General practitioners' management of mastitis in breastfeeding women: a mixed method study in Australia.

BACKGROUND: Mastitis is a common reason new mothers visit their general practitioner (GP). In Australia, the Therapeutic Guidelines: Antibiotic provides practical advice to GPs managing a range of infections, including mastitis. It is not known if Australian GPs prescribe antibiotics and order investigations as recommended for the management of mastitis. METHODS: A convergent mixed methods design integrated quantitative analysis of a general practice dataset with analysis of interviews with GPs. Using the large-scale primary care dataset, MedicineInsight, (2021-2022), antibiotics prescribed and investigations ordered for mastitis encounters were extracted. Mastitis encounters were identified by searching 'Encounter reason', 'Test reason' and 'Prescription reason' free text field for the term 'mastitis'; 'granulomatous mastitis' was excluded. Clinical encounters for mastitis occurring within 14 days of a previous mastitis encounter were defined as belonging to the same treatment episode. Semi-structured interviews were conducted with 14 Australian GPs using Zoom or telephone in 2021-2022, and analysed thematically. The Pillar Integration Process was used to develop a joint display table; qualitative codes and themes were matched with the quantitative items to illustrate similarities/contrasts in findings. RESULTS: During an encounter for mastitis, 3122 (91.7%) women received a prescription for an oral antibiotic; most commonly di/flucloxacillin ([59.4%]) or cefalexin (937 [27.5%]). Investigations recorded ultrasound in 303 (8.9%), blood tests (full blood examination [FBE]: 170 [5.0%]; C-reactive protein [CRP]: 71 [2.1%]; erythrocyte sedimentation rate [ESR]: 34 [1.0%]) and breast milk or nipple swab cultures in approximately 1% of encounters. Analysis using pillar integration showed consistency between quantitative and qualitative data regarding mastitis management. The following themes were identified: - GPs support continued breastfeeding. - Antibiotics are central to GPs' management. - Antibiotics are mostly prescribed according to Therapeutic Guidelines. - Analgesia is a gap in the Therapeutic Guidelines. - Low use of breast milk culture. CONCLUSIONS: Prescribing antibiotics for mastitis remains central to Australian GPs' management of mastitis. Interview data clarified that GPs were aware that antibiotics might not be needed in all cases of mastitis and that delayed prescribing was not uncommon. Overall, GPs followed principles of antibiotic stewardship, however there is a need to train GPs about when to consider ordering investigations.

Trends in clinical management of lactational mastitis among women attending Australian general practice: a national longitudinal study using MedicineInsight, 2011-2022.

OBJECTIVE: To examine longitudinal trends in clinical management of lactational mastitis in women attending general practice. DESIGN: Open cohort study. SETTING: Australian general practice using data from MedicineInsight. PARTICIPANTS: Women aged 18 to 44 years with one or more clinical encounters for lactational mastitis between January 2011 and July 2022. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was the proportion of prescribed oral antibiotics based on the antibiotic type. Secondary outcome measures were the proportion of women prescribed other medications (eg, antifungals, lactation suppressants) or ordered selected clinical investigations including breast ultrasound, blood test, breast milk culture, nipple swab culture or breast aspirate. Outcomes were examined based on the calendar year and individual- or clinical practice-level characteristics. RESULTS: Among 25 002 women who had one or more clinical encounters related to mastitis, 90.9% were prescribed oral antibiotics. While the proportion of women prescribed an oral antibiotic remained consistent from 2011 to 2022 (91.1% vs 92.5%), there were changes in the proportion receiving prescriptions for di/flucloxacillin (46.1% vs 60.4%) and cefalexin (38.6% vs 26.5%). Fewer than 12% of women were clinically investigated for their mastitis encounter, most commonly a breast ultrasound (7.1%), followed by a selected blood test (3.8%). Requests for breast milk cultures, nipple swab cultures or breast aspirates occurred in less than 1.1% of individuals. Significant increases were evident with respect to ordering of all clinical investigations, with rates at least doubling between 2011 and 2022 (6.6% vs 14.7%). Large variability in clinical management was evident according to both individual- (eg, concessional status) and clinical practice-level characteristics (eg, remoteness). CONCLUSIONS: Australian general practitioners commonly prescribe oral antibiotics to women with mastitis and largely in line with clinical guidelines. Their use of clinical investigations as part of mastitis management has increased over the last decade.

Breastfeeding outcomes at 3 months for women with diabetes in pregnancy: Findings from the Diabetes and Antenatal Milk Expressing randomized controlled trial.

BACKGROUND: Women with diabetes in pregnancy have decreased exclusivity and duration of breastfeeding compared with women without diabetes, and their infants are at increased risk of hypoglycemia. Clinicians often suggest pregnant women with diabetes to express breastmilk, and studies have reported increased breastfeeding exclusivity in the early postnatal period for patients who have expressed. Little is known about longer term outcomes. We investigated whether advising low-risk women with diabetes in pregnancy to express beginning at 36 weeks of pregnancy increased exclusivity and maintenance of breastfeeding at 3 months. METHODS: We conducted a multicenter, two-group, randomized controlled trial at six hospitals in Melbourne, Australia, between 2011 and 2015. Women were randomized to either standard maternity care or advised to hand express for 10 min twice daily, in addition to standard care. Women were telephoned at 12-13 weeks postpartum and asked a series of questions about feeding their baby, perceptions of their milk supply, and other health outcomes. RESULTS: Of 631 women in the study, data for 570 (90%) were analyzed at 12-13 weeks. After adjustment, we found no evidence that women allocated to antenatal expressing were more likely to be giving only breastmilk (aRR 1.07 [95% CI 0.92-1.22]) or any breastmilk (aRR 0.99 [95% CI 0.92-1.06]) at 12-13 weeks postpartum compared with women in the standard care group. CONCLUSION: While the practice of antenatal expression for low-risk women with diabetes during pregnancy is promising for increasing exclusivity of breastmilk feeding in hospital, at 12-13 weeks, there was no association with breastfeeding outcomes.

Family Bonds with Pets and Mental Health during COVID-19 in Australia: A Complex Picture.

The COVID-19 pandemic has drawn attention to the health-promoting features of human-animal relationships, particularly for families with children. Despite this, the World Health Organization's (1986) Ottawa Charter remains human-centric. Given the reciprocal health impacts of human-animal relationships, this paper aims to (i) describe perceived pet-related benefits, worries, and family activities; and to (ii) examine differences in perceived benefits, worries, and activities for parents and children with and without clinical mental health symptoms. We recruited 1034 Australian parents with a child < 18 years and a cat or dog via a national online survey between July and October 2020. Most parents reported their pet was helpful for their own (78%) and their child's mental health (80%). Adjusted logistic regression revealed parents with clinical psychological distress were 2.5 times more likely to be worried about their pet's care, well-being, and behaviour (OR = 2.56, p < 0.001). Clinically anxious children were almost twice as likely to live in a family who engages frequently in pet-related activities (e.g., cooked treats, taught tricks, OR = 1.82, p < 0.01). Mental health and perceived benefits of having a pet were not strongly associated. Data support re-framing the Ottawa Charter to encompass human-animal relationships, which is an often-neglected aspect of a socioecological approach to health.

How the mental health of working parents in Australia changed during COVID-19: A pre- to during pandemic longitudinal comparison.

BACKGROUND: Cross-sectional studies indicate that mental health has deteriorated in Australia during the COVID-19 pandemic, including for parents. However, robust longitudinal studies interrogating change from before to during the pandemic remain rare. The current study analysed data from Australian parents surveyed in 2016 and August 2020. We investigate whether distress was higher in the COVID-19 period compared to pre-pandemic levels, and whether any increases in distress were greatest for parents living in Victoria (who had entered their second prolonged lockdown). METHODS: A community cohort of Australian working parents (n = 5197) was recruited online in 2016. In August 2020, 25.9 % (n = 1348) completed a follow-up survey. Analyses were restricted to those employed at both time-points (n = 1311). Random effects longitudinal models examined the association between time (i.e. pre vs. during-pandemic) and distress (K6 scale). Fixed effects models specifically tested change between time periods in association with change in distress. LIMITATIONS: The initial sample were recruited online with highly educate parents over-represented. Attrition between survey time-points may also limit generalisability. RESULTS: All models consistently showed that the pandemic period was associated with greater distress. Overall, serious mental illness (i.e. K6 score ≥ 18) increased by 5.3 percentage points (from 8.0 to 13.3). This increase was greater (by 4.7 percentage points) for those parents in Victoria. CONCLUSIONS: This study is one of few to longitudinally assess mental health pre- to during the pandemic. Psychological distress and serious mental illness increased for Australian working parents, and this effect was greatest for those experiencing a prolonged lockdown in Victoria.

Does place matter in the implementation of an evidence-based program policy in an Australian place-based initiative for children?

Policy-mandated requirements for use of evidence-based programs (EBP) in place-based initiatives are becoming more common. Little attention has been paid to the geographic aspects of uneven market development and urbanicity in implementing EBPs in large place-based initiatives. The aim of this study was to explore geographic variation in knowledge, attitudes, and experiences of service providers who implemented an EBP policy in Australia's largest place-based initiative for children, Communities for Children. A cross-sectional online survey of Communities for Children service providers was conducted in 2018-2019, yielding 197 participants from all of Australia's eight states and territories. Relationships between two measures of 'place' (thick and thin market states; urbanicity: urban, regional and remote) and study-designed measures of knowledge, attitudes, and implementation experiences were analyzed using adjusted logistic and multinomial regressions. Participants from thin market states (outside the Eastern Seaboard) were more resistant to the policy and experienced greater implementation challenges than those from thick market states (Eastern Seaboard). Regional participants reported greater knowledge about EBPs but experienced greater dissatisfaction and implementation challenges with the policy than both urban and remote participants. Our study found that place does matter when implementing EBPs in a place-based initiative.

Parent and child mental health during COVID-19 in Australia: The role of pet attachment.

Restrictions, social isolation, and uncertainty related to the global COVID-19 pandemic have disrupted the ways that parents and children maintain family routines, health, and wellbeing. Companion animals (pets) can be a critical source of comfort during traumatic experiences, although changes to family routines, such as those caused by COVID-19, can also bring about challenges like managing undesirable pet behaviours or pet-human interactions. We aimed to examine the relationship between pet attachment and mental health for both parents and their children during the COVID-19 pandemic in Australia. A total of 1,034 parents living with a child under 18 years and a cat or dog completed an online cross-sectional survey between July and October 2020. Path analysis using multivariate linear regression was conducted to examine associations between objective COVID-19 impacts, subjective worry about COVID-19, human-pet attachment, and mental health. After adjusting for core demographic factors, stronger pet-child attachment was associated with greater child anxiety (parent-reported, p < .001). Parent-pet attachment was not associated with self-reported psychological distress (p = .42), however, parents who reported a strong emotional closeness with their pet reported greater psychological distress (p = .002). Findings highlight the role of pets during times of change and uncertainty. It is possible that families are turning to animals as a source of comfort, during a time when traditional social supports are less accessible. Alternatively, strong pet attachment is likely to reflect high levels of empathy, which might increase vulnerability to psychological distress. Longitudinal evidence is required to delineate the mechanisms underpinning pet attachment and mental health.

'Is there any point in me doing this?' Views and experiences of women in the Diabetes and Antenatal Milk Expressing (DAME) trial.

The Diabetes and Antenatal Milk Expressing (DAME) randomised controlled trial (RCT) was conducted in 2011-2015, at six sites in Melbourne, Australia to explore the effect of advising women with diabetes in pregnancy to express breast milk from 36 weeks gestation. Infants whose mothers were randomised to express in pregnancy were more likely to be exclusively breast milk fed during their hospital stay, and there was no evidence of harm. This paper explores women's views and experiences of antenatal expressing. In this two-arm RCT, 635 women with diabetes in pregnancy who were otherwise of low medical risk were randomised at 36-37 weeks gestation to usual care (not expressing, n = 316), or the intervention, where women were advised to hand express for 10 min twice daily until birth (n = 319). Semistructured face-to-face interviews were conducted with 10 women who expressed antenatally. They were asked about their experiences of antenatal expressing, including how they felt about the overall experience, the amount of breast milk they expressed, making time to express, and their experience of breastfeeding. Thematic analysis of the in-depth interviews identified six themes: (1) learning and adapting expressing, (2) feelings and sensations associated with expressing, (3) support, (4) dis/empowerment, (5) health, and (6) the value of breast milk. Women had both positive and negative experiences of antenatal expressing. If health professionals are advising antenatal expressing to women, it is important they understand the range of outcomes and experiences.

Place-based approaches to improve health and development outcomes in young children: A scoping review.

This scoping review examines the strength of evidence for the effectiveness of public policy-led place-based initiatives designed to improve outcomes for disadvantaged children, their families and the communities in which they live. Study designs and methods for evaluating such place-based initiatives were assessed, along with the contexts in which initiatives were implemented and evaluated. Thirty-two reports relating to 12 initiatives were included. Eleven initiatives used a quasi-experimental evaluation to assess impact, although there were considerable design variations within this. The remaining initiative used a pre- and post- evaluation design. Place-based initiatives by definition aim to improve multiple and interrelated outcomes. We examined initiatives to determine what outcomes were measured and coded them within the five domains of pregnancy and birth, child, parent, family and community. Across the 83 outcomes reported in the 11 studies with a comparison group, 30 (36.4%) demonstrated a positive outcome, and all but one initiative demonstrated a positive outcome in at least one outcome measure. Of the six studies that examined outcomes more than once post baseline, 10 from 38 outcomes (26.3%) demonstrated positive sustained results. Many initiatives were affected by external factors such as policy and funding changes, with unknown impact on their effectiveness. Despite the growth of place-based initiatives to improve outcomes for disadvantaged children, the evidence for their effectiveness remains inconclusive.

Ethical Considerations in Using Social Media to Engage Research Participants: Perspectives of Australian Researchers and Ethics Committee Members.

Researchers increasingly use social media (SM) to recruit, retain, and trace participants, yet empirical literature investigating the ethics of engaging participants via SM is lacking. We conducted a survey of 401 Australian researchers and human research ethics committee (HREC) members to examine their experience, attitudes, and ethical concerns toward engaging participants via SM. Data revealed that researchers and HREC members share similar concerns and attitudes about using SM in general and in research. We identified a strong demand for additional support, training, and guidance on SM research ethics. This need reflects researchers' and HREC members' limited confidence and knowledge of ethical issues in this context and a lack of awareness of available SM-specific ethical guidelines.

Using Paid and Free Facebook Methods to Recruit Australian Parents to an Online Survey: An Evaluation.

BACKGROUND: The prevalence of social media makes it a potential alternative to traditional offline methods of recruiting and engaging participants in health research. Despite burgeoning use and interest, few studies have rigorously evaluated its effectiveness and feasibility in terms of recruitment rates and costs, sample representativeness, and retention. OBJECTIVE: This study aimed to determine the feasibility of using Facebook to recruit employed Australian parents to an online survey about managing work and family demands, specifically to examine (1) recruitment rates and costs; (2) sample representativeness, compared with a population-based cohort of parents; and (3) retention, including demographic and health characteristics of parents who returned to complete a follow-up survey 6 weeks later. METHODS: Recruitment was conducted using 20 paid Facebook advertising campaigns, supplemented with free advertising approaches such as posts on relevant Facebook pages and requests for professional networks to circulate the survey link via Facebook. Recruitment rates and costs were evaluated using the Checklist for Reporting Results of Internet E-Surveys, including view rate, participation rate, completion rate, cost per consent, and cost per completer. Sample representativeness was evaluated by comparing demographic and outcome variables with a comparable sample from the Longitudinal Study of Australian Children including educational attainment, marital status, country of birth, neighborhood disadvantage, work-family conflict, and psychological distress. Retention was evaluated by comparing the number and demographic characteristics of participants at recruitment and at 6-week follow-up. RESULTS: Recruitment strategies together resulted in 6653 clicks on the survey link, from which 5378 parents consented to participate and 4665 (86.74%) completed the survey. Of those who completed the survey, 85.94% (4009/4665) agreed to be recontacted, with 57.79% (2317/4009) completing the follow-up survey (ie, 43.08% [2317/5378] of parents who consented to the initial survey). Paid Facebook advertising recruited nearly 75% of the sample at Aus $2.32 per completed survey (Aus $7969 spent, 3440 surveys completed). Compared with a population-based sample, participants at baseline were more likely to be university educated (P<.001), experience greater work-family conflict (P<.001) and psychological distress (P<.001), and were less likely to be born outside Australia (P<.001) or live in a disadvantaged neighborhood (P<.001). CONCLUSIONS: Facebook provided a feasible, rapid method to recruit a large national sample of parents for health research. However, some sample biases were observed and should be considered when recruiting participants via Facebook. Retention of participants at 6- to 8-week follow-up was less than half the initial sample; this may reflect limited ongoing participant engagement for those recruited through social media, compared with face-to-face.

Ethical issues in using the internet to engage participants in family and child research: A scoping review.

BACKGROUND: The internet is an increasingly popular tool in family and child research that is argued to pose new ethical challenges, yet few studies have systematically assessed the ethical issues of engaging parents and children in research online. This scoping review aims to identify and integrate evidence on the ethical issues reported when recruiting, retaining and tracing families and children in research online, and to identify ethical guidelines for internet research. METHODS: Academic literature was searched using electronic academic databases (Scopus, PsycINFO, Embase, ERIC, CINAHL and Informit) and handsearching reference lists for articles published in English between January 2006 and February 2016. Grey literature was searched using Google to identify relevant ethical guidelines. RESULTS: Sixty-five academic articles were included after screening 3,537 titles and abstracts and 205 full-text articles. Most articles reported using the internet to recruit participants (88%) with few reporting online retention (12%) or tracing (10%). Forty percent commented on ethical issues; the majority did not discuss ethics beyond general consent or approval procedures. Some ethical concerns were specific to engaging minors online, including parental consent, age verification and children's vulnerability. Other concerns applied when engaging any research participant online, including privacy and confidentiality, informed consent and disparities in internet access. Five professional guidelines and 10 university guidelines on internet research ethics were identified. Few academic articles (5%) reported using these guidelines. CONCLUSIONS: Engaging families and children in research online introduces unique challenges requiring careful consideration. While researchers regarded themselves as responsible for ensuring research is conducted ethically, lack of use of available guidelines and limited academic literature suggests internet research is occurring without suitable guidance. We recommend broad dissemination of ethical guidelines and encourage researchers to report the methodological and ethical issues of using the internet to engage families and children in research.

What Influences Parents' Fear about Children's Independent Mobility? Evidence from a State-Wide Survey of Australian Parents.

PURPOSE: To identify factors associated with generalized and stranger-specific parental fear (PF) about children's independent mobility (CIM), a critical aspect of physical activity. DESIGN: Cross-sectional survey; random sampling frame, minimum quotas of fathers, rural residents. SETTING: State of Victoria, Australia. SUBJECTS: Parents of children aged 9 to 15 years (n = 1779), 71% response rate. MEASURES: Validated measures of PF and fear of strangers (FoS); parent, child, social, and environmental factors. ANALYSIS: Unadjusted and adjusted linear regression stratified by child age (9-10; 11-13; 14-15). RESULTS: Adjusted models explained a substantial proportion of variance across all age groups (PF: 33.6%-36.7%; FoS: 39.1%-44.0%). Perceived disapproval from others was consistently associated with both outcomes (PF: ß =.11 to 23, p ≤ .05; FoS: ß =.17-.21, p ≤ .001) as was parents' perception of children's competence to travel safely (PF: ß = -.24 to -.11, p ≤ .05; FoS: ß = -.16 to -.13, p ≤ .01). Factors associated with FoS included having a female child (ß = -.21 to -.13, p ≤ .001), language other than English (ß = .09 to.11, p ≤ .01), and low levels of parent education (ß = -.14 to -08, p ≤ .05). CONCLUSION: The current study suggests that social norms, child competence, and perceptions about the benefits of CIM underpin PF. This evidence informs the development of interventions to reduce PF and promote CIM and children's physical activity.

Postpartum maternal separation anxiety, overprotective parenting, and children's social-emotional well-being: longitudinal evidence from an Australian cohort.

Postpartum maternal separation anxiety refers to a mothers' experience of worry and concern about leaving her child for short-term separations. The long-term effects of high maternal separation anxiety on maternal parenting behaviors and child outcomes have been not been established empirically. The aim of this study was to ascertain the prospective relationships between maternal separation anxiety during the child's first year of life, and overprotective parenting and children's social and emotional functioning at age 2-3 years. Structural equation modeling with a large representative cohort of Australian mother-child dyads (N = 3,103) indicated that high maternal separation anxiety was associated with more overprotective parenting behaviors and poorer child socioemotional functioning at age 2-3 years. Findings suggest women with high postpartum maternal separation anxiety may sustain this vigilance across the first years following birth, promoting overprotective behaviors, and resulting in increased behavior problems in their children. Support for women around negotiating separation from their children early in parenthood may prevent the establishment of a repertoire of parenting behaviors that includes unnecessarily high vigilance, monitoring, and anxiety about separation.