Characterizing fall risk factors in Belgian older adults through machine learning: a data-driven approach | BMC Public Health

Characterizing fall risk factors in Belgian older adults through machine learning: a data-driven approach | BMC Public Health
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  • Public Schools Are NYC’s Main Youth Mental Health System. Where Kids Land Often Depends on What Their Parents Can Pay.

    Public Schools Are NYC’s Main Youth Mental Health System. Where Kids Land Often Depends on What Their Parents Can Pay.

    This article was produced for ProPublica’s Local Reporting Network in partnership with THE CITY. Sign up for ProPublica’s Dispatches to get stories like this one as soon as they are published.


    On Staten Island, a middle schooler with a hair-trigger temper was in a fistfight every week. In north Brooklyn, a ninth grader cut class for months before he tried to commit suicide. A few miles east, where Brooklyn meets the marshlands of Jamaica Bay, a 13-year-old ended up in a psychiatric emergency room after the COVID-19 pandemic shut down her school.

    These kids all had two things in common: First, they were part of a growing cohort of students with serious mental health and behavioral problems that got in the way of their education. And second, they lived in New York City, which meant that their problems became, at least in part, the responsibility of the city’s school system.

    Under federal law, school districts are required to provide all students, including those with mental health and behavioral problems, a “free and appropriate education.” In theory, this means that when a student is struggling to learn, districts must conduct assessments, create individualized plans and, if a child’s needs can’t be met in public schools, pay tuition for a private school — all at no cost to kids or their families.

    In practice, however, what happens to students in New York City’s special education system often depends on the personal resources a family brings to the table. At each step of the way — identifying a disability, creating a service plan, deciding where a child will learn and who will pay for it — a family’s ability to spend its own money can secure a completely different outcome from the city’s public education system.

    In the city’s wealthiest neighborhoods, thousands of parents tap their personal funds to send children to private schools for students with disabilities and then sue the city Department of Education to reimburse them for tuition or other services. The schools these kids attend often charge well over $100,000 a year. Many offer the trappings of elite boarding schools, with bucolic settings and promises of advanced college prep. At some, students ride horses as part of their therapy.

    The city doesn’t publish specific demographic data about students whose expenses are paid this way — commonly known as “Carter cases” after a 1993 U.S. Supreme Court decision, Florence County School District Four v. Carter, that affirmed schools had a duty to reimburse tuition in certain situations. However, Carter cases are not evenly distributed across New York City, which divides its massive school system into 32 geographical regions sometimes referred to as community school districts. Last school year, more than half of settlement agreements involved students who live in just four of the richest and whitest districts, which include neighborhoods such as Manhattan’s Upper East Side and Park Slope in Brooklyn. The poorest community school districts rarely see Carter case settlement money at all.

    Meanwhile, more than 2,600 other kids — most of them Black or Latino and nearly all low-income — are labeled as having an “emotional disability” and shunted into city-run special-education schools, many of which fail across just about every measurable metric: At the schools where the city Department of Education most often places emotionally disabled kids, attendance rates are among the lowest in the city and dropout rates among the highest. By the end of high school, public school students with emotional disability classifications are far more likely to have quit school than to have graduated with a diploma, according to data provided by the New York City Independent Budget Office. Hundreds end up in juvenile justice facilities or on Rikers Island.

    The inequities are not new. Critics have long argued that money for private tuition reimbursements should instead be invested in improving services for kids with disabilities in public schools. But the costs of Carter cases to taxpayers have grown exponentially in the past decade, with payouts reaching $918 million last year. And while the cases have historically been driven by kids with autism or learning disorders, something has shifted in recent years: Attorneys who represent students say there is an influx of young people who need private schooling because of mental health conditions. “I’m seeing more and more kids whose anxiety has gotten more severe since COVID, or who are really behind in social skills,” said Lauren Goldberg, a partner at The AGS Firm, which represents students in education law cases.

    School closures and other pandemic stressors have contributed to the crisis, Goldberg and other attorneys say. But even before the coronavirus arrived in New York, schools were feeling the impact of shutdowns of another kind: As THE CITY and ProPublica have reported, New York state made a deliberate choice over the past decade to eliminate hundreds of beds for children and adolescents in psychiatric hospitals and residential programs while failing to follow through on promises to dramatically expand community-based mental health care.

    When kids can’t find mental health services in their communities, the onus falls on school systems, which don’t have the option to turn students away. “As soon as the residential programs closed, those kids came to us,” said one social worker at a New York City special education high school that serves hundreds of students with emotional disability classifications. “The entire state of New York has shifted the burden of mental health to the school districts.”

    In a written statement to THE CITY and ProPublica, Nicole Brownstein, a spokesperson for the city Department of Education, said her agency is working to expand access to high-quality programs that allow students with disabilities to succeed in all schools. The city has invested in software that will improve assessments and service plans, has expanded programs for students with sensory and mental health needs, has conducted trainings on implicit bias, and is creating a strategic plan to support students with emotional disabilities, Brownstein said. “We continue to work towards dismantling inequities in the special education process.”

    ProPublica and THE CITY have documented the stories of three New York City kids, each of whom had a very different experience navigating the school system when they had a mental health crisis. We spoke extensively to each child’s mother, though not to the kids themselves; reviewed medical and educational documents; and interviewed dozens of mental health and education professionals who work with these and other students with disabilities. We also asked the city Department of Education to comment on the experiences of the two students who struggled to get the help they needed; Brownstein offered a brief statement on one. We allowed parents to decide whether and how we could identify their children. Read their stories below.

    Holly Stapleton for ProPublica

    1. A Child and a Crisis

    Gary

    Gary’s mom was sure that, if she didn’t do something drastic, her son would wind up arrested or dead.

    Things had been scary for a long time. Gary was a ninth grader at a prestigious and competitive public school in Brooklyn, but he skipped class more often than he went. At the beginning of the school year, in the fall of 2018, he’d attempted suicide at least once — maybe twice, his parents still weren’t sure — and spent a week in a hospital psychiatric unit, said his mom, who asked us to identify Gary by his middle name to protect his privacy.

    Still, it wasn’t until Gary left his Instagram account open that his mom’s worst fears were confirmed. She saw messages, going back for months, about using and selling hard drugs. “My stomach dropped,” she said. “We have serious addiction in the family. My sister drank herself to death.”

    Months earlier, a counselor had suggested that Gary go to a residential program for kids with acute mental health conditions, but his parents had dismissed the idea. They didn’t want to send their child away from home, and anyway, they knew that a good program could cost thousands of dollars a week — not the kind of money they had sitting around.

    Now, “full-on desperation set in,” said Gary’s mom. She mined her network, contacting other parents of struggling teens, talking to friends of friends who were mental health professionals. She turned to her own mom and her husband’s parents for help with money — a lot of it.

    Within a week, she and her husband had a plan: They hired what’s known as a “youth transportation service” — two burly guys who came to Gary’s home in the middle of the night and escorted him by plane to Utah, where, at a cost of $60,000, he spent four months at a wilderness therapy program, getting sober and doing intensive individual and group therapy.

    Sending her son away was one of the hardest things Gary’s mom had ever done, she said. But there was more bad news: At the end of wilderness therapy, Gary’s counselors said he still wasn’t ready to come home. His mom would need to find an even longer-term program — one that could keep him safe and continue to provide treatment while letting him move forward with high school.

    “They told me, ‘You can’t bring this kid home. He’ll relapse right away,’” Gary’s mom said.

     

    Taylor

    Taylor Cardin had just turned 13 when the COVID-19 pandemic shut down schools across New York City, including the school she’d attended for years in Queens. Taylor is autistic, and when her routines disappeared, she panicked, said her mom, Tiffany Caldwell.

    Taylor stopped sleeping at night and refused to go outside during the day. She’d always been a gentle, affectionate kid, but now little things infuriated her. As the months at home dragged on, she grew aggressive with her mom, hitting and scratching Caldwell when she got upset. When her school finally opened back up in person, she refused to get off the bus, crying and lashing out at anyone who tried to help her.

    Taylor’s doctor recommended that Caldwell take her to a psychiatrist for an evaluation. Caldwell had always thought that she had good health insurance. She’d worked for nearly 20 years for New York state’s Office of Mental Health as an aide in a psychiatric hospital for adults. But when she called the list of psychiatrists in her insurance network, she found that not a single one was available to see Taylor. “They didn’t answer, or they weren’t taking new patients, or, if they were, the first appointment was sometime next year,” Caldwell said.

    Desperate, Caldwell paid out of pocket — “money I didn’t have,” she said — for a session via Zoom with an out-of-network psychiatrist, who diagnosed Taylor with depression and anxiety and prescribed her a cocktail of medications that seemed to Caldwell to make everything worse. Taylor picked up new behaviors, like slamming doors and the toilet seat over and over again. “She had this look in her eyes like she was on another planet,” Caldwell said. Taylor’s violent episodes got so bad that Caldwell had to call the police to restrain her and take her to a psychiatric emergency room. Each time, hospital staff sedated her and sent her home. “They didn’t have any beds,” Caldwell said. “Once, I begged them to keep her overnight. They told me, ‘If you’re not here in the morning, we’ll call child services.’ It was like a punitive thing. There’s such a lack of regard and empathy and respect.” 

    By the end of 2020, Taylor had been out of school for nine months. She was talking less and refusing to do basic things, like shower and get dressed. Caldwell, who raises Taylor on her own, had used up her family medical leave and was on the verge of losing both her job and her apartment. The thought of separating from her daughter broke her heart, Caldwell said, but she realized that Taylor needed a residential school: “I was just watching my child regress every day.”

     

    Davon

    For Davon, the problems started in elementary school. He was skinny and shy, and kids picked on him, said his mom, Latoya Patterson, who asked us not to use Davon’s last name to protect his privacy. Patterson asked school officials for help, but Davon was quiet and didn’t cause problems, she said, so the school ignored him until fifth grade, when he started to fight back.

    “He got sick of the bullying,” Patterson said. “If someone did something to him, he was reactive right away.” By middle school, Patterson was getting calls at least once a week to say that Davon had been in another fight.

    Holly Stapleton for ProPublica

    In sixth grade, Davon was classified as having an emotional disturbance, a term that was formally changed in New York this year to “emotional disability.” An emotional disability classification is not a medical diagnosis. Rather, it’s a catch-all term used by education departments for any number of mental health or behavioral challenges that show up in school. An emotionally disturbed student could be a first grader who hits other kids or a 10th grader who has psychotic episodes, or who’s too persistently sad to concentrate. Critics argue that the classification is far too vague and subjective. Under federal and state regulations, for example, students can be classified as emotionally disabled for such criteria as exhibiting “inappropriate types of behavior or feelings under normal circumstances.” 

    In New York City, Black boys get classified with emotional disabilities at a far higher rate than other kids. In the 2020-2021 school year, the most recent for which data is available, Black students made up less than a quarter of students overall, yet they accounted for nearly half of students classified as having an  emotional disability. White students, who made up 15{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of all students in New York City public schools, accounted for just 8{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of emotional disability classifications.

    That’s in part because evaluators may be more likely to interpret Black boys’ behavior as aggressive, advocates and attorneys say. But it’s also because white families more often come to the assessment process armed with detailed private evaluations and attorneys who advise them to push for a classification that carries less potential stigma, such as “other health impairment” or “multiple disabilities.” 

    “You want to get the right classification,” said Goldberg, the education attorney. “Colleges are going to see this. Middle and high schools are going to see this. You’re thinking about your kid’s future.”

    Patterson, who’s Black, raises Davon by herself and works as a construction laborer. She didn’t know that some parents hire lawyers and paid educational advocates to represent them at special education meetings. Certainly, nobody suggested that she get Davon a private neurological or psychiatric evaluation. Instead, she participated in planning meetings, filled out paperwork and, for the most part, took Department of Education staff at their word when they said they wanted to help her son. 

    It was a belief that she came to regret.

    2. ‘Please! We’re Drowning! Help Us!’

    ‘Please! We’re drowning! Help us!’

    Gary

    By the time Gary finished wilderness therapy, his mom had spoken to plenty of parents who’d sent their kids to private schools and then sued the city to be reimbursed for the cost. She knew that success depended on hiring the right people.

    The frequency with which families pursue these Carter cases has given rise, in New York City, to an elaborate ecosystem of high-priced professional advisers and advocates. Parents frequently start by paying $5,000 to an educational consultant, whose job it is to broker admission to a private school. Sought-after schools often maintain relationships with particular attorneys, who might charge a family anywhere from $5,000 to $10,000 per year to pursue tuition reimbursement. In turn, attorneys may point parents to trusted psychologists, who — for another $5,000 or more — conduct detailed assessments and write reports that might support the claim that a child can’t be served in public school. That’s all in addition to the price of tuition, which, even if a family wins its case, may not be reimbursed for months or years.

    Not everyone who pursues Carter cases has hundreds of thousands of dollars on hand. It’s not uncommon for parents to refinance their homes or pull cash from retirement plans to pay the deposit on a residential school that a family hopes will rescue their suicidal or addicted child. And there’s no shortage of GoFundMe pages set up by families begging for help with the final $10,000 or $15,000. There are also some attorneys in New York who specialize in taking on severely disabled kids without charging a retainer, and there are private schools that reserve spots for kids whose families can’t pay tuition upfront.

    Nonetheless, the typical buy-in costs are high enough to rule out the vast majority of New York City families. “There’s a huge industry around teenage mental health, but it’s only for a particular demographic of our society,” said Gary’s mom, who is white and describes her family as middle-class. “It’s so clearly unjust. At the same time, when your child is attempting suicide, you can’t really get picky about diversity at the institutions you’re sending them to because you need to save your kid’s life.”

    Gary’s mom had heard enough horror stories about abusive residential programs to know that she wanted professional advice on which one to choose. Based on recommendations from a friend, she hired an educational consultant who found a therapeutic boarding school in Arizona and then managed Gary’s application. “She had the relationships; she knew what to say,” Gary’s mom said.

    With her in-laws’ help, Gary’s mom was able to cover tuition: a $25,000 deposit and then $11,000 per month. The next step was to try to get that money back from the public school system.

    ‘Please! We’re drowning! Help us!’

    Taylor

    Because Taylor was diagnosed with autism when she was little, Caldwell had years of experience navigating New York City’s special education system. She knew that most decisions go through a dedicated committee in a student’s local area, which is charged with approving individualized education programs and deciding which services kids should receive. To Caldwell, those decisions often seemed arbitrary. She’d wondered why some kids seemed to get more services than others, and whether Taylor might be getting less help because she’s Black.

    After schools closed down in 2020, Caldwell reached out to her local committee, but months went by with no help. “I kept reporting, reporting, reporting: ‘This child is in crisis and it’s getting worse,’” she said. “It all fell on deaf ears.” Some of Taylor’s instructors tried to continue working with her virtually, but Taylor couldn’t engage via the computer screen, so she ended up receiving nothing — no classes, no speech therapy, no contact with anyone except her mom. “It’s like we’re floating around with an inner tube, and I’m yelling, ‘Please! We’re drowning! Help us!’” Caldwell said. 

    There was no way that Caldwell could pay upfront for Taylor to go to a private boarding school — she’d never even heard of anyone who did that. Her only option was to convince the Department of Education to approve Taylor for placement at a residential school and get the agency to pay the tuition directly.

    The New York State Education Department holds contracts with approximately 200 private schools — typically shorthanded as “state-approved” schools — that serve kids from across New York who have disabilities that affect their education, such as intellectual delays, autism or emotional disabilities. While these state-approved schools are free for families, they vary enormously in quality, according to advocates and education attorneys. Some schools have excellent reputations and get far more applicants than they can take; others have been the subject of multiple complaints and lawsuits alleging mistreatment of kids. Little information is available publicly about each school, so parents who don’t have paid consultants or deep networks may have nothing to go on but online reviews.

    State-approved schools are also deeply segregated by race. For example, at the Queens campuses of The Summit School, which attorneys describe as being highly sought after, 70{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of students were white, while just 22{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} were Black or Hispanic during the 2021-2022 school year, according to state data. Just a couple of miles away, at the Theresa Paplin School, which is run by a large foster care and mental health services agency, 83{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of students were Black or Hispanic, while just 13{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} were white.

    Holly Stapleton for ProPublica

    Getting placed at any of these schools can be a long and circuitous process, involving multiple meetings, referrals and interviews. And even then, there’s no guarantee that an appropriate school will have space. Kids sometimes wait months for a bed to open up at a therapeutic residential school on the state-approved list. In the worst cases, they cycle in and out of emergency rooms, sit in psychiatric hospitals or land in the juvenile justice system while they wait.

    On her own, Caldwell couldn’t even get to the first step: scheduling a meeting to review Taylor’s special education plan. By the time Taylor had been out of school for close to a year, Caldwell’s own health was suffering, and she was exhausted and furious. “Children with disabilities are disregarded and pushed to the side,” she said. “They’re treated like second-class citizens.” 

    In January 2021, Caldwell found an education attorney who was willing to take Taylor’s case against the Department of Education without charging an upfront fee. “You have to fight for everything,” she said, “because they’re not going to willingly give it to you.” 

    ‘Please! We’re drowning! Help us!’

    Davon

    While many parents battle to get their kids approved for private placement, Patterson found that Davon’s school was all too happy to recommend that Davon go elsewhere. 

    That’s not unusual for kids who are seen as aggressive, education experts say. Once a student has been classified with a disability, federal law requires school districts to educate them in the least restrictive possible setting, integrated with their nondisabled peers. In reality, teachers often don’t have the training to deal with kids who have repeated behavioral problems, said Kristen GoldMansour, a former teacher who works as a consultant in dozens of New York City schools. 

    The result is that struggling kids get punished for behaviors that are beyond their control, GoldMansour said. “If a kid is coming in to us completely traumatized and we just keep saying, ‘Sit down, pay attention, calm down,’ we’re not helping.”

    Over time, the pressure can build up to drive difficult students out of general education schools, even if that child is academically and cognitively capable of doing grade-level work. A Brooklyn-based social worker who conducts special education evaluations, and who asked to remain anonymous for fear of repercussions at work, described the process like this: “My supervisor would be saying, ‘Let’s try a smaller class. Let’s try a paraprofessional.’ But the principal wants that kid out of the school immediately. It’s a touchy thing.”

    At first, the special education committee that reviewed Davon’s case suggested that he transfer to a special day program for kids with mental health challenges, but the waitlist was months long, so the Department of Education changed his recommendation to a state-approved residential school. To Patterson, it sounded like Davon would be placed in a specialized boarding school, with all the mental health services that she couldn’t find for him at home. “They’re saying he’ll get therapy,” she recounted. “He’ll get a lot of different programs that will help him. I’m thinking this will be great.”

    It was only after Davon got to the residential school — a campus in Westchester operated by the social service agency Graham Windham — that Patterson learned that many of the students had been placed there by a judge and seemed to have far more serious behavioral and psychological problems than Davon. Sending him there “was the worst decision I ever made,” she said.

    Davon had been slightly behind his grade level when he left home; now he fell way back. Patterson said he never got the therapy he was promised because — like many mental health providers that rely on public funding — the school couldn’t keep counselors on staff. “It was like a revolving door,” Patterson said. “If he got two months of consistent therapy, I’d be surprised.” She asked the special education committee if she could bring Davon home, but was told that since he’d left the system with a record of behavior problems, a community school would be unlikely to take him back.

    Graham Windham did not respond to requests for comment.

    Davon started sneaking off campus with other kids and getting into increasingly serious trouble. He was arrested for being a passenger in a stolen car, and then again at the scene of a robbery, Patterson said. After he violated the curfew in his probation agreement, a judge sent him to a juvenile justice group home in Brooklyn, where he spent nine months.

    To Patterson, the irony was excruciating. She had agreed to send Davon to the residential school in part because she was afraid that at home he’d end up in trouble with the police. Now she believed that the school system had put him on a direct path to the criminal justice system.

    It’s a common trajectory for young people with emotional disabilities, who make up close to half the students enrolled at schools in New York City’s juvenile detention centers and in the Rikers Island jail, according to data from the Independent Budget Office. “There’s a school-to-prison pipeline for these kids,” said Dawn Yuster, an attorney who directs the School Justice Project at the community group Advocates for Children.

    3. An Education in Treatment

    An Education in Treatment

    Gary

    Gary’s therapeutic boarding school was exactly what his mom had hoped. It was small and family-run. Most of the staff had many years of experience; several were in recovery themselves. Gary got individual therapy multiple times a week, as well as evidence-based addiction treatment and full weekends of intensive family therapy. He and the other residents spent hours every day outside, taking care of horses and riding them through the desert. For years before Gary went to the program, “our house was so sad and tense,” his mom said. Now, “he was free. It was the coolest thing ever, to see your kid be a cowboy.”

    From the start, Gary’s attorney was optimistic about the family’s prospects of getting a tuition reimbursement. “They won’t tell you that you’ll definitely win. They were like, ‘You have a good case,’” Gary’s mom said. “The suicide attempts help; making it a life-or-death situation helps.” 

    From a historical perspective, there was good reason to be hopeful. Back in the early 2000s, then-New York City Mayor Michael Bloomberg staffed up on lawyers to make it harder for parents to force the city to pay for private schools and services. In 2014, his successor, Bill de Blasio, changed tack, promising to make the settlement process easier and faster for families. The number of New York City students receiving Carter case settlements shot up, growing from less than 5,300 in 2015 to more than 17,700 in 2022, according to data provided by the Independent Budget Office. The city Department of Education declined to say what percentage of Carter case filings are successful or how many are settled without going to a hearing. But education attorneys say that they win reimbursement cases far more often than they lose.

    It’s unclear whether the current administration under Mayor Eric Adams will try to bring the Carter case numbers down. At an advisory meeting over the summer, New York City’s schools chancellor, David Banks, infuriated some advocates by saying that private school parents had figured out how to game this system,” siphoning funds at a time when public schools are contending with massive budget cuts. At a later City Council hearing, Department of Education staffers attempted to walk that accusation back, pinning the blame instead on attorneys and consultants who’ve turned filing Carter cases into a business model. In response, parents and City Council members argued that families wouldn’t need to resort to private schools if the city weren’t so abjectly failing students with disabilities.

    Holly Stapleton for ProPublica

    In the end, Gary’s case didn’t even go to a hearing. The city agreed to settle, reimbursing his family for $100,000 of the more than $140,000 they had paid in tuition at the therapeutic boarding school.

    Gary came home in 2021, after 13 months at the private school, and enrolled in 11th grade at a public alternative school. He still gets hit by intense bouts of depression, his mom said. “It’s a hard road, and it probably always will be.” But he has strategies for dealing with his illness now — a fact that his mom credits almost entirely to the excellence of the treatment he received. “He came away with a lot of coping skills, a lot of integrity and a very clear understanding of who he is,” she said. “That’s a testament to the quality of the program, one hundred percent.”

    “That place saved his life,” she continued. “The horses, the other boys, the therapists — they saved his life.”

    An Education in Treatment

    Taylor

    About the time that Gary was flying home from Arizona, Taylor’s case began to crawl its way through the New York City special education system.

    On the advice of her attorney, Caldwell made a formal request that the Department of Education reevaluate Taylor and write her a new education plan. “Taylor has regressed significantly,” she wrote in a January 2021 email. “I have been voicing my concern with the team for months.”

    In response, the special education committee had Caldwell fill out forms and conducted a brief social-psychological assessment by video. But more months passed, and nothing changed: There was no meeting, no plan, no new services.

    In April 2021, Taylor’s attorney filed a due process complaint with the Department of Education, charging that the city had failed to provide Taylor with a free and appropriate education. By law, that should have triggered what’s called an “impartial hearing” within 30 days, but the hearing system is notoriously backlogged, and Taylor and Caldwell waited four months. (This year, the city moved impartial hearings to a new administrative office and hired 40 new hearing officers, which has reduced the standing backlog of unassigned cases from thousands to hundreds, wrote Brownstein, the city Department of Education spokesperson.)

    When Taylor’s hearing finally took place, the hearing officer ruled in her favor on all counts. The Department of Education must not only consider approving her for placement in a residential school, the officer wrote, but must also immediately start providing the services she should have been receiving all along, including tutoring, counseling, and speech and occupational therapy.

    Even then, every step was a battle, Caldwell said. The Department of Education refused to provide in-home instruction; a request for an iPad to help Taylor communicate dragged on for months. Meanwhile, the question of Taylor’s residential school placement inched forward while Taylor sat at home. Two months after the hearing officer’s order, the Department of Education sent an application packet on Taylor’s behalf to multiple schools on the state-approved list. Six of those schools rejected her outright, probably because of her history of aggressive behavior, the attorney told Caldwell. One school — The School at Springbrook in Oneonta, New York — offered Taylor a spot, but they were full and couldn’t say how long it might take for a bed to become available. 

    In January, the Department of Education offered Caldwell a new option: She could send Taylor to a residential school in Pennsylvania, which had vacancies and would accept her right away. At first Caldwell was thrilled, but then she looked up online reviews for the facility and found dozens of stories referencing abuse and neglect. One reviewer alleged that her daughter had been raped by a staff member; others said their kids came home with bruises. Caldwell turned the placement down.

    A space finally opened up for Taylor at The School at Springbrook in April, after she’d been at home for more than two years. Taylor’s thriving at the school, which uses evidence-based therapies designed for people with autism and emotional disabilities, Caldwell said. She’s going on field trips, getting along with other kids and regaining some of the skills she lost. Caldwell plans to move upstate, closer to the school, because she wants Taylor to stay.

    But it still hurts her to think about the time that Taylor lost, Caldwell said. “She’ll never get those two years back.”

    “I’m not going to let anyone dehumanize my daughter,” she continued. “She’s going to get the same quality education as if she didn’t have a disability. She should have the same rights as her peers. She’s human. She matters.”

    An Education in Treatment

    Davon

    Ironically, the juvenile justice group home was better for Davon’s education than the residential school. He caught up on credits and did well in his classes, according to teachers who described him in written reports as a “polite student” who helped his peers with their work. By the time he left, he’d decided that he wanted to go to college and become a lawyer.

    Still, when it was time to come home, rather than allowing Davon to attend a general education school, the Department of Education placed him at South Richmond High School — a special education school on the south shore of Staten Island. Like all such schools in New York City, South Richmond is run by an administrative entity called District 75.

    Advocates have long argued that the city places far too many students in District 75 schools, where they receive a vastly inferior education with fewer resources and little hope of graduation. More than a decade ago, a city-commissioned report found that District 75 students were more isolated than students with disabilities in any other major urban school district. “District 75’s expectations for the students that it serves need to be elevated. Its programs and supports need to be improved,” the report said.

    The Department of Education told THE CITY and ProPublica that it is working to ensure that students can receive the social and emotional support they need in all school districts. “We cannot live in a system,” Brownstein wrote, where “students receiving District 75 special education services are separated physically, academically and socially from their peers.”

    Still, students with emotional disability classifications are placed in special education schools at an extraordinarily high rate: In the 2020-21 school year, over 33{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of students with emotional disability classifications were in District 75, according to data provided by the Independent Budget Office. And within the district, those students were heavily concentrated into just a handful of schools. At several, students with emotional disability classifications made up close to half the student body.

    Concentrating kids with emotional and behavioral problems into one school is a setup for failure, say parents, advocates and staff who work at the schools. “These schools tend to be … I don’t want to say ‘dumping grounds,’” said another social worker who has spent years working in District 75 high schools with very high concentrations of students with emotional disability classifications, and who did not have permission to speak on the record. Students come in throughout the year, often directly from juvenile justice facilities or residential foster care programs. One dysregulated student can easily set off others, leading to fights and chaos that make it impossible for other students to learn, the social worker said. “They’re in fight-or-flight all of the time.”

    While most people who work in the schools are doing their best to make positive connections with students, the social worker continued, “We also have a number of staff who couldn’t get jobs in any other school.”

    At South Richmond, where Davon was referred, nearly 60{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of the school’s students were classified as having an emotional disability in the 2020-21 school year, compared to less than 1{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of New York City public school students overall, the Independent Budget Office data shows. (The remaining South Richmond students have other educational disabilities, such as cognitive delays.) Like other schools where the city concentrates students with emotional disability classifications, South Richmond has exceptionally high rates of chronic absenteeism — 60{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of students missed 20 days or more in the 2019-20 school year — and a dropout rate that is nearly five times as high as that of high school students citywide. Every year, it is on a short list of the schools that most frequently call in police officers to respond to students in emotional crisis, according to an analysis by Advocates for Children.

    After a Daily News article highlighting problems with District 75 was published in July, New York City Mayor Eric Adams promised to improve conditions for kids with emotional disability classifications. Like several other District 75 schools, South Richmond has an on-site partnership with a mental health care agency, Brownstein wrote. This school year, the Department of Education is expanding after-school and Saturday programs for students with intensive sensory needs that affect their learning and behavior. 

    The city is also building on a pilot project that began in 2021, which places kindergarteners with emotional disability classifications in classrooms that are intentionally integrated with nondisabled peers. The program is now running in three classrooms, each of which has two teachers, a dedicated counselor and an occupational therapist to support students. An additional three classrooms are slated to open in January in community school districts with high numbers of referrals to District 75 schools. 

    “These are students who may have been on a trajectory to District 75,” Christina Foti, the city’s special education chief, told THE CITY and ProPublica. “We are rerouting them.”

    To Patterson, any changes are too little and too late. Placing Davon at South Richmond was evidence that the school system had long since given up on her son, she said. “He felt like the classes were boring. The work was too easy. I think they just didn’t expect him to graduate.” Outside of class, Patterson continued, “the school was chaotic. They have a lot of fights. They can’t control the kids. Why are you putting a bunch of kids that get into trouble in the same place? It doesn’t make sense.”

    Nearly as soon as he started at the school, Davon felt that he was being targeted by an assistant principal and school safety officers who knew that he had a history of being arrested. Things came to a head in May, when, according to Patterson, Davon refused to allow a school safety agent to search his bag. The school called the police, and Davon was handcuffed and eventually taken to a precinct. School officials told Patterson that Davon had marijuana in the bag and that he’d head-butted a safety agent. Davon said that the agent knocked him down when he was already in handcuffs. The Staten Island district attorney’s office declined to pursue a case against Davon, Patterson said, but he was briefly assigned an attorney, who advised Patterson to get in touch with Yuster from Advocates for Children.

    The Department of Education said Davon was passing classes and earning credits at South Richmond High School. “He was offered the opportunity to participate in summer school programming for additional credit accumulation, which his family declined,” Brownstein wrote.

    After months of letters, phone calls and meetings, Yuster helped Davon get a new education plan, which allows him to attend a general education school this year for the first time since seventh grade. “That’s what I wanted, to get him out of District 75,” Patterson said. 

    But it’s hard to have faith, Patterson continued, in a school system that seemed ready to throw her child away when he was in middle school. “My son is really smart,” she said. “But it feels like he’s never going to have a fair shot.”

    THE CITY will be hosting an event related to this story virtually and in person early next year. Sign up for THE CITY’s daily newsletter The Scoop, which will include more event details when they are available.

    Associations between children’s physical literacy and well-being: is physical activity a mediator? | BMC Public Health

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  • Physical activity and healthcare utilization in France: evidence from the European Health Interview Survey (EHIS) 2014 | BMC Public Health

    Characterizing fall risk factors in Belgian older adults through machine learning: a data-driven approach | BMC Public Health

    Recent statistics show that the total cost of healthcare accounted 9.6{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of GDP across all the EU countries, ranging from over 11{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} in France, Germany, and Sweden to the lowest ratio of 5{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} recorded in Romania. Even if health spending grew in the previous years in line with the economy in Europe, a continuous increase of such expenses could implicate a great financial burden not only on health systems, but also on social security programs [1] and, indirectly, on society in form of reduced employment and productivity [2]. Therefore, for all EU countries, irrespective of the type of healthcare system and financing arrangement, managing the increase of health services cost is a medium- and long-term strategic objective [3]. To support this approach, it is a priority to carry out specialized studies on the population health needs, the types and frequency of the demand of health services, the factors that determine the structure and dynamics of healthcare utilization, the profile of people using the healthcare services, etc. It is equally important to assess possible means of reducing healthcare expenditure not only for ensuring access to needed care, but also for strengthening the effectiveness and the resilience of health systems [1]. In this respect, important instruments to be considered, besides cost containment policies [4] and care management strategies [5], are those related to diseases prevention and health promotion [6].

    As a response to the need to prevent and control diseases and to promote a healthier lifestyle, the literature emphasizes the positive influence of physical activity on the health status of the population. It is well known that regular physical activity (1) reduces the risks for non-communicable diseases, mainly cardiovascular diseases, various types of cancer, chronic respiratory diseases and diabetes [7], (2) provides protection against future depression [8], (3) reduces stress reactions and delays the effects of various forms of dementia [9], (4) prevents the obesity, given that it is a key determinant of energy expenditure [7]. Physical activity could be considered not only as a preventive measure but also as an alternative or complementary treatment for various physical or mental health conditions. For instance, some recent studies [10,11,12,13] find consistent evidences supporting that physical activity with moderate intensity is effective in alleviating or even treating the severe symptoms of depression in affected adolescents. Interventions involving physical activity are also an accessible way of reducing the symptoms of severe anxiety or mental illness among adults, including schizophrenia-spectrum disorders, major depressive disorder, and bipolar disorder [14,15,16,17,18]. The effects of physical activity as an additional or stand-alone treatment are sustained in the case of other medical conditions such as: alcohol use disorder [19,20,21,22,23]; functional outcome after stroke [24,25,26,27,28,29,30]; cardiovascular disease [31]; type 2 diabetes [32]; cancer [33]. This double role of physical activity [34] reflects its negative association with demand of health services, which could lead to lower spending on healthcare systems [3, 35,36,37].

    Studies on the relationship between physical activity and healthcare utilization

    Following our critical analysis of the literature on the relationship between physical activity and healthcare utilization, several observations are noteworthy to be mentioned. These remarks concern (1) the population for which the studies were performed, (2) the indicators used as measurements for healthcare utilization, (3) the methods and means of measuring physical activity, and (4) the control variables used in modelling the relationship between physical activity and healthcare utilization.

    Types of population

    The first observation results from the fact that most of the existing literature examines the link between physical activity and healthcare utilization just for certain segments of the population, which could depend on factors as age, gender, a particular disease, etc. A large part of such studies concentrates on older adults [36, 38,39,40,41,42,43,44,45,46], underlining that physical activity is strongly associated with lower usage of healthcare services. According to [38], reduced physical activity, such as walking activity, could be the most promising modifiable predictor of healthcare utilization as measured by the number of drugs and number of physician contacts over 12 months among older adults. The findings of [41, 43] indicate that being physically active might lead to beneficial results and a quicker recovery for hospitalized older adults. Analyzing only the category of older women, Silva [44] concludes that higher volumes of physical activity are significantly associated with lower usage of medications in women who are involved in a physical activity program. In this research direction, there are also strong evidence suggesting that the many benefits of physical activity for older adults extend beyond better health, improved physical function, reduced impairment, independent living, and increased quality of life to include significantly reduced healthcare costs and mortality [42,43,44,45,46,47]. Another range of studies reveals the role of regular physical activity interventions in lowering the usage of health resources and services and saving a substantial amount of healthcare expenditure among people with specific health conditions, such as asthma, cardiovascular disease, obstructive pulmonary disease, arthritis, and diabetes [42, 48,49,50,51,52], or those suffering from obesity problem [42, 50, 53,54,55,56]. However, it is noteworthy that the effects on healthcare utilization and costs are likely to be a result of long-time regular physical activity behaviour rather than a short-term behaviour change [56]. Of these studies, several focus on persons engaged in clinical trials fitness activity or in health program [42, 44, 45]. While their empirical evidences support that engaging in regular physical activity only involves health benefits and therefore reduced use of some health services as hospital admissions or medicine consumption, these studies have a restrictive ability to generalize to a larger population. By contrast, the literature on using representative sample from the general population is relatively limited. In this respect, a relevant, but not exhaustive enumeration of prior studies regarding the relationship between physical activity and healthcare utilization encompasses the analyses of Katzmarzyk et al. [57], Bertoldi et al. [58], Sari [59], Maresova and Vokoun [60], Rocca et al. [2], Fernandez-Navarro [61], and Kang and Xiang [37].

    Healthcare services

    The second observation concerns the dependent variables used in literature. Related to the measurement of healthcare utilization, the literature is not very explicit, but a classification of studies can be outlined. One stream focuses on obtaining an objective measure of different healthcare services through medical records kept by the family doctor, the generalist or specialist physicians [44, 45], while the second stream includes a subjective (self-related) health evaluation based on the respondents data obtained from questionnaires [2, 37,38,39,40, 42, 56, 59,60,61]. Within the second approach, the measures for healthcare utilization concern both service contacts [2, 39, 42, 44, 61] and volume of services [37, 38, 40, 42, 44, 45, 56, 58,59,60]. Usually, the literature presents four categories of healthcare utilization: medicine use, expressed in number of consumed and prescribed medication, inpatient (hospitalization and home health services), outpatient (use of generalist and specialist physicians’ services) and preventive services (dental check-up, flu shot, blood pressure check-up, cholesterol check-up, blood glucose test, immunological test).

    According to literature, most of the studies concern the relationship between physical activity and one or a few healthcare categories. For instance, for the association between physical activity and medicine use there are findings to support both a significant and non-significant relationship. On the one hand, higher levels of physical activity are significantly associated with lower use of medication [27, 38, 44, 58, 61]. On the other hand, an insignificant link between physical activity and the number of medication consumed was found [27, 45]. The latest results could be attributed to the fact that these studies focused only on older adults, suggesting that other factors also should be engaged in discussions related to physical activity. Other findings from literature imply also that if people are more physically active, they will use significantly fewer inpatient services [42, 56, 59, 60] or outpatient services [38, 42, 56, 59, 60]. Having an opposite effect, physical activity appears to be a stronger predictor of all types of preventive services, emphasizing that active people may be more health conscious and thus may use precautionary measures more frequently compared to inactive persons [42]. In contrast to these results, there are studies that failed to find a significant association between physical activity and the number of days spent in hospital [38], the number of home consultations from a medical professional [45] or the number of physician’s visits [45]. In addition, the home healthcare services [45] appear not to be significantly explained by leisure time physical activity. In contrast, only few studies have analyzed the relationship between physical activity and multiple categories of healthcare utilization. For instance, Fisher et al. [39] have used both service contacts (services used versus services not used) and volume of general and specialist physician services, and hospital services, while Kang and Xiang [37] have added 10 measures of preventive services, outpatient visits, home visits, emergencies, and prescribed medicine. Their results are consistent with other studies mentioned above, but they allow to obtain a more in-depth analysis of the association between physical activity and different categories of healthcare utilization.

    Measurements of physical activity

    Another relevant remark is related to the use of different types and measurements of physical activity in relation to healthcare utilization. The physical activity is divided into four main classes, namely leisure time, household, transportation, and work. While a vast body of research focuses only on one dimension of physical activity, especially related to leisure time [2, 39, 40, 59, 61], a more narrow range of studies considers an indicator encompassing more types of physical activities [37, 56, 58, 60]. With respect to the type of physical activity, an important issue is linked to the various methods used to measure the indicator’s levels. In this matter, Dishman et al. [62], Miles [63], Sallis [64], and Sylvia et al. [65] distinguish between objective monitors (pedometers, accelerometers, heart rate monitors, armbands, and direct observations), physiological measures of energy expenditure (doubly labelled water), and self-reports (questionnaires or activity diaries). In addition, the analysis of the literature as a whole stresses the lack of studies measuring the level of physical activity by factors such as age, gender, body weight, or psychiatric and medical co-morbidities [66]. Most empirical studies evaluate and test the differences between physical activity patterns with regard to these type of factors [37, 40, 56, 61, 67,68,69,70,71,72,73,74,75] or explore their impact on the relation between physical activity and healthcare utilization [2, 39, 42, 45, 58, 60, 61, 76], but the authors do not integrate them into the indicator’s measuring level.

    Other determinants of healthcare utilization

    In order to gain better insight into the relationship between physical activity and healthcare utilization, most studies include a set of variables such as demographic and socioeconomic factors, health status or health behaviour. The findings adjusted for these individual characteristics reveal that involvement in physical activity still reduces the use of healthcare utilization through its relationship with chronic diseases, physical and mental health status [38, 42, 44, 56, 61], personal health practices such as smoking and drinking [44, 58], body mass index [38, 44, 58], age [2, 38, 42, 44, 56, 58], gender – with a higher effect for men [2, 38, 42, 58, 61], educational level [2, 44], economic level [2, 58], employment status [39, 60].

    Beyond the use of these factors as control variables in the relationship between physical activity and healthcare utilization, there is an extensive literature on their association with the use of healthcare services [76]. It is well known that people’s health status, including inherited diseases and conditions, requires medical care. More precisely, asthma, chronic conditions, and depression are frequently related to number of physician contacts and number of drugs. In particular, prescription drugs are most strongly associated with diseases such as coronary heart disease, diabetes, hypertension, thyroid problems, osteoporosis, and heart failure [38]. Outpatient health services are more likely to be used by those who have poor to good health status, are experiencing declining health, and have chronic diseases. Meanwhile, hospitalization is more likely among those people with poor health status or having a chronic disease. However, the prevalence of these medical conditions differs by gender, age, occupational status, and other factors. The role of age is essential since, as people age, they become more susceptible to disease and disability, which implies more frequent use of various healthcare services [77]. With regard to gender, there are wide evidence that women, having higher rates of disability and self-reported fair or poor health status than men, generally use more healthcare services than their counterparts [78]. In this respect, Salganicoff et al. [79] and NCHS [80] stress that women are more likely to have primary care visits, hospitalization or emergency visit, and to receive more diagnostic services, screening services, diet and nutrition counseling than men even though men generally have higher rates of obesity and cardiovascular problems. Individual behaviours such as smoking, excessive alcohol consumption, poor diet or obesity also cause conditions that require medical attention [81]. Concerning other socioeconomic determinants of health, the literature emphasizes that higher levels of education, having economic stability, being employed, or having community safety are correlated with better health status [81].

    In summary, the relatively vast body of research on the topic of this study states that interventions aimed at increasing physical activity may result in significant reductions in healthcare utilization. In addition, most of the empirical studies outlines that this potential role of physical activity is better clarify in relation to other individual characteristics. Besides identifying the determinants and assessing their association with healthcare utilization, in the end, the empirical results of such studies must be analyzed in relation to a country’s public and/or private health system and have to serve as support for other countries by sharing successes or even failures and exchanging experiences to provide inspiration for further development, refinement and implementation of effective policies.

    Physical activity in France: facts and policies

    For the French population, the existing literature emphasizes a lack of physical activity and consequent sedentary behaviours, as well as a continuous degradation of these indicators in the last decades [82, 83]. Analyzing data from the ENNS study 2006–2007 and Esteban study 2014–2016, Verdot et al. [83] observe a decrease in the level of physical activity among all adult women (18–74 years old), from 63.2 to 52.7{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} people that are reaching the WHO recommendations on physical activity for health, while an increase is noticeable only for men (18–74 years old), from 63.2 to 70.6{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} [63]. The same study estimates that the prevalence of physical activity account only 50{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} for boys 6–17 years old and 33{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} for girls of the same age group. These percentages have not changed significantly between 2006 and 2016. Moreover, at the level of the EU, France is the country with the second highest prevalence of insufficient activity among school-going adolescents (86.2{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} in 2011 and 87.0{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} in 2016) [82]. For the adolescents between 11 and 14 years old it is recorded a decrease of physical activity prevalence from 38.1 to 33.7{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} for boys and from 23 to 20{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} for girls [83].

    In response to this alarming reality, France was concerned to implement several national physical activity plans that include components for increasing physical activity in different sectors such as health, education, sports, transport, and workplace. In France, the integration of physical activity into public health policy dates back to the 2000s. These policies target a wide range of the population, including the people with disabilities, those suffering from chronic diseases, the elderly, the adolescents, the migrants, and other low socioeconomic groups for which specific physical activity programs are either at low cost or completely free of charge [3]. The French National Nutrition and Health Program (PNNS – Programme National Nutrition Santé), which was launched in 2001, is a public health plan that aims to improve the health status of the population by acting on one of its major determinants: nutrition. For the PNNS, nutrition is understood as the balance between food intake and physical activity. The Health Act 2004–806 also establishes certain objectives for public health policy to reduce sedentary lifestyles and increase physical activity among the French population. Another example is the accession of French specialists and institutions to the European Network for the Promotion of Health-Enhancing Physical Activity (HEPA) in 2006, one year after its launch. It should also be noted that France has taken over in various forms the guidelines formulated by The Toronto Charter for Physical Activity which was adopted in 2010 by the Global Advocacy Council of Physical Activity, International Society for Physical Activity and Health. Last but not least, in France the idea of prescribing physical activity as a treatment according to the patient’s condition, physical ability and medical risk has been formulated several times, and the idea will be implemented through the Health Act of 2016. Another successful action, called “Medicosportsanté”, is taken by the national sports federation who provides guidance on adapting sports programs for participants with chronic diseases or for the elderly. As for promoting physical activity among children and young people, an effective national intervention based on a socio-ecological approach was implemented [3]. This intervention encourages them to engage in physical activities during and outside school hours by receiving social support from parents, teachers and sports instructors. Besides the strategies countering insufficient physical activity, other recent and equally important measures to prevent diseases and promote health at the national level refer to the campaigns on tobacco and alcohol consumption and obesity among young people, raising alcohol and tobacco taxes, assessing programs and reducing work-related risks [84].

    Objective and motivation

    In the EU context, all member states, including France, are involved in different projects and programs in order to promote physical activity and to evaluate its relationship with population health, and health systems. The WHO strategy for physical activity underlines as major future aims the surveillance and evaluation of policy initiatives and also the strengthening of the evidence base for physical activity and health for the EU countries [85]. Such strategy requires strengthening empirical evidence and highlighting the specificity of the relationships between physical activity, healthcare, health status, and other health risk factors in the EU context for different population groups depending on gender, age, profession or geographical area. Thereby, the implementation and the efficiency of public policies promoting physical activity and population health depend to a large extent on the health system of a country, the population structure, and a number of cultural and educational factors that can cause changes and behaviours regarding the individuals’ lifestyle and health [86].

    The existing literature underlines the relevance of the association between physical activity and healthcare utilization. The increase of healthcare costs and the rising pressure on health insurance and health systems determined companies and governments to recommend physical activity as well as as complementary treatment, which in the end impacts the cost of healthcare [87]. To the best of our knowledge, in the case of French population, the research on the association between physical activity and different types of healthcare utilization is still insufficiently developed. In this regard, the outcomes of Gasparini et al. [88] and Lanhers et al. [87] should be outlined, as the authors have related the lower number of medical prescription for chronically ill patients and a lower cost of medication for type 2 diabetes in older adults to high volume of physical activities. But both studies were conducted on small and restrictive samples. Despite the generalization of their findings to the entire population, Nichèle and Yen [89] limit their study to an investigation of the role of physical activity, besides other socioeconomic characteristics and lifestyle, in the link between obesity and mental health for French adults.

    Moreover, while a large body of literature provides strong evidences on the impact of physical activity and health status over healthcare utilization, only a few studies address the problem of endogeneity of these two determinants. This implies that physical activity can be itself influenced by healthcare utilization, which leads to the problem of reverse causality between the two variables. For example, as physical inactivity increases the duration of hospitalization, longer stays in hospital may also be related to the likelihood of being inactive [90]. As for the relation between healthcare utilization and health status, Bilgel and Can Karahasan [91] argue that health status is endogenous for the fact that individuals may receive healthcare and observe health status. Moreover, as Sari [59] states, it is also plausible that individuals with certain health conditions can be physically inactive and, at the same time, use more healthcare services.

    In compliance with all the above underlined coordinates on the existing literature and with the EU strategy for physical activity, we aim at analyzing the association between physical activity and healthcare utilization, controlled by a set of socioeconomic and demographic factors, for a French representative sample. The contribution of this paper to the existing literature is threefold. Firstly, it provides an overall analysis of the context of healthcare utilization in relation to physical activity at the national level of France. To the best of our knowledge, no such studies have been conducted using a complex set of data provided by the European Health Interview Survey (EHIS) and the Health and Social Protection Survey (ESPS) 2014. Thus, our study provides valuable insights for policy-makers on how to improve solutions or developing programs to promote physical activity for a healthy life style in France. Secondly, following the WHO global recommendations on physical activity for health, in our paper we develop a more general measurement of physical activity that includes more components/dimensions of the indicator and also considers the age group. Hence, a more accurate classification of the population depending on the type and intensity of physical activities and age is obtained, which would be further reflected in its association with healthcare utilization. Thirdly, the methodological approach employed in the empirical analysis enables to cope with the problem of endogeneity caused by unobserved heterogeneity and possible reverse causality of healthcare utilization in relation to health status and physical activity by using instrumental variables provided by the EHIS-ESPS 2014 survey.

    Attendance in physical education classes, sedentary behavior, and different forms of physical activity among schoolchildren: a cross-sectional study | BMC Public Health

    Characterizing fall risk factors in Belgian older adults through machine learning: a data-driven approach | BMC Public Health

    Participants

    Schoolchildren (7–12 years-old) from 2nd to 5th-grade in part-time public schools in Feira de Santana (Bahia) participated in this cross-sectional study. Feira de Santana is in the Northeast region of Brazil (inhabitants: 624,107; Human Development Index: 0.712). Data collection covered weekdays (Tuesday to Friday), from March to October of the year 2019 and included a probability sample of students from 2nd to 5th-grade, from public schools in the urban area, with broadband Internet. The sample size was defined based on the following parameters: a population of 15,920 students enrolled in the education system, according to data from the Municipal Department of Education; expected prevalence of outcomes of 50{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}; confidence limit of three percentage points; design effect (deff) of 2.0; and 95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} confidence interval (95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}CI). Based on these parameters, the sample size was calculated at 2,000 students. A further 20{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} was added to make up for presumed losses, resulting in a sample of 2,400 students (Fig. 1).

    Fig. 1
    figure 1

    The cluster sampling process was carried out in three stages: I) all schools in the municipal network were stratified according to the 11 geographic and administrative centers of the Department of Education (clusters); II) one school from each center was randomly drawn; III) all classrooms from 2nd to 5th grade within each school were selected (159 classrooms), and all subjects within the selected classrooms were invited to participate in the study. All methods were carried out in accordance with relevant guidelines and regulations of ethical standards set out in Resolution No. 466/2012 of Brazil’s National Research Ethics Council. Informed consent was obtained from all participants involved in the study and their parents/guardians provided authorization in writing. The study protocol was approved by the Research Ethics Council of the State University of Feira de Santana (Approval No. 02307918.5.0000.0053, Opinion No.: 3.116.495). The Municipal Department of Education provided information regarding the sex, age, and school shift of participants.

    Measurement of sedentary behaviors and physical activities

    The participants self-reported the SB and physical activity on the Food Intake and Physical Activity of Schoolchildren (Web-CAAFE) questionnaire. The Web-CAAFE is a previously validated self-report questionnaire [27], completed on the internet and based on the previous-day recall. The instrument collects information on weight status, food consumption, physical activity, and SB and includes screens to evaluate physical education classes and to investigate modes of commuting to school.

    Participants choose up to 32 items, out of a total of 50 stored in the system, which they had performed the day before across three periods (morning, afternoon, evening). The list contains five SB icons (one for academic tasks, e.g. reading, writing, drawing, painting; four electronic devices, e.g. TV, video game, computer, and cell phone), and 27 physical activity icons classified into: Active play (Play with a ball, Play catch, Soccer, Dance, Marbles, Jump rope, Gymnastics, Elastics, Play in the park, Play in the water/Swim, Ride a bicycle, Rollerblade/Skateboard/Ride a scooter, Fly a kite, Dodgeball, Hide and seek, Play with a dog, Hopscotch), Non-active play (Board games, Playing with dolls/action figures, Playing with toy cars, Spinning top/Bayblade, Listen to music, Play musical instrument), Structured physical activity (Ballet, Fight Sports), and Household chores (Wash the dishes, Sweep). Information on the weekly frequency of participation in physical education classes is assessed through the question “How many times a week do you take part in physical education classes?” (none, 1, 2 3, 4, every day of the week). The closed list of leisure activities, sports, home chores, and sedentary activities was compiled based on results from focal groups, previous instruments for this age range, and the 7-day recall completed by 180 schoolchildren [28].

    Participants completed the Web-CAAFE at the school, after receiving verbal explanations about how the software works and how to complete the questionnaire. Students were instructed not to interact during the task and the research team helped when requested, without inducing responses.

    Anthropometric measurements

    The study included weight and height measurements to calculate the Body Mass Index (BMI), measured by trained researchers, following recommended standardization [29]. Weight was measured using an AVAnutri® digital scale with graduation every 100 g and a maximum capacity of 200 kg. Height was measured using a portable stadiometer, detachable, with a square platform, Seca® brand, with a 205 cm maximum height and graduation every 1 mm. The students were barefoot, wearing school uniform, and with no headwear during measurements. Age-and sex-specific BMI z-scores were calculated according to the International Obesity Task Force (IOTF) [30]. The weight status was categorized into non-overweight (underweight and normal weight), overweight, and obesity according to IOTF reference values [30].

    Classification of economic level

    Socioeconomic status was investigated based on the analysis of possession of items, education level of the head of the household, and access to public services, according to the Brazilian Economic Classification Criteria [31]. The socioeconomic status was classified into classes, related to the average household income in Reais (R$): A (R$25,554.33), B-C (R$1,748.59 to R$11,279.14), and D-E (R$719.81). Based on the average dollar exchange rate between March and October 2019, income ranges in these classes were: A (US$ 6,485.87), B-C (US$ 443.80 to 2,862.72), and D-E (US$ 182.69).

    Data processing and analysis

    The weekly attendance in PE was the main exposure analyzed (0/week; 1/week; ≥ 2/week). Daily frequencies of active play, non-active play, and structured physical activity were the main outcomes (count outcomes). These frequencies were obtained by summing all reports in the morning, afternoon, and night. For example, if a participant reported riding a bike in the morning period, playing with a ball in the afternoon, and playing with a dog in the evening, then their sum was 3 counts of active play. SB frequency was obtained by summing the daily reports of academic tasks and screen use. DPA frequency was obtained by summing the daily reports of all physical activities.

    Students with intellectual disabilities and ages outside the age group of seven to 12 years participated in the study but were excluded from the statistical analyses. Descriptive statistics are used to present the study variables. Variables without normal distribution after verification of the histograms and the Shapiro–Wilk test are described by median and interquartile range values. Differences in non-normally distributed continuous variables were evaluated using the non-parametric Mann–Whitney test (U). Categorical variables are described as absolute and relative values and compared using Pearson’s chi-square test (Χ2).

    The associations between weekly attendance in PE and frequencies of active play, non-active play, and structured physical activity were analyzed using the values of prevalence ratios (PR) and respective 95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}CI estimated via multiple Negative Binomial Regression, with adjustment for age (7–9 years; ≥ 10 years), school shift (morning; afternoon), and BMI z-scores, adopting a robust variance estimation method. Negative Binomial models analyzing the association between weekly attendance in PE and DPA and SB were also adjusted by the daily frequency of household chores. The group of household chores was not included in the present analysis as an outcome because there is no evidence of an association with attendance in PE.

    The Negative Binomial distribution is suitable for fitting count data susceptible to overdispersion. In addition, it showed higher linearity in the comparison between observed and predicted values of the outcome. The zero-inflation between the factors was assumed to be constant. Although the negative binomial regression models provide a measure of association such as Incidence-Rate Ratios (IRR), we adopted the prevalence ratio (PR) as the most appropriate way to present our results, considering the cross-sectional design of the study. Statistical significance was assessed using p value < 0.05. Effect modification was tested using interaction terms between weekly attendance in PE and sex, age, school shift, and BMI z-scores. Interactions that showed statistical significance at the critical value of p < 0.05 were described.

    When Covid hit, Vermont’s public school enrollment dropped and homeschooling spiked. Then the trend reversed.

    When Covid hit, Vermont’s public school enrollment dropped and homeschooling spiked. Then the trend reversed.

    Observe: This story is extra than a week outdated. Given how rapidly the Covid-19 pandemic is evolving, we advise that you study our most up-to-date protection here.

    Students head toward Edmunds Middle Faculty in Burlington on the initially day of classes in August. File photograph by Glenn Russell/VTDigger

    Concerning the fall of 2019 and 2020, amid a pandemic year that noticed the introduction of digital instruction, K-12 enrollment in Vermont’s general public schools dropped by thousands. 

    At the identical time, the selection of Vermont youngsters staying homeschooled spiked to a high not found in virtually 40 decades.

    But amongst 2020 and 2021, the reverse occurred: The number of homeschooled youngsters reduced, while community universities saw a new inflow of learners. 

    State enrollment facts from the Covid-19 pandemic university yr, last current over the summer, reveals a surge in fascination in homeschooling — adopted by an apparent reversal, as college students returned to public university buildings.  

    Enrollment in Vermont general public educational institutions and home study have exhibited continual but reverse tendencies around the many years. Because 2004, the year with the earliest commonly available data, Vermont’s community faculty enrollment has lowered by about 10,000 college students. 

    The variety of Vermont children enrolled in homeschool, meanwhile, has ticked up above the a long time, to approximately 2,600 by the slide of 2019 from 92 in 1981. 

    But the Covid-19 pandemic experienced an influence on equally kinds of schooling.

    Involving drop 2019 and fall 2020, Vermont community faculty enrollment dropped by approximately 2,900 college students — meaning the state dropped about 3.5{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of its public faculty pupils. (That decline improves to approximately 5{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} if pre-K enrollment is factored in.)

    At the exact time, the range of homeschooled college students far more than doubled, expanding from about 2,600 to 5,500. 

    That determine arrives from Company of Education and learning facts structured by Retta Dunlap, who operates the homeschool advocacy team Vermont Residence Education Community.

    Dad and mom experienced multiple reasons for switching to homeschool in 2020, Dunlap reported.

    Homeschooling parents are “not any one particular label,” she mentioned. “I suggest, they are across the board. You are unable to simply call them all Christians. You can’t simply call them all atheists or Democrats or Republicans. They are just all about.” 

    For several, she reported, the shift was prompted by worries about faculty mask mandates and the likelihood of Covid-19 vaccine mandates. (Vermont has not needed the Covid-19 vaccine to go to university.) 

    Some were frustrated with the digital mastering that colleges had carried out in the spring of 2020, Dunlap reported. Distant instruction also gave moms and dads a likelihood to see what their children’s classrooms and curricula seemed like — and some did not like what they saw. 

    “Covid place a major window on to the general public college technique, and what they do in a classroom,” she reported. “And a picture’s well worth 1,000 terms. Which is not heading to be so (easy) to shake from parents’ minds.”

    Some mothers and fathers who manufactured the switch to homeschooling during the pandemic strategy to adhere with it, in accordance to Dunlap. But, according to the Agency of Education and learning, a lot of household analyze college students returned to community faculty in the drop of 2021 — the 1st yr given that the pandemic when faculties planned to be in session complete time. 

    Among Oct 2020 and Oct 2021, enrollment in the state’s general public schools enhanced by in excess of 1,100.  

    Meanwhile, the amount of Vermont pupils enrolled in household examine dropped by about 1,500. The motive for the discrepancy in between the two figures is unclear. 

    “In (the slide of 2021), we observed many individuals swap from homestudy to in-individual mastering,” claimed Suzanne Sprague, a spokesperson for the Vermont Agency of Instruction.

    Vermont’s college enrollment knowledge is collected in Oct, soon after pupils have settled into their faculties, and normally becomes publicly readily available the subsequent yr. Data for the slide of 2022 will come to be available early future calendar year, a point out spokesperson explained.

    The state transformed its data collection procedures in the 2018-19 school yr, Sprague reported, which “had impacts” on that year’s facts.

    The state has also found an influx of citizens through the pandemic. Involving 2020 and 2021, the condition welcomed around 4,800 new individuals, the broad vast majority of whom arrived from other components of the country. 

    It’s not distinct if that migration experienced an influence on the bump in enrollment in the slide of 2021 — or if it alerts a change in the lengthy decrease in the state’s college-aged population. 

    “There’s so several factors at enjoy, right?” explained Ted Fisher, an Company of Education spokesperson. “The all round narrative about declining enrollment has been that just younger Vermonters are a lot less very likely to want to stay in Vermont than they were in former generations.”

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