Identifying latent classes of physical activity profiles over time among adolescents in Ontario, Canada

BACKGROUND

Physical activity behaviours are known to be highly correlated. Adolescents who participate in one type of physical activity (e.g., physical education) have a greater likelihood of participating in other physical activities (e.g., organized sports); however, little research has examined participation rates in various physical activity behaviours concurrently. This study identified longitudinal physical activity profiles among secondary school aged youth in Ontario, Canada.

METHODS

We used data from the COMPASS Study, a school-based prospective cohort study of adolescents in Canada. Using a repeated measures latent class analysis, Ontario students who participated in grade 9 PE in 2015-16 were analysed through to 2018-19 (n = 1,917). Latent classes were defined by: PE participation, guideline adherence (≥ 60 min/day of moderate to vigorous activity over the last 7 days), and sport participation (varsity, community, and/or intramural). Multinomial logistic regression models were used to examine associations between latent class membership and student characteristics.

RESULTS

Three distinct latent classes were identified for females and four were identified for males. These classes were: (1) Guidelines (high probability of guideline adherence; females: 44%; males: 16%), (2) PE & Sports (high probability of PE and sport participation; females: 33%; males: 43%), (3) Guidelines & Sports (high probability of guideline adherence and sport participation; females: 23%; males: 23%;), and (4) Inactive (low probability of all physical activity indicators; males: 18%). Strength training, sleep, and English grade were associated with class membership among females. Ethno-racial identity, weekly spending money, strength training, and English and math grades were associated with class membership among males.

CONCLUSIONS

Findings suggest that latent physical activity profiles differ by sex. Guideline adherence was the most common class among females, indicating high levels of independent physical activity, whereas PE & Sport participation was the most common class among males, indicating greater tendency towards organized activities. Additionally, a substantial number of male students were not engaging in any physical activity. Participation in both PE and sports did not necessarily lead to meeting physical activity guidelines, highlighting that these activities alone may not be providing sufficient levels of physical activity that align with current recommendations for Canadian youth.

Impact of Exposure to a Mixture of Organophosphate Esters on Adrenal Cell Phenotype, Lipidome, and Function

Organophosphate esters (OPEs) are used primarily as flame retardants and plasticizers. Previously, we reported that adrenal cells are important targets of individual OPEs. However, real-life exposures are to complex mixtures of these chemicals. To address this, we exposed H295R human adrenal cells to varying dilutions (1/1000K to 1/3K) of a Canadian household dust-based OPE mixture for 48 hours and evaluated effects on phenotypic, lipidomic, and functional parameters. Using a high-content screening approach, we assessed phenotypic markers at mixture concentrations at which there was greater than 70% cell survival; the most striking effect of the OPE mixture was a 2.5-fold increase in the total area of lipid droplets. We then determined the response of specific lipid species to OPE exposures with novel, nontargeted lipidomic analysis of isolated lipid droplets. These data revealed that house dust OPEs induced concentration-dependent alterations in the composition of lipid droplets, particularly affecting the triglyceride, diglyceride, phosphatidylcholine, and cholesterol ester subclasses. The steroid-producing function of adrenal cells in the presence or absence of a steroidogenic stimulus, forskolin, was determined. While the production of 17β-estradiol remained unaffected, a slight decrease in testosterone production was observed after stimulation. Conversely, a 2-fold increase in both basal and stimulated cortisol and aldosterone production was observed. Thus, exposure to a house dust-based mixture of OPEs exerts endocrine-disrupting effects on adrenal cells, highlighting the importance of assessing the effects of environmentally relevant mixtures.

A study protocol for a predictive model to assess population-based avoidable hospitalization risk: Avoidable Hospitalization Population Risk Prediction Tool (AvHPoRT)

INTRODUCTION

Avoidable hospitalizations are considered preventable given effective and timely primary care management and are an important indicator of health system performance. The ability to predict avoidable hospitalizations at the population level represents a significant advantage for health system decision-makers that could facilitate proactive intervention for ambulatory care-sensitive conditions (ACSCs). The aim of this study is to develop and validate the Avoidable Hospitalization Population Risk Tool (AvHPoRT) that will predict the 5-year risk of first avoidable hospitalization for seven ACSCs using self-reported, routinely collected population health survey data.

METHODS AND ANALYSIS

The derivation cohort will consist of respondents to the first 3 cycles (2000/01, 2003/04, 2005/06) of the Canadian Community Health Survey (CCHS) who are 18-74 years of age at survey administration and a hold-out data set will be used for external validation. Outcome information on avoidable hospitalizations for 5 years following the CCHS interview will be assessed through data linkage to the Discharge Abstract Database (1999/2000-2017/2018) for an estimated sample size of 394,600. Candidate predictor variables will include demographic characteristics, socioeconomic status, self-perceived health measures, health behaviors, chronic conditions, and area-based measures. Sex-specific algorithms will be developed using Weibull accelerated failure time survival models. The model will be validated both using split set cross-validation and external temporal validation split using cycles 2000-2006 compared to 2007-2012. We will assess measures of overall predictive performance (Nagelkerke R2), calibration (calibration plots), and discrimination (Harrell's concordance statistic). Development of the model will be informed by the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD) statement.

ETHICS AND DISSEMINATION

This study was approved by the University of Toronto Research Ethics Board. The predictive algorithm and findings from this work will be disseminated at scientific meetings and in peer-reviewed publications.

'Feeling Ready': A Feminist Poststructural Analysis of Postpartum Sexual Health

There exists a lack of literature surrounding how postpartum individuals define feeling 'ready' to resume sexual activities after childbirth. Many factors may influence feelings of desire or readiness for sexual activities, such as breastfeeding. Therefore, it is important to understand why and how postpartum individuals understand and make meaning of their experiences surrounding postpartum sexual activities, as well as how those experiences are influenced or negotiated through relations of power. This study was guided by feminist poststructuralism and discourse analysis. Eleven participants who were between 1 and 6 months postpartum and living in Nova Scotia, Canada, were interviewed using semi-structured interviews. Participants challenged certain discourses surrounding sexual activities postpartum, including the social discourse that positions sexual activities as a requirement within romantic relationships and the discourse that positions health care providers as the authority on postpartum sexual health. 'Feeling ready' centered on four main issues: (1) navigating physical recovery; (2) personal knowing and emotional readiness; (3) the 6-week check; and (4) redefining intimacy. This article describes one branch of the findings within the overall study. Choosing to resume sexual activities postpartum, or feeling ready to do so, is individual, fluid, and complex. This research has important implications for practice and policy, specifically as it pertains to postpartum care.

School learning modes during the COVID-19 response and pre- to during pandemic mental health changes in a prospective cohort of Canadian adolescents

PURPOSE

Considerable debate centered on the impact of school closures and shifts to virtual learning on adolescent mental health during the COVID-19 pandemic. We evaluated whether mental health changes differed by school learning modes during the pandemic response among Canadian adolescents and whether associations varied by gender and perceived home life.

METHODS

We used prospective survey data from 7270 adolescents attending 41 Canadian secondary schools. Conditional change linear mixed effects models were used to examine learning mode (virtual optional, virtual mandated, in-person, and blended) as a predictor of change in mental health scores (depression [Centre for Epidemiologic Studies - Depression], anxiety [Generalized Anxiety Disorder-7], and psychosocial well-being [Flourishing scale]), adjusting for baseline mental health and covariates. Gender and home life happiness were tested as moderators. Least square means were calculated across interaction groups.

RESULTS

Students learning in a blended learning mode had greater anxiety increases relative to their peers in other learning modes. Females learning fully in-person and males learning virtually when optional reported less of an increase in depression scores relative to their gender counterparts in other learning modes. Learning virtually when optional was associated with greater declines in psychosocial well-being in students without happy home lives relative to other learning modes.

CONCLUSION

Findings demonstrate the importance of considering gender and home environments as determinants of mental health over the pandemic response and when considering alternative learning modes. Further research is advised before implementing virtual and blended learning modes. Potential risks and benefits must be weighed in the context of a pandemic.

Upper Limb Morbidity in Newly Diagnosed Individuals After Unilateral Surgery for Breast Cancer: Baseline Results from the AMBER Cohort Study

PURPOSE

We aimed to examine potential associations between post-surgical upper limb morbidity and demographic, medical, surgical, and health-related fitness variables in newly diagnosed individuals with breast cancer.

METHODS

Participants were recruited between 2012 and 2019. Objective measures of health-related fitness, body composition, shoulder range of motion, axillary web syndrome, and lymphedema were performed within 3 months of breast cancer surgery, and prior to or at the start of adjuvant cancer treatment.

RESULTS

Upper limb morbidity was identified in 54% of participants and was associated with poorer upper limb function and higher pain. Multivariable logistic regression analysis identified mastectomy versus breast-conserving surgery (odds ratio [OR] 3.51, 95% confidence interval [CI] 2.65-4.65), axillary lymph node dissection versus sentinel lymph node dissection (OR 2.67, 95% CI 1.73-4.10), earlier versus later time from surgery (OR 1.58, 95% CI 1.15-2.18), and younger versus older age (OR 1.01, 95% CI 1.00-1.03) as significantly associated with a higher odds of upper limb morbidity, while mastectomy (OR 1.57, 95% CI 1.10-2.25), axillary lymph node dissection (OR 2.20, 95% CI 1.34-3.60), lower muscular endurance (OR 1.10, 95% CI 1.01-1.16) and higher percentage body fat (OR 1.04, 95% CI 1.00-1.07) were significantly associated with higher odds of moderate or greater morbidity severity.

CONCLUSIONS

Upper limb morbidity is common in individuals after breast cancer surgery prior to adjuvant cancer treatment. Health-related fitness variables were associated with severity of upper limb morbidity. Findings may facilitate prospective surveillance of individuals at higher risk of developing upper limb morbidity.

The association between income inequality and adolescent body mass index: findings from the COMPASS study (2016-2019)

OBJECTIVES

Income inequality has been linked to high and unhealthy body mass index (BMI), though there is a dearth of evidence in adolescents. Therefore, this study examines the association between income inequality and BMI in a large sample of Canadian adolescents.

METHODS

A pooled cross-sectional design was used. Participants were adolescents (n = 101,901) from 157 Canadian secondary schools participating in the 2016-2017, 2017-2018, or 2018-2019 waves of the Cannabis, Obesity, Mental health, Physical activity, Alcohol, Smoking, and Sedentary behaviour (COMPASS) study. BMI was calculated from self-reported height and weight and converted to World Health Organization (WHO) z-BMI scores. Gini coefficients were calculated at the census division level (n = 49) using data from the 2016 Canadian Census. Multilevel modelling was performed to account for the clustering of students nested within schools, which were nested within census divisions. Interactions were included to determine whether associations were heterogeneous for males and females.

RESULTS

Income inequality demonstrated a non-linear association with WHO z-BMI score (z-Gini: β = 0.05, 95%CI: 0.02, 0.08; z-Gini2: β = -0.02, 95% CI: -0.04, -0.01) among adolescents after adjusting for student-, school-, and census division-level covariates. This association was more pronounced among females.

CONCLUSION

The association between income inequality and BMI, being overweight, or having obesity appears to be non-linear. Public health units and schools may benefit from incorporating upstream factors such as income inequality into their interventions attempting to promote healthy weights.

Circumstances and outcome of active transportation injuries: protocol of a British Columbian inception cohort study

INTRODUCTION

Active transport (AT) is promoted by urban planners and health officials for its environmental, economic and societal benefits and its uptake is increasing. Unfortunately, AT users can be injured or killed due to falls or collisions. Active transport injury (ATI) prevention efforts are hindered by limited research on the circumstances, associated infrastructure, injury pattern, severity and outcome of ATI events. This study seeks to address these knowledge gaps by identifying built environment features associated with injury and risk factors for a poor outcome following ATI.

METHODS AND ANALYSIS

This prospective observational study will recruit an inception cohort of 2000 ATI survivors, including pedestrians, cyclists and micromobility users aged 16 years and older who arrive at a participating emergency department within 48 hours of sustaining an ATI. Baseline interviews capture demographic and socioeconomic information, pre-injury health and functional status, as well as circumstances of the injury event and recovery expectations. Follow-up interviews at 2, 4, 6 and 12 months postinjury (key stages of recovery) use standardised health-related quality of life tools to determine physical and mental health outcomes, functional recovery and healthcare resource use and lost productivity costs.

ETHICS AND DISSEMINATION

The Active Transportation Injury Circumstances and Outcome Study is approved by our institutional research ethics board and the research ethics boards of all participating sites. This study aims to provide healthcare providers with knowledge of risk factors for poor outcome following ATI with the goal of improving patient management. Additionally, this study will provide insight into the circumstances of ATI events including built environment features and how those circumstances relate to recovery outcomes. This information can be used to inform city engineers and planners, policymakers and public health officials to plan roadway design and injury prevention policy.

Walking hand in hand: The role of affection-sharing in understanding the social network effect in same-sex, mixed-sex, and gender-diverse relationships

Individuals who perceive greater support or approval for their relationships from friends and family also report greater relationship stability and commitment and better mental and physical health (known as the "social network effect"). These associations have been explained, in part, through three cognitive-affective processes: uncertainty reduction, cognitive balance, and dyadic identity formation. However, we know less about cognitive-behavioral mechanisms that might help explain the social network effect. In this study, we propose and test a model in which physical affection-sharing acts as one such behavioral mechanism. In a sample of 1848 individuals in same-sex (n = 696), mixed-sex (n = 1045), and gender-diverse (n = 107) relationships, we found support for our overall model. Our findings suggest that perceived support for one's relationships is a significant predictor of perceived support for physical affection-sharing, which in turn predicts the frequency of affection-sharing in private and public contexts and, ultimately, relationship well-being. However, we also found that relationship type moderates these associations, highlighting how the experience of sharing affection with one's partner changes for many in marginalized relationships, especially in public. We conclude by discussing how our findings contribute to theories of social support for relationships, underscoring the importance of considering affective, cognitive, and behavioral factors relevant to the process. We also emphasize the understudied role of context in shaping affection-sharing experiences across all relationship types.

The impact of 12 modifiable lifestyle behaviours on depressive and anxiety symptoms in middle adolescence: prospective analyses of the Canadian longitudinal COMPASS study

BACKGROUND

Unhealthy lifestyle behaviours are becoming increasingly common and might contribute to the growing burden of mental disorders in adolescence. We examined the associations between a comprehensive set of lifestyle behaviours and depression and anxiety in middle adolescents.

METHODS

School-based survey responses were collected from 24,274 Canadian high school students at baseline and 1-year follow-up (average age 14.8 and 15.8 years, respectively). Using linear mixed-effects models, we examined prospective associations of adherence to recommendations for vegetables and fruit, grains, milk and alternatives, meat and alternatives, sugar-sweetened beverages [SSB], physical activity, screen time, sleep, and no use of tobacco, e-cigarettes, cannabis, and binge drinking at baseline with the depressive and anxiety symptoms (measured by CESD-R-10 and GAD-7 scales, respectively) at follow-up.

RESULTS

Adherence to recommendations was low overall, particularly for vegetables and fruit (3.9%), grains (4.5%), and screen time (4.9%). Students adhering to individual recommendations, particularly for meat and alternatives, SSB, screen time, sleep, and no cannabis use, at baseline had lower CESD-R-10 and GAD-7 scores at follow-up. Adhering to every additional recommendation was associated with lower CESD-R-10 (β=-0.15, 95% CI -0.18, -0.11) and GAD-7 scores (β=-0.10, 95% CI -0.14, -0.07) at follow-up. Assuming cumulative impact, this might translate into 7.2- and 4.8-point lower CESD-R-10 and GAD-7 scores, respectively, among students adhering to 12 vs. 0 recommendations over four years of high school.

CONCLUSIONS

The results highlight the preventive potential of population-based approaches promoting healthy lifestyle behaviours, particularly those with the lowest prevalence, as a strategy to improve mental health in adolescence.

Hospital Paperworlds: Medical (Mis)Reporting and Maternal Health in Northern Pakistan

Global health metrics come into being in complex circumstances. Through ethnography that focuses closely on the forces driving uneven obstetric case reporting in a government hospital in northern Pakistan, this article challenges the integrity of the health care system documentation on which the state and non-state interventions and evaluations rely. Incomplete and skipped case records not only resulted from the time constraints posed by work on a busy maternity ward. They also helped vulnerable frontline providers disguise and avoid accountability for the aftermaths of the medical mismanagement and maltreatment made more likely by infrastructural scarcity and disarray. Yet the provider-side protections these tactics afforded came at patients' expense because they rendered error, wrongdoing, and iatrogenesis as invisible and unactionable. The sum of these reporting practices was "hospital paperworlds": defensively authored and aspirational datasets that conveyed desired rather than achieved outcomes, decontextualized risks and harms, and were too-rarely triangulated for their correlational significances or deficiencies. [hospital ethnography, obstetrics, case reporting, metrics, Pakistan].

Wastewater-Based Surveillance Is an Effective Tool for Trending COVID-19 Prevalence in Communities: A Study of 10 Major Communities for 17 Months in Alberta

The correlations between SARS-CoV-2 RNA levels in wastewater from 12 wastewater treatment plants and new COVID-19 cases in the corresponding sewersheds of 10 communities were studied over 17 months. The analysis from the longest continuous surveillance reported to date revealed that SARS-CoV-2 RNA levels correlated well with temporal changes of COVID-19 cases in each community. The strongest correlation was found during the third wave (r = 0.97) based on the population-weighted SARS-CoV-2 RNA levels in wastewater. Different correlations were observed (r from 0.51 to 0.86) in various sizes of communities. The population in the sewershed had no observed effects on the strength of the correlation. Fluctuation of SARS-CoV-2 RNA levels in wastewater mirrored increases and decreases of COVID-19 cases in the corresponding community. Since the viral shedding to sewers from all infected individuals is included, wastewater-based surveillance provides an unbiased and no-discriminate estimation of the prevalence of COVID-19 compared with clinical testing that was subject to testing-seeking behaviors and policy changes. Wastewater-based surveillance on SARS-CoV-2 represents a temporal trend of COVID-19 disease burden and is an effective and supplementary monitoring when the number of COVID-19 cases reaches detectable thresholds of SARS-CoV-2 RNA in wastewater of treatment facilities serving various sizes of populations.

Impacts of economic inequality on healthcare worker safety at the onset of the COVID-19 pandemic: cross-sectional analysis of a global survey

OBJECTIVES

To assess the extent to which protection of healthcare workers (HCWs) as COVID-19 emerged was associated with economic inequality among and within countries.

DESIGN

Cross-sectional analysis of associations of perceptions of workplace risk acceptability and mitigation measure adequacy with indicators of respondents' respective country's economic income level (World Bank assessment) and degree of within-country inequality (Gini index).

SETTING

A global self-administered online survey.

PARTICIPANTS

4977 HCWs and healthcare delivery stakeholders from 161 countries responded to health and safety risk questions and a subset of 4076 (81.2%) answered mitigation measure questions. The majority (65%) of study participants were female.

RESULTS

While the levels of risk being experienced at the pandemic's onset were consistently deemed as unacceptable across all groupings, participants from countries with less income inequality were somewhat less likely to report unacceptable levels of risk to HCWs regarding both workplace environment (OR=0.92, p=0.012) and workplace organisational factors (OR=0.93, p=0.017) compared with counterparts in more unequal national settings. In contrast, considerable variation existed in the degree to which mitigation measures were considered adequate. Adjusting for other influences through a logistic regression analysis, respondents from lower middle-income and low-income countries were comparatively much more likely to assess both occupational health and safety (OR=10.91, p≤0.001) and infection prevention and control (IPC) (OR=6.61, p=0.001) protection measures as inadequate, despite much higher COVID-19 rates in wealthier countries at the time of the survey. Greater within-country income inequality was also associated with perceptions of less adequate IPC measures (OR=0.94, p=0.025). These associations remained significant when accounting for country-level differences in occupational and gender composition of respondents, including specifically when only female care providers, our study's largest and most at-risk subpopulation, were examined.

CONCLUSIONS

Economic inequality threatens resilience of health systems that rely on health workers working safely to provide needed care during emerging pandemics.

On guard: Public versus private affection-sharing experiences in same-sex, gender-diverse, and mixed-sex relationships

This study compared public versus private affection-sharing experiences of individuals in mixed-sex (N = 1018), same-sex (N = 561), and gender-diverse (N = 96) relationships. Private affection-sharing was similar across groups, except those in mixed-sex relationships reported somewhat less comfort doing so. Despite having a stronger desire to engage in public affection-sharing, those in same-sex and gender-diverse relationships shared public affection less frequently, were less comfortable doing so, refrained from doing so more often, and experienced much higher levels of vigilance related to public affection-sharing, compared to those in mixed-sex relationships. Heightened PDA-related vigilance may have health consequences, as higher levels were associated with worse psychological and physical well-being in all groups. However, individuals in same-sex relationships showed weaker associations between vigilance and well-being than those in mixed-sex relationships, suggesting possible resilience. Still, engaging in vigilance may take its toll, potentially serving as a mechanism through which minority stress works its effects. When we controlled for PDA-related vigilance, psychological and physical well-being levels in same-sex relationships increased relative to mixed-sex peers.

Effectiveness of case-area targeted interventions including vaccination on the control of epidemic cholera: protocol for a prospective observational study

INTRODUCTION

Cholera outbreaks in fragile settings are prone to rapid expansion. Case-area targeted interventions (CATIs) have been proposed as a rapid and efficient response strategy to halt or substantially reduce the size of small outbreaks. CATI aims to deliver synergistic interventions (eg, water, sanitation, and hygiene interventions, vaccination, and antibiotic chemoprophylaxis) to households in a 100-250 m 'ring' around primary outbreak cases.

METHODS AND ANALYSIS

We report on a protocol for a prospective observational study of the effectiveness of CATI. Médecins Sans Frontières (MSF) plans to implement CATI in the Democratic Republic of the Congo (DRC), Cameroon, Niger and Zimbabwe. This study will run in parallel to each implementation. The primary outcome is the cumulative incidence of cholera in each CATI ring. CATI will be triggered immediately on notification of a case in a new area. As with most real-world interventions, there will be delays to response as the strategy is rolled out. We will compare the cumulative incidence among rings as a function of response delay, as a proxy for performance. Cross-sectional household surveys will measure population-based coverage. Cohort studies will measure effects on reducing incidence among household contacts and changes in antimicrobial resistance.

ETHICS AND DISSEMINATION

The ethics review boards of MSF and the London School of Hygiene and Tropical Medicine have approved a generic protocol. The DRC and Niger-specific versions have been approved by the respective national ethics review boards. Approvals are in process for Cameroon and Zimbabwe. The study findings will be disseminated to the networks of national cholera control actors and the Global Task Force for Cholera Control using meetings and policy briefs, to the scientific community using journal articles, and to communities via community meetings.

A virus unites the world while national border closures divide it: Epidemiologic, legal, and political analysis on border closures during COVID-19

This article critically examines the use of national border closures at the outset of the COVID-19 pandemic. After explaining why targeted border closures generally do not work and how they violated international law at the time, we examine the unprecedented case of total border closures. Positing that since the current instruments and institutions of global health governance did not anticipate this phenomenon, the legality of total border closures rests on less certain grounds. Then, after asking why nearly every government implemented some form of border closure in March 2020 if neither science nor law provided adequate motivation for their use, we conclude that in the face of a global health emergency, border closures represent an opportunity for political leaders to show determined action, redirect blame to other jurisdictions, and reinforce nationalism. We proceed to argue that both targeted and total border closures have profound legal, epidemiological, and political significance as performances that contradict global realities while undermining notions of global solidarity. Such political theatre means that citizens must weigh these consequences against any perceived benefits of border closures as they would any other politically driven government action, and contest and challenge them appropriately. Citizens must not unduly defer to scientists or lawyers on early COVID-19 border closures because these were primarily political-not scientific or legal-decisions. In this vein, we conclude with some guiding political considerations for scrutinizing government decisions to close borders and observations for the future of global health cooperation during infectious disease outbreaks.

Impact of employing primary healthcare professionals in emergency department triage on patient flow outcomes: a systematic review and meta-analysis

OBJECTIVES

To identify, critically appraise and summarise evidence on the impact of employing primary healthcare professionals (PHCPs: family physicians/general practitioners (GPs), nurse practitioners (NP) and nurses with increased authority) in the emergency department (ED) triage, on patient flow outcomes.

METHODS

We searched Medline (Ovid), EMBASE (Ovid), Cochrane Library (Wiley) and CINAHL (EBSCO) (inception to January 2020). Our primary outcome was the time to provider initial assessment (PIA). Secondary outcomes included time to triage, proportion of patients leaving without being seen (LWBS), length of stay (ED LOS), proportion of patients leaving against medical advice (LAMA), number of repeat ED visits and patient satisfaction. Two independent reviewers selected studies, extracted data and assessed study quality using the National Institute for Health and Care Excellence quality assessment tool.

RESULTS

From 23 973 records, 40 comparative studies including 10 randomised controlled trials (RCTs) and 13 pre-post studies were included. PHCP interventions were led by NP (n=14), GP (n=3) or nurses with increased authority (n=23) at triage. In all studies, PHCP-led intervention effectiveness was compared with the traditional nurse-led triage model. Median duration of the interventions was 6 months. Study quality was generally low (confounding bias); 7 RCTs were classified as moderate quality. Most studies reported that PHCP-led triage interventions decreased the PIA (13/14), ED LOS (29/30), proportion of patients LWBS (8/10), time to triage (3/3) and repeat ED visits (5/6), and increased the patient satisfaction (8/10). The proportion of patients LAMA did not differ between groups (3/3). Evidence from RCTs (n=8) as well as other study designs showed a significant decrease in ED LOS favouring the PHCP-led interventions.

CONCLUSIONS

Overall, PHCP-led triage interventions improved ED patient flow metrics. There was a significant decrease in ED LOS irrespective of the study design, favouring the PHCP-led interventions. Evidence from well-designed high-quality RCTs is required prior to widespread implementation.

PROSPERO REGISTRATION NUMBER

CRD42020148053.

Measuring the Commercial Determinants of Health and Disease: A Proposed Framework

The commercial determinants of health (CDoH) describe the adverse health effects associated with for-profit actors and their actions. Despite efforts to advance the definition, conceptualization, and empirical analyses of CDoH, the term's practical application to mitigate these effects requires the capacity to measure the influences of specific components of CDoH and the cumulative impacts of CDoH on the health and well-being of specific populations. Building on the Global Burden of Disease Study, we begin by conceptualizing CDoH as risk factor exposures that span agency and structural influences. We identify 6 components of these influences and propose an initial set of indicators and datasets to rank exposures as high, medium, or low. These are combined into a commercial determinants of health index (CDoHi) and illustrated by 3 countries. Although now a proof of concept, comparative analysis of CDoH exposures by population, over time and space, and their associated health outcomes will become possible with further development of indicators and datasets. Expansion of the CDoHi and application to varied populations groups will enable finer targeting of interventions to reduce health harms. The measurement of improvements to health and wellness from such interventions will, in turn, inform overall efforts to address the CDoH.

Renal effectiveness and safety of the sodium-glucose cotransporter-2 inhibitors: a population-based cohort study

INTRODUCTION

To assess the comparative effectiveness and safety of renal-related outcomes associated with sodium-glucose cotransporter-2 inhibitors (SGLT2-i) initiation among patients with type 2 diabetes using real-world data.

RESEARCH DESIGN AND METHODS

We conducted a population-based cohort study using administrative healthcare data from Alberta (AB), Canada and primary care data from the Clinical Practice Research Datalink (CPRD), UK. From a cohort of new metformin users, we identified initiators of a SGLT2-i or dipeptidyl peptidase-4 inhibitor (DPP4-i) between January 1, 2014 and March 30, 2018 (AB) or between January 1, 2013 and November 29, 2018 (CPRD). Initiators of an SGLT2-i or DPP4-i were followed until death, disenrolment, therapy discontinuation, or study end date. The effectiveness outcome was renal disease progression, defined as a composite of new-onset macroalbuminuria, serum creatinine doubling with estimated glomerular filtration rate of ≤45 mL/min/1.73 m², renal replacement therapy, hospital admission or death from renal causes. The safety outcome was hospitalization due to acute kidney injury (AKI). We adjusted for confounding using high-dimensional propensity score matching and estimated HRs using Cox proportional hazards regression. Aggregate data from each database were combined by random-effects meta-analysis.

RESULTS

Among the 29 465 included patients (20 564 AB, 8901 CPRD), 37.5% were new SGLT2-i users in AB and 21.3% in CPRD. Compared with DPP4 initiators, SGLT2-i initiators were associated with a reduced risk of renal disease progression (pooled HR 0.79, 95% CI 0.62 to 1.00); however, there was no significant difference in the risk of AKI (pooled HR 0.89, 95% CI 0.58 to 1.36). These findings were consistent with other exposure definitions and antidiabetic comparators.

CONCLUSIONS

Our findings support a renoprotective effect of SGLT2-i without an increased risk of AKI, compared with clinically relevant active comparators.

Global stakeholder perspectives of home birth: a systematic scoping review

Home birth is experienced by people very differently worldwide. These experiences likely differ by the type of stakeholder involved (women, their support persons, birth attendants, policy-makers), the experience itself (low-risk birth, transfer to hospital, previous deliveries), and by the health system within which home birth occurs (e.g., high-resource versus low- and middle-resource countries). Research evidence of stakeholders' perspectives of home birth could usefully inform personal and policy decisions about choosing and providing home birth, but the current literature is fragmented and its breadth is not fully understood.We conducted a systematic scoping review to understand how the research literature on stakeholders' perspectives of home birth is characterized in terms of populations, settings and identified issues, and what potential gaps exist in the research evidence. A range of electronic, web-based and key informant sources of evidence were searched. Located references were assessed, data extracted, and descriptively analyzed using robust methods.Our analysis included 460 full reports. Findings from 210 reports of studies in high-resource countries suggested that research with fathers and same-sex partners, midwives, and vulnerable populations and perspectives of freebirth and transfer to hospital could be synthesized. Gaps in primary research exist with respect to family members, policy makers, and those living in rural and remote locations. A further 250 reports of studies in low- and middle-resource countries suggested evidence for syntheses related to fathers and other family members, policy makers, and other health care providers and examination of issues related to emergency transfer to hospital, rural and remote home birth, and those who birth out of hospital, often at home, despite receiving antenatal care intended to increase healthcare-seeking behavior. Gaps in primary research suggest an examination is needed of perspectives in countries with higher maternal mortality and among first-time mothers and young mothers.Our scoping review identified a considerable body of research evidence on stakeholder perspectives of home birth. These could inform the complex factors influencing personal decisions and health system planning around home birth in both high- and low- and middle-resource countries. Future primary research is warranted on specific stakeholders worldwide and with vulnerable populations in areas of high maternal mortality.

Public acceptability of the UK Soft Drinks Industry Levy: repeat cross-sectional analysis of the International Food Policy Study (2017-2019)

OBJECTIVES

To determine whether public acceptability, in terms of both support for and perceived effectiveness of, the UK Soft Drinks Industry Levy (SDIL) changed between 4 months prior to, and 8 and 20 months after, implementation.

DESIGN

Repeat cross-sectional online survey.

SETTING

The UK.

PARTICIPANTS

UK respondents to the International Food Policy Study aged 18-64 years who provided information on all variables of interest in November-December 2017 (4 months prior to SDIL implementation), 2018 (8 months after) or 2019 (20 months after; n=10 284).

OUTCOME MEASURES

Self-reported support for, and perceived effectiveness of, the SDIL.

RESULTS

The adjusted logistic regression model predicted that 70% (95% CI: 68% to 72%) of participants supported the SDIL in 2017, 68% (95% CI: 67% to 70%) in 2018 and 68% (95% CI: 66% to 70%) in 2019. There was no evidence of a difference in support in 2018 vs 2017 (OR: 0.93; 95% CI: 0.81 to 1.05); or in 2019 vs 2017 (OR: 0.90; 95% CI: 0.78 to 1.03). The adjusted logistic regression model predicted that 72% (95% CI: 70% to 74%) of participants perceived the SDIL to be effective in 2017, 67% (95% CI: 65% to 69%) in 2018 and 67% (95% CI: 64% to 69%) in 2019. There was evidence that perceived effectiveness decreased a small amount in 2018 vs 2017 (OR: 0.78; 95% CI: 0.69 to 0.88). The difference in 2019 vs 2017 was similar.

CONCLUSIONS

We found high support for the SDIL among UK adults and this did not change between 4 months before implementation and 8 or 20 months after. While perceived effectiveness remained high, there was evidence that this decreased slightly after implementation in 2018, but no further in 2019. Greater understanding of influences on public acceptability of effective structural public health interventions is required.

COVID-19 epidemiological, sociological and anthropological investigation: study protocol for a multidisciplinary mixed methods research in Burkina Faso

BACKGROUND

The world has high hopes of vaccination against COVID-19 to protect the population, boost economies and return to normal life. Vaccination programmes are being rolled out in high income countries, but the pandemic continues to progress in many low-and middle-income countries (LMICs) despite implementation of strict hygiene measures. We aim to present a comprehensive research protocol that will generate epidemiological, sociological and anthropological data about the COVID-19 epidemic in Burkina Faso, a landlocked country in West Africa with scarce resources.

METHODS

We will perform a multidisciplinary research using mixed methods in the two main cities in Burkina Faso (Ouagadougou and Bobo-Dioulasso). Data will be collected in the general population and in COVID-19 patients, caregivers and health care professionals in reference care centers: (i) to determine cumulative incidence of SARS-CoV-2 infection in the Burkinabe population using blood samples collected from randomly selected households according to the WHO-recommended protocol; (ii) develop a score to predict severe complications of COVID-19 in persons infected with SARS-CoV-2 using retrospective and prospective data; (iii) perform semi-structured interviews and direct observation on site, to describe and analyze the healthcare pathways and experiences of patients with COVID-19 attending reference care centers, and to identify the perceptions, acceptability and application of preventive strategies among the population.

DISCUSSION

This study will generate comprehensive data that will contribute to improving COVID-19 response strategies in Burkina Faso. The lessons learned from the management of this epidemic may serve as examples to the country authorities to better design preventive strategies in the case of future epidemics or pandemics. The protocol was approved by the Ministry for Health (N° 2020-00952/MS/CAB/INSP/CM) and the Health Research Ethics Committee in Burkina Faso (N° 2020-8-140).

Assessing the impact of sports and recreation facility density within school neighbourhoods on Canadian adolescents' substance use behaviours: quasi-experimental evidence from the COMPASS study, 2015-2018

OBJECTIVES

There has been relatively little exploration to date of potential protective effects within school neighbourhoods, such as those conferred by facilities that seek to promote health with respect to substance use and related harms. This study examined how the density of sports and recreation facilities in the school neighbourhood is associated with the likelihood of binge drinking, e-cigarette use, cigarette smoking and cannabis use among Canadian secondary school students.

DESIGN

Longitudinal data from the COMPASS study on Canadian youth health behaviours from 2015/2016 to 2017/2018 was linked with school neighbourhood data capturing the number of sports and recreation facilities within a 1500 m radius of schools.

SETTING

Secondary schools and school neighbourhoods in Alberta, British Columbia, Ontario and Quebec who participated in the COMPASS study.

PARTICIPANTS

16 471 youth who participated in the COMPASS study over three school years (2015/2016-2017/2018).

PRIMARY AND SECONDARY OUTCOME MEASURES

Binge drinking, e-cigarette use, cigarette use, cannabis use.

RESULTS

Logistic regression models using generalised estimating equations identified that greater density of sports and recreation facilities within the school neighbourhood was significantly associated with lower likelihood of binge drinking and e-cigarette use but was not associated with cigarette smoking or cannabis use.

CONCLUSIONS

This research can help to support evidence-informed school community-based efforts to prevent substance-related harms among youth.

"The health equity curse": ethical tensions in promoting health equity

BACKGROUND

Public health (PH) practitioners have a strong moral commitment to health equity and social justice. However, PH values often do not align with health systems values, making it challenging for PH practitioners to promote health equity. In spite of a growing range of PH ethics frameworks and theories, little is known about ethical concerns related to promotion of health equity in PH practice. The purpose of this paper is to examine the ethical concerns of PH practitioners in promoting health equity in the context of mental health promotion and prevention of harms of substance use.

METHODS

As part of a broader program of public health systems and services research, we interviewed 32 PH practitioners.

RESULTS

Using constant comparative analysis, we identified four systemic ethical tensions: [1] biomedical versus social determinants of health agenda; [2] systems driven agendas versus situational care; [3] stigma and discrimination versus respect for persons; and [4] trust and autonomy versus surveillance and social control.

CONCLUSIONS

Naming these tensions provides insights into the daily ethical challenges of PH practitioners and an opportunity to reflect on the relevance of PH frameworks. These findings highlight the value of relational ethics as a promising approach for developing ethical frameworks for PH practice.

Challenges in control of COVID-19: short doubling time and long delay to effect of interventions

Early assessments of the growth rate of COVID-19 were subject to significant uncertainty, as expected with limited data and difficulties in case ascertainment, but as cases were recorded in multiple countries, more robust inferences could be made. Using multiple countries, data streams and methods, we estimated that, when unconstrained, European COVID-19 confirmed cases doubled on average every 3 days (range 2.2-4.3 days) and Italian hospital and intensive care unit admissions every 2-3 days; values that are significantly lower than the 5-7 days dominating the early published literature. Furthermore, we showed that the impact of physical distancing interventions was typically not seen until at least 9 days after implementation, during which time confirmed cases could grow eightfold. We argue that such temporal patterns are more critical than precise estimates of the time-insensitive basic reproduction number R0 for initiating interventions, and that the combination of fast growth and long detection delays explains the struggle in countries' outbreak response better than large values of R0 alone. One year on from first reporting these results, reproduction numbers continue to dominate the media and public discourse, but robust estimates of unconstrained growth remain essential for planning worst-case scenarios, and detection delays are still key in informing the relaxation and re-implementation of interventions. This article is part of the theme issue 'Modelling that shaped the early COVID-19 pandemic response in the UK'.

An examination of the prospective association between physical activity and academic achievement in youth at the population level

Exercise has significant benefits for brain health and this may have downstream learning benefits for youth. However existing studies looking at links between physical activity and academic achievement are limited by relatively small sample sizes and/or cross-sectional designs. The objective of this study is to determine the direction and magnitude of the association between physical activity and academic achievement in a large prospective sample of adolescents. Linear mixed models with random intercepts and multinomial ordinal generalized estimating equations were employed to analyze the prospective relationship between measures of physical activity and academic achievement from the COMPASS study (N = 9,898 linked participant data cases from year 2 (2013-2014) to year 4 (2015-2016)). The linear relationships between minutes of moderate to vigorous physical activity and academic achievement (English: r = -.047, p < .000; Math: r = -.026, p = .008) as well as meeting the national physical activity guidelines and academic achievement (English: est = -.052, p = .004; Math: est = -.052, p = .028) were negative and trivial in magnitude. Organized sport participation showed slight positive associations with academic achievement indices, but these were also of trivial magnitude. In conclusion, the relationship between physical activity and academic achievement was effectively null in this population sample. Advocacy for physical activity programming for adolescent populations may best be undertaken with reference to lack of net academic achievement cost, rather than presence of benefit, or simply with reference to the many other physical and mental health benefits for youth.

Experiences with sexual orientation and gender identity conversion therapy practices among sexual minority men in Canada, 2019-2020

BACKGROUND

"Conversion therapy" practices (CTP) are organized and sustained efforts to avoid the adoption of non-heterosexual sexual orientations and/or of gender identities not assigned at birth. Few data are available to inform the contemporary prevalence of CTP. The aim of this study is to quantify the prevalence of CTP among Canadian sexual and gender minority men, including details regarding the setting, age of initiation, and duration of CTP exposure.

METHODS

Sexual and gender minority men, including transmen and non-binary individuals, aged ≥ 15, living in Canada were recruited via social media and networking applications and websites, November 2019-February 2020. Participants provided demographic data and detailed information about their experiences with CTP.

RESULTS

21% of respondents (N = 9,214) indicated that they or any person with authority (e.g., parent, caregiver) ever tried to change their sexual orientation or gender identity, and 10% had experienced CTP. CTP experience was highest among non-binary (20%) and transgender respondents (19%), those aged 15-19 years (13%), immigrants (15%), and racial/ethnic minorities (11-22%, with variability by identity). Among the n = 910 participants who experienced CTP, most experienced CTP in religious/faith-based settings (67%) or licensed healthcare provider offices (20%). 72% of those who experienced CTP first attended before the age of 20 years, 24% attended for one year or longer, and 31% attended more than five sessions.

INTERPRETATION

CTP remains prevalent in Canada and is most prevalent among younger cohorts, transgender people, immigrants, and racial/ethnic minorities. Legislation, policy, and education are needed that target both religious and healthcare settings.

Evaluation of COVID-19 vaccination strategies with a delayed second dose

Two of the Coronavirus Disease 2019 (COVID-19) vaccines currently approved in the United States require 2 doses, administered 3 to 4 weeks apart. Constraints in vaccine supply and distribution capacity, together with a deadly wave of COVID-19 from November 2020 to January 2021 and the emergence of highly contagious Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) variants, sparked a policy debate on whether to vaccinate more individuals with the first dose of available vaccines and delay the second dose or to continue with the recommended 2-dose series as tested in clinical trials. We developed an agent-based model of COVID-19 transmission to compare the impact of these 2 vaccination strategies, while varying the temporal waning of vaccine efficacy following the first dose and the level of preexisting immunity in the population. Our results show that for Moderna vaccines, a delay of at least 9 weeks could maximize vaccination program effectiveness and avert at least an additional 17.3 (95% credible interval [CrI]: 7.8-29.7) infections, 0.69 (95% CrI: 0.52-0.97) hospitalizations, and 0.34 (95% CrI: 0.25-0.44) deaths per 10,000 population compared to the recommended 4-week interval between the 2 doses. Pfizer-BioNTech vaccines also averted an additional 0.60 (95% CrI: 0.37-0.89) hospitalizations and 0.32 (95% CrI: 0.23-0.45) deaths per 10,000 population in a 9-week delayed second dose (DSD) strategy compared to the 3-week recommended schedule between doses. However, there was no clear advantage of delaying the second dose with Pfizer-BioNTech vaccines in reducing infections, unless the efficacy of the first dose did not wane over time. Our findings underscore the importance of quantifying the characteristics and durability of vaccine-induced protection after the first dose in order to determine the optimal time interval between the 2 doses.

The unintended consequences of COVID-19 mitigation measures matter: practical guidance for investigating them

BACKGROUND

COVID-19 has led to the adoption of unprecedented mitigation measures which could trigger many unintended consequences. These unintended consequences can be far-reaching and just as important as the intended ones. The World Health Organization identified the assessment of unintended consequences of COVID-19 mitigation measures as a top priority. Thus far, however, their systematic assessment has been neglected due to the inattention of researchers as well as the lack of training and practical tools.

MAIN TEXT

Over six years our team has gained extensive experience conducting research on the unintended consequences of complex health interventions. Through a reflexive process, we developed insights that can be useful for researchers in this area. Our analysis is based on key literature and lessons learned reflexively in conducting multi-site and multi-method studies on unintended consequences. Here we present practical guidance for researchers wishing to assess the unintended consequences of COVID-19 mitigation measures. To ensure resource allocation, protocols should include research questions regarding unintended consequences at the outset. Social science theories and frameworks are available to help assess unintended consequences. To determine which changes are unintended, researchers must first understand the intervention theory. To facilitate data collection, researchers can begin by forecasting potential unintended consequences through literature reviews and discussions with stakeholders. Including desirable and neutral unintended consequences in the scope of study can help minimize the negative bias reported in the literature. Exploratory methods can be powerful tools to capture data on the unintended consequences that were unforeseen by researchers. We recommend researchers cast a wide net by inquiring about different aspects of the mitigation measures. Some unintended consequences may only be observable in subsequent years, so longitudinal approaches may be useful. An equity lens is necessary to assess how mitigation measures may unintentionally increase disparities. Finally, stakeholders can help validate the classification of consequences as intended or unintended.

CONCLUSION

Studying the unintended consequences of COVID-19 mitigation measures is not only possible but also necessary to assess their overall value. The practical guidance presented will help program planners and evaluators gain a more comprehensive understanding of unintended consequences to refine mitigation measures.

Do you mind if I smoke here? Exploring the insights that public benches bring to public health research

In this commentary, we illustrate how exploring the meanings and uses of everyday, seemingly mundane, public objects can advance our understanding of health-related practices and the social norms that shape them. We use the example of the public bench and smoking for this purpose. By observing the design of public benches, the places where they are found, the meanings people attribute to them, and the way people use them, we can learn what health-related practices (e.g., smoking) and who (e.g., people who smoke or who do not smoke) are included and excluded as part of local community life. We thus consider the idea that public benches can be instructive in helping us understand how our health-related practices may be shaped by what can be seen enacted on or from public benches. We ultimately demonstrate how this type of object-based experiential exploration, largely absent from public health research, can provide a novel and insightful perspective to public health research.

Determining the long-term health burden and risk of sequelae for 14 foodborne infections in British Columbia, Canada: protocol for a retrospective population-based cohort study

INTRODUCTION

Over one in eight Canadians is affected by a foodborne infection annually; however, the long-term consequences, including the risks and costs of sequelae, are unclear. We aim to estimate the health burden and direct costs of 14 infections commonly transmitted by food, considering the acute illness and subsequent sequelae and mortality, for the population of British Columbia, Canada (~4.7 million).

METHODS AND ANALYSIS

We will conduct a population-based retrospective cohort study of the British Columbia provincial population, over a 10-year study period (1 January 2005 to 31 December 2014). Exposure is defined as a provincially reported illness caused by Clostridium botulinum, Campylobacter, Cryptosporidium, Cyclospora, Giardia, hepatitis A virus, Listeria, non-typhoidal Salmonella spp, Salmonella Typhi, Salmonella Paratyphi, Shiga toxin-producing Escherichia coli, Shigella, Vibrio parahaemolyticus or Yersinia (excluding pestis). We will link individual-level longitudinal data from eight province-wide administrative health and reportable disease databases that include physician visits, hospitalisations and day surgeries, deaths, stillbirths, prescription medications (except those to treat HIV) and reportable foodborne diseases. Using these linked databases, we will investigate the likelihood of various sequelae and death. Hazard models will be used to estimate the risk of outcomes and their association with the type of foodborne infection. Epidemiological analyses will be conducted to determine the progression of illness and the fraction of sequelae attributable to specific foodborne infections. Economic analyses will assess the consequent direct healthcare costs.

ETHICS AND DISSEMINATION

This study has been approved by a University of Waterloo Research Ethics Committee (no 30645), the University of British Columbia Behavioral Research Ethics Board (no H16-00021) and McGill University's Institutional Review Board (no A03-M12-19A). Results will be disseminated via presentations to academics, public health practitioners and knowledge users, and publication in peer-reviewed journals. Where such publications are not open access, manuscripts will also be available via the University of Waterloo's Institutional Repository (https://uwspace.uwaterloo.ca).

Income inequality and social gradients in children's height: a comparison of cohort studies from five high-income countries

BACKGROUND

Health and well-being are better, on average, in countries that are more equal, but less is known about how this benefit is distributed across society. Height is a widely used, objective indicator of child health and predictor of lifelong well-being. We compared the level and slope of social gradients in children's height in high-income countries with different levels of income inequality, in order to investigate whether children growing up in all socioeconomic circumstances are healthier in more equal countries.

METHODS

We conducted a coordinated analysis of data from five cohort studies from countries selected to represent different levels of income inequality (the USA, UK, Australia, the Netherlands and Sweden). We used standardised methods to compare social gradients in children's height at age 4-6 years, by parent education status and household income. We used linear regression models and predicted height for children with the same age, sex and socioeconomic circumstances in each cohort.

RESULTS

The total analytic sample was 37 063 children aged 4-6 years. Gradients by parent education and household income varied between cohorts and outcomes. After adjusting for differences in age and sex, children in more equal countries (Sweden, the Netherlands) were taller at all levels of parent education and household income than children in less equal countries (USA, UK and Australia), with the greatest between-country differences among children with less educated parents and lowest household incomes.

CONCLUSIONS

The study provides preliminary evidence that children across society do better in more equal countries, with greatest benefit among children from the most disadvantaged socioeconomic groups.

Implementation of mifepristone medical abortion in Canada: pilot and feasibility testing of a survey to assess facilitators and barriers

BACKGROUND

Direct primary care provision of first-trimester medical abortion could potentially address inequitable abortion access in Canada. However, when Health Canada approved the combination medication Mifegymiso® (mifepristone 200 mg/misoprostol 800 mcg) for medical abortion in July 2015, we hypothesized that the restrictions to distribution, prescribing, and dispensing would impede the uptake of this evidence-based innovation in primary care. We developed and pilot-tested a survey related to policy and practice facilitators and barriers to assess successful initiation and ongoing clinical provision of medical abortion service by physicians undertaking mifepristone training. Additionally, we explored expert, stakeholder, and physician perceptions of the impact of facilitators and barriers on abortion services throughout Canada.

METHODS

In phase 1, we developed a survey using 2 theoretical frameworks: Greenhalgh's conceptual model for the Diffusion of Innovations in health service organizations (which we operationalized) and Godin's framework to assess the impact of professional development on the uptake of new practices operationalized in Légaré's validated questionnaire. We finalized questions in phase 2 using the modified Delphi methodology. The survey was then tested by an expert panel of 25 nationally representative physician participants and 4 clinical content experts. Qualitative analysis of transcripts enriched and validated the content by identifying these potential barriers: physicians dispensing the medication, mandatory training to become a prescriber, burdens for patients, lack of remuneration for mifepristone provision, and services available in my community. To assess the usability and reliability of the online survey, in phase 3, we pilot-tested the survey for feasibility.

RESULTS

We developed and tested a 61-item Mifepristone Implementation Survey suitable to study the facilitators and barriers to implementation of mifepristone first-trimester medical abortion practice by physicians in Canada.

CONCLUSIONS

Our team operationalized Greenhalgh's theoretical framework for Diffusion of Innovations in health systems to explore factors influencing the implementation of first-trimester medical abortion provision. This process may be useful for those evaluating other health system innovations. Identification of facilitators and barriers to implementation of mifepristone practice in Canada and knowledge translation has the potential to inform regulatory and health system changes to support and scale up facilitators and mitigate barriers to equitable medical abortion provision.

Effect of psychosocial work factors on the risk of depression: a protocol of a systematic review and meta-analysis of prospective studies

INTRODUCTION

Depression is a common and disabling health problem that contributes to an important social and economic burden, particularly among the working age population. The deleterious effect of psychosocial work factors on depression has been documented. However, the most recent systematic reviews had restrictive eligibility criteria and, since their publications, several original studies have been published. The proposed systematic review aims to update, evaluate and synthesise the effect of psychosocial work factors from three recognised theoretical models, the demand-control-support, effort-reward imbalance and organisational justice models, on the risk of depression among workers.

METHOD AND ANALYSIS

A systematic literature search will be conducted in seven academic databases (Medline, Embase, CINAHL, Web of Science, PsycInfo, Sociological abstracts and IBSS) as well as three grey literature databases. The search strategy was first run on January 2017, updated in October 2017 and will be updated 6 months prior to submission for publication. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations, study selection will be carried out using a rigorous multistep screening process in duplicate by independent reviewers. Prospective studies evaluating the effect of at least one psychosocial work factor from the three theoretical models on depression or antidepressant medication use among working adults will be included. Extracted data will be used for evidence synthesis as well as to assess risk of bias and methodological quality. Meta-estimates will be provided after considering homogeneity and number of studies.

ETHICS AND DISSEMINATION

This study will only draw from published studies and grey literature available in electronic databases; ethics approval is not required. The results of this review will be published in a peer review journal and presented at relevant conferences. Given that psychosocial work factors are frequent and modifiable, the results can help reduce the social and economic burden of depression and support public policy-makers to improve occupational health standards.

PROSPERO REGISTRATION NUMBER

CRD42018107666.

Association between participation in the Families First Home Visiting programme and First Nations families' public health outcomes in Manitoba, Canada: a retrospective cohort study using linked administrative data

OBJECTIVE

To determine whether the Families First Home Visiting (FFHV) programme, which provides home visiting services to families across Manitoba, is associated with improved public health outcomes among First Nations families facing multiple parenting challenges.

DESIGN

Retrospective cohort study using population-based administrative data.

SETTING

Manitoba, Canada.

PARTICIPANTS

First Nations children born in Manitoba in 2003-2009 (n=4010) and their parents enrolled in FFHV compared with non-enrolled families with a similar risk profile.

INTERVENTION

FFHV supports public health in Manitoba by providing home visiting services to First Nations and non-First Nations families with preschool children and connecting them with resources in their communities.

OUTCOMES

Predicted probability (PP) and relative risk (RR) of childhood vaccination, parental involvement in community support programmes and children's development at school entry.

RESULTS

FFHV participation was associated with higher rates of complete childhood vaccination at age 1 (PP: FFHV 0.715, no FFHV 0.661, RR 1.08, 95% CI 1.03 to 1.14) and age 2 (PP: FFHV 0.465, no FFHV 0.401, RR 1.16, 95% CI 1.08 to 1.25), and with parental involvement in community support groups (PP: FFHV 0.149, no FFHV 0.097, RR 1.54, 95% CI 1.27 to 1.86). However, there was no difference between FFHV participants and non-participants in rates of children being vulnerable in at least one developmental domain at age 5 (PP: FFHV 0.551, no FFHV 0.557, RR 1.00, 95% CI 0.91 to 1.11).

CONCLUSIONS

FFHV supports First Nations families in Manitoba by promoting childhood vaccination and connecting families to parenting resources in their communities, thus playing an important role in fulfilling the mandate of public health practice.

An ethnography of chronic pain management in primary care: The social organization of physicians' work in the midst of the opioid crisis

BACKGROUND

This study reports on physicians' experiences with chronic pain management. For over a decade prescription opioids have been a primary treatment for chronic pain in North America. However, the current opioid epidemic has complicated long-standing practices for chronic pain management which historically involved prescribing pain medication. Caring for patients with chronic pain occurs within a context in which a growing proportion of patients suffer from chronic rather than acute conditions alongside rising social inequities.

METHODS

Our team undertook an ethnographic approach known as institutional ethnography in the province of Ontario, Canada in order to explore the social organization of chronic pain management from the standpoint of primary care physicians. This paper reports on a subset of this study data, specifically interviews with 19 primary care clinicians and 8 nurses supplemented by 40 hours of observations. The clinicians in our sample were largely primary care physicians and nurses working in urban, rural and Northern settings.

FINDINGS

In their reflections on providing care for patients with chronic pain, many providers describe being most challenged by the work involved in helping patients who also struggled with poverty, mental health and addiction. These frustrations were often complicated by concerns that they could lose their license for inappropriate prescribing, thus shifting their work from providing treatment and care to policing their patients for malingering and opioid abuse.

INTERPRETATION

Our findings show that care providers find the treatment of patients with chronic pain-especially those patients also experiencing poverty-to be challenging at best, and at worst frustrating and overwhelming. In many instances, their narratives suggested experiences of depersonalization, loss of job satisfaction and emotional exhaustion in relation to providing care for these patients, key dimensions of burnout. In essence, the work that they performed in relation to their patients' social rather than medical needs seems to contribute to these experiences. Their experiences were further exacerbated by the fact that restricting and reducing opioid dosing in patients with chronic pain has become a major focus of care provision.

Assessing the strength of secondary school tobacco policies of schools in the COMPASS study and the association to student smoking behaviours

OBJECTIVES

The school environment is an ideal setting to introduce policies to prevent smoking behaviour. However, there may be variability in the strength of school board and secondary school tobacco policies, which may affect student smoking behaviours. This study assessed the strength of a sample of school board and secondary school tobacco policies and examined the association with student smoking behaviours.

METHODS

Tobacco policies from school boards (n = 21/26) and secondary schools (n = 43/81) that participated in the COMPASS study during 2015-2016 were obtained online. A standardized instrument was used to assess the strength of school board and secondary school tobacco policies on four domains. Using the sample of students from schools with identified policies (n = 22,696), separate multilevel regression models examined the association between school policy scores and a student's susceptibility to smoking, ever smoking, current smoking, and perceived support of the school environment.

RESULTS

The mean school board tobacco policy score was 13.7/40 and the mean secondary school tobacco policy score was 11.3/40. Students were significantly less likely to report current smoking (OR 0.95, 95% CI 0.91-0.99) and more likely to report a supportive school environment (OR 1.06, 95% CI 1.04-1.08) with each four-unit (i.e., 10%) increase in school tobacco policy score.

CONCLUSIONS

The vast majority of school board and secondary school tobacco policies were missing components and therefore could not be considered comprehensive. Stronger school tobacco policies may help to reduce student current smoking behaviours.

A Pilot Study of "Peer Navigators" to Promote Uptake of HIV Testing, Care and Treatment Among Street-Connected Children and Youth in Eldoret, Kenya

Research suggests a burden of HIV among street-connected youth (SCY) in Kenya. We piloted the use of peer navigators (PNs), individuals of mixed HIV serostatus and with direct experience of being street-connected, to link SCY to HIV testing and care. From January 2015 to October 2017, PNs engaged 781 SCY (585 male, 196 female), median age 16 (IQR 13-20). At initial encounter, 52 (6.6%) were known HIV-positive and 647 (88.8%) agreed to HIV testing. Overall, 63/781 (8.1%) SCY engaged in this program were HIV-positive; 4.6% males and 18.4% females (p < 0.001). Of those HIV-positive, 48 (82.8%) initiated ART. As of October 2017, 35 (60.3%) of the HIV-positive SCY were alive and in care. The pilot suggests that PNs were successful in promoting HIV testing, linkage to care and ART initiation. More research is needed to evaluate how to improve ART adherence, viral suppression and retention in care in this population.

Prelegalisation patterns and trends of cannabis use among Canadian youth: results from the COMPASS prospective cohort study

OBJECTIVE

Canada federally legalised recreational cannabis use among adults in October 2018. The impact this will have on Canadian youth is cause for concern. The current study examined changes in youth cannabis use over the time prior to legalisation to explore the impact of the beginning federal discourse around legalisation during the 2016/2017 school year.

DESIGN

COMPASS, a prospective cohort study based on annual self-administered questionnaires.

SETTING

Ontario and Alberta during the first 6 years of the COMPASS study (2012/2013 to 2017/2018).

PARTICIPANTS

Canadian grade 9-12 students attending secondary schools participating in COMPASS. In total, 2 30 404 questionnaires were included in the analysis (Y1: 2012/2013, n=24 173; Y2: 2013/2014, n=45 298; Y3: 2014/2015, n=42 355, Y4: 2015/2016, n=40 436; Y5: 2016/2017, n=37 060; Y6: 2017/2018, n=34 897).

PRIMARY AND SECONDARY OUTCOME MEASURES

Lifetime cannabis use, past-year cannabis use, weekly cannabis use, ease of access to cannabis and age at first cannabis use.

RESULTS

Cannabis never-use decreased between Y5 and Y6. Changes in age at first cannabis use mirrored this trend, with male students consistently starting younger. Cannabis access rates increased from Y4, mainly led by female students. Lifetime and past-year use rates were lowest in Y4 then increased in Y5 and Y6 due to a rise in the occasional use more common among female students, who reported use increases first. Non-white students were more likely use cannabis, with black and Aboriginal students the only two groups consistently reporting more weekly than occasional use, though with opposing trajectories. Overall, Aboriginal students had the highest odds of reporting lifetime, past-year and weekly use among the demographic groups examined.

CONCLUSION

After a steady decrease in patterns of cannabis among youth over several years, it appears that there has been a gradual increase in cannabis use among youth following the start of discourse around cannabis legalisation, with some populations of youth being at greater risk.

Disparities in breast cancer diagnosis for immigrant women in Ontario and BC: results from the CanIMPACT study

BACKGROUND

In Canada, clinical practice guidelines recommend breast cancer screening, but there are gaps in adherence to recommendations for screening, particularly among certain hard-to-reach populations, that may differ by province. We compared stage of diagnosis, proportion of screen-detected breast cancers, and length of diagnostic interval for immigrant women versus long-term residents of BC and Ontario.

METHODS

We conducted a retrospective cohort study using linked administrative databases in BC and Ontario. We identified all women residing in either province who were diagnosed with incident invasive breast cancer between 2007 and 2011, and determined who was foreign-born using the Immigration Refugee and Citizenship Canada database. We used descriptive statistics and bivariate analyses to describe the sample and study outcomes. We conducted multivariate analyses (modified Poisson regression and quantile regression) to control for potential confounders.

RESULTS

There were 14,198 BC women and 46,952 Ontario women included in the study population, of which 11.8 and 11.7% were foreign-born respectively. In both provinces, immigrants and long-term residents had similar primary care access. In both provinces, immigrant women were significantly less likely to have a screen-detected breast cancer (adjusted relative risk 0.88 [0.79-0.96] in BC, 0.88 [0.84-0.93] in Ontario) and had a significantly longer median diagnostic interval (2 [0.2-3.8] days in BC, 5.5 [4.4-6.6] days in Ontario) than long-term residents. Women from East Asia and the Pacific were less likely to have a screen-detected cancer and had a longer diagnostic interval, but were diagnosed at an earlier stage than long-term residents. In Ontario, women from Latin America and the Caribbean and from South Asia were less likely to have a screen-detected cancer, had a longer median diagnostic interval, and were diagnosed at a later stage than long-term residents. These findings were not explained by access to primary care.

CONCLUSIONS

There are inequalities in breast cancer diagnosis for Canadian immigrant women. We have identified particular immigrant groups (women from Latin America and the Caribbean and from South Asia) that appear to be subject to disparities in the diagnostic process that need to be addressed in order to effectively reduce gaps in care.

HPV vaccination discourses and the construction of "at-risk" girls

RéSUMé: OBJECTIF: L'objectif était d'étudier le déploiement des discours sur la vaccination contre les VPH (VVPH) et leur impact sur les filles, les parents, les infirmiers/infirmières et les médecins canadiens. MéTHODES: Des entrevues ont été réalisées avec des participant(e)s (n = 146) de quatre provinces canadiennes. Une analyse poststructuraliste du discours a permis d'examiner les campagnes de VVPH et les transcriptions d'entrevues pour documenter la façon dont les participant(e)s interprètent les VVPH et se positionnent comme sujets au sein des discours de l'industrie ou des agences de santé publique. RéSULTATS: Les campagnes de VVPH sont sexistes, hétéro-normatives et trompeuses. Émergeant de l'analyse des entrevues est le manque d'information des filles et des parents en ce qui a trait à la VVPH. Les mères se construisent en tant que bio-citoyennes responsables, mais au prix de l'impuissance, de l'anxiété et de la peur ressenties parallèlement à l'impératif d'agir pour minimiser le risque de cancer de leur fille. Quant aux professionnel(le)s de la santé, ils s'approprient les discours dominants sur la VVPH et utilisent la peur comme stratégie pour fabriquer le consentement pour la VVPH. Les occasions de dialogue sur la VVPH et la santé sexuelle des filles sont perdues et les positions en tant que sujets sont problématiques pour tous les types de participant. CONCLUSIONS: Nous nous questionnons à savoir si la santé publique est bien servie quand les discours sur la VVPH transforment des corps en santé en corps « à risque » et quand la peur du cancer est instrumentalisée pour la pharmacologisation de la santé publique.

Formalisation and subordination: a contingency theory approach to optimising primary care teams

OBJECTIVE

While there is consensus on the need to strengthen primary care capacities to improve healthcare systems' performance and sustainability, there is only limited evidence on the best way to organise primary care teams. In this article, we use a conceptual framework derived from contingency theory to analyse the structures and process optimisation of multiprofessional primary care teams.

DESIGN

We focus specifically on inter-relationships between three dimensions: team size, formalisation of care processes and nurse autonomy. Interview-based qualitative data for each of these three dimensions were converted into ordinal scores. Data came from eight pilot sites in Quebec (Canada).

RESULTS

We found a positive association between team size and formalisation (correlation score 0.55) and a negative covariation (correlation score -0.64) between care process formalisation and nurses' autonomy/subordination. Despite the study being exploratory in nature, such relationships validate the idea that these dimensions should be analysed conjointly and are coherent with our suggestion that using a framework derived from a contingency approach makes sense.

CONCLUSIONS

The results provide insights about the structural design of nurse-intensive primary care teams. Non-physicians' professional autonomy is likely to be higher in smaller teams. Likewise, a primary care team that aims to increase nurses' and other non-physicians' professional autonomy should be careful about the extent to which it formalises its processes.

Effect of psychosocial work factors on the risk of certified absences from work for a diagnosed mental health problem: a protocol of a systematic review and meta-analysis of prospective studies

INTRODUCTION

Mental health problems (MHPs) are frequent and disabling and are the first or second leading cause of certified sickness absences from work in industrialised countries. They are generally long lasting and generate a considerable human and socioeconomic burden. The deleterious effect of adverse psychosocial work factors on MHP has been documented. However, the evidence regarding the effect of these factors on absences from work for an MHP has not been synthesised since 2007. The proposed systematic review aims to synthesise the effect of adverse psychosocial work factors from three validated theoretical models (the demand-control-support, effort-reward-imbalance and organisational justice models) on the risk of certified absences from work for diagnosed MHP among workers.

METHOD AND ANALYSIS

A systematic search strategy will be conducted in seven databases: Medline, Embase, CINAHL, Web of Science, PsycInfo, Sociological abstracts and IBSS. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations, a multistep screening process by independent reviewers will lead to study selection. The search strategy was first run in 16 January 2017 and will be updated in October 2018. Only quantitative, prospective studies evaluating the effect of at least one psychosocial work factor from the validated theoretical models on certified absence from work for a diagnosed MHP will be considered for inclusion. Extracted data will be used for quantitative and qualitative evidence synthesis as well as to assess risk of bias and methodological quality. Meta-estimates will be provided for high-quality studies and by each psychosocial work factor, after considering homogeneity and number of studies.

ETHICS AND DISSEMINATION

As this study will be based only on published studies, ethics approval is not required. Given that psychosocial works factors are frequent and modifiable, the results of this systematic review may provide evidence to support prevention strategies that can help to reduce the human social and economic burden associated with medically certified absences from work for an MHP.

PROSPERO REGISTRATION NUMBER

CRD42018091632.

Understanding child and parent perceptions of barriers influencing children's active school travel

BACKGROUND

Physical activity plays a fundamental role in the health and well-being of children. Walking is the most common form of physical activity and the journey to and from school provides an opportunity for children to be active every day. This study examines how child and parent perceptions of barriers to active school travel influences children's behaviour.

METHODS

Participants were recruited from 48 elementary schools in Southwestern Ontario, Canada. The study sample includes 1296 children (ages 9-14 years) who live within walking distance of their school, defined as 1.6 km network distance. Chi-square analysis examined differences between child and parent perceptions of barriers to active school travel. Logistic regression models examined how parent and child perceptions of barriers influence active school travel behaviour, while controlling for key intrapersonal, interpersonal, and physical environment factors.

RESULTS

The results indicate that there are significant differences in how parents and children perceive barriers to active school travel. Model results find older children, children without siblings, households with no vehicles, and children who live closer to school are most likely to use active school travel. Parent perceptions of barriers are found to have a greater influence on children's active school travel behaviour than children's perceptions. Different perceptions of barriers influence active school travel to school compared to returning home from school.

CONCLUSIONS

Child and parent perceptions of barriers to active school travel differ and have different impacts on children's travel behaviour. Understanding how child and parent perceptions of barriers differ can help policymakers and practitioners develop specialized interventions aimed at increasing children's use of active school travel and children's overall physical activity. Interventions used to promote active school travel should focus on safety, as well as perceptions of distance to break parental habits of routinely driving their children to school. Overall, this study highlights the importance of considering both child and parent perceptions to create a safe and accessible environment to allow for an increase in active school travel behaviour among elementary school children who live within walking distance of their school.

Risky business: a longitudinal study examining cigarette smoking initiation among susceptible and non-susceptible e-cigarette users in Canada

OBJECTIVES

Given that many adolescent e-cigarette users are never-smokers, the possibility that e-cigarettes may act as a gateway to future cigarette smoking has been discussed in various studies. Longitudinal data are needed to explore the pathway between e-cigarette and cigarette use, particularly among different risk groups including susceptible and non-susceptible never-smokers. The objective of this study was to examine whether baseline use of e-cigarettes among a sample of never-smoking youth predicted cigarette smoking initiation over a 2-year period.

DESIGN

Longitudinal cohort study.

SETTING

89 high schools across Ontario and Alberta, Canada.

PARTICIPANTS

A sample of grade 9-11 never-smoking students at baseline (n=9501) who participated in the COMPASS study over 2 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Participants completed in-class questionnaires that assessed smoking susceptibility and smoking initiation.

RESULTS

Among the baseline sample of non-susceptible never-smokers, 45.2% of current e-cigarette users reported trying a cigarette after 2 years compared with 13.5% of non-current e-cigarette users. Among the baseline sample of susceptible never-smokers, 62.4% of current e-cigarette users reported trying a cigarette after 2 years compared with 36.1% of non-current e-cigarette users. Overall, current e-cigarette users were more likely to try a cigarette 2 years later. This association was stronger among the sample of non-susceptible never-smokers (AOR=5.28, 95% CI 2.81 to 9.94; p<0.0001) compared with susceptible never-smokers (AOR=2.78, 95% CI 1.84 to 4.20; p<0.0001).

CONCLUSIONS

Findings from this large, longitudinal study support public health concerns that e-cigarette use may contribute to the development of a new population of cigarette smokers. They also support the notion that e-cigarettes are expanding the tobacco market by attracting low-risk youth who would otherwise be unlikely to initiate using cigarettes. Careful consideration will be needed in developing an appropriate regulatory framework that prevents e-cigarette use among youth.

The impact of social and psychological consequences of disease on judgments of disease severity: An experimental study

Background

The Global Burden of Disease (GBD) project systematically assesses mortality, healthy life expectancy, and disability across 195 countries and territories, using the disability-adjusted life year (DALY). Disability weights in the DALY are based upon surveys that ask users to rate health states based on lay descriptions. We conducted an experimental study to examine whether the inclusion or removal of psychological, social, or familial implications from a health state description might affect individual judgments about disease severity, and thus relative disability weights.

Methods

We designed a survey consisting of 36 paired descriptions in which information about plausible psychological, social, or familial implications of a health condition was either present or absent. Using a Web-based platform, we recruited 1,592 participants, who were assigned to one of two experimental groups, each of which were asked to assign a value to the health state description from 0 to 100 using a slider, with 0 as the “worst possible health” and 100 as the “best possible health.” We tested five hypotheses: (1) the inclusion of psychological, social, or familial consequences in health state descriptions will reduce the average rating of a health state; (2) the effect will be stronger for diseases with lower disability weights (i.e., less severe diseases); (3) the effect will vary across the type of additional information added to the health state description; (4) the impact of adding information on familial consequences will be stronger for female than male; (5) the effect of additional consequences on ratings of health state descriptions will not differ by levels of completed education and age.

Results

On average, adding social, psychological, or familial consequences to the health state description lowered individual ratings of that description by 0.78 points. The impact of adding information had a stronger impact on ratings of the least severe conditions, reducing average ratings in this category by 1.67 points. Addition of information about child-rearing had the strongest impact, reducing average ratings by 2.09 points. We found little evidence that the effect of adding information on ratings of health descriptions varied by gender, education, or age.

Conclusions

Including information about health states not directly related to major functional consequences or symptoms, particularly with respect to child-rearing and specifically for descriptions of less severe conditions, can lead to lower ratings of health. However, this impact was not consistent across all conditions or types of information, and was most pronounced for inclusion of information about child-rearing, and among the least severe conditions.

Population health intervention research training: the value of public health internships and mentorship

BACKGROUND

Better alignment between academia and public health practice and policies are critical to improve public health actions. Training of future researchers to address complex issues and to conduct transdisciplinary and collaborative research will help improve this alignment. In this paper, we describe the role of internship placements and mentorship for trainees' skills development in population health intervention research and the benefits of embedding research trainees within public health organizations.

METHODS

This qualitative descriptive study assessed the perceptions of the role and benefits of internships and mentorship for population health intervention research training among former doctoral and postdoctoral students, public health mentors, and senior public health managers who participated in the 4P Program, a research training program which bridges academic training and the public health system in Quebec, Canada. Two types of interviews were conducted: telephone semi-structured interviews by an external evaluator and face-to-face trainee "exit" interviews by the Program co-director. Semi-annual evaluation reports from each trainee were also reviewed. Qualitative data were subjected to a thematic analysis.

RESULTS

Internships provided trainees with a working knowledge of the public health system and the context in which decisions and public health interventions are implemented. It was an opportunity for trainees to interact with knowledge-user partners and assess the gap between research and practice. Effective mentorship was key to help trainees interpret the public health reality and develop population health intervention research skills. Trainees learned to ask the "how" questions that are critical for in-depth understanding of complex interventions and the conditions under which they can be best implemented. Conditions of success of internships and mentorship for population health intervention research included the alignment of the interests between the trainee, the mentor and the public health organization, quality mentoring, and the acquisition of specific population health intervention skills, especially collaborative research skills.

CONCLUSIONS

The findings suggest that public health internships and mentorship facilitate trainee engagement in applied public health research.

Cohort profile: the Comparative Outcomes And Service Utilization Trends (COAST) Study among people living with and without HIV in British Columbia, Canada

PURPOSE

The Comparative Outcomes And Service Utilization Trends (COAST) Study in British Columbia (BC), Canada, was designed to evaluate the determinants of health outcomes and health care services use among people living with HIV (PLHIV) as they age in the period following the introduction of combination antiretroviral therapy (cART). The study also assesses how age-associated comorbidities and health care use among PLHIV may differ from those observed in the general population.

PARTICIPANTS

COAST was established through a data linkage between two provincial data sources: The BC Centre for Excellence in HIV/AIDS Drug Treatment Program, which centrally manages cART dispensation across BC and contains prospectively collected data on demographic, immunological, virological, cART use and other clinical information for all known PLHIV in BC; and Population Data BC, a provincial data repository that holds individual event-level, longitudinal data for all 4.6 million BC residents. COAST participants include 13 907 HIV-positive adults (≥19 years of age) and a 10% random sample inclusive of 516 340 adults from the general population followed from 1996 to 2013.

FINDINGS TO DATE

For all participants, linked individual-level data include information on demographics, health service use (eg, inpatient care, outpatient care and prescription medication dispensations), mortality, and HIV diagnostic and clinical data. Publications from COAST have demonstrated the significant mortality reductions and dramatic changes in the causes of death among PLHIV from 1996 to 2012, differences in the amount of time spent in a healthy state by HIV status, and high levels of injury and mood disorder diagnosis among PLHIV compared with the general population.

FUTURE PLANS

To capture the dynamic nature of population health parameters, regular data updates and a refresh of the data linkage are planned to occur every 2 years, providing the basis for planned analysis to examine age-associated comorbidities and patterns of health service use over time.

Street-level workers' inadequate knowledge and application of exemption policies in Burkina Faso jeopardize the achievement of universal health coverage: evidence from a cross-sectional survey

BACKGROUND

Street-level workers play a key role in public health policies in Africa, as they are often the ones to ensure their implementation. In Burkina Faso, the State formulated two different user-fee exemption policies for indigents, one for deliveries (2007), and one for primary healthcare (2009). The objective of this study was to measure and understand the determinants of street-level workers' knowledge and application of these exemption measures.

METHODS

We used cross-sectional data collected between October 2013 and March 2014. The survey targeted 1521 health workers distributed in 498 first-line centres, 18 district hospitals, 5 regional hospitals, and 11 private or other facilities across 24 districts. We used four different random effects models to identify factors associated with knowledge and application of each of the above-mentioned exemption policies.

RESULTS

Only 9.2% of workers surveyed knew of the directive exempting the worst-off, and only 5% implemented it. Knowledge and application of the delivery exemption were higher, with 27% of all health workers being aware of the delivery exemption directive and 24.2% applying it. Mobile health workers were found to be consistently more likely to apply both exemptions. Health workers who were facility heads were significantly more likely to know about the indigent exemption for primary health care and to apply it. Health workers in districts with higher proportions of very poor people were significantly more likely to know about and apply the delivery exemption. Nearly 60% of respondents indicated either 5% or 10% as the percentage of people they would deem adequate to target for exemption.

CONCLUSION

This quantitative study confirmed earlier qualitative results on the importance of training and informing health workers and monitoring the measures targeting equity, to ensure compliance with government directives. The local context (e.g., hierarchy, health system, interventions) and the ideas that street-level workers have about the policy instruments can influence their effective implementation. Methods for remunerating health workers and health centres also need to be adapted to ensure equity measures are applied to achieve universal healthcare.

Donor-funded project's sustainability assessment: a qualitative case study of a results-based financing pilot in Koulikoro region, Mali

BACKGROUND

Results-based financing (RBF) is emerging as a new alternative to finance health systems in many African countries. In Mali, a pilot project was conducted to improve demand and supply of health services through financing performance in targeted services. No study has explored the sustainability process of such a project in Africa. This study's objectives were to understand the project's sustainability process and to assess its level of sustainability.

METHODS

Sustainability was examined through its different determinants, phases, levels and contexts. These were explored using qualitative interviews to discern, via critical events, stakeholders' ideas regarding the project's sustainability. Data collection sites were chosen with the participation of different stakeholders, based on a variety of criteria (rural/urban settings, level of participation, RBF participants still present, etc.). Forty-nine stakeholders were then interviewed in six community health centres and two referral health centres (from 11/12/15 to 08/03/16), including health practitioners, administrators, and those involved in implementing and conceptualizing the program (government and NGOs). A theme analysis was done with the software © QDA Miner according to the study's conceptual framework.

RESULTS

The results of this project show a weak level of sustainability due to many factors. While some gains could be sustained (ex.: investments in long-term resources, high compatibility of values and codes, adapted design to the implementations contexts, etc.) other intended benefits could not (ex.: end of investments, lack of shared cultural artefacts around RBF, loss of different tasks and procedures, need of more ownership of the project by the local stakeholders). A lack of sustainability planning was observed, and few critical events were associated to phases of sustainability.

CONCLUSIONS

While this RBF project aimed at increasing health agents' motivation through different mechanisms (supervision, investments, incentives, etc.), these results raise questions on what types of motivation could be more stable and what could be the place of local stakeholders in the project; all this with the aim of more sustained and efficient results.