Presentation on theme: "A Follow-Up of Children At-Risk For Developmental Disabilities and Their Families Presenters: Dr. Hillel Goelman, Dr. Jill Houbé, Mari Pighini, Dr. Anne."— Presentation transcript:
A Follow-Up of Children At-Risk For Developmental Disabilities and Their Families Presenters: Dr. Hillel Goelman, Dr. Jill Houbé, Mari Pighini, Dr. Anne Synnes Dr. Hillel Goelman, Dr. Anne Synnes, Dr. Jill Houbé, Dr. Anne Klassen, Mari Pighini, Dr Sarka Lisonkova, Zhen Li The Human Early Learning Partnership The University of British Columbia Children and Womens Health Centre of British Columbia Mc Master University Dana Brynelsen, Provincial Advisor. The Infant Development Program of British Columbia The Early Years Conference 2008: Valuing All Children Vancouver, BC, February 1 st, 2008
Outline for Todays Presentation: I.An Interdisciplinary Study of the Trajectories of At-Risk Infants and Children 1.Background: What do we know about the development at risk children from the research in: Neonatology (Dr. Anne Synnes) Early child development (Dr. Hillel Goelman) Developmental pediatrics (Dr. Jill Houbé) Quality of life studies (Dr. Anne Klassen) Rationale for study (Dr. Hillel Goelman) 2.The early years: Background on early child development/Research challenges
Outline for Todays Presentation (2) 3. Objectives of study 4. Research questions 5.Phases of the study Phase 1: Finding the children Finding children in databases: BCLHD, Edudata Canada Preliminary findings on health service utilization of non risk vs. at-risk children Phase 2: Linking health and educational information of at-risk infants and children (1996/7 Birth cohort) The role of the Population Health and Learning Observatory (PHLO)
Outline for Todays Presentation (3) Phase 3: (a) Linking health and educational information of at-risk infants and children (1997 Birth cohort until present) (b) Identifying and linking information of special subgroups of at-risk children Cases Studies of Children and Families in the Infant Development Program of BC (Mari Pighini ) 6. Concluding thoughts
1. Background (a) At-Risk children ( Anne Synnes) At risk children are those, who as a result of medical, biological or environmental factors are more likely than typical children to have developmental delays and school difficulties Level II and III regional neonatal-perinatal centers (NICUs) provide care for high risk pregnancies & intensive care for severely ill infants. Babies born in BC with extremely low birth weight (ELBW, under 801 grams), are followed by the provincial Neonatal Follow-up Programme at the Womens and Childrens Health Centre of BC.
at risk Children treated in Neonatal Intensive Care Units (NICUS) are at risk for developmental problems because of: o anomalies they are born with o complications of treatments required in the newborn period o effects of their newborn condition on their family/environment and/or concomitant risk factors
Background continued ( b ) Health Related Quality of Life (Anne Klassen) Definitions of HRQL vary, but most view HRQL as being…. Subjective -- assessed from the patients perspective whenever possible Multidimensional -- e.g., the WHOs definition of health, which is a state of complete physical, mental, and social well-being and not merely the absence of disease
Definitions of HRQL vary, but most view HRQL as being Subjective -- assessed from the patients perspective whenever possible Multidimensional -- e.g., the WHOs definition of health, which is a state of complete physical, mental, and social well-being and not merely the absence of disease
2. The Early Years : Challenges to studying the developmental trajectories of at-risk children (1) Hillel Goelman, Jill Houbé The early years are critical for childrens physical, cognitive, language, social and emotional development. Pre-term and other at-risk babies admitted in the NICUs are at risk for neurodevelopmental, behavioral and social dysfunction
There is a dearth of: interdisciplinary research to provide the multiple perspectives needed to fully understand the childs development across various domains of development ecologically valid research on the social determinants of optimal child development Clyde Hertzman: What differences make a difference? (or maybe Gertrude Stein).
There are few population-based studies of preterm infant outcomes that permit interpretation of the impact of environmental factors/multiple determinants of long-term outcomes (family, community and health policy) Limited number of population based longitudinal research on at-risk children who are NICU survivors is also due to many methodological challenges.
Neonatal Follow-Up Clinics provide multidisciplinary diagnostic services for former preterm infants Community intervention services provide on- going support for children and families Almost all intervention services terminate upon school entry Education policy, budgets and staffing prohibit on-going provision of remedial services to all but the most disabled school-age former preterm infants
The challenges to studying the developmental trajectories of these children (2) Data collected on these children in BC are stored in (at least) different databases and in different formats: The BC Health Linked Database (BCHLD) Neonatal Follow-up Programme (NFUP) at BC Childrens Hospital Edudata Canada There is currently no systematic way of tracking the development of any of these children from their treatment in the NICUs through to school entry at age 5. There have been no previous attempts to link the childrens health records in their early childhood to their later school performance
When at risk infants reach school age Research has shown: Approx. 50% of extremely low birth weight children have a learning disability (Walther, den Ouden & Verloove-Vanhorick, 2000; Wolke & Meyer, 1999) but it is less clear how bigger low birth weight children do behavioural difficulties are common but little is known how this affects school performance (Whitfield, Grunau & Holsti, 1997) Early identification/ intervention of at-risk children can have a significant positive effects upon the childrens development (Goelman et al, 2005)
3. Objectives of the study To better understand the health and developmental trajectories of a population of at-risk children from birth to age 9 To better understand the social determinants that impact on the developmental health trajectories of a population of at-risk children from birth to age 9 and To conduct an interdisciplinary study of a population of at-risk infants that draws on the strengths and complementary perspectives of psychology, neonatology, and developmental pediatrics and population health
4. Research Questions: In comparing a cohort of at-risk children admitted to Level II/III NICUs with a matched comparison group of non-risk children: 1)What differences are there in the medical histories of the two cohorts? 2)What differences are there in the educational progress of the two cohorts in their elementary school years in such areas as: a)Receiving learning assistance services b)Scores on standardized outcome measures
5. Phases of Study Phase 1 To identify at-risk infants born in BC in 1996/7 admitted to the BC Level II/III NICUs (Cohort 1) and a matched comparison group (Cohort 2) of non-risk infants born in BC in 1996/7 through the BC Linked Health Data Base (BCLHD).
What data on these children are there in the BCLHD? How many at-risk children were admitted to the Level II/III Neonatal Intensive Care Units in B.C., The reasons for their referral, and The history of their medical treatments, intervention and assessments Data on medical services that have been billed to and paid for by provincial health insurance Fields include visits to physicians (e.g., chronic illnesses), hospitalizations and surgeries and Interventions, therapies (e.g., physiotherapy, speech and language therapy) Preliminary findings, Preliminary findings, Some examples of the type of information being currently examined
What are some of the diagnoses identified through these analyses?
Percentage of non-NICU children vs. NICU Level II and NICU Level III children with more than 2 hospital re-admissions in the first year of life Mean days spent in hospital: Non-NICU <4 days; NICU Level II, 8 – 24days; NICU Level III, up to 40+ days (Jan 2008)
Percentage of non-NICU children vs. NICU Level II and NICU Level III children with more than 2 hospital re-admissions in the 2 nd year of life
Percentage of non-NICU children vs. NICU Level II and NICU Level III children with more than 2 hospital re-admissions in the 3rd year of life
Preliminary findings (2): September 2007-January 2008 o Updated reports on: An overall population view: Who are these children? Where do they live? Where do they go to get their medical care? Look at all the at-risk children admitted to NICUs –not only the VLBW or ELBW –Identify whether services are hospital vs ambulatory based, where children live (urban vs rural locations) Overview of clinical, hospitalization and other medical and non- medical interventions between birth and age 9 years old Comparing health and service utilization trends in at-risk vs. non- risk children in BC Some examples of the type of data that is currently being analysed include…
Table 1(a). Mean birth weight (BW) and gestational age (GA) of at risk infants in the study cohort when compared with non-risk children-Urban URBAN Non-RiskAt-Risk Infants – Time in NICU Level II, >= 24 hoursLevel II, >48 hoursLevel III, >= 24 hoursLevel III, >48 hours Gender MFTMFTMFTMFTMFT Number Per cent Outborn (n=) N/A Outborn (%) N/A (N) GA Mean gestational age (GA) (weeks ) (N) BW (Hosp) Mean birth weight (BW) (grams) Hosp
Table 1(b).Mean birth weight (BW) and gestational age (GA) of at risk infants in the study cohort when compared with non-risk children-Rural RURAL Non-RiskAt-Risk Infants – Time in NICU Level II, >= 24 hoursLevel II, >48 hoursLevel III, >= 24 hoursLevel III, >48 hours Gender MFTMFTMFTMFTMF T Number Per cent [[ Outborn (n=) N/A Outborn (%) N/A (n=) for GA Mean gestation al age (GA) (weeks) (N=) fo[ BW (hosp)[ Mean birth weight (BW) (gram) H
Phase 2 To link the health information on Cohort 1 and Cohort 2 obtained through the BCHLD in Phase I with their respective educational outcome measures in Grade 4 through Edudata Canada. Edudata Canada is a database which includes information on children in the public school system starting when the child enters kindergarten, usually at age 5.
Linking the databases: Edudata Canada Edudata Canada includes information on the childs developmental and academic progress, as well as demographics information, for example: In Phase 2, these childrens anonymized Personal Health Numbers (PHNs) will be linked with their Permanent Education Numbers (PENs). This will enable us to obtain and compare anonymous and confidential records of educational achievement and status (for example, standardized test scores i.e., FSA scores; special education designation and school support services, i.e., the student being assigned with a special support worker, among others
The BC Linked Health Database The Edudata Database The crosswalk linking the two data bases
What are some answers we can find from BCHLD /Edudata Canada crosswalk? The crosswalk will enable us to: Link neonatal medical information on a given child with information on that childs school performance on standardized assessment measures in Grade 4, i.e., the Foundations Skills Assessment or FSA. Inferential and predictive statistical techniques will be used to identify the relative weight contributed by different social, economic, health and developmental variables to the school outcome variables from Edudata Canada
Phase 3 To identify and to link health information on specific sub-groups of at-risk children in BC who were admitted to the BC Level II/III NICUs and matched comparison groups. Population-based study informed by case studies:
Case Studies of the Infants and Children in the IDP of BC ~ Preliminary findingsCase Studies of the Infants and Children in the IDP of BC ~ Preliminary findings Background Absence of systematic data gathering in early childhood development - - this creates a gap in ability to conduct longitudinal research for children who are developmentally at risk. The IDP Programs have collected invaluable medical, developmental and family information on more than children in British Columbia since 1975 (Brynelsen, 2003). Information: entered manually and stored in different files until recently Currently: Key information is being entered under a Central Registry database (e.g. fields like date of intake, reason for referral) Academic and community partnership: First time for IDP to participate in a study of this kind
Collaborative partnership study ~ guided and inspired by: 1.Discussions with an IDP Program Coordinator; IDP consultants, and with the IDP Provincial Advisor; 2.Informal discussions with a few parents: Tell us about your experience with IDP; used the IDP Post Service Evaluation Questionnaire 3.These statements: … how help is provided matters as much, if not more, than what is done if positive consequences are to be realized…(Karuza, Rabinowitz & Zevon, 1986), and …in effective home-based, family-centred early intervention programs parents complement the intervention program instead of supplementing it… (Mahoney et al, 1998 )
Objectives of Study This qualitative, retrospective case study looks into the experiences of families with children who are at-risk for/ identified with developmental disabilities from their childs birth to their entry into school
FRAMING OF STUDY 1. FRAMING OF STUDY Literature with previous research on and/or descriptions of… Children at-risk for developmental disabilities, children with developmental delays, and children who develop typically ( Synnes et al, 1994; Walther, den Ouden, & Verloove-Vanhorick, 2000) Early intervention programs – effectiveness of early intervention (Mahoney, 2003; McCollum, 2002 ) Special needs services and programs in British Columbia Family centred programs Therapy/Center focused programs (Brynelsen, Cummings & Gonzales, 1993; Goelman et al, 2005) Academic-Community Collaboration/Partnerships (Goelman et al, 2005 ) MEANING OF STUDY 2. MEANING OF STUDY voices Unique perspectives through the voices of parents (different tradition in literature concerning special needs) A first step in trying to connect the dots of childrens life paths, from the time of their birth and into to their school ages, within their individual family contexts.
Research Questions 1. What are some of the unique experiences of developmentally at-risk children and their families who participated in the IDP in terms of access to resources and programs? 2. What are some of the unique experiences of developmentally at-risk children and their families who participated in the IDP in terms of their child current developmental needs? 3. In what ways do the experiences described in a) and b) relate to the current preschool/school demands on these parents; to the demands from other family members, and to financial/work pressures?
Methods and Procedures Naturalistic qualitative research design; multiple case study approach: (Creswell, 1998, 2003); two stages Stage 1: Purposefully targeted sample of 12 participants of four families (8 parents, four children) Two mail-outs to 28 IDP families Criteria for Inclusion for participant families comprised, among others: Received IDP home visitation services for their children between the ages of zero to three years Expressed their wish to be re-contacted for research purposes during the discharge process ( IDP Post Service Evaluation Questionnaire) Two-step ethics approval for participation in study
Table 1. Family Demographics FamilyComposition Children in participating familiesAge of siblings Languagesspoken at home by parent(s) Parent's Level of EducationParent'sEmploymentStatus Families FM # of children #Age E.Other H. S Post Sec.FM 0001 YY217 yrs; 10 mos. 10 years Y N Y (F, M) full- time part- time 0002 YY116 yrs; 9 mos. N/A YY Y (F,M) full- time 0003 YY214 yrs; 8 mos 6 yearsYY Y (M) Y (F) home- business self- employed 0004 YY212 yrs; 10 mos. 7 yearsYY Y (F, M) part time All two- parent families with high-school/post-secondary education At least one parent per family employed/self-employed –no income assistance Three families also spoke another language 0002 child had no siblings
Data collection 1.Reviews of childrens files conducted at IDP Program site No personal names and/or identifiers included 2.Three to four 45 minutes open ended individual interviews - digitally recorded Final individual session with participating parents revising information from reviewed files 3.Two focus groups (before and after interviews) Only parents participated in interviews and focus groups 4.Transcriptions: combination of verbatim and summaries (Quinn- Patton, 1999) 5.Post-data collection: Member-check in sessions to ensure integrity of transcribed interviews
Table 2. Interview of Parent Participation in the Focus Groups, Interview Sessions and File Revision Sessions* Families Focus Group 1Interview Session 1 Interview Session 2 Interview Session 3 Interview Session 4 File Reviews Session Focus Group XMMMMMF 0002 MMMMMMM 0003 MMMMMMM 0004 XMFM N/AMX * F=Father; M= Mother; X= no attendance/participation; N/A= no session Only one family had both parents participating throughout interviews Focus groups attendance was limited due to unforeseen circumstances Focus Group 1 questions introduced before Interview 1 for 0002/0004
Data Analysis Data sources: Data sources: File reviews; digitally recorded and transcribed interviews, focus groups, memos Mostly thematiccontent analysis Mostly thematic content analysis to interpret the identified themes (Krippendorf, 2004) integrity of study, : Ensuring integrity of study, through rigorous three-step process of: 1.Inter-coded reliability with 90% + agreement; inter-coding disagreement was reported and alternatives presented 2.Inter-coder audibility -- until themes, categories and subcategories established (Use of NVIVO software) 3.Second set of member-checks with participants confirming their agreement with identified themes and categories
Preliminary Findings: File Reviews ~ Information Fields Referral source Identified condition Medical history IDP intake Wait time Developmental status IDP home visitation (frequency) Therapy/ies Other Programs (accessed ) Other Referrals Other Services (provided ) Assessment Transition Discharge Excerpts: Consultants comments Family feedback: Artifacts
Summary of Researchers Perceptions of Family Profiles Memos added to information fields re: Family profile (memo) Family profile (memo) Level of family involvement with program, e.g. family 0001: Level of family involvement with program, e.g. family 0001: Responses to reviews Responses to reviews Unique connections between families and consultants, Unique connections between families and consultants, e.g., comments, artifacts, letters Memo summarizing characteristics of consultant/ -family contact and relationship: Overwhelming number of medical- related information … 3 specialists; in- depth… assessment process: …screening and formal assessments. Complex process of referrals/ gathering documents for different programs & agencies –t… all in place; successful referrals/intakes Family regularly involved with IDP consultant and Physiotherapy services Family regularly involved with IDP consultant and Physiotherapy services ( once every 3-4 weeks)
Preliminary Findings, Stage 1: File Reviews ~ Across families referral Age of referral to the IDP: by 6 months sources Referral sources: Pediatrician (2), Community Health Nurse (2) Wait-times Wait-times before intake: under four months Home visits Home visits: monthly (IDP consultant, IDP physiotherapy consultant or both. diagnosis by year 1; ddelays: Medical/developmental diagnosis by year 1; developmental delays: Moderate to severe level of intensity (All) surveillance Ongoing medical surveillance by a pediatrician (All) complications conditionsspecialists therapists Additional complications or conditions - specialists, physio-, occupational, speech-language therapists (All) programs Other programs, e.g., Parent-Child Mother Goose (3) Designation: funding Designation: special needs designation by age three (special funding for support) (All) Referrals Referrals to: Therapy program; Program after their discharge (3) Transition Transition into an inclusive preschool/daycare setting (age 3) Family childcare support (1)
Preliminary Conclusions Themes emerged through coded categories /subcategories Interviews-Topic 1: Early experiences What are things you recall…e.g. at the time your child was referred to the IDP?What are things you recall…e.g. at the time your child was referred to the IDP? Early memories and experiencesEarly memories and experiences are difficult to recall – time span, emotional referral family centred model informationaccess/availability consultantImportance of referral to IDP – the value of home visitation, within a family centred model comfort, flexible, safe; the value of the information, access/availability of resources; consultant as an ally and an advocate for other referrals and services
Preliminary Conclusions Themes emerged through coded categories /subcategories Interviews-Topics 2 & 3: What were your experiences during each transition (to Preschool, to School ) Changing needsChanging needs: As children grow and develop their disability remains, but the special needs change Awareness of Special Needs:Awareness of Special Needs: Child grows but does not become independent, parent MUST grow stronger, more, independent --an advocate Multiple Roles:Multiple Roles: Perception he/she has to become Case Manageron top of their family dutiesas service providers move towards an agency-focused, therapy centred approach
Preliminary Conclusions Themes emerged through coded categories /subcategories Preliminary Conclusions Themes emerged through coded categories /subcategories cont. (2) Interviews -Topic 4: How did you and your family cope with transitions and change? Stressors job related and financial family logisticsStressors were mainly job related and financial and juggling with family logistics networkExtended family/community network support was key Role of IDP consultant empowering information/knowledge translation systemRole of IDP consultant: Central case manager providing help for access to programs and services; empowering parents: supporting parents to become advocates; providing information/knowledge translation to understand childs needs and to understand system
C ommon themes through interview topics, and across themes & categories : Follow up: What are some of the most relevant issues for parents C ommon themes through interview topics, and across themes & categories : 1.Home based, family centred model 1.Home based, family centred model appears to be preferred one – in contrast to centre-based and exclusively therapy and child focused Relationship valuesRelationship with consultant in home based services is a key feature for parents; e.g., Frequently coded terms that reflect participants values: (quotes) trust, feeling comfortable, and friendship, wonderful… Inclusionparticipation of siblingsInclusion and participation of siblings in home-visits and therapies are highly valued. Example of quote … siblings are teachers too
Follow up…(contd..) 2.Transitions 2.Transitions from IDP to other centre-based programs appear to be hard on parents; e.g. (quote) Feeling you have been dropped and Wanting to be hand held until the school years system –Parents suggest: a chart showing how system and services work 3.Hardest transition: from preschool to school case management resources;Lack of centralized case management; shortage of resources; insufficient contact with teachers/administrators Key contact person: School Support Worker
Themes within participant families … 1.Values and belief: protecting the public health/education systems Conflicts of interest: shortage of resources or difficulty matching professionals with child/familys unique needs –hiring private practitioner (family 0001) 2.The value of network and support Learning the difference of their childs growth and development through the experiences and stories shared by other families re anticipating needs and resources (e.g. requiring a w (family 0002) wheelchair; different type of child minding arrangements) 3.The need to ally, to search for answers and to advocate Recognizing that there is a fight to be fought every step of the way and that families need allies to overcome major barriers (family 0003) 4.Inclusion of all members above all Listening to the needs of the family to have all members participate in each process and decision, recognizing their lifestyle and validating their complex needs –more valuable than any measurable (developmental) progress (family 0004)
Stage 2: Update Method and Procedures in Multiple Case Study (Winter ) Rationale: Rationale: Gilliam, Meisels & Mayes (2005): The need for screening and surveillance for children who are at-risk for developmental disabilities, who do not have identifiable special needs by age 3; but who exhibit indicators of specific learning, behavioural, social-emotional, motor difficulties between ages 3 – 5 and who required some kind of special assistance in the Elementary years.
Stage 2: Update Method and Procedures in Multiple Case Study (Winter , cont.) Purpose: Purpose: To present a more comprehensive portrayal of the experiences of families receiving early intervention support in B.C.: Participants: Targeted sample of two to three familiesParticipants: Targeted sample of two to three families Representing families with children in the grey area Children identified as at-risk for developmental delays shortly after birth (e.g. premature, very low-birth weight (< 1500 gr.) Followed by the IDP of BC in the monitoring level of services (as opposed to home visitation) --discharged by age e.g. Child caught up to norm Recruitment, Procedures, Data Collection and Proposed Data Analyses:Recruitment, Procedures, Data Collection and Proposed Data Analyses: Similar to Stage 1 Timeline:Timeline: Study completion anticipated for August 2008
6. Concluding Thoughts Significance of studies Anticipated outcomes and benefits Theory to Practice: The Social Inclusion for At- Risk Children and Families Project (SDPP) * List of References available upon request*
Two studies: 1. A series of case studies of the children and families of the IDP of BC, and, 2. A population-based study that will link the health and developmental trajectories of at- risk children Social Inclusion for At-Risk Children and Their Families Social Inclusion for At-Risk Children and Their Families Linking research to practice, to families and communities Social Development Partnership Program, Social Development Canada A partnership between IDP of BC, The CHILD Project and HELP A two-fold project set in BCs Lower Mainland targeting the most vulnerable children and families – those who experience social exclusion in both mainstream and special needs contexts Case Studies of the Infants and Families of the Infant Development Program of BC or (IDP Case Study): 1.1.Parents are expressing the need of a family- centred, continuous, seamless system of early intervention services between birth and the early school years (K – 1) 1.2. Services should include screening, diagnostic and referral programs for at-risk children and their families An Interdisciplinary Study of the Trajectories of At- Risk Infants and Children or NICUstudy: 2.1. At-risk children who were admitted to Level II/II NICUs in BC continue to require additional medical attention over time, when compared to non-risk children (not admitted to NICU LevelII/III) Poster template : Angela Jaramillo, The CHILD Project Poster design : Lara El Khatib and Mari Pighini, SDPP, HELP In consultation with Ellen Larcombe, GIS, HELP provide To provide… …the parents of developmentally at- risk infants and young children with information to better understand and address their concerns regarding their childrens developmental needs … a model for a seamless continuum of services for at risk children and their families …parents and professionals with centralized online and printed information about resources, as well as training (including online courses) …service providers with key information to support them in better serving the children and families they work with Deliverables follow Bronfenbrenners ecological framework (Bronfenbrenner 1976, 1989). Tools/ (questionnaires) organized as follows: A micro system level addressing concerns about childrens development Meso and exo system levels addressing the identification of barriers to social inclusion of at risk children and their families Online/printed lists of resources addressing child development concerns for parents and professionals, to be accessed by geographic area or developmental domain SDPP TEAM: Hillel Goelman, Ph.D.,SDPP Project Director Clyde Hertzman, Ph.D, Director, HELP Dana Brynelsen, Provincial Advisor, IDP of BC Lara El-Khatib, Ph.D.,SDPP Project Coordinator, HELP Mari Pighini, Ph.D. Cand., SDPP, Research Coordinator, HELP Ginny Chu, SDPP Project Assistant, HELP WHAT IS THE SDPP PROJECT? Research Component DESCRIPTION OF PROJECT PROJECT OBJECTIVES 1. Information about resources and tools for parents and service providers in the Lower Mainland, and, 2. Training and dissemination of information Building community capacity and knowledge creation and dissemination, through a research and a deliverables component. PROJECT GOAL Deliverables Component 4 DELIVERABLES COMPONENT: 5 September-October 2007 Search/ review online resources for parents, professionals and community service providers Develop a list of relevant community agencies and professionals Develop questionnaires addressing concerns about young childrens development November-December 2007 Hold focus groups with parents and professionals for input and feedback Handouts and posters available throughout communities in BCs Lower Mainland; e.g., local libraries, grocery stores, community centers/neighbourhood houses, day care centers, preschools and schools, among other places January-February 2008 Further updating and dissemination of online tools and resources Introduction of online courses and TV/video production Design and production of the training and information dissemination component March-April 2008 Project wrap-up Project follow-up Presentations/publication executive summaries Proposal to expand project throughout BC Timeline : RESEARCH COMPONENT: PRELIMINARY FINDINGS 5 6 At The University of British Columbia