Discussion
This Australian pilot study aimed to test the feasibility and short-term impacts of a systematic referral pathway between universal CFH and financial counselling services. While financial hardship screening by CFH providers was broadly acceptable to caregivers of young children, a feasible referral model was established in only one of five sites. Challenges to implementation were exacerbated by the COVID-19 pandemic. Australian policies are increasingly recognising the role of healthcare in addressing early adversitiesStrengths of this study included the iterative, dynamic approach to piloting in five sites across two Australian states. Adaptation of the protocol during the COVID-19 pandemic enabled identification of design components that contributed to feasibility. Recognised by the dynamic sustainability framework,Limitations include the small sample sizes and limited demographic data for describing the qualitative cohorts; the short-term follow-up; lack of control group; and lack of quantitative data on non-financial impacts. In site 5, the pre–post evaluation could have provided a self-control design if pre-enrolment experiences of financial activities (eg, counselling, use of MoneySmart, legal aid) were measured. Further, the high levels of missing data on emotional well-being measures reflected the difficulty in embedding new measures into CFH and financial counselling practice. Indeed, the latter does not typically inquire about caregivers’ mental health needs because it can require a therapeutic response that is outside the scope of practice. Of the available data, there were high levels of emotional distress (low well-being) at screening and intake. While it was reassuring that the available measures (MGMQ and PWI) demonstrated higher emotional well-being at follow-up than intake, the sample sizes were too small to draw conclusions. The substantive challenges encountered in developing a feasible model of HWF (sites 1–4), and collecting quantitative data on non-financial impacts to enable evaluation of a feasible model (site 5) highlight the challenges that are inherent in conducting a definitive multisite effectiveness trial of HWF. Any implementation at scale will require careful and staged adaptations that test how HWF can benefit communities in the ‘post-COVID-19’ landscape. This includes matching of population characteristics to the healthcare intervention, and low burden evaluation through routine data collection. However, we anticipate that the HWF model would become more feasible in the postpandemic context, especially as financial supports ended, and cost-of-living pressures increased.The intention of HWF is to use universal healthcare to screen and respond to financial hardship, to prevent financial crisis and its negative impacts on children and families. The sizeable proportion of caregivers disclosing financial hardship in the universal CFH services was commensurate with the low socioeconomic status of the participating sites. Even so, screening for financial hardship challenged many providers’ perception of their model of care. The levels of financial hardship did not outweigh other negatives such as stigma, lack of knowledge of financial counselling, the burden of the research processes or the pandemic disruption. There are parallels between this study and evaluation of the roll-out of family violence screening by CFH services in Victoria, which found that CFH providers selectively screened women about family violence.