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This study measures public health policies' and healthcare system's influence, by assessing the contributions of avoidable deaths, on the gender gaps in life expectancy and disparity (GGLD and GGLD, respectively) in the United States (US) and Canada from 2001 to 2019. To estimate the GGLE and GGLD, we retrieved age- and sex-specific causes of death from the World Health Organization's mortality database. By employing the continuous-change model, we decomposed the GGLE and GGLD by age and cause of death for each year and over time using females as the reference group. In Canada and the US, the GGLE (GGLD) narrowed (increased) by 0.9 (0.2) and 0.2 (0.3) years, respectively. Largest contributor to the GGLE was non-avoidable deaths in Canada and preventable deaths in the US. Preventable deaths had the largest contributions to the GGLD in both countries. Ischemic heart disease contributed to the narrowing GGLE/GGLD in both countries. Conversely, treatable causes of death increased the GGLE/GGLD in both countries. In Canada, "treatable & preventable" as well as preventable causes of death narrowed the GGLE while opposite was seen in the US. While lung cancer contributed to the narrowing GGLE/GGLD, drug-related death contributed to the widening GGLE/GGLD in both countries. Injury-related deaths contributed to the narrowing GGLE/GGLD in Canada but not in the US. The contributions of avoidable causes of death to the GGLE declined in the age groups 55–74 in Canada and 70–74 in the US, whereas the GGLE widened for ages 25–34 in the US. Canada experienced larger reduction in the GGLE compared to the US attributed mainly to preventable causes of death. To narrow the GGLE and GGLD, the US needs to address injury deaths. Urgent interventions are required for drug-related death in both countries, particularly among males aged 15–44 years. • Avoidable causes of death contributed to the narrowing GGLE/GGLD in Canada. • Avoidable causes of death contributed to the narrowing GGLE and the widening GGLD in the US. • Drug-related deaths contributed to the widening GGLE/GGLD in both countries. • Injury deaths contributed to the narrowing GGLE in Canada but not in the US. [ABSTRACT FROM AUTHOR]

Investments in public health – prevention of illnesses, and promotion, surveillance, and protection of population health – may improve population health, however, effects may only be observed over a long period of time. To investigate the potential long-run relationship between expenditures on public health and avoidable mortality from preventable causes. We focused on the country spending the most on public health in the OECD, Canada. We constructed a longitudinal dataset on mortality, health care expenditures and socio-demographic information covering years 1979–2017 for the ten Canadian provinces. We estimated error correction models for panel data to disentangle short-from long-run relationships between expenditures on public health and avoidable mortality from preventable causes. We further explored some specific causes of mortality to understand potential drivers. For comparison, we also estimated the short-run relationship between curative expenditures and avoidable mortality from treatable causes. We find evidence of a long-run relationship between expenditures on public health and preventable mortality, and no consistent short-run associations between these two variables. Findings suggest that a 1% increase in expenditures on public health could lead to 0.22% decrease in preventable mortality. Reductions in preventable mortality are greater for males (−0.29%) compared to females (−0.09%). These results are robust to different specifications. Reductions in some cancer and cardiovascular deaths are among the probable drivers of this overall decrease. By contrast, we do not find evidence of a consistent short-run relationship between curative expenditures and treatable mortality, except for males. This study supports the argument that expenditures on public health reap health benefits primarily in the long run, which, in this case, represents a reduction in avoidable mortality from preventable causes. Reducing public health expenditures on the premise that they have no immediate measurable benefits might thus harm population health outcomes in the long run. • Literature on health expenditures and health outcomes rarely separates long-run and short-run. • Public health requires time to produce health effect, hence a need to model the long-run relationship. • Expenditures on public health are associated with a long run reduction of preventable mortality. • This long run relationship is stronger for preventable mortality among males than females. • There is a limited influence of curative expenditures on treatable mortality. [ABSTRACT FROM AUTHOR]

This study examined several factors affecting the perception of Canadian parents about their children's mental health during COVID-19. The contribution of this research included fresh evidence from examining the demographic and sociological factors influencing children's well-being during COVID-19 using the Canadian context. We used a cross-sectional dataset from Statistics Canada titled Impacts of COVID-19 on Canadians - Parenting during the Pandemic (2020). We relied on an ordered logit model and computed the respective odds ratios. Our results showed that parents with a university degree and those working from home are less concerned about their children's mental health. Nonetheless, having a disabled child, belonging to a minority, having children aged six-to fourteen-years old, and having lost a job or experienced a drop in working hours increased parents' worry. Additionally, having worries about being connected with family and friends, being concerned about work-life balance, feeling lonely at home, and waiting for the reopening of childcare services all increased the likelihood of parents' anxiety about their child's mental health. When running the analysis by province, we saw that being an immigrant and belonging to a minority increased parents' worry only in Ontario and British Columbia. Policymakers are encouraged to foster working-from-home practices as working from home has been linked to less worry about child mental health, mainly among mothers, as indicated in our gender heterogeneity analysis. In addition, it is advised that families with a disabled child, and families belonging to a minority received additional support. Lastly, policymakers are advised to consider the social cost of preventive measures and incorporate this into any future preventative policymaking as the social impact variables were robust across all models. • Examined perceptions of Canadian parents about their children's mental health during COVID-19. • Focused on the role of the individual, household, labor market, and social factors. • The findings demonstrate a key role for the social drivers. • Working from home reduces the likelihood of worry about children's mental health. • We document heterogeneous province and gender effects. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has led to an unprecedented global crisis. It has exposed and exacerbated weaknesses in public health systems worldwide, particularly with regards to reaching the most vulnerable populations, disproportionately impacted by the pandemic. The objective of our study was to examine whether and how social inequalities in health (SIH) were considered in the design and planning of public health responses to COVID-19 in jurisdictions of Brazil, Canada, France, and Mali. This article reports on a qualitative multiple case study of testing and contact tracing interventions in regions with high COVID-19 incidence in each country, namely: Manaus (Brazil), Montréal (Canada), Île-de-France (France), and Bamako (Mali). We conducted interviews with 108 key informants involved in these interventions in the four jurisdictions, focusing on the first and second waves of the pandemic. We analyzed our data thematically using a theoretical bricolage framework. Our analysis suggests that the lack of a common understanding of SIH among all actors involved and the sense of urgency brought by the pandemic eclipsed the prioritization of SIH in the initial responses. The pandemic increased intersectoral collaboration, but decision-making power was often unequal between Ministries of Health and other actors in each jurisdiction. Various adaptations to COVID-19 interventions were implemented to reach certain population groups, therefore improving the accessibility, availability, and acceptability of testing and contact tracing. Our study contributes to identifying lessons learned from the current pandemic, namely that the ways in which SIH are understood shape how interventions are planned; that having clear guidelines on how to integrate SIH into public health interventions could lead to more inclusive pandemic responses; that for intersectoral collaboration to be fruitful, there needs to be sufficient resources and equitable decision-making power between partners; and that interventions must be flexible to respond to emerging needs while considering long-standing structural inequalities. • Equity was not prioritized in planning the initial responses to COVID-19. • Stakeholders involved had different perceptions of health inequalities. • Perceptions of health inequalities shaped the approach favored to tackle COVID-19. • Intersectoral collaboration was difficult because of unequal decision-making power. • Adaptations were gradually implemented to address health inequalities. [ABSTRACT FROM AUTHOR]

• Intersectional stigma research examining pathways to HIV outcomes is limited. • Adapted conceptual frameworks to examine intersectional stigma and health outcomes. • Stigma interacted with social/institutional support to increase depression. • Depression led to maladaptive coping, lowering adherence and CD4 count. • Argues for multi-level strategies, including women-centred HIV care. [ABSTRACT FROM AUTHOR]

The North American Free Trade Agreement (NAFTA) was introduced in 1994 between Canada, Mexico, and the United States to encourage trilateral trade. In 2008, an unrestricted reciprocal sugar trade agreement, was implemented between Mexico and the United States as part of NAFTA, which led to a significant decrease in the United States' sugar price. However, critics argue that free trade agreements that reduce trade barriers on products such as sugar threaten public health. This study uses the synthetic control method to investigate the causal impact of the unrestricted sugar trade agreement on sugar consumption and diabetes prevalence in the United States. First, we show that sugar consumption in the United States increased by an average of 16% annually after the agreement was signed, corresponding to 5240g per capita. Second, we show that the crude prevalence of diabetes increased by an average of 1% annually in the United States after the agreement was signed, with an increase of 1% and 2% for men and women, respectively. This unintended consequence of NAFTA has had an estimated economic cost of $324.37 million annually. • Estimates changes in sugar consumption and diabetes prevalence in the U.S. due to NAFTA. • Sugar consumption and diabetes prevalence increase after NAFTA. • The increase in diabetes prevalence differs among women and men. • Unrestricted sugar trade agreements have unintended economic costs. [ABSTRACT FROM AUTHOR]

Medical assistance in dying (MAiD) was introduced into Canadian legislation in 2016. Mental illness as the sole underlying medical condition (MI-SUMC) is excluded from eligibility; this is expected to change in 2024. Incurability, intolerable suffering, capacity to make healthcare decisions, and suicidality have been publicly debated in connection with mental illness. Few studies have explored the views of persons with mental illness on the introduction and acceptability of MAiD MI-SUMC; this study aimed to fill this gap. Thirty adults, residing in Ontario, Canada, who self-identified as living with mental illness participated. A semi-structured interview including a persona-scenario exercise was designed to discuss participants' views on MAiD MI-SUMC and when it could be acceptable or not. Reflexive thematic analysis was used to inductively analyze data. Codes and themes were developed after extensive familiarization with the dataset. A lived-experience advisory group was engaged throughout the study. We identified six themes: The certainty of suffering ; Is there a suffering threshold to be met? The uncertainty of mental illness ; My own limits, values, and decisions ; MAiD MI- SUMC as acceptable when therapeutic means, and other supports, have been tried to alleviate long-term suffering ; and Between relief and rejection. These themes underline how the participants' lived experience comprised negative impacts caused by long-term mental illness, stigma, and in some cases, socioeconomic factors. The need for therapeutic and non-therapeutic supports was highlighted, along with unresolved tensions about the links between mental illness, capacity, and suicidality. Although not all participants viewed MAiD MI-SUMC as acceptable for mental illness, they autonomously embraced limits, values, and decisions of their own along their search for relief. Identifying individual and contextual elements in each person's experience of illness and suffering is necessary to understand diverse perspectives on MAiD MI-SUMC. • People with lived experience discuss medical assistance in dying in mental illness. • Suffering elicited by mental illness can only be understood by those living with it. • Contextual and social elements that can exacerbate suffering are identified. • Healthcare decisions are viewed as built on individual limits and values. • Medical assistance in dying can be acceptable under specific circumstances. [ABSTRACT FROM AUTHOR]

A tax on sugar-sweetened beverages (SSB) has been implemented in various jurisdictions. Though research confirmed this tax to reduce sugar consumption and to prevent chronic diseases, it also revealed concerns: one concern relates to the small proportion of sugar in the diet coming from SSBs; and another concern relates to the disproportional tax burden to low-income groups. To inform public health decision makers on alternatives, we examined three 'real world' taxation and subsidy scenarios in Canada: 1) a CAD$0.75/100 g tax on SSBs; 2) a CAD$0.75/100 g tax on free sugar in all foods; and 3) a 20% subsidy on vegetables and fruit (V&F). Using national survey data and a proportional multi-state life table-based Markov model, we simulated the changes in disability-adjusted life years, healthcare costs, tax revenue, intervention costs, and incremental cost-effectiveness ratio for five income quintiles after implementing the three scenarios, over a lifetime of the 2015 Canadian adult population. The first, second and third scenario would prevent 28,921, 262,348 and 551 cases of type 2 diabetes, respectively. They would avert 752,353, 12,167,113, and 29,447 disability-adjusted life years and save CAD$12,942 million, 149,927 million, and 442 million in health care costs, respectively, over a lifetime. Combining the second and third scenarios would lead to the largest health and economic benefits. Although the lowest income quintile would bear a higher sugar tax burden (0.81% of income, CAD$120/person/year), this would be compensated by a coinciding subsidy on V&F (1.30% of income, CAD$194/person/year). These findings support policies that include a tax on all free sugar in foods and a subsidy on V&F as an effective means to reduce chronic diseases and health care costs. Although the sugar tax was financially regressive, the V&F subsidy could compensate for the tax burden of the disadvantaged groups and improve health and economic equity. • Sugar tax and fruit and vegetables subsidy can gain health and economic benefits. • Tax on all sugary foods is more beneficial than tax on sugar-sweetened beverages. • The simulated sugar taxes and vegetable and fruit (V&F) subsidy were cost-effective. • Sugar tax burden on low-income groups could be compensated by a V&F subsidy policy. [ABSTRACT FROM AUTHOR]

A growing body of research has documented a well-established link between socioeconomic conditions and mortality among older adults. This study aims to understand (a) whether housing assets and income are associated with mortality and (b) if the value of housing assets affects the relationship between income and mortality; both questions are studied among older adults aged 65 or over in Canada. Using the population-based linked dataset (2011 Canadian Census Health and Environment Cohorts) of 881,220 older adults over six years of follow-up (2011–2017), this study uses survival analysis to estimate the link between housing assets, income level and mortality. We also assess the potential moderating effect of housing asset levels on the association between income and mortality by categorizing individuals along two dimensions: whether they are income-poor and whether they are housing assets-poor. The mortality rate was higher among both the lowest asset (HR = 1.346) and the lowest income group (HR = 1.203). The association is pronounced for older adults aged 65 to 74. Assets did not significantly moderate the link between income and mortality. Income-related inequalities in mortality are observed among each group of housing asset level. Compared to those who are neither income-poor nor housing assets-poor, individuals who were income poor but not housing assets-poor were more likely to die (HR = 1.067) over seven years of follow-up, and people who were housing assets-poor only were more likely to die (HR = 1.210). Being housing-assets poor and income-poor yielded a higher hazard ratio (HR = 1.291). Housing assets and income are associated with mortality of older adults. It is important to identify people who are assets poor and/or income poor who are at higher risks of mortality. Social policies aimed at reducing income insecurity and housing insecurity can reduce mortality inequalities. • The levels of housing assets and income predicted mortality risks of older adults. • The observed association was manifest in older adults aged 65 to 74. • Housing assets did not moderate the association between income and mortality. • Housing asset poor and income poor were the most vulnerable to mortality risks. [ABSTRACT FROM AUTHOR]

People may choose to receive vaccines in response to pressures that outweigh any concerns that they have. We explored Racialized minority and Indigenous Peoples' motivations for, perceptions of choice in, and concerns about, COVID-19 vaccination. We used a sequential explanatory mixed methods approach, including a national survey administered around the time vaccines were first authorized (Dec 2020) followed by qualitative interviews when vaccines were becoming more readily available to adults (May–June 2021). We analyzed survey data using descriptive statistics and interviews using critical feminist methodologies. Survey respondents self-identified as a Racialized minority (n = 1488) or Indigenous (n = 342), of which 71.4% and 64.6%, respectively, intended to receive a COVID-19 vaccine. Quantitative results indicated perceptions of COVID-19 disease were associated with vaccination intention. For instance, intention was associated with agreement that COVID-19 disease is severe, risk of becoming sick is great, COVID-19 vaccination is necessary, and vaccines available in Canada will be safe (p < 0.001). COVID-19 vaccines were in short supply in Canada when we subsequently completed qualitative interviews with a subset of Racialized minority (n = 17) and Indigenous (n = 10) survey respondents. We coded interview transcripts around three emergent themes relating to governmentality and cultural approaches to intersectional risk theories: feelings of collective responsibility, choice as privilege, and remaining uncertainties about COVID-19 vaccines. For example, some mentioned the responsibility and privilege to receive a vaccine earlier than those living outside of Canada. Some felt constraints on their freedom to choose to receive or refuse a vaccine from intersecting oppressions or their health status. Although all participants intended to get vaccinated, many mentioned uncertainties about the safety and effectiveness of COVID-19 vaccination. Survey respondents and interview participants demonstrated nuanced associations of vaccine acceptance and hesitancy shaped by perspectives of vaccine-related risks, symbolic associations of vaccines with hope, and intersecting social privileges and inequities (including racialization). • Mixed methods exploration of social privileges and inequities in vaccine intentions. • Explored acceptance of new COVID-19 vaccines instead of framing refusal as abnormal. • Theoretical insights into vaccines from intersectional approaches to risk governance. • Practical need to support those intending to be vaccinated despite uncertainties. [ABSTRACT FROM AUTHOR]

Access to medicines treating rare diseases ('orphan medicines') has proven challenging due to high prices and clinical uncertainty. To optimise market access to these medicines, some healthcare systems are implementing specialised pathways and/or processes during marketing authorisation (MA) and/or health technology assessment (HTA). Comparing one setting where these medicines are classed as "orphan" (Scotland) to another where they considered "non-orphan" (Canada), this study aims to explore whether the presence of specialised pathways and processes at MA and HTA levels is associated with more favourable funding recommendations and faster time to market access. A matched sample of 116 medicine-indication pairs with MA approval from 2001 to 2019 in Europe and Canada was identified, and publicly available sources were used for data extraction. Descriptive statistics were used for data analysis. All medicines were commercially marketed in both countries, except one instance in Scotland. In Scotland, more orphan medicines (68.1%) had a favourable HTA recommendation than in Canada (60.4%), while Canada issued more negative HTA recommendations (20.7%) than Scotland (15.5%). Low levels of agreement on HTA recommendations and the main reasons driving recommendations were found between settings. In both countries, medicines with specialised MA approval were less likely to receive negative HTA recommendations than medicines with standard MA. Time to market access was faster in Canada than Scotland, though medicines with specialised MA approval had slower timelines than medicines with standard MA approval in both countries. However, it is unclear whether the presence of orphan designation and HTA specialised processes alone could result in favourable funding recommendations without accounting for other healthcare system-related factors and differences in the decision-making processes across settings. Holistic approaches and better alignment of evidentiary requirements across regulators are needed to optimise access to orphan medicines. • Canada approved more orphan medicines through specialised pathways than Scotland. • Less negative HTA outcomes for medicines with specialised MA in both countries. • Less negative HTA recommendations for orphan medicines in Scotland than Canada. • Low levels of agreement in HTA for orphan medicines between Scotland and Canada. • Time to market access occurred considerably faster in Canada than Scotland. [ABSTRACT FROM AUTHOR]

This paper contributes to the literature on Indigenous health, human dimensions of climate change, and place-based dimensions of health by examining the role of environment for Inuit health in the context of a changing climate. We investigated the relationship between one key element of the environment – sea ice – and diverse aspects of health in an Inuit community in northern Canada, drawing on population health and health geography approaches. We used a case study design and participatory and collaborative approach with the community of Nain in northern Labrador, Canada. Focus groups (n = 2), interviews (n = 22), and participant observation were conducted in 2010–11. We found that an appreciation of place was critical for understanding the full range of health influences of sea ice use for Inuit. Negative physical health impacts were reported on less frequently than positive health benefits of sea ice use, which were predominantly related to mental/emotional, spiritual, social, and cultural health. We found that sea ice means freedom for sea ice users, which we suggest influences individual and collective health through relationships between sea ice use, culture, knowledge, and autonomy. While sea ice users reported increases in negative physical health impacts such as injuries and stress related to changing environmental conditions, we suggest that less tangible climate change impacts related to losses of health benefits and disruptions to place meanings and place attachment may be even more significant. Our findings indicate that climate change is resulting in and compounding existing environmental dispossession for Inuit. They also demonstrate the necessity of considering place meanings, culture, and socio-historical context to assess the complexity of climate change impacts on Indigenous environmental health. [ABSTRACT FROM AUTHOR]

There has been a growing interest in better understanding the trends and determinants of health tourism activities. While much of the expanding literature on health tourism offers theoretical or qualitative discussion, empirical evidences has been lacking. This study employs Canada's outbound health tourism activities as an example to examine the trends in health tourism and its association with changing domestic health care market characteristics. A time-series model that accounts for potential structural changes in the trend is employed to analyze the quarterly health-related travel spending series reported in the Balance of Payments Statistics (BOPS) during 1970–2010 (n = 156). We identified a structural shift point which marks the start of an accelerated growth of health tourism and a flattened seasonality in such activities. We found that the health tourism activities of Canadian consumers increase when the private investment in medical facilities declines or when the private MPI increases during the years following the structural-change. We discussed the possible linkage of the structural shift to the General Agreement on Trade in Services (GATS), which went into effect in January, 1995. [ABSTRACT FROM AUTHOR]

Social supports have been shown to affect health in a variety of ways. This paper explores a hitherto ignored avenue linking social supports to health, namely through their influence on having a regular family doctor. We examine the role played by social supports in helping to explain why a significant portion of the Canadian population does not have a regular family doctor even though primary care is fully covered by the public insurer and when having a regular physician is associated with better care and with access to specialists. Five Canadian Community Health Surveys spanning 2001 to 2010 (n = 13,872 to n = 30,814) are employed, containing information on three measures of social support: sense of belonging to the local community, how often an individual has someone to confide in, and number of close friends and relatives. We find evidence of a positive link between social supports, especially sense of belonging, and having a regular doctor. Our results suggest that the benefits associated with policies geared towards community development and strengthening neighborhoods may also include facilitating access to primary-care physicians and, importantly, improving the matching of patients with regular family doctors. [ABSTRACT FROM AUTHOR]

Abstract: Techniques to manage scarce healthcare resources continue to evolve in response to changing, growing and competing demands. Yet there is no standard definition in the priority setting literature of what might constitute the desired impact or success of resource management activities. In this 2006–09 study, using action research methodology, we determined the impact of implementing a formal priority setting model, Program Budgeting and Marginal Analysis (PBMA), in a Canadian health authority. Qualitative data were collected through post year-1 (n = 12) and year-2 (n = 9) participant interviews, meeting observation and document review. Interviews were analyzed using a constant comparison technique to identify major themes. Impact can be defined as effects at three levels: system, group, and individual. System-level impact can be seen in the actual selection of priorities and resource re-allocation. In this case, participants prioritized a list of $760,000 worth of investment proposals and $38,000 of disinvestment proposals; however, there was no clear evidence as to whether financial resources were reallocated as a result. Group and individual impacts, less frequently reported in the literature, included changes in priority setting knowledge, attitudes and practice. PBMA impacts at these three levels were found to be interrelated. This work argues in favor of attempts to expand the definition of priority setting success by including both desired system-level outcomes like resource re-allocation and individual or group level impacts like changes to priority setting knowledge, attitudes and practice. These latter impacts are worth pursuing as they appear to be intrinsic to successful system-wide priority setting. A broader definition of PBMA impact may also suggest conceptualizing PBMA as both a priority setting approach and as a tool to develop individual and group priority setting knowledge and practice. These results should be of interest to researchers and decision makers using or considering a formal priority setting approach to manage scarce healthcare resources. [Copyright &y& Elsevier]

Abstract: The paper addresses a critically important area in Canadian immigration and health from both a social and a spatial perspective. It employs multilevel and contextual approaches to examine the social determinants of immigrant health as well as the place effects on self-reported health at a regional and neighborhood scale. The data come from the raw microdata file of the 2005–10 Canadian Community Health Survey (a random national health survey) and the publicly available Canadian Marginalization index based on the 2006 Census. Three populations are compared: Canadian-born, overall foreign-born, and Chinese immigrants. The results suggest various degrees of association between self-reported health, individual and lifestyle behavioral characteristics, and neighborhood material deprivation and ethnic concentration in census tracts. These factors contribute differently to the reported health of Chinese immigrants, Canada's largest recent immigrant group. A healthy immigrant effect is partially evident in the overall foreign-born population, but appears to be relatively weak in Chinese immigrants. For all groups, neighborhood deprivation moderately increases the likelihood of reporting poor health. Ethnic concentration negatively affects self-rated health, with the exception of the slight protective effect of Chinese-specific ethnic density in census tracts. The multilevel models reveal significant area inequalities across Census Metropolitan Areas/Census Agglomerations in risk of reporting unhealthy status, with greater magnitude in the foreign-born population. The vast regional variations in health among Chinese immigrants should be interpreted carefully due to the group's heavy concentration in large cities. The study contributes to the literature on ethnicity and health by systematically incorporating neighborhood contextual effects in modeling the social determinants of immigrant health status. It fills a gap in the literature on neighborhoods and health by focusing on ethnically disparate groups rather than on the general population. By revealing regional disparities in health, the paper adds a spatial perspective to the work on immigrant health. [Copyright &y& Elsevier]

Complexity is a useful frame of reference for disaster management and understanding population health. An important means to unraveling the complexities of disaster management is to recognize the interdependencies between health care and broader social systems and how they intersect to promote health and resilience before, during and after a crisis. While recent literature has expanded our understanding of the complexity of disasters at the macro level, few studies have examined empirically how dynamic elements of critical social infrastructure at the micro level influence community capacity. The purpose of this study was to explore empirically the complexity of disasters, to determine levers for action where interventions can be used to facilitate collaborative action and promote health among high risk populations. A second purpose was to build a framework for critical social infrastructure and develop a model to identify potential points of intervention to promote population health and resilience. A community-based participatory research design was used in nine focus group consultations ( n = 143) held in five communities in Canada, between October 2010 and March 2011, using the Structured Interview Matrix facilitation technique. The findings underscore the importance of interconnectedness of hard and soft systems at the micro level, with culture providing the backdrop for the social fabric of each community. Open coding drawing upon the tenets of complexity theory was used to develop four core themes that provide structure for the framework that evolved; they relate to dynamic context, situational awareness and connectedness, flexible planning, and collaboration, which are needed to foster adaptive responses to disasters. Seven action recommendations are presented, to promote community resilience and population health. [ABSTRACT FROM AUTHOR]

Abstract: Material deprivation is an important determinant of health inequalities in adults but there remains debate about the extent of its importance for adolescent wellbeing. Research has found limited evidence for an association between adolescent health and socio-economic status, leading authors to suggest that there is an ‘equalisation’ of health across socio-economic groups during the adolescent stage of the life-course. This paper explores this ‘equalisation’ hypothesis for adolescent psychological wellbeing from a geographical perspective by investigating associations between neighbourhood deprivation and self-esteem in Britain and Canada. Data from the British Youth Panel (BYP) and the National Longitudinal Survey of Children and Youth (NLSCY) on adolescents aged 11–15 for the time period 1994–2004 were used to estimate variations in low self-esteem between neighbourhoods using multilevel logistic regression. Models were extended to estimate associations between self-esteem and neighbourhood deprivation before and after adjustment for individual and family level covariates. Moderation by age, sex, urban/rural status, household income and family structure was investigated. There were no significant differences in self-esteem between the most deprived and most affluent neighbourhoods (Canada unadjusted OR = 1.00, 95% CI 0.76, 1.33; Britain unadjusted OR = 1.25, 95% CI 0.74, 2.13). The prevalence of low self-esteem was higher (in Canada) for boys in the least deprived neighbourhoods compared to other neighbourhoods. No other interactions were observed. The results presented here offer some (limited) support for the socio-economic equalisation in youth hypothesis from a geographical perspective: with specific reference to equalisation of the relationship between neighbourhood deprivation and self-esteem and psychological health in early adolescence. This contrasts with previous research in the United States but supports related work from Britain. The lack of interactions with key social and economic variables suggests that findings might apply across a range of family circumstances and different communities in Britain and Canada. Policy implications are discussed. [Copyright &y& Elsevier]

Abstract: Informed by intersectionality theory, a tradition that theorizes intersecting power relations of racism, patriarchy, classism and heterosexism, this paper investigates the degree to which race, gender, class and sexuality manifest distinct and interconnected associations with self-reported hypertension in nationally-representative survey data from Canada. Binary logistic regression is used to model the main effects of, and interactions between, race, gender, education, household income and sexual orientation on hypertension, controlling for age, using data from the 2003 Canadian Community Health Survey (n = 90,310). From a main effects (‘additive’) perspective, Black respondents, respondents with less than high school and poorer respondents were significantly more likely than White respondents, university-educated Canadians and wealthier Canadians, respectively, to report hypertension. However, the interactive models indicate that the additive models were poor predictors of hypertension for wealthy Black men, wealthy South Asian women, women with less than a high school diploma and wealthy bisexual respondents, who were more likely than expected to report hypertension, and for poor Black men, poor South Asian women, poor South Asian men and women with a university degree, who were less likely than expected to report hypertension. It appears that, with regard to blood pressure at least, Canadians experience the health effects of education differently by their genders and the health effects of income differently by their identities defined at the intersection of race and gender. This study provides empirical support for the intersectional approach to cardiovascular health inequalities by demonstrating that race, gender, class and sexuality cannot be disentangled from one another as predictors of hypertension. [Copyright &y& Elsevier]

Abstract: Illicit and prescription drug use disorders are two to four times more prevalent among Aboriginal peoples in North America than the general population. Research suggests Aboriginal cultural participation may be protective against substance use problems in rural and remote Aboriginal communities. As Aboriginal peoples continue to urbanize rapidly around the globe, the role traditional Aboriginal beliefs and practices may play in reducing or even preventing substance use problems in cities is becoming increasingly relevant, and is the focus of the present study. Mainstream acculturation was also examined. Data were collected via in-person surveys with a community-based sample of Aboriginal adults living in a mid-sized city in western Canada (N = 381) in 2010. Associations were analysed using two sets of bootstrapped linear regression models adjusted for confounders with continuous illicit and prescription drug problem scores as outcomes. Psychological mechanisms that may explain why traditional culture is protective for Aboriginal peoples were examined using the cross-products of coefficients mediation method. The extent to which culture served as a resilience factor was examined via interaction testing. Results indicate Aboriginal enculturation was a protective factor associated with reduced 12-month illicit drug problems and 12-month prescription drug problems among Aboriginal adults in an urban setting. Increased self-esteem partially explained why cultural participation was protective. Cultural participation also promoted resilience by reducing the effects of high school incompletion on drug problems. In contrast, mainstream acculturation was not associated with illicit drug problems and served as a risk factor for prescription drug problems in this urban sample. Findings encourage the growth of programs and services that support Aboriginal peoples who strive to maintain their cultural traditions within cities, and further studies that examine how Aboriginal cultural practices and beliefs may promote and protect Aboriginal health in an urban environment. [Copyright &y& Elsevier]

Authorities within the field of palliative care frequently espouse that assisted death is – and must remain – separate from palliative care. This fault line, between palliative care and assisted death, has important implications for how we enact end-of-life care, particularly in jurisdictions where assisted death is legal. And yet little is known about how direct-care clinicians providing palliative care navigate this demarcation in everyday practice. This qualitative study reports on semi-structured interviews with 22 palliative care nurses from across Canada, where assisted death was legalized in 2016. Although a minority of participants did express categorical opinions around the (non) legitimacy of assisted death as an ethical end-of-life care option, most engaged in an ongoing and sometimes painful process of questioning and self-examination. Their ethical reflections were more nuanced than simply dismissing MAiD as incompatible with palliative care philosophy; yet this idea of incompatibility weighed heavily as they reasoned through their experiences and questioned their own perspectives. Nurses described grappling with the finality of assisted death, which contradicts their belief in the telos of palliative care; when adequately resourced, palliative care should be available to support people to live well before death. At the same time, commitment to important palliative care values such as the non-abandonment of dying people and respecting peoples' individual end-of-life choices reveal the possibility of overlap between the ethos of assisted death and that of palliative care nursing. Drawing on scholarship in feminist ethics, our study sheds light on the moral identity work that assisted dying catalyzes amongst palliative care nurses. We highlight what is at stake for them as they navigate a delicate tension in responding ethically to patients whose suffering motivates an interest in assisted death, from within a wider professional collective that upholds a master narrative about the incompatibility of assisted death and palliative care. • Palliative care typically claims to be distinct from assisted death. • Everyday nursing practice with patients seeking assisted death nuances this distinction. • A feminist analysis invites reflection on how the ethics of palliative care and the ethics of assisted death might overlap. I thought I knew death ... and yet this felt profoundly different from the many deaths I had experienced – Beuthin and Bruce, 2019 [ABSTRACT FROM AUTHOR]

Abstract: The effect of school violence on mental health was examined among 12,366 Aboriginal children and adolescents, primarily First Nations, Métis, and Inuit residing off reservations in the Canadian provinces and territories. Analyses were based on the 2006 Aboriginal Peoples'' Survey, a postcensal national survey of Aboriginal youth aged 6–14 years. More than one-fifth of students in the sample attended schools where violence was perceived as a problem. The occurrence of psychological or nervous disorders was about 50% higher among students exposed to school violence than among other students. School violence was a significant predictor of mental health difficulties, irrespective of socioeconomic and demographic characteristics. Virtually the entire effect was mediated by interpersonal processes, or negative quality of parent–child and peer relationships, while the effect was not explained by cultural detachment through lack of interactions with Elders and traditional language ability/use. Results underscored school violence as a significant public health concern for Aboriginal elementary and high school students, and the need for evidence-based mental health interventions for at-risk populations. [Copyright &y& Elsevier]

Abstract: The International Classification of Functioning, Disability and Health framework describes human functioning through body structure and function, activity and participation in the context of a person''s social and physical environment. This work tested the temporal relationships of these components. Our hypotheses were: 1) there would be associations among physical impairment, activity limitations and participation restrictions within time; 2) prior status of a component would be associated with future status; 3) prior status of one component would influence status of a second component (e.g. prior activity limitations would be associated with current participation restrictions); and, 4) the magnitude of the within time relationships of the components would vary over time. Participants from Canada with primary hip or knee joint replacement (n = 931), an intervention with predictable improvement in pain and disability, completed standardized outcome measures pre-surgery and five times in the first year post-surgery. These included physical impairment (pain), activity limitations and participation restrictions. ICF component relationships were evaluated cross-sectionally and longitudinally using path analysis adjusting for age, sex, BMI, hip vs. knee, low back pain and mood. All component scores improved significantly over time. The path coefficients supported the hypotheses in that both within and across time, physical impairment was associated with activity limitation and activity limitation was associated with participation restriction; prior status and change in a component were associated with current status in another component; and, the magnitude of the path coefficients varied over time with stronger associations among components to three months post surgery than later in recovery with the exception of the association between impairment and participation restrictions which was of similar magnitude at all times. This work enhances understanding of the complexities of the ICF component relationships in evaluating disability over time. Further longitudinal studies including evaluation of contextual factors are required. [Copyright &y& Elsevier]

Abstract: Around 25% of practicing physicians in Canada are graduates of medical schools outside of Canada. These physicians are more likely to be working in rural communities, and in particular account for more than half of new physicians starting practice in rural regions. The extent to which particular health regions and provinces are able to retain their physicians is crucial if shortages in the delivery of physician and surgeon services in both the short and longer terms are to be avoided. In this paper, we use data from the confidential master files of the Canadian Census over the years 1991–2006 to study the geographic mobility of immigrant and non-immigrant physicians who are already resident in Canada. We consider both inter- and intra-provincial migration, with a particular focus on migration to and from rural areas of Canada. We exploit the fact that it is possible to link individuals within families in the Census files in order to investigate the impact on the migration decision of the characteristics of a married physician’s spouse. Our results indicate that the magnitude of outflows is substantial and that the retention of immigrant physicians in rural areas and in some provinces will continue to be difficult. We find strong evidence that migration is a family decision, and spousal characteristics (education, age, years in Canada for immigrants) are important. As well, we find that large Canadian cities (mainly in Ontario) are the likely destination for the types of immigrant physicians typically able to be recruited to other areas, implying recruitment efforts of smaller provinces may have significant implications for the size of health care costs in larger provinces. [Copyright &y& Elsevier]

Abstract: Partnered individuals live longer, healthier lives. In explaining this association, processes involving both social causation (in which partnership provides health benefits to individuals) and health selection (in which those who find partners were healthier than those who do not) have been invoked. Since much of this literature is focused in the U.S., comparative studies of the potential impact of policy on the causation and selection components of this association have been scant. Using comparable data from the U.S. Panel Study of Income Dynamics (N = 25,862, followed from 1984 to 2005) and the Canadian Survey of Labour and Income Dynamics (N = 15,632, followed from 1999 to 2005), we test the selective and causal relationships evident during entrance into partnership. We use fixed change-point analysis with multilevel models to fit trajectories of change in both the U.S. and Canada. In Canada, partnership benefits were evident, while health selection was limited. In contrast, in the U.S., health selection was prominent in both men and women, but partnership benefits were not significant. We argue that the differences in the extent of defamilialization of social policy between the two countries may impact the way and extent to which people choose partners and benefit from those partnerships. [Copyright &y& Elsevier]

Abstract: The immigrant paradox refers to the contrasting observations that immigrants usually experience similar or better health outcomes than the native-born population despite socioeconomic disadvantage and barriers to health care use. This paradox, however, has not been examined simultaneously in relation to varying degrees of exposure to the receiving society and across multiple outcomes and risk factors. To advance knowledge on these issues, we analysed data of the Maternity Experiences Survey, a nationally representative cross-sectional survey of 6421 Canadian women who delivered singleton infants in 2006–07. We compared the prevalence of adverse pregnancy outcomes and related risk factors according to women''s ethnicity and time since migration to Canada. We calculated prevalences and prevalence ratios (PR) with 95% confidence intervals. Compared to Canadian-born women of European descent, recent immigrants were at lower risk of preterm delivery and morbidity during pregnancy despite having the highest prevalence of low income and low support during pregnancy among all groups, but the paradox was not observed among immigrants with a longer stay in Canada. In contrast, recent immigrants were at higher risk of postpartum depression. Immigrants of non-European origin also had higher prevalence of postpartum depression, irrespective of their length of residence in Canada, but immigrants from European-origin countries did not. Exposure to Canada was also positively associated with higher alcohol and tobacco consumption and body mass index. Canadian-born women of non-European descent were at higher risk of preterm birth and hospitalisation during pregnancy than their European-origin counterparts. Our findings suggest that the healthy migrant hypothesis and the immigrant paradox have limited generalisability. These hypotheses may be better conceptualised as outcome-specific and dependent on immigrants'' ethnicity and length of stay in the receiving country. [Copyright &y& Elsevier]

Abstract: It has been theorized that suicide behaviours amongst indigenous peoples may be an outcome of mass trauma experienced as a result of colonization. In Canada, qualitative evidence has suggested that the Indian Residential School System set in motion a cycle of trauma, with some survivors reporting subsequent abuse, suicide, and other related behaviours. It has been further postulated that the effects of trauma can also be passed inter-generationally. Today, there are four generations of Canadian First Nations residential school survivors who may have transmitted the trauma they experienced to their own children and grandchildren. No empirical study has ever been undertaken to demonstrate this dynamic. This study is therefore the first to investigate whether a direct or indirect exposure to Canada''s residential school system is associated with trauma and suicide behaviour histories. Data were collected in 2002/2003 from a representative sample of Manitoba, Canada, First Nations adults (N = 2953), including residential (N = 611) and non-residential school attendees (N = 2342). Regression analyses showed that for residential school attendees negative experiences in residential school were associated with a history of abuse, and that this history and being of younger age was associated with a history of suicide thoughts, whereas abuse history only was associated with a history of suicide attempts. For First Nations adults who did not attend a residential school, we found that age 28–44, female sex, not having a partner, and having a parent or grandparent who attended a residential school was associated with a history of abuse. This history, along with age and having had a parent or grandparent who attended residential school was associated with a history of suicide thoughts and attempts. In conclusion, this is the first study to empirically demonstrate, at the population level, the mental health impact of the residential school system on survivors and their children. [Copyright &y& Elsevier]

Abstract: This study investigates the relationship between business cycle fluctuations and health in the Canadian context, given that a procyclical relationship between mortality rates and unemployment rates has already been well established in the U.S. literature. Using a fixed effects model and provincial data over the period 1977–2009, we estimate the effect of unemployment rates on Canadian age and gender specific mortality rates. Consistent with U.S. results, there is some evidence of a strong procyclical pattern in the mortality rates of middle-aged Canadians. We find that a one percentage point increase in the unemployment rate lowers the predicted mortality rate of individuals in their 30s by nearly 2 percent. In contrast to the U.S. data, we do not find a significant cyclical pattern in the mortality rates of infants and seniors. [Copyright &y& Elsevier]

Abstract: This study sought to examine the influence of length of stay and language proficiency on immigrants’ access to and utilization of care in Canada and the United States (US). Data came from the 2007–2008 Canadian Community Health Survey and the National Health Interview Survey. Analyses were limited to foreign-born, non-elderly adults in each country (n = 12,870 in Canada and n = 7440 in the US). Health care indicators included having a usual source of care; annual consultation with a health professional, dentist, and eye doctor; flu shot in the past year; and Pap test in the past 3 years. Logistic regression models were employed to estimate the relative odds of access or use of care, adjusting for need, demographic factors, socioeconomic status, and insurance coverage. In general, rates of health care access and utilization were higher in Canada than the US among all immigrant groups. In both countries, adjusted analyses indicated that immigrants with shorter length of stay (less than 10 years) and limited language proficiency generally had lower rates of access/use compared with those with longer length of stay (10 years or more) and proficiency in each country’s official language(s), respectively. There was one exception to this pattern in the US: immigrants with limited English had higher odds of having a recent Pap test relative to English-proficient immigrants. The persistence of disparities in health care experiences based on length of stay and language proficiency in Canada suggests that universal health insurance coverage may not be sufficient for ensuring access to and utilization of primary and preventive care for this population. [Copyright &y& Elsevier]

Abstract: Canadian frontline careworkers are six times more likely to experience daily physical violence than their Scandinavian counterparts. This paper draws on a comparative survey of residential careworkers serving older people across three Canadian provinces (Manitoba, Nova Scotia, Ontario) and four countries that follow a Scandinavian model of social care (Denmark, Finland, Norway, Sweden) conducted between 2005 and 2006. Ninety percent of Canadian frontline careworkers experienced physical violence from residents or their relatives and 43 percent reported physical violence on a daily basis. Canadian focus groups conducted in 2007 reveal violence was often normalized as an inevitable part of elder-care. We use the concept of “structural violence” () to raise questions about the role that systemic and organizational factors play in setting the context for violence. Structural violence refers to indirect forms of violence that are built into social structures and that prevent people from meeting their basic needs or fulfilling their potential. We applied the concept to long-term residential care and found that the poor quality of the working conditions and inadequate levels of support experienced by Canadian careworkers constitute a form of structural violence. Working conditions are detrimental to careworker’s physical and mental health, and prevent careworkers from providing the quality of care they are capable of providing and understand to be part of their job. These conditions may also contribute to the physical violence workers experience, and further investigation is warranted. [Copyright &y& Elsevier]

The practice of prescription opioid (PO) diversion remains highly controversial and has been characterized as a source of significant drug-related harm by physicians and public health officials. We critically analyze the "problem" of diversion through an examination of the perspectives of people who divert POs during an overdose epidemic to better understand the practice, including benefits and challenges, as well as how diversion is shaped by structural contexts. Qualitative semi-structured interviews were conducted with 21 participants recruited from ongoing cohort studies involving people who use drugs in Vancouver, Canada. Prohibitive prescribing policies made accessing POs difficult, leading some to smuggle drugs out of clinics. Others would buy POs in bulk or do trades to acquire them. Participants risked having their prescriptions terminated, but rationalized this risk as a protective measure that allows them to provide safer drugs to others (e.g., to prevent overdose or treat withdrawal). Poverty also framed diversion, with some participants diverting their POs to generate income to pay for expenses including food and sometimes illicit fentanyl (perceived as a stronger alternative). However, diversion was shaped by other constraints, including criminalization, negative health impacts from not consistently consuming POs, and supplies running out, which led some participants to rely on other illegal means to generate income. This study highlights the intricate means by which POs are acquired and diverted and how environmental contexts frame how participants negotiated risk and rationalized diversion. Our study provides an alternative perspective on the "problem" of diversion and demonstrate a positive effect in providing a safer drug supply to others during an overdose crisis. Given that drug policy, criminalization, and poverty created challenges, our findings demonstrate the need for strategies that engender greater safety, reduce harm, and alleviate the effects of these constraints, including through policies promoting safer drug supplies, decriminalization, and employment. • The "problem" of prescription opioid diversion is examined. • Diversion was rationalized as a protective measure for others. • Social and structural contexts framed motivations for diversion. • Strategies are needed to reduce harms and alleviate contextual constraints. • Policies promoting decriminalization and a safer drug supply are needed. [ABSTRACT FROM AUTHOR]

Caregiver mental health is crucial to the wellbeing of children. This is most apparent when caregivers face high levels of stress or life adversity. To study this phenomenon in the current global context, this study examined the relation between stress/disruption from the COVID-19 pandemic and the mental health of female and male caregivers. Pre-pandemic childhood adversity was considered as a moderator of this association. A multi-national sample (United Kingdom, 76%; United States, 19%; Canada, 4%, and Australia, 1%) was recruited in May 2020, of whom 348 female and 143 male caregivers of 5–18 year-old children provided data on the constructs of interest. At this time, caregivers reported on their history of adverse childhood experiences (ACEs) and COVID stress/disruption. About two months later (July 2020) caregiver mental health was evaluated. We examined differences between female and male caregivers on ACEs, COVID stress/disruption, and mental health (distress, anxiety, substance use, and posttraumatic stress). Main and interactive effects of ACEs and COVID stress/disruption on each mental health outcome were examined. Female caregivers reported higher COVID stress/disruption, more ACEs, and greater distress, anxiety, and posttraumatic stress symptoms compared to male caregivers. Among female caregivers, higher COVID stress/disruption and more adverse childhood experiences (ACEs) independently predicted all mental health outcomes, consistent with a stress accumulation model. Among male caregivers, a pattern of interactions between COVID stress/disruption and ACEs suggested that the effects of COVID stress/disruption on mental health was stronger for those with higher ACEs, especially for substance use, consistent with a stress sensitization model. Higher levels of stress and mental health difficulties among female caregivers suggests a disproportionate burden due to pandemic-related disruption compared to male caregivers. Findings speak to the disparate effects of COVID-19 on the mental health of female compared to male caregivers, and the role of pre-existing vulnerabilities in shaping current adaptation. • Cross-national sample of caregiver mental health and COVID-19 stress/disruption. • Compared to male caregivers, female caregivers report more COVID stress/disruption. • Female caregivers report higher distress, anxiety, and posttraumatic stress. • For female caregivers, COVID stress and ACEs independently predict mental health. • For male caregivers, COVID stress and ACEs interact to predict mental health. [ABSTRACT FROM AUTHOR]

Although a large body of literature has examined the effect of social capital on health and theoretical models suggest a reciprocal relationship between the two variables, there are relatively few studies that have investigated the effect of mental health on social capital. This paper evaluates the impact of mental health on the stock of social capital using data from the cross-sectional 2012 (N = 21,844) and 2002 (N = 31,089) Canadian Community Health Survey – Mental Health editions. Mental health was measured retrospectively as self-rated mental health, past year mental health conditions, and past 30-day psychological distress. Given the reciprocal relationship, we used an instrumental variable approach with family history of mental health problems as the instrument and examined forms of social capital – sense of belonging and workplace social support – that are largely measures of social capital provided by non-family members in the community and workplace. The analysis suggests there are large and significant associations between measures of mental health and both outcomes, which persist in the instrumental variable analyses. These findings highlight the urgent need for policy makers to implement greater prevention and treatment of poor mental health, and provide greater support for individuals with poor mental health so they can build and maintain their social capital. • The causal impact of mental health on social capital has been relatively unexplored. • All measures of mental health were associated with a lower sense of belonging. • Workplace social supports were similarly affected by all measures of mental health. • Instrumental variable analyses suggest the observed effects are causal. [ABSTRACT FROM AUTHOR]

First responders—including police officers—play a prominent role in managing the risk of fentanyl overdoses. In many jurisdictions, they have Naloxone (also commercially available as Narcan) at their disposal to counter the effects of an opioid overdose. Little empirical research exists on how effectively police are incorporating this emergency rescue medication into routine practice. Between 2018 and 2019, we conducted semi-structured interviews with police officers from two Western Canadian police organizations. We also administered organization-wide web surveys to determine what factors facilitate or inhibit the incorporation of Narcan into police practice by looking at two domains: 1) the inner setting of the police organization and 2) personal knowledge of, and attitudes toward, an intervention. Whether officers administered Narcan depended on several personal and organizational factors, including: 1) having sufficient knowledge and concern about the fentanyl situation, 2) being knowledgeable about Narcan and trained in its use, 3) the medication being readily available to officers, and 4) being willing to administer it to citizens. • Brings "implementation science" framework to literature on policing the opioid crisis. • Factors facilitating and inhibiting incorporation of Narcan into police practices. • Personal and organizational factors impede police use of Narcan on civilians. • Provides policies for better police incorporation of Narcan for overdose reversal. [ABSTRACT FROM AUTHOR]

The challenge of novel and high cost health technologies has encouraged the growth of regulatory agencies such as Health Technology Assessment (HTA) organizations and Group Procurement Organizations (GPO). Yet the existence of several agencies in the same polycentric regulatory regime raises questions about whether and how their work can be coordinated. Drawing on a case study of GPOs and HTA agencies across four provinces in Canada, involving document review and key informant interviews (n = 44) conducted between 2013 and 2016, we explore the separate evolution of these agencies, emerging connections between them for non-drug technologies, and the organizational processes and evaluative judgments that underpin coordination efforts. HTA agencies and GPOs developed separately; connections emerged recently in three provinces and suggest four modes of coordination. One mode aligns most closely with that recommended by health economists and HTA practitioners, whereby HTA precedes procurement, with coverage decisions informing technology acquisition. The second mode is a version of the first, where procurement refers cases to HTA for coverage or technology management support; unlike the first, it recognizes procurement's evaluative strengths. Yet both the first and second modes focus on exceptional cases and will be infrequent. The third mode is more systemic, reflecting a generalized complementary of purpose as public agencies. HTA could support GPOs in contested technology acquisition efforts through timely and responsive input, while procurement could expand HTA's impact and inform HTA's growing interest in responsible innovation and environmental sustainability. The final mode is non-coordination, reflecting the potential for agencies to occupy quite distinct regulatory niches within the same regime. We conclude that consistency and convergence around a single model of resource allocation is not inevitable; nor is it necessary for coordinated effort. Thus, where differences in regulatory practice and epistemology persist, mutual accommodation and shared learning may prove most productive. • Regulatory agencies to manage technology adoption have grown internationally. • HTA agencies and Group Procurement Organizations now exist in the same regime. • We identify four "modes of coordination" in the regime, including no coordination. • Only one mode aligns with the assumption of shared problem solving, guided by HTA. • Mutual learning is needed given differences in regulatory practice & epistemology. [ABSTRACT FROM AUTHOR]

Self-rated health is widely used in studies of the socioeconomic gradient of health in community-based populations. Its subjectivity may lead to under- or over-estimation of a true underlying socioeconomic gradient and has increased interest in searching for alternative, objective measures of health. Grip strength has emerged as one such alternative for community-based older populations, yet no study has directly assessed the relationship between these two measures and compared their associations with socioeconomic status and health behaviours. Using 26,754 participants aged 45–85 years in the baseline data of the Canadian Longitudinal Study on Aging Comprehensive Cohort, we estimated adjusted-grip strength through indirect standardization using age, sex, height, weight, and their square terms and used ANOVA to assess the variance of adjusted-grip strength within and between each self-rated health category. We ran four separate logistic regression models, examining unhealthy tails (those reporting poor health vs. not and those at the bottom 8th percentile of adjusted-grip strength vs. above) and healthy tails (those reporting excellent health vs. not and those at the top 20th percentile of adjusted-grip strength vs. below). Stronger adjusted-grip strength correlated with better self-rated health, but only 2% of the total variance of adjusted-grip strength was explained by variance between the self-rated health categories. While self-rated health largely showed the expected socioeconomic gradients and positive relationships with health enhancing behaviours, adjusted-grip strength showed no clear, consistent associations with either socioeconomic or health behaviour variables. The results give caution about using grip strength as an objective alternative to self-rated health in studies of social inequalities in health. Empirical approaches demand careful considerations as to which dimensions of health and corresponding measures of health are most relevant to the context being studied. • Grip strength has emerged as a potential alternative to self-rated health. • Grip strength is a poor predictor of self-rated health. • Grip strength has no consistent association with socioeconomic status. • Grip strength has no consistent association with health behaviours. • Grip strength is not a better alternative to self-rated health. [ABSTRACT FROM AUTHOR]