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Building strong partnerships between sectors. Enhancing outcomes for vulnerable groups Associate Professor Margarita Frederico 5th International Conference on Public Health among Greater Mekong Sub-regional Countries 28 - 29 September 2013, Yangon, Myanmar

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Introduction – The challenge of complexity

What can we learn from one study of response to complexity

Example from research of response to a complex problem - Group Analysis

Responding to the co-existence of family violence, parental substance use and parental mental illness: An integrated multi-service system response

Method

Findings

Translation of research findings

Presentation Outline

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The challenge of complexity

Health and social issues are complex. The responses required are complicated and the complex and there is a need for constant flexibility and ability to recalibrate as understanding of the issue/problem develops.

A reductionist approach to addressing complex issues will not be effective. Separating the parts of a problem until we no longer see the whole cannot find lasting solutions (Sturmberg and Martin, 2009, Plsek P E & Greenhalgh T, 2001).

The placement of the components of the problem in different government and social sectors compounds the challenge to respond effectively.

An approach is required to ensure the sectors work effectively together to achieve the best outcomes.

Need a “both and” ….approach.

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Example of divisions between sectors addressing a complex problem: Responding to the co-existence of family violence, parental substance use and parental mental illness: An integrated multi-service system response to the wellbeing and protection of vulnerable children

• Common issues of the co-existence of parental risk factors associated with family violence, parental substance use and mental illness on children where identified in a review of deaths of children known to Child Protection Services.

• This study focused upon analysis of 16 child deaths reviews (VCDRC) 2004 - 2008. Although the causes of death were not necessarily associated with these risk factors, these were evident to varying degrees throughout their lives.

• The purpose was to assist in understanding the impact of the co-existence of these factors for the child when all 3 risk factors are present and to propose a model for service development and achieving a more integrated practice approach.

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Method

• The research methodology integrated a Group Analysis of Child Death Inquiry reports in which the three risk factors were present and accompanying documents, which had been purposively selected by VCDRC with a literature review and interviews with key informants.

• With a small in-depth qualitative sample, each case provides a rich illustration of the issues which can affect children. The generalisation of findings beyond this sample is supported by similar findings in the literature and enhanced by the input of key informants.

• The study was supported by a rigorous review of the literature which explored existing evidence and conceptual frameworks in relation to the phenomena being researched.

• The major themes emerging from the group analysis are integrated into an ecological and developmentally informed framework which is refined and adapted in further exploration of themes, key findings and opportunities for enhancing practice and program development.

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Overview of process of analysis through to developing a draft framework for Group Analysis of co-existence of parental risk factors

Literature review

Child death group analysis of 16 cases

Audit of programs, practice and networks: via

surveys & focus groups

Identification of practice models that already exist, constraints to effective

practice and promising or best practice initiatives

Develop draft framework and strategies for multi-service

response and prepare report

Physical safety

Critical experiences at different stages

Healthy promoting environments

Relationships that provide nurturance, regulation, guidance

and protection

Coherence between child’s development and multiple

contexts

Positive and realistic perception of self and others

Access and perception of access to supports throughout life

Sense of identity and security

Belonging and connectedness to family, community and

culture

Hope and trust that others will care for them & that they

are worthwhile.

Health

Cognitive

Education

Social

Emotional

Behavioural

Physical

Spiritual/ moral

Areas of

Development

Child Needs include:

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Selection of Findings: Responding to the co-existence of family violence, parental substance use and parental mental illness: An integrated multi-service system response to the wellbeing and protection of vulnerable children

Language/ Definitions

For each of the risk factors of family violence, alcohol and other drug abuse and mental illness there is debate over definition. These are not just academic or ideological debates but have implications for policy, programs and practice.

Co-morbidity

Very few studies have reported on the prevalence of these three risk factors co-occurring, and even fewer have reported on their co-occurring for parents of dependent children. Exceptions are Brandon et al (2009) who found in a study of CDRs that these families shared many characteristics particularly family violence, parental mental health problems and parental substance abuse.

Leadership

At the grass roots direct service level workers focus on addressing the problem and tend to work within their sector. Without drive from leadership to look beyond their own sector the integration cannot occur.

Implications for service systems

Need for a multi a multi-service system framework

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Selection of Findings: An integrated multi-service system response to the

wellbeing and protection of vulnerable children

Where all 3 risk factors are present, the combination of these factors create their own dynamic, which cannot be explained or managed by simply attending to each of the factors on an individual basis.

Family violence, alcohol and other drug problems and mental health problems as separate factors can have a varying degree of impact on parenting capacity.

Dealing with more than two risk factors appears to present stronger barriers to collaboration across service systems

Barriers to effective collaboration extend beyond practice issues and exist in the structures, cultures and programs of the sectors.

Recommendation

Development of a global, multi sector ,multi-service collaborative framework

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Translation of research findings from a small study to global issues

• The co-existence of other risk factors such as poverty, transience and unemployment which could be said to be both a cause and an outcome of the parental risk factors, was disastrous to the children.

• Evidence from the international research indicates these constraints and barriers to effective multi-service system responses to these combined risk factors are not unique to Victoria and yet this also emphasises the challenges ahead to achieve meaningful change.

• The opportunity to build an international paradigm supported by evidence is a challenge for our sector. The high level of complexity of the problems being addressed makes the development of gold standard evidence challenging if seemingly impossible. However sharing of findings and building upon knowledge developed in different countries based on rigorous studies is a start in developing the paradigm.

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Strategies to achieve global, multi-sector, multi -service collaboration framework

• Leadership

• A common language – definitions

• Subsidiarity – addressing the issues at the local level- utilising strengths – building on culture

• Supportive Policy – integrative

• Sector , service systems and collaboration at all levels

• Research, knowledge building strategies and sharing

• Training and other aspects of workforce development

• Program strategies

• Practice and Intervention strategies

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Extent of knowledge held at different levels within the community

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Conclusion

•

really understand it, and the way forward is to break the problem down into its parts

to make sense of it

•

•

• A clear framework for integration at all levels

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References Brandon M, Belderson P, Warren C ,Gardner R, Howe D and Dodsworth J (2008)The Preoccupation with Thresholds in Cases of Child

Death or Serious Injury through Abuse and Neglect Child Abuse Review vol 17 313-33

Bromfield L,Lamont A, Parker R, Horsfall B (2010) Issues for safety and wellbeing of children in families with multiple and complex problems: the co –existence of domestic violence, parental substance abuse and mental health problems NCPC Issues national Child Protection Clearing House Melbourne AIFS

Blas, E., Gilson, L., Kelly, M. P., et al. (2008) Addressing social determinants of health inequities: what can the state and civil society do? Lancet, 372 (9650), 1684–1689.

Council of Australian Governments (2009). Protecting children is everyone’s business: National framework for protecting Australia’s children 2009–2020

Frederico M , Jackson A & Dwyer J ( 2011) Responding to the co-existence of family violence, parental substance use and parental mental illness: An integrated multi-service system response to the wellbeing and protection of vulnerable children La Trobe University (Unpublished)

Frederico M, Jackson A and Jones S(2006) Child Death Group Analysis: Effective Responses to Chronic Neglect OCSC Melbourne Vic Gov Printer

Frederico M., Jackson A., Black C.,(2010) More than Words –The Language of Relationships- Take Two Third Evaluation Report. La Trobe University pp208

Frederico M., Jackson A., Black C., (2006) Giving Sorrow Words - A language for healing. Take Two Second Evaluation Report. La Trobe University pp250

Frederico M., Jackson A., & Black C (2005) Reflections on Complexity. Take Two First Evaluation Report La Trobe University pp198

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Office of the Child Safety Commissioner (2012) Connecting services: Learning from child death inquiries when the co-existing parental characteristics of family violence, substance misuse and mental illness place children at risk Melbourne Victorian Government printer

Plsek P E & Greenhalgh T (2001) Complexity science The challenge of complexity in health care BMJ. September 15; 323(7313): 625–628.

Resnicow, & K Page, S E (2008) Embracing Chaos and Complexity: A Quantum Change for Public Health Am J Public Health. August; 98(8): 1382–1389.

Sturmberg J P and Martin C. (2009) Complexity and health – yesterday’s traditions, tomorrow’s future. Journal of Evaluation in Clinical Practice 15; 543-548

The Swiss Agency for Development and Cooperation (SDC), the International Federation of Red Cross and Red Crescent Societies (IFRC), the International Council of Voluntary Agencies (ICVA), and the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) INTERNATIONAL DIALOGUE :ON STRENGTHENING PARTNERSHIP IN DISASTER RESPONSE: Bridging national and international support :25, 26 October 2011, Geneva, Switzerland

Thank you

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