"I Know How to Advocate": Parents' Experiences in Advocating for Children and Youth Diagnosed With Autism Spectrum Disorder.

BACKGROUND: Parental advocacy is a dynamic process that changes depending on the circumstances and needs of the child and parent. Communication deficits related to an Autism Spectrum Disorder (ASD) diagnosis often necessitate parental advocacy. This study describes how parents and caregivers of children and youth diagnosed with ASD engage in parental advocacy, the challenges they encounter and the advocacy skills they develop. METHOD: We used descriptive exploratory methodology informed by reflexive thematic analysis. The aim of the study was to explore advocacy in parents and caregivers of children and youth diagnosed with ASD. RESULTS: We conducted in-depth, semi-structured interviews with 15 parents of children and youth with an ASD diagnosis living in 4 provinces of Atlantic Canada. The pathway in parents' advocacy journey included: (1) Expressing concerns; (2) Seeking help, assessment, and diagnosis; (3) Acquiring services; (4) Removing barriers; and (5) Developing advocacy skills. CONCLUSIONS: Our findings illustrate the process of parental advocacy, skill development, and the barriers parents encounter in advocating for their children with ASD. Future research might explore how health professionals can support parents' advocacy efforts.

Cost analysis and critical success factors of the use of oxygen concentrators versus cylinders in sub-divisional hospitals in Fiji.

BACKGROUND: Oxygen is vital in the treatment of illnesses in children and adults, yet is lacking in many low and middle-income countries health care settings. Oxygen concentrators (OCs) can increase access to oxygen, compared to conventional oxygen cylinders. We investigated the costs and critical success factors of OCs in three hospitals in Fiji, and extrapolated these to estimate the oxygen delivery cost to all Sub-Divisional hospitals (SDH) nationwide. METHODS: Data sources included key personnel interviews, and data from SDH records, Ministry of Health and Medical Services, and a non-governmental organisation. We used Investment Logic Mapping (ILM) to define key issues. An economic case was developed to identify the investment option that optimised value while incorporating critical success factors identified through ILM. A fit-for-purpose analysis was conducted using cost analysis of four short-listed options. Sensitivity analyses were performed by altering variables to show the best or worst case scenario. All costs are presented in Fijian dollars. RESULTS: Critical success factors identifed included oxygen availability, safety, ease of use, feasibility, and affordability. Compared to the status quo of having only oxygen cylinders, an option of having a minimum number of concentrators with cylinder backup would cost $434,032 (range: $327,940 to $506,920) over 5 years which would be 55% (range: 41 to 64%) of the status quo cost. CONCLUSION: Introducing OCs into all SDHs in Fiji would reduce overall costs, while ensuring identified critical success factors are maintained. This study provides evidence for the benefits of OCs in this and similar settings.

Longitudinal examination of youth readmission to mental health inpatient units.

OBJECTIVE: Significant barriers exist for youth in obtaining mental health services. These barriers are exacerbated by growing demand, attributed partially to children and adolescents who have repeat hospital admissions. The purpose of this study was to identify demographic, socioeconomic and clinical predictors of readmission to inpatient psychiatric services in New Brunswick, Canada. METHOD: Key demographic, support and clinical predictors of readmission were identified. The New Brunswick Discharge Abstract Database (DAD) was used to compile a cohort of all children and adolescents ages 3-19 years with psychiatric hospital admissions between 1 April 2003 and 31 March 2014 (N = 3825). Primary analyses consisted of Kaplan-Meier survival methods with log-rank tests to assess time-to-readmission variability, and Cox regression to identify significant predictors of readmission. RESULTS: In total, 27.8% of admitted children and adolescents experienced at least one readmission within the 10-year period, with 57.3% readmitted to hospital within 90 days following discharge. Bivariate results indicated that male, upper-middle socioeconomic status (SES) youths aged 11-15 years from nonrural communities were most likely to be readmitted. Notable predictors of increased readmission likelihood were older age, being male, higher SES, referral to care by medical practitioner, discharge to another health facility, psychosis, and previous psychiatric admission. CONCLUSION: A significant portion of the variance in readmission was accounted for by youth demographic characteristics (i.e. age, SES, geographic location) and various support structures, including referrals to inpatient care and aftercare support services. KEY PRACTITIONER MESSAGE: Readmission to inpatient psychiatric care among youth is affected by a number of multifaceted risk factors across individual, environmental and clinical domains. This study used provincial population-scale longitudinal administrative data to demonstrate the influence of various individual and demographic factors on likelihood of readmission, which is notably absent from the majority of studies that make use of smaller, short-term data samples. Ensuring that multiple factors outside of the clinical context are considered when examining readmission among youth may contribute to a more thorough understanding of youth hospitalization patterns.

"Managing the Wait": Parents' Experiences in Accessing Diagnostic and Treatment Services for Children and Adolescents Diagnosed With Autism Spectrum Disorder.

BACKGROUND: Parents of children and adolescents diagnosed with autism spectrum disorder (ASD) report delays in accessing timely diagnostic and treatment services for their children. Research has generally focused on parents' experiences in caring for a child diagnosed with ASD. This study describes the process of how parents access ASD services for their children and adolescents. METHOD: This study used a qualitative research design that was informed by grounded theory methodology. We used constant comparative analysis to develop a process model and a core concept. RESULTS: Seventeen parents of children and adolescents diagnosed with ASD were interviewed. Our process model included 3 main phases: Watchful waiting (noticing suspected behaviors, and searching for assessment and diagnosis); Informed waiting (receiving the diagnosis, facing challenges in accessing treatment services, and realizing the impact of an ASD diagnosis); and Contemplative waiting (pondering the future, reflecting on the past, and making recommendations). "Managing the Wait" was identified as the core category central to parents' experience of this process. This process was found to be impacted by socioeconomic status, parents' skills and capacity to advocate on their child's behalf, and severity of their child's ASD. CONCLUSIONS: Our findings illustrate the many barriers families face during their journey in accessing ASD services. Our results illustrate the need to address wait times for services, and provide education and support services for parents as a means of improving their self-advocacy skills, especially for parents of children and adolescents with severe disability.

Associations of Prenatal and Childhood Antibiotic Exposure With Obesity at Age 4 Years.

Importance: Although antibiotics are associated with obesity in animal models, the evidence in humans is conflicting. Objective: To assess whether antibiotic exposure during pregnancy and/or early childhood is associated with the development of childhood obesity, focusing particularly on siblings and twins. Design, Setting, and Participants: This cross-sectional national study included 284 211 participants (132 852 mothers and 151 359 children) in New Zealand. Data analyses were performed for 150 699 children for whom data were available, 30 696 siblings, and 4188 twins using covariate-adjusted analyses, and for 6249 siblings and 522 twins with discordant outcomes using fixed-effects analyses. Data analysis was performed November 2017 to March 2019. Exposure: Exposure to antibiotics during pregnancy and/or early childhood. Main Outcomes and Measures: The main outcome is odds of obesity at age 4 years. Anthropometric data from children born between July 2008 and June 2011 were obtained from the B4 School Check, a national health screening program that records the height and weight of 4-year-old children in New Zealand. These data were linked to antibiotics (pharmaceutical records) dispensed to women before conception and during all 3 trimesters of pregnancy and to their children from birth until age 2 years. Results: The overall study population consisted of 132 852 mothers and 151 359 children (77 610 [51.3%] boys) who were aged 4 to 5 years when their anthropometrical measurements were assessed. Antibiotic exposure was common, with at least 1 course dispensed to 35.7% of mothers during pregnancy and 82.3% of children during the first 2 years of life. Results from covariate-adjusted analyses showed that both prenatal and early childhood exposures to antibiotics were independently associated with obesity at age 4 years, in a dose-dependent manner. Every additional course of antibiotics dispensed to the mothers yielded an adjusted odds ratio (aOR) of obesity in their children (siblings) of 1.02 (95% CI, 0.99-1.06), which was similar to the odds across pregnancy for the whole population (aOR, 1.06; 95% CI, 1.04-1.07). For the child's exposure, the aOR for the association between antibiotic exposure and obesity was 1.04 (95% CI, 1.03-1.05) among siblings and 1.05 (95% CI, 1.02-1.09) among twins. However, fixed-effects analyses of siblings and twins showed no associations between antibiotic exposure and obesity, with aORs of 0.95 (95% CI, 0.90-1.00) for maternal exposure, 1.02 (95% CI, 0.99-1.04) for child's exposure, and 0.91 (95% CI, 0.81-1.02) for twins' exposure. Conclusions and Relevance: Although covariate-adjusted analyses demonstrated an association between antibiotic exposure and odds of obesity, further analyses of siblings and twins with discordant outcomes showed no associations. Thus, these discordant results likely reflect unmeasured confounding factors.

Identifying cases of chronic pain using health administrative data: A validation study.

BACKGROUND: Most prevalence estimates of chronic pain are derived from surveys and vary widely, both globally (2%-54%) and in Canada (6.5%-44%). Health administrative data are increasingly used for chronic disease surveillance, but their validity as a source to ascertain chronic pain cases is understudied. AIM: The aim of this study was to derive and validate an algorithm to identify cases of chronic pain as a single chronic disease using provincial health administrative data. METHODS: A reference standard was developed and applied to the electronic medical records data of a Newfoundland and Labrador general population sample participating in the Canadian Primary Care Sentinel Surveillance Network. Chronic pain algorithms were created from the administrative data of patient populations with chronic pain, and their classification performance was compared to that of the reference standard via statistical tests of selection accuracy. RESULTS: The most performant algorithm for chronic pain case ascertainment from the Medical Care Plan Fee-for-Service Physicians Claims File was one anesthesiology encounter ever recording a chronic pain clinic procedure code OR five physician encounter dates recording any pain-related diagnostic code in 5 years with more than 183 days separating at least two encounters. The algorithm demonstrated 0.703 (95% confidence interval [CI], 0.685-0.722) sensitivity, 0.668 (95% CI, 0.657-0.678) specificity, and 0.408 (95% CI, 0.393-0.423) positive predictive value. The chronic pain algorithm selected 37.6% of a Newfoundland and Labrador provincial cohort. CONCLUSIONS: A health administrative data algorithm was derived and validated to identify chronic pain cases and estimate disease burden in residents attending fee-for-service physician encounters in Newfoundland and Labrador.

Contexte: La plupart des estimations de prévalence de la douleur chronique sont tirées d'enquêtes et varient considérablement, à la fois dans le monde (2 % -54 %) et au Canada (6,5 % - 44 %). Les données administratives sur la santé utilisées pour la surveillance des maladies chroniques, mais leur validité comme source pour déterminer les cas de douleur chronique est sous-étudiée.Objectif: Le but de cette étude était de dériver et de valider un algorithme pour répertorier les cas de douleur chronique comme une seule maladie chronique en utilisant les données administratives provinciales sur la santé.Méthodes: Une norme de référence a été élaborée et appliquée aux données des dossiers médicaux électroniques d'un échantillon de la population générale de Terre-Neuve-et-Labrador participant au Réseau canadien de surveillance sentinelle en soins primaires. Des algorithmes de douleur chronique ont été créés à partir des données administratives de populations de patients souffrant de douleur chronique et leur rendement en matière de classification a été comparé à celui de la norme de référence par le biais de tests statistiques sur la précision de sélection.Résultats: L'algorithme le plus performant pour la détermination des cas de douleur chronique à partir du Registre des paiements des soins médicaux rémunérés à l'acte était une seule consultation en anesthésiologie au cours de laquelle un code de procédure d'intervention clinique en matière de douleur chronique était enregistré OU cinq consultations médicales en cinq ans au cours desquelles était enregistré tout code de diagnostic lié à la douleur, avec une période de plus de 183 jours entre au moins deux consultations.L'algorithme a démontré une sensibilité de 0,703 (intervalle de confiance [IC] à 95 %, 0,685 à 0,722), une spécificité de 0,668 (IC 95 %, 0,657-0,678) et une valeur prédictive positive de 0,408 (IC 95 %, 0,393-0,423). L'algorithme de la douleur chronique a sélectionné 37,6 % d'une cohorte provinciale de Terre-Neuve-et-Labrador.Conclusions: Un algorithme de données administratives sur la santé a été dérivé et validé pour répertorier les cas de douleur et estimer le fardeau de la maladie chez les résidents ayant consulté un médecin rémunéré à l'acte à Terre-Neuve et Labrador.

A dynamic, multi-professional, needs-based simulation model to inform human resources for health planning.

BACKGROUND: As population health needs become more complex, addressing those needs increasingly requires the knowledge, skills, and judgment of multiple types of human resources for health (HRH) working interdependently. A growing emphasis on team-delivered health care is evident in several jurisdictions, including those in Canada. However, the most commonly used HRH planning models across Canada and other countries lack the capacity to plan for more than one type of HRH in an integrated manner. The purpose of this paper is to present a dynamic, multi-professional, needs-based simulation model to inform HRH planning and demonstrate the importance of two of its parameters-division of work and clinical focus-which have received comparatively little attention in HRH research to date. METHODS: The model estimates HRH requirements by combining features of two previously published needs-based approaches to HRH planning-a dynamic approach designed to plan for a single type of HRH at a time and a multi-professional approach designed to compare HRH supply with requirements at a single point in time. The supplies of different types of HRH are estimated using a stock-and-flow approach. RESULTS: The model makes explicit two planning parameters-the division of work across different types of HRH, and the degree of clinical focus among individual types of HRH-which have previously received little attention in the HRH literature. Examples of the impacts of these parameters on HRH planning scenarios are provided to illustrate how failure to account for them may over- or under-estimate the size of any gaps between the supply of and requirements for HRH. CONCLUSION: This paper presents a dynamic, multi-professional, needs-based simulation model which can be used to inform HRH planning in different contexts. To facilitate its application by readers, this includes the definition of each parameter and specification of the mathematical relationships between them.

Child obesity prevalence across communities in New Zealand: 2010-2016.

OBJECTIVE: To assess community-level differences in four-year-old obesity prevalence in New Zealand (NZ), trends over time, and the extent to which differences can be explained by ethnicity, deprivation and urbanicity. METHODS: Obesity measures from the Ministry of Health's B4 School Check were available for 72-92% of NZ four-year-olds for fiscal years 2010/11-2015/16. Ethnicity, deprivation and urbanicity data for the 78 communities were obtained by linking to administrative records. Growth models were used to examine variability in obesity levels and trends over time, and the extent to which ethnicity, deprivation and urbanicity contributed to differences between communities. RESULTS: There were large variations in obesity across communities (range 8.4% to 28.8%). A decline in the prevalence of childhood obesity was observed in most (48 of 78) communities from 2010/11 to 2015/16 (average change=0.2%, range=-2.0% to 1.9%). Around 50% of the variance in obesity between territorial authorities could be explained by differences in socioeconomic deprivation and ethnic composition. CONCLUSIONS: Child obesity varies between NZ communities, but most territorial authorities have experienced a decrease in obesity over the period 2010/11-2015/16. Implications for public health: Addressing deprivation and ethnic inequalities in obesity could substantially reduce community-level differences in obesity in NZ.

Perceived economic burden associated with an inherited cardiac condition: a qualitative inquiry with families affected by arrhythmogenic right ventricular cardiomyopathy.

PURPOSE: Significant gaps remain in the literature on the economic burden of genetic illness. We explored perceived economic burden associated with one inherited cardiac condition, arrhythmogenic right ventricular cardiomyopathy (ARVC). METHODS: Semistructured interviews were held with individuals from families affected by ARVC. Data on the perceived financial and economic impacts of ARVC were used to identify emerging categories and themes using the method of constant comparison. RESULTS: Data analysis revealed four themes that described participants' perceptions of the economic impact ARVC had on them and their families: (i) economic impact during childhood, (ii) impact on current and future employment, (iii) impact on current and future financial well-being, and (iv) no perceived economic impact. CONCLUSIONS: This study is the first to explore the economic burden of ARVC from the perspective of affected families. It revealed a number of perceived burdens, from employment and career choices to worry about insurance for self and children, decreased household spending, and the need for childhood employment. Findings highlight potential areas of discussion for genetic counseling sessions, as well as areas for future research.Genet Med 18 6, 584-592.

An Evaluation of In-Person and Online Engagement in Central Newfoundland.

BACKGROUND: This study evaluates the use of in-person focus groups and online engagement within the context of a large public engagement initiative conducted in rural Newfoundland. METHODS: Participants were surveyed about their engagement experience and demographic information. Pre and post key informant interviews were also conducted with organizers of the initiative. RESULTS: Of the 111 participants in the focus groups, 97 (87%) completed evaluation surveys; as did 23 (88%) out of 26 online engagement participants. Overall, focus group participants were positive about their involvement, with 87.4% reporting that they would participate in a similar initiative. Online participation was below expectations and these participants viewed their experience less positively than in-person participants. Organizers viewed the engagement initiative and the combined use of online and in-person engagement positively. CONCLUSIONS: This study presents a real-world example of the use of two methods of engagement. It also highlights the importance of the successful execution of whatever engagement mechanism is selected.

Hand sanitiser provision for reducing illness absences in primary school children: a cluster randomised trial.

BACKGROUND: The potential for transmission of infectious diseases offered by the school environment are likely to be an important contributor to the rates of infectious disease experienced by children. This study aimed to test whether the addition of hand sanitiser in primary school classrooms compared with usual hand hygiene would reduce illness absences in primary school children in New Zealand. METHODS AND FINDINGS: This parallel-group cluster randomised trial took place in 68 primary schools, where schools were allocated using restricted randomisation (1:1 ratio) to the intervention or control group. All children (aged 5 to 11 y) in attendance at participating schools received an in-class hand hygiene education session. Schools in the intervention group were provided with alcohol-based hand sanitiser dispensers in classrooms for the winter school terms (27 April to 25 September 2009). Control schools received only the hand hygiene education session. The primary outcome was the number of absence episodes due to any illness among 2,443 follow-up children whose caregivers were telephoned after each absence from school. Secondary outcomes measured among follow-up children were the number of absence episodes due to specific illness (respiratory or gastrointestinal), length of illness and illness absence episodes, and number of episodes where at least one other member of the household became ill subsequently (child or adult). We also examined whether provision of sanitiser was associated with experience of a skin reaction. The number of absences for any reason and the length of the absence episode were measured in all primary school children enrolled at the schools. Children, school administrative staff, and the school liaison research assistants were not blind to group allocation. Outcome assessors of follow-up children were blind to group allocation. Of the 1,301 and 1,142 follow-up children in the hand sanitiser and control groups, respectively, the rate of absence episodes due to illness per 100 child-days was similar (1.21 and 1.16, respectively, incidence rate ratio 1.06, 95% CI 0.94 to 1.18). The provision of an alcohol-based hand sanitiser dispenser in classrooms was not effective in reducing rates of absence episodes due to respiratory or gastrointestinal illness, the length of illness or illness absence episodes, or the rate of subsequent infection for other members of the household in these children. The percentage of children experiencing a skin reaction was similar (10.4% hand sanitiser versus 10.3% control, risk ratio 1.01, 95% CI 0.78 to 1.30). The rate or length of absence episodes for any reason measured for all children also did not differ between groups. Limitations of the study include that the study was conducted during an influenza pandemic, with associated public health messaging about hand hygiene, which may have increased hand hygiene among all children and thereby reduced any additional effectiveness of sanitiser provision. We did not quite achieve the planned sample size of 1,350 follow-up children per group, although we still obtained precise estimates of the intervention effects. Also, it is possible that follow-up children were healthier than non-participating eligible children, with therefore less to gain from improved hand hygiene. However, lack of effectiveness of hand sanitiser provision on the rate of absences among all children suggests that this may not be the explanation. CONCLUSIONS: The provision of hand sanitiser in addition to usual hand hygiene in primary schools in New Zealand did not prevent disease of severity sufficient to cause school absence. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12609000478213. Please see later in the article for the Editors' Summary.

How are population-based funding formulae for healthcare composed? A comparative analysis of seven models.

BACKGROUND: Population-based funding formulae act as an important means of promoting equitable health funding structures. To evaluate how policy makers in different jurisdictions construct health funding formulae and build an understanding of contextual influences underpinning formula construction we carried out a comparative analysis of key components of funding formulae across seven high-income and predominantly publically financed health systems: New Zealand, England, Scotland, the Netherlands, the state of New South Wales in Australia, the Canadian province of Ontario, and the city of Stockholm, Sweden. METHODS: Core components from each formula were summarised and key similarities and differences evaluated from a compositional perspective. We categorised approaches to constructing funding formulae under three main themes: identifying factors which predict differential need amongst populations; adjusting for cost factors outside of needs factors; and engaging in normative correction of allocations for 'unmet' need. RESULTS: We found significant congruence in the factors used to guide need and cost adjustments. However, there is considerable variation in interpretation and implementation of these factors. CONCLUSION: Despite broadly similar frameworks, there are distinct differences in the composition of the formulae across the seven health systems. Ultimately, the development of funding formulae is a dynamic process, subject to availability of data reflecting health needs, the influence of wider socio-political objectives and health system determinants.

Do different types of financial support after illness or injury affect socio-economic outcomes? A natural experiment in New Zealand.

BACKGROUND: In New Zealand, people unable to work due to an illness may be eligible for a means-tested benefit whereas injured people are eligible for a wide range of support including earnings-related compensation through the no-fault Accident Compensation Corporation (ACC). The effect of this difference on socio-economic outcomes has not been investigated before. METHODS: A comparative cohort study was undertaken of stroke versus injury. Individuals aged 18-64, who had a first-stroke (n = 109) were matched by age, sex and functional impairment with injured individuals (n = 429) participating in the Prospective Outcomes of Injury Study. Data were collected by interview 3.5 and 12 months after stroke or injury. Logistic regression adjusting for the matching variables at 3.5 months, and functional impairment at 12 months, was undertaken. RESULTS: Median personal income declined by 60% over 12 months for the Stroke Group compared to 13% decline in the Injury Group. Decline in income was greater for those in both groups who had a higher income initially, and for those who had not returned to work. The proportion of the Stroke Group reporting 'Fairly low/low' standard of living increased from 8% to 28% and 'Just/not enough' income increased from 35% to 61% whereas the Injury Group increased only from 5% to 12% and 33%-44% respectively. The odds of reporting low standard of living and income inadequacy at 12 months were significantly less for the Injury Group. Despite earnings-related compensation (80% of income), the odds of being back at work were greater for the Injury Group compared to the Stroke Group (Adjusted Odds Ratio 3.1; 95% CI 1.7-5.6). CONCLUSIONS: These findings support the conclusions that earnings-related compensation and rehabilitative support, available to injured people via ACC, largely prevents the downward spiral into poverty and ill health. It also appears to enhance return to work though residual confounding cannot be ruled out.

Rural practice and retention in New Zealand: an examination of New Zealand-trained and foreign-trained doctors.

In this paper we examine the problems New Zealand faces with regards the identified shortage and uneven distribution of medical practitioners across urban and rural areas. In particular, we examine the extent to which the origin of training and location of practice affect the mobility of medical practitioners over the period 2000-2008. We find that foreign-trained doctors have a greater propensity to practice in minor urban and rural areas, and in less affluent communities, than New Zealand (domestic)-trained doctors. We also find that mobility among doctors is becoming more pronounced in recent years, with doctors generally being more mobile, with movement out of rural areas and doctors leaving practice in New Zealand being areas of particular concern.

Hand sanitisers for reducing illness absences in primary school children in New Zealand: a cluster randomised controlled trial study protocol.

BACKGROUND: New Zealand has relatively high rates of morbidity and mortality from infectious disease compared with other OECD countries, with infectious disease being more prevalent in children compared with others in the population. Consequences of infectious disease in children may have significant economic and social impact beyond the direct effects of the disease on the health of the child; including absence from school, transmission of infectious disease to other pupils, staff, and family members, and time off work for parents/guardians. Reduction of the transmission of infectious disease between children at schools could be an effective way of reducing the community incidence of infectious disease. Alcohol based no-rinse hand sanitisers provide an alternative hand cleaning technology, for which there is some evidence that they may be effective in achieving this. However, very few studies have investigated the effectiveness of hand sanitisers, and importantly, the potential wider economic implications of this intervention have not been established. AIMS: The primary objective of this trial is to establish if the provision of hand sanitisers in primary schools in the South Island of New Zealand, in addition to an education session on hand hygiene, reduces the incidence rate of absence episodes due to illness in children. In addition, the trial will establish the cost-effectiveness and conduct a cost-benefit analysis of the intervention in this setting. METHODS/DESIGN: A cluster randomised controlled trial will be undertaken to establish the effectiveness and cost-effectiveness of hand sanitisers. Sixty-eight primary schools will be recruited from three regions in the South Island of New Zealand. The schools will be randomised, within region, to receive hand sanitisers and an education session on hand hygiene, or an education session on hand hygiene alone. Fifty pupils from each school in years 1 to 6 (generally aged from 5 to 11 years) will be randomly selected for detailed follow-up about their illness absences, providing a total of 3400 pupils. In addition, absence information will be collected on all children from the school rolls. Investigators not involved in the running of the trial, outcome assessors, and the statistician will be blinded to the group allocation until the analysis is completed. TRIAL REGISTRATION: ACTRN12609000478213.

Where did the doctors go? A study of retention and migration of provisionally licensed international medical graduates practising in Newfoundland and Labrador between 1995 and 2006.

INTRODUCTION: More than any other Canadian province, Newfoundland and Labrador (NL) relies on provisionally licensed international medical graduates (PLIMGs) to provide primary health care, particularly in rural communities. However, turnover among PLIMGs is high, and this is expensive and disruptive to the populations they serve. METHODS: We developed and analyzed a database that allowed us to quantify the turnover among PLIMGs and also to determine the Canadian destinations of PLIMGs who cease practising in NL. RESULTS: We found that about 1 in 5 PLIMGs remain in province for a period of 5 years and that those who emigrate within Canada are most likely to go to Ontario. Many PLIMGs cannot be tracked after they leave the province. CONCLUSION: We speculate that many PLIMGs are moving on to the more lucrative US market.