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Background: The onset of the COVID-19 pandemic drove a rapid and widespread shift to virtual care, followed by a gradual return to in-person visits. Virtual visits may offer more convenient access to care for some, but others may experience challenges accessing care virtually, and some medical needs must be met in-person. Experiences of the shift to virtual care and benefits of in-person care may vary by immigration experience (immigration status and duration), official language level, and age. We examined use of virtual care and return to in-person visits in the Canadian province of British Columbia (BC), comparing patterns by age and across immigration groups, including length of time in Canada and language level (official languages English and French) at time of arrival. Methods: We used linked administrative health and immigration data to examine total primary care visits (virtual or in-person) and return to in-person visits during the COVID-19 pandemic (2019/20–2021/2) in BC. We examined the proportion of people with any primary care visits and with any in-person visits within each year as measures of access to primary care. We estimated the odds of any primary care visits and any in-person visits by immigration group and official language level assessed prior to arrival: non-immigrants, long-term immigrants, recent immigrants (< 5 years) with high assessed official language level and recent immigrants (< 5 years) with low assessed official language level (assessed prior to arrival), stratified by age. Results: In general, changes in access to primary care (odds of any visits and odds of any in-person visits) were similar across immigration groups over the study period. However, we observed substantial disparities in access to primary care by immigration group among people aged 60 + , particularly in recent immigrants with low official language level (0.42, 0.40–0.45). These disparities grew wider over the course of the pandemic. Conclusion: Though among younger adults changes in access to primary care between 2019–2021 were similar across immigration groups, we observed significant and growing inequities among older adults, with particularly limited access among adults who immigrated recently and with low assessed official language level. Targeted interventions to ensure acceptable, accessible care for older immigrants are needed. [ABSTRACT FROM AUTHOR]

Background: Advance care planning (ACP) is a process which enables patients to communicate wishes, values, fears, and preferences for future medical care. Despite patient interest in ACP, the frequency of discussions remains low. Barriers to ACP may be mitigated by involving non-physician clinic staff, preparing patients ahead of visits, and using tools to structure visits. An ACP care pathway incorporating these principles was implemented in longitudinal generalist outpatient care, including primary care/family medicine and general internal medicine, in two Canadian provinces. This study aims to understand clinician experiences implementing the pathway. Methods: The pathway was implemented in one family practice in Alberta, two family practices in British Columbia (BC), and one BC internal medicine outpatient clinic. Physicians and allied health professionals delivered structured pathway visits based on the Serious Illness Conversation Guide. Twelve physicians and one social worker participated in interviews or focus groups at the end of the study period. Qualitative data were coded inductively using an iterative approach, with regular meetings between coders. Results: Clinicians described experiences with the ACP care pathway, impact at the clinician level, and impact at the patient level. Within each domain, clinicians described barriers and facilitators experienced during implementation. Clinicians also reflected candidly about potential for future implementation and the sustainability of the pathway. Conclusions: While the pathway was implemented slightly differently between provinces, core experiences were that implementation of the pathway, and integration with current practice, were feasible. Across settings, similar themes recurred regarding usefulness of the pathway structure and its tools, impact on clinician confidence and interactions with patients, teamwork and task delegation, compatibility with existing workflow, and patient preparation and readiness. Clinicians were supportive of ACP and of the pathway. Trial registration: The study was prospectively registered with clinicaltrials.gov (NCT03508557). Registered April 25, 2018. https://classic.clinicaltrials.gov/ct2/show/NCT03508557. [ABSTRACT FROM AUTHOR]

Introduction: The age of diagnosis is crucial for optimal health outcomes; however, some individuals with Autism Spectrum Disorder (ASD) may not be diagnosed until adulthood. Limited information is available about the lived experience of receiving a diagnosis during adulthood. Thus, we aimed to investigate stakeholders' experiences about the ASD diagnosis during adulthood. Method: We interviewed 18 individuals including 13 adults with ASD who had received a late diagnosis during adulthood and 5 parents of individuals with ASD from various Canadian provinces. Results: Using a thematic analysis, three main themes emerged: (a) noticing differences and similarities, (b) hindering elements to diagnosis, and (c) emotional response to diagnostic odyssey. Conclusion: This study adds to the literature about experiences of receiving ASD diagnosis in adulthood. Given the impact of diagnosis on individuals, it is important to minimize the barriers to ensure individuals who require ASD-related supports can access them in a timely and effective manner. This study highlights the importance of receiving an ASD diagnosis and facilitates positive health outcomes. The findings from the current study can be used to guide adult diagnostic processes and practices to help make ASD diagnosis more accessible. [ABSTRACT FROM AUTHOR]

Background: 'Syndemic' refers to socially produced, intertwined, and co-occurring epidemics. Syndemic theory is increasingly used to understand the population-level relationships between sexual health (including HIV) and mental health (including problematic substance use) epidemics. Syndemic-informed clinical interventions are rare.Methods: We therefore asked 22 sexual health practitioners from six sexual health clinics in British Columbia, Canada to define the word 'syndemic' and then asked how the theory related to their clinical practice.Results: Responses to syndemic theory ranged widely, with some practitioners providing nuanced and clinically informed definitions, others expressing a vague familiarity with the term, and others still having no prior knowledge of it. Where practitioners acknowledged the relevance of syndemic theory to their practice, they articulated specific ways in which syndemics create moral distress, that is, feeling that the most ethical course of action is different from what they are mandated to do. While some practitioners routinely used open-ended questions to understand the social and economic contexts of patients' sexual health needs, they described an uneasiness at potentially having surfaced concerns that could not be addressed in the sexual health clinic. Many observed persistent social, mental health, and substance use-related needs among their patients, but were unable to find feasible solutions to these issues.Conclusions: We therefore propose that interventions are needed to support sexual health practitioners in addressing psychosocial health needs that extend beyond their scope of practice, thereby reducing 'syndemic moral distress'. [ABSTRACT FROM AUTHOR]

Background: Strong primary care systems have been associated with improved health equity. Primary care system reforms in Canada may have had equity implications, but these have not been evaluated. We sought to determine if changes in primary care service use between 1999/2000 and 2017/2018 differ by neighbourhood income in British Columbia. Methods: We used linked administrative databases to track annual primary care visits, continuity of care, emergency department (ED) visits, specialist referrals, and prescriptions dispensed over time. We use generalized estimating equations to examine differences in the magnitude of change by neighbourhood income quintile, adjusting for age, sex/gender, and comorbidity, and stratified by urban/rural location of residence. We also compared the characteristics of physicians providing care to people living in low- and high-income neighbourhoods at two points in time. Results: Between 1999/2000 and 2017/8 the average number of primary care visits per person, specialist referrals, and continuity of care fell in both urban and rural settings, while ED visits and prescriptions dispensed increased. Over this period in urban settings, primary care visits, continuity, and specialist referrals fell more rapidly in low vs. high income neighbourhoods (relative change in primary care visits: Incidence Rate Ratio (IRR) 0.881, 95% CI: 0.872, 0.890; continuity: partial regression coefficient -0.92, 95% CI: -1.18, -0.66; specialist referrals: IRR 0.711, 95%CI: 0.696, 0.726), while ED visits increased more rapidly (IRR 1.06, 95% CI: 1.03, 1.09). The percentage of physicians who provide the majority of visits to patients in neighbourhoods in the lower two income quintiles declined from 30.6% to 26.3%. Conclusion: Results raise concerns that equity in access to primary care has deteriorated in BC. Reforms to primary care that fail to attend to the multidimensional needs of low-income communities may entrench existing inequities. Policies that tailor patterns of funding and allocation of resources in accordance with population needs, and that align accountability measures with equity objectives are needed as part of further reform efforts. [ABSTRACT FROM AUTHOR]

Background: Sex work criminalization and occupational stigma pose barriers to sex workers' access to support services, including community participation — engagement with sex work specific community organizing at both formalized and grassroots capacities. In light of gaps in evidence regarding impacts of community participation on sex workers' occupational health in higher-income settings, we evaluated engagement in community participation and associations with occupational sexual health outcomes among sex workers in Vancouver, Canada. Methods: Prospective data from a community-based cohort of 943 women sex workers in Vancouver, British Columbia (2010–2019). We used logistic regression with generalised estimating equations (GEE) to model correlates of community participation, and a confounder modeling approach to examine the association of community participation on sexually transmitted infection (STI) seropositivity. Results: Among participants, 38.1% were Indigenous, 31.4% identified as women of colour (e.g., East Asian, Southeast Asian, Black) and 29.3% were im/migrants to Canada. Over a quarter (28.3%, n = 267) serviced in informal indoor spaces, while 38.0% (n = 358) serviced clients in outdoor/public and 31.4% (n = 296) in formal in-call spaces. 8.9% of participants reported sex work community participation at least once over the 9-year study. In multivariable GEE analysis, Indigenous (adjusted odds ratio(aOR) 1.71, 95% confidence interval (CI) 0.88–3.32) and trans women (aOR 4.69, 95%CI 2.43–9.06) had higher odds of community participation; women of colour had lower odds (aOR 0.18, 95%CI 0.06–0.57). In a multivariable GEE confounder model, community participation was independently associated with lower odds of STI seropositivity (aOR 0.66, 95% CI0.45–0.96). Conclusion: Sex workers who engaged in sex work community participation faced reduced odds of STI seropositivity. Building off reserach evaluating community interventions in low and middle income contexts, our study provides some of the first quantitative evidence on community participation among sex workers in Canada, and is the first to examine this in relation to sexual health outcomes. This research demonstrates the need to scale up community participation access for sex workers, via linguistically diverse community spaces, anti-stigma initiatives, and decriminalization to reduce barriers faced by racialized sex workers and support occupational health and rights for all sex workers. [ABSTRACT FROM AUTHOR]

Objectives: Nurses are at a high risk of developing mental health problems due to exposure to work environment risk factors. Previous research in this area has only examined a few factors within nurses' work environments, and those factors were not conceptualized with the goal of improving workplace mental health. The purpose of this study is to identify the most important work environment predictors of nurse mental health using a comprehensive and theoretically grounded measure based on the National Standard of Psychological Health and Safety in the Workplace. Methods: This is an exploratory cross-sectional survey study of nurses in British Columbia, Canada. For this study, responses from a convenience sample of 4029 actively working direct care nurses were analyzed using random forest regression methods. Key predictors include 13 work environment factors. Study outcomes include depression, anxiety, post-traumatic stress disorder (PTSD), burnout and life satisfaction. Results: Overall, healthier reports of work environment conditions were associated with better nurse mental health. More specifically balance, psychological protection and workload management were the most important predictors of depression, anxiety, PTSD and emotional exhaustion. While engagement, workload management, psychological protection and balance were the most important predictors of depersonalization, engagement was the most important predictor of personal accomplishment. Balance, psychological protection and engagement were the most important predictors of life satisfaction. Conclusions: Routine assessment with standardized tools of nurses' work environment conditions and mental health is an important, evidence-based organizational intervention. This study suggests nurses' mental health is particularly influenced by worklife balance, psychological protection and workload management. [ABSTRACT FROM AUTHOR]

Background: We assessed the prevalence and trends in racial discrimination among African Canadian adolescents in British Columbia. The association between racial discrimination and self-rated health, access to mental health services, substance use, suicidal thoughts and attempts, experience of extreme stress, among others were examined within the 2018 dataset. Methods: Secondary analysis used the data collected from African Canadian adolescents (n = 2448) as part of the British Columbia Adolescent Health Surveys (2003–2018). We examined whether racial discrimination increased, decreased, or remained stable over time. We evaluated experiences of racial discrimination for all adolescents, and then disaggregated analyses for boys, girls, immigrant, and Canadian-born African adolescents. We used Rao-Scott's adjusted chi-square to test differences in racial discrimination and adjusted logistic regressions to test trends across survey years, widening or narrowing gaps in racial discrimination, as well as the link to health outcomes. Results: Racial discrimination was significantly different across the survey years (Adjusted F = 4.60, p <.01), with the highest percentage of adolescents reporting past year racial discrimination in 2018 (29.9%) and the lowest percentage in 2013 (21.3%). Girls and immigrant African Canadian adolescents were more likely to have experienced racial discrimination. However, girls and Canadian-born adolescents had the highest odds of reporting racial discrimination in 2018 compared to 2003, AOR = 1.85, and 1.58, respectively. The findings reveal significant differences in the experiences of racial discrimination for boys and girls, as well as for immigrant and Canadian-born African adolescents. Significant differences were noted in the link between racial discrimination and self-rated health and engaging in behaviours that might expose them to health risks. The worst negative health outcomes were found for boys and immigrant African Canadian adolescents. Conclusion: The study suggests that more than 1 in 4 African Canadian adolescents in British Columbia report racial discrimination, which is an increasing trend in recent years. Those who reported racial discrimination also had the worst adverse health outcomes. There is a need for more public health action to reduce racism, create awareness about the negative health impacts, and provide better support for African Canadian adolescents. [ABSTRACT FROM AUTHOR]

Background: Our objective was to explore intentional injury disparity between Indigenous populations and the total population in the province of British Columbia (BC), Canada. We focus on hospitalizations, including both self-inflicted injuries and injuries inflicted by others. Methods: We used data from BC's universal health care insurance plan, 1991 to 2010, linked to Vital Statistics databases. Indigenous people were identified through the insurance premium group, and birth and death records. Place of residence was identified through postal code. We calculated crude hospitalization incidence rates and the Standardized Relative Risk (SRR) of hospitalization, standardized by gender, 5-year age group, and Health Service Delivery Area (HSDA). With HSDA populations as the units of observation, linear regression was used to test hypothesized associations of Indigenous ethnicity, geographic, and socio-economic characteristics with SRR of injury. Results: During the period 1991-2010, the crude rate of hospitalization for intentional injuries was 8.4 per 10,000 person-years (95% confidence interval (CI): 8.3 to 8.5) for the total BC population, compared to 45.3 per 10,000 (95% CI: 44.5 to 46.1) for the Indigenous population. For both populations, risk declined over the period for injuries self-inflicted and inflicted by others. The linear regression model predicts that the off-reserve Indigenous population will have SRR of intentional injury 3.98 greater, and the on-reserve Indigenous population 4.17, greater than the total population. The final model was an excellent fit (R² = 0.912, F = 177.632, p < 0.001), and found that three variables - occupational risk, high school diploma, and university degree - each provide independent effects when interacting multiplicatively with Indigenous ethnicity. Conclusions: The observation of substantially declining rates of intentional injury for both the Indigenous and total BC populations is off-set by the high disparity in risk between the two populations, which will likely continue until Canada reduces disparity with respect to discriminatory practices, and physical, social, and economic conditions. [ABSTRACT FROM AUTHOR]

Background: Children diagnosed with cancer often require extensive care for medical, psychosocial and educational problems during and after therapy. Part of this care is provided by family physicians and non-cancer specialists, but their involvement in the first years after diagnosis has barely been studied. Studying non-oncology physician visits may provide insight into the roles of different health care providers. Methods: We included 757 children diagnosed with cancer under age 15 between 1991 and 2001 from a Canadian provincial registry, and matched each to 10 controls of the same birth year and sex. We determined the number of family physician and non-cancer specialist visits in the 5 years after diagnosis (for patients) or inclusion (for controls) using data from the provincial health insurance plan. Results: In the first year after diagnosis, almost all patients visited both a family physician and non-cancer specialist. Although after 5 years percentages decreased to 85 and 76 %, respectively, these were still significantly higher than in controls. In the first year after diagnosis, both family physicians and non-cancer specialists were often consulted for neoplasms (62 and 90 %, respectively) and to discuss results of lab tests. In addition, family physicians were often consulted for general symptoms and non-cancer specialists for nervous system problems and complications of medical care. Conclusions: Family physicians and non-cancer specialists are highly involved in the care for children with cancer in the first years after diagnosis, including for health problems related to cancer or its treatment. This necessitates good communication among all physicians. [ABSTRACT FROM AUTHOR]

Background: Because little is known about food insecurity in people with mental health conditions, we investigated relationships among food insecurity, nutrient intakes, and psychological functioning in adults with mood disorders. Methods: Data from a study of adults randomly selected from the membership list of the Mood Disorder Association of British Columbia (n = 97), Canada, were analyzed. Food insecurity status was based on validated screening questions asking if in the past 12 months did the participant, due to a lack of money, worry about or not have enough food to eat. Nutrient intakes were derived from 3-day food records and compared to the Dietary Reference Intakes (DRIs). Psychological functioning measures included Global Assessment of Functioning, Hamilton Depression scale, and Young Mania Rating Scale. Using binomial tests of two proportions, Mann-Whitney U tests, and Poisson regression we examined: (1) food insecurity prevalence between the study respondents and a general population sample from the British Columbia Nutrition Survey (BCNS; n = 1,823); (2) differences in nutrient intakes based on food insecurity status; and (3) associations of food insecurity and psychological functioning using bivariate and Poisson regression statistics. Results: In comparison to the general population (BCNS), food insecurity was significantly more prevalent in the adults with mood disorders (7.3% in BCNS vs 36.1%; p < 0.001). Respondents who were food-insecure had lower median intakes of carbohydrates and vitamin C (p < 0.05). In addition, a higher proportion of those reporting food insecurity had protein, folate, and zinc intakes below the DRI benchmark of potential inadequacy (p < 0.05). There was significant association between food insecurity and mania symptoms (adjusted prevalence ratio = 2.37,95% Cl 1.49-3.75, p< 0.05). Conclusions: Food insecurity is associated with both nutritional and psychological health in adults with mood disorders. Investigation of interventions aimed at food security and income can help establish its role in enhancing mental health. [ABSTRACT FROM AUTHOR]

Background: Some patients receiving treatment in conventional health care systems access therapeutic yoga outside their mainstream care to improve cancer symptoms. Given the current knowledge gap around patient preferences and documented experiences of yoga in adult cancer, this study aimed to describe patient-reported benefits, barriers and characteristics of programming for yoga practice during conventional treatment. Methods: In depth semi-structured interviews (n = 10) were conducted in men and women recruited from cancer care clinics in Vancouver, Canada using a purposive sampling technique. The exploratory interviews were audio-recorded, transcribed and analyzed using Interpretive Description methodology and constant comparative analysis methods. Results: Four themes emerged from the data to address our research objectives: patient-perceived benefits of yoga, reasons and motivations for practising yoga, hurdles and barriers to practising yoga, and advice for effective yoga program delivery in adult cancer. Several patients reported yoga reduced stress and other symptoms associated with cancer treatment. Thematic analysis found the social dimension of group yoga was important, as well as yoga's ability to encourage personal empowerment and awareness of physical body and self. Barriers to yoga adherence from the patient perspective included lack of time, scheduling conflicts and worries about financial burden. Conclusion: This small, diverse sample of patients reported positive experiences and no adverse effects following yoga practice for management of cancer and its symptoms. Results of this qualitative study identified patient-reported preferences, barriers and characteristics of yoga intervention optimal during adult cancer treatment. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to determine whether general practitioner visits for alcohol-attributed diseases increased in a decade when several regulatory changes were made to the distribution and price of alcohol in British Columbia Canada. Methods: General practitioner consultations for alcohol-attributed diseases were examined using data from British Columbia’s Medical Services Plan database. Negative binomial regression was used to measure the significance of yearly variations using incidence rate ratios by disease type per year. Results: From 2001 to 2011, 690,401 visits were made to general practitioners by 198,623 persons with alcoholattributed diseases. Most visits (86.2%) were for alcohol dependency syndrome (N = 595,371). General practitioner visits for alcohol-attributed diseases increased significantly (p < .001) by 53.3% from 14,882 cases in 2001 to 22,823 cases in 2011. While the number of cases increased from 2001-2011, the frequency of visits to general practitioners significantly decreased from 3.9 in 2001 to 2.7 visits per case in 2011 (F = 428.1, p < .001). Conclusion: From 2001 to 2011 there were significant increases in the number of persons presenting to general practitioners with alcohol-attributed diseases in British Columbia. The results of this study demonstrate the need to provide enhanced support to general practitioners in the treatment of patients with substance use disorders given the increasing number of primary health care patients with alcohol-attributed diseases. [ABSTRACT FROM AUTHOR]

Background The use of palliative radiotherapy (PRT) is variable in advanced cancer. Little is known about PRT utilization by end-of-life (EOL) cancer patients in Canada. This study examined the PRT utilization rates and factors associated with its use in a cohort of cancer patients who died in British Columbia (BC). Methods BC residents with invasive cancer who died between April 1, 2010 and March 31, 2011 were included in the study. Their cancer registry and radiotherapy treatment records were extracted from the BC Cancer Agency information systems and linked for the analysis. The PRT utilization rates by age, sex, primary cancer diagnosis, geographic region, survival time and travel time to the cancer centre were examined. Multivariable logistic regression was used to determine the factors that influenced the PRT utilization rates. Results Of the 12,300 decedents in the study 2,669 (21.7%) had received at least one course of PRT in their last year of life. The utilization rates dropped to 5.0% and 2.2% in the last 30 and 14 days of life, respectively. PRT utilization varied across diagnosis and was highest for lung cancer (45.7%) and lowest for colorectal cancer (8.9%). The rates also varied by age, survival time and travel time to the nearest radiotherapy centre. There was a greater odds of receiving PRT for those with primary lung cancer, survival time between 1.5-26 months from diagnosis or living within 2 hours from a cancer centre. The 85+ age group was least likely to receive PRT in their last year of life. Conclusions This study found PRT utilization rates of EOL cancer decedents to be variable across the province of BC. Age, diagnosis, survival time and travel time to the nearest radiotherapy centre were found to influence the odds of PRT treatment. Further work is still needed to establish the appropriate PRT utilization rates for the EOL cancer population. [ABSTRACT FROM AUTHOR]

Background High rates of childhood obesity have generated interest among policy makers to improve the school food environment and increase students' levels of physical activity. The purpose of this study was to examine school-level changes associated with implementation of the Food and Beverage Sales in Schools (FBSS) and Daily Physical Activity (DPA) guidelines in British Columbia, Canada. Methods Elementary and middle/high school principals completed a survey on the school food and physical activity environment in 2007-08 (N = 513) and 2011-12 (N = 490). Hierarchical mixed effects regression was used to examine changes in: 1) availability of food and beverages; 2) minutes per day of Physical Education (PE); 3) delivery method of PE; and 4) school community support. Models controlled for school enrollment and community type, education and income. Results After policy implementation was expected, more elementary schools provided access to fruits and vegetables and less to 100% fruit juice. Fewer middle/high schools provided access to sugar-sweetened beverages, French fries, baked goods, salty snacks and chocolate/candy. Schools were more likely to meet 150 min/week of PE for grade 6 students, and offer more minutes of PE per week for grade 8 and 10 students including changes to PE delivery method. School community support for nutrition and physical activity policies increased over time. Conclusion Positive changes to the school food environment occurred after schools were expected to implement the FBSS and DPA guidelines. Reported changes to the school environment are encouraging and provide support for guidelines and policies that focus on increasing healthy eating and physical activity in schools. [ABSTRACT FROM AUTHOR]

Background: The goal of the study was to assess perceived level of satisfaction with end-of-life care, focusing on the last 48 hours of life. Methods: A previously validated instrument was used in a telephone survey with bereaved family members (n=90) of patients who died within an organization in British Columbia. Results: Bereaved family members had many unmet needs for information about the patient's changing condition, the process of dying, how symptoms would be managed and what to do at the time of death. In addition, many bereaved relatives felt that the patient or resident had an unmet need for emotional support and that their own emotional needs were not addressed adequately. The last place of care had the most significant effect on all of these variables, with acute care and residential care having the most unmet needs. Hospice had the fewest unmet needs, followed by the palliative and the intensive care units. Conclusions: We discuss these findings in relation to overall satisfaction with care, focus on individual, ethnocultural and diversity issues, information and decision-making, symptom management and attending to the family. We conclude by offering possible practices address the end-of-life needs of patients and family members. [ABSTRACT FROM AUTHOR]

Background: As Canada's population ages, the location of end of life care (whether at home, extended care facility or hospital) may change depending on the location of death. We carried out a study to identify determinants of the place of death. Methods: Data on deaths in British Columbia between 2004 and 2008 were obtained from the Vital Statistics Agency. Place of death was categorized into home, extended care facility, hospital or other. Logistic regression analyses were used to estimate the effects of age, sex, marital status, residence, place of birth and cause of death on place of death using adjusted odds ratios and 95% confidence intervals (95% CI). Results: Of the 153,111 deaths in the study, 16.5% occurred at home, 29.0% in extended care, 51.0% in hospital and 3.5% occurred elsewhere. Male deaths were less likely to occur in extended care as compared with female deaths (odds ratio 0.73, 95% CI 0.71-0.75). Age (odds ratio 3.31, 95% CI 3.19-3.45 for those for ≥90 vs 70-79 years), marital status (odds ratio 1.42, 95% CI 1.38-1.47 widowed vs married), residence (odds ratio 0.80, 95% CI 0.76-0.83 rural vs Vancouver), place of birth (odds ratio 0.80, 95% CI 0.75-0.86 China vs Canada) and cause of death (odds ratio 3.91, 95% CI 3.69-4.13 dementia vs cancer) were also associated with death in extended care. Conclusions: Information on determinants of place of death can inform public health policy regarding care at the end of life and make resource allocation more efficient. [ABSTRACT FROM AUTHOR]

Background: Transitioning to parenthood is a major life event that may impact parents’ personal lifestyles, yet there is an absence of theory-based research examining the impact of parenthood on motives for dietary behaviour. As a result, we are unaware of the social cognitive variables that predict eating behaviour among those transitioning to parenthood. The purpose of the study was to examine eating behaviour motives across 12 months within the framework of the theory of planned behavior (TPB) and compare these across groups of new parents, non-parents, and established parents. Methods: Non-parents (n = 92), new parents (n = 135), and established parents (n = 71) completed TPB questionnaires assessing attitudes, subjective norms, perceived behavioral control (PBC), and intentions and three day food records at baseline, and 6- and 12-months post-delivery (for parents) and 6- and 12-months post-baseline (for non-parents). Results: Repeated measures ANOVAs revealed that among men, new- and established-parents had greater intentions to eat healthy compared to non-parents, F(2) = 3.59, p = .03. Among women, established parents had greater intentions than new- and non-parents, F(2) = 5.33, p = .01. Among both men and women during the first 6-months post-delivery, new-parents experienced decreased PBC, whereas established parents experienced increased PBC. Overall, affective attitudes were the strongest predictor of intentions for men (β = 0.55, p < .001) and women (β = 0.38, p < .01). PBC predicted changes in fruit and vegetable consumption for men (β = 0.45, p = .02), and changes in fat consumption for men (β = −0.25, p = .03) and women (β = −.24, p < .05), regardless of parent status. Conclusion: The transition to parenthood for new and established parents may impact motivation for healthy eating, especially PBC within the framework of TPB. However, regardless of parental status, affective attitudes and PBC are critical antecedents of intentions and eating behaviour. Interventions should target affective attitudes and PBC to motivate healthy eating and may need to be intensified during parenthood. [ABSTRACT FROM AUTHOR]

Background: The school food environment is important to target as less healthful food and beverages are widely available at schools. This study examined whether the availability of specific food/beverage items was associated with a number of school environmental factors. Methods: Principals from elementary (n = 369) and middle/high schools (n = 118) in British Columbia (BC), Canada completed a survey measuring characteristics of the school environment. Our measurement framework integrated constructs from the Theories of Organizational Change and elements from Stillman's Tobacco Policy Framework adapted for obesity prevention. Our measurement framework included assessment of policy institutionalization of nutritional guidelines at the district and school levels, climate, nutritional capacity and resources (nutritional resources and participation in nutritional programs), nutritional practices, and school community support for enacting stricter nutritional guidelines. We used hierarchical mixed-effects logistic regression analyses to examine associations with the availability of fruit, vegetables, pizza/hamburgers/hot dogs, chocolate candy, sugar-sweetened beverages, and french fried potatoes. Results: In elementary schools, fruit and vegetable availability was more likely among schools that have more nutritional resources (OR = 6.74 and 5.23, respectively). In addition, fruit availability in elementary schools was highest in schools that participated in the BC School Fruit and Vegetable Nutritional Program and the BC Milk program (OR = 4.54 and OR = 3.05, respectively). In middle/high schools, having more nutritional resources was associated with vegetable availability only (OR = 5.78). Finally, middle/high schools that have healthier nutritional practices (i.e., which align with upcoming provincial/state guidelines) were less likely to have the following food/ beverage items available at school: chocolate candy (OR = .80) and sugar-sweetened beverages (OR = .76). Conclusions: School nutritional capacity, resources, and practices were associated with the availability of specific food/beverage items in BC public schools. Policies targeting the school environment are increasingly being considered as one of the strategies used to address childhood obesity, as a result it is important to further understand the factors associated with the availability of specific food/beverage items at school. [ABSTRACT FROM AUTHOR]

Background: Transformational leadership is conceptualized as a set of behaviors designed to inspire, energize and motivate others to achieve higher levels of functioning, and is associated with salient health-related outcomes in organizational settings. Given (a) the similarities that exist between leadership within organizational settings and parenting within families, and (b) the importance of the family environment in the promotion of adolescent healthenhancing behaviors, the purpose of this exploratory study was to examine the cross-sectional relationships between parents' transformational leadership behaviors and adolescent dietary and physical activity behaviors. Methods: 857 adolescents (aged 13-15, mean age = 14.70 yrs) completed measures of transformational parenting behaviors, healthful dietary intake and leisure-time physical activity. Regression analyses were conducted to examine relationships between family transformational leadership and adolescent health outcomes. A further 'extreme group analysis' was conducted by clustering families based on quartile splits. A MANCOVA (controlling for child gender) was conducted to examine differences between families displaying (a) HIGH levels of transformational parenting (consistent HIGH TP), (b) LOW levels of transformational parenting (consistent LOW TP), and (c) inconsistent levels of transformational parenting (inconsistent HIGH-LOW TP). Results: Results revealed that adolescents' perceptions of family transformational parenting were associated with both healthy dietary intake and physical activity. Adolescents who perceived their families to display the highest levels of transformational parenting (HIGH TP group) displayed greater healthy eating and physical activity behaviors than adolescents who perceived their families to display the lowest levels of transformational parenting behaviors (LOW TP group). Adolescents who perceived their families to display inconsistent levels of transformational parenting behaviors (HIGH-LOW TP group) displayed the same levels of healthy eating behaviors as those adolescents from the LOW TP group. For physical activity behaviors, adolescents who perceived their families to display inconsistent levels of transformational parenting behaviors (HIGH-LOW TP group) did not differ in terms of physical activity than those in either the HIGH TP or LOW TP group. Conclusions: Family transformational parenting behaviors were positively associated with both healthful dietary intake and leisure-time physical activity levels amongst adolescents. The findings suggest that transformational leadership theory is a useful framework for understanding the relationship between family leadership behaviors and adolescent health outcomes. [ABSTRACT FROM AUTHOR]

Retrenchment of government services has occurred across a wide range of sectors and regions. Care services, in particular, have been clawed away in the wake of fiscal policies of cost containment and neoliberal policies centred on individual responsibility and market autonomy. Such policies have included the deinstitutionalisation of care from hospitals and clinics, and early discharge from hospital, both of which are predicated on the notion that care can be provided informally within families and communities. In this paper we examine the post-birth "care crisis" that new mothers face in one region of Canada. Method: The data are drawn from a larger study of social determinants of pregnant and new mothers' health in Victoria, Canada. Mixed methods interviews were conducted among a purposive sample of women at three points in time. This paper reports data on sample characteristics, length of stay in hospital and health service gaps. This data is contextualised via a more in-depth analysis of qualitative responses from Wave 2 (4-6 weeks postpartum). Results: Out results show a significant portion of participants desired services that were not publically available to them during the post-birth period. Among those who reported a gap in care, the two most common barriers were: cost and unavailability of home care supports. Participants' open-ended responses revealed many positive features of the public health care system but also gaps in services, and economic barriers to receiving the care they wanted. The implications of these findings are discussed in relation to recent neoliberal reforms. Discussion & conclusions: While Canada may be praised for its public provision of maternity care, mothers' reports of gaps in care during the early postpartum period and increasing use of private doulas is a worrying trend. To the extent that individual mothers or families rely on the market for care provision, issues of equity and quality of care are pivotal. This paper concludes with suggestions for further research on the impact of recent changes in post-birth care on new fathers and on inequities in pre and post-birth care in less-resourced regions of the world. [ABSTRACT FROM AUTHOR]

Background: Unattached patients do not have a regular primary care provider. Initiatives are being developed to increase attachment rates across Canada. Most existing attention paid to patient unattachment has focused on quantifying the problem and health system costs. Our purpose is to qualitatively identify the implications of chronically ill patients' experiences of unattachment for health policy and planning to provide policy-relevant insights for Canadian attachment initiatives. Methods: Three focus groups were conducted with marginalized chronically ill individuals residing in a mid-sized city in British Columbia who are unattached to a family doctor. We use the term marginalized as a descriptor to acknowledge that by virtue of their low socio-economic status and lack of attachment the participants are marginalized in Canada's health care system Focus groups were structured as an open conversation organized around a series of probing questions. They were digitally recorded and transcribed verbatim. Thematic analysis was employed. Results: Twenty-six individuals participated in the focus groups. The most common chronic illnesses reported were active drug addiction or recovery (and their associated symptoms), depression, arthritis, and hepatitis C. Participants identified life transitions as being the root cause for not having a family doctor. There was a strong sense that unsuccessful attempts to get a family doctor reflected that they were undesirable patients. Participants wanted to experience having a trusting relationship with a regular family doctor as they believed it would encourage greater honesty and transparency. One of the main health concerns regarding lack of access to a regular family doctor is that participants lacked access to preventative care. Participants were also concerned about having a discontinuous medical record due to unattachment. Conclusions: Participants perceived that there are many benefits to be had by having attachment to a regular family doctor and that experiencing unattachment challenged their health and access to health care. We encourage more research to be done on the lived experience of unattachment in order to provide on-the-ground insights that policy-makers require in order to develop responsive, patient-centred supports and programs. [ABSTRACT FROM AUTHOR]

Background: Pregnant girls/young women and new mothers living in situations of social and economic disadvantage are at increased risk for poor health. Rural living may compound marginalization and create additional challenges for young mothers. Public health nurses (PHNs) delivering the Nurse-Family Partnership (NFP) to mothers living in rural communities may help to improve maternal and child health outcomes. The purpose of this analysis, grounded in data collected as part of a broader process evaluation, was to explore and understand the influence of rural geography on the delivery of NFP in British Columbia, Canada. Methods: For the analysis of this qualitative data, principles of inductive reasoning based on the methodology of interpretive description were applied. A total of 10 PHNs and 11 supervisors providing the NFP program in rural communities were interviewed. Results: The results of this analysis reflect the factors and challenges of providing the NFP program in rural communities. PHNs noted the importance of NFP in the lives of their rural clients, especially in the face of extreme financial and social disparity. Remaining flexible in their approach to rural nursing and protecting time to complete NFP work supported nurses practicing in rural environments. Rural PHNs were often the sole NFP nurse in their office and struggled to remain connected to their supervisors and other NFP colleagues. Challenges were compounded by the realities of rural geography, such as poor weather, reduced accessibility, and long travel distances; however, these were considered normal occurrences of rural practice by nurses. Conclusions: PHNs and NFP supervisors are well-positioned to identify the modifications that are required to support the delivery of NFP in rural geography. NFP nurses need to articulate what classifies as rural in order to effectively determine how to best provide services to these populations. Environmental conditions must be considered when offering NFP in rural communities, particularly if they impact the time required to deliver the program and additional services offered to young mothers. Regular NFP meetings and education opportunities address common problems associated with rural nursing but could be enhanced by better use of technology. [ABSTRACT FROM AUTHOR]