Development and implementation of a municipal outdoor play policy for children and youth in Nova Scotia, Canada: a community case study.

Background: Children and youth benefit from outdoor play; however, environments and policies to support outdoor play are often limited. The purpose of this paper is to describe a case study of the development of a municipal outdoor play policy in Nova Scotia, Canada. The outdoor play policy was developed by the Town of Truro with support from the UpLift Partnership, a School-Community-University Partnership in Nova Scotia, Canada. UpLift supports the health and well-being of school-aged children and youth using a Health Promoting Schools approach which identifies the important role of municipal government in creating healthy school communities. The UpLift Partnership and the municipality hosted online workshops for municipal staff, community leaders and partners that included content about the importance of outdoor play, barriers and facilitators to outdoor play, best practices for youth engagement, the policy development process, and how policy actions can support outdoor play. Workshop participants developed policy actions for their community of Truro, Nova Scotia to increase opportunities for outdoor play for children and youth. Following the workshops, a small team from the municipality and UpLift drafted an outdoor play policy and submitted it to Truro town council for approval. The outdoor play policy was adopted in Fall 2021 and has since informed recreation and municipal planning decisions. By presenting a case study of the development of this outdoor play policy, we hope other communities may be inspired to develop and adopt their own outdoor play policies to benefit children and youth in their communities.

Adherence to clinical practice guidelines for pulmonary valve intervention after tetralogy of Fallot repair: A nationwide cohort study.

Objectives: To determine guideline adherence pertaining to pulmonary valve replacement (PVR) referral after tetralogy of Fallot (TOF) repair. Methods: Children and adults with cardiovascular magnetic resonance imaging scans and at least moderate pulmonary regurgitation were prospectively enrolled in the Comprehensive Outcomes Registry Late After TOF Repair (CORRELATE). Individuals with previous PVR were excluded. Patients were classified according to presence (+) versus absence (-) of PVR and presence (+) versus absence (-) of contemporaneous guideline satisfaction. A validated score (specific activity scale [SAS]) classified adult symptom status. Results: In total, 498 participants (57% male, mean age 32 ± 14 years) were enrolled from 14 Canadian centers (2013-2020). Mean follow-up was 3.8 ± 1.8 years. Guideline criteria for PVR were satisfied for the majority (n = 422/498, 85%), although referral for PVR occurred only in a minority (n = 167/498, 34%). At PVR referral, most were asymptomatic (75% in SAS class 1). One participant (0.6%) received PVR without meeting criteria (PVR+/indication-). The remainder (n = 75/498, 15%) did not meet criteria for and did not receive PVR (PVR-/indication-). Abnormal cardiovascular imaging was the most commonly cited indication for PVR (n = 61/123, 50%). The SAS class and ratio of right to left end-diastolic volumes were independent predictors of PVR in a multivariable analysis (hazard ratio, 3.33; 95% confidence interval, 1.92-5.8, P < .0001; hazard ratio, 2.78; 95% confidence interval, 2.18-3.55, P < .0001). Conclusions: Although a majority of patients met guideline criteria for PVR, only a minority were referred for intervention. Abnormal cardiovascular imaging was the most common indication for referral. Further research will be necessary to establish the longer-term clinical impact of varying PVR referral strategies.

Process and experience of youth researchers within a Health Promoting Schools study in Nova Scotia, Canada.

Youth Participatory Action Research (YPAR) is an approach to research that engages youth across the research process. The peer researcher method is a technique used in YPAR where youth are trained in research and ethics to interview their peers. The purpose of this study was to: (i) describe the process of engaging youth as peer researchers in a Health Promoting Schools (HPS) and student engagement project and (ii) understand the peer researchers' perspectives of their experience throughout the project. Youth from across Nova Scotia, Canada in grades 7-10 (ages 12-16) were recruited as peer researchers in the Summer, 2022. The project included three stages: (i) peer researcher training, (ii) practicing, recruiting and conducting interviews and (iii) data interpretation workshop. To understand the peer researcher's experience, quantitative data were collected from an evaluation questionnaire. Outputs were produced using descriptive statistics. Qualitative data were collected through a focus group and interviews and analyzed using inductive content analysis. A total of 11 youth were recruited and completed peer researcher training. Most youth provided positive feedback on the training with a satisfaction score of 8.7/10. Qualitative analysis indicated benefits to the peer researchers including opportunities to build interview and social skills and learn about other's perspectives. This study provides a detailed overview of how to use a peer researcher method in a YPAR project to involve youth in research related to HPS and student engagement. The research also highlights the benefits of engaging youth in YPAR. Future research will report on the findings from the peer interviews.

Patient-Reported Outcomes After Tetralogy of Fallot Repair.

BACKGROUND: Comprehensive assessment of tetralogy of Fallot (TOF) outcomes extends beyond morbidity and mortality to incorporate patient-reported outcomes (PROs), including quality of life (QOL) and health status (HS). OBJECTIVES: This study explored PROs in adolescents and adults with TOF and delineated variables associated with PROs. METHODS: This was a cross-sectional observational study within a larger prospective registry of adolescents and adults with repaired TOF and moderate or greater pulmonary regurgitation from North America, Europe, and Asia. Participants completed PROs, including a QOL linear analogue scale (QOL-LAS) and an HS visual analogue scale (HS-VAS). Scores were classified according to age cohorts: <18, 18 to 25, 26 to 40, and >40 years. RESULTS: The study included 607 patients (46.3% female; median age 28.5 years). Median QOL-LAS scores (0-100) were similar across age cohorts (85, 80, 80, 80; P = 0.056). Median HS-VAS scores (0-100) were lowest for the oldest cohort (77) compared with the 3 younger cohorts (85, 80, 80) (P = 0.004). With advancing age, there were increased reports of poor mobility (P < 0.001) and pain or discomfort (P = 0.004); problems in these dimensions were reported by 19.1% and 37.2% of patients aged >40 years, respectively. Of factors associated with superior PROs on multivariable regression modeling (ie, being White, being nonsyndromic, having employment, and having better left ventricular function; P < 0.05), asymptomatic status (functional class I) was the variable associated with the greatest number of QOL and HS measures (P < 0.001). CONCLUSIONS: Strategies to improve TOF outcomes should consider PROs alongside conventional clinical variables. Factors associated with poorer PROs represent opportunities to intervene to improve the lives of patients with TOF.

Peering in: youth perspectives on Health Promoting Schools and youth engagement in Nova Scotia, Canada.

Health Promoting Schools (HPS) is a whole-school approach that shapes the conditions necessary to support student health and well-being. Youth engagement is recognized as key to HPS implementation, yet research related to the involvement of youth voice in school health promotion initiatives is limited. The purpose of this study was to understand youth perspectives on HPS and school youth engagement. Ten youth (grades 9-10, ages 14-16) were trained as peer researchers using a Youth Participatory Action Research approach. The peer researchers interviewed 23 of their peers (grades 7-10, ages 12-16) on perspectives related to HPS and school youth engagement. All interviews were audio-recorded, transcribed and data were analysed using inductive 'codebook' thematic analysis. Themes related to a healthy school community were mapped onto the pillars of HPS: (i) Social and Physical Environment, (ii) Teaching and Learning, (iii) Partnerships and Services and (iv) School Policies. Participants placed more importance on the social and physical environment of the school including respect, inclusivity, supportive relationships and the design of spaces. Key factors for youth engagement were: (i) safe and supportive spaces, (ii) passion and interest, (iii) using their voice, (iv) power dynamics, (v) accessibility and (vi) awareness. With recognition that youth engagement is a crucial part of HPS, this work provides relevant and applicable information on areas of the healthy school community that are important to youth, and if/how they are meaningfully engaged in school decision-making.

Schools are a place for students to develop and learn about health. Schools in Nova Scotia have applied Health Promoting Schools (HPS) activities since 2005. HPS activities support students' health and well-being by developing safe spaces, offering healthy food options and increasing time for physical activity. There is a lack of research outlining what youth think about HPS or how they are involved. We trained youth to interview their peers to find out what parts of the school they think are healthy, and how they are involved in school decision-making. We found that youth wanted to be part of a school where they felt safe, included and respected. Students also described a healthy school as welcoming, and clean. Youth felt their involvement in decision-making was important. Youth shared that teacher support and personal interest helped them be involved in decision-making. Fear of sharing their opinions and not knowing how to be involved made it harder for youth to be part of decision-making. Our research identified what parts of the school youth think are important for their health, and what makes it easier or harder for them to be engaged. The results of this research can support HPS activities moving forward.

The Effects of the COVID-19 Pandemic on Health and Well-Being of Children and Youth in Nova Scotia: Youth and Parent Perspectives.

Objectives: The COVID-19 pandemic led to school closures, cancellations of major events, and loss of in-person social interactions for children and youth. These restrictions undoubtedly impacted the lives of children and youth. This study describes the well-being of children and youth in Nova Scotia during the COVID-19 pandemic and their thoughts and feelings about the return to school, from the perspectives of both youth and parents. Methods: A province-wide survey was conducted in August 2020 with parents of school-age children and youth and youth to measure youth well-being since the pandemic began. Results: Parents of children and youth in grades pre-primary to 12 (n = 699; 53% girls) and youth in grades 3-12 (n = 279; 69% girls) completed the online survey. Perceptions of parents about children's emotions during the pandemic were: bored, safe, lonely, happy, and anxious. Youth reported feeling bored, relaxed, depressed, safe, and worried. Sixty-three percent of youth and 72% of parents reported that they/their child felt they were missing important life events. Parents reported that being with parents, being physically active and being with friends made their child feel positive. Youth reported that being with friends, pets and watching TV made them feel good during this time. Seventy-six percent of parents and 62% of youth reported they/their child were getting more screen time than before the pandemic. With schools closed, participants most frequently shared that they missed friends and social interactions, in-person learning, and extra-curricular activities. Youth and parents expressed worries about COVID-19 outbreaks and related restrictions when schools re-opened to in-person learning. Conclusion: The well-being of children and youth in Nova Scotia was greatly impacted by the COVID-19 pandemic and related school closures in 2020. It is essential that pandemic recovery plans prioritize the health and well-being of children and youth.

Understanding the Environment for Health-Promoting Schools Policies in Nova Scotia: A Comprehensive Scan at the Provincial and Regional School Level.

The World Health Organization has identified the school community as a key setting for health promotion efforts, laying out its priorities in the Health-Promoting Schools (HPS) framework. This framework offers a comprehensive approach that has been adopted in countries around the globe, with defining characteristics focused around the school curriculum and environment. Nova Scotia (NS) adopted the HPS framework at a provincial level in 2005, but it has been variably implemented. We aimed to identify, categorize, and broadly describe the environment for HPS policies in NS. Four iterative steps were employed: (1) a scan of government and regional school websites to identify publicly available policies; (2) consultations with provincial departments with respect to policy relevance and scope; (3) cross-comparison of policies by two reviewers; (4) compilation of policies into an online database. Seventy policies at the provincial level and 509 policies across eight public school regions were identified. Policies focusing on a 'safe school environment' were most common; those addressing mental health and well-being, physical activity, nutrition and healthy eating, and substance use were among those least commonly identified. This scan provides a comprehensive overview of HPS-relevant policies in NS, along with relative proportions and growth over time. Our findings suggest areas of policy action and inaction that may help or hinder the implementation of HPS principles and values.

Tricuspid Intervention Following Pulmonary Valve Replacement in Adults With Congenital Heart Disease.

BACKGROUND: Tricuspid regurgitation (TR) is common among adults with corrected tetralogy of Fallot (TOF) or pulmonary stenosis (PS) referred for pulmonary valve replacement (PVR). Yet, combined valve surgery remains controversial. OBJECTIVES: This study sought to evaluate the impact of concomitant tricuspid valve intervention (TVI) on post-operative TR, length of hospital stay, and on a composite endpoint consisting of 7 early adverse events (death, reintervention, cardiac electronic device implantation, infection, thromboembolic event, hemodialysis, and readmission). METHODS: The national Canadian cohort enrolled 542 patients with TOF or PS and mild to severe TR who underwent isolated PVR (66.8%) or PVR+TVI (33.2%). Outcomes were abstracted from charts and compared between groups using multivariable logistic and negative binomial regression. RESULTS: Median age at reintervention was 35.3 years. Regardless of surgery type, TR decreased by at least 1 echocardiographic grade in 35.4%, 66.9%, and 92.8% of patients with pre-operative mild, moderate, and severe insufficiency. In multivariable analyses, PVR+TVI was associated with an additional 2.3-fold reduction in TR grade (odds ratio [OR]: 0.44; 95% confidence interval [CI]: 0.25 to 0.77) without an increase in early adverse events (OR: 0.85; 95% CI: 0.46 to 1.57) or hospitalization time (incidence rate ratio: 1.17; 95% CI: 0.93 to 1.46). Pre-operative TR severity and presence of transvalvular leads independently predicted post-operative TR. In contrast, early adverse events were strongly associated with atrial tachyarrhythmia, extracardiac arteriopathy, and a high body mass index. CONCLUSIONS: In patients with TOF or PS and significant TR, concomitant TVI is safe and results in better early tricuspid valve competence than isolated PVR.

A Risk Management Strategy for Managing Critical Human Resource Changes in a Pediatric Heart Program.

BACKGROUND: Relocation, recruitment, or retirement of critical team members may lead to changes in the expertise pool that could threaten patient outcomes in a pediatric heart program. We developed a quality initiative aimed at risk management that uses risk-stratified case complexity and outcomes to guide a program during critical fluxes in the expert staff. The Ramp Down/Up protocol is a systematic, voluntary reduction in the complexity of cases performed, followed by a transparent and intentional escalation of case complexity. METHODS: Institutional Ethics Review Board approval for this quality initiative was obtained. Patient/caregiver consent for quality data collection is obtained at the time of hospital admission. Every surgical patient having their index cardiac surgical procedure at the Izaak Walton Killam (IWK) from January 1, 2003, to December 2015 is included. The Ramp Down/Up protocol evolved to have to 4 critical elements: (1) a trigger and a reduction in case complexity; (2) an external/objective expert observer; (3) an escalation in case complexity; and (4) data (qualitative and quantitative) collection and analysis. RESULTS: The Ramp Down/Up protocol was used 3 times over a 12-year period to address critical expert human resource challenges. The protocol was used for variable duration (3.5-9 months). Patient operative mortality was benchmarked to the Congenital Cardiac Surgery database, and outcomes were stable during and after protocol employment. CONCLUSIONS: A quality initiative aimed at risk management has allowed 1 pediatric heart team to ensure that patient outcomes were maintained during critical human resource changes.

CONTEXTE: La relocalisation, le recrutement ou le départ à la retraite de membres critiques d'une équipe peuvent amener des changements dans le bassin d'expertises pouvant compromettre les résultats obtenus par les patients au sein d'un programme de pédiatrie cardiaque. Nous avons conçu une initiative relative à la qualité de la gestion des risques, qui évalue la complexité des cas et les résultats, stratifiés selon le risque, afin d'orienter le programme durant les flux critiques de personnel spécialisé. Le protocole de réduction/d'augmentation réalise une diminution méthodique et délibérée de la complexité des cas suivie d'une intensification transparente et intentionnelle de celle-ci. MÉTHODOLOGIE: Cette initiative sur la qualité a obtenu l'approbation du comité d'examen de l'éthique des établissements. Le consentement du patient/de l'aidant requis pour la collecte de données sur la qualité est obtenu au moment de l'admission à l'hôpital. L'initiative incluait tous les patients de chirurgie pour lesquels on disposait de l'indice de chirurgie cardiaque établi au centre Izaak Walton Killiam (IWK) entre le 1er janvier 2003 et décembre 2015. Le protocole de réduction/d'augmentation a évolué pour intégrer quatre éléments critiques : 1) un facteur déclencheur et une réduction de la complexité des cas; 2) un observateur externe/expert objectif; 3) une intensification de la complexité des cas; 4) la collecte et l'analyse des données (qualitatives et quantitatives). RÉSULTATS: Le protocole de réduction/d'augmentation a été utilisé à trois reprises sur une période de 12 ans et sur des durées variables (de 3,5 à 9 mois) dans le but de relever des défis majeurs liés aux ressources humaines spécialisées. Les taux de mortalité opératoire des patients ont été comparés à ceux de la base de données sur les chirurgies cardiaques congénitales, et les résultats se sont révélés stables durant et après l'emploi du protocole. CONCLUSIONS: Une initiative sur la qualité ciblant la gestion des risques a permis à une équipe de pédiatrie cardiaque de s'assurer que les patients continuaient d'obtenir des résultats similaires lors de changements critiques des ressources humaines.