Teachers reported that children with special health care needs displayed more attention problems.

AIM: Children with special health care needs (SHCN) perform more poorly at school compared to their classmates. Specific causal pathways have not yet been extensively studied. Therefore, we investigated teacher-rated global attention, an important prerequisite for educational attainment, in children with SHCN. METHODS: Data of a population-based prospective cohort study, which recruited preschool children from the Mainz-Bingen area, Germany, were analysed. Children with SHCN were identified by the Children with Special Health Care Needs screening tool. In 2016, global attention was reported by teachers at the end of first grade (mean age: 7.3 years) on a 5-point rating scale ranging from -2 through +2. Associations between SHCN consequences and teacher-rated attention were estimated by linear mixed models, adjusted for confounding variables. RESULTS: We included 1921 children (51% males); of these, 14% had SHCN. Compared to their classmates, children with SHCN had poorer teacher-rated attention scores (adjusted mean difference: -0.35, 95% CI: -0.52 to -0.17). The effect was strongest among children with treatment or counselling for mental health problems or functional limitations. The effect remained after excluding children with attention deficit hyperactivity disorder from the analysis. CONCLUSION: Children with SHCN showed more teacher-rated attention problems, which could explain their lower educational attainment.

School absenteeism in children with special health care needs. Results from the prospective cohort study ikidS.

OBJECTIVE: Children with special health care needs (SHCN) due to a chronic health condition perform more poorly at school compared to their classmates. There is still little knowledge on the causal pathways and which factors could be targeted by interventions. We, therefore, investigated school absenteeism in children with SHCN compared to their peers. METHODS: This study was based on data from the German population-based prospective cohort study ikidS (German for: I will start school). Children with SHCN were identified by the Children with Special Health Care Needs screener that captures five consequences of physical or mental chronic health conditions: (1) use or need of prescription medication, (2) above average use or need of medical, mental health, or educational services, (3) functional limitations compared with others of the same age, (4) use or need of specialized therapies, and (5) treatment or counseling for emotional, behavioral, or developmental problems. School absenteeism was defined as days absent from school due to illness during first grade and was reported by classroom teachers. Associations between SHCN consequences and school absenteeism were investigated by negative binomial regression models. Effect estimates were adjusted for confounding variables identified by a causal framework and directed acyclic graphs. RESULTS: 1,921 children (mean age at follow-up 7.3 years, standard deviation 0.3; 49% females) were included; of these, 14% had SHCN. Compared to their classmates, children with SHCN had more days absent (adjusted rate ratio: 1.37; 95% confidence interval 1.16, 1.62). The effect was strongest among children with i) functional limitations, ii) treatment or counseling for emotional, behavioral, or developmental problems, and iii) those who experienced two or more SHCN consequences. CONCLUSIONS: Children with SHCN have higher school absenteeism, which could-at least partly-explain their poorer school performance and lower educational attainment. SHCN-specific targeted interventions may reduce the adverse effects of SHCN on educational outcomes in children.

The 3G Multigenerational Cohort of Nova Scotian women and their mothers and offspring.

BACKGROUND: The negative impact of exposures such as maternal obesity, excessive gestational weight gain, and hypertension in pregnancy on the health of the next generation has been well studied. Evidence from animal studies suggests that the effects of in utero exposures may persist into the second generation, but the epidemiological literature on the influence of pregnancy-related exposures across three generations in humans is sparse. OBJECTIVES: This cohort was established to investigate associations between antenatal and perinatal exposures and health outcomes in women and their offspring. POPULATION: The cohort includes women who were born and subsequently had their own pregnancies in the Canadian province of Nova Scotia from 1980 onward. DESIGN: Intergenerational linkage of data in the Nova Scotia Atlee Perinatal Database was used to establish a population-based dynamic retrospective cohort. METHODS: The cohort has prospectively collected information on sociodemographics, maternal health and health behaviours, pregnancy health and complications, and obstetrical and neonatal outcomes for two generations of women and their offspring. PRELIMINARY RESULTS: As of October 2018, the 3G cohort included 14 978 grandmothers (born 1939-1986), 16 766 mothers or cohort women (born 1981-2003), and 28 638 children (born 1996-2018). The cohort women were generally younger than Nova Scotian women born after 1980, and as a result, characteristics associated with pregnancy at a younger age were more frequently seen in the cohort women; sampling weights will be created to account for this design effect. The cohort will be updated annually to capture future deliveries to women who are already in the cohort and women who become eligible for inclusion when they deliver their first child. CONCLUSIONS: The 3G Multigenerational Cohort is a population-based cohort of women and their mothers and offspring, spanning a time period of 38 years, and provides the opportunity to study inter- and transgenerational associations across the maternal line.

Cesarean Delivery and Healthcare Utilization and Costs in the Offspring: A Retrospective Cohort Study.

OBJECTIVE: To examine the association between cesarean delivery and healthcare utilization and costs in offspring from birth until age 7 years. STUDY DESIGN: A retrospective cohort study of singleton term births in the Canadian province of Nova Scotia between 2003 and 2007 followed until age 7 years was conducted using data from the Nova Scotia Atlee Perinatal Database and administrative health data. The main exposure was mode of delivery (cesarean delivery vs vaginal birth); the outcome was healthcare utilization and costs during the first 7 years of life. Associations were modeled using multiple regression adjusting for maternal prepregnancy weight and sociodemographic factors. RESULTS: In total, 32 464 births were included in the analysis. Compared with children born by vaginal birth, children born by cesarean delivery had more physician visits (incidence rate ratio 1.06, 95% CI 1.05-1.08) and longer hospital stays (incidence rate ratio 1.12, 95% CI 1.03-1.21) and were more likely to be high utilizers of physician visits (OR 1.23, 95% CI 1.10-1.37). Physician and hospital costs were $775 higher for children born by cesarean delivery compared with vaginal birth. CONCLUSIONS: Cesarean delivery compared with vaginal birth is associated with small but statistically significant increases in healthcare utilization and costs during the first 7 years of life.

Maternal pre-pregnancy obesity and health care utilization and costs in the offspring.

BACKGROUND/OBJECTIVE: The association between maternal pre-pregnancy obesity and adverse child health outcomes is well described, but there are few data on the relationship with offspring health service use. We examined the influence of maternal pre-pregnancy obesity on offspring health care utilization and costs over the first 18 years of life. METHODS: This was a population-based retrospective cohort study of children (n = 35,090) born between 1989 and 1993 and their mothers, who were identified using the Nova Scotia Atlee Perinatal Database and linked to provincial administrative health data from birth through 2014. The primary outcome was health care utilization as determined by the number and cost of physician visits, hospital admissions and days, and high utilizer status (>95th percentile of physician visits). The secondary outcome was health care utilization by ICD chapter. Maternal pre-pregnancy weight was categorized as normal weight, overweight, or obese. Multivariable-adjusted regression models were used to examine the association between maternal weight status and offspring health care use. RESULTS: Children of mothers with pre-pregnancy obesity had more physician visits (10%), hospital admissions (16%), and hospital days (10%) than children from mothers of normal weight over the first 18 years of life. Offspring of mothers with obesity had C$356 higher physician costs and C$1415 hospital costs over 18 years than offspring of normal weight mothers. Children of mothers with obesity were 1.74 times more likely to be a high utilizer of health care and had higher rates of physician visits and hospital stays for nervous system and sense organ disorders, respiratory disorders, and gastrointestinal disorders compared to children of normal weight mothers. CONCLUSION: Our findings suggest that maternal pre-pregnancy overweight and obesity are associated with slightly higher offspring health care utilization and costs in the first 18 years of life.

Characteristics and Outcomes of Adolescent Births in Nova Scotia: A Retrospective Cohort Study.

OBJECTIVE: This study sought to examine the maternal characteristics and outcomes of adolescent births in Nova Scotia. METHODS: The investigators conducted a retrospective population-based cohort study using the Nova Scotia Atlee Perinatal Database. Maternal characteristics and maternal and neonatal outcomes of singleton live births between 2006 and 2015 were compared between adolescent (aged 12 to 19) and adult (aged 20 to 35) women. Associations were examined using log-binomial regression models. RESULTS: Of the 35 111 births that occurred during the study period, 11% were to adolescent mothers. Compared with adult women, adolescents had higher rates of smoking and substance abuse and were of lower socioeconomic status. Adolescent mothers were more than twice as likely as women aged 20 to 35 to smoke during pregnancy. Adolescent women were significantly less likely to have gestational diabetes, need induction of labour, have an assisted vaginal delivery, require a Caesarean section, have a large-for-gestational age infant, or breastfeed at discharge compared with the 20 to 35 age group. Birth of a small-for-gestational age infant and other adverse neonatal outcomes were more frequently seen in adolescents compared with adult women in the unadjusted models, but this difference vanished in models adjusted for sociodemographic factors and smoking. CONCLUSION: This study highlights disparities in socioeconomic characteristics and health behaviours between births in adolescent and adult mothers and suggests that a targeted multidisciplinary approach would be valuable for the pregnant adolescent. The role of antenatal support for pregnant adolescents is reinforced because sociodemographic factors and smoking accounted for differences in neonatal outcomes relative to adult women.

Integrated knowledge translation in population health intervention research: a case study of implementation and outcomes from a school-based project.

BACKGROUND: Integrated knowledge translation (IKT) is encouraged in population health intervention research (PHIR) to ensure the co-production of policy-relevant research, yet there is little published literature that reports its implementation and outcomes. The purpose of this study was to describe and evaluate the IKT approach used in a school-based PHIR project to understand how the research informed policy and practice and identify what influenced the IKT process. METHODS: A case study approach was used to provide an in-depth description of the IKT process and understand the co-production and application of research evidence. Data were collected through document review, a survey with all elementary school principals in the school board (n = 18) following dissemination of School Reports and interviews with the IKT research team (including two researchers and three knowledge users). RESULTS: Approximately half of the principals reported reading their School Report (52%) and almost all of these principals attributed the partial or full adoption, or implementation, of a new practice as a result of using the information (89%). Key themes related to the IKT process emerged across the interviews, including supportive relationships, role clarity, competing priorities and the complexities of population health interventions. CONCLUSIONS: The findings suggest that, while IKT can support policy and practice, it can be challenging to maintain engagement due to differing priorities and role ambiguity. Additional recognition, investment and research would enable better implementation of the approach, thereby bridging the gap between research, policy and practice.

A translational approach to characterization and measurement of health-promoting school ethos.

A health promoting schools (HPS) approach is hypothesized to influence student health and wellbeing by promoting a 'school ethos' that reflects the physical environment, social relations, organisational structure, policies and practices within schools. This complex set of factors makes health promoting school ethos (HPSE) challenging to define and measure. This work sought to theorise, develop and pilot a measure of HPSE as the context for implementation of HPS initiatives. We used a multi-method, iterative process to identify relevant HPSE concepts through triangulation of conceptual literature, existing tools and the tacit knowledge of school stakeholders. The HPSE measurement tool was administered to 18 elementary schools through a principal and teacher survey and an environmental assessment, followed by the development of HPSE scores for each school. Testing for internal consistency of items was used to examine theorized concepts, and scores for each school are summarised. HPSE included eight conceptual dimensions with internal consistency ranging from α = 0.60 to α = 0.87. Total HPSE scores across schools (N = 18) ranged from 1 to 8 (mean = 3.94, SD = 2.1), with 28-65% of schools reporting 'high' on respective HPSE dimensions. Schools included a heterogeneous mixture of HPSE scores, particularly across different dimensions. Our novel approach to tool development allowed us to conceptualize HPSE using a flexible process comprising different types and sources of evidence. The HPSE tool holds potential for identification and measurement of critical components of different school context as it relates to HPS.

Fruit and vegetable preferences and intake among children in Alberta.

PURPOSE: The association between preference for and intake of fruits and vegetables was examined among Albertan children. METHODS: Data used were collected as part of a provincial population-based survey among grade 5 children in Alberta. Intake of two fruits and five vegetables was assessed using the Harvard food frequency questionnaire, and preference for individual fruit and vegetable items was rated using a three-point Likert-type scale. Random effects models with children nested within schools were used to test for associations between fruit and vegetable preference and intake. RESULTS: A total of 3398 children aged 10 to 11 years returned completed surveys. Children who reported a greater liking for fruits and vegetables also reported significantly (p<0.001) higher intake. On average, children who liked a food a lot ate 0.5 to 2.7 more weekly servings of the food than did children who did not like the food. CONCLUSIONS: These findings suggest that focusing on interventions designed to increase taste preference may lead to increased fruit and vegetable intake among children. Introducing children to unfamiliar fruits and vegetables through taste testing may be an effective and practical health promotion approach for improving dietary habits.

Cost analyses of obesity in Canada: scope, quality, and implications.

BACKGROUND: Rapid changes in lifestyle have led to a global obesity epidemic. Understanding the economic burden associated with the obesity epidemic is essential to decision making of cost-effective interventions. This study reviewed costs of obesity and intervention programs in Canada, assessed the scope and quality of existing cost analyses, and identified implications for economic evaluations and public health decision makers. METHODS: A systematic search of costs associated with obesity or intervention program in Canada between 1990 and 2011 yielded 10 English language articles eligible for review. RESULTS: The majority of studies was prevalence-based or top-down costing; 40% had excellent quality assessed using the Quality of Health Economic Study scale. The aggregated annual costs of obesity in Canada ranged from 1.27 to 11.08 billion dollars. Direct costs accounted for 37.2% to 54.5% of total annual costs. Between 2.2% and 12.0% of Canada's total health expenditures were attributable to obesity. The average annual physician cost of overweight male ($ 427) and female ($ 578) adults was lower than that of obese male ($ 475) and female ($ 682) adults; this cost differential across weight status groups was comparable to that found in adolescents. The cost for implementation and maintenance of a school-based obesity prevention program was $ 23 per student. CONCLUSIONS: We observed high costs associated with overweight and obesity and modest costs for obesity prevention programs; however, no cost-effectiveness study of obesity interventions has been performed in Canada. Cost-effectiveness analyses of preventive programs that constitute incidence-based life-time modeling of costs and health outcomes from societal perspective are urgently needed.

Health behaviours and health-care utilization in Canadian schoolchildren.

OBJECTIVE: Poor nutritional habits and physical inactivity are two health behaviours believed to be linked with increasing rates of overweight and obesity in children. The objective of the present study was to determine whether children who reported healthier behaviours, specifically in relation to nutrition and physical activity, also had lower health-care utilization. DESIGN: Population-based cross-sectional study, linking survey data from the 2003 Children's Lifestyle and School Performance Study (CLASS) with Nova Scotia administrative health data. Health-care utilization was defined as both (i) the total physician costs and (ii) the number of physician visits, for each child from 2001 to 2006. Exposures were two indices of healthy eating, the Diet Quality Index and the Healthy Eating Index, and self-reported physical activity and screen time behaviours. SETTING: Elementary schools in the Canadian province of Nova Scotia. SUBJECTS: Grade 5 students and their parents; of the 5200 students who participated in CLASS and completed surveys, 4380 (84 %) could be linked with information in the administrative data sets. RESULTS: The study found a relationship between both indices of healthy eating and a borderline significant trend towards lower health-care utilization in this population sample of children. No statistically significant relationships were seen for physical activity or screen time. CONCLUSIONS: Both measures of diet quality produced similar results. The study suggests that healthy eating habits established in childhood may be associated with lower health-care utilization, although further research over a longer time frame is needed to demonstrate statistical significance.

From "best practice" to "next practice": the effectiveness of school-based health promotion in improving healthy eating and physical activity and preventing childhood obesity.

BACKGROUND: In 2005, we reported on the success of Comprehensive School Health (CSH) in improving diets, activity levels, and body weights. The successful program was recognized as a "best practice" and has inspired the development of the Alberta Project Promoting active Living and healthy Eating (APPLE) Schools. The project includes 10 schools, most of which are located in socioeconomically disadvantaged areas. The present study examines the effectiveness of a CSH program adopted from a "best practice" example in another setting by evaluating temporal changes in diets, activity levels and body weight. METHODS: In 2008 and 2010, we surveyed grade 5 students from approximately 150 randomly selected schools from the Canadian province of Alberta and students from 10 APPLE Schools. Students completed the Harvard Youth/Adolescent Food Frequency Questionnaire, questions on physical activity, and had their height and weight measured. Multilevel regression methods were used to analyze changes in diets, activity levels, and body weight between 2008 and 2010. RESULTS: In 2010 relative to 2008, students attending APPLE Schools were eating more fruits and vegetables, consuming fewer calories, were more physically active and were less likely obese. These changes contrasted changes observed among students elsewhere in the province. CONCLUSIONS: These findings provide evidence on the effectiveness of CSH in improving health behaviors. They show that an example of "best practice" may lead to success in another setting. Herewith the study provides the evidence that investments for broader program implementation based on "best practice" are justified.

Comparison of ICD code-based diagnosis of obesity with measured obesity in children and the implications for health care cost estimates.

BACKGROUND: Administrative health databases are a valuable research tool to assess health care utilization at the population level. However, their use in obesity research limited due to the lack of data on body weight. A potential workaround is to use the ICD code of obesity to identify obese individuals. The objective of the current study was to investigate the sensitivity and specificity of an ICD code-based diagnosis of obesity from administrative health data relative to the gold standard measured BMI. METHODS: Linkage of a population-based survey with anthropometric measures in elementary school children in 2003 with longitudinal administrative health data (physician visits and hospital discharges 1992-2006) from the Canadian province of Nova Scotia. Measured obesity was defined based on the CDC cut-offs applied to the measured BMI. An ICD code-based diagnosis obesity was defined as one or more ICD-9 (278) or ICD-10 code (E66-E68) of obesity from a physician visit or a hospital stay. Sensitivity and specificity were calculated and health care cost estimates based on measured obesity and ICD-based obesity were compared. RESULTS: The sensitivity of an ICD code-based obesity diagnosis was 7.4% using ICD codes between 2002 and 2004. Those correctly identified had a higher BMI and had higher health care utilization and costs. CONCLUSIONS: An ICD diagnosis of obesity in Canadian administrative health data grossly underestimates the true prevalence of childhood obesity and overestimates the health care cost differential between obese and non-obese children.

Associations between household food insecurity and health outcomes in the Aboriginal population (excluding reserves).

BACKGROUND: Aboriginal people are more vulnerable to food insecurity and morbidity than is the Canadian population overall. However, little information is available about the association between food insecurity and health in Aboriginal households. DATA AND METHODS: Data from the 2004 Canadian Community Health Survey-Nutrition were used to examine the relationships between household food security and self-reported health, well-being and health behaviours in a sample of 837 Aboriginal adults living off reserve. Household food security status was based on Health Canada's interpretation of the United States Household Food Security Survey Module. Multivariable logistic regression was used to identify significant relationships, while adjusting for potential confounders. RESULTS: An estimated 29% of Aboriginal people aged 18 or older lived in food-insecure households. They were more likely to report poor general and mental health, life dissatisfaction, a very weak sense of community belonging, high stress and cigarette smoking, compared with their counterparts in food-secure households. When age, gender and household education were taken into account, respondents from food-insecure households had significantly higher odds of poor general health, high stress, life dissatisfaction, and a very weak community belonging. INTERPRETATION: Reductions in household food insecurity may improve the health and well-being of Aboriginals living off-reserve.

Use and cost of health services among overweight and obese Canadian children.

BACKGROUND: Along with a dramatic rise in the rates of childhood obesity, obesity-related disorders, such as type 2 diabetes, hypertension, and obstructive sleep apnea, are seen with increasing frequency in children. As a consequence, overweight and obese children may use health care services more often than their normal weight peers. The aim of the current study was to assess health service use and costs across categories of weight status. METHODS: Prospective cohort study using data from a population-based survey among grade 5 children in the Canadian province of Nova Scotia linked with administrative health data, using a combination of deterministic and probabalistic matching (n = 4 380). Total health care costs (physician and hospital costs), lifetime (up to age 14 years) physician costs and number of physician visits were assessed in a series of multiple regression models. RESULTS: There was a gradient for higher costs and utilization across the three weight groups. Total health care costs in the three years following the survey were 21% (95% CI: 2-43) higher in obese children compared with normal weight children. Obese children also had significantly higher lifetime physician costs and more physician visits than their normal weight peers. The health care cost trajectories of normal weight and obese children drift apart as early as 3 years of age. Interpretation. Obese children in the Canadian province of Nova Scotia have significantly higher health care costs and more physician visits and specialist referrals than their normal weight peers, highlighting the need for cost-effectiveness studies of obesity prevention programs.

A province-wide school nutrition policy and food consumption in elementary school children in Prince Edward Island.

OBJECTIVE: Although the majority of Canadian provinces have indicated that they have adopted new school nutrition policies, there have been few if any systematic evaluations of these policies. In Prince Edward Island, a nutrition policy for elementary schools was adopted province-wide in 2006. In the present study, we assessed the nutritional benefits of the new policy by examining changes in student food consumption prior to and one year following implementation of the policy. METHODS: We surveyed fifth and sixth grade children from 11 elementary schools in Prince Edward Island in 2001/02 (pre-policy implementation) and fifth and sixth grade children from the same 11 schools in 2007 (post-policy implementation). Food consumption was assessed using a self-administered validated food frequency questionnaire. We applied multilevel logistic regression to compare pre-/post-policy implementation differences in the proportion of students meeting Canada's Food Guide recommendations for vegetables and fruit (VF) and milk and alternatives (MA) and in the proportion of students consuming < 3 servings of low nutrient dense foods (LNDF) daily. RESULTS: Relative to students in 2001/02, students surveyed in 2007 were 2.14 (95% CI 1.62-2.82) times more likely to report consuming less than three daily servings of LNDF and were more likely to meet recommendations for VF (OR 1.44, 95% CI 1.00-2.07) and MA (OR 1.27, 95% CI 0.98-1.64). CONCLUSION: The present study is the first in Canada to show favourable changes in student food consumption that parallel the introduction of a school nutrition policy.

Prevalence and sociodemographic risk factors related to household food security in Aboriginal peoples in Canada.

OBJECTIVE: Canada's Aboriginal population is vulnerable to food insecurity and increasingly lives off-reserve. The Canadian Community Health Survey, Cycle 2.2 Nutrition, was used to compare the prevalence and sociodemographic correlates of food insecurity between non-Aboriginal and off-reserve Aboriginal households. DESIGN: Food insecurity status was based on Health Canada's revised interpretation of responses to the US Household Food Security Survey Module. Logistic regression was used to assess if Aboriginal households were at higher risk for food insecurity than non-Aboriginal households, adjusting for household sociodemographic factors. SETTING: Canada. SUBJECTS: Households (n 35,107), 1528 Aboriginal and 33 579 non-Aboriginal. RESULTS: Thirty-three per cent of Aboriginal households were food insecure as compared with 9 % of non-Aboriginal households (univariate OR 5.2, 95 % CI 4.2, 6.3). Whereas 14 % of Aboriginal households had severe food insecurity, 3 % of non-Aboriginal households did. The prevalence of sociodemographic risk factors for household food insecurity was higher for Aboriginal households. Aboriginal households were more likely to have three or more children (14 % v. 5 %), be lone-parent households (2 1 % v. 5 %), not have home ownership (52 % v. 31 %), have educational attainment of secondary school or less (43 % v. 26 %), have income from sources other than wages or salaries (38 % v. 29 %), and be in the lowest income adequacy category (33 % v. 12 %). Adjusted for these sociodemographic factors, Aboriginal households retained a higher risk for food insecurity than non-Aboriginal households (OR 2.6, 95 % CI 2.1, 3.2). CONCLUSIONS: Off-reserve Aboriginal households in Canada merit special attention for income security and poverty alleviation initiatives.

Why does the social gradient in health not apply to overweight?

BACKGROUND: In developed countries, there is a negative association between socioeconomic status (SES) and a variety of health outcomes, known as the social gradient in health. This is contrasted by a weak, absent or even positive gradient for overweight. The objective of this study was to investigate why overweight does not follow the social gradient. DATA AND METHODS: Data from adult respondents to the 2004 Canadian Community Health Survey (cycle 2.2) were used. A series of multivariate models regressing overweight and determinants of overweight on household education and household income were performed, stratified by gender. RESULTS: Except for education among women, negative associations between SES measures and overweight emerged. Respondents from higher household income groups reported more meals away from home, compared with those from lower household income groups. In addition, adults in higher-education households were more likely than those in lower-education households to have quit smoking. INTERPRETATION: Differences in food consumption patterns and smoking cessation between SES groups may have contributed to the lack of a clear negative association between household education and income and overweight in the CCHS.