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ABSTRACT
ObjectivesOur objective was to develop a comprehensive longitudinal data resource, which population health research scientists could use to study the social determinants of child health and health equity.
MethodsThe PATHS Resource was created from data holdings within the Manitoba Population Health Research Data Repository. The Manitoba Health Registry sits at the centre of the Repository and includes information – including a scrambled personal health identification number (PHIN) and date when coverage commenced and expired – on every individual registered with the province's universal healthcare system. The Repository also includes administrative data spanning several sectors including health, social services, justice, and education. We used individuals' scrambled PHINs to link children's administrative records across sectors to build a holistic picture of their health and development. We developed metadata, including routinized SAS algorithms and variable definitions, to ensure consistent operationalization of variables across studies. The longitudinal nature of these data allowed us to construct individual-level health and development trajectories from birth through adolescence for children born from 1984-2014. We used income data from the Canadian Census to develop both indicators of socioeconomic status (average neighbourhood level income) and provincial measures of income inequality (the Gini coefficient).
ResultsThe PATHS Resource includes data on the social determinants of health as well as health and development for children born 1984 to 2014 (n=608,007). We are able to follow children for a median observation period of 15.4 years. Income inequality – measured using the Gini coefficient – increased from 1984 to 2014: 0.16 to 0.21 (p<0.01). The proportion of children born to women from the bottom income quintile (i.e., the poorest 20% of families) also grew from 23.2% in 1984 to 27.2% in 2014 (p<0.01). When we followed children over their life course, we found that they were most likely to experience poverty (measured by family receipt of income assistance) at 2 years of age (p<0.01). Many studies from a variety of researchers have utilized the PATHS metadata to conduct child health and development research, ensuring consistent variable operationalization. These data have been used to identify policy levers for improving child health and reducing health inequalities.
ConclusionA resource such as the PATHS Resource can facilitate research into the health and development of children. Having data on the entire population allows investigators to both monitor trends in health inequities and identify strategies for improving health. Metadata ensure variable consistency and comparability across studies.

ABSTRACT
ObjectivesThere is increased interest in identifying strategies the reduce health inequities. With this focus, population health scientists have applied equity measures first developed in other disciplines to health equity research. The objective of this study is to illustrate the application of these measures in research using linkable administrative databases. This presentation will provide a brief description of some commonly-used equity measures and issues investigators face when applying them in their own health equity research.
MethodsAnalyses focused on children born in Manitoba, 1984 to 2014. We used linkable administrative data from health, social services, and education to develop indicators of health and the social determinants of health. Income data from the Canadian Census were used to stratify children by socioeconomic status. Our study considered the distribution of several child outcomes: breastfeeding initiation, mortality, complete immunization rates at age 2, Grade 9 completion, and high school completion. We examined several measures often used to capture income-related health inequities: rate ratios and rate differences comparing children from high-income neighbourhoods with children from low-income neighbourhoods; the concentration index which quantifies the equity in the distribution of outcomes across the entire socioeconomic gradient; and the relative and absolute indices of inequality which compare the most advantaged individuals with the least advantaged individuals in the population while accounting for the distribution of health across the population.
ResultsWhen these measures are applied to health equity, they can be affected by factors not initially considered by investigators. The application of Concentration measures using health outcomes that are frequently dichotomized, and the prevalence of the health outcome can affect the degree of inequity that is possible, with highly prevalent outcomes showing very little divergence from the line of equity. Comparing concentration measures to the inequality indices can produce contradictory and seemingly incompatible results. Sample selection that alters the distribution of income from the population can also change the apparent equity of health outcomes. These matters are complicated when monitoring changes in health equity, over time.
ConclusionsSummary measures of equity can be useful but come with limitations that need to be considered when interpreting and applying study findings. We offer some suggestions to consider when applying these measures in health equity research.

ABSTRACT
ObjectivesThe objective of this study was to identify whether breastfeeding inequalities have increased between 1984 and 2014 and to examine whether trends in income inequality are related to breastfeeding inequalities.
MethodsWe used linkable administrative data from the Population Health Research Data Repository. Our sample included all infants born in Manitoba, 1984 to 2014. We used area-level income – derived from the Canadian Census – to stratify infants into income quintiles. Canadian Census income data were also used to quantify provincial level income inequality for each fiscal year in our study period. Data from the hospital discharge abstract database were used to classify infants according to whether or not they had initiated breastfeeding. We linked infant data to maternal data using the Manitoba health insurance registry to capture maternal characteristics – including the mother's postal code of residence and her age at first birth. We used generalized linear models to calculate income quintile-specific breastfeeding rates for each fiscal year in our observation period for all of Manitoba. We also calculated age-adjusted breastfeeding rates to account for the changing age distribution in Manitoba mothers, over time. We measured breastfeeding inequities using the concentration index as well as the rate ratio and rate difference (comparing the breastfeeding rate between the highest and lowest income quintiles). We quantified income inequality using the Gini coefficient on income. Trend analyses and two-sided Z-tests tested for changes, over time. Time by income-quintile interactions tested whether breastfeeding rates were statistically significantly different, across socioeconomic groups.
ResultsBreastfeeding rates increased from 1985 to 2014, from 72% to 81% (p<0.01). The Gini coefficient increased from 0.16 to 0.21; a linear trend test of the Gini coefficient showed income inequality increased over the study period (p<0.05). Rate differences, rate ratios, and the Concentration index showed that significant breastfeeding inequalities existed throughout the study period. Trend tests revealed that breastfeeding inequalities did not increase, over time.
ConclusionsAggregate analyses may suggest overall improvement when inequality persists. Although there was improvement in breastfeeding initiation rates, children from lower socioeconomic status continue to lag behind their counterparts. Policy-focused health equity research needs to measure outcomes, overall, and inequity across time.

IntroductionThe quality of early education children receive influences their developmental trajectories, with long-term effects extending into adulthood. First Nations children face many structural barriers to academic success. Few studies have examined the impact of education programs on removing these barriers to support better outcomes amongst First Nations children.
Objectives and ApproachWe examined educational outcomes associated with full-day (FDK) versus half-day (HDK) kindergarten among First Nations children using data from the Manitoba Population Research Data Repository. We linked children's education records with the Manitoba Health Registry and the First Nations Registry to identify all First Nations children who attended kindergarten in a Winnipeg school division (1998-2011). Children enrolled FDK were age- and sex- matched to children enrolled in HDK. Propensity scores used to adjust for confounding. Outcomes included academic achievements in grades 3, 7, and 8 and high school graduation. We used generalized linear models to test for differences in education.
ResultsWe identified 324 First Nations children enrolled in FDK and 595 matches in HDK in the study period. Among these, 37% FDK and 31% HDK students met or approached numeracy expectations in grade 3; and 30% FDK and 33% HDK met or approached numeracy expectations in grade 7. For reading expectations, 37% FDK and 33% HDK met or approached grade 3 reading expectations; in grade 8, roughly half of each group met or approached expectations for reading and writing. High school graduation rate for First Nations children in both FDK and HDK children was 60%. We found no differences in education outcomes when we tested for differences between HDK and FDK children.
Conclusion/ImplicationsEducation outcomes did not differ between First Nations children enrolled in FDK vs. HDK programs. Kindergarten programs may be insufficient to overcome structural barriers to academic success that these children face. Culturally appropriate education strategies may be needed to support improved outcomes amongst this population.

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.

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.

IntroductionThe province-wide Families First Home Visiting Program (FFHV) provides home visiting to families with children living in conditions of risk. It remains unknown if First Nations families are benefiting from the program. Using existing administrative and population-wide data is an innovative practice to evaluate programs that have been scaled up.
Objectives and ApproachThe objective is to determine FFHV's effectiveness at improving outcomes for First Nations children and parents. The partnership with First Nations Health and Social Secretariat of Manitoba facilitated access to First Nations identifiers and provided guidance in conducting the study. Program data from 4,010 First Nations children and parents were linked at an individual-level to administrative data housed at the Manitoba Centre for Health Policy. We compared the predictive probability of outcomes of program and non-program families. Inverse probability of treatment weights were used to adjust for confounders related to both entry into FFHV and the outcomes under study.
ResultsThe cohort of First Nations children and parents was successfully linked through an individual scrambled health identifier. FFHV was associated with higher rates of child immunization at age one (71% versus 66%) and age two (47% versus 41%) and parental involvement in community support groups (21% versus 17%). It was also associated with lower rates of being in care of child welfare at age one (10% versus 14%) and age two (15% versus 19%); maltreatment-related hospitalizations at age three (0.4% versus 1.0%); and child victimization as measured by justice system records (1.7% versus 3.0%). However, there were no differences in being "not ready for school" between the two groups of children, nor between the groups of mothers in physician visits for mental health reasons.
Conclusion/ImplicationsHome visiting services can play a role in supporting healthy development of First Nations children by providing support to parents and connecting children to health and social services, however, there also remains an urgent need for long term strategies to address structural inequality and the ongoing effects of colonization.

ABSTRACT
ObjectivePerinatal outcomes have improved overall in developed countries over the last several decades but remain poor for disadvantaged populations. In Manitoba, Canada, the Healthy Baby Prenatal Benefit (HBPB), a cash transfer to low-income pregnant women, was introduced with the goal of improving perinatal outcomes. The objective of this study was to use linked administrative and program datasets to determine whether this unconditional income supplement was associated with improved birth outcomes for a low-income population.
ApproachThis study used data from the PATHS Data Resource, which contains population-level health and social service records as well as program data for approximately 600,000 children in Manitoba, Canada, over a 30-year period, linkable at the individual level. All mother-newborn pairs, from 2003-2010, who met the following criteria were included for analyses: i) the mother was on social assistance (i.e., low income); ii) the infant was born in hospital; and, iii) the pair had a newborn risk screen (n=14,591), documenting factors such as prenatal alcohol and tobacco exposure and maternal and family characteristics. Low-income women who received HBPB (exposed, 10,738) were compared with low-income women who did not receive HBPB (unexposed, 3,853) on several outcomes: low birth weight, preterm, small- and large-for-gestational age, 5-minutes Apgar scores, breastfeeding initiation, neonatal readmission, and newborn hospital length of stay (LOS). Covariates from the risk screens were used to develop propensity scores to construct Inverse Probability of Treatment Weights, to balance differences between exposed and unexposed groups in regression models. Gamma sensitivity analyses assessed sensitivity to unmeasured confounding. Population attributable and preventable fractions were calculated.
ResultsHBPB exposure was associated with reductions in low birth weight (adjusted risk ratio, aRR=0.71, 95% CI=0.63, 0.81), preterm (aRR=0.76 (0.69, 0.84)) and small-for-gestational age (aRR=0.90 (0.81, 0.99)) births and increases in breastfeeding (aRR=1.06 (1.03, 1.09)) and large-for-gestational age births (aRR=1.13 (1.05, 1.23)). For vaginal births, HBPB was associated with shortened LOS (mean=2.86, p<0.0001). Results for breastfeeding, low birth weight, preterm and LOS were robust to unmeasured confounding. Reductions of 21% (95% CI 13.6, 28.3) of low birth weight and 17.5% (11.2, 23.8) of preterm were associated with receipt of the HBPB.
ConclusionsA modest income supplement during pregnancy was associated with improved birth outcomes for infants born to low-income women. Placing conditions on income supplements to low income pregnant women may not be necessary to promote prenatal and perinatal health. Linked administrative data can be a valuable tool for program evaluation.

ABSTRACTObjectivesTo determine whether an intensive multi-modal ADHD intervention for children and teens resulted in improved long-term health and educational outcomes and in reduced inequity in these outcomes across the socioeconomic gradient.
ApproachWe used administrative data from the healthcare and education sectors in the Population Health Data Repository at the Manitoba Centre for Health Policy. We identified children and teens aged 5-17 who had 3+ visits to the ADHD intervention program between 2007 and 2012. A matched control group was constructed, and confounders were controlled using inverse probability of treatment weights. We examined rates of hospital episodes, emergency department visits, psychostimulant use and adherence, contact with child and family services, and whether the children were in the school grade appropriate to their age. We calculated concentration indices to measure changes in inequity.
ResultsThere were 485 children in the ADHD intervention group and 1,884 controls. Children who received the intervention were more likely to be prescribed medication (patients with 1+ prescription(s), rate ratio [RR] 1.21, 95% CI 1.08-1.36) and be adherent to their medication (RR 1.42, 95% CI 1.03-1.96). They were also more likely to be in their age-appropriate grade (RR 1.33, 95% CI 1.09-1.63) compared to controls. Moreover, the intervention was associated with reduced inequity in these outcomes across income deciles. No difference in the rates of hospital episodes or emergency department visits was found, nor in rates of contact with child and family services.
ConclusionsA multi-modal ADHD intervention program was associated with increased use and adherence to medication, and may boost academic achievement for vulnerable children and teens. It contributed to closing the equity gap between children from low- and high-income families. ADHD interventions that combine approaches may be more effective than medication alone.

IntroductionAdministrative data studies routinely report that First Nations mothers and children experience a disproportionate burden of poor health. Due to the nature of administrative data, research often takes a deficits-oriented approach. First Nations health research needs to consider the role that community- and individual-level strengths play in promoting wellbeing and examine how these interact with the delivery and outcomes of health programs.
Objectives and ApproachThe First Nations Health and Social Secretariat of Manitoba (FNHSSM) and the University of Manitoba partnered to construct measures of community-level strengths that can be linked with administrative data to examine the delivery and outcomes associated with population health programs delivered in First Nations communities.
We linked data from the FNHSSM-administered Regional Health Survey (RHS) with administrative data housed in the Manitoba Population Research Data Repository. We identified 60 questions from the child, youth, and adult versions of the RHS to measure community strengths. We used principal component analysis to identify strength-based constructs. We used Eigen values and percent of variance explained to determine the final number of factors. We used random group resampling and bootstrap methods to test for community-level homogeneity. Community-level factor scores were calculated as the scaled combination of RHS questions within each factor and averaged to the community.
ResultsWe identified 12 constructs of community strength: 5 from child responses, 4 from youth, and 3 from adult responses. Strength-based constructs common to all age groups included knowledge of traditional language, involvement in cultural events, and connection with community.
Conclusion / ImplicationsColonial approaches to health research perpetuate deficit-based dialogues and negative portrayal of First Nations peoples. First Nations health research should consider how community strengths promote health and interact with program delivery. Including measures of community strength leads to richer understandings of factors that promote wellness among First Nations peoples.

We explored the particularities of the Healthy Baby Prenatal Benefit (HBPB), an unconditional cash transfer program for low-income pregnant women in Manitoba, Canada, which aims to connect recipients with prenatal care and community support programs, and help them access healthy foods during pregnancy. While previous studies have shown associations between HBPB and improved birth outcomes, here we focus on how the intervention contributed to positive outcomes. Using a case study design, we collected data from government and program documents and interviews with policy makers, academics, program staff, and recipients of HBPB. Key informants identified using evidence and aligning with government priorities as key facilitators to the implementation of HBPB. Program recipients described how HBPB helped them improve their nutrition, prepare for baby, and engage in self-care to moderate the effect of stressful life events. This study provides important contextualized evidence to support government decision making on healthy child development policies.

IntroductionIn Manitoba, low-income pregnant women are eligible for the Healthy Baby Prenatal Benefit (HBPB), an unconditional income supplement provided during the second and third trimester of pregnancy. HBPB is associated with improved birth outcomes for Manitoba women; its association with birth outcomes for First Nations (Indigenous) women is unknown.
Objectives and ApproachTo determine the association between HBPB and First Nations' (FN) newborn and early childhood outcomes, we linked whole-population data from health, public health, family services and education. We included only FN women receiving income assistance during pregnancy (n=7074) to develop comparable treatment (received HBPB; n=5283) and comparison (no HBPB; n=1791) groups. Propensity score weighting adjusted for differences in maternal characteristics between groups. Multi-variable regressions compared groups on breastfeeding initiation, low birth weight, preterm birth, small- and large-for-gestational age, Apgar scores, complete immunizations at 1 and 2 years, and developmental vulnerability in kindergarten measured with the Early Development Instrument (EDI).
ResultsReceipt of the HBPB was associated with reductions in low birth weight births (adjusted Relative Risk (aRR): 0.77; 95% CI: 0.63, 0.93) and preterm births (aRR: 0.78 (0.68, 0.90)), and increases in breastfeeding initiation (aRR: 1.05 (1.00, 1.09)) and large-for-gestational age births (aRR: 1.11 (1.01, 1.23)). HBPB receipt during pregnancy was also associated with increases in 1- and 2-year immunizations for FN children (aRR: 1.14 (1.09, 1.19), and aRR: 1.28 (1.19, 1.36), respectively). Reductions in the risk of being developmentally vulnerable in the language and cognitive domain of the EDI were also found for FN children whose mothers had received the HBPB during pregnancy (aRR: 0.85 (0.74, 0.97).
Conclusion/ImplicationsA modest unconditional income supplement during pregnancy was associated with improved birth outcomes, increased immunization rates, and improved language and cognitive development at kindergarten for children born to low-income First Nations women. Long-term strategies to address structural inequities and the ongoing effects of colonization are also needed.