Building the capacity of family day care educators to promote children's social and emotional wellbeing: an exploratory cluster randomised controlled trial

Building the capacity of family day care educators to promote children's social and emotional wellbeing: an exploratory cluster randomised controlled trial
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  Deakin Research Online This is the published version: Davis, Elise, Williamson, Lara, Mackinnon, Andrew, Cook, Kay, Waters, Elizabeth, Herrman, Helen, Sims, Margaret, Mihalopoulos, Cathrine, Harrison, Linda and Marshall, Bernard 2011, Building the capacity of family day care educators to promote children’s so cial and emotional wellbeing : an exploratory cluster randomised controlled trial  , BMC public health , vol. 11, Article no. 842, pp. 1-7. Available from Deakin Research Online: This is an open access article distributed under the terms of the attached BioMed Central License. See license for details.  Copyright : 2011, Davis et al; licensee BioMed Central Ltd.    STUDY PROTOCOL Open Access Building the capacity of family day careeducators to promote children ’ s social andemotional wellbeing: an exploratory clusterrandomised controlled trial Elise Davis 1* , Lara Williamson 1 , Andrew Mackinnon 2 , Kay Cook  3 , Elizabeth Waters 1 , Helen Herrman 2 ,Margaret Sims 4 , Cathrine Mihalopoulos 3 , Linda Harrison 5 and Bernard Marshall 3 Abstract Background:  Childhood mental health problems are highly prevalent, experienced by one in five children living insocioeconomically disadvantaged families. Although childcare settings, including family day care are ideal to promotechildren ’ s social and emotional wellbeing at a population level in a sustainable way, family day care educators receivelimited training in promoting children ’ s mental health. This study is an exploratory wait-list control cluster randomisedcontrolled trial to test the appropriateness, acceptability, cost, and effectiveness of   “  Thrive, ”  an intervention program tobuild the capacity of family day care educators to promote children ’ s social and emotional wellbeing. Thrive aims toincrease educators ’  knowledge, confidence and skills in promoting children ’ s social and emotional wellbeing. Methods/Design:  This study involves one family day care organisation based in a low socioeconomic area of Melbourne. All family day care educators (term used for registered carers who provide care for children for financialreimbursement in the carers own home) are eligible to participate in the study. The clusters for randomisation will be thefieldworkers (n = 5) who each supervise 10-15 educators. The intervention group (field workers and educators) willparticipate in a variety of intervention activities over 12 months, including workshops; activity exchanges with othereducators; and focused discussion about children ’ s social and emotional wellbeing during field worker visits. The controlgroup will continue with their normal work practice. The intervention will be delivered to the intervention group andthen to the control group after a time delay of 15 months post intervention commencement. A baseline survey will beconducted with all consenting educators and field workers (n = ~70) assessing outcomes at the cluster and individuallevel. The survey will also be administered at one month, six months and 12 months post-intervention commencement. The survey consists of questions measuring perceived levels of knowledge, confidence and skills in promoting children ’ ssocial and emotional wellbeing. As much of this intervention will be delivered by field workers, field worker-family daycare educator relationships are key to its success and thus supervisor support will also be measured. All educators willalso have an in-home quality of care assessment at baseline, one month, six months and 12 months post-interventioncommencement. Process evaluation will occur at one month, six months and 12 months post-interventioncommencement. Information regarding intervention fidelity and economics will also be assessed in the survey. Discussion:  A capacity building intervention in child mental health promotion for family day care is an essentialcontribution to research, policy and practice. This initiative is the first internationally, and essential in building anevidence base of interventions in this extremely policy-timely setting. Trial Registration number: 343312 * Correspondence: 1 Jack Brockhoff Child Health and Wellbeing Program, McCaughey Centre,University of Melbourne, Level 5, 207 Bouverie Street, Carlton, Victoria, 3152,AustraliaFull list of author information is available at the end of the article Davis  et al  .  BMC Public Health  2011,  11 :842 © 2011 Davis et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (, which permits unrestricted use, distribution, and reproduction inany medium, provided the srcinal work is properly cited.  Background Early mental health promotion is important for preven-tion of mental disorders and for mental health statusthroughout life. The period from conception to schoolage is critical to neural wiring and brain development [1].Mental health problems have significant and long-termpersonal, social and economic implications for the indivi-dual, their family and the wider community. Childhoodmental health problems are highly prevalent, experiencedby one in seven Australian children aged between 4-17 years [2]. There are marked inequalities in the distribu-tion of mental health problems, with the rate increasingto one in five children for those living in low-income orsingle parent families [2]. Mental health problems arealso apparent in young children [3,4]. For example, a recent study reporting population data from the Longitu-dinal Study of Australian Children found that 11.5% of children aged 4-5 years had scores indicating abnormalor concerning mental health [5].Child mental health is more than the absence of mentalillness; it is  “ the achievement of expected developmentalcognitive, social, and emotional milestones and by secureattachments, satisfying social relationships, and effectivecoping skills ”  (p.123) [6]. Positive mental health, though variously defined, includes emotion (affect/feeling), cog-nition (perception, thinking, reasoning), social function-ing (relations with others and society), and a sense of meaning in life [7]. To promote positive mental health,infants and children require good maternal health, ade-quate nutrition, secure attachments with caregivers, andcaregivers who are knowledgeable, skilled and competentwith access to support services and networks [8].Childcare settings are ideal to promote children ’ ssocial and emotional wellbeing and to identify early mental health problems in the population in a sustain-able way, given the large number of children whoattend. In Australia, use of childcare has increased inrecent years, with 35.2% of all children aged 0-4 yearsaccessing some form of formal childcare in 2005 com-pared to 23.6% in 1996 [9].Family day care (FDC), where registered educators pro- vide formal paid care in their own homes for other people ’ schildren under the management of a local coordinationscheme, is a popular form of childcare in Australia. It isutilised by 20.5% of all parents of children aged 0-4 yearswho accessed some form of formal care in 2004 [9,10]. Recent changes in Victorian childcare regulations now require all educators to have attained or to be workingtowards gaining a formal childcare qualification. The mini-mum level of attainment is a Certificate III in Children ’ sServices which requires around 12 months study. Upon itscompletion the educator can then undertake an additional year of study to qualify for the Diploma in Children ’ sServices. Recent surveys illustrate an increase in FDC edu-cator qualifications, from 25% holding a Certificate III in2004 [8] to over 50% in 2010 [11]. This is significant given that both educator education and training are better pre-dictors of childcare quality than educator age and workexperience [12]. Despite this, FDC educators do not study mental health promotion in the curriculum of the Certifi-cate III or the Diploma in Children ’ s Services nor is thistype of training common in professional developmentprograms.In the absence of any international research examiningthe knowledge, skills and competencies of FDC educatorsin the area of child mental health promotion, our teamconducted a qualitative study which highlighted severalchallenges faced by educators [13]. Educators had diffi-culty identifying the causes and early signs of mentalhealth problems for children. The strategies they used topromote children ’ s mental health were informal anddependent on the educator ’ s individual skills. They haddifficulty identifying mental health promoting policies, andconnecting families with community health services. Com-mon barriers to mental health promotion include financialresources, a lack of knowledge about child mental health,and a fear of discussing mental health concerns with par-ents. Educators also requested training in child mentalhealth and communication with parents.To date, only one intervention program has been devel-oped to promote Australian childcare workers ’  (includingfamily day care educators ’ ) knowledge of mental healthproblems. The Healthy Start Program [14] involved train-ing for child educators in risk and protective factors of mental health, and communication with parents aroundchild mental health issues. The intervention program wasassociated with an increase in educators ’  confidence, skillsand knowledge about promoting children ’ s mental healthat six months; however these gains were not retainedwhen educators were re-tested at 12 months. Althoughevidence suggests that training improves the competenciesof child educators (professional attitude, knowledge andskills) [12] and that family day care educators who partici-pate in training offer higher quality care than providerswho do not participate [15], for training to be effectiveand long lasting, it has to be part of a strategy thataddresses organisational policies, procedures, resources,standards of practice and supervision [16], consistent witha capacity building approach.Capacity building involves actions aimed at strengthen-ing the skills and capabilities of individuals, organisations,systems and communities [17]. Capacity building strate-gies for mental health promotion have been developedfor school settings, including mental health promotingpolicies, curricula, and systems across the whole sector,building the skills and knowledge of teachers, as well as Davis  et al  .  BMC Public Health  2011,  11 :842 2 of 7  strengthening links with other organizations and groupswithin the community [18,19]. A new program, KidsMat- ter Early Childhood, an extension of MindMatters (sec-ondary school) and KidsMatter (primary school) hasrecently been developed to fill this gap and has beentrialled. KidsMatter Early Childhood aims to:  “ improvethe mental health and wellbeing of children from birth toschool age; reduce mental health problems among chil-dren and; achieve greater support for children experien-cing mental health difficulties and their families ”  ( Due to logistical challenges,FDC was not included in the implementation of this pro-gram. In the absence of any programs that aim to buildthe capacity of family day educators in order to promotechildren ’ s social and emotional wellbeing, a new programhas been developed ("Thrive: Promoting Children ’ s Socialand Emotional Wellbeing in Family Day Care ” ). Development of Thrive The initial stages of the project comprised telephone inter- views and focus groups with FDC educators. Theirresponses guided the development of the interventionprogram. Telephone interviews were completed with50 educators to help gain insight into their knowledge andconfidence in promoting children ’ s social and emotionalwellbeing. This information provided useful insights andallowed educators to be categorised into different  ‘ stages of change ’  [20] around their willingness to promote children ’ ssocial and emotional wellbeing. The Stages of Changemodel has been widely used in health promotion programsand describes the stages an individual or organisationmoves through from before they contemplate changing, tocontemplating change, taking action, maintaining the new practice and also relapsing. These categories were used toassemble focus groups bringing together educators whowere at similar stages of willingness to actively promotechildren ’ s social and emotional wellbeing in their FDCpractice. Four focus groups were conducted (three witheducators in the action/maintenance phase, and one withfieldworkers) and five individual interviews with educatorsin the  ‘ relapse ’ ,  ‘ pre-contemplation ’  and  ‘ preparation ’ stages. In addition, system perspectives were gainedthrough six key informant interviews with representativesfrom peak bodies, training organisations, scheme sponsormanagement and government.The Thrive program includes several activities for fieldworkers and FDC educators. These activities includeworkshops for field workers (N = 4) and FDC educators(N = 3), activity exchanges with other educators andfocused discussion on social and emotional wellbeingduring field worker visits. The intervention group willalso receive resources associated with the workshops onpromoting children ’ s social and emotional wellbeing. Acluster randomised controlled trial design is being usedbecause the effectiveness of some of the interventionactivities (i.e. activity exchange and field worker visits) isdependent on the field worker.  Aims This study is the first stage in evaluating the appropriate-ness, acceptability, cost and effectiveness of an interven-tion program to build the capacity of FDC educators topromote children ’ s social and emotional wellbeing. It ishypothesised that the intervention program will:a) increase FDC educators ’  knowledge, confidence andskills in promoting children ’ s social and emotionalwellbeingb) increase field workers ’  knowledge and confidence inpromoting children ’ s social and emotional wellbeingc) build the capacity of the FDC organisation (as mea-sured by workforce development, resource allocationand leadership).This is the first intervention program designed tobuild the capacity of FDC educators to promote chil-dren ’ s social and emotional wellbeing internationally. Methods/Design Study Design Approval for the trial has been obtained from The Univer-sity of Melbourne Human Research Ethics Committee(HREC 1136446). This study uses a wait-list control clus-ter randomised controlled trial to test the appropriateness,acceptability, feasibility, costs and effectiveness of theThrive intervention program. The intervention program isbeing conducted with one FDC scheme based in a low socioeconomic area of Melbourne. A low socioeconomicarea was selected because the prevalence of child mentalhealth problems is higher in poorer areas [2].Figure 1 summarises the study design and timelines. AllFDC educators and field workers within the scheme areeligible to receive the intervention program. The clustersfor randomisation will be the field workers (n = 5) whoeach supervise 10-15 educators. Randomisation will beconducted in accordance with ICH Guideline E9 [21] by CI Mackinnon, who is independent of the administrationof the intervention.The intervention group will receive the interventionover a 12-month period, during which time the controlgroup will continue standard practice. The interventionprogram will be delivered to the intervention group andthen to the control group after a time delay of 15 monthspost intervention commencement. The Thrive interven-tion program includes several activities for field workersand FDC educators. These activities include workshopsfor field workers (N = 4) and family day care educators(N = 3), activity exchanges with other educators coordi-nated by their fieldworker and focused discussion onsocial and emotional wellbeing during field worker visits.The intervention group will also receive resources Davis  et al  .  BMC Public Health  2011,  11 :842 3 of 7  associated with the workshops on promoting children ’ ssocial and emotional wellbeing.All FDC educators will be informed that the interven-tion will roll out in a two-stage process. Fieldworkerswill not be blinded as to which arm they are involved inwith educators but will be made aware of the blindingprocess and its necessity. The researchers involved indata collection will be blinded as to which interventioneducators are receiving. Participants and Recruitment A cover letter, plain language statement and consentform describing the Thrive intervention and evaluationwill be mailed to all educators, fieldworkers and manage-ment. An administrative assistant from the FDC schemewill then telephone educators to determine if they areinterested in participating in the study. If so, administra-tors will request consent from the subjects to pass ontheir contact details to researchers. The researchers will ‘Control’ - Waitlist  Fieldwrkers and educators continue work as normalFieldworkers and educators invited to join in Thrive programProcess evaluation – 1 month, 6 month and 12 month post intervention commencement12 month – also qualitative interviewsEvaluationImmediate post-Thrive Post intervention Evaluation 1 month, 6 month and 12 month post intervention commencement- Questionnaire assessing knowledge of children’s social and emotional wellbeing1 month, 6 month and 12 month post intervention commencement – Observation of quality of care Thrive Program Fieldworkers and educators receive Thrive Program (12 month period)Fieldworkers randomly assigned to either groupBaseline questionnaire:       In home observation: All educators At 15 months Figure 1  Thrive randomised control trial flow chart . Davis  et al  .  BMC Public Health  2011,  11 :842 4 of 7
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