Acceptability and feasibility of screening with a pediatric care provider-led social determinants of health identification tool

BACKGROUND

Complex social determinants of health may not be easily recognized by health care providers and pose a unique challenge in the vulnerable pediatric population where patients may not be able to advocate for themselves. The goal of this study was to examine the acceptability and feasibility of health care providers using an integrated brief pediatric screening tool in primary care and hospital settings.

METHODS

The framework of the Child and Adolescent Needs and Strengths (CANS) and Pediatric Intermed tools was used to inform the selection of items for the 9-item Child and Adolescent Needs and Strengths-Pediatric Complexity Indicator (CANS-PCI). The tool consisted of three domains: biological, psychological, and social. Semi-structured interviews were conducted with health care providers in pediatric medical facilities in Ottawa, Canada. A low inference and iterative thematic synthesis approach was used to analyze the qualitative interview data specific to acceptability and feasibility.

RESULTS

Thirteen health care providers participated in interviews. Six overarching themes were identified: acceptability, logistics, feasibility, pros/cons, risk, and privacy. Overall, participants agreed that a routine, trained provider-led pediatric tool for the screening of social determinants of health is important (n = 10, 76.9%), acceptable (n = 11; 84.6%), and feasible (n = 7, 53.8%).

INTERPRETATION

Though the importance of social determinants of health are widely recognized, there are limited systematic methods of assessing, describing, and communicating amongst health care providers about the biomedical and psychosocial complexities of pediatric patients. Based on this study's findings, implementation of a brief provider-led screening tool into pediatric care practices may contribute to this gap.

Exploring the perspectives of caregivers of urban Inuit children on child health knowledge mobilisation

Our study sought to explore the experiences of caregivers of urban Inuit children with respect to child health knowledge acquisition to develop community-specific best practices for health promotion initiatives. A needs assessment was conducted to understand how caregivers access child health knowledge and services; what child health issues require improved knowledge mobilisation; and how caregivers would like to access this knowledge. Four focus groups were held with twenty-four parents and caregivers of Inuit children. Child health knowledge acquisition was influenced by dynamics of trust and discrimination, making caregivers' social networks and Indigenous health services highly valued sources. Health topics identified as requiring improved knowledge mobilisation were those in which caregivers faced tensions between Indigenous and non-Indigenous ways of knowing. Such topics included parenting and development, adolescent mental and sexual health, common childhood illnesses, infant care, and nutrition. Caregivers preferred a multi-modal approach to health promotion, highlighting importance of in-person gatherings while also valuing accessible multi-media components. The presence of Elders as facilitators was especially important for child development, parenting, and nutrition. For health promotion to be effective, it must consider community-specific health knowledge sharing processes; tensions between Indigenous and non-Indigenous ways of knowing; and community ownership in health promotion endeavors.

Urgent air transfers for acute respiratory infections among children from Northern Canada, 2005–2014

Background

The incidence of hospitalizations for acute respiratory infections (ARI) among young Indigenous children from Northern Canada is consistently high. ARIs requiring urgent air transfer can be life-threatening and costly. We aimed to describe their epidemiology, estimate age-specific incidences, and explore factors associated with level of care required.

Methods

We undertook a retrospective cohort study of children <5 years old from Northern Canada transferred by urgent air transport for ARI from 2005 through 2014 to 5 pediatric tertiary care centers in Vancouver, Edmonton, Winnipeg, Ottawa and Montreal. Admissions were identified via ARI-related ICD-9/10 coding and forward sortation area. Descriptive statistics and univariable analyses were performed.

Results

Among 650 urgent air transfers, the majority were from Nunavut (n = 349, 53.7%) or Nunavik (n = 166, 25.5%), <6 months old (n = 372, 57.2%), and without underlying comorbidity (n = 458; 70.5%). Estimated annual tertiary care ARI admission rates in infants <1 year old from Nunavut (40.7/1000) and Nunavik (44.5/1000) were tenfold higher than in children aged 1 to 4 years. Bronchiolitis (n = 333, 51.2%) and pneumonia (n = 208, 32.0%) were the most common primary discharge diagnoses. Nearly half required critical care (n = 316, 48.6%); mechanical ventilation rates ranged from 7.2% to 55.9% across centres. The most common primary pathogen was respiratory syncytial virus (n = 196, 30.1%). Influenza A or B was identified in 35 cases (5.4%) and vaccine-preventable bacterial infections in 27 (4.1%) cases.

Interpretation

Urgent air transfers for ARI from Northern Canada are associated with high acuity. Variations in levels of care were seen across referral centers, age groups and pathogens.

70 Sharing Child Health Knowledge in an Urban Inuit Community: A Needs Assessment

Primary Subject area

Public Health and Preventive Medicine

Background

It is well established that significant health disparities continue to affect Canadian Indigenous children living both in remote and urban areas. A critical component of health promotion is health knowledge dissemination. A 2011 Health Council of Canada study identified the need for better community knowledge of parenting and child health as intervention targets among Indigenous communities across Canada.

Objectives

In the present study, we aimed to explore the perspectives of Inuit parents and caregivers in one urban setting (Ottawa, Ontario) on the dissemination of child health knowledge specifically, with the intention of guiding future community-based child health promotion initiatives.

Design/Methods

Ottawa, being home to the largest Inuit population living outside Inuit Nunangat, provided an ideal study location. Many Inuit report relocating to Ottawa for employment, education, or for greater access to heath services. We therefore partnered with the Ottawa-based Inuuqatigiit Centre for Children, Youth, and Families, to design and conduct a needs assessment through a series of focus groups. Focus groups explored participants’ current sources of child health knowledge, child health topics of interest, and preferred formats for child health knowledge dissemination. Focus groups were held at Inuuqatigiit and included a meal of country food shared by study participants and research team members to support relationship-building and engagement. Focus groups were analyzed using an inductive approach to qualitative thematic analysis.

Results

24 Inuit parents and caregivers participated in 4 focus groups. Factors affecting preferred sources of health knowledge included trustworthiness, fear of discrimination, cultural differences, and having a holistic approach. Participants identified several child health issues that should be the focus of future child health knowledge sharing initiatives, in particular those in which a sense of cultural dissonance was felt between traditional and Western approaches. In-person and online/interactive sessions were preferred over written materials. Many participants agreed that child health knowledge-sharing initiatives should be designed and delivered with involvement of the community. Participants also emphasized the importance of synthesizing traditional knowledge of Elders with that of health professionals.

Conclusion

There is a need for better child health knowledge dissemination strategies among the Ottawa Inuit community as a crucial aspect of health promotion. Special considerations when designing such initiatives must be given to historical dynamics of trust and mistrust of the health professions, to addressing cultural differences, and to the role of community members in the design and implementation of initiatives.

136 Characterizing the medical and social complexity of Inuit children, youth, and their families from Nunavut who access care at an urban tertiary level paediatric hospital – A retrospective chart review of an Inuit child health clinic

Primary Subject area

Social Paediatrics

Background

The Inuit Child Health Clinic is a consulting general pediatric outpatient clinic at an urban tertiary level paediatric designed to improve integration and coordination of care for Inuit children, youth, and their families from Nunavut. Characterizing medical and social complexity for this patient population will help to address existing gaps in health and social care, as well as contribute to the development of a culturally safe and sensitive determinants of health screening tool.

Objectives

To study and characterize the complexities that families cared for by the Inuit Child Health Clinic experience in navigating the health and community environments to identify gaps that exist within their care and understand how we can better support their unique needs. We define medical complexity similarly, referenced in existing literature as multi-system or multi-service involvement or prolonged stay in the city of the urban tertiary level paediatric hospital to access medical care.

Design/Methods

A retrospective chart review of patients (children and youth between the ages of 0-18 years old) and their caregivers that attended an outpatient general paediatric medicine clinic visit appointment with the Inuit Child Health Clinic between September 30, 2016, and September 30, 2019. A review of 59 patient charts were completed by 2 independent reviewers each for demographic information, medical complexity variables, and social complexity variables. This research has been approved by a local Research Ethics Board as well as the Nunavut Research Institute.

Results

There are high levels of medical and social complexity as evident through the high average number of healthcare services accessed, number of comorbidities, and number of admissions to hospital. We also found considerable inconsistencies with respect to documentation by providers on the social determinants of health of patients. Note: In collaboration with the Inuuqatigiit Centre for Inuit Children Youth and Families, Qikiqtani Inuit Association (QIA), Nunavut Tunngavik Incorporated (NTI), and the Department of Health in Nunavut, the results and knowledge will be shared and mobilized to reflect a narrative that is community-driven and comments on any possible gaps in social determinants of health screening in clinical settings. Furthermore, in collaboration with the Qaujigiartiit Health Research Centre, this work will inform and support the broader program evaluation of the Inuit Child Health Clinic to meet the needs of patients, families, caregivers, and healthcare professionals.

Conclusion

A multidisciplinary team approach that focuses on integrative care may be an effective and efficient means to promote communication and collaboration between multiple service providers that are often involved in providing care to this population that is put at-risk due to systemic health and social inequities. Improving social history taking and integrating more formal screening for social determinants of health within the Inuit Child Health Clinic practice should be considered.

Tuberculosis among First Nations, Inuit and Métis children and youth in Canada: Beyond medical management

First Nations, Inuit and Métis people in Canada continue to be disproportionately affected by tuberculosis (TB), a disparity rooted primarily in factors such as poverty, crowded and inadequate housing, food insecurity, and inequitable health care access. Historical TB control practices in Canada have contributed to stigma and discrimination toward those with the disease, as well as fear and mistrust of the health system. These individual and system-level factors result in delays in TB diagnoses, ongoing transmission, poorer outcomes, and lower treatment completion rates. Children are especially vulnerable, as they are more likely to develop disease once infected with TB bacteria and to experience life-threatening conditions such as TB meningitis. Paediatric health professionals can help to increase TB awareness and literacy, reduce stigma and discrimination, and ultimately, improve the quality and uptake of services for treatment and prevention in families and communities at risk. They can also advocate for sustainable, community-driven TB elimination strategies that incorporate First Nations, Inuit and Métis principles of wellness, healing and self-determination.

Supporting children and youth during the COVID-19 pandemic and beyond: A rights-centred approach

The COVID-19 pandemic is an unprecedented global crisis, affecting millions globally and in Canada. While efforts to limit the spread of the infection and ‘flatten the curve’ may buffer children and youth from acute illness, these public health measures may worsen existing inequities for those living on the margins of society. In this commentary, we highlight current and potential long-term impacts of COVID-19 on children and youth centring on the UN Convention of the Rights of the Child (UNCRC), with special attention to the accumulated toxic stress for those in difficult social circumstances. By taking responsive action, providers can promote optimal child and youth health and well-being, now and in the future, through adopting social history screening, flexible care models, a child/youth-centred approach to “essential” services, and continual advocacy for the rights of children and youth.

95 Child Health Promotion Through Community Educational Sessions in an Urban Inuit Community: A Needs Assessment

Introduction/Background

Canadian Inuit children experience significant health disparities compared to their non-Inuit counterparts. Despite almost one-fifth of Canadian Inuit living in urban centres, few studies have explored their health needs. Current literature surveying Indigenous leaders identifies the need for improved access to child health and parenting knowledge. Community-based initiatives have been shown to improve Indigenous maternal and child health outcomes. Our study aimed to describe urban Inuit parents’ perspectives on accessing child health knowledge to guide development of Inuit-specific health knowledge-sharing initiatives.

Objectives

Design/Methods

In conjunction with community partners, we conducted a qualitative needs assessment through focus groups at an urban-situated organization that provides cultural, educational, and social services to Inuit children and families. Participants were parents and caregivers of Inuit children. All focus groups were recorded, transcribed, and imported into NVivo software. Inductive coding was used to identify themes related to participants’ sources of health knowledge, barriers and facilitators to accessing health knowledge, and health topics that participants hoped to learn more about.

Results

Twenty-four individuals participated in four focus groups, of which twenty-one (88%) identified as Inuit. While participants represented a range of ages (19-40 years), most participants (42%) were 31-40 years old. The majority of participants (88%) identified as female. Participants had lived a median of 15 years in an urban setting (interquartile range 10-23). Seventeen participants (71%) cared for children aged 5 or younger.

The main sources of health knowledge reported were Indigenous-focused services, online resources, telehealth and social networks (e.g. family and peers).

The most notable barrier to accessing child health information was cultural differences (i.e. lifestyle and parenting practices). Discrimination and challenges with systems navigation also emerged as themes.

Key health topics of interest included common childhood complaints (e.g. infections and immunizations), infant care, nutrition, parenting and development, mental health, and sexual education for adolescents.

Preferred modes of child health information delivery were in-person sessions, pamphlets, and online videos with preferences for both health care providers and Inuit Elders as facilitators. Key access factors included Inuit language/translation, convenience of location, transportation, scheduling, and presence of food and childcare.

Conclusion

Our results reveal important factors affecting access to child health knowledge among Inuit families in a large urban setting, as well as key child health topics of interest to this population. Informed by these findings and with help from our community partners, we are co-developing child health knowledge-sharing initiatives specific to the needs of the Inuit community in our region.

Nonauscultatory clinical criteria are sensitive for cardiac pathology in low-risk paediatric heart murmurs

Background

Healthy children with likely innocent heart murmurs are frequently referred to cardiologists for reassurance. Existing guidelines that advise against these referrals are not consistently followed partly because they involve subjective auscultatory judgements with which many care providers are uncomfortable. Here, we investigate whether clinical criteria with no subjective auscultatory component are sensitive for cardiac pathology.

Methods

A retrospective chart review was performed of all new patients seen in our paediatric cardiology clinic for assessment of a murmur from January 1, 2016 through June 30, 2018. Patients were characterized as "low-risk" if they met all of the following criteria: asymptomatic; normal physical examination other than the murmur; no risk factors for congenital heart disease; and age over 12 months. The primary outcomes were the sensitivity for ruling out pathology and the negative predictive value of the proposed criteria.

Results

Of 915 total patients, 214 met the low-risk criteria. The sensitivity of our criteria for ruling out pathology was 97.2% (95% confidence interval 94.1% to 99.0%) and the negative predictive value was also 97.2% (95% confidence interval 94.0% to 98.7%). Six of the 214 low-risk patients had pathology (2.8%; 95% confidence interval 1.3% to 6.0%), none of which has required intervention since diagnosis. Each of these six children had a murmur that sounded pathological to the auscultating cardiologist.

Conclusions

Basic clinical criteria that do not require auscultation are highly sensitive for ruling out significant cardiac pathology in children over 12 months of age.

Les besoins en fer jusqu’à l’âge de deux ans

Le fer est un micronutriment essentiel à la synthèse de l’hémoglobine, au développement du système nerveux central et à la protection contre les infections. La petite enfance est une période de vulnérabilité au cours de laquelle la carence en fer est liée à une perturbation du développement neurologique. Une situation socioéconomique défavorisée, une naissance prématurée et un régime alimentaire sous-optimal sont des facteurs de risque de carence en fer. Une surcharge de fer attribuable à une insuffisance du mécanisme d’excrétion du fer peut également se manifester. Il est capital d’offrir un apport en fer suffisant aux nourrissons jusqu’à l’âge de deux ans.

Iron requirements in the first 2 years of life

Iron is an essential micronutrient required for hemoglobin synthesis, central nervous system development, and protection from infection. Early childhood is a time of vulnerability as iron deficiency in this period is associated with impaired neurodevelopment. Low socioeconomic status, preterm birth, and suboptimal diet are risk factors for iron deficiency. Due to a lack of iron excretory mechanism, the possibility of iron excess also exists. Appropriate iron intake in the first 2 years of life is critical.

Practice variation in the management of children hospitalized with bronchiolitis: A Canadian perspective

Objectives

To describe variations in the monitoring, treatment, and discharge of children hospitalized with bronchiolitis among physicians across Canadian paediatric teaching hospitals.

Methods

We conducted an electronic survey of paediatricians with experience in the management of inpatient bronchiolitis at 20 Canadian paediatric teaching hospitals. Only physicians who worked a minimum of 6 weeks on their hospital inpatient unit in the 2015 calendar year were eligible to participate in the study. The questionnaire explored the monitoring, treatment, and discharge of children with bronchiolitis. Central tendency (mean) and dispersion (SD) statistics were produced for continuous variables and frequency distributions for categorical variables.

Results

A total of 142 respondents were included in the analysis. 45.1% reported the routine use of continuous oxygen saturation monitoring. 27.5% used a higher cut-off for oxygen supplementation of 92% and 12.7% use a lower cut-off of 88%. 29.6% routinely used deep nasal suctioning. Seventy-three per cent reported using nebulized therapies. 55.6% reported having preprinted order sheets or guidelines for management of inpatient bronchiolitis at their institutions and 28.2% reported having specific discharge criteria. The length of time required to be off oxygen prior to discharge varied (31% at 12 hours, 27.5% at 24 hours, and 24.6% after the last sleep period without oxygen).

Conclusion

There is significant practice variation in the monitoring, treatment, and discharge of children hospitalized with bronchiolitis within and between Canadian paediatric teaching hospitals. Future research is needed to establish best practices, effective knowledge translation, and implementation strategies to standardize care and decrease length of stay.

The impact of implementing a preprinted order form for inpatient management of otherwise healthy children admitted to a tertiary care centre with a diagnosis of bronchiolitis

Objective

To examine the effect on length of stay (LOS) of a preprinted order (PPO) set for children admitted to hospital with a diagnosis of bronchiolitis, as well as on quality improvement measures, medical errors, and resource utilization.

Patients and methods

A retrospective chart review was performed of children admitted to the inpatient units at the Children's Hospital of Eastern Ontario (CHEO) with a discharge diagnosis of bronchiolitis. Primary and secondary outcomes were compared between the pre-PPO (December 1, 2014 to June 30, 2015) and post-PPO (December 1, 2015 to June 30, 2016) periods. The primary outcome was LOS in days. Secondary outcomes included the proportion of quality improvement measures reached, the number of medical errors, and resource utilization.

Results

A total of 245 patients were included; 122 patients from the pre-PPO period (December 1, 2014 to June 30, 2015) and 123 patients from the post-PPO period (December 1, 2015 to June 30, 2016). Mean LOS was 3.1 days (2.7 to 3.5 days) and 2.8 days (2.4 to 3.2 days) in the pre- and post-PPO periods, respectively (multivariate analysis, P-value = 0.13). There were significant differences between the pre- and post-PPO periods in a number of quality improvement measures, although not in the number of medical errors. Significant reductions in oxygen, corticosteroid, antibiotic, and bronchodilator use were noted post-PPO implementation.

Conclusion

Although our bronchiolitis PPO did not significantly shorten LOS, it led to important improvements in quality improvement measures and in resource utilization efficiency.

Dexamethasone versus prednisone for children receiving asthma treatment in the paediatric inpatient population: protocol for a feasibility randomised controlled trial

INTRODUCTION

Asthma exacerbations are a leading cause of paediatric hospitalisations. Corticosteroids are key in the treatment of asthma exacerbations. Most current corticosteroids treatment regimens for children admitted with asthma exacerbation consist of a 5-day course of prednisone or prednisolone. However, these medications are associated with poor taste and significant vomiting, resulting in poor compliance with the treatment course. While some centres already use a short course of dexamethasone for treating children hospitalised with asthma, there is no evidence to support this practice in the inpatient population.

METHODS AND ANALYSIS

This single-site, pragmatic, feasibility randomised controlled trial will determine the feasibility of a non-inferiority trial, comparing two treatment regimens for children admitted to the hospital and receiving asthma treatment. Children 18 months to 17 years presenting to a Canadian tertiary care centre will be randomised to receive either a short course of dexamethasone or a longer course of prednisone/prednisolone once admitted to the inpatient units. The primary clinical outcome for this feasibility study will be readmission to hospital or repeat emergency department visits, or unplanned visits to primary healthcare providers for asthma symptoms within 4 weeks of hospital discharge. Feasibility outcomes will include recruitment and allocation success, compliance with study procedures, retention rate, and safety and tolerability of study medications. We plan on recruiting 51 children, and between-group comparisons of the clinical outcome will be conducted to gain insights on probable effect sizes.

ETHICS AND DISSEMINATION

Research Ethics Board approval has been obtained for this study. The results of this study will inform a multisite trial comparing prednisone/prednisolone to dexamethasone in inpatient asthma treatment, which will have the potential to improve the delivery of asthma care, by improving compliance with a mainstay of treatment. Results will be disseminated through peer-reviewed publications, organisations and meetings.

TRIAL REGISTRATION NUMBER

NCT03133897; Pre-results.

Tobacco use and misuse among Indigenous children and youth in Canada

While tobacco is sacred in many Indigenous cultures, the recreational misuse of commercial tobacco is highly addictive and harmful. Tobacco misuse is the leading preventable cause of premature death in the world. Smoking rates among Canadian Indigenous youth are at least three times higher than for their non-Aboriginal peers, an alarming statistic on many levels. The tolls on health from extensive tobacco use range from disproportionately high individual mortality and morbidity to heavy socioeconomic burdens on Indigenous communities. Paediatric health care providers are uniquely positioned to collaborate with community stakeholders to prevent and treat tobacco misuse in young people and their families, while understanding the cultural value of tobacco for many Indigenous peoples. Targeted interventions can positively impact length and quality of life, improve overall health and decrease the immense social and human costs of tobacco misuse.