Parent and Service Provider Perspectives of a Digital Developmental Surveillance and Service Navigation Program in Rural Australia: A Qualitative Study

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Hawker, Karlen R. Barr, Teresa Winata, Si Wang, Melissa Smead, and 20 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6373635/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 Encouraging healthy childhood development and aiding the early identification of developmental difficulties are crucial to providing the best possible outcomes. Young children in rural areas are at a higher risk of missing timely developmental screening than their non-rural counterparts. This study examined the feasibility and acceptability of a digital developmental surveillance program with a service navigator, Watch Me Grow-Electronic (WMG-E), trialled in rural Australia via a randomised controlled trial (RCT). Methods Qualitative data were collected from semi-structured interviews with ten parents who participated in the RCT (six intervention, four control) and six service providers. Transcripts were analysed via reflexive thematic analysis. Results The study revealed barriers and enablers of both the existing Child and Family Health Services (CFHS) and the WMG-E program comprising of a weblink and service navigation. Enablers of the CFHS included the flexible service options and comprehensive support model, while also acknowledging the resource barriers and service capacity limitations during the COVID-19 pandemic. Enablers of WMG-E weblink included its valuable feedback on child development, digital accessibility benefits, and user-friendly interface. Barriers of the WMG-E weblink included limited clinician oversight during survey completion, and technological barriers related to the digital format. Enablers of the WMG-E service navigation included the ability to address service gaps by connecting families to local services, provide support during waitlist periods, and alleviate the strain on understaffed remote healthcare facilities. Conclusions Access to digital support was perceived as particularly valuable during the COVID-19 pandemic when services were closed. The WMG-E program offers a promising avenue to improve the accessibility and uptake of developmental screening services in rural Australia when functioning in harmony with existing care providers. Trial registration: The study is part of a randomised controlled trial (Protocol No. 1.0, Version 3.1) registered with ANZCTR (registration number: ACTRN12621000766819, July 21st, 2021) and reporting of the trial results will be according to recommendations in the CONSORT Statement. Child development Developmental checks Digital developmental surveillance Service navigation Regional and rural families Qualitative inquiry Figures Figure 1 BACKGROUND The early detection of childhood developmental conditions is pivotal for increasing the uptake of targeted intervention programs and providing the best outcomes for children ( 1 – 4 ). Yet, a substantial number of children who could benefit from early interventions are not identified in a timely manner to receive relevant intervention and supports, particularly in the rural setting ( 5 , 6 ). Hence policies and strategies that focus on the early years have recommended the integration of universal developmental surveillance with opportunistic and routine service contacts such as childhood immunisation in preschool children ( 7 – 9 ). Children in rural areas are at greater risk of missing well-child visits that provide routine developmental screening, and hence at greater risk of delayed identification and intervention for developmental disorders ( 10 ). Rural families also face many barriers to accessing health services, including the limited availability of health services, lengthy journeys to service providers, financial constraints, and the complexity of navigating the health system ( 11 , 12 ). These barriers are magnified in Australia, where the vast land area combined with a highly dispersed population results in nearly a third of the population living in regional and remote areas ( 13 ). In the state of New South Wales (NSW), the Child and Family Health Service (CFHS) provides comprehensive care services, including well-child checks, at no cost to families. However, for individuals in geographically isolated areas, access to these services is limited ( 11 , 12 ). Hence, Australia’s context requires a robust developmental surveillance system that can accommodate for a rural context. Previous work has shown that other disadvantaged populations can benefit from digital developmental surveillance programs. In a multicultural community, parents who used an electronic developmental screening system felt empowered to access developmental checks, access relevant services and learn more about their child’s development ( 14 ). However, research is needed to understand whether digital developmental screening could benefit rural populations. The upscale of virtual care models could overcome travel- or workforce-related barriers posed by rural geography ( 15 ). However, the feasibility and acceptability of implementing digital developmental screening solutions in rural areas requires an exploration among end-users. Engaging patients, service providers and the public directly in the development of health systems ensures that research outcomes are grounded in lived experience, which is crucial for high-quality and relevant findings ( 16 , 17 ). People living in rural and remote areas often face increased barriers to participation in health research and may be inadvertently excluded from participation. It is therefore important to capture the perspectives of community members to support partnered research in underserved areas ( 17 ). A qualitative approach that captures the richly textured and nuanced perspectives of rural families/end users is likely to enrich the research process, resulting in higher quality outcomes that are actionable and beneficial in real-world settings, with a tangible impact on healthcare delivery in the rural and remote setting ( 18 ). Research aims This study was conducted as part of a broader implementation research trial. Its aim was to qualitatively evaluate engagement with developmental surveillance, access to child and family health services, and uptake of service recommendations. The study focused on identifying the barriers and enablers of a digital developmental surveillance program, “Watch Me Grow-Electronic (WMG-E)”, implemented in a rural context. To address the research aims, the following research questions were developed: What are the perceived barriers and enablers to family engagement in relation to the current CFHS model in a rural community, as reported by family members, service navigators, and service providers? How does the implementation of the WMG-E digital surveillance (weblink) impact access to child and family health services, and what are the key factors influencing the uptake of service recommendations among rural families, according to the perspectives of family members, service navigators, and service providers? What roles do service navigators play in facilitating engagement with the WMG-E program and improving service access and uptake of recommendations, and what challenges and strategies do they encounter in a rural community context? METHODS Study Context This qualitative study was part of a randomised controlled trial (RCT) to evaluate a health services implementation research trial – the WMG-E digital surveillance approach and a service navigation component during the COVID-19 pandemic. The protocol for the RCT has been published separately ( 19 ). The WMG-E program includes a digital weblink screening tool that was developed to empower parents to monitor their child’s development and facilitate access to relevant services when risks are identified ( 19 ). The weblink incorporates the Centre for Disease Control and Prevention’s “Learn the Signs. Act Early.” (LTSAE) developmental surveillance tool in a digital format with age-specific developmental checklists and ‘red flags’ for children aged zero to five years ( 20 ) as recommended in the NSW Health Personal Health record (“Blue Book”) ( 21 ). This digital integration enables parents to actively participate in their child’s developmental monitoring from the convenience of their homes and other community services they engage with, using mobile phones or laptops, decreasing the reliance on face-to-face visits. Once engaged, the program sends automated reminders to complete the developmental checks again at the next recommended ages and stages, facilitating routine screening and ongoing monitoring. If concerns are raised on LTSAE red flag items, parents are guided to contact local services. In the RCT, the weblink was evaluated to determine its capacity to identify child developmental needs and examine whether a service navigator increases engagement and uptake of services by facilitating access to relevant services and providing continuity of care. Participants (parents/caregivers) were allocated into either a 'care as usual' (CaU) group or an intervention group. Both groups used the WMG-E weblink to complete a digitalised version of the LTSAE child developmental surveillance tool ( 15 ), the Kessler Psychological Distress Scale (K10) ( 22 ) for parental mental health, and the WE CARE ( 23 ) to determine family social care needs (employment, housing, financial and food security). If risks were identified (i.e., one or more developmental and/or psychosocial concerns, or K10 scores ranging from 20–24), participants received electronic resources guiding them to health services that could be accessed for more detailed assessments and supports. If there were no risks identified, participants received a results page which states no particular risks or concerns have been raised. Intervention Group After completing the questionnaires, families in the intervention group received continuity of care in the form of a service navigator who supported families on a case-by-case basis, to identify their needs and link them to relevant services or resources, as required. The primary role of the service navigator was to build working relationships, address any barriers and support families while they learn to self-navigate the health and social care system. Follow-up questionnaires at six and 12 months measured engagement with and use of support services. Control Group (CaU) The CaU group did not receive continuity of care via a service navigator. Participants received the results of the LTSAE questionnaire, along with electronic resources for general guidance and a recommendation to contact local services for additional support if developmental concerns were identified. If questionnaire results indicated an acute crisis (i.e., K10 ≥ 25 and/or risk of homelessness, domestic violence, loss of electricity or food), participants were excluded from the study and immediately contacted by a researcher to assist them in engaging with support services. Sampling and recruitment Families who attended CFHS, refugee health services, supported playgroups, non-government organisation services, general practitioner (GP) clinics, or paediatric clinics within the Murrumbidgee Local Health District (LHD) were informed of the WMG-E study by their service provider. Those who consented to the study and participated in the RCT were asked to indicate their consent to being contacted regarding participation in the qualitative component of the study. Those who consented were contacted for feedback on their overall experience about the WMG-E program. Convenience sampling was used whereby approximately one in ten of the 227 families from the regional/rural site of Murrumbidgee (i.e., 25 families) were invited directly by a researcher after the 12-month follow-up period for an interview. Ten parents (six intervention, four control) were available to be interviewed, and they formed the study sample. Similarly, service providers who participated in the study’s implementation were approached to provide their feedback. Six service providers and one service navigator were invited to participate in a semi-structured interview. Information about the study was presented to potential participants using information sheets. Written informed consent was obtained from participants, including consent for audiotaping. Setting Murrumbidgee LHD spans 125,243 km 2 across southern NSW, operating 33 public hospitals and 12 community health centres ( 24 ). Approximately 13% of the district’s population live in areas of high socioeconomic disadvantage, with 10% of families experiencing low-income and welfare-dependence (compared to 8.8% for entire NSW) ( 24 ). The Murrumbidgee primary care network consists of CFHS, GPs, paediatricians, pharmacies, and local government councils. In NSW, the My Personal Health Record (“Blue Book”) ( 25 ) that records the child’s health and illnesses, and growth and development, and contains related health information is the primary tool available for families to monitor the progress of their child’s growth and development. The Blue Book is provided to parents at the time of their child’s birth, and available to children born interstate or overseas. Links to a range of support and parenting services are available in the Blue Book, including translated versions for non-English speaking families. Conducted in the context of the COVID-19 pandemic, this study coincided with a significant reduction in the in-person service capacity of the CFHS. This period was marked by heightened health and safety measures, necessitating a shift in traditional service delivery methods. Face-to-face health services were hindered due to closure of the community clinics and the reassignment of staff for COVID-19-related duties. Study Procedure This study was approved by the South Western Sydney Local Health District Human Research Ethics Committee (HREC reference 2020/ETH01418), and all participants provided written informed consent. Qualitative interviews were conducted online and lasted between 15 and 30 minutes. A researcher trained in qualitative inquiry conducted the interviews guided by a semi-structured interview schedule with open-ended questions to encourage detailed responses (see Appendix 1). The interviews were digitally recorded and transcribed verbatim. All transcripts were de-identified prior to uploading the files to NVivo 12 software (Version 12.6.0.959, Pro Edition; QSR International, United States of America) for data analysis. Data analysis Reflexive thematic analysis ( 26 , 27 ) was used to analyse the transcript data. A predominantly inductive approach was used, while incorporating a small degree of deductive analysis to ensure that the coding contributed to the identification of themes that align with the research objectives. Both semantic and latent coding were used to capture the explicit and underlying meanings within the data, with no attempt to prioritise one over the other. Braun and Clarke’s six-phase analytical process ( 27 ) guided the analysis. First, familiarisation of the data occurred by reading transcripts multiple times. Using NVivo 12, participant responses with similar meanings were organised into nodes, and those with conceptual similarities were developed into candidate themes. Themes were then revised and renamed through discussions with the research team and final themes were decided upon during the writing process. To enrich the depth of the analysis, two external researchers (PJH and KRB) independently coded all the data and identified themes, with ongoing discussions around themes and subthemes facilitated by the WMG-E project manager (TW). KRB had extensive previous experience with qualitative research, and PJH was trained in qualitative methods prior to analysis. The researchers met several times over a few months to discuss themes, and any disagreements were resolved through discussions with the WMG-E project manager. The process of converging on the final themes involved a discussion between the researchers. Participant quotes included in the results section were edited for grammatical errors to increase readability. The study has been reported in line with the Standards for Reporting Qualitative Research (see Appendix 2) ( 28 ). RESULTS Participants Data were collected from 16 participants including ten parents and six service providers. Of the ten parents, six were intervention families and the remaining four were control participants. Most parents (90%) were females; with 60% aged between 31 to 40 years, 30% aged between 21 to 30, and the remaining aged 41 to 50. All participants had attained education to the level of high school (30%) or above, with 20% having a bachelor and 20% a postgraduate degree and 30% a Vocational Education Training. Most of the family participants (80%) identified themselves as Australian, with one as Aboriginal/Torres Strait Islander Australian, and another identified as non-Australian. All parents identified English as their primary language spoken at home. Service providers included five staff employed within Murrumbidgee LHD and one service navigator. Of the five Murrumbidgee staff, three were engaged in management or leadership roles within the LHD, and two were employed as nurses. Themes Three major themes were identified regarding enablers, barriers, and feedback suggestions about the current CFHS, the WMG-E weblink, and the WMG-E service navigator (Fig. 1). Note WMG-E, Watch Me Grow-Electronic. Light blue = expressed by family members and service providers; dark blue = expressed by family members; green = expressed by service providers. Enablers of the current CFHS Comprehensive, Friendly, and Personalised Support Service providers emphasised the comprehensive support measures available for families. They elaborated on the diversity of support offered, from child development and playgroups to mental health and psychosocial assistance: “[CFHS provides] a holistic approach in relation to families – keeping them safe and giving them information about making healthy and good choices for themselves and their children” (Service Provider SP07). Flexibility Both families and service providers reflected on the adaptability of the CFHS, emphasising the benefits of the quick adoption of a flexible virtual care model during COVID-19: “We also formally implemented a two-pronged approach to our universal home visits, which meant that the first half of it was delivered by the virtual care. The second part was delivered in the home, cutting down the amount of time clinician was in the home and keeping everyone safe” (Service Provider SP07). The flexibility of the virtual care model was exemplified by an option for in-person engagements for families who could not participate in telehealth consults. Parents described a positive experience using telehealth and service providers reported positive feedback from the service: “ If they couldn't participate in my virtual care, we went and did the universal home visit after COVID-19 screening… the feedback from the clients is they really like it [telehealth]” (Service Provider SP07). Barriers of the current CFHS Service Capacity Families and service providers noted limitations of the local CFHS capacity in the context of the COVID-19 pandemic. Service providers reported difficulties engaging families and COVID-related staffing challenges: “We don’t have a local child and family health nurse, so we have to borrow one from other towns… and their visits are quite quick because they have to do community health as well” (Parent MU128). It was reported that some families missed routine developmental screens due to staffing challenges. Service providers voiced their concern that staffing challenges would be ongoing: “We haven't been able to fully fill the vacancies that have been left. And while we are in a situation like that, obviously we can't be offering our full range of services in the timely way, because we've had to prioritize those who most need the service” (Service Provider SP08). One parent described how their remote location posed difficulties for accessing in-person services. Perceived enablers of the WMG-E weblink Informative Numerous parents remarked on the weblink’s utility and how the feedback offered valuable insights into their child's growth and development: “I would've had no idea that [my child] was behind with his speaking if there wasn't that simple survey” (Parent MU23). For families where the weblink identified developmental issues, participants highlighted the weblink’s effectiveness in alerting parents to address these concerns and seek assistance: “If you had issues, [the weblink] would flag it and then you could follow that up” (Parent MU02). “I would recommend this program for families to use as it has alerted me with some issues that I can address” (Parent MU186). Accessibility Both families and service providers praised the accessibility of a digital approach. Service providers described how the increasing societal transition to a digital era means that many families now have access to electronic devices. Families discussed how the weblink was readily accessible, particularly for those who prefer connecting through technology or might be more comfortable with a digital service: “I'm not gonna go and sit down with a nurse and open my heart up with them, but that app or something like it would be more feasible and I wouldn’t have done the checks without it” (Parent MU23). Service providers mirrored the notion that apps are beneficial in a digital era. They suggested that the weblink may be particularly helpful for connecting with tech-savvy parents: “I think if we are going to stay relevant and engage people, apps are really necessary now” (Service Provider SP08). Service providers highlighted benefits of the weblink for families who don’t engage with CFHS: “Not all parents engage in child and family health. Like they may go to their GP for immunisations and sometimes the GP doesn't even look at the Blue Book. So, for them having that weblink would be really good” (Service Provider SP06). One parent described how their remote location posed difficulties for accessing in-person services, while providers highlighted the weblink’s advantage in connecting families situated far from metropolitan areas: “I also think in a rural area, some families don't have the ability to travel, and they don't have a car, or the nurse can't come out to visit them because it's too far. I think this [weblink] is another alternative” (Service Navigator). User-Friendly Most families expressed that the weblink was user-friendly and simple to navigate, and they could complete the survey quickly: “I didn’t have any issues. I found it [the weblink] really easy… I think it’s a really simple tool to use” (Parent MU02). Barriers of the WMG-E weblink Digital Format While the use of digital technology was identified as an enabler for service accessibility, concerns were raised about the weblink’s capacity to service families in rural and remote regions. Particular concerns were raised about the internet access requirements: “ Some of our most vulnerable families that can't access services might also be the ones that live in really remote, out of the way places that may not have the greatest service… they're also the ones that might be the most financially strapped… and they don't have access to data” (Service Provider SP09). Additionally, one parent expressed difficulties accessing the weblink. Concerns were raised that the weblink may not be readily accessible for non-English speaking families (although translations are available in select languages), those with learning difficulties, or those with low health literacy: “The next barrier would be probably their [families’] capacity to use it [the weblink]” (Service Provider SP08). Limited Oversight Parents and service providers expressed concerns about a model that did not directly involve clinicians for developmental and psychosocial screening. Parents indicated there was a potential for the weblink to overlook certain concerns: “If they [parents] actually have like serious mental health concerns, maybe things aren't getting picked up because it's behind a screen. A trained nurse can observe things in a face-to-face” (Parent MU19). Service providers echoed this sentiment, emphasising that the survey should be conducted under the guidance of a qualified professional. They suggested that the weblink may fail to grasp the broader context and impact of parents: “It can quite often come down to how the person's feeling on the day and how they might think that the child behaved at that particular very point when they're doing [the digital questionnaire]... unless [a clinician] is there to actually screen and talk to them around the questions and that sort of thing, they may not get the full picture” (Service Provider SP09). Service providers shared how parents might become anxious or perceive a problem with their child if they received survey results without clinician or service navigator input: “By [Parents] getting the results before we talk to them, they kind of freak out and it’s a bit like looking up Google doctor cause they kind of go, oh, I got a problem with my child. How am I gonna fix this?… Anxiety sort of sinks in a bit. If they didn’t have mental health [problems], then they start having them” (Service Navigator). Service providers discussed how mental health and psychosocial risk might not be identified or that risk may be identified but not appropriately followed up through the weblink: “[Parents] maybe don't see themselves as vulnerable sometimes as we do... So they can be putting in part of the information, but if they were sitting face-to-face with somebody who was skilled, that could be looking quite different” [Service Provider SP08). One service provider shared how service navigators could help parents understand the survey results and provide parents with connection: “I think having a service navigator [call] saying, ‘I've noticed you completed survey results. I just want to have a chat to you. Look, there's help at hand and I'll be able to give you this. And I think sort of having that sort of connection rather than just black and white writing” (Service Navigator). Enablers of the WMG-E Service Navigator Connection to Services Service providers highlighted the value of the service navigator in assisting families to navigate an increasingly complicated healthcare system: “[The service navigator] would be very useful because quite often people actually don't know what the first step is to access services. And it's a bit of a minefield. And if you haven't been through that system before you know, an assisted program is a good one” (Service Provider SP07). Parents commented that the navigator provided regular follow-ups while connecting them to relevant supports: “[The service navigator] called me a couple of times and it was all good” (Parent MU180). “It [the service navigator] was definitely a push I needed to help get those services” (Parent MU102). Service providers discussed the ability of the service navigator to connect with families who do not interact with CFHS: “It's good for those families that do not want to reach out to us or a direct service, as this program allows families to get support via a service navigator, at least this way we can cover all families in Murrumbidgee LHD and those we have missed” (Service Provider SP10). Support While Waiting Service providers indicated that the service navigator offers ongoing support and provides alternative options for families during long waitlist periods: “We are down on staff so I can see an absolute advantage for people to be able to use something like this, have a point of contact, have someone they can talk to who can reassure redirect, prioritize. I think it's fantastic” (Service Provider SP08). Alleviates Strain on Services Service providers described the beneficial nature of the service navigator in redirecting and/or reprioritising workload in rural and remote regions where the service capacity is limited: “In a remote area where we've got limited services for child and family, definitely it [the service navigator] is a good idea” (Service Provider SP06). Feedback suggestions provided by study participants Strengthen Collaboration One service provider shared they were not made aware of families in need and that the project could have been improved with more collaboration between the service navigators and CFHS: “I think it would be a good idea to have monthly meetings to discuss those families in need and we can brainstorm together in what support we could provide and to also look if we are already seeing these families and providing support. I think working together would have been better” (Service Provider SP10). DISCUSSION As digital technologies are increasingly embedded within daily life, there is heightened interest in the application of electronic health and digital health tools ( 29 – 32 ). This study examined family and service provider attitudes towards WMG-E, a developmental screening and service navigation program that was implemented in remote and regional Australia. The aim of the study was to determine the feasibility and acceptability of WMG-E weblink as a developmental screening/monitoring tool for rural families and local service providers, and examine whether the addition of a service navigator increased access to and uptake of support services. The findings highlight the growing demand for digital-friendly early childhood services, with the digital nature of WMG-E described as a useful avenue to connect with parents who prefer digital mediums. While CFHS provides a comprehensive and diverse range of support services including telehealth, providers acknowledged the discernible gap when connecting with parents that lean towards non-traditional communication avenues. Through WMG-E’s digital interface, CFHS can now tap into a previously unexplored and rapidly expanding consumer group who desire the versatility of digital healthcare engagement ( 33 ). Further, WMG-E enables wider reach to identify people with concerns and hence would benefit from further assessment. This allows those who are identified through the WMG-E screening to be followed up by the state developmental services via the CFHS, thereby increasing efficiency of the limited resources. For families in remote areas, physical distance presents a significant barrier to health services ( 11 , 12 ). This is amplified in Australia where nearly a third of the population live in regional or remote locations ( 13 ). Service providers described how the weblink allowed families to access developmental screening services without undergoing an extensive journey to their local service provider. Given the limited reach of CFHS in some areas ( 34 ), the weblink can address a service gap. It would be particularly helpful in reducing rural families' reliance on travel, enabling them to engage with developmental checks more readily and those with specific needs to be prioritised for assessment by CFHS. However, it is possible that not all rural families can embrace the accessibility benefits of digital health tools, with providers suggesting that the program’s dependence on internet connectivity might exclude some families. The Australian context presents a pronounced disparity between populations that can effectively use digital resources and those who cannot, often referred to as a ‘digital divide’ ( 35 ). Only one third of Australia’s total land area has mobile connectivity, leaving many rural and remote families digitally disconnected ( 36 ). Additionally, the financial burden of acquiring and maintaining a stable internet connection disproportionately affects vulnerable populations, leading to their exclusion from digital services ( 37 ). Service providers voiced concern over internet related financial strains. They indicated that programs dependent on internet connection might pose accessibility challenges for rural and vulnerable populations. Providing pre-paid internet dockets to remote families as part of the roll-out of such initiatives would help address this. Studies corroborate that individuals living with a disability, racial or ethnic minorities, low income households, people over the age of 75 years, and people living in remote parts of Australia are less likely to have the financial security to secure internet access ( 38 – 40 ). Additionally, nearly 30% of Aboriginal and Torres Strait Islander people living in remote communities remain without internet ( 35 ). Thus, the combination of inadequate rural infrastructure and the financial challenges of maintaining internet connection creates a significant hurdle for priority populations, limiting their ability to engage with digital health services. It is crucial to sustain in-person services for people who cannot leverage the benefits of digital health while efforts are made to strengthen rural network coverage and equitable internet access. The global impact of the COVID-19 pandemic reshaped many avenues of care and necessitated healthcare innovations. In NSW, there was a significant reduction in face-to-face services ( 41 ). Service providers described how CFHS adopted a virtual care model to minimise health service disruption. While the model was well-received, providers reported significant staffing challenges which they anticipated would persist in a post-pandemic era. WMG-E serves as an example of innovation in remote service delivery with the potential to alleviate staff workload. However, apprehension exists about the efficacy of developmental screening in the absence of a clinician – as such, it is critical that when a concern is identified, parents are connected with relevant services so that the parental concerns can be clarified by a clinician. Similarly, providers noted that the absence of parent-child interactions as observed by a clinician might overlook concerns if this follow-up engagement with a clinician is not available. Evidence suggests that clinician observation of parent-child interaction provides a more accurate characterisation of children’s social-communication ability ( 42 ). However, remotely delivered screening tools have yielded equivalent psychometric data to those delivered in-person ( 43 ). Regardless, several factors need to be considered to optimise digital administration, such as the involvement of a service provider or navigator throughout the screening process ( 43 ). The WMG-E weblink is intended to be completed in collaboration with a service provider who the family has an established relationship with, and in this regard, it is not to be completed in isolation. Parents expressed concern that when problems were identified via remote use of the weblink, as it was during the COVID-19 pandemic, there was no immediate follow-up to support parents in their queries, explain what the results might mean, or provide guidance in accessing services. Service providers echoed this sentiment, noting that receiving results without supportive care could be a risk for vulnerable families. The limited scope of research investigating actions taken after positive developmental screens ( 44 ) makes it difficult to determine the best ways to support families who are flagged as at risk. However, the incorporation of a service navigator to remote screening tools as it was done in the intervention arm of the WMG-E RCT, study will address this issue as the navigator can help parents understand the screening results and guide them towards appropriate services ( 45 ). Supportive care provided by the service navigator might overcome some of the barriers identified on the use of the weblink on its own. Transitions between various healthcare services can be confusing and complicated for patients resulting in fragmented care ( 46 ). Service providers indicated that the convoluted nature of the health system posed significant challenges for families. They described the benefits of the service navigator in providing a ‘warm hand over’ and a smooth transition between local services. Service providers also acknowledged the staffing limitations of traditional services that can lead to lengthy wait periods for families. They suggested that the weblink and navigator are particularly beneficial in a rural area with limited services, allowing families to receive supportive care during the waiting period, thereby potentially increasing ongoing engagement and follow-up with positive results. Providing continuity of care via a service navigator is a means to integrate health systems and facilitate better transitioning across care settings ( 45 ). In other fields, patient navigation systems have increased participation in both screening and adherence to diagnostic follow-up care after a positive screen ( 47 ). Service providers indicated that a navigation system would help CFHS reach families who would otherwise not engage and thus be missed. Hence, this system has the potential to increase the rate of both developmental screening and subsequent follow-up with specialist providers in rural areas. In terms of study implementation, a service provider identified a need for increased collaboration between service navigators and CFHS, particularly in recognising and addressing the needs of families. While monthly ‘triage and review’ meetings to collectively identify and support families in need were an original part of the WMG-E implementation, they were disrupted by the COVID-19 pandemic, underscoring the challenges faced in maintaining collaborative practices in restricted service environments. Implications for Health Practice and Policy This study underscores the growing demand for digital health services, especially in remote and rural areas where access to traditional health services is a persistent challenge due to distance from services and limited resources. The WMG-E weblink offers a promising solution to developmental screening barriers faced by geographically isolated families in regional Australia. Its capability to engage parents and reduce the need for physical commutes addresses significant gaps in traditional service delivery. However, there are limitations. The requirement of internet accessibility and its associated financial burden might pose challenges for certain populations. Additionally, while digital tools might offer convenience, they cannot yet fully replicate the depth of clinician observations during face-to-face assessments. The introduction of service navigators can mitigate some of these concerns, offering supportive care post-screening and guiding families towards appropriate care pathways. Service navigation might also enhance care continuity and assist in bridging fragmented health services. Thus, while digital developmental screening tools like WMG-E hold significant promise, they should ideally be integrated into a broader care model, ensuring that families not only have access to digital screening but also receive necessary follow-up care and support with CFHS. Hence, the weblink and service navigator might function best in harmony with CFHS to alleviate staffing challenges and travel burden for rural families where appropriate, while keeping face-to-face visits embedded within routine practice. Outcomes from the RCT will shed light on the effectiveness of WMG-E in this respect. Strengths and Limitations This study has several strengths. The use of a qualitative approach has provided rich and detailed insights into the end-user’s experiences of the WMG-E platform, offering an in-depth understanding of the context and nuances that quantitative data alone cannot capture. Sample size was informed by the concept of information power and its dimensions of study aim, sample specificity, use of established theory, quality of dialogue and analysis strategy ( 48 ). Specifically, the study was relatively narrow in focus and dialogue was strong with an interviewer with expertise in qualitative inquiry, creating higher information power. The use of multiple researchers throughout the coding and theme development process ensured research rigor and a rich interpretation of the data. The study also has several limitations. The sample was not diverse in terms of gender, with 90% of parents and all service providers identifying as female. The limited inclusion of fathers and male service providers might overlook gender-based differences in experiences and outcomes. All participating families and service providers were English-speaking, which could restrict the applicability of the study's results to non-English-speaking populations. However, the WMG-E weblink was made available in four other languages besides English. Insights from a multicultural community, distinct from this study’s scope, are presented separately ( 14 ). CONCLUSIONS Digital health tools like WMG-E have the potential to transform developmental screening in rural and remote areas, addressing logistical barriers and tapping into the digital preferences of the younger generation. However, to fully embrace this potential, governments must address infrastructure and financial limitations posed by internet access. It is paramount that such tools do not inadvertently exacerbate healthcare disparities, particularly in remote Australian communities. Integrating supportive elements, such as service navigators, can ensure that families are adequately guided and supported for further assessments and follow up support when needs are identified, thereby increasing the capacity and efficiency of the service system, and offering continuity of care. Abbreviations Care as usual (CaU); Child and Family Health Services (CFHS); General practitioner (GP); Kessler Psychological Distress Scale (K10); Learn the Signs. Act Early. (LTSAE); Local Health District (LHD); New South Wales (NSW); Randomised controlled trial (RCT); Watch Me Grow-Electronic (WMG-E) Declarations Ethics approval and consent to participate The study conforms to the principles outlined in the Declaration of Helsinki. All methods were carried out in accordance with relevant guidelines and regulations of The National Statement on Ethical Conduct in Human Research (2023). The South Western Sydney Local Health District Human Research Ethics Committee approved this study (2020/ETH01418). All participating parents have provided written informed consent prior to participation. Consent for publication Not applicable. Availability of data and materials Data from the current study will not be made available, as participants did not consent for their transcripts to be publicly released. Instead, extracts of participant responses have been made available within the manuscript. Please contact the corresponding author, Professor Valsamma Eapen, for any data requests. Competing interests The authors declare that they have no competing interests. Funding This work underwent an independent peer review and was funded by the NSW Health COVID-19 Research Grants Round 2 in partnership with University of New South Wales, South Western Sydney Local Health District, Murrumbidgee Local Health District NSW Health, Sydney Children’s Hospital Randwick, Western Sydney University, Ingham Institute for Applied Medical Research, Black Dog Institute, Uniting and Karitane. The funding body did not contribute to the design of the study or in writing of the manuscript. Authors' contributions PH – data analysis and writing- original draft. KRB – data analysis and writing- review and editing. TW – study design, participant recruitment, data collection, data analysis, and writing- review and editing. SW – participant recruitment, data collection and writing- review and editing. CLC – writing- review and editing. MS –participant recruitment, data collection and writing- review and editing. JK – study design and writing- review and editing. JP – study design and writing- review and editing. SW – study design, supervision and writing- review and editing. VE – study design, supervision and writing- review and editing. All authors read and approved the final version of the manuscript. Acknowledgements We would like to acknowledge the parents, service providers, and service navigator who participated in this study. We also would like to acknowledge and thank the Watch Me Grow-Electronic (WMG-E) study group that contributed to the scope of the project: Valsamma Eapen, John Preddy, Susan Woolfenden, Teresa Winata, Si Wang, Melissa Smead, Jane Kohlhoff, Virginia Schmied, Bin Jalaludin, Kenny Lawson, ST Liaw, Raghu Lingam, Andrew Page, Christa Lam-Cassettari, Katherine Boydell, Daniel P. Lin, Ilan Katz, Ann Dadich, Shanti Raman, Rebecca Grace, Aunty Kerrie Doyle, Tom McClean, Blaise Di Mento,Sara Cibralic, Anthony Mendoza Diaz, Jodie Bruce, Nicole Myers, Joseph Descallar, Cathy Kaplun, Amit Arora, Victoria Blight, and Angela Wood. References Clark MLE, Vinen Z, Barbaro J, Dissanayake C. School Age Outcomes of Children Diagnosed Early and Later with Autism Spectrum Disorder. J Autism Dev Disord. 2018;48(1):92–102. Barger B, Rice C, Wolf R, Roach A. Better together: Developmental screening and monitoring best identify children who need early intervention. Disabil Health J. 2018;11(3):420–6. 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Routine developmental screening in Australian general practice: a pilot study. BMC Prim Care. 2023;24(1):143. Featherstone D. Remote Indigenous communications review. 2020. Infrastructure Australia. An Assessment of Australia’s Future Infrastructure Needs. 2019. Good Things Foundation Australia. Digital Nation Australia. Good Things Foundation Australia; 2021. Thomas J, Barraket J, Wilson CK, Holcombe-James I, Kennedy J, Rennie E et al. Measuring Australia’s digital divide: The Australian digital inclusion index 2020. 2020. Nelson D, Inghels M, Kenny A, Skinner S, McCranor T, Wyatt S, et al. Mental health professionals and telehealth in a rural setting: a cross sectional survey. BMC Health Serv Res. 2023;23(1):200. Nguyen A, Mosadeghi S, Almario CV. Persistent digital divide in access to and use of the Internet as a resource for health information: Results from a California population-based study. Int J Med Informatics. 2017;103:49–54. Sutherland K, Chessman J, Zhao J, Sara G, Shetty A, Smith S et al. Impact of COVID-19 on healthcare activity in NSW, Australia. Public Health Res Pract. 2020;30(4). Federico A, Shi D, Bradshaw J. Agreement Between Parental Report and Clinician Observation of Infant Developmental Skills. Front Psychol. 2021;12:734341. Komanchuk J, Cameron JL, Kurbatfinski S, Duffett-Leger L, Letourneau N. A realist review of digitally delivered child development assessment and screening tools: Psychometrics and considerations for future use. Early Hum Dev. 2023;183:105818. Cibralic S, Hawker P, Khan F, Lucien A, Mendoza Diaz A, Woolfenden S et al. Developmental screening tools for identification of children with developmental difficulties in high-income countries: a systematic review. Front Child Adolesc Psychiatry. 2023;2. Manderson B, McMurray J, Piraino E, Stolee P. Navigation roles support chronically ill older adults through healthcare transitions: a systematic review of the literature. Health Soc Care Commun. 2012;20(2):113–27. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831–41. Wells KJ, Battaglia TA, Dudley DJ, Garcia R, Greene A, Calhoun E, et al. Patient navigation: state of the art or is it science? Cancer. 2008;113(8):1999–2010. Malterud K, Siersma VD, Guassora AD. Sample Size in Qualitative Interview Studies: Guided by Information Power. Qual Health Res. 2016;26(13):1753–60. Additional Declarations No competing interests reported. Supplementary Files Appendix1InterviewSchedule.docx Appendix2StandardsforReportingQualitativeResearchChecklist.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 05 May, 2025 Editor assigned by journal 29 Apr, 2025 Editor invited by journal 08 Apr, 2025 Submission checks completed at journal 08 Apr, 2025 First submitted to journal 08 Apr, 2025 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. 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class=\"CitationRef\"\u003e4\u003c/span\u003e). Yet, a substantial number of children who could benefit from early interventions are not identified in a timely manner to receive relevant intervention and supports, particularly in the rural setting (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Hence policies and strategies that focus on the early years have recommended the integration of universal developmental surveillance with opportunistic and routine service contacts such as childhood immunisation in preschool children (\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eChildren in rural areas are at greater risk of missing well-child visits that provide routine developmental screening, and hence at greater risk of delayed identification and intervention for developmental disorders (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Rural families also face many barriers to accessing health services, including the limited availability of health services, lengthy journeys to service providers, financial constraints, and the complexity of navigating the health system (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). These barriers are magnified in Australia, where the vast land area combined with a highly dispersed population results in nearly a third of the population living in regional and remote areas (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In the state of New South Wales (NSW), the Child and Family Health Service (CFHS) provides comprehensive care services, including well-child checks, at no cost to families. However, for individuals in geographically isolated areas, access to these services is limited (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Hence, Australia\u0026rsquo;s context requires a robust developmental surveillance system that can accommodate for a rural context.\u003c/p\u003e \u003cp\u003ePrevious work has shown that other disadvantaged populations can benefit from digital developmental surveillance programs. In a multicultural community, parents who used an electronic developmental screening system felt empowered to access developmental checks, access relevant services and learn more about their child\u0026rsquo;s development (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). However, research is needed to understand whether digital developmental screening could benefit rural populations. The upscale of virtual care models could overcome travel- or workforce-related barriers posed by rural geography (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). However, the feasibility and acceptability of implementing digital developmental screening solutions in rural areas requires an exploration among end-users. Engaging patients, service providers and the public directly in the development of health systems ensures that research outcomes are grounded in lived experience, which is crucial for high-quality and relevant findings (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). People living in rural and remote areas often face increased barriers to participation in health research and may be inadvertently excluded from participation. It is therefore important to capture the perspectives of community members to support partnered research in underserved areas (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). A qualitative approach that captures the richly textured and nuanced perspectives of rural families/end users is likely to enrich the research process, resulting in higher quality outcomes that are actionable and beneficial in real-world settings, with a tangible impact on healthcare delivery in the rural and remote setting (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eResearch aims\u003c/h3\u003e\n\u003cp\u003eThis study was conducted as part of a broader implementation research trial. Its aim was to qualitatively evaluate engagement with developmental surveillance, access to child and family health services, and uptake of service recommendations. The study focused on identifying the barriers and enablers of a digital developmental surveillance program, \u0026ldquo;Watch Me Grow-Electronic (WMG-E)\u0026rdquo;, implemented in a rural context.\u003c/p\u003e \u003cp\u003eTo address the research aims, the following research questions were developed:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are the perceived barriers and enablers to family engagement in relation to the current CFHS model in a rural community, as reported by family members, service navigators, and service providers?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow does the implementation of the WMG-E digital surveillance (weblink) impact access to child and family health services, and what are the key factors influencing the uptake of service recommendations among rural families, according to the perspectives of family members, service navigators, and service providers?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat roles do service navigators play in facilitating engagement with the WMG-E program and improving service access and uptake of recommendations, and what challenges and strategies do they encounter in a rural community context?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"METHODS","content":" \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eStudy Context\u003c/h2\u003e \u003cp\u003eThis qualitative study was part of a randomised controlled trial (RCT) to evaluate a health services implementation research trial \u0026ndash; the WMG-E digital surveillance approach and a service navigation component during the COVID-19 pandemic. The protocol for the RCT has been published separately (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe WMG-E program includes a digital weblink screening tool that was developed to empower parents to monitor their child\u0026rsquo;s development and facilitate access to relevant services when risks are identified (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The weblink incorporates the Centre for Disease Control and Prevention\u0026rsquo;s \u0026ldquo;Learn the Signs. Act Early.\u0026rdquo; (LTSAE) developmental surveillance tool in a digital format with age-specific developmental checklists and \u0026lsquo;red flags\u0026rsquo; for children aged zero to five years (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) as recommended in the NSW Health Personal Health record (\u0026ldquo;Blue Book\u0026rdquo;) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). This digital integration enables parents to actively participate in their child\u0026rsquo;s developmental monitoring from the convenience of their homes and other community services they engage with, using mobile phones or laptops, decreasing the reliance on face-to-face visits. Once engaged, the program sends automated reminders to complete the developmental checks again at the next recommended ages and stages, facilitating routine screening and ongoing monitoring. If concerns are raised on LTSAE red flag items, parents are guided to contact local services.\u003c/p\u003e \u003cp\u003eIn the RCT, the weblink was evaluated to determine its capacity to identify child developmental needs and examine whether a service navigator increases engagement and uptake of services by facilitating access to relevant services and providing continuity of care. Participants (parents/caregivers) were allocated into either a 'care as usual' (CaU) group or an intervention group. Both groups used the WMG-E weblink to complete a digitalised version of the LTSAE child developmental surveillance tool (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), the Kessler Psychological Distress Scale (K10) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) for parental mental health, and the WE CARE (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) to determine family social care needs (employment, housing, financial and food security). If risks were identified (i.e., one or more developmental and/or psychosocial concerns, or K10 scores ranging from 20\u0026ndash;24), participants received electronic resources guiding them to health services that could be accessed for more detailed assessments and supports. If there were no risks identified, participants received a results page which states no particular risks or concerns have been raised.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eIntervention Group\u003c/h3\u003e\n\u003cp\u003eAfter completing the questionnaires, families in the intervention group received continuity of care in the form of a service navigator who supported families on a case-by-case basis, to identify their needs and link them to relevant services or resources, as required. The primary role of the service navigator was to build working relationships, address any barriers and support families while they learn to self-navigate the health and social care system. Follow-up questionnaires at six and 12 months measured engagement with and use of support services.\u003c/p\u003e\n\u003ch3\u003eControl Group (CaU)\u003c/h3\u003e\n\u003cp\u003eThe CaU group did not receive continuity of care via a service navigator. Participants received the results of the LTSAE questionnaire, along with electronic resources for general guidance and a recommendation to contact local services for additional support if developmental concerns were identified. If questionnaire results indicated an acute crisis (i.e., K10\u0026thinsp;\u0026ge;\u0026thinsp;25 and/or risk of homelessness, domestic violence, loss of electricity or food), participants were excluded from the study and immediately contacted by a researcher to assist them in engaging with support services.\u003c/p\u003e\n\u003ch3\u003eSampling and recruitment\u003c/h3\u003e\n\u003cp\u003e Families who attended CFHS, refugee health services, supported playgroups, non-government organisation services, general practitioner (GP) clinics, or paediatric clinics within the Murrumbidgee Local Health District (LHD) were informed of the WMG-E study by their service provider. Those who consented to the study and participated in the RCT were asked to indicate their consent to being contacted regarding participation in the qualitative component of the study. Those who consented were contacted for feedback on their overall experience about the WMG-E program. Convenience sampling was used whereby approximately one in ten of the 227 families from the regional/rural site of Murrumbidgee (i.e., 25 families) were invited directly by a researcher after the 12-month follow-up period for an interview. Ten parents (six intervention, four control) were available to be interviewed, and they formed the study sample. Similarly, service providers who participated in the study\u0026rsquo;s implementation were approached to provide their feedback. Six service providers and one service navigator were invited to participate in a semi-structured interview. Information about the study was presented to potential participants using information sheets. Written informed consent was obtained from participants, including consent for audiotaping.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eMurrumbidgee LHD spans 125,243 km\u003csup\u003e2\u003c/sup\u003e across southern NSW, operating 33 public hospitals and 12 community health centres (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Approximately 13% of the district\u0026rsquo;s population live in areas of high socioeconomic disadvantage, with 10% of families experiencing low-income and welfare-dependence (compared to 8.8% for entire NSW) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The Murrumbidgee primary care network consists of CFHS, GPs, paediatricians, pharmacies, and local government councils. In NSW, the My Personal Health Record (\u0026ldquo;Blue Book\u0026rdquo;) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) that records the child\u0026rsquo;s health and illnesses, and growth and development, and contains related health information is the primary tool available for families to monitor the progress of their child\u0026rsquo;s growth and development. The Blue Book is provided to parents at the time of their child\u0026rsquo;s birth, and available to children born interstate or overseas. Links to a range of support and parenting services are available in the Blue Book, including translated versions for non-English speaking families. Conducted in the context of the COVID-19 pandemic, this study coincided with a significant reduction in the in-person service capacity of the CFHS. This period was marked by heightened health and safety measures, necessitating a shift in traditional service delivery methods. Face-to-face health services were hindered due to closure of the community clinics and the reassignment of staff for COVID-19-related duties.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Procedure\u003c/h3\u003e\n\u003cp\u003e This study was approved by the South Western Sydney Local Health District Human Research Ethics Committee (HREC reference 2020/ETH01418), and all participants provided written informed consent. Qualitative interviews were conducted online and lasted between 15 and 30 minutes. A researcher trained in qualitative inquiry conducted the interviews guided by a semi-structured interview schedule with open-ended questions to encourage detailed responses (see Appendix 1). The interviews were digitally recorded and transcribed verbatim. All transcripts were de-identified prior to uploading the files to NVivo 12 software (Version 12.6.0.959, Pro Edition; QSR International, United States of America) for data analysis.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eReflexive thematic analysis (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) was used to analyse the transcript data. A predominantly inductive approach was used, while incorporating a small degree of deductive analysis to ensure that the coding contributed to the identification of themes that align with the research objectives. Both semantic and latent coding were used to capture the explicit and underlying meanings within the data, with no attempt to prioritise one over the other. Braun and Clarke\u0026rsquo;s six-phase analytical process (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) guided the analysis. First, familiarisation of the data occurred by reading transcripts multiple times. Using NVivo 12, participant responses with similar meanings were organised into nodes, and those with conceptual similarities were developed into candidate themes. Themes were then revised and renamed through discussions with the research team and final themes were decided upon during the writing process. To enrich the depth of the analysis, two external researchers (PJH and KRB) independently coded all the data and identified themes, with ongoing discussions around themes and subthemes facilitated by the WMG-E project manager (TW). KRB had extensive previous experience with qualitative research, and PJH was trained in qualitative methods prior to analysis. The researchers met several times over a few months to discuss themes, and any disagreements were resolved through discussions with the WMG-E project manager. The process of converging on the final themes involved a discussion between the researchers. Participant quotes included in the results section were edited for grammatical errors to increase readability. The study has been reported in line with the Standards for Reporting Qualitative Research (see Appendix 2) (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eData were collected from 16 participants including ten parents and six service providers. Of the ten parents, six were intervention families and the remaining four were control participants. Most parents (90%) were females; with 60% aged between 31 to 40 years, 30% aged between 21 to 30, and the remaining aged 41 to 50. All participants had attained education to the level of high school (30%) or above, with 20% having a bachelor and 20% a postgraduate degree and 30% a Vocational Education Training. Most of the family participants (80%) identified themselves as Australian, with one as Aboriginal/Torres Strait Islander Australian, and another identified as non-Australian. All parents identified English as their primary language spoken at home.\u003c/p\u003e \u003cp\u003eService providers included five staff employed within Murrumbidgee LHD and one service navigator. Of the five Murrumbidgee staff, three were engaged in management or leadership roles within the LHD, and two were employed as nurses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eThemes\u003c/h2\u003e \u003cp\u003eThree major themes were identified regarding enablers, barriers, and feedback suggestions about the current CFHS, the WMG-E weblink, and the WMG-E service navigator (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e \u003cb\u003e\u0026lt;INSERT FIGURE 1 HERE\u0026gt;\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eNote\u003c/strong\u003e \u003cp\u003eWMG-E, Watch Me Grow-Electronic.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eLight blue\u0026thinsp;=\u0026thinsp;expressed by family members and service providers; dark blue\u0026thinsp;=\u0026thinsp;expressed by family members; green\u0026thinsp;=\u0026thinsp;expressed by service providers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eEnablers of the current CFHS\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eComprehensive, Friendly, and Personalised Support\u003c/h2\u003e \u003cp\u003eService providers emphasised the comprehensive support measures available for families. They elaborated on the diversity of support offered, from child development and playgroups to mental health and psychosocial assistance:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;[CFHS provides] a holistic approach in relation to families \u0026ndash; keeping them safe and giving them information about making healthy and good choices for themselves and their children\u0026rdquo; (Service Provider SP07).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eFlexibility\u003c/h2\u003e \u003cp\u003eBoth families and service providers reflected on the adaptability of the CFHS, emphasising the benefits of the quick adoption of a flexible virtual care model during COVID-19:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We also formally implemented a two-pronged approach to our universal home visits, which meant that the first half of it was delivered by the virtual care. The second part was delivered in the home, cutting down the amount of time clinician was in the home and keeping everyone safe\u0026rdquo; (Service Provider SP07).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe flexibility of the virtual care model was exemplified by an option for in-person engagements for families who could not participate in telehealth consults. Parents described a positive experience using telehealth and service providers reported positive feedback from the service:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eIf they couldn't participate in my virtual care, we went and did the universal home visit after COVID-19 screening\u0026hellip; the feedback from the clients is they really like it [telehealth]\u0026rdquo; (Service Provider SP07).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eBarriers of the current CFHS\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eService Capacity\u003c/h2\u003e \u003cp\u003eFamilies and service providers noted limitations of the local CFHS capacity in the context of the COVID-19 pandemic. Service providers reported difficulties engaging families and COVID-related staffing challenges:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We don\u0026rsquo;t have a local child and family health nurse, so we have to borrow one from other towns\u0026hellip; and their visits are quite quick because they have to do community health as well\u0026rdquo; (Parent MU128).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIt was reported that some families missed routine developmental screens due to staffing challenges. Service providers voiced their concern that staffing challenges would be ongoing:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We haven't been able to fully fill the vacancies that have been left. And while we are in a situation like that, obviously we can't be offering our full range of services in the timely way, because we've had to prioritize those who most need the service\u0026rdquo; (Service Provider SP08).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne parent described how their remote location posed difficulties for accessing in-person services.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePerceived enablers of the WMG-E weblink\u003c/h2\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003eInformative\u003c/h2\u003e \u003cp\u003eNumerous parents remarked on the weblink\u0026rsquo;s utility and how the feedback offered valuable insights into their child's growth and development:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I would've had no idea that [my child] was behind with his speaking if there wasn't that simple survey\u0026rdquo; (Parent MU23).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFor families where the weblink identified developmental issues, participants highlighted the weblink\u0026rsquo;s effectiveness in alerting parents to address these concerns and seek assistance:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If you had issues, [the weblink] would flag it and then you could follow that up\u0026rdquo; (Parent MU02). \u0026ldquo;I would recommend this program for families to use as it has alerted me with some issues that I can address\u0026rdquo; (Parent MU186).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eAccessibility\u003c/h2\u003e \u003cp\u003eBoth families and service providers praised the accessibility of a digital approach. Service providers described how the increasing societal transition to a digital era means that many families now have access to electronic devices. Families discussed how the weblink was readily accessible, particularly for those who prefer connecting through technology or might be more comfortable with a digital service:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I'm not gonna go and sit down with a nurse and open my heart up with them, but that app or something like it would be more feasible and I wouldn\u0026rsquo;t have done the checks without it\u0026rdquo; (Parent MU23).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eService providers mirrored the notion that apps are beneficial in a digital era. They suggested that the weblink may be particularly helpful for connecting with tech-savvy parents:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think if we are going to stay relevant and engage people, apps are really necessary now\u0026rdquo; (Service Provider SP08).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eService providers highlighted benefits of the weblink for families who don\u0026rsquo;t engage with CFHS:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Not all parents engage in child and family health. Like they may go to their GP for immunisations and sometimes the GP doesn't even look at the Blue Book. So, for them having that weblink would be really good\u0026rdquo; (Service Provider SP06).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne parent described how their remote location posed difficulties for accessing in-person services, while providers highlighted the weblink\u0026rsquo;s advantage in connecting families situated far from metropolitan areas:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I also think in a rural area, some families don't have the ability to travel, and they don't have a car, or the nurse can't come out to visit them because it's too far. I think this [weblink] is another alternative\u0026rdquo; (Service Navigator).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eUser-Friendly\u003c/h2\u003e \u003cp\u003eMost families expressed that the weblink was user-friendly and simple to navigate, and they could complete the survey quickly:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I didn\u0026rsquo;t have any issues. I found it [the weblink] really easy\u0026hellip; I think it\u0026rsquo;s a really simple tool to use\u0026rdquo; (Parent MU02).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eBarriers of the WMG-E weblink\u003c/h2\u003e \u003cdiv id=\"Sec24\" class=\"Section4\"\u003e \u003ch2\u003eDigital Format\u003c/h2\u003e \u003cp\u003eWhile the use of digital technology was identified as an enabler for service accessibility, concerns were raised about the weblink\u0026rsquo;s capacity to service families in rural and remote regions. Particular concerns were raised about the internet access requirements:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eSome of our most vulnerable families that can't access services might also be the ones that live in really remote, out of the way places that may not have the greatest service\u0026hellip; they're also the ones that might be the most financially strapped\u0026hellip; and they don't have access to data\u0026rdquo; (Service Provider SP09).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAdditionally, one parent expressed difficulties accessing the weblink. Concerns were raised that the weblink may not be readily accessible for non-English speaking families (although translations are available in select languages), those with learning difficulties, or those with low health literacy:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The next barrier would be probably their [families\u0026rsquo;] capacity to use it [the weblink]\u0026rdquo; (Service Provider SP08).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eLimited Oversight\u003c/h2\u003e \u003cp\u003eParents and service providers expressed concerns about a model that did not directly involve clinicians for developmental and psychosocial screening. Parents indicated there was a potential for the weblink to overlook certain concerns:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If they [parents] actually have like serious mental health concerns, maybe things aren't getting picked up because it's behind a screen. A trained nurse can observe things in a face-to-face\u0026rdquo; (Parent MU19).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eService providers echoed this sentiment, emphasising that the survey should be conducted under the guidance of a qualified professional. They suggested that the weblink may fail to grasp the broader context and impact of parents:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It can quite often come down to how the person's feeling on the day and how they might think that the child behaved at that particular very point when they're doing [the digital questionnaire]... unless [a clinician] is there to actually screen and talk to them around the questions and that sort of thing, they may not get the full picture\u0026rdquo; (Service Provider SP09).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eService providers shared how parents might become anxious or perceive a problem with their child if they received survey results without clinician or service navigator input:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;By [Parents] getting the results before we talk to them, they kind of freak out and it\u0026rsquo;s a bit like looking up Google doctor cause they kind of go, oh, I got a problem with my child. How am I gonna fix this?\u0026hellip; Anxiety sort of sinks in a bit. If they didn\u0026rsquo;t have mental health [problems], then they start having them\u0026rdquo; (Service Navigator).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eService providers discussed how mental health and psychosocial risk might not be identified or that risk may be identified but not appropriately followed up through the weblink:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e \u0026ldquo;[Parents] maybe don't see themselves as vulnerable sometimes as we do... So they can be putting in part of the information, but if they were sitting face-to-face with somebody who was skilled, that could be looking quite different\u0026rdquo; [Service Provider SP08).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne service provider shared how service navigators could help parents understand the survey results and provide parents with connection:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think having a service navigator [call] saying, \u0026lsquo;I've noticed you completed survey results. I just want to have a chat to you. Look, there's help at hand and I'll be able to give you this. And I think sort of having that sort of connection rather than just black and white writing\u0026rdquo; (Service Navigator).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eEnablers of the WMG-E Service Navigator\u003c/h2\u003e \u003cdiv id=\"Sec27\" class=\"Section4\"\u003e \u003ch2\u003eConnection to Services\u003c/h2\u003e \u003cp\u003eService providers highlighted the value of the service navigator in assisting families to navigate an increasingly complicated healthcare system:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;[The service navigator] would be very useful because quite often people actually don't know what the first step is to access services. And it's a bit of a minefield. And if you haven't been through that system before you know, an assisted program is a good one\u0026rdquo; (Service Provider SP07).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParents commented that the navigator provided regular follow-ups while connecting them to relevant supports:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;[The service navigator] called me a couple of times and it was all good\u0026rdquo; (Parent MU180). \u0026ldquo;It [the service navigator] was definitely a push I needed to help get those services\u0026rdquo; (Parent MU102).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eService providers discussed the ability of the service navigator to connect with families who do not interact with CFHS:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It's good for those families that do not want to reach out to us or a direct service, as this program allows families to get support via a service navigator, at least this way we can cover all families in Murrumbidgee LHD and those we have missed\u0026rdquo; (Service Provider SP10).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eSupport While Waiting\u003c/h2\u003e \u003cp\u003eService providers indicated that the service navigator offers ongoing support and provides alternative options for families during long waitlist periods:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We are down on staff so I can see an absolute advantage for people to be able to use something like this, have a point of contact, have someone they can talk to who can reassure redirect, prioritize. I think it's fantastic\u0026rdquo; (Service Provider SP08).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eAlleviates Strain on Services\u003c/h2\u003e \u003cp\u003eService providers described the beneficial nature of the service navigator in redirecting and/or reprioritising workload in rural and remote regions where the service capacity is limited:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;In a remote area where we've got limited services for child and family, definitely it [the service navigator] is a good idea\u0026rdquo; (Service Provider SP06).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFeedback suggestions provided by study participants\u003c/h3\u003e\n\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eStrengthen Collaboration\u003c/h2\u003e \u003cp\u003eOne service provider shared they were not made aware of families in need and that the project could have been improved with more collaboration between the service navigators and CFHS:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think it would be a good idea to have monthly meetings to discuss those families in need and we can brainstorm together in what support we could provide and to also look if we are already seeing these families and providing support. I think working together would have been better\u0026rdquo; (Service Provider SP10).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAs digital technologies are increasingly embedded within daily life, there is heightened interest in the application of electronic health and digital health tools (\u003cspan additionalcitationids=\"CR30 CR31\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). This study examined family and service provider attitudes towards WMG-E, a developmental screening and service navigation program that was implemented in remote and regional Australia. The aim of the study was to determine the feasibility and acceptability of WMG-E weblink as a developmental screening/monitoring tool for rural families and local service providers, and examine whether the addition of a service navigator increased access to and uptake of support services.\u003c/p\u003e \u003cp\u003eThe findings highlight the growing demand for digital-friendly early childhood services, with the digital nature of WMG-E described as a useful avenue to connect with parents who prefer digital mediums. While CFHS provides a comprehensive and diverse range of support services including telehealth, providers acknowledged the discernible gap when connecting with parents that lean towards non-traditional communication avenues. Through WMG-E\u0026rsquo;s digital interface, CFHS can now tap into a previously unexplored and rapidly expanding consumer group who desire the versatility of digital healthcare engagement (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Further, WMG-E enables wider reach to identify people with concerns and hence would benefit from further assessment. This allows those who are identified through the WMG-E screening to be followed up by the state developmental services via the CFHS, thereby increasing efficiency of the limited resources.\u003c/p\u003e \u003cp\u003eFor families in remote areas, physical distance presents a significant barrier to health services (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This is amplified in Australia where nearly a third of the population live in regional or remote locations (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Service providers described how the weblink allowed families to access developmental screening services without undergoing an extensive journey to their local service provider. Given the limited reach of CFHS in some areas (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), the weblink can address a service gap. It would be particularly helpful in reducing rural families' reliance on travel, enabling them to engage with developmental checks more readily and those with specific needs to be prioritised for assessment by CFHS.\u003c/p\u003e \u003cp\u003eHowever, it is possible that not all rural families can embrace the accessibility benefits of digital health tools, with providers suggesting that the program\u0026rsquo;s dependence on internet connectivity might exclude some families. The Australian context presents a pronounced disparity between populations that can effectively use digital resources and those who cannot, often referred to as a \u0026lsquo;digital divide\u0026rsquo; (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Only one third of Australia\u0026rsquo;s total land area has mobile connectivity, leaving many rural and remote families digitally disconnected (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Additionally, the financial burden of acquiring and maintaining a stable internet connection disproportionately affects vulnerable populations, leading to their exclusion from digital services (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Service providers voiced concern over internet related financial strains. They indicated that programs dependent on internet connection might pose accessibility challenges for rural and vulnerable populations. Providing pre-paid internet dockets to remote families as part of the roll-out of such initiatives would help address this.\u003c/p\u003e \u003cp\u003eStudies corroborate that individuals living with a disability, racial or ethnic minorities, low income households, people over the age of 75 years, and people living in remote parts of Australia are less likely to have the financial security to secure internet access (\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Additionally, nearly 30% of Aboriginal and Torres Strait Islander people living in remote communities remain without internet (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Thus, the combination of inadequate rural infrastructure and the financial challenges of maintaining internet connection creates a significant hurdle for priority populations, limiting their ability to engage with digital health services. It is crucial to sustain in-person services for people who cannot leverage the benefits of digital health while efforts are made to strengthen rural network coverage and equitable internet access.\u003c/p\u003e \u003cp\u003eThe global impact of the COVID-19 pandemic reshaped many avenues of care and necessitated healthcare innovations. In NSW, there was a significant reduction in face-to-face services (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Service providers described how CFHS adopted a virtual care model to minimise health service disruption. While the model was well-received, providers reported significant staffing challenges which they anticipated would persist in a post-pandemic era. WMG-E serves as an example of innovation in remote service delivery with the potential to alleviate staff workload. However, apprehension exists about the efficacy of developmental screening in the absence of a clinician \u0026ndash; as such, it is critical that when a concern is identified, parents are connected with relevant services so that the parental concerns can be clarified by a clinician. Similarly, providers noted that the absence of parent-child interactions as observed by a clinician might overlook concerns if this follow-up engagement with a clinician is not available. Evidence suggests that clinician observation of parent-child interaction provides a more accurate characterisation of children\u0026rsquo;s social-communication ability (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). However, remotely delivered screening tools have yielded equivalent psychometric data to those delivered in-person (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Regardless, several factors need to be considered to optimise digital administration, such as the involvement of a service provider or navigator throughout the screening process (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). The WMG-E weblink is intended to be completed in collaboration with a service provider who the family has an established relationship with, and in this regard, it is not to be completed in isolation.\u003c/p\u003e \u003cp\u003e Parents expressed concern that when problems were identified via remote use of the weblink, as it was during the COVID-19 pandemic, there was no immediate follow-up to support parents in their queries, explain what the results might mean, or provide guidance in accessing services. Service providers echoed this sentiment, noting that receiving results without supportive care could be a risk for vulnerable families. The limited scope of research investigating actions taken after positive developmental screens (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) makes it difficult to determine the best ways to support families who are flagged as at risk. However, the incorporation of a service navigator to remote screening tools as it was done in the intervention arm of the WMG-E RCT, study will address this issue as the navigator can help parents understand the screening results and guide them towards appropriate services (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSupportive care provided by the service navigator might overcome some of the barriers identified on the use of the weblink on its own. Transitions between various healthcare services can be confusing and complicated for patients resulting in fragmented care (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Service providers indicated that the convoluted nature of the health system posed significant challenges for families. They described the benefits of the service navigator in providing a \u0026lsquo;warm hand over\u0026rsquo; and a smooth transition between local services. Service providers also acknowledged the staffing limitations of traditional services that can lead to lengthy wait periods for families. They suggested that the weblink and navigator are particularly beneficial in a rural area with limited services, allowing families to receive supportive care during the waiting period, thereby potentially increasing ongoing engagement and follow-up with positive results. Providing continuity of care via a service navigator is a means to integrate health systems and facilitate better transitioning across care settings (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). In other fields, patient navigation systems have increased participation in both screening and adherence to diagnostic follow-up care after a positive screen (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Service providers indicated that a navigation system would help CFHS reach families who would otherwise not engage and thus be missed. Hence, this system has the potential to increase the rate of both developmental screening and subsequent follow-up with specialist providers in rural areas.\u003c/p\u003e \u003cp\u003eIn terms of study implementation, a service provider identified a need for increased collaboration between service navigators and CFHS, particularly in recognising and addressing the needs of families. While monthly \u0026lsquo;triage and review\u0026rsquo; meetings to collectively identify and support families in need were an original part of the WMG-E implementation, they were disrupted by the COVID-19 pandemic, underscoring the challenges faced in maintaining collaborative practices in restricted service environments.\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Health Practice and Policy\u003c/h2\u003e \u003cp\u003eThis study underscores the growing demand for digital health services, especially in remote and rural areas where access to traditional health services is a persistent challenge due to distance from services and limited resources. The WMG-E weblink offers a promising solution to developmental screening barriers faced by geographically isolated families in regional Australia. Its capability to engage parents and reduce the need for physical commutes addresses significant gaps in traditional service delivery. However, there are limitations. The requirement of internet accessibility and its associated financial burden might pose challenges for certain populations. Additionally, while digital tools might offer convenience, they cannot yet fully replicate the depth of clinician observations during face-to-face assessments. The introduction of service navigators can mitigate some of these concerns, offering supportive care post-screening and guiding families towards appropriate care pathways. Service navigation might also enhance care continuity and assist in bridging fragmented health services. Thus, while digital developmental screening tools like WMG-E hold significant promise, they should ideally be integrated into a broader care model, ensuring that families not only have access to digital screening but also receive necessary follow-up care and support with CFHS. Hence, the weblink and service navigator might function best in harmony with CFHS to alleviate staffing challenges and travel burden for rural families where appropriate, while keeping face-to-face visits embedded within routine practice. Outcomes from the RCT will shed light on the effectiveness of WMG-E in this respect.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis study has several strengths. The use of a qualitative approach has provided rich and detailed insights into the end-user\u0026rsquo;s experiences of the WMG-E platform, offering an in-depth understanding of the context and nuances that quantitative data alone cannot capture. Sample size was informed by the concept of information power and its dimensions of study aim, sample specificity, use of established theory, quality of dialogue and analysis strategy (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Specifically, the study was relatively narrow in focus and dialogue was strong with an interviewer with expertise in qualitative inquiry, creating higher information power. The use of multiple researchers throughout the coding and theme development process ensured research rigor and a rich interpretation of the data.\u003c/p\u003e \u003cp\u003eThe study also has several limitations. The sample was not diverse in terms of gender, with 90% of parents and all service providers identifying as female. The limited inclusion of fathers and male service providers might overlook gender-based differences in experiences and outcomes. All participating families and service providers were English-speaking, which could restrict the applicability of the study's results to non-English-speaking populations. However, the WMG-E weblink was made available in four other languages besides English. Insights from a multicultural community, distinct from this study\u0026rsquo;s scope, are presented separately (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eDigital health tools like WMG-E have the potential to transform developmental screening in rural and remote areas, addressing logistical barriers and tapping into the digital preferences of the younger generation. However, to fully embrace this potential, governments must address infrastructure and financial limitations posed by internet access. It is paramount that such tools do not inadvertently exacerbate healthcare disparities, particularly in remote Australian communities. Integrating supportive elements, such as service navigators, can ensure that families are adequately guided and supported for further assessments and follow up support when needs are identified, thereby increasing the capacity and efficiency of the service system, and offering continuity of care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCare as usual (CaU); Child and Family Health Services (CFHS); General practitioner (GP); Kessler Psychological Distress Scale (K10); Learn the Signs. Act Early. (LTSAE); Local Health District (LHD); New South Wales (NSW); Randomised controlled trial (RCT); Watch Me Grow-Electronic (WMG-E)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study conforms to the principles outlined in the Declaration of Helsinki. All methods were carried out in accordance with relevant guidelines and regulations of The National Statement on Ethical Conduct in Human Research (2023). The South Western Sydney Local Health District Human Research Ethics Committee approved this study (2020/ETH01418). All participating parents have provided written informed consent prior to participation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData from the current study will not be made available, as participants did not consent for their transcripts to be publicly released. Instead, extracts of participant responses have been made available within the manuscript. Please contact the corresponding author, Professor Valsamma Eapen, for any data requests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work underwent an independent peer review and was funded by the NSW Health COVID-19 Research Grants Round 2 in partnership with University of New South Wales, South Western Sydney Local Health District, Murrumbidgee Local Health District NSW Health, Sydney Children’s Hospital Randwick, Western Sydney University, Ingham Institute for Applied Medical Research, Black Dog Institute, Uniting and Karitane. The funding body did not contribute to the design of the study or in writing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePH – data analysis and writing- original draft. KRB – data analysis and writing- review and editing. TW – study design, participant recruitment, data collection, data analysis, and writing- review and editing. SW – participant recruitment, data collection and writing- review and editing. CLC – writing- review and editing. MS –participant recruitment, data collection and writing- review and editing. JK – study design and writing- review and editing. \u0026nbsp; JP – study design and writing- review and editing. \u0026nbsp;SW – study design, supervision and writing- review and editing. \u0026nbsp;VE – study design, supervision and writing- review and editing. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the parents, service providers, and service navigator who participated in this study. We also would like to acknowledge and thank the Watch Me Grow-Electronic (WMG-E) study group that contributed to the scope of the project: Valsamma Eapen, John Preddy, Susan Woolfenden, Teresa Winata, Si Wang, Melissa Smead, Jane Kohlhoff, Virginia Schmied, Bin Jalaludin, Kenny Lawson, ST Liaw, Raghu Lingam, Andrew Page, Christa Lam-Cassettari, Katherine Boydell, Daniel P. Lin, Ilan Katz, Ann Dadich, Shanti Raman, Rebecca Grace, Aunty Kerrie Doyle, Tom McClean, Blaise Di Mento,Sara Cibralic, Anthony Mendoza Diaz, Jodie Bruce, Nicole Myers, Joseph Descallar, Cathy Kaplun, Amit Arora, Victoria Blight, and Angela Wood.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eClark MLE, Vinen Z, Barbaro J, Dissanayake C. School Age Outcomes of Children Diagnosed Early and Later with Autism Spectrum Disorder. J Autism Dev Disord. 2018;48(1):92\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarger B, Rice C, Wolf R, Roach A. Better together: Developmental screening and monitoring best identify children who need early intervention. Disabil Health J. 2018;11(3):420\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZwicker JG, Lee EJ. Early intervention for children with/at risk of developmental coordination disorder: a scoping review. 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Qual Health Res. 2016;26(13):1753\u0026ndash;60.\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":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Child development, Developmental checks, Digital developmental surveillance, Service navigation, Regional and rural families, Qualitative inquiry","lastPublishedDoi":"10.21203/rs.3.rs-6373635/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6373635/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEncouraging healthy childhood development and aiding the early identification of developmental difficulties are crucial to providing the best possible outcomes. Young children in rural areas are at a higher risk of missing timely developmental screening than their non-rural counterparts. This study examined the feasibility and acceptability of a digital developmental surveillance program with a service navigator, Watch Me Grow-Electronic (WMG-E), trialled in rural Australia via a randomised controlled trial (RCT).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eQualitative data were collected from semi-structured interviews with ten parents who participated in the RCT (six intervention, four control) and six service providers. Transcripts were analysed via reflexive thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study revealed barriers and enablers of both the existing Child and Family Health Services (CFHS) and the WMG-E program comprising of a weblink and service navigation. Enablers of the CFHS included the flexible service options and comprehensive support model, while also acknowledging the resource barriers and service capacity limitations during the COVID-19 pandemic. Enablers of WMG-E weblink included its valuable feedback on child development, digital accessibility benefits, and user-friendly interface. Barriers of the WMG-E weblink included limited clinician oversight during survey completion, and technological barriers related to the digital format. Enablers of the WMG-E service navigation included the ability to address service gaps by connecting families to local services, provide support during waitlist periods, and alleviate the strain on understaffed remote healthcare facilities.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAccess to digital support was perceived as particularly valuable during the COVID-19 pandemic when services were closed. The WMG-E program offers a promising avenue to improve the accessibility and uptake of developmental screening services in rural Australia when functioning in harmony with existing care providers.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003eThe study is part of a randomised controlled trial (Protocol No. 1.0, Version 3.1) registered with ANZCTR (registration number: ACTRN12621000766819, July 21st, 2021) and reporting of the trial results will be according to recommendations in the CONSORT Statement.\u003c/p\u003e","manuscriptTitle":"Parent and Service Provider Perspectives of a Digital Developmental Surveillance and Service Navigation Program in Rural Australia: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-09 11:04:15","doi":"10.21203/rs.3.rs-6373635/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-05-05T08:25:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-29T06:54:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-08T12:27:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-08T12:01:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-04-08T11:59:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cd6b0fef-1d48-47eb-aa4f-c7144ac55d53","owner":[],"postedDate":"May 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-05-09T11:04:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-09 11:04:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6373635","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6373635","identity":"rs-6373635","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}