Impact of "early intervention" parent workshops on outcomes for caregivers of children with neurodisabilities: a mixed-methods study

PURPOSE

This study explored the feasibility, impact and parent experiences of ENVISAGE (ENabling VISions And Growing Expectations)-Families, a parent-researcher co-designed and co-led program for parents/caregivers raising children with early-onset neurodisabilities.

METHODS

Parents/caregivers of a child with a neurodisability aged ≤6 years, recruited in Australia and Canada, participated in five weekly online workshops with other parents. Self-report measures were collected at baseline, immediately after, and 3 months post-ENVISAGE-Families; interviews were done following program completion. Quantitative data were analyzed with generalized estimating equations and qualitative data using interpretive description methodology.

RESULTS

Sixty-five parents (86% mothers) were recruited and 60 (92%) completed the program. Strong evidence was found of effects on family empowerment and parent confidence (all p ≤ 0.05 after the program and maintained at 3-month follow-up). The ENVISAGE-Families program was relevant to parents' needs for: information, connection, support, wellbeing, and preparing for the future. Participants experienced opportunities to reflect on and/or validate their perspectives of disability and development, and how these perspectives related to themselves, their children and family, and their service providers.

CONCLUSIONS

ENVISAGE was feasible and acceptable for parent/caregivers. The program inspired parents to think, feel and do things differently with their child, family and the people who work with them.Implications for rehabilitationENVISAGE (ENabling VISions And Growing Expectations)-Families is a co-designed, validated parent/researcher "early intervention and orientation" program for caregivers raising a child with neurodevelopmental disabilities (NDDs).ENVISAGE-Families empowered parents' strengths-based approaches to their child, family, disability, and parenting.ENVISAGE-Families increased caregivers' confidence in parenting children with NDD's and provided them tools to support connection, collaboration, and wellbeing.Raising children with NDD can have a profound impact on caregivers, who can benefit from strengths-based, future focused supports early in their parenting experience.

Individual and community-level income and the risk of diabetes rehospitalization among women and men: a Canadian population-based cohort study

BACKGROUND

Marked disparities by socioeconomic status in the risk of potentially avoidable hospitalization for chronic illnesses have been observed in many contexts, including those with universal health coverage. Less well known is how gender mediates such differences. We conducted a population-based cohort study to describe associations between household and community-level income and rehospitalizations for types 1 and 2 diabetes mellitus among Canadian women and men.

METHODS

Our cohorts were drawn from respondents to the 2006 mandatory long-form census linked longitudinally to 3 years of nationally standardized hospital records. We included adults 30-69 years hospitalized with diabetes at least once during the study period. We used logistic regressions to estimate odds ratios for 12-month diabetes rehospitalization associated with indicators of household and community-level income, with separate models by gender, and controlling for a range of other sociodemographic characteristics. Since diabetes may not always be recognized as the main reason for hospitalization, we accounted for disease progression through consideration of admissions where diabetes was previously identified as a secondary diagnosis.

RESULTS

Among persons hospitalized at least once with diabetes (n = 41,290), 1.5% were readmitted within 12 months where the initial admission had diabetes as the primary diagnosis, and 1.8% were readmitted where the initial admission had diabetes as a secondary diagnosis. For men, being in the lowest household income quintile was associated with higher odds of rehospitalization in cases where the initial admission listed diabetes as either the primary diagnosis (OR = 2.21; 95% CI = 1.38-3.51) or a secondary diagnosis (OR = 1.51; 95% CI = 1.02-2.24). For women, we found no association with income and rehospitalization, but having less than university education was associated with higher odds of rehospitalization where diabetes was a secondary diagnosis of the initial admission (OR = 1.88; 95% CI = 1.21-2.92). We also found positive, but insignificant associations between community-level poverty and odds of rehospitalization.

CONCLUSIONS

Universal health coverage remains insufficient to eliminate socioeconomic inequalities in preventable diabetes-related hospitalizations, as illustrated in this Canadian context. Decision-makers should tread cautiously with gender-blind poverty reduction actions aiming to enhance population health that may inadequately respond to the different needs of disadvantaged women and men with chronic illness.

Complex relationships between greenness, air pollution, and mortality in a population-based Canadian cohort

BACKGROUND

Epidemiological studies have consistently demonstrated that exposure to fine particulate matter (PM_2.5) is associated with increased risks of mortality. To a lesser extent, a series of studies suggest that living in greener areas is associated with reduced risks of mortality. Only a handful of studies have examined the interplay between PM_2.5, greenness, and mortality.

METHODS

We investigated the role of residential greenness in modifying associations between long-term exposures to PM_2.5 and non-accidental and cardiovascular mortality in a national cohort of non-immigrant Canadian adults (i.e., the 2001 Canadian Census Health and Environment Cohort). Specifically, we examined associations between satellite-derived estimates of PM_2.5 exposure and mortality across quintiles of greenness measured within 500 m of individual's place of residence during 11 years of follow-up. We adjusted our survival models for many personal and contextual measures of socioeconomic position, and residential mobility data allowed us to characterize annual changes in exposures.

RESULTS

Our cohort included approximately 2.4 million individuals at baseline, 194,270 of whom died from non-accidental causes during follow-up. Adjustment for greenness attenuated the association between PM_2.5 and mortality (e.g., hazard ratios (HRs) and 95% confidence intervals (CIs) per interquartile range increase in PM_2.5 in models for non-accidental mortality decreased from 1.065 (95% CI: 1.056-1.075) to 1.041 (95% CI: 1.031-1.050)). The strength of observed associations between PM_2.5 and mortality decreased as greenness increased. This pattern persisted in models restricted to urban residents, in models that considered the combined oxidant capacity of ozone and nitrogen dioxide, and within neighbourhoods characterised by high or low deprivation. We found no increased risk of mortality associated with PM_2.5 among those living in the greenest areas. For example, the HR for cardiovascular mortality among individuals in the least green areas was 1.17 (95% CI: 1.12-1.23) compared to 1.01 (95% CI: 0.97-1.06) among those in the greenest areas.

CONCLUSIONS

Studies that do not account for greenness may overstate the air pollution impacts on mortality. Residents in deprived neighbourhoods with high greenness benefitted by having more attenuated associations between PM_2.5 and mortality than those living in deprived areas with less greenness. The findings from this study extend our understanding of how living in greener areas may lead to improved health outcomes.

Influence of Socioeconomic Status on Stage at Presentation of Laryngeal Cancer in the United States

Objective

Identify socioeconomic predictors of stage at diagnosis of laryngeal cancer in the United States.

Study Design

Retrospective analysis of the North American Association of Central Cancer Registries’ Incidence Data–Cancers in North America Deluxe Analytic File for expanded races.

Setting

All centers reporting to the US Centers for Disease Control and Prevention’s National Program of Cancer Registries.

Subjects and Methods

All cases of laryngeal cancer in adult patients from 2005 to 2013 were reviewed. Ordinal logistic regression models were used to evaluate odd ratios (ORs) for socioeconomic indicators potentially predictive of advancing American Joint Committee on Cancer stage at diagnosis.

Results

A total of 72,472 patients were identified and included. Analysis revealed significant correlation between advanced stage at diagnosis and: Medicaid insurance, lack of insurance, female sex, older age, black race, and certain states of residence. The strongest predictor of advanced stage was lack of insurance (OR, 2.212; P < .001; 95% CI, 2.035-2.406). The strongest protective factor was residing in the state of Utah (OR, 0.571; P < .001; 95% CI, 0.536-0.609). Once adjusted for regional price and wage disparities, relative income was not a significant predictor of stage at presentation across multiple analyses.

Conclusion

Multiple socioeconomic factors were predictive of severity of disease at presentation of laryngeal cancer in the United States. This study demonstrated that insurance type was strongly predictive, whereas relative income had surprisingly little influence.

Does Socioeconomic Status Affect Stage at Presentation for Larynx Cancer in Canada’s Universal Health Care System?

Objective

Diagnosis of laryngeal cancer is dependent on awareness that persistent hoarseness needs to be investigated as well as access to an otolaryngologist. This study aimed to better classify and understand 3 factors that may lead to variability in stage at presentation of laryngeal cancer: (1) socioeconomic status (SES), (2) differences in access to health care by location of residence (rural vs urban or by province), and (3) access to an otolaryngologist (by otolaryngologists per capita).

Study Design

Registry-based multicenter cohort analysis.

Setting

This was a national study across Canada, a country with a single-payer, universal health care system.

Subjects

All persons 18 years or older who were diagnosed with laryngeal cancer from 2005 to 2013 inclusive were extracted from the Canadian Cancer Registry (CCR).

Methods

Ordered logistic regression was used to determine the effect of income, age, sex, province of residence, and rural vs urban residence on stage at presentation.

Results

A total of 1550 cases were included (1280 males and 265 females). The stage at presentation was earlier in the highest income quintile (quintile 5) compared to the lower income quintiles (quintiles 1-4) (odds ratio [OR], 0.68; P < .05). There was a statistically significant difference in stage at presentation based on rural or urban residence within the highest income quintile (OR, 1.73; P < .005).

Conclusion

There is a relationship between SES and stage at presentation for laryngeal cancer even in the Canadian universal health care system.

Associations between Living Near Water and Risk of Mortality among Urban Canadians

BACKGROUND

Increasing evidence suggests that residential exposures to natural environments, such as green spaces, are associated with many health benefits. Only a single study has examined the potential link between living near water and mortality.

OBJECTIVE

We sought to examine whether residential proximity to large, natural water features (e.g., lakes, rivers, coasts, "blue space") was associated with cause-specific mortality.

METHODS

Our study is based on a population-based cohort of nonimmigrant adults living in the 30 largest Canadian cities [i.e., the 2001 Canadian Census Health and Environment Cohort) (CanCHEC)]. Subjects were drawn from the mandatory 2001 Statistics Canada long-form census, who were linked to the Canadian mortality database and to annual income-tax filings, through 2011. We estimated associations between living within of blue space and deaths from several common causes of death. We adjusted models for many personal and contextual covariates, as well as for exposures to residential greenness and ambient air pollution.

RESULTS

Our cohort included approximately 1.3 million subjects at baseline, 106,180 of whom died from nonaccidental causes during follow-up. We found significant, reduced risks of mortality in the range of 12-17% associated with living within of water in comparison with living farther away, among all causes of death examined, except with external/accidental causes. Protective effects were found to be higher among women and all older adults than among other subjects, and protective effects were found to be highest against deaths from stroke and respiratory-related causes.

CONCLUSIONS

Our findings suggest that living near blue spaces in urban areas has important benefits to health, but further work is needed to better understand the drivers of this association. https://doi.org/10.1289/EHP3397.

Urban greenness and mortality in Canada's largest cities: a national cohort study

BACKGROUND

Findings from published studies suggest that exposure to and interactions with green spaces are associated with improved psychological wellbeing and have cognitive, physiological, and social benefits, but few studies have examined their potential effect on the risk of mortality. We therefore undertook a national study in Canada to examine associations between urban greenness and cause-specific mortality.

METHODS

We used data from a large cohort study (the 2001 Canadian Census Health and Environment Cohort [2001 CanCHEC]), which consisted of approximately 1·3 million adult (aged ≥19 years), non-immigrant, urban Canadians in 30 cities who responded to the mandatory 2001 Statistics Canada long-form census. The cohort has been linked by Statistics Canada to the Canadian mortality database and to annual income tax filings through 2011. We measured greenness with images from the moderate-resolution imaging spectroradiometer from NASA's Aqua satellite. We assigned estimates of exposure to greenness derived from remotely sensed Normalized Difference Vegetation Index (NDVI) within both 250 m and 500 m of participants' residences for each year during 11 years of follow-up (between 2001 and 2011). We used Cox proportional hazards models to estimate associations between residential greenness (as a continuous variable) and mortality. We estimated hazard ratios (HRs) and corresponding 95% CIs per IQR (0·15) increase in NDVI adjusted for personal (eg, education and income) and contextual covariates, including exposures to fine particulate matter, ozone, and nitrogen dioxide. We also considered effect modification by selected personal covariates (age, sex, household income adequacy quintiles, highest level of education, and marital status).

FINDINGS

Our cohort consisted of approximately 1 265 000 individuals at baseline who contributed 11 523 770 person-years. We showed significant decreased risks of mortality in the range of 8-12% from all causes of death examined with increased greenness around participants' residence. In the fully adjusted analyses, the risk was significantly decreased for all causes of death (non-accidental HR 0·915, 95% CI 0·905-0·924; cardiovascular plus diabetes 0·911, 0·895-0·928; cardiovascular 0·911, 0·894-0·928; ischaemic heart disease 0·904, 0·882-0·927; cerebrovascular 0·942, 0·902-0·983; and respiratory 0·899, 0·869-0·930). Greenness associations were more protective among men than women (HR 0·880, 95% CI 0·868-0·893 vs 0·955, 0·941-0·969), and among individuals with higher incomes (highest quintile 0·812, 0·791-0·834 vs lowest quintile 0·991, 0·972-1·011) and more education (degree or more 0·816, 0·791-0·842 vs did not complete high school 0·964, 0·950-0·978).

INTERPRETATION

Increased amounts of residential greenness were associated with reduced risks of dying from several common causes of death among urban Canadians. We identified evidence of inequalities, both in terms of exposures to greenness and mortality risks, by personal socioeconomic status among individuals living in generally similar environments, and with reasonably similar access to health care and other social services. The findings support the development of policies related to creating greener and healthier cities.

FUNDING

None.

Chest injuries: a clinical and autopsy profile

The clinical profiles and management of 236 consecutive chest injury patients treated and followed up at All India Institute of Medical Sciences between January 1983 and July 1985 were analyzed prospectively. There were 149 blunt and 87 penetrating injuries; 21 patients (9%) required thoracotomy. Single- or multiple-tube thoracostomy was performed in 141 patients (60%). The remaining 74 patients (31%) required only observation for a period of 24-48 hours. Fifteen patients (6.3%) died, the mortality being related to head injury in four, irreversible hypovolemic shock in four, pulmonary embolism in three, septicemia in two, and respiratory failure in two. Nonfatal complications included residual hemothorax in 18 cases, persistent air leak in 13, pulmonary infection in eight, pulmonary embolism in one, and empyema in one. The average hospital stay was 6.9 days. Evidence of chest injury of various magnitudes was found in 756 of 2,286 autopsies conducted for trauma-deaths during the same study period analyzed retrospectively; however, it was the major cause of death in only 147 (19%). Cardiac injuries accounted for 41% of the deaths resulting primarily from chest trauma. Only 10% of the patients who sustained cardiac injury reached hospital alive.

Fate of thrombectomized Björk-Shiley valves. A long-term cinefluoroscopic, echocardiographic, and hemodynamic evaluation

Fourteen patients underwent thrombectomy for thrombosis of implanted Björk-Shiley valves (13 in the mitral and one in the aortic position) between January, 1975, and July, 1984. There was no operative mortality or perioperative embolism. Over a follow-up period of 1 to 96 months (average 23.5 months), there was no late mortality. Serial evaluation of valve function by cinefluoroscopy and echocardiography has shown no evidence of rethrombosis or valve dysfunction in any of the patients. Cardiac catheterization and angiocardiography done in 10 patients at various intervals (1 month to 6 years) postoperatively have shown normal valve function in all and normalization of elevated preoperative intracardiac pressures in the majority. Our experience suggests that thrombectomy of thrombosed Björk-Shiley valves provides excellent early and long-term results in terms of patient survival and valve function.

Thrombotic obstruction of Bjork-Shiley valves--diagnostic and surgical considerations

We have evaluated 12 patients with thrombotic obstruction of the Bjork-Shiley valve since 1975, 11 in the mitral and 1 in the aortic position. During this period 442 patients with 303 mitral (181 plano-convex and 122 convexo-concave) and 205 aortic (112 plano-convex and 93 convexo-concave) Bjork-Shiley valves were available for follow-up. The incidence of thrombosis for the plano-convex model was 1.06% per patient year for the mitral position and 0.19% per patient year for the aortic position. The new convexo-concave model has brought down the incidence to 0.78% per patient year for the mitral (P less than 0.01) and 0% per patient year for the aortic valve. The onset of symptoms was acute (less than 15 days) in 41.7% and subacute (greater than 15 days) in 58.3% patients. All patients presented with pulmonary edema. Evidence of inadequate anticoagulation was present in only 3 (25%) patients. Reduction of prosthetic sounds and appearance of a new murmur was highly suggestive of valve thrombosis. Echocardiography and cinefluoroscopy was very useful for the instant recognition of this condition and had obviated the need for cardiac catheterisation in the last 6 patients. Emergency surgery was obligatory in all. Thrombectomy alone was successful in 9 patients. Three patients required replacement of the prosthesis. There was one operative death (mortality 8.3%). The long-term follow-up of these patients (3-82 months, mean 34 months) is excellent. We conclude that thrombotic obstruction of the Bjork-Shiley valve is often not related to inadequate anticoagulation, and more than half of the patients do not present with abrupt onset of symptoms. The convexo-concave model has significantly reduced this problem. Emergency surgery with thrombectomy is the procedure of choice for clotted prostheses.