A Levesque-Guided Qualitative Study to Understand Equity in Child and Family Health Services: Insights from an Australian Health District

A Levesque-Guided Qualitative Study to Understand Equity in Child and Family Health Services: Insights from an Australian Health District | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Levesque-Guided Qualitative Study to Understand Equity in Child and Family Health Services: Insights from an Australian Health District Limin Buchanan, Naome Reid, Janice Oliver, Rachel Walker, Dianna Jagers, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9217963/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Child and Family Health Services (CFHS) provide universal early childhood health and developmental support in Australia, aiming to give every child an equitable start in life. However, despite this universal intent, not all families are able to access or sustain engagement with these services in a timely way. Guided by Levesque’s Conceptual Framework for Healthcare Access, this study examined how system design and service delivery processes influence families’ ability to perceive, seek, reach, and engage with CFHS within a metropolitan Local Health District. Methods A qualitative design was used, incorporating four focus groups with 42 service providers and six semi-structured interviews with parents or carers who accessed CFHS in the preceding 12 months. Data was collected between August and October 2023. Thematic analysis followed Braun and Clarke’s six-phase approach, combining deductive coding using Levesque’s five dimensions of access with inductive identification of emerging themes. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guided reporting. Results Five inter-related themes described access determinants across the Levesque framework: (1) system complexity and navigation burden, (2) variation in prioritisation and advocacy, (3) service demand and workflow duplication, (4) hidden costs of workforce and system inefficiency, and (5) mismatched referrals and family readiness. Families and referrers frequently encountered unclear entry points and fragmented communication, while staff described duplicated triage processes and capacity-driven rather than needs-driven allocation. Centralised intake and free-of-charge services were key enablers, though operational pressures limited responsiveness and timeliness. Conclusions Findings highlight how system fragmentation and inconsistent operational practices translate into inequitable access, even within a universal model. Addressing these gaps requires standardised, equity-weighted triage, integrated digital referral pathways, and flexible service delivery aligned with family circumstances. Applying Levesque’s framework provided a practical lens to connect organisational variation with the lived experience of access, informing service redesign toward more equitable, timely care. Equitable access to health services child health and development child and family health services community health Levesque’s Conceptual Framework for Healthcare Access Figures Figure 1 Background The early years of a child’s life are widely recognised as a critical period that shapes lifelong health and wellbeing [ 1 ]. Providing children with access to a universal platform of early health and developmental services supports equitable opportunities for optimal development [ 2 ]. In Australia, this platform is delivered through Child and Family Health Services (CFHS), publicly funded primary health care services providing universal childhood health surveillance, parenting support, and referral pathways to specialist services [ 3 ]. CFHS play a vital role in supporting children and families from birth, offering health and development checks, immunisations, psychosocial support, and community-based medical and allied health care [ 4 ]. Timely access during the first 2000 days is critical, as early intervention can strongly influence life-long health, education, and wellbeing [ 1 ]. Yet, access remains inconsistent across jurisdictions, and many families do not engage with services [ 5 ]. National and international evidence highlights persistent challenges for families with complex developmental and psychosocial needs. Barriers include fragmented service pathways, variable eligibility, and long wait times [ 2 ]. These issues are magnified for culturally and linguistically diverse (CALD) families, and those experiencing disadvantage, who face additional barriers such as language, stigma, financial hardship, and systemic discrimination [ 6 , 7 ]. Studies in Australia and overseas further demonstrate that children from minority backgrounds or with high psychosocial needs are less likely to access preventive programs and more likely to experience delays in assessment and support [ 8 – 11 ]. At a systems level, variation in models of care and referral pathways contributes to inequities. While some variation reflects responsiveness to family needs, ‘unwarranted’ clinical variation— differences not explained by need or preference— remains a significant barrier to equitable access [ 12 , 13 ]. Families requiring multidisciplinary input are particularly vulnerable, often experiencing disjointed care, duplication of assessments, or extended waits [ 14 , 15 ]. Addressing these systemic inconsistencies is essential to reduce inequities and ensure services deliver client-centred timely, integrated care. Therefore, we conducted this study to systematically identify barriers to accessing Child and Family Health Services. By applying an equity lens, the study aimed to inform service redesign, reduce unwarranted variation, and strengthen timely and equitable access. Methods Study design This study adopted qualitative approach. Focus groups and semi-structured interviews were used to obtain study data. This study is reported following the Consolidated Criteria for Reporting Qualitative Research (COREC) guidelines [ 16 ] (see Additional File 1 for COREQ Checklist). Theoretical framework Levesque’s conceptual framework for healthcare access [ 17 ] underpins this study. This framework highlights that access is shaped not only by the characteristics of health services, but also the abilities of individuals and communities to engage. This framework outlines five inter-related dimensions of accessibility: approachability, acceptability, availability and accommodation, affordability, and appropriateness , which align with corresponding client abilities to perceive, seek, reach, pay, and engage . Together, these dimensions provide a comprehensive lens for examining how health systems and populations interact to enable or hinder access. Ethics The study received ethical approval from the Ethics Review Committee of Sydney Local Health District (Protocol No. X23-0273 & 2023/STE02667). Participant recruitment The study was conducted within Community Health Services, Sydney Local Health District, using convenience sampling to identify participants with relevant experience and knowledge of the study scope. A total of 48 participants were included: 42 service providers (including clinicians, intake officers, and managers), and six service users (parents/carers of child who had accessed Child and Family Health Services in the past 12 months) (See Table 1 a and b for participant profiles). Table 1 a: Profile of service providers Disciplines/Services Number of participants Child and Family Health Nurses 4 Clinicians (Early Childhood Social Work) 4 Clinicians (Counselling- Psychology and Social Work) 10 Clinicians (Physiotherapy) 3 Clinicians (Occupational Therapy) 4 Clinicians (Speech Pathology) 4 Community Paediatrics 3 Intake officers 4 Staff from service support and leadership roles, such as Child and Family Health executive, Aboriginal Health, Multicultural Health, Performance and Data Analysis 6 Total 42 Table 1 b: Profile of interviewed clients (parents/carers) and services accessed by their children Client ID Parent Age (years) Number of services accessed by child Services accessed Age of child/ren (years) A 36 2 Physiotherapy; Early Childhood Social Work 1.5 B 42 1 Occupational Therapy 2, 4 C 39 2 Occupational Therapy; Social Work 3, 5 D 39 4 Occupational Therapy; Social Work; Psychology; Speech Pathology 6 E 41 2 Early Childhood Social Work; Speech Pathology 3 F 38 3 Social Work, Psychology, Occupational Therapy 9 Service providers represented a range of Child and Family Allied Health disciplines, Child and Family Health Nursing, Community Paediatrics, as well as staff in leadership roles. Researchers (LB, NR) circulated an expression of interest email to relevant staff and key stakeholders. Interested service providers were provided with a Participant Information Sheet. Service users were existing clients of Child and Family Health Services. Between September and October 2023, clinicians informed eligible clients about the study and directed those interested to an online REDCap registration form [ 18 ], which included the Participant Information Sheet. Data collection Data collection was conducted at Child and Family Health Centres in Sydney Local Health District, between August and October 2023. Four face-to-face focus groups were held with service providers, and six semi-structured interviews were undertaken with service users via Microsoft Teams, phone or in-person, according to participants’ preferences. Written consent (service providers) and verbal consent (service users) were obtained prior to each session. Focus group and interview guides (See Additional Files 3 and 4 for guides) were used to facilitate discussion, with questions informed by the key components of the Levesque’s framework [ 17 ]. All sessions were audio-recorded, with focus group lasting approximately 90 minutes and the interview lasting around 30 minutes. Field notes were taken during and after each session. Recruitment and data collection continued until data saturation was reached, when no new information emerged. No repeat interviews were conducted. Data collection was undertaken by two female project leads LB, and NR. LB holds a Doctorate in Public Health and has extensive experience in health services evaluation and quality improvement. Prior to data collection, LB reviewed resources on Levesque’s framework and led the development of the focus group and interview guides. NR has a background in Social Work, a Master of Social Work in Advanced Clinical Practice, and experience as a Service Manager. Neither LB nor NR were involved in service delivery to participants, and their combined research, clinical and managerial experience provided complementary perspectives and ensured that data collection was both systematic and contextually grounded. Data analysis Data transcription was conducted manually using Microsoft Word. Participants were given the option to review their interview transcripts for comment or correction. However, none chose to do so. Thematic analysis was undertaken following Braun and Clarke’s six-phase approach [ 19 ], using a hybrid strategy that combined deductive and inductive coding [ 20 ]. The Levesque Conceptual Framework of Access to Health Care [ 17 ] provided an initial deductive structure, with its 10 constructs guiding early coding and categorisation. Concurrently, the analysis remained open to new patterns and concepts emerging directly from participants’ narratives, allowing additional themes and sub-themes to be developed inductively. (See Additional file 2 for complete list of codes, sub-themes and themes). Coding process All interview and focus group transcripts were manually coded in Microsoft Word. After familiarisation with the data, the primary researcher (LB) applied comments to relevant text segments, labelling them with descriptive codes. These codes were refined iteratively as new insights emerged, and earlier transcripts were revisited to ensure consistency. NR and RW reviewed a subset of coded transcripts to support reliability. Codes were then grouped into broader categories, forming the basis for theme development. The process was reflexive and iterative, balancing theoretical guidance with participants’ voices. RESULTS Our study results were categorised using Levesque Framework’s five dimensions of healthcare access. Figure 1 illustrates the key themes against these dimensions from both service provider and user perspectives. Key aspects from staff and client perspectives were reported collectively and presented below. See Additional File 2 for the full list of codes and sub-themes. Determinants of services approachability and service users’ ability to perceive Approachability - System complexity and fragmented pathways On the service side, clients’ ability to identify and approach appropriate support was often constrained not by motivation, but by the fragmented and opaque nature of the service system. Limited integration and inconsistent information pathways meant that even proactive parents found it difficult to navigate and uncertain if they have reached the right service. Client E described needing support to find out about available services: I had to ask around. No one told me about these services at first. Only when I spoke to the caseworker at the Refuge she told me to ask for speech therapy and dental check. In another example, Client F reported her GP was unaware of the services. She expressed uncertainty about whether she had reached the right service when calling intake: I had to Google because when I raised my son’s concerns with my GP, it seems like my GP is not aware of any kind of support or didn't point me in the right direction. I’m not sure if this is the right number to be calling and, yeah, I was just really confused what to ask for. Ability to perceive- Navigating unclear referrals, clients’ health literacy and understanding of child development For service users, varying levels of health literacy and understanding of child development influenced how well clients could understand and articulate concerns. Staff noted that unclear referrals often reflected this variability where parents recognised something was wrong but were unsure how to describe it. Intake officer’s elicitation skills played a critical role in interpreting vague concerns and guiding clients toward appropriate services. But they (clients) sometimes are not actually able to articulate clearly about what concerns they have, this poses challenges on how the intake officer manages to make referral if the person they talk to isn’t clear about what they need. It really speaks to the skill and capability of our intake officers… facilitating the conversation to try and see what is concerning them about their child's development. Clients’ capacity to understand and articulate concerns was in turn influenced by both the appropriateness of services and service availability. In terms of service appropriateness, having highly skilled staff at the centralised intake service was seen as a crucial bridge in supporting families to interpret concerns, clarify service options, and connect to the right care. In regards to service availability - Staff observed that high intake volumes intensified the challenges of an already complex system. So they (intake officers) are needing to manage the 10 models of care they might need to know about while they're on the phone with the parent, the phone tags, the demand of incoming calls from internal, external referrers and clients. More than 120 calls on some days. Determinants of services acceptability and service users’ ability to seek Service acceptability was shaped by staff’s professional values, experience, interpretation of service criteria, and how well services aligned with families’ personal, cultural or social values, particularly in relation to trust, communication, and system navigation. Perception of inconsistent prioritisation and variability in advocacy Staff Noted that prioritisation practices varied across sites and were sometimes influenced by individual advocacy or experience. This affected both acceptability and availability of services. And I would say it (prioritisation) is not consistent. Some of our more senior staff who have been here are good in advocating. On the other hand, our junior staff like new graduates would think: well, it is just it is …. Across different sites, the way clients get picked up can be a bit different. Some sites seem to pick up clients faster depending on how they work or interpret prioritisation criteria. Client cultural acceptability of health services From the client perspective, their ability to seek service was shaped by cultural familiarity, health literacy, and trust. Language barriers and uncertainty about whether they were contacting the correct service affected their confidence to seek help. Client A described language as a barrier: Because English is not my first language, sometimes I’m not sure how to explain what’s going on with my son. Client C shared uncertainty around navigating services: People that are not as well educated or have that background knowledge might not know that they're calling the right people. Staff confirmed that some families do not follow through with referrals and this might have been due to cultural or emotional barriers. Some families never make the call, even if they’ve been referred. It might be cultural or just overwhelmed by the process. Determinants of services availability and service users’ ability to reach This theme explores logistic and structural factors influencing service access, including demand, scheduling, and geographic access. Service demand and workflow duplication High demand and inefficient internal processes strained service availability. Staff described repeated triaging and referral steps that added administrative burden and contributed to delayed care. CHIL (intake team) is prioritising, then you (clinical team) re-prioritise again in another meeting. It’s like double meetings. In a context of long wait lists, allocation was sometimes driven by staff capacity rather than client need: Instead of being guided by what meets the client’s needs, like the right therapy at the right time. We’re prioritising based on which site has the shortest wait time. Scheduling challenges and geographic accessibility Centralised intake staff noted the logistical challenges of coordinating interpreters and appointments across sites, while flexibility to accept clients from nearby centres helped manage demand. Families, however, described difficulty fitting appointments around work commitments and variable access across locations: Client D shared: “It's logistically hard because the last appointment is at 4pm..he (child’s father) is essentially gonna leave work at 3pm, which is really quite early. “ Client E commented: "It depends on which location. Clinic A is very busy, so we decided to go to the Clinic B. The appointment is so easy to get.” Determinants of services affordability and service users’ ability to ‘pay’ The interpretation of service affordability revolves around clients’ financial capacity and the resource burden on services, including time, staffing, and system inefficiencies. Operational burden from system inefficiencies Technology and procedural burdens undermine productivity. Staff discussed how the fragmented digital infrastructure and inconsistent referral processes consumed staff time and undermined productivity. We’re using different systems - eMR, fax, email, phone calls, and none of the tools talk to each other. Different teams are all using separate spreadsheets or databases. It creates confusion and things fall through the cracks. I've been given two referral or intake forms plus our internal intake forms… Even that would be so confusing. Imagine how it is like for people who are not from our organisation trying to refer in? Time and workforce as hidden costs Staff identified time pressure and workforce constraints as hidden costs affecting service quality and timeliness. Similarly, client E shared their view on service improvement: I think that maybe you could put more people, or open more hours by putting more workers… if the government or whoever is in charge can hire more people and train more people, more kids will be looked after, more parents will be happier. Free service as an enabler to care access The absence of out-of-pocket costs was essential to accessing services. Clients emphasised that free services enabled continuity. Client B said that: I am on Centrelink and it’s hard to pay for anything extra. If this wasn’t free, I couldn’t afford it. Client A compared public and private service access: We went to a private physio and it cost $ 190 for an hour. Like, what’s the difference between free and not free? It’s the same. Determinants of services appropriateness and service users’ ability to engage Service appropriateness reflected how well referrals, care pathways, and engagement processes aligned with family needs and readiness. Mismatches between referral intent, eligibility, and readiness to engage were reported by staff and clients. Referral complexity and mismatches Staff reported that families were sometimes referred despite being ineligible, such as those already accessing National Disability Insurance Scheme (NDIS) pathways, leading to delayed redirection and frustration. They also noted that external referrers did not always understand the purpose or scope of services, creating confusion for families. Families already have a diagnosis and it is clear that they’re not eligible to access our services… Sometimes we only realise 3,4 or 6 months later (due to number of clients on waitlist). External referrers don’t always understand what they’re referring for… when we ask families why they think they’re here, it often doesn’t match the referral. Staff reported referral appropriateness improved when intake officers had discipline-specific knowledge, enabling more accurate triage. Family emotional readiness and engagement Client’s ability to engage was influenced by their emotional readiness Client C described feeling overwhelmed and fearful when making initial contact, reflecting common emotional responses to uncertainty, diagnosis, perceived parental inadequacy: “I got really overwhelmed when I first called… it’s like that first phone call you’re just in survival mode or you're in fear mode…you’re just not receptive. Staff (clinicians) reported that engagement often strengthened over time as trust developed. It might not be disclosed at the first intake. It often takes time and trust. For example, if a mum’s mental health challenges aren’t mentioned early on, they might disclose it after a few appointments. Supporting ongoing participation Clients described the importance of clear communication, follow-up, and reminders in supporting ongoing engagement. Client A recalled: We can tell she’s (Physio) like very experienced, very calm, she will explain to us in detail, so she will email us back the exercises that need to be done, so I’m not stressed. In contrast, the absence of follow-up mechanisms e.g. reminder that child remains on waitlist, discouraged continued engagement. Client F commented: Once you make a phone call, you're not 100% sure what's happened. And there's no way to really check unless you call back. I don't have that much energy to call back. Discussion Drawing on a local exemplar from Sydney Local Health District, this qualitative study examined how families access to and experience of services was shaped by organisational and person level factors. We found that system complexity, inconsistent prioritisation and advocacy, duplicated workflows, hidden workforce and system costs, and mismatches between referral intent and family readiness collectively created navigation burden, delays, and missed windows for engagement. Centralised intake, free-of-charge care, and experienced staff were important enabling features, but they operated within organisational and policy constraints that limited responsiveness and timeliness. Clients’ health literacy ,0 understanding of child development, the families’ unmet social needs or social determinants of health status shaped their ability to recognise, articulate and act on the concerns, while organisational health literacy – through intake processes, communication and staff elicitation skills played a role in either mitigating or compounding these challenges. Importantly these findings illustrate how, even in universal health systems, the conditions under which services are accessed and experienced can reproduce or amplify inequities. The Levesque framework provided a useful organising lens to integrate both service providers and users’ perspectives. Mapping themes to the five dimensions of accessibility and corresponding abilities (approachability/ability to perceive; acceptability/ability to seek; availability, accommodation/ability to reach; affordability/ability to pay; appropriateness/ability to engage) enabled us to connect client level factors with service design and processes. For example, “system complexity and fragmented pathways” highlighted how limited integration, inconsistent referral information and unclear entry points compromised approachability and families’ ability to perceive that CFHS was relevant to their concerns. Service demand, workflow duplication and fragmented systems undermined availability and affordability at the system level, translating into longer waits and capacity-driven rather than needs-driven allocation. In turn, “mismatched referrals and family readiness” linked to appropriateness and ability to engage, where referral pathways did not align with service scope or where families’ readiness and competing demands limited their capacity to take up offered care. By applying Levesque’s framework, we show how “unwarranted” system variation and duplicated workflows translate into navigation confusion, longer waits, missed windows of engagement, and attrition – mechanisms that entrench inequity. Consistent with the empirical literature, the framework was useful for distinguishing between service-side characteristics and population-side abilities while still conceptualising access as a dynamic, negotiated process. However, many access determinants did not sit neatly within a single domain, with several themes cutting across multiple dimensions and abilities, an issue also identified by [ 21 ]. Common with other forms of categorisation/frameworks, we found that the process of categorising themes (putting them in boxes) draws attention away from how they are interconnected. This has relevance in terms of when deciding ‘what to do’ to address identified inequities in access. Our themes emphasised how triage processes, referral tools, digital infrastructure and scheduling practices as important and potentially modifiable levers within the Local Health District. However, these proximal factors sit within a wider structural context that was less visible in participants’ accounts, and in the Levesque-guided analysis, with limited reference to influences such as structural racism, colonisation, trust and stigma The framework orientation towards proximal access issues encourage incremental adjustment to systems rather than reflection on structural and systemic causes. Focusing these proximal factors was, however, aligned with what CFHS could reasonably influence. Our findings align with national and international evidence that CALD and high-need families face more challenges in accessing preventive child health services [ 22 – 24 ]. This study extends that evidence by identifying specific operational mechanisms including fragmented referral pathways, duplicated triage process, and advocacy-driven prioritisation, that shaped inequitable access within a universal CFHS context. The emphasis on intake workload and skill (eliciting vague concerns across multiple models of care, > 120 calls/day) adds practical insight into how access barriers manifest at the first contact point. Although this study was not designed to focus specifically on CALD or high-need families, the navigation difficulties and service fragmentation identified here reflect patterns observed in Australian studies involving CALD communities [ 22 ]. Within this context, practices such as capacity-driven allocation and late redirection to external schemes (e.g., NDIS/Early Childhood Approach) risked delaying support beyond families’ windows of readiness [ 25 ]. In line with similar studies, equity-focused strategies include standardised, need-based triage [ 26 ], streamlining referrals through single-front-door models [ 27 – 28 ], and protecting flexible or after-hours capacity for working carers [ 29 ]. Strengths of this study include the integration of dual perspectives from staff and clients, and the use of an explicit Levesque-guided, hybrid (deductive–inductive) analytical approach that traced mechanisms from participant quotes to system processes. The study limitations include convenience sampling within a single Local Health District, and potential selection of more engaged clients. The qualitative design cannot quantify effect sizes or causal impacts; however, consistency of themes across participant groups and sites strengthens the credibility and transferability of the findings. Policy and practice implications (building on current CFHS work) To close equity gaps, CFHS will leverage two core enablers already in place: (i) Model of Care (MoC): applies standardised, equity-weighted triage using social risks criteria, clarifies roles, and streamlines workflow so families get the right care at first contact. (ii) Online referral and service-enquiry form: strengthens the single front door by improving approachability, reducing navigation burden, and enabling consistent data capture. Our findings point to several opportunities to strengthen system navigation, consistency, and equity across Child and Family Health Services. First, families and referrers often experience difficulty in identifying the right entry point due to the need for clearer referral pathways, consistent messaging, and a more visible centralised intake. Second, variation in prioritisation practices and duplicated triage processes contributed to inefficiencies and extended wait times, indicating the importance of shared criteria and streamlined workflows. Third, consolidating digital tools into a single, integrated referral front door would minimise administrative burden and errors, supporting timeliness and continuity. Aligning clinic hours and locations with carer availability, while maintaining no-cost access would enhance reach for working parents and families with limited flexibility. Finally, improving access requires both supporting families’ ability to navigate care and reducing system complexity. Complementary steps include reducing duplicated triage and case discussions (through clear criteria and decision making) and offering more flexible appointment times to improve timeliness. These measures directly addressed the fragmentation, administrative duplication, and missed engagement windows identified in this study. Future research Future studies could consider redesigned intake pathways from triage to discharge using mixed methods to assess equity impacts across CALD and psychosocial-risk groups. Routine analytics from unified referral tools could track time from referral to allocation, the numbers of clients who fail to attend their appointment and completed appointments. This can inform continuous improvement. Future research could build on our findings by combining Levesque’s framework with explicitly structural or critical theories of health equity to consider service level access barriers within the broader conditions that produce them. Conclusion Changing health and economic circumstances demands require more efficient and flexible ways of delivering care. In a universal CFHS system, how services are organised determines who gets timely care. We identified improvement opportunities including enhancing pathway clarity, standardising prioritisation, better aligning allocation with capacity, and streamlining referral tools that collectively could bolster families’ ability to perceive, seek, reach, and engage with care. By eliminating unwarranted variation and administrative duplication at the point of entry, and by tailoring navigation and capacity to families with the least flexible resources, Local Health Districts can convert “universal availability” into one of proportionate universalism enabling equitable, timely access. Declarations Ethics approval and consent to participate All study procedures were performed according to the guidelines of ethics approval for study. Ethics Review Committee of Sydney Local Health District (Protocol No. X23-0273). Site Specific Assessment was obtained from Royal Prince Alfred Hospital (2023/STE02667). Informed consent was obtained from all participants included in the study. Consent was provided prior to participation. Consent for publication All participants provided informed consent for their anonymised data, including direct quotes, to be used for publication purposes. Funding The study was self-funded by Community Health Services, Sydney Local Health District and did not receive any financial support from any source. Author Contribution LB and NR developed the study design, and participated in data collection. LB developed the protocol and data collection tools. LB, NR and RW undertook the data analysis. LB conceived the article, interpretation of data analysis, and was responsible for the final draft. SW, FH participated in the interpretation of the results. SW, FH, NR, JO, RW, DJ, participated in critical review of the article. All authors have approved the manuscript in its present form. Acknowledgement This study stems from a clinical redesign course delivered by New South Wales Agency for Clinical Innovation (ACI) and the University of Tasmania. The authors would like to sincerely thanks the ACI course facilitators, Sydney Local Health District (SLHD) Redesign leads at the time, Barbye Castillo, and Dimitra Kaldelis for their guidance. We are also grateful for the leadership and endorsement from the executive of Clinical Services Integration and Population Health, Community Health Services, SLHD. We would also like to sincerely thank all the participants who generously shared their time, experiences and perspectives with us. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to confidentiality and privacy considerations. Competing interests The authors declare no competing interests. References NSW Health. First 2000 days framework. Sydney: NSW Ministry of Health. 2019. https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2019_008.pdf . Accessed 21 October 2024. Clark H, Coll-Seck AM, Banerjee A, Peterson S, Dalglish SL, Ameratunga S, et al. A future for the world’s children? Lancet. 2020;395(10224):605–58. Australian Government Department of Health and Ageing. National framework for universal child and family health services. Canberra: Commonwealth of Australia. 2011. https://www.health.gov.au/resources/publications/national-framework-for-universal-child-and-family-health-services?language=en . Accessed 10 November 2025. NSW Maternal and Child Health. Maternal & Child Health Primary Health Care Policy. Sydney: NSW Ministry of Health; 2021. Schmied V, Homer C, Kemp L, Thomas C, Fowler C, Kruske S. The role and nature of universal health services for pregnant women, children and families in Australia. Aust Health Rev. 2015;39(5):514–9. World Health Organization. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: WHO; 2008. Woolfenden S, Eapen V, Williams K, Hayen A, Spencer N, Kemp L, et al. A systematic review of the prevalence of parental concerns measured by the Parents’ Evaluation of Developmental Status indicating developmental risk. BMC Pediatr. 2016;16:68. Halfon N, Larson K, Russ S. Why social determinants? Healthc. 2014;2(1):8–14. Goldfeld S, O’Connor M, Mithen J, Sayers M, Brinkman S. Early development of emerging and English-proficient bilingual children at school entry in an Australian population cohort. Int J Behav Dev. 2018;42(4):1–10. Woolfenden S, Posada N, Krchnakova R, Crawford J, Gilbert J, Jursik B, et al. Equitable access to developmental surveillance and early intervention—understanding the barriers for children from culturally and linguistically diverse backgrounds. Health Expect. 2014;18(6):3286–301. 10.1111/hex.12318 . Woolfenden S, Eapen V, Jalaludin B, Hayen A, Kemp L, Dissanyake C, et al. Prevalence and factors associated with parental concerns about development detected by the Parents’ Evaluation of Developmental Status at 6-, 12-, and 18-month well-child checks in a birth cohort. BMJ Open. 2015;6:e012144. 10.1136/bmjopen-2016-012144 . Sutherland K, Levesque JF. Unwarranted clinical variation in health care: definitions and proposal of an analytic framework. J Eval Clin Pract. 2020;26(3):687–96. Duggan A, Koff E, Sutherland K. What can policymakers do to improve care and reduce unwarranted variation? Aust Health Rev. 2016;40(3):318–22. Kuhlthau K, Bloom S, Van Cleave J, Knapp AA, Romm D, Klatka K, et al. Evidence for Family-Centered Care for Children With Special Health Care Needs: A Systematic Review. Acad Pediatr. 2011;11(2):136–43. Davy C, Bleasel J, Liu H, Tchan M, Ponniah S, Brown A. Factors influencing the implementation of chronic care models: a systematic literature review. BMC Fam Pract. 2016;16(1):102. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research: a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. Levesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12:18. Vanderbilt University. Version 15.0.37. Sydney Local Health District; 2025. REDCap (Research Electronic Data Capture) [computer software]. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. Swain J. A hybrid approach to thematic analysis in qualitative research: Using a practical example. SAGE Research Methods Cases. London: SAGE; 2018. Cu A, Meister S, Lefebvre B, Ridde V. Assessing healthcare access using the Levesque conceptual framework: a scoping review. Int J Equity Health. 2021;20:116. 10.1186/s12939-021-01416-3 . Khatri RB, Assefa Y. Access to health services among culturally and linguistically diverse populations in Australia: a literature review. BMC Public Health. 2022;22:1598. Coughlan CH, Ruzangi J, Neale FK, Maldonado BN, Blair M, Bottle A, et al. Social and ethnic group differences in healthcare use by children aged 0–14 years in England, 2007–2017. BMJ Open. 2021;11(9):e045154. Abdus S, Selden TM. Racial and ethnic disparities in attendance to well-child visits before, during, and after the COVID-19 pandemic. JAMA Netw Open. 2024;7(4):e241234. Gavidia-Payne S, Ruth R, Kerry B, Forster J. The changing narrative of early childhood intervention in Australia under the National Disability Insurance Scheme. Child Youth Serv Rev. 2024;152:107254. Bezem J, Kocken PL, Kamphuis M, Theunissen MHC, Buitendijk SE, Numans ME. Triage in preventive child healthcare: a prospective cohort study. Eur J Public Health. 2017;27(3):494–500. Rocks S, Glogowska M, Stepney M, Tsiachristas A, Fazel M. Introducing a single point of access to child and adolescent mental health services in England: a mixed-methods observational study. BMC Health Serv Res. 2020;20:623. Ganga RN, Santa K, Ali M, Smith G. The impact of a digital referral platform (CYP as One) to improve access to CAMHS. Int J Environ Res Public Health. 2024;21(10):1318. O’Malley AS, Samuel D, Bond AM, Carrier E. After-hours access to primary care and emergency department use. Health Aff. 2013;32(1):175–83. Additional Declarations No competing interests reported. Supplementary Files AdditionalFile1COREQchecklist.docx AdditionalFile2Fulllistofcodesandsubthemes.docx AdditionalFile3FocusGroupGuide.docx AdditionalFile4InterviewGuide.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 07 Apr, 2026 Reviewers invited by journal 02 Apr, 2026 Editor assigned by journal 30 Mar, 2026 Submission checks completed at journal 30 Mar, 2026 First submitted to journal 25 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9217963","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":618910847,"identity":"f6c99e6a-dc68-4fa3-b270-d8da012d52a0","order_by":0,"name":"Limin Buchanan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABJUlEQVRIiWNgGAWjYBACPmYGhgNgJAHm2yQwMDA3MOPTwoamJQ2ohbGxGa8WCAXXcpgILezciYcLGO4k9s9ufvbg547zefzsB9sfA0XsDQ6wX3zMw2CX2IDuMN4Nh2cwPEucceeYuWHvmdvFkj2Jjc0gkQ0HeIqNeRiSsWrhYTicuEEiwUyCt+02UCVQC1AkwewAT5rkDAZmPFrSv0n+bTuXuP/8Q7AWe6iWejxacsykedsOABkQWxi3HWA/JvEBKIVVi8Ez4xk3csqkZduSE2fceNg4m8fgcOL+wzzMBh8MjhujaeHnP7v5M0/FHdn+GenbJN+22SX29ycfAIoctpdsb3/4IKGiWhZNCwQYYBVh5jHAJoUXsD8gTf0oGAWjYBQMUwAAuWh4Vfn4Sz4AAAAASUVORK5CYII=","orcid":"","institution":"Sydney Local Health District","correspondingAuthor":true,"prefix":"","firstName":"Limin","middleName":"","lastName":"Buchanan","suffix":""},{"id":618910849,"identity":"29229eb8-b6df-42ff-8af0-c5e0b8971aac","order_by":1,"name":"Naome Reid","email":"","orcid":"","institution":"Sydney Local Health District","correspondingAuthor":false,"prefix":"","firstName":"Naome","middleName":"","lastName":"Reid","suffix":""},{"id":618910851,"identity":"335cb943-dd6a-42e7-a169-d88c85d16961","order_by":2,"name":"Janice Oliver","email":"","orcid":"","institution":"Sydney Local Health District","correspondingAuthor":false,"prefix":"","firstName":"Janice","middleName":"","lastName":"Oliver","suffix":""},{"id":618910854,"identity":"41baf70f-ce05-445f-923f-231211559013","order_by":3,"name":"Rachel Walker","email":"","orcid":"","institution":"Sydney Local Health District","correspondingAuthor":false,"prefix":"","firstName":"Rachel","middleName":"","lastName":"Walker","suffix":""},{"id":618910855,"identity":"fe267935-48c3-4ed9-8957-eb8e6c0455cf","order_by":4,"name":"Dianna Jagers","email":"","orcid":"","institution":"Sydney Local Health District","correspondingAuthor":false,"prefix":"","firstName":"Dianna","middleName":"","lastName":"Jagers","suffix":""},{"id":618910856,"identity":"0f5dcb93-7dd0-43da-8aeb-3311a3795f4f","order_by":5,"name":"Fiona Haigh","email":"","orcid":"","institution":"Sydney Local Health District","correspondingAuthor":false,"prefix":"","firstName":"Fiona","middleName":"","lastName":"Haigh","suffix":""},{"id":618910858,"identity":"c8450e97-1fbe-4e73-8666-2d5056d39e26","order_by":6,"name":"Sue Woolfenden","email":"","orcid":"","institution":"The University of Sydney","correspondingAuthor":false,"prefix":"","firstName":"Sue","middleName":"","lastName":"Woolfenden","suffix":""}],"badges":[],"createdAt":"2026-03-25 04:23:41","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9217963/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9217963/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106532916,"identity":"5e3c8995-a4f1-40ea-bc1e-3b60c2a93ea3","added_by":"auto","created_at":"2026-04-09 14:56:01","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":695047,"visible":true,"origin":"","legend":"\u003cp\u003eMapping of study themes (in grey boxes) against Levesque’s Framework for Healthcare Access\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9217963/v1/cfbb78467ae09efe65000f63.jpg"},{"id":106724696,"identity":"2e262a23-206b-4a6d-9a21-646a162931af","added_by":"auto","created_at":"2026-04-12 18:29:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1822187,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9217963/v1/41bb3c42-96bf-448d-aeb2-e9b7bfccc2c1.pdf"},{"id":106532795,"identity":"ab129e40-904f-4bb6-ac65-b7aaa56db0eb","added_by":"auto","created_at":"2026-04-09 14:55:30","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":36450,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile1COREQchecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-9217963/v1/a0ad014f0a595b1bf60baf20.docx"},{"id":106532897,"identity":"6f69ba18-16f7-4a6f-8a52-c734997289fe","added_by":"auto","created_at":"2026-04-09 14:55:50","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":31653,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile2Fulllistofcodesandsubthemes.docx","url":"https://assets-eu.researchsquare.com/files/rs-9217963/v1/2de71dbbe8599f2870d76f6b.docx"},{"id":106532927,"identity":"f103550b-b8a9-4b85-ae28-15de7528afac","added_by":"auto","created_at":"2026-04-09 14:56:04","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":30128,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile3FocusGroupGuide.docx","url":"https://assets-eu.researchsquare.com/files/rs-9217963/v1/1f4766dbd63e0b8df3323960.docx"},{"id":106532908,"identity":"2fa90a56-be6a-4021-b227-f0abc3a0977d","added_by":"auto","created_at":"2026-04-09 14:55:59","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":30449,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile4InterviewGuide.docx","url":"https://assets-eu.researchsquare.com/files/rs-9217963/v1/cd37afde813abf2cb2303d30.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Levesque-Guided Qualitative Study to Understand Equity in Child and Family Health Services: Insights from an Australian Health District","fulltext":[{"header":"Background","content":"\u003cp\u003eThe early years of a child\u0026rsquo;s life are widely recognised as a critical period that shapes lifelong health and wellbeing [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Providing children with access to a universal platform of early health and developmental services supports equitable opportunities for optimal development [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In Australia, this platform is delivered through Child and Family Health Services (CFHS), publicly funded primary health care services providing universal childhood health surveillance, parenting support, and referral pathways to specialist services [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCFHS play a vital role in supporting children and families from birth, offering health and development checks, immunisations, psychosocial support, and community-based medical and allied health care [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Timely access during the first 2000 days is critical, as early intervention can strongly influence life-long health, education, and wellbeing [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Yet, access remains inconsistent across jurisdictions, and many families do not engage with services [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNational and international evidence highlights persistent challenges for families with complex developmental and psychosocial needs. Barriers include fragmented service pathways, variable eligibility, and long wait times [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These issues are magnified for culturally and linguistically diverse (CALD) families, and those experiencing disadvantage, who face additional barriers such as language, stigma, financial hardship, and systemic discrimination [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Studies in Australia and overseas further demonstrate that children from minority backgrounds or with high psychosocial needs are less likely to access preventive programs and more likely to experience delays in assessment and support [\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt a systems level, variation in models of care and referral pathways contributes to inequities. While some variation reflects responsiveness to family needs, \u0026lsquo;unwarranted\u0026rsquo; clinical variation\u0026mdash; differences not explained by need or preference\u0026mdash; remains a significant barrier to equitable access [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Families requiring multidisciplinary input are particularly vulnerable, often experiencing disjointed care, duplication of assessments, or extended waits [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Addressing these systemic inconsistencies is essential to reduce inequities and ensure services deliver client-centred timely, integrated care.\u003c/p\u003e \u003cp\u003eTherefore, we conducted this study to systematically identify barriers to accessing Child and Family Health Services. By applying an equity lens, the study aimed to inform service redesign, reduce unwarranted variation, and strengthen timely and equitable access.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study adopted qualitative approach. Focus groups and semi-structured interviews were used to obtain study data. This study is reported following the Consolidated Criteria for Reporting Qualitative Research (COREC) guidelines [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] (see Additional File 1 for COREQ Checklist).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTheoretical framework\u003c/h3\u003e\n\u003cp\u003eLevesque\u0026rsquo;s conceptual framework for healthcare access [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] underpins this study. This framework highlights that access is shaped not only by the characteristics of health services, but also the abilities of individuals and communities to engage. This framework outlines five inter-related dimensions of \u003cem\u003eaccessibility: approachability, acceptability, availability and accommodation, affordability, and appropriateness\u003c/em\u003e, which align with corresponding client abilities \u003cem\u003eto perceive, seek, reach, pay, and engage\u003c/em\u003e. Together, these dimensions provide a comprehensive lens for examining how health systems and populations interact to enable or hinder access.\u003c/p\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003eThe study received ethical approval from the Ethics Review Committee of Sydney Local Health District (Protocol No. X23-0273 \u0026amp; 2023/STE02667).\u003c/p\u003e\n\u003ch3\u003eParticipant recruitment\u003c/h3\u003e\n\u003cp\u003eThe study was conducted within Community Health Services, Sydney Local Health District, using convenience sampling to identify participants with relevant experience and knowledge of the study scope. A total of 48 participants were included: 42 service providers (including clinicians, intake officers, and managers), and six service users (parents/carers of child who had accessed Child and Family Health Services in the past 12 months) (See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003ea and b for participant profiles).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ea: Profile of service providers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisciplines/Services\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of participants\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild and Family Health Nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinicians (Early Childhood Social Work)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinicians (Counselling- Psychology and Social Work)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinicians (Physiotherapy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinicians (Occupational Therapy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinicians (Speech Pathology)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity Paediatrics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntake officers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStaff from service support and leadership roles, such as Child and Family Health executive, Aboriginal Health, Multicultural Health, Performance and Data Analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e42\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eb: Profile of interviewed clients (parents/carers) and services accessed by their children\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClient ID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParent Age (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of services accessed by child\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eServices accessed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAge of child/ren (years)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhysiotherapy; Early Childhood Social Work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOccupational Therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2, 4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOccupational Therapy; Social Work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3, 5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOccupational Therapy; Social Work; Psychology; Speech Pathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEarly Childhood Social Work;\u003c/p\u003e \u003cp\u003eSpeech Pathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSocial Work, Psychology, Occupational Therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eService providers represented a range of Child and Family Allied Health disciplines, Child and Family Health Nursing, Community Paediatrics, as well as staff in leadership roles. Researchers (LB, NR) circulated an expression of interest email to relevant staff and key stakeholders. Interested service providers were provided with a Participant Information Sheet.\u003c/p\u003e \u003cp\u003eService users were existing clients of Child and Family Health Services. Between September and October 2023, clinicians informed eligible clients about the study and directed those interested to an online REDCap registration form [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], which included the Participant Information Sheet.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData collection was conducted at Child and Family Health Centres in Sydney Local Health District, between August and October 2023. Four face-to-face focus groups were held with service providers, and six semi-structured interviews were undertaken with service users via Microsoft Teams, phone or in-person, according to participants\u0026rsquo; preferences. Written consent (service providers) and verbal consent (service users) were obtained prior to each session. Focus group and interview guides (See Additional Files 3 and 4 for guides) were used to facilitate discussion, with questions informed by the key components of the Levesque\u0026rsquo;s framework [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. All sessions were audio-recorded, with focus group lasting approximately 90 minutes and the interview lasting around 30 minutes. Field notes were taken during and after each session. Recruitment and data collection continued until data saturation was reached, when no new information emerged. No repeat interviews were conducted.\u003c/p\u003e \u003cp\u003eData collection was undertaken by two female project leads LB, and NR. LB holds a Doctorate in Public Health and has extensive experience in health services evaluation and quality improvement. Prior to data collection, LB reviewed resources on Levesque\u0026rsquo;s framework and led the development of the focus group and interview guides. NR has a background in Social Work, a Master of Social Work in Advanced Clinical Practice, and experience as a Service Manager. Neither LB nor NR were involved in service delivery to participants, and their combined research, clinical and managerial experience provided complementary perspectives and ensured that data collection was both systematic and contextually grounded.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData transcription was conducted manually using Microsoft Word. Participants were given the option to review their interview transcripts for comment or correction. However, none chose to do so. Thematic analysis was undertaken following Braun and Clarke\u0026rsquo;s six-phase approach [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], using a hybrid strategy that combined deductive and inductive coding [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The Levesque Conceptual Framework of Access to Health Care [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] provided an initial deductive structure, with its 10 constructs guiding early coding and categorisation. Concurrently, the analysis remained open to new patterns and concepts emerging directly from participants\u0026rsquo; narratives, allowing additional themes and sub-themes to be developed inductively. (See Additional file 2 for complete list of codes, sub-themes and themes).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCoding process\u003c/h3\u003e\n\u003cp\u003eAll interview and focus group transcripts were manually coded in Microsoft Word. After familiarisation with the data, the primary researcher (LB) applied comments to relevant text segments, labelling them with descriptive codes. These codes were refined iteratively as new insights emerged, and earlier transcripts were revisited to ensure consistency. NR and RW reviewed a subset of coded transcripts to support reliability. Codes were then grouped into broader categories, forming the basis for theme development. The process was reflexive and iterative, balancing theoretical guidance with participants\u0026rsquo; voices.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eOur study results were categorised using Levesque Framework\u0026rsquo;s five dimensions of healthcare access. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the key themes against these dimensions from both service provider and user perspectives. Key aspects from staff and client perspectives were reported collectively and presented below. See Additional File 2 for the full list of codes and sub-themes.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDeterminants of services approachability and service users\u0026rsquo; ability to perceive\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eApproachability - System complexity and fragmented pathways\u003c/h2\u003e \u003cp\u003eOn the service side, clients\u0026rsquo; ability to identify and approach appropriate support was often constrained not by motivation, but by the fragmented and opaque nature of the service system. Limited integration and inconsistent information pathways meant that even proactive parents found it difficult to navigate and uncertain if they have reached the right service.\u003c/p\u003e \u003cp\u003eClient E described needing support to find out about available services:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI had to ask around. No one told me about these services at first. Only when I spoke to the caseworker at the Refuge she told me to ask for speech therapy and dental check.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn another example, Client F reported her GP was unaware of the services. She expressed uncertainty about whether she had reached the right service when calling intake:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI had to Google because when I raised my son\u0026rsquo;s concerns with my GP, it seems like my GP is not aware of any kind of support or didn't point me in the right direction.\u003c/p\u003e\u003cp\u003eI\u0026rsquo;m not sure if this is the right number to be calling and, yeah, I was just really confused what to ask for.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAbility to perceive- Navigating unclear referrals, clients\u0026rsquo; health literacy and understanding of child development\u003c/h2\u003e \u003cp\u003eFor service users, varying levels of health literacy and understanding of child development influenced how well clients could understand and articulate concerns. Staff noted that unclear referrals often reflected this variability where parents recognised something was wrong but were unsure how to describe it. Intake officer\u0026rsquo;s elicitation skills played a critical role in interpreting vague concerns and guiding clients toward appropriate services.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eBut they (clients) sometimes are not actually able to articulate clearly about what concerns they have, this poses challenges on how the intake officer manages to make referral if the person they talk to isn\u0026rsquo;t clear about what they need.\u003c/p\u003e\u003cp\u003eIt really speaks to the skill and capability of our intake officers\u0026hellip; facilitating the conversation to try and see what is concerning them about their child's development.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eClients\u0026rsquo; capacity to understand and articulate concerns was in turn influenced by both the appropriateness of services and service availability. In terms of service appropriateness, having highly skilled staff at the centralised intake service was seen as a crucial bridge in supporting families to interpret concerns, clarify service options, and connect to the right care. In regards to service availability - Staff observed that high intake volumes intensified the challenges of an already complex system.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSo they (intake officers) are needing to manage the 10 models of care they might need to know about while they're on the phone with the parent, the phone tags, the demand of incoming calls from internal, external referrers and clients. More than 120 calls on some days.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eDeterminants of services acceptability and service users\u0026rsquo; ability to seek\u003c/h2\u003e \u003cp\u003eService acceptability was shaped by staff\u0026rsquo;s professional values, experience, interpretation of service criteria, and how well services aligned with families\u0026rsquo; personal, cultural or social values, particularly in relation to trust, communication, and system navigation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePerception of inconsistent prioritisation and variability in advocacy\u003c/h2\u003e \u003cp\u003eStaff Noted that prioritisation practices varied across sites and were sometimes influenced by individual advocacy or experience. This affected both acceptability and availability of services.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAnd I would say it (prioritisation) is not consistent. Some of our more senior staff who have been here are good in advocating. On the other hand, our junior staff like new graduates would think: well, it is just it is \u0026hellip;.\u003c/p\u003e\u003cp\u003eAcross different sites, the way clients get picked up can be a bit different. Some sites seem to pick up clients faster depending on how they work or interpret prioritisation criteria.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eClient cultural acceptability of health services\u003c/h2\u003e \u003cp\u003eFrom the client perspective, their ability to seek service was shaped by cultural familiarity, health literacy, and trust. Language barriers and uncertainty about whether they were contacting the correct service affected their confidence to seek help.\u003c/p\u003e \u003cp\u003eClient A described language as a barrier:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eBecause English is not my first language, sometimes I\u0026rsquo;m not sure how to explain what\u0026rsquo;s going on with my son.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eClient C shared uncertainty around navigating services:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePeople that are not as well educated or have that background knowledge might not know that they're calling the right people.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eStaff confirmed that some families do not follow through with referrals and this might have been due to cultural or emotional barriers.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSome families never make the call, even if they\u0026rsquo;ve been referred. It might be cultural or just overwhelmed by the process.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eDeterminants of services availability and service users\u0026rsquo; ability to reach\u003c/h2\u003e \u003cp\u003eThis theme explores logistic and structural factors influencing service access, including demand, scheduling, and geographic access.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eService demand and workflow duplication\u003c/h2\u003e \u003cp\u003eHigh demand and inefficient internal processes strained service availability. Staff described repeated triaging and referral steps that added administrative burden and contributed to delayed care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eCHIL (intake team) is prioritising, then you (clinical team) re-prioritise again in another meeting. It\u0026rsquo;s like double meetings.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn a context of long wait lists, allocation was sometimes driven by staff capacity rather than client need:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eInstead of being guided by what meets the client\u0026rsquo;s needs, like the right therapy at the right time. We\u0026rsquo;re prioritising based on which site has the shortest wait time.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eScheduling challenges and geographic accessibility\u003c/h2\u003e \u003cp\u003eCentralised intake staff noted the logistical challenges of coordinating interpreters and appointments across sites, while flexibility to accept clients from nearby centres helped manage demand. Families, however, described difficulty fitting appointments around work commitments and variable access across locations:\u003c/p\u003e \u003cp\u003eClient D shared:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It's logistically hard because the last appointment is at 4pm..he (child\u0026rsquo;s father) is essentially gonna leave work at 3pm, which is really quite early. \u0026ldquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eClient E commented: \u003cem\u003e\"It depends on which location. Clinic A is very busy, so we decided to go to the Clinic B. The appointment is so easy to get.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eDeterminants of services affordability and service users\u0026rsquo; ability to \u0026lsquo;pay\u0026rsquo;\u003c/h2\u003e \u003cp\u003eThe interpretation of service affordability revolves around clients\u0026rsquo; financial capacity and the resource burden on services, including time, staffing, and system inefficiencies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eOperational burden from system inefficiencies\u003c/h2\u003e \u003cp\u003eTechnology and procedural burdens undermine productivity. Staff discussed how the fragmented digital infrastructure and inconsistent referral processes consumed staff time and undermined productivity.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe\u0026rsquo;re using different systems - eMR, fax, email, phone calls, and none of the tools talk to each other. Different teams are all using separate spreadsheets or databases. It creates confusion and things fall through the cracks.\u003c/p\u003e\u003cp\u003eI've been given two referral or intake forms plus our internal intake forms\u0026hellip; Even that would be so confusing. Imagine how it is like for people who are not from our organisation trying to refer in?\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eTime and workforce as hidden costs\u003c/h2\u003e \u003cp\u003eStaff identified time pressure and workforce constraints as hidden costs affecting service quality and timeliness. Similarly, client E shared their view on service improvement:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI think that maybe you could put more people, or open more hours by putting more workers\u0026hellip; if the government or whoever is in charge can hire more people and train more people, more kids will be looked after, more parents will be happier.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eFree service as an enabler to care access\u003c/h2\u003e \u003cp\u003eThe absence of out-of-pocket costs was essential to accessing services. Clients emphasised that free services enabled continuity.\u003c/p\u003e \u003cp\u003eClient B said that:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI am on Centrelink and it\u0026rsquo;s hard to pay for anything extra. If this wasn\u0026rsquo;t free, I couldn\u0026rsquo;t afford it.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eClient A compared public and private service access:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe went to a private physio and it cost \u003cspan\u003e$\u003c/span\u003e190 for an hour. Like, what\u0026rsquo;s the difference between free and not free? It\u0026rsquo;s the same.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eDeterminants of services appropriateness and service users\u0026rsquo; ability to engage\u003c/h2\u003e \u003cp\u003eService appropriateness reflected how well referrals, care pathways, and engagement processes aligned with family needs and readiness. Mismatches between referral intent, eligibility, and readiness to engage were reported by staff and clients.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eReferral complexity and mismatches\u003c/h2\u003e \u003cp\u003eStaff reported that families were sometimes referred despite being ineligible, such as those already accessing National Disability Insurance Scheme (NDIS) pathways, leading to delayed redirection and frustration. They also noted that external referrers did not always understand the purpose or scope of services, creating confusion for families.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFamilies already have a diagnosis and it is clear that they\u0026rsquo;re not eligible to access our services\u0026hellip; Sometimes we only realise 3,4 or 6 months later (due to number of clients on waitlist).\u003c/p\u003e\u003cp\u003eExternal referrers don\u0026rsquo;t always understand what they\u0026rsquo;re referring for\u0026hellip; when we ask families why they think they\u0026rsquo;re here, it often doesn\u0026rsquo;t match the referral.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eStaff reported referral appropriateness improved when intake officers had discipline-specific knowledge, enabling more accurate triage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eFamily emotional readiness and engagement\u003c/h2\u003e \u003cp\u003eClient\u0026rsquo;s ability to engage was influenced by their emotional readiness Client C described feeling overwhelmed and fearful when making initial contact, reflecting common emotional responses to uncertainty, diagnosis, perceived parental inadequacy:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I got really overwhelmed when I first called\u0026hellip; it\u0026rsquo;s like that first phone call you\u0026rsquo;re just in survival mode or you're in fear mode\u0026hellip;you\u0026rsquo;re just not receptive.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eStaff (clinicians) reported that engagement often strengthened over time as trust developed.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt might not be disclosed at the first intake. It often takes time and trust. For example, if a mum\u0026rsquo;s mental health challenges aren\u0026rsquo;t mentioned early on, they might disclose it after a few appointments.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eSupporting ongoing participation\u003c/h2\u003e \u003cp\u003eClients described the importance of clear communication, follow-up, and reminders in supporting ongoing engagement. Client A recalled:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe can tell she\u0026rsquo;s (Physio) like very experienced, very calm, she will explain to us in detail, so she will email us back the exercises that need to be done, so I\u0026rsquo;m not stressed.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn contrast, the absence of follow-up mechanisms e.g. reminder that child remains on waitlist, discouraged continued engagement. Client F commented:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eOnce you make a phone call, you're not 100% sure what's happened. And there's no way to really check unless you call back. I don't have that much energy to call back.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eDrawing on a local exemplar from Sydney Local Health District, this qualitative study examined how families access to and experience of services was shaped by organisational and person level factors. We found that system complexity, inconsistent prioritisation and advocacy, duplicated workflows, hidden workforce and system costs, and mismatches between referral intent and family readiness collectively created navigation burden, delays, and missed windows for engagement. Centralised intake, free-of-charge care, and experienced staff were important enabling features, but they operated within organisational and policy constraints that limited responsiveness and timeliness. Clients\u0026rsquo; health literacy ,0 understanding of child development, the families\u0026rsquo; unmet social needs or social determinants of health status shaped their ability to recognise, articulate and act on the concerns, while organisational health literacy \u0026ndash; through intake processes, communication and staff elicitation skills played a role in either mitigating or compounding these challenges. Importantly these findings illustrate how, even in universal health systems, the conditions under which services are accessed and experienced can reproduce or amplify inequities.\u003c/p\u003e \u003cp\u003eThe Levesque framework provided a useful organising lens to integrate both service providers and users\u0026rsquo; perspectives. Mapping themes to the five dimensions of accessibility and corresponding abilities (approachability/ability to perceive; acceptability/ability to seek; availability, accommodation/ability to reach; affordability/ability to pay; appropriateness/ability to engage) enabled us to connect client level factors with service design and processes. For example, \u0026ldquo;system complexity and fragmented pathways\u0026rdquo; highlighted how limited integration, inconsistent referral information and unclear entry points compromised approachability and families\u0026rsquo; ability to perceive that CFHS was relevant to their concerns. Service demand, workflow duplication and fragmented systems undermined availability and affordability at the system level, translating into longer waits and capacity-driven rather than needs-driven allocation. In turn, \u0026ldquo;mismatched referrals and family readiness\u0026rdquo; linked to appropriateness and ability to engage, where referral pathways did not align with service scope or where families\u0026rsquo; readiness and competing demands limited their capacity to take up offered care.\u003c/p\u003e \u003cp\u003eBy applying Levesque\u0026rsquo;s framework, we show how \u0026ldquo;unwarranted\u0026rdquo; system variation and duplicated workflows translate into navigation confusion, longer waits, missed windows of engagement, and attrition \u0026ndash; mechanisms that entrench inequity. Consistent with the empirical literature, the framework was useful for distinguishing between service-side characteristics and population-side abilities while still conceptualising access as a dynamic, negotiated process. However, many access determinants did not sit neatly within a single domain, with several themes cutting across multiple dimensions and abilities, an issue also identified by [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCommon with other forms of categorisation/frameworks, we found that the process of categorising themes (putting them in boxes) draws attention away from how they are interconnected. This has relevance in terms of when deciding \u0026lsquo;what to do\u0026rsquo; to address identified inequities in access.\u003c/p\u003e \u003cp\u003eOur themes emphasised how triage processes, referral tools, digital infrastructure and scheduling practices as important and potentially modifiable levers within the Local Health District. However, these proximal factors sit within a wider structural context that was less visible in participants\u0026rsquo; accounts, and in the Levesque-guided analysis, with limited reference to influences such as structural racism, colonisation, trust and stigma The framework orientation towards proximal access issues encourage incremental adjustment to systems rather than reflection on structural and systemic causes. Focusing these proximal factors was, however, aligned with what CFHS could reasonably influence.\u003c/p\u003e \u003cp\u003eOur findings align with national and international evidence that CALD and high-need families face more challenges in accessing preventive child health services [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This study extends that evidence by identifying specific operational mechanisms including fragmented referral pathways, duplicated triage process, and advocacy-driven prioritisation, that shaped inequitable access within a universal CFHS context. The emphasis on intake workload and skill (eliciting vague concerns across multiple models of care, \u0026gt;\u0026thinsp;120 calls/day) adds practical insight into how access barriers manifest at the first contact point.\u003c/p\u003e \u003cp\u003eAlthough this study was not designed to focus specifically on CALD or high-need families, the navigation difficulties and service fragmentation identified here reflect patterns observed in Australian studies involving CALD communities [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Within this context, practices such as capacity-driven allocation and late redirection to external schemes (e.g., NDIS/Early Childhood Approach) risked delaying support beyond families\u0026rsquo; windows of readiness [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In line with similar studies, equity-focused strategies include standardised, need-based triage [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], streamlining referrals through single-front-door models [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], and protecting flexible or after-hours capacity for working carers [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStrengths of this study include the integration of dual perspectives from staff and clients, and the use of an explicit Levesque-guided, hybrid (deductive\u0026ndash;inductive) analytical approach that traced mechanisms from participant quotes to system processes. The study limitations include convenience sampling within a single Local Health District, and potential selection of more engaged clients. The qualitative design cannot quantify effect sizes or causal impacts; however, consistency of themes across participant groups and sites strengthens the credibility and transferability of the findings.\u003c/p\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003ePolicy and practice implications (building on current CFHS work)\u003c/h2\u003e \u003cp\u003eTo close equity gaps, CFHS will leverage two core enablers already in place: (i) Model of Care (MoC): applies standardised, equity-weighted triage using social risks criteria, clarifies roles, and streamlines workflow so families get the right care at first contact. (ii) Online referral and service-enquiry form: strengthens the single front door by improving approachability, reducing navigation burden, and enabling consistent data capture.\u003c/p\u003e \u003cp\u003eOur findings point to several opportunities to strengthen system navigation, consistency, and equity across Child and Family Health Services. First, families and referrers often experience difficulty in identifying the right entry point due to the need for clearer referral pathways, consistent messaging, and a more visible centralised intake. Second, variation in prioritisation practices and duplicated triage processes contributed to inefficiencies and extended wait times, indicating the importance of shared criteria and streamlined workflows. Third, consolidating digital tools into a single, integrated referral front door would minimise administrative burden and errors, supporting timeliness and continuity. Aligning clinic hours and locations with carer availability, while maintaining no-cost access would enhance reach for working parents and families with limited flexibility. Finally, improving access requires both supporting families\u0026rsquo; ability to navigate care and reducing system complexity.\u003c/p\u003e \u003cp\u003eComplementary steps include reducing duplicated triage and case discussions (through clear criteria and decision making) and offering more flexible appointment times to improve timeliness. These measures directly addressed the fragmentation, administrative duplication, and missed engagement windows identified in this study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFuture research\u003c/h3\u003e\n\u003cp\u003eFuture studies could consider redesigned intake pathways from triage to discharge using mixed methods to assess equity impacts across CALD and psychosocial-risk groups. Routine analytics from unified referral tools could track time from referral to allocation, the numbers of clients who fail to attend their appointment and completed appointments. This can inform continuous improvement. Future research could build on our findings by combining Levesque\u0026rsquo;s framework with explicitly structural or critical theories of health equity to consider service level access barriers within the broader conditions that produce them.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eChanging health and economic circumstances demands require more efficient and flexible ways of delivering care. In a universal CFHS system, how services are organised determines who gets timely care. We identified improvement opportunities including enhancing pathway clarity, standardising prioritisation, better aligning allocation with capacity, and streamlining referral tools that collectively could bolster families\u0026rsquo; ability to perceive, seek, reach, and engage with care. By eliminating unwarranted variation and administrative duplication at the point of entry, and by tailoring navigation and capacity to families with the least flexible resources, Local Health Districts can convert \u0026ldquo;universal availability\u0026rdquo; into one of proportionate universalism enabling equitable, timely access.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e All study procedures were performed according to the guidelines of ethics approval for study. Ethics Review Committee of Sydney Local Health District (Protocol No. X23-0273). Site Specific Assessment was obtained from Royal Prince Alfred Hospital (2023/STE02667).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed consent\u003c/strong\u003e \u003cp\u003ewas obtained from all participants included in the study. Consent was provided prior to participation.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003e All participants provided informed consent for their anonymised data, including direct quotes, to be used for publication purposes.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe study was self-funded by Community Health Services, Sydney Local Health District and did not receive any financial support from any source.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eLB and NR developed the study design, and participated in data collection. LB developed the protocol and data collection tools. LB, NR and RW undertook the data analysis. LB conceived the article, interpretation of data analysis, and was responsible for the final draft. SW, FH participated in the interpretation of the results. SW, FH, NR, JO, RW, DJ, participated in critical review of the article. All authors have approved the manuscript in its present form.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThis study stems from a clinical redesign course delivered by New South Wales Agency for Clinical Innovation (ACI) and the University of Tasmania. The authors would like to sincerely thanks the ACI course facilitators, Sydney Local Health District (SLHD) Redesign leads at the time, Barbye Castillo, and Dimitra Kaldelis for their guidance. We are also grateful for the leadership and endorsement from the executive of Clinical Services Integration and Population Health, Community Health Services, SLHD. We would also like to sincerely thank all the participants who generously shared their time, experiences and perspectives with us.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to confidentiality and privacy considerations.\u003c/p\u003e \u003cp\u003eCompeting interests\u003c/p\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNSW Health. First 2000 days framework. Sydney: NSW Ministry of Health. 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2019_008.pdf\u003c/span\u003e\u003cspan address=\"https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2019_008.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 21 October 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClark H, Coll-Seck AM, Banerjee A, Peterson S, Dalglish SL, Ameratunga S, et al. A future for the world\u0026rsquo;s children? Lancet. 2020;395(10224):605\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAustralian Government Department of Health and Ageing. National framework for universal child and family health services. Canberra: Commonwealth of Australia. 2011. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.health.gov.au/resources/publications/national-framework-for-universal-child-and-family-health-services?language=en\u003c/span\u003e\u003cspan address=\"https://www.health.gov.au/resources/publications/national-framework-for-universal-child-and-family-health-services?language=en\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 10 November 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNSW Maternal and Child Health. Maternal \u0026amp; Child Health Primary Health Care Policy. Sydney: NSW Ministry of Health; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchmied V, Homer C, Kemp L, Thomas C, Fowler C, Kruske S. The role and nature of universal health services for pregnant women, children and families in Australia. Aust Health Rev. 2015;39(5):514\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: WHO; 2008.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoolfenden S, Eapen V, Williams K, Hayen A, Spencer N, Kemp L, et al. A systematic review of the prevalence of parental concerns measured by the Parents\u0026rsquo; Evaluation of Developmental Status indicating developmental risk. BMC Pediatr. 2016;16:68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHalfon N, Larson K, Russ S. Why social determinants? Healthc. 2014;2(1):8\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoldfeld S, O\u0026rsquo;Connor M, Mithen J, Sayers M, Brinkman S. Early development of emerging and English-proficient bilingual children at school entry in an Australian population cohort. Int J Behav Dev. 2018;42(4):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoolfenden S, Posada N, Krchnakova R, Crawford J, Gilbert J, Jursik B, et al. Equitable access to developmental surveillance and early intervention\u0026mdash;understanding the barriers for children from culturally and linguistically diverse backgrounds. Health Expect. 2014;18(6):3286\u0026ndash;301. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/hex.12318\u003c/span\u003e\u003cspan address=\"10.1111/hex.12318\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoolfenden S, Eapen V, Jalaludin B, Hayen A, Kemp L, Dissanyake C, et al. Prevalence and factors associated with parental concerns about development detected by the Parents\u0026rsquo; Evaluation of Developmental Status at 6-, 12-, and 18-month well-child checks in a birth cohort. BMJ Open. 2015;6:e012144. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2016-012144\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2016-012144\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSutherland K, Levesque JF. Unwarranted clinical variation in health care: definitions and proposal of an analytic framework. J Eval Clin Pract. 2020;26(3):687\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuggan A, Koff E, Sutherland K. What can policymakers do to improve care and reduce unwarranted variation? Aust Health Rev. 2016;40(3):318\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuhlthau K, Bloom S, Van Cleave J, Knapp AA, Romm D, Klatka K, et al. Evidence for Family-Centered Care for Children With Special Health Care Needs: A Systematic Review. Acad Pediatr. 2011;11(2):136\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavy C, Bleasel J, Liu H, Tchan M, Ponniah S, Brown A. Factors influencing the implementation of chronic care models: a systematic literature review. BMC Fam Pract. 2016;16(1):102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research: a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12:18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVanderbilt University. Version 15.0.37. Sydney Local Health District; 2025. REDCap (Research Electronic Data Capture) [computer software].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSwain J. A hybrid approach to thematic analysis in qualitative research: Using a practical example. SAGE Research Methods Cases. London: SAGE; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCu A, Meister S, Lefebvre B, Ridde V. Assessing healthcare access using the Levesque conceptual framework: a scoping review. Int J Equity Health. 2021;20:116. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12939-021-01416-3\u003c/span\u003e\u003cspan address=\"10.1186/s12939-021-01416-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhatri RB, Assefa Y. Access to health services among culturally and linguistically diverse populations in Australia: a literature review. BMC Public Health. 2022;22:1598.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoughlan CH, Ruzangi J, Neale FK, Maldonado BN, Blair M, Bottle A, et al. Social and ethnic group differences in healthcare use by children aged 0\u0026ndash;14 years in England, 2007\u0026ndash;2017. BMJ Open. 2021;11(9):e045154.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbdus S, Selden TM. Racial and ethnic disparities in attendance to well-child visits before, during, and after the COVID-19 pandemic. JAMA Netw Open. 2024;7(4):e241234.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGavidia-Payne S, Ruth R, Kerry B, Forster J. The changing narrative of early childhood intervention in Australia under the National Disability Insurance Scheme. Child Youth Serv Rev. 2024;152:107254.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBezem J, Kocken PL, Kamphuis M, Theunissen MHC, Buitendijk SE, Numans ME. Triage in preventive child healthcare: a prospective cohort study. Eur J Public Health. 2017;27(3):494\u0026ndash;500.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRocks S, Glogowska M, Stepney M, Tsiachristas A, Fazel M. Introducing a single point of access to child and adolescent mental health services in England: a mixed-methods observational study. BMC Health Serv Res. 2020;20:623.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGanga RN, Santa K, Ali M, Smith G. The impact of a digital referral platform (CYP as One) to improve access to CAMHS. Int J Environ Res Public Health. 2024;21(10):1318.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Malley AS, Samuel D, Bond AM, Carrier E. After-hours access to primary care and emergency department use. Health Aff. 2013;32(1):175\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Equitable access to health services, child health and development, child and family health services, community health, Levesque’s Conceptual Framework for Healthcare Access","lastPublishedDoi":"10.21203/rs.3.rs-9217963/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9217963/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChild and Family Health Services (CFHS) provide universal early childhood health and developmental support in Australia, aiming to give every child an equitable start in life. However, despite this universal intent, not all families are able to access or sustain engagement with these services in a timely way. Guided by Levesque\u0026rsquo;s Conceptual Framework for Healthcare Access, this study examined how system design and service delivery processes influence families\u0026rsquo; ability to perceive, seek, reach, and engage with CFHS within a metropolitan Local Health District.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative design was used, incorporating four focus groups with 42 service providers and six semi-structured interviews with parents or carers who accessed CFHS in the preceding 12 months. Data was collected between August and October 2023. Thematic analysis followed Braun and Clarke\u0026rsquo;s six-phase approach, combining deductive coding using Levesque\u0026rsquo;s five dimensions of access with inductive identification of emerging themes. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guided reporting.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFive inter-related themes described access determinants across the Levesque framework: (1) system complexity and navigation burden, (2) variation in prioritisation and advocacy, (3) service demand and workflow duplication, (4) hidden costs of workforce and system inefficiency, and (5) mismatched referrals and family readiness. Families and referrers frequently encountered unclear entry points and fragmented communication, while staff described duplicated triage processes and capacity-driven rather than needs-driven allocation. Centralised intake and free-of-charge services were key enablers, though operational pressures limited responsiveness and timeliness.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eFindings highlight how system fragmentation and inconsistent operational practices translate into inequitable access, even within a universal model. Addressing these gaps requires standardised, equity-weighted triage, integrated digital referral pathways, and flexible service delivery aligned with family circumstances. Applying Levesque\u0026rsquo;s framework provided a practical lens to connect organisational variation with the lived experience of access, informing service redesign toward more equitable, timely care.\u003c/p\u003e","manuscriptTitle":"A Levesque-Guided Qualitative Study to Understand Equity in Child and Family Health Services: Insights from an Australian Health District","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 14:53:37","doi":"10.21203/rs.3.rs-9217963/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"314967609073536584944971295410447121321","date":"2026-04-07T11:41:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-02T09:39:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-30T18:08:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-30T18:08:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal for Equity in Health","date":"2026-03-25T04:12:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"57c802a4-7ad4-4d2e-802a-e2474b56e74e","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T14:53:42+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 14:53:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9217963","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9217963","identity":"rs-9217963","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}