Design
RECRUITMENT
When the HWF pilot study was registered with the Australian and New Zealand Controlled Trials Registry (ACTRN12620000154909, 13 February 2020), it was designed as a feasibility RCT in one Victorian site. However, implementation and evaluation during the COVID-19 pandemic required protocol iterations developed through continuous quality improvement, which incorporated quantitative and qualitative elements. When recruitment ended on 30 June 2022, we had attempted iterations of HWF in five sites across two states. Overall, the model was infeasible in sites 1–4 and feasible in site 5. Healthier Wealthier Families data collection phases and research designs. RCT, randomised controlled trial.Methods for the Healthier Wealthier Families implementation and quantitative evaluationIn the last year, because of money pressure, caregiver missed or put off: (a) mortgage or rent repayments, (b) electricity, gas, water bills, (c) buying prescription medicines, (d) paying home or car insurance.No one in household has a paid job.Family does not have at least $A500 in savings for an emergency.Potential participants who agreed to complete screening survey (CFH report based on service records).Eligible caregivers who consented to participate (CFH and study records).Participants who accessed, attended and completed the intervention (financial counsellor report, caregiver report).Caregivers who completed the follow-up questionnaire (study completion records).CFH, child and family health; CONSORT, Consolidated Standards of Reporting Trials; RCT, randomised controlled trial; STROBE, Strengthening The Reporting of Observational Studies in Epidemiology.To understand barriers to feasibility encountered in 2020, a qualitative implementation evaluation commenced in February 2021 (Methods for the Healthier Wealthier Families implementation and qualitative evaluationIn sites 2 and 3, R3 and R4 conducted interviews with the service providers. R3 and R4 had established relationships with the team in site 3 from regular project meetings but no previous relationship with the provider in site 2.In sites 4 and 5, R2 conducted interviews with the service providers; there were no existing relationships. As R1 had previous interactions they did not conduct these interviews.In site 5, R1 and R2 conducted the caregiver interviews; there were no existing relationships.The involvement of R1 and R3 in the conceptualisation and implementation of the project meant there was the potential for bias related to emotional investment.Reflexive journals were kept by R1 and R3 and used to document reflections after their interviews/focus group.In sites 2 and 3: R3 conducted a focus group with 5 CFH providers and one interview with a CFH provider.In site 3: R4 conducted interviews with CFH providers and one financial counsellor.In sites 4 and 5: R2 conducted interviews with 6 service providers one caregiver.In site 5: R1 conducted interviews with seven caregivers.In site 3, 5 service providers were invited to participate and none (0) declined.In site 4, 10 service providers were invited to participate, 4 did not respond, 1 declined, 1 agreed but was sick on the day of the interview and was not rescheduled.In site 5, 10 caregivers were interested in participating; however, 2 were not interviewed. One was unavailable at their scheduled interview time. One was not engaged due to difficulties in finding an interpreter in their first language.Data in sites 2 and 3 were collected by a focus group held face-to-face and individual interviews conducted by phone. These were recorded verbatim, transcribed by an external agency, cleaned and saved as Word document.Data in sites 4 and 5 were collected via phone or videoconferencing. These were electronically transcribed, cleaned and saved as Word documents.CFH, child and family health; NSW, New South Wales.Experiences and perceptions of the screening and referral processes:1.1. CFH providers had differing opinions about the usefulness of financial screening and relevance to their own practice, which were related to delivery of universal or higher intensity services.1.2. There were issues with engagement due to the research processes.1.3. The COVID-19 pandemic affected service provision and levels of financial hardship.Barriers to identifying financial hardship and accepting help included:2.1. Stigma surrounding financial hardship and accepting a referral to a financial counsellor.2.2. Financial counselling was not well understood by CFH providers or families.2.3. Clients in crisis may have other priorities.2.4. Financial literacy and cultural and family considerations.Factors that enable engagement with families with the HWF model (classified as suggestions rather than subthemes):Support service providers to understand the role of financial counselling.Provide resources to families about financial hardship and financial counselling.Ensure accessible and inclusive communication.Financial counselling services provide client-centred care, not service led.The above themes and findings informed iterations to the HWF protocol that were trialled with two new sites (sites 4 and 5, commencing mid-late 2021, see 