Background: Patients who discharge against medical advice (DAMA) from hospital carry a significant risk of readmission and have increased rates of morbidity and mortality. We sought to identify the demographic and clinical characteristics of DAMA patients from a tertiary paediatric hospital. Methods: Data were extracted retrospectively from electronic medical records for all inpatient admissions over a 5-year period. Demographic characteristics (age, sex, Aboriginality, socioeconomic status and remoteness of residence) and clinical characteristics (admitting hospital site, level of urgency on admission, diagnosis and previous DAMA) were extracted and logistic regression models were used to identify predictors of DAMA with 95% confidence intervals. Results: There were 246,359 admissions for 124,757 patients, of which 1871 (0.8%) admissions and 1730 patients (1.4%) DAMA. Predictors of DAMA in a given admission were hospital site (OR 4.8, CI 4.2–5.7, p < 0.01), a mental health/behavioural diagnosis (OR 3.3, CI 2.2–4.8, p < 0.01), Aboriginality (OR 1.6, CI 1.3–2.1, p < 0.01), emergency rather than elective admissions (OR 0.7ha, CI 0.6–0.8, p < 0.01), a gastrointestinal diagnosis (OR 1.5, CI 1.1–2.0, p = 0.04) and a history of previous DAMA (OR 2.0, CI 1.2–3.2, p = 0.05). Conclusions: There are clear predictors of DAMA in this tertiary hospital admission cohort and identification of these provides opportunities for intervention at a practice and policy level in order to prevent adverse outcomes.

IntroductionImmigration detention has a profound and negative impact on the physical health, mental health, development and social-emotional well-being of children, adolescents and their families. Australian clinicians will report results from detailed health and well-being assessments of asylum seeking children and adolescents who have experienced prolonged immigration detention.Methods and analysisThis is a national, multicentre study with a longitudinal cohort design that will document health and well-being outcomes of the children and adolescents who have been detained in offshore detention on the remote island of Nauru. Outcome measures will be reported from the time arrival in Australia and repeated over a 5-year follow-up period. Measures include demographics, residency history and refugee status, physical health and well-being outcomes (including mental health, development and social-emotional well-being), clinical service utilisation and psychosocial risk and protective factors for health and well-being (eg, adverse childhood experiences). Longitudinal follow-up will capture outcomes over a 5-year period after arrival in Australia. Analysis will be undertaken to explore baseline risk and protective factors, with regression analyses to assess their impact on health and well-being outcomes. To understand how children’s outcomes change over time, multilevel regression analysis will be utilised. Structural equation modelling will be conducted to explore the correlation between baseline factors, mediational factors and outcomes to assess trajectories over time.Ethics and disseminationThis research project was approved by the Sydney Children’s Hospitals Network Human Research Ethics Committee. Subsequent site-specific approvals have been approved in 5 of the 11 governing bodies where the clinical consultations took place. In order to ensure this research is relevant and sensitive to the needs of the cohort, our research team includes an asylum seeker who has spent time in Australian immigration detention. Results will be presented at conferences and published in peer-reviewed Medline-indexed journals.

Multi‐site research studies are essential if we are to conduct national research across all Australian jurisdictions. There is widespread agreement among clinicians and researchers that obtaining essential approvals to conduct multi‐site research studies in Australia can be complex, bureaucratic and time consuming. Although there is inherent value in the review process, resources and months of valuable research time are often expended long before the study has begun. Using our recent experience for a multi‐site, longitudinal paediatric cohort study of children and adolescents who were detained in offshore immigration detention on Nauru, we describe the process of navigating the ethics and governance approval systems. We identify tips for researchers and clinicians conducting multi‐site studies, including early consultation with ethics and governance committees, using their recommended templates, anticipating time delays, and commencing time consuming processes as early as permissible. Our recommendations at the systemic level include streamlined and integrated ethics and governance review processes for all Australian jurisdictions, with co‐ordinated requests for further information, a standardised approach across all Research Governance Offices, a rapid system for addressing amendments and individualised study support and consultations. Above all, a nationally agreed framework whereby ethics and governance committees across jurisdictions communicate with each other, use the same electronic platform and present a unified process whilst protecting the welfare, rights, dignity and safety of research participants is required. The complexity of the current ethics and governance processes may inadvertently and unintentionally be a barrier to conducting ethical research.

ObjectiveTo describe the health and well-being of children and young people (CYP) seeking asylum subjected to Australia’s immigration policy of indefinite mandatory detention on Nauru.DesignCross-sectional analysis of a cohort of CYP seeking asylum.SettingAustralian paediatric clinicians from 10 health services completed detailed health assessments around the time of transfer from Nauru, mostly to Australia.ParticipantsSixty-two CYP who were ≤18 years on entry into offshore immigration detention on Nauru between 2013 and 2019. Mean age at health assessment was 9 years.Main measuresHealth outcomes were categorised as physical, mental or neurodevelopmental concerns/conditions. Risk and protective factor data were collected using the adverse childhood experiences and refugee-specific adverse childhood experiences tools.ResultsOver half of the CYP (n=32, 52%) were held on Nauru for ≥4 years. The vast majority of CYP had physical health (n=55, 89%) and mental health (n=49, 79%) concerns including self-harm or suicidal ideation/attempt (n=28, 45%). Mental health concerns were more likely in CYP who were school-aged (p=0.001), had been held on Nauru for ≥1 year (p=0.01); originated from the Eastern Mediterranean region (p<0.05); witnessed trauma (p<0.05) or had exposure to ≥4 refugee-specific adverse childhood experiences (p<0.05). Neurodevelopmental concerns were seen in eight children (13%).ConclusionsThis study highlights the almost universal physical and mental health difficulties in a sample of CYP who experienced forced migration and were subjected to Australia’s offshore immigration detention policy. Immigration detention in recipient countries, a known adverse childhood experience, may contribute to or exacerbate harmful outcomes in CYP seeking asylum.

A literature review of overweight and obesity prevention and management programmes for Australian Aboriginal and Torres Strait Islander children 5–17 years to inform a co‐design weight management intervention in an urban Aboriginal community. Systematic searching of PubMed, Science Direct, Lowitja LitSearch and hand‐searching of references, government and Aboriginal websites. Programmes were categorised as including nutrition and food literacy, cooking skills, health education and cultural components. Quality was assessed against the CREATE QAT Tool. Eight programmes, including two evaluations and six programme descriptions, were identified. Interventions ranged in duration from 1 day to 10 weeks involving nutrition education, health information, cooking skills, exercise and cultural content. There were no significant reductions in weight outcomes, although there were reported positive health changes to the children including a reduction in waist circumference and an increase in exercise levels. Insights for future research include effective co‐design with community and the delivery of flexible content through an Aboriginal‐led, multifaceted programme. There is limited evidence for the prevention and management of weight in Aboriginal children with overweight and obesity. Future research efforts should include more time‐intensive, multifaceted, community‐run programmes that are supported by medical, advocacy and evaluation expertise from health services.

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