Associations between socioeconomic status and pregnancy outcomes: a greater magnitude of inequalities in perinatal health in Montreal than in Brussels.

BACKGROUND: Comparing health inequalities between countries helps us to highlight some factors specific to each context that contribute to these inequalities, thus contributing to the identification of courses of action likely to reduce them. This paper compares the associations between socioeconomic status (SES) and 1) low birth weight (LBW) and 2) preterm birth, in Brussels and Montreal (in general population, natives-born mothers, and immigrant mothers). METHODS: A population-based study examining associations between SES and pregnancy outcomes was conducted in each city, using administrative databases from Belgian and Quebec birth records (N = 97,844 and 214,620 births in Brussels and Montreal, respectively). Logistic regression models were developed in order to estimate the relationship between SES (maternal education and income quintile) and pregnancy outcomes, in each region. The analyses were first carried out for all births, then stratified according to the mother's origin. RESULTS: For the general population, SES is associated with LBW and preterm birth in both regions, except for income and preterm birth in Brussels. The association is stronger for mothers born in Belgium and Canada than for those born abroad. The main difference between the two regions concerns the magnitude of inequalities in perintal health, which is greater in Montreal than in Brussels among the general population. For native-born mothers, the magnitude of inequalities in perinatal health is also greater for mothers born in Canada than for those born in Belgium, except for the association between income and preterm birth. The socioeconomic gradient in perinatal health is less marked among immigrant mothers than native mothers. CONCLUSION: Significant differences in inequalities in perinatal health are observed between Brussels and Montreal. These differences can be explained by : on the one hand, the existence of greater social inequalities in Montreal than in Brussels and, on the other hand, the lower vulnerability of immigrants with low SES in Brussels. Future studies seeking to understand the mechanisms that lead to inequalities in health in different contexts should take into account a comparison of immigration and poverty contexts, as well as the public policies related to these factors.

Social inequalities in breast cancer screening: evaluating written communications with immigrant Haitian women in Montreal.

BACKGROUND: The province of Quebec (Canada) has implemented a breast cancer screening program to diagnose this cancer at an early stage. The strategy is to refer women 50 to 69 years old for a mammogram every two years by sending an invitation letter that acts as a prescription. Ninety per cent (90%) of deaths due to breast cancer occur in women aged 50 and over. Numerous studies have shown social inequalities in health for most diseases. With breast cancer, a significant paradox arises: its incidence is lower among disadvantaged women and yet, more of them die from this disease. The health care system might play a role in this inequality. The scientific literature documents the potential for creating such inequalities when prevention does not consider equity among social groups. Immigrant women are often disadvantaged. They die of breast cancer more than non-immigrants. Studies attribute this to late-stage diagnosis due to poor adherence to mammography screening programs. PURPOSE OF THE STUDY: The main objective of our research is to assess how Haitian immigrant women in Montreal are reached by the Quebec Breast Cancer Screening Program, and specifically how they perceive the mammogram referral letter sent by the program. METHODS: The study uses a two-step qualitative method: i) In-depth interviews with influential community workers to identify the most relevant issues; ii) Focus groups with disadvantaged women from Montreal's Haitian community. RESULTS: A mammogram referral letter from the Breast Cancer Screening Program may be a barrier to compliance with mammography by underprivileged Haitian women in Montreal. This might be attributable to a low level of literacy, poor knowledge of the disease, and lack of financial resources. CONCLUSION: Barriers may be underestimated in underprivileged immigrant and non-immigrant communities. A preventive strategy must be adapted to different sub-groups and must also take into account lower literacy levels. To increase mammography uptake, it is crucial that the benefits of prevention be clearly identified and described in understandable terms. Finally, economic access to follow-up measures should be considered.

Early Childhood Education and Care Access for Children from Disadvantaged Backgrounds: Using a Framework to Guide Intervention.

Early childhood education and care (ECEC) can have substantial beneficial effects on overall child development and educational success for children from disadvantaged backgrounds. Unfortunately, it is well documented that they are underrepresented in quality ECEC programs. In order to improve access to quality ECEC, it is important to understand the factors leading to these inequities. This paper is based on a synthesis of published literature on interventions aimed at improving access to ECEC. We propose a framework identifying the spectrum of factors influencing access to quality ECEC for disadvantaged populations. We also present, in the context of our proposed framework, different interventions that have been taken to improve access to ECEC opportunities for children from low socioeconomic and/or new immigrant backgrounds. We believe that the framework proposed in this paper serves not only as a framework by which to understand the overlapping processes, factors, and stages affecting access to ECEC, but also as a model to help decision makers coordinate their efforts and maximize their impact towards more equity in access to quality early childhood education.

Temporal trends in social disparities in maternal smoking and breastfeeding in Canada, 1992-2008.

A steady decrease in maternal smoking during pregnancy and a steady increase in breastfeeding rates have been observed in Canada in the past two decades. However, the extent to which all socioeconomic classes have benefited from this progress is unknown. Therefore, this study was undertaken to determine: (1) whether progress achieved benefited the entire population or was limited to specific strata; and (2) whether disparities among strata decreased, stayed the same, or increased over time. We used data from the National Longitudinal Survey of Children and Youth, which enrolled children aged 0-3 years between 1994 and 2008. Data collected at entry was analyzed in a cross-sectional manner. Between birth years 1992-1996 and 2005-2008, smoking during pregnancy decreased from 11.5 % (95 % CI 10.0-13.0 %) to 5.2 % (95 % CI 4.1-6.3 %) among mothers with a college or university degree and from 43.0 % (95 % CI 38.8-47.2 %) to 38.6 % (95 % CI 32.9-44.2 %) among those with less than secondary education. During the same period, the rate of breastfeeding initiation increased from 83.8 % (95 % CI 81.9-85.6 %) to 91.5 % (95 % CI 90.2-92.8 %) among mothers with a college or university degree and from 63.1 % (95 % CI 58.9-67.4 %) to 74.7 % (95 % CI 69.8-79.7 %) among those with less than secondary education. The risks of smoking and of not breastfeeding remained significantly higher in the least educated category than in the most educated throughout the study period, and these associations remained statistically significant after controlling for maternal age. Gaps between the least and the most educated mothers narrowed for breastfeeding but widened for smoking during pregnancy.

Developing practice guidelines to integrate physical activity promotion as part of routine cancer care: A knowledge-to-action protocol.

BACKGROUND: Cancer is a leading cause of disease burden worldwide and the first cause of mortality in Canada with 30.2% of deaths attributable to cancer. Given aging of the population and the improvement of prevention and treatment protocols, the number of cancer survivors is steadily increasing. These individuals have unique physical and mental health needs some of which can be addressed by integrating physical activity promotion into ongoing and long-term care. Despite the benefits of being active, delivery of PA programs for cancer patients in both clinical and community settings remains challenging. This knowledge-to-action protocol-called Kiné-Onco-aims to develop a practice guideline for the delivery, implementation, and scaling-up of cancer-specific physical activity promotion programs and services in clinical and community settings located in Québec, Canada. METHOD: The Kiné-Onco project involves knowledge synthesis of scientific and grey literature to establish the benefits and added value of physical activity for cancer patients and survivors, describes current practices in delivering physical activity programs, analyses quantitative data from electronic health records (EHR) of patients participating in a novel hospital-based physical activity program, collects and analyses qualitative data from patients and healthcare providers interviews about lived experience, facilitators, and barriers to physical activity promotion, outlines deliberative workshops among multidisciplinary team members to develop implementation guidelines for physical activity promotion, and summarizes a variety of knowledge transfer and exchange activities to disseminate the practice guidelines. DISCUSSION: This paper describes the protocol for a knowledge-to-action project aimed at producing and sharing actionable evidence. Our aim is that physical activity promotion programs and services be scaled up in such a way as to successfully integrate physical activity promotion throughout cancer treatment and survivorship in order to improve the physical and mental health of the growing population of individuals having received a cancer diagnosis.

Measurement of gender inequality in neighbourhoods of Québec, Canada.

INTRODUCTION: Few studies have measured gender inequality at levels lower than the country. We sought to develop neighbourhood indicators of gender inequality, and assess their ability to capture variability in gender inequality across Québec, Canada. METHODS: Aggregate 2001 census data for 11,564 neighbourhoods were obtained for men and women. Twelve indicators of gender inequality representing demographic/household characteristics, education, income, work/leisure, and political participation were selected. Neighbourhood-level gender inequality scores were computed for each indicator, and examined across parts of Québec (metropolitan areas, mid-sized cities, rural areas). Monte Carlo simulations were used to assess the ability of indicators to capture heterogeneity in gender inequality across neighbourhoods. RESULTS: Male-dominant neighbourhood-level gender inequality tended to be present for average employment income, labour force participation, employment rate, and employment in managerial positions. Female-dominant gender inequality tended to be present for divorce, single-headed households, and participation in unpaid housework, child and elderly care. Neighbourhood-level gender inequality tended to vary across metropolitan areas, mid-sized cities, and rural areas. Gender inequality scores also varied within these geographic areas. For example, there was greater income-related gender inequality in high than low income neighbourhoods. Monte Carlo simulations suggested that the variation in gender inequality across neighbourhoods was greater than expected with chance alone. CONCLUSION: Neighbourhood-level gender inequality tended to be present in Québec, and varied across parts of the province. Greater awareness of and research on neighbourhood-level gender inequality may be warranted to inform gender policies in Québec and other nations.

Children and youth perceive smoking messages in an unbranded advertisement from a NIKE marketing campaign: a cluster randomised controlled trial.

BACKGROUND: How youth perceive marketing messages in sports is poorly understood. We evaluated whether youth perceive that the imagery of a specific sports marketing advertisement contained smoking-related messages. METHODS: Twenty grade 7 to 11 classes (397 students) from two high schools in Montréal, Canada were recruited to participate in a cluster randomised single-blind controlled trial. Classes were randomly allocated to either a NIKE advertisement containing the phrase 'LIGHT IT UP' (n = 205) or to a neutral advertisement with smoking imagery reduced and the phrase replaced by 'GO FOR IT' (n = 192). The NIKE logo was removed from both advertisements. Students responded in class to a questionnaire asking open-ended questions about their perception of the messages in the ad. Reports relating to the appearance and text of the ad, and the product being promoted were evaluated. RESULTS: Relative to the neutral ad, more students reported that the phrase 'LIGHT IT UP' was smoking-related (37.6% vs. 0.5%) and that other parts of the ad resembled smoking-related products (50.7% vs. 10.4%). The relative risk of students reporting that the NIKE ad promoted cigarettes was 4.41 (95% confidence interval: 2.64-7.36; P < 0.001). CONCLUSIONS: The unbranded imagery of an advertisement in a specific campaign aimed at promoting NIKE hockey products appears to have contained smoking-related messages. This particular marketing campaign may have promoted smoking. This suggests that the regulation of marketing to youth may need to be more tightly controlled.

Risk of Low Birth Weight According to Household Composition in Brussels and Montreal: Do Income Support Policies Variations Explain the Differences Observed between Both Regions?

Variations in social policy between countries provide opportunities to assess the impact of these policies on health inequities. This study compares the risk of low birth weight in Brussels and Montreal, according to household composition, and discusses the impact of income support policies. For each context, we estimated the impact of income support policies on the extent of poverty of welfare recipients, using the model family method. Based on the differences found, we tested hypotheses on the association between low birth weight and household composition, using administrative data from the birth register and social security in each region. The extent of poverty of welfare families differs according to household composition. In Quebec, the combination of low welfare benefits and larger family allowances widens the gap between households with children and those without children. The risk of LBW also differs between these two contexts according to the number of children. Compared to children born into large welfare families, first-born children are more at risk in Montreal than in Brussels. In addition to the usual comparative studies on the topic, our study highlights the importance of an evaluative perspective that considers the combination of different types of income support measures to better identify the most vulnerable households.

A rapid review of the impacts of "Big Events " on risks, harms, and service delivery among people who use drugs: Implications for responding to COVID-19.

BACKGROUND: "Big Events" are major disruptions to physical, political, and economic environments that can influence vulnerability to drug-related harms. We reviewed the impacts of Big Events with relevance to the COVID-19 pandemic on drug-related risk and harms and access to drug treatment and harm reduction services. METHODS: We conducted a rapid review of quantitative, qualitative, and mixed methods literature relating to the following Big Events: respiratory infection pandemics, natural disasters, financial crises, and heroin shortages. Included studies reported data on changes to risks, harms, and/or service provisioning for people who use illicit drugs (other than cannabis) in the context of these Big Events. Searches were conducted in PubMed in May 2020, and two reviewers screened studies for inclusion. Peer-reviewed studies published in English or French were included. We used a narrative synthesis approach and mapped risk pathways identified in the literature. RESULTS: No studies reporting on respiratory infection pandemics were identified. Twelve studies reporting on natural disaster outcomes noted marked disruption to drug markets, increased violence and risk of drug-related harm, and significant barriers to service provision caused by infrastructure damage. Five studies of the 2008 global financial crisis indicated increases in the frequency of drug use and associated harms as incomes and service funding declined. Finally, 17 studies of heroin shortages noted increases in heroin price and adulteration, potentiating drug substitutions and risk behaviors, as well as growing demand for drug treatment. CONCLUSION: Current evidence reveals numerous risk pathways and service impacts emanating from Big Events. Risk pathway maps derived from this literature provide groundwork for future research and policy analyses, including in the context of the COVID-19 pandemic. In light of the findings, we recommend responding to the pandemic with legislative and financial support for the flexible delivery of harm reduction services, opioid agonist treatment, and mental health care.

Unmet healthcare needs among migrants without medical insurance in Montreal, Canada.

While access to healthcare for permanent residents in Canada is well known, this is not the case for migrants without healthcare coverage. This is the first large-scale study that examines the unmet healthcare needs of migrants without healthcare coverage in Montreal. 806 participants were recruited: 436 in the community and 370 at the NGO clinic. Proportions of individuals reporting unmet healthcare needs were similar (68.4% vs. 69.8%). The main reason invoked for these unmet needs was lacking money (80.6%). Situations of not working or studying, not having had enough food in the past 12 months, not having a medical prescription to get medication and having had a workplace injury were all significantly associated with higher odds of having unmet healthcare needs. Unmet healthcare needs were more frequent among migrants without healthcare coverage than among recent immigrants or the citizens with health healthcare coverage (69%, 26%, 16%). Canada must take measures to enable these individuals to have access to healthcare according to their needs in order to reduce the risk of worsening their health status, something that may have an impact on the healthcare system and population health. The Government of Quebec announced that all individuals without any healthcare coverage will have access to COVID-19 related health care. We hope that this right, the application of which is not yet obvious, can continue after the pandemic for all health care.

Stillbirth Among Arab Women in Canada, 1981-2015.

OBJECTIVES: The Arabic-speaking population is increasing in Europe and North America. Evidence suggests that Arab migrants have a greater risk of adverse birth outcomes than nonmigrants, but the risk of stillbirth is largely understudied. We examined inequality in stillbirth rates between Arab women and the French and English majority of women in Quebec, Canada. METHODS: We conducted a retrospective study of all births in Quebec from 1981 through 2015. We computed stillbirth rates by period and cause of death, and we used log binomial regression to estimate the association between Arabic mother tongue and stillbirth, adjusted for maternal characteristics. RESULTS: Stillbirth rates per 1000 births overall were lower among women with Arabic mother tongue (3.89) than among women with French or English mother tongue (4.52), and rates changed little over time. However, Arabic-speaking women from Arab countries had a higher adjusted risk of stillbirth than French- or English-speaking women (risk ratio = 1.23; 95% confidence interval, 1.07-1.42). Congenital anomalies, termination of pregnancy, and undetermined causes contributed to a disproportionate number of stillbirths among women with Arabic mother tongue compared with the French- and English-speaking majority. CONCLUSIONS: Arabic-speaking women from Arab countries have higher risks of stillbirth compared with the French and English majority in Quebec. Strategies to reduce stillbirth risk among Arabic speakers should focus on improving identification of causes of death.

Evaluating the effect of income support policies on social health inequalities (SHIs) at birth in Montreal and Brussels using a contextualised comparative approach and model family method: a study protocol.

INTRODUCTION: Assessing the effects of social policies on social health inequalities (SHIs) is a complex issue. Variations in social policy between countries or regions provide natural experiments in policy implementation to perform comparative research. Comparisons are most enlightening when: the object of the evaluation is well defined (types of policies, population groups); the context of policy is analysed (history, implementation); the impact of policy on household poverty is outlined in detail; the influence of various factors (other than poverty) on SHI is taken into consideration. METHODS AND ANALYSIS: This study aims to understand how income support policies (ISPs) in Brussels and Montreal influence the poverty level of households receiving social assistance, and how they are associated with SHI at birth. Two cases studies will be carried out from a comparative perspective. The analysis includes four stages : (1) The model family method will be used to compare ISPs and their impact on disposable income and poverty of households receiving social assistance in both regions. (2) Statistical analysis of administrative databases will enable the description and comparison of SHI in adverse pregnancy outcomes across the two regions. (3) Analysis of databases and documents will allow for description of various factors which are likely to interact with poverty and influence SHI at birth. (4) Based on the Diderichsen model, results from the previous stages will be used to formulate hypotheses about the mechanisms by which ISPs contribute to increasing or reducing SHI at birth in both regions. ETHICS AND DISSEMINATION: This research was approved by the Human Research Ethics Committee for Health research of Université de Montréal. In Belgium, the access to linked databases was approved by the Commission for the Protection of Privacy. Databases de-identified according to Belgian and Canadian legislation will be used. Results will be disseminated in scientific publications and will be shared with policy makers and field actors through collaborations with local organisations in Brussels and Montreal.

Community unemployment and immigrants' health in Montreal.

This research examines the relationship between community unemployment and the physical and mental health of immigrants in comparison to non-immigrants in Montreal under the hypothesis that high unemployment in the community may generate more negative effects on the health of immigrants than on non-immigrants. Possible gender differences in these associations are also examined. Montreal residents were studied via multilevel analysis, using both individual survey data and neighbourhood data from 49 police districts. Individual-level data were excerpted from a 1998 health survey of Montreal residents, while neighbourhood data originated from survey data collected in the 49 Montreal police districts and the 1996 Canadian Census. The associations between community unemployment and self-rated health, psychological distress and obesity are examined, and hypotheses regarding the modifying mechanisms via which male and female immigrants may run a greater risk of poor health than non-immigrants when living in areas of high unemployment were tested. Between neighbourhoods, variations in the three health outcomes were slight, and differences in health were not associated with differences in community unemployment. The associations between community unemployment and health varied according to immigration status. At the individual level, immigrants do not differ from non-immigrants with respect to the three health indicators, except that second-generation males are slightly heavier. However, when living in areas of high unemployment, immigrants tend to report poor physical and mental health in comparison to non-immigrants. Among first-generation immigrants, community unemployment was associated with psychological distress. Among second-generation immigrants, the probability of obesity and poor self-rated health increased significantly for those living in areas with high unemployment, but these associations reached statistical significance only for men. Findings among first-generation immigrants are interpreted with respect to the effects of possible discrimination in areas with low job availability. Among second-generation men, poor physical health and obesity may be the result of poor health habits stemming from perceived lack of life opportunities.

Summarizing health inequalities in a Balanced Scorecard. Methodological considerations.

The association between social determinants and health inequalities is well recognized. What are now needed are tools to assist in disseminating such information. This article describes how the Balanced Scorecard may be used for summarizing data on health inequalities. The process begins by selecting appropriate social groups and indicators, and is followed by the measurement of differences across person, place, or time. The next step is to decide whether to focus on absolute versus relative inequality. The last step is to determine the scoring method, including whether to address issues of depth of inequality.

The future of tobacco marketing in Canada.

With the advent of the Tobacco Act, tobacco marketing is now severely restricted in Canada. This article considers how the tobacco industry may conduct future marketing in order to circumvent the Tobacco Act. Past tobacco marketing strategies are discussed in light of how such strategies could be used in future marketing campaigns. In addition, this article highlights the need for private industries unrelated to tobacco to conduct socially responsible advertising so as to avoid inadvertently promoting tobacco.

Unintended messages in online advertising to youth: illicit drug imagery in a Canadian sports marketing campaign.

PURPOSE: We assessed the potential for harmful messages in online advertisements targeted to youth, using the example of the Canadian "Light It Up" marketing campaign from a large sports corporation. METHODS: We undertook a cluster randomized controlled trial of 20 secondary school classes in Montreal, Canada. Classes were randomly allocated to view a "Light It Up" advertisement (n = 205) or a neutral comparison advertisement (n = 192). The main outcome measures were self-reports of illicit drug messages in the advertisements. RESULTS: Of the students, 22.9% reported that the "Light It Up" advertisement contained illicit drug messages compared with 1.0% for the comparison advertisement (relative risk, 22.0; 95% confidence interval, 6.5-74.9). CONCLUSIONS: Although meant to promote sports, youth in this study believed that the "Light It Up" advertisement was related to illicit drugs. The campaign illustrates how advertisements may inadvertently market unwanted behaviors to children.

Child Care Services, Socioeconomic Inequalities, and Academic Performance.

OBJECTIVE: To determine if child-care services (CCS) at a population level can reduce social inequalities in academic performance until early adolescence. METHODS: A 12-year population-based prospective cohort study of families with a newborn (n = 1269). Two CCS variables were estimated: "intensity" (low, moderate, and high number of hours) and "center-based CCS type" (early onset, late onset, and never exposed to center-based CCS). RESULTS: Children from low socioeconomic status (SES) families who received high-intensity CCS (any type), compared with those who received low-intensity CCS, had significantly better reading (standardized effect size [ES] = 0.37), writing (ES = 0.37), and mathematics (ES = 0.46) scores. Children from low-SES families who received center-based CCS, compared with those who never attended center care, had significantly better reading (ESearly onset = 0.68; ESlate onset = 0.37), writing (ESearly onset = 0.79), and mathematics (ESearly onset = 0.66; ESlate onset = 0.39) scores. Furthermore, early participation in center-based CCS eliminated the differences between children of low and adequate SES on all 3 examinations (ES = -0.01, 0.13, and -0.02 for reading, writing, and mathematics, respectively). These results were obtained while controlling for a wide range of child and family variables from birth to school entry. CONCLUSIONS: Child care services (any type) can reduce the social inequalities in academic performance up to early adolescence, while early participation in center-based CCS can eliminate this inequality. CCS use, especially early participation in center-based CCS, should be strongly encouraged for children growing up in a low-SES family.

Health of migrants with precarious status: results of an exploratory study in Montreal--Part B.

Increasingly, migrants with precarious status (MPS) are recognized as being particularly vulnerable. This exploratory study assesses whether the health of MPS in Montreal, Canada, is similar to that reported in the international literature (see Health situation of migrants with precarious status: Review of the literature and implications for the Canadian context--Part A, Social Work in Public Health, 27 (4), 330-344). The results of this study show that, as in other parts of the world, MPS in Canada appear to be confronted by multiple obstacles to health, many of which are linked to their precarious migration status and its impact on living conditions and access to health care. To reduce health inequalities, therefore, it is crucial to better understand and address the specific needs of this highly vulnerable population.

Health situation of migrants with precarious status: review of the literature and implications for the Canadian context--Part A.

Migrants with precarious status (MPS) are an understudied population. Yet there are indications that they could be particularly vulnerable and confronted to health inequalities. This review of Canadian and international literature highlights that MPS, like other migrants, are confronted with deleterious living conditions and multiple obstacles to access healthcare. However, their status brings additional challenges and harmful health determinants. The situation of MPS may well be similar in Canada, where they could be numerous. Therefore it is crucial to better document this issue within the Canadian context. Part B of this article, reported elsewhere, further explores this topic.