jenna Thornton

Olivia Marshall

Celeste Lauren

Divya Sreevardhanan

Project Method

This project employed a mixed methods research design over a series of concurrent studies to investigate and implement change in the system of Perinatal and Infant Mental Health services in the cities of Joondalup and Wanneroo. Equal emphasis was given in the project to qualitative and quantitative methods making this a fully mixed concurrent equal status design using the Leech and Onwuegbuzie (2009) typology.

Qualitative data were collected from individual interviews, focus groups, training forums, reference group meetings and innovative workshops using a participatory action research model. Quantitative data were collected in the form of data from multiple versions of SNA questionnaires collected from consumers, hard to reach consumers, service providers and managers in education, health care, and community organisations. Data were also collated from publicly available data bases and sources.

Procedure

Ethics approvals were sought from Government Departments of Health and Communities, from King Edward Memorial Hospital, Edith Cowan University and from Joondalup Health Campus.

Reference Group

A snowball method was employed to invite a purposive sample of service providers and managers from the Cities of Wanneroo and Joondalup and from services that were seen as state wide and integral to the PIMH network to form the Better Together Reference Group.

This group continued to evolve over the life of the project and included representatives from over 40 agencies/organisations across the continuum of care, cross cutting across multiple sectors (education, health, mental health, adult and child, community, government departments, clinicians, managers, administrators and policy makers).

The Better Together Reference Group met on four occasions at Edith Cowan University for two hour sessions. Terms of reference were established, and a chairperson was elected. The data collected was bi-directional in that data from this group was used to inform research activities and data from the activities in turn informed the research group.

Consumer Reference group

Three consumers were initially recruited through the WA Consumer and Community Health Research Network. Parents of children aged 0-3 years from the cities of Wanneroo and Joondalup were invited to participate on the reference group with the support of the Consumer Advocate. They agreed to attend meetings, to assist with designing resources including questionnaires and to support activities of the project as they evolved. Over the course of the project these three consumers recruited additional consumers to attend the reference group as consumer representatives. The final group of consumer representatives numbered eight and included two fathers. All signed confidentiality agreements and all were paid an honorarium for their participation.

The consumer representatives undertook the following tasks:

• Review of the questionnaire developed by the research team
• Recruited and administered the questionnaire to families in the catchment area to gain a more comprehensive understanding of families’ experiences of the services and supports in PIMH in the Cities of Wanneroo and Joondalup
• Provided qualitative feedback through consumer reference focus group
• Participated in the larger Reference Group meetings
• Responsibility for recruitment and leading consumer focus groups.

Interview Data

As material emerged from the Collaborative Inquiry and Participatory Action Research process additional consultations and interviews were held with representatives from primary health care groups identified by the reference group. Specifically, interviews were held with representatives of government departments and with the peak bodies for general practitioners, pharmacies and community organisations.

Two focus groups were conducted with members of the consumer reference group and families from the Cities of Wanneroo and Joondalup.

Quantitative Survey Data

1. Social Network Analysis (SNA)

The project understands the importance of a robust learning and evaluation process and assessment on multiple fronts. The project adopted a ‘shared measurement’ approach as demonstrated by use of Social Network Analysis to process outcomes and ‘intangibles’ like trust, reciprocity and learning culture. Specifically, the project used SNA to answer the question: What are interactions among mental health, education, government organisations, community services and primary health involved in the delivery of PIMH services in the cities of Wanneroo and Joondalup?

Collaboration with developmental psychologists at Michigan State University who were also expert in researching systems and in the use of SNA was vital for Better Together. With the support of this consultancy the team developed a series of questionnaires that were to be answered by service managers, service providers and consumers and that were suitable for analysis using SNA software and approaches. These questionnaires were relevant for agencies/organisations providing services across the continuum of care as well as across education, community, health, and mental health.

PARTNER is a SNA tool designed to measure and monitor collaboration among people and agencies/organisations. Data demonstrates how members of a system are connected, how resources are leveraged and exchanged, the levels of trust among members, and how outcomes are linked to the process of collaboration.

Exploratory PARTNER analyses provided the first steps to develop a ‘shared measurement’ lens and a primary focus on improving responses to the complex issues within the PIMH system. It was anticipated that the network approach will tackle issues such as effective service delivery, service implementation, service coordination and action.

2. Economic and Social Mapping

Publically available data are used to develop a socio-economic profile of the two cities. The ABS Statistical Area Level 2 (SA2 region) level data is used, as this is designed to reflect functional areas that represent a community that interacts together socially and economically. This is also the smallest area for the release of many ABS statistics.

Chapter 2:

Economic and Social Context

Introduction

This chapter of the report provides an economic and social context for the City of Joondalup and the City of Wanneroo. Specifically, using Census data, we look at population demographics in 2016 and changes since 2011. We focus on key target groups such as 0-4 year olds, and females aged between 15 and 39. The incidence of lone parents is also presented. Key socio-economic indicators such as median income, unemployment rates, and level of education and levels of relative socio-economic disadvantage (SEIFA) are presented. Finally here, aspects of cultural diversity, including language and religion are addressed. We look at the immigrants as a proportion of the population, and immigrants by region of origin.

We draw primarily on Census of Population data, and draw comparisons between the Cities (SA3 level1) and their sub-areas (SA2 level2).

Together the two cities comprise almost 18 per cent of the Greater Perth population, and 14 per cent of the State’s population.

1 Statistical Areas Level 3 (SA3) are geographical areas built from whole Statistical Areas Level 2 (SA2). They have been designed for the output of regional data, including 2016 Census data. SA3s create a standard framework for the analysis of ABS data at the regional level through clustering groups of SA2s that have similar regional characteristics. Whole SA3s aggregate to form Statistical Areas Level 4 (SA4) (ABS, 2018).

2 Statistical Areas Level 2 (SA2) are medium-sized general purpose areas built up from whole Statistical Areas Level 1. Their purpose is to represent a community that interacts together socially and economically.

Demographics

City of Joondalup

Table 2 reports on various demographic characteristics for all fourteen SA2 regions for the City of Joondalup. The City has a total population of 155,000 (Table 2), with a total land area of approximately 99 square kilometres3. Almost 6.3 per cent of WA’s population live in the city, with close to 8 per cent of those living in Greater Perth. Of the 155,000, Duncraig has the largest share of the Cities’ population with 9.9 per cent followed by Currambine - Kinross (8.9%), Joondalup - Edgewater (8.8%) and Greenwood-Warwick (8.6%). The smallest share of the population is in Ocean Reef (5.1%), followed by Padbury (5.3%).

Table 2 Population, Births and Fertility Rates, City of Joondalup, 2016

| City of Joondalup | Demographics 2016 ||||||||| | :— | :— | :— | :— | :— | :— | :— | :— | :— | | | Total Population | % of City Population | % Change on 2011 | 0-4 Age Band | % of City Population | % Change on 2011 | Births 2016 | % of 0-4 Population | Fertility Rate | 15-39 Age Band Females | % of Population | | Craigie - Beldon | 9,801 | 6.3 | 2.2 | 765 | 7.8 | 8.8 | 211 | 27.6 | 2.16 | 1,844 | 18.8 | | Currambine - Kinross | 13,803 | 8.9 | -1.0 | 806 | 5.8 | -9.3 | 158 | 19.6 | 1.84 | 2,335 | 16.9 | | Duncraig | 15,270 | 9.9 | 1.6 | 879 | 5.8 | -11.4 | 153 | 17.4 | 1.76 | 1,970 | 12.9 | | Greenwood - Warwick | 13,344 | 8.6 | -0.6 | 859 | 6.4 | -10.8 | 182 | 21.2 | 1.90 | 1,978 | 14.8 | | Heathridge - Connolly | 10,304 | 6.7 | -1.1 | 662 | 6.4 | 1.7 | 170 | 25.7 | 1.98 | 1,772 | 17.2 | | Hillarys | 10,813 | 7.0 | 1.3 | 529 | 4.9 | -12.6 | 99 | 18.7 | 1.71 | 1,500 | 13.9 | | Iluka - Burns Beach | 8,640 | 5.6 | 40.1 | 464 | 5.4 | 34.1 | 61 | 13.1 | 1.62 | 1,274 | 14.7 | | Joondalup - Edgewater | 13,596 | 8.8 | -1.0 | 748 | 5.5 | 2.6 | 171 | 22.9 | 1.62 | 2,572 | 18.9 | | Kingsley | 13,059 | 8.4 | -1.2 | 732 | 5.6 | -7.5 | 149 | 20.4 | 1.83 | 1,698 | 13.0 | | Mullaloo - Kallaroo | 11,164 | 7.2 | 1.4 | 561 | 5.0 | -11.8 | 113 | 20.1 | 1.64 | 1,580 | 14.2 | | Ocean Reef | 7,846 | 5.1 | -3.3 | 323 | 4.1 | -13.9 | 53 | 16.4 | 1.41 | 1,094 | 13.9 | | Padbury | 8,186 | 5.3 | -2.1 | 630 | 7.7 | -10.3 | 138 | 21.9 | 2.28 | 1,337 | 16.3 | | Sorrento - Marmion | 9,619 | 6.2 | 0.9 | 431 | 4.5 | -4.4 | 69 | 16.0 | 1.46 | 1,148 | 11.9 | | Woodvale | 9,282 | 6.0 | 0.9 | 415 | 4.5 | 2.0 | 71 | 17.1 | 1.66 | 1,282 | 13.8 | | City of Joondalup | 154,727 | 100.0 | 1.5 | 8,804 | 5.7 | -4.7 | 1,798 | 20.4 | 1.78 | 23,384 | 15.1 | | Greater Perth | 1,943,860 | | 12.4 | 126,764 | 6.5 | 10.4 | 3,385 | 2.7 | 1.81 | 346,114 | 17.8 | | WA | 2,474,414 | | 10.5 | 161,728 | 6.5 | 6.9 | 6,612 | 4.1 | 1.89 | 424,613 | 17.2 |

Source: Authors’ calculations from Census of Population 2016 and 2011. Data extracted using TableBuilder.

Compared to 2016, with the exception of Iluka - Burns Beach in the upper North-West of the City, all other SA2 regions saw a decline in population between 2011 and 2016. Iluka - Burns Beach saw a 40 per cent growth in population, which can be expected for a relatively new area of development. The overall decline in the Cities’ population (-1.5%) compares to a growth in population of 10.5 per cent for WA and 12.4 per cent for Greater Perth over the same period.

0-4 year olds comprises 5.7 per cent of the Cities’ population, compared to 6.5 per cent for WA and Greater Perth. For the City of Joondalup, this is a decline of 4.7 per cent compared to an increase in this age cohort of 10.4 per cent for the Greater Perth region. The related fertility rate of 1.78 is also lower than that of 1.89 for WA. Females aged between 15 and 39 years of age comprised 15.1 per cent of the population, with 17.2 per cent reported for WA and 17.8 per cent for Greater Perth.

3 City of Joondalup website, accessed on 01/02/2018 here http://www.joondalup.wa.gov.au/Welcome/AboutJoondalup.aspx

City of Wanneroo

Table 3 reports on various demographic characteristics for all fourteen SA2 regions for the City of Wanneroo. The City has a total population of 188,000, with a total land area of approximately 685 square kilometres4.

Table 3 Population, Births and Fertility Rates, City of Wanneroo, 2016

| City of Wanneroo | Demographics 2016 ||||||||| | :— | :— | :— | :— | :— | :— | :— | :— | :— | | | Total Population | % of City Population | % Change on 2011 | 0-4 Age Band | % of City Population | % Change on 2011 | Births 2016 | % of 0-4 Population | Fertility Rate | 15-39 Age Band Females | % of Population | | Alexander Heights - Koondoola | 11,981 | 6.4 | 3.4 | 792 | 6.6 | 0.1 | 160 | 20.2 | 1.95 | 1,997 | 16.7 | | Butler - Merriwa - Ridgewood | 23,441 | 12.5 | 21.9 | 2,071 | 8.8 | 8.5 | 425 | 20.5 | 2.15 | 4,577 | 19.5 | | Carramar | 16,619 | 8.8 | 46.7 | 1,567 | 9.4 | 41.4 | 311 | 19.8 | 2.08 | 3,592 | 21.6 | | Clarkson | 12,964 | 6.9 | 10.9 | 1,101 | 8.5 | -7.3 | 270 | 24.5 | 2.05 | 2,831 | 21.8 | | Girrawheen | 8,764 | 4.7 | 5.2 | 662 | 7.6 | -4.1 | 136 | 20.5 | 2.34 | 1,564 | 17.8 | | Madeley - Darch - Landsdale | 25,403 | 13.5 | 33.9 | 2,061 | 8.1 | 25.0 | 456 | 22.1 | 1.95 | 4,862 | 19.1 | | Marangaroo | 10,588 | 5.6 | 0.7 | 670 | 6.3 | -5.2 | 159 | 23.7 | 1.88 | 1,821 | 17.2 | | Mindarie - Quinns Rocks - Jindalee | 18,782 | 10.0 | 7.3 | 1,017 | 5.4 | -16.7 | 211 | 20.7 | 1.77 | 2,837 | 15.1 | | Tapping - Ashby - Sinagra | 13,262 | 7.1 | 5.8 | 1,113 | 8.4 | -13.7 | 207 | 18.6 | 2.05 | 2,348 | 17.7 | | Wanneroo | 25,623 | 13.6 | 11.6 | 1,968 | 7.7 | 7.1 | 446 | 22.7 | 2.05 | 4,645 | 18.1 | | Alkimos - Eglinton | 7,953 | 4.2 | n/a | 908 | 11.4 | n/a | 212 | 23.3 | 2.03 | 1,973 | 24.8 | | Carabooda - Pinjar | 730 | 0.4 | n/a | 24 | 3.3 | n/a | 5 | 20.8 | - | 97 | 13.3 | | Two Rocks | 2,990 | 1.6 | n/a | 206 | 6.9 | n/a | 52 | 25.2 | 2.44 | 443 | 14.8 | | Yanchep | 8,857 | 4.7 | 18.9 | 810 | 9.1 | 58.8 | 162 | 20.0 | 2.45 | 1,579 | 17.8 | | City of Wanneroo | 187,957 | 100.0 | 23.6 | 14,970 | 8.0 | 16.0 | 3,212 | 21.5 | 1.94 | 35,166 | 18.7 | | Greater Perth | 1,943,860 | | 12.4 | 126,764 | 6.5 | 10.4 | 6,264 | 4.9 | 1.81 | 346,114 | 17.8 | | WA | 2,474,414 | | 10.5 | 161,728 | 6.5 | 6.9 | 12,103 | 7.5 | 1.89 | 424,613 | 17.2 |

Notes: Excludes SA2 region Neerabup National Park due to population size of three persons only. Source: Authors’ calculations from Census of Population 2016 and 2011. Data extracted using TableBuilder.

Almost 7.6 per cent of WA’s population live in the City, with close to 9.7 per cent of those living in Greater Perth. Of the 188,000, Wanneroo has the largest share of the Cities’ population with 13.6 per cent followed by Madeley - Darch - Landsdale (15.5%), Butler - Merriwa - Ridgewood (12.5%) and Carramar (8.8%). The smallest share of the population is in Carabooda - Pinjar (0.4%), followed by Two Rocks (1.6%).

A recurring theme throughout this chapter is the difference between the City of Joondalup and City of Wanneroo. For Joondalup we saw that only one SA2 region had a population growth between the 2011 and

4 City of Wanneroo website, accessed on 27/08/2018 here http://www.wanneroo.wa.gov.au/

2016 Census periods, with the overall population growing by 1.5 per cent. Meanwhile the City of Wanneroo had a population growth of almost 24 per cent between 2011 and 2016, with all SA2 regions displaying population growth - ranging from 0.7 per cent for Marangaroo to 46.7 per cent in Carramar. The population of the latter now stands at 16,620. Madeley - Darch - Landsdale’s population grew by 34 per cent, with a population in 2016 of 25,400.

The 0-4 year old population contributed to 8.0 per cent of the Cities’ population, compared to 5.7 per cent for Joondalup and 6.9 per cent for WA. For the City of Wanneroo, this is a 16.0 per cent increase compared to an increase in this age cohort of 10.4 per cent for the Greater Perth region. Yanchep saw a 58.8 per cent increase over the same period, with 41.4 per cent increase for Carramar.

The related fertility rate of 1.94 is above the WA average of 1.89. Females aged between 15 and 39 years of age comprised 18.7 per cent of the population, also higher than that of Joondalup (13.8%) and Greater Perth (17.8%).

Such demographic changes over such a relatively short period of time has significant implications for service delivery – a point which will be returned to latter in this report. Further population growth is projected for the City of Wanneroo, with projected increases of almost 100 per cent by 20415.

A Tale of Two Cities – Part I: Population

Comparisons of the City populations by SA2 region are further highlighted in Figure 5. Across the two cities, five of the largest SA2 regions by population are in the City of Wanneroo. While the latter also has two of the smallest populations, Carabooda - Pinjar is for the most part a bushland area, and Two-Rocks is likely to grow further – sitting on the upper North West of the City boundary.

Figure 5 Total Population by SA2 region, City of Joondalup and City of Wanneroo, 2016

Source: Authors’ calculations from Census of Population 2016 and 2011. Data extracted using TableBuilder.

5 See http://www.wanneroo.wa.gov.au/info/20003/council/18/city_of_wanneroo_statistics

The City of Wanneroo also has the 8 largest SA2 regions in terms of 0-4 population, with the top three being over double that of the 0-4 year olds reported for Duncraig - the largest reported for the City of Joondalup. By this measure, the City of Joondalup’s SA2 regions are very much skewed to the right, indicating much lower numbers of 0-4 year olds. These differences are also visible in the heat maps shown in Figure 7.

Figure 6 0-4 Year Old Population by SA2 region, City of Joondalup and City of Wanneroo, 2016

Source: Authors’ calculations from Census of Population 2016 and 2011. Data extracted using TableBuilder.

Figure 7 0-4 Year Olds as a percentage of total population, 2016

Source: Authors’ calculations from Census of Population 2016 and 2011. Data extracted using TableBuilder.

In terms of the number of females aged 15-39 (those most likely to be of birthing age) six of the largest SA2 regions are also in the City of Wanneroo (Figure 8). Again here, the City of Joondalup is skewed to the right, indicating that, relative to the City of Wanneroo, natural population growth is likely to remain significantly lower for the City of Joondalup relative to the City of Wanneroo.

Figure 8 15-39 Year old Female Population by SA2 region, City of Joondalup and City of Wanneroo, 2016

Notes: Excludes SA2 region Neerabup National Park due to population size of three persons only. Source: Authors’ calculations from Census of Population 2016 and 2011. Data extracted using TableBuilder.

Socio-economic Indicators

While the City of Wanneroo bounds the eastern and northern boundaries of the City of Joondalup, there are some striking differences in the socio-economic profile of the two cities. Some of this is to be expected, with for example, on average, house prices being much higher in the coastal suburbs and as one lives closer to Perth city. Many of the SA2 regions in the City of Wanneroo are new developments, with younger populations moving into these regions due with great housing access and affordability. Extensions to the Mitchell Freeway and train line have also opened up the northern corridor for further residential and economic development.

City of Joondalup

The median weekly income for the City of Joondalup was $2,230 in 2016 Table 4. This was $320 more than that reported for WA as a whole. The highest median income for the City was reported in Illuka - Burns Beach ($2,960) while the lowest was in Craigie - Beldon ($1,870). Eleven of the fourteen SA2 regions in the City of Joondalup had a median income above $2,000.

Table 4 Socio-economic Indicators, Education and Need for Assistance, City of Joondalup, 2016

| City of Joondalup | Socio-Economic Indicators |||| Education || Assistance | | :— | :— | :— | :— | :— | :— | :— | :— | :— | | | Population | Median Weekly Income | Rank | Unemployment Rate % | SEIFA (2016) Score | Pre-School 4 Age Band No. | Pre-School 4 Age Band % | 0 - Primary School 4 Age Band No. | 0 - Primary School 4 Age Band % | 0 - Needing Assistance 0-4 Age Band No. | 0 - Needing Assistance 0-4 Age Band % of Age Band | | Craigie - Beldon | 9,801 | 1,870 | 14 | 7.5 | 6 | 87 | 11.4 | 58 | 7.6 | 3 | 0.4 | | Currambine - Kinross | 13,803 | 2,194 | 8 | 7.7 | 8 | 118 | 14.6 | 63 | 7.8 | 11 | 1.4 | | Duncraig | 15,270 | 2,389 | 6 | 6.0 | 10 | 154 | 17.5 | 56 | 6.4 | 13 | 1.5 | | Greenwood - Warwick | 13,344 | 1,906 | 13 | 6.9 | 8 | 129 | 15.0 | 54 | 6.3 | 3 | 0.3 | | Heathridge - Connolly | 10,304 | 2,044 | 10 | 7.0 | 8 | 85 | 12.8 | 49 | 7.4 | - | n/a | | Hillarys | 10,813 | 2,563 | 3 | 6.4 | 10 | 93 | 17.6 | 39 | 7.4 | 4 | 0.8 | | Iluka - Burns Beach | 8,640 | 2,961 | 1 | 6.3 | 10 | 88 | 19.0 | 42 | 9.1 | 8 | 1.7 | | Joondalup - Edgewater | 13,596 | 1,976 | 12 | 9.0 | 7 | 112 | 15.0 | 53 | 7.1 | 4 | 0.5 | | Kingsley | 13,059 | 2,188 | 9 | 6.1 | 9 | 114 | 15.6 | 49 | 6.7 | 4 | 0.5 | | Mullaloo - Kallaroo | 11,164 | 2,262 | 7 | 6.2 | 10 | 96 | 17.1 | 41 | 7.3 | 8 | 1.4 | | Ocean Reef | 7,846 | 2,419 | 4 | 6.9 | 10 | 57 | 17.6 | 38 | 11.8 | 5 | 1.5 | | Padbury | 8,186 | 2,024 | 11 | 6.6 | 8 | 88 | 14.0 | 54 | 8.6 | 5 | 0.8 | | Sorrento - Marmion | 9,619 | 2,662 | 2 | 5.8 | 10 | 74 | 17.2 | 41 | 9.5 | 5 | 1.2 | | Woodvale | 9,282 | 2,393 | 5 | 6.3 | 10 | 58 | 14.0 | 51 | 12.3 | 9 | 2.2 | | City of Joondalup | 154,727 | 2,229 | | 6.9 | 9 | 1,353 | 15.4 | 688 | 7.8 | 82 | 0.9 | | Greater Perth | 1,943,860 | 1,955 | | 8.1 | n/a | 16,379 | 12.9 | 8,435 | 6.7 | 1,247 | 1.0 | | WA | 2,474,414 | 1,910 | | 7.8 | n/a | 20,461 | 12.7 | 10,524 | 6.5 | 1,551 | 1.0 |

Notes: Socio-Economic Indexes for Areas (SEIFA) is a product developed by the ABS that ranks areas in Australia according to relative socio-economic advantage and disadvantage. The Index of Relative Socio-Economic Disadvantage (IRSD) is used. Needing assistance refers to the number of people with a profound or severe disability. Source: Authors’ calculations from Census of Population 2016 and 2011. Data extracted using TableBuilder.

The City of Joondalup has an overall SEIFA score of decile 9 (Table 4). SEIFA is a measure of relative socio-economic disadvantage. SA2 regions falling into decile 1 have the highest level of relative socio-economic disadvantage (compared to other SA2 regions within the State), with those in decile 10 reporting the lowest level of socio-economic disadvantage (compared to other SA2 regions within the State).

Outside of Craigie-Beldon (SEIFA 6) and Joondalup-Edgewater (SEIFA 7), the remaining twelve SA2 regions in the City of Joondalup have a SEIFA score of 8 or above. In fact, seven of the fourteen SA2 regions have a SEIFA score of 10.

15.4 per cent of 0-4 year olds in the City of Joondalup attend Pre-school, with that number as high as 19 per cent in Illuka - Burns Beach, and a low of 11.4 per cent in Craigie - Beldon. It is interesting that the latter has the lowest median income in the City, while the former has the highest median income. This indicates, as expected, that affordability issues affect Pre-school attendance. Of course other factors are at play, such as family choice, culture, availability of family supports and access, amongst others.

Less than 1.0 per cent of 0-4 year olds are reported as needing assistance (having a profound or severe disability)6 in the City of Joondalup, with the highest in Woodvale, standing at 2.2 per cent.

Previous research has shown that single parents have additional financial difficulties, and are more likely to suffer from financial distress than couples (for example, for WA see (Duncan, Leong, Ong, Salazar, & Twomey, 2017) and (Bond-Smith, Duncan, Kiely, & Salazar, 2018). This is turn may make it more difficult for single parents to access health services, both for themselves and their children.

Almost 11 per cent of parents reported as being single parents in the City of Joondalup (Table 5). This figure was highest in Craigie - Beldon, standing at almost 18 per cent, and lowest in Illuka - Burns Beach. The association with median income is again striking for these two SA2 regions. While expected, and in line with trends in other developed economies, it is worth pointing out that there are more single parent males than single parent females across all SA2 regions.

Table 5 Lone Parents by Gender, City of Joondalup, 2016

Source: Authors’ calculations from Census of Population 2016 and 2011. Data extracted using TableBuilder.

6 The 2006 Census was the first Census to include the variable Core Activity Need for Assistance. The Core Activity Need for Assistance variable has been developed to measure the number of people with a profound or severe disability. As with the ABS Surveys of Disability, Ageing and Carers, the Census of Population and Housing defines the profound or severe disability population as: ‘Those people needing help or assistance in one or more of the three core activity areas of self-care, mobility and communication, because of a long-term health condition (lasting six months or more), a disability (lasting six months or more), or old age’.

City of Wanneroo

The median weekly income for the City of Wanneroo is $1,874 in 2016 Table 6. This is $36 lower than that reported for WA as a whole, but is $355 lower than that reported for the City of Joondalup. The highest median income for the City was reported in Mindarie-Quinns Rocks-Jindalee ($2,220), which is $750 lower than that reported for Illuka-Burns Beach ($2,960) in the City of Joondalup.

For the City of Wanneroo, the lowest median income in 2016 was in Girrawheen ($1,210), $670 lower than the lowest reported in the City of Joondalup (Craigie - Beldon, $1,870). Only four of the fourteen SA2 regions in the City of Wanneroo had a median income above $2,000, compared to eleven for the City of Joondalup.

Table 6 Socio-economic Indicators, Education and Need for Assistance, City of Wanneroo, 2016

| City of Joondalup | Socio-Economic Indicators |||| Education || Assistance | | :— | :— | :— | :— | :— | :— | :— | :— | :— | | | Population | Median Weekly Income | Rank | Unemployment Rate % | SEIFA (2016) Score | Pre-School 4 Age Band No. | Pre-School 4 Age Band % | 0 - Primary School 4 Age Band No. | 0 - Primary School 4 Age Band % | 0 - Needing Assistance 0-4 Age Band No. | 0 - Needing Assistance 0-4 Age Band % of Age Band | | Alexander Heights - Koondoola | 11,981 | 1,475 | 13 | 10.6 | 2 | 118 | 14.9 | 55 | 6.9 | 8 | 1.0 | | Butler - Merriwa - Ridgewood | 23,441 | 1,617 | 10 | 10.3 | 3 | 224 | 10.8 | 136 | 6.6 | 33 | 1.6 | | Carramar | 16,619 | 2,012 | 5 | 8.0 | 7 | 171 | 10.9 | 130 | 8.3 | 20 | 1.3 | | Clarkson | 12,964 | 1,762 | 8 | 10.1 | 5 | 128 | 11.6 | 72 | 6.5 | 12 | 1.1 | | Girrawheen | 8,764 | 1,208 | 14 | 12.7 | 1 | 76 | 11.5 | 48 | 7.3 | - | n/a | | Madeley - Darch - Landsdale | 25,403 | 2,180 | 2 | 6.6 | 9 | 286 | 13.9 | 129 | 6.3 | 15 | 0.7 | | Marangaroo | 10,588 | 1,534 | 11 | 9.6 | 2 | 73 | 10.9 | 34 | 5.1 | 9 | 1.3 | | Mindarie - Quinns Rocks - Jindalee | 18,782 | 2,220 | 1 | 8.5 | 8 | 184 | 18.1 | 84 | 8.3 | 10 | 1.0 | | Tapping - Ashby - Sinagra | 13,262 | 2,131 | 3 | 6.7 | 8 | 158 | 14.2 | 95 | 8.5 | 16 | 1.4 | | Wanneroo | 25,623 | 1,949 | 7 | 7.3 | 7 | 224 | 11.4 | 125 | 6.4 | 21 | 1.1 | | Alkimos - Eglinton | 7,953 | 2,105 | 4 | 6.3 | 8 | 85 | 9.4 | 49 | 5.4 | 10 | 1.1 | | Carabooda - Pinjar | 730 | 1,965 | | 7.3 | 6 | - | n/a | - | n/a | - | n/a | | Two Rocks | 2,990 | 1,509 | 12 | 11.3 | 3 | 37 | 18.0 | 16 | 7.8 | - | n/a | | Yanchep | 8,857 | 1,728 | 9 | 9.3 | 5 | 119 | 14.7 | 56 | 6.9 | 12 | 1.5 | | City of Wanneroo | 187,957 | 1,874 | | 8.5 | 5 | 1,883 | 12.6 | 1,029 | 6.9 | 166 | 1.1 | | Greater Perth | 1,943,860 | 1,955 | | 8.1 | n/a | 16,379 | 12.9 | 8,435 | 6.7 | 1,247 | 1.0 | | WA | 2,474,414 | 1,910 | | 7.8 | n/a | 20,461 | 12.7 | 10,524 | 6.5 | 1,551 | 1.0 |

Notes: Excludes SA2 region Neerabup National Park due to population size of three persons only. Socio-Economic Indexes for Areas (SEIFA) is a product developed by the ABS that ranks areas in Australia according to relative socio-economic advantage and disadvantage. The Index of Relative Socio-Economic Disadvantage (IRSD) is used. Source: Authors’ calculations from Census of Population 2016 and 2011. Data extracted using TableBuilder.

The City of Wanneroo has an overall SEIFA score of decile 5, compared to 9 for Joondalup. Half of the SA2 regions in the City of Wanneroo have a SEIFA score of 5 or below – denoting very high levels of relative socio-economic disadvantage. Girrawheen has a SEIFA score of 1, followed by Marangaroo and Alexander Heights - Koondoola (both with a SEIFA score of 2), and Butler - Merriwa - Ridgewood and Two Rocks (both with a SEIFA score of 3). This again shows the strong variation between the two Cities – with the lowest SEIFA score in the City of Joondalup being in Craigie-Beldon (SEIFA 6).

Pre-school attendance in the City of Wanneroo is 2.8PPts lower than the City of Joondalup, but only slightly lower than that reported for WA as a whole. Keeping in mind that the absolute numbers are higher in the City of Joondalup, there were also a larger proportion of children aged 0-4 requiring assistance (1.1%; 166 children) in the City of Wanneroo, relative to Joondalup (0.9%; 82 children).

Compared to the 11 per cent reported for the City of Joondalup, over 18 per cent of parents in the City of Wanneroo are single parents (Table 7). In Butler-Merriwa-Ridgewood as many as 30 per cent of parents are single parents, with a low of 10 per cent in Madeley - Darch - Landsdale. While no SA2 region in the City of Joondalup reported more than 18 per cent of parents being single parents, eight of the fourteen SA2 regions in the City of Wanneroo have single parent rates of 20 per cent and above. As per the City of Joondalup case, single parents are dominated by females.

Table 7 Lone Parents by Gender, City of Wanneroo, 2016

Notes: Excludes SA2 regions Neerabup National Park and Carabooda - Pinjar due to low population size. Source: Authors’ calculations from Census of Population 2016 and 2011. Data extracted using TableBuilder.

A Tale of Two Cities – Part 2: Socio-economic Profile

Returning to the ‘Tale of Two Cities’, seven of the highest median incomes by SA2 region are in the City of Joondalup, while the lowest seven are in the City of Wanneroo Figure 9. The difference between the highest and lowest median incomes are also striking, with the median income of Girrawheen being 41 per cent of that of Illuka - Burns Beach (a $1,750 difference).

Figure 9 Median Weekly Income by SA2 region, City of Joondalup and City of Wanneroo, 2016

Notes: Excludes SA2 region Neerabup National Park due to population size of three persons only. Source: Authors’ calculations from Census of Population 2016 and 2011. Data extracted using TableBuilder.

Girrawheen also reports the highest unemployment rate (12.7%), with seven of the highest unemployment rates by SA2 region reported for the City of Wanneroo (Figure 10). The highest unemployment rate for the City of Joondalup was in Joondalup - Edgewater (9%), with the City of Joondalup also reporting six of the lowest unemployment rates by SA2 region.

Figure 10 Unemployment rates by SA2 region, City of Joondalup and City of Wanneroo, 2016

Notes: Excludes SA2 region Neerabup National Park due to population size of three persons only. Source: Authors’ calculations from Census of Population 2016 and 2011. Data extracted using TableBuilder.

Culture, Language and Religion

City of Joondalup

This section compares the City of Joondalup and the City of Wanneroo in terms of cultural, linguistic and religious diversity. These aspects are important in terms of ensuring that services are delivered in a culturally appropriate manner, and that parents and their babies have adequate language capabilities that allows them to access information about services and to access such services. Religion is another aspect which requires attention from a health service delivery perspective, but is also be a potential aspect of the support system for the families in the community.

For the City of Joondalup (Table 8), only 1.4 per cent of the 0-4 age group identify as being Indigenous, compared to 5.2 per cent across WA. A similarly low Indigenous population is reported amongst the 15-39 year old female group, with 0.8 per cent identifying as Indigenous in the City of Joondalup relative to 3.4 per cent for WA. By SA2, Craigie Beldon has the highest proportion of Indigenous people across both of these cohorts.

Almost four out of every ten people in the City of Joondalup are migrants (Table 8), higher than the 32 per cent reported across the state, as presented in Table 9. Of those migrants, 66 per cent are from the more traditional European source countries, with 17.4 per cent African, 13.4 per cent Asian and 3.1 per cent from the Americas.

Joondalup-Edgewater has the lowest proportion of Europeans (58.7%) in the City of Joondalup, and the highest Asian population (20%). Illuka - Burns Beach has the highest African population as a proportion of its overall population (22.7%).

Table 8 Culture, Language and Religion, City of Joondalup, 2016

Source: Authors’ calculations from Census of Population 2016 and 2011. Data extracted using TableBuilder.

Returning to Table 8, English language proficiency is not a major concern for the City of Joondalup, with 0.6 per cent of females aged 15-39 stating that they do not speak English well or not at all. It is however, something of note in some SA2 regions, with for example 2.6 per cent of those in Joondalup - Edgewater reporting poor or no English language.

In terms of religion, 56 per cent of people in the City of Joondalup identify as being Christian, with 41 per cent having no religion (or not stated), with only 3 per cent identifying with Other religions. This is much lower than the 7 per cent reported for WA.

Table 9 Immigrant Population by Region of Origin, City of Joondalup, 2016

Source: Authors’ calculations from Census of Population 2016 and 2011. Data extracted using TableBuilder.

City of Wanneroo

For both the 0-4 age group and the 15-39 age groups (Table 10), the Indigenous population in the City of Wanneroo (2.5% and 1.5%, respectively) is higher than that reported in the City of Joondalup (1.4% and 0.8%, respectively). While the proportion of Indigenous people in the City of Wanneroo for the reported groups is below the WA average, for Girrawheen, they are higher for both 0-4 year olds and females aged 15-39 years.

Table 10 Culture, Language and Religion, City of Wanneroo, 2016

Notes: Excludes SA2 region Neerabup National Park due to population size of three persons only. Source: Authors’ calculations from Census of Population 2016 and 2011. Data extracted using TableBuilder.

The proportion of immigrants is higher in the City of Wanneroo (41%) is only slightly higher than that of the City of Joondalup (38%). However, there is greater variation by source region, with lower proportions from the traditional European source countries and more from Africa and particularly the Asian region (Table 11).

While some of the more northerly coastal regions in the City of Wanneroo, such as Two Rocks (79% European) and Mindarie (73%) have large cohorts of their immigrant population from Europe, Girrawheen (26% European), Alexander Heights - Koondoola (30% European), and Madeley - Darch - Landsdale (37% European) and Marangaroo (37% European) have a much lower proportion of immigrants from the more traditional economies. This in turn implies a higher proportion of immigrants from the more culturally and linguistically diverse regions of Africa and Asia. For example, in Girrawheen, 55 per cent of immigrants are Asian, and 18 per cent African.

Returning to Table 10, the latter results are strongly associated with English language competency. Over 10 per cent of females aged 15-39 years have poor or no English language capability in Alexander Heights - Koondoola. It is similarly high for Girrawheen (9.2%) and Marangaroo (6.9%). This raises some important considerations for the delivery of health services for women and their families in these locations, and highlights the importance of ‘place based’ service design and delivery.

The City of Wanneroo also have great religious diversity, with a lower proportion identifying as Christian relative to the City of Joondalup, and a great proportion of those identifying with Other religions, which includes Buddhism, Hinduism and Islam.

Table 11 Immigrant Population by Region of Origin, City of Wanneroo, 2016

Notes: Excludes SA2 region Neerabup National Park due to population size of three persons only. Source: Authors’ calculations from Census of Population 2016 and 2011. Data extracted using TableBuilder.

Chapter 3:

Service Mapping

Introduction

This chapter presents geographical maps of key services available towards supporting families and children in the City of Joondalup and City of Wanneroo. With 0-4 year old children as the primary target group, using a collection of spatial coordinates, these services are mapped upon a heat map of the number of 0-4 year olds by SA2 region in each city. It is worth repeating here that, as reported in Table 2 and Table 3, there were 8,800 children in the City of Joondalup on Census night 2016 (down 5% on 2011), representing 5.7 per cent of the City’s population, compared to almost 15,000 in the City of Wanneroo (up 16% on 2011), making up 8 per cent of the City’s population.

Maps are presented according to three main themes, namely: Government Health and Mental Health Services; Early Childhood Education and Care, Community Services and Libraries; and Universal Services. Every effort was made by the authors to include all services known to the authors at the time of publication.

Government Health and Mental Health Services

Figure 11 maps the Government Health and Mental Health Services across the two cities. There is one (1) major hospital across the two cities, located in the City of Joondalup. There are thirteen (13) Community Health Services in the City of Joondalup and fifteen (15) in the City of Wanneroo, with four (4) Community Mental Health services in Joondalup and two in the City of Wanneroo. Therefore, based on the larger number of 0-4 year olds in the City of Wanneroo, there are, by this metric, and relative to the City of Joondalup, a lack of services in the City of Wanneroo. Visually, in relation to the density of 0-4 year olds, a lack of such services is particularly evident in the SA2 regions of Wanneroo, Madeley - Darch - Landsdale and Caramar, with gaps also evident in the newer growth areas to the north west of the City of Wanneroo (Yanchep and Alkimos – south of Two Rocks). It is important that services keep pace with the growth in population in these regions.

By its very nature, there is a natural clustering of services around the Joondalup hospital and Joondalup Health Campus. While the Joondalup health campus is reasonably close to the City of Wanneroo, consumers have noted that access to transport and related affordability constraints are barriers to accessing such services. Lake Joondalup, and Yellagonga Regional Park mean that there are additional challenges for many living in the City of Wanneroo toward accessing such services. This is something to consider from a policy perspective.

Figure 11 Government Health and Mental Health Services, 2018

Source: Authors’ calculations from Census of Population 2016 and 2011; WA Primary Health Alliance, Primary Health Care Data Collection 2018; ECU Better Together Service Provision Database

Early Childhood Education and Care, Community Services and Libraries

Figure 12 maps Early Childhood Education and Care (ECEC) services together with Community Services and Library service. In many cases, libraries are co-located with Community Services, with those stand-alone libraries categorised differently for mapping purposes.

There are thirty eight (38) ECEC’s in the City of Joondalup, with fifty eight (58) in the City of Wanneroo. Both cities have sixteen (16) Community Services, with both also displaying four (4) stand-alone libraries. By these metrics the City of Wanneroo presents relatively well. The volume of ECEC services is the City of Wanneroo is particularly noteworthy, especially given that the vast majority of such services are privately operated.

Figure 12 Early Childhood Education and Care, Community Services and Libraries, 2018

Source: Authors’ calculations from Census of Population 2016 and 2011; WA Primary Health Alliance, Primary Health Care Data Collection 2018; ECU Better Together Service Provision Database

Universal Services

Figure 13 maps Universal Service – Hospital, Medical Centre/GP Practices and Pharmacies. It also plots the major shopping centres in the two cities. The clustering of such services is to be expected and is particularly evident in the more densely populated areas such as Joondalup-Edgewater, with clusters also near the major shopping centres – such as at Whitfords and Wanneroo. The latter emphasises the role of shopping centres as important hubs for families and infants, young children.

Figure 13 Universal Services, 2018

Source: Authors’ calculations from Census of Population 2016 and 2011; WA Primary Health Alliance, Primary Health Care Data Collection 2018; ECU Better Together Service Provision Database

General Practitioners play a critical role for parents, infants and young children, and are for many (along with pharmacists – a point developed latter in this report), a critical first point of contact for any health or mental health related issues.

Therefore, Figure 14 looks at the number of General Practitioner Services (GPS7), mapping the number of GPS per 1,000 of the population of 0-4 year olds. On this metric, there are 4.5 GPS per 1,000 of the population of 0-4 year olds in the City of Joondalup. This compares to only 2.8 GPS per 1,000 of the population in the City of Wanneroo.

7 This is the number of GP Services (GPS) only and not a headcount of General Practitioners (GPs) or a Functional Service Equivalent (FSE).

Of course, GPS cover all population cohorts, but in terms of the target group under consideration in this report (0-4 year olds and their parents/families), there is an apparent lack of GPS in the City of Wanneroo8 relative to the City of Joondalup. This is particularly evident in areas such as Marangaroo (1.5), Carramar (1.9), and Butler (1.9), and again in the new growth areas of Yanchep (2.5) and Alkimos (2.2). More striking is the absence of GPS in Tapping - Ashby - Sinagra, which as previously shown, also had a high proportion of 0-4 year olds and a high migrant population.

However, some areas in the City of Wanneroo report quite well, with for example, Girrawheen reporting 7.6 GPS per 1,000 of the 0-4 year old population, followed by Alexander-Heights (5.1) and Two Rocks (4.9).

For the City of Joondalup, Ocean Reef (12.4), Joondalup-Edgewater (10.7) and Woodvale (7.4) report a high density of GPS, with none reported in Iluka - Burns Beach or Heathridge - Connolly, albeit with both neighbouring those SA2 regions with high densities.

Figure 14 General Practitioner Services per 1,000 of the Population of 0-4 Year olds, City of Joondalup and City of Wanneroo

Source: Authors’ calculations from Census of Population 2016 and 2011; WA Primary Health Alliance, Primary Health Care Data Collection 2018; ECU Better Together Service Provision Database

8 This assumes a similar number of General Practitioners (FSE), for which the authors of this report did not have data at the time of writing this report.

Chapter 4:

Provider Survey Results

Introduction and Characteristics of Survey Respondents

This chapter provides an overview of the participants in the Better Together survey data. Demographics including gender, age, education and countries of birth are collated. The chapter also provides analysis of the type of service respondents work in and characteristics of those services including perceptions of success, training in PIMH, client characteristics and referral pathways.

There were 111 respondents to the survey from organisations, (Managers = 39; Providers = 72). Managers had additional questions that applied to managerial roles, i.e. funding and staffing matters.

Amongst the providers and managers that responded to the survey, 86 per cent were female, with 14 per cent male. The majority of respondents were in the 25-64 age category; with specifically, 15 per cent aged 25-34; 32 per cent aged 35-44; 33 per cent aged 45-54; and 17 per cent aged 55-64. Two per cent were over the age of 65 with 1 per cent aged 18-24.

Fifty percent of respondents were born in Australia or New Zealand, 28 per cent in the UK and Ireland, 8.5 per cent in South Africa, with 6 per cent in other European countries and 6 per cent in other countries. By ethnicity, 57 per cent identified as being Australia; 24 per cent European; 6 per cent African; 5 per cent Middle East; with 8 per cent from other ethnic backgrounds.

Forty-eight percent of respondents had a postgraduate degree or higher, 30 per cent had a bachelor degree, with 22 per cent having a certificate or diploma. Only 1 per cent had a qualification of Year 12 or below.

The proportion of respondents by service category are displayed in Figure 15 below. Forty percent of respondents were from Community agencies/organisations; 21 per cent from health; 13.5 per cent from Mental Health; 13.5 per cent from Primary health care with the remaining 12 per cent from Education.

Figure 15 Proportion of Respondents by Service Category

Notes: N = 111. Source: Authors’ calculations from ECU Better Together Workforce Survey data.

Twenty-three percent of respondents have worked in their selected category for over 21 years, 28 per cent between 11 and 20 years, 26 per cent between 5 and 10 years, with 22 per cent between 0 and 4 years (Figure 16). Overall, this indicates that respondents have had significant experience in their relevant field.

For the latter, individuals do move within their category however, with over 9 per cent of respondents working in their current role position for 10 years or more, 32 per cent between 5 and 10 years, 34 per cent between 1 and 4 years, with 24 per cent less than one year.

Figure 16 Length of Time Working in Current Category

Notes: N = 99 Source: Authors’ calculations from ECU Better Together Workforce Survey data.

Thirteen percent of the agencies/organisations represented offered only one service (Figure 17). Thirty percent offered between 2 and 4 services, with 35 per cent offering between 5 and 7 services. Twenty-two percent of agencies/organisations offered between 8 and 12 services.

Figure 17 Number of services or programs provided by the Agency/organisation

Notes: N = 91 Source: Authors’ calculations from ECU Better Together Workforce Survey data.

Agency/organisation Success

When asked to report on the perceived success of the agency/organisation in supporting the needs of children aged 0-3 years and their families, 13 per cent of respondents believed they were completely successful, 38 per cent very successful, and 31 per cent successful. Of the remaining 17 per cent, 15 per cent felt that they were somewhat successful, with 2 per cent not successful.

Figure 18 Self-reported Agency/organisation Success in supporting the needs of children aged 0-3 and their families

Notes: N = 99 Source: Authors’ calculations from ECU Better Together Workforce Survey data.

Breaking this down by service category shows that 93 per cent of those in Primary health care believe they are successful or better, with a similar figure for Health (90%), and Education (92%). This figure for community organisations was somewhat lower at 84 per cent. Most striking is that only 53 per cent of those working in the mental health category felt that their agency/organisation success was successful or better, with 47 per cent feeling that they were only somewhat successful or not successful. Perceptions of success from providers and managers requires further investigation.

Figure 19 Self-reported Agency/organisation Success in supporting the needs of children aged 0-3 and their families, by Service Category

Notes: N = 99. Community (37); Education (12); Health (20); Mental Health (15); Primary health care (15). Source: Authors’ calculations from ECU Better Together Workforce Survey data.

The primary factor contributing to the success of the Network was seen to be the ‘bringing together of diverse stakeholders’, with 68 per cent of respondents pointing to this factor (Figure 20). A further 18 per cent noted a similar factor – meeting regularly, with the exchange of information (8%), sharing of resources (2.6%) and having a shared vision/goal (2.6%) given less significance.

Figure 20 Aspects of Network Contributing to Agency/organisation Success

Notes: N = 38 Source: Authors’ calculations from ECU Better Together Workforce Survey data.

More than half (52%) of respondents felt that staff turnover was the greatest barrier to network success (Figure 21). This emphasises the importance of relationships in building the success of the Network, and related trust. Lack of resources (17%) was the second largest barrier identified, followed by the political landscape (14%), and geographic location/distance (8%). Lack of time (5.6%) and competing priorities (2.8%) were seen as lesser barriers to the success of the Network.

Figure 21 Barriers to Network Success

Notes: N = 36 Source: Authors’ calculations from ECU Better Together Workforce Survey data.

In regards to the expected benefits of greater cohesion of services, 26 per cent of respondents felt that improved health outcomes would be the greatest benefit, together with an improved understanding of mental health issues (26%). These are followed by improved communication between agencies/organisations (14%) and improved services (11%). 7.5 per cent of respondents felt that greater cohesion would lead to better engagement with families/consumers and improved referral pathways.

Figure 22 Expected benefits if greater cohesion of services existed

Notes: N = 107 Source: Authors’ calculations from ECU Better Together Workforce Survey data.

Agency/organisation Source of Funding and Staffing Resources

Seventy-four percent of agencies/organisations surveyed noted that their main source of funding was public (government) funding, with 8 per cent mainly funded privately (Figure 23). Five percent had philanthropic funding as their main source, with 13 per cent noting ‘other unspecified’ funding sources. Forty-eight and one-half percent of respondents received funding based on both service use and client outcomes; 6.5 per cent received funding based on client outcome only, with 22 per cent receiving funding based on service use only. Only 43 per cent of respondents had ongoing funding and 57 per cent had funding over a specific time period. The impact of such funding arrangements on the Network, on trust and level of cooperation and collaboration requires further investigation.

Figure 23 Main source of funding

Notes: N = 39 Source: Authors’ calculations from ECU Better Together Workforce Survey data.

As shown in Figure 24, 37.5 per cent of agencies/organisations surveyed do not allocate funding directly to the services of children aged 0-3 years. Thirty-four percent allocated between 1 and 20 per cent of their overall funding to 0-3 year old services. Almost 16 per cent of agencies/organisations survey allocate over 90 per cent of their funding specifically to the services of 0-3 year old age groups. Although funding to organisations may not be directly allocated to this age group, some organisations agencies/organisations do distribute a percentage of total resources such as staff time and/or funding to the PIMH period.

Figure 24 Proportion of Agency/Organisation funding allocated to services for children aged 0-3 years

Notes: N = 32. Based on an estimate provided by respondents. Source: Authors’ calculations from ECU Better Together Workforce Survey data.

In terms of the allocation of funding to serving 0-3 year olds and their families, only 15 per cent of agencies/organisations have over 90 per cent of their budget specifically allocated to this age group. Many (37.5%) operate in the space without any specific funding.

Figure 25 Proportion of Agency/Organisation staff providing services to 0-3 year olds

Notes: N = 31. Based on an estimate provided by respondents. Source: Authors’ calculations from ECU Better Together Workforce Survey data.

Sixty-five percent of agencies/organisations surveyed did not have an Aboriginal or Torres Strait Islander Liaison Officer, while 30 per cent of agencies/organisations surveyed had between one and five Aboriginal and Torres Strait Islander Liaison Officers.

Ninety-three and one-half percent of agencies/organisations did not have an ethnic assistant. The latter is somewhat concerning in the context of the socio-economic indicators provided earlier, and as our Cities become increasingly diverse. Furthermore, the agencies/organisations surveyed indicated that over 30 per cent of their clients are from culturally and linguistically diverse backgrounds. Ensuring that service delivery is culturally and linguistically appropriate is an important consideration moving forward.

Training – Agency/organisation Respondents

Previously in this report, the importance of staff to the Network and the negative impact of staff turnover was highlighted. Figure 26 presents another important dimension of staff in the Network – that of training availability in Infant mental Health (IMH) and Perinatal Infant Mental Health (PIMH). For IMH, panel (a), 50 per cent of Agency/organisation staff reported having access to IMH related training within their workplace, with 35 per cent having access to such training outside of their workplace. Fifteen per cent said that they did not have access to or were unaware of access to IMH training.

Turning to PIMH, 37.6 per cent of respondents reported having access to PIMH related training within their agency/organisation, with almost 43 per cent having access to such training externally. Almost 20 per cent of respondents said that they did not have access to or were unaware of such training opportunities.

Despite the increased awareness and availability of PIMH training for professionals and practitioners in child and family serving disciplines, there remains a significant proportion of the workforce who are unaware or do not access this. Building workforce capacity in PIMH is imperative for building of effective services across the continuum of care. Staff who have specific training in PIMH and confidence in the models and frameworks that underpin this are more likely to recognise and respond appropriately to PIMH needs in families who access services in the System of Care. It is essential that all staff working in these fields have awareness of the training available, and access such training to ensure that they are aware of best practice in the field.

Shared training models have the potential to increase the level of awareness of others in the System of Care, and lead to a greater establishment of trust (Australian Association for Infant Mental Health WA Branch, 2016; Priddis, Matacz, & Weatherston, 2015; Zeanah, 2019).

Figure 26 Availability of Training in IMH and PIMH for Agency/organisation Staff

Notes: N = 100 for IMH and N = 101 for PIMH. Percentage of respondents. Source: Authors’ calculations from ECU Better Together Workforce Survey data.

By agency/organisation category, in terms of the availability of training in IMH (Figure 27, Panel a), IMH training within the organisation was highest in Education (73%), followed by Health (65%). It is likely that early childhood trained educators have a focus on some of the principles of PIMH such as child development and behavioural health. PIMH trained practitioners have a more specific focus on the relational aspects that are the fundamental building blocks for early social and emotional development (Weatherston, 2005).

Panel a of Figure 28 shows that only 7.7.5 of staff in primary health care have access to IMH related training within the organisation; almost 31 per cent reported not having any access to training or that they were not aware of such training opportunities. The latter is high relative to only 7 per cent reporting similarly in the perinatal mental health field (in panel B), and compared to an average of 15 per cent across all categories (the total reported). This may be accounted for by heightened awareness of perinatal mental health issues in the medical and primary health care settings as well as awareness of pharmacological and other interventions for post-natal depression.

Panel b of Figure 27 reports on the availability of training in Perinatal Mental Health (PMH). Within organisation training is highest in Mental health (57%), followed by Health (50%). The low levels of access (or awareness) to training within the organisation is again high for the primary health care sector (23%), although higher rates are reported for Education (33%) and Community (26%).

Figure 27 Availability of Training in IMH and PMH for Staff, by Agency/organisation Category

Notes: N = 100 and 101. Source: Authors’ calculations from ECU Better Together Workforce Survey data.

The importance of training from the perspective of agency/organisation respondents is further highlighted in Figure 28, where they report that the primary benefit of additional training would be in improving awareness of relevant agencies/organisations and services. In fact, over 70 per cent of respondents placed this as the main benefit. Awareness of complementary agencies/organisations, services and programs and developing connections with individuals with these services are critical first steps towards a better functioning Network, and is something that requires urgent action.

Respondents noted earlier screening and detection of problems in the perinatal period as another benefit of further training. This again is a critical factor in ensuring better outcomes for 0-3 year olds and their families. This result suggests that practitioners are aware of the importance of early intervention for parental mental health, but not all feel adequate skill levels to screen and detect problems or identify clinical symptoms in an infant presentation. This may relate to the lack of referrals for PIMH concerns being made within the System of Care (Figure 50).

Figure 28 Areas where agency/organisation would benefit from further training

Notes: N = 98. Source: Authors’ calculations from ECU Better Together Workforce Survey data.

Client Characteristics

In terms of the characteristics of Agency/organisation clients (as reported by the respondents), across all agencies/organisations, on average, 57 per cent of clients are of low socio-economic status (SES), with 34 per cent from medium SES status and 9 per cent from high SES.

Across all agencies/organisations, on average, 61 per cent of clients are reported as identifying of English speaking background; 9 per cent are Aboriginal and Torres Strait Islanders, with 30 per cent being from culturally and linguistically diverse backgrounds. Based on our earlier analysis of the socio-economic characteristics of the City of Joondalup and Wanneroo, the latter would suggest that many of the most vulnerable groups are well represented in the system.

Referral Pathways

In terms of referral pathways 4.2 per cent of agencies/organisations noted that of all referrals received all services were actioned i.e. the client referred took up the service that was offered. Forty-two per cent said that between 90-99 per cent of referrals were actioned, with 46 per cent reported that that between 60-88 per cent of referrals were actioned. Eight percent said that between zero and 59 per cent of referrals were actioned. These shows there are a large proportion of families not availing themselves of services offered.

This requires further investigation. Focus group data suggest that socioeconomic factors, lack of flexible and whole family approach to services may impede families attending appointments. (See Chapter six of this report).

In terms of referral pathways, 16 per cent of respondents said that they do not make formal referrals (that is, using a referral form or writing a referral letter), while 9.7 per cent said that all of their referrals are informal (that is, the agency/organisation suggests to the client to access a particular service). This suggests that the System of Care does not yet have a coordinated and systematic process of referring young families who present with PIMH issues.

Conclusion

The findings from this chapter reveal that providers of PIMH services across the continuum of care value ‘bringing together a number of diverse stakeholders’ (68%) and that they perceive this as contributing to their agency/organisation’s success in providing services to families. The value placed on collaboration gives impetus for creating new ways of working together that involve a shift in thinking from individual service providers working in relative isolation to more collective working together in order to improve the well-being of families from pregnancy through to three years. Although for the most part service providers view themselves as very successful (38%) or successful (31%) in supporting the need of families with infants and infants, young children, individual agency/organisation outcomes are unlikely to lead to better outcomes for an entire community. Committing to a focus on how agencies/organisations work together through sharing information, meeting regularly and sharing resources can create new possibilities and innovative ways of engaging in collective action towards improving well-being of families. Continual long term investment into supporting how organisations work together will promote long term system level changes, address broader complex social issues such as poverty and social inequity and improve population mental health across the Cities of Wanneroo and Joondalup.

With regards to specific training in PIMH principles, the provider survey data identified that the workforce recognises the importance of PIMH training and education in relation to building skills and expertise in screening and detection of PIMH problems. Furthermore, they recognised and reported that PIMH training can act as a vehicle for improving organisations awareness of other organisations and PIMH services available for families.

The results indicate that staff turnover (52%) is a significant barrier for building a successful network across multiple organisations within the PIMH System of Care. High staff turnover may be connected to government funding structures by which over half of the organisations (57%) that provide PIMH services receive time limited funding. The lack of continuous funding for services has a direct negative impact on how families experience services. The focus group data supported this finding as families reported valuable services coming to an abrupt ending due to funding cycles ending and not been renewed.

Investigation of the funding allocation to WA Mental Health and Alcohol and Other Drugs reveals that only 21 million dollars of the 914-million-dollar budget for 2017-2018 was allocated to prevention across the lifespan and accounted for the lowest percentage of growth (2%) in the State Budget. Interestingly investment in preventative services was directed to two youth mental health programs. The State Budget for mental health reveals an emphasis on youth mental health as preventative care, rather than drilling down to the earliest possible point of entry (pregnancy and infancy). Considering this, at a policy level there is an urgent need for advocacy, education and training of PIMH principles, services and the role early social and emotional health and wellbeing plays in determining mental health across the lifespan. Increased understanding of PIMH at a policy level may result in considering different funding allocations for mental health services and supports and prioritising PIMH as a preventative strategy. Furthermore, it may shift more emphasis towards building the level of connectedness between organisations within the PIMH System of Care as a way of developing more structured referral pathways for families, increased cohesion across the continuum of care and better access to vulnerable groups within the two cities.

Chapter 0:

Consumer Survey Results

Introduction and Characteristics of Survey Respondents

This chapter provides an analysis of the consumers surveyed as part of this report. Fifty-three individuals responded to the consumer survey. Of these, 12 (23%) were from the City of Joondalup (representing five suburbs), with 41 (77%) from the City of Wanneroo (representing 13 suburbs). Fifty (96%) of the 52 respondents were mothers, with one response completed by a mother and father. Sixty percent of respondents were married, with 29 per cent in defacto relationships. 11 per cent were either single or divorced. Sixty-seven percent of respondents were the owner-occupier of their place of residence, with 33 per cent renting.

Of the total respondents, 58 per cent reported having one child between the age of 0 and 5, with 40 per cent having 2 children in this age range, and one respondent having three children. Thirteen per cent (7) of the respondents reported being pregnant at the time the survey was conducted.

Fifty-seven percent (30) of respondents were aged 25-34, with 38 per cent (20) being between 35-44, and 5 per cent (3) between 18 and 24 years of age.

Thirteen percent identified being from a cultural and linguistically diverse background. Sixty-eight percent (36) of respondents identified as being of Australian ethnicity, with 23 per cent (12) identifying as European, and 12 per cent (6) identifying with other ethnic backgrounds.

In terms of level of education, 29 per cent of respondents had a Bachelor degree, with 17 per cent having an Advanced Diploma. Almost 20 per cent had a Graduate certificate or Postgraduate degree. Seventeen per cent reporting having a Year 12 level of education, with almost 8 per cent having Year 11 or below.

Fifty-eight percent of respondents are currently employed, with 42 per cent not working. Of those employed, 40 per cent were employed on a full-time basis, 43 per cent part-time, and the remaining 15 per cent being casual or self-employed.

Thirty-one percent of respondents relied on some Centrelink payments as a source of income, of which over a third relied entirely on this form of income. Sixty-nine per cent of respondents noted employment as the households’ sole source of income.

Fifty percent of respondents had an annual household income of over $100,000. Seventeen percent earned between $80,000 to $100,000, 16 per cent between $60,000 and $80,000, and 10 per cent between $20,000 and $40,000. Almost 8 per cent of respondents reported having less than $20,000 in annual household income.

Point of Contact

In cases where the respondents had difficulty during pregnancy or in the early years (0-3 year old) of raising their child, 68 per cent reported that their first point of contact or support would be their General Practitioner (GP) (Figure 29). This highlights the critical role of GPs in the Network. Their centrality means that raising GP awareness of the overall system, the appropriate referral pathways and support systems in place is essential, and of urgent importance. Although the Better Together project was creative and energetic in attempts to engage GPs form the System of Care in this project, it proved to be very difficult, with many not responding to invitations to participate. The factors behind this need to be better understood, and any barriers to engagement addressed, given the critical role of GPs in the community and network.

Figure 29 First point of contact if difficulty during pregnancy or raising 0-3 year old child, 2018

(Bar chart showing percentage of respondents for GP (67.9), Family (13.2), Child Health Nurse (7.5), Hospital / Antenatal Clinic (5.7), Obstetrician (3.8), Paediatrician (1.9), Pharmacist (0.0))

Notes: N = 53. Source: Authors’ calculations from ECU Better Together Workforce Survey data.

Awareness of Agencies/Organisations, Services and Programs

Of the above services, all respondents were aware of their local child health centres, and their local GP. However, 10 per cent of respondents were not aware of the Joondalup Health Campus Antenatal clinic, and 4 per cent were not aware of the Joondalup Health Campus Maternity Ward.

Level of Difficulty in Accessing Services

Consumers were asked to identify various difficulties they encountered in accessing services within organisations. The ten difficulties presented to respondents are reported in Figure 30. Responses are categorised on a scale of 0 to 10, with 0 denoting no difficulty of access, 1-3 low level of difficulty, 4-6 medium difficulty, 7-9 high difficulty and 10 extreme level of difficulty.

Across all categories, a large proportion of respondents reported having no or very low levels of difficulty in accessing services. Of those who reported difficulties over 25 per cent of all respondents noted that Waitlists provided an extreme level of difficulty towards accessing services. This was followed by Private health insurance (18%), financial constraints (15%), and insufficient service (12%); with 10 per cent of respondents noting that transport, quality of service, and flexibility of service availability were sources of extreme difficulty in accessing services. These findings are consistent with the themes reported across the two consumer focus groups.

Figure 30 Source of Difficulty in Accessing Services, 2018

(Four charts displayed: Distance/Transport, Private Health Insurance, Financial Constraints, Language/Cultural)

Notes: N = between 37 and 46. Responses are categorised on a scale of 0 to 10, with 0 denoting no difficulty, 1-3 low level of difficulty, 4-6 medium difficulty, 7-9 high difficulty and 10 extreme level of difficulty. Source: Authors’ calculations from ECU Better Together Workforce Survey data.

Figure 30 Source of Difficulty in Accessing Services, 2018 (continued)

(Six charts displayed covering Waitlists, Flexibility or Service, Insufficient Service, Inappropriate Quality of Service, No response from Agency/organisation, Agency/organisation Closed)

Notes: N = between 37 and 46. Responses are categorised on a scale of 0 to 10, with 0 denoting no difficulty, 1-3 low level of difficulty, 4-6 medium difficulty, 7-9 high difficulty and 10 extreme level of difficulty. Source: Authors’ calculations from ECU Better Together Workforce Survey data.

Communication

Consumers have provided mixed perceptions in relation to the level of communication/coordination between services when they had accessed two or more services. Twenty-one percent of respondents said that such services had not communicated with each other, with 29 per cent having a small amount of communication (Figure 31). Forty-two percent felt that such services/agencies/organisations had communicated ‘a fair amount’, with 8 per cent communicating a great deal.

The SNA illustrated that few organisations (7%) work in an integrated way with each other and most operate at a level of awareness only (58%). This finding was also reflected in the consumer focus groups with comments such as > “yeah they don’t connect. I can’t think of any experience where I’ve had any two services connect that I haven’t had to connect the dots myself.”

Figure 31 Communication between services when two or more services/agencies/organisations accessed by the client, 2018

(Bar chart showing Not at all 20.8%, A small Amount 29.2%, A fair amount 41.7%, A great deal 8.3%)

Notes: N = 24. If you have accessed two or more agencies/organisations/services/programs at once, did they communicate with each other when you needed them to (or would have liked them to)? Source: Authors’ calculations from ECU Better Together Workforce Survey data.

Success of Agencies/organisations, Support Systems and Sources of Information

Thirty-two percent of consumers felt that, for those agencies/organisations they had engaged with, they were either very successful or completely successful in supporting the needs of children aged 0-3 and their families (Figure 32). A further 32 per cent felt that such agencies/organisations were successful, with 34 per cent noting that they were somewhat successful. Only 2 per cent felt that such services were not successful.

Focus group data suggests these result are variable and that many inequities remain, with consumers confused as to the process of access and how family’s needs are prioritised.

Figure 32 Success of Agencies/Organisations in supporting the needs of children aged 0-3 and their families, 2018

(Bar chart showing distribution of success levels)

Notes: N = 53. Source: Authors’ calculations from ECU Better Together Workforce Survey data.

As for consumers informal supports towards meeting the social and emotional wellbeing of their 0-3 year olds, 60 per cent felt that such supports were very successful or completely successful, with a further 9 per cent saying successful (Figure 33). Twenty-four percent felt that such supports were only somewhat successful, with almost 6 per cent felling that informal supports were not successful. The latter is likely linked to aspects such as geographic distance from family and friends, with some denoting this as a barrier to various services and supports.

Figure 33 Success of Informal Supports towards emotional and social needs of 0-3 year old children

(Bar chart showing distribution of success)

Notes: N = 53. Source: Authors’ calculations from ECU Better Together Workforce Survey data.

The primary source of information for parents regarding parental wellbeing during pregnancy and the early stages of a newborns life (Figure 34) is the agencies/organisations with whom the parents are already connected to (with 73% of respondents noting this as a source of information). This was followed by family and friends (63%), and internet and social media (54%). Almost 6 per cent said that they would not know where to turn to for such information.

Figure 34 Source of Information regarding Parental well-being during pregnancy and after baby is born

(Bar chart showing sources of information)

Notes: N = 52. Multiple responses were allowed, meaning the results do not sum to 100 per cent. Source: Authors’ calculations from ECU Better Together Workforce Survey data.

A similar trend is presented for those sourcing information regarding social, emotional and/or behavioural concerns for their 0-3 year old, with a higher rate reported for agencies/organisations with which one is not connected. It seems that if a family are isolated and not connected to an agency/organisation then the internet is their main source of information. Focus group data identified that their relationships with service providers that are sustained over time are most important sources of information and support.

Figure 35 Source of Information regarding social, emotional and/or behavioural concerns in 0-3 Year old

(Bar chart showing sources of information)

Notes: N = 51. Multiple responses were allowed, meaning the results do not sum to 100 per cent. Source: Authors’ calculations from ECU Better Together Workforce Survey data.

In regards to gaining additional information during pregnancy and the early years of their newborn, 58 per cent of consumers felt that they would have liked additional information on the agencies/organisations and services available for support during these periods (Figure 36). Fifty-seven percent felt that additional information relating to issues of concern relating to their 0-3 year olds would have been valuable, with 34 per cent noting that additional information towards issues of concern during pregnancy would have been beneficial.

Figure 36 Areas where additional information would have benefitted during pregnancy and early years

(Bar chart showing areas for additional information)

Notes: N = 53. Multiple responses were allowed, meaning the results do not sum to 100 per cent. Source: Authors’ calculations from ECU Better Together Workforce Survey data.

Conclusion

Findings from the consumer data reveal that majority of respondents identified as Australian, aged between 25 to 35 years with nearly half having a university degree level of education. Respondents also reported a high rate of employment (58%) and at least half of the households had an annual income over $100,000. The characteristics of the survey respondents are an important consideration when interpreting the findings given the likelihood that vulnerable groups are not well represented in this sample of families in the City and Wanneroo and Joondalup. The results revealed that a large proportion of families identify the GP as their first point of contact for PIMH concerns, which is a consistent finding across this project. It further highlights the urgent need to create ways of engaging GPs with the broader PIMH network. Findings from the survey data and focus groups can be the foundation for investigating ways to utilise the family’s experiences and to mobilise families to advocate for increased engagement of GPs within the PIMH System of Care.

In line with findings from the focus groups, the survey data revealed that families value the connection they have with an agency/organisation and will source additional information pertaining to PIMH from those agencies/organisations they are already engaged with. This finding emphasises the significance of the intangible factors that families value such as trust and having an authentic relationship with service providers. Attention can be directed towards improving the capacity of agencies/organisations within the PIMH System of Care to work within a relationship based framework with families and focus on building this approach across the system. This has commenced through the multiple intervention strands conducted through the Better Together Project (Reference Group, GP and Pharmacy Training, Urban95 Workshop). Moving forward there is a drive to continue building and connecting organisations across the PIMH System of Care and develop a network that places families and their experiences at the centre. Engaging families as Better Together continues its capacity building efforts is a crucial element of successfully working towards achieving a longstanding social change in the complex system of PIMH.

Chapter 6:

Participatory Action Research Findings

Introduction

This chapter reports on the outcomes of four reference group meetings which were held at ECU. The Reference Group provided important steer throughout the research process and ensured that key stakeholders were engaged at all stages of the research process.

This chapter also explores families experiences of current PIMH services available within the cities of Wanneroo and Joondalup and based on these findings, consideration is given to ways to further investigate and to improve current service delivery models and develop more client centred services that focus on ‘whole family’ needs.

Summary of Reference Group Meetings

The number of attendees and meeting activities for the four Reference Group meetings are summarised in Table 12, with further details on each meeting detailed after that.

Table 12 Summary of Better Together Reference Group Meetings

Reference Group 1

A questionnaire comprising seven questions was provided to all reference group attendees and subsequently to consumer members and other service providers who wished to complete the questions but were unable to attend the first meeting. A summary of these responses was provided at the second reference group meeting, held 20th November 2017. Questions and summaries of answers provided are as follows:

Question 1: From your perspective, what in the community is helping to support the emotional and social wellbeing of infants and infants, young children when all is going well in a family?

• Consumers and service providers agreed Child Health Nurses were an important contact when things are going well in the family
• Playgroups were also identified by both group as being important (including Dad’s playgroup)
• A range of other services were also identified, with some differences between service providers and consumers.
  • Those identified by service providers were:
    • Child parent centres; Recreational facilities/community activities/festivals & family days, library programs, daycare (when affordable), Medical services; GP; Informal supports; mother’s group; Transport - when available; Parenting programs; access to parenting information; hospitals; Early Learning & Care Centres; Ngala; Govt support; Employment flexibility; Child health centres
  • Consumers identified:
    • Maggie Dent workshops (parenting workshops); Library based programs (It’s All About Play; It’s All About Rhymes; Local daycare workshops; Baby Expo and play based activities/parks

Question 2: From your perspective, what in the community is helping to support the emotional and social wellbeing of infants and infants, young children when concerns are identified?

• Similar responses between both consumers and service providers - Child Health Nurses identified as being important and most likely first point of contact
• Consumers identified informal support as being an important source when concerns are identified
• Service providers also identified agencies/organisations such as:
  • Ngala, Child Parent Centres, Enhanced home visiting, Best Beginnings Plus; Early Learning & Child Centres; Child Health Centres; Non-Government Organisations (general)
• Consumers identified
  • Child Health Centres; Child Development Centres; Ngala; Breastfeeding WA; Daycare; Joondalup MH Team; Maggie Dent; mother’s groups, Clarkson CAMHS, Workshops (behavioural, speech, toilet training); Baby Expo; Beyond Blue; Health Direct; informal support including a local Facebook mother’s support page

Question 3: What do you think are the biggest challenges facing families in pregnancy, infancy and early childhood?

• Consumer and service providers held some consensus on challenges facing families, with both groups noting that social isolation and lack of transport was most common response. Financial problems were also highlighted, as well as lack of awareness of which services are available and consumers not knowing how to access them
• Mental health and FIFO were also common responses across both groups

• Other responses from service providers included:
  • Lack of village mindset (not knowing neighbours); Families with complex needs, including parental MH/AOD issues, family violence; Accessing services for special needs; parenting education for Dads; cultural issues - lack of cultural appropriateness; cultural differences in parenting styles/knowledge; single parenting & support for post-separation parenting; Lack of cohesive policy/planning; rapid growth & inability of services to keep pace; geographical service coverage; lack of resources; poor information; lack of access; waitlists; language barriers
• Responses from consumers included:
  • Birthing and postpartum education; Lack of knowledge/understanding re: systems (e.g. education, health); Finding a good GP; Expensive daycare; lack of breastfeeding support.

Question 4: To what extent are quality, accessible services & supports in place to meet the needs of infants, infants, young children & their families who present with social and emotional difficulties?

• A range of agencies/organisations were reported positively by Service Providers, including: Ngala, Child Health Nurses
• An issue pointed out by one service provider is that CH nurses provide a great service but are too heavily relied upon
• Consumers provided positive feedback regarding access to services, although noted a decrease in CH Nurse visits
• However, responses by consumers also suggested a lack of knowledge regarding services available which is likely to be prohibiting access

Question 5: Which organisations and/or specific people provide high quality services in Wanneroo and Joondalup for families with emotional and social difficulties in pregnancy, infancy & early childhood?

• Most common response by service providers regarding high quality service provision was Child Health Nurses
• Other services commonly identified were P2P, Women’s Health, Hospitals and Social Workers
• Consumers identified a range of services, including Child Development Services, CH Nurses, Ngala, Libraries, CAMHS
• Pharmacies (with one in particular) were identified as providing high quality services
• Dads WA identified as being an important support, especially for first time Dads with limited supports in the area

Question 6: Which organisations/stakeholders have the most leverage to be change agents in the system of PIMH care in Wanneroo/Joondalup?

• Government was mainly identified by both consumers and service providers - Federal, State, Local as being primary agents for change
• Researchers were also identified
• A range of not for profit organisations including Kidsmatter; Nursery Room Staff (Child Care Centres); Parents; GPs; Nurses; Social Workers; Ngala; Therapy Focus; WACOSS; COLAB; Mirrabooka Family Support Network; Early Years Networks; Early Childhood Youth Support; P2P; Community Development workers.
• Parents (mummy bloggers) and childhood educators such as Maggie Dent were identified by consumers as being change agents

Question 7: General comments:

• Aboriginal families are in great need due to isolation and socio-economic issues. It was also identified by a consumer representative that more Indigenous staff are needed within agencies/organisations and this was in line with some service providers highlighting need for cultural sensitivity as an area for improvement
• More home visiting is needed
• Services have short life spans and this creates difficulties for consumers in terms of having continuity of care, but also keeping track of what services are available to them
• Better coordination among services is needed
• CaLD communities need greater support and more tailored services for their specific needs

Reference Group 2: Network Mapping Exercise

The second Reference Group Meeting for Better Together was held on 20th November 2017. It was attended by 23 service providers and two consumer representatives. Attendees were invited to participate in an activity, comprised of six small groups. They were provided with a vignette involving a family with perinatal and infant mental health needs. Each group was asked to create two boards to map service provision relating to the vignette; the first indicating actual current networks, and the second board reflecting an ‘ideal’ network.

One group consisted mainly of consumers, whereas the remaining five groups were comprised of service providers. Health services were colour coded on the boards to reflect primary health, secondary health, mental health, education and community services. A post-activity discussion was held following the activity.

The following responses were collated from the respective groups, noting that the first group included the two attending consumer representatives and therefore responses were formulated from the consumer perspective.

Summary of Board Contents

Actual

• It appeared that some groups were familiar with their own agencies/organisations and connections and had limited knowledge beyond that.
• On face value, current pathways seem complex and convoluted - which gives some indication of the difficulties consumers may have in accessing services. Consumers clearly displayed in their boards that they had no knowledge of referral pathways.
• There appeared to be a lack of awareness and considered decision making around pathways - choices among groups seemed almost random based on which services individual clinicians were aware of

Ideal

• Five of six groups (including consumers) suggested either a hub or central contact person would be ideal to service families such as that in the vignette provided
• The ‘Hub’ was often primary health/health rather than community based
• E.g. often said GP, CH Nurse, Midwife, Health Nurse should be referring on to other more specialised services

• A range of other community and primary health services were mentioned by consumers on their board, however, no connections were made between these services. Notably consumers commented during the activity that they were not aware of how or which services connect with one another. They added they would like to be more aware, so they might have a better understanding of these pathways.
• Furthermore, consumers suggested that “trust and rapport” were the most important aspects in terms of who they would connect with; they would then hope services they had developed such relationships with would advocate for them and link them in with appropriate services.

Identified current gaps in services:

• Care coordination and a resource for care coordination
• Lack of formal care, communication and agreement between agencies/organisations
• Lack of/patchy service level knowledge
• Sustainable/consistent relationships (impact of high staff turnover)
• Lack of centralised services
• Lack of forward planning
• Accessibility/public transport/distance
• Long waitlists
• Funding changes leading to service cuts
• Language issues and lack of culturally appropriate services (CaLD and ATSI)
• Lack of early intervention programs
• Connecting to appropriate service
• Lack of after-hours services
• Need for services for whole family (childcare - siblings)
• Child friendly environments

Post Activity Discussion

Discussion was oriented around the questions:

What are the gaps between the ‘actual’ and ‘ideal’ network maps?

What do you consider are action steps that can minimise the gaps identified in Question 1?

Main points of discussion:

• Consumer group spokesperson: Most important factors are consistency of services and trust in relationship with provider. However, the ideal network would be services localised to a ‘one-stop-shop’ in which ‘everything we need’ would be located, for example: GP, social services, postnatal physio, café, playground, exercise class, etc.
• Service Provider group spokesperson: Headspace is a good example of a ‘one-stop-shop’. Most important factor is coordination and connection of services so that people don’t fall through the cracks (i.e., ‘no wrong door’ policy). If people are psychologically distressed it can be difficult to source help, especially when the system doesn’t make it easy. A ‘one-stop-shop’, which might be virtual (i.e., online).
• Need to think about frontline services and how we get this information to consumers. Need to consider that people are often only given help for their presenting problem at frontline services.

• Consider how to reach ‘hard-to-reach’ (vulnerable) families
• The information should be easy to access in a non-judgmental environment, with the opportunity to build rapport/trust and return to re-consult if needed
• A web-based list of services could be used - central, kept up-to-date with those no longer running, consumer-driven, utilise social media, available to those who don’t use social media
• Libraries could be a good base but need to be better supported by local government.

Reference Group 3: Discussion Questions - Looking Forward

Reference group attendees were provided with four questions to consider prior to attending the meeting held on Monday 26th February 2018. Small random groups were then selected at the meeting to discuss these questions with a chairperson from each group nominated to feed back the responses to the larger group. An overall summary of the responses is provided below:

Question 1: For the cities of Wanneroo and Joondalup, what priorities around families (conception to 3 years) would you like to see embraced? How would you know this is happening?

• Two groups responded by suggesting that CALD groups need support; one group elaborated by suggesting culturally appropriate and sensitive staff are needed to understand cultural issues such as differences in disciplinary approaches and problems with alienating families who are not able to adjust in accordance with Australian values/legislation
• Two groups responded by noting that vulnerable mums or hard to reach families need to be considered and measures taken to ensure services are provided to this population
• Early intervention was mentioned by one group
• Cohesion of services and networks between consumers/peers/services identified
• Prioritisation of 0-3 from governmental level and more training for first points of contact - such as GP training
• Funding flexibility and continuity of programs (group 8 - not recorded in minutes)

Question 2: If the priorities you’ve identified were actioned/implemented what would this look like?

NB Answers not necessarily corresponding with question, however, points summarised as follows:

• Referrals - GPs need to know what’s available to refer people accordingly
• Early intervention paramount - including planning ahead with development; one stop shop emphasised as being ideal and having antenatal services locally accessible
• Greater frequency of CHN visits
• Service cohesion and collaboration

Question 3: What are the priorities of your agency/organisation/service?

NB Answers not necessarily corresponding with question, however, points summarised as follows:

• New parents need list of services - provided by first point of contact (eg CHN) (raising awareness for families and ensuring services are integrated)
• Educators need training in PIMH as they can often be first point of contact for developmental concerns
• Face to face rather than phone support and linguistically diverse options

• Opportunity/space for families to share information/ successes
• Importance of service integration

Question 4: What outcomes would you like to see from the current research project?

• Improvement in service provision and formalisation of agency/organisation networks; longitudinal tracking (through educational progress?) or through service engagement - evaluation?
• More services for Dads
• Improvement in transport (mobility)/access to facilities (pram-friendly)

Reference Group 4: Presentation of findings and group discussion

Attendance at the fourth Reference Group meeting was outside the funding term of the project and was planned due to unanimous agreement in Reference Group Three to continue to meet and grow this network by:

1. Working towards creating a shared vision for the well-being of families from pregnancy to three years which represents families voices and the diverse range of stakeholders in the Cities of Wanneroo and Joondalup.
2. Work together to develop some kind of shared measurement between services for families with multiple needs. The tool suggested to pilot at the meeting was the Early Childhood Service Intensity Instrument (ECSII). This is a tool based on a concept of service intensity rather than level of care and is designed for service providers to determine the intensity of services needed for infants, toddlers, and children from ages 0-5 years across the continuum of care and range of agencies/organisations involved (American Academy of Child and Adolescent Psychiatry). Members were given a description of this tool and asked to familiarise themselves with the measure. In addition an on-line version of the Checklist to Assess Organisational Readiness for Implementation (CARI) of the ECSII was planned to guide how the group moved forward together and to inform understanding of the barriers and the potential opportunities.
3. Shared hosting of the Reference Group by members.

The meeting was scheduled to be held in early September and due to some confusion regarding who was hosting it and where it was to be held it was postponed to include the thoughts and feedback about reporting of the data from Distinguished Professor Hiram Fitzgerald from Michigan State University.

Twelve attendees attended this meeting; there were 11 apologies mostly due to the change of day and several queries about what their roles would be as the group continued as well as new requests to join the group. A snapshot of the report was presented to the group with input and commentary from Distinguished Professor Hiram Fitzgerald. Engaged discussion was held and the consensus was that the snapshot captured the existing network very well.

Summary and Recommendations

Creating the Better Together Reference Group membership (see Appendix) was and remains a dynamic process. The project team aimed to be as inclusive as possible in order to have a strong foundation for ongoing development of the network and from the outset worked hard to develop relationships with both key stakeholders as well as those on the peripheries of the system. The Reference Group meetings typically included practitioners and manager representatives from a diverse range of services, professional bodies, organisations, and agencies/organisations in the PIMH System of Care in Wanneroo and Joondalup as well as consumer representatives. That new members were inquiring about participation up to the and including the last meeting is testament to stakeholder interest in building a better system in PIMH in the two cities. Key stakeholders were keen to participate and in the main managed to navigate their own systems to bring appropriate permissions and good will to the table.

Reference Group meetings were chaired by an elected member from the network; participants were expected and encouraged to be active in the meetings and to have a voice in guiding the agendas. The Better Together project team provided a backbone structure for all meetings. Clear agendas were sent out ahead of time and included new concepts and material for members to consider and to discuss in situ as well as pre and post meetings. There are many possibilities as to why attendance fell in the last group including the ending of the funding period, a need for more consolidation of what was achieved before moving into new territory as well as simple physical issues such as changing the day and time of the meeting. In general, the level of active and engaged participation in the Better Together Reference Group meetings revealed energy from both consumers and those working within the System of Care for improving system efficiency and for ongoing development.

Consumer Focus Group Findings

Better Together has a strong commitment to overall system evaluation and improvement and considers gaining feedback from families as integral to the development of a more cohesive, and integrated PIMH System of Care. This section of the Better Together report aims to explore families experiences of current PIMH services available within the cities of Wanneroo and Joondalup and based on these findings will consider ways to further investigate and to improve current service delivery models and develop more client centred services that focus on ‘whole family’ needs. It will outline findings from a qualitative investigation of families’ experiences of the Wanneroo and Joondalup PIMH System of Care and explore how families navigate their way through services across the continuum of care. The experiences and perspectives of families was examined by conducting two semi structured flexible focus group with families from the Cities of Wanneroo and Joondalup who were either in pregnancy and/or had infants and infants, young children in their care. A qualitative inductive approach was adopted to capture the participants’ account of the experiences of accessing PIMH services across the continuum of care.

Procedure

An invitation to participate was sent to families who were members of the consumer reference group and through a snowball method local families were recruited. In the first focus group there were seven participants and in the second focus group there were eight participants. Across the two groups there was representation from mothers, fathers and single parents. There was also representation from ‘hard to reach’ families as defined by Better Together across both focus groups. Hard-to-reach participants were recruited based on the definition of Cortis, Katz & Patulny (2009) which requires one of the following family characteristics:

• No father: no father present in the household
• Jobless household: mother is unemployed or not in the labour force and father not working or not present
• Poor parents: parental income is less than $500 per week
• Low education: maternal education is Year 10 or less
• Indigenous
• At least one parent born overseas who speaks English as a second language

Persons who meet any of these criteria were identified as hard-to-reach.

The semi structured focus groups were conducted by two research assistants and interview questions included:

• Tell us about your experiences in accessing services to support you and your family’s social and emotional well-being in pregnancy and the infancy and early childhood period?
• Did the services meet your needs?
• What kind of services do you need as a parent, a mum and a dad?

Information was sent to participants prior to setting up the group time. Consent to participate and for the data to be included in the project was obtained at time of the focus groups. With participant consent the focus groups were audio recorded and pseudonyms have been used in the reporting of the results.

Analysis

The interviews were transcribed in their entirety and coding was the first step in interpreting the data. Transcripts were read by four researchers with the purpose of capturing words or phrases that represented important content for understanding the overall experience of participants. As data was read and reread and coded the researchers gained insight into what constituted salient information.

Results

Analysis of focus groups data resulted in one overall theme and several subthemes which will be listed and then further explained below.

Theme

A desire for the PIMH System of Care to have a unique, flexible and tailored approach to meet needs of the whole family, specifically to include father’s in practice.

Subthemes

• Limited awareness and knowledge by consumers of services available to them; issues of timing and availability of services
• Long waiting lists
• Negative experiences by consumers including perceptions of judgement and dismissive attitudes from service provider staff
• Importance of relationships and role of those in primary healthcare as supports for consumers
• Isolation
• Lack of integrated services across the continuum of care

There was consensus that most people have had significant variation in the experience of different services. Participants reflected on services being inconsistently responsive to people in different circumstances. There was a feeling that although families can receive highly responsive and excellent services, this is random-same service, different experiences, for no apparent reasons. There was some speculation about the causes of this inconsistency and seemingly preferential treatment of some clients. However, there was the overall feeling of being a consumer within a rigid system that is not built around the consumer’s actual needs (but the agency/organisation’s needs). Participants also described a stressed system that cannot meet community needs or expectations. Illustrative quotes by consumers about service provision:

• It’s a business
• it’s a lack of continuity (continuing) of care
• I think a lot of services need to be made bigger now because Perth’s a very fast growing place, and the hospitals are full everywhere, and they are not keeping up with the times, so people are on waiting lists too much for everything in Perth.

In addition, participants identified limited times that services are available as a major barrier to accessing services across the continuum of care. They also described how the large geographical areas in both cities were a barrier since consumers needed a car to access nearly everything.

Service flexibility was one characteristic that participants identified as important. Participants unanimously reported the need for a ‘whole family approach’ and more father inclusive practice. One participant illustrates how a ‘whole family approach’ made such a significant impact to how they experienced the service:

The best thing for me was when Sue (clinician) said ok we’ll find someone to look after the kids. Because you have got more than one and even when you’ve got three or two even…finding someone to look after all of them at the same time can be tricky, that’s where you go, oh look it’s too hard.

Participants also identified the need to offer more flexible appointment times to ensure fathers can attend and there was an acknowledgement that fathers may need a different kind of service that it traditionally offered to mothers. They reported concern for the lack of support available for father’s coupled with a realisation that fathers can also experience post-natal depression and struggle to form a positive attachment relationship with their infant:

• ….he works Monday to Friday and generally those appointments (child health nurse) are 12 o’clock at lunchtime, so he can’t make a lot of the appointments…so even making it on a weekend or afternoon or something like that to get them (fathers) more involved. Because he just was not involved whatsoever. And I think he found it really hard to bond with Sally in the beginning there. He really struggled too…he says I missed all this. He missed so much with her because he was so depressed.
• It was the family that needed help. It wasn’t just me that needed help.

Fathers in the focus groups expressed concern about their experiences with services as a father. The main issues they identified in regards to accessing services centred was around feeling excluded. There was a discussion about needing a general culture change to include fathers. Male participants reported that men do feel ‘the odd one out’ which fathers may find very difficult. Several participants acknowledged there were changes towards inclusivity however it was still a major service gap. This is illustrated in the statement below:

• Yeah, I think dads will be a lot more heard probably in the future, get a lot more help than we’re probably getting now. But you do it on your own, really.

Subthemes

1. Awareness, accessing services and timing

A common experience discussed by participants was not knowing there were services available to support families when they developed perinatal and/or infant mental health concerns. This was highlighted by a participant sharing her experience of needing help during pregnancy:

I just didn’t know where to go. Especially at the start, I wasn’t telling my parents, so I was really lost and scared. And my now ex was not helpful at all. And to be honest I googled pregnancy help.

Other illustrative quotes related to lack of awareness of services:

• And because Jill was my first I didn’t know where to start looking. I just got handed this purple book and was like, here you go, you’ve got a child health appointment. So yeah it was very, I didn’t even know, I don’t know what people did before Google.
• The only one I really knew about what the child health nurse.

Participants raised challenges in the process of officially being able to obtain a referral followed by then accessing a service. Participants reported that once organisations accepted a referral, typically the service or program provided was brief and rarely met the needs of the family. Participants also reported disappointment in services and programs they found extremely helpful suddenly ceasing due to lack of recurrent funding. One participant described her young son receiving help but due to the structure of the service, it was only offered for a three-month period:

If he needs help again re-refer yourself. There’s no seeing him until he is sorted, its of their timeline… I want to come every week and they are like well I haven’t got time sorry.

Other illustrative quotes by consumers in relation to accessing services:

• With the difficult of accessing services…they kind of rush you out the door type of thing. That’s a big thing
• Yeah they just go, well sorry we’re on a deadline to get in and out with our clients
• Even when you have a baby, they want you to get out of the hospital as soon as you can. Six hours isn’t it? They would get you out in six minutes if they could.
• Because Jacinta was born in November and it was Christmas…so they said to me it would be after Christmas. And no one ever rang and I never followed up. Because I thought they had forgotten about me.

2. Long waiting lists

Participants noted that waiting times to access services were too long. They described needing services immediately following identification of a PIMH concern, however, participants experiences were that they usually had to wait a long period of time before a service was available. They expressed a desire to have no waiting time for services. This is illustrated by one participant, who accessed PIMH services and described the experience of waiting:

I think, hiccough for us is that by the time I got to the point where I needed help, having to wait just made it difficult.

Participants also reported that once a referral had been accepted it was difficult to access actual interventions and that there was a lack of formal follow up after accessing services. Jane illustrated this point as she described receiving intervention services for her young son:

They said ’Oh yeah, we’ll see him again in three months, maybe six months, but we’ll send you an appointment

One participant recounted her experiences of having a child with multiple needs and commented that connected services resulted in quicker responsiveness to complex needs for infants, young children:

One thing I have noticed you get referred for speech, they notice something else needs to happen, so they noticed with my son he needs physio, they referred and that process was so, he got seen within a couple of weeks instead of if he was referred through the GP for the Physio it would have then been a 6-12 month wait.

3. Consumer perceptions of judgement and dismissive attitude by service providers

Participants described often feeling judged by professionals and experienced disrespect and a lack of compassion when interacting with service providers. Subsequently many participants felt unable to trust service providers and did not fully disclose their struggles with mental health, adjustment to parenthood and/or building a positive attachment with their baby. At times participants felt service providers lacked authenticity.

An illustrative quote describing a routine screening check for the mother’s mental health:

She gave me this questionnaire and I was like, yeah I am feeling ‘fabulous’ and I just filled it all out and even went back when I had my second, when I had Judy and I said to her, I said remember when I sat here with Max (first child) and I faked the whole thing. I really needed somebody to say are you alright? I needed someone to say it, but I just faked it because I didn’t really know you.

4. Importance of relationships and role of those in primary healthcare as supports for consumers.

Many participants described having a trusted relationship that is sustainable over time as fundamental to engaging and accessing PIMH services. Participants reported hesitancy in engaging in services when they did not feel they had established a trusting relationship with a service provider. Participants explained that the safety of a relationship sustained over time provided a safe space to open up about challenges and emotional difficulties they were experiencing. Some illustrative quotes from participants related to the importance of relationships:

• If I don’t have a relationship with that person, I am not going to then go yes yes yes yes help me.
• I was seeing a different person every time you go to the clinic. Then they were telling me different things. You’re just like I don’t know who to trust.
• My primary health care provider wasn’t terrible, but I think because I didn’t feel 100 per cent comfortable with telling her the truth of how I was parenting, which I was 100 per cent comfortable with. I didn’t feel comfortable to say, hey, I might be needing help here. You know those things you just tick off when you are with the primary health care provider.

Specifically, a number of participants mentioned primary health care providers as an important source of support for PIMH concerns and the transition to parenthood. Many highlighted that either a general medical practitioner (GP) or Child Health Nurse would be their first point of call if they had a PIMH concern. They also reported variability in the quality of service and type of relationship established with primary health care providers:

• ..like for health and along the lines of a good understanding GP, longstanding, and not one you have a year and they leave, and then you’ve got to find another one. Like a good family doctor that listens and respects your opinion. That is something I want.
• And the other thing about child health nurses was they obviously must be limited in what they are allowed to say, so you are better off going to a computer and putting in a question and then going a yes or a no, because that is exactly what the child health nurses do. So they must be limited in what they can feed back to you, are their answers are very uniformed.
• For someone to check in on you, that you have a relationship with. So you trust, and the child health nurse is good if you get a good one.

5. Importance of informal supports

Most participants stressed the importance of accessing informal supports and parenting support services that emphasis peer support and shared experiences with other parents. Some participants highlighted this as a particularly important local resource and source of support for families who have emigrated from other countries and are socially isolated. In addition, fathers in the group reported the crucial role informal supports play in supporting fathers during the transition to parenthood.

Some illustrative quotes from participants regarding the importance of informal supports:

• And you walk out of there having amazing friends, because you have spent two years going through your highs and lows, like you can walk in there and lay it on the table and no one of them will go…oh god not you
• Yeah there is no judgement, none whatsoever, and even when there is disagreeing personalities with mums and things.
• I think if there was some kind of support whereby you knew other people who were in the same boat and you were able to connect..it would be quite good.

6. Isolation

From the experience of participants, social isolation was common, especially in relation to people who have just moved to Western Australia from other states or countries. This appears multidimensional and includes culturally diverse groups, language barriers, being away from family, conflict with family and being physically isolated.

Some illustrative quotes from participants in regards to isolation:

• I think another thing as well, we didn’t have, we’ve got nobody here. So there is just the three of us (mother, father and baby). Which is a bit hard as we’ve got nobody here, we just kind of got on with it.
• I think services just assume because you have family, that they are available. I’ve got family but they are not available. So we are basically on our own. It would be good to access help that is outside our family and friends.

7. Lack of integrated services across the continuum of care

Many of the participants reported that services often did not communicate with each other. They expressed surprise that services are supposed to talk to each other, as this is outside participants experience and expectations. Participants reported a lack of continuity of care across levels of service and two participants described a feeling of ‘being dumped’ by services immediately following childbirth. The lack of continuity of care during pregnancy and after birth was highlighted as a concern by participants who expressed a wish to connect with one midwife through pregnancy and post birth.

Some illustrative quotes from participants regarding their experience of how services don’t connect with each other:

• Referring to the importance of having one midwife, ’Mary stated ‘they shouldn’t be doing that (series of four different midwives during pregnancy)…from the moment you walk through the maternity centre, you know the prenatal, all the way up to post birth’.
• They are more like, they use you. They go, you need to go and call that person or you need to source an ENT or you need to go and do that.
• I even find with my own health they will say, I’ll just print these referrals and you can go home and scan them…well not everyone has a scanner or a fax.
• Yeah they don’t connect, I can’t think of anything in any experience where you’ve had two services connect that I haven’t had to connect the dots myself.

Implications and Recommendations

This part of the project investigated the PIMH System of Care from the perspective of the families living in the Cities of Wanneroo and Joondalup. The findings indicate that overall families have had a negative experience of accessing and using PIMH services. Findings revealed the families interviewed lacked knowledge and awareness of available services. It also became evident that these families from the cities of Wanneroo and Joondalup experience multiple dimensions of social isolation. Families describe a System of Care that is inflexible and not integrated and when accessed for PIMH concerns often the families feel judged and dismissed by organisations. The lack of integration that participants experienced is a consistent finding across many components of Better Together. The SNA revealed that organisations do not tend to connect with each other in an integrative or coordinated way.

Negative experiences identified by consumers including perceptions of judgement and dismissive attitudes from service providers is supported in the low levels of trust between organisations that was identified in the SNA across the System of Care. For participants, developing a trusting relationship that is sustained over time with one service provider is a critical component required to ensure families feel safe to engage with and access services within the PIMH System of Care. Participants expressed a desire to have a PIMH System of Care that responds to the whole family and creates unique, flexible and tailored approaches to meet the needs of caregivers and their infants and infants, young children. Participants also expressed a need to develop more father inclusive practices across the continuum of care in addition to families having the opportunity to access a range of informal support systems that are outside family and friends.

The current findings increase our understanding of how families experience PIMH services within the cities of Wanneroo and Joondalup. It has provided further evidence for the importance of creating strategies that focus on: (1) ensuring the PIMH System of Care is client centred and (2) includes a way of actively incorporating and using client feedback to inform the way services are developed and how the overall System of Care functions.

It is recommended that:

1. The network consider how to develop ways that families (and in particular vulnerable families) who access PIMH services across the continuum of care are provided with a consistent service provider who is available across the perinatal and infant-early childhood period. It maybe that the consistent service provider is identified within the current services that offer primary health care (GP and Child Health Nurses).
2. Families are supported to take an active role as they navigate their way through the PIMH System of Care. The Early Childhood Service Intensity Instrument (ECSII) is one tool that might be used as a pilot to develop collaboration and shared communication with families across and within services.
3. Families continue to engage directly with organisations within the PIMH System of Care and the Better Together network and specifically have direct involvement in dialogue with government to influence policy and practice. We recommend there is a continued emphasis on shared dialogue with families to facilitate collaboration across government, consumers and other peak bodies in PIMH. Regular dialogue will ensure families are directly involved in the implementation of PIMH initiatives and innovations to improve outcomes for themselves and their infants and infants, young children.

Chapter 7:

Interventions

Introduction

This Chapter describes the background to and nature of training offered to two groups of primary health care providers: General Medical Practioners (GPs) and Pharmacists. For both trainings evaluations are also described, analysed and discussed. It also includes an overview of a unique community based training facilitated by Mr Yigit Aksagoglu from the Bernard van Leer Foundation on taking a global approach to creating collective impact in the PIMH field.

Primary Health Training and Evaluation: General Practitioners (GP)

Community health care consultations at the commencement of the project identified the need for training for General Practitioners (GPs) relating to Perinatal and Infant Mental Health (PIMH), with a GP noting that he was not familiar with this area and as such he felt most GPs “won’t know what that is”. This was supported by data from a second community consultation which identified that (regular) GPs do not have time to provide any additional care beyond standard antenatal services. If social and emotional issues were identified, it was identified that (regular) GPs do not have time to provide any additional care beyond standard antenatal services. If social and emotional issues were identified, referrals might be made to a paediatric consultant, since other referral options were unknown, in addition knowledge and interest of GPs was described as “hit and miss”, and there was no sharing of information. Both consultations recommended GP training with opportunity for CPD points as a means of engaging GPs in PIMH training. It was also suggested the training should be started from ground level, assuming GPs know nothing about PIMH and that as many take away tools as possible for assessing PIMH should be provided.

Participants

Twenty-two GPs attended the GP training, 8 GPs completed the pre-post case study. In addition, several community-based nurses contacted the research team directly requesting to attend the training in their own time; however, these additional attendees did not participate in the data collection. Several staff and volunteers from a multidisciplinary workforce contributed to delivery of the training presentations.

Procedure

A Two PowerPoint presentations was prepared and delivered over dinner at a function centre after office hours. The content of the presentation was tailored to meet the needs of the workforce, keeping in mind their specific roles in the community. In addition, in order to enhance engagement of stakeholders in the training, Continuing Professional Development (CPD) accreditation for the training event was approved by both the Royal Australian College of General Practitioners (RACGP).

GP Training

The following themes were incorporated into the GP training and were delivered by two Clinical Psychologists, two Perinatal Psychiatrists, a Social Worker and a GP:

• Definitions and practice of perinatal and infant mental health across the continuum of care.
• Utilising tools and clinical observation to increase capacity for recognising, assessing and responding to perinatal and infant mental health concerns.
• Perinatal Psychiatry.
• An overview of a zero to five’s PIMH service available to families in the local area.
• An introduction to the Health Pathways online portal (designed to support GPs to make referrals).

All participants were asked to complete a pilot pre and post case study by reading a brief vignette and then documenting how they would respond if this family presented at the GP clinic where they worked.

GP Training - qualitative themes pre training

Analysis of themes from the pre-case studies identified that they cluster around four main themes: the GP role, systemic factors and social support, maternal physical and emotional health and baby’s physical and emotional health (see appendix 5). Overall GPs indicated a comprehensive approach to their assessment and exploration of the presenting concerns, yet across the group there was no explicit mention of the parent-child relationship and in addition there were no clear referral pathways identified. One participant did mention the parent child relationship and the Circle of Security intervention; however, as this was not common across the group the codes from this participant’s response were not included in the thematic analysis

GP Training - qualitative themes post training

Analysis of the themes from the post-case studies identified that they cluster around six main themes: the GP role, systemic factors and social support, maternal mental health, perinatal assessment, parent-child relationship and targeted referral pathways. There was a clear shift in participants’ responses to incorporate aspects of the parent-child relationship as well as more explicit referral options.

Summary

Qualitative analysis at pre-test revealed broad ranging consideration of systemic factors, as well as maternal and child physical and mental health. Yet, there was a tendency for GPs to consider the needs of the parent and child in discrete categories. At post-test GPs appeared to demonstrate greater awareness of the implications of challenges in the perinatal period and the transition to motherhood, as well as a capacity to notice and consider different aspects of the parent-child relationship and activate more targeted referral pathways.

Primary Health Training and Evaluation: Pharmacists

Pharmacies were identified by consumers as amongst their first port of call when concerned about their infants and infants, young children’s wellbeing.

Participants

Eleven pharmacists indicated they would attend the training, 7 community-based pharmacists then attended the training and completed the pre-post case study. Several staff and volunteers from a multidisciplinary workforce contributed to delivery of the training presentations.

Procedure

A two hour PowerPoint presentation was prepared and was delivered at the Edith Cowan University Clinic after office hours. The content of the presentations was tailored to meet the needs of the workforce. In addition, in order to enhance engagement of stakeholders in the training, Continuing Professional Development (CPD) accreditation approved by the Australian College of Pharmacy (ACP)

Pharmacy Training

The following themes were incorporated into the training and were delivered by two clinical psychologists, two representatives of Wanneroo city council, a pharmacist from a tertiary service with specialised knowledge of perinatal and infancy:

• Definitions and practice of perinatal and infant mental health across the continuum of care.
• Utilising tools and clinical observation to increase capacity for recognising, assessing and responding to perinatal and infant mental health concerns.
• Pharmacology in Pregnancy and lactation Perinatal Psychiatry.
• An overview of a zero to fives PIMH service available to families in the local area.

Pharmacy Training - qualitative themes pre training

Analysis of the themes from the pre-case studies identified that they cluster around three main themes: the pharmacist’s role, focus on physical needs and no focus on the parent-child relationship. Overall the data indicated that pharmacists view it as their role to build an empathic relationship with the mother to explore the presenting issues, however, the pharmacists’ curiosity and exploration of the presenting issues typically focussed on the physical or emotional needs of the mother, the physical needs of the baby and then activating a medical referral to the GP.

Pharmacy Training - qualitative themes pre training

Analysis of the codes and themes from the post-case studies identified that they cluster around three main themes: the pharmacist’s role, a holistic view of health and wellbeing that includes the mother and baby and focus on the parent-child relationship (see appendix 8). Overall the data indicated a greater curiosity to explore the presenting concerns and finding ways to support the mother to access a referral to a GP, community or psychological service. The data also demonstrated a focus on the physical and emotional needs of the mother and baby and explicit reference to the parent-child relationship.

Summary

Qualitative analysis revealed that at post-test there was greater acknowledgement and awareness of mental health challenges and a greater awareness of aspects of the child-parent relationship. Whilst there was some indication at post-test that pharmacists better understood services available to families experiencing challenges related to PIMH (and targeted referral pathways were more explicitly articulated), the emphasis on a referral to a GP was still prominent.

Overall the findings from both the GP and pharmacy training highlight the benefits of training in PIMH for GPs and Pharmacists working in primary care in enhancing their awareness of and capacity to notice aspects of the parent-child relationship.

PIMH Community Training

Translating a Global Approach to create a collective impact for the wellbeing of Western Australian young families (Bernard Van Leer Urban 95 Workshop).

Background History

The ECU Better Together Project in collaboration with Centre for Parenting Excellence Bernard Van Leer Foundation and City of Wanneroo hosted the Bernard Van Leer - Urban95 Workshop on June 18th, 2018. The workshop was attended by 59 participants and included practitioners across all levels of care, representatives’ from local and state government, policy and administration across health, education, community, housing and child protection.

It was facilitated by Yigit Aksakoglu, Turkish representative of the Bernard Van Leer Strategy ‘Urban95’. As a collective, the diverse and broad group of professionals and consumers considered how the Urban95 global and international perspective might inform local community responses so that families with infants, young children have a positive experience of living in Western Australia.

Guided by a participatory action response method, agencies/organisations represented in the Reference Group came together to co-fund and resource this workshop (City of Wanneroo, Centre of Parenting Excellence and ECU in collaboration with Bernard Van Leer Foundation), with the aim of increasing knowledge and awareness of how broader issues of mobility and greenspaces (that were identified in the Reference Group and Consumer Reference Focus Group) are connected to the emotional and social well-being of infants, infants, young children and their families.

The workshop was an opportunity to expand and reinforce a more cohesive system working towards a common shared vision for infants, infants, young children and their families in the Cities of Wanneroo and Joondalup. It was specifically designed to foster cross sector collaboration and communication and to offer an opportunity for agencies/organisations in the City of Wanneroo and Joondalup to consider how they would initiate action for social change on a larger scale.

The workshop

Part 1: Understanding Urban95

Urban95 is the global strategy of the Bernard van Leer Foundation, invited city leaders, designers and planners to look at cities from 95cm, the average height of a healthy 3-year-old. Urban95 focusses the lens on the needs of children and provides a unifying theme across all sectors of the community. Yigit Aksakoglu demonstrated how place-based environments are an important factor for improving developmental outcomes. He provided an overview of the four key domains of Urban95; Data Driven Decision Making (mapping); Greenspaces; Parent Coaching and Mobility. A brief description of each domain is provided below:

• Green public space: Transforming existing physical spaces into places for infants, young children to play and explore nature, and for their caregivers to meet and rest.
• Mobility for families: Making it possible for caregivers and infants, young children to walk and cycle to healthcare, childcare, a safe place to play and a place to get fresh food.
• Data-driven decision-making: Collecting neighbourhood-level data on infants, young children and caregivers and using it to better target resources and facilitate coordination across sectors.
• Parent coaching: Combining coaching on early childhood development for parents and other caregivers with services that meet families’ basic needs.

Part II: Panel Discussion with representatives from Western Australia

Each panellist was provided a specific question and invited to offer a brief response. Following this, a panel discussion took place in which audience members were invited to pose questions and comments. Below is a list of panellists and what questions they are asked to respond to.

The panel discussion with members of the audience highlighted the importance of ensuring that children and families have a voice that needs to be heard, acknowledged and responded to. This was one of the main messages from the Commissioner for Children and Young People’s presentation, which was re-emphasised by Ms Sara Dale’s recount of her experiences of accessing services for her young son. Feedback from the audience reaffirmed this important message and the role that families play formed a central theme of the day.

Part III: Urban95 Workshop

A series of small group activities were facilitated by Yigit Aksakoglu focussing on building a local collective response to improving the well-being of infants, infants, young children and their families across the domains identified in the morning session. The random allocation of members to groups was designed to consider how we can improve the way in which the complex array of stakeholders intersect and come together to build a healthy thriving community for families in Western Australia.

The audience was randomly assigned in a group of approximately 6 to 8 members. In their groups members were asked to work on the following questions and use the Urban95 Tool Kit to guide responses.

1. Identify a vision for change
2. What would you do to work towards your vision for the: a. First 100 days b. 1000 days

Evaluation and Outcomes

This project recognises the need to build a foundation within this Reference Group and the wider community that is centred on promoting a culture of learning. The workshop supported a learning process that introduced the group to innovative and international perspectives that were not common practice in Western Australia. This is viewed as an important component to building the conditions necessary to support and grow a strong successful network that has capacity to address complexities connected to establishing clear referral pathways and processes (ie. Inclusion and exclusion criteria) and reducing fragmentation within the PIMH system.

Thirty-nine respondents completed the Urban95 evaluation form.

One of the main findings from the workshop was identification of a collective vision across the different groups. The focus of each group’s vision centred on fostering a community in which children can thrive and feel safe. All groups created innovative ideas of how to engage in activities that promote change across 100 and 1000 days. Sharing these ideas as a larger group prompted a shift in energy and momentum in how they could effect change in their local community and this was also reflected in the formal evaluation forms. There appeared to be a shift in thinking as individual participants and/or agencies/organisations to thinking more like a network and collective group.

The ideas that developed from the small group discussions included:

• 100 days: consulting with the community, research and mapping existing resources and map where families are going and how do they get there, activities to promote ‘getting to know your community’ (street gatherings, champions), measure and benchmark connection and engagement, activate parks, connecting parents with antenatal and child health services via the GP.
• 1000 days: safe breastfeeding spaces, improve local parks and ‘streets for the people’ (closing down streets for gatherings), footpaths connecting parks, street planting and using social media to inform community, promote neighbourhoods facilitating support to local families, develop localised grants to address specific gaps, mobilize services to be place-based, monitor traffic speeds and create calming devices, trial ’street play, creating ‘hubs’ (one stop shops).

On asking participants their views on the benefits and key take homes of participating in the workshop, the following themes were identified:

• Learning about Urban95 and using this international model as a way of conceptualising how to work in a cohesive way to improve lives of infants, infants, young children and families

  ‘broad visioning and love all the Urban95 ideas and tool kit gives great options’ ‘Global ideas and creating local solutions’ ‘finding out about Urban95 and how that translates to improving outcomes for our children, families and broader community’

• Prioritising the voice and experience of infants, infants, young children and their families:

  ‘Ask your children what is important’ ‘Remembering not to assume what a child needs or wants….always ask the child’

• Building quality engagement through all aspects of the workshop (diverse range of attendees, discussions that arose from the panel discussion and the practical ideas generated from listening to each other)

  ‘I enjoyed meeting people across the different areas and finding how our experiences and aspirations intersected’ ‘Thought provoking intersectorial collaboration’ ‘Really practical ideas and taking money out of the equation’

• Possibility of simple solutions to the complex problem of creating a community in which all children can thrive.

  ‘I have 20 asterixed ideas in my notes! all directly actionable by myself and others in current projects’ ‘small ideas can make a big change’

• Importance of collaboration in moving forwards. The workshop promoted ideas about how to foster more collaboration and community engagement in current workplaces.

  ‘importance placed on relationships and how broad and complex this area of work is’ ‘collaborating with more agencies/organisations’ ‘Invite more ideas from communities and consumers’ ‘importance of constant messaging and engaging with community’ ‘will go back and have discussions with other leaders’

• A broader, more diverse community perspective and a deeper appreciation of the cross sectorial nature of the field.

  ‘Helpful to have broad visioning’ ‘Combining the physical and social factors’ ‘Usefulness of tool kit to stimulate ideas for working towards improvement for families’ ‘How to translate the information we have to improving outcomes for children and families’

Summary and Recommendations

Representatives across early childhood and parenting services, local government, architecture and urban design community, housing, transport systems, universities and economists collaborated in this workshop to build a broader understanding of the factors that influence the social and emotional well-being of infants, infants, young children and their families. It was a learning opportunity for the Reference Group and wider City of Joondalup and Wanneroo community that promoted a deeper and broader understanding of the context in which the PIMH system exists within. This resulted in:

1. Identification of key agencies/organisations and individuals within the Reference Group that had capacity and motivation to invest funding and resources into this innovative engagement and learning opportunity.
2. Development of a vision that was shared across the group and engagement in activities that successfully linked individuals and agencies/organisations within the network to explore possibilities for collective action (identifying key leverage point between key organisations).
3. A deeper form of engagement that shifted the group members’ perspective moving from sharing to linking-an important component of working towards an effective system change over time.
4. This capacity building workshop built upon existing collaborations and created tangible, simple and practical ideas that individuals, organisations and larger network groups can implement and continue to build upon over time.

Recommendations based on evaluation of the Urban95 workshop:

1. Continue to engage in regular capacity building sessions to strengthen the capacity of the Reference Group and wider community. The intensive sharing and linking component of the project has established the foundations for a process of trying to align around a common vision. This step is necessary to develop long term sustainable clear and responsive pathways across perinatal and infant mental health services and a more cohesive PIMH model of care.
2. Continue to leverage the relationships built within the Reference Group and the existing networks in the City of Wanneroo and Joondalup to learn in more detail what is effective in producing positive outcomes for families. To enhance, improve, create value and build upon what each service is doing and where successful collaborations across services have resulted in positive outcomes for families, services and the overall system.

Chapter 8:

Social Network Analysis

Introduction

“A major challenge facing organisations today is how to partner with other organisations, and groups to collaboratively address social and political goals while effectively maximising resource sharing of the partners involved” http://partnertool.net/tools-and-training/partner-tool/

To address the complex nature of how the PIMH System of Care functions in the Cities of Wanneroo and Joondalup, the Better Together Project implemented a social network analysis (SNA) tool called PARTNER (Program to Analyse, Record, and Track Networks to Enhance Relationships). SNA is a quantitative methodology that focuses on relationships between and among organisations, measuring and mapping relationships and flows between organisations. PARTNER was used in this project to collect data and assess the ways in which organisations within the system currently connect with one another and with families within the two communities.

The SNA was designed and implemented to:

1. Understand and assess the processes of engagement and the extent to which stakeholders in the PIMH System of Care are interconnected
2. Identify facilitators and barriers within the system, as perceived collectively by stakeholders and consumers
3. Establish baseline data that can be used to assess whether future interventions, activities, and community and stakeholder engagement results in positive change to the overall system and how it functions
4. Use the findings to develop innovative initiatives designed to create a more cohesive and integrated PIMH System of Care.

Method

The SNA survey was designed for stakeholders and consumers in Wanneroo and Joondalup so they could identify agencies/organisations with which they are related for service delivery through the PIMH System of Care. Questions were also asked related to the interactions among these organisations, the degree of inter-organisation trust (operationalised as reliability and open communication), the degree of inter-organisational value (defined as operationalised as power/influence, resource contributions, and time commitments), and the degree of intra-organisational perceived success. The PARTNER tool questionnaire was adapted for use in Western Australia and a number of questions were added for the purposes of the Better Together Project. Dr Jessica Barnes Najor from Michigan State University provided guidance at every stage of the survey development.

The survey was administered during May and July 2018. The survey was completed by 78 agencies/organisations (implying a 68% response rate) and families (representing 14 suburbs) within the PIMH network. For the 78 organisations, some agencies/organisations had multiple respondents, leading to over 100 survey respondents. For organisations with multiple respondents, medians were applied, to ensure that each organisation was only represented once in the SNA Partner analysis.

For families the snowball sampling method was used. This sampling method involved the consumer reference group members identifying other potential families to complete the survey. 55 families completed the survey.

Amongst the agencies/organisations and families that responded, collectively, there were 2,460 partnerships. On average, each organisation had 31.54 partnerships (that is, out of a possible 77, n-1).

SNA Survey Participants

Figure 37 shows the composition of the agenices/organisations that participated in the survey; Community 40 per cent; Consumers 19 per cent; Mental Health 15 per cent; Education 12 per cent; Health 10 per cent and Primary Healthcare 4 per cent.

Figure 37 Types of Agency/Organisation that participated in the SNA survey

Source: ECU Better Together based on PARTNER Report September 2018.

Perceptions of Success

Findings revealed that the majority of respondents (36%) viewed their agency/organisation as ‘Very Successful’ at achieving their goals, with only 2 per cent perceiving their organisation as ‘Not Successful’ (Figure 38). The three highest aspects of collaboration that contributed to an organisation’s success were: (i) Exchanging information/knowledge; (ii) Informal relationship created and (iii) Meeting regularly (see Figure 39).

Figure 38 Perceptions of Success

Notes: Question: How successful would you say your agency is in supporting the needs of children aged 0-3 years and their families in the community? Source: ECU Better Together PARTNER Report September 2018.

Figure 39 Contributing Aspects of Collaboration Success

Notes: What aspects of collaboration contribute to this success? (Choose all that apply) Source: ECU Better Together PARTNER Report September 2018.

These findings suggest that the majority of agencies/organisations in the network view themselves as successful in supporting the needs of families with infants and infants, young children and that there are varying perspectives on how the collaboration across the system contributes to this success. To develop this concept further the next stage of the Project will assess issues related to what criteria actually define success at each agency/organisation, and how these criteria may vary across the system.

Interestingly, there was a low number of respondents that identified ‘collective decision making’ as a factor contributing to success. This may suggest that collaborating across agencies/organisations is not viewed as a crucial factor in determining successful outcomes for families in City of Wanneroo and Joondalup. If so, it may be a potential barrier when working toward improving system integration and creating better outcomes for families based on cross agency/organisation collaboration. On the other hand, it could also mean that at face value, agencies/organisations viewed other factors as contributing more to their success than collective decision making. In that case, interventions most likely should focus on strengthening the strongest perceptions of success, rather than viewing collective decision making as a deficit.

Perception of Barriers

When asked to identify the main barriers to the PIMH System of Care’s success the highest three responses were lack of time, staff turnover and competing priorities (see Figure 40). Staff turnover may be connected to the restructuring of departments and funding allocations that resulted from changes in government policies/practices. These changes have directly impacted the provision of perinatal and infant-early childhood services. They might also account for the significant variation in time individuals have been in their positions within particular organisations. When asked ‘How long have you been in this position (in months)?’, respondents indicated an average of 4.54 years, with a range of 2 months to 19 years.

Figure 40 Barriers to Success

Notes: What would you say are the barriers to its success? (Select all that apply) Source: ECU Better Together PARTNER Report September 2018.

Contribution of Agencies/Organisations to Network

The highest seven services provided by agencies/organisations are (i) Advocacy, (ii) Parenting Support, (iii) Community Support, (iv) Education, (v) Counselling, (vi) Clinical Assessment and (vii) Therapeutic Intervention. These contributions relate to the type of services offered by community, health, mental health and education organisations. The network map reveals that agencies/organisations that identified as providing ‘Other’ services (that were not cited in the survey) are less connected to other organisations in the SNA, with the exception of one community organisation (Community 27) (see Figure 41). Visually the network map presented in Figure 41 also reveals a cluster of agencies/organisations providing Parenting Support (community and education organisations) that are more closely connected with each other than organisations providing other kinds of PIMH services. In SNA mapping agencies/organisations are represented by circles and the lines between these represent connections; the greater the density of the lines the greater the number of connections.

Figure 41 Agencies/organisations Most Important Contribution to the Network

Source: ECU Better Together based on PARTNER Report September 2018.

Density, Degree of Centralisation, and Dimensions of Trust

Table 13 summarises the density, degree of centralisation, and dimensions of trust that characterise the agencies/organisations participating in the PIMH. The density score is a measure of the percentage of ties or relationships present in the network in relation to the total number of possible ties in the entire network. Although 20 per cent indicates many relationships currently exist within the PIMH network of organisations, it also suggests that many more connections are possible.

The centralization score of 43 per cent represents the degree to which the network is “centralized” around a few nodes. A high centralisation score would indicate that nearly all service agencies/organisations were connected with one centralise agency/organisation, but relatively few would be connected collaboratively with one another. The lower the centralization score, the more similar the members are in terms of their number of connections to others (e.g. more decentralised), which generally is linked to provision of a more integrated System of Care available to consumers. In addition, a more decentralised network is more resilient, to any changes that may affect single system component because interconnections between each other are more evenly distributed and less hierarchical.

On dimensions of Trust, respondents rated relationships low to moderate with respect to Reliability and Openness to Discussion, with neither dimension reaching levels considered to be in an optimal range. The current levels of trust indicate that organisations within the network do not have a high degree of trust between each other, and that they need to increase opportunities to engage in clear and open communication to enhance partnership reliability and ultimately, trust in system effectiveness

At a network level the results reveal a high density, where agencies/organisations are connected with each other and relationships are dispersed across the network (decentralised). Despite the inter-connectivity of the agencies/organisations within the system, the small to moderate degree of trust between them is a concern. These findings identify the need for an engagement strategy that has a specific focus on interventions that build trust, concentrating on establishing open and clear communication, developing mutual respect and working towards a shared vision and set of goals. The lower centralisation score may also be a protective mechanism going forwards in relation to high staff turn-over, (an identified barrier to success of the network) and changes that may occur across the system over time (change of government, funding allocation models, department and agency/organisational restructures).

Table 13 Network Scores: Density, Centrality and Dimensions of Trust

Source: ECU Better Together based on PARTNER Report September 2018.

Overall Value and Trust Measure

Building on the previous section, this next component of the SNA investigates overall value and trust dimensions and includes visual mapping of these two measures. The overall value score is an average of the three value measures of power/influence, level of involvement, and resource contributions. Measuring value is important for an effective network to ensure that one is leveraging all members’ value within the network adequately. There are two dimensions of trust which are measures of reliability and open to discussion. Measuring trust is important for capacity-building within the network and is fundamental for network effectiveness.

Figure 42 and Figure 43 show the relative value and trust of agencies/organisations within the network. The larger nodes have more perceived overall value and trust among other organisations within the network than do the smaller nodes. For more details on perceptions of value and trust, see “Network Scores-All Members” in the next section.

Figure 42 The Relative Value of Organisations

Source: ECU Better Together based on PARTNER Report September 2018.

Figure 43 The Relative Trust of Organisations

Source: ECU Better Together based on PARTNER Report September 2018.

Figure 42 and Figure 43 offer a visual representation of the overall value and dimensions of trust within the network. There are similar patterns across the value and trust network maps in relation to where agencies/organisations are positioned, suggesting those which are considered valuable are also trusted and vice versa. There are a small number of community agencies/organisations (community 4, 8, 12, 14 & 23) and a primary health care organisation (primary health care 2) that are have less perceived value and trust from other organisations (depicted by smaller size node) in the network. These organisations are also positioned on the periphery and have noticeably less connections with other organisations on both maps.

There is a noticeable difference across the two maps in relation to density towards the centre of the network with the ‘Overall Value’ map including a higher density of organisations positioned towards the centre. The ‘Overall Trust’ map has less density towards the centre. There also appears to be several organisations across the different groups that are highly valued (organisations with larger nodes and positioned towards the centre of the map) in comparison to the ‘Overall Trust’ map in which organisations are more dispersed and not as well connected.

Moving forward, these findings build on results from the previous section and highlight the need to develop ways to strengthen trust within the network. The visual mapping offers an opportunity to identify and support organisations that are on the periphery to become more connected within the system. Furthermore, as a next stage it will be important to align information contained in the SNA, with information in the service mapping to determine whether geographical location accounts of the degree of connectedness to other organisations within the system.

Value Measures

Value measures include power/influence, level of involvement, and resource contributions. Measuring value is important for an effective network to ensure one is leveraging all participants’ value within the network adequately. Organisations do not supply value in the same way, some use their power and influence, some donate their time through based on their level of involvement, and some are able to contribute specific resources that the network needs to function. Figure 44 shows the all organisations’ averaged perceptions along the three dimensions of value.

Figure 44 Perceptions of Value

Notes: 1 = Not at all; 2 = A Small Amount; 3 = A Fair Amount; 4 = A Great Deal. Scores above 3 are considered good. All members. Source: ECU Better Together based on PARTNER Report September 2018.

Dimensions of Trust Measure

Dimensions of trust measure included reliability and open to discussion. Measuring trust is fundamental for an effective network, including having strong participants who work well together, establishing clear and open communication, developing mutual respect and trust, and working toward a shared mission and goals. Figure 45 shows the all organisations’ averaged perceptions along the two dimensions of trust.

Figure 45 Dimensions of Trust

Notes: 1 = Not at all; 2 = A Small Amount; 3 = A Fair Amount; 4 = A Great Deal. Scores above 3 are considered good. All members. Source: ECU Better Together based on PARTNER Report September 2018.

Partnership Intensity

Partnerships are increasingly recognised as an important common element of government and non-government initiatives aimed at solving complex social problems in society. This is evidenced by new state and federal funding structures in which (i) initiatives are funded across multiple organisations and (ii) partnerships across agencies/organisations is an outcome requirement for funding. This highlights the importance of evaluating partnerships and incorporating an assessment of the complex relationships between organisations within a System of Care.

In the Better Together Project, a baseline measurement of partnership intensity between organisations within the network was assessed. This was conducted to understand how effective current relationships are within the system and how they can potentially enhance outcomes for infants, children and young families. The social network analysis assessed the extent to which organisations were connected with each other through; awareness only, cooperative only, coordination only and/or integrated activities, which are defined in the Table 14.

Table 14 Definitions of Partnership Intensity

Source: ECU Better Together based on PARTNER Report September 2018.

Figure 46 to Figure 49 visually depict the different levels of partnership intensity and each coloured circle represents one member of the network. The black lines demonstrate when respondents indicated that they had a relationship with another member of the network. A high number of lines indicate that a large number of partners indicated relationships to that organisation.

Findings revealed a large number of partnerships across the network (N=1877), however further analysis indicates that 58 per cent of the organisations are connected through ‘none/awareness only’ (Figure 46). This finding reveals that organisations are mainly working with each other through understanding what each organisation provides in the network, rather than actively engaging in activities together. It appears that collaboration between organisations is characterised by sharing information and that there are several organisations that are not connected within the network (mental health agency/organisation 8, community 4,

community 12, primary health care 2), which is visually represented across Figure 46, Figure 47, Figure 48 and Figure 49. Consistent with findings in the other network maps it appears that the network of organisations is relatively decentralised with reference to the type of activities organisations engage in with each other.

Figure 47 revealed that there are only 23 per cent of organisations that engage in cooperative activities, which is the second highest form of partnership engagement within the network. This finding reveals that a small proportion of organisations are actively engaging with each other through information sharing and attending meetings. Organisations within the network identified more relationships with each other through engaging in cooperative activities, evidence in Figure 47 by the high number of lines between the nodes. This suggests that there is a higher level of interconnectedness between those organisations that are engaged in cooperative activities, when compared to other types of activities (awareness only, coordinated and integrated).

Figure 48 and Figure 49 indicate that only 12 per cent of organisations are coordinated (Figure 48) and 7 per cent of organisations are integrated with each other. This is an important finding when considering the current functioning of the network. It seems that the nature of the relationships between organisations in the network may be one potential barrier to building a more integrated and cohesive PIMH System of Care in the Cities of Wanneroo and Joondalup. The very small proportion of organisations that are engaged in coordinated and integrated activities indicate that in practice within the PIMH System of Care, majority of organisations are not working together to jointly plan and deliver services or combine delivering services to families. It also suggests there is minimal shared accountability, which is in line with current funding models that typically fund individual organisations rather than a collective of agencies/organisations and subsequently have individual organisation outcome goals.

Findings from the partnership intensity network maps have provided detailed information about the practical processes that occur between organisations and an accurate understanding of intangible aspects of partnerships within the network. In developing a more cohesive and integrated PIMH System of Care an in depth understanding of the kind of relationships that exists between organisations is crucial. Baseline data collected has provided an understanding of how organisations are connected with each other across the network, which is characterised by some relatedness across organisations in knowing who each other is and a small amount of information sharing. In light of these findings, it is recommended that the next stage of the Better Together Project considers ways of connecting organisations within the system around activities that promote coordination and integration of services.

These activities need to be designed to build stronger relationships between organisations that aim to build a more integrated approach across the PIMH System of Care. Important factors to consider when creating these opportunities are; (i) is there appropriate infrastructure in place for organisations to work together, (ii) an understanding among organisations that working together will enhance creativity and innovation in design and delivery of services; and (iii) a commitment that together organisations can achieve better outcomes for families with infants, young children than they could on their own.

Figure 46 Partnership Intensity: None/Awareness only

Notes: N = 1,081 (58 per cent of respondents)

Source: ECU Better Together based on PARTNER Report September 2018.

Figure 47 Partnership Intensity: Cooperative Only

Notes: N = 436 (23 per cent of respondents)

Source: ECU Better Together based on PARTNER Report September 2018.

Figure 48 Partnership Intensity: Coordinated Only

Notes: N = 226 (12 per cent of respondents)

Source: ECU Better Together based on PARTNER Report September 2018.

Figure 49 Partnership Intensity: Integrated Only

Notes: N = 134 (7 per cent of respondents)

Source: ECU Better Together based on PARTNER Report September 2018.

Referred Clients

Respondents were asked to identify those agencies/organisations to which their service had referred clients to in the past either formerly or informally. Findings revealed that 45 per cent of organisations have referred to other organisations and 55 per cent have not referred to other organisations within the network (Figure 50). The two maps in Figure 50 show that organisations referring to each other are more connected, as indicated by the high number of lines and increased density. In comparison, organisations that do not refer to each other have fewer relationships and are less connected. On closer examination of the Referral Network Maps it is evident that Community and Education organisations are not as connected to other organisations when considering referral of families to other agencies/organisations.

Figure 50 Referred Clients

Source: ECU Better Together based on PARTNER Report September 2018.

These findings raise important questions about referral pathways and the role that referring to other organisations may play in developing a more cohesive and integrated PIMH Model of Care. In the Cities of Wanneroo and Joondalup there are less than half of the organisations referring to each other, revealing that organisations within the network are not cohesively connected to each other across the continuum of care when making referrals to other agencies/organisations. Community and Education are the most disconnected organisations within the network and interestingly Mental Health organisations are on the periphery of connectivity.

Although there are more relationships between organisations if they are referring families to each other the network maps revealed there was no systematic pattern in how this is carried out. The absence of any consistent patterns between Community, Health, Mental Health, Community, Primary Health and Education organisations within the network maps may be explained by the absence of any established formal referral pathways in the PIMH System of Care in the Cities of Wanneroo and Joondalup. There is no systematic care plan for families presenting with perinatal and/or infant-early childhood mental health concerns, which may in part explain the lack of connectivity between organisations. When practitioners within organisations are required to refer a family to another service based on PIMH needs it will be dependent on the knowledge, skill and awareness of individual practitioners rather than a defined process based on standardised screening and assessment across the System of Care.

Further analysis revealed that relationships between agencies/organisations are built mostly from referral pathways and educational programming (38%). Developing new initiatives, training needs and service delivery also underpin agency/organisation relationships (20-25%). The factors contributing to relationship development included, developing relationships with specific individuals (36%), practice efforts leading to connections with other individuals (31%), and participation in service related committee (48%).

Based on the findings from this series of network maps it can be recommended that the network consider ways in which more formal referral pathways might be established and how a stepped care approach can be implemented focussing on family needs (perinatal, infant early childhood mental health, family supports) and enhancing family strengths. Piloting the implementation of the ECSII may help establish pathways for families who present with complex needs and systematic way of triaging based on family’s individual needs. Developing a more comprehensive model of routine screening and early detection for both perinatal and infant mental health concerns with primary health care practitioners may also be another strategy for increasing a more systematic and cohesive referral process. A possible priority for the network group might be to begin to develop a PIMH stepped care model that incorporates building on existing network engagement, prioritising PIMH training for primary health care providers, screening and early detection and family support and therapeutic interventions and treatment.

Implications and Recommendations

The Social Network Analysis reveals that some agencies/organisations within the PIMH System of Care are only loosely connected to each other, through awareness and through some co-operative activities. A more complete and well-functioning network requires building partnerships that centre on coordinated and integrated activities and that foster more connectivity with those agencies/organisations that are consistently on the periphery of the network. It is also important to consider the role that dimensions of trust and value play in building a more cohesive and integrated network. The low trust and value scores suggest that the overall network needs to consider strategies to strengthen and build trusted relationships among organisations within the network in which each is valued for its unique contribution to the System of Care.

Further investigation is needed to determine if there is a relationship between organisations that are positioned on the periphery of the network (with fewer relationships with other organisations) and their geographical location. Furthermore, to establish whether organisations positioned in the centre of the network map and connected with many other organisations are geographically located where there are larger proportions of families with higher levels of vulnerability.

In considering future directions, the Better Together project recommends:

1. Investigating ways to enhancing cohesion and integration in the System of Care using technology. a. One suggested step is to pilot the implementation of the ‘Person Centered Network App (PCN App) to continue capturing families’ experiences in the PIMH System of Care and track which agencies/organisations within the network they access when a PIMH presenting concern emerges. The Person-Centered Network (PCN App) is a tool for use by a provider or family to first screen a person to assess their gaps and strengths in their personal support systems and then, based on the results, link them to available community resources. The basic PCN App allows a user to collect data on a person’s personal network, identifying who they are connected to and how well connected (or not) those network members are to one another. It also assesses the content, strength, and importance of those connections. An additional feature to the App is an automated link to available community resources (https://partnertool.net/tools-and-training/pcn-app/).
2. Building innovative ways of increasing the connectivity between agencies/organisations and between families and organisations across the PIMH System of Care in the Cities of Wanneroo and Joondalup. Engaging in activities that builds trust and value in the network will result in a more cohesive and integrative PIMH System of Care. a. The Early Childhood Service Intensity Instrument (ECSII) is one way of establishing a system and structure that provides a coordinated and integrated care pathway for families with complex needs. It is proposed that Better Together pilot this tool as an innovative intervention aimed at increasing cohesiveness within the PIMH System of Care. The ECSII is a standardized aid to service planning and monitoring of progress for infants, toddlers, and children from ages 0-5 years by determining needed intensity of service. The ECSII is a tool for providers and others involved in the care of infants, young children with emotional, behavioural, and/or developmental needs, and their families, including those children who are experiencing environmental stressors that may put them at risk for such problems. b. Continue offering innovative workshops that broaden and mobilise agencies/organisations within the PIMH System of Care. To continue a partnership with the Bernard Van Leer Foundation and explore contemporary ways of viewing the importance of early childhood through different lenses such as town planning, architecture, housing and transport.

110

Chapter 9:

Summary and Discussion

Summary and Discussion

This report provides a comprehensive insight into the PIMH System of Care in the Cities of Joondalup and Wanneroo. Through collaborative inquiry and participatory action research, the Better Together project engaged key stakeholders in the community and actively including families who live in the two cities at every stage of the project. The project used multiple strands of inquiry including collation of survey data from service providers and families, qualitative data from the reference group meetings and focus groups, implementation of a Social Network Analysis and multiple interventions targeting specific components of the system. This multifaceted approach enabled Better Together to develop a deep understanding of the capacity, current functioning and degree of connectedness of agencies/organisations within this system and how families experience PIMH services across the continuum of care.

While City of Wanneroo and City of Joondalup are in close geographic proximity, from a socio-economic and demographic perspective they are quite diverse. The City of Wanneroo has a rapidly growing population compared to a declining population in the City of Joondalup, with the former also having a greater level of population diversity, by region of origin. The City of Wanneroo also has a higher proportion of 0-4 year olds relative to the City of Joondalup. Furthermore, the City of Wanneroo has a significantly higher level of socio-economic disadvantage, with lower median incomes, higher unemployment rates and a greater level of females aged 18-39 having no English. Overall therefore, the City of Wanneroo has a higher level of vulnerability, with a likely higher demand for services and greater need to support families and their children.

Through the mapping of services this report shows that, by SA2 regional level, there are some striking differences both within and between cities in relation to the services available to support 0-4 year olds and their families. In general, there is a lower availability of such services in the City of Wanneroo. This was particularly noteworthy in relation to GP services, with only 2.8 GPs per 1,000 of the 0-4 year old population in the City of Wanneroo relative to 4.5 GPs per 1,000 of the 0-4 year old population for the City of Joondalup. As discussed elsewhere in the report, GPs, along with pharmacies are often the first ports of call for vulnerable children and their families.

The process of creating a Better Together Reference Group that included a broad range of stakeholders including families from the community contributed to establishing the preconditions necessary for embarking on a successful system level change to the PIMH System of Care. The Better Together Reference Group was an essential step towards creating a network with strength in trust, establishing strong foundations to understand what is required in the System to best support the social and emotional wellbeing of families from pregnancy through to three years. Through establishing a relationship based framework and collaborative inquiry approach to all reference group meetings and activities members’ co created a culture of learning and exploration of multiple perspectives that contributed to a more complete and authentic understanding of key leverage points, effective engagement strategies and barriers within the system. Findings revealed that stakeholders value the need to exchanging knowledge, create informal relationships and meet regularly with each other. Often these ways of connecting and building relationships are not prioritised or valued by agencies/organisations and the challenge is compounded by time requirements needed to build meaningful engagement across the system. While not a replacement for face-to-face interaction, going forward, technology can play a key role in engaging stakeholders and can offer a platform of communication that requires less time and resources, from the provider, client and broader stakeholder perspective.

Moving forward this established network of agencies/organisations (reference group) across the continuum of care has the potential to support capacity building that strengthens the system, explore emerging threats and opportunities and engagement in on going activities that connect people and services within the PIMH System of Care. Government and funding bodies need to consider the impact of funding cycles and related funding discontinuities on initiatives such as Better Together. This will ensure there is capacity to have a centralised infrastructure, dedicated staff and a structured process that leads to developing a shared vision, shared measurement, continuous learning and evaluation and mutually reinforcing activities among all within the PIMH System of Care. Change at a system level takes time and Better Together has created an opportunity for ongoing collective action that has the potential to achieve a long lasting change to the System, towards providing a better means to how we support the social and emotional well-being of families with infants and infants, young children.

Although there are some examples of positive experiences of PIMH services in the Cities of Wanneroo and Joondalup, overall qualitative and quantitative data analysis revealed a lack of cohesion and integration within the PIMH System of Care. In particular, both service providers and families highlighted the need for services to be designed and delivered in a more culturally sensitive manner and to build more father inclusive practice across the continuum of care. This is in line with demographic data that reveals a steady growth in population of families that includes non-English speaking migrants, which is not in alignment with the profile of service providers (predominantly female and Australian). This finding requires an urgent need to grow and support a

more diverse workforce to meet the needs of a changing population and develop a diversity informed training program to fully meet the needs of culturally and linguistically diverse families.

Training needs for primary health care providers was also identified as a priority area that required an immediate response by the Better Together project. A pilot training intervention offered to general practitioners and pharmacists showed promising results. Findings revealed that specific PIMH training leads to increased knowledge and skills in early detection and screening of both perinatal and infant mental health and increased awareness of referral pathways when PIMH problems have been detected. This training package provided has the potential to be rolled out to a wide variety of primary health care professionals. It is recommended that this training be embedded in a capacity building strategy across the PIMH System of Care so that primary health care providers can become more engaged in the system and there is more opportunity for a larger scale change and stronger relationships across the continuum of care.

Families shared the multiple challenges they face when accessing services such as waiting lists, minimal communication between services and perceived judgement and dismissive attitude by service providers. Both service providers and families also reported the need for more community and informal social supports for families navigating their way through pregnancy and early parenthood.

The Better Together Community Intervention (Bernard Van Leer Urban95 Workshop) highlighted how broader issues such as green spaces and access to transport impact on the wellbeing of families. It led to the surprising discovery of a collective vision among organisations and families within the Cities of Wanneroo and Joondalup of ‘fostering a community in which children can thrive and feel safe’. This shared vision has created stronger relationships for collective action beyond the Reference Group and across a broader range of stakeholders, increasing momentum and motivation for collective action. There is a need to continue engaging stakeholders in intensive capacity building opportunities to harness the connections that have been established. Moving forward Better Together, in collaboration with other key organisations and community groups, needs to develop innovative ways of funding engagement and capacity development activities for the PIMH System of Care. This will be a crucial component of improving the cohesiveness of the system.

Better Together recognises the crucial importance of understanding how organisations within the PIMH System of Care work together and the role this plays in building a more cohesive and integrated system. Using a Social Network Analysis tool (PARTNER Tool), Better Together mapped for the first time (to the authors knowledge) in Western Australia, the network of relationships between organisations within the PIMH System of Care. The findings reveal that organisations within the network have low levels of trust and value and minimal coordinated and integrated activities with each other. These results highlight the need to adopt new approaches in the way organisations work with each other and are the first stage of making a shift towards thinking together as a network, rather than individual actors. By focusing more intentionally on building interconnectedness between organisations within the PIMH System of Care through continuous learning, connecting and collaborative action the quality of how organisations work together will directly impact on ability to achieve system level outcomes. There is a greater need to address intangible factors that are barriers to creating an integrated and cohesive System of Care. Implementing strategies and interventions designed to increase trust and value among organisations are essential and can be offered through capacity building engagement activities in addition to formal tools that promote communication and collaboration such as the Early Childhood Service Intensity Instrument (ECSII).

Better Together is striving to create a systems change in PIMH in the cities of Wanneroo and Joondalup. Building a successful network to address the problems that exist within a complex PIMH System of Care takes time and patience. Understanding the dynamics of this complex system has enabled Better Together to be in a position to now develop innovative ways in which decisions, strategies and interventions can be created to improve the outcomes and make a long term sustainable social change for infants, infants, young children and their families. The current momentum must continue as we make further strides towards working Better Together.

Chapter 10:

Appendix

Appendix

Reference Group Member Agencies/Organisations

Adult Mental Health BankWest Curtin Economics Centre (BCEC) Child and Adolescent Mental Health Service (CAMHS) Centre for Parenting Excellence: Department of Local Government and Communities Child and Adolescent Community Health Service (CACH) Child Development Services (CDS) Consumer Network Department of Child Protection and Family Support (DCPFS) Department of Education Department of Communities: Disability Services Early Childhood Australia Edith Cowan University Goodstart Early Learning Centres General Practitioners Health Consumer Council: Consumer Representatives Ishar Multicultural Women’s Health Services Joondalup Health Campus Joondalup Health Campus: Antenatal Clinic Joondalup Women’s Health and Family Services (WHFS) Lendlease Mental Health Commission, Planning Policy & Strategy Nido Early Learning Centre Parenting Connection WA Parliament of Western Australia Valuing Children Initiative WA Perinatal Infant Mental Health Subnetwork Group Wanneroo City Council Early Childhood Officers WA Primary Health Alliance Western Australian Council of Social Services (WACOSS) Women and Newborn Health Service Women’s Health, Genetics and Mental Health

Glossary

Glossary

IMH

Infant Mental Health refers to the ability of infants from conception to three years, to develop physically, cognitively, and socially in a manner which allows them to master the primary emotional tasks of early childhood without serious disruption caused by harmful life events. Because infants grow in a context of nurturing environments, infant mental health involves the psychological balance of the infant-family system.

Network

A network refers to a social structure that is comprised of connections between agencies/organisations and individuals. In Better Together, network is used to refer to the connections between all those who are involved in working with infants, children and young families in the cities of Wanneroo and Joondalup.

PIMH

Perinatal and Infant Mental Health refers to the social and emotional wellbeing of those who are pregnant and through the first year following the birth of a child.

SEIFA

Socio-Economic Indexes for Areas (SEIFA) is a product developed by the ABS that ranks areas in Australia according to relative socio-economic advantage and disadvantage. The indexes are based on information from the five-yearly Census. Four different indexes are produces. In this report, the Index of Relative Socio-Economic Disadvantage (IRSD) is used.

SNA

Social Network Analysis (SNA) is a quantitative method that uses graphs and network theory to analyse connections and ties between people and agencies/organisations. It offers both visual and quantitative descriptors to show connections, collaborations and relationships. As a guideline lines mean connections and the thickness of the line means stronger connections; where circles represent a measure the larger the circle the greater that measure.

Statistical Area Level 2 (SA2)

This is a construct of the Australian Bureau of Statistics, and part of their Australian Statistical Geography Standard (ASGS). An SA2 is designed to reflect functional areas that represent a community that interacts together socially and economically. The SA2 is the smallest area for the release of many ABS statistics.

System of Care

In this report the System of Care refers to the system of services supporting young infants and children in their families and communities across levels of service delivery as well as across sectors in the Cities of Wanneroo and Joondalup in Western Australia.

Chapter 11:

References

a EA lhe

References

American Academy of Child and Adolescent Psychiatry. https://www.aacap.org/aacap/member_resources/practice_information/ECSII.aspx

Ackoff, R. L. (1999). Recreating the corporation. New York: Oxford University Press

Australian Association for Infant Mental Health WA Branch. (2016). Australian Association for Infant Mental Health competency guidelines for culturally sensitive, relationship-focused practice promoting infant mental health. Perth, Western Australia

Australian Bureau of Statistics (2017) Census of Population and Housing, 2011 and 2016

Bond-Smith, S., Duncan, A., Kiely, D., & Salazar, S. (2018). Falling Through the Net: The Digital Divide in Western Australia

Center on the Developing Child at Harvard University. (2014). Decade of Science Informing Policy: The Story of the National Scientific Council on the Developing Child

Commissioner for Children and Young People WA. (2015). Our Children Can’t Wait – Review of the implementation of recommendations of the2011 Report of the Inquiry into the mental health and wellbeing of children and young people in WA, Commissioner for Children and Young People Retrieved from Perth, WA

Cortis, N., Katz, I., & Patulny, R. (2009). Occasional paper no. 26, engaging hard-to-reach families and children, stronger families and communities strategy. Australian Government Department of Families, Housing, Community Services and Indigenous Affairs

Duncan, A., Leong, K., Ong, R., Salazar, S., & Twomey, C. (2017). The Price is Right? An Examination of the Cost of Living in Western Australia’. Retrieved from Perth.

ECU Better Together Service Provision Database (2018)

ECU Better Together Workforce Survey Data (2018)

Elango, S., Garcia, J. L., Heckman, J. J., & Hojman, A. (2015). Early childhood education. White House summit on early education, Dec. 2015. https://heckmanequation.org/resource/early-childhood-education/

Felitti, Vincent J; Anda, Robert F; et al. (May 1998). “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study”. American Journal of Preventive Medicine. 14 (4): 245–258. doi:10.1016/S0749-3797(98)00017-8. PMID 9635069

Fitzgerald, H. E., & Barton, L. M. R. (2000). History of infant mental health: Origins and emergence of an interdisciplinary field. In J. D. Osofsky & H. E. Fitzgerald (Eds.), WAIMH handbook of infant mental health: Perspectives on infant mental health (Vol. 1, pp. 1-36). New York: Wiley

Fitzgerald, H. E., & Zientek, R. (2015). Learning Cities, systems Change, and Community Engagement Scholarship New Directions for Adult and Continuing Education, 145, 21-35

Foster-Fishman, P. G., Nowell, B., & Yang, H. (2007). Putting the system back into systems change: A framework for understanding and changing organisational and community systems. American Journal of Community Psychology, 39, 197-215

Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytical approach to the problems of impaired infant-mother relationships. In S. Fraiberg (Ed.), Clinical studies in infant mental health (pp. 164-196). New York: Basic Books

Kania, J., Kramer, M., & Senge, P. (2018). The Water of Systems Change. Retrieved from www.FSG.org

Leech, N. L., & Onwuegbuzie, A. J. (2009). A typology of mixed methods research designs. Quality & Quantity: International Journal of Methodology, 43(2), 265-275. http://dx.doi.org/10.1007/s11135-007-9105-3

Matacz, R., & Priddis, L. E. (2015). Responding to the identified need to build workforce capacity in Infant Mental Health: Launch of the AAIMHI WA Competency Guidelines ® in Western Australia. WAIMH: Perspectives in Infant Mental Health, 23(3)

McNall, M. A., Barnes-Najor, J. V., Brown, R. E., Doberneck, D., & Fitzgerald, H. E. (2015). Systemic Engagement: Universities as Partners in Systemic Approaches to Community Change. Journal of Higher Education Outreach and Engagement, 19(1), 1

Mental Health Commission. (2012). Mental Health 2020: Making it personal and everybody’s business: Reforming Western Australia’s mental health system. Retrieved from Perth http://www.mentalhealth.wa.gov.au/Libraries/pdf_docs/Mental_Health_Commission_strategic_plan_2020.sflb.ashx

Overton, W. F. (2015). Processes, relations, and relational-developmental-systems. In W. F. O. P. C. M. Molenaar (Ed.), Handbook of child psychology and developmental science: Theory and Method (Vol. 1). New York: John Wiley

Priddis, L. E., Matacz, R. M., & Weatherston, D. (2015). Building a Workforce Competency Based Training Programme in Infant-Early Childhood Mental Health. Infant Mental Health Journal, 36(6), 623-631

Stokes, B. (2012). Review of the admission or referral to and the discharge and transfer practices of public mental health facilities/services in Western Australia. Retrieved from Perth, WA: www.health.wa.gov.au/publications

WA Primary Health Alliance (2018), Primary Health Care Data Collection

Weatherston, D. J. (2005). Returning the treasure to babies: An introduction to infant mental health service and training. In K. M. Finello (Ed.), The handbook of training and practice in infant and preschool mental health (pp. 3-30). San Francisco, CA: Jossey-Bass

Western Australian Mental Health Commission. (2015). Better Choices. Better Lives

Western Australian Mental Health, Alcohol and Other Drug Services Plan 2015-2025. Retrieved from Perth

Zeanah, C. H. (2019). Handbook of Infant Mental Health. New York: Guilford Press

Zero To Three. (2012). Making It Happen: Overcoming Barriers to Providing Infant-Early Childhood Mental Health. Retrieved from http://www.zerotothree.org/public-policy/federal-policy/early-child-mental-health-final-singles.pdf

122

Disclaimers

The information in this report does not necessarily reflect the views of WAPHA, Bankwest Curtin Economics Centre, Curtin University and/or Bankwest or Edith Cowan University.

The information contained in this report is provided for general information only. You should carefully evaluate its accuracy, currency, completeness and relevance for your purposes, and should obtain any appropriate professional advice relevant to your particular circumstances. If you place any reliance upon the information contained in this report, then you do so at your own risk.

WAPHA, Bankwest Curtin Economics Centre, Curtin University and/or Bankwest or Edith Cowan University are not responsible in negligence or otherwise for any injury, loss or damage however arising from the use or reliance on the information provided in this report.

Authorised Use

© WA Primary Health Alliance and Edith Cowan University

ISBN: 978-0-6484444-2-8 e-book; 978-0-6484444-2-8 print book.

This report was compiled by: Lynn Priddis and Rochelle Matacz, from Edith Cowan University and by Daniel Kiely from the Bankwest Curtin Economics Centre at Curtin Business School pursuant to a funding agreement with the WAPHA.

This report may be cited as: Priddis, L.E., Matacz, R.A., Kiely, D., Bayes, S., Barratt-Pugh, C., Pooley, J.A., Lauren, C., Thornton, J., Fitzgerald, H.E. (2018), Better Together: Supporting Perinatal and Infant Mental Health Services.

The authors would like to thank all the reference group, survey and focus group participants in this project as well as those who participated in the interventions and who gave feedback. Particular thanks to the WA Primary Health Alliance, Bankwest Curtin Economics Centre and to Edith Cowan University.

Acknowlegdements

WA Primary Health Alliance for graphics.

Contacts

Dr Lynn Priddis
Mobile: +61 417 986 710
Email: l.priddis@ecu.edu.au

Ms Rochelle Matacz
Mobile: +61 420 787 437
Email: r.matacz@ecu.edu.au

An online version of the report can be found at bcec.edu.au

© Edith Cowan 2019
CRICOS Provider Codes Edith Cowan University 00279B, Curtin Univerity 00301J
ADV120428

BANKWEST CURTIN ECONOMICS CENTRE

BEHIND THE LINE

Poverty and disadvantage in Australia 2022

Alan Duncan

Focus on the States Series, No. 9/22
March 2022

About the Centre

The Bankwest Curtin Economics Centre is an independent economic and social research organisation located within the Curtin Business School at Curtin University. The Centre was established in 2012 through the generous support of Bankwest, a division of the Commonwealth Bank of Australia. The Centre’s core mission to deliver high quality, accessible research that enhances our understanding of key economic and social issues that contribute to the wellbeing of West Australian families, businesses and communities.

The Bankwest Curtin Economics Centre is the first research organisation of its kind in WA, and draws great strength and credibility from its partnership with Bankwest, Curtin University and the Western Australian government. The Centre brings a unique philosophy to research on the major economic issues facing the State.

By bringing together experts from the research, policy and business communities at all stages of the process – from framing and conceptualising research questions, through the conduct of research, to the communication and implementation of research findings – we ensure that our research is relevant, fit for purpose, and makes a genuine difference to the lives of Australians, both in WA and nationally.

The Centre is able to capitalise on Curtin University’s reputation for excellence in economic modelling, forecasting, public policy research, trade and industrial economics and spatial sciences. Centre researchers have specific expertise in economic forecasting, quantitative modelling, micro-data analysis and economic and social policy evaluation. The Centre also derives great value from its close association with experts from the corporate, business, public and not-for-profit sectors.

This report was written by: Professor Alan Duncan, Director of the Bankwest Curtin Economics Centre.

This report may be cited as: Duncan A, ‘Behind the Line: Poverty and disadvantage in Australia 2022’, Bankwest Curtin Economics Centre Focus on the States Series, #9, March 2022.

This publication contains confidential and proprietary information of the Bankwest Curtin Economics Centre. All of the material in this publication is for your exclusive use and may not be otherwise used or modified for, or by, any other person or sold to or otherwise provided in whole or in part to any other person or entity without the prior written consent of the Bankwest Curtin Economics Centre.

A standard hard copy of, or electronic subscription to, this publication entitles employees of the same organisation and same physical location as the subscriber to the use of its contents for internal reporting purposes only. Multiple user licenses are available for organisations with more than one location.

BCEC REPORT SERIES

Focus on Western Australia

This series presents a West Australia centric approach at analysing global events and domestic policy issues

First release 2014

Focus on the States

This series presents a critical comparison of topical issues between the states and territories of Australia

First release 2014

Focus on Industry

This series examines trends in important industries and sectors within the context of the West Australian economy

First release 2016

Piadete

IN ECONOMIC CENTRE FOCUS ON THE STAT!

CONTENTS

LIST OF FIGURES

LIST OF TABLES

FOREWORD

This latest report in the Bankwest Curtin Economics Centre Focus on The States series throws new light on the prevalence of poverty and disadvantage in Australia, and the depth and impacts of poverty across different sections of our society.

Our research explores the depth of income poverty and disadvantage in Australia, and more especially, how it has changed from pre-COVID levels.

We look at how employment, poverty and wellbeing were affected both by the pandemic, but also by the government stimulus and support measures put in place to navigate the crisis.

But we were determined to look behind the poverty line, to explore how the experience of poverty impacts on people’s quality of life, social isolation, security and wellbeing.

Deep and prolonged disadvantage clearly impacts on both current and future wellbeing. When we deprive our fellow Australians of the opportunity to thrive and contribute we are all poorer as a society, and our future is smaller and less bright.

This is particularly true for children growing up in impoverished households, who deserve the opportunity to be all that they can be.

The release of this Focus on The States report coincides with International Women’s Day, and it could not be more fitting that many of the findings speak directly to the financial hardships and pressures that many women in Australia face.

Our research explores the challenges faced by single parents, and by women across the course of their lives, and examines how adverse life events affect women’s economic security.

If you care about gender equity then you should read this report and care about poverty because of its disproportionate impact on women.

Professor Alan Duncan
Director, Bankwest Curtin Economics Centre
Faculty of Business and Law, Curtin University

EXECUTIVE SUMMARY

The health and economic wellbeing of any society is a key barometer not just of a nation’s material prosperity, but of its compassion and core values. The overarching goal for economic and social policy should be to create a safe, secure environment in which everyone can achieve their potential, and to maintain adequate protections for the most vulnerable sections of our community.

Yet in Australia there are still groups in society who fall through the cracks, with some facing serious hardship or consistent financial disadvantage over much of their lives.

This Bankwest Curtin Economics Centre Focus on the States report provides the latest examination of the prevalence of poverty within Australia, how this has changed over time, and which groups in society face the greatest risks of financial hardship and material deprivation.

We also look at how income poverty has changed through the experiences of the COVID-19 pandemic. We examine how Australia’s states and territories compare in the prevalence of poverty and disadvantage, and seek to understand more about people’s journeys into poverty, and the pathways and supports to escape from financial hardship.

The measurement of income poverty in the report assesses the number of people whose incomes fall below a poverty line as a representation of a basic living standard.

But much of this Focus on the States report looks ‘behind the line’, exploring deeper issues that highlight how poverty affects people’s livelihoods and life chances, and their sense of wellbeing. We reveal the scarring effects of childhood poverty on life outcomes in adulthood, and show the extent to which prolonged experiences of poverty affect mental health and exert psychological trauma. And we put forward for consideration a range of policy recommendations that would go some way to alleviating and assisting people to escape the poverty trap.

Poverty in Australia

One approach to modelling the incidence of income poverty in this Focus on the States report assesses the share of the Australian population whose incomes fall below particular thresholds. This includes a commonly used benchmark of half the typical (median) per capita equivalent household income, controlling for housing costs and adjusting for differences in family composition - one that is generally deemed sufficient to deliver an adequate standard of living. Our modelling reveals a ‘standard’ poverty line of $451.50 per person per week once housing costs have been paid.

Just under three million Australians are assessed to live under the poverty line of half median income - 11.8 per cent of the population - including nearly 750,000 children. The number of people defined to be in poverty has somewhat surprisingly fallen by around 350,000 over the last year, partly due to the availability of COVID-19 supports paid through government allowances and wage subsidies.

A number of factors contribute to a heightened risk of poverty. Over a quarter of single parents are in poverty, with one in ten experiencing severe poverty. Single person households, those in social housing and those with a disability are most exposed to deep and persistent poverty and disadvantage. Joblessness is unsurprisingly one of the key drivers of poverty, particularly among single people and those supporting larger families. Nearly two thirds of single jobless people and 55 per cent of single parents without jobs have incomes below the ‘standard’ poverty line.

Our report reveals a gender gap in poverty that is more pronounced for young women and women approaching retirement. Single women aged 55 and over who live in private rental accommodation are particularly exposed to financial hardship, with two thirds experiencing income poverty.

Below the line: the depth of poverty

One of the problems with defining poverty against a single poverty line is that it categorises some people as poor, but others who are pretty much identical in terms of their disposable incomes as out of poverty. There are ongoing debates on the precise threshold that best differentiates people in poverty from those that remain out of poverty.

For a more nuanced view of the extent of income-based hardship experienced by individuals and families, we take advantage of an approach which differentiates according to progressively more stringent poverty lines. In particular, we measure the share of families below 30 per cent, 40 per cent, 50 per cent and 60 per cent of standardised per capita household income. In doing so, this gives us a better sense of the proportion families that are doing it especially tough - and what this means in terms of the number of people in severe poverty.

Nearly one million Australians - around 5.8 per cent of the population - are living in severe income poverty, having access to per capita equivalent income below 30 per cent of the national median. The 30 per cent median income threshold equates to around $270 each week after housing costs, but many in severe poverty have to make do with less than $150 per week after housing. For the poorest couples, a typical weekly income of around $270 per week is not uncommon, with some having to survive on much less.

And among the 750,000 children who are living in families below the income poverty line, over 190,000 are experiencing severe poverty. Severe income poverty is an unwanted outcome for any group, but particularly for children whose living standards while in the home will adversely affect their future life outcomes.

Unemployed single people in rented housing currently receive $388.35 per week from JobSeeker, including rent assistance and the energy supplement. Around 105,000 people who are unemployed are in severe poverty in Australia, the majority of whom are single people living in private rentals or social housing.

Using data from the HILDA survey, modelling in this report projects that an increase of $20 per day in the base JobSeeker rate combined with 30 per cent increase in the maximum rent assistance would go a long way towards eliminating severe poverty in Australia.

The scarring effect of poverty

Poverty scars people. It gets under the skin.

The innovative research in this report compares life outcomes of children who experienced poverty in the family home with those that didn’t, and uncovers compelling evidence of inferior economic outcomes and poorer mental and psychological health throughout the life course - even after controlling for age, gender, Indigenous and ethnic background, future family status and educational achievement.

The survey data used in this report tracks the economic, social and health outcomes for the same individuals for up to twenty years. This means that we are able to follow the progress of children and young people into their adult lives.

People who experience childhood poverty are up to 8 percentage points more likely to remain in poverty in adult life. The chances of securing future employment after a poverty in childhood are up to 11 percentage points lower compared to those who did not come from a poor childhood background, and they are significantly more likely to suffer from nervousness or feel unhappy with their lives for up to 10 years after leaving home.

1. The Household Income and Labour Dynamics in Australia (HILDA) survey, managed by the Melbourne Institute (including 2020 data).

The analysis in this report reinforces our understanding of how far the impacts of poverty extend, and for how long they endure over the course of people’s lives and the lives of their children. Equally, the report’s findings demonstrate the scale of the economic return from targeted strategies to reduce poverty, as well as the positive social, psychological and health benefits from doing so.

Rental costs are a large contributor to financial hardship

For families on lower incomes, financial hardship is more acute when housing costs are high. The first priority is to put a roof over their heads and food on the table before anything else.

Our data show that financially vulnerable people are forced to make spending decisions on really tight margins with little or no discretionary income, and that’s exactly the situation facing the 1.5 million renters across the country who are experiencing poverty. It is not unusual for the poorest families to have to survive on less than $150 per week once housing costs have been paid - that is only $21.50 a day.

How much income a family has left for food, clothing and other necessities once housing costs have been paid is heavily affected when rents rise, and this explains much of the growth in poverty rates among those in private rented accommodation.

People receiving government allowances who pay rent of $159 or more per week are eligible for the maximum weekly Commonwealth rent assistance of $71.40, but for most, the cheapest rents that can be accessed on the private rental market are at least $300. This means that every dollar of increase in private rental costs is a dollar less on disposable income. The impact of rapidly rising housing costs is especially acute for families whose incomes are relatively fixed, as is the case for those without a job and who rely on government allowances as their main source of income.

The experience of rising rental costs over the last two years brings to the fore the importance of the maximum entitlement to rent assistance, and the need for it to adequately reflect the (very different) costs incurred by low income families across the country.

People have substantially different experiences of housing cost stress across states and territories, and between cities and regional areas, but the maximum level of rent assistance remains fixed at a single rate for all. The weekly rental costs available in the private sector - even at the lowest price points - have increased over the last five years by $100 in Canberra and by at least $50 in Sydney, Adelaide and Perth. Rents have risen even more so in some regional centres. Yet the maximum rate of rent assistance has increased over the same period by only $6.10. This necessarily creates inequities in the degree of financial support for housing costs among the poorest sections of society driven solely by where they live.

There are fewer levers at the disposal of state and territory governments to tackle poverty, but amongst those that they do have, the provision of social housing features among the most important. Findings from this report show that while poverty is far higher among people who rent from a government housing authority, at 53.8 per cent (due to stringent eligibility criteria that rations limited social housing to those most in need), the prevalence of poverty for those in social housing has reduced by 6.7 percentage points over the last two years.

A lifetime of hardship?

Financial hardship can be short-term or transitory for some, but for many, the experience of poverty can endure over an extended period of time. This report uncovers compelling evidence that persistent poverty is destructive, damaging health and wellbeing to a significant degree.

Around 575,000 people have been in poverty for at least five of the last ten years, with a further 115,000 having faced financial hardship consistently for a decade or more. Single people face a heightened risk of persistent poverty, while a third of a million single people and a quarter of a million single parents have been in poverty for at least five of the last ten years.

Our report shows that people who face persistent poverty are more likely to experience psychological distress, and the longer the time in poverty, the worse the mental health impacts are. Those who were in poverty for at least five of the last ten years are 3 times more likely to suffer acute mental stress compared to people who have never experienced poverty.

The psychological trauma from years in poverty rises more steeply for women than for men in most age cohorts and family settings. Older age cohorts provide the one exception, with more than a quarter of single men aged 55 and over who have endured poverty for 5 years or more experiencing psychological distress, compared to one in five older women.

Journeys into poverty

That life events have an impact on people’s financial wellbeing should not come as a surprise, but until now there has been less empirical evidence on which life transitions affect people’s experiences of poverty the most, and for how long those impacts last.

Both partners are at greater risk of poverty when relationships break down, but the effects are both more severe and more enduring for women. The risk of descending into poverty is three times higher for women than for men following separation or divorce, and twice as high following the death of a partner. Women also suffer adverse impacts from life events for longer. The poverty risks for women remain at the same heightened level for three or more years after a relationship breakdown or the death of a partner.

The working poor

One in five people in poverty are in low paid employment, with one in eight agriculture workers and nearly 10 per cent of workers in the accommodation and food services sector earning below the poverty line. Poverty rates did fall by 6 percentage points among casual workers who held onto their jobs during the COVID-19 pandemic, but this needs to be balanced against the fact that nearly 220,000 casuals left employment between 2019 and 2020.

The fieldwork for the 2020 HILDA survey took place between August 2020 and February 2021. This provides an important opportunity to compare labour market outcomes among workers according to whether their employers have been able to claim the JobKeeper wage subsidy payment.

One of the clearest findings to emerge from this analysis is that rates of working poverty for those employed on casual contracts dropped between 2019 and 2020 by a far greater margin for workers in organisations that were able to claim the JobKeeper payment.

In 2019, around one eighth of workers on casual contracts (12.5%) took home earning below the 50 per cent poverty line. In 2020, the poverty rate dropped to 9.4 per cent among workers for whom no JobKeeper payments were claimed, but to a much lower rate of 5.6 per cent for workers in companies that both qualified for and claimed JobKeeper.

The initial design of JobKeeper led to average weekly earnings for those on casual contracts rising from $616 per week in 2019 to $754 per week when their employers were able to claim JobKeeper, but to only $650 per week when this was not the case.

What is more surprising is that the reverse appears to be true for workers on permanent or fixed term contracts in JobKeeper-eligible organisations. For example, the rates of working poverty for employees on fixed term contracts rose from 4.3 per cent to 5.9 per cent between 2019 and 2020 - nearly twice the 3.1 per cent poverty rate for fixed term workers in organisations that did not qualify for the subsidy. The same effect is present to a lesser degree among permanent contract holders.

RECOMMENDATIONS:

• Increase base JobSeeker and related social security payments by $20 per day as a minimum amount to lift recipients above a threshold for severe poverty.
• Increase the level of Commonwealth Rent Assistance maximum payment by 30 per cent to better align CRA support with rental costs.
• Consider how CRA maximum payment rates can be indexed to an agreed basic measure of rental costs.
• Increase investment in social housing to deliver new housing units on a scale that meets needs.
• Invest in local services that provide immediate advice and support to newly jobless people in accessing government services, and connections to new employment opportunities.
• Extend free public transport to all concession card holders and job seekers.
• Ensure that household fees and charges for essential services remain affordable for low-income households.

Key Findings

POVERTY AND DISADVANTAGE IN AUSTRALIA 2022

Poverty incidence in Australia

• Income poverty in this report is measured by comparing per capita income with a poverty threshold of $451.50 per person per week after housing costs.
• Just under 3 million people in Australia are assessed to be in poverty in 2020.
• The incidence of poverty has fallen by around 350,000 people over the last year.

Who is most likely to face poverty?

• Over a quarter of single parents are in poverty, with one in ten experiencing severe poverty.
• Poverty is more pronounced for women than men, with larger gender differences in rates of poverty for young women and women aged 55 and over.
• Joblessness is a key driver of poverty, particularly for single people and people living in large families.
• Nearly two thirds of single jobless people and 55 per cent of single parents without jobs have incomes below the ‘standard’ poverty line.

Poverty depth

• Severe poverty is assessed against a weekly income threshold of $270 per person after housing costs
• Single people in severe poverty have to live on less than $150 per week after housing costs are paid.
• The poorest couples in Australia survive on less than $270 per week.
• Nearly one million Australians - around 5.8 per cent of the population - are living in severe income poverty with income below 30 per cent of the national median.
• Of the 750,000 children living in poverty, over 190,000 are experiencing severe poverty.
• JobSeeker payments are currently $388.35 per week including rent assistance and the energy supplement.
• Around 105,000 unemployed people are in severe poverty in Australia.
• An increase of $20 per day in the JobSeeker base rate combined with a 30 per cent increase in rent assistance ($21.42 per week) would virtually eliminate severe poverty in Australia.

A lifetime of hardship

• Persistent poverty is shown to be damaging to health and wellbeing.
• 575,000 people have been in poverty for at least five of the last ten years.
• 330,000 single people and a 250,000 single parents have been in poverty for at least five of the last ten years
• 115,000 people have experienced financial hardship consistently for a decade or more
• People in poverty for at least five of the last ten years are 3 times more likely to suffer acute mental stress compared to people who have never experienced poverty.
• The psychological trauma from persistent poverty rises more steeply for women than for men in most age groups.

Working poor

• One in five people in poverty are in low paid employment.
• One in eight agriculture workers and 10 per cent of workers in accommodation and food services have earnings below the poverty line.
• Poverty rates fell by 6 percentage points among casual workers who remained in employment during the COVID-19 pandemic.
• There were 220,000 fewer casual workers in 2020 than 2019.
• Poverty rates for casual workers dropped between 2019 and 2020 by a far greater margin for workers in organisations that were able to claim the JobKeeper payment.
• Poverty rates dropped to 9.4 per cent in 2020 for casual workers in organisations where no JobKeeper payments were claimed, but to 5.6 per cent for workers in companies that claimed JobKeeper
• Average weekly earnings for casual workers rose from $616 per week in 2019 to $754 per week when their employers were able to claim JobKeeper, but to only $650 per week when this was not the case.

Poverty and housing

• 1.5 million renters in Australia are in poverty, with the poorest families left with no more than $150 per week after housing costs are paid.
• The maximum Commonwealth rent assistance is $71.40 per week, compared to private sector rents of at least $300 per week.
• Rental costs have increased over the last five years by $100 in Canberra and by at least $50 in Sydney, Adelaide and Perth.
• The maximum rate of rent assistance has increased by $6.10 over five years.
• 53.8 per cent of people who rent from a government housing authority are in poverty.
• The poverty rate for people in social housing has fallen by 6.7 percentage points over the last two years.

The scarring effects of childhood poverty

• Poverty scars children and affects their economic, social and health outcomes in adulthood.
• This report finds that people who come from a poor family experience inferior economic outcomes and poorer mental and psychological health.
• People who experience childhood poverty are up to 8 percentage points more likely to remain in poverty in adult life.
• The probability of employment is up to 11 percentage points lower for children who experienced poverty in childhood compared to those who did not come from a poor childhood background
• Poor children are significantly more likely to suffer from nervousness or feel unhappy with their lives for up to 10 years after leaving home.
• Targeted strategies to reduce poverty will deliver economic returns, and positive social, psychological and health benefits.

Recommendations

• Increase base JobSeeker and related social security payments by $20 per day as a minimum amount to lift recipients above a threshold for severe poverty.
• Increase the level of Commonwealth Rent Assistance maximum payment by 30 per cent to better align CRA support with rental costs.
• Consider how CRA maximum payment rates can be indexed to an agreed basic measure of rental costs.
• Increase investment in social housing to deliver new housing units on a scale that meets needs.
• Invest in local services that provide immediate advice and support to newly jobless people in accessing government services, and connections to new employment opportunities.
• Extend free public transport to all concession card holders and job seekers.
• Ensure that household fees and charges for essential services remain affordable for low-income households.

INTRODUCTION

There is perhaps a prevailing belief that Australia is a land of opportunity, with a strong sense of egalitarianism that means everyone is given ‘a fair go’.

But it’s hard to reconcile this picture with a society in which people still suffer from deep and persistent disadvantage, and where they continue to struggle and fall behind.

Which groups have the highest risk of experiencing poverty, and how has this shifted over time? Does the experience of poverty impact differently on different groups - such as women, children growing up in poverty, or those retiring in private rental?

What are the knock on effects to our health and mental health - our future prosperity and wellbeing? Is there a long-term scarring effect?

Do particular life events - such as job loss, retirement, separation or bereavement increase our risk of poverty? What does the gender poverty gap look like in 2022?

To provide answers to these questions we begin by looking at the definition, incidence and depth of poverty in Australia to determine who is most at risk of extreme poverty, and examine the role that housing costs play in financial hardship.

The COVID-19 pandemic provides an important context to any consideration of poverty in Australia, and would be impossible to ignore.

Fortunately, the research for this report is based on the 2020 Household Income and Labour Dynamics in Australia (HILDA) survey, which gives us a unique opportunity to draw insights from the first large scale, representative survey to cover the COVID-19 pandemic.

We consider the circumstances of the nearly one in five Australians who are working and living in poverty, and look at the differential impacts of COVID-19 measures on labour force status for those who are full-time, part-time or casual workers or not in the labour force.

We also examine the impacts of JobKeeper Payments on poverty rates for women versus men, depending on whether they were permanent employees, casual, or on fixed term contracts, and whether working full-time or part-time.

We examine different domains of vulnerability - from financial insecurity to emotional vulnerability and housing insecurity. We consider how significant life events - such as separation or bereavement - affect the risk of poverty for women and men, and how long those effects persist.

And we look at the links between poverty and psychological stress, tracking how the persistence of poverty impacts on long-term wellbeing through the life course. Finally we look at the scarring effects of poverty in childhood and adolescence to see how early depravation manifests in longer term disadvantage.

“THE OVERARCHING GOAL FOR ECONOMIC AND SOCIAL POLICY SHOULD BE TO CREATE A SAFE, SECURE ENVIRONMENT IN WHICH EVERYONE CAN ACHIEVE THEIR POTENTIAL, AND TO MAINTAIN ADEQUATE PROTECTIONS FOR THE MOST VULNERABLE SECTIONS OF OUR COMMUNITY.”

WHAT DOES POVERTY IN AUSTRALIA LOOK LIKE?

INTRODUCTION

The health and economic wellbeing of any society is a key barometer not just of a nation’s material prosperity, but of its compassion and core values. The overarching goal for economic and social policy should be to create a safe, secure environment in which everyone can achieve their potential, and to maintain adequate protections for the most vulnerable sections of our community.

Yet in Australia there are still groups in society who face serious hardship or consistent financial disadvantage over much of their lives.

This Bankwest Curtin Economics Centre Focus on the States report provides the latest examination of the prevalence of poverty within Australia, how this has changed over time, and which groups in society face the greatest risks of financial hardship. We also examine how poverty rates compare across Australia’s states and territories.

The standard measurement of income poverty assesses the number of people whose incomes fall below a defined poverty line as a representation of a basic living standard. This is useful as a broad indication of patterns and trends, but depending on the income threshold chosen, can conceal factors which are critically important in the understanding of severe poverty.

This report, building on the Centre’s 2014 Falling Through The Cracks? report, looks ‘behind the line’, exploring the prevalence of deeper degrees of poverty, surfacing issues that highlight how poverty affects people’s livelihoods and life chances, their capacity to secure work, and their sense of wellbeing.

2 Rebecca Cassells, Michael Dockery and Alan Duncan (2014), Falling Through The Cracks: poverty and disadvantage in Australia, BCEC Focus on the States Report Series, Issue #1. October 2014.

DEFINING POVERTY

One approach to modelling the incidence of income poverty in this Focus on the States report assesses the share of the Australian population whose incomes fall below particular thresholds. This includes a commonly used (‘standard’) benchmark of half the typical (median) per capita equivalent household income, controlling for housing costs and adjusting for differences in family composition - one that is generally deemed sufficient to deliver an adequate standard of living.

The choice of index against which poverty is to be measured, and the process of determining the income thresholds used to classify the incidence of poverty, are subject to a number of key decisions and assumptions, each of which impose an implicit or explicit judgement regarding the needs of families and what poverty itself actually means as a concept.

The representative population data we use for this report is drawn from the Household Income and Labour Dynamics in Australia (HILDA) survey managed by the Melbourne Institute. The data are longitudinal, which allows us to track individuals over a period of twenty years. The HILDA survey contains exceptional details of people’s incomes, labour force and work patterns, socioeconomic characteristics and education outcomes, as well as a host of information on life events, attitudes and measures of subjective well-being.

The income measure we use is total household disposable income after housing costs, the benefits of which are assumed to be shared across family members. This means that all members of the same household are assumed to have the same status of poverty. Depending on the nature of the income sharing within households, this may or may not be true. However there is insufficient information in most household surveys to capture different circumstances where not all family members are able to access household resources to the same degree.

Using these data, we assess poverty based on the adequacy of income relative to a benchmark poverty line.

Poverty rates are assessed by calculating the percentage of people whose real equivalised household disposable incomes fall below different fractions of the median. Equivalisation is a method of standardising income to take account of household size and composition differences. Here, we use the OECD modified equivalence scales to standardise income. These scales apply 1.0 for the first adult in the household, 0.5 for any subsequent adults and 0.3 for children.

Our ‘standard’ income poverty measure is set at 50 per cent of the typical (median) standardised incomes, but we also consider different poverty depths down to 30 per cent of the median.

Our modelling reveals a ‘standard’ poverty line of $453.50 per person per week once housing costs have been paid.

Using this as a baseline, the equivalent poverty lines for family income can be calculated using the OECD modified equivalence scales (Table 1). We can also vary poverty depth by adjusting the percentage of median income that defines the degree of poverty. These include a threshold of 30 per cent of median equivalent per capita income. We consider families to be in severe poverty when their income falls below this threshold.

TABLE 1 Poverty line equivalences

Note: Poverty lines are calculated for real equivalised household disposable incomes (after housing costs). Nil and negative incomes are excluded from poverty calculations. Data are re-based to December 2021 prices. Housing costs included mortgage repayments, rent and property rates. See technical notes for further detail.

Source: Bankwest Curtin Economics Centre | Author’s calculations from HILDA Survey Waves 2-20 (2002-2020).

POVERTY INCIDENCE IN AUSTRALIA

Our analysis reveals that just under 3 million people in Australia (2,958,800) are assessed to live under a ‘standard’ poverty line of 50 per cent of median income in 2020 (Table 2). This represents nearly 11.8 per cent of the population, and includes nearly 750,000 children.

The number of people defined to be in poverty has fallen by 356,000 over the last year, a drop of 1.6 percentage points. This may be driven partly due to the availability of COVID-19 supports paid through government allowances and wage subsidies.

TABLE 2 Poverty rates and counts: 2015, 2019 and 2020

| Units | Household poverty lines (after housing costs) |||||| Changes in poverty rates and numbers |||| |—|—|—|—|—|—|—|—|—|—| | | 2015 || 2019 || 2020 || 2015 to 2020 (5 years) || 2019 to 2020 (1 year) || | | # | % | # | % | # | % | count | ppt | count | ppt | | Households | 1,335,500 | 14.8 | 1,551,800 | 16.0 | 1,472,400 | 15.0 | +136,900 | +0.2 | -79,400 | -1.0 | | Persons | 2,760,900 | 11.9 | 3,314,900 | 13.4 | 2,958,800 | 11.8 | +197,900 | -0.1 | -356,100 | -1.6 | | Childen | 650,900 | 12.5 | 836,900 | 15.7 | 746,600 | 13.9 | +95,700 | +1.5 | -90,300 | -1.7 |

Note: Poverty lines are calculated for real equivalised household disposable incomes (after housing costs). Nil and negative incomes are excluded from poverty calculations. Data are re-based to December 2021 prices. Housing costs included mortgage repayments, rent and property rates. See technical notes for further detail.

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 2 to 20 (2002-2020).

Just under 1.5 million households are modelled to be in poverty, which translates to a household poverty rate of 15 per cent. This rate has also fallen slightly, by 1 percentage point, over the last year. The reason that household poverty rates are higher than the individual rate is because a higher share of single adult families tend to experience poverty in Australia.

Looking across states and territories, the rate of individual poverty ranks highest Queensland at 13.5 per cent, followed by the Northern Territory at 13.3 per cent (Table 3). The lowest rates of poverty are to be found in the ACT (at 5.4%) and Victoria (10.9%).

TABLE 3 Poverty rates and counts by state/territory: 2020

Note: Due to smaller sample sizes, NT and ACT figures are averaged over two years, 2019 to 2020. Poverty calculations are based on real equivalised household disposable incomes, after housing costs. Nil and negative incomes are excluded from poverty calculations. Housing costs included mortgage repayments, rent and property rates.

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 2 to 20 (2002-2020).

POVERTY INCIDENCE IN AUSTRALIA

Some interesting and contrasting patterns emerge when we look at changes in poverty rates over time across Australia’s states and territories over the last decade.

New South Wales has improved reasonably consistently over the last 10 years, with individual poverty rates dropping from 14.9 per cent in 2012 to 11.4 per cent by 2020. Victoria has maintained relatively low rates of around 11 per cent for most of the decade.

Rates have risen gradually in Queensland and more strongly in the Northern Territory, while for Western Australia the rate of poverty reduced over the first half of the last decade to 8.7 per cent in 2014 but has then risen over the last six years to 12.8 per cent in 2020.

ACT has the lowest poverty rates, reflecting the relative prosperity and higher average salaries for the majority of its population, but rates have been climbing gradually, reaching 5.4 per cent in 2020.

FIGURE 1 Share of people in income poverty by state/territory: 2010 to 2020

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 2 to 20 (2002-2020).

BELOW THE LINE: THE DEPTH OF POVERTY

One of the problems with the use of a single poverty line as a binary indicator of poverty, is that it categorises families or individuals who are substantially similar in terms of their disposable incomes into separate groups. There are also ongoing debates on the precise threshold that best differentiates people in poverty from those that remain out of poverty.

For a more nuanced view of the extent of financial hardship experienced by individuals and families, we take advantage of an approach which differentiates according to progressively more stringent poverty lines. In particular, we measure the share of families below 30 per cent, 40 per cent, 50 per cent and 60 per cent of standardised per capita household income. In doing so this gives us a sense of proportion of families that are doing it especially tough - with the 30 per cent threshold representing a clear indicator of severe poverty.

Nearly one million Australians - around 5.8 per cent of the population - are living in severe income poverty, having access to income below 30 per cent of the national median (Table 4). The 30 per cent median income threshold equates to around $270 each week after housing costs, but many in severe poverty have to make do with less than $150 per week after housing. For the poorest couples, a typical weekly income of around $270 per week is not uncommon, with some having to survive on much less.

Among the 750,000 children who are living in families below the income poverty line, over 190,000 are growing up in severe poverty. Severe income poverty is an unwanted outcome for any group, but particularly for children whose living standards while in the home will adversely affect their future life outcomes. Poor childhood nutrition and lack of access to developmental opportunities has been shown to have lifelong impacts.3

TABLE 4 Numbers and share at different depths of income poverty: 2020

| Depth of income poverty | Households || Persons || Children | |—|—|—|—|—|—|—| | | # | % | # | % | # | % | | 30% | 564,500 | 5.8 | 982,600 | 3.9 | 190,300 | 3.5 | | 40% | 967,500 | 9.9 | 1,802,800 | 7.2 | 403,000 | 7.4 | | 50% | 1,472,400 | 15.0 | 2,958,800 | 11.8 | 746,600 | 13.9 | | 60% | 2,302,000 | 23.5 | 4,740,500 | 19.0 | 1,189,100 | 22.2 |

Note: Poverty depth calculations are based on real equivalised household disposable incomes, after housing costs. Housing costs included mortgage repayments, rent and property rates. Nil and negative incomes are excluded from poverty calculations.

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey Waves 2 to 20 (2002-2020).

3 H Monks (2017) ‘The impact of poverty on the developing child’, CoLab Evidence Report, Telethon Kids Institute, colab.telethonkids.org.au/resources/

FIGURE 2 Depths of income poverty: by state or territory, 2020

Note: Due to smaller sample sizes, NT and ACT figures are averaged over two years, 2019 to 2020. Poverty calculations are based on real equivalised household disposable incomes, after housing costs. Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 2 to 20 (2002-2020).

WHO IS MOST LIKELY TO FACE POVERTY?

Figure 3 explores the proportion of people experiencing different depths of poverty by main family type. What is immediately apparent is that lone person and single parent households are far more likely to experience the deepest levels of financial hardship.

Being single, either with or without children, substantially increases the risk of being in poverty. In fact, single households are continuously over-represented throughout all poverty depth groups.

Around one in 11 people in couple-only households (8.9%) live on incomes below the standard 50 per cent poverty line. For parents in two-adult households, the figure is even lower at 7.4 per cent. In contrast, more than a quarter of single parents and single adults are in poverty according to the standard definition. Around one in 10 single parents and more than one in eight single adults (13%) experience severe income poverty.

Single people and single parent families experiencing poverty are more susceptible to various forms of deprivation - for example struggling to heat homes, raise cash in an emergency, or pay bills - and seek assistance from community organisations more regularly than other types of families.

FIGURE 3 Share of people at different depths of poverty: by broad family type, 2020

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 2 to 20 (2002-2020).

A number of factors contribute to a heightened risk of poverty. Over a quarter of single parents are in poverty, with one in ten experiencing severe poverty. Single person households, those in social housing and those with a disability are most exposed to deep and persistent poverty and disadvantage.

Joblessness is unsurprisingly one of the key drivers of poverty, particularly among single people and those supporting larger families.

Nearly two thirds of single jobless people and 55 per cent of single parents without jobs have incomes below the ‘standard’ poverty line.

And there is a gender gap in poverty that is more pronounced for young women and women approaching retirement (Figure 4). Single women aged 55 and over who live in private rental accommodation are particularly exposed to financial hardship, with two thirds experiencing income poverty.

FIGURE 4 The gender poverty gap: income poverty rates by age and gender: 2020

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 2 to 20 (2002-2020).

THE ROLE OF HOUSING COSTS IN DRIVING POVERTY

Our research finds that nearly a quarter of renters (23.6%) fell below the poverty line in 2020, an increase of 2.2 percentage points in two years (Table 5).

Single parents on low incomes can access more in government payments in respect of their children, but also need access to larger homes and have greater commitments to spending on absolute necessities. Around four in 10 single parents in rented property (37.8%) fall below the poverty line. Financial hardship is especially severe for single people living in rented housing in older age, with two thirds of single women aged 55 and a half of older single men in the same age range surviving on incomes below the 50 per cent median poverty line.

There are fewer levers at the disposal of state and territory governments to tackle poverty, but amongst those that they do have, the provision of social housing features among the most important. At 53.8 per cent overall, poverty is far higher among people who rent from a government housing authority. This is to be expected, as there are far fewer social housing places available than there are households in need, so that stringent income and eligibility criteria are used to ration access to limited stock. However, Table 5 shows that the prevalence of poverty for those in social housing has reduced by 6.7 percentage points over the last two years, indicating that once they are settled as social housing tenants it makes a meaningful difference to their ability to get by on a low income.

Financially vulnerable people are forced to make spending decisions on really tight margins with little or no discretionary income, and that’s exactly the situation facing the 1.5 million renters across the country who are experiencing poverty. It is not unusual for the poorest families to have to survive on less than $150 per week once housing costs have been paid - that’s only $21.50 a day.

How much income a family has left for food, clothing and other necessities once housing costs have been paid is heavily affected when rents rise, and this explains much of the growth in poverty rates among those in private rented accommodation.

These results are consistent with findings from the 2021 BCEC Housing Affordability Survey that found more than a third of private renters regularly struggle with housing costs compared to a quarter of those with a mortgage.

TABLE 5 Poverty and housing tenure, 2020 and change 2018 to 2020: by family type

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 18 to 20 (2018-2020).

Supply pressures, high housing costs and rental vacancy rates at unprecedented lows across a lot of the country have driven rental costs to record highs in some states and territories. The typical (median) rental cost for a three-bedroomed house (Figure 5) is currently at least $400 per week across all state and territory jurisdictions, with rental prices in Sydney touching $520 per week. The most expensive city in Australia for renters is Canberra, where the typical rent has rocketed to $570 per week up to the end of 2021.

Rental prices in Darwin rose to an unprecedented $650 per week in 2013, but had been dropping consistently up to 2020.

However, the pattern has again reversed - it now costs $540 per week to rent a typical three-bedroomed house in Darwin.

Weekly rental costs available in the private sector have increased over the last two years by $30 in Sydney and Canberra, and by $50 or more in Perth and Darwin. The same pattern is substantially true for those renting at the lowest price points. Rents have risen even higher in some regional centres, from a combination of low vacancy rates and high demand.

FIGURE 5 Rental costs by state/territory and housing type: 2020

Source: Bankwest Curtin Economics Centre | Real Estate Institute of Australia (REIA).

The rise in rental costs since the onset of the COVID-19 pandemic will inevitably have put more pressure on the abilities of many families to meet their housing costs, especially those who are either out of work or reliant on government payments as their main source of income.

These challenges are shown clearly in the numbers of people who report being unable to meet their housing costs in 2020 compared to the two previous years. Nearly 170,000 more people can’t pay for their housing in 2020, the majority of whom are either in part-time work or not in the labour force (Figure 6).

More than 72,000 unemployed people report not being able to meet their housing costs in 2020, around a third of whom have moved into unemployment from full-time work a year earlier with high mortgage or rent payments.

FIGURE 6 Number of people unable to meet housing costs: 2018 to 2020, by labour market status

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 18 to 20.

Rising housing cost pressures have added significantly to the financial pressure faced by families in rented accommodation, especially those who are either out of work or reliant on government payments as their main source of income.

So what supports are available to low income families in the face of accelerating rental costs?

People receiving government allowances who pay rent of $159 or more per week are eligible for the maximum weekly Commonwealth Rent Assistance (CRA) of $71.40, but for most, the cheapest rents that can be accessed on the private rental market are at least $300. This means that every dollar of increase in private rental costs is a dollar less of disposable income. The impact of rapidly rising housing costs is especially acute for families whose incomes are relatively fixed, as is the case for those without a job and who rely on government allowances as their main source of income.

The experience of rising rental costs over the last two years brings to the fore the importance of the CRA maximum rent assistance entitlement, and the need for it to adequately reflect the (very different) costs incurred by low income families across the country.

People have substantially different experiences of housing cost stress across states and territories, and between cities and regional areas, but the maximum level of rent assistance remains fixed at a single rate for all regardless of their location.

And the maximum CRA rate has increased by only $6.10 over the last five years - an equivalent annual percentage growth of only 2 per cent - when rents have grown far faster, as evidenced Figure 5. We find typical rents to have increased annually by at least 3 per cent in Sydney, Adelaide and Canberra, and by nearly 7 per cent in Perth.

This necessarily creates inequities in the degree of financial support for housing costs among the poorest sections of society driven solely by where they live.

Unemployed single people in rented housing currently receive $388.35 per week from JobSeeker, Commonwealth Rent Assistance and the energy supplement combined. Yet despite this, around 105,000 people who are unemployed are in severe poverty in Australia, the majority of whom are single people living in private rentals or social housing.

To see what it might take to mitigate the incidence of severe poverty in Australia, we use data from the HILDA survey to project the impact of different combinations of government income supports on poverty rates.

We find the most efficient targeting of poverty comes from a combination approach involving changes to both JobSeeker payments and the maximum CRA rate. Our analysis suggests that an increase of $20 per day in the base JobSeeker rate combined with 30 per cent increase in the maximum CRA rent assistance rate would go a long way towards eliminating severe poverty in Australia. The other area where state and territory governments can have an important policy impact on the poverty of their citizens is in relation to the effect of household fees and charges on living costs, particularly in relation to the cost of essential services (such as electricity, water, public transport and telecommunications) and the effectiveness of concessions. Accessible and well targeted concessions policy is a way of ensuring those in greatest need are supported, while keeping household fees and charges low for all citizens is a good way to ensure that working poor individuals and households do not miss out.

UNEMPLOYMENT AND POVERTY THROUGH COVID-19: DID THE CORONAVIRUS SUPPLEMENT HELP?

Unemployment is one of the strongest drivers of poverty for Australian families, and potentially most significant among jobless households. With no salaries or employment income to draw from, many families - particularly those with children - will inevitably face financial challenges in making ends meet, especially with high or rising housing costs.

To understand the scale of the issue, this section of the report looks at the association between joblessness and financial hardship, using a poverty line of 50 per cent median per capita income.

The poverty rate for working single adults came to around 16.1 per cent in 2020, and for working single parents to 15.3 per cent (Figure 7). Around 55 per cent of unemployed single parents experienced poverty, with a similar rate among those who were not in the labour force.

Poverty rates were around 25.5 per cent for jobless couples without children where both partners were unemployed, rising to 43.1 per cent for jobless unemployed couples with children. Similar rates applied where both partners were not in the labour force. However the poverty rate is much higher, at 43.3 per cent, among jobless couples without children where one partner is unemployed and the other is not in the labour force.

FIGURE 7 Poverty rates among jobless households: 2020, by family type

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey wave 20.

FIGURE 8 Changes in poverty incidence by value of JobSeeker coronavirus supplement

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 20.

Poverty among jobless households has fallen in 2020 compared to 2019, largely as a result of the emergency COVID-19 measures put in place - principally the Coronavirus supplement to JobSeeker (Figure 8).

The share of the unemployed below the ‘standard’ (50 per cent median) poverty line fell by just under 6 percentage points to 24.6 per cent among HILDA respondents interviewed up to 24 September 2020, when the Coronavirus supplement was set at $550 per fortnight, compared to Q4 2019.

The poverty rate then increased 7.9 percentage points to 32.5 per cent for respondents interviewed from 25 September 2020 to 31 December 2020, when the Coronavirus supplement was reduced to $250 per fortnight, and by a further 3.8 percentage points to 36.3 per cent from 1 January 2021.

Joblessness and long-term unemployment has long presented a challenge, and a difficult one, in the design of effective policy initiatives. But the social and economic payoff from reducing the number of people in the deepest or most persistent financial hardship would be considerable. It remains a priority for coordinated State and Federal programs to address issues of severe and persistent hardship among those who have been out of work for an extended period of time.

These associations provide a pretty clear demonstration of the effectiveness of potential mitigation of poverty if JobSeeker payments are set at a sufficient base level. This evidence highlights the importance of the current debates regarding JobSeeker adequacy, to which we turn now.

FIGURE 9 Relativity of JobSeeker payment rates to poverty line: 2000 to 2021

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 20.

What level of income protection is provided by government payments? And is the basic income support afforded adequate to meet families’ basic needs?

On the question of adequacy, Figure 9 shows the trajectory of maximum JobSeeker, including the maximum entitlement to the Commonwealth Rent Assistance (CRA), for a single person. Figure 9 also shows the standard poverty line, the schedule of Age Pension single rate, and the hypothetical values of JobSeeker if uprated in line with the Age Pension from 2020.

The impact of the Coronavirus Supplement from September 2020 is clear, with the maximum level of financial support lifting comfortably above the poverty line for recipients. But equally, the maximum rate of JobSeeker and CRA returns to well below the poverty line once the supplement ended.

Following its withdrawal, the maximum weekly income from JobSeeker and CRA combined comes to $386.15 per week, which includes maximum Commonwealth Rent Assistance at $71.40 per week. This is well below a ‘standard’ poverty line of 50 per cent of median income.

In fact, the entitlement is actually likely to keep recipients below the threshold for severe poverty, which we set at 30 per cent of median income, worth $271 per week after housing costs.

For even a minimal rental cost of $250 per week, the maximum entitlement to JobSeeker and CRA leaves recipients with only $136.15 to live on once housing costs have been covered - well into severe poverty according to the definition in this report.

A LIFETIME OF HARDSHIP?

Financial hardship can be short-term or transitory for some, but for many, the experience of poverty can endure over an extended period of time. And research shown later in this report uncovers compelling evidence that persistent poverty is destructive, damaging health and wellbeing to a significant degree.

Around 575,000 people have been in poverty for at least five of the last ten years, with a further 115,000 having faced financial hardship consistently for a decade or more.

Single people face a heightened risk of persistent poverty, while a third of a million single people and a quarter of a million single parents have been in poverty for at least five of the last ten years.

Poverty across the life-course is especially prevalent for those renting, particularly for single person households. Around 30 per cent of single people aged under 35 and renting are in poverty, but more than 70 per cent of single renters aged 55 and over experience poverty.

FIGURE 10 Number of years in poverty and severe poverty: 2019-2020

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA survey waves 19-20.

“POVERTY, LIKE FREEDOM, IS A QUESTION OF DEGREE.”

EMPLOYMENT, POVERTY AND COVID-19

INTRODUCTION

It is understandable to interpret poverty largely as a challenge faced by people without employment, and of course the majority of the poorest people (and of course their children) are either unemployed or outside of the labour market. However, there is a significant share of people in Australia who are employed, but whose incomes keep them below the poverty line.

THE WORKING POOR

In 2020, 8.8 per cent of people classed as poor (that is, earning below 50% of equivalised median income) were in full-time employment (Figure 11) and a further 10.8 per cent were part-time workers - taken together, that is nearly one in five of the poor who are working. Just over a quarter of people in poverty are not in the labour force and of working age, while 20 per cent are retired.

The unemployed make up 7.2 per cent of the poor, but of course the number of unemployed people is a small fraction of the total adult population. It is also worth highlighting that a far larger share of unemployed people are in poverty than any other group in the labour force.

FIGURE 11 The labour market characteristics of people in poverty: 2020

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey wave 20 (2020).

And in which industries are the working poor most likely to be employed?

Rates of poverty are highest in the agriculture sector, with 12.6 per cent of agriculture workers earning below the ‘standard’ (50 per cent median) poverty line (Figure 12), and 9.2 per cent classed as being in severe poverty. Nearly one in 10 people in accommodation, food and hospitality services are working in poverty, with rental hiring and real estate services and administrative and support services also ranking highly.

FIGURE 12 Working poverty rates (including severe poverty): 2020, by industry sector

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey wave 20.

EMPLOYMENT TRANSITIONS THROUGH COVID-19

A change of labour force status is likely to be one of the most influential factors in peoples’ descent into or escape from poverty. And labour markets were clearly affected by the COVID-19 pandemic. Using the HILDA survey, Figure 13 compares the number of people in four broad labour force categories, comprising full-time work, part-time work, unemployment, and not in the labour force.

The numbers of people working full-time in 2018 and 2019 were virtually identical, at just below and just above 7.5 million people in each year. However, between 2019 and 2020 the number of full-time workers fell nearly 480,000 to just over 7 million in 2020, demonstrating the significant effect that COVID-19 had on the labour market.

The count of part-time workers increased by just under 163,000 to 3,983,000 in 2020, and the number of unemployed rose by nearly 185,000 to 731,000. The number of people not in the labour force grew by 310,000 between 2018 and 2019 and increased by a further 241,000 in 2020, to 6,183,000.

FIGURE 13 Employment numbers by labour market status: HILDA estimates, 2018 to 2020

Note: Working poverty rates are estimated on the subset of HILDA survey respondents in full-time or part-time employment. HILDA Wave 20 survey responses were collected between August 2020 and February 2021. Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 18 to 20.

To get more of a sense of labour market flows, Figure 14 explores transitions across four broad labour market categories, comprising full-time work, part-time work, unemployment, and not in the labour force.

As a benchmark, each panel of Figure 14 reports two sets of transitions: the first, in gold, shows transitions to each of the four labour market states between 2018 and 2019. The second, in blue, shows transitions between 2019 and 2020.

Of the 7 million full-time workers in 2020, 6,296,000 people remained in full-time work between 2019 and 2020, while 524,000 entered full-time employment from part-time work (Figure 14 Panel a). Just over 82,000 full-time workers in 2020 were unemployed in the previous year, and 121,500 entered the labour market to work full-time.

Nearly 768,000 people moved from full-time to part-time work between 2019 and 2020, an increase of more than 240,000 compared to the previous year (Panel b). This reflects the adjustments that many employers were making to their workforce during the first year of COVID-19.

The composition of the 731,000 unemployed in 2020 are highly relevant to our understanding of changes to poverty rates in 2020, as shown in Panel (c). More than 180,000 people entered unemployment in 2020 from full-time work a year earlier, nearly triple the comparable flow moving into unemployment from full-time work in 2019. The flow into unemployment from part-time work came to 126,500, an increase of more than 50 per cent compared to the previous year. Collectively, that means more than 300,000 people who were unemployed in 2020 were in paid work a year before.

FIGURE 14 Employment transitions by labour force status: HILDA estimates, 2019 and 2020

Note: Working poverty rates are estimated on the subset of HILDA survey respondents in full-time or part-time employment. HILDA Wave 20 survey responses were collected between August 2020 and February 2021. Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 19 and 20.

WORK TRANSITIONS AND POVERTY INCIDENCE DURING COVID-19

The transition from work to unemployment inevitably represents a significant shock to financial security, affecting the capacity to cover accustomed outlays on housing, food, utilities, loans and recreation when they were working.

So how did these labour force transitions affect poverty rates in 2020? And did the protections introduced through the JobSeeker COVID-19 supplements and the JobKeeper wage subsidy alleviate poverty during 2020?

Poverty rates by labour force status over the three years from 2018 to 2020 are shown in Figure 15. For full-time workers, poverty rates have typically been low, but have dropped by 1.4 percentage points in 2020 to 3.4 per cent.

Around 7.7 per cent of part-time workers were in poverty in 2020, down 2.2 percentage points from 9.9 per cent in 2019. Taken together, these two changes are indicative of a degree of protection afforded to workers by the JobKeeper wage subsidy that was introduced on 30 March 2020.

Poverty rates for the unemployed rose steeply to over 30 per cent in 2019, before falling 4.2 percentage points to 26.2 per cent in 2020, while just over one in five of those not in the labour force are below the 50 per cent median poverty line.

FIGURE 15 Poverty by labour market status: HILDA estimates, 2018 to 2020

Note: Working poverty rates are estimated on the subset of HILDA survey respondents in full-time or part-time employment. HILDA Wave 20 survey responses were collected between August 2020 and February 2021. Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 18 to 20.

To explore whether people who moved between labour market states were at greater risk of financial hardship than those who remain at their current status, Figure 16 further breaks down the changes in poverty rates between 2019 and 2020 by labour markets transitions across the four labour market states.

Poverty rates for full-time workers fell across all prior labour force states (Panel a), while only 5.2 per cent of workers who moved from full-time to part-time work in 2020 dropped below the ‘standard’ poverty line (Panel b) - half the rate compared to those who made the same transition a year earlier.

The fall in poverty rates for the unemployed in 2020 (shown earlier in Figure 15) coincided with the introduction of the COVID-19 supplement to JobSeeker. This could indicate that the additional $550 on top of the base JobSeeker payment provided financial protection, either to those who moved into unemployment in 2020, or who have been out of work since 2019. So which is the case?

Nearly one in five (19.3%) of those who moved from part-time work to unemployment experienced poverty in 2020 (Figure 16 Panel c). This is 4.7 percentage points lower than the equivalent poverty rate among those who made the same transition into unemployment in 2019. Poverty rates for people who moved from full-time work to unemployment dropped to 11.4 per cent in 2020, down 3.1 percentage points, while poverty rates for those that remained unemployed across 2019 through to 2020 rose slightly to 37.1 per cent.

FIGURE 16 Poverty by labour force transitions: HILDA estimates, 2019 and 2020

Note: Working poverty rates are estimated on the subset of HILDA survey respondents in full-time or part-time employment. HILDA Wave 20 survey responses were collected between August 2020 and February 2021. Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 19 and 20.

HOW HAVE COVID-19 STIMULUS MEASURES AFFECTED WORKING POVERTY?

Another innovation in this report centres on the manner in which we compare the depth of poverty between workers according to contract type, including those on permanent contracts, those working to fixed term contracts, and those employed casually.

The fieldwork for the 2020 HILDA survey took place between August 2020 and February 2021. This provides us with an important opportunity to compare labour market outcomes among workers according to whether their employers have been able to claim the JobKeeper wage subsidy payment.

FIGURE 17 Working poverty rates: by gender and contract status

Note: Working poverty rates are estimated on the subset of HILDA survey respondents in full-time or part-time employment. HILDA Wave 20 survey responses were collected between August 2020 and February 2021. Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 19 and 20.

Figure 18 provides a benchmark poverty rate in 2019 for workers on permanent contracts, fixed term contracts and in casual employment. We then compare the share of workers in poverty in 2020 by contract status in organisations that claimed JobKeeper payments, versus organisations that did not claim the wage subsidy (Panel a) and their incomes (Panel b).

One of the clearest findings to emerge from this analysis is that rates of working poverty for those employed on casual contracts dropped between 2019 and 2020 but by a far greater margin for workers and organisations that were able to claim the JobKeeper payment.

In 2019, around one eighth of workers on casual contracts were below the 50 per cent poverty line. In 2020, the poverty rate dropped to 9.4 per cent among workers for whom no JobKeeper payments were claimed, but to a much lower rate of 5.6 per cent for workers and companies that both qualified for and claimed JobKeeper.

FIGURE 18 Working poverty rates and incomes: by contract status and receipt of JobKeeper

Note: Working poverty rates are estimated on the subset of HILDA survey respondents in full-time or part-time employment. HILDA Wave 20 survey responses were collected between August 2020 and February 2021. Employed respondents in the 2020 JobKeeper category reported that their employers had accessed the JobKeeper wage subsidy in respect of their employment. Those in the 2020 No JobKeeper category reported no JobKeeper wage subsidy payments were received by their employer. Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 19 and 20.

The reason for such a marked difference stems from the requirement for companies receiving JobKeeper to pass the wage subsidy payments fully to eligible workers. The subsidy payments were initially worth $750 per week, regardless of the workers’ salaries. As Cassells and Duncan (2020) demonstrated, this meant that a considerable share of those on casual contracts saw their incomes increase significantly during the majority of 2020 and the first quarter of 2021.4

This explains why the average weekly earnings for those on casual contracts rose from $616 per week in 2019 to $754 per week when their employers were able to claim JobKeeper, but to only $650 per week when this was not the case (Figure 18 Panel b).

However, what is less obvious and more surprising is that the reverse appears to be true for workers on permanent or fixed term contracts in JobKeeper-eligible organisations. For example, the rates of working poverty for employees on fixed term contracts rose from 4.3 per cent to 5.9 per cent between 2019 and 2020 - that’s nearly twice the 3.1 per cent poverty rate for casual employees in organisations that did not qualify for the subsidy. The same effect is present to a lesser degree among permanent contract holders.

We can see this effect playing out in a comparison of the average weekly earnings of workers in 2020 according to contract status (Figure 18 Panel b). The average weekly pay for workers on permanent or fixed term contracts was around $350 per week lower when their employers were able to claim JobKeeper payments compared to those organisations that remained ineligible for the wage subsidy.

FIGURE 19 Share of full-time and part-time workers below poverty line: by JobKeeper receipt and contract status

Note: Working poverty rates are estimated on the subset of employed people. HILDA Wave 20 survey responses were collected between August 2020 and February 2021. Employed respondents in the 2020 JobKeeper category reported that their employers had accessed the JobKeeper wage subsidy in respect of their employment. Those in the 2020 No JobKeeper category reported no JobKeeper wage subsidy payments were received by their employer. Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 19 and 20.

5 Cassells and Duncan (2020) Jobkeeper: The efficacy of Australia’s first short-time wage subsidy. Australian Journal of Labour Economics, Volume 23/2, pp 99-128. https://bcec.edu.au/publications/jobkeeper-the-efficacy-of-australias-first-short-time-wage-subsidy/

Casual employees benefited from an increase in their earnings due to the conditions of JobKeeper, leading to a significant reduction in rates of working poverty (Figure 19). The rate of working poverty for full-time workers on fixed term contracts more than doubled to 8.5 per cent between 2019 and 2020, but fell to 2.3 per cent among part-time fixed term workers. This indicates that a share of fixed term employees were moved from full-time to part-time hours in 2020, and a greater share of workers on fixed-term contracts lost employment during 2020 (Figure 20).

These findings suggest that the introduction of JobKeeper led to a substitution of pay and conditions between workers according to contract status. One of the key learnings from the COVID crisis and previous economic downturns (such as the Global Financial Crisis in 2008 and the Nineties recession) is that our best strategy to reduce the scarring effects of job loss and support an effective economic recovery is to reach out and engage with the newly jobless to quickly provide advice and support.

The sooner we can provide advice on careers and skills, and support to avoid financial stress, deteriorating mental health or relationship breakdown, the fewer households will face long-term joblessness and poverty.

The problem we faced was that many of these households had not engaged with services before, may be living in areas with less disadvantage and fewer social services, and put off reaching out for help because of stigma and the complexity of navigating the bureaucracy.

Models using local community connectors, who are accessible in local libraries, community resource centres, or shopfronts in local shopping centres in affected towns and regions can be most effective.6

FIGURE 20 Change in the number of workers, 2019 to 2020: by contract status

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 19 and 20.

6 WA Community Recovery Plan, June 2020, WACOSS. https://www.wacoss.org.au/library/stage-one-wa-community-recovery-plan/.

E: HOW DOES POVERTY IMPACT ON PEOPLES’ LIVES?

INTRODUCTION

Experiences of financial hardship will inevitable impact on people’s quality of life, their security, health and sense of wellbeing. This section of the report explores the strength of the connections between poverty and broader aspects of economic and social disadvantage.

DOMAINS OF VULNERABILITY

The HILDA survey includes a broad set of indicators that document survey respondents’ attitudes towards their financial and social circumstances, as well as broader measures of life satisfaction. Interrogating these data offers some insights into the experiences of living with poverty.

Statistical modelling was used to reveal broader domains of vulnerability from the many indicators of financial and social wellbeing collected in the HILDA survey. The approach, known as Principal Components Analysis (PCA), can be used to construct social indices by exploiting similarities and contrasts between a set of indicators. The PCA analysis uncovered relatively tightly grouped clusters of indicators that revealed three informative concepts of vulnerability or disadvantage (Figure 21) which could be helpful in framing the coordination of policies to address disadvantage and improve individual wellbeing:

• Financial vulnerability and deprivation: relating to the inability to pay bills or afford essential utilities, difficulties in meeting housing costs or raising cash for an emergency, going without meals, and needing to reach out for financial assistance or help from community or welfare organisations;
• Emotional vulnerability and social exclusion: relating to social isolation and the absence of a social life, not being able to connect with friends and family, loneliness and emotional distress, a feeling of lack of support;
• Housing insecurity: relating to dissatisfaction with housing circumstances, a feeling of lack of safety in the home, a sense of disconnection through eviction, or pressure to compromise on the location because of challenges with housing affordability.

FIGURE 21 Domains of vulnerability

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 19 and 20.

TABLE 6 Prevalence of financial vulnerabilities, all people and those in poverty: 2019 and 2020

Note: Poverty calculations are based on real equivalised household disposable incomes, after housing costs, with nil and negative incomes excluded. The relative odds measure is the ratio of prevalence for families in poverty compared to all families.

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 19 and 20 (2002-2020).

Table 6 shows how measures within the financial vulnerability and deprivation domain have changed between 2019 and 2020 for people experiencing poverty, and for the broader population.

More than 1 in 12 (8.7%) of people on low incomes went without meals in 2020, which is 2.8 times the rate for all families. However, the share of people in poverty who went without meals did fall by 2.3 percentage points between 2019 and 2020.

The share of people experiencing poverty who had difficulties in meeting bills also fell between 2019 and 2020, dropping by 1.2 percentage points to 15.9 per cent, but remained at 9.8 per cent for the broader population. More people were able to heat their homes in 2020, but it is worth noting that the HILDA survey does pre-date the more recent increases in living costs, so this trend may not reflect the current situation - especially now that the extra financial supports made available during the COVID-19 pandemic are no longer available.

FIGURE 22 Prevalence of financial vulnerabilities among families in poverty: 2002 to 2020

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 2 to 20.

The improvements in most indicators of financial vulnerability for people on lower incomes during 2020 (Figure 22) suggest that, despite the pandemic, the Coronavirus supplement was effective in alleviating their financial stresses compared to a year earlier.

A number of the indicators in the emotional vulnerability and social exclusion domain deteriorated in 2020 both for those people experiencing financial hardship and for the broader population, which reflects the influence of restrictions put in place during the COVID-19 pandemic.

TABLE 7 Prevalence of social isolation, all people and those in poverty: 2019 and 2020

Note: Poverty calculations are based on real equivalised household disposable incomes, after housing costs, with nil and negative incomes excluded. Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 19 and 20 (2002-2020).

The share of people that reported having no social life during 2020 increased by 3.8 percentage among all families, and by 3.5 percentage points for people experiencing poverty (Table 7). The share of people having no visitors also rose in 2020 for both groups.

Nearly one in seven people in poverty (14.6%) feeling very lonely in 2020. These findings match those in the Centre’s Loneliness and Belonging report, which shows the heightened degree of social isolation experienced by people in poverty.

FIGURE 23 Prevalence of social isolation among families in poverty: 2002 to 2020

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 2 to 20.

JOURNEYS INTO POVERTY: LIFE EVENTS AND FINANCIAL HARDSHIP

For many, the journey into poverty will have been triggered by a life event that substantially changes their financial situation and outlook. Circumstances change substantially for people who suffer relationship breakdown or the death of a partner. People lose their jobs or retire. Each of these life transitions can have profound impacts on people’s personal well-being, and may bring a significant material change to their financial circumstances.

One of the great opportunities afforded by using the HILDA survey is that its longitudinal nature, which makes it possible for life events to be tracked, and related to measures of financial hardship.

For this report, we employ statistical regression methods to assess to what extent each of these life events affects poverty incidence, and how long the effects on poverty endure. We consider the likelihood both of being in poverty, and of moving into poverty, among people whose life histories we observe for at least five years. We test the impacts of four life events on poverty incidence and transition separately for women and men, including divorce or separation from a partner, the death of a partner, retirement, and the loss of employment. Each model relates current poverty status to life transitions that occurred in the previous year, two years ago, and three or more years ago. Additional factors are added to explain poverty status, including gender and Indigenous status, employment status, proficiency in English, family characteristics, age and birth cohort.

The results reported in Table 8 provide a number of important insights:

• The risk of poverty increases by 6.7 percentage points for women following relationship breakdown in the previous year, and by 4.6 percentage points for men.
• The risk of poverty after the death of a partner in the previous year increases by 5.9 percentage points for women, and by 4.6 percentage points for men.
• The poverty risks for women remain at a heightened level for three or more years after a relationship breakdown or the death of a partner.
• The risk of moving into poverty is three times higher for women than for men following separation or divorce, and nearly twice as high following the death of a partner.
• The effects on the likelihood of poverty of the loss of employment in the previous year is higher for men than women, at 3.7 percentage points compared to 1.7 percentage points.
• Similarly, the chance of moving into poverty due to the loss of a job in the previous year increases by 5.7 percentage points for men and 3.2 percentage points for women.
• Retirement increases the probability of moving into poverty by two percentage points for women and 2.6 percentage points for men.
• The impacts of both retirement and job are short term and typically last for no more than one year.
• Indigenous women and men are more likely both to be in poverty, and to move into poverty, than non-Indigenous women and men
• The lack of English proficiency is also a significant factor in poverty incidence and transition.

The overall take-homes messages on the relationship between poverty and life events from these findings are relatively clear.

Both partners are at greater risk of poverty when relationships break down, but the effects are both more severe and more enduring for women. The poverty risks for women remain at a heightened level for three or more years after a relationship breakdown or the death of a partner. The loss of a partner increases the risk of poverty for both men and women for an extended period, but is more likely to move women into poverty compared to men.

BEHIND THE LINE:

POVERTY AND DISADVANTAGE IN AUSTRALIA 2022

TABLE 8

Relationship between life events, poverty incidence and transitions into poverty: regression

| Marginal impacts of life events on the incidence and transition into poverty |||| | — | — | — | — | — | | Life event | on likelihood of poverty (ppt change) || on moving into poverty (ppt change) | | | Women | Men | Women | Men | | Divorce/separation from partner ||||| | Last year | 6.69 *** | 4.65 *** | 4.20 *** | 1.57 ** | | 2 years ago | 5.43 *** | 3.15 *** | 2.84 *** | 1.50 ** | | 3+ years ago | 5.80 *** | 3.64 *** | 2.86 *** | 2.22 *** | | Death of partner ||||| | Last year | 5.89 *** | 4.51 *** | 3.05 *** | 1.71 | | 2 years ago | 4.07 *** | 4.74 ** | 2.03 ** | 1.20 * | | 3+ years ago | 6.67 *** | 4.38 ** | 3.26 *** | 2.38 | | Retirement ||||| | Last year | 0.20 | 1.66 ** | 2.05 *** | 2.62 *** | | 2 years ago | 0.93 | 2.71 *** | -0.45 | 1.06 | | 3+ years ago | 0.54 | 0.50 | -0.98 | -0.88 | | Fired from job ||||| | Last year | 1.73 ** | 3.36 *** | 3.20 *** | 5.73 *** | | 2 years ago | 0.86 | 1.04 | 0.48 | 0.83 | | 3+ years ago | 1.12 | 0.45 | 0.70 | 0.85 | | Gender ||||| | Non-Indigenous woman | (reference) || (reference) | | Non-Indigenous man | -5.69 *** || -7.30 *** | | Indigenous woman | 14.37 *** || 8.63 *** | | Indigenous man | 8.10 *** || 3.05 *** | | English proficiency ||||| | Proficient in english | (reference) || (reference) | | Very poor english | 21.49 *** || 1.31 | | Poor english | 15.09 *** || 5.27 *** | | Labour force status ||||| | Employed full-time | (reference) || (reference) | | Employed part-time | 8.21 *** || 4.46 *** | | Unemployed | 28.11 *** || 16.29 *** | | Not in the labour force | 22.18 *** || 10.16 *** | | Additional controls ||||| | Year | (reference) || (reference) | | Age x gender | YES || YES | | Birth cohort | YES || YES |

Note: Regression estimates use poverty incidence measures based on 50 per cent median equivalised household disposable incomes, after housing costs. Nil and negative incomes are excluded. Moving into poverty is defined as someone within the HILDA survey who is modelled to be in poverty in the current year but not to be in poverty in the previous year. Life events variables are constructed using the longitudinal cross-wave identifier in the HILDA survey. To ensure sufficient history for previous life events, only individuals who are present for at least 10 survey years are included in the estimating sample. Estimated regression parameters are reported as significant at 1 per cent (), 5 per cent () and 10 per cent ().

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 2 to 20 (2002-2020).

56 BANKWEST CURTIN ECONOMIC CENTRE | FOCUS ON THE STATES SERIES

POVERTY AND HEALTH

POVERTY AND HEALTH

We showed earlier in this report that close to 600,000 people have been in poverty for at least five of the last ten years, 20 per cent of whom have faced financial hardship consistently for a decade or more. To be in poverty for so long will inevitably take its toll on people’s life satisfaction, well-being and mental health. But to what degree does poverty persistence affect psychological well-being?

BANKWEST CURTIN ECONOMIC CENTRE | FOCUS ON THE STATES SERIES 57

People who face persistent poverty are more likely to experience psychological distress, and the longer the time in poverty, the worse the mental health impacts.

THE LINK BETWEEN PERSISTENT POVERTY AND PSYCHOLOGICAL DISTRESS

The Kessler K10 index of psychological distress measures ten component indicators of distress, each scored on a scale of 1 (low) to 5 (high) building up to a composite score (10-50). A banded measure based on K10 scores categorises the level of psychological distress felt as low (for K10 scores of 10-15), moderate (16-21), high (22-29) and very high (30-50).

So does poverty persistence affect either of these two measures of psychological distress? If it does, how robust is the relationship between psychological distress and poverty?

FIGURE 24

People who face persistent poverty are more likely to experience psychological distress, and the longer the time in poverty, the worse the mental health impacts (Figure 24).

Those who are in poverty for at least five of the last ten years are three times more likely to suffer acute mental stress compared to people who are never in poverty (shown in red bars in Figure 24).

A similar pattern can be seen for those falling within the high psychological distress category (in orange) - as poverty duration increases, so does the level of acute psychological distress.

The relationship between persistent poverty and psychological distress

70

60

50

40

30

Share of people (%)

20

10

0

Never in poverty

1 year

2 years

3 years

4 years

5 years

6+ years

20

19

18

17

16

15

14

13

K10 score

Low stress

Moderate stress

High stress

Very high stress

K10 score

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 2 to 20.

The relationship between psychological distress and poverty is a complex one to unpack, with many potential drivers.

To what extent is psychological distress elevated by poor living standards, the experiences living on low incomes - especially for families with children? It may also be the case that psychological distress itself creates difficulties in securing work, and resolving the challenges of financial hardship.

The effects of persistent poverty can be felt differently at certain ages for women and men. We might expect those impacts also to be felt more acutely by parents, especially by the primary carer.

To explore these associations in more depth, Figure 25 looks separately at the relationship between the number of years in poverty and the prevalence of high or very high psychological distress for single people versus partnered couples with and without children, and by age range.

We find that the psychological trauma from years in poverty rises more steeply for women than for men in most age cohorts and family settings.

The escalation is especially acute on single women aged less than 55 (Panel d), with 40 per cent or more of women who have been in poverty for at least three years experiencing high psychological distress. Psychological stress also rises with the number of years in poverty for single men, albeit to a lesser degree.

More than a third (34.6%) of single parent women who have been in poverty for between three and five years suffer from elevated levels of stress (Panel c), rising to 36.7 per cent when poverty persists for at least six years over the last decade. For male single parents, the rate is somewhat smaller, at just over 24 per cent.

Older age cohorts provide the one exception (Panel f), with more than a quarter of single men aged 55 who have endured poverty for five years or more experiencing psychological distress, compared to one in five older women.

We find that the psychological trauma from years in poverty rises more steeply for women than for men in most age cohorts and family settings.

BEHIND THE LINE: POVERTY AND DISADVANTAGE IN AUSTRALIA 2022

FIGURE 25 Number of years in poverty and the prevalence of psychological distress: by gender

(a) People in couples without children, aged 17-54

(b) People in couples with children, aged 17-54

(c) Single parents aged 17-54

(d) Single people aged 17-54

(e) People in couples, aged 55+

(f) Single people aged 55+

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA waves 2 to 20.

60 BANKWEST CURTIN ECONOMIC CENTRE | FOCUS ON THE STATES SERIES

THE SCARRING EFFECTS OF CHILDHOOD AND ADOLESCENT POVERTY

Does financial vulnerability in childhood and adolescence have an impact on the future economic, social and health outcomes of young people?

As a first test of whether there exists a relationship between childhood poverty and adult outcomes, we use HILDA survey data7 to compare young people according to the degree of financial vulnerability they faced while in the family home. Specifically, we compare employment outcomes for young adults who experienced no poverty at home with adults who experienced poverty during childhood - including those that experienced persistent poverty at home.

The analysis shows that the likelihood of securing future employment is up to 11 percentage points lower for young adults who experienced poverty in the family home compared to those who did not come from a poor childhood background (Figure 26).

The employment trajectories of the two groups narrow once the young adults approach 30 years of age, but the gap remains strongly significant from the age of 18.

These differences could potentially be explained purely by compositional differences, and differences in personal characteristics and sociodemographic background.

To explore the question, we use the HILDA survey to track the economic, social and health outcomes for the same individuals for up to twenty years. This means that we are able to follow the progress of children and young people into their adult lives.

To examine whether the experience of poverty whilst in the family home affects future economic, social and health outcomes, we compare the life outcomes of children who experienced poverty in the family home with those that did not for each of the 10 years after they leave home.

FIGURE 26 Adult employment rates for young adults aged 17 to 30: by incidence and persistence of family poverty in childhood

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 19 and 20.

7 The Household Income and Labour Dynamics in Australia (HILDA) survey, managed by the Melbourne Institute.

The innovative research presented in this report uncovers compelling evidence that children’s experiences of poverty are damaging to their future economic outcomes and mental and psychological health.

Our method uses a matching approach to compare the outcomes from ages 17 through to 30 for young adults in the HILDA survey who experienced poverty in their childhood years with similar people who were not exposed to poverty during childhood.3 Only those young people who were observed for at least three years before and three years after leaving home are included in the matching process. This ensure adequate measurement of outcomes both in childhood through to young adulthood.

The series of charts presented in Figure 27 compare the trajectories of young adults who experienced poverty in childhood (in gold) with similar people who faced no poverty (in blue), across a range of economic, social and health outcomes.4

The specific measures we choose to compare include; (a) employment, (b) unemployment, (c) the incidence of poverty and (d) severe poverty, (e) whether people suffer from anxiety or nervousness, and; (f) whether they regularly feel down emotionally.

The first chart (a) confirms that the trajectories shown earlier in Figure 26 were not driven by differences in education, age, gender or other sociodemographic characteristics in adulthood.

The likelihood of employment for young adults who come from a background of child poverty is around 11 percentage points lower than employment rates for those who didn’t experience poverty in the family home (Panel a). The differences are a little larger in the first five years after leaving home, and narrow to around 8 percentage points in the late 20s.

Unemployment rates are significantly higher among adults who experienced poverty at home, even after controlling for differences in characteristics (Panel b). People who experience childhood poverty are up to 8 percentage points more likely to remain in poverty in adult life (Panel c), while the incidence of severe poverty is broadly the same across the two groups (Panel d). They are also significantly more likely to suffer from nervousness (Panel e) or feel unhappy with their lives (Panel f) for up to 10 years after leaving home.

The innovative research presented in this report uncovers compelling evidence that children’s experiences of poverty are damaging to their future economic outcomes and mental and psychological health - even after controlling for age, gender, Indigenous and ethnic background, and future family status and educational achievement.

The analysis in this report reinforces our understanding of how far the impacts of poverty extend, and for how long they endure over the course of people’s lives and the lives of their children. Equally, the report’s findings demonstrate the scale of the economic return from targeted strategies to reduce poverty, as well as the positive social, psychological and health benefits from doing so.

3 The matching process uses the statistical technique of nearest-neighbour matching to pair as closely as possible each person who is first recorded in the HILDA sample as a child and who is modelled to live in a poor household during childhood with up to 10 other children who didn’t experience childhood poverty. Each pairing is aligned as closely as possible on a range of characteristics and attributes, including age, gender, age left home, current family type, number of children and highest educational qualification.

4 In each chart, the differences (the red bars) are marked according to their level of statistical significance.

THE SCARRING EFFECTS OF CHILDHOOD AND ADOLESCENT POVERTY

FIGURE 27 The impact of childhood poverty on adult’s outcomes after leaving the family home

(a) Probability of employment

(b) Probability of unemployment

(c) Probability of poverty

(d) Probability of severe poverty

(e) Probability of nervousness

(f) Probability of feeling down

Note: Comparison groups are constructed using nearest neighbour matching to pair each person who is first recorded in the HILDA sample as a child and who is modelled to live in a poor household during childhood with up to 10 other children who didn’t experience childhood poverty. Matched pairs are selected at each age from 18 to 30 by Mahalanobis distance aligned to gender, age left home, current family type, number of children and highest educational qualification. Life outcomes are constructed using the longitudinal cross-wave identifier in the HILDA survey. To ensure sufficient history for previous life events, the estimating sample includes only individuals who are present as a chiild for at least three years in the family home, and for at least 3 years after leaving the family home. Estimated differences are reported as significant at 1 per cent (), 5 per cent () and 10 per cent ().

Source: Bankwest Curtin Economics Centre | Author’s calculations based on HILDA Survey waves 2 to 20.

BANKWEST CURTIN ECONOMIC CENTRE | FOCUS ON THE STATES SERIES 63

BEHIND THE LINE:

“THE GREATEST EVILS AND THE WORST OF CRIMES IS POVERTY.”

GEORGE BERNARD SHAW

64 BANKWEST CURTIN ECONOMIC CENTRE FOCUS ON THE STATES SERIES

SUMMARY AND RECOMMENDATIONS

SUMMARY AND RECOMMENDATIONS

Economic and social policy should be concerned with creating a safe, secure environment in which everyone can achieve their potential, and thrive. Good economic and social policy should ensure adequate protections for the most vulnerable sections of our community to ensure we are all better off.

Yet in Australia, there are still far too many people who face serious financial hardship, with many experiencing disadvantage over much of their lives.

This Bankwest Curtin Economics Centre Focus on the States report provides the latest examination of the prevalence of poverty within Australia, how this has changed over time, and which groups in society face the greatest risks of financial hardship and material deprivation.

Our analysis reveals that just under 3 million people in Australia live in income poverty, as defined by a poverty line of 50 per cent of median income. This represents nearly 11.8 per cent of the population, and includes nearly 750,000 children.

Poverty fell by just over 350,000 over the last year, driven partly by the COVID-19 supports paid through government allowances and wage subsidies.

However, the story since then has very much been about rising housing and living costs, and the extent to which rent increases are having a far greater impact on those in deepest income disadvantage.

High housing costs represent a significant economic and social issue for Australians, adding directly to a higher incidence of poverty and more severe financial hardship. Those who are unable to enter the housing market are particularly vulnerable, with the overall poverty rate for renters in Australia more than twice that for mortgage holders and three times the rate for owners without mortgages.

For many, the journey into poverty has been triggered by a life event that substantially changes their financial situation and outlook. Circumstances change substantially for people who suffer relationship breakdown or the death of a partner. People lose their jobs or retire, and each of these events have profound impacts on people’s economic security and well-being.

We find that both partners are at greater risk of poverty when relationships break down, but the effects are both more severe and more enduring for women. And women suffer adverse impacts from divorce or separation for longer.

This research shows just how far the effects of poverty extend, and also for how long the impacts last. Findings in this report show that the effects of poverty in childhood stay with those people as they move into adulthood.

But it also shows, if such a demonstration were ever needed, that there is an economic return to strategies that target a reduction in poverty, to go alongside the positive social, psychological and health benefits from doing so.

Deep and persistent poverty affects not just people’s current wellbeing, but the disadvantages from financial hardship extend well into the future, affecting their economic potential, their health and social connectedness.

Joblessness and long-term unemployment has long presented a challenge, and a difficult one, in the design of effective policy initiatives. But the social and economic payoff from reducing the number of people in the deepest or most persistent financial hardship would be considerable.

It remains a priority for coordinated State and Federal programs to address issues of severe and persistent hardship among those who have been out of work for an extended period of time.

Added to this, the pandemic has led to a growing class of newly unemployed people who may well be experiencing unemployment for the first time in their lives, carrying commitments that align with their previous work status, and who may be entirely unfamiliar with the situation.

Interventions that would address the immediate service needs of newly unemployed, including measures to reconnect with the labour market, would be both beneficial and economically highly efficient.

JobSeeker and Commonwealth Rent Assistance together provides a total of $386.15, which is simply not adequate as a protection against rising rents and broader living costs. Even if recipients can find rental accommodation at $250 per week, this leaves only $136 per week to live on.

The COVID-19 pandemic has given government support systems for people in poverty a stress test, and has found them wanting. It also showed how a substantial increase in income support to those living in poverty can transform their lives and effectively stimulate our economy.

This report recommends an increase of 30 percent in the CRA maximum payment together with a $20 per day increase in the base JobSeeker rate and related payments.

These achievable increases will protect up to 1,000,000 people across the country from rising rents and high costs of living, and go a long way towards reducing severe poverty in Australia.

Social housing is one of the most important levers at the disposal of state and territory governments in the fight against poverty.

It has probably never been more important than now as a way to provide housing security to those in deepest financial hardship as a basis for economic and social participation.

If you already care about gender equity and the status of women within our society, then you should really care about poverty - because it impacts disproportionately on women.

Our research shows that poverty has a greater and more persistent impact on the health and wellbeing of women, their economic security, and their ability to safely participate in our community as equals.

Women are also more likely to take on caring roles and responsibilities that are further impeded by poverty.

Raising children and young people or caring for ageing parents becomes dramatically harder with poverty - and the knock-on impacts to the wellbeing of others is increased.

We hope that by looking behind the line, the relevance to each of us of targeting poverty is clear.

Poverty is, and should always remain, a critical issue for Australia, but this report is about more than that.

It’s about equity and fairness.

It’s about narrowing the gap between Indigenous and non-Indigenous peoples.

It’s about making sure our children have the best opportunities to reach their potential and their dreams.

It’s about women’s economic security, and gender equity.

It’s about economic efficiency and the effective delivery of public services.

And ultimately, it’s about how Australia protects, cares for, and nurtures the most important resource of all - its people.

BEHIND THE LINE:

“POVERTY IS NOT AN ACCIDENT. LIKE SLAVERY AND APARTHEID, IT IS MAN-MADE AND CAN BE REMOVED BY THE ACTIONS OF HUMAN BEINGS.”

NELSON MANDELA

68 BANKWEST CURTIN ECONOMIC CENTRE FOCUS ON THE STATES SERIES

GLOSSARY AND TECHNICAL NOTES

GLOSSARY AND TECHNICAL NOTES

Consumer Price Index (CPI) The Consumer Price Index measures quarterly changes in the price of a ‘basket’ of goods and services which account for a high proportion of expenditure by metropolitan households.

Coronavirus Restriction Period (CRP) The period from March to May 2020 when COVID-19 restrictions were at their peak. For the LSAC survey, respondents were asked to ‘think back’ to their experiences during the CRP.

Community support groups Whether the person has been actively involved in a community support group in the last 12 months.

Examples of community support groups include:

• service clubs
• welfare organisations
• education and training
• parenting/children/youth
• health promotion and support
• emergency services
• international aid and development.

Employment rate The number of employed persons expressed as a percentage of the civilian population in the same group.

HILDA survey The Household, Income and Labour Dynamics in Australia is a household-based panel study which began in 2001. It tracks information on economic and subjective well-being of the respondents along with family and labour market dynamics.

Kessler psychological distress scale (K10) The status of a person’s mental health is based on the Kessler psychological distress scale (K10). The K10 measure is an aggregate of scores to 10 questions about emotional states, each of which are recorded on a five-level response scale, giving rise to a K10 score of between 10 to 50. The mental health of respondents is categorised according to the following K10 scores:

• Likely to be well (K10 score from 10 to 19);
• Likely to be in mild psychological distress (20 to 24);
• Likely to be in moderate psychological distress (25 to 29), or;
• Likely to be in severe psychological distress (30 to 50).

Life satisfaction Whether respondents are happy with how things are for them in their life. Respondents answered on a scale from ‘strongly disagree’ to ‘strongly agree’.

Principle component analysis Principle component analysis (PCA) is a statistical procedure that can be used to reduce a large set of variables to a small set that still contains most of the information in the large set.

Socioeconomic status The relative socio-economic advantage and disadvantage in terms of people’s access to material and social resources, and their ability to participate in society. Areas in Australia are ranked according to relative socio-economic advantage and disadvantage, constructed by factoring in the proportion of individuals with a tertiary education, people emploued in a skilled occupation and the proportion of families with high incomes.

Statistical Area Level 2 (SA2) The Statistical Area Level 2 (SA2) is an area defined in the Australian Statistical Geography Standard (ASGS), and consists of one or more whole Statistical Areas Level 1 (SA1s). Wherever possible SA2s are based on officially gazetted State suburbs and localities. In urban areas SA2s largely conform to whole suburbs and combinations of whole suburbs, while in rural areas they define functional zones of social and economic links. Geography is also taken into account in SA2 design. SA2s cover, in aggregate, the whole of Australia without gaps or overlaps.

Unemployment rate The unemployment rate is the proportion of the labour force that is unemployed.

Unemployed persons A person who is not employed for one hour or more, is actively seeking work, and is currently available for work.

Unpaid voluntary work through an organisation The provision of unpaid help willingly given in the form of time, service or skills, to an organisation, club, or association. The GSS excludes unpaid voluntary work through an organisation if undertaken overseas.

BEHIND THE LINE: POVERTY AND DISADVANTAGE IN AUSTRALIA 2022

Income poverty

Measurement

Poverty rates are assessed by calculating the percentage of people whose real equivalised household disposable incomes (after housing costs) fall below different fractions of the median. Nil and negative incomes are excluded from all poverty calculations. Data are re-based to 2014 prices.

Exclusions

Excluding particular groups from the income distribution and poverty analysis is common practice among researchers. (see Saunders 2008; Rodgers 2012; Wilkins 2013) . Groups are often excluded if their reported or measured income is deemed to not reflect their real standard of living, or access to economic resources. The self-employed, business owners and those households that report negative or nil income are among those that are typically excluded from poverty analysis.

72 BANKWEST CURTIN ECONOMIC CENTRE | FOCUS ON THE STATES SERIES

REFERENCES

REFERENCES

BANKWEST CURTIN ECONOMIC CENTRE | FOCUS ON THE STATES SERIES 73

REFERENCES

Australian Bureau of Statistics (2019), Household Income and Wealth, Australia: Summary of Results, 2017-18. ABS Cat No.4922.0. Australian Bureau of Statistics: Canberra.

Abello A., Cassells R., Daly A., D’Souza G., and Miranti R. (2016). Youth Social Exclusion in Australian Communities: A New Index. Social Indicators Research, 128, 635-660.

Abello A., Gong H., Daly A. and McNamara J. (2012), Spatial Dimensions of Child Social Exclusion Risk in Australia: Widening the Scope, Child Indicators Research, 5(4), pp. 685-703.

Australian Bureau of Statistics (2012) Information paper - A Statistical Definition of Homelessness, ABS Cat No.4922.0

Australian Bureau of Statistics (2013); Life Tables for Aboriginal and Torres Strait Islander Australians, 2010-2072 (cat. no. 3302.0.55.003), ABS, Canberra.

Australian Bureau of Statistics (2014), Estimates and projections, Aboriginal and Torres Strait Islander Australians, 2001 to 2006, Catalogue No. 3238.0, Australian Bureau of Statistics: Canberra.

Cassells, R., Dockery, A.M., Duncan, A.S., Gao, G. and Seymour, R. (2017). Educate Australia Fair? Education Inequality in Australia, Bankwest Curtin Economics Centre Focus on the States report #5, June 2017.

Cassells, R., Dockery, A.M., Duncan, A.S., Kiely, D., Kirkness, M., Nguyen, T., Seymour, R. and Twomey, C. (2020). The Early Years: Investing in Our Future. Bankwest Curtin Economics Centre, Focus on Western Australia report #13, August 2020.

Cassells, R. and Duncan, A.S. (2020). JobKeeper: The efficacy of Australia’s first short-time wage subsidy. Australian Journal of Labour Economics, 23(2), pp. 99-128.

Cassells, R., Dockery, A.M., Duncan, A.S., Gao, G. and Seymour, R. (2017). Educate Australia Fair? Education Inequality in Australia, Bankwest Curtin Economics Centre Focus on the States report #5, June 2017.

Cassells, R., Dockery, A.M., Duncan, A.S., Kiely, D., Kirkness, M., Nguyen, T., Seymour, R. and Twomey, C. (2020). The Early Years: Investing in Our Future. Bankwest Curtin Economics Centre, Focus on Western Australia report #13, August 2020.

Cassells, R. and Duncan, A.S. (2020). JobKeeper: The efficacy of Australia’s first short-time wage subsidy. Australian Journal of Labour Economics, 23(2), pp. 99-128.

Cassells, R. and Duncan, A.S. (2014). Falling Through The Cracks: poverty and disadvantage in Australia, Bankwest Curtin Economics Centre Focus on the States report #1. October 2014.

Cassells, R., Duncan, A.S. and Gao, G. (2014). Sharing the Boom: The Distribution of Income and Wealth in WA. Bankwest Curtin Economics Centre, Focus on Western Australia report #1, February 2014.

Cassells, R., Duncan, A., Gao, G., James, A., Leong, K., Markkanen, S. and Rowley, S. (2014) Housing Affordability: The real costs of housing in WA, Bankwest Curtin Economics Centre, Focus on Western Australia report #2. April 2014.

Cassells, R., Dockery, A.M., Duncan, A.S., Gao, G. and Seymour, R. (2017). Educate Australia Fair? Education Inequality in Australia, Bankwest Curtin Economics Centre Focus on the States report #5, June 2017.

Crowe .A, Duncan, A.S., James, A. and Rowley, S. (2021). Housing Affordability in WA: A tale of two tenures. Bankwest Curtin Economics Centre Focus on Western Australia report #15, June 2021.

Cruwuys, T., Berry, H., Cassells, R., Duncan, A.S., O’Brien, L., Sage, B. and D’Souza, G. (2013). Marginalised Australians: Characteristics and Predictors of Exit Over Ten Years 2001-10. University of Canberra, Australia.

Davidson, P., Saunders, P., Bradbury, B. and Wong, M. (2020). Poverty in Australia 2020: Part 1, Overview. ACOSS/UNSW Poverty and Inequality Partnership Report No. 3, Sydney: ACOSS.

Davidson, P., Bradbury, B., and Wong, M. (2020), Poverty in Australia 2020: Part 2, Who is affected? ACOSS/UNSW Poverty and Inequality Partnership Report No. 4, Sydney: ACOSS.

Duncan, A., Kiely, D., Mavisakalyan, A., Peters, A., Seymour, R., Twomey, C. and Vu, L. (2021). Stronger Together: Loneliness and social connectedness in Australia. Bankwest Curtin Economics Centre Focus on the States Series, #8, November 2021.

Ui, J., Duncan A.S. and Miranti., R. (2015). Underemployment among mature age workers in Australia, The Economic Record, 91, pp.438-462.

McNamara, J., Cassells, R., Wicks, P. and Vidyattama, Y. (2010), Children in Housing Disadvantage in Australia: Development of a Summary Small Area Index, Housing Studies, 25(5), pp. 625-646.

Ong, R., Pawson, H., Singh, R. and Martin, C. (2020) Demand side assistance in Australia’s rental housing market: exploring reform options. AHURI Final Report No. 342. Australian Housing and Urban Research Institute Limited, Melbourne.

Productivity Commission (2017). Introducing Competition and Informed User Choice into Human Services: Reforms to Human Services, Report No. 85, Productivity Commission, Canberra.

Rodgers, J. (2012), Living Arrangements and Income Poverty. Australian Journal of Labour Economics, 15(3), pp. 217-234.

Rowley, S. and Ong, R. (2012) Housing Affordability, Housing Stress and Household Wellbeing in Australia. Final Report No. 192, Australian Housing and Urban Research Institute, Melbourne.

Saunders, P. (2013) Researching povertu: Methods, results and impact. The Economic and Labour Relations Review, 24 (2), 205-218.

Steering Commission for the Review of Government Service Provision (SCRGSP) (2011), Overcoming Indigenous disadvantage: Key Indicators 2011, Productivity Commission, Melbourne.

Townsend, P. (1979). Poverty in the United Kingdom. Harmondsworth, England: Penguin Books.

WA Council of Social Services (2020). WA Community Recovery Plan. WACOS, June 2020. Accessed from https://www.wacoss.org.au/library/stage-one-wa-community-

BEHIND THE LINE: POVERTY AND DISADVANTAGE IN AUSTRALIA 2022

Wilkins, R., Vera-Toscano, E., Botha, F. and Dahmann, S. (2021) The Household, Income and Labour Dynamics in Australia Survey: Selected Findings from Waves 1 to 19. Melbourne Institute of Applied Economic & Social Research, the University of Melbourne.

Wilkins, R. (2013), ‘Relative income poverty’ in Families, Incomes and Jobs, Volume 8: A statistical Report on Waves 1 to 10 of the Household, Income and Labour Dynamics in Australia Survey: Melbourne.

76 BANKWEST CURTIN ECONOMIC CENTRE | FOCUS ON THE STATES SERIES

Disclaimer

While every effort has been made to ensure the accuracy of this document, the uncertain nature of economic data, forecasting and analysis means that the centre, Curtin University and/or Bankwest are unable to make any warranties in relation to the information contained herein. Any person who relies on the information contained in this document does so at their own risk. The centre, Curtin University, Bankwest, and/or their employees and agents disclaim liability for any loss or damage, which may arise as a consequence of any person relying on the information contained in this document. Except where liability under any statute cannot be excluded, the centre, Curtin University, Bankwest and/or their advisors, employees and officers do not accept any liability (whether under contract, tort or otherwise) for any resulting loss or damage suffered by the reader or by any other person.

The views in this publication are those of the authors and do not represent the views of Curtin University and/or Bankwest or any of their affiliates. This publication is provided as general information only and does not consider anyone’s specific objectives, situation or needs. Neither the authors nor the centre accept any duty of care or liability to anyone regarding this publication or any loss suffered in connection with the use of this publication or any of its content.

Acknowledgements

We would like to thank the many stakeholders we’ve met with for their invaluable insights and contributions to shaping this report. This report uses unit record data from the Household, Income and Labour Dynamics in Australia (HILDA) Survey. The HILDA Project was initiated and is funded by the Australian Government Department of Social Services (DSS) and is managed by the Melbourne Institute of Applied Economic and Social Research (Melbourne Institute). The findings and views reported in this paper, however, are those of the author and should not be attributed to either DSS or the Melbourne Institute.

Authorised Use © Bankwest Curtin Economics Centre, March 2022

Bankwest Curtin Economics Centre Focus on the States Series

ISBN: 978-1-925757-20-0

Contact

Bankwest Curtin Economics Centre
Tel: +61 8 9266 2873
Email: bcec@curtin.edu.au

bcec.edu.au

© Curtin University 2022
CRICOS Provider Code 00301J
ADV141253