Search

Background Within-country inequalities in birth registration coverage (BRC) have been documented according to wealth, place of residence and other household characteristics. We investigated whether sex of the head of household was associated with BRC. Methods Using data from nationally-representative surveys (Demographic and Health Survey or Multiple Indicator Cluster Survey) from 93 low and middle-income countries (LMICs) carried out in 2010 or later, we developed a typology including three main types of households: male-headed (MHH) and female-led with or without an adult male resident. Using Poisson regression, we compared BRC for children aged less than 12 months living the three types of households within each country, and then pooled results for all countries. Analyses were also adjusted for household wealth quintiles, maternal education and urban-rural residence. Results BRC ranged from 2.2% Ethiopia to 100% in Thailand (median 79%) while the proportion of MHH ranged from 52.1% in Ukraine to 98.3% in Afghanistan (median 72.9%). In most countries the proportion of poor families was highest in FHH (no male) and lowest in FHH (any male), with MHH occupying an intermediate position. Of the 93 countries, in the adjusted analyses, FHH (no male) had significantly higher BRC than MHH in 13 countries, while in eight countries the opposite trend was observed. The pooled analyses showed t BRC ratios of 1.01 (95% CI: 1.00; 1.01) for FHH (any male) relative to MHH, and also 1.01 (95% CI: 1.00; 1.01) for FHH (no male) relative to MHH. These analyses also showed a high degree of heterogeneity among countries. Conclusion Sex of the head of household was not consistently associated with BRC in the pooled analyses but noteworthy differences in different directions were found in specific countries. Formal and informal benefits to FHH (no male), as well as women’s ability to allocate household resources to their children in FHH, may explain why this vulnerable group has managed to offset a potential disadvantage to their children.

Background Occupational exposures may result in Canadian military Veterans having poorer health and higher use of health services after transitioning to civilian life compared to the general population. However, few studies have documented the physical health and health services use of Veterans in Canada, and thus there is limited evidence to inform public health policy and resource allocation. Methods In a retrospective, matched cohort of Veterans and the Ontario general population between 1990–2019, we used routinely collected provincial administrative health data to examine chronic disease prevalence and health service use. Veterans were defined as former members of the Canadian Armed Forces or RCMP. Crude and adjusted effect estimates, and 95% confidence limits were calculated using logistic regression (asthma, COPD, diabetes, myocardial infarction, rheumatoid arthritis, family physician, specialist, emergency department, and home care visits, as well as hospitalizations). Modified Poisson was used to estimate relative differences in the prevalence of hypertension. Poisson regression compares rates of health services use between the two groups. Results The study included 30,576 Veterans and 122,293 matched civilians. In the first five years after transition to civilian life, Veterans were less likely than the general population to experience asthma (RR 0.50, 95% CI 0.48–0.53), COPD (RR 0.32, 95% CI 0.29–0.36), hypertension (RR 0.74, 95% CI 0.71–0.76), diabetes (RR 0.71, 95% CI 0.67–0.76), myocardial infarction (RR 0.76, 95% CI 0.63–0.92), and rheumatoid arthritis (RR 0.74, 95% CI 0.60–0.92). Compared to the general population, Veterans had greater odds of visiting a primary care physician (OR 1.76, 95% CI 1.70–1.83) or specialist physician (OR 1.39, 95% CI 1.35–1.42) at least once in the five-year period and lower odds of visiting the emergency department (OR 0.95, 95% CI 0.92–0.97). Risks of hospitalization and of receiving home care services were similar in both groups. Conclusions Despite a lower burden of comorbidities, Veterans had slightly higher physician visit rates. While these visits may reflect an underlying need for services, our findings suggest that Canadian Veterans have good access to primary and specialty health care. But in light of contradictory findings in other jurisdictions, the underlying reasons for our findings warrant further study.

Background Food insecurity, as an indicator of socioeconomic disadvantages and a determinant of health, may be associated with injury by increasing risk exposure and hampering risk mitigation. We examined the association between food insecurity and common causes of injury in the general population. Methods Linking the Canadian Community Health Survey 2005–2017 to National Ambulatory Care Reporting System 2003–2017, this retrospective cohort study estimated incidence of injury-related emergency department (ED) visits by food insecurity status among 212,300 individuals 12 years and above in the Canadian provinces of Ontario and Alberta, adjusting for prior ED visits, lifestyle, and sociodemographic characteristics including income. Results Compared to those in food-secure households, individuals from moderately and severely food-insecure households had 1.16 (95% confidence interval [CI] 1.07–1.25) and 1.35 (95% CI 1.24–1.48) times higher incidence rate of ED visits due to injury, respectively, after confounders adjustment. The association was observed across sex and age groups. Severe food insecurity was associated with intentional injuries (adjusted rate ratio [aRR] 1.81; 95% CI 1.29–2.53) including self-harm (aRR 1.87; 95% CI 1.03–3.40) and violence (aRR 1.79; 95% CI 1.19–2.67) as well as non-intentional injuries (aRR 1.34; 95% CI 1.22–1.46) including fall (aRR 1.43; 95% CI 1.24–1.65), medical complication (aRR 1.39; 95% CI 1.06–1.82), being struck by objects (aRR 1.43; 95% CI 1.07–1.91), overexertion (aRR 1.31; 95% CI 1.04–1.66), animal bite or sting (aRR 1.60; 95% CI 1.08–2.36), skin piercing (aRR 1.80; 95% CI 1.21–2.66), and poisoning (aRR 1.65; 95% CI 1.05–2.59). Moderate food insecurity was associated with more injuries from violence (aRR 1.56; 95% CI 1.09–2.21), falls (aRR 1.22; 95% CI 1.08–1.37), being struck (aRR 1.20; 95% CI 1.01–1.43), and overexertion (aRR 1.25; 95% CI 1.04–1.50). Moderate and severe food insecurity were associated with falls on stairs and being struck in non-sports settings but not with falls on same level or being struck during sports. Food insecurity was not related to transport injuries. Conclusions Health inequity by food insecurity status extends beyond diseases into differential risk of injury, warranting policy intervention. Researchers and policymakers need to address food insecurity as a social determinant of injury to improve health equity.

BackgroundWe sought to explore the perceptions of the socio-cultural contexts and health concerns of consuming sugar-sweetened beverages (SSB) among Indian adults working or studying at a post-secondary institution in Karnataka, India.MethodsWe completed a qualitative study, including 24 semi-structured interviews between 2017 and 2018 at the University of Agricultural Sciences, Dharwad, Karnataka, India. Data were analyzed using thematic content analysis.ResultsOne over-arching theme emerged,westernization and changing perceptions of food, sugar, and health. Participants discussed SSB and associated health concerns in the broad context of westernization and overall economic development in India. Three sub-themes regarding the health perceptions of consuming SSB were:healthy drinks are clean and natural;hydration and energy;andmoderation and body weight. Hygienically-prepared beverages were a consistent concern among participants. Juices and beverages, such as tea or coffee, sweetened with jaggery were viewed positively due to their naturalness and lack of processed sugar. Participants perceived SSB as providing hydration and energy, particularly in hot weather. Lastly, if consumed in moderation, SSB were thought to have no direct adverse health consequences. Though some participants noted excessive, ‘addictive’ consumption would contribute to weight gain and diabetes.ConclusionPerceived health concerns of SSB reflect dominant health issues in India, namely, food insecurity, food safety, and increasingly, diabetes. Policymakers tend to prioritize acute challenges over long-term concerns. As such, the capacity of any policy to address chronic nutritional concerns related to SSB are likely to be muted in the absence of improvements to food safety and security.

Background We evaluated the validity and reliability of the Neilands sexual stigma scale administered to 871 gay, bisexual, and other men who have sex with men (GBMSM) at two research locations in Kenya. Methods Using cross-validation, exploratory factor analysis (EFA) was performed on a randomly selected subset of participants and validated using confirmatory factor analysis (CFA) on the remaining participants. Associations of the initial and final stigma scale factors with depressive symptoms, alcohol use, and other substance use were examined for the entire dataset. Results EFA produced a two-factor scale of perceived and enacted stigma. The CFA model fit to the two-factor scale was improved after removing three cross-loaded items and adding correlated errors (chi-squared = 26.5, df 17, p = 0.07). Perceived stigma was associated with depressive symptoms (beta = 0.34, 95% CI 0.24, 0.45), alcohol use (beta = 0.14, 95% CI 0.03, 0.25) and other substance use (beta = 0.19, 95% CI 0.07, 0.31), while enacted stigma was associated with alcohol use (beta = 0.17, 95% CI 0.06, 0.27). Conclusions Our findings suggest enacted and perceived sexual stigma are distinct yet closely related constructs among GBMSM in Kenya and are associated with poor mental health and substance use.

Background Research consistently demonstrates that physical punishment of children including “spanking” is harmful. Interest in effective prevention is growing rapidly. The aim of the current study is to examine spanking beliefs among adolescents and parents in relation to reports of spanking that the adolescents experienced before 11 years of age. Methods Data were drawn from Wave 1 of a study conducted in 2017–2018 that included adolescents (14–17 years old) and one of their parents/caregivers from Manitoba, Canada (n = 1000 pairs). The study objectives were to examine: 1) spanking beliefs of adolescents and their parents; 2) the correlation between parent and adolescent spanking beliefs; 3) whether parents perceive the words “spank” vs. “hit” differently using intraclass correlation; 4) the association between parents’ beliefs about spanking and parent- and adolescent-reported use of it; and 5) the relationship between sociodemographic variables and spanking. The data were analyzed using descriptive statistics, Spearman’s correlation, intraclass correlation, and binary and multinomial logistic regression analyses. Results The prevalence of adolescent-reported and parents’-reported spanking were 46.0% and 39.6%, respectively. The proportions agreeing that spanking is a normal part of parenting were similar among adolescents (22.0%) and parents (18.5%), and were moderately correlated (intraclass correlation = 0.38, SE = 0.038). More than five times as many parents believed that “spanking” is necessary (19.5%) than believed that “hitting” is necessary (3.5%). Parents’ positive spanking beliefs were associated with increased likelihood of adolescent- and parent-reported spanking. Few significant associations were found between sociodemographic variables and parent-reported or adolescent-reported spanking. Conclusions Adolescents’ spanking beliefs are related to their parents’ spanking beliefs, suggesting that they are transmitted across generations. Public education and law reform are needed to decrease the normalization and perceived necessity of spanking in child-rearing. Efforts should include improving the understanding that spanking is a form of violence against children. With only a few significant differences noted between sociodemographic variables and parent- and adolescent- reported spanking and the prevalent use of spanking across all sociodemographic variable categories, it may be useful to develop universal approaches to awareness-raising and implementation of education strategies in Canada.

ObjectivesThere is a paucity of research on patterns of cyber-victimization in minority groups, including immigrants. This study aimed to identify individual, interpersonal and contextual characteristics associated with cyber-victimization among immigrants and non-immigrants.MethodsWe drew on nationally representative data from adolescents and adults in the Canadian General Social Survey on victimization (2014). We used multivariable logistic regression to identify potential factors associated with cyber-victimization in the last 12 months, stratified by immigrant status and sex.ResultsAmong 27,425 survey respondents, the weighted prevalence of cyber-victimization in the last 12 months was 2.1% among immigrants and 2.3% among non-immigrants. Cyber-victimization rates differed significantly by sex among immigrants (2.8% for males vs. 1.4% for females), but not among non-immigrants (2.1% for males vs. 2.4% for females). While most other factors associated with cyber-victimization were similar for immigrants and non-immigrants, there were pronounced associations of past child maltreatment (adjusted prevalence odds ratio [aPOR] 4.85, 95% confidence interval [CI] 2.76, 8.52) and residence in an unwelcoming neighbourhood (aPOR 5.08, 95% CI 2.44, 10.55) with cyber-victimization among immigrants that were diminished or absent among non-immigrants. Additionally, sex-stratified analyses among immigrants showed cyber-victimization to be strongly associated with having a mental health condition (aPOR 3.50, 95% CI 1.36, 8.97) among immigrant males only, and with perceived discrimination (aPOR 4.08, 95% CI 1.65, 10.08), as well as being under 24 years old (aPOR 3.24, 95% CI 1.09, 9.60) among immigrant females.ConclusionsImmigration status and sex were differentially associated with cyber-victimization. Findings support the salience of a social-ecological perspective and gender-stratified analyses to better elucidate complex pathways linking cyber-victimization to potential gender-based health inequities among immigrants.

Background TB is a preventable and treatable disease. Yet, successful treatment outcomes at desired levels are elusive in many national TB programs, including India. We aim to identify risk factors for unfavourable outcomes to TB treatment, in order to subsequently design a care model that would improve treatment outcomes among these at-risk patients. Methods We conducted a cohort analysis among TB patients who had been recently initiated on treatment. The study was part of the internal program evaluation of a USAID-THALI project, implemented in select towns/cities of Karnataka and Telangana, south India. Community Health Workers (CHWs) under the project, used a pre-designed tool to assess TB patients for potential risks of an unfavourable outcome. CHWs followed up this cohort of patients until treatment outcomes were declared. We extracted treatment outcomes from patient’s follow-up data and from the Nikshay portal. The specific cohort of patients included in our study were those whose risk was assessed during July and September, 2018, subsequent to conceptualisation, tool finalisation and CHW training. We used bivariate and multivariate logistic regression to assess each of the individual and combined risks against unfavourable outcomes; death alone, or death, lost to follow up and treatment failure, combined as ‘unfavourable outcome’. Results A significantly higher likelihood of death and experiencing unfavourable outcome was observed for individuals having more than one risk (AOR: 4.19; 95% CI: 2.47–7.11 for death; AOR 2.21; 95% CI: 1.56–3.12 for unfavourable outcome) or only one risk (AOR: 3.28; 95% CI: 2.11–5.10 for death; AOR 1.71; 95% CI: 1.29–2.26 for unfavourable outcome) as compared to TB patients with no identified risk. Male, a lower education status, an initial weight below the national median weight, co-existing HIV, previous history of treatment, drug-resistant TB, and regular alcohol use had significantly higher odds of death and unfavourable outcome, while age > 60 was only associated with higher odds of death. Conclusion A rapid risk assessment at treatment initiation can identify factors that are associated with unfavourable outcomes. TB programs could intensify care and support to these patients, in order to optimise treatment outcomes among TB patients.

Background Algorithms used to identify disease cases in administrative health data may be sensitive to changes in the data over time. Control charts can be used to assess how variations in administrative health data impact the stability of estimated trends in incidence and prevalence for administrative data algorithms. We compared the stability of incidence and prevalence trends for multiple juvenile diabetes algorithms using observed-expected control charts. Methods Eighteen validated algorithms for juvenile diabetes were applied to administrative health data from Manitoba, Canada between 1975 and 2018. Trends in disease incidence and prevalence for each algorithm were modelled using negative binomial regression and generalized estimating equations; model-predicted case counts were plotted against observed counts. Control limits were set as predicted case count ±0.8*standard deviation. Differences in the frequency of out-of-control observations for each algorithm were assessed using McNemar’s test with Holm-Bonferroni adjustment. Results The proportion of out-of-control observations for incidence and prevalence ranged from 0.57 to 0.76 and 0.45 to 0.83, respectively. McNemar’s test revealed no difference in the frequency of out-of-control observations across algorithms. A sensitivity analysis with relaxed control limits (2*standard deviation) detected fewer out-of-control years (incidence 0.19 to 0.33; prevalence 0.07 to 0.52), but differences in stability across some algorithms for prevalence. Conclusions Our study using control charts to compare stability of trends in incidence and prevalence for juvenile diabetes algorithms found no differences for disease incidence. Differences were observed between select algorithms for disease prevalence when using wider control limits.

Background The Indigenous Youth Mentorship Program (IYMP) is a 20-week communal, relationship-based afterschool healthy living program for Indigenous youth in Canada. IYMP embraces the Anishnaabe/Nehiyawak concepts of Mino-Bimaadiziwin/miyo-pimâtisiwin (“living in a good way”) via its core components of physical activities/games, healthy snacks, and relationship-building. A strength of IYMP is that it values autonomy, adaptability, and the school community context. However, this presents challenges when evaluating its implementation, given that traditional implementation science methods tend to oversimplify the process. In response, essential conditions for the implementation of school-based healthy living programs across diverse contexts have been developed. The purpose of this research was to understand the applicability of these essential conditions within the context of IYMP. Methods 15 participants (n = 10 Young Adult Health Leaders; n = 5 coordinators) with experience implementing IYMP in the provinces of Alberta, Saskatchewan, Manitoba, and Quebec were purposefully sampled. Focused ethnography was the guiding method and one-on-one semi-structured interviews were used as the data generation strategy. The purpose of the interviews was to understand what conditions are needed to implement IYMP. The interview guide was based on previously established essential conditions developed by the research team. Interviews were audio-recorded and transcribed, and content analysis was used to identify patterns in the data. Results The overarching theme that emerged from the interviews was the applicability of the essential conditions when implementing IYMP. Participants felt the eight core conditions (students as change agents, school/community-specific autonomy, demonstrated administrative leadership, higher-level support, dedicated champion(s) to engage school community, community support, quality and use of evidence, and professional development) and four contextual conditions (time, funding and project support, readiness and understanding, and prior community connectivity) were necessary, but made suggestions to modify two conditions (youth led and learning opportunities) to better reflect their experiences implementing IYMP. In addition, a new core condition, rooted in relationship, emerged as necessary for implementation. Conclusions This research adds to the literature by identifying and describing what is needed in practice to implement a communal, relationship-based afterschool healthy living program. The essential conditions may support other researchers and communities interested in implementing and rippling similar programs. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-12412-1.

Background Nunavut, the northernmost Arctic territory of Canada, experienced three community outbreaks of the coronavirus disease 2019 (COVID-19) from early November 2020 to mid-June 2021. We sought to investigate how non-pharmaceutical interventions (NPIs) and vaccination affected the course of these outbreaks. Methods We used an agent-based model of disease transmission to simulate COVID-19 outbreaks in Nunavut. The model encapsulated demographics and household structure of the population, the effect of NPIs, and daily number of vaccine doses administered. We fitted the model to inferred, back-calculated infections from incidence data reported from October 2020 to June 2021. We then compared the fit of the scenario based on case count data with several counterfactual scenarios without the effect of NPIs, without vaccination, and with a hypothetical accelerated vaccination program whereby 98% of the vaccine supply was administered to eligible individuals. Results We found that, without a territory-wide lockdown during the first COVID-19 outbreak in November 2020, the peak of infections would have been 4.7 times higher with a total of 5,404 (95% CrI: 5,015—5,798) infections before the start of vaccination on January 6, 2021. Without effective NPIs, we estimated a total of 4,290 (95% CrI: 3,880—4,708) infections during the second outbreak under the pace of vaccination administered in Nunavut. In a hypothetical accelerated vaccine rollout, the total infections during the second Nunavut outbreak would have been 58% lower, to 1,812 (95% CrI: 1,593—2,039) infections. Vaccination was estimated to have the largest impact during the outbreak in April 2021, averting 15,196 (95% CrI: 14,798—15,591) infections if the disease had spread through Nunavut communities. Accelerated vaccination would have further reduced the total infections to 243 (95% CrI: 222—265) even in the absence of NPIs. Conclusions NPIs have been essential in mitigating pandemic outbreaks in this large, geographically distanced and remote territory. While vaccination has the greatest impact to prevent infection and severe outcomes, public health implementation of NPIs play an essential role in the short term before attaining high levels of immunity in the population.

Background As of 2019, men who have sex with men (MSM) in Canada are ineligible to donate blood if they have had oral or anal sex with another man in the last 3 months. Deferral policies targeting MSM are largely interpreted as unjust by gay, bisexual, and other men who have sex with men (GBMSM) – shaping their desire to donate blood and engage with blood operators. This mixed methods study explores interest in blood donation among GBMSM as well as willingness (and eligibility) to donate under four different deferral policies. Methods We surveyed 447 GBMSM who were recruited from the Ontario-wide #iCruise study. Participants were asked whether they were interested in blood donation and if they were willing to donate under each of our four deferral policies. We also completed interviews with 31 of these GBMSM. Participants were asked to describe their feelings about blood donation, their views on our different deferral policies, the impact of a policy change, as well as other means of redress. Results Most participants (69%) indicated that they were interested in donating blood. Despite this, an interpretation of the MSM deferral policy as discriminatory was common among all participants. Our mixed methods findings indicate that, among those who were interested in blood donation, the adoption of one of the alternative policies presented in this study (specifically Policy 2 or Policy 3) would significantly increase the number of participants willing to donate and be viewed as “a step in the right direction.” However, many participants who were not interested in blood donation argued that a gender-neutral deferral policy would need to be implemented for them to donate. Participants recommended that blood operators consider efforts to repair relations with GBMSM beyond policy change, including pop-up clinics in predominantly queer areas and diversity sensitivity training for staff. Conclusion We argue that the most impactful policy shift would be the implementation of an individual risk-based deferral policy that is applied to all donors regardless of sexual orientation or gender identity. However, given MSM’s historical exclusion from blood donations, blood operators should pair this policy shift with community relationship-building efforts.

Objectives The COVID-19 pandemic has impacted all aspects of the food system, including the retail grocery sector. We sought to (objective 1) document and (objective 2) analyze the policies implemented in the grocery sector during the first wave of the pandemic in Manitoba, Canada. Methods Our qualitative policy analysis draws from organizational communications (websites and social media) (n = 79), news media articles (n = 95), and key informant interviews with individuals (n = 8) working within the grocery sector in urban and rural, Manitoba. Media and communications were extracted between March 9-May 8, 2020 and interviews were conducted in July–August, 2020. Results Newly implemented policies due to the pandemic fell under four inter-related themes: Employee health and wellbeing, Safety measures, Operational measures, and Community support. Employee health and wellbeing included sub-themes of financial and social support, health recommendations and protocols, and new employee guidelines. Safety measures encompassed numerous policies pertaining to sanitation, personal protection, transmission prevention, physical distancing, and limiting access. Overall, new policies were discussed as effective in making grocery shopping as safe as possible given the situation. Compliance and enforcement, employee teamwork, and support for employees were key themes related to perceptions of policy success in a challenging and inequitable context. Nevertheless, government support and communication was needed as well to ensure safety within the grocery sector. Conclusions The grocery sector reacted to the pandemic with the swift implementation of policies to address food supply issues, prevent transmission of the virus, support their employees as essential workers, and better serve high-risk populations.

Background Diagnosis codes in administrative health data are routinely used to monitor trends in disease prevalence and incidence. The International Classification of Diseases (ICD), which is used to record these diagnoses, have been updated multiple times to reflect advances in health and medical research. Our objective was to examine the impact of transitions between ICD versions on the prevalence of chronic health conditions estimated from administrative health data. Methods Study data (i.e., physician billing claims, hospital records) were from the province of Manitoba, Canada, which has a universal healthcare system. ICDA-8 (with adaptations), ICD-9-CM (clinical modification), and ICD-10-CA (Canadian adaptation; hospital records only) codes are captured in the data. Annual study cohorts included all individuals 18 + years of age for 45 years from 1974 to 2018. Negative binomial regression was used to estimate annual age- and sex-adjusted prevalence and model parameters (i.e., slopes and intercepts) for 16 chronic health conditions. Statistical control charts were used to assess the impact of changes in ICD version on model parameter estimates. Hotelling’s T2 statistic was used to combine the parameter estimates and provide an out-of-control signal when its value was above a pre-specified control limit. Results The annual cohort sizes ranged from 360,341 to 824,816. Hypertension and skin cancer were among the most and least diagnosed health conditions, respectively; their prevalence per 1,000 population increased from 40.5 to 223.6 and from 0.3 to 2.1, respectively, within the study period. The average annual rate of change in prevalence ranged from -1.6% (95% confidence interval [CI]: -1.8, -1.4) for acute myocardial infarction to 14.6% (95% CI: 13.9, 15.2) for hypertension. The control chart indicated out-of-control observations when transitioning from ICDA-8 to ICD-9-CM for 75% of the investigated chronic health conditions but no out-of-control observations when transitioning from ICD-9-CM to ICD-10-CA. Conclusions The prevalence of most of the investigated chronic health conditions changed significantly in the transition from ICDA-8 to ICD-9-CM. These results point to the importance of considering changes in ICD coding as a factor that may influence the interpretation of trend estimates for chronic health conditions derived from administrative health data.

Background Our objectives were to describe both the development, and content, of a charitable food dataset that includes geographic information for food pantries in 12 American states. Methods Food pantries were identified from the foodpantries.org website for 12 states, which were linked to state-, county-, and census-level demographic information. The publicly available 2015 Food Access Research Atlas and the 2010 US Census of Population and Housing were used to obtain demographic information of each study state. We conducted a descriptive analysis and chi-square tests were used to test for differences in patterns of food pantries according to various factors. Results We identified 3777 food pantries in 12 US states, providing an estimated 4.84 food pantries per 100,000 people, but ranged from 2.60 to 7.76 within individual states. The majority of counties (61.2%) had at least one food pantry. In contrast, only 15.7% of all census tracts in the study states had at least one food pantry. A higher proportion of urban census tracts had food pantries compared to rural tracts. We identified 2388 (63.2%) as being faith-based food pantries. More than a third (34.4%) of food pantries did not have information on their days of operation available. Among the food pantries displaying days of operation, 78.1% were open at least once per week. Only 13.6% of food pantries were open ≤1 day per month. Conclusions The dataset developed in this study may be linked to food access and food environment data to further examine associations between food pantries and other aspects of the consumer food system (e.g. food deserts) and population health from a systems perspective. Additional linkage with the U.S. Religion Census Data may be useful to examine associations between church communities and the spatial distribution of food pantries.

Background Self-rated health (SRH) is a commonly used survey measure as a substitute for a clinical measure of health, which has demonstrated validity and reliability in a variety of populations. The referents that individuals incorporate into their self-evaluations have been shown to include health-related behaviours, though these relationships are not static. Our purpose was to describe and test for relationships between health-related behaviours and SRH among Canadian adults. Methods We used pooled data from the Canadian Health Measures Surveys Cycles 3 (2012–13) and 4 (2014–15). All men and non-pregnant women aged 18 years and older were included (n = 6,789). We used binary logistic regression to test for relationships between health-related behaviours and SRH, including smoking status, adequate fruit and vegetable intake, inadequate sleep, alcohol use, and adequate physical activity. Results The majority of respondents rated their health as good, very good, or excellent, though differences in SRH were found according to age group, highest level of household education, and income adequacy. Inadequate sleep was most strongly associated with poorer SRH among men and women combined, as compared to other health-related behaviours. Among women only, those who report heavy episodic drinking (OR, 2.64) or daily drinking (OR, 3.51) rated their health better, as compared to women who report low-risk alcohol use. Conclusions Sleep quality is an important predictor of SRH for both men and women. Second, sex/gender differences must be considered in strategies to address alcohol use, as we may not be fully appreciating potentially health-affirming qualities associated with alcohol use among women.

Background Active transportation, such as walking and biking, is a healthy way for children to explore their environment and develop independence. However, children can be injured while walking and biking. Many cities make changes to the built environment (e.g., traffic calming features, separated bike lanes) to keep people safe. There is some research on how effective these changes are in preventing adult pedestrians and bicyclists from getting hurt, but very little research has been done to show how safe various environments are for children and youth. Our research program will study how features of the built environment affect whether children travel (e.g., to school) using active modes, and whether certain features increase or decrease their likelihood of injury. Methods First, we will use a cross-sectional study design to estimate associations between objectively measured built environment and objectively measured active transportation to school among child elementary students. We will examine the associations between objectively measured built environment and child and youth pedestrian-motor vehicle collisions (MVCs) and bicyclist-MVCs. We will also use these data to determine the space-time distribution of pedestrian-MVCs and bicyclist-MVCs. Second, we will use a case-crossover design to compare the built environment characteristics of the site where child and youth bicyclists sustain emergency department reported injuries and two randomly selected sites (control sites) along the bicyclist’s route before the injury occurred. Third, to identify implementation strategies for built environment change at the municipal level to encourage active transportation we will conduct: 1) an environmental scan, 2) key informant interviews, 3) focus groups, and 4) a national survey to identify facilitators and barriers for implementing built environment change in municipalities. Finally, we will develop a built environment implementation toolkit to promote active transportation and prevent child pedestrian and bicyclist injuries. Discussion This program of research will identify the built environment associated with active transportation safety and form an evidence base from which municipalities can draw information to support change. Our team’s national scope will be invaluable in providing information regarding the variability in built environment characteristics and is vital to producing evidence-based recommendations that will increase safe active transportation.

Background India lacks data on the incidence of Paediatric HIV. In 2010, the Indian Council of Medical Research commissioned a task force study to estimate the paediatric HIV burden in Belgaum district, Karnataka, India. We estimated the HIV incidence, prevalence and associated risk factors of mother to child transmission of HIV among children exposed to maternal HIV by age 24 months. Methods We included Belgaum resident pregnant women who tested HIV positive between January 1st, 2011 and May 31st, 2013 and who provided consent. Their babies were tested for HIV at three time intervals using DNA PCR dry blood spot (DBS) method at 6–10 weeks and 6–9 months, and using Antibody tests at 18–24 months of age. We estimated cumulative incidence using survival analysis that considered censoring of cases and prevalence rates of HIV by age 24 months. Using competing-risk survival regression model, we examined the correlates of transmission of HIV among babies exposed to maternal HIV. Results Among 487 children of HIV positive mothers recruited in the study, the cumulative incidence rate by 24 months of age was 4.8 per 1000 person months [95% CI: 3.5–6.6]. The HIV prevalence rate among babies exposed to maternal HIV until 24 months was 7.8% [95% CI: 5.7–10.7]. Mother’s age above 30 years, and breastfeeding duration of more than six months were factors that significantly increased the HIV transmission; adjusted hazard ratio (AHR) 6.98 [95% CI: 1.73–28.16] and 5.28 [95% CI, 1.75–15.90], respectively. The risk of MTCT was significantly reduced if both mother and baby had received Nevirapine at delivery [AHR 0.25; 95%CI: 0.10–0.61] and if either mother or baby had been given Nevirapine at delivery [AHR 0.12; 95%CI: 0.03–0.49]. Conclusion The study findings suggest that mother’s age above 30 years and breastfeeding beyond 26 weeks is associated with higher rates of HIV transmission from mother to child. It confirms the benefits of providing anti-retrovirals (Nevirapine) in reducing mother to child transmission of HIV. Effective strategies to promote safe infant feeding practices, including avoidance of mixed feeding beyond 26 weeks among HIV infected mothers, is critical to reduce incidence of paediatric HIV in India.

Background Child maltreatment (CM) and peer victimization (PV) are serious issues affecting children and adolescents. Despite the interrelatedness of these exposures, few studies have investigated their co-occurrence and combined impact on health outcomes. The study objectives were to determine the overall and sex-specific prevalence of lifetime exposure to CM and past-month exposure to PV in adolescents, and the impact of CM and PV co-occurrence on non-suicidal self-injury, suicidality, mental health disorders, and physical health conditions. Methods Adolescents aged 14–17 years (n = 2,910) from the 2014 Ontario Child Health Study were included. CM included physical, sexual, and emotional abuse, physical neglect, and exposure to intimate partner violence. PV included school-based, cyber, and discriminatory victimization. Logistic regression was used to compare prevalence by sex, examine independent associations and interaction effects in sex-stratified models and in the entire sample, and cumulative effects in the entire sample. Results About 10% of the sample reported exposure to both CM and PV. Sex differences were as follows: females had increased odds of CM, self-injury, suicidality, and internalizing disorders, and males had greater odds of PV, externalizing disorders, and physical health conditions. Significant cumulative and interaction effects were found in the entire sample and interaction effects were found in sex-stratified models, indicating that the presence of both CM and PV magnifies the effect on self-injury and all suicide outcomes for females, and on suicidal ideation, suicide attempts, and mental health disorders for males. Conclusions Experiencing both CM and PV substantially increases the odds of poor health outcomes among adolescents, and moderating relationships affect females and males differently. Continued research is needed to develop effective prevention strategies and to examine protective factors that may mitigate these adverse health outcomes, including potential sex differences.

Background Manitoba is a central Canadian province with annual rates of new HIV infections consistently higher than the Canadian average. National surveillance statistics and data from the provincial HIV care program suggest that epidemiological heterogeneity exists across Manitoba. New HIV cases are disproportionately reported among females, Indigenous-identifying individuals, and those with a history of injection drug use. Given the heterogeneity in acquisition, it is of interest to understand whether this translates into inequalities in HIV care across Manitoba. Methods A sample of 703 participants from a clinical cohort of people living with HIV in Manitoba, with data current to the end of 2017, was used to conduct cross-sectional, disaggregated analyses of the HIV care cascade to identify heterogeneity in service coverage and clinical outcomes among different groups receiving HIV care in Manitoba. Equiplots are used to identify and visualize inequalities across the cascade. Exploratory multivariable logistic regression models quantify associations between equity variables (age, sex, geography, ethnicity, immigration status, exposure category) and progression along the cascade. Adjusted odds ratios (AOR) and 95% confidence intervals (95%CI) are reported. Results Equity analyses highlight inequalities in engagement in and coverage of HIV-related health services among cohort participants. Equiplots illustrate that the proportion of participants in each cascade step is greater for those who are older, white, non-immigrants, and report no history of injection drug use. Compared to those living in Winnipeg, participants in eastern Manitoba have greater odds of achieving virologic suppression (AOR[95%CI] = 3.8[1.3–11.2]). The odds of Indigenous participants being virologically suppressed is half that of white participants (AOR[95%CI] = 0.5[0.3–0.7]), whereas African/Caribbean/Black participants are significantly less likely than white participants to be in care and retained in care (AOR[95%CI] = 0.3[0.2–0.7] and 0.4[0.2–0.9], respectively). Conclusions Inequalities exist across the cascade for different groups of Manitobans living with HIV; equiplots are an innovative method for visualizing these inequalities. Alongside future research aiming to understand why inequalities exist across the cascade in Manitoba, our equity analyses can generate hypotheses and provide evidence to inform patient-centred care plans that meet the needs of diverse client subgroups and advocate for policy changes that facilitate more equitable HIV care across the province.

Background In Canada, anaphylaxis-level food allergy constitutes a legal disability. Yet, no nationwide policies exist to support families. We sought to understand what parents of children with food allergy perceive as the most pressing food allergy-related policy concerns in Canada. Methods Between March–June 2019, we interviewed 23 families whose food allergic children (N = 28mean age 7.9 years) attending an allergy clinic in Winnipeg, Canada. Interviews were audio-recorded, transcribed and analyzed using content analysis. Results Over 40% of children had multiple food allergies, representing most of Health Canada’s priority allergens. We identified four themes: (1) High prevalence. High priority?. (2) Food labels can be misleading, (3) Costs and creative ideas, and (4) Do we have to just deal with the status quo around allergies? Conclusion Food allergy ought to be a national policy priority, to improve the process for precautionary labelling, to improve funding, educational tools access to care, and knowledge of current allergy guidelines.

Background Gender inequality varies across countries and is associated with poor outcomes including violence against women and depression. Little is known about the relationship of source county gender inequality and poor health outcomes in female immigrants. Methods We used administrative databases to conduct a cohort study of 299,228 female immigrants ages 6–29 years becoming permanent residence in Ontario, Canada between 2003 and 2017 and followed up to March 31, 2020 for severe presentations of suffering assault, and selected mental health disorders (mood or anxiety, self-harm) as measured by hospital visits or death. Poisson regression examined the influence of source-country Gender Inequality Index (GII) quartile (Q) accounting for individual and country level characteristics. Results Immigrants from countries with the highest gender inequality (GII Q4) accounted for 40% of the sample, of whom 83% were from South Asia (SA) or Sub-Saharan Africa (SSA). The overall rate of assault was 10.9/10,000 person years (PY) while the rate of the poor mental health outcome was 77.5/10,000 PY. Both GII Q2 (Incident Rate Ratio (IRR): 1.48, 95% Confidence Interval (CI): 1.08, 2.01) and GII Q4 (IRR: 1.58, 95%CI: 1.08, 2.31) were significantly associated with experiencing assault but not with poor mental health. For females from countries with the highest gender inequality, there were significant regional differences in rates of assault, with SSA migrants experiencing high rates compared with those from SA. Relative to economic immigrants, refugees were at increased risk of sustaining assaults (IRR: 2.96, 95%CI: 2.32, 3.76) and poor mental health (IRR: 1.73, 95%CI: 1.50, 2.01). Higher educational attainment (bachelor’s degree or higher) at immigration was protective (assaults IRR: 0.64, 95%CI: 0.51, 0.80; poor mental health IRR: 0.69, 95% CI: 0.60, 0.80). Conclusion Source country gender inequality is not consistently associated with post-migration violence against women or severe depression, anxiety and self-harm in Ontario, Canada. Community-based research and intervention to address the documented socio-demographic disparities in outcomes of female immigrants is needed.

Background Population and environmental health research illustrate a positive relationship between access to greenspace or natural environments and peoples’ perceived health, mental health, resilience, and overall well-being. This relationship is also particularly strong among Canadian Indigenous populations and social determinants of health research where notions of land, health, and nature can involve broader spiritual and cultural meanings. Among Indigenous youth health and resilience scholarship, however, research tends to conceptualize land and nature as rural phenomena without any serious consideration on their impacts within urban cityscapes. This study contributes to current literature by exploring Indigenous youths’ meaning-making processes and engagements with land and nature in an urban Canadian context. Methods Through photovoice and modified Grounded Theory methodology, this study explored urban Indigenous youth perspectives about health and resilience within an inner-city Canadian context. Over the course of one year, thirty-eight in-depth interviews were conducted with Indigenous (Plains Cree First Nations and Métis) youth along with photovoice arts-based and talking circle methodologies that occurred once per season. The research approach was also informed by Etuaptmumk or a “two-eyed seeing” framework where Indigenous and Western “ways of knowing” (worldviews) can work alongside one another. Results Our strength-based analyses illustrated that engagement with and a connection to nature, either by way of being present in nature and viewing nature in their local urban context, was a central aspect of the young peoples’ photos and their stories about those photos. This article focuses on three of the main themes that emerged from the youth photos and follow-up interviews: (1) nature as a calming place; (2) building metaphors of resilience; and (3) providing a sense of hope. These local processes were shown to help youth cope with stress, anger, fear, and other general difficult situations they may encounter and navigate on a day-to-day basis. Conclusions This study contributes to the literature exploring Indigenous youths’ meaning-making process and engagements with land and nature in an urban context, and highlights the need for public health and municipal agencies to consider developing more culturally safe and meaningful natural environments that can support the health, resilience, and well-being of Indigenous youth within inner-city contexts.

Background Bacille Calmette-Guérin (BCG) vaccination against tuberculosis (TB) is widespread in high-TB-burden countries, however, BCG vaccination policies in low-burden countries vary. Considering the uncertainties surrounding BCG efficacy and the lower likelihood of TB exposure in low-incidence countries, most have discontinued mass vaccination, choosing instead a targeted vaccination strategy among high-risk groups. Given the increased risk of TB infection in Canadian Indigenous communities compared to the general Canadian population, these communities are a pertinent example of high-incidence groups in an otherwise low-burden country, warranting particular consideration regarding BCG vaccination strategy. This systematic review aims to synthesise and critically appraise the literature on BCG vaccination strategies in high-risk groups in low-incidence settings to provide policy considerations relevant to the Canadian Indigenous context. Methods: A literature search of the Medline and Embase databases was conducted, returning studies pertaining to BCG vaccine efficacy, TB incidence under specific vaccination policies, BCG-associated adverse events, and vaccination policy guidelines in low-burden countries. Study screening was tracked using the Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia), and data pertaining to the above points of interest were extracted. Results The final review included 49 studies, spanning 15 countries. Although almost all of these countries had implemented a form of mass or routine vaccination previously, 11 have since moved to targeted vaccination of selected risk groups, in most cases due to the low risk of infection among the general population and thus the high number of vaccinations needed to prevent one case in the context of low-incidence settings. Regarding identifying risk groups for targeted screening, community-based (rather than individual risk-factor-based) vaccination has been found to be beneficial in high-incidence communities within low-incidence countries, suggesting this approach may be beneficial in the Canadian Indigenous setting. Conclusions Community-based vaccination of high-incidence communities may be beneficial in the Canadian Indigenous context, however, where BCG vaccination is implemented, delivery strategies and potential barriers to achieving adequate coverage in this setting should be considered. Where an existing vaccination program is discontinued, it is crucial that an effective TB surveillance system is in place, and that case-finding, screening, and diagnostic efforts are strengthened in order to ensure adequate TB control. This is particularly relevant in Canadian Indigenous and other remote or under-served communities, where barriers to surveillance, screening, and diagnosis persist.

Background Health-related behaviours such as physical inactivity, low fruit and vegetable intake, smoking, alcohol use, and inadequate sleep are significant predictors of adverse health outcomes. Health promotion strategies often focus on one behavior, though research suggests health-related behaviours tend to co-occur. The purpose of this study is to describe the relationships between health-related behaviours in the Canadian adult population. Methods Data from cycles 3 (2012–2013) and 4 (2014–2015) of the Canadian Health Measures Survey were pooled to describe health-related behaviours (current smoking status, high-risk alcohol use, fruit and vegetable intake, inadequate sleep, and physical activity) among adults according to sex, age group, household education, and income adequacy. Logistic regression was used to test for relationships between health-related behaviours. Results Findings indicated that adverse health-related behaviours co-occur frequently, with approximately half of Canadians reporting two or more adverse health-related behaviours. Overall, Canadian men were more likely to report adverse health-related behaviours compared to women, with the exception of inadequate sleep. Smoking status, fruit and vegetable intake, sleep and physical activity exhibited an income and education gradient. Sex-based patterns in grouping of behaviours were present such that adverse health-related behaviours were associated with current smoking among men and with high-risk alcohol use among women. Conclusion Our findings suggest that health-related behaviours should be considered in both isolation and combination when designing intervention strategies. Sex-specific patterns of how these behaviours co-occur must also be taken into account.

Background HIV prevalence among men having sex with men (MSM) in Kenya is 18.2%. Despite scale-up of HIV testing services, many MSM remain unaware of their HIV status and thus do not benefit from accessing HIV treatment or prevention services. HIV self-testing (HIVST) may help address this gap. However, evidence is limited on how, when, and in what contexts the delivery of HIVST to MSM could increase awareness of HIV status and lead to early linkage to HIV treatment and prevention. Methods The study will be embedded within existing MSM-focused community-based HIV prevention and treatment programmes in 3 counties in Kenya (Kisumu, Mombasa, Kiambu). The study is designed to assess three HIV testing outcomes among MSM, namely a) coverage b) frequency of testing and c) early uptake of testing. The study will adopt a mixed methods programme science approach to the implementation and evaluation of HIVST strategies via: (i) a baseline and endline bio-behavioural survey with 1400 MSM; (ii) a socio-sexual network study with 351 MSM; (iii) a longitudinal qualitative cohort study with 72 MSM; (iv) routine programme monitoring in three sites; (v) a programme-specific costing exercise; and (vi) mathematical modelling. This protocol evaluates the impact of community-based implementation of HIV self-testing delivery strategies among MSM in Kenya on reducing the undiagnosed MSM population, and time for linkage to prevention, treatment and care following HIV self-testing. Baseline data collection started in April 2019 and the endline data collection will start in July 2020. Discussion This study is one of the first programme science studies in Sub-Saharan Africa exploring the effectiveness of integrating HIVST interventions within already existing HIV prevention and treatment programmes for MSM in Kenya at scale. Findings from this study will inform national best approaches to scale up HIVST among MSM in Kenya.

Background India accounts for more than two-third of mortality due to non-communicable diseases (NCDs) in south-east Asia. The burden is high in Karnataka, one of the largest states in southern India. There is a need for integration of disease prevention, health promotion, treatment and care within the national program at primary level. A public-private partnership initiative explored evidence gaps to inform a health system based, integrated NCD programme across care continuum with a focus on hypertension and diabetes. Methods The study was conducted during 2017–18 in urban parts of Mysore city, covering a population of 58,000. Mixed methods were used in the study; a population-based screening to estimate denominators for those with disease and at risk; cross-sectional surveys to understand distribution of risk factors, treatment adherence and out of pocket expenses; facility audits to assess readiness of public and private facilities; in-depth interviews and focus group discussions to understand practices, myths and perceptions in the community. Chi-square tests were used to test differences between the groups. Framework analysis approach was used for qualitative analysis. Results Twelve and 19% of the adult population had raised blood sugar and blood pressure, respectively, which increased with age, to 32 and 44% for over 50 years. 11% reported tobacco consumption; 5.5%, high alcohol consumption; 40%, inadequate physical activity and 81%, inappropriate diet consumption. These correlated strongly with elderly age and poor education. The public facilities lacked diagnostics and specialist services; care in the private sector was expensive. Qualitative data revealed fears and cultural myths that affected treatment adherence. The results informed intervention design across the NCD care continuum. Conclusions The study provides tools and methodology to gather evidence in designing comprehensive NCD programmes in low and middle income settings. The study also provides important insights into public-private partnership driving effective NCD care at primary care level. Electronic supplementary material The online version of this article (10.1186/s12889-019-6735-z) contains supplementary material, which is available to authorized users.

Background Multimorbidity can be defined as the presence of more than one chronic condition in an individual. Research on multimorbidity has predominantly focused on older adults and few studies have examined multimorbidity in middle-aged people. The objectives of this study were to: 1) examine the prevalence of multimorbidity among middle-aged Canadians; and 2) examine the association between lifestyle factors (smoking, alcohol intake, physical activity) and multimorbidity in this age group. Methods In this analysis of the Canadian Longitudinal Study on Aging (CLSA) baseline data, we extracted data from 29,841 participants aged 45–64 years from a database of 51,338 people aged 45–85 years. Self-reported data on 27 chronic physical health conditions were used to derive different multimorbidity definitions. We estimated the prevalence of 3+ to 5+ chronic physical health conditions in different subgroups for descriptive purposes. Multivariable logistic regression analyses were performed to determine the association between socio-demographic and lifestyle factors, and multimorbidity using a 3+ multimorbidity case definition. Result We found that 39.6% (99% CI 38.4–40.7) of participants had three or more chronic conditions with a mean number of chronic condition of 2.41 (99% CI 2.37–2.46). The prevalence of multimorbidity increased with age from 29.7% in the 45–49-year-old age group to 52% in individuals aged 60–64 years. The prevalence of 4+ and 5+ chronic conditions was 24.5 and 14.2% respectively. Analyses indicated that female sex and low income were associated with higher odds of multimorbidity, whereas daily or weekly alcohol intake were associated with lower odds of multimorbidity. Exercise was not associated with multimorbidity. Results were similar when analyses were conducted separately for women and men. Conclusions Multimorbidity is not limited to older adults, but is a common phenomenon among middle-aged people. Longitudinal research is needed to better understand the temporal relationship between lifestyle factors and multimorbidity.

Background Canada’s Food Guide (CFG) has been an important health promotion tool for over seventy years. The most recent version was released in 2007. This study examined Canadians’ exposure to, knowledge, and use of CFG. Methods Data came from the Canadian Community Health Survey’s Rapid Response on the Awareness and Usage of Canada’s Food Guide, which included 10,098 Canadians ≥12 y in all ten provinces. Questions were asked on familiarity, awareness and usage of CFG and Canada’s Food Guide for First Nations, Inuit and Métis, as well as healthy eating principles and behaviours. Descriptive statistics and logistic regression were used to observe counts and differences among key demographic variables. Results More than 80% of Canadians have heard of CFG however significantly more women than men were aware of the Guide. Most knew that ‘Vegetables and Fruit’ had the most recommended servings and that dark green vegetables should be consumed daily; however fewer than half knew this of orange vegetables. Just under one third had a copy in their homes, and the most common sources for obtaining CFG were child’s school and health professional/trainer. Those who consulted CFG recently were more likely to consume the recommended servings of vegetables and fruits, and to state that their eating habits were ‘much better’ than one year previously. Conclusions CFG has “brand recognition” among Canadians however there are gaps between awareness and eating behaviours. The new Food Guide could consider additional dissemination tools including social media, videos and workbooks tailored to various age groups, demographic groups and settings.

ᅟ

Background Female sex workers (FSWs) are at increased risk of HIV and STIs compared to women in the general population, and frequently experience violence in their working and domestic lives from a variety of perpetrators, which can enhance this risk. While progress has been made in addressing violence by police and clients, little work has been done to understand and prevent violence by intimate partners (IPs) among FSW populations. Methods Samvedana Plus is a multi-level intervention programme that works with FSWs, their IPs, the sex worker community, and the general population, and aims to reduce violence and increase consistent condom use within these ‘intimate’ relationships. The programme involves shifting norms around the acceptability of beating as a form of discipline, challenging gender roles that give men authority over women, and working with men and women to encourage new relationship models based on gender equity and respect. The programme will aim to cover 800 FSWs and their IPs living in 47 villages in Bagalkot district, northern Karnataka. The study is designed to assess two primary outcomes: the proportion of FSWs who report: (i) physical or sexual partner violence; and (ii) consistent condom use in their intimate relationship, within the past 6 months. The evaluation will employ a cluster-randomised controlled trial design, with 50 % of the village clusters (n = 24) randomly selected to receive the intervention for the first 24 months and the remaining 50 % (n = 23) receiving the intervention thereafter. Statisticians will be blinded to treatment arm allocation. The evaluation will use an adjusted, cluster-level intention to treat analysis, comparing outcomes in intervention and control villages at midline (12 months) and endline (24 months). The evaluation design will involve quantitative and qualitative assessments with (i) all FSWs who report an IP (ii) IPs; and process/ implementation monitoring. Baseline data collection was completed in April 2015, and endline data collection is anticipated in May 2017. Conclusions This is an innovative intervention programme that aims to address violence by IPs as part of HIV prevention programming with FSWs. Reducing violence is expected to reduce vulnerability to HIV acquisition, and help women to work and live without fear of violence. Trial registration Clinical Trials NCT02807259 Jun 24 2016 (retrospectively registered). Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3356-7) contains supplementary material, which is available to authorized users.

Background Home visiting programs focused on improving early childhood environments are commonplace in North America. A goal of many of these programs is to improve the overall health of children, including promotion of age appropriate vaccination. In this study, population-based data are used to examine the effect of a home visiting program on vaccination rates in children. Methods Home visiting program data from Manitoba, Canada were linked to several databases, including a provincial vaccination registry to examine vaccination rates in a cohort of children born between 2003 and 2009. Propensity score weights were used to balance potential confounders between a group of children enrolled in the program (n = 4,562) and those who were eligible but not enrolled (n = 5,184). Complete and partial vaccination rates for one and two year old children were compared between groups, including stratification into area-level income quintiles. Results Complete vaccination rates from birth to age 1 and 2 were higher for those enrolled in the Families First program [Average Treatment Effect Risk Ratio (ATE RR) 1.06 (95 % CI 1.03–1.08) and 1.10 (95 % CI 1.05–1.15) respectively]. No significant differences were found between groups having at least one vaccination at age 1 or 2 [ATE RR 1.01 (95 % CI 1.00–1.02) and 1.00 (95 % CI 1.00–1.01) respectively). The interaction between program and income quintiles was not statistically significant suggesting that the program effect did not differ by income quintile. Conclusions Home visiting programs have the potential to increase vaccination rates for children enrolled, despite limited program content directed towards this end. Evidence-based program enhancements have the potential to increase these rates further, however more research is needed to inform policy makers of optimal approaches in this regard, especially with respect to cost-effectiveness.

Background Essential to building cardiovascular health promotion capacity in youth, which extends into adulthood, are approaches that seek to empower, educate, and support. The Five Cs model of positive youth development (PYD) guided this study. This model represents the ability of youth to develop competence, confidence, connection, character, and caring when given the appropriate resources. The purpose of this two-year school-based feasibility study was to determine if providing a research intervention in the form of education, empowerment, and support build youth’s capacity for cardiovascular health promotion. Methods A mixed methods case study design was used to evaluate the process, and outcome of a youth-led cardiovascular health promotion program. Twenty-six youth aged 12–13 years from a Canadian middle school took part in the study. Youth participating in this study planned, implemented, and monitored cardiovascular health promotion activities in four areas: smoking, physical inactivity, nutrition and obesity. Qualitative data was collected from the youth participants using three focus groups and individual reflective journals. Quantitative data was collected with the PYD.2, a self-report questionnaire that assesses positive youth development and consists of 5 subscales: character, competence, caring, connection, and confidence. The participants completed the PYD before and after the program to determine if there were any changes in PYD scores after the intervention. The quantitative data was analyzed using paired samples t-tests, and the qualitative data was analyzed using constant comparative analysis. Results While the PYD scores showed no significant changes, the qualitative findings confirmed that the youth acquired increased awareness and understanding of cardiovascular health promotion initiatives. Four themes emerged from the qualitative data, (1) doing the right thing, (2) wanting to make a change, but feeling constrained, (3) I get it, and (4) The project has changed me! The intervention was found to be acceptable and feasible for the youth participants and their school. Conclusions The contributions of this study were twofold. It generated evidence to support integrating positive youth development strategies into cardiovascular health promotion programs. Secondly, this study determined that the research intervention improved the participants’ knowledge and attitudes about cardiovascular health and were suitable for further implementation and testing.

Background Parental influences are essential to the behaviours and physical activity of their children. Our study aimed to determine if parental beliefs and support are associated with children’s pedometer measured physical activity levels on school days and weekend days. Methods In the spring of 2009 and 2011, we analyzed cross-sectional data from 1,355 grade five students and parents in 30 schools in Alberta, Canada. Parents reported how much they care about exercising, how much they encourage their child to be physically active, and how frequently they engage in physical activities with their child. Physical activity was assessed from step counts obtained from time-stamped pedometers collected over nine consecutive days. Results Increased parental encouragement was positively associated with boys’ and girls’ physical activity on school days (Boys: beta = 1373, 95% CI: 606, 2139; Girls: beta = 632, 95% CI: 108, 1155) and girls’ physical activity on weekend days (beta = 997, 95% CI: 130, 1864). Increased parental care was positively associated with boys’ physical activity on weekend days (beta = 1381, 95% CI: 85, 2676). Increased parental support and engagement was associated with an additional 632–1381 steps/day for children in this study. Conclusions Parental care, encouragement and engagement are associated with physical activity levels of children 10–11 years of age. Policy makers and researchers should consider the importance of targeting parents when designing strategies to promote physical activity in children. This is particularly relevant to weekends and holidays when children’s activity levels are low.

Background Bowel disorders have destructive impacts on the patients social and mental aspects of life and can cause emotional distress. The risk of developing bowel incontinence also increases with age. The rate of incidence of inflammatory bowel disease in Manitoba, Canada, has been unusually raised. Therefore, it is important to identify trends in the incidence of bowel disorders that may suggest further epidemiological studies to identify risk factors and identify any changes in important factors. Methods An important part of spatial epidemiology is cluster detection as it has the potential to identify possible risk factors associated with disease, which in turn may lead to further investigations into the nature of diseases. To test for potential disease clusters many methods have been proposed. The focused detection methods including the circular spatial scan statistic (CSS), flexible spatial scan statistic (FSS), and Bayesian disease mapping (BYM) are among the most popular disease detection procedures. A frequentist approach based on maximum likelihood estimation (MLE) has been recently used to identify potential focused clusters as well. The aforementioned approaches are studied by analyzing a dataset of bowel disorders in the province of Manitoba, Canada, from 2001 to 2010. Results The CSS method identified less regions than the FSS method in the south part of the province as potential clusters. The same regions were identified by the BYM and MLE methods as being potential clusters of bowel disorders with a slightly different order of significance. Most of these regions were also detected by the CSS or FSS methods. Conclusions Overall, we recommend using the methods BYM and MLE for cluster detection with the similar population and structure of regions as in Manitoba. The potential clusters of bowel disorders are generally located in the southern part of the province including the eastern part of the city of Winnipeg. These results may represent real increases in bowel disorders or they may be an indication of other covariates that were not adjusted for in the model used here. Further investigation is needed to examine these findings, and also to explore the cause of these increases.

Background Ontario’s 36 Public Health Units (PHUs) were responsible for implementing the H1N1 Pandemic Influenza Plans (PIPs) to address the first pandemic influenza virus in over 40 years. It was the first under conditions which permitted mass immunization. This is therefore the first opportunity to learn and document what worked well, and did not work well, in Ontario’s response to pH1N1, and to make recommendations based on experience. Methods Our objectives were to: describe the PIP models, obtain perceptions on outcomes, lessons learned and to solicit policy suggestions for improvement. We conducted a 3-phase comparative analysis study comprised of semi-structured key informant interviews with local Medical Officers of Health (n = 29 of 36), and Primary Care Physicians (n = 20) and in Phase 3 with provincial Chief-Medical Officers of Health (n = 6) and a provincial Medical Organization. Phase 2 data came from a Pan-Ontario symposium (n = 44) comprised leaders representing: Public Health, Primary Care, Provincial and Federal Government. Results PIPs varied resulting in diverse experiences and lessons learned. This was in part due to different PHU characteristics that included: degree of planning, PHU and Primary Care capacity, population, geographic and relationships with Primary Care. Main lessons learned were: 1) Planning should be more comprehensive and operationalized at all levels. 2) Improve national and provincial communication strategies and eliminate contradictory messages from different sources. 3) An integrated community-wide response may be the best approach to decrease the impact of a pandemic. 4) The best Mass Immunization models can be quickly implemented and have high immunization rates. They should be flexible and allow for incremental responses that are based upon: i) pandemic severity, ii) local health system, population and geographic characteristics, iii) immunization objectives, and iv) vaccine supply. Conclusion “We were very lucky that pH1N1 was not more severe.” Consensus existed for more detailed planning and the inclusion of multiple health system and community stakeholders. PIPs should be flexible, allow for incremental responses and have important decisions (E.g., under which conditions Public Health, Primary Care, Pharmacists or others act as vaccine delivery agents.) made prior to a crisis.

Background Early reports of the 2009 A/H1N1 influenza pandemic (pH1N1) indicated that a disproportionate burden of illness fell on First Nations reserve communities. In addition, the impact of the pandemic on different communities may have been influenced by differing provincial policies. We compared hospitalization rates for pneumonia and influenza (P&I) attributable to pH1N1 influenza between residents of First Nations reserve communities and the general population in three Canadian provinces. Methods Hospital admissions were geocoded using administrative claims data from three Canadian provincial data centres to identify residents of First Nations communities. Hospitalizations for P&I during both waves of pH1N1 were compared to the same time periods for the four previous years to establish pH1N1-attributable rates. Results Residents of First Nations communities were more likely than other residents to have a pH1N1-attributable P&I hospitalization (rate ratio [RR] 2.8-9.1). Hospitalization rates for P&I were also elevated during the baseline period (RR 1.5-2.1) compared to the general population. There was an average increase of 45% over the baseline in P&I admissions for First Nations in all 3 provinces. In contrast, admissions overall increased by approximately 10% or less in British Columbia and Manitoba and by 33% in Ontario. Subgroup analysis showed no additional risk for remote or isolated First Nations compared to other First Nations communities in Ontario or Manitoba, with similar rates noted in Manitoba and a reduction in P&I admissions during the pandemic period in remote and isolated First Nations communities in Ontario. Conclusions We found an increased risk for pH1N1-related hospital admissions for First Nations communities in all 3 provinces. Interprovincial differences may be partly explained by differences in age structure and socioeconomic status. We were unable to confirm the assumption that remote communities were at higher risk for pH1N1-associated hospitalizations. The aggressive approach to influenza control in remote and isolated First Nations communities in Ontario may have played a role in limiting the impact of pH1N1 on residents of those communities.

Background The most appropriate public health approach to vaccine-associated measles in immunocompromised patients is unknown, mainly because these cases are rare and transmission of vaccine-associated measles has not been previously documented. In this case report, we describe Peel Public Health’s response to a vaccine-associated measles case in an immunocompromised child in Ontario, Canada. Case presentation A five-year-old Canadian-born boy with a history of a hematopoetic stem cell transplant three years previously received live attenuated measles, mumps, and rubella (MMR) vaccine. Over the subsequent 7 to 14 days, he developed an illness clinically consistent with measles. There was no travel history or other measles exposure. Serology and polymerase chain reaction (PCR) testing confirmed acute measles infection. Following discussion with pediatric infectious diseases specialists, but prior to the availability of virus sequencing, it was felt that this case was most likely due to vaccine strain. Although no microbiologically confirmed secondary cases of vaccine-associated measles have been previously described, we sent notification letters to advise all contacts of measles symptoms since the likelihood of transmission from an immunocompromised patient was low, but theoretically possible. We decided to stratify contacts into immune competent and compromised and to deal with the latter group conservatively by excluding them as if they were exposed to wild-type measles because the risk of transmission of disease in this population, while presumably very low, is unknown. However, no contacts self-identified as immunocompromised and there were no secondary cases. Subsequent genotyping confirmed that this case was caused by vaccine strain measles virus. Conclusion The public health approach to contact tracing and exclusions for vaccine-associated measles in immunocompromised patients is unclear. The rarity of secondary cases provides further evidence that the risk to the general public is likely extremely low. Although the risk appears negligible, exclusion and administration of immune globulin may be considered for susceptible, immunocompromised contacts of cases of vaccine-associated measles in immunocompromised patients.

Background While community mobilization has been widely endorsed as an important component of HIV prevention among vulnerable populations such as female sex workers (FSWs), there is uncertainty as to the mechanism through which it impacts upon HIV risk. We explored the hypothesis that individual and collective empowerment of FSW is an outcome of community mobilization, and we examined the means through which HIV risk and vulnerability reduction as well as personal and social transformation are achieved. Methods This study was conducted in five districts in south India, where community mobilization programs are implemented as part of the Avahan program (India AIDS Initiative) of the Bill & Melinda Gates Foundation. We used a theoretically derived “integrated empowerment framework” to conduct a secondary analysis of a representative behavioural tracking survey conducted among 1,750 FSWs. We explored the associations between involvement with community mobilization programs, self-reported empowerment (defined as three domains including power within to represent self-esteem and confidence, power with as a measure of collective identity and solidarity, and power over as access to social entitlements, which were created using Principal Components analysis), and outcomes of HIV risk reduction and social transformation. Results In multivariate analysis, we found that engagement with HIV programs and community mobilization activities was associated with the domains of empowerment. Power within and power with were positively associated with more program contact (p

Background Interventions designed to prevent HIV and STIs in female sex-workers (FSWs) reach women after they formally enter the sex-trade. We aimed to characterize the pattern of sexual behaviour among FSWs from first-sex to when they identify as sex-workers (transition period) in a region with traditional (historically characterized by dedication into sex-work at first-sex) and non-traditional forms of sex-work. Methods We conducted a cross-sectional survey of 246 traditional and 765 non-traditional FSWs across three districts in Karnataka, India. We performed univariate and multivariate logistic regression to profile FSWs most likely to engage in a commercial first-sex before identifying as a sex-worker. Sexual life-course patterns were distinguished using univariate and multivariate linear regression based on key events associated with length of transition period. Results Overall, 266 FSWs experienced a commercial first-sex, of whom 45.9% (95% CI: 38.2,53.7) continued a long-term relationship with the first partner. In adjusted analysis, traditional FSWs were more likely to experience a commercial first-sex (AOR 52.5, 95% CI: 27.4,100.7). The average transition time was 8.8 years (SD 3.9), but there was considerable variability between respondents. Among women who experienced a commercial first-sex, a slower transition was independently associated with non-traditional sex-work, the presence of long-term partnerships during the transition period, and ongoing partnerships at time of entry into sex-work. In the absence of a commercial first-sex, a faster transition was associated with traditional sex-work and the dissolution of long-term partnerships, while a slower transition was associated with the presence of long-term partnerships and widowhood. Only 18.5% (95% CI: 12.7,26.2) and 47.3% (95% CI: 32.7,62.3) of women reported ‘always’ condom use with their long-term and occasional partners during the transition period, respectively. Conclusions FSWs identify as sex-workers several years after becoming sexually active, even when the first-sex is commercial in nature. Long-term partnerships are common after a commercial first-sex, and are associated with a delay in formally entering the sex-trade. The findings call for a better understanding of HIV/STI risk before FSWs identify as sex-workers, and an adaptive programme to reach this period of vulnerability.

Background Since the completion of three clinical trials indicating that voluntary medical male circumcision (VMMC) is an effective method to reduce men’s chances of acquiring HIV, use of the procedure has been advocated in Kenya. Media messages shape popular understandings of the benefits and limitations of male circumcision. The objectives of this study were to (1) investigate promotion messages in a popular online newspaper to determine how the limitations of male circumcision are represented, and whether condom use is still being promoted; and (2) gain insight into popular understandings of the limitations of this new procedure through newspaper reader comments. Methods A content analysis was conducted on 34 online media articles published by the Daily Nation between January 1, 2008 and December 31, 2010. Information about condom promotion, partial immunity, limitations and complications of the procedure, as well as emergent themes, were analyzed. Results Results demonstrated an irregular and occasionally misleading presentation of these topics and a perceived lack of objective information about the risks and limitations of VMMC. Conclusions There is a need for governmental and non-governmental public health organizations to engage with the media to improve risk messaging.

Background Condoms are effective in preventing the transmission of HIV and other sexually transmitted infections, when properly used. However, recent data from surveys of female sex workers (FSWs) in Karnataka in south India, suggest that condom breakage rates may be quite high. It is important therefore to quantify condom breakage rates, and examine what factors might precipitate condom breakage, so that programmers can identify those at risk, and develop appropriate interventions. Methods We explored determinants of reported condom breakage in the previous month among 1,928 female sex workers in four districts of Karnataka using data from cross-sectional surveys undertaken from July 2008 to February 2009. Using stepwise multivariate logistic regression, we examined the possible determinants of condom breakage, controlling for several independent variables including the district and client load. Results Overall, 11.4% of FSWs reported at least one condom break in the previous month. FSWs were much more likely to report breakage if under 20 years of age (AOR 3.43, p = 0.005); if divorced/ separated/widowed (AOR 1.52, p = 0.012); if they were regular alcohol users (AOR 1.63, p = 0.005); if they mostly entertained clients in lodges/rented rooms (AOR 2.99, p = 0.029) or brothels (AOR 4.77, p = 0.003), compared to street based sex workers; if they had ever had anal sex (AOR 2.03, p = 0.006); if the sex worker herself (as opposed to the client) applied the condom at last use (AOR 1.90, p < 0.001); if they were inconsistent condom users (AOR 2.77, p < 0.001); and if they had never seen a condom demonstration (AOR 2.37, p < 0.001). Conclusions The reported incidence of condom breakage was high in this study, and this is a major concern for HIV/STI prevention programs, for which condom use is a key prevention tool. Younger and more marginalized female sex workers were most vulnerable to condom breakage. Special effort is therefore required to seek out such women and to provide information and skills on correct condom use. More research is also needed on what specific situational parameters might be important in predisposing women to condom breakage.

Background Stepping Stones training aims to help individuals explore sexual relationships and recognize gender inequalities, the structural drivers of the HIV epidemic, in order to understand risk behaviours and to seek solutions to factors that increase HIV vulnerability. Despite earlier studies suggesting the success of Stepping Stones, little data exist to show diffusion to trainees' social networks or the wider community. Methods A mixed-methods evaluation of this approach was undertaken using in-depth interviews of trainees and friends, and polling booth surveys in 20 villages where Stepping Stones training took place and in another 20 villages with no Stepping Stones intervention. Results The interview respondents and their friends reported significant changes in their relationships after training, and benefit from discussion of gender, sexuality, condom use and HIV vulnerability issues. However, though diffusion of this knowledge at the level of personal contacts was strong, the evaluation revealed that diffusion to the community level was limited. Conclusions The qualitative part of this study reflects other studies in different settings, in that SS participants gained immensely from the training. Wider behaviour change is a challenging goal that many programmes fail to attain, with most interventions too limited in scope and intensity to produce larger community effects. This may have contributed to the fact that we observed few differences between interventions and non-intervention villages in this study. However, it is also possible that we had excessive expectations of individual change at the community level, and that it might have been more appropriate to have had broader community level rather than individual behavioural change indicators. We suggest that SS could be enhanced by efforts to better engage existing community opinion leaders, to empower and train participants as community change agents, and to support the development of village-level action plans that combat sexual stereotyping and risky behaviours that lead to unhealthy sexual relationships.

Background Evidence is growing that sleep problems in adolescents are significant impediments to learning and negatively affect behaviour, attainment of social competence and quality of life. The objectives of the study were to determine the level of sleepiness among students in high school, to identify factors to explain it, and to determine the association between sleepiness and performance in both academic and extracurricular activities Methods A cross-sectional survey of 2201 high school students in the Hamilton Wentworth District School Board and the Near North District School Board in Ontario was conducted in 1998/9. A similar survey was done three years later involving 1034 students in the Grand Erie District School Board in the same Province. The Epworth Sleepiness Scale (ESS) was used to measure sleepiness and we also assessed the reliability of this tool for this population. Descriptive analysis of the cohort and information on various measures of performance and demographic data were included. Regression analysis, using the generalised estimating equation (GEE), was utilized to investigate factors associated with risk of sleepiness (ESS>10). Results Seventy per cent of the students had less than 8.5 hours weeknight sleep. Bedtime habits such as a consistent bedtime routine, staying up late or drinking caffeinated beverages before bed were statistically significantly associated with ESS, as were weeknight sleep quantity and gender. As ESS increased there was an increase in the proportion of students who felt their grades had dropped because of sleepiness, were late for school, were often extremely sleepy at school, and were involved in fewer extracurricular activities. These performance measures were statistically significantly associated with ESS. Twenty-three percent of the students felt their grades had dropped because of sleepiness. Most students (58–68%) reported that they were "really sleepy" between 8 and 10 A.M. Conclusion Sleep deprivation and excessive daytime sleepiness were common in two samples of Ontario high school students and were associated with a decrease in academic achievement and extracurricular activity. There is a need to increase awareness of this problem in the education and health communities and to translate knowledge already available to strategies to address it.

Background As communities face serious pressures on traditional values, such as those posed by HIV infection, cultural inertia may result, whereby existing trends towards more liberalized views of sexuality are stalled. We examined changes in attitudes around HIV in Bagalkot district, south India, between 2003 and 2009. Methods General population surveys were conducted in 2003 and 2009, among approximately 6,600 randomly sampled men and women in 10 villages and 20 urban blocks of Bagalkot. Questions about HIV knowledge, sexuality, gender and condoms were included. We compared responses in the two surveys using a multivariate logistic regression model. Results Awareness of HIV increased significantly from 76.9% in 2003 to 87.8% in 2009, and condom awareness increased significantly (37.4% to 65.4%) in all groups studied. However, in 2009, only 23% of people mentioned condoms as a means of prevention, an improvement from 8% in 2003 (adjusted odds ratio (AOR) 3.3; 95%CI 2.6-4.1, p Conclusions Despite increases over time in HIV-related knowledge and reductions in stigmatizing attitudes, resistance to changing cultural mores was apparent, with less willingness to embrace openness and discuss sexuality. Young and female respondents appeared to be the most resistant to change, reflecting a cultural inertia that mirrors studies of other pressures on traditional societal values. More effort is required to advocate among women and young people for healthy sexuality, openness and safe sex practices.

Background Population-based administrative data have been used to study osteoporosis-related fracture risk factors and outcomes, but there has been limited research about the validity of these data for ascertaining fracture cases. The objectives of this study were to: (a) compare fracture incidence estimates from administrative data with estimates from population-based clinically-validated data, and (b) test for differences in incidence estimates from multiple administrative data case definitions. Methods Thirty-five case definitions for incident fractures of the hip, wrist, humerus, and clinical vertebrae were constructed using diagnosis codes in hospital data and diagnosis and service codes in physician billing data from Manitoba, Canada. Clinically-validated fractures were identified from the Canadian Multicentre Osteoporosis Study (CaMos). Generalized linear models were used to test for differences in incidence estimates. Results For hip fracture, sex-specific differences were observed in the magnitude of under- and over-ascertainment of administrative data case definitions when compared with CaMos data. The length of the fracture-free period to ascertain incident cases had a variable effect on over-ascertainment across fracture sites, as did the use of imaging, fixation, or repair service codes. Case definitions based on hospital data resulted in under-ascertainment of incident clinical vertebral fractures. There were no significant differences in trend estimates for wrist, humerus, and clinical vertebral case definitions. Conclusions The validity of administrative data for estimating fracture incidence depends on the site and features of the case definition.

Background The burden caused by the coexistence of obesity and underweight in Low and Middle Income Countries is a challenge to public health. While prevalence of underweight among youth has been well documented in these countries, overweight, obesity and their associated risk factors are not well understood unlike in high income countries. Methods Cross-sectional data from the Global School-based Student Health Survey (GSHS) conducted in seven African countries were used for this study. The survey used a clustered design to obtain a representative sample (n = 23496) from randomly selected schools. 53.6% of the sample was male, and participants ranged in age from 11-17 years old. Body Mass Index (BMI) was calculated using age and sex adjusted self-reported heights and weights. Classification of weight status was based on the 2007 World Health Organization growth charts (BMI-for-age and sex). Multivariable Logistic Regression reporting Odds Ratios was used to assess potential risk factors on BMI, adjusting for age, sex, and country. Statistical analyses were performed with Stata with an alpha of 0.05 and reporting 95% confidence intervals. Results Unadjusted rates of being underweight varied from 12.6% (Egypt) to 31.9% (Djibouti), while being overweight ranged from 8.7% (Ghana) to 31.4% (Egypt). Obesity rates ranged from 0.6% (Benin) to 9.3% (Egypt). Females had a higher overweight prevalence for every age group in five of the countries, exceptions being Egypt and Malawi. Overall, being overweight was more prevalent among younger (≤12) adolescents and decreased with age. Males had a higher prevalence of being underweight than females for every country. There was a tendency for the prevalence of being underweight to increase starting in the early teens and decrease between ages 15 and 16. Most of the potential risk factors captured by the GSHS were not significantly associated with weight status. Conclusions The prevalence of both overweight and underweight was relatively high, demonstrating the existence of the double burden of malnutrition among adolescents in developing countries. Several factors were not associated with weight status suggesting the need to explore other potential risk factors for overweight and underweight, including genetic factors and socioeconomic status.

Background Peer influence, peer selection, and health risk awareness are factors in smoking among youth. Despite the numerous studies on the social context, social network, and how youth define themselves and their smoking status in relation to tobacco use, qualitative knowledge about the role of smoking within peer relationships from youth themselves is only emerging. In this paper, qualitative findings describing Canadian youth’s perspectives and experiences of smoking within the context of peer relationships are presented. Methods To examine youth’s perceptions, a qualitative research study design was used. Seventy-five Canadian youth aged 11–19 years participated in open-ended interviews, focus groups, and photovoice methods. Data analysis involved several levels of analysis consistent with qualitative research. Results Youth who smoked were perceived by non-smoking peers as less popular and less socially accepted as represented by the theme: The coolness (not so cool) factor. Non-smoking youth felt that peers who smoked strained relationships and forced them to set boundaries and negotiate friendships as denoted by the theme: Negotiating friendships: Being influenced, but also influencing. Finally, in the theme of Making sense of peers who smoke, youth struggled to understand peers who continued to smoke and why they would start in the first place. Conclusions As reinforced in this study, Canadian youth increasingly view smoking as unhealthy and uncool. Moreover, youth report resisting peer influence to smoke and in fact, are now influencing their friends who smoke to quit. The self-empowerment stories of non-smoker youth reinforces the idea that the social meaning of smoking with peers is continuing to change from one where youth accepted and participated in the smoking behaviors of their peers, to an environment where youth’s perceptions of personal health is paramount. Findings from this study could be used to guide health promotion and smoking prevention programs and campaigns for youth.

Background During the first wave of the H1N1 influenza pandemic in 2009, Aboriginal populations in Canada experienced disproportionate rates of infection, particularly in the province of Manitoba. To protect those thought to be most at-risk, health authorities in Manitoba listed all Aboriginal people, including Metis, among those able to receive priority access to the novel vaccine when it first became available. Currently, no studies exist that have investigated the attitudes, influences, and vaccine behaviors among Aboriginal communities in Canada. This paper is the first to systematically connect vaccine behavior with the attitudes and beliefs that influenced Metis study participants’ H1N1 vaccine decision-making. Methods Researchers held focus groups (n = 17) with Metis participants in urban, rural, and remote locations of Manitoba following the conclusion of the H1N1 pandemic. Participants were asked about their vaccination decisions and about the factors that influenced their decisions. Following data collection, responses were coded into the broad categories of a social-ecological model, nuanced by categories stemming from earlier research. Responses were then quantified to show the most influential factors in positively or negatively affecting the vaccine decision. Results Media reporting, the influence of peer groups, and prioritization all had positive and negative influential effects on decision making. Whether vaccinated or not, the most negatively influential factors cited by participants were a lack of knowledge about the vaccine and the pandemic as well as concerns about vaccine safety. Risk of contracting H1N1 influenza was the biggest factor in positively influencing a vaccine decision, which in many cases trumped any co-existing negative influencers. Conclusions Metis experiences of colonialism in Canada deeply affected their perceptions of the vaccine and pandemic, a context that health systems need to take into account when planning response activities in the future. Participants felt under-informed about most aspects of the vaccine and the pandemic, and many vaccine related misconceptions and fears existed. Recommendations include leveraging doctor-patient interactions as a site for sharing vaccine-related knowledge, as well as targeted, culturally-appropriate, and empowering public information strategies to supply reliable vaccine and pandemic information to potentially at-risk Aboriginal populations.

Background A central question in the debate about exploitation in international research is whether investigators and sponsors from high-income countries (HIC) have obligations to address background conditions of injustice in the communities in which they conduct their research, beyond the healthcare and other research-related needs of participants, to aspects of their basic life circumstances. Discussion In this paper, we describe the Majengo sexually transmitted disease (STD) Cohort study, a long-term prospective, observational cohort of sex workers in Nairobi, Kenya. Despite important scientific contributions and a wide range of benefits to the women of the cohort, most of the women have remained in the sex trade during their long-standing participation in the cohort, prompting allegations of exploitation. The Majengo STD cohort case extends the debate about justice in international research ethics beyond clinical trials into long-term observational research. We sketch the basic features of a new approach to understanding and operationalizing obligations of observational researchers, which we call 'relief of oppression'. 'Relief of oppression' is an organizing principle, analogous to the principle of harm reduction that is now widely applied in public health practice. Relief of oppression aims to help observational researchers working in conditions of injustice and deprivation to clarify their ethical obligations to participants. It aims to bridge the gap between a narrow, transaction-oriented account of avoiding exploitation and a broad account emphasizing obligations of reparation for historic injustices. We propose that relief of oppression might focus researchers' consideration of benefits on those that have some relevance to background conditions of injustice, and so elevate the priority of these benefits, in relation to others that might be considered and negotiated with participants, according to the degree to which the participating communities are constrained in their realization of fundamental freedoms. Summary The over-arching aim of relief of oppression is that, within the range of benefits negotiated over time with the local communities and organizations, an increasing proportion reflects a shared interest in improving participants' fundamental freedoms. We describe how harm reduction serves as a useful analogy for how we envision relief of oppression functioning in international research.