Suchergebnisse

ABSTRACT
ObjectivesAlmost one-fifth of Australian Aboriginal mothers give birth before 20 years of age compared with 3% of non-Aboriginal mothers. We aim to quantify the effect of maternal age at birth on child development outcomes in Aboriginal compared with non-Aboriginal children.
ApproachThe 'Seeding Success' study cohort comprises an almost complete population of children who started school in Australia's most populous state, New South Wales (NSW), in 2009 or 2012, and were born in NSW, identified by linking Australian Early Development Census (AEDC) data to perinatal and birth registration datasets. Of the 154,936 children in the cohort, 8001 (5%) were Aboriginal. We calculated the risk of developmental vulnerability on one or more AEDC domains by maternal age at birth and Aboriginality. Risk differences and risk ratios (RR) were estimated as measures of absolute and relative inequalities, respectively. Multilevel Poisson regression was used to test the effect of maternal age on child development by Aboriginality.
Results1383 (17%) Aboriginal children were born to a mother <20 years compared with 4310 (3%) non-Aboriginal children. Among Aboriginal and non-Aboriginal children, the risk of developmental vulnerability decreased with increasing maternal age up to 35 years; the risk increased for children born to mothers >35 years. Among Aboriginal children, the risk decreased from 46% (95%CI, 39-52) to 31% (95%CI, 24-38) in children born to mothers' aged ≤16 years to age 35 years, respectively. In non-Aboriginal children, the risk decreased from 38% (95%CI, 33-43) to 16% (95%CI, 15-17) in those born to mothers' aged ≤16 years to 35 years, respectively. Risk differences and risk ratios for developmental vulnerability between Aboriginal and non-Aboriginal children increased with increasing maternal age. Compared to non-Aboriginal children born to mothers aged ≥20 years (ref group, RR, 1.0), the RR for developmental vulnerability was 1.7 (95% CI, 1.6-1.9) for non-Aboriginal children born to mothers aged <20 years; 1.6 (95% CI, 1.6-1.7) for Aboriginal children born to mothers aged ≥20 years; and 2.2 (95% CI, 2.0-2.3) for Aboriginal children born to mothers aged <20 years.
ConclusionChildren born to very young mothers had a high risk of vulnerability regardless of Aboriginality, whereas Aboriginal children had a greater risk of developmental vulnerability across the rest of the maternal age range. Both absolute and relative inequalities in developmental vulnerability increased with increasing maternal age. Early intervention and support services targeted at Aboriginal mothers and their children, regardless of the mother's age, may reduce this inequality.

A newborn screen designed to predict family risk was examined to: (a) determine whether all families with newborns were screened; (b) evaluate its predictive validity for identifying risk of out-of-home placement, as a proxy for maltreatment; (c) determine which items were most predictive of out-of-home placement. All infants born in Manitoba, Canada from 2000 to 2002 were followed until March 31, 2004 ( N = 40,886) by linking four population-based data sets: (a) newborn screening data on biological, psychological, and social risks; (b) population registry data on demographics; (c) hospital discharge data on newborn birth records; (d) data on children entering out-of-home care. Of the study population, 18.4% were not screened and 3.0% were placed in out-of-home care at least once during the study period. Infants not screened were twice as likely to enter care compared to those screened (4.9% vs. 2.5%). Infants screening at risk were 15 times more likely to enter care than those screening "not at risk." Sensitivity and specificity of the screen were 77.6% and 83.3%, respectively. Screening efforts to identify vulnerable families missed a substantial portion of families needing support. The screening tool demonstrated moderate predictive validity for identifying children at risk of entering care in the first years of life.

IntroductionOut-of-school or after-school programs are designed to support healthy behaviours, boost academic achievement and strengthen social skills. The Boys and Girls Clubs of Winnipeg (BGCW) in Manitoba, Canada, have been offering out-of-school programs to children and adolescents in low-income neighbourhoods for more than 40 years. Many BGCW participants face considerable risk of poor health, social and educational outcomes due to challenges they experience at home, in school and in their communities.
ObjectiveWe examined whether BGCW participation among children and adolescents aged 5-18 is associated with improved school outcomes and lower risk of justice system encounters and adverse health outcomes.
MethodsWe linked de-identified data on BGCW participation for children and adolescents born 1987-2010 to administrative data from the healthcare system, education system, and social services in the Population Research Data Repository, Manitoba Centre for Health Policy. The exposure group (n = 8,990$) included children and adolescents who visited BGCW at least once from 2005—2016. The comparison group (n = 69,980) comprised children and adolescents matched on school year and neighbourhood who had never participated in BGCW.
ResultsParticipation in BGCW was significantly associated with better scores in grade 3 numeracy and grade 7 student engagement assessments. The risk of justice system encounters among adolescents (aged 12—17) dropped as the frequency of BGCW participation increased, as did justice system encounters among young adults (aged 18—24) who had participated in BGCW as adolescents. The likelihood of teen pregnancy among female adolescents (aged 13—19) and sexually transmitted infections among adolescents (aged 13—19) also declined as the frequency of participation in BGCW increased.
ConclusionsThe findings suggest that participation in BGCW is associated with positive outcomes for children and adolescents in multiple domains and despite socioeconomic and family challenges faced by many in this population.

IntroductionRoutine health care information systems only capture a portion of violence against women because some victimized women may not seek health care and some events may not require medical attention. Population-based estimates of the risk of violent injury (VI) among women with a history of intimate partner victimization (IPV) are lacking.
Objectives and ApproachTo determine the risk of violent injury following IPV among women living in Manitoba, Canada, 2004-2016. Linked administrative justice, healthcare, and social databases were used. Exposure began after a woman was first involved with the Manitoba Justice system as a victim of IPV, assessed through provincial prosecution and disposition records. IPV victims (n= 20,469) were matched to three non-victims (n= 61,407) on age, relationship status and place of residence at the date of the IPV incident. The main outcomes were first health care use for violent injury and violent death. Outcomes were assessed through emergency department, hospital and vital statistics records. Conditional Cox Regression was used to obtain Hazard Ratios with 95% confidence intervals (CI).
ResultsThe crude risk of VI was 8.5 per 1000 women among non-victims and 55.8 among victims of IPV. Compared to non-victims, IPV victims were 3.8 [95% confidence interval (CI): 3.4, 4.3] times more likely to suffer IIIO and 4.5 [95% CI: 2.3, 9.0] times to have a violent death, after adjustment. Victims had approximately half the risk of VI if the accused is on probation.
Conclusion / ImplicationsJustice System-identified victims of IPV are at higher risk of assault and violent death than women not exposed to IPV. Justice involvement represents an opportunity for prevention of violent injury and homicide among IPV victims.

IntroductionStudies have consistently demonstrated a gradient between median neighbourhood income and child developmental outcomes. By investigating statistical outliers—neighbourhoods with children exhibiting less or more developmental vulnerability than that predicted by median neighbourhood income—there is an opportunity to identify other neighbourhood characteristics that may be enhancing or impeding early childhood development.
ObjectiveTesting a variety of neighbourhood factors, including immigrant or ethnic concentration and characteristics of structural disadvantage (proportion of social assistance recipients, homes in need of major repair, residents with high school education only, lone parent families, and residents moving in the last year) we sought to identify factors associated with more or less developmental vulnerability than that predicted by median neighbourhood income, for young children.
MethodsFor this cross-sectional study we used validated Early Development Instrument (EDI) data (2003-2013) linked to demographic and socioeconomic Census and Tax Filer data for 98.3% of Canadian neighbourhoods (n=2,023). The purpose of the instrument is to report, at a population-level, children's school readiness. Children's developmental vulnerability was assessed in five domains (physical health and well-being, emotional maturity, social competence, language and cognitive development, and communication and general knowledge) in relation to the 10th percentile from a national normative sample. Levels of children's neighbourhood vulnerability were determined per domain, as percent of children vulnerable at a given domain. Neighbourhoods were grouped into three cohorts, those having lower than predicted, as predicted, or higher than predicted children's vulnerability according to neighbourhood median income. Using multivariable binary logistic regression we modelled the association between select neighbourhood characteristics and neighbourhoods with lower or higher than predicted vulnerability per domain, compared to neighbourhoods with predicted vulnerability. This allowed us to determine neighbourhood characteristics associated with better or worse child developmental outcomes, at a neighbourhood-level, than that predicted by income.
ResultsIn neighbourhoods with less child developmental vulnerability than that predicted by income, high or low immigrant concentration and ethnic homogeneity was associated with less vulnerability in physical (adjusted odds ratio (aOR) 1.66, 95% CI: 1.43, 1.94), social (aOR 1.30, 95% CI: 1.11, 1.51), and communication domains (aOR 1.24, 95% CI: 1.03, 1.47) compared to neighbourhoods with vulnerability concordant with income. Neighbourhood ethnic homogeneity was consistently associated with less developmental vulnerability than predicted by income across all developmental domains. Neighbourhood-level structural disadvantage was strongly associated with child developmental vulnerability beyond that predicted by median neighbourhood income.
ConclusionCanadian neighbourhoods demonstrating less child developmental vulnerability than that predicted by income have greater ethnic and ethnic-immigrant homogeneity than neighbourhoods with child developmental vulnerability concordant with income. Neighbourhood social cohesion and cultural identity may be contributing factors. Neighbourhood structural disadvantage is associated with poorer early childhood development, over and above that predicted by neighbourhood income. Neighbourhood-level policy and programming should address income and non-income related barriers to healthy child development.

IntroductionThe literature provides abundant evidence of socioeconomic gradients in health outcomes. However, it is unclear, and particularly understudied in early child development research, whether these observed gradients are linear, whether they diminish as socioeconomic status (SES) increases, and if they ultimately reverse in slope at the highest SES values.
Objectives and ApproachWe linked neighbourhood-level Census and Tax Filer data with Early Development Instrument (EDI) data across Canada. The EDI is a kindergarten teacher-completed measure of five domains of early child development. We used this linked database to statistically compare and choose the most appropriate functional form of the relationship between each of the EDI domains (dependent variables), and the Canadian Neighbourhoods and Early Child Development (CanNECD) study's SES index (predictor) in regression models. Model comparison approaches included: visual checks of lines fitted using Generalized Additive Models, Akaike and Bayesian Information Criterions, Ramsay's RESET, J and Cox tests.
ResultsThe results indicate the optimal functional form of the gradient varies across domains of the EDI. The best model for the Physical Health and Well-Being domain was quadratic, suggesting there may be some reversal in slope at higher values of SES. The best models for the Social Competence and Language and Cognitive Development domains were logarithmic, indicating diminishing returns to SES but with no slope reversal. The best model for the Emotional Maturity domain was linear, suggesting the gradient was consistent across all values of SES. The best fit for the Communication Skills and General Knowledge domain was a cubic 'S' curve, suggesting the curve is positive and concave for lower levels of SES but curves upwards beyond a certain SES threshold.
Conclusion/ImplicationsThe results demonstrate the importance of examining functional forms when modeling socioeconomic gradients. Assuming linear relationships between SES and health outcomes (early child development, in this case) may distort and bias the true nature of the relationships, thus leading to misinterpretations, especially at the highest and lowest values of SES.

ABSTRACTObjectiveThe objective of this population health intervention research was to determine the effectiveness in improving children's outcomes of a provincial home visiting program for at-risk families in Manitoba, Canada. Home visiting programs have been evaluated in highly structured and supervised conditions which may provide different results than those evaluated in real-world delivery systems.
ApproachIn this retrospective cohort study, data for 4,562 children from home visiting program families and 5,184 comparison children were linked to de-identified administrative health, social services, and education data held securely at the Manitoba Centre for Health Policy. Inverse probability of treatment weights were used to address the selection bias inherent in delivering a voluntary program. We used generalized linear modelling to calculate program effects among those exposed to the program, those unexposed and the average effect. Child outcomes examined included being taken into care of child welfare, hospitalizations for maltreatment-related injuries, and child development scores at school entry.
ResultsThe home visiting program was associated with lower rates of children being taken into care and lower rates of hospitalization for maltreatment-related injuries. For being taken into care by child's first birthday, the adjusted Risk Ratio (aRR) was 0.75 (95% Confidence Interval [CI]: 0.66, 0.86); for being taken into care by second birthday, aRR=0.79, (95% CI: 0.70, 0.88); and for hospitalizations for maltreatment-related injuries by third birthday, aRR=0.59 (95% CI: 0.35, 0.99). Similar program effects would be expected among comparison children if they had received the program (i.e., average treatment effect for the untreated). No differences between groups were found across five domains of child development at school entry.
ConclusionHome visiting programs can be an effective strategy for decreasing child maltreatment at a population level. Home visiting program enhancements are necessary to improve child development scores when children enter school. Use of population-based linkable data systems provides an opportunity to evaluate interventions using large, real-world samples, adjusting for a wide range of risk factors, and examining a variety of outcomes.

ABSTRACT
ObjectiveDespite the implementation of full-day kindergarten (FDK) in several Canadian provinces, there is little evidence on the long-term outcomes associated with this program. Our objective was to use population-level linked data sources from Manitoba, Canada, to determine whether FDK results in better long-term academic outcomes and reduced inequities in outcomes.
ApproachUsing data held in the Manitoba Centre for Health Policy Data Repository we examined provincial reading and numeracy assessments in grades 3, 7, and 8 and a performance index in grade 9 for students in two Manitoba school divisions between 1999-2012. In School Division A (SDA), FDK is targeted in the lowest SES schools; in School Division B (SDB) FDK was gradually introduced universally. SDA FDK students were matched using propensity scores to students in an adjacent school division with similar socioeconomic status (SES) but no FDK; in SDB a stepped-wedge design was used. Logistic regressions accounted for confounders including classroom effects and sex. Gamma sensitivity analyses were used to assess sensitivity of results to unmeasured confounding. The Kakwani Progressivity Index (KPI) determined how FDK affected equity.
ResultsThere were 224-544 children in FDK and 869-1923 non-FDK matches in SDA, depending on the outcome examined; numbers in SDB ranged from 335-707 (FDK) and 222-475 (non-FDK). Including interactions, 35 comparisons were examined in SDA and 24 in SDB. None of the outcomes examined in SDB showed statistically significant effects of FDK that were robust to unmeasured confounding. In SDA there were only 3 statistically significant and robust findings of benefits of FDK, all related to math. Comparisons of KPIs for FDK and non-FDK children in both school divisions demonstrated inequities in outcomes associated with SES, however there were no significant differences in equity between the FDK and non-FDK children for any of the outcomes.
ConclusionsOur findings indicate no apparent benefits of universal FDK, and limited benefits from targeted FDK, specifically long-term improvements in numeracy for low-income girls. No reductions in inequity were found. Decisions regarding FDK implementation should weigh the costs of this program against the limited long-term academic benefits.

ObjectivesLack of consistent and relevant Indigenous identifiers in Canadian data sources leads to misclassification and under-recognition of the health and social issues impacting Indigenous Peoples, further perpetuating the harms of colonization. We are evaluating and optimizing our approach for identifying First Nations (FN) individuals in administrative data in Manitoba.
MethodsIn partnership between the First Nations Health and Social Secretariat of Manitoba and the Manitoba Centre for Health Policy, we sought to evaluate to what extent four distinct Manitoba datasets derived from surveillance and social programs were able to identify FN individuals among a cohort of children in low-income Winnipeg neighbourhoods between 2005-2016. In choosing data sources to identify FNs, the population and research question were considered.
We then compared the number of FNs identified in each dataset to the First Nations population research file, considered gold standard, but cognizant of its roots in colonial systems of registration.
ResultsThe total cohort comprised N=78,864; among these, n=27,347 children were identified as FN in either the FN registry or at least one of the datasets. The FN registry was the most sensitive dataset and identified 85.7% of these individuals. The two program datasets identified 58.2% and 46.2%, and the surveillance-based datasets each identified less than 10%.
The First Nations Registry is critical to accurately identify FN individuals. Our analyses demonstrated that without it we would miss 23.5% of those identified as FN in at least one other dataset. However, using it alone could potentially cause us to miss 15% of FN individuals identified in other datasets.
The proportions of FN individuals that would be missed by excluding any of the other datasets were smaller (<6%).
ConclusionWe found inconsistent FN identification across the datasets evaluated. Among the issues is that some datasets rely on self-identification. In Manitoba, no single administrative dataset can reliably and comprehensively identify FN individuals, and linking multiple datasets together is currently our best approach.

IntroductionIt is important to investigate the use of prescription opioids during pregnancy to gain insight into the potential impact of maternal opioid exposure during pregnancy on children. We report the prevalence of prescription opioid use and concurrent psychotropic drug use in a large, Canadian population-based cohort of pregnant women.
Objectives and ApproachUsing population-level linked administrative data from a universal health care system, this study included all women with a live birth in Manitoba from 1996 to 2014. Dispensing of opioids was determined from prescription drug data. Patterns of prescription opioids dispensed to pregnant women were investigated by demographic characteristics, region of residence, and socioeconomic status. Concurrent psychotropic therapies were also measured. These data address limitations associated with re-call bias, cilitate longitudinal analaysis, and allow the investigation of rare outcomes, difficult to study using other data sources.
ResultsIn a large population level sample of pregnancies (N=245,784), 2.43% of pregnancies were exposed to 2+ dispensations of opioids. An additional 4.95% of pregnancies recorded at a single opioid dispensation. Compared to women who were not dispensed any opioid prescriptions, the proportion of opioid exposed pregnancies who were also prescribed anti-depressants (SSRI/SNRI) was sevenfold higher (22.5% vs 3.05%). The same pattern was found for anxiolytics (37.2% vs 1.5%) and antipsychotics (3.5% vs 0.34%).
Conclusion/ImplicationsThese data demonstrate high proportions of women were dispensed opioids during pregnancy. Further research should be done on the short term and long term effects of these medications on infants and children. Moreover, these results highlight the need for further investigation into the effects of exposure to multiple psychotropic drugs

IntroductionThe Boys & Girls Clubs of Winnipeg (BGCW) provide out-of-school programs to children and youth living in low-income neighbourhoods in Winnipeg, Canada. These programs aim to set participants on a path to success by supporting healthy behaviours, academic achievement and social skills. First Nation children and youth make up a substantial proportion of BGCW participants, but there are few empirical data available on how the programs influence health, social and education outcomes in this population.
Objectives and ApproachWe linked BGCW attendance records for all Manitoba children born 1987-2010 to the individual-level administrative health, social and education data in the population-based Data Repository at the Manitoba Centre for Health Policy in Winnipeg. The comparison group of non-participants was matched on age and neighbourhood of residence. We narrowed the cohort to First Nation participants by linking to datasets containing First Nation identifiers. Education outcomes were examined using a generalized additive model, and health and justice system outcomes with a time-to-event model, adjusted for socioeconomic status, mother's mental health and age at first birth, and involvement in the child welfare system.
Results3,754 First Nation children and youth participated in BGCW from 2005-2016. The comparison group comprised 23,593 First Nation children and youth. Greater BGCW participation was associated with higher likelihood of performing well in grade 3 numeracy, but not other education outcomes (grade 3 reading, grade 7 student engagement or mathematics, grade 7/8 reading/writing, or graduating high school). Greater BGCW participation was also associated with lower risk of becoming involved with the justice system among youth aged 12-17 (i.e., lower risk of being charged with a crime) and with lower risk of teen pregnancy.
Conclusion / ImplicationsParticipation in BGCW programs may contribute to improved health, justice and education outcomes for First Nation children and youth in Winnipeg.

IntroductionMany studies demonstrating an association between in utero exposure to serotonergic antidepressants and higher risk of neurodevelopmental disorders in children are confounded by history of maternal depression and disease severity. We conducted a population-based analysis of women diagnosed with mood/anxiety disorder, a patient population for whom pharmacotherapy is clearly indicated.
Objectives and ApproachUsing linked population-based administrative data, we identified all mother-newborn pairs in Manitoba (born 1996 to 2009, with follow-up through 2014). High dimensional propensity scores and inverse probability treatment weighting were used to address confounding by indication and disease severity. The final trimmed cohort consisted of mothers who were diagnosed with a mood/anxiety disorder from 90 days prior to conception until delivery (n=4995). Cox Proportional Hazard Regression models were used to estimate risk of Autism Spectrum Disorder, epilepsy and attention deficit hyperactivity disorder (ADHD) in offspring. In addition to clinical data, we used novel education data to define outcomes in children.
ResultsAmong the cohort of mothers diagnosed with a mood/anxiety disorder during pregnancy or up to 90 days before, 16.8% received at least two dispensations of an SSRI or SNRI during pregnancy. We did not observe an association between use of SSRIs/SNRIs during pregnancy and increased risk of Autism Spectrum Disorder (hazard ratio 0.92; 95% CI 0.42 to 2.03), epilepsy (hazard ratio 1.21; 95% CI 0.48 to 3.05), or ADHD (hazard ratio 1.13, 95% CI 0.78 to 1.64) among offspring.
Conclusion/ImplicationsIn the absence of randomized control trials, large observation studies using sophisticated data analysis are the gold standard of evidence to help patients and clinicians making the decision to continue antidepressant use during pregnancy. Results of this study reassure women for whom the medication is clinically indicated.

Introduction: Australian Aboriginal children are more likely than non-Aboriginal children to have developmental vulnerability at school entry that tracks through to poorer literacy and numeracy outcomes and multiple social and health disadvantages in later life. Empirical evidence identifying the key drivers of positive early childhood development in Aboriginal children, and supportive features of local communities and early childhood service provision, are lacking. Methods and analysis: The study population will be identified via linkage of Australian Early Development Census data to perinatal and birth registration data sets. It will include an almost complete population of children who started their first year of full-time school in New South Wales (NSW), Australia, in 2009 and 2012. Early childhood health and development trajectories for these children will be constructed via linkage to a range of administrative data sets relating to birth outcomes, congenital conditions, hospital admissions, emergency department presentations, receipt of ambulatory mental healthcare services, use of general practitioner services, contact with child protection and out-of-home care services, receipt of income assistance and fact of death. Using multilevel modelling techniques, we will quantify the contributions of individual-level and area-level factors to variation in early childhood development outcomes in Aboriginal and non-Aboriginal children. Additionally, we will evaluate the impact of two government programmes that aim to address early childhood disadvantage, the NSW Aboriginal Maternal and Infant Health Service and the Brighter Futures Program. These evaluations will use propensity score matching methods and multilevel modelling. Ethics and dissemination: Ethical approval has been obtained for this study. Dissemination mechanisms include engagement of stakeholders (including representatives from Aboriginal community controlled organisations, policy agencies, service providers) through a reference group, and writing of summary reports for policy and community audiences in parallel with scientific papers.

Introduction: Australian Aboriginal children are more likely than non-Aboriginal children to have developmental vulnerability at school entry that tracks through to poorer literacy and numeracy outcomes and multiple social and health disadvantages in later life. Empirical evidence identifying the key drivers of positive early childhood development in Aboriginal children, and supportive features of local communities and early childhood service provision, are lacking. Methods and analysis: The study population will be identified via linkage of Australian Early Development Census data to perinatal and birth registration data sets. It will include an almost complete population of children who started their first year of full-time school in New South Wales (NSW), Australia, in 2009 and 2012. Early childhood health and development trajectories for these children will be constructed via linkage to a range of administrative data sets relating to birth outcomes, congenital conditions, hospital admissions, emergency department presentations, receipt of ambulatory mental healthcare services, use of general practitioner services, contact with child protection and out-of-home care services, receipt of income assistance and fact of death. Using multilevel modelling techniques, we will quantify the contributions of individual-level and area-level factors to variation in early childhood development outcomes in Aboriginal and non-Aboriginal children. Additionally, we will evaluate the impact of two government programmes that aim to address early childhood disadvantage, the NSW Aboriginal Maternal and Infant Health Service and the Brighter Futures Program. These evaluations will use propensity score matching methods and multilevel modelling. Ethics and dissemination: Ethical approval has been obtained for this study. Dissemination mechanisms include engagement of stakeholders (including representatives from Aboriginal community controlled organisations, policy agencies, service providers) through a reference group, and writing of summary reports for policy and community audiences in parallel with scientific papers.

The current study examined school readiness for children placed in care of child protection services before age 5. This association was assessed using a population-based cohort of children born in Manitoba, Canada, between 2000 and 2009 ( n = 53,477) and subcohorts of discordant siblings (one sibling taken into care, one sibling not taken into care; n = 809) and discordant cousins ( n = 517). In the population analysis, children placed in care were significantly less likely to be ready for school; this difference was not seen in the discordant sibling or cousin analysis. The findings suggested that differences in school readiness for children placed in care are a result of broader social factors affecting families, not placement into care.