Presentation on theme: "Presenters: Dr. Hillel Goelman, Dr. Jill Houbé, Mari Pighini,"— Presentation transcript:
1A Follow-Up of Children At-Risk For Developmental Disabilities and Their Families Presenters: Dr. Hillel Goelman, Dr. Jill Houbé, Mari Pighini,Dr. Anne SynnesDr. Hillel Goelman, Dr. Anne Synnes, Dr. Jill Houbé,Dr. Anne Klassen, Mari Pighini, Dr Sarka Lisonkova, Zhen LiThe Human Early Learning PartnershipThe University of British ColumbiaChildren and Women’s Health Centre of British ColumbiaMc Master UniversityDana Brynelsen, Provincial Advisor.The Infant Development Program of British ColumbiaThe Early Years Conference 2008: Valuing All ChildrenVancouver, BC, February 1st, 2008
2Outline for Today’s Presentation: An Interdisciplinary Study of the Trajectories of At-Risk Infants and Children1. 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)The early years: Background on early child development/Research challenges
3Outline for Today’s Presentation (2) 3. Objectives of study4. Research questionsPhases of the studyPhase 1: Finding the childrenFinding children in databases: BCLHD, Edudata CanadaPreliminary findings on health service utilization of non risk vs. at-risk childrenPhase 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)
4Outline for Today’s 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 childrenCases Studies of Children and Families in the Infant Development Program of BC (Mari Pighini)6. Concluding thoughts
51. 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 difficultiesLevel 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 Women’s and Children’s Health Centre of BC.
6anomalies they are born with Children treated in Neonatal Intensive Care Units (NICUS) are at risk for developmental problems because of:anomalies they are born withcomplications of treatments required in the newborn periodeffects of their newborn condition on their family/environment and/or concomitant risk factors
7Background continued ( b ) Health Related Quality of Life (Anne Klassen) Definitions of HRQL vary, but most view HRQL as being….Subjective -- assessed from the patient’s perspective whenever possibleMultidimensional -- e.g., the WHO’s definition of health, which is “a state of complete physical, mental, and social well-being and not merely the absence of disease
8Definitions of HRQL vary, but most view HRQL as being Subjective -- assessed from the patient’s perspective whenever possibleMultidimensional -- e.g., the WHO’s definition of health, which is “a state of complete physical, mental, and social well-being and not merely the absence of disease
92. The Early Years : Challenges to studying the developmental trajectories of at-risk children (1) Hillel Goelman, Jill HoubéThe early years are critical for children’s 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
10There is a dearth of:interdisciplinary research to provide the multiple perspectives needed to fully understand the child’s development across various domains of development“ecologically valid” research on the social determinants of optimal child developmentClyde Hertzman: “What differences make a difference?” (or maybe Gertrude Stein).
11There 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.
12Neonatal Follow-Up Clinics provide multidisciplinary diagnostic services for former preterm infants Community intervention services provide on-going support for children and familiesAlmost all intervention services terminate upon school entryEducation policy, budgets and staffing prohibit on-going provision of remedial services to all but the most disabled school-age former preterm infants
13The 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 Children’s HospitalEdudata CanadaThere 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 children’s health records in their early childhood to their later school performance
14When 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 dobehavioural 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 children’s development (Goelman et al, 2005)
153. Objectives of the study To better understand the health and developmental trajectories of a population of at-risk children from birth to age 9To better understand the social determinants that impact on the developmental health trajectories of a population of at-risk children from birth to age 9 andTo 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
164. 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:What differences are there in the medical histories of the two cohorts?What differences are there in the educational progress of the two cohorts in their elementary school years in such areas as:Receiving learning assistance servicesScores on standardized outcome measures
175. Phases of StudyPhase 1To 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).
18What 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, andThe history of their medical treatments, intervention and assessmentsData on medical services that have been billed to and paid for by provincial health insuranceFields include visits to physicians (e.g., chronic illnesses), hospitalizations and surgeries and Interventions, therapies (e.g., physiotherapy, speech and language therapy)Preliminary findings,Some examples of the type of information being currently examined
19What are some of the diagnoses identified through these analyses?
20Percentage of non-NICU children vs 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 lifeMean days spent in hospital: Non-NICU <4 days; NICU Level II, 8 – 24days; NICU Level III, up to 40+ days (Jan 2008)
21Percentage of non-NICU children vs Percentage of non-NICU children vs. NICU Level II and NICU Level III children with more than 2 hospital re-admissions in the 2nd year of life
22Percentage of non-NICU children vs 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
23Preliminary findings (2): September 2007-January 2008 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 NICU’s –not only the VLBW or ELBWIdentify 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 oldComparing health and service utilization trends in at-risk vs. non-risk children in BCSome examples of the type of data that is currently being analysed include…
24At-Risk Infants – Time in NICU 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-UrbanURBANNon-RiskAt-Risk Infants – Time in NICULevel II, >= 24 hoursLevel II, >48 hoursLevel III, >= 24 hoursLevel III, >48 hoursGenderMFTNumber284072715755564241319314344140311192522432339771150125275Per cent51.148.910055.544.555.644.456.044.054.545.5Outborn (n=)N/A1122901202368855012380.00Outborn (%)34.97273361.427.2922.1249.1(N) GA555012515Mean gestational age (GA) (weeks)39.2539.339.2837.4837.5537.5136.6836.0136.6935.535.1535.3535.2432.6432.59(N) BW (Hosp)Mean birth weight (BW) (grams) Hosp.3446.7
25At-Risk Infants – Time in NICU 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-RuralRURALNon-RiskAt-Risk Infants – Time in NICULevel II, >= 24 hoursLevel II, >48 hoursLevel III, >= 24 hoursLevel III, >48 hoursGenderMFTNumber475146269377188159347119102221433174191534Per cent50.6649.310054.245.853.846.258.8141.955.944.1100[Outborn (n=)N/A185158343141122263.00Outborn (%)33.2727.9761.2433.0328.3761.4(n=) for GA473346119344187346117101219Mean gestational age (GA) (weeks)39.4239.43-36.9037.1937.035.9636.4036.1634.2333.8134.0533.2130.8032.15(N=) fo[ BW (hosp)171145316118220Mean birth weight (BW) (gram) H2452.42315.0
26Phase 2To 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.
27Linking the databases: Edudata Canada Edudata Canada includes information on the child’s developmental and academic progress, as well as demographics information, for example: In Phase 2, these children’s 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
28The BC Linked Health Database The Edudata DatabaseThe BC Linked Health DatabaseThe crosswalk linking the two data bases
29The crosswalk will enable us to: 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 child’s 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
30Phase 3To 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:
31“Case Studies of the Infants and Children in the IDP of BC ~ Preliminary findings” BackgroundAbsence 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 recentlyCurrently: 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
32Collaborative partnership study ~ guided and inspired by: Discussions with an IDP Program Coordinator; IDP consultants, and with the IDP Provincial Advisor;Informal discussions with a few parents: “Tell us about your experience with IDP”; used the IDP Post Service Evaluation QuestionnaireThese 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)
33Objectives of StudyThis qualitative, retrospective case study looks into the experiences of families with children who are at-risk for/ identified with developmental disabilities from their child’s birth to their entry into school
34◊Literature with previous research on and/or descriptions of… 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 ColumbiaFamily centred programsTherapy/Center focused programs(Brynelsen, Cummings & Gonzales, 1993; Goelman et al, 2005)Academic-Community Collaboration/Partnerships(Goelman et al, 2005)2. MEANING OF STUDY◊ Unique perspectives through the voices of parents (different tradition in literature concerning special needs)◊ A first step in trying to “connect the dots” of children’s life paths, from the time of their birth and into to their school ages, within their individual family contexts.
35Research Questions1. 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?
36Methods 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 yearsExpressed 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
37Table 1. Family Demographics FamilyCompositionChildren in participatingfamiliesAgeof siblingsLanguagesspokenat homeby parent(s)Parent'sLevel ofEducationEmploymentStatusFamilies FM# ofchildren#E.OtherH. SPostSec.0001Y217 yrs; 10 mos.10 yearsNY (F, M)full-timepart-time00026 yrs; 9 mos.N/AY (F,M)full- time00034 yrs; 8 mos6 yearsY (M)Y (F)home-businessself-employed00042 yrs; 10 mos.7 yearspart 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
38Data collectionReviews of children’s files conducted at IDP Program siteNo personal names and/or identifiers includedThree to four 45 minutes open ended individual interviews - digitally recordedFinal individual session with participating parents revising information from reviewed filesTwo focus groups (before and after interviews)Only parents participated in interviews and focus groupsTranscriptions: combination of verbatim and summaries (Quinn-Patton, 1999)Post-data collection: Member-check in sessions to ensure integrity of transcribed interviews
39Table 2. Interview of Parent Participation in the Focus Groups, Interview Sessions and File Revision Sessions*FamiliesFocus Group1InterviewSession 1Session 2Interview Session 3Interview Session 4File ReviewsSession20001XMF000200030004FMN/A*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
40Data Analysis◊ Data sources: File reviews; digitally recorded and transcribed interviews, focus groups, memos◊ Mostly thematic content analysis to interpret the identified themes (Krippendorf, 2004)◊ Ensuring integrity of study, through rigorous three-step process of:Inter-coded reliability with 90% + agreement; inter-coding disagreement was reported and alternatives presentedInter-coder audibility -- until themes, categories and subcategories established (Use of NVIVO software)Second set of member-checks with participants confirming their agreement with identified themes and categories
42Summary of Researchers’ Perceptions of Family Profiles “Memos” added to information fields re:◊ Family profile (memo)◊ Level of family involvement with program, e.g. family 0001:◊ Responses to reviews◊ Unique connections between families and consultants, e.g., comments, artifacts, letters◊ Memo summarizingcharacteristics of consultant/-family contact and relationship:Family regularly involved with IDP consultant and Physiotherapy services ( once every 3-4 weeks)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
43Preliminary Findings, Stage 1: File Reviews ~ Across families ◊ Age of referral to the IDP: by 6 months◊ Referral sources: Pediatrician (2), Community Health Nurse (2)◊ Wait-times before intake: under four months◊ Home visits: monthly (IDP consultant, IDP physiotherapy consultant or both.◊ Medical/developmental diagnosis by year 1; developmental delays: Moderate to severe level of intensity (All)◊ Ongoing medical surveillance by a pediatrician (All)◊ Additional complications or conditions - specialists, physio-, occupational, speech-language therapists (All)◊ Other programs, e.g., Parent-Child Mother Goose (3)◊ Designation: “special needs” designation by age three (special funding for support) (All)◊ Referrals to: “Therapy” program; “3-12” Program after their discharge (3)◊ Transition into an inclusive preschool/daycare setting (age 3)◊ Family childcare support (1)
44Interviews-Topic 1: Early experiences Preliminary Conclusions Themes emerged through coded categories /subcategoriesInterviews-Topic 1: Early experiences“What are things you recall…e.g. at the time your child was referred to the IDP?Early memories and experiences are difficult to recall – time span, emotionalImportance 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
45Preliminary Conclusions Themes emerged through coded categories /subcategories Interviews-Topics 2 & 3:What were your experiences during each transition (to Preschool, to School )Changing needs: As children grow and develop their disability remains, but the special needs changeAwareness of Special Needs: Child grows but does not become independent, parent MUST grow stronger, more, independent --an advocateMultiple Roles: Perception he/she has to become Case Manager—on top of their family duties—as service providers move towards an agency-focused, therapy centred approach
46How did you and your family cope with transitions and change? 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 were mainly job related and financial and juggling with family logisticsExtended family/community network support was keyRole 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 child’s needs and to understand system
47Follow up: What are some of the most relevant issues for parents Common themes through interview topics, and across themes & categories:Home based, family centred model appears to be preferred one – in contrast to centre-based and exclusively therapy and child focusedRelationship 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”…Inclusion and participation of siblings in home-visits and therapies are highly valued. Example of quote “… siblings are teachers too”
48Follow up…(contd..)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”Parents suggest: a chart showing how system and services workHardest transition: from preschool to schoolLack of centralized case management; shortage of resources; insufficient contact with teachers/administratorsKey contact person: School Support Worker
49Themes within participant families… Values and belief: protecting the public health/education systemsConflicts of interest: shortage of resources or difficulty matching professionals with child/family’s unique needs –hiring private practitioner (family 0001)The value of network and supportLearning the difference of their child’s 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)The need to ally, to search for answers and to advocateRecognizing that there is a “fight” to be fought every step of the way and that families need allies to overcome major barriers (family 0003)Inclusion of all members above allListening 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)
50Stage 2: Update Method and Procedures in Multiple Case Study (Winter 2007-2008) 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.
51Stage 2: Update Method and Procedures in Multiple Case Study (Winter 2007-2008, cont.) 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 familiesRepresenting 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: Similar to Stage 1Timeline: Study completion anticipated for August 2008
52* List of References available upon request* 6. Concluding ThoughtsSignificance of studiesAnticipated outcomes and benefitsTheory to Practice: The Social Inclusion for At-Risk Children and Families Project (SDPP)* List of References available upon request*
53“Social Inclusion for At-Risk Children and Their Families” Linking research to practice, to families and communities Social Development Partnership Program, Social Development CanadaA partnership between IDP of BC, The CHILD Project and HELPAt The University of British ColumbiaSDPP 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, HELPWHAT IS THE SDPP PROJECT?1PROJECT OBJECTIVES14DELIVERABLES COMPONENT:6To provide……the parents of developmentally at- risk infants and young children with information to better understand and address their concerns regarding their children’s 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 withDeliverables follow Bronfenbrenner’s ecological framework (Bronfenbrenner 1976, 1989). Tools/ (questionnaires) organized as follows:A micro system level addressing concerns about children’s developmentMeso and exo system levels addressing the identification of barriers to social inclusion of at risk children and their familiesOnline/printed lists of resources addressing child developmentconcerns for parents and professionals, to be accessed by geographic area or developmental domainA two-fold project set in BC’s Lower Mainland targeting the most vulnerable children and families –those who experience social exclusion in both “mainstream” and “special needs” contexts.PROJECT GOAL2TimelineBuilding community capacity and knowledge creation and dissemination, through a research and a deliverables component.September-October 2007Search/ review online resources for parents,professionals andcommunity service providersDevelop a listof relevant communityagencies and professionalsDevelopquestionnaires addressingconcerns about youngchildren’s developmentNovember-December 2007Hold focusgroups with parents and professionals for input and feedbackHandouts and posters available throughout communities in BC’s Lower Mainland; e.g., local libraries, grocery stores, community centers/neighbourhood houses, day care centers, preschools and schools, among other placesJanuary-February 2008Further updating and dissemination of online tools and resourcesIntroduction of online courses and TV/video productionDesign and production of the training and information dissemination componentMarch-April 2008Project wrap-upProject follow-upPresentations/publication executive summariesProposal to expand project throughout BCDESCRIPTION OF PROJECT352RESEARCH COMPONENT: PRELIMINARY FINDINGS5Research Component1. 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 families2. An Interdisciplinary Study of the Trajectories of At-Risk Infants and Children or “NICU”study:2.1. At-risk children who were admitted to Level II/II NICU’s in BC continue to require additional medical attention over time, when compared to non-risk children (not admitted to NICU LevelII/III)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 childrenDeliverables Component1. Information about resources and tools for parents and service providers in the Lower Mainland, and,2. Training and dissemination of informationPoster template: Angela Jaramillo, The CHILD ProjectPoster design: Lara El Khatib and Mari Pighini, SDPP, HELPIn consultation with Ellen Larcombe, GIS, HELP