Models, theoretical design and formal evaluation of integrated specialist community health service provision for the first 2000 days: a scoping review.

OBJECTIVE: This scoping review identifies evidence for design, models and evaluation of integrated care service provision for families and children in the first 2000 days, in the context of community-based specialised health, education and welfare services. DESIGN: Scoping review following the Joanna Briggs scoping review method. DATA SOURCES: Medline, CINAHL, Cochrane and PsycINFO. Grey literature used a manual search of original articles, and snowball technique to identify government and policy documents relevant to Australia. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Inclusion criteria were 'population' of prebirth to age 5; 'concept' of design, models and delivery of integrated specialist care for children and families; and 'context' of community-based specialised health, education and welfare services. Medical Subject Heading (MeSH) and free text searches were conducted in electronic database sources. Limits January 2010 to October 2022, full text, English language, human. DATA EXTRACTION AND SYNTHESIS: Data were extracted independently by two authors using a piloted data extraction table and presented in table and narrative form. RESULTS: Full text of 11 articles were reviewed, domains were coded using four domains of a framework identified in one reviewed article to maintain consistency of reporting; 'governance,' 'leadership,' 'organisational culture and ethos,' and 'front-line interdisciplinary practice.' A fifth domain was identified, 'access.' CONCLUSIONS: Services providing integrated care for families in the early years will ideally be based on values generated through codesign with families and the community. Considerations include sound governance and leadership, shared vision, and commitment to providing accessible and culturally safe family-centred care.

A new children's hospital with a larger floor space, single rooms, and V-shaped ward design: A pre-post evaluation of nurse time providing patient care and nurse, patient, and family experiences.

BACKGROUND: The impact of hospital building design on patients, families and nurses related to nursing care interactions is not well understood. This study reports a pre-post intervention study to understand the effects of the move to a new children's hospital in Perth, Australia, on nurse workflow activities and on patient, family, and nurse experiences. METHODS: We used a pre-post explanatory sequential design involving observation of nurse work tasks; measurement of the Practice Environment Scale and Nurse Work Index; weekly surveys of nurse, patient and family experiences; and nurse focus groups and interviews with patients and families. Survey data were analysed using linear regression; qualitative data analysis used a thematic approach. RESULTS: Nurse time spent walking almost doubled (p < 0.001), from an estimated 10 min at T1 (pre-move) to around 20 min at T4 (12 months post-move), but there was no difference in nurse time providing patient care (p = 0.114). The Practice Environment Scale and Nurse Work Index showed significantly reduced scores for nursing foundations for quality of care (adjusted mean difference -0.08, p = 0.016) and staffing and resource adequacy (adjusted mean difference -0.19, p < 0.001).This fall was mirrored in nurse experience surveys with a reduction in mean scores from T1 to T3 (3 months post-move) of -0.7 (p < 0.001) and from T1 to T4 of -0.4 (p = 0.002). Thematic analysis of qualitative data found that initial challenges appeared to reduce over time. Nurses reported difficulties managing workflow in the new wards and feelings of exhaustion at T3, but this changed to more positive accounts at T4. For patients and families there was a tension between leaving the old and familiar, enjoying the light and space of the new and shared observations that nurses appeared to be busier at T3. At T4, these experiences had changed to 'being a family in hospital' and confidence that a nurse was always close by. CONCLUSIONS: Both benefits and challenges of the new hospital design were encountered from the perspective of nurses, patients, and families. Nurses spent double the time walking in the new environment, but time spent providing patient care was unchanged. Over time, the initial practice challenges reduced as nurses adapted to working in the new environment. TRIAL REGISTRATION: ACTRN12618000775213.

Identification of models, theoretical design and formal evaluation of integrated specialist community health service provision for the first 2000 days: a protocol for a scoping review.

INTRODUCTION: The first 2000 days of a child's life (during pregnancy up to age 5 years) represent a critical period, in which early interventions reduce risk associated with developmental delay, disability and intergenerational disadvantage. The risk is exacerbated by barriers to specialised early intervention for children and families. This scoping review seeks to contribute to the evidence for sustaining integrated community-based specialist care in these earliest years of a child's life. METHODS AND ANALYSIS: The Joanna Briggs Institute scoping review framework will be followed. Inclusion and exclusion criteria for screening of literature is predefined, guided by the criteria of population, concept and context. The review will identify models of care delivery, and will identify quality of care outcomes that have been measured, including evidence of reliability and validity. Sources of evidence will include CINAHL, Cochrane databases, Medline, PsycINFO and Scopus. ETHICS AND DISSEMINATION: In a three-part study, evidence synthesis from the scoping review of the literature; mapping of existing specialist early years services in one community and a consumer consultation (Curtin University Human Research Ethics approval HRE2021-0546) in the same community will inform a model of integrated care that accounts for the context of the community it seeks to serve. Results will be disseminated by peer-reviewed publications and conference presentations, contributing to the evidence base for delivering sustainable community-based integrated care in the context of the first 2000 days. This protocol is specific to the scoping review.

Pediatric and child health nursing: A three-phase research priority setting study in Western Australia.

PURPOSE: Priority settings are important to plan and direct future research. The aim of this study was to identify the top ten pediatric and child health nursing research priorities from the perspectives of consumers, community, and healthcare professionals in Western Australia. DESIGN AND METHODS: This study used an adapted James Lind Alliance Priority Setting Partnership design with three phases. 1) A planning workshop to inform a survey. 2) A survey using five open-ended-questions distributed between October 2020 and January 2021 through social media and healthcare professionals' emails. Responders' statements were analyzed with content analysis. 3) A consensus workshop to finalize and rank the themes. RESULTS: The planning workshop participants (n = 25) identified gaps such as community child healthcare and confirmed lack of consumer engagement in previous studies. The survey responses (n = 232) generated 911 statements analyzed into 19 themes. The consensus workshop participants (n = 19) merged and added themes, resulting in 16 final themes. The top three ranked themes were: 'access to service', 'mental health and psychological wellbeing', and 'communication'. CONCLUSIONS: The research themes are necessarily broad to capture the wide range of issues raised, reflecting the scope of pediatric and child health nursing. PRACTICE IMPLICATIONS: The priorities will inform future research to be directed to areas of priority for stakeholders who have often not had a say in setting the research agenda.

Patient experience surveys for children's community health services: A scoping review.

Patient experience surveys have a user focus and measure the quality of person-centered health care for hospital inpatients and consumers of community health services, providing a governance process to evaluate the quality of care and to action improvement. Experience of care has been described as effective communication, respect and dignity, and emotional support. Measurement criteria for these domains are not standardized, leading to inconsistent reporting of patient experience. The objective of this scoping review was to synthesize evidence for measuring experience of care in children's community health services using the Joanna Briggs Institute framework for scoping review method. Three parent-reported surveys met the inclusion criteria, and 50 survey items were assessed by expert reviewers for fit to domains of healthcare experience. Conceptual domains of parent experience in children's community health services included respect and dignity, effective communication, and emotional support. A gap was identified, in that few items in identified surveys measured emotional support. This contribution will promote consistent reporting of healthcare experience, informing policy and practice for person-centered health care.

Measuring 8 to 12 year old children's self-report of power imbalance in relation to bullying: development of the Scale of Perceived Power Imbalance.

BACKGROUND: While power imbalance is now recognized as a key component of bullying, reliable and valid measurement instruments have yet to be developed. This research aimed to develop a self-report instrument that measures power imbalance as perceived by the victim of frequent aggressive behavior. METHODS: A mixed methods approach was used (468 participants, Grade 4 to 6). This paper describes the exploratory (n = 111) and confirmatory factor analysis of the new instrument (n = 337), and assessment of reliablity and construct validity. RESULTS: A 2-factor model represented physical and social aspects of power imbalance (n = 127: normed chi-square = 1.2, RMSEA = .04, CF1 = .993). The social factor included constructs of group and peer valued characteristics. CONCLUSIONS: This research will enhance health and education professionals understanding of power imbalance in bullying and will inform the design and evaluation of interventions to address bullying in children.

Preadolescent children's perception of power imbalance in bullying: A thematic analysis.

Bullying in schools is associated with an extensive public health burden. Bullying is intentional and goal oriented aggressive behavior in which the perpetrator exploits an imbalance of power to repeatedly dominate the victim. To differentiate bullying from aggressive behavior, assessment must include a valid measure of power imbalance as perceived by the victim. And yet, to date, there remains no agreement as to how to most accurately measure power imbalance among preadolescent children. This qualitative study explored children's (age 9 to 11) understanding of power imbalance through thematic analysis of focus group discussions. Subthemes that emerged as influencing power imbalance include: age of victim, peer valued characteristics, and group membership and position. Subthemes of empathy and peer valued characteristics emerged as protecting against the negative impact of power imbalance.

Intramuscular oxytocin versus oxytocin/ergometrine versus carbetocin for prevention of primary postpartum haemorrhage after vaginal birth: study protocol for a randomised controlled trial (the IMox study).

BACKGROUND: Postpartum haemorrhage remains a major cause of maternal mortality and morbidity worldwide. Active management of the third stage of labour reduces the risk of postpartum haemorrhage. Oxytocin and oxytocin/ergometrine are commonly used in the UK, with oxytocin/ergometrine being more effective at preventing moderate, but not severe, blood loss. Many guidelines specifically recommend using oxytocin for all vaginal births, as it is associated with fewer adverse events. However, a survey conducted by the Southmead Hospital Maternity Research Team revealed that 71.4% of UK obstetric units still routinely use oxytocin/ergometrine. Carbetocin is a newer medication that may be as effective but has fewer side effects. No studies have directly compared all three medications. METHODS: The IMox study aims to determine the most effective, acceptable and cost-effective drug for primary prevention of postpartum haemorrhage following vaginal birth. The IMox study is a prospective, multi-centre, double-blind, randomised trial directly comparing oxytocin, oxytocin/ergometrine and carbetocin given intramuscularly for the prevention of postpartum haemorrhage in the third stage of labour. The primary effectiveness outcome is the use of an additional uterotonic drug. Secondary effectiveness outcomes reflect maternal morbidity and mortality within the immediate postpartum period. Participant questionnaires and subjective reporting of side effects will be used to evaluate maternal acceptability. Maternal quality of life utilities will be collected antenatally, and on days 1 and 14 after birth to enable a cost-effectiveness assessment of each studied drug. Participants will be pregnant women planning a vaginal birth in six hospitals in England. Participants will be approached and invited to provide consent to participate from 20 weeks gestation until in established labour. A complete sample of 5712 participants (1904 per arm) providing data for the primary outcome will allow for a robust determination of efficacy between all three study drugs. Data will be collected until participants are discharged from the hospital and on postnatal days 1 and 14 regardless of location. All analyses will be on a modified intention-to-treat basis, and additionally repeated on a per protocol basis. Data collection commenced in Feburary 2015 and was completed in August 2018. DISCUSSION: This study is the first to directly compare oxytocin, oxytocin/ergometrine and carbetocin in the same population for the prevention of postpartum haemorrhage following vaginal birth. Furthermore, this study will be the first to directly compute health economic outcomes from such a three-way comparison. This study is limited to using short-term outcomes, and so will not provide evidence for important outcomes such as long-term maternal psychological well-being and time to next conception. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02216383 . Registered on 18 August 2014. EudraCT, 2014-001948-37. Registered on 23 September 2014. ISRCTN, ISRCTN10232550. Retrospectively registered on 6 March 2018).

Measuring Critical Care Providers' Attitudes About Controlled Donation After Circulatory Death.

INTRODUCTION: Unfavorable attitudes and insufficient knowledge about donation after cardiac death among critical care providers can have important consequences for the appropriate identification of potential donors, consistent implementation of donation after cardiac death policies, and relative strength of support for this type of donation. The lack of reliable and valid assessment measures has hampered research to capture providers' attitudes. Design and Research Aims: Using stakeholder engagement and an iterative process, we developed a questionnaire to measure attitudes of donation after cardiac death in critical care providers (n = 112) and examined its psychometric properties. Exploratory factor analysis, internal consistency, and validity analyses were conducted to examine the measure. RESULTS: A 34-item questionnaire consisting of 4 factors (Personal Comfort, Process Satisfaction, Family Comfort, and System Trust) provided the most parsimonious fit. Internal consistency was acceptable for each of the subscales and the total questionnaire (Cronbach α > .70). A strong association between more favorable attitudes overall and knowledge ( r = .43, P < .001) provides evidence of convergent validity. Multivariable regression analyses showed that white race ( P = .002) and more experience with donation after cardiac death ( P < .001) were significant predictors of more favorable attitudes. CONCLUSION: Study findings support the utility, reliability, and validity of a questionnaire for measuring attitudes in critical care providers and for isolating targets for additional education on donation after cardiac death.

The Factors That Influence and Protect Against Power Imbalance in Covert Bullying Among Preadolescent Children at School: A Thematic Analysis.

In this article, the perceptions of preadolescent children (ages 9-11) regarding factors that influence and protect against power imbalance associated with covert aggression and bullying are explored. In aggression research, the term covert has been typically used to describe relational, indirect, and social acts of aggression that are hidden. These behaviors contrast with overt physical and verbal aggression. Children have previously conveyed their belief that covert aggression is harmful because adults do not see it even though children, themselves, are aware. We used focus groups to explore children's understanding of covert aggression and to identify children's experience and perception of adult support in relation to bullying. Thematic analysis supported the definition of covert aggression as that which is intentionally hidden from adults. Friendship, social exclusion, and secret from teacher were identified as factors that influence power imbalance, while support from friends and adult support protected against power imbalance.

The need and opportunity for donation after circulatory death worldwide.

PURPOSE OF REVIEW: The global shortage of organ donors will not be resolved solely by relying on deceased donation following a brain death determination (DBD). Expansion of deceased donation after circulatory death (DCD) will be needed to address the shortfall of organs for transplantation. Approximately 120 000 organ transplants are performed each year; however, the WHO estimates that this number of transplants only resolves 10% of the annual worldwide transplant need. RECENT FINDINGS: The report addresses the opportunity of DCD expansion by evaluating the DCD potential that is not being realized, the utility of DCD enabling DBD to emerge in some clinical situations, by the effectiveness of a donor registry in achieving DCD, and by the current clinical research of heart, lung, and liver transplantation from DCD. SUMMARY: The future of deceased donation must include DCD and ex-vivo organ repair if the organ shortage is to be reconciled even partially to the ongoing demand. Although the religious and legal impediments have been overcome to determine brain death, the possibility of DCD has not been addressed. A program of DCD is feasible in all countries with transplantation services. The excellent results following kidney and lung transplantation suggest opportunities of heart and liver transplantation should be the focus of needed DCD accomplishment in the near future.

Management of obstetric postpartum hemorrhage: a national service evaluation of current practice in the UK.

BACKGROUND: Postpartum hemorrhage (PPH) continues to be one of the major causes of maternal mortality and morbidity in obstetrics. Variations in practice often lead to adverse maternity outcomes following PPH. Our objective was to assess the current practice in managing PPH in the UK. METHODS: We performed a national multicenter prospective service evaluation study over one calendar month and compared the current performance to national standards for managing PPH. We used a standardized data collection tool and collected data on patients' demographics, incidence of PPH, estimated blood loss (EBL), prophylactic and treatment measures, onset of labor, and mode of delivery. RESULTS: We collected data from 98 obstetric units, including 3663 cases of primary PPH. Fifty percent of cases were minor PPH (EBL 500-1000 mL, n=1900/3613, 52.6%) and the remaining were moderate PPH (EBL >1000 to <2000 mL, n=1424/3613, 39.4%) and severe PPH (EBL >2000 mL, n=289/3613, 8%). The majority of women received active management of the third stage of labor (3504/3613, 97%) most commonly with Syntometrine intramuscular (1479/3613, 40.9%). More than half required one additional uterotonic agent (2364/3613, 65.4%) most commonly with Syntocinon intravenous infusion (1155/2364, 48.8%). There was a poor involvement of consultant obstetricians and anesthetists in managing PPH cases, which was more prevalent when managing major PPH (p=0.0001). CONCLUSION: There are still variations in managing PPH in the UK against national guidelines. More senior doctor involvement and regular service evaluation are needed to improve maternal outcomes following PPH.

Carbetocin versus oxytocin for prevention of post-partum haemorrhage at caesarean section in the United Kingdom: An economic impact analysis.

OBJECTIVE: To determine the economic impact of the introduction of carbetocin for the prevention of postpartum haemorrhage (PPH) at caesarean section, compared to oxytocin. STUDY DESIGN: The model is a decision tree conducted from a UK National Health Service perspective. 1500 caesarean sections (both elective and emergency) were modelled over a 12 month period. Efficacy data was taken from a published Cochrane meta-analysis, and costs from NHS Reference costs, the British National Formulary and the NHS electronic Medicines Information Tool. A combination of hospital audit data and expert input from an advisory board of clinicians was used to inform resource use estimates. The main outcome measures were the incidence of PPH and total cost over a one year time horizon, as a result of using carbetocin compared to oxytocin for prevention of PPH at caesarean section. RESULTS: The use of carbetocin compared to oxytocin for prevention of PPH at caesarean section was associated with a reduction of 30 (88 vs 58) PPH events (>500ml blood loss), and a cost saving of £27,518. In probabilistic sensitivity analysis, carbetocin had a 91.5% probability of producing better outcomes, and a 69.4% chance of being dominant (both cheaper and more effective) compared to oxytocin. CONCLUSION: At list price, the introduction of carbetocin appears to provide improved clinical outcomes along with cost savings, though this is subject to uncertainty regarding the underlying data in efficacy, resource use, and cost.

Could low Safety Attitudes Questionnaire scores be indicative of an environment where it may be difficult to get new training practices established?

Introduction: Simulation-based, multiprofessional team training (SBMPTT) is used widely in healthcare, with evidence that it can improve clinical outcomes and be associated with a positive safety culture. Our aim was to explore the impact of introducing this type of training to a gynaecological team. Methods: In this interrupted time-series study, 'Safety Attitudes Questionnaire' (SAQ) data was collected both before and after SBMPTT was introduced to a gynaecological team. Results: Low baseline SAQ scores coincided with difficulty in establishing the training, meaning that at the end of our study period only a small proportion of staff had actually attended a training session. Despite trends towards improvement in scores for safety climate, teamwork climate and job satisfaction, no statistically significant difference was observed. There was however an improved perception of the level of collaboration between nursing staff and doctors after the introduction of training. Conclusions and Discussion: In this paper we explore a hypothesis that low baseline SAQ scores may highlight that the multiprofessional teams most in need of training work in environments where it is more challenging to implement. There is evidence from other specialties that multiprofessional team training works, now we need to understand how to address the barriers to getting it started. In this paper we suggest how the SAQ could be used as a directive tool for improvement; using the detailed analysis of the local safety culture it provides to both inform future training design and also provide management with an objective marker of progress.

A Scoping Review of Self-Report Measures of Aggression and Bullying for Use With Preadolescent Children.

Bullying in schools is a major health concern throughout the world, contributing to poor educational and mental health outcomes. School nurses are well placed to facilitate the implementation and evaluation of bullying prevention strategies. To evaluate the effect of such strategies, it is necessary to measure children's behavior over time. This scoping review of instruments that measure the self-report of aggressive behavior and bullying by children will inform the evaluation of bullying interventions. This review aimed to identify validated instruments that measure aggression and bullying among preadolescent children (age 8-12). The review was part of a larger study that sought to differentiate bullying from aggressive behavior by measuring the self-report of power imbalance between the aggressor and the child being bullied. The measurement of power imbalance was therefore a key aspect of the scoping review.

Comparison of two systemic antifungal agents, itraconazole and terbinafine, for the treatment of dermatophytosis in European hedgehogs (Erinaceus europaeus).

BACKGROUND: Dermatophytosis caused by Trichophyton erinacei is a common scaling and crusting skin disease affecting European hedgehogs (Erinaceus europaeus) admitted to wildlife rescue centres. The application of topical therapy can be challenging because wild hedgehogs are subject to stress and often roll into a ball when handled. Systemic antifungal therapy is more convenient but has not been evaluated in this species. HYPOTHESIS/OBJECTIVES: To compare the efficacy of oral itraconazole versus oral terbinafine for the treatment of dermatophytosis affecting hedgehogs. ANIMALS: A treatment trial was undertaken in a wildlife hospital involving 165 hedgehogs with naturally occurring dermatophytosis. METHODS: Animals were randomly divided into two groups and treated with either itraconazole or terbinafine orally for 28 days. The therapeutic efficacy was evaluated after 14 and 28 days by mycological culture and clinical dermatological lesion scores. RESULTS: Both drugs were well tolerated and clinically effective. After 14 and 28 days of treatment, the respective mycological cure rate was 36.6% and 65.9% for the itraconazole-treated group and 92.8% and 98.8% for the terbinafine-treated group. CONCLUSION AND CLINICAL IMPORTANCE: Itraconazole and terbinafine were both effective for the treatment of dermatophytosis affecting hedgehogs; however, terbinafine was more effective.

Successful Recovery and Transplantation of 11 Organs Including Face, Bilateral Upper Extremities, and Thoracic and Abdominal Organs From a Single Deceased Organ Donor.

We report on the to date largest recovery of 11 organs from a single deceased donor with the transplantation of face, bilateral upper extremities, heart, 1 lung, liver (split for 2 recipients), kidneys, pancreas, and intestine. Although logistically challenging, this case demonstrates the feasibility and safety of the recovery of multiple thoracic and abdominal organs with multiple vascular composite allotransplants and tissues. Our experience of 8 additional successful multiple vascular composite allotransplants, thoracic, and abdominal organ recoveries suggests that such procedures are readily accomplishable from the same deceased donor.

Changing Patterns of Organ Donation: Brain Dead Donors Are Not Being Lost by Donation After Circulatory Death.

The clinical characteristics of all New England Organ Bank (NEOB) donors after circulatory death (DCD) donors were analyzed between July 1, 2009, and June 30, 2014. During that 5-year period, there were 494 authorized medically suitable potential DCDs that the NEOB evaluated, constituting more than 30% of deceased donors coordinated annually by the NEOB. From the cohort of 494 authorized potential DCDs, 331 (67%) became actual DCD, 82 (17%) were attempted as a DCD but did not progress to donation, and 81 (16%) transitioned to an actual donor after brain death (DBD). Two hundred seventy-six organs were transplanted from the 81 donors that transitioned from DCD to actual DBD, including 24 heart, 70 liver, 12 single and 14 bilateral lung, and 12 pancreas transplants. When patients with devastating brain injury admitted to the intensive care units are registered donors, the Organ Procurement Organization staff should share the patient's donation decision with the health care team and the patient's family, as early as possible after the comfort measures only discussion has been initiated. The experience of the NEOB becomes an important reference of the successful implementation of DCD that enables an expansion of deceased donation (inclusive of DBD).

Identifying Deteriorating Patients Through Multidisciplinary Team Training.

Multidisciplinary training has improved maternity outcomes when the training has been well attended, regular, in house, used high-fidelity simulators, and integrated teamwork training. If these principles were used in other settings, better clinical care may result. This before-after study sought to establish whether a short multidisciplinary training intervention can improve recognition of the deteriorating patient using an aggregated physiological parameter scoring system (Early Warning Score [EWS]). Nursing, medical, and allied nursing staff participated in an hour-long training session, using real-life scenarios with simple tools and structured debriefing. After training, staff were more likely to calculate EWS scores correctly (68.02% vs 55.12%; risk ratio [RR] = 1.24, 95% confidence interval [CI] = 1.07-1.44), and observations were more likely to be performed at the correct frequency (78.57% vs 68.09%; RR = 1.20, 95% CI = 1.09-1.32). Multidisciplinary training, according to core principles, can lead to more accurate identification of deteriorating patients, with implications for subsequent care and outcome.

Protocol for the design of an instrument to measure preadolescent children's self-report of covert aggression and bullying.

INTRODUCTION: Covert bullying in schools is associated with a range of academic, social, emotional and physical health problems. Much research has focused on bullying, but there remains a gap in understanding about covert aggression and how to most accurately and reliably measure children's own reports of this behaviour. This paper reviews relevant literature and outlines a research project that aims to develop a self-report instrument that effectively measures covert aggression and bullying. It is anticipated that this research will result in a standardised instrument that is suitable for exploring preadolescent children's experiences of covert aggressive behaviour. The data collected by the instrument will enhance health and education professionals understanding of covert bullying behaviours and will inform the design and evaluation of interventions. METHODS AND ANALYSIS: Relational developmental systems theory will guide the design of an online self-report instrument. The first phase of the project will include a critical review of the research literature, focus groups with children aged 8-12 years (grades 4-6) in Perth, Western Australia, and expert review. The instrument will be explored for content and face validity prior to the assessment of convergent and discriminant validity, internal consistency and test-retest reliability. ETHICS AND DISSEMINATION: The study has been approved by the Curtin University of Human Research Ethics Committee (RDHS-38-15) and by the Executive Principal of the participating school.