Youth Vaping During the Early Stages of the COVID-19 Pandemic Period: Adjusted Annual Changes in Vaping Between the Pre-COVID and Initial COVID-Lockdown Waves of the COMPASS Study.

BACKGROUND: Adolescence is a critical period for vaping onset. The purpose of this article was to examine the effect of the early stages of the COVID-19 pandemic period on youth vaping. METHODS: We used 3-year linked data from the COMPASS study, including 7585 Canadian (Quebec, Ontario) adolescents from which 1949 completed all three survey waves (pre-COVID-19 [2018, 2019] and online [2020] during the early pandemic period [May-July 2020]) and provided vaping data. Structural equation modeling (SEM) and difference-in-difference (DD) models were used to estimate pre-COVID-19 to initial COVID-19 pandemic period change (2019-2020) in vaping (monthly, weekly, daily) compared with 2018-2019 change to adjust for age-related effects. Models were adjusted for age of entry into the cohort and sociodemographic characteristics. RESULTS: In the SEM and DD models, the proportion of youth who were monthly and weekly vaping increased from 2018 to 2019 but decreased from 2019 to 2020; daily vaping increased across all waves. However, for all vaping outcomes modeled, the expected increases from the pre-COVID-19 wave (2019) to the initial COVID-19 period wave (2020) were lesser relative to the changes seen across the 2018 to 2019 waves. CONCLUSION: The early stages of the COVID-19 pandemic period appear to be associated with a reduction in the proportion of youth who were monthly and weekly vapers in our adjusted longitudinal models. While daily vaping increased over this same period of time, the magnitude of the increase in our adjusted longitudinal models appears attenuated by the early stages of the pandemic. IMPLICATIONS: This large prospective study of youth that included pre-pandemic data is unique in that we were able to identify that the early stages of the COVID-19 pandemic period was associated with a reduction in the proportion of youth who were monthly and weekly vapers in our adjusted longitudinal models. Conversely, the proportion of youth who were daily vaping increased over this same period of time, but the magnitude of the increase appears smaller than expected during the early stages of the pandemic in our adjusted longitudinal models. This study provides novel robust evidence that the patterns of vaping most aligned with onset and progression (i.e., monthly and weekly use) appear attenuated during the initial pandemic period.

Socioeconomic disparities and concentration of the spread of the COVID-19 pandemic in the province of Quebec, Canada.

BACKGROUND: Recent studies suggest that the risk of SARS-CoV-2 infection may be greater in more densely populated areas and in cities with a higher proportion of persons who are poor, immigrant, or essential workers. This study examines spatial inequalities in SARS-CoV-2 exposure in a health region of the province of Quebec in Canada. METHODS: The study was conducted on the 1206 Canadian census dissemination areas in the Capitale-Nationale region of the province of Quebec. The observation period was 21 months (March 2020 to November 2021). The number of cases reported daily in each dissemination area was identified from available administrative databases. The magnitude of inequalities was estimated using Gini and Foster-Greer-Thorbecke (FGT) indices. The association between transmission and socioeconomic deprivation was identified based on the concentration of transmission in socially disadvantaged areas and on nonparametric regressions relating the cumulative incidence rate by area to ecological indicators of spatial disadvantage. Quantification of the association between median family income and degree of exposure of dissemination areas was supplemented by an ordered probit multiple regression model. RESULTS: Spatial disparities were elevated (Gini = 0.265; 95% CI [0.251, 0.279]). The spread was more limited in the less densely populated areas of the Quebec City agglomeration and outlying municipalities. The mean cumulative incidence in the subsample made up of the areas most exposed to the pandemic was 0.093. The spread of the epidemic was concentrated in the most disadvantaged areas, especially in the densely populated areas. Socioeconomic inequality appeared early and increased with each successive pandemic wave. The models showed that areas with economically disadvantaged populations were three times more likely to be among the areas at highest risk for COVID-19 (RR = 3.55; 95% CI [2.02, 5.08]). In contrast, areas with a higher income population (fifth quintile) were two times less likely to be among the most exposed areas (RR = 0.52; 95% CI [0.32, 0.72]). CONCLUSION: As with the H1N1 pandemics of 1918 and 2009, the SARS-CoV-2 pandemic revealed social vulnerabilities. Further research is needed to explore the various manifestations of social inequality in relation to the pandemic.

Birthweight, gestational age, and early school trajectory.

BACKGROUND: Birthweight and gestational age are important factors of not only newborn health by also child development and can contribute to delayed cognitive abilities. However, no study has analyzed the association of birthweight and gestational age with school trajectory measured simultaneously by school entry, grade repetition, and school dropout. This study aims, first, to analyze the association of birthweight or gestational age with school entry, and second, to explore the relationship between birthweight or gestational age and grade repetition and school dropout among children in Ouagadougou, Burkina Faso. METHODS: This study used longitudinal data from the Ouagadougou Health and Demographic Surveillance System. Our samples consisted of children born between 2008 and 2014 who were at least three years old at the beginning of the 2017-18 school year. Samples included 13,676, 3152, and 3498 children for the analysis of the school entry, grade repetition, and dropout, respectively. A discrete-time survival model was used to examine the relationship between birthweight or gestational age and school entry, grade repetition, and dropout. The association between birthweight or gestational age and age at school entry were assessed using a Poisson regression. RESULTS: The incidence rate of school entry was 18.1 per 100 people-years. The incidence of first repetition and dropout were 12.6 and 5.9, respectively. The probability of school entry decreased by 31% (HR:0.69, 95%CI: 0.56-0.85) and 8% (HR:0.92, 95%CI: 0.85-0.99) for children weighing less than 2000 g and those weighing between 2000 and 2499 g, respectively, compared to those born with a normal weight (weight ≥ 2500 g). The age at school entry of children with a birthweight less than 2000 g and between 2000 and 2499 g was 7% (IRR: 1.07, 95%CI: 1.06-1.08) and 3% (IRR: 1.03, 95%CI: 1.00-1.06) higher than children born at a normal birthweight, respectively. Gestational age was not associated with school entry or age at school entry. Similarly, birthweight and gestational age were not associated with grade repetition or dropout. CONCLUSION: This study shows that low birthweight is negatively associated with school entry and age at school entry in Ouagadougou. Efforts to avoid low birthweights should be part of maternal and prenatal health care because the associated difficulties may be difficult to overcome later in the child's life. Further longitudinal studies are needed to better understand the relationship between development at birth and school trajectory.

Disparities in high schools' vaccination coverage (COVID-19). A natural experiment in the Province of Quebec.

Teenagers' vaccination has become crucial to limit the COVID-19 transmission in the population. To increase the vaccination rate of this age group, a school-based vaccination campaign was launched in Québec, Canada from June 7 to 18, 2021. This study aimed to analyze trajectories of vaccination coverage over time among students attending 37 high schools. The study explored whether school-based vaccination campaigns contributed to the progression of the vaccination coverage and attenuated disparities in vaccination coverage across schools. On average, first dose coverage quickly increased from 30.6% to 81.5% between June 6 and 18, 2021, after the launch of the campaign. As of August 13, 2021, first dose coverage had reached 87.9% and 64.9% for the second dose coverage. Public schools with poorer student populations had 6.5 points of percentage lower first dose vaccination rates (95%CI 0.3%; 12.6%) compared to other schools. A higher level of concern related to the pandemic among students was associated with a 4.3 points of percentage increased coverage (95%CI 0.7%; 8.0%). The initial uneven distribution in first dose coverage decreased dramatically by the end of the campaign. Similar trends were observed for the second dose, although between schools' inequality at the end of the period of observation was significantly larger. The school-based vaccination campaign might have initially contributed to a prompt rise in vaccination coverage and helped the disadvantaged schools to reach similar vaccination coverage as seen in other schools. In addition to being an efficient way to achieve rapidly high vaccination coverage, the school-based approach might contribute to increase equity in vaccination distribution.

Understanding Sexual Health Indicators During Adolescence: A Study to Consider Time Since Sexual Debut When Exploring Multiple Sexual Partners.

Understanding risky sexual behaviors among adolescents is key in efforts devoted to reducing the health burden related to sexually transmitted infections and unintended or unplanned pregnancies. The aims of this study were to understand the association between number of lifetime sexual partners and time since sexual debut (TSSD) among adolescents and to determine whether sex modified this association. Data were drawn from the 2018-2019 COMPASS-Quebec study, a cohort study conducted in secondary schools in the province of Quebec, Canada. Of 18,467 respondents aged 14 years and older, 6991 (37.9%; mean age 15.3) reported consensual sexual intercourse and answered questions on their age at sexual initiation and number of lifetime sexual partners. Multilevel Poisson regressions with robust standard errors were estimated to adjust for covariates and produce adjusted group mean differences. The adjusted mean number of lifetime sexual partners ranged from 1.5 for those who had recently begun sexual activity (< 12 months) to 4.0 for those who had been active for > 35 months, an average rise of about 0.6 per year. Females-to-males adjusted mean differences showed that males reported more sexual partners than females at all time points, but the differences were only significant at the shorter (< 12 months) and longer (> 35 months) time spans. This study highlights the importance of taking into account TSSD when using and interpreting the number of lifetime sexual partners as risky sexual behavior among adolescents. Sex did not have a significant modifying effect on the relationship between number of lifetime sexual partners and TSSD.

Stunting, age at school entry and academic performance in developing countries: A systematic review and meta-analysis.

AIM: To review evidence of the effects of stunting, or height-for-age, on schooling level and schooling trajectories, defined as the combination of school entry age, grade repetition and dropouts. METHODS: We conducted a systematic review of studies (last update 20 March 2021) that assessed the association between stunting, or height-for-age, and at least one component of school trajectory using five databases (PubMed, Embase, Education Resources Information Center [ERIC], Web of Science and PsycINFO). Two independent reviewers performed study selection and data extraction. Pooled effects were calculated using the generic inverse variance weighting random-effect model. The risk of bias was assessed using the ROBINS-I tool (PROSPERO ID: CRD42020198346). RESULTS: We screened 3944 articles, and 16 were eligible for the qualitative and quantitative syntheses. Meta-analysis showed that an increase in height-for-age leads to an increase in early enrolment [OR = 1.34 (95% CI, 1.07-1.67)], a reduction in late enrolment [OR = 0.63 (95% CI, 0.51-0.78)], an increase in schooling level [MD = 0.24 (95% CI, 0.14-0.34)] and a reduction in school overage [OR = 0.79 (95% CI, 0.70-0.90)]. Stunted children were more likely to repeat a grade than non-stunted [OR = 1.59 (95% CI, 1.18-2.14)]. CONCLUSION: This review suggests that stunting in childhood might negatively affect school trajectories. Future research should evaluate the effect of stunting on school trajectories and the modification effect of socioeconomic status.

Examining the impact of the early stages of the COVID-19 pandemic period on youth cannabis use: adjusted annual changes between the pre-COVID and initial COVID-lockdown waves of the COMPASS study.

BACKGROUND: Given the high rates of cannabis use among Canadian youth and that adolescence is a critical period for cannabis use trajectories, the purpose of this paper was to examine the effect of the early stages of the COVID-19 pandemic period on youth cannabis use in the context of a natural experiment. We used 3-year linked data from the COMPASS study, including 7653 Canadian (Quebec, Ontario) adolescents from which 1937 completed all 3 survey waves (pre-COVID-19 [2018, 2019] and online [2020] during the early pandemic period [May-July 2020]). Structural equation modeling (SEM) and double difference (DD) models were used to estimate pre-COVID-19 to initial COVID-19 pandemic period change (2019-2020) in cannabis use (monthly, weekly, daily) compared to 2018 to 2019 change to adjust for age-related effects. Models were adjusted for age of entry into the cohort and sociodemographic characteristics. RESULTS: In the SEM and DD models, monthly, weekly, and daily cannabis use increased across all waves; however, the expected increases from the pre-COVID-19 wave (2019) to the initial COVID-19 period wave (2020) were lesser relative to the changes seen across the 2018 to 2019 waves. The cross-sectional data from May to July 2020 identified that the majority of youth who use cannabis did not report increased cannabis use due to COVID-19 or using cannabis to cope with COVID-19. CONCLUSION: During the early stages of the COVID-19 pandemic period, there does not appear to be a detrimental effect on youth cannabis use, when adjusted for age-related changes. Further prospective research is needed to explore the impact of the ongoing pandemic response on youth cannabis use onset and progression.

Longitudinal analysis of the capacities of community health workers mobilized for seasonal malaria chemoprevention in Burkina Faso.

BACKGROUND: Seasonal malaria chemoprevention (SMC) relies on community health workers to distribute drugs. This study assessed: (1) the capacity of community-based distributors (CBDs) at the start and end of a campaign and from one campaign to another after training or refresher courses before each round; (2) to what extent CBDs' experience over several campaigns contributed to measurable increase in their capacities; and (3) to what extent the training and experience of committed CBDs helped the less productive to catch up. METHODS: A longitudinal analysis was conducted in one Burkina Faso health district during the 2017 and 2018 campaigns. A panel including all CBDs was created. Their capacities were observed after: (1) initial training for the 2017 season; (2) refresher training for that year's fourth round; and (3) initial training for the 2018 season. All were invited to complete a questionnaire at the end of training with 27 multiple-choice questions on their main tasks. Observers noted content coverage and conditions under which training sessions were conducted. RESULTS: The 612 CBDs showed, on average, high understanding of their tasks from the start of the annual campaigns. Tasks related to communicating with parents and reporting were best mastered. Their capacities grew from round to round and campaign to campaign, after most had undergone training and been supervised by head nurses. The greatest progress was in the technical components, considered more complex, which involved selecting eligible children, choosing the correct drug packet, and referring children to health professionals. Retaining CBDs from one round to the next benefited everyone, whatever their starting level. Groups that initially obtained the lowest scores (women, illiterates, youngest/oldest) progressed the most. CONCLUSION: These results confirm the potential of using CBDs under routine programme implementation. Mandating CBDs with targeted tasks is a functional model, as they achieve mastery in this context where investments are made in training and supervision. Losing this specificity by extending CBDs' mandates beyond SMC could have undesirable consequences. The added value of retaining committed CBDs is high. It is suggested that motivation and commitment be considered in recruitment, and that a supportive climate be created to foster retention.

Canada's global health role: supporting equity and global citizenship as a middle power.

Canada's history of nation building, combined with its status as a so-called middle power in international affairs, has been translated into an approach to global health that is focused on equity and global citizenship. Canada has often aspired to be a socially progressive force abroad, using alliance building and collective action to exert influence beyond that expected from a country with moderate financial and military resources. Conversely, when Canada has primarily used economic self-interest to define its global role, the country's perceived leadership in global health has diminished. Current Prime Minister Justin Trudeau's Liberal federal government has signalled a return to progressive values, driven by appreciation for diversity, equality, and Canada's responsibility to be a good global citizen. However, poor coordination of efforts, limited funding, and the unaddressed legacy of Canada's colonisation of Indigenous peoples weaken the potential for Canadians to make meaningful contributions to improvement of global health equity. Amid increased nationalism and uncertainty towards multilateral commitments by some major powers in the world, the Canadian federal government has a clear opportunity to convert its commitments to equity and global citizenship into stronger leadership on the global stage. Such leadership will require the translation of aspirational messages about health equity and inclusion into concrete action at home and internationally.

Analysis of the quality of seasonal malaria chemoprevention provided by community health Workers in Boulsa health district, Burkina Faso.

BACKGROUND: Since 2014, the Burkina Faso government has made Seasonal Malaria Chemoprevention (SMC) a priority in its strategic plan to fight against malaria among children aged from 3 to 59 months. Very few studies have examined the care provided by community health workers in the framework of this strategy. The purpose of this study was to evaluate the level of quality of care provided by the latter. METHODS: This was a mixed study. The quantitative component consisted of a non-participant observation of community health workers during the administration of care. The qualitative component consisted of one-on-one interviews with community health workers, child caregivers and head nurses. Five dimensions (organizational accessibility, interpersonal relationship, technical competence, safety of care and satisfaction of child caregivers) adapted from the Donabedian quality of care model were used to assess the quality level of care. The Corlien et al. Health Systems Research Program Implementation Scale was used to establish quality scores for each of the five dimensions. The study sites were the health centers located in the administrative centers of the 4 communes of the health district of Boulsa. The data were collected during the first cycle of the 2017 SMC campaign. RESULTS: A total of 14 active pairs (28 CHWs) were observed and 40 in-depth interviews with community health workers, Head nurses in duty and community leaders were conducted. The results show that community health workers worked in pairs. They had all received SMC training and possessed equipment to do their job. The dimensions of organizational accessibility and satisfaction of the caregivers were rated as good. The dimensions of interpersonal relationship and technical competence were judged to be of an acceptable score. Safety of care was judged to be of a low-level score. The overall quality of care was considered acceptable. CONCLUSION: The results of this study have shown that despite the difficulties faced by community health workers, they manage to deliver acceptable quality of care. Their use would be an asset for SMC in particular and for the health system in general.

Utilization of community health workers for malaria treatment: results from a three-year panel study in the districts of Kaya and Zorgho, Burkina Faso.

BACKGROUND: Malaria is holo-endemic in Burkina Faso and causes approximately 40,000 deaths every year. In 2010, health authorities scaled up community case management of malaria with artemisinin-based combination therapy. Previous trials and pilot project evaluations have shown that this strategy may be feasible, acceptable, and effective under controlled implementation conditions. However, little is known about its effectiveness or feasibility/acceptability under real-world conditions of implementation at national scale. METHODS: A panel study was conducted in two health districts of Burkina Faso, Kaya and Zorgho. Three rounds of surveys were conducted during the peak malaria-transmission season (in August 2011, 2012 and 2013) in a panel of 2,232 randomly selected households. All sickness episodes in children under five and associated health-seeking practices were documented. Community health worker (CHW) treatment coverage was evaluated and the determinants of consulting a CHW were analysed using multi-level logistic regression. RESULTS: In urban areas, less than 1% of sick children consulted a CHW, compared to 1%-9% in rural areas. Gaps remained between intentions and actual practices in treatment-seeking behaviour. In 2013, the most frequent reasons for not consulting the CHW were: the fact of not knowing him/her (78% in urban areas; 33% in rural areas); preferring the health centre (23% and 45%, respectively); and drug stock-outs (2% and 12%, respectively). The odds of visiting a CHW in rural areas significantly increased with the distance to the nearest health centre and if the household had been visited by a CHW during the previous three months. CONCLUSIONS: This study shows that CHWs are rarely used in Burkina Faso to treat malaria in children. Issues of implementation fidelity, a lack of adaptation to the local context and problems of acceptability/feasibility might have undermined the effectiveness of community case management of malaria. While some suggest extending this strategy in urban areas, total absence of CHW services uptake in these areas suggest that caution is required. Even in rural areas, treatment coverage by CHWs was considerably less than that reported by previous trials and pilot projects. This study confirms the necessity of evaluating public health interventions under real-world conditions of implementation.

The elimination of healthcare user fees for children under five substantially alleviates the burden on household expenses in Burkina Faso.

BACKGROUND: Since September 2008, an intervention has made it possible to provide free care to children under five in public health facilities in two districts of Burkina Faso. This study evaluated the intervention's impact on household expenses incurred for services (consultations and medications) to the children targeted. METHODS: The study is based on a survey of a representative panel of 1,260 households encountered in two waves, one month before and 12 months after the introduction of the intervention. The questions explored the illness episodes of all children under five in the 30 days before each wave. The analysis of health expenses incurred during an illness episode distinguished between total expenses and those incurred in public health facilities (charges for services and medications). Analyses based on multilevel simultaneous equation models were used to estimate the probability of spending and the amount spent, in a context where a large number of observations returned a count of zero. RESULTS: The burden on household expenses was greatly alleviated under the intervention. Average expenditure dropped from US$11 per episode of care to less than US$2 after the intervention was implemented. The risk of incurring an expense at a public health facility was reduced by two-thirds. The facility users' savings were primarily related to medication purchases. In rural areas, where barriers to access health services are more acute, both poor and non-poor families benefited from the intervention. The probability of spending on medications dropped dramatically for both the poor and the non-poor under the exemption (-75% vs.-77%), and the reduction in expenses for medications generated by the intervention was comparable for both groups in relative values (-86% vs.-89%). CONCLUSION: User fees abolition at the point of service substantially alleviated the burden on household expenses. The intervention benefited both poor and non-poor families and provided financial protection.

Quality of care, risk management, and technology in obstetrics to reduce hospital-based maternal mortality in Senegal and Mali (QUARITE): a cluster-randomised trial.

BACKGROUND: Maternal mortality is higher in west Africa than in most industrialised countries, so the development and validation of effective interventions is essential. We did a trial to assess the effect of a multifaceted intervention to promote maternity death reviews and onsite training in emergency obstetric care in referral hospitals with high maternal mortality rates in Senegal and Mali. METHODS: We did a pragmatic cluster-randomised controlled trial, with hospitals as the units of randomisation and patients as the unit of analysis. 46 public first-level and second-level referral hospitals with more than 800 deliveries a year were enrolled, stratified by country and hospital type, and randomly assigned to either the intervention group (n=23) or the control group with no external intervention (n=23). All women who delivered in each of the participating facilities during the baseline and post-intervention periods were included. The intervention, implemented over a period of 2 years at the hospital level, consisted of an initial interactive workshop and quarterly educational clinically-oriented and evidence-based outreach visits focused on maternal death reviews and best practices implementation. The primary outcome was reduction of risk of hospital-based mortality. Analysis was by intention-to-treat and relied on the generalised estimating equations extension of the logistic regression model to account for clustering of women within hospitals. This study is registered with ClinicalTrials.gov, number ISRCTN46950658. FINDINGS: 191,167 patients who delivered in the participating hospitals were analysed (95,931 in the intervention groups and 95,236 in the control groups). Overall, mortality reduction in intervention hospitals was significantly higher than in control hospitals (odds ratio [OR] 0·85, 95% CI 0·73-0·98, p=0·0299), but this effect was limited to capital and district hospitals, which mainly acted as first-level referral hospitals in this trial. There was no effect in second-level referral (regional) hospitals outside the capitals (OR 1·02, 95% CI 0·79-1·31, p=0·89). No hospitals were lost to follow-up. Concrete actions were implemented comprehensively to improve quality of care in intervention hospitals. INTERPRETATION: Regular visits by a trained external facilitator and onsite training can provide health-care professionals with the knowledge and confidence to make quality improvement suggestions during audit sessions. Maternal death reviews, combined with best practices implementation, are effective in reducing hospital-based mortality in first-level referral hospitals. Further studies are needed to determine whether the benefits of the intervention are generalisable to second-level referral hospitals. FUNDING: Canadian Institutes of Health Research.

Estimation of maternal and child mortality one year after user-fee elimination: an impact evaluation and modelling study in Burkina Faso.

OBJECTIVE: To estimate the impact on maternal and child mortality after eliminating user fees for pregnant women and for children less than five years of age in Burkina Faso. METHODS: Two health districts in the Sahel region eliminated user fees for facility deliveries and curative consultations for children in September 2008. To compare health-care coverage before and after this change, we used interrupted time series, propensity scores and three independent data sources. Coverage changes were assessed for four variables: women giving birth at a health facility, and children aged 1 to 59 months receiving oral rehydration salts for diarrhoea, antibiotics for pneumonia and artemesinin for malaria. We modelled the mortality impact of coverage changes in the Lives Saved Tool using several scenarios. FINDINGS: Coverage increased for all variables, however, the increase was not statistically significant for antibiotics for pneumonia. For estimated mortality impact, the intervention saved approximately 593 (estimate range 168-1060) children's lives in both districts during the first year. This lowered the estimated under-five mortality rate from 235 deaths per 1000 live births in 2008 to 210 (estimate range 189-228) in 2009. If a similar intervention were to be introduced nationwide, 14,000 to 19,000 (estimate range 4000-28,000) children's lives could be saved annually. Maternal mortality showed a modest decrease in all scenarios. CONCLUSION: In this setting, eliminating user fees increased use of health services and may have contributed to reduced child mortality.

Insecticide-treated nets ownership and utilization among under-five children following the 2010 mass distribution in Burkina Faso.

BACKGROUND: Periodic mass distributions contribute significantly to universal access to insecticide-treated nets (ITNs). However, due to the limited number of nets distributed, needs remain unsatisfied, particularly in large households. METHODS: This study was conducted in Kaya health district following the 2010 mass distribution of ITNs in Burkina Faso. Data were collected on the socio-economic and geo-spatial characteristics and ITN possession and utilization levels of 2,004 households. The study explored: 1) ITN access, in terms of intra-household saturation with ITNs (households with at least one ITN for every two members) correctly installed and in very good physical condition; and 2) factors influencing the decision to place under-five children under a net. Particular attention was given to vector control activities undertaken by mothers. RESULTS: Of the 2,004 households, 90% possessed at least one ITN. However, intra-household saturation with ITNs was below 60% in small households and below 20% in large ones (>6 members). Crude proportion ratios comparing possession and levels of intra-household saturation with ITNs varied between 1.5 (small households) and 7.8 (large households). The proportions of households with ITNs for every two members that were correctly hung or in very good physical condition ranged from 0% to 6.5% in large households and 27.8% to 40.7% in small ones. ITN use to protect under-five children was lower in large households; it was significantly higher when there was at least one ITN for every two members. In large households, it was significantly higher when a child had experienced an episode of any illness in the previous two weeks and when the mother had taken actions to control vector proliferation. In small households, ITN use was significantly higher in families with agricultural land and children aged 12-23 months. CONCLUSION: Ownership rates were high, but real access to bed nets remained limited. The allocation process disadvantages large families. Real access to bed nets implies they are available, properly installed, and in good condition. More post-campaign awareness-raising activities targeting preventive practices in households could foster more effective ITN use.

Evolution of Sleep Duration and Screen Time Between 2018 and 2022 Among Canadian Adolescents: Evidence of Drifts Accompanying the COVID-19 Pandemic.

PURPOSE: We quantified the joint evolution of sleep duration and screen time between 2018 and 2022 in a large sample of adolescents from Quebec, Canada, to ascertain changes that occurred during the COVID-19 pandemic. METHODS: A natural experiment design was used to compare variations from year to year and in association with the pandemic outbreak. Using structural equation modeling on data collected between 2018 and 2022 among adolescents attending 63 high schools, we analyzed the joint evolution of sleep duration and screen time while adjusting for previous year values, concurrent flourishing score, sex, age, and family level of material deprivation. RESULTS: A total of 28,307 adolescents, aged on average 14.9 years, were included in the analyses. Between 2019 and 2022, sleep duration increased by 9.6 (5.7, 13.5) minutes and screen time by 129.2 (120.5, 138.0) minutes on average. In 2022, the adolescents spent almost equal amounts of time sleeping and using screens. Lower flourishing scores were associated with shorter sleep duration and lengthier screen time. Girls' screen time became similar to boys' over time. DISCUSSION: Adolescents now spend almost equal amounts of time sleeping and using screens, a situation that calls for urgent public health actions. These findings highlight the importance of tracking changes in adolescents' behaviours over time, to design and implement interventions adapted to the changing health needs of different groups.

Adolescents' Depression and Anxiety Symptoms During the COVID-19 Pandemic: Longitudinal Evidence From COMPASS.

PURPOSE: There is concern over the potentially detrimental impact of the COVID-19 pandemic on adolescents' mental health. We examined changes in depression and anxiety symptoms from before (2018-19) to the early (2019-20) and ongoing pandemic (2020-21) responses among Canadian adolescents in the context of a natural experiment. METHODS: We used linked survey data from 5,368 Canadian secondary school students who participated in three consecutive waves of the cannabis use, obesity, mental health, physical activity, alcohol use, smoking, and sedentary behaviour study during the 2018-19, 2019-20, and 2020-21 school year. Separate fixed effects models examined whether changes in depression (Center for Epidemiologic Studies Depression Scale Revised-10) and anxiety (General Anxiety Disorder-7) symptoms differed between two cohorts. The cohorts differed in the timing of their second data collection wave; one cohort participated before the pandemic and the other cohort participated in the early pandemic (spring 2020). RESULTS: Depression and anxiety symptoms increased during the early and ongoing pandemic periods in the overall sample and both cohorts. The two cohorts experienced similar elevations in their symptoms. Females and younger respondents presented greater elevations over time. The proportion of adolescents with significant depressive (29.4%) and moderate-to-severe anxiety (17.6%) symptoms at baseline increased by 1.5 times, reaching 44.8% and 29.8% in the ongoing pandemic period, respectively. DISCUSSION: Findings suggest that internalizing symptoms have consistently increased since before the onset of COVID-19, particularly in the ongoing pandemic period; however, we found no evidence of the increase being due to the pandemic in the early COVID-19 period when comparing the two cohorts. Ongoing evaluation of adolescents' mental health is necessary to capture potentially dynamic impacts over time.

Mapping of initiatives to increase membership in mutual health organizations in Benin.

INTRODUCTION: Mutual health organizations (MHO) have been implemented across Africa to increase access to healthcare and improve financial protection. Despite efforts to develop MHOs, low levels of both initial enrolment and membership renewals continue to threaten their financial viability. The purpose of this study was to map initiatives implemented to increase the pool of MHO members in Benin. METHODS: A multiple case study was conducted to assess MHOs supported by five major promoters in Benin. Three months of fieldwork resulted in 23 semi-structured interviews and two focus groups with MHO promoters, technicians, elected members, and health professionals affiliated with the MHOs. Fifteen non-structured interviews provided additional information and a valuable source of triangulation. RESULTS: MHOs have adopted a wide range of initiatives targeting different entry points and involving a variety of stakeholders. Initiatives have included new types of collective health insurance packages and efforts to raise awareness by going door-to-door and organizing health education workshops. Different types of partnerships have been established to strengthen relationships with healthcare professionals and political leaders. However, the selection and implementation of these initiatives have been limited by insufficient financial and human resources. CONCLUSIONS: The study highlights the importance of prioritizing sustainable strategies to increase MHO membership. No single MHO initiative has been able to resolve the issue of low membership on its own. If combined, existing initiatives could provide a comprehensive and inclusive approach that would target all entry points and include key stakeholders such as household decision-makers, MHO elected members, healthcare professionals, community leaders, governmental authorities, medical advisors, and promoters. There is a need to evaluate empirically the implementation of these interventions. Mechanisms to promote dialogue between MHO stakeholders would be useful to devise innovative strategies, avoid repeating unsuccessful ones, and develop a coordinated plan to promote MHOs.