Housing Instability and Policy Considerations for Equitable Aging in Place in Canada

BACKGROUND

In this article, we apply a gender-based analysis plus framework to research the housing experiences of older, low-income adults living and aging in Hamilton. Low-income older adults with intersectional identities are at risk of not aging in place due to marginalization and housing instability.

OBJECTIVE

Policy currently homogenizes the experience of aging by sidelining intersectional factors that have a bearing on aging well in place. The research aims to develop policy recommendations to address this gap.

METHODS

Several methods captured the housing experiences of low-income older adults, including interviews, participant observation, and arts-based techniques.

FINDINGS

Findings illustrate how gender and intersectional factors shape both housing trajectories and agentive practices low-income adults utilize to try to age well and in place. These strategies encompass practicing cultural citizenship, which is a claim for inclusion when excluded from mainstream ideals of aging in place.

DISCUSSION

We provide policy recommendations informed by participants' lived experiences aimed at promoting equitable aging in place as fundamental to full citizenship.

Friendly Visiting Programs for Older People Experiencing Social Isolation: A Realist Review of what Works, for whom, and under what Conditions

Many social interventions have been developed with the hopes of reducing and preventing social isolation among older people (e.g., recreation, arts-based programs and social prescription). Friendly visiting programs, also known as befriending schemes, have been a mainstay in this area for decades and are largely thought to be effective at reconnecting older people (≥ 60 years of age) experiencing isolation. Research and evaluations have yet to determine, however, how and why these programs may be most successful, and under what conditions. This article presents the findings of a realist synthesis aimed at identifying the critical mechanisms and contextual factors that lead to successful outcomes in friendly visiting programs. Seven studies are synthesized to inform a friendly visiting program theory accounting for key mechanisms (e.g., provision of informal support) and underlying contexts (e.g., training of volunteers) that can be used to inform future programs. Recommendations for future research are also presented.

Molecular characterization and phylogenetic analysis of Marek's disease virus in chickens from Ogun State, Nigeria

Marek's disease (MD) is caused by oncogenic MD virus serotype 1 (MDV1) and is characterized by lymphoproliferative lesions resulting in high morbidity and mortality in chickens. Despite being ubiquitous on poultry farms, there is a dearth of information on its molecular characteristics in Nigeria. This study aimed at characterizing three virulence genes (Meq, pp38, and vIL-8) of MDV1 from chickens in Ogun state, Nigeria. Blood, feather quill, and tumour samples of chickens from different commercial poultry farms in Ogun State were pooled, spotted on 107 FTA cards, and screened for MDV1 by polymerase chain reaction (PCR). Phylogenetic analysis was carried out to compare Nigerian MDV1 Meq, pp38, and vIL-8 genes sequences with the published references. Thirteen samples were MDV1-positive and the Meq, as well as pp38, and vIL-8 genes from the different samples were 100% identical. The Meq genes contained 339 amino acids (aa) with three PPPP motifs in the transactivation domain and two interruptions of the PPPP motifs due to proline-to-arginine substitutions at positions 176 and 217 resulting in a 20.88% proline composition. Phylogenetic analysis revealed that the Meq gene clustered with strains from Egypt and very virulent ATE2539 strain from Hungary. Mutations were observed in the pp38 protein (at positions 107 and 109) and vIL-8 protein (at positions 4 and 31). Based on the molecular analysis of the three genes, the results indicate the presence of MDV1 with virulence signatures; therefore, further studies on in vivo pathotyping of Nigerian MDV1 from all states should be performed.RESEARCH HIGHLIGHTS Meq, pp38 and vIL-8 genes were 100% identical between Nigerian MDV strains.Proline content in Nigerian meq gene was 20.88% with two PPPP motifs interruptions.Meq, pp38 and vIL-8 genes of Nigerian MDV were similar to Egyptian and Indian strains.

Short-term impact of a neighbourhood-based intervention on mental health and self-rated health in Hamilton, Ontario, Canada

The Hamilton Neighbourhoods Study aimed to measure the short-term impact of a neighbourhood-based intervention known as the City of Hamilton's Neighbourhood Action Strategy on health and neighbourhood outcomes. A quasi-experimental study with 881 intervention participants across six targeted neighbourhoods and 173 control participants was conducted to investigate changes in self-rated health and mental health from baseline to follow-up. There was evidence of small improvements in mental health in two neighbourhoods, but there was no change in self-rated health. Place-based interventions aimed at high poverty neighbourhoods may have only modest impacts on health in the short-term.

The association between housing cost burden and avoidable mortality in wealthy countries: cross-national analysis of social and housing policies, 2000-2017

BACKGROUND

It has been shown that the high cost of housing can be detrimental to individual health. However, it is unknown (1) whether high housing costs pose a threat to population health and (2) whether and how social policies moderate the link between housing cost burden and mortality. This study aims to reduce these knowledge gaps.

METHODS

Country-level panel data from Organisation for Economic Co-operation and Development (OECD) countries are used. Housing cost to income ratio and age-standardised mortality were obtained from the OECD database. Fixed effects models were conducted to estimate the extent to which the housing cost to income ratio was associated with preventable mortality, treatable mortality, and suicides. In order to assess the moderating effects of social and housing policies, different types of social spending per capita as well as housing policies were taken into account.

RESULTS

Housing cost to income ratio was significantly associated with preventable mortality, treatable mortality, and suicide during the post-global financial crisis (2009-2017) but not during the pre-global financial crisis (2000-2008). Social spending on pensions and unemployment benefits decreased the levels of mortality rate associated with housing cost burden. In countries with higher levels of social housing stock, the link between housing cost burden and mortality was attenuated. Similar patterns were examined for countries with rent control.

CONCLUSION

Our findings suggest that housing cost burden can be related to population health. Future studies should examine the role of protective measures that alleviate health problems caused by housing cost burden.

At odds: How intraprofessional conflict and stratification has stalled the Ontario paramedic professionalization project

Historically, self-regulation has provided some professions with power and market control. Currently, however, governments have scrutinized this approach, and priorities have shifted toward other mandates. This study examines the case of paramedics in Ontario, Canada, where self-regulation is still the dominant regulatory model for the healthcare professions but not for paramedics. Instead, paramedics in Ontario are co-regulated by government and physician-directed groups, with paramedics subordinate to both. This paper, which draws on interviews with paramedic industry leaders analyzed through the lens of institutional work, examines perspectives on the relevance of self-regulation to the paramedic professionalization project. Participants had varying views on the importance of self-regulation in obtaining professional status, with some rejecting its role in professionalization and others embracing regulatory reform. Because paramedics disagree on what being a profession means, the collective professionalization project has stalled. This research has implications for understanding the impact of intraprofessional relationships and conflict on professionalization projects.

Income inequality and population health: a political-economic research agenda

There is more than 30 years of research on relationships between income inequality and population health. In this article, we propose a research agenda with five recommendations for future research to refine existing knowledge and examine new questions. First, we recommend that future research prioritise analyses with broader time horizons, exploring multiple temporal aspects of the relationship. Second, we recommend expanding research on the effect of public expenditures on the inequality-health relationship. Third, we introduce a new area of inquiry focused on interactions between social mobility, income inequality and population health. Fourth, we argue the need to examine new perspectives on 21st century capitalism, specifically the population health impacts of inequality in income from capital (especially housing), in contrast to inequality in income from labour. Finally, we propose that this research broaden beyond all-cause mortality, to cause-specific mortality, avoidable mortality and subcategories thereof. We believe that such a research agenda is important for policy to respond to the changes following the COVID-19 pandemic.

Health and social outcomes in the Housing First model: Testing the theory of change

BACKGROUND

Homelessness continues to grow globally. The Housing First (HF) model offers immediate access to housing and support services without preconditions and has a growing body of evidence documenting its effectiveness at ending homelessness. HF has a robust theory of change that hypothesizes how unique program components (i.e., immediate access to housing, separation of services from housing, client choice, etc.) drive positive social and health changes over time. We advance the understanding of how HF causes client improvement by empirically testing this program's theory of change.

METHODS

Using a unique longitudinal quantitative data from the large Canadian At Home/Chez Soi Housing First trial we used path analysis to test the theory of change for Quality of Life, Crisis related events or service utilization, and Recovery.  Program pathways and health and social outcomes were measured at enrolment, 6-, 12- and 24-months post-enrolment.

FINDINGS

Most hypothesized pathways were confirmed with path analysis.  Confirmed pathways for two outcomes- Quality of Life (QOL) and Recovery - were similar. Health and social consultations at enrolment, health status at 6- and 12-months post enrolment, and social connectedness at 12-months were important predictors of the 24-month outcomes of Quality of Life and Recovery, but not for Crisis related events or service utilization.

INTERPRETATION

This analysis directly responds to recent calls for more empirical evidence about intervention mechanisms. Ensuring linkages to health and social service consultations for clients, supporting clients' engagement with family and community, and enabling clients to improve or maintain good health will drive better longer term client outcomes within Housing First.

FUNDING

Funding Mental Health Commission of Canada.

Primary care-based interventions to address the financial needs of patients experiencing poverty: a scoping review of the literature

BACKGROUND

It is broadly accepted that poverty is associated with poor health, and the health impact of poverty has been explored in numerous high-income country settings. There is a large and growing body of evidence of the role that primary care practitioners can play in identifying poverty as a health determinant, and in interventions to address it.

PURPOSE OF STUDY

This study maps the published peer-reviewed and grey literature on primary care setting interventions to address poverty in high-income countries in order to identify key concepts and gaps in the research. This scoping review seeks to map the tools in use to identify and address patients' economic needs; describe the key types of primary care-based interventions; and examine barriers and facilitators to successful implementation.

METHODS

Using a scoping review methodology, we searched five databases, the grey literature and the reference lists of relevant studies to identify studies on interventions to address the economic needs-related social determinants of health that occur in primary health care delivery settings, in high-income countries. Findings were synthesized narratively, and examined using thematic analysis, according to iteratively identified themes.

RESULTS

Two hundred and fourteen papers were included in the review and fell into two broad categories of description and evaluation: screening tools, and economic needs-specific interventions. Primary care-based interventions that aim to address patients' financial needs operate at all levels, from passive sociodemographic data collection upon patient registration, through referral to external services, to direct intervention in addressing patients' income needs.

CONCLUSION

Tools and processes to identify and address patients' economic social needs range from those tailored to individual health practices, or addressing one specific dimension of need, to wide-ranging protocols. Primary care-based interventions to address income needs operate at all levels, from passive sociodemographic data collection, through referral to external services, to direct intervention. Measuring success has proven challenging. The decision to undertake this work requires courage on the part of health care providers because it can be difficult, time-consuming and complex. However, it is often appreciated by patients, even when the scope of action available to health care providers is quite narrow.

Effects of household chaos and parental responsiveness on child executive functions: a novel, multi-method approach

Background

Executive functions can be adversely affected by contextual risks in the home environment including chaos and parenting challenges. Furthermore, household chaos negatively influences parenting practices. Few studies, however, have examined the role of parenting in the association between household chaos and child executive functions.

Methods

Using a sample of 128 school-aged children (mean = 61.9 months, SD = 2.0, range 58–68 months) and their mothers, the present study examined direct and indirect effects (via parental responsiveness) of household chaos on child executive functioning. Multi-measures were used including performance-based assessments, behavioural observations, questionnaires, and video-home tours.

Results

Household chaos had both a direct effect on child executive functions (β = − .31, 95% CI [− .58, − .04]) and an indirect effect (β = − .05, 95% [− .13, − .01]) via parental responsiveness. Further, the indirect effect was only significant for household instability.

Conclusion

These findings indicate that parental responsiveness may be compromised by household chaos, with implications for the executive functions of school-aged children. Preventative strategies are needed to improve the stability in the home and strengthen parenting practices.

Housing and Healthy Child Development: Known and Potential Impacts of Interventions

Housing is often described as an important determinant of health, but less commonly of child health. Despite acknowledgment of the importance of housing to health, however, there are relatively few studies of the effects of housing interventions on health, and again even fewer on child health. This article argues that a broad focus on healthy child development-as opposed to just physical health-coupled with a conceptual framework outlining specific attributes of housing with the potential to influence child health, should be adopted to guide a comprehensive approach to public health policy for healthy child development. Most housing interventions address direct pathways linking in-home hazard exposures to child health outcomes, with promising but mixed results. But few housing interventions address the broader aspects of healthy child development. This review addresses potential housing interventions that could impact the broader determinants of healthy child development and accompanying methodological challenges.

Residential moves, neighbourhood walkability, and physical activity: a longitudinal pilot study in Ontario Canada

Background

Numerous cross-sectional studies have consistently demonstrated an association between attributes of urban form or ‘walkability’ and individual- and population-level physical activity (PA) patterns. However, in the absence of longitudinal research, the self-selection problem undermines the claim that a walkable built form produces more physically active people. Through a longitudinal pilot study of ‘imminent movers’ in Ontario using a quasi-experimental approach, we sought to examine the feasibility of longitudinal methods that would produce stronger evidence for a causal relationship between the built environment and PA levels.

Methods

Participants were recruited using publicly available real estate listings. Successful recruits were sent a PA diary to track their activity for a week, and were also scheduled for a 45-min phone interview that collected demographic details, neighbourhood perceptions and self-efficacy for walking, and verified the PA diary. Following their move, participants were given the same tasks and then sorted into groups based on changes in their neighbourhood walkability (measured with Walk Score) from baseline to follow-up.

Results

There were challenges in recruiting a sufficient number of participants and counter-factuals to examine the relationship between changes in walkability and PA. Our limited sample showed a substantial decrease in Walk Score over the entire sample, from an average of 45.8 to 30.6, with most participants moving to less walkable areas. From baseline to follow-up, the largest declines in reported self-efficacy for walking were to grocery stores, banks, and for entertainment. For the entire sample, utilitarian PA decreased, while recreational and job-related PA increased.

Conclusions

This pilot study highlighted the methodological challenges involved in collecting quasi-experimental evidence on the effect of walkable environments on PA. Additionally, the low sample size and the tendency for most participants to move to less walkable areas meant there were insufficient counter-factuals for study of the effect of walkability on PA. Despite these challenges, we saw important changes in self-efficacy for walking that were commensurate with changes to the built environment. In sum, while longitudinal research on health and the built environment is urgently needed, recruiting an adequate sample size for a quasi-experimental study such as this is extremely challenging.

Men's experiences of early life trauma and pathways into long-term homelessness

Previous studies that have explored the association between childhood trauma and homelessness indicate that traumatic events can lead to survivor distrust of interpersonal relationships and institutions, prolonged homelessness and poor health and social outcomes. The majority of this literature relies on quantitative data and fails to investigate the personal experiences of childhood trauma that are found to impact housing status later in life. Semi-structured, qualitative interviews were conducted with 25 men living in an urban area in Ontario who had spent more than 30 consecutive nights in an emergency shelter over the course of their housing histories. During data analysis, it was observed that all of the men had experienced some form of trauma or neglect in childhood which contributed to their entries into homelessness. Using a case study approach, three entry pathways into long term homelessness are described: 1) youth; 2) emerging or early adulthood; and 3) middle adulthood. Participants are classified into the pathways by the developmental period at which they first entered homelessness. These findings have implications for policy makers and service providers, as key intervention points are identified. Establishing effective interventions that address crises experienced at these points could assist with homelessness prevention across the life course.

Rabies risk and use of post-exposure prophylaxis associated with dog bites in Tennessee

The canine variant of the rabies virus has been eliminated in the United States. Among the public and many healthcare providers, however, dog bites are still associated with risk for rabies transmission. This study examined the risk of rabies in biting dogs and the use of rabies post-exposure prophylaxis (rPEP) for dog bite victims in Tennessee. The study included a retrospective analysis of laboratory testing requisitions for dogs from 2002 to 2016, collection of clinical data on confirmed rabies-positive dogs from 2008 to 2016 and analysis of hospital discharge data for rPEP from 2007 to 2014. Among dogs submitted for rabies testing, those having a recent history of biting were significantly less likely to test positive for rabies than dogs with no reported bite (OR = 0.01; 95% CI [0.003-0.04]). The most common clinical signs reported among rabies-positive dogs were anorexia, dysphagia, ataxia, limb paresis or paralysis, and lethargy; aggressiveness was uncommon. Among hospital patients with an animal-related injury who received rPEP, more than half (52%) presented with dog bites. These data show that laboratory submissions for rabies testing and prescriptions for rPEP do not reflect the epidemiology of rabies in Tennessee. Education and outreach targeting the public and healthcare providers should emphasize the animal species and situations associated with a greater risk for rabies transmission, such as bites from rabies reservoir species or animals exhibiting signs of neurologic disease.

Enabling the participation of marginalized populations: case studies from a health service organization in Ontario, Canada

We examined efforts to engage marginalized populations in Ontario Community Health Centers (CHCs), which are primary health care organizations serving 74 high-risk communities. Qualitative case studies of community participation in four Ontario CHCs were carried out through key informant interviews with CHC staff to identify: (i) the approaches, strategies and methods used in participation initiatives aimed specifically at engaging marginalized populations in the planning of and decision making for health services; and (ii) the challenges and enablers for engaging these populations. The marginalized populations involved in the community participation initiatives studied included Low-German Speaking Mennonites in a rural town, newcomer immigrants and refugees in an urban downtown city, immigrant and francophone seniors in an inner city and refugee women in an inner city. Our analysis revealed that enabling the participation of marginalized populations requires CHCs to attend to the barriers experienced by marginalized populations that constrain their participation. Key informants outlined the features of a 'community development approach' that they rely on to address the barriers to marginalized peoples' involvement by strengthening their skills, abilities and leadership in capacity-building activities. The community development approach also shaped the participation methods that were used in the engagement process of CHCs. However, key informants also described the challenges of applying this approach, influenced by the cultural values of some groups, which shaped their willingness and motivation to participate. This study provides further insight into the approach, strategies and methods used in the engagement process to enable the participation of marginalized populations, which may be transferable to other health services settings.

Effects of T-2 Toxin on Turkey Herpesvirus-Induced Vaccinal Immunity Against Marek's Disease

T-2 toxin, a very potent immunotoxic Type A trichothecene, is a secondary metabolite produced primarily by Fusarium spp., which grows on cereal grains and can lead to contaminated livestock feed. Repeated exposure to T-2 toxin has been shown to cause immunosuppression and decrease the resistance of exposed animals to a variety of infectious diseases; however, the effects of T-2 toxin on Marek's disease (MD) vaccinal immunity have not been reported. Four trials were conducted to determine the effects of T-2 toxin on vaccinal immunity against MD. Day-old, white leghorn chicks of Avian Disease and Oncology Laboratory line 15I5 × 71 were treated daily for 7 days via crop gavage with T-2 toxin at a sublethal dose of 1.25 mg/kg body weight. Treated and untreated chicks were also vaccinated with turkey herpesvirus (HVT) at hatch and were challenged with the JM strain of MD virus (MDV) at 8 days of age. Chickens were tested for HVT viremia at 1 wk postvaccination immediately before challenge, and for HVT and MDV viremia at 3 wk postchallenge. Chickens were observed for the development of MD lesions and mortality within 8 wk of age. T-2 toxin significantly reduced body weight and titers of HVT viremia within 7 days after hatch. T-2 toxin shortened the incubation period for the development of MD lesions and mortality, but only in unvaccinated chickens. The percent MD protection in T-2-toxin-treated, HVT-vaccinated chickens ranged from 82% to 96% and was comparable to that in HVT-vaccinated untreated control chickens (89%-100%). The data suggest that exposure of chickens to sublethal doses of T-2 toxin for 7 consecutive days after hatch may influence the development of 1) HVT viremia; and 2) MD lesions and mortality, but only in unvaccinated chickens.

Relative and absolute availability of fast-food restaurants in relation to the development of diabetes: A population-based cohort study

OBJECTIVES

To determine whether residents living in areas with a high proportion of fast-food restaurants (FFR) relative to all restaurants are more likely to develop diabetes and whether the risk varies according to the volume of FFR.

METHODS

The study cohort consisted of adult respondents (20-84 years) to the Canadian Community Health Survey (cycles 2005, 2007/2008, 2009/2010) who resided within walking distance (720 m) of at least one restaurant in Toronto, Brampton, Mississauga or Hamilton, ON. The development of diabetes was established by linking participants to the Ontario Diabetes Database. Cox proportional hazards models were used to estimate hazard ratios (HRs) of incident diabetes associated with relative and absolute measures of restaurant availability.

RESULTS

During a median follow-up of 5 years, 347 of 7,079 participants (4.6%) developed diabetes. Among younger adults (20-65 years, n = 5,806), a greater proportion of fast-food relative to all restaurants was significantly associated with incident diabetes after adjustment for a range of individual and area-level covariates, but only in areas with high volumes of fast-food retailers (3+ outlets) (HR = 1.79, 95% confidence interval: 1.03-3.12, across the interquartile range). Adjusting for body mass index rendered this association non-significant. No significant associations were observed in areas with low volumes of FFR or among older adults (65-84 years, n = 1,273). Absolute availability (number) of fast-food and other restaurants was generally unrelated to incident diabetes.

CONCLUSION

Areas with the double burden of a high volume of FFR and few dining alternatives may represent an adverse environment for the development of diabetes.

Establishing stability: exploring the meaning of 'home' for women who have experienced intimate partner violence

There is evidence that involuntary housing instability may undermine health and well-being. For women who have experienced intimate partner violence (IPV), achieving stability is likely as important for other groups, but can be challenging. Through our analysis of 41 interviews with women who have experienced low income and IPV, we argue that definitions of housing stability are multifaceted and for many centred on a shared understanding of the importance of creating an environment of "home". We found that obtaining housing that satisfied material needs was important to women. However, in asking women to define what housing stability meant to them, we found that other factors related to ontological security and the home, such as safety, community, and comfort, contributed to women's experiences of stability. Through our discussion of the importance these women placed on establishing stable homes, we argue that future research on women's experiences with housing stability and IPV should include definitions of stability that capture both material security and women's experiences with building emotionally stable homes.

Absolute and relative densities of fast-food versus other restaurants in relation to weight status: Does restaurant mix matter?

BACKGROUND

Given the continuing epidemic of obesity, policymakers are increasingly looking for levers within the local retail food environment as a means of promoting healthy weights.

PURPOSE

To examine the independent and joint associations of absolute and relative densities of restaurants near home with weight status in a large, urban, population-based sample of adults.

METHODS

We studied 10,199 adults living in one of four cities in southern Ontario, Canada, who participated in the Canadian Community Health Survey (cycles 2005, 2007/08, 2009/10). Multivariate models assessed the association of weight status (obesity and body mass index) with absolute densities (numbers) of fast-food, full-service and other restaurants, and the relative density (proportion) of fast-food restaurants (FFR) relative to all restaurants within ~10-minute walk of residential areas.

RESULTS

Higher numbers of restaurants of any type were inversely related to excess weight, even in models adjusting for a range of individual covariates and area deprivation. However, these associations were no longer significant after accounting for higher walkability of areas with high volumes of restaurants. In contrast, there was a direct relationship between the proportion of FFR relative to all restaurants and excess weight, particularly in areas with high volumes of FFR (e.g., odds ratio for obesity=2.55 in areas with 5+ FFR, 95% confidence interval: 1.55-4.17, across the interquartile range).

CONCLUSIONS

Policies aiming to promote healthy weights that target the volume of certain retail food outlets in residential settings may be more effective if they also consider the relative share of outlets serving more and less healthful foods.

The impact of job strain on smoking cessation and relapse in the Canadian population: a cohort study

BACKGROUND

The aim of this study is to investigate the impact of job strain, as measured by the Karasek demand/control model (DCM), on smoking cessation and relapse in a representative general population sample.

METHODS

A secondary analysis of data from the Canadian National Population Health Survey (NPHS) was undertaken. Daily smokers and former daily smokers (n=1287 and 1184, respectively) at cycle 1 (1994/1995) of the NPHS were followed up at cycle 2 (1996/1997). Measures of job strain (the independent variables) were based on data from cycle 1, predicting smoking status at cycle 2. Logistic regression analysis was employed in two ways. Individuals were stratified into job strain quartiles while continuous measures were also employed in separate analyses for job strain and its component dimensions.

RESULTS

In the quartile analysis, no effect of job strain was observed on the likelihood of cessation, while a non-linear effect was observed on the likelihood of relapse, although this relationship lost significance (p>0.05 and <0.10) after controlling for personal characteristics. No effect was observed using the continuous measure of job strain or the continuous measure of job demand on either cessation or relapse. For job control, no effect was observed on the likelihood of cessation, but increased control was found to decrease the likelihood of relapse in the unadjusted model only.

CONCLUSIONS

Psychosocial work environments may be too diverse for uniform trends in the relationship between job stress and smoking behaviour to emerge in a population sample. Future research should avoid use of the scaled-down DCM instrument where possible.

Foodscapes of southern Ontario: neighbourhood deprivation and access to healthy and unhealthy food retail

OBJECTIVES

We examined whether access to retail sources of healthy and unhealthy food varies according to level of neighbourhood material deprivation in three Ontario regions and whether urban form characteristics help to explain any such variations.

METHODS

Food retail (FR) outlets were identified from a commercial database for 804 urban neighbourhoods in Toronto, Brampton/Mississauga and Hamilton, Ontario. The median number of healthy and unhealthy FR outlets and percentage of outlets that were unhealthy were derived using 720-metre network buffers based on dissemination blocks and aggregated up to neighbourhood level (census tract). The 2006 Canadian Census was used to derive a composite index of material deprivation and three urban form measures related to zoning and urbanization. Multivariate regression models assessed the association between material deprivation, urban form and each measure of FR access.

RESULTS

Compared with the least deprived areas, the most materially deprived neighbourhoods had 2 to 4 times more healthy and unhealthy FR outlets within 720 metres (~ a 10-minute walk) of where most people lived, with the exception of Toronto, where unhealthy FR was more plentiful in less deprived areas. Urban form measures attenuated these associations for Brampton/Mississauga and Hamilton more so than for Toronto. The percentage of unhealthy outlets was generally unrelated to level of neighbourhood deprivation or urban form characteristics.

CONCLUSION

More deprived neighbourhoods had greater access to both healthy and unhealthy FR outlets, with some variation across study regions. Plentiful access to local retail sources of unhealthy food suggests a possible point of intervention for healthy public policy.

Physical health and gender as risk factors for usage of services for mental illness

Background

People with comorbid mental and physical illness (PI) experience worse health, inadequate care and increased mortality relative to those without mental illness (MI). The role of gender in this relationship is not fully understood. This study examined gender differences in onset of mental health service usage among people with physical illness (COPD, asthma, hypertension and type II diabetes) compared with a control cohort.

Methods

We used a unique linked dataset consisting of the 2000–2001 Canadian Community Health Survey and medical records (n=17 050) to examine risk of onset of MI among those with and without PI among Ontario residents (18–74 years old) over a 10-year period (2002–2011). Adjusted COX proportional survival analysis was conducted.

Results

Unadjusted use of MI medical services in the PI cohort was 55.6% among women and 44.7% (p=0.0001) among men; among controls 48.1% of the women and 36.7% of the men used MI medical services (p=0.0001). The relative risk of usage among women in the PI group relative to controls was 1.16. Among men, the relative risk was 1.22. Women were 1.45 times more likely to use MI medical services relative to men (HR=1.45, CI 1.35 to 1.55). Respondents in the PI cohort were 1.32 times more likely to use MI medical services (HR=1.32, CI 1.23 to 1.42) relative to controls. Women in the PI cohort used MI medical services 6.4 months earlier than PI males (p=0.0059). In the adjusted model, women with PI were most likely to use MI medical services, followed by women controls, men with PI and men controls. There was no significant interaction between gender and PI cohort.

Conclusions

Further, gender-based research focusing on onset of usage of MI services among those with and without chronic health problems will enable better understanding of gender-based health disparities to improve healthcare quality, delivery and public health policy.

The untold story: examining Ontario's community health centres' initiatives to address upstream determinants of health

BACKGROUND

Unlike traditional primary care centres, part of the Community Health Centre (CHC) mandate is to address upstream health determinants. In Ontario, CHCs refer to these activities as Community Initiatives (CIs); yet, little is known about how CIs operate. The objective of this study was to examine the scope, resource requirements, partnerships, successes and challenges among selected Ontario CIs.

METHODS

We conducted qualitative interviews with 10 CHC staff members representing 11 CIs across Ontario. CIs were identified through an online inventory, recruited by e-mail and interviewed between March and June 2011.

RESULTS

Most CIs aim to increase community participation, while addressing social isolation and poverty. They draw minimal financial resources from their CHC, and employ highly skilled staff to support implementation. Most enlist support from various partners, and use numerous methods for community engagement. Successes include improved community relations, increased opportunities for education and employment and rewarding partnerships, while insufficient funding was a commonly identified challenge.

CONCLUSIONS

Despite minimal attention from researchers and funders, our findings suggest that CIs play key capacity-building roles in vulnerable communities across Ontario, and warrant further investigation.

Mental health status and gender as risk factors for onset of physical illness over 10 years

Background

There is a growing interest in understanding the connection between mental illness (MI) and the onset of new physical illnesses among previously physically healthy individuals. Yet the role of gender is often forgotten in research focused on comorbidity of health problems. The objective of this study was to examine gender differences in the onset of physical illness in a cohort of respondents who met criteria for MI compared with a control cohort without mental health problems.

Methods

This cohort study, conducted in Ontario, Canada, used a unique linked dataset with information from the 2000–2001 Canadian Community Health Survey and medical records (n=15 902). We used adjusted Cox proportional survival analysis to examine risk of onset of four physical health problems (chronic obstructive pulmonary disorder, asthma, hypertension and diabetes) for those with and without baseline MI across a 10-year period (2002–2011) among respondents aged 18–74 years. We controlled for socioeconomic and health indicators associated with health.

Results

The incidence of physical illness in the MI cohort was 28.5% among women and 29.9% among men (p=0.85) relative to controls (23.8% and 24%, respectively; p=0.48). Women in the MI cohort developed secondary physical health problems a year earlier than their male counterparts (p=0.002). Findings from the Cox proportional survival regression showed that women were at 14% reduced risk of developing physical illness, meaning that men were more disadvantaged (HR=0.89, CI 0.80 to 0.98). Those in the MI cohort were at 10 times greater risk of developing a secondary physical illness over the 10-year period (HR=1.10, CI 0.98 to 1.21). There was no significant interaction between gender and MI cohort (HR=1.05, CI 0.85 to 1.27).

Conclusions

Policy and clinical practice have to be sensitive to these complex-needs patients. Gender-specific treatment and prevention practices can be developed to target those at higher risk of multiple health conditions.

Improving health equity through theory-informed evaluations: a look at housing first strategies, cross-sectoral health programs, and prostitution policy

The emergent realist perspective on evaluation is instructive in the quest to use theory-informed evaluations to reduce health inequities. This perspective suggests that in addition to knowing whether a program works, it is imperative to know 'what works for whom in what circumstances and in what respects, and how?' (Pawson & Tilley, 1997). This addresses the important issue of heterogeneity of effect, in other words, that programs have different effects for different people, potentially even exacerbating inequities and worsening the situation of marginalized groups. But in addition, the realist perspective implies that a program may not only have a greater or lesser effect, but even for the same effect, it may work by way of a different mechanism, about which we must theorize, for different groups. For this reason, theory, and theory-based evaluations are critical to health equity. We present here three examples of evaluations with a focus on program theories and their links to inequalities. All three examples illustrate the importance of theory-based evaluations in reducing health inequities. We offer these examples from a wide variety of settings to illustrate that the problem of which we write is not an exception to usual practice. The 'Housing First' model of supportive housing for people with severe mental illness is based on a theory of the role of housing in living with mental illness that has a number of elements that directly contradict the theory underlying the dominant model. Multisectoral action theories form the basis for the second example on Venezuela's revolutionary national Barrio Adentro health improvement program. Finally, decriminalization of prostitution and related health and safety policies in New Zealand illustrate how evaluations can play an important role in both refining the theory and contributing to improved policy interventions to address inequalities. The theoretically driven and transformative nature of these interventions create special demands for the use of theory in evaluations.

Development of the Canadian Marginalization Index: a new tool for the study of inequality

OBJECTIVES

Area-based measures of socio-economic status are increasingly used in population health research. Based on previous research and theory, the Canadian Marginalization Index (CAN-Marg) was created to reflect four dimensions of marginalization: residential instability, material deprivation, dependency and ethnic concentration. The objective of this paper was threefold: to describe CAN-Marg; to illustrate its stability across geographic area and time; and to describe its association with health and behavioural problems.

METHODS

CAN-Marg was created at the dissemination area (DA) and census tract level for census years 2001 and 2006, using factor analysis. Descriptions of 18 health and behavioural problems were selected using individual-level data from the Canadian Community Health Survey (CCHS) 3.1 and 2007/08. CAN-Marg quintiles created at the DA level (2006) were assigned to individual CCHS records. Multilevel logistic regression modeling was conducted to examine associations between marginalization and CCHS health and behavioural problems.

RESULTS

The index demonstrated marked stability across time and geographic area. Each of the four dimensions showed strong and significant associations with the selected health and behavioural problems, and these associations differed depending on which of the dimensions of marginalization was examined.

CONCLUSION

CAN-Marg is a census-based, empirically derived and theoretically informed tool designed to reflect a broader conceptualization of Canadian marginalization.

Development of the Canadian Marginalization Index: a new tool for the study of inequality

OBJECTIVES

Area-based measures of socio-economic status are increasingly used in population health research. Based on previous research and theory, the Canadian Marginalization Index (CAN-Marg) was created to reflect four dimensions of marginalization: residential instability, material deprivation, dependency and ethnic concentration. The objective of this paper was threefold: to describe CAN-Marg; to illustrate its stability across geographic area and time; and to describe its association with health and behavioural problems.

METHODS

CAN-Marg was created at the dissemination area (DA) and census tract level for census years 2001 and 2006, using factor analysis. Descriptions of 18 health and behavioural problems were selected using individual-level data from the Canadian Community Health Survey (CCHS) 3.1 and 2007/08. CAN-Marg quintiles created at the DA level (2006) were assigned to individual CCHS records. Multilevel logistic regression modeling was conducted to examine associations between marginalization and CCHS health and behavioural problems.

RESULTS

The index demonstrated marked stability across time and geographic area. Each of the four dimensions showed strong and significant associations with the selected health and behavioural problems, and these associations differed depending on which of the dimensions of marginalization was examined.

CONCLUSION

CAN-Marg is a census-based, empirically derived and theoretically informed tool designed to reflect a broader conceptualization of Canadian marginalization.

Health status, quality of life, residential stability, substance use, and health care utilization among adults applying to a supportive housing program

Supportive housing, defined as subsidized housing in conjunction with site-based social services, may help improve the health and residential stability of highly disadvantaged individuals. This study examined changes in health status, quality of life, substance use, health care utilization, and residential stability among 112 homeless and vulnerably housed individuals who applied to a supportive housing program in Toronto, Canada, from December 2005 to June 2007. Follow-up interviews were conducted every 6 months for 18 months. Comparisons were made between individuals who were accepted into the program (intervention) and those who were wait-listed (usual care) using repeated-measures analyses. Individuals who were accepted into the housing program experienced significantly greater improvements in satisfaction with living situation compared with individuals in the usual care group (time, F(3,3,261) = 47.68, p < 0.01; group × time, F(3,3,261) = 14.60, p < 0.01). There were no significant differences in other quality of life measures, health status, health care utilization, or substance use between the two groups over time. Significant improvement in residential stability occurred over time, independent of assigned housing group (time, F(3,3,261) = 9.96, p < 0.01; group × time, F(3,3,261) = 1.74, p = 0.17). The ability to examine the effects of supportive housing on homeless individuals was limited by the small number of participants who were literally homeless at baseline and by the large number of participants who gained stable housing during the study period regardless of their assigned housing status. Nonetheless, this study shows that highly disadvantaged individuals with a high prevalence of poor physical and mental health and substance use can achieve stable housing.

La Crosse encephalitis surveillance using single versus paired serologic testing

We evaluated the validity of single versus paired serologic testing for La Crosse virus (LACV) encephalitis surveillance. Compared with paired serology, a single positive IgG or IgM immunoflourescent antibody titre appears useful for LACV encephalitis surveillance with sensitivity, 75%; specificity, 98%; positive predictive value, 95%; and overall test efficiency 92%.

Inequalities in determinants of health among Aboriginal and Caucasian persons living with HIV/AIDS in Ontario: results from the Positive Spaces, Healthy Places Study

OBJECTIVES

Aboriginal Canadians (i.e., First Nations, Inuit and Métis) are disproportionately affected by HIV/AIDS, and experience greater social and economic marginalization and poorer housing conditions. This study sought to understand the differences in the determinants of health and housing-related characteristics between samples of Aboriginal and Caucasian adults living with HIV/AIDS in Ontario.

METHODS

We analyzed baseline demographic, socio-economic, health, and housing-related data from 521 individuals (79 Aboriginal and 442 Caucasian) living with HIV/AIDS and enrolled in the Positive Spaces, Healthy Places study. We compared the characteristics of Aboriginal and Caucasian participants to identify determinants of health and housing-related characteristics independently associated with Aboriginal ethnicity.

RESULTS

Compared to Caucausian participants living with HIV, Aboriginal participants were more likely to be younger, female or transgender women, less educated, unemployed, and homeless or unstably housed. They were also more likely to have low incomes and to have experienced housing-related discrimination. In a multivariate model, gender, income, and experiences of homelessness were independently associated with Aboriginal ethnicity.

CONCLUSION

Aboriginal individuals living with HIV/AIDS in our sample are coping with significantly worse social and economic conditions and are more likely to experience challenging housing situations than a comparison group of Caucasian individuals living with HIV/AIDS. To develop effective care, treatment and support strategies for Aboriginal peoples with HIV, it is critical to address and improve their socio-economic and housing conditions.

Influence of neighborhood deprivation, gender and ethno-racial origin on smoking behavior of Canadian youth

OBJECTIVE

Deprived neighborhoods play an important role in adult smoking behavior, but little research exists about youth on this topic. This study explored the relationship between deprivation and youth smoking to examine whether this association differs by gender and ethno-racial origin.

METHODS

Individual-level data from the Canadian Community Health Survey (2000-2005) were combined with neighborhood-level data from the 2001 Canada Census to assess smoking among youth aged 12-18 (n = 15,615).

RESULTS

Youth who were female (OR = 1.27, 95%CI:1.16-1.38), White (OR = 1.95, 95%CI:1.71-2.21) and living in deprived neighborhoods (OR = 1.22, 95%CI:1.16-1.28) were more likely to smoke. In multilevel models, White females were more likely to smoke relative to non-White females and males (OR = 1.42, 95%CI:1.06-1.89). Youth with a strong sense of community belonging and living in deprived neighborhoods were at increased risk of smoking (OR = 1.18, 95%CI:1.06-1.32). The individual-level risk factor, household smoker, contributed substantially to youth smoking reducing the bivariate association between material deprivation and smoking by 33%.

CONCLUSION

White females, youth cohabiting with other smokers and youth living in poor neighborhoods with a strong sense of community belonging, are at an increased risk of smoking. Future anti-smoking efforts might have greater impact if they target at-risk youth as well as household members who cohabit with youth.

Inequalities in determinants of health among Aboriginal and Caucasian persons living with HIV/AIDS in Ontario: results from the Positive Spaces, Healthy Places Study

OBJECTIVES

Aboriginal Canadians (i.e., First Nations, Inuit and Métis) are disproportionately affected by HIV/AIDS, and experience greater social and economic marginalization and poorer housing conditions. This study sought to understand the differences in the determinants of health and housing-related characteristics between samples of Aboriginal and Caucasian adults living with HIV/AIDS in Ontario.

METHODS

We analyzed baseline demographic, socio-economic, health, and housing-related data from 521 individuals (79 Aboriginal and 442 Caucasian) living with HIV/AIDS and enrolled in the Positive Spaces, Healthy Places study. We compared the characteristics of Aboriginal and Caucasian participants to identify determinants of health and housing-related characteristics independently associated with Aboriginal ethnicity.

RESULTS

Compared to Caucausian participants living with HIV, Aboriginal participants were more likely to be younger, female or transgender women, less educated, unemployed, and homeless or unstably housed. They were also more likely to have low incomes and to have experienced housing-related discrimination. In a multivariate model, gender, income, and experiences of homelessness were independently associated with Aboriginal ethnicity.

CONCLUSION

Aboriginal individuals living with HIV/AIDS in our sample are coping with significantly worse social and economic conditions and are more likely to experience challenging housing situations than a comparison group of Caucasian individuals living with HIV/AIDS. To develop effective care, treatment and support strategies for Aboriginal peoples with HIV, it is critical to address and improve their socio-economic and housing conditions.

Brucella melitensis infection following military duty in Iraq

Brucellosis is a common zoonotic disease worldwide; however, few cases are reported in the US. Brucella melitensis infections are primarily acquired via consumption of high-risk foods or travel to endemic areas. We describe a case of B. melitensis infection in a Tennessee soldier following deployment in Iraq. Initial symptoms included knee and back pain. Culture of an aspirate of the left sacroiliac joint yielded B. melitensis. Genetic analysis indicated that this isolate came from the Middle East. Investigation of laboratory workers identified risky exposures and positive serology prompting post-exposure prophylaxis. Military personnel and other travellers should be advised to reduce risk regarding food consumption and animal contact in endemic areas. Additionally, medical providers should remain vigilant for non-endemic zoonoses among recent travellers.

Mortality of one-week-old chickens during naturally occurring Marek's disease virus infection

Marek's disease (MD) is a disease of chickens that occurs worldwide and has serious economic consequences. MD can present as one of several forms, with the most commonly occurring forms being the lymphoproliferative diseases. Under experimental conditions, an early mortality syndrome has been recognized following infection by some but not all strains of MD virus (MDV). This is the first report of a confirmed case of mortality due to naturally occurring MDV infection in 1-week-old, nonvaccinated, chickens. Necrotizing lesions were observed in the bursa of Fabricius, lung, duodenum, jejunum, and proventriculus, and large intranuclear inclusion bodies were a striking feature in tissues with lesions in all birds. Immunohistochemical staining for the pp38 protein of MDV revealed abundant pp38 antigen in the affected tissues, confirming the presence of MDV within the lesions. PCR yielded an amplicon with 97% homology to the meq gene of MDV. No evidence of co-infection by either of the immunosuppressive agents chicken anemia virus and infectious bursal disease virus was detected.

Neighbourhood deprivation and regional inequalities in self-reported health among Canadians: are we equally at risk?

Individual-level data from the Canadian Community Health Survey was combined with area-level data from the 2001 Canada Census to explore the relationship between neighbourhood deprivation and regional inequalities in self-reported health (n=120,290). While neighbourhood deprivation was a significant predictor of fair/poor health in all geographic regions (OR=1.11; 95% CI: 1.08, 1.14), living on the Atlantic and Pacific coasts exacerbated the detrimental effects of neighbourhood deprivation on the perceived health of respondents (OR=1.21; 1.28). By failing to explore regional variations in risk, we could fail to identify areas where provincial policies may interact with neighbourhood factors to reinforce health inequalities amongst deprived communities.

Genetics and vaccine efficacy: host genetic variation affecting Marek's disease vaccine efficacy in White Leghorn chickens

Marek's disease (MD) is a T-cell lymphoma disease of domestic chickens induced by MD virus (MDV), a naturally oncogenic and highly contagious cell-associated α-herpesvirus. Earlier reports have shown that the MHC haplotype as well as non-MHC genes are responsible for genetic resistance to MD. The MHC was also shown to affect efficiency of vaccine response. Using specific-pathogen-free chickens from a series of 19 recombinant congenic strains and their 2 progenitor lines (lines 6(3) and 7(2)), vaccine challenge experiments were conducted to examine the effect of host genetic variation on vaccine efficacy. The 21 inbred lines of White Leghorns share the same B*2 MHC haplotype and the genome of each recombinant congenic strain differs by a random 1/8 sample of the susceptible donor line (7(2)) genome. Chickens from each of the lines were divided into 2 groups. One was vaccinated with turkey herpesvirus strain FC126 at the day of hatch and the other was treated as a nonvaccinated control. Chickens of both groups were inoculated with a very virulent plus strain of MDV on the fifth day posthatch. Analyses of the MD data showed that the genetic line significantly influenced MD incidence and days of survival post-MDV infection after vaccination of chickens (P<0.01). The protective indices against MD varied greatly among the lines with a range of 0 up to 84%. This is the first evidence that non-MHC host genetic variation significantly affects MD vaccine efficacy in chickens in a designed prospective study.