Clustering of Risk Factors among Postpartum Families in Ontario

1. Clustering of Risk Factors among Postpartum Families in Ontario Canadian Public Health Association May 28,2014 | Toronto, ON Anne Philipneri, MPH, PhD(c) Helen Cerigo, MSc Adrienne Alayli, MSc, PhD Eunice Chong, MPH Lori Webel-Edgar, RN, MN, CCHN(C) Natalie Bocking, MD Sarah Muir, MPH Heather Manson, MD, FRCPC, MHSc

2. Background • Early life experiences set the stage for lifelong health and wellbeing • Early childhood development begins before conception and can impact development of chronic diseases, neurodevelopment, school performance, and behaviors • In Ontario, there is currently a lack of comprehensive knowledge regarding the clustering of risk in postpartum population

3. To examine the clustering of risk factors in postpartum families in Ontario Objective

4. Methods: Data Healthy Babies Healthy Children • Foundational program by the Ministry of Children and Youth Services (MCYS) introduced in 1998. Recent enhancements introduced in 2013 • Designed to help children in Ontario have a healthy start in life and reach their full potential • Implemented in all 36 public health units • Universal screening (HBHC Screen) with targeted services for vulnerable families • In 2013/14, at the request of MCYS, PHO accessed HBHC-IRSS to undertake a process implementation evaluation of the renewed HBHC program • Cluster analysis was completed as an add-on to the HBHC evaluation

5. Methods: Sample • Screened HBHC postpartum population in Ontario • Families with infants from birth to 6 weeks of age • Recruited in the first six months of implementation of the enhanced program • Feb 2013-Oct 2013 (staggered implementation) • Screen data entered by staff into HBHC-ISCIS; extracted from HBHC-IRSS database by PHO HBHC evaluation epidemiologist • Exclusion criteria: • Families with infants over 6 weeks of age • Non-HBHC clients • Families with missing HBHC Screen data who did not receive HBHC services • Final sample included 56,903 infants • Provides a good perspective of Ontario’s postpartum population because this represents over 80% of provincial births

6. Methods: Indicators • HBHC Screen has 36 items: • Pregnancy and birth • (i.e., birth-weight, multiple births, premature, Apgar score, labor and delivery complications) • Socio-demographics (family) • (i.e., age, educational attainment, access to OHIP, concerns about money) • Infant/child • (i.e., congenital or acquired health challenge ) • Risk behaviours during pregnancy • (i.e., smoking, alcohol use, drug use) • Parenting and parenting-related • (i.e.,parenting concerns, history of depression/anxiety/mental illness in parent(s)) • Other infant/child development risk factors

7. Methods: Analysis • Tetrachoric correlations were used to create a matrix of association among screen questions • Exploratory cluster analysis was used to identify risk profile • Agglomerative hierarchical clustering • Visual representation using dendrogram • Average distance was used to determine clusters • All analyses were preformed using SAS 9.3 • Ethics approval was obtained from Public Health Ontario’s Ethics Review Board (ERB)

8. Results Figure 1: Top Ranked HBHC Screen Risk Factors among Postpartum Clients (n=56,873) Note: Only infants with a response to at least one screen question were included in the analysis

9. Results • 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 Average Distance Between Clusters

10. Results: Cluster #1 Cluster #1: Pregnancy, labour, and delivery • 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 Average Distance Between Clusters

11. Results: Cluster #2 Cluster #2: Socio-demographic, Behavioural, and Parenting risk factors • 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 Average Distance Between Clusters

12. Results: Cluster #2 Closely Related Pair of Risk factors • 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 Average Distance Between Clusters

13. Results: Cluster #2 Smoking, Drug Use, and Previous Involvement with Child Protection Services • 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 Average Distance Between Clusters

14. Results: Cluster #2 Teen Mothers • 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 Average Distance Between Clusters

15. Results: Cluster #2 Single Parents • 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 Average Distance Between Clusters

16. Results • 69% of the population belonged to one of the three clusters; the remaining 31% had no risk factor identified (screen score = 0) • Similar percentages were identified in pregnancy, labor, and delivery cluster (42%) and socio-demographic, behavioural, and parenting cluster (41%) • Approximately 1 in 5 infants (19%) belonged to both cluster#1 and cluster #2 31% (no identified cluster) Cluster #1: Pregnancy, labour, and delivery Cluster #2: Socio-demographic, behavioural and parenting 14% 17% 18% 5% 5% 5% 5% Cluster #3: Experienced previous loss of pregnancy or child

17. Limitations • The dataset is not complete for all postpartum families in Ontario • Those who did not consent for screening, were missed by the program, or participated in the Aboriginal HBHC were not included • Not all risk factors for child health development were examined (e.g., physical environment of the home, nutrition) • Risk factor information was self-reported by families to staff performing screening • Not all 36 questions were answered on the HBHC Screen • Sensitive questions had higher rate of non-response • This will likely contribute to the underestimation of these risk factors to the clusters

18. Conclusion • Based on 36 medical, socioeconomic, and parenting risk factors three clusters were identified • There appears to be a separate cluster of postpartum clients with pregnancy and labour/delivery related risk factors • Burden of socio-demographic, behavioural, and parenting risk factors appear to be similar to that of pregnancy and labour/delivery related risk factors • Risk factors in the postpartum population are linked and these will likely impact program planning and delivery for this population

19. Questions, comments and/or feedback?