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Background Fewer than half of individuals with a mental disorder seek formal care in a given year. Much research has been conducted on the factors that influence service use in this population, but the methods generally used cannot easily identify the complex interactions that are thought to exist. In this paper, we examine predictors of subsequent service use among respondents to a population health survey who met criteria for a past-year mood, anxiety or substance-related disorder. Methods To determine service use, we use an administrative database including all physician consultations in the period of interest. To identify predictors, we use classification tree (CART) analysis, a data mining technique with the ability to identify unsuspected interactions. We compare results to those from logistic regression models. Results We identify 1213 individuals with past-year disorder. In the year after the survey, 24% (n=312) of these had a mental health-related physician consultation. Logistic regression revealed that age, sex and marital status predicted service use. CART analysis yielded a set of rules based on age, sex, marital status and income adequacy, with marital status playing a role among men and by income adequacy important among women. CART analysis proved moderately effective overall, with agreement of 60%, sensitivity of 82% and specificity of 53%. Conclusion Results highlight the potential of data-mining techniques to uncover complex interactions, and offer support to the view that the intersection of multiple statuses influence health and behaviour in ways that are difficult to identify with conventional statistics. The disadvantages of these methods are also discussed. [ABSTRACT FROM AUTHOR]

Background: There appears to be considerable variation between different national jurisdictions and between different sectors of public policy in the use of evidence and particularly the use of randomised controlled trials (RCTs) to evaluate non-healthcare sector programmes. Methods: As part of a wider study attempting to identify RCTs of public policy sector programmes and the reasons for variation between countries and sectors in their use, we carried out a pilot study which interviewed 10 policy makers and researchers in six countries to elicit views on barriers to and facilitators of the use of RCTs for social programmes. Results: While in common with earlier studies, those interviewed expressed a need for unambiguous findings, timely results and significant effect sizes, users could, in fact, be ambivalent about robust methods and robust answers about what works, does not work or makes no difference, particularly where investment or a policy announcement was planned. Different national and policy sector cultures varied in their use of and support for RCTs. Conclusions: In order to maximise the use of robust evaluations of public programmes across the world it would be useful to examine, systematically, cross-national and cross-sectoral variations in the use of different methods including RCTs and barriers to and facilitators of their use. Sound research methods, whatever their scientific value, are no guarantee that findings will be useful or used. 'Stories' have been shown to influence policy; those advocating the use of RCTs may need to provide convincing narratives to avoid repetition about their value. [ABSTRACT FROM AUTHOR]

Background Obesity prevalence varies between geographic regions in Canada. The reasons for this variation are unclear but most likely implicate both individual-level and population-level factors. The objective of this study was to examine whether equalising correlates of body mass index (BMI) across these geographic regions could be reasonably expected to reduce differences in BMI distributions between regions. Methods Using data from three cycles of the Canadian Community Health Survey (CCHS) 2001, 2003 and 2007 for males and females, we modelled between-region BMI cross-sectionally using quantile regression and Blinder-Oaxaca decomposition of the quantile regression results. Results We show that while individual-level variables (ie, age, income, education, physical activity level, fruit and vegetable consumption, smoking status, drinking status, family doctor status, rural status, employment in the past 12 months and marital status) may be Caucasian important correlates of BMI within geographic regions, those variables are not capable of explaining variation in BMI between regions. Discussion Equalisation of common correlates of BMI between regions cannot be reasonably expected to reduce differences in the BMI distributions between regions. [ABSTRACT FROM AUTHOR]

Background Several cross-sectional studies have demonstrated associations between diet quality, including fruit and vegetable consumption, and mental health. However, research examining these associations longitudinally, while accounting for related lifestyle factors (eg, smoking, physical activity) is scarce. Methods This study used data from the National Population Health Survey (NPHS), a large, national longitudinal survey of Canadians. The sample included 8353 participants aged 18 and older. Every 2 years from 2002/2003 to 2010/2011, participants completed self-reports of daily fruit and vegetable consumption, physical activity, smoking and symptoms of depression and psychological distress. Using generalised estimating equations, we modelled the associations between fruit and vegetable consumption at each timepoint and depression at the next timepoint, adjusting for relevant covariates. Results Fruit and vegetable consumption at each cycle was inversely associated with next-cycle depression (β= -0.03, 95% CI -0.05 to -0.01, p<0.01) and psychological distress (β=-0.03, 95% CI -0.05 to -0.02, p<0.0001). However, once models were adjusted for other health-related factors, these associations were attenuated (β=-0.01, 95% CI -0.04 to 0.02, p=0.55; β=-0.00, 95% CI -0.03 to 0.02, p=0.78 for models predicting depression and distress, respectively). Conclusions These findings suggest that relations between fruit and vegetable intake, other health-related behaviours and depression are complex. Behaviours such as smoking and physical activity may have a more important impact on depression than fruit and vegetable intake. Randomised control trials of diet are necessary to disentangle the effects of multiple health behaviours on mental health. [ABSTRACT FROM AUTHOR]

Background Recent work in comparative social epidemiology uses an expenditures approach to examine the link between welfare states and population health. More work is needed that examines the impact of disaggregated expenditures within nations. This study takes advantage of provincial differences within Canada to examine the effects of subnational expenditures and a provincial welfare generosity index on population health. Methods Time-series cross-sectional data are retrieved from the Canadian Socio-Economic Information Management System II Tables for 1989-2009 (10 provinces and 21 years=210 cases). Expenditures are measured using 20 disaggregated indicators, total expenditures and a provincial welfare generosity index, a ombined measure of significant predictors. Health is measured as total, male and female age-standardised mortality rates per 1000 deaths. Estimation techniques include the Prais-Winsten regressions with panel-corrected SEs, a first-order autocorrelation correction model, and fixed-unit effects, adjusted for alternative factors. Results Analyses reveal that four expenditures effectively reduce mortality rates: medical care, preventive care, other social services and postsecondary education. The provincial welfare generosity index has even larger effects. For an SD increase in the provincial welfare generosity index, total mortality rates are expected to decline by 0.44 SDs. Standardised effects are larger for women (β=-0.57, z(19)=-5.70, p<0.01) than for men (β=-0.38, z(19)=-5.59, p<0.01). Conclusions Findings show that the expenditures approach can be effectively applied within the context of Canadian provinces, and that targeted spending on health, social services and education has salutary effects. [ABSTRACT FROM AUTHOR]

Background There is a growing interest in understanding the connection between mental illness (MI) and the onset of new physical illnesses among previously physically healthy individuals. Yet the role of gender is often forgotten in research focused on comorbidity of health problems. The objective of this study was to examine gender differences in the onset of physical illness in a cohort of respondents who met criteria for MI compared with a control cohort without mental health problems. Methods This cohort study, conducted in Ontario, Canada, used a unique linked dataset with information from the 2000-2001 Canadian Community Health Survey and medical records (n=15 902). We used adjusted Cox proportional survival analysis to examine risk of onset of four physical health problems (chronic obstructive pulmonary disorder, asthma, hypertension and diabetes) for those with and without baseline MI across a 10-year period (2002-2011) among respondents aged 18-74 years. We controlled for socioeconomic and health indicators associated with health. Results The incidence of physical illness in the MI cohort was 28.5% among women and 29.9% among men ( p=0.85) relative to controls (23.8% and 24%, respectively; p=0.48). Women in the MI cohort developed secondary physical health problems a year earlier than their male counterparts ( p=0.002). Findings from the Cox proportional survival regression showed that women were at 14% reduced risk of developing physical illness, meaning that men were more disadvantaged (HR=0.89, CI 0.80 to 0.98). Those in the MI cohort were at 10 times greater risk of developing a secondary physical illness over the 10-year period (HR=1.10, CI 0.98 to 1.21). There was no significant interaction between gender and MI cohort (HR=1.05, CI 0.85 to 1.27). Conclusions Policy and clinical practice have to be sensitive to these complex-needs patients. Genderspecific treatment and prevention practices can be developed to target those at higher risk of multiple health conditions. [ABSTRACT FROM AUTHOR]

Background The widespread use of risk algorithms in clinical medicine is testimony to how they have helped transform clinical decision-making. Risk algorithms have a similar but underdeveloped potential to support decision-making for population health. Objective To describe the role of predictive risk algorithms in a population setting. Methods First, predictive risk algorithms and how clinicians use them are described. Second, the population uses of risk algorithms are described, highlighting the strengths of risk algorithms for health planning. Lastly, the way in which predictive risk algorithms are developed is discussed briefly and a guide for algorithm assessment in population health presented. Conclusion For the past 20 years, absolute and baseline risk has been a cornerstone of population health planning. The most accurate and discriminating method to generate such estimates is the use of multivariable risk algorithms. Routinely collected data can be used to develop algorithms with characteristics that are well suited to health planning and such data are increasingly available. The widespread use of risk algorithms in clinical medicine is testimony to how they have helped transform clinical decision-making. Risk algorithms have a similar but underdeveloped potential to support decision-making for population health. INSETS: Case example of risk prediction in clinical medicined algorithms.;Case example of population use of a clinical risk algorithm. [ABSTRACT FROM AUTHOR]

Background Mortality and morbidity have been shown to follow a 'social gradient' in Canada and many other countries around the world. Comparatively little, however, is known about whether ageing amplifies, diminishes or sustains socio-economic inequalities in health. Methods Growth curve analysis of seven cycles of the Canadian National Population Health Survey (n=13 682) for adults aged 20 and older at baseline (1994/95). The outcome of interest is the Health Utilities Index Mark 3, a measure of health-related quality of life (HRQL). Models include the deceased so as not to present overly optimistic HRQL values. Socio-economic position is measured separately by household-size-adjusted income and highest level of education attained. Results HRQL is consistently highest for the most affluent and the most highly educated men and women, and is lower, in turn, for middle and lower income and education groups. HRQL declines with age for both men and women. The rate of the decline in HRQL, however, was related neither to income nor to education for men, suggesting stability in the social gradient in HRQL over time for men. There was a sharper decline in HRQL for upper-middle and highest-income groups for women than for the poorest women. Conclusion HRQL is graded by both income and education in Canadian men and women. The grading of HRQL by social position appears to be 'set' in early adulthood and is stable through mid- and later life. [ABSTRACT FROM AUTHOR]

Background Findings from contextual studies have shown that living in both poor and affluent neighbourhoods increases the risk of drinking and drug use, but few studies have examined the connection between neighbourhood context and drinking from a gender perspective. Methods We investigated the association between gender, neighbourhood deprivation and weekly drinking behaviour (number of drinks) in a national sample of 93 457 Canadians using multilevel zero-inflated Poisson regression. A cross-level interaction between gender and neighbourhood deprivation was examined while controlling for other potential risk factors. Results 53% of Canadians reported having at least one drink in the last year (men=61%; women=46%). Among respondents who were drinkers, the average number of drinks per week was 6.4 with male drinkers reporting an average of 7.9 and female drinkers reporting an average of 4.6. Neighbourhood material deprivation was independently associated with weekly drinking. Findings from multilevel analysis showed a u-shaped curve between neighbourhood deprivation and drinking, but only for men. Men living in the poorest neighbourhoods drank more weekly (8.5 drinks) than men living in neighbourhoods of wealthy (4.5 drinks) and mid-range deprivation (3.7 drinks). No difference in drinking by neighbourhood material deprivation was observed among women. Conclusion Men, like women, experience gender-specific health difficulties (eg, alcohol-related problems) suggesting the need for a gendered focus on policies and services related to women's and men's health. The challenge for public health and primary care is to work together to target risk-taking behaviours among men through treatment, prevention and cultural/educational messages aimed at building healthy lifestyles. [ABSTRACT FROM AUTHOR]

Background National estimates of the upcoming diabetes epidemic are needed to understand the distribution of diabetes risk in the population and to inform health policy. Objective To create and validate a population-based risk prediction tool for incident diabetes using commonly collected national survey data. Methods With the use of a cohort design that links baseline risk factors to a validated population-based diabetes registry, a model (Diabetes Population Risk Tool (DPoRT)) was developed to predict 9-year risk for diabetes. The probability of developing diabetes was modelled using sex-specific Weibull survival functions for people >20 years of age without diabetes (N=19 861). The model was validated in two external cohorts in Ontario (N=26 465) and Manitoba (N=9899). Predictive accuracy and model performance were assessed by comparing observed diabetes rates with predicted estimates. Discrimination and calibration were measured using a C statistic and Hosmer--Lemeshow X2 statistic (X2H-L). Results Predictive factors included were body mass index, age, ethnicity, hypertension, immigrant status, smoking, education status and heart disease. DPoRT showed good discrimination (C=0.77-0.80) and calibration (X2 H-L <20) in both external validation cohorts. Conclusions This algorithm can be used to estimate diabetes incidence and quantify the effect of interventions using routinely collected survey data. [ABSTRACT FROM AUTHOR]

Background The relationships of home and school environments, health risk behaviours and two sentinel adolescent health outcomes were examined in an aetiological analysis. The analysis focused on determinants of the health of young people and the role of school settings in the optimisation of health. Methods Records were examined from the Canadian sample of the Health Behaviour in School-aged Children (HBSC) Survey. 3402 young people in Ontario, Canada were administered this survey in 2006, of which 1966 were re-administered the survey 1 year later and supplied complete data. Individual items and factoranalytically derived scales were used to examine potential aetiological relationships in a series of structural equation models. Health outcomes examined were serious injury and psychosomatic symptoms. Models developed from cross-sectional data were confirmed longitudinally. Results Adolescents who reported negative home and school environments reported higher levels of substance use, psychosomatic symptoms and serious injuries (the latter identified in longitudinal analysis only). Engagement in health risk behaviour partially mediated the link between these two environments and the sentinel health outcomes. Positive school environments were protective in that they moderated associations between negative home environments and engagement in health risk behaviours. The effects observed in longitudinal analyses were generally consistent with those observed crosssectionally. Conclusions Negative home environments clearly place adolescents at risk for engagement in health risk behaviours and associated physical health outcomes. Positive school environments can in part moderate these relationships. Optimisation of school social environments therefore remains warranted as a population health strategy. [ABSTRACT FROM AUTHOR]

Background It has been hypothesised that dehydration in infancy could permanently increase sodium retention, raising blood pressure in later life. In this study, the association between gastrointestinal tract infection in infancy, a clinically relevant exposure often accompanied by dehydration, and raised blood pressure in childhood was investigated. Methods Data from a cohort study nested within a cluster-randomised trial of breastfeeding promotion in the Republic of Belarus were analysed. 17 046 healthy breastfed infants were enrolled from 31 maternity hospitals. 13 889 (81.5%) children were followed-up at 6.5 years. Exposure measures were any gastrointestinal infection in infancy (to 1 year) and hospitalisations for gastrointestinal infection in infancy and in childhood (1-6.5 years). The outcomes were systolic and diastolic blood pressure at age 6.5 years. Results The prevalence of any gastrointestinal infection in infancy, and of hospitalisation for gastrointestinal infection in infancy or childhood, was 11.4%, 3.2% and 6.0%, respectively. No associations were observed between systolic blood pressure and any gastrointestinal infection (mean difference in those with minus those without infection -0.04 mm Hg; 95% CI -0.52 to 0.43) or hospitalisation for gastrointestinal infection (difference=-0.22 mm Hg; -1.07 to 0.64) in infancy. Nor were associations observed between diastolic blood pressure and any gastrointestinal infection during infancy or hospitalisation for gastrointestinal infection during infancy or childhood. Conclusion No evidence was found to prove that hospitalisation for gastrointestinal infection in infancy or childhood leads to raised blood pressure at age 6.5 years in a developed country setting. [ABSTRACT FROM AUTHOR]

Background There has been an ongoing debate about the extent and nature of gender differences in the experience of intimate partner violence (IPV). Disagreement about the appropriate definition of IPV is central to this debate. Methods This study used latent class analysis (LCA) to map the patterns of physical violence, sexual coercion, psychological abuse and controlling behaviour, and examined whether LCA can better illuminate the gendered nature of this experience than conventional measures of IPV. Data from the 2004 Canadian General Social Survey were analysed, which included 8360 women and 7056 men 15 years of age and over who reported a current or ex-spouse or common-law partner. Results Results revealed more variation in the patterns of IPV for women than for men. Six classes were found for women, whereas four classes were found for men. Women and men were equally likely to experience less severe acts of physical aggression that were not embedded in a pattern of control. However, only women experienced a severe and chronic pattern of violence and control involving high levels of fear and injury. For women and men, intermediate patterns of violence and control, and patterns describing exclusively non-physical acts of abuse were also found. The results also revealed substantial differences in the IPV subtypes for those reporting about a current versus an ex-partner. Conclusion These results support the use of LCA in identifying meaningful patterns of IPV and provide a more nuanced understanding of the role of gender than conventional measures. Implications for sampling within IPV research are discussed. [ABSTRACT FROM AUTHOR]