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Background Compared with those with a higher socio-economic position (SEP), individuals with a lower SEP have higher cancer morbidity and mortality. However, the contribution of modifiable risk factors to these inequities is not known. This study aimed to quantify the mediating effects of modifiable risk factors to associations between SEP and cancer morbidity and mortality. Methods This study used a prospective observational cohort design. We combined eight cycles of the Canadian Community Health Survey (2000/2001–2011) as baseline data to identify a cohort of adults (≥35 years) without cancer at the time of survey administration (n = 309 800). The cohort was linked to the Discharge Abstract Database and the Canadian Mortality Database for cancer morbidity and mortality ascertainment. Individuals were followed from the date they completed the Canadian Community Health Survey until 31 March 2013. Dates of individual first hospitalizations for cancer and deaths due to cancer were captured during this time period. SEP was operationalized using a latent variable combining measures of education and household income. Self-reported modifiable risk factors, including smoking, excess alcohol consumption, low fruit-and-vegetable intake, physical inactivity and obesity, were considered as potential mediators. Generalized structural equation modelling was used to estimate the mediating effects of modifiable risk factors in associations between low SEP and cancer morbidity and mortality in the total population and stratified by sex. Results Modifiable risk factors together explained 45.6% of associations between low SEP and overall cancer morbidity and mortality. Smoking was the most important mediator in the total population and for males, accounting for 15.5% and 40.2% of the total effect, respectively. For females, obesity was the most important mediator. Conclusions Modifiable risk factors are important mediators of socio-economic inequities in cancer morbidity and mortality. Nevertheless, more than half of the variance in these associations remained unexplained. Midstream interventions that target modifiable risk factors may help to alleviate inequities in cancer risk in the short term. However, ultimately, upstream interventions that target structural determinants of health are needed to reduce overall socio-economic inequities in cancer morbidity and mortality.

Financial well-being describes when people feel able to meet their financial obligations, feel financially secure and are able to make choices that benefit their quality of life. Financial strain occurs when people are unable to pay their bills, feel stressed about money and experience negative impacts on their quality of life and health. In the face of the global economic repercussions of the COVID-19 pandemic, community-led approaches are required to address the setting-specific needs of residents and reduce the adverse impacts of widespread financial strain. To encourage evidence-informed best practices, a provincial health authority and community-engaged research centre collaborated to conduct a rapid review. We augmented the rapid review with an environmental scan and interviews. Our data focused on Western Canada and was collected prior to the pandemic (May–September 2019). We identified eight categories of community-led strategies to promote financial well-being: systems navigation and access; financial literacy and skills; emergency financial assistance; asset building; events and attractions; employment and educational support; transportation; and housing. We noted significant gaps in the evidence, including methodological limitations of the included studies (e.g. generalisability, small sample size), a lack of reporting on the mechanisms leading to the outcomes and evaluation of long-term impacts, sparse practice-based data on evaluation methods and outcomes, and limited intervention details in the published literature. Critically, few of the included interventions specifically targeted financial strain and/or well-being. We discuss the implications of these gaps in addition to possibilities and priorities for future research and practice. We also consider the results in relation to the COVID-19 pandemic and its economic consequences.

Objective:Increasing evidence links unhealthy food environments with diet quality and overweight/obesity. Recent evidence has demonstrated that relative food environment measures outperform absolute measures. Few studies have examined the interplay between these two measures. We examined the separate and combined effects of the absolute and relative densities of unhealthy food outlets within 1600 m buffers around elementary schools on children’s diet- and weight-related outcomes.Design:This is a cross-sectional study of 812 children from thirty-nine schools. The Youth Healthy Eating Index (Y-HEI) and daily vegetables and fruit servings were derived from the Harvard Food Frequency Questionnaire for Children and Youth. Measured heights and weights determined BMI Z-scores. Food outlets were ranked as healthy, somewhat healthy and unhealthy according to provincial paediatric nutrition guidelines. Multilevel mixed-effects regression models were used to assess the effect of absolute (number) and relative (proportion) densities of unhealthy food outlets within 1600 m around schools on diet quality and weight status.Setting:Two urban centres in the province of Alberta, Canada.Participants:Grade 5 students (10–11 years).Results:For children attending schools with a higher absolute number (36+) of unhealthy food outlets within 1600 m, every 10 % increase in the proportion of unhealthy food outlets was associated with 4·1 lower Y-HEI score and 0·9 fewer daily vegetables and fruit.Conclusions:Children exposed to a higher relative density of unhealthy food outlets around a school had lower diet quality, specifically in areas where the absolute density of unhealthy food outlets was also high.

Financial strain was an issue for many Canadians long before the arrival of the global novel coronavirus pandemic in early 2020. However, it has worsened in recent months in relation to the pandemic and public health measures put in place to prevent the spread of COVID-19. Members of underserved groups and people who experience poverty are particularly vulnerable to financial strain and its negative health impacts. As public health professionals, we should be concerned. In this commentary, we discuss the concept of financial strain and its health consequences and highlight how existing research in the area is falling short and why. We suggest next steps to guide research and practice related to financial strain such that it reflects the core values of public health, including equity, life course approaches, and the social determinants of health. This commentary is a call to action for public health researchers and practitioners in Canada to take a more prominent role in shaping the agenda on financial strain to support financial well-being for all.RéSUMé: De nombreux Canadiens subissaient une pression financière bien avant l’arrivée de la pandémie mondiale du nouveau coronavirus au début de 2020. Cette pression s’est toutefois aggravée ces derniers mois en raison de la pandémie et des mesures de santé publique mises en place pour prévenir la propagation de la COVID-19. Les membres des groupes mal desservis et les personnes aux prises avec la pauvreté sont particulièrement vulnérables à la pression financière et à ses effets néfastes sur la santé. En tant que professionnels de la santé publique, nous devrions nous en inquiéter. Dans notre commentaire, nous abordons la notion de pression financière et ses conséquences pour la santé et nous soulignons en quoi et pourquoi la recherche actuelle dans ce domaine n’est pas à la hauteur. Nous proposons des mesures pour orienter la recherche et la pratique liées à la pression financière afin qu’elles reflètent les valeurs fondamentales de la santé publique : l’équité, les approches axées sur la vie entière et les déterminants sociaux de la santé. Ce commentaire est un appel à l’action lancé aux chercheurs et aux praticiens en santé publique du Canada pour qu’ils jouent un plus grand rôle dans la définition des mesures à prendre face à la pression financière afin de favoriser le bien-être financier de tous.

Play is key to healthy childhood development, yet, there is growing international concern around decreasing opportunities for children to engage in unstructured, outdoor play. While municipalities ...

The suggestion that recreation needs to reaffirm historic values has become a common narrative throughout Canada’s contemporary recreation literature. A central assumption underlying these calls is...

The purpose of this paper is to analyze how the problem of exclusion and the solution of inclusion have been discursively produced within A Framework for Recreation in Canada 2015: Pathways to Well...

POINTS CLES Une etude connexe realisee par Campbell et ses collegues illustre adroitement la maniere dont les personnes qui ont vecu ou qui vivent des problemes de sante sont les mieux placees pour reveler et transmettre de facon evocatrice les conditions nuancees, circonstancielles

Objectif Évaluer, dans deux provinces canadiennes, l’appui du grand public et d’influenceurs en matière de politiques vis-à-vis de politiques de lutte contre le tabagisme à l’échelle de la population. Méthodologie En 2016, nous avons mis en oeuvre le sondage Prévention des maladies chroniques auprès d’un échantillon d’influenceurs (n = 302) et d’un échantillon aléatoire de la population (n = 2400) en Alberta et au Québec (Canada). Les participants ont exprimé leur degré d’appui vis-à-vis de diverses politiques de lutte contre le tabagisme, au moyen d’une échelle de type Likert dont les réponses ont été regroupées sous forme de pourcentages favorables nets. Le degré de soutien a ensuite été analysé à l’aide du codage de chaque politique au moyen de l’échelle d’intervention du Nuffield Council on Bioethics, afin de mieux définir le degré d’intrusion qu’elle représente par rapport aux libertés individuelles. Résultats Si les influenceurs comme le grand public ont évalué comme « extrêmement » ou « très » positives une grande majorité des politiques de lutte contre le tabagisme, l’avis des influenceurs en Alberta et au Québéc a divergé sur plus de la moitié des politiques, l’appui ayant été plus marqué au Québec. Les influenceurs comme le grand public ont exprimé un soutien solide à plusieurs politiques de lutte contre le tabagisme très intrusives (c.-à-d. les politiques ciblant les enfants et les jeunes et les nouveaux produits associés au tabagisme comme les cigarettes électroniques), malgré des effets escomptés sur les libertés individuelles. Ils ont fait preuve d’un soutien moins important aux politiques fiscales de lutte contre le tabagisme (c.-à-d. la taxation), malgré l’efficacité prouvée de telles politiques. Conclusion Dans l’ensemble, les influenceurs et le grand public se sont montrés très favorables à des politiques plus restrictives de lutte contre le tabagisme. Cette étude révèle quelles politiques reçoivent un appui unanime dans les deux groupes de population (de potentielles « victoires rapides » pour les défenseurs de la santé). Elle indique aussi pour quels sujets des efforts supplémentaires de sensibilisation sont nécessaires afin de mieux faire comprendre les avantages des politiques antitabac pour la santé des populations.

In recent years there has been an increase in the number of recreation and public health professionals calling for a common agenda to address physical inactivity. A major reason for this has been t...

Background: Attitudes and beliefs of policy influencers and the general public toward physical activity policy may support or impede population-level action, requiring improved understanding of aggregate preferences toward policies that promote physical activity. Methods: In 2016, the Chronic Disease Prevention Survey was administered to a census sample of policy influencers (n = 302) and a stratified random sample of the public (n = 2400) in Alberta and Québec. Using net favorable percentages and the Nuffield Council on Bioethics’ intervention ladder framework to guide analysis, the authors examined support for evidence-based healthy public policies to increase physical activity levels. Results: Less intrusive policy options (ie, policies that are not always the most impactful) tended to have higher levels of support than policies that eliminated choice. However, there was support for certain types of policies affecting influential determinants of physical activity such as the built environment (ie, provided they enabled rather than restricted choice) and school settings (ie, focusing on children and youth). Overall, the general public indicated stronger levels of support for more physical activity policy options than policy influencers. Conclusions: The authors’ findings may be useful for health advocates in identifying support for evidence-based healthy public policies affecting more influential determinants of physical activity.

Public health is critical to a healthy, fair, and sustainable society. Realizing this vision requires imagining a public health community that can maintain its foundational core while adapting and responding to contemporary imperatives such as entrenched inequities and ecological degradation. In this commentary, we reflect on what tomorrow’s public health might look like, from the point of view of our collective experiences as researchers in Canada who are part of an Applied Public Health Chairs program designed to support “innovative population health research that improves health equity for citizens in Canada and around the world.” We view applied public health research as sitting at the intersection of core principles for population and public health: namely sustainability, equity, and effectiveness. We further identify three attributes of a robust applied public health research community that we argue are necessary to permit contribution to those principles: researcher autonomy, sustained intersectoral research capacity, and a critical perspective on the research-practice-policy interface. Our intention is to catalyze further discussion and debate about why and how public health matters today and tomorrow, and the role of applied public health research therein.

Cities are increasingly home to the world's population. Creating healthy and vibrant cities is one way to positively contribute to the health of populations. Parks and green spaces in cities contribute many health benefits. This case study explored the perceived health and well-being effects of access to Natural Area Parks in Edmonton, Canada through photovoice interviews with 33 participants. The research found the wild aspects of the parks of particular importance. Critically, the therapeutic value of the park emerged from the totality of the experience rather than from its individual components. Access to wilderness increased opportunities for relaxation, deep connection, and reflection.

Summary Children are exposed to food environments that make nutrient-poor, energy-dense food cheap, readily available and heavily marketed; all conditions with potential negative impacts on diet and health. While the need for programmes and policies that improve the status of food environments is clear, greater public support is needed for governments to act. The purpose of this qualitative collective case study was to examine if community engagement in the Local Environment Action on Food (LEAF) project, a community-based food environment intervention in Alberta, Canada, could build public support and create action to promote healthy food environments. Semi-structured interviews with a purposeful sample of 26 stakeholders from 7 communities explored LEAF’s impact and stakeholder experiences creating change. Data collection and analysis were iterative, following Charmaz’s constant comparative analysis strategy. Participants reported environmental and community impacts from LEAF. Notably, LEAF created a context-specific tool, a Mini Nutrition Report Card, that communities used to promote and support food environment action. Further, analysis outlined perceived barriers and facilitators to creating community-level food environment action, including level of engagement in LEAF, perceived controllability, community priorities, policy enforcement and resources. Findings from this study suggest that community-based interventions, such as LEAF, can help build community capacity and reduce existing barriers to community-level food environment action. Thus, they can provide an effective method to build public awareness, demand and action for healthier food environments.

OBJECTIVES: Socioeconomic inequities in cardiovascular diseases (CVDs) are greater in females than males. However, the mechanisms underpinning the excess CVD risk conferred by low socioeconomic position (SEP) in females remain unclear. This study aimed to quantify the mediating effects of modifiable risk factors to associations between SEP and CVD morbidity and mortality. METHODS: We combined eight cycles of the nationally-representative cross-sectional Canadian Community Health Survey (2000–2011) to identify a cohort of adults (≥35 years) without CVD at the time of survey administration (n = 289,800). Survey data were linked to administrative health (Hospital Discharge Abstract Database) and mortality (Canadian Mortality Database) records for 2000–2012. SEP was captured by a latent variable consisting of self-reported educational level and household income. Self-reported modifiable risk factors, including smoking, physical inactivity, obesity, diabetes, and hypertension were considered as potential mediators. The outcome was CVD morbidity and mortality as reported in administrative health and mortality databases. Generalized structural equation modeling was used to estimate the mediating effects of modifiable risk factors in associations between SEP and CVD morbidity and mortality in males and females. RESULTS: The total effects of SEP on CVD morbidity and mortality were higher in females than in males. The modifiable risk factors mediated the higher proportion of the total effects in females than in males (87.80% vs 687.8%). Smoking was the most important mediator of associations between SEP and CVD morbidity and mortality for both males and females. The pathways linking SEP with obesity, diabetes and hypertension and subsequent CVD morbidity and mortality were significant in females but not among males. CONCLUSIONS: These findings revealed evidence of some sex-specific patterns in the mediating effects of modifiable risk factors on associations between SEP and CVD morbidity and mortality. The findings suggest that different strategies may be required to reduce inequities in CVD in males and females. FUNDING SOURCES: This study was funded by a Libin Cardiovascular Research Institute of Alberta Innovation Seed Grant and the Petro-Canada Young Innovator Award in Community Health.

International audience; The article "Why public health matters today and tomorrow: the role of applied public health research," written by Lindsay McLaren et al., was originally published Online First without Open Access.

Objectives School-based daily physical activity (DPA) policies represent a promising intervention for increasing physical activity levels among children. Between 2005 and 2010, five Canadian provinces adopted and implemented DPA policies. This national case study explored facilitators and challenges to developing, adopting and implementing DPA policies from the perspective of key stakeholders (‘policy-influencers’) in these five provinces. Methods Development, adoption and implementation of DPA policies at the provincial level was the phenomenon of interest, with each province constituting a distinct case. Semi-structured interviews were conducted with 15 purposively selected policy-influencers across the five case provinces. Cases were first analyzed separately, and then concurrently in a cross-case comparison. Qualitative content analysis was used to code interviews and develop themes. Results Four themes related to the development, adoption, and implementation of DPA policies emerged: existing resources and capacity for policy change; top-down policy development/adoption and bottom-up implementation; political will and windows of opportunity; and, ideology and policy change. Each of these themes encompassed facilitators and challenges related to policy processes surrounding development, adoption and implementation of DPA policies. Conclusion These findings can inform development of future health-related polices in schools. Stakeholders can, for instance, remain attuned to the opening of political windows and capitalize on them as an opportunity to advocate for policy change or create communities of practice to enhance coordination among policy stakeholders. Future studies that explore why other jurisdictions have failed to adopt DPA policies might yield novel insights regarding leverage points to support widespread diffusion of DPA policies., Highlights • Between 2005 and 2010, five Canadian provinces adopted and implemented DPA policies. • A national case study explored facilitators and challenges to adopting and implementing provincial DPA policies. • Four key themes related to policy change: capacity, adoption and implementation, political will, and ideology. • Recommendations can inform development and implementation of school-based physical activity and health promotion policy.

Free play, play controlled by the player(s), is an essential and positive determinant of children’s social, physical, and emotional health. Ensuring opportunities for dynamic free play in rich phys...

[See related article at [www.cmaj.ca/lookup/doi/10.1503/cmaj.202537][2]][2] KEY POINTS A related study by Campbell and colleagues deftly illustrates how people with lived or living experience of a health concern are in the best position to reveal and evocatively convey the nuanced, circumstantial

Introduction Les aliments malsains sont facilement accessibles dans les lieux publics au Canada, ce qui favorise les maladies chroniques liées au régime alimentaire, comme l’obésité. Cette réalité est préoccupante, car les établissements publics servent souvent une grande quantité d’aliments destinés à des groupes vulnérables, tels que les enfants et les personnes âgées. L’adoption de politiques sur l’approvisionnement en aliments sains, qui soutiennent l’achat, la distribution, la vente ou l’offre d’aliments plus sains, apparaît depuis peu comme une stratégie prometteuse pour contrer ce problème de santé publique, en rendant plus accessibles les aliments sains. De telles politiques n’ont cependant pas encore été adoptées à grande échelle au Canada, malgré les recommandations de nombreuses organisations canadiennes à vocation scientifique et du domaine de la santé. Méthodologie Afin d’étayer la prise de mesures stratégiques qui favoriseront l’approvisionnement en aliments sains au Canada, nous avons, en premier lieu, réalisé une synthèse des données probantes en vue d’évaluer les répercussions des politiques sur l’approvisionnement en aliments du point de vue des résultats sur la santé, ainsi que des ventes, de la consommation et de l’offre d’aliments plus sains. En second lieu, nous avons tenu une conférence de consensus en septembre 2014. Cette conférence, qui a réuni des experts en recherche sur la santé publique et les politiques nutritionnelles, ainsi que des professionnels de la santé et des services alimentaires, a permis l’étude des données probantes, la mise en commun des expériences et l’élaboration d’un énoncé de consensus et de recommandations sur l’approvisionnement en aliments sains au Canada. Résultats Cet article expose les constatations de la synthèse des données probantes et les recommandations consensuelles sur l’approvisionnement en aliments sains au Canada. Plus précisément, nous décrivons les recommandations qui s’adressent aux gouvernements, aux établissements publics, aux décideurs et aux professionnels, aux citoyens et aux chercheurs. Conclusion La mise en oeuvre de politiques sur l’approvisionnement en aliments sains, dans le cadre d'une politique alimentaire globale au Canada, peut accroître l’accès des Canadiens à des aliments plus sains.

Population ageing combined with physical inactivity has critical implications for the public health of communities in the twenty-first century. In the last decade, the World Health Organization launched the age-friendly cities agenda, aiming to address population ageing through whole-systems, rights-based, health equity-focused approaches. An important intervention for age-friendly communities is modifying built environments to support population-level physical activity. Physical activity can help mitigate impacts of chronic diseases and social isolation on older adults. Need for advocacy and action in this area raises questions of how to develop supportive environments for physical activity across age-friendly community types. In Canada, a substantial proportion of older adults live outside large urban municipalities, for which scant research exists on fostering age-friendly built environments. To this end, we conducted qualitative research involving semi-structured interviews with 21 municipal policy influencers in Alberta, Canada to gather perspectives on development and early implementation of an age-friendly policy framework in the small urban and rural context. Our findings are organised by three main themes providing key lessons for advocacy and action, namelypursuing comprehensive planning,promoting public engagementandprioritising the needs of older adults. This research informs advocacy and action priorities in promoting built environment modification for routine physical activity as part of an age-friendliness agenda for small urban and rural regions of Canada and other countries.

This review synthesized evidence from controlled studies pertaining to the impact of targeted policies on anthropometric, dietary and physical activity outcomes amongst socioeconomically disadvantaged children and adults. Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Equity guidelines were followed. Eligible studies were published from 2004 to August 2015 and examined the impact of targeted policies on anthropometric, dietary and physical activity outcomes amongst socioeconomically disadvantaged populations. Twenty articles (18 studies) were included. Eight studies examined organizational policies within multi-component interventions in schools. Common elements of successful policy-containing interventions included nutritional standards, enhancements to physical education, additional physical activity opportunities, school self-assessments, and nutrition and physical activity education. Of the 10 studies of government policies, policies providing information/education and fruit and vegetable subsidies had positive impacts amongst children, but no impact amongst adults. Policies involving changes to built environments yielded nearly uniformly null findings in children and adults. Overall, the largest quantity of high-quality evidence of effectiveness was for comprehensive interventions that included school policies, and government policies targeting disadvantaged children in schools. None of the government policies targeting disadvantaged adults proved effective. Interventions during childhood may ameliorate negative obesity-related manifestations of socioeconomic disadvantage. Gaps in knowledge remain surrounding effective policies in adults, adolescents and very young children.

Although alcohol consumption is considered a major modifiable risk factor for chronic disease, policies to reduce alcohol-related harm remain low on the Canadian policy agenda. The objective of this study was to understand support for population-level healthy public policies to reduce alcohol-related harm by assessing the attitudes of policy influencers and the public in two Canadian provinces, and by sociodemographic characteristics.A stratified sample of the general public (n = 2,400) and a census sample of policy influencers (n = 302) in Alberta and Quebec participated in the 2016 Chronic Disease Prevention Survey, which included questions to assess support for alcohol-specific policies. Differences in levels of support were determined by calculating differences in the proportion of support for alcohol control policies, comparing groups by regional and sociodemographic characteristics. The modified Nuffield Council on Bioethics Intervention Ladder was used to assess support according to the level of individual intrusiveness.We found that policy influencers and general public respondents were supportive of both information-based policies, with the exception of warning labels, and more restrictive policies targeting youth (e.g., enforcement). Both groups were less favorable to alcohol-specific policies that guided choice through disincentives (e.g., taxation). There were more differences in policy support by sociodemographic characteristics among the public.For health advocates to advance policies to reduce alcohol-related harms at the population level, they will need to mobilize additional support for more intrusive, yet more effective, policy interventions. Advocacy efforts should focus on communicating the effectiveness and positive outcomes of these interventions to help garner support.

To assess general public and policy influencer support for population-level tobacco control policies in two Canadian provinces.We implemented the Chronic Disease Prevention Survey in 2016 to a census sample of policy influencers (n = 302) and a random sample of members of the public (n = 2400) in Alberta and Quebec, Canada. Survey respondents ranked their support for tobacco control policy options using a Likert-style scale, with aggregate responses presented as net favourable percentages. Levels of support were further analyzed by coding each policy option using the Nuffield Council on Bioethics intervention ladder framework, to assess its level of intrusiveness on personal autonomy.Policy influencers and the public considered the vast majority of tobacco control policy options as "extremely" or "very" favourable, although policy influencers in Alberta and Quebec differed on over half the policies, with stronger support in Quebec. Policy influencers and the public strongly supported more intrusive tobacco control policy options, despite anticipated effects on personal autonomy (i.e. for policies targeting children/youth and emerging tobacco products like electronic cigarettes). They indicated less support for fiscally based tobacco control policies (i.e. taxation), despite these policies being highly effective.Overall, policy influencers and the general public strongly supported more restrictive tobacco control policies. This study further highlights policies where support among both population groups was unanimous (potential "quick wins" for health advocates). It also highlights areas where additional advocacy work is required to communicate the population-health benefit of tobacco control policies.Évaluer, dans deux provinces canadiennes, l’appui du grand public et d’influenceurs en matière de politiques vis-à-vis de politiques de lutte contre le tabagisme à l’échelle de la population.En 2016, nous avons mis en oeuvre le sondage Prévention des maladies chroniques auprès d’un échantillon d’influenceurs (n = 302) et d’un échantillon aléatoire de la population (n = 2400) en Alberta et au Québec (Canada). Les participants ont exprimé leur degré d’appui vis-à-vis de diverses politiques de lutte contre le tabagisme, au moyen d’une échelle de type Likert dont les réponses ont été regroupées sous forme de pourcentages favorables nets. Le degré de soutien a ensuite été analysé à l’aide du codage de chaque politique au moyen de l’échelle d’intervention du Nuffield Council on Bioethics, afin de mieux définir le degré d’intrusion qu’elle représente par rapport aux libertés individuelles.Si les influenceurs comme le grand public ont évalué comme « extrêmement » ou « très » positives une grande majorité des politiques de lutte contre le tabagisme, l’avis des influenceurs en Alberta et au Québéc a divergé sur plus de la moitié des politiques, l’appui ayant été plus marqué au Québec. Les influenceurs comme le grand public ont exprimé un soutien solide à plusieurs politiques de lutte contre le tabagisme très intrusives (c.-à-d. les politiques ciblant les enfants et les jeunes et les nouveaux produits associés au tabagisme comme les cigarettes électroniques), malgré des effets escomptés sur les libertés individuelles. Ils ont fait preuve d’un soutien moins important aux politiques fiscales de lutte contre le tabagisme (c.-à-d. la taxation), malgré l’efficacité prouvée de telles politiques.Dans l’ensemble, les influenceurs et le grand public se sont montrés très favorables à des politiques plus restrictives de lutte contre le tabagisme. Cette étude révèle quelles politiques reçoivent un appui unanime dans les deux groupes de population (de potentielles « victoires rapides » pour les défenseurs de la santé). Elle indique aussi pour quels sujets des efforts supplémentaires de sensibilisation sont nécessaires afin de mieux faire comprendre les avantages des politiques antitabac pour la santé des populations.Previous research has demonstrated that policy and environmental interventions are high-impact approaches to reducing smoking and tobacco consumption at the population level. Understanding the attitudes of policy influencers and members of the general public is essential, as their support can hinder or promote effective policy action. This study provides recent evidence on the attitudes of policy influencers and the public towards population-level tobacco control policies in two Canadian provinces. These findings will be useful for health advocates to identify policy areas where support is unanimous i.e. potential “quick wins”) as well as areas where support is weak or lacking consensus.Des recherches antérieures ont démontré que les interventions sous forme de politiques et au sein des milieux contribuaient grandement à la réduction, à l’échelle de la population, de la consommation du tabac (à fumer et sous ses autres formes). La compréhension des attitudes des influenceurs et du grand public est essentielle, car la mise en place de politiques efficaces sera difficile si leur appui est faible et sera facile si leur appui est vigoureux. Cette étude fait état de données récentes sur les attitudes des influenceurs et du grand public, dans deux provinces canadiennes, envers les politiques de lutte contre le tabagisme à l’échelle de la population. Ces données vont être utiles à la définition, par les promoteurs de la santé, des secteurs des politiques où l’appui est unanime (c.-à-d. les potentielles « victoires rapides ») et des secteurs où l’appui est faible ou inégal.

Background Socio-economically deprived children face a disproportionate burden of respiratory diseases. The association between area-level material and social deprivation and emergency department (ED) visits and hospitalisations for paediatric respiratory diseases has not been explored. Objectives We evaluated health inequalities in emergency department (ED) visits and hospitalisations for paediatric respiratory diseases according to material and social deprivation indexes. Methods This population-based retrospective cohort study deterministically linked birth, ED visits and hospitalisation data, and census-based, area-level deprivation indexes for all singleton children born in the province of Alberta, Canada, between 2005 and 2010 who had at least one recorded ED visit or hospitalisation for respiratory diseases in their first five years of life. We classified ED visits and hospitalisations for seven respiratory diseases by deprivation indexes. Concentration indexes (CInd) and area-level concentration curves measured health gradients across deprivation groups. Rate ratios (RR) evaluated associations between deprivation indexes and respiratory episodes of care. Results The study cohort included 198 572 newborns. The highest CInd were found in ED visits for other acute lower respiratory tract infections (oLRTI; CInd -0.22, 95% confidence interval [CI] -0.32, -0.12) and bronchiolitis (CInd -0.21, 95% CI -0.29, -0.12), and for pneumonia hospitalisations (CInd -0.23, 95% CI -0.33, -0.13). Croup ED visits had a low inequality degree. Compared to social deprivation, the material deprivation index presented a more consistent health gradient of increased episodes of care with increasing deprivation. oLRTI ED visits (RR 2.60, 95% CI 2.34, 2.92) and pneumonia hospitalisations (RR 2.57, 95% CI 2.31, 2.86) presented the largest inequalities between the least and most materially deprived groups. Conclusions We found a concentration of ED visits and hospitalisations for paediatric respiratory diseases in the most deprived groups. However, health inequalities are present across the material and social deprivation spectrum. Compared to the social deprivation index, the material index presented clearer paediatric respiratory health gradients.

OBJECTIVES: Morbidity and mortality from cardiovascular diseases (CVDs) are higher among individuals with a lower, compared to those with a higher socioeconomic position (SEP). However, the contribution of modifiable risk factors to these inequities is not known. This study aimed to examine whether and to what extent modifiable risk factors mediate associations between SEP and CVD morbidity and mortality in a nationally representative sample of Canadian adults. METHODS: We used a population-based prospective observational cohort design whereby participants who completed the Canadian Community Health Survey (2000–2011; n = 289,800) were followed longitudinally for CVD morbidity and mortality using administrative health and mortality data in the Discharge Abstract Database and the Canadian Mortality Database until 31 March 2013. Participants were included if they were at least 35 years of age and did not self-report CVD at the time of survey administration. The exposure of interest was SEP, which was measured as a latent variable consisting of annual household income and educational attainment. Potential mediators included smoking, physical inactivity, obesity, diabetes, and hypertension. The primary outcome of interest was CVD morbidity and mortality, which was defined as the first fatal or nonfatal CVD event that occurred during follow-up (6.2 years). Generalized structural equation modeling was used to test the mediating effects of modifiable risk factors in associations between SEP and CVD morbidity and mortality. RESULTS: SEP was associated with CVD morbidity and mortality. Modifiable risk factors mediated 80% of associations between SEP and CVD morbidity and mortality. Smoking was the most important mediator of these associations. Obesity mediated associations between SEP and CVD individually and jointly with diabetes or hypertension. CONCLUSIONS: These findings point to modifiable risk factors as potential targets for interventions to reduce inequities in CVD morbidity and mortality. Knowledge of pathways linking SEP with CVD is essential to inform targeted interventions to reduce socioeconomic inequities in CVD morbidity and mortality. FUNDING SOURCES: This study was funded by a Libin Cardiovascular Research Institute of Alberta Innovation Seed Grant and the Petro-Canada Young Innovator Award in Community Health.

Nutritional health of children and youth is an increasing cause for concern in Canada. Through food and beverage messaging in multiple environments, young people develop eating behaviours with ramifications throughout their life course. Unhealthy food retailers near schools, recreation facilities, and childcare centres—key activity settings for healthy eating promotion—present repeated, compounding exposures to commercial geomarketing. Geomarketing impacts nutritional health by promoting highly processed, calorie-dense, and nutrient-poor foods and beverages across urban landscapes. While food retail mix (as a ratio of healthy to unhealthy food retailers) can be used to assess food environments at multiple scales, such measures may misrepresent young people's unique experience of these geographic phenomena. Moving beyond uniform conceptualization of food environments, new research methods and tools are needed for children and youth. We investigated young people's food environments in the major Canadian cities of Calgary and Edmonton. Using government-initiated nutrition guidelines, we categorized 55.8% of all food retailers in Calgary, and 59.9% in Edmonton as ‘unhealthy’. A Bernoulli trial at the 0.05 alpha level indicated few differences in prevalence proximal to activity settings versus elsewhere in both cities, demonstrating the limited applicability of food retail mix for characterizing young people's food environments. To model unhealthy food retailers geomarketing to children and youth, we considered their proximity to multiple activity settings, using overlapping radial buffers at the 250 m, 500 m, 1000 m, and 1500 m scales. Examining young people's food environments relative to the spaces where they learn and play, we determined that as many as 895 out of 2663 unhealthy food retailers fell within 1500 m of 21+ activity settings. By conceptualizing, measuring, and problematizing these “super-proximal” unhealthy food retailers, urban planners and public health researchers can use these techniques to pinpoint unhealthy food retailers, or “weeds in the food swamp,” as a critical site for healthy eating promotion in municipalities., Highlights • Young people are exposed to food environments in proximity to their activity settings. • Nutrition guidelines for activity settings can be used to categorize food retailers. • Measures of food retail mix may not capture young people's exposure patterns. • Unhealthy food retailers can be super-proximal to multiple activity settings. • Evidence from two Canadian cities shows high prevalence of super-proximal exposures.

People's perceptions of local food environments influence their abilities to eat healthily. PhotoVoice participants from four communities in Alberta, Canada took pictures of barriers and opportunities for healthy eating and shared their stories in one-on-one semi-structured interviews. Using a socioecological framework, emergent themes were organized by type and size of environment. Findings show that, while availability and access to food outlets influence healthy eating practices, these factors may be eclipsed by other non-physical environmental considerations, such as food regulations and socio-cultural preferences. This study identifies a set of meta-themes that summarize and illustrate the interrelationships between environmental attributes, people's perceptions, and eating behaviors: a) availability and accessibility are interrelated and only part of the healthy eating equation; b) local food is synonymous with healthy eating; c) local food places for healthy eating help define community identity; d) communal dining (commensality) does not necessarily mean healthy eating; e) rewarding an achievement or celebrating special occasions with highly processed foods is socially accepted; f) food costs seemed to be driving forces in food decisions; g) macro-environmental influences are latent in food decisions. Recognizing the interrelationship among multiple environmental factors may help efforts to design effective community-based interventions and address knowledge gaps on how sociocultural, economic, and political environments intersect with physical worlds.

Walk Score® is a proprietary walkability metric that ranks locations by proximity to destinations, with emerging health promotion applications for increasing walking as physical activity. Currently, field validations of Walk Score® have only occurred in metropolitan regions of the United States; moreover, many studies employ an earlier Walk Score® version utilizing straight line distance. To address this gap, we conducted a field validation of the newest, network-based metric for three municipal types along a rural-urban continuum in Alberta, Canada. In 2015, using street-level systematic observations collected in Bonnyville, Medicine Hat, and North Central Edmonton in 2008 (part of the Community Health and the Built Environment (CHBE) project), we reverse engineered 2181 scores with the network Walk Score® algorithm. We computed means, 95% confidence intervals, and t-tests (α = 0.05) for both sets of scores. Applying the Clifford-Richardson adjustment for spatial autocorrelation, we calculated Spearman's Rank Correlation Coefficients (rho, rs) and adjusted p-values to measure the strength of association between the derived scores and original network scores provided by Walk Score®. Spearman's rho for scores were very high for Bonnyville (rs = 0.950, adjusted p, Highlights • Physical inactivity linked to chronic disease can be addressed by increasing walking. • Understanding walkability can support health promotion policies and interventions. • Walk Score provides a uniquely accessible and generalizable metric for walkability • Walk Score has been field validated in urban America but not internationally. • We validated Walk Score in Alberta, Canada using field observation and correlation.

This systematic review examined the impact of universal policies on socioeconomic inequities in obesity, dietary and physical activity behaviours among adults and children. PRISMA-Equity guidelines were followed. Database searches spanned from 2004 to August 2015. Eligible studies assessed the impact of universal policies on anthropometric, dietary or physical activity-related outcomes in adults or children according to socioeconomic position. Thirty-six studies were included. Policies were classified as agentic, agento-structural or structural, and their impact on inequities was rated as positive, neutral, negative or mixed according to the dominant associations observed. Most policies had neutral impacts on obesity-related inequities regardless of whether they were agentic (60% neutral), agento-structural (68% neutral) or structural (67% neutral). The proportion of positive impacts was similar across policy types (10% agentic, 18% agento-structural and 11% structural), with some differences for negative impacts (30% agentic, 14% agento-structural and 22% structural). The majority of associations remained neutral when stratified by participant population, implementation level and socioeconomic position measures and by anthropometric and behavioural outcomes. Fiscal measures had consistently neutral or positive impacts on inequities. Findings suggest an important role for policy in addressing obesity in an equitable manner and strengthen the case for implementing a broad complement of policies spanning the agency-structure continuum.

ObjectiveTo assess and compare the favourability of healthy public policy options to promote healthy eating from the perspective of members of the general public and policy influencers in two Canadian provinces.DesignThe Chronic Disease Prevention Survey, administered in 2016, required participants to rank their level of support for different evidence-based policy options to promote healthy eating at the population level. Pearson’sχ2significance testing was used to compare support between groups for each policy option and results were interpreted using the Nuffield Council on Bioethics’ intervention ladder framework.SettingAlberta and Québec, Canada.ParticipantsMembers of the general public (n2400) and policy influencers (n302) in Alberta and Québec.ResultsGeneral public and policy influencer survey respondents were more supportive of healthy eating policies if they were less intrusive on individual autonomy. However, in comparing levels of support between groups, we found policy influencers indicated significantly stronger support overall for healthy eating policy options. We also found that policy influencers in Québec tended to show more support for more restrictive policy options than their counterparts from Alberta.ConclusionsThese results suggest that additional knowledge brokering may be required to increase support for more intrusive yet impactful evidence-based policy interventions; and that the overall lower levels of support among members of the public may impede policy influencers from taking action on policies to promote healthy eating.

IntroductionLow-income populations have poorer diet quality and lower psychosocial well-being than their higher-income counterparts. These inequities increase the burden of chronic disease in low-income populations. Farmers’ market subsidies may improve diet quality and psychosocial well-being among low-income populations. In Canada, the British Columbia (BC) Farmers’ Market Nutrition Coupon Programme (FMNCP) aims to improve dietary patterns and health among low-income participants by providing coupons to purchase healthy foods from farmers’ markets. This study will assess the impact of the BC FMNCP on the diet quality and psychosocial well-being of low-income adults and explore mechanisms of programme impacts.Methods and analysisIn a parallel group randomised controlled trial, low-income adults will be randomised to an FMNCP intervention (n=132) or a no-intervention control group (n=132). The FMNCP group will receive 16 coupon sheets valued at CAD$21/sheet over 10–15 weeks to purchase fruits, vegetables, dairy, meat/poultry/fish, eggs, nuts and herbs at farmers’ markets and will be invited to participate in nutrition skill-building activities. Overall diet quality (primary outcome), diet quality subscores, mental well-being, sense of community, food insecurity and malnutrition risk (secondary outcomes) will be assessed at baseline, immediately post-intervention and 16 weeks post-intervention. Dietary intake will be assessed using the Automated Self-Administered 24-hour Dietary Recall. Diet quality will be calculated using the Healthy Eating Index-2015. Repeated measures mixed-effect regression will assess differences in outcomes between groups from baseline to 16 weeks post-intervention. Furthermore, 25–30 participants will partake in semi-structured interviews during and 5 weeks after programme completion to explore participants’ experiences with and perceived outcomes from the programme.Ethics and disseminationEthical approval was obtained from the University of Calgary Conjoint Health Research Ethics Board, Rutgers University Ethics and Compliance, and University of Waterloo Office of Research Ethics. Findings will be disseminated through policy briefs, conference presentations and peer-reviewed publications.Trial registration numberNCT03952338.

BackgroundChronic disease prevention and screening (CDPS) has been identified as a top priority in primary care. However, primary care providers often lack time, evidence-based tools, and consistent guidelines to effectively address CDPS. Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care (BETTER) is a novel approach that introduces a new role, that of the prevention practitioner; the prevention practitioner meets with patients, one on one, to undertake a personalised CDPS visit. Understanding patients’ perspectives is important for clinicians and other stakeholders aiming to address and integrate CDPS.AimTo describe patients’ perspectives regarding visits with a prevention practitioner in BETTER 2, an implementation study that was carried out after the BETTER trial and featured a higher proportion of patients in rural and remote locations.Design & settingQualitative description based on patient feedback surveys, completed by patients in three primary care clinics (urban, rural, and remote) in Newfoundland and Labrador, Canada.MethodPatients’ perspectives were assessed based on responses from 91 feedback forms. In total, 154 patients (aged 40–65 years) received ≥1 prevention visit(s) from a prevention practitioner and were asked to provide written feedback. In addition to demographics, patients were asked what they liked about their visit(s), what they would have liked to be different, and invited to make any other comments. Qualitative description was used to analyse the data.ResultsFour main themes emerged from patients’ feedback: value of visit (patients appreciated the visit with a prevention practitioner); visit characteristics (the visit was personalised, comprehensive, and sufficiently long); prevention practitioners' characteristics (professionalism and interpersonal skills); and patients’ concerns (termination of the programme and access to preventative care).ConclusionPatients appreciated the visits they received with a prevention practitioner and expressed their desire to receive sustained CDPS in primary care.

Health in all policies can address chronic disease morbidity and mortality by increasing population-level physical activity and healthy eating, and reducing tobacco and alcohol use. Both governmental and nongovernmental policy influencers are instrumental for health policy that modifies political, economic, and social environments. Policy influencers are informed and persuaded by coalitions that support or oppose changing the status quo. Empirical research examining policy influencers' contact with coalitions, as a social psychological exposure with health policy outcomes, can benefit from application of health communication theories. Accordingly, we analyzed responses to the 2014 Chronic Disease Prevention Survey for 184 Canadian policy influencers employed in provincial governments, municipalities, large workplaces, school boards, and the media. In addition to contact levels with coalitions, respondents' jurisdiction, organization, and ideology were analyzed as potential moderators. Calculating authority score centrality using network analysis, we determined health policy supporters to be more central in policy influencer networks, and theorized their potential to impact health policy public agenda setting via priming and framing processes. We discuss the implications of our results as presenting opportunities to more effectively promote health policy through priming and framing by coordinating coalitions across risk behaviors to advance a societal imperative for chronic disease prevention.

Purpose. To identify perceptions of how sociocultural environment enabled and hindered physical activity (PA) participation. Design. Community-based participatory research. Setting. Two semirural and two urban communities located in Alberta, Canada. Participants. Thirty-five people (74.3% females, 71.4% aged 25–64 years) across the four communities. Method. PhotoVoice activities occurred over 3 months during the spring of 2009. Participants were asked to document perceived environmental attributes that might foster or inhibit PA in their community. Photographs and narratives were shared in one-on-one interviews. Line-by-line coding of the transcripts was independently conducted by two researchers using an inductive approach. Codes were arranged into themes and subthemes, which were then organized into the Analysis Grid for Environments Linked to Obesity (ANGELO) framework. Results. Six main themes (accompanied by subthemes) emerged: sociocultural aesthetics, safety, social involvement, PA motivation, cultural ideas of recreation, and car culture. Representative quotes and photographs illustrate enablers and obstacles identified by participants. Conclusion. This PhotoVoice study revealed how aspects of participants' sociocultural environments shaped their decisions to be physically active. Providing more PA resources is only one step in the promotion of supportive environments. Strategies should also account for the beautification and maintenance of communities, increasing feelings of safety, enhancement of social support among community members, popularization of PA, and mitigating car culture, among others.