Journal articles on the topic 'Mental health services Victoria Melbourne Evaluation'

ABSTRACTBackground: This paper describes the evaluation of the Memory Lane Café service in Victoria, Australia. The Alzheimer's Australia Vic Memory Lane Café model aims to provide a social and educational service to people living with dementia and their carers, family members or friends. Dementia is a serious health issue in Australia, with prevalence estimated at 6.5% of people over 65 years of age. Living with dementia has significant social and psychological ramifications, often negatively affecting quality of life. Social support groups can improve quality of life for people living with dementia.Methods: The evaluation included focus groups and surveys of people with dementia and their carers, staff consultation, service provider interviews, and researcher observation. The Melbourne Health Mental Health Human Research Ethics Committee approved the project. Participants included people with dementia (aged 60 to 93 years, previously enrolled in the Alzheimer's Australia Vic's six-week Living With Memory Loss Program), their carers, friends and/or family members, staff working in the Cafés, and service providers with links to the Cafés.Results: This evaluation found that Memory Lane Cafés promote social inclusion, prevent isolation, and improve the social and emotional well-being of attendees. However, Cafés did not meet the needs of all potential attendees.Conclusions: The evaluation recommended that existing Café services be continued and possibilities for extending the Cafés be explored. Based on evaluation outcomes, the Department of Health Victoria is funding four additional pilot programs in café style support services.

ABSTRACTBackground: In the next decades of the twenty-first century, the global aging of populations will challenge every nation's ability to provide leadership by qualified health professionals to reshape and improve health care delivery systems. The challenge for educators is to design and deliver courses that will give students the knowledge and skills they need to fill that leadership role confidently in dementia care services. This paper explores the ways in which a curriculum can develop graduates who are ready to become leaders in shaping their industry.Method: The Master of Health Science – Aged Services (MHSAS) program at Victoria University, Melbourne, Australia is applied as a case study to describe the process by which the concept of leadership is applied as the key driver in curriculum development, teaching practices and learning outcomes.Results: Evaluation instruments employed in a variety of purposes including teaching, curriculum planning and unit appraisal are discussed. Challenges for the future are proposed including the need for postgraduate programs in dementia to seek stronger national and international benchmarks and associations with other educational institutions to promote leadership and a vision of what is possible and desirable in dementia care provision.Conclusions: In the twenty-first century, effective service provision in the aged health care sector will require postgraduate curricula that equip students for dementia care leadership. The MHSAS program provides an established template for such curricula.

In April 1995 the Royal Children's Hospital Mental Health Service in Melbourne piloted the use of videoconferencing in providing access for rural service providers and their clients to specialist child and adolescent psychiatric input. What began as a pilot project has in two years become integrated into the service-delivery system for rural Victoria. The experience of the service in piloting and integrating the use of videoconferencing to rural Victoria has been an important development for child and adolescent mental health services in Australia.

In 1995, the Royal Children's Hospital Mental Health Service in Melbourne developed the first telepsychiatry programme in child and adolescent mental health services (CAMHS) in Australia. A survey of 25 CAMHS clinicians in five rural regions who had used videoconferencing showed that 64% had used the technology for more than 18 months, and 20% had used it for 7–12 months. Also, 60% had used the technology on over 30 occasions, and 24% had used it on 20–29 occasions. Respondents clearly recognized its benefits in terms of their increased knowledge and skills (96%), strengthening of relationships with colleagues (92%) and decreased sense of isolation (92%). To build on the success of telepsychiatry there are a number of challenges that health service managers will need to address. Telepsychiatry works most effectively as a tool to complement face-to-face contact. It cannot be promoted as the total solution to the issue of isolation from mainstream services.

The Families First Pilot Program in the then Outer East metropolitan region of Melbourne began in mid-1991 as an intensive family preservation and reunification service for children on the verge of state care. The service offered was brief (4-6 week), intensive (up to 20 hours per week), home-based and flexible (24 hour a day, 7 day a week availability) and all members of the household or family were the focus of service even though the goals were clearly grounded in the protection of the child. This paper begins with some of the apprehension expressed both in the field and in Children Australia in 1993, and reports upon the now completed evaluation of the pilot, which covered the first 18 months of operation. The evaluation examined implementation and program development issues and considered the client population of the service against comparative data about those children at risk who were not included. The paper concludes that there is room for Families First in the Victorian system of protective and family services and points to several developmental issues.

Purpose The purpose of this paper is to understand and inform the development and implementation of a newly established Discovery College (a youth-focused Recovery College). It also aims to contribute to a broader understanding of the benefits and barriers to establishing Recovery Colleges. Design/methodology/approach The overall study took a mixed-methods approach to the evaluation of Discovery College, including a qualitative process evaluation component as well as a mixed-methods outcomes evaluation. This paper reports on the findings of the process evaluation, which undertook key informant interviews with a range of stakeholders in the implementation process. Findings A total of 16 themes emerged from the qualitative data, which were then clustered into four main areas: establishing Discovery College, organisational context, nature of Discovery College and service transformation. Implementation was reported as both feasible and effective. Initial tension between fidelity to the model and a pragmatic approach to action was negotiated during implementation and through an ability of staff to tolerate uncertainty, enabled by the efforts and support of senior service management and college staff. Originality/value Recovery Colleges co-designed and implemented in youth mental health services are a recent development in the field of mental health care and very little has previously been published regarding the feasibility, effectiveness and acceptability of youth-focused Recovery Colleges. This paper is one of the first to assess the barriers and enablers to the implementation of Discovery College within a clinical youth mental health service.

BackgroundProviding specialised services to individuals experiencing first-episode psychosis (FEP) is a relatively new endeavour.AimsTo overview developing services for newly diagnosed cases of FEP and the context in which they develop.MethodThis paper describes five model multi-element FEP programmes, outlines recent evaluation studies of FEP services, discusses current evidence gaps relating to the evaluation of complex interventions and specific interventions for FEP and illustrates attempts to examine aspects of clinical work practised at the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Australia.ResultsConsiderable progress has been made in terms of influencing practice in the assessment and treatment of early psychosis.ConclusionsThere is need for quality clinical and research efforts to inform and accelerate progress in this burgeoning field.

This study aimed to describe regional variations in service use and distance travelled to post-discharge health services in the first three years following hospital discharge for people with transport-related orthopaedic, brain, and spinal cord injuries. Using linked data from the Victorian State Trauma Registry (VSTR) and Transport Accident Commission (TAC), we identified 1597 people who had sustained transport-related orthopaedic, brain, or spinal cord injuries between 2006 and 2016 that met the study inclusion criteria. The adjusted odds of GP service use for regional participants were 76% higher than for metropolitan participants in the orthopaedic and traumatic brain injury (TBI) groups. People with spinal cord injury (SCI) living in regional areas had 72% lower adjusted odds of accessing mental health, 76% lower adjusted odds of accessing OT services, and 82% lower adjusted odds of accessing physical therapies compared with people living in major cities. People with a TBI living in regional areas on average travelled significantly further to access all post-discharge health services compared with people with TBI in major cities. For visits to medical services, the median trip distance for regional participants was 76.61 km (95%CI: 16.01–132.21) for orthopaedic injuries, 104.05 km (95% CI: 51.55–182.78) for TBI, and 68.70 km (95%CI: 8.34–139.84) for SCI. Disparities in service use and distance travelled to health services exist between metropolitan Melbourne and regional Victoria following serious injury.

IntroductionAlmost 78 000 women gave birth in the state of Victoria, Australia, in 2019. While most births occurred in metropolitan Melbourne and large regional centres, a significant proportion of women birthed in rural services. In late 2016, to support clinicians to recognise and respond to clinical deterioration, the Victorian government mandated provision of an emergency training programme, called Maternity and Newborn Emergencies (MANE), to rural and regional maternity services across the state. This paper describes the evaluation of MANE.Design and settingA quasi-experimental study design was used; the Kirkpatrick Evaluation Model provided the framework.ParticipantsParticipants came from the 17 rural and regional Victorian maternity services who received MANE in 2018 and/or 2019.Outcome measuresBaseline data were collected from MANE attendees before MANE delivery, and at four time points up to 12 months post-delivery. Clinicians’ knowledge of the MANE learning objectives, and confidence ratings regarding the emergencies covered in MANE were evaluated. The Safety Attitudes Questionnaire (SAQ) assessed safety climate pre-MANE and 6 months post-MANE among all maternity providers at the sites.ResultsImmediately post-MANE, most attendees reported increased confidence to escalate clinical concerns (n=251/259). Knowledge in the non-technical and practical aspects of the programme increased. Management of perinatal emergencies was viewed as equally stressful pre-MANE and post-MANE, but confidence to manage these emergencies increased post-delivery. Pre-MANE SAQ scores showed consistently strong and poor performing services. Six months post-MANE, some services showed improvements in SAQ scores indicative of improved safety climate.ConclusionMANE delivery resulted in both short-term and sustained improvements in knowledge of, and confidence in, maternity emergencies. Further investigation of the SAQ across Victoria may facilitate identification of services with a poor safety climate who could benefit from frequent targeted interventions (such as the MANE programme) at these sites.

IntroductionThe ambulance clinical triage-for acute stroke treatment (ACT-FAST) algorithm is a severity based 3-step paramedic triage tool for pre-hospital recognition of large vessel occlusion (LVO), designed to improve specificity and paramedic assessment reliability compared to existing triage scales. ACT-FAST sequentially assesses 1. Unilateral arm fall to stretcher <10 s; 2a. Severe language disturbance (right arm weak), or 2b. Severe gaze deviation/hemi-neglect assessed by shoulder tap (left arm weak); 3. Clinical eligibility questions. We present the results of the ongoing Ambulance Victoria paramedic validation study.MethodsAmbulance Victoria paramedics assessed ACT-FAST in all suspected stroke patients pre-hospital in metropolitan Melbourne, Australia, and in the Royal Melbourne Hospital Emergency Department since July 2017. Algorithm results were validated against a comparator of ICA/M1 occlusion on CT-angiography with NIHSS ≥6 (Class 1 indications for endovascular thrombectomy).ResultsData were available from n=119 assessments (ED n=68, pre-hospital n=51). Patient diagnoses were LVO n=20 (15.6%), non-LVO infarcts n=45 (38.5%), ICH n=10 (8.3%) and no stroke on imaging n=44 (37.6%). ACT-FAST showed 85% sensitivity, 88.9% specificity, 60.7% (72% excluding ICH) positive predictive value and 96.7% negative predictive value for LVO. Of 10 false-positives, 4 received thrombectomy for non-Class 1 indications (basilar/M2 occlusions/cervical dissection), 3 were ICH, and 1 was tumour. Three false-negatives were LVO with milder syndromes.DiscussionThe ongoing ACT-FAST algorithm validation study shows high accuracy for clinical recognition of LVO. The streamlined algorithmic approach with just two examination items provides a more practical option for implementation in large emergency service networks. Accurate pre-hospital recognition of LVO will allow bypass to endovascular centres and early activation of neuro-intervention services to expedite endovascular thrombectomy.

Recently arrived older refugees in resettlement countries are a particularly vulnerable population who face many risks to their health and well‐being, and many challenges in accessing services. This paper reports on a project undertaken in Victoria, Australia to explore the needs of older people from 14 recently arrived refugee communities, and the barriers to their receiving health and aged care. Findings from consultations with community workers and service providers highlight the key issues of isolation, family conflict and mental illness affecting older refugees, and point to ways in which policy‐makers and service providers can better respond to these small but deserving communities.

Objective: The objective was to describe and evaluate a community mental health service developed during 1991–1992 in an attempt to meet the mental illness needs of an isolated rural community. The setting was the Grampians health region in Western Victoria: this region has an area of 45,000 square kilo-metres and a population of 182,000. Method: The method involved firstly describing the evolution of the service delivery model. This comprised a team of travelling psychiatrists and community psychiatric nurses which succeeded in providing a combined inpatient and outpatient service which was integrated with general practitioners. Secondly, diagnostic and case load descriptions of patients receiving service were compared for both the inpatient and outpatient settings. Results: The results were that reduced reliance on inpatient beds and increased consumer satisfaction were achieved. Conclusion: It was concluded that on initial evaluation of the service it was seen to be meeting its objective of treating the seriously mentally ill in an isolated rural community based setting.

Objective: The COVID-19 pandemic may cause a major mental health impact. We aimed to identify demographic or clinical factors associated with psychiatric admissions where COVID-19 was attributed to contribute to mental state, compared to admissions which did not. Methods: A retrospective cohort study was undertaken of inpatients admitted to Northern Psychiatric Unit 1, Northern Hospital in Melbourne, Victoria, Australia during 27/02/2020 to 08/07/2020. Data were extracted for participants who identified COVID-19 as a stressor compared to participants who did not. Fisher’s exact test and Mann-Whitley rank sum test were used. Results: Thirty six of 242 inpatients reported the COVID-19 pandemic contributed to mental ill health and subsequent admission. Reasons given included social isolation, generalized distress about the pandemic, barriers to support services, disruption to daily routine, impact on employment, media coverage, re-traumatization, cancelled ECT sessions, loss of loved ones, and increased drug use during the lockdown. Chronic medical conditions or psychiatric multimorbidity were positively associated and smoking status was negatively associated with reporting the COVID-19 pandemic as a contributor to mental ill health. Conclusion: Screening and identifying vulnerable populations during and after the global disaster is vital for timely and appropriate interventions to reduce the impact of the pandemic worldwide.

IntroductionOver 310 000 women gave birth in Australia in 2016, with approximately 80 000 births in the state of Victoria. While most of these births occur in metropolitan Melbourne and other large regional centres, a significant proportion of Victorian women birth in local rural health services. The Victorian state government recently mandated the provision of a maternal and neonatal emergency training programme, called Maternal and Newborn Emergencies (MANE), to rural and regional maternity service providers across the state. MANE aims to educate maternity and newborn care clinicians about recognising and responding to clinical deterioration in an effort to improve clinical outcomes. This paper describes the protocol for an evaluation of the MANE programme.Methods and analysisThis study will evaluate the effectiveness of MANE in relation to: clinician confidence, skills and knowledge; changes in teamwork and collaboration; and consumer experience and satisfaction, and will explore and describe any governance changes within the organisations after MANE implementation. The Kirkpatrick Evaluation Model will provide a framework for the evaluation. The participants of MANE, 27 rural and regional Victorian health services ranging in size from approximately 20 to 1000 births per year, will be invited to participate. Baseline data will be collected from maternity service staff and consumers at each health service before MANE delivery, and at four time-points post-MANE delivery. There will be four components to data collection: a survey of maternity services staff; follow-up interviews with Maternity Managers at health services 4 months after MANE delivery; consumer feedback from all health services collected through the Victorian Healthcare Experience Survey; case studies with five regional or rural health service providers.Ethics and disseminationThis evaluation has been approved by the La Trobe University Science, Health and Engineering College Human Ethics Sub-Committee. Findings will be presented to project stakeholders in a deidentified report, and disseminated through peer-reviewed publications and conference presentations.

This paper reports on preliminary findings of a novel program piloted in 2010 to address rural mental health workforce shortages. The program involved exposing allied health and nursing students from rural backgrounds studying in Melbourne to mental health service employment opportunities in Gippsland. A longitudinal study is underway to evaluate the effect and outcomes of the program and includes surveying participants’ interest in rural mental health work through an online questionnaire immediately prior to and following the program; and surveying career decisions at 6 months and yearly intervals. Paired sample t-tests were used to analyse participants’ level of interest in rural work (pre-event 4.67 (1.50); post-event 5.93 (0.96); P = 0.001), career in a rural setting (pre-event 4.67 (1.63); post-event 5.67 (1.23); P = 0.006), mental health work (pre-event 4.73 (1.39); post-event 6.07 (0.80); P < 0.000) and rural mental health career (pre-event 4.73 (1.33); post-event 5.80 (1.21); P = 0.002). These findings indicate a significant increase from pre- to post-event and are supported by strong effect sizes suggesting that the program had a significant effect on participant interest in rural mental health work. Longer-term evaluation will determine whether the program influences participant career decisions and thereby addressing mental health workforce shortages in Gippsland. What is known about the topic? Despite the ongoing challenges that regional and rural mental health services face recruiting and retaining mental health professionals, there is a lack of evidence available to inform rural mental health workforce recruitment strategies. What does this paper add? This paper describes a novel recruitment initiative and preliminary data from a longitudinal evaluation program. The initiative targets allied health and nursing students with rural backgrounds who are studying at a large urban centre (Melbourne). What are the implications for practitioners? This study provides a potentially successful recruiting tool for mental health sector policy-makers and managers which will be evaluated over the long-term.

Purpose Music therapy programs are increasingly common and necessary in mental health services. However, there is little knowledge of the key factors which influence the successful implementation of new therapeutic programs. The purpose of this paper is to explore how stakeholder input influenced the implementation and sustainability of a new music therapy program in four services within a large government funded mental health department in Melbourne, Australia. Design/methodology/approach For a period of 12 months, two cycles of assessment, action and evaluation were conducted where data were collected through interviews with staff members, feedback from consumers and attendance in sessions. Findings A number of influential factors were identified as important in the successful implementation and future sustainability of the music therapy program. These included: the degree of staff support received; how the program was structured and facilitated; promotion of the program within the service; evaluation of the program; and congruence with the existing therapeutic program. Research limitations/implications Results suggest that successful implementation and future sustainability of a music therapy program is dependent on the flexibility of the program to the context and culture of the existing setting. Originality/value This is the first study to incorporate contributions from stakeholders in the implementation of a new music therapy program in a mental health service.

IntroductionSmoke-free policies have been introduced in prisons internationally. However, high rates of relapse to smoking after release from prison indicate that these policies typically result in short-term smoking cessation only. These high rates of relapse, combined with a lack of investment in relapse prevention, highlight a missed opportunity to improve the health of a population who smoke tobacco at two to six times the rate of the general population. This paper describes the rationale and design of a randomised controlled trial, testing the effectiveness of a caseworker-delivered intervention promoting smoking cessation among former smokers released from smoke-free prisons in Victoria, Australia.Methods and analysisThe multicomponent, brief intervention consists of behavioural counselling, provision of nicotine spray and referral to Quitline and primary care to promote use of government-subsidised smoking cessation pharmacotherapy. The intervention is embedded in routine service delivery and is administered at three time points: one prerelease and two postrelease from prison. Control group participants will receive usual care. Smoking abstinence will be assessed at 1 and 3 months postrelease, and confirmed with carbon monoxide breath testing. Linkage of participant records to survey and routinely collected administrative data will provide further information on postrelease use of health services and prescribed medication.Ethics and disseminationEthical approval has been obtained from the Corrections Victoria Research Committee, the Victorian Department of Justice Human Research Ethics Committee, the Department of Human Services External Request Evaluation Committee and the University of Melbourne Human Research Ethics Committee. Results will be submitted to major international health-focused journals. In case of success, findings will assist policymakers to implement urgently needed interventions promoting the maintenance of prison-initiated smoking abstinence after release, to reduce the health disparities experienced by this marginalised population.Trial registration numberACTRN12618000072213; Pre-results.

Objective. To outline the major findings of a qualitative evaluation of an Early Psychosis Service 3 years after its establishment. Design. Data to evaluate the service were collected from team meetings, focus groups, individual interviews and questionnaires administered to clinicians, school staff, patients, carers and families. Setting. Barwon Health; Mental Health, Drug and Alcohol Services provide public mental health care to the Geelong, Victoria, region (population 270 000), which is a mixed urban and rural setting. The Early Psychosis Service model implemented involved the placement of two early psychosis workers into each of five adult geographically based Area Mental Health Teams rather than the establishment of a single Early Psychosis Team. Results. The service was found not to adhere to its original design in several key respects. Caseloads and periods of case management were found to be lower and shorter respectively than was originally planned for, caseworkers often experienced isolation and resentment from their adult service coworkers, the service was perceived to be difficult to access and premises not to be youth friendly and communication and engagement with external agencies and service providers was perceived to be poor. Conclusions. The choice of service model, inadequate consultation with stakeholders and inadequate promotion of the service contributed to its failure to reach early expectations. Because of these and other issues, including difficulties distinguishing between early psychosis and non-psychosis, a decision was made to restructure youth services and a separate youth mental health service, which incorporated the Early Psychosis Service function, was established.

The growth and diversification of alcohol and drug services and the increased demand for accountability of public monies, has stimulated the development of monitoring and review systems. This article describes the development and utilisation of an agency review system to monitor a broad range of alcohol and drug agencies. The review contains standard practices and indicators which identify and measure the quality of organisational structure and services. This is a developmental approach to agency review which emphasises the involvement of management and staff in a process evaluation of their agency. This system has been piloted in Victoria and its future implementation and its wider application is discussed.

Objective: In Australia, mental health services are delivered by a complex web of publicand private-sector providers. There is a growing recognition that linkages between these groups are not optimal, and a concern that this may lead to poor outcomes. This paper illustrates a conceptual framework for developing, implementing and evaluating programmes concerned with linkages. Method: Drawing on theoretical and practical literature, this paper identifies different levels of integration, issues in evaluating programmes to address poor linkages, and features of useful evaluations. Within this context, it describes the method by which the Public and Private Partnerships in Mental Health Project (Partnership Project) is being evaluated. Conducted by St Vincent's Mental Health Service and The Melbourne Clinic, this is one of several Demonstration Projects in Integrated Mental Health Care funded under the National Mental Health Strategy. Results: Collaboration is hard to conceptualize and collaborative programmes usually have many players and components, and tend to operate within already-complex systems. This creates difficulties for evaluation, in terms of what to measure, how to measure it, and how to interpret findings. In spite of these difficulties, the illustrative example demonstrates a model for evaluating collaborative programmes that is currently working well because it is strongly conceptualized, descriptive, comparative, constructively sceptical, positioned from the bottom up, and collaborative. Conclusions: This model, or aspects of it, could be extended to the evaluation of other mental health programmes and services that have collaborative elements.

Purpose Anecdotal feedback obtained from alcohol and drug and mental health staff across the eastern metropolitan region of Melbourne, Australia suggests that attitudes towards working with people experiencing a dual diagnosis are becoming more positive. The purpose of this paper is to understand if dual diagnosis-specific training delivered to staff within mental health and alcohol and other drug services was a factor positively influencing attitudes. Design/methodology/approach No formal evaluation assessing the impact of dual diagnosis-specific training on staff attitudes had previously occurred within this region of Australia. Access to staff on two occasions from three distinct sectors provided an opportunity to examine if and, to what degree, attitudes can be influenced by dual diagnosis-specific training. Using a co-designed attitudes survey, information was gathered from mental health and alcohol and drug staff on their attitudes to working with people with co-occurring mental health and substance use problems. Findings Two surveys were conducted involving 186 staff in 2012 and 110 staff in 2016. The dual diagnosis attitudes survey showed that positive attitudes to working with people experiencing a dual diagnosis were associated with recency of training. While attitudes may be improved by dual diagnosis training, these findings cannot exclude the impact of other dual diagnosis capacity building activities. Originality/value This study highlights the benefits of a regional partnership between mental health and alcohol and drug services and people with lived experience of dual diagnosis and the benefit of recent co-designed dual diagnosis training on longitudinally assessed worker attitudes.

This article reviews a Quality Improvement Project concerning how GP clinics approach after hours (AH) primary care information for themselves and their patients. Medicare Locals have been given the responsibility of coordinating AH services in their catchments and supporting health systems and patients in accessing care appropriate to their needs. The AH project conducted by Inner North West Melbourne Medicare Local (INWMML) sought to explore how a range of GP clinics approached AH information before an educational forum, evaluation of its developed resources for increasing awareness of AH options and how clinics would choose to change their approach to AH following this process. The findings suggested that 46 participating clinic staff had a strong focus on hospitals and locum services as the main AH options despite telephone advice line options being available. Additionally, there was a lack of awareness for some clinic staff concerning services for mental health, dental health and residential aged care. The educational forum and the AH resources developed (i.e. brochures, posters and service directory) by INWMML were rated as valuable and would be used and shared with other health care providers and patients. Confidence that patients would be able to find appropriate care in the AH period after clinics had finished implementing planned changes, rose significantly in key areas after participating in the AH project.

Health literacy courses for health professionals have emerged in response to health professionals’ perceived lack of understanding of health literacy issues, and their failure to routinely adopt health literacy practices. Since 2013 in Victoria, Australia, the Centre for Culture, Ethnicity and Health has delivered an annual health literacy demonstration training course that it developed. Course development and delivery partners included HealthWest Partnership and cohealth. The courses are designed to develop the health literacy knowledge, skills and organisational capacity of the health and community services sector in the western metropolitan region of Melbourne. This study presents key learnings from evaluation data from three health literacy courses using Wenger’s professional educational learning design framework. The framework has three educational learning architecture components (engagement, imagination and alignment) and four educational learning architecture dimensions (participation, emergent, local/global, identification). Participatory realist evaluation approaches and qualitative methods were used. The evaluations revealed that the health literacy courses are developing leadership in health literacy, building partnerships among course participants, developing health literacy workforce knowledge and skills, developing ways to use and apply health literacy resources and are serving as a catalyst for building organisational infrastructure. Although the courses were not explicitly developed or implemented using Wenger’s educational learning design pedagogic features, the course structure (i.e. facilitation role of course coordinators, providing safe learning environments, encouraging small group work amongst participants, requiring participants to conduct mini-projects and sponsor organisation buy-in) provided opportunities for engagement, imagination and alignment. Wenger’s educational learning design framework can inform the design of future key pedagogic features of health literacy courses. What is known about the topic? Health professionals are increasingly participating in health literacy professional development courses. What does this paper add? This paper provides key lessons for designing health literacy professional development courses by reflecting upon Wenger’s professional educational learning design framework. What are the implications for practitioners? To ensure health professionals are receiving evidence-informed health literacy professional education, we encourage future health literacy courses be designed, implemented and evaluated using existing professional educational learning design frameworks.

Objective The aim of this study was to present the views of four stakeholder groups, namely general practitioners (GP), employers (EMP), injured workers (IW) and compensation agents (CA), about the content and usability of the draft of the new Victorian sickness certificate. Methods A cross-sectional mixed-methods qualitative study was conducted in GP clinics and community settings in Melbourne, Australia. Interviews were conducted with GPs, EMPs and IWs and one focus group discussion was completed with CAs (n = 29). Data were collected between October and December 2013. Thematic analysis was performed. Results All stakeholders viewed the new draft certificate as an improvement on the old one. GPs saw the certificate as a form of communication, whereas EMPs and CAs saw it as a therapeutic device. GPs continued to certify based on incapacity and provided little information about what IWs could do on return to work. All groups said that assessments for mental health needed more clarity and specificity. GPs, EMPs and CAs also said that the new certificates must be electronically available and integrated into existing medical software to streamline uptake. Conclusions To ensure appropriate use of the new certificate, stakeholders must share a common understanding about its purpose and the certificate must be incorporated into existing medical software. Content on mental health assessment, an area of continued difficulty, needs additional refinement. The new certificate replaced the old certificate in March 2015; after it has been established in clinical practice, an impact evaluation should be completed to determine whether GPs are certifying capacity and earlier return to work. What is known about the topic? When it comes to sickness certification, GPs tend to focus on what injured patients cannot do, rather than what they can do. The new sickness certificate aims to change GP behaviour by focusing the certificate more on capacity (i.e. what the injured patient can do). What does this paper add? Four stakeholder groups agreed that the content and usability of the new certificate has improved. However, they agreed that the assessment of mental health capacity needs further specificity. Dissonances also remain between the stakeholders on the purpose of the certificate. What are the implications for practitioners? Appropriate use of the new certificate requires a common understanding about the purpose of the certificate, training on its appropriate use, incorporation into existing medical software and clarity on mental health assessment.

Quantitative fit testing was utilised to evaluate the Department of Health and Human Services in Victoria (DHHS) recommended fit check and determine pass/fail rates for self-selected P2/N95 respirators. Survey experience and training related to P2/N95 respirators were also obtained. This was an observational study at a specialist tertiary referral centre, Melbourne, Australia, between 29 May 2020 and 5 June 2020. The primary outcome was quantitative fit test pass/fail results, with fit check reported against fit test as a 2 × 2 contingency table. The secondary outcomes were the number of adjustments needed to pass, as well as the pass rates for available sizes and types of self-selected respirators, survey data for attitudes, experience and training for P2/N95 respirators. The fit check predicts respirator seal poorly (PPV 34.1%, 95% CI 25.0–40.5). In total, 69% (40/58) of respirators failed quantitative fit testing after initial respirator application and is a clinically relevant finding (first-up failure rate for P2/N95 respirators). Only one person failed the fit test for all three respirator fit tests. There was significant variability between each of the seven types of self-selected P2/N95 respirators, although sample sizes were small. Few participants were trained in the use of P2/N95 respirators or the fit check prior to COVID-19, with a high number of participants confident in achieving a P2/95 respirator seal following a fit test. The fit check alone was not a validated method in confirming an adequate seal for P2/N95 respirators. Quantitative fit testing can facilitate education, improve the seal of P2/N95 respirators, and needs to be integrated into a comprehensive Respiratory Protection Program (RPP).

The Community Correction Order, introduced in Victoria, Australia in 2012, provides a sentencing option that enables eligible offenders to serve their sanction in the community, with access to treatment or other rehabilitative activities. This paper contributes to a scant body of research investigating the specific needs of this group, their barriers to inclusion and the extent to which they experience the rehabilitative aspects of Community Correction Orders. It draws on survey data collected from 200 adults (137 men and 63 women) on Community Correction Orders in outer west metropolitan Melbourne and qualitative analysis of in-depth interviews conducted with a sub-set of 20 participants. Long-term unemployment, severe economic hardship, physical and mental health issues, social isolation and troubled personal relationships were common. While participants experienced the punitive aspects of Community Correction Orders, there was limited evidence that they were supported to address key issues that may be predictive of future offending. Support to re/engage in education, training and employment was a key area of unmet need and engagement in other therapeutic programs was low. Opportunities to enhance the rehabilitative potential of Community Correction Orders are discussed, with the paper highlighting that there is a need for rigorous evaluation of community work program activities.

Purpose Police play an essential role in reducing harms associated with family violence by identifying people at increased risk of physical or mental health-related harm and linking them with support services. Yet police are often poorly trained and resourced to conduct the kind of assessments necessary to identify family violence cases presenting with increased risk. The paper aims to discuss this issue. Design/methodology/approach This paper describes a multi-project collaboration between law enforcement, forensic mental health, and academia that has over three years worked to improve risk assessment and management of family violence by police in Victoria, Australia. Findings Evaluation of existing risk assessment instruments used by the state-wide police force showed they were ineffective in predicting future police reports of family violence (AUC=0.54-0.56). However, the addition of forensic psychology expertise to specialist family violence teams increased the number of risk management strategies implemented by police, and suggested that the Brief Spousal Assault Form for the Evaluation of Risk assessment instrument may be appropriate for use by Australian police (AUC=0.63). Practical implications The practical implications of this study are as follows: police risk assessment procedures should be subject to independent evaluation to determine whether they are performing as intended; multidisciplinary collaboration within police units can improve police practice; drawing on expertise from agencies external to police offers a way to improve evidence-based policing, and structured professional judgement risk assessment can be used in policing contexts with appropriate training and support. Originality/value The paper describes an innovative collaboration between police, mental health, and academia that is leading to improved police practices in responding to family violence. It includes data from the first evaluation of an Australian risk assessment instrument for family violence, and describes methods of improving police systems for responding to family violence.

Objective: To determine the efficacy, safety and acceptability as well as the patient demographics of three newly developed emergency department–embedded Psychiatric Assessment and Planning Units located in Metropolitan Melbourne at Austin, Peninsula and Eastern Health Services. Methods: The evaluation reviewed a 12-month period of service activity from 1 September 2017 to 31 August 2018, when all three Psychiatric Assessment and Planning Units services were operational. A 12-month period from 1 September 2014 to 31 August 2015 was compared as the pre-Psychiatric Assessment and Planning Units period. Mixed qualitative and quantitative methods were used. This included semi-structured interviews of 30 Psychiatric Assessment and Planning Units patients and 30 emergency department staff (10 of each for all 3 sites), patient survey, statistical analysis of Client Management Interface data for the emergency department and related Psychiatric Assessment and Planning Units as well as audit of RISKMAN registers. Results: There were 365 Austin, 567 Eastern and 791 Peninsula Psychiatric Assessment and Planning Units admissions. Psychiatric Assessment and Planning Units were generally well accepted by patients and emergency department staff, relatively safe, operating within the Key Performance Indicators with mixed effect on emergency department flow. Austin emergency department processing times improved post-Psychiatric Assessment and Planning Units (4 hours 57 minutes to 4 hours 19 minutes; p < 0.001) while deteriorating at Eastern and Peninsula. Adjustment Disorder and Depression and Borderline Personality Disorder were the most common admission diagnoses. While the Psychiatric Assessment and Planning Units had mixed utility on emergency department processing times, they appear to serve a demographic not previously accommodated in traditional emergency department psychiatry models. Conclusion: The emergency department–embedded Psychiatric Assessment and Planning Unit model of care appears effective on some measures, safe and acceptable to patients and staff. The Psychiatric Assessment and Planning Units seem to service a group not previously accommodated in traditional emergency psychiatry models.

The objectives of this study were to perform an economic evaluation of a targeted school-based dental checkup program in northern metropolitan Melbourne, Victoria. A 12-mo retrospective case-control cohort analysis using the decision tree method evaluated the incremental cost-utility and cost-effectiveness ratio (ICUR/ICER) for passive standard care dental services and an outreach pilot intervention completed in 2013. A societal perspective was adopted. A total of 273 children ( n = 273) aged between 3 and 12 y met the inclusion/exclusion criteria: 128 in the standard care group and 145 in the intervention group. The total society costs included health sector costs, patient/family costs, and productivity losses in 2014 Australian dollars. Outcome measures were evaluated using quality-adjusted tooth years (QATY) and the combined deciduous and permanent decayed, missing, and filled teeth prevented (DMFT-prevented). A generic outcome variable was created to determine the impact of the intervention to reach underserved populations based on government concession eligibility (cardholder status). Uncertainties were incorporated using 95% confidence intervals. The mean total society cost per child is $463 and $291 ( P = 0.002), QATY utility difference is 0.283 and 0.293 ( P = 0.937), effectiveness difference is 0.16 and 0.10 ( P = 0.756), and cardholder status is 50.0% and 66.2% ( P = 0.007), respectively, for the standard care and intervention groups. On average per child, there was a cost saving of $172 and improvement of 0.01 QATY, with an additional proportion of 16.2% of cardholder children reached. The calculated ICER was $3,252 per DMFT-prevented. The intervention dominates standard care for QATY and per 1% cardholder reached outcome measures. Our study found the pilot checkup program was largely less costly and more effective compared with the current standard care. Further research is needed to quantify the value of outreach interventions to prevent dental caries development and progression in populations from low socioeconomic status. Knowledge Transfer Statement: The findings of this research demonstrated that an outreach dental program can be less costly and more effective than standard models of dental care. It showed that a school-based dental checkup program is beneficial despite other opinions that dental screening is ineffective as a method to improve public dental health. There is fiscal economic evidence to support broader expansion of similar programs locally and internationally to reduce dental caries for children from low-income families.

Objectives: Despite substantial investment by governments, the prevalence of mental health disorders in developed countries remains unchanged over the past 20 years. As 50% of mental health conditions present before 14 years of age, access to high-quality mental health care for children is crucial. Barriers to access identified by parents include high costs and long wait times, difficulty navigating the health system, and a lack of recognition of the existence and/or severity of the child’s mental health disorder. Often neglected, but equally important, are clinician views about the barriers to and enablers of access to high-quality mental health care. We aimed to determine perspectives of Australian clinicians including child and adolescent psychiatrists, paediatricians, psychologists and general practitioners, on barriers and enablers within the current system and components of an optimal system. Methods: A total of 143 clinicians (approximately 35 each of child and adolescent psychiatrists, paediatricians, child psychologists and general practitioners) from Victoria and South Australia participated in semi-structured phone interviews between March 2018 and February 2019. Inductive content analysis was applied to address the broad study aims. Findings: Clinician-identified barriers included multi-dimensional family factors, service fragmentation, long wait times and inadequate training for paediatricians and general practitioners. Rural and regional locations provided additional challenges but a greater sense of collaboration resulting from the proximity of clinicians in rural areas, creating an opportunity to develop support networks. Suggestions for an optimal system included novel ways to improve access to child psychiatry expertise, training for paediatricians and general practitioners, and co-located multidisciplinary services. Conclusion: Within the current mental health system for children, structural, training and workforce barriers prevent optimal access to care. Clinicians identified many practical and systemic ideas to improve the system. Implementation and evaluation of effectiveness and cost effectiveness of these ideas is the next challenge for Australia’s children’s mental health.

IntroductionIntegrated community healthcare Hubs may offer a ‘one stop shop’ for service users with complex health and social needs, and more efficiently use service resources. Various policy imperatives exist to implement Hub models of care, however, there is a dearth of research specifically evaluating Hubs targeted at families experiencing adversity. To contribute to building this evidence, we propose to co-design, test and evaluate integrated Hub models of care in two Australian community health services in low socioeconomic areas that serve families experiencing adversity: Wyndham Vale in Victoria and Marrickville in New South Wales.Methods and analysisThis multisite convergent mixed-methods study will run over three phases to (1) develop the initial Hub programme theory through formative research; (2) test and, then, (3) refine the Hub theory using empirical data. Phase 1 involves co-design of each Hub with caregivers, community members and practitioners. Phase 2 uses caregiver and Hub practitioner surveys at baseline, and 6 and 12 months after Hub implementation, and in-depth interviews at 12 months. Two stakeholder groups will be recruited: caregivers (n=100–200 per site) and Hub practitioners (n=20–30 per site). The intervention is a co-located Hub providing health, social, legal and community services with no comparator. The primary outcomes are caregiver-reported: (i) identification of, (ii) interventions received and/or (iii) referrals received for adversity from Hub practitioners. The study also assesses child, caregiver, practitioner and system outcomes including mental health, parenting, quality of life, care experience and service linkages. Primary and secondary outcomes will be assessed by examining change in proportions/means from baseline to 6 months, from 6 to 12 months and from baseline to 12 months. Service linkages will be analysed using social network analysis. Costs of Hub implementation and a health economics analysis of unmet need will be conducted. Thematic analysis will be employed to analyse qualitative data.Ethics and disseminationRoyal Children’s Hospital and Sydney Local Health District ethics committees have approved the study (HREC/62866/RCHM-2020). Participants and stakeholders will receive results through meetings, presentations and publications.Trial registration numberISRCTN55495932.

IntroductionStillbirth continues to be a public health concern in high-income countries, and with mixed results from several stillbirth prevention interventions worldwide the need for an effective prevention method is ever present. The Safer Baby Bundle (SBB) proposes five evidence-based care packages shown to reduce stillbirth when implemented individually, and therefore are anticipated to produce significantly better outcomes if grouped together. This protocol describes the planned economic evaluation of the SBB quality improvement initiative in Australia.Methods and analysisThe implementation of the SBB will occur over three state-based health jurisdictions in Australia—New South Wales, Queensland and Victoria, from July 2019 onwards. The intervention is being applied at the state level, with sites opting to participate or not, and no individual woman recruitment. The economic evaluation will be based on a whole-of-population linked administrative dataset, which will include the data of all mothers, and their resultant children, who gave birth between 1 January 2016 and 31 December 2023 in these states, covering the preimplementation and postimplementation time period. The primary health outcome for this economic evaluation is late gestation stillbirths, with the secondary outcomes including but not limited to neonatal death, gestation at birth, mode of birth, admission to special care nursery and neonatal intensive care unit, and physical and mental health conditions for mother and child. Costs associated with all healthcare use from birth to 5 years post partum will be included for all women and children. A cost-effectiveness analysis will be undertaken using a difference-in-difference analysis approach to compare the primary outcome (late gestation stillbirth) and total costs for women before and after the implementation of the bundle.Ethics and disseminationEthics approval for the SBB project was provided by the Royal Brisbane & Women’s Hospital Human Research Ethics Committee (approval number: HREC/2019/QRBW/47709). Approval for the extraction of data to be used for the economic evaluation was granted by the New South Wales Population and Health Services Research Ethics Committee (approval number: 2020/ETH00684/2020.11), Australian Institute of Health and Welfare Human Research Ethics Committee (approval number: EO2020/4/1167), and Public Health Approval (approval number: PHA 20.00684) was also granted. Dissemination will occur via publication in peer reviewed journals, presentation at clinical and policy-focused conferences and meetings, and through the authors’ clinical and policy networks.This study will provide evidence around the cost effectiveness of a quality improvement initiative to prevent stillbirth, identifying the impact on health service use during pregnancy and long-term health service use of children.

Objectives: This narrative paper describes the influences behind the development of, and key components of a specialist younger-onset dementia service located in metropolitan Victoria, Australia. Conclusion: The Melbourne Young-Onset Dementia Service was established in 2013 and provides diagnosis and ongoing care for people with younger-onset dementia and their families, through collaboration with other medical units, allied health and community services. It is potentially a model for other younger-onset dementia services nationally and internationally.

Objective To evaluate the Mental Health and Primary Care Partnership (MaP) pilot program which operated in a metropolitan Melbourne setting in 2020. Method Data collection included: surveys, interviews, file audits, and an evaluation of routinely collected data, with MaP consumers, their carers, GPs, Practice Managers and Nurses located in Boroondara, and MaP and Aged Person’s Mental Health Service staff. Results Thirty-five consumers aged between 66 and 101 years old (of whom 63% were female) received support from the MaP program throughout its 12-month operation. Statistically significant improvements in outcome measures assessing for psychological distress and symptoms of mental illness were observed. Strengths of the program included the single referral pathway and the provision of services for those not meeting criteria to access tertiary mental health support. Consumers and clinicians made recommendations for service improvement including provision of a longer duration of care to consumers and greater integration of community and primary care. Conclusions It is hoped that the learnings from the MaP pilot program can be used to guide future program development.

Objective: A spreadsheet-based model for supporting equitable mental health resource distribution in Australia was developed, based on the Australian Health Survey (AHS) psychological distress findings associated with area socio-economic disadvantage (SED). An illustrative application is presented. Method: Stratum-specific psychological-distress rates for area SED quintiles are applied to local government areas, catchment areas and local health networks (LHNs). A case study applies the model to Victoria, including examining recommendations in the Royal Commission into Victoria’s Mental Health Services (RCVMHS) 2019 interim report for increases to bed stock in two LHNs. Results: Need-adjusted demand estimates considered as a ratio of raw population proportions for catchments range between 0.6 to 1.4 in Victoria. Applying the formula to the Royal Commission recommendations suggests the proposed distribution of beds is a reasonable correction for these two LHNs and indicates next expansion priorities for more equitable distribution to other LHNs. Conclusions: The spreadsheet, adaptable for other states and territories, could complement National Mental Health Services Planning Framework outputs and assist in evaluation, for instance, determining potential supply shortages in the tele-mental-health response to COVID-19. We outline research directions including consideration of the moral bases of value judgements and identification of other variables including their use in parameterisation and calibration.

Abstract Background Certain migrant groups are at an increased risk of psychotic disorders compared to the native-born population; however, research to date has mainly been conducted in Europe. Less is known about whether migrants to other countries, with different histories and patterns of migration, such as Australia, are at an increased risk for developing a psychotic disorder. We tested this for first-generation migrants in Melbourne, Victoria. Methods This study included all young people aged 15–24 years, residing in a geographically-defined catchment area of north western Melbourne who presented with a first episode of psychosis (FEP) to the Early Psychosis Prevention and Intervention Centre (EPPIC) between 1 January 2011 and 31 December 2016. Data pertaining to the at-risk population were obtained from the Australian 2011 Census and incidence rate ratios were calculated and adjusted for age, sex and social deprivation. Results In total, 1220 young people presented with an FEP during the 6-year study period, of whom 24.5% were first-generation migrants. We found an increased risk for developing psychotic disorder in migrants from the following regions: Central and West Africa (adjusted incidence rate ratio [aIRR] = 3.53, 95% CI 1.58–7.92), Southern and Eastern Africa (aIRR = 3.06, 95% CI 1.99–4.70) and North Africa (aIRR = 5.03, 95% CI 3.26–7.76). Migrants from maritime South East Asia (aIRR = 0.39, 95% CI 0.23–0.65), China (aIRR = 0.25, 95% CI 0.13–0.48) and Southern Asia (aIRR = 0.44, 95% CI 0.26–0.76) had a decreased risk for developing a psychotic disorder. Conclusion This clear health inequality needs to be addressed by sufficient funding and accessible mental health services for more vulnerable groups. Further research is needed to determine why migrants have an increased risk for developing psychotic disorders.

Purpose The purpose of this study was to identify and understand the barriers and enablers to the implementation of youth peer support in a clinical mental health service. The development of a lived experience workforce in mental health is a key component of policy at both the state and the federal level in Australia. Implementing a peer workforce within existing clinical services, however, can be a challenging task. Furthermore, implementing peer support in a youth mental health setting involves a further degree of complexity, involving a degree of care for young people being invited to provide peer support when they may be still early in their own recovery journey. Design/methodology/approach This paper reports on a formative evaluation of the beginning stages of implementation of a youth peer workforce within an existing clinical mental health service in Melbourne. Findings The project found that it was feasible and beneficial to implement youth peer support; however, significant challenges remain, including lack of appropriate training for young people, uncertainty amongst clinical staff about the boundaries of the peer role and the potential for “tokenism” in the face of slow cultural change across the whole service. Originality/value Very little evaluation has yet been undertaken into the effectiveness of implementing peer support in youth mental health services. This paper offers an opportunity to investigate where services may need to identify strengths and address difficulties when undertaking future implementation efforts.

LAY SUMMARY This two-year study implemented a Housing First approach among homelessness services for Veterans in four cities across Canada (Victoria, Calgary, London, and Toronto). This approach included peer support and harm reduction resources for Veterans. To obtain a detailed evaluation of personal experiences and opinions, focus groups were held with Veterans, housing staff, and stakeholders at three time points during the study: July-September 2012, May-June 2013, and January 2014. Harm reduction and peer support were regarded as positive aspects of this new approach to housing and homelessness. It was suggested that greater mental health support, support from peers with military experience, and issues regarding roommates should be considered in future implementations of housing services for Veterans. It was also noted that to support personal stabilization, permanent housing is preferred over transitional or temporary housing. Future housing programs serving Veterans experiencing homelessness should consider the addition of harm reduction and peer support to further enhance services and help maintain housing stability.

Abstract Introduction 'No Jab, No Play' and 'No Jab, No Pay' mandatory immunisation policies were introduced in the state of Victoria and Australia nationally in January 2016. They restrict access to childcare/kindergarten and family assistance payments respectively, for under-vaccinated children. We aimed to describe the proportion of attendees to immunisation services of a tertiary hospital, the Royal Children's Hospital Melbourne (RCH), who were motivated by the policies to discuss or catch up vaccination. We also explored the association between policy motivation, vaccine hesitancy (VH) and intent to seek medical exemption, with vaccine-uptake. Referrals to the Specialist Immunisation Clinic (SIC) were also reviewed. Methods Parents/Guardians and clinicians completed surveys October 2016-May 2017 from the nurse-led immunisation Drop in Centre (DIC) or physician-led SIC. Vaccine-uptake was measured using the Australian Immunisation Register at baseline, 1 and 7 months post-attendance. The association between vaccine-uptake, policy motivation and VH was explored by logistic regression. Results Of 607 children included, 393 (65%) were from the DIC and 214 (35%) SIC. 74 (12%) of parents were motivated by the policies to attend immunisation services and 19% were VH. Only 50% of VH parents planned to catch-up vaccination for enrolment to childcare/kindergarten. Fewer children were fully immunised at 7 months if their parents were VH (difference 18%; OR 0.24, CI 0.1-0.54,p&lt;0.001) or seeking medical exemption (difference 33%, OR 0.08, CI 0.01-0.6, p 0.015). Conclusions The 'No Jab' policies motivated attendance to a tertiary immunisation service but children of vaccine hesitant parents and those seeking medical exemption to immunisation were less likely to be fully immunised post attendance, compared to baseline. These data will be used to inform a comprehensive evaluation of the impact of the policies, particularly the educational impact from loss of early childhood education.

Abstract Background Health services implemented a range of initiatives during the COVID-19 pandemic to support employee wellbeing and assist employees to manage the professional and personal challenges they experienced. However, it is not known if such initiatives were acceptable to employees or met their needs. Aims To evaluate the wellbeing and support initiatives implemented at an Australian health service during the COVID-19 pandemic from the perspectives of employees (both users and non-users) and key stakeholders. Methods A mixed-methods design (survey, interviews and data audit) to investigate employees’ and key stakeholders’ perceptions, experiences and use of the wellbeing and support initiatives implemented at a large tertiary metropolitan health service in Melbourne, Australia. Results Ten employees participated in an interview and 907 completed a survey. The initiatives were well used and appreciated by staff. There was no significant difference in the proportion of clinical staff who had used the initiatives compared to non-clinical staff (44% versus 39%; P=0.223). Survey respondents reported the initiatives improved their mental health (n = 223, 8%), ability to cope with COVID-19 related stress and anxiety (n = 206, 79%), do their work (n = 200, 77%) and relationships with colleagues (n = 174, 67%). Staff would like many of the initiatives (with some modifications) to continue after the COVID-19 pandemic. Conclusions The findings suggest a high level of staff satisfaction with the implemented wellbeing and support initiatives, and confirm the need for, and importance of, developing and implementing initiatives to support health service staff during outbreaks of infectious diseases such as the COVID-19 pandemic.

Abstract Background Numerous studies across international settings have highlighted a need to improve the appropriateness and continuity of services for young people experiencing mental ill health. This paper examines key features of a sub-acute youth mental health residential service model, Youth Prevention and Recovery Care (Y-PARC) service. Y-PARC provides up to 4 weeks care to 16 to 25 year-olds at risk of hospitalisation and to those transitioning out of hospital inpatient units. The research was conducted at one of three Y-PARCs located in Victoria, Australia. Methods This paper presents findings from analysis of two data sources collected during evaluation of a Y-PARC service in 2015–17. Routinely collected administrative data of Y-PARC residents (n = 288) were analysed and semi-structured interviews were conducted with 38 participants: a) former residents (n = 14); b) family members of group a) (n = 5); key stakeholders (n = 9); and, Y-PARC staff (n = 10 respondents in 3 group interviews). Analysis of the qualitative data was thematic and structured by the interview guide, which covered the key service aims. Results Consistent with the aims of the service, respondents described practice at Y-PARC that aligns with recovery-oriented care. Key features emphasised were: a safe and welcoming environment for residents and families; provision of person-centred care; promotion of autonomy and self-help; informal interactions with staff allowing for formation of naturalistic relationships; time spent with other young people with similar experiences; and, assurance upon exit that the ‘door is always open.’ High levels of satisfaction were reported. Outcomes described included: improved resilience; better understanding of mental health; the importance of seeking help; and, stronger connections to therapeutic services. Longer and multiple stays were associated with progressive and sustained change. Family members and stakeholders widely reported that the service fills a gap between community services and acute inpatient mental health hospital wards. Some challenging areas of practice identified included: integration of evidence-based psychosocial interventions; provision of care within a model that blends clinical and psychosocial support services; and, negotiation of family-inclusive practice. Conclusions The Y-PARC service model shows promise with young people experiencing mental ill health, particularly in improving the range and availability of options across a spectrum of need.

Abstract Background Half of mental health disorders begin before the age of 14, highlighting the importance of prevention and early-intervention in childhood. Schools have been identified globally by policymakers as a platform to support good child mental health; however, the majority of the research is focused on secondary schools, with primary schools receiving very little attention by comparison. The limited available evidence on mental health initiatives in primary schools is hindered by a lack of rigorous evaluation. This quasi-experimental cluster study aims to examine the implementation and effectiveness of a Mental Health and Wellbeing Co-ordinator role designed to build mental health capacity within primary schools. Methods This is a primary (ages 5–12) school-based cluster quasi-experimental study in Victoria, Australia. Before baseline data collection, 16 schools selected by the state education department will be allocated to intervention, and another 16 matched schools will continue as ‘Business as Usual’. In intervention schools, a mental health and well-being coordinator will be recruited and trained, and three additional school staff will also be selected to receive components of the mental health training. Surveys will be completed by consenting staff (at 2-, 5-, 10- and 17-months post allocation) and by consenting parents/carers (at 3-, 10- and 17-months post allocation) in both intervention and business as usual schools. The primary objective is to assess the change in teacher’s confidence to support student mental health and wellbeing using the School Mental Health Self-Efficacy Teacher Survey. Secondary objectives are to assess the indirect impact on systemic factors (level of support, prioritisation of child mental health), parent and teachers’ mental health literacy (stigma, knowledge), care access (school engagement with community-based services), and student mental health outcomes. Implementation outcomes (feasibility, acceptability, and fidelity) and costs will also be evaluated. Discussion The current study will examine the implementation and effectiveness of having a trained Mental Health and Wellbeing Coordinator within primary schools. If the intervention increases teachers’ confidence to support student mental health and wellbeing and builds the capacity of primary schools it will improve student mental health provision and inform large-scale mental health service reform. Trial registration The trial was retrospectively registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) on July 6, 2021. The registration number is ACTRN12621000873820.

Objectives: Australian general practitioners (GPs) are pivotal in mental health care. The REFOCUS-PULSAR (Principles Unite Local Services Assisting Recovery) primary care study aimed to improve personal recovery outcomes in adults with mental health problems consulting GPs.Design: Modified from an intended stepped-wedge cluster study, an exploratory (pre- and post-intervention) design employed cross-sectional surveys of patients consulting GPs.Setting: Eighteen primary care sites (clusters) in Victoria, Australia in 2013–2017.Participants: From 30 GPs recruited, 23 participated (76%), with 235 patient surveys returned from adults aged &lt;75 years receiving mental health care.Intervention: A co-delivered face-to-face training intervention for GPs in recovery-oriented practice (ROP), with personal recovery a key focus, used multimedia, mnemonics, and targeted interview schedules to encourage ROP—with availability of support sessions for 1 year.Outcome Measures: Primary: the Questionnaire about the Process of Recovery full-scale score (outcome). Secondary: INSPIRE (experience), Warwick-Edinburgh Mental Well-being Scale (WEMWBS) and Kessler Psychological Distress Scale (K10) (outcomes). Other: General-practice-Users Perceived-need Inventory (experience).Results: Small positive significant effects indicated primary-outcome post-intervention improvements [t-test (233) = −2.23, p = 0.01], also improvement in two secondary outcomes (WEMWBS t(233) = −2.12, p = 0.02 and K10 t(233) = 2.44, p = 0.01). More patients post-intervention reported “no need” for further help from their GP; but in those reporting needs, there was greater unmet need for counseling.Conclusions: ROP implementation, internationally influential in specialist mental health care, here is explored in primary care where it has had less attention. These exploratory findings suggest better patient outcomes followed introducing GPs to ROP in routine practice conditions. Higher unmet need for counseling post-intervention reported by patients might be a sign of limited supply despite ROP facilitating better identification of needs. Challenges in project implementation means that these findings carry risks of bias and flag the importance establishing research infrastructure in primary care.Clinical Trial Registration:www.clinicaltrials.gov/, The Australian and New Zealand Clinical Trial Registry Identifier: ACTRN12614001312639.

Abstract Background There is increasing recognition of the substantial burden of mental health disorders at an individual and population level, including consequent demand on mental health services. Lifestyle-based mental healthcare offers an additional approach to existing services with potential to help alleviate system burden. Despite the latest Royal Australian New Zealand College of Psychiatrists guidelines recommending that lifestyle is a ‘first-line’, ‘non-negotiable’ treatment for mood disorders, few such programs exist within clinical practice. Additionally, there are limited data to determine whether lifestyle approaches are equivalent to established treatments. Using an individually randomised group treatment design, we aim to address this gap by evaluating an integrated lifestyle program (CALM) compared to an established therapy (psychotherapy), both delivered via telehealth. It is hypothesised that the CALM program will not be inferior to psychotherapy with respect to depressive symptoms at 8 weeks. Methods The study is being conducted in partnership with Barwon Health’s Mental Health, Drugs & Alcohol Service (Geelong, Victoria), from which 184 participants from its service and surrounding regions are being recruited. Eligible participants with elevated psychological distress are being randomised to CALM or psychotherapy. Each takes a trans-diagnostic approach, and comprises four weekly (weeks 1-4) and two fortnightly (weeks 6 and 8) 90-min, group-based sessions delivered via Zoom (digital video conferencing platform). CALM focuses on enhancing knowledge, behavioural skills and support for improving dietary and physical activity behaviours, delivered by an Accredited Exercise Physiologist and Accredited Practising Dietitian. Psychotherapy uses cognitive behavioural therapy (CBT) delivered by a Psychologist or Clinical Psychologist, and Provisional Psychologist. Data collection occurs at baseline and 8 weeks. The primary outcome is depressive symptoms (assessed via the Patient Health Questionnaire-9) at 8 weeks. Societal and healthcare costs will be estimated to determine the cost-effectiveness of the CALM program. A process evaluation will determine its reach, adoption, implementation and maintenance. Discussion If the CALM program is non-inferior to psychotherapy, this study will provide the first evidence to support lifestyle-based mental healthcare as an additional care model to support individuals experiencing psychological distress. Trial registration Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12621000387820, Registered 8 April 2021.

Abstract Background With increasing numbers of people living with dementia relying on family to care for them at home, there is an urgent need for practical and evidence-based programs to support carers in maintaining their mental health and well-being. The objective of this study was to evaluate the acceptability and feasibility of a modified STrAtegies for RelaTives (START) program delivered online (START-online). Method A mixed-methods non-blinded evaluation of START-online (using Zoom as videoconferencing platform) for acceptability and feasibility (completion rates and qualitative feedback through surveys and focus groups) and quantitative evaluation. This occurred at the National Ageing Research Institute, in metropolitan Victoria, Australia. Results Twenty-nine eligible carers were referred, 20 (70%) consented to the study. Of these, 16 (80%) completed all 8 sessions, 2 completed only 3 sessions, and 2 withdrew. Carers’ qualitative feedback indicated that the therapist interaction was valued, content and online delivery of the program was acceptable. Feedback was mixed on the appropriate stage of caring. Conclusion START-online was feasible and acceptable for carers, including those living outside of metropolitan areas who might otherwise be unable to access face-to-face programs. With the recent COVID-19 pandemic necessitating social distancing to avoid infection, interventions such as this one have increasing relevance in the provision of flexible services.

The National Cultural Policy Discussion Paper—drafted to assist the Australian Government in developing the first national Cultural Policy since Creative Nation nearly two decades ago—envisages a future in which arts, cultural and creative activities directly support the development of an inclusive, innovative and productive Australia. "The policy," it says, "will be based on an understanding that a creative nation produces a more inclusive society and a more expressive and confident citizenry by encouraging our ability to express, describe and share our diverse experiences—with each other and with the world" (Australian Government 3). Even a cursory reading of this Discussion Paper makes it clear that the question of impact—in aesthetic, cultural and economic terms—is central to the Government's agenda in developing a new Cultural Policy. Hand-in-hand with the notion of impact comes the process of measurement of progress. The Discussion Paper notes that progress "must be measurable, and the Government will invest in ways to assess the impact that the National Cultural Policy has on society and the economy" (11). If progress must be measurable, this raises questions about what arts, cultural and creative workers do, whether it is worth it, and whether they could be doing it better. In effect, the Discussion Paper pushes artsworkers ever closer to a climate in which they have to be skilled not just at making work, but at making the impact of this work clear to stakeholders. The Government in its plans for Australia's cultural future, is clearly most supportive of artsworkers who can do this, and the scholars, educators and employers who can best train the artsworkers of the future to do this. Teaching Artsworkers to Measure the Impact of Their Work: The Challenges How do we train artsworkers to assess, measure and articulate the impact of what they do? How do we prepare them to be ready to work in a climate that will—as the National Cultural Policy Discussion Paper makes clear—emphasise measuring impact, communicating impact, and communicating impact across aesthetic, cultural and economic categories? As educators delivering training in this area, the Discussion Paper has made this already compelling question even more pressing as we work to develop the career-ready graduates the Government seeks. Our program, the Master of Creative Industries (Creative Production & Arts Management) offered in the Creative Industries Faculty at Queensland University of Technology in Brisbane, Australia, is, like most programs in arts and cultural management in the US, UK, Europe and Australia, offering a three-Semester postgraduate program that allows students to develop the career-ready skills required to work as managers of arts, cultural or creative organisations. That we need to train our graduates to work not just as producers of plays, paintings or recordings, but as entrepreneurial arts advocates who can measure and articulate the value of their programs to others, is not news (Hadley "Creating" 647-48; cf. Brkic; Ebewo and Sirayi; Beckerman; Sikes). Our program—which offers training in arts policy, management, marketing and budgeting followed by training in entrepreneurship and a practical project—is already structured around this necessity. The question of how to teach students this diverse skill set is, however, still a subject of debate; and the question of how to teach students to measure the impact of this work is even more difficult. There is, of course, a body of literature on the impact of arts, cultural and creative activities, value and evaluation that has been developed over the past decade, particularly through landmark reports like Matarasso's Use or Ornament? The Social Impact of Participation in the Arts (1997) and the RAND Corporation's Gifts of the Muse: Reframing the Debate about the Benefits of the Arts (2004). There are also emergent studies in an Australian context: Madden's "Cautionary Note" on using economic impact studies in the arts (2001); case studies on arts and wellbeing by consultancy firm Effective Change (2003); case studies by DCITA (2003); the Asia Pacific Journal of Arts and Cultural Management (2009) issue on "value"; and Australia Council publications on arts, culture and economy. As Richards has explained, "evaluation is basically a straightforward concept. E-value-ation = a process of enquiry that allows a judgment of amount, value or worth to be made" (99). What makes arts evaluation difficult is not the concept, but the measurement of intangible values—aesthetic quality, expression, engagement or experience. In the literature, discussion has been plagued by debate about what is measured, what method is used, and whether subjective values can in fact be measured. Commentators note that in current practice, questions of value are still deferred because they are too difficult to measure (Bilton and Leary 52), discussed only in terms of economic measures such as market share or satisfaction which are statistically quantifiable (Belfiore and Bennett "Rethinking" 137), or done through un-rigorous surveys that draw only ambiguous, subjective, or selective responses (Merli 110). According to Belfiore and Bennett, Public debate about the value of the arts thus comes to be dominated by what might best be termed the cult of the measurable; and, of course, it is those disciplines primarily concerned with measurement, namely, economics and statistics, which are looked upon to find the evidence that will finally prove why the arts are so important to individuals and societies. A corollary of this is that the humanities are of little use in this investigation. ("Rethinking" 137) Accordingly, Ragsdale states, Arts organizations [still] need to find a way to assess their progress in …making great art that matters to people—as evidenced, perhaps, by increased enthusiasm, frequency of attendance, the capacity and desire to talk or write about one's experience, or in some other way respond to the experience, the curiosity to learn about the art form and the ideas encountered, the depth of emotional response, the quality of the social connections made, and the expansion of one's aesthetics over time. Commentators are still looking for a balanced approach (cf. Geursen and Rentschler; Falk and Dierkling), which evaluates aesthetic practices, business practices, audience response, and results for all parties, in tandem. An approach which evaluates intrinsic impacts, instrumental impacts, and the way each enables the other, in tandem—with an emphasis not on the numbers but on whether we are getting better at what we are doing. And, of course, allows evaluators of arts, cultural and creative activities to use creative arts methods—sketches, stories, bodily movements and relationships and so forth—to provide data to inform the assessment, so they can draw not just on statistical research methods but on arts, culture and humanities research methods. Teaching Artsworkers to Measure the Impact of Their Work: Our Approach As a result of this contested terrain, our method for training artsworkers to measure the impact of their programs has emerged not just from these debates—which tend to conclude by declaring the needs for better methods without providing them—but from a research-teaching nexus in which our own trial-and-error work as consultants to arts, cultural and educational organisations looking to measure the impact of or improve their programs has taught us what is effective. Each of us has worked as managers of professional associations such as Drama Australia and Australasian Association for Theatre, Drama and Performance Studies (ADSA), members of boards or committees for arts organisations such as Youth Arts Queensland and Young People and the Arts Australia (YPAA), as well as consultants to major cultural organisations like the Queensland Performing Arts Centre and the Brisbane Festival. The methods for measuring impact we have developed via this work are based not just on surveys and statistics, but on our own practice as scholars and producers of culture—and are therefore based in arts, culture and humanities approaches. As scholars, we investigate the way marginalised groups tell stories—particularly groups marked by age, gender, race or ability, using community, contemporary and public space performance practices (cf. Hadley, "Bree"; Gattenhof). What we have learned by bringing this sort of scholarly analysis into dialogue with a more systematised approach to articulating impact to government, stakeholders and sponsors is that there is no one-size-fits-all approach. What is needed, instead, is a toolkit, which incorporates central principles and stages, together with qualitative, quantitative and performative tools to track aesthetics, accessibility, inclusivity, capacity-building, creativity etc., as appropriate on a case-by-case basis. Whatever the approach, it is critical that the data track the relationship between the experience the artists, audience or stakeholders anticipated the activity should have, the aspects of the activity that enabled that experience to emerge (or not), and the effect of that (or not) for the arts organisation, their artists, their partners, or their audiences. The combination of methods needs to be selected in consultation with the arts organisation, and the negotiations typically need to include detailed discussion of what should be evaluated (aesthetics, access, inclusivity, or capacity), when it should be evaluated (before, during or after), and how the results should be communicated (including the difference between evaluation for reporting purposes and evaluation for program improvement purposes, and the difference between evaluation and related processes like reflection, documentary-making, or market research). Translating what we have learned through our cultural research and consultancy into a study package for students relies on an understanding of what they want from their study. This, typically, is practical career-ready skills. Students want to produce their own arts, or produce other people's arts, and most have not imagined themselves participating in meta-level processes in which they argue the value of arts, cultural and creative activities (Hadley, "Creating" 652). Accordingly, most have not thought of themselves as researchers, using cultural research methods to create reports that inform how the Australian government values, supports, and services the arts. The first step in teaching students to operate effectively as evaluators of arts, cultural and creative activities is, then, to re-orient their expectations to include this in their understanding of what artsworkers do, what skills artsworkers need, and where they deploy these skills. Simply handing over our own methods, as "the" methods, would not enable graduates to work effectively in a climate were one size will not fit all, and methods for evaluating impact need to be negotiated again for each new context. 1. Understanding the Need for Evaluation: Cause and Effect The first step in encouraging students to become effective evaluators is asking them to map their sector, the major stakeholders, the agendas, alignments and misalignments in what the various players are trying to achieve, and the programs, projects and products through which the players are trying to achieve it. This starting point is drawn from Program Theory—which, as Joon-Yee Kwok argues in her evaluation of the SPARK National Mentoring Program for Young and Emerging Artists (2010) is useful in evaluating cultural activities. The Program Theory approach starts with a flow chart that represents relationships between activities in a program, allowing evaluators to unpack some of the assumptions the program's producers have about what activities have what sort of effect, then test whether they are in fact having that sort of effect (cf. Hall and Hall). It could, for example, start with a flow chart representing the relationship between a community arts policy, a community arts organisation, a community-devised show it is producing, and a blog it has created because it assumes it will allow the public to become more interested in the show the participants are creating, to unpack the assumptions about the sort of effect this is supposed to have, and test whether this is in fact having this sort of effect. Masterclasses, conversations and debate with peers and industry professionals about the agendas, activities and assumptions underpinning programs in their sector allows students to look for elements that may be critical in their programs' ability to achieve (or not) an anticipated impact. In effect to start asking about, "the way things are done now, […] what things are done well, and […] what could be done better" (Australian Government 12).2. Understanding the Nature of Evaluation: PurposeOnce students have been alerted to the need to look for cause-effect assumptions that can determine whether or not their program, project or product is effective, they are asked to consider what data they should be developing about this, why, and for whom. Are they evaluating a program to account to government, stakeholders and sponsors for the money they have spent? To improve the way it works? To use that information to develop innovative new programs in future? In other words, who is the audience? Being aware of the many possible purposes and audiences for evaluation information can allow students to be clear not just about what needs to be evaluated, but the nature of the evaluation they will do—a largely statistical report, versus a narrative summary of experiences, emotions and effects—which may differ depending on the audience.3. Making Decisions about What to Evaluate: Priorities When setting out to measure the impact of arts, cultural or creative activities, many people try to measure everything, measure for the purposes of reporting, improvement and development using the same methods, or gather a range of different sorts of data in the hope that something in it will answer questions about whether an activity is having the anticipated effect, and, if so, how. We ask students to be more selective, making strategic decisions about which anticipated effects of a program, project or product need to be evaluated, whether the evaluation is for reporting, improvement or innovation purposes, and what information stakeholders most require. In addition to the concept of collecting data about critical points where programs succeed or fail in achieving a desired effect, and different approaches for reporting, improvement or development, we ask students to think about the different categories of effect that may be more or less interesting to different stakeholders. This is not an exhaustive list, or a list of things every evaluation should measure. It is a tool to demonstrate to would-be evaluators points of focus that could be developed, depending on the stakeholders' priorities, the purpose of the evaluation, and the critical points at which desired effects need to occur to ensure success. Without such framing, evaluators are likely to end up with unusable data, which become a difficulty to deal with rather than a benefit for the artsworkers, arts organisations or stakeholders. 4. Methods for Evaluation: Process To be effective, methods for collecting data about how arts, cultural or creative activities have (or fail to have) anticipated impact need to include conventional survey, interview and focus group style tools, and creative or performative tools such as discussion, documentation or observation. We encourage students to use creative practice to draw out people's experience of arts events—for example, observation, documentation still images, video or audio documentation, or facilitated development of sketches, stories or scenes about an experience, can be used to register and record people's feelings. These sorts of methods can capture what Mihaly Csikszentmihalyi calls "flow" of experience (cf. Belfiore and Bennett, "Determinants" 232)—for example, photos of a festival space at hourly intervals or the colours a child uses to convey memory of a performance can capture to flow of movement, engagement, and experience for spectators more clearly than statistics. These, together with conventional surveys or interviews that comment on the feelings expressed, allow for a combination of quantitative, qualitative and performative data to demonstrate impact. The approach becomes arts- and humanities- based, using arts methods to encourage people to talk, write or otherwise respond to their experience in terms of emotion, connection, community, or expansion of aesthetics. The evaluator still needs to draw out the meaning of the responses through content, text or discourse analysis, and teaching students how to do a content analysis of quantitative, qualitative and performative data is critical at this stage. When teaching students how to evaluate their data, our method encourages students not just to focus on the experience, or the effect of the experience, but the relationship between the two—the things that act as "enablers" "determinants" (White and Hede; Belfiore and Bennett, "Determinants" passim) of effect. This approach allows the evaluator to use a combination of conventional and creative methods to describe not just what effect an activity had, but, more critically, what enabled it to have that effect, providing a firmer platform for discussing the impact, and how it could be replicated, developed or deepened next time, than a list of effects and numbers of people who felt those effects alone. 5. Communicating Results: Politics Often arts, cultural or creative organisations can be concerned about the image of their work an evaluation will create. The final step in our approach is to alert students to the professional, political and ethical implications of evaluation. Students learn to share their knowledge with organisations, encouraging them to see the value of reporting both correct and incorrect assumptions about the impact of their activities, as part of a continuous improvement process. Then we assist them in drawing the results of this sort of cultural research into planning, development and training documents which may assist the organisation in improving in the future. In effect, it is about encouraging organisations to take the Australian government at its word when, in the National Cultural Policy Discussion Paper, it says it that measuring impact is about measuring progress—what we do well, what we could do better, and how, not just success statistics about who is most successful—as it is this that will ultimately be most useful in creating an inclusive, innovative, productive Australia. Teaching Artsworkers to Measure the Impact of Their Work: The Impact of Our Approach What, then, is the impact of our training on graduates' ability to measure the impact of work? Have we made measurable progress in our efforts to teach artsworkers to assess and articulate the impact of their work? The MCI (CP&AM) has been offered for three years. Our approach is still emergent and experimental. We have, though, identified a number of impacts of our work. First, our students are less fearful of becoming involved in measuring the value or impact of arts, cultural and creative programs. This is evidenced by the number who chooses to do some sort of evaluation for their Major Project, a 15,000 word individual project or internship which concludes their degree. Of the 50 or so students who have reached the Major Project in three years—35 completed and 15 in planning for 2012—about a third have incorporated evaluation into their Major Project. This includes evaluation of sector, business or producing models (5), youth arts and youth arts mentorship programs (4), audience development programs (2), touring programs (4), and even other arts management training programs (1). Indeed, after internships in programming or producing roles, this work—aligned with the Government's interest in improving training of young artists, touring, audience development, and economic development—has become a most popular Major Project option. This has enabled students to work with a range of arts, cultural and creative organisations, share their training—their methods, their understanding of what their methods can measure, when, and how—with Industry. Second, this Industry-engaged training has helped graduates in securing employment. This is evidenced by the fact that graduates have gone on to be employed with organisations they have interned with as part of their Major Project, or other organisations, including some of Brisbane's biggest cultural organisations—local and state government departments, Queensland Performing Arts Centre, Brisbane Festival, Metro Arts, Backbone Youth Arts, and Youth Arts Queensland, amongst others. Thirdly, graduates' contribution to local organisations and industry has increased the profile of a relatively new program. This is evidenced by the fact that it enrols 40 to 50 new students a year across Graduate Certificate / MCI (CP&AM) programs, typically two thirds domestic students and one third international students from Canada, Germany, France, Denmark, Norway and, of course, China. Indeed, some students are now disseminating this work globally, undertaking their Major Project as an internship or industry project with an organisation overseas. In effect, our training's impact emerges not just from our research, or our training, but from the fact that our graduates disseminate our approach to a range of arts, cultural and creative organisations in a practical way. We have, as a result, expanded the audience for this approach, and the number of people and contexts via which it is being adapted and made useful. Whilst few of students come into our program with a desire to do this sort of work, or even a working knowledge of the policy that informs it, on completion many consider it a viable part of their practice and career pathway. When they realise what they can achieve, and what it can mean to the organisations they work with, they do incorporate research, research consultant and government roles as part of their career portfolio, and thus make a contribution to the strong cultural sector the Government envisages in the National Cultural Policy Discussion Paper. Our work as scholars, practitioners and educators has thus enabled us to take a long-term, processual and grassroots approach to reshaping agendas for approaches to this form of cultural research, as our practices are adopted and adapted by students and industry stakeholders. Given the challenges commentators have identified in creating and disseminating effective evaluation methods in arts over the past decade, this, for us—though by no means work that is complete—does count as measurable progress. References Beckerman, Gary. "Adventuring Arts Entrepreneurship Curricula in Higher Education: An Examination of Present Efforts, Obstacles, and Best pPractices." The Journal of Arts Management, Law, and Society 37.2 (2007): 87-112. Belfiore, Eleaonora, and Oliver Bennett. "Determinants of Impact: Towards a Better Understanding of Encounters with the Arts." Cultural Trends 16.3 (2007): 225-75. ———. "Rethinking the Social Impacts of the Arts." International Journal of Cultural Policy 13.2 (2007): 135-51. Bilton, Chris, and Ruth Leary. "What Can Managers Do for Creativity? Brokering Creativity in the Creative Industries." International Journal of Cultural Policy 8.1 (2002): 49-64. Brkic, Aleksandar. "Teaching Arts Management: Where Did We Lose the Core Ideas?" Journal of Arts Management, Law and Society 38.4 (2009): 270-80. Czikszentmihalyi, Mihaly. "A Systems Perspective on Creativity." Creative Management. Ed. Jane Henry. Sage: London, 2001. 11-26. Australian Government. "National Cultural Policy Discussion Paper." Department of Prime Minster and Cabinet – Office for the Arts 2011. 1 Oct. 2011 ‹http://culture.arts.gov.au/discussion-paper›. Ebewo, Patrick, and Mzo Sirayi. "The Concept of Arts/Cultural Management: A Critical Reflection." Journal of Arts Management, Law and Society 38.4 (2009): 281-95. Effective Change and VicHealth. Creative Connections: Promoting Mental Health and Wellbeing through Community Arts Participation 2003. 1 Oct. 2011 ‹http://www.vichealth.vic.gov.au/en/Publications/Social-connection/Creative-Connections.aspx›. Effective Change. Evaluating Community Arts and Community Well Being 2003. 1 Oct. 2011 ‹http://www.arts.vic.gov.au/Research_and_Resources/Resources/Evaluating_Community_Arts_and_Wellbeing›. Falk, John H., and Lynn. D Dierking. "Re-Envisioning Success in the Cultural Sector." Cultural Trends 17.4 (2008): 233-46. Gattenhof, Sandra. "Sandra Gattenhof." QUT ePrints Article Repository. Queensland University of Technology, 2011. 1 Oct. 2011 ‹http://eprints.qut.edu.au/view/person/Gattenhof,_Sandra.html›. Geursen, Gus and Ruth Rentschler. "Unravelling Cultural Value." The Journal of Arts Management, Law and Society 33.3 (2003): 196-210. Hall, Irene and David Hall. Evaluation and Social Research: Introducing Small Scale Practice. London: Palgrave McMillan, 2004. Hadley, Bree. "Bree Hadley." QUT ePrints Article Repository. Queensland University of Technology, 2011. 1 Oct. 2011 ‹http://eprints.qut.edu.au/view/person/Hadley,_Bree.html›. ———. "Creating Successful Cultural Brokers: The Pros and Cons of a Community of Practice Approach in Arts Management Education." Asia Pacific Journal of Arts and Cultural Management 8.1 (2011): 645-59. Kwok, Joon. When Sparks Fly: Developing Formal Mentoring Programs for the Career Development of Young and Emerging Artists. Masters Thesis. Brisbane: Queensland University of Technology, 2010. Madden, Christopher. "Using 'Economic' Impact Studies in Arts and Cultural Advocacy: A Cautionary Note." Media International Australia, Incorporating Culture & Policy 98 (2001): 161-78. Matarasso, Francis. Use or Ornament? The Social Impact of Participation in the Arts. Bournes Greens, Stroud: Comedia, 1997. McCarthy, Kevin. F., Elizabeth H. Ondaatje, Laura Zakaras, and Arthur Brooks. Gifts of the Muse: Reframing the Debate about the Benefits of the Arts. Santa Monica: RAND Corporation, 2004. Merli, Paola. "Evaluating the Social Impact of Participation in Arts Activities." International Journal of Cultural Policy 8.1 (2002): 107-18. Muir, Jan. The Regional Impact of Cultural Programs: Some Case Study Findings. Communications Research Unit - DCITA, 2003. Ragsdale, Diana. "Keynote - Surviving the Culture Change." Australia Council Arts Marketing Summit. Australia Council for the Arts: 2008. Richards, Alison. "Evaluation Approaches." Creative Collaboration: Artists and Communities. Melbourne: Victorian College of the Arts, University of Melbourne, 2006. Sikes, Michael. "Higher Education Training in Arts Administration: A Millennial and Metaphoric Reappraisal. Journal of Arts Management, Law and Society 30.2 (2000): 91-101.White, Tabitha, and Anne-Marie Hede. "Using Narrative Inquiry to Explore the Impact of Art on Individuals." Journal of Arts Management, Law, and Society 38.1 (2008): 19-35.

Introduction As social-distancing mandates in response to COVID-19 restricted in-person data collection methods such as participant observation and interviews, researchers turned to socially distant methods such as interviewing via video-conferencing technology (Lobe et al.). These were not new tools nor methods, but the pandemic muted any bias towards face-to-face data collection methods. Exemplified in crowd-sourced documents such as Doing Fieldwork in a Pandemic, researchers were encouraged to pivot to digital methods as a means of fulfilling research objectives, “specifically, ideas for avoiding in-person interactions by using mediated forms that will achieve similar ends” (Lupton). The benefits of digital methods for expanding participant cohorts and scope of research have been touted long before 2020 and COVID-19, and, as noted by Murthy, are “compelling” (“Emergent” 172). Research conducted by digital methods can expect to reap benefits such as “global datasets/respondents” and “new modalities for involving respondents” (Murthy, “Emergent” 172). The pivot to digital methods is not in and of itself an issue. What concerns us is that in the dialogues about shifting to digital methods during COVID-19, there does not yet appear to have been a critical consideration of how participant samples and collected data will be impacted upon or skewed towards recording the experiences of advantaged cohorts. Existing literature focusses on the time-saving benefits for the researcher, reduction of travel costs (Fujii), the minimal costs for users of specific platforms – e.g. Skype –, and presumes ubiquity of device access for participants (Cater). We found no discussion on data costs of accessing such services being potential barriers to participation in research, although Deakin and Wakefield did share our concern that: Online interviews may ... mean that some participants are excluded due to the need to have technological competence required to participate, obtain software and to maintain Internet connection for the duration of the discussion. In this sense, access to certain groups may be a problem and may lead to issues of representativeness. (605) We write this as a provocation to our colleagues conducting research at this time to consider the cultural and material capital of their participants and how that capital enables them to participate in digitally-mediated data gathering practices, or not, and to what extent. Despite highlighting the potential benefits of digital methods within a methodological tool kit, Murthy previously cautioned against the implications posed by digital exclusion, noting that “the drawback of these research options is that membership of these communities is inherently restricted to the digital ‘haves’ ... rather than the ‘have nots’” (“Digital” 845). In this article, we argue that while tools such as Zoom have indeed enabled fieldwork to continue despite COVID disruptions, this shift to online platforms has important and under-acknowledged implications for who is and is not able to participate in research. In making this argument, we draw on examples from the Connected Students project, a study of digital inclusion that commenced just as COVID-19 restrictions came into effect in the Australian state of Victoria at the start of 2020. We draw on the experiences of these households to illustrate the barriers that such cohorts face when participating in online research. We begin by providing details about the Connected Students project and then contextualising it through a discussion of research on digital inclusion. We then outline three areas in which households would have experienced (or still do experience) difficulties participating in online research: data, devices, and skills. We use these findings to highlight the barriers that disadvantaged groups may face when engaging in data collection activities over Zoom and question how this is impacting on who is and is not being included in research during COVID-19. The Connected Students Program The Connected Students program was conducted in Shepparton, a regional city located 180km north of Melbourne. The town itself has a population of around 30,000, while the Greater Shepparton region comprises around 64,000 residents. Shepparton was chosen as the program’s site because it is characterised by a unique combination of low-income and low levels of digital inclusion. First, Shepparton ranks in the lowest interval for the Australian Bureau of Statistics’ Socio-Economic Indexes for Areas (SEIFA) and the Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD), as reported in 2016 (Australian Bureau of Statistics, “Census”; Australian Bureau of Statistics, “Index”). Although Shepparton has a strong agricultural and horticultural industry with a number of food-based manufacturing companies in the area, including fruit canneries, dairies, and food processing plants, the town has high levels of long-term and intergenerational unemployment and jobless families. Second, Shepparton is in a regional area that ranks in the lowest interval for the Australian Digital Inclusion Index (Thomas et al.), which measures digital inclusion across dimensions of access, ability, and affordability. Funded by Telstra, Australia’s largest telecommunications provider, and delivered in partnership with Greater Shepparton Secondary College (GSSC), the Connected Students program provided low-income households with a laptop and an unlimited broadband Internet connection for up to two years. Households were recruited to the project via GSSC. To be eligible, households needed to hold a health care card and have at least one child attending the school in year 10, 11, or 12. Both the student and a caregiver were required to participate in the project to be eligible. Additional household members were invited to take part in the research, but were not required to. (See Kennedy & Holcombe-James; and Kennedy et al., "Connected Students", for further details regarding household demographics.) The Australian Digital Inclusion Index identifies that affordability is a significant barrier to digital inclusion in Australia (Thomas et al.). The project’s objective was to measure how removing affordability barriers to accessing connectivity for households impacts on digital inclusion. By providing participating households with a free unlimited broadband internet connection for the duration of the research, the project removed the costs associated with digital access. Access alone is not enough to resolve the digital exclusion confronted by these low-income households. Digital exclusion in these instances is not derived simply from the cost of Internet access, but from the cost of digital devices. As a result, these households typically lacked sufficient digital devices. Each household was therefore provided both a high speed Internet connection, and a brand new laptop with built-in camera, microphone, and speakers (a standard tool kit for video conferencing). Data collection for the Connected Students project was intended to be conducted face-to-face. We had planned in-person observations including semi-structured interviews with household members conducted at three intervals throughout the project’s duration (beginning, middle, and end), and technology tours of each home to spatially and socially map device locations and uses (Kennedy et al., Digital Domesticity). As we readied to make our first research trip to commence the study, COVID-19 was wreaking havoc. It quickly became apparent we would not be travelling to work, much less travelling around the state. We thus pivoted to digital methods, with all our data collection shifting online to interviews conducted via digital platforms such as Zoom and Microsoft Teams. While the pivot to digital methods saved travel hours, allowing us to scale up the number of households we planned to interview, it also demonstrated unexpected aspects of our participants’ lived experiences of digital exclusion. In this article, we draw on our first round of interviews which were conducted with 35 households over Zoom or Microsoft Teams during lockdown. The practice of conducting these interviews reveals insights into the barriers that households faced to digital research participation. In describing these experiences, we use pseudonyms for individual participants and refer to households using the pseudonym for the student participant from that household. Why Does Digital Inclusion Matter? Digital inclusion is broadly defined as universal access to the technologies necessary to participate in social and civic life (Helsper; Livingstone and Helsper). Although recent years have seen an increase in the number of connected households and devices (Thomas et al., “2020”), digital inclusion remains uneven. As elsewhere, digital disadvantage in the Australian context falls along geographic and socioeconomic lines (Alam and Imran; Atkinson et al.; Blanchard et al.; Rennie et al.). Digitally excluded population groups typically experience some combination of education, employment, income, social, and mental health hardship; their predicament is compounded by a myriad of important services moving online, from utility payments, to social services, to job seeking platforms (Australian Council of Social Service; Chen; Commonwealth Ombudsman). In addition to challenges in using essential services, digitally excluded Australians also miss out on the social and cultural benefits of Internet use (Ragnedda and Ruiu). Digital inclusion – and the affordability of digital access – should thus be a key concern for researchers looking to apply online methods. Households in the lowest income quintile spend 6.2% of their disposable income on telecommunications services, almost three times more than wealthier households (Ogle). Those in the lowest income quintile pay a “poverty premium” for their data, almost five times more per unit of data than those in the highest income quintile (Ogle and Musolino). As evidenced by the Australian Digital Inclusion Index, this is driven in part by a higher reliance on mobile-only access (Thomas et al., “2020”). Low-income households are more likely to access critical education, business, and government services through mobile data rather than fixed broadband data (Thomas et al., “2020”). For low-income households, digital participation is the top expense after housing, food, and transport, and is higher than domestic energy costs (Ogle). In the pursuit of responsible and ethical research, we caution against assuming research participants are able to bear the brunt of access costs in terms of having a suitable device, expending their own data resources, and having adequate skills to be able to complete the activity without undue stress. We draw examples from the Connected Students project to support this argument below. Findings: Barriers to Research Participation for Digitally Excluded Households If the Connected Students program had not provided participating households with a technology kit, their preexisting conditions of digital exclusion would have limited their research participation in three key ways. First, households with limited Internet access (particularly those reliant on mobile-only connectivity, and who have a few gigabytes of data per month) would have struggled to provide the data needed for video conferencing. Second, households would have struggled to participate due to a lack of adequate devices. Third, and critically, although the Connected Students technology kit provided households with the data and devices required to participate in the digital ethnography, this did not necessarily resolve the skills gaps that our households confronted. Data Prior to receiving the Connected Students technology kit, many households in our sample had limited modes of connectivity and access to data. For households with comparatively less or lower quality access to data, digital participation – whether for the research discussed here, or in contemporary life – came with very real costs. This was especially the case for households that did not have a home Internet connection and instead relied solely on mobile data. For these households, who carefully managed their data to avoid running out, participating in research through extended video conferences would have been impossible unless adequate financial reimbursement was offered. Households with very limited Internet access used a range of practices to manage and extend their data access by shifting internet costs away from the household budget. This often involved making use of free public Wi-Fi or library internet services. Ellie’s household, for instance, spent their weekends at the public library so that she and her sister could complete their homework. While laborious, these strategies worked well for the families in everyday life. However, they would have been highly unsuitable for participating in research, particularly during the pandemic. On the most obvious level, the expectations of library use – if not silent, then certainly quiet – would have prohibited a successful interview. Further, during COVID-19 lockdowns, public libraries (and other places that provide public Internet) became inaccessible for significant periods of time. Lastly, for some research designs, the location of participants is important even when participation is occurring online. In the case of our own project, the house itself as the site of the interview was critical as our research sought to understand how the layout and materiality of the home impacts on experiences of digital inclusion. We asked participants to guide us around their home, showing where technologies and social activities are colocated. In using the data provided by the Connected Students technology kit, households with limited Internet were able to conduct interviews within their households. For these families, participating in online research would have been near impossible without the Connected Students Internet. Devices Even with adequate Internet connections, many households would have struggled to participate due to a lack of suitable devices. Laptops, which generally provide the best video conferencing experience, were seen as prohibitively expensive for many families. As a result, many families did not have a laptop or were making do with a laptop that was excessively slow, unreliable, and/or had very limited functions. Desktop computers were rare and generally outdated to the extent that they were not able to support video conferencing. One parent, Melissa, described their barely-functioning desktop as “like part of the furniture more than a computer”. Had the Connected Students program not provided a new laptop with video and audio capabilities, participation in video interviews would have been difficult. This is highlighted by the challenges students in these households faced in completing online schooling prior to receiving the Connected Students kit. A participating student, Mallory, for example, explained she had previously not had a laptop, reliant only on her phone and an old iPad: Interviewer: Were you able to do all your homework on those, or was it sometimes tricky?Mallory: Sometimes it was tricky, especially if they wanted to do a call or something ... . Then it got a bit hard because then I would use up all my data, and then didn’t have much left.Interviewer: Yeah. Right.Julia (Parent): ... But as far as schoolwork, it’s hard to do everything on an iPad. A laptop or a computer is obviously easier to manoeuvre around for different things. This example raises several common issues that would likely present barriers to research participation. First, Mallory’s household did not have a laptop before being provided with one through the Connected Students program. Second, while her household did prioritise purchasing tablets and smartphones, which could be used for video conferencing, these were more difficult to navigate for certain tasks and used up mobile data which, as noted above, was often a limited resource. Lastly, it is worth noting that in households which did already own a functioning laptop, it was often shared between several household members. As one parent, Vanessa, noted, “yeah, until we got the [Connected Students] devices, we had one laptop between the four of us that are here. And Noel had the majority use of that because that was his school work took priority”. This lack of individuated access to a device would make participation in some research designs difficult, particularly those that rely on regular access to a suitable device. Skills Despite the Connected Students program’s provision of data and device access, this did not ensure successful research participation. Many households struggled to engage with video research interviews due to insufficient digital skills. While a household with Internet connectivity might be considered on the “right” side of the digital divide, connectivity alone does not ensure participation. People also need to have the knowledge and skills required to use online resources. Brianna’s household, for example, had downloaded Microsoft Teams to their desktop computer in readiness for the interview, but had neglected to consider whether that device had video or audio capabilities. To work around this restriction, the household decided to complete the interview via the Connected Students laptop, but this too proved difficult. Neither Brianna nor her parents were confident in transferring the link to the interview between devices, whether by email or otherwise, requiring the researchers to talk them through the steps required to log on, find, and send the link via email. While Brianna’s household faced digital skills challenges that affected both parent and student participants, in others such as Ariel’s, these challenges were focussed at the parental level. In these instances, the student participant provided a vital resource, helping adults navigate platforms and participate in the research. As Celeste, Ariel’s parent, explained, it's just new things that I get a bit – like, even on here, because your email had come through to me and I said to Ariel "We're going to use your computer with Teams. How do we do this?" So, yeah, worked it out. I just had to look up my email address, but I [initially thought] oh, my god; what am I supposed to do here? Although helpful in our own research given its focus on school-aged young people, this dynamic of parents being helped by their dependents illustrates that the adults in our sample were often unfamiliar with the digital skills required for video conferencing. Research focussing only on adults, or on households in which students have not developed these skills through extended periods of online education such as occurred during the COVID-19 lockdowns, may find participants lacking the digital skills to participate in video interviews. Participation was also impacted upon by participants' lack of more subtle digital skills around the norms and conventions of video conferencing. Several households, for example, conducted their interviews in less ideal situations, such as from both moving and parked cars. A portion of the household interview with Piper’s household was completed as they drove the 30 minutes from their home into Shepperton. Due to living out of town, this household often experienced poor reception. The interview was thus regularly disrupted as they dropped in and out of range, with the interview transcript peppered with interjections such as “we’re going through a bit of an Internet light spot ... we’re back ... sorry ...” (Karina, parent). Finally, Piper switched the device on which they were taking the interview to gain a better connection: “my iPad that we were meeting on has worse Internet than my phone Internet, so we kind of changed it around” (Karina). Choosing to participate in the research from locations other than the home provides evidence of the limited time available to these families, and the onerousness of research participation. These choices also indicate unfamiliarity with video conferencing norms. As digitally excluded households, these participants were likely not the target of popular discussions throughout the pandemic about optimising video conferences through careful consideration of lighting, background, make-up and positioning (e.g. Lasky; Niven-Phillips). This was often identified by how participants positioned themselves in front of the camera, often choosing not to sit squarely within the camera lens. Sometimes this was because several household members were participating and struggled to all sit within view of the single device, but awkward camera positioning also occurred with only one or two people present. A number of interviews were initially conducted with shoulders, or foreheads, or ceilings rather than “whole” participants until we asked them to reposition the device so that the camera was pointing towards their faces. In noting this unfamiliarity we do not seek to criticise or apportion responsibility for accruing such skills to participating households, but rather to highlight the impact this had on the type of conversation between researcher and participant. Such practices offer valuable insight into how digital exclusion impacts on individual’s everyday lives as well as on their research participation. Conclusion Throughout the pandemic, digital methods such as video conferencing have been invaluable for researchers. However, while these methods have enabled fieldwork to continue despite COVID-19 disruptions, the shift to online platforms has important and under-acknowledged implications for who is and is not able to participate in research. In this article, we have drawn on our research with low-income households to demonstrate the barriers that such cohorts experience when participating in online research. Without the technology kits provided as part of our research design, these households would have struggled to participate due to a lack of adequate data and devices. Further, even with the kits provided, households faced additional barriers due to a lack of digital literacy. These experiences raise a number of questions that we encourage researchers to consider when designing methods that avoid in person interactions, and when reviewing studies that use similar approaches: who doesn’t have the technological access needed to participate in digital and online research? What are the implications of this for who and what is most visible in research conducted during the pandemic? Beyond questions of access, to what extent will disadvantaged populations not volunteer to participate in online research because of discomfort or unfamiliarity with digital tools and norms? When low-income participants are included, how can researchers ensure that participation does not unduly burden them by using up precious data resources? And, how can researchers facilitate positive and meaningful participation among those who might be less comfortable interacting through mediums like video conferencing? In raising these questions we acknowledge that not all research will or should be focussed on engaging with disadvantaged cohorts. Rather, our point is that through asking questions such as this, we will be better able to reflect on how data and participant samples are being impacted upon by shifts to digital methods during COVID-19 and beyond. As researchers, we may not always be able to adapt Zoom-based methods to be fully inclusive, but we can acknowledge this as a limitation and keep it in mind when reporting our findings, and later when engaging with the research that was largely conducted online during the pandemic. 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In this article I discuss a story told by the South Australian Ngarrindjeri Aboriginal elder, Aunty Hilda Wilson (nee Varcoe), about the time when, at not quite sixteen, she was sent from the Point Pearce Aboriginal Station to work in the Adelaide Hills, some 500 kilometres away, as a housekeeper for “one of Adelaide’s leading doctors”. Her secondment was part of a widespread practice in early and mid-twentieth century Australia of placing young Aboriginal women “of marriageable age” from missions and government reserves into domestic service. Consciously deploying Indigenous storytelling practices as pedagogy, Hilda Wilson recounted this episode in a number of distinct ways during the late 1990s and early 2000s. Across these iterations, each building on the other, she exhibited a personal resilience in her subjectivity, embedded in Indigenous knowledge systems of relationality, kin and work, which informed her agency and determination in a challenging situation in which she was both caring for a white socially-privileged family of five, while simultaneously grappling with the injustices of a state system of segregated indentured labour. Kirmayer and colleagues propose that “notions of resilience emerging from developmental psychology and psychiatry in recent years address the distinctive cultures, geographic and social settings, and histories of adversity of indigenous peoples”. Resilience is understood here as an ability to actively engage with traumatic change, involving the capacity to absorb stress and to transform in order to cope with it (Luthar et al.). Further to this, in an Indigenous context, Marion Kickett has found the capacity for resilience to be supported by three key factors: family connections, culture and belonging as well as notions of identity and history. In exploring the layers of this autobiographical story, I employ this extended psychological notion of resilience in both a domestic ambit as well as the broader social context for Indigenous people surviving a system of external domination. Additionally I consider the resilience Aunty Hilda demonstrates at a pivotal interlude between girlhood and womanhood within the trajectory of her overall long and productive life, and within an intergenerational history of resistance and accommodation. What is especially important about her storytelling is its refusal to be contained by the imaginary of the settler nation and its generic Aboriginal-female subject. She refuses victimhood while at the same time illuminating the mechanisms of injustice, hinting also at possibilities for alternative and more equitable relationships of family and work across cultural divides. Considered through this prism, resilience is, I suggest, also a quality firmly connected to ideas of Aboriginal cultural-sovereignty and standpoint and to, what Victoria Grieves has identified as, the Aboriginal knowledge value of sharing (25, 28, 45). Storytelling as Pedagogy The story I discuss was verbally recounted in a manner that Westphalen describes as “a continuation of Dreaming Stories”, functioning to educate and connect people and country (13-14). As MacGill et al. note, “the critical and transformative aspects of decolonising pedagogies emerge from storytelling and involve the gift of narrative and the enactment of reciprocity that occurs between the listener and the storyteller.” Hilda told me that as a child she was taught not to ask questions when listening to the stories of an Elder, and her own children were raised in this manner. Hilda's oldest daughter described this as a process involving patience, intrigue and surprise (Elva Wanganeen). Narratives unfold through nuance and repetition in a complexity of layers that can generate multiple levels of meaning over time. Circularity and recursivity underlie this pedagogy through which mnemonic devices are built so that stories become re-membered and inscribed on the body of the listener. When a perceived level of knowledge-transference has occurred, a narrator may elect to elaborate further, adding another detail that will often transform the story’s social, cultural, moral or political context. Such carefully chosen additional detail, however, might re-contextualise all that has gone before. As well as being embodied, stories are also emplaced, and thus most appropriately told in the Country where events occurred. (Here I use the Aboriginal English term “Country” which encompasses home, clan estate, and the powerful complex of spiritual, animate and inanimate forces that bind people and place.) Hilda Wilson’s following account of her first job as a housekeeper for “one of Adelaide’s leading doctors”, Dr Frank Swann, provides an illustration of how she expertly uses traditional narrative forms of incrementally structured knowledge transmission within a cross-cultural setting to tell a story that expresses practices of resilience as resistance and transformation at its core. A “White Doctor” Story: The First Layer Aunty Hilda first told me this story when we were winding along the South Eastern Freeway through the Adelaide hills between Murray Bridge and Mount Barker, in 1997, on our way home to Adelaide from a trip to Camp Coorong, the Ngarrindjeri cultural education centre co-founded by her granddaughter. She was then 86 years old. Ahead of us, the profile of Mt Lofty rose out of the plains and into view. The highest peak in the Mount Lofty ranges, Yurrebilla, as it is known to Kaurna Aboriginal people, or Mt Lofty, has been an affluent enclave of white settlement for Adelaide’s moneyed elite since early colonial times. Being in place, or in view of place, provided the appropriate opportunity for her to tell me the story. It belongs to a group of stories that during our initial period of working together changed little over time until one day two years later she an added contextual detail which turned it inside out. Hilda described the doctor’s spacious hill-top residence, and her responsibilities of caring for Dr Swann’s invalid wife (“an hysteric who couldn't do anything for herself”), their twin teenage boys (who attended private college in the city) along with another son and younger daughter living at home (pers. com. Hilda Wilson). Recalling the exhilaration of looking down over the sparkling lights of Adelaide at night from this position of apparent “privilege” on the summit, she related this undeniably as a success story, justifiably taking great pride in her achievements as a teenager, capable of stepping into the place of the non-Indigenous doctor's wife in running the large and demanding household. Successfully undertaking a wide range of duties employed in the care of a family, including the disabled mother, she is an active participant crucial to the lives of all in the household, including to the work of the doctor and the twin boys in private education. Hilda recalled that Mrs Swann was unable to eat without her assistance. As the oldest daughter of a large family Hilda had previously assisted in caring for her younger siblings. Told in this way, her account collapses social distinctions, delineating a shared social and physical space, drawing its analytic frame from an Indigenous ethos of subjectivity, relationality, reciprocity and care. Moreover Hilda’s narrative of domestic service demonstrates an assertion of agency that resists colonial and patriarchal hegemony and inverts the master/mistress-servant relationship, one she firmly eschews in favour of the self-affirming role of the lady of the house. (It stands in contrast to the abuse found in other accounts for example Read, Tucker, Kartinyeri. Often the key difference was a continuity of family connections and ongoing family support.) Indeed the home transformed into a largely feminised and cross-culturalised space in which she had considerable agency and responsibility when the doctor was absent. Hilda told me this story several times in much the same way during our frequent encounters over the next two years. Each telling revealed further details that fleshed a perspective gained from what Patricia Hill Collins terms an “epistemic privilege” via her “outsider-within status” of working within a white household, lending an understanding of its social mechanisms (12-15). She also stressed the extent of her duty of care in upholding the family’s well-being, despite the work at times being too burdensome. The Second Version: Coming to Terms with Intersecting Oppressions Later, as our relationship developed and deepened, when I began to record her life-narrative as part of my doctoral work, she added an unexpected detail that altered its context completely: It was all right except I slept outside in a tin shed and it was very cold at night. Mount Lofty, by far the coldest part of Adelaide, frequently experiences winter maximum temperatures of two or three degrees and often light snowfalls. This skilful reframing draws on Indigenous storytelling pedagogy and is expressly used to invite reflexivity, opening questions that move the listener from the personal to the public realm in which domestic service and the hegemony of the home are pivotal in coming to terms with the overlapping historical oppressions of class, gender, race and nation. Suddenly we witness her subjectivity starkly shift from one self-defined and allied with an equal power relationship – or even of dependency reversal cast as “de-facto doctor's wife” – to one diminished by inequity and power imbalance in the outsider-defined role of “mistreated servant”. The latter was signalled by the dramatic addition of a single signifying detail as a decoding device to a deeper layer of meaning. In this parallel stratum of the story, Hilda purposefully brings into relief the politics in which “the private domain of women's housework intersected with the public domain of governmental social engineering policies” (Haskins 4). As Aileen Moreton-Robinson points out, what for White Australia was cheap labour and a civilising mission, for Indigenous women constituted stolen children and slavery. Protection and then assimilation were government policies under which Indigenous women grew up. (96) Hilda was sent away from her family to work in 1927 by the universally-feared Sister Pearl McKenzie, a nurse who too-zealously (Katinyeri, Ngarrindjeri Calling, 23) oversaw the Chief Protector’s policies of “training” Aboriginal children from the South Australian missions in white homes once they reached fourteen (Haebich, 316—20). Indeed many prominent Adelaide hills’ families benefited from Aboriginal labour under this arrangement. Hilda explained her struggle with the immense cultural dislocation that removal into domestic service entailed, a removal her grandfather William Rankine had travelled from Raukkan to Government House to protest against less than a decade earlier (The Register December 21, 1923). This additional layer of story also illuminates Hilda’s capacity for resilience and persistence in finding a way forward through the challenge of her circumstances (Luthar et al.), drawing on her family networks and sense of personhood (Kickett). Hilda related that her father visited her at Mount Lofty twice, though briefly, on his way to shearing jobs in the south-east of the state. “He said it was no good me living like this,” she stated. Through his active intervention, reinforcement was requested and another teenager from Point Pearce, Hilda’s future husband’s cousin, Annie Sansbury, soon arrived to share the workload. But, Hilda explained, the onerous expectations coupled with the cultural segregation of retiring to the tin shed quickly became too much for Annie, who stayed only three months, leaving Hilda coping again alone, until her father applied additional pressure for a more suitable placement to be found for his daughter. In her next position, working for the family of a racehorse trainer, Hilda contentedly shared the bedroom with the small boy for whom she cared, and not long after returned to Point Pearce where she married Robert Wilson and began a family of her own. Gendered Resilience across Cultural Divides Hilda explicitly speaks into these spaces to educate me, because all but a few white women involved have remained silent about their complicity with state sanctioned practices which exploited Indigenous labour and removed children from their families through the policies of protection and assimilation. For Indigenous women, speaking out was often fraught with the danger of a deeper removal from family and Country, even of disappearance. Victoria Haskins writes extensively of two cases in New South Wales where young Aboriginal women whose protests concerning their brutal treatment at the hands of white employers, resulted in their wrongful and prolonged committal to mental health and other institutions (147-52, 228-39). In the indentured service of Indigenous women it is possible to see oppression operating through Eurocentric ideologies of race, class and gender, in which Indigenous women were assumed to take on, through displacement, the more oppressed role of white women in pre-second world war non-Aboriginal Australian society. The troubling silent shadow-figure of the “doctor’s wife” indeed provides a haunting symbol of - and also a forceful rebellion against – the docile upper middle-class white femininity of the inter-war era. Susan Bordo has argued that that “the hysteric” is archetypal of a discourse of ‘pathology as embodied protest’ in which the body may […] be viewed as a surface on which conventional constructions of femininity are exposed starkly to view in extreme or hyperliteral form. (20) Mrs Swann’s vulnerability contrasts markedly with the strength Hilda expresses in coping with a large family, emanating from a history of equitable gender relations characteristic of Ngarrindjeri society (Bell). The intersection of race and gender, as Marcia Langton contends “continues to require deconstruction to allow us to decolonise our consciousness” (54). From Hilda’s brief description one grasps a relationship resonant with that between the protagonists in Tracy Moffat's Night Cries, (a response to the overt maternalism in the film Jedda) in which the white mother finds herself utterly reliant on her “adopted” Aboriginal daughter at the end of her life (46-7). Resilience and Survival The different versions of story Hilda deploys, provide a pedagogical basis to understanding the broader socio-political framework of her overall life narrative in which an ability to draw on the cultural continuity of the past to transform the future forms an underlying dynamic. This demonstrated capacity to meet the challenging conditions thrown up by the settler-colonial state has its foundations in the connectivity and cultural strength sustained generationally in her family. Resilience moves from being individually to socially determined, as in Kickett’s model. During the onslaught of dispossession, following South Australia’s 1836 colonial invasion, Ngarrindjeri were left near-starving and decimated from introduced diseases. Pullume (c1808-1888), the rupuli (elected leader of the Ngarrindjeri Tendi, or parliament), Hilda’s third generation great-grandfather, decisively steered his people through the traumatic changes, eventually negotiating a middle-path after the Point McLeay Mission was established on Ngarrindjeri country in 1859 (Jenkin, 59). Pullume’s granddaughter, the accomplished, independent-thinking Ellen Sumner (1842—1925), played an influential educative role during Hilda’s youth. Like other Ngarrindjeri women in her lineage, Ellen Sumner was skilled in putari practice (female doctor) and midwifery culture that extended to a duty of care concerning women and children (teaching her “what to do and what not to do”), which I suggest is something Hilda herself drew from when working with the Swann family. Hilda’s mother and aunties continued aspects of the putari tradition, attending births and giving instruction to women in the community (Bell, 171, Hughes Grandmother, 52-4). As mentioned earlier, when the South Australian government moved to introduce The Training of Children Act (SA) Hilda’s maternal grandfather William Rankine campaigned vigorously against this, taking a petition to the SA Governor in December 1923 (Haebich, 315-19). As with Aunty Hilda, William Rankine used storytelling as a method to draw public attention to the inequities of his times in an interview with The Register which drew on his life-narrative (Hughes, My Grandmother, 61). Hilda’s father Wilfred Varcoe, a Barngarrla-Wirrungu man, almost a thousand kilometres away from his Poonindie birthplace, resisted assimilation by actively pursuing traditional knowledge networks using his mobility as a highly sought after shearer to link up with related Elders in the shearing camps, (and as we saw to inspect the conditions his daughter was working under at Mt Lofty). The period Hilda spent as a servant to white families to be trained in white ways was in fact only a brief interlude in a long life in which family connections, culture and belonging (Kickett) served as the backbone of her resilience and resistance. On returning to the Point Pearce Mission, Hilda successfully raised a large family and activated a range of community initiatives that fostered well-being. In the 1960s she moved to Adelaide, initially as the sole provider of her family (her husband later followed), to give her younger children better educational opportunities. Working with Aunty Gladys Elphick OBE through the Council of Aboriginal Women, she played a foundational role in assisting other Aboriginal women establish their families in the city (Mattingly et al., 154, Fisher). In Adelaide, Aunty Hilda became an influential, much loved Elder, living in good health to the age of ninety-six years. The ability to survive changing circumstances, to extend care over and over to her children and Elders along with qualities of leadership, determination, agency and resilience have passed down through her family, several of whom have become successful in public life. These include her great-grandson and former AFL football player, Michael O’Loughlin, her great-nephew Adam Goodes and her-grand-daughter, the cultural weaver Aunty Ellen Trevorrow. Arguably, resilience contributes to physical as well as cultural longevity, through caring for the self and others. Conclusion This story demonstrates how sociocultural dimensions of resilience are contextualised in practices of everyday lives. We see this in the way that Aunty Hilda Wilson’s self-narrated story resolutely defies attempts to know, subjugate and categorise, operating instead in accord with distinctively Aboriginal expressions of gender and kinship relations that constitute an Aboriginal sovereignty. Her storytelling activates a revision of collective history in ways that valorise Indigenous identity (Kirmayer et al.). Her narrative of agency and personal achievement, one that has sustained her through life, interacts with the larger narrative of state-endorsed exploitation, diffusing its power and exposing it to wider moral scrutiny. Resilience in this context is inextricably entwined with practices of cultural survival and resistance developed in response to the introduction of government policies and the encroachment of settlers and their world. We see resilience too operating across Hilda Wilson’s family history, and throughout her long life. The agency and strategies displayed suggest alternative realities and imagine other, usually more equitable, possible worlds. References Bell, Diane. Ngarrindjeri Wurruwarrin: A World That Is, Was and Will Be. Melbourne: Spinifex, 1998. 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