Children's Oral Health Initiative: workers' perspectives on its impact in First Nations communities. / Initiative en santé buccodentaire des enfants : le point de vue des intervenants quant à ses effets dans les communautés des Premières Nations.

INTRODUCTION: Since 2004, the Children's Oral Health Initiative (COHI) has been working in many First Nations and Inuit communities in Canada to address oral health disparities, specifically early childhood caries (ECC). The COHI community-based approach improves early childhood oral health (ECOH) by balancing prevention with minimally invasive dentistry. The goal is to reduce the burden of oral disease, mainly by minimizing the need for surgery. We investigated program success in First Nations communities in the province of Manitoba, from the perspective of COHI staff. METHODS: First Nations community-based dental therapists and dental worker aides participated in three focus groups and an in-depth semistructured interview. The collected data were thematically analyzed. RESULTS: Data from 22 participants yielded converging and practitioner-specific themes. Participants reported that dental therapists and dental worker aides provide access to basic oral care in their communities including oral health assessments, teeth cleaning, fluoride varnish applications and sealants. The participants agreed that education, information sharing and culturally appropriate parental engagement are crucial for continuous support and capacity building in the community programs. Low enrolment, difficulty accessing homes and getting consent, limited human resources as well as lack of educational opportunities for dental worker aides were identified challenges. CONCLUSION: Overall, the participants reported that the COHI program positively contributes to ECOH in First Nations communities. However, increased community-based training for dental workers, community awareness about the program, and engagement of parents to facilitate culturally appropriate programming and consent processes are critical to improving program outcomes.

Improvement in Serum Vitamin D Following Dental Rehabilitation to Treat Severe Early Childhood Caries.

Purpose: The purpose of this study was to investigate changes in 25-hydroxyvitamin D (25(OH)D) levels in children with severe early childhood caries (S-ECC) following rehabilitative surgery using general anesthesia (GA). Methods: Children with S-ECC were recruited on the day of surgery for a prospective study investigating changes in nutritional status and well-being before and after surgery. Venipunctures for 25(OH)D were performed while children were in the operating room, and parents completed a questionnaire regarding nutritional intake, oral health, quality of life, and family demographics. Participants returned at a minimum of three months for a follow-up venipuncture, questionnaire, and dental examination. Analyses included descriptive, bivariate, and multivariable regression analyses. A P-value of ≤ 0.05 was significant. Results: Overall, 150 children participated, with a mean age of 47.7±14.1 months. The mean baseline 25(OH)D concentration was 49.8±16.9 nmol/L, with 17 percent having deficient levels. Overall, 106 returned for follow-up. Paired t-tests revealed significant improvements in the mean 25(OH)D levels following rehabilitation (50.1±17.1 nmol/L versus 61.2±18.7, P<0.001). The proportion with optimal and adequate 25(OH)D levels increased from 9.2 percent to 24.1 percent and from 48.3 percent to 67.8 percent, respectively, while those classified as deficient decreased from 17.2 percent to 8.1 percent from baseline to follow-up. Conclusions: Significant improvements in vitamin D concentrations were observed following dental rehabilitation. This provides additional evidence of the association between oral health and nutritional status.

First Nations and Metis peoples' access and equity challenges with early childhood oral health: a qualitative study.

BACKGROUND: Inequities in early childhood oral health are evident amongst Indigenous peoples and communities in Manitoba, Canada. Early childhood caries (ECC) is decay in primary dentition in children under 6 years of age. A severe form of the disease occurs at a higher rate in Indigenous populations compared to the general population. ECC has been strongly associated with social determinants of health. METHODS: Focus groups and sharing circles were conducted with four First Nations and Metis communities in urban and rural communities in Manitoba. There were eight groups in total of purposively sampled participants (n = 59). A grounded theory approach guided thematic analysis of audio recorded and transcribed data. RESULTS: Indigenous participants experienced challenges similar to those found in the general population, such as encouraging and motivating parents and caregivers to establish regular oral hygiene routines for their children. However other challenges reported, disproportionately affect Indigenous communities. These include poor access to dental care, specifically no dental offices within 1 h driving radius and not having transportation to get there. Not having evidence-based oral health information to support good oral hygiene practices, preventing parents from making the best choices of oral hygiene products and oral health behaviours for their children. Poverty and food insecurity resulting in poor nutritional choices and leading to ECC. For example, feeding children sugary foods and beverages because those are more readily avialble than healthy options. Confusing or difficult encounters with dental professionals, highlighted as a factor that can erode trust, reduce compliance and impact continued attendance at dental offices. CONCLUSION: Closing existing early childhood oral health gaps for First Nations and Metis peoples and communities requires equity-oriented healthcare approaches to address specific problems and challenges faced by these populations. Family, community and systemic level interventions that directly implement community recommendations are needed.

Early childhood oral health promotion for First Nations and Métis communities and caregivers in Manitoba. / Promotion de la santé buccodentaire des jeunes enfants auprès des collectivités et des fournisseurs de soins des Premières Nations et des Métis du Manitoba.

INTRODUCTION: Early childhood caries is a public health concern, and the considerable burden exhibited by Indigenous children highlights the oral health inequities across populations in Canada. Barriers include lack of access to oral health care and lack of culturally appropriate oral health promotion. The purpose of this study was to determine where and how First Nations and Métis parents, caregivers and community members learn about caring for young children's oral health, and what ideas and suggestions they have on how to disseminate information and promote early childhood oral health (ECOH) in Indigenous communities. METHODS: Sharing circles and focus groups engaged eight groups of purposively sampled participants (n = 59) in four communities in Manitoba. A grounded theory approach guided thematic analysis of audiorecorded and transcribed data. RESULTS: Participants said that they learned about oral health from parents, caregivers and friends, primary care providers, prenatal programs, schools and online. Some used traditional medicines. Participants recommended sharing culturally appropriate information through community and prenatal programs and workshops; schools and day care centres; posters, mailed pamphlets and phone communication (calls and text messages) to parents and caregivers, and via social media. Distributing enticing and interactive oral hygiene products that appeal to children was recommended as a way to encourage good oral hygiene. CONCLUSION: Evidence-based oral health information and resources tailored to First Nations and Métis communities could, if strategically provided, reach more families and shift the current trajectory for ECOH.

The Effectiveness of Silver Diamine Fluoride and Fluoride Varnish in Arresting Caries in Young Children and Associated Oral Health-Related Quality of Life.

OBJECTIVE: To investigate the efficacy of silver diamine fluoride (SDF) with 5% fluoride varnish (FV) in treating cavitated caries in young children and to explore the association between SDF treatment and oral-health-related quality of life (OHRQoL). METHODS: Children with active dentinal caries in primary teeth underwent treatment with 38% SDF and 5% FV at baseline and 4 months later. Treated lesions were assessed 4 and 8 months after baseline. Child-level analysis focused on classifying SDF treatment as completely successful if all of a child's treated lesions were arrested or incompletely successful if at least 1 lesion was not arrested. The Early Childhood Oral Health Impact Scale questionnaire was completed at second and third visits. Statistical analyses included descriptive and bivariate methods. A p value ≤ 0.05 was considered significant. RESULTS: This pilot study enrolled 40 children with 239 caries lesions; mean age 40.2 ± 14.9 months and 45% male. Lesion arrest rates after 1 and 2 applications of SDF were 74.1% and 96.2%, respectively. Children who reportedly brushed twice daily were more likely to be in the completely successful group compared with those who brushed less (p = 0.006). Those in the completely successful group had a significantly lower mean baseline dmft score than those in the incompletely successful group (p = 0.048). No significant difference in OHRQoL was observed between the 2 groups. CONCLUSIONS: SDF with 5% FV is an effective approach to the management of early childhood caries; more than 1 application is recommended, along with regular follow up of patients and twice daily brushing. OHRQoL was not found to be affected by the level of success of SDF treatment.

Indigenous community members' views on silver diamine fluoride to manage early childhood caries.

OBJECTIVES: Early childhood caries (ECC) continues to be the leading reason for pediatric dental surgery in Canada and is particularly prevalent among Indigenous children. Silver diamine fluoride (SDF) offers an alternative method to manage non-restoratively caries. It is important to determine Indigenous communities' views on and receptivity toward SDF. AIM: To understand Indigenous community members' views on pediatric dental surgery to treat ECC under general anesthesia (GA) and receptivity to SDF as an alternative to restorative surgery. METHODS: Focus groups and sharing circles congruent with an Indigenous ways of gathering information were conducted. Three interviewers engaged eight groups of First Nation and Metis communities in three rural Indigenous communities and ne metropolitan urban setting in Manitoba, Canada. Overall, 59 individuals participated. Open coding was guided by grounded theory and further analysis using Nvivo 12 software™. RESULTS: Participants mean age was 35.6 years, 88 percent (52 individuals) had a least one child, and 32 percent (19 individuals) were employed. Eight themes emerged, including respondents' fear of dental surgery under GA, fear of pain after dental surgery, parents' need for more information before accepting SDF treatment, and concern about the black staining of treated lesions. CONCLUSIONS: Indigenous parents' acceptance of SDF as a treatment option is contingent on having more information and assurance that treatment under GA can be avoided. Understanding Indigenous parents' views may ensure better acceptance of SDF as a minimally invasive treatment option to manage ECC. A cautious and informative approach to SDF implementation in Indigenous communities is recommended.

The association of body mass index and severe early childhood caries in young children in Winnipeg, Manitoba: A cross-sectional study.

BACKGROUND: Associations between body mass index (BMI) and caries have been reported. AIM: To evaluate the direction of the relationship between BMI and severe early childhood caries (S-ECC). DESIGN: Children were recruited as part of a larger prospective cohort study assessing changes in nutritional status following dental rehabilitation under general anaesthetic. Pre-operative anthropometric measurements were used to calculate BMI z-scores (BMIz). Operative reports were reviewed to calculate caries scores based on treatment rendered. Analysis included descriptive statistics, bivariate analyses, and simple and multiple linear regression. RESULTS: Overall, 150 children were recruited with a mean age of 47.7 ± 14.2 (SD) months; 52% female. Over 42% were at risk for overweight, overweight or obese. Although simple linear regression demonstrated a significant positive association between dmfs score and BMIz, adjusted multiple linear regression found no significant relationship between BMIz and dmfs, but highlighted a relationship between BMI z-score and family income, Registered First Nations Status and physical activity. CONCLUSIONS: Although a significant relationship between BMI and S-ECC was not found, poverty was a key confounding variable. As both S-ECC and obesity are known predictors of future disease, it is important for healthcare professionals to identify children at risk. Diet and behaviour modification may play a role in disease prevention.

Predictors of Women's Satisfaction with Prenatal Care in a Canadian Setting.

OBJECTIVE: Prenatal care is a vital and important part of a healthy pregnancy, providing many maternal and health benefits. Despite Canada's publically funded health care system with universal access, inadequate rates of prenatal care continue to be observed. As a modifiable risk factor, the process variables that influence satisfaction with prenatal care in Canadian settings have received little attention. The objective of this study was to identify the predictors of satisfaction with prenatal care. METHODS: A cross-sectional, descriptive, correlational design was used to examine the relationships between expectations, interpersonal processes of care, the quality of prenatal care, personal characteristics, and the type of provider with overall satisfaction, and with four dimensions of satisfaction. A convenience sample of 216 pregnant women was surveyed using self-administered questionnaires with women in their third trimester. Multiple linear regression analyses were used to identify predictors of satisfaction. RESULTS: The quality of prenatal care and provider interpersonal style together explained 80% of the variance in overall satisfaction. Patient-centered decision-making was a significant predictor of satisfaction with information, while having a midwife was a predictor of satisfaction with system characteristics. Expectations were not related to satisfaction. CONCLUSIONS FOR PRACTICE: Improving quality of care, provider interpersonal style and patient-centered decision making, and improving the structural characteristics of prenatal care may be effective in improving women's satisfaction and utilization of prenatal care.

Oral Health-Related Quality of Life of Canadian Preschoolers with Severe Caries After Dental Rehabilitation Under General Anesthesia.

Purpose: The purpose was to determine changes in the oral health-related quality-of-life (OHRQoL) of children with severe early childhood caries (S-ECC) following dental rehabilitation under general anesthesia (DRGA). Methods: This prospective cohort study involved caregivers completing questionnaires, including the Early Childhood Oral Health Impact Scale (ECOHIS). Data analysis included descriptive statistics, bivariate analyses, effect size, and multiple linear regression. Results: Initially, 150 children were enrolled, mean age of 47.7±14.2 (SD) months. The baseline mean total ECOHIS score was 6.3±5.3. Higher baseline ECOHIS scores were associated with single-parent families, low-income house-holds, higher decayed, missing, and filled primary teeth (dmft) scores, and having extractions (P ≤ 0.05). Multiple linear regression results showed low household income (P=0.01) and the child not having Registered First Nation status (a specific population of Indigenous Canadians; P=0.03) were significantly and independently associated with higher total baseline ECOHIS scores. At follow-up, 103 children had a mean total ECOHIS score of 3.5±2.9 versus a baseline score of 6.3±5.4. Change in total ECOHIS and three of four Child Impact Section domains showed significant improvement (P<0.001) post-DRGA. Worse follow-up ECOHIS scores were only associated with the child being male (P=0.02). Conclusions: Improvements in oral health-related quality of life were observed following DRGA. Consideration should be given for using the Early Childhood Oral Health Impact Scale to help prioritize children waiting for DRGA. (Pediatr Dent 2019;41(3):221-8) Received November 22, 2018 | Last Revision February 28, 2019 | Accepted April 1, 2019.

The Relation Between Periodontal Disease and Vitamin D.

BACKGROUND: There is conflicting evidence regarding the association between vitamin D and periodontal disease. The purpose of this study was to explore that relation. METHODS: This cross-sectional study used data from the Canadian Health Measures Survey for respondents 13-79 years of age. Vitamin D status was determined by measuring plasma 25-hydroxyvitamin D (25(OH)D) concentrations. Periodontal disease was defined by gingival index (GI) and calculated loss of attachment (LOA). Statistical analyses included bivariate tests and multiple logistic regression. RESULTS: At the bivariate level, 25(OH)D concentrations below the cutoff levels of 50 nmol/L and 75 nmol/L were associated with GI. However, multiple regression analyses for GI revealed no association with mean 25(OH)D level or either concentration. Although no significant association between LOA and 25(OH)D status was identified at the bivariate level, a statistically significant association was observed between LOA and 25(OH)D levels < 75 nmol/L on multiple regression analysis. However, mean 25(OH)D concentrations and those < 50 nmol/L were not associated with LOA on multiple regression analysis. CONCLUSION: Vitamin D status was inversely associated with GI at the bivariate level, but not at the multivariate level. Conversely, vitamin D status was not associated with LOA at the bivariate level, but it was inversely associated with LOA at the multivariate level. These results provide modest evidence supporting a relation between low plasma 25(OH)D concentrations and periodontal disease as measured by GI and LOA.

Increased rates of 25-hydroxy vitamin D testing: Dissecting a modern epidemic.

INTRODUCTION: Laboratories have noted marked increases in the analysis of 25-hydroxy vitamin D (25(OH)D) in recent decades. Our objectives were to describe the annual number of 25(OH)D tests, examine the characteristics of those tested and those ordering them, and determine the proportion of potentially unnecessary tests in Manitoba. METHODS: Manitoba residents who were tested between 2006/7 and 2012/13 had their data anonymously linked to Manitoba Centre for Health Policy comprehensive administrative datasets. Patient and physician characteristics, location of residence, and 25(OH)D concentrations were determined. Descriptive statistics and multivariable regression models were utilized. RESULTS: There was a quadrupling in testing from 2006 to 2013, with >20,000 tests performed in 2012/13. The median annual number of tests was one per patient; the maximum was >10 tests per year. Adult females had twice the number of tests compared to males (p < 0.001). There was a rise in 25(OH)D concentrations over time with hypervitaminosis D increasing disproportionately (2006/7 to 212/13 (0% vs. 0.15%, p < 0.001)). Apparently unnecessary testing rose by 1/3 over time, frequently ordered by Family Medicine practitioners. A revised 25(OH)D requisition resulted in striking reduction of 25(OH)D requests (~80%). DISCUSSION: Manitoba noted a rapid increase in testing, and rise in 25(OH)D concentrations with levels that may be associated with toxicities; both have been reported in other jurisdictions. There appeared to a striking rise in 'unnecessary' tests. We similarly report the benefit of the implementation of a mandatory requisition specifying eligibility criteria for 25(OH)D and education about appropriate testing.

Caffeine is a risk factor for osteopenia of prematurity in preterm infants: a cohort study.

BACKGROUND: Caffeine, the most commonly used medication in Neonatal Intensive Care Units, has calciuric and osteoclastogenic effects. METHODS: To examine the association between the cumulative dose and duration of therapy of caffeine and osteopenia of prematurity, a retrospective cohort study was conducted including premature infants less than 31 weeks and birth weight less than 1500 g. Osteopenia of prematurity was evaluated using chest X-rays on a biweekly basis over 12 weeks of hospitalization. RESULTS: The cohort included 109 infants. 51% had osteopenia of prematurity and 8% had spontaneous rib fractures. Using the generalized linear mixed model, caffeine dose and duration of caffeine therapy showed a strong association with osteopenia of prematurity. Steroids and vitamin D were also significantly correlated with osteopenia of prematurity while diuretic use did not show a statistically significant effect. CONCLUSION: The cumulative dose and duration of therapy of caffeine, as well as steroid are associated with osteopenia of prematurity in this cohort. Future studies are needed to confirm these findings and determine the lowest dose of caffeine needed to treat effectively apnea of prematurity.

Parents' and caregivers' perspectives on the Manitoba Dental Association's Free First Visit program.

OBJECTIVES: The Free First Visit (FFV) program was implemented in 2010 to promote early preventive dental visits for children <36 months of age in Manitoba, Canada. The purpose was to understand parents' and caregivers' perspectives on the program. METHODS: Three focus groups with 21 participants were conducted in Winnipeg, Canada using an interview guide in this qualitative study. RESULTS: Most participants were aware of the FFV program and the appropriate age for a child's first visit. Almost all agreed with the recommendation to see a dentist by one year of age. Some reported that general dentists advised them to bring their child after three years of age. Participants appreciated that the program was free, and some noted that the program made them aware of the appropriate age for a first visit. About half of the participants had taken their child for a FFV. Reasons for not taking their child for a FFV included: nothing wrong with their child's teeth, they believed there was still time as their child was not three years old, they had government insurance, child's temperament, and feelings of apathy. There were mixed opinions regarding whether the program was helping those who needed it the most. CONCLUSIONS: The majority of participants liked the FFV program and believed that it should continue. Parents would benefit from further education and encouragement to seek oral care for their child by age one. Some general dentists may need further training and skills to meet the recommendations for first dental visits.

DENTISTS' PERSPECTIVES ON THE MANITOBA DENTAL ASSOCIATION'S FREE FIRST VISIT PROGRAM.

BACKGROUND: In 2010, the Manitoba Dental Association implemented the Free First Visit (FFV) program to provide access to dental screenings for children under 3 years of age and promote the concept of the age 1 dental visit. In this article, we report on dentists' views of the program. METHODS: This qualitative study included 3 focus groups held in Winnipeg, Canada. An interview guide was developed to structure discussions. RESULTS: Thirty dentists participated. They were extremely supportive of the FFV program and its continuation. Promoting early visits and providing parents with anticipatory guidance were some reasons dentists participated. The most common reason for not participating was that dentists were already providing free dental care for children. Dentists viewed the goals of the program as increasing public awareness of the importance of early dental visits, establishing dental homes, educating parents, identifying early signs of caries and increasing children's level of comfort in the dental clinic. They indicated that the FFV program prompted some parents to take their children earlier than they might have otherwise. They said that most FFVs were provided to families who were already part of their practice. According to participating dentists, most parents were unaware of the FFV program and did not know about the age 1 visit recommendation. Dentists recommended that the FFV program concentrate on promoting the first visit by age 1 message with the free component as a secondary message. Participants recommended increasing general dentists' involvement in the program as most FFVs are currently provided by pediatric dentists. CONCLUSIONS: Most dentists participating in this study were supportive of the FFV program and advocated its continuation in Manitoba.

Evaluating the impact of a community developed collaborative project for the prevention of early childhood caries: the Healthy Smile Happy Child project.

INTRODUCTION: To determine the effectiveness of the Healthy Smile Happy Child (HSHC) project, a community-developed initiative promoting early childhood oral health in Manitoba, Canada. Specific aims were to assess improvements in caregiver knowledge, attitudes, and behaviours relating to early childhood oral health, and the burden of early childhood caries (ECC) and severe ECC (S-ECC). METHODS: A serial cross-sectional study design was selected to contrast findings following the Healthy Smile Happy Child (HSHC) campaign in four communities with the previous baseline data. One community was a remote First Nation in northern Manitoba and another was a rural First Nation in southern Manitoba. The other two communities were urban centres, one of which was located in northern Manitoba. A community-development approach was adopted for the project to foster community solutions to address ECC. Goals of the HSHC program were to promote the project in each community, use existing community-based programs and services to deliver the oral health promotion and ECC prevention activities, and recruit and train natural leaders to assist in program development and to deliver the ECC prevention program. The HSHC coordinator worked with communities to develop a comprehensive list of potential strategies to address ECC. Numerous activities occurred in each community to engage members and increase their knowledge of early childhood oral health and ultimately lead them to adopt preventive oral health practices for their young children. Children under 71 months of age and their primary caregivers participated in this follow-up study. A -value ≤0.05 was statistically significant. RESULTS: 319 children (mean age 38.2±18.6 months) and their primary caregivers participated. Significant improvements in caregiver knowledge and attitudes were observed following the HSHC campaign, including that baby teeth are important (98.8%), that decay involving primary teeth can impact on health (94.3%), and the importance of a dental visit by the first birthday (82.4%). Significantly more respondents indicated that their child had visited the dentist (50.2%) and had started brushing their child's teeth (86.7%) when compared to baseline. Overall, 52.0% had ECC, 38.6% had S-ECC. The mean deft score was 3.85±4.97 (range 0-20). There was no significant change is ECC prevalence between the follow-up and baseline investigations. However, age-adjusted logistic regression for S-ECC in this follow-up study revealed a significant reduction in prevalence compared with the baseline study (=0.021). Similarly, age-adjusted Poisson regression revealed that there were significant reductions in both the decayed teeth and decayed, extracted and filled teeth scores between follow-up and baseline study periods (0.016 and .0001, respectively). CONCLUSIONS: Follow-up study results suggest that the HSHC initiative may have contributed to improvements in caregiver knowledge, attitudes, and behaviours towards early childhood oral health and subsequently modest yet statistically significant reductions in caries scores and the prevalence of S-ECC.

Geographical variation analysis of all-cause hospital readmission cases in Winnipeg, Canada.

BACKGROUND: Hospital readmission is costly and potentially avoidable. The concept of virtual wards as a new model of care is intended to reduce hospital readmissions by providing short-term transitional care to high-risk and complex patients in the community. In order to provide information regarding the development of virtual wards in the Winnipeg Health Region, Canada, this study used spatial statistics to identify geographic variations of hospital readmissions in 25 neighborhood clusters. METHODS: The data were obtained from the Population Health Research Data Repository housed at the Manitoba Centre for Health Policy. We used a Bayesian Disease Mapping approach which applied Markov chain Monte Carlo (MCMC) for cluster detection. RESULTS: Between 2005/06 and 2008/09, 123,842 patients were hospitalized in all Winnipeg hospitals. Of these, 41,551 (33%) were readmitted to hospital in the year following discharge. Most of these readmitted patients (89.4%) had 1-2 readmissions, while 11.6% of readmitted patients had more than 2 readmissions after initial discharge. The smoothed age- and sex- adjusted relative risk rates of hospital readmission in 25 Winnipeg neighborhood clusters ranged between 0.73 and 1.27. We found that there were spatial cluster variations of hospital readmission across the Winnipeg Health Region. Seven neighborhood clusters are more likely to be significant potential clusters for hospital readmissions (p < .05), while six neighborhood clusters are less likely to be significant potential clusters. CONCLUSIONS: This study provides the foundation and implementation guide for the Winnipeg Regional Health Authority virtual ward program. The findings will also help to improve long-term condition management in community settings and will help program planners to assure the efficient use of healthcare resources.

Barriers and facilitators related to use of prenatal care by inner-city women: perceptions of health care providers.

BACKGROUND: Socioeconomic disparities in the use of prenatal care (PNC) exist even where care is universally available and publicly funded. Few studies have sought the perspectives of health care providers to understand and address this problem. The purpose of this study was to elicit the experiential knowledge of PNC providers in inner-city Winnipeg, Canada regarding their perceptions of the barriers and facilitators to PNC for the clients they serve and their suggestions on how PNC services might be improved to reduce disparities in utilization. METHODS: A descriptive exploratory qualitative design was used. Semi-structured interviews were conducted with 24 health care providers serving women in inner-city neighborhoods with high rates of inadequate PNC. Content analysis was used to code the interviews based on broad categories (barriers, facilitators, suggestions). Emerging themes and subthemes were then developed and revised through the use of comparative analysis. RESULTS: Many of the barriers identified related to personal challenges faced by inner-city women (e.g., child care, transportation, addictions, lack of support). Other barriers related to aspects of service provision: caregiver qualities (lack of time, negative behaviors), health system barriers (shortage of providers), and program/service characteristics (distance, long waits, short visits). Suggestions to improve care mirrored the facilitators identified and included ideas to make PNC more accessible and convenient, and more responsive to the complex needs of this population. CONCLUSIONS: The broad scope of our findings reflects a socio-ecological approach to understanding the many determinants that influence whether or not inner-city women use PNC services. A shift to community-based PNC supported by a multidisciplinary team and expanded midwifery services has potential to address many of the barriers identified in our study.

Development and validation of a predictive model for all-cause hospital readmissions in Winnipeg, Canada.

OBJECTIVE: A number of predictive models have been developed to identify patients at risk of hospital readmission. Most of these have focused on readmission within 30 days of discharge. We used population-based health administrative data to develop a predictive model for hospital readmission within 12 months of discharge in Winnipeg, Canada. METHODS: This was a retrospective cohort study with derivation and validation data sets. Multivariable logistic regression analyses were performed and factors significantly associated with readmission were selected to construct a risk scoring tool. RESULTS: Several variables were identified that predicted readmission (i.e. older age, male, at least one hospital admission in the previous two years, an emergent (index) hospital admission, Charlson comorbidity score >0 and length of stay). Discrimination power was acceptable (C statistic =0.701). At a median risk score threshold, the sensitivity, specificity, positive and negative predictive values were 45.5%, 79%, 68.8% and 58.6%. CONCLUSIONS: This predictive model demonstrated that hospital readmission within 12 months of discharge can be reasonably well predicted based on administrative data. It will help health care providers target interventions to prevent unnecessary hospital readmissions.

Perceptions of barriers, facilitators and motivators related to use of prenatal care: A qualitative descriptive study of inner-city women in Winnipeg, Canada.

OBJECTIVE: The objective of this qualitative descriptive study was to explore the perceptions of women living in inner-city Winnipeg, Canada, about barriers, facilitators, and motivators related to their use of prenatal care. METHODS: Individual, semi-structured interviews were conducted in person with 26 pregnant or postpartum women living in inner-city neighborhoods with high rates of inadequate prenatal care. Interviews averaged 67 min in length. Recruitment of participants continued until data saturation was achieved. Inductive content analysis was used to identify themes and subthemes under four broad topics of interest (barriers, facilitators, motivators, and suggestions). Sword's socio-ecological model of health services use provided the theoretical framework for the research. This model conceptualizes service use as a product of two interacting systems: the personal and situational attributes of potential users and the characteristics of health services. RESULTS: Half of the women in our sample were single and half self-identified as Aboriginal. Participants discussed several personal and system-related barriers affecting use of prenatal care, such as problems with transportation and child care, lack of prenatal care providers, and inaccessible services. Facilitating factors included transportation assistance, convenient location of services, positive care provider qualities, and tangible rewards. Women were motivated to attend prenatal care to gain knowledge and skills and to have a healthy baby. CONCLUSION: Consistent with the theoretical framework, women's utilization of prenatal care was a product of two interacting systems, with several barriers related to personal and situational factors affecting women's lives, while other barriers were related to problems with service delivery and the broader healthcare system. Overcoming barriers to prenatal care and capitalizing on factors that motivate women to seek prenatal care despite difficult living circumstances may help improve use of prenatal care by inner-city women.