Facilitators and barriers for implementing screening brief intervention and referral for health promotion in a rural hospital in Alberta: using consolidated framework for implementation research.

BACKGROUND: Screening, brief intervention, and referral (SBIR) is an evidence-based, comprehensive health promotion approach commonly implemented to reduce alcohol and substance use. Implementation research on SBIR demonstrate that patients find it acceptable, reduces hospital costs, and it is effective. However, SBIR implementation in hospital settings for multiple risk factors (fruit and vegetable consumption, physical activity, alcohol and tobacco use) is still emergent. More evidence is needed to guide SBIR implementation for multiple risk factors in hospital settings. OBJECTIVE: To explore the facilitators and barriers of SBIR implementation in a rural hospital using the Consolidated Framework for Implementation Research (CFIR). METHODS: We conducted a descriptive qualitative investigation consisting of both inductive and deductive analyses. We conducted virtual, semi-structured interviews, guided by the CFIR framework. All interviews were audio-recorded, and transcribed verbatim. NVivo 12 Pro was used to organize and code the raw data. RESULTS: A total of six key informant semi-structured interviews, ranging from 45 to 60 min, were carried out with members of the implementation support team and clinical implementers. Implementation support members reported that collaborating with health departments facilitated SBIR implementation by helping (a) align health promotion risk factors with existing guidelines; (b) develop training and educational resources for clinicians and patients; and (c) foster leadership buy-in. Conversely, clinical implementers reported several barriers to SBIR implementation including, increased and disrupted workflow due to SBIR-related documentation, a lack of knowledge on patients' readiness and motivation to change, as well as perceived patient stigma in relation to SBIR risk factors. CONCLUSION: The CFIR provided a comprehensive framework to gauge facilitators and barriers relating to SBIR implementation. Our pilot investigation revealed that future SBIR implementation must address organizational, clinical implementer, and patient readiness to implement SBIR at all phases of the implementation process in a hospital.

Effective strategies for Fecal Immunochemical Tests (FIT) programs to improve colorectal cancer screening uptake among populations with limited access to the healthcare system: a rapid review.

BACKGROUND: Colorectal cancer (CRC) is one of the leading causes of cancer death globally. CRC screening can reduce the incidence and mortality of CRC. However, socially disadvantaged groups may disproportionately benefit less from screening programs due to their limited access to healthcare. This poor access to healthcare services is further aggravated by intersecting, cumulative social factors associated with their sociocultural background and living conditions. This rapid review systematically reviewed and synthesized evidence on the effectiveness of Fecal Immunochemical Test (FIT) programs in increasing CRC screening in populations who do not have a regular healthcare provider or who have limited healthcare system access. METHODS: We used three databases: Ovid MEDLINE, Embase, and EBSCOhost CINAHL. We searched for systematic reviews, meta-analysis, and quantitative and mixed-methods studies focusing on effectiveness of FIT programs (request or receipt of FIT kit, completion rates of FIT screening, and participation rates in follow-up colonoscopy after FIT positive results). For evidence synthesis, deductive and inductive thematic analysis was conducted. The findings were also classified using the Cochrane Methods Equity PROGRESS-PLUS framework. The quality of the included studies was assessed. RESULTS: Findings from the 25 included primary studies were organized into three intervention design-focused themes. Delivery of culturally-tailored programs (e.g., use of language and interpretive services) were effective in increasing CRC screening. Regarding the method of delivery for FIT, specific strategies combined with mail-out programs (e.g., motivational screening letter) or in-person delivery (e.g., demonstration of FIT specimen collection procedure) enhanced the success of FIT programs. The follow-up reminder theme (e.g., spaced out and live reminders) were generally effective. Additionally, we found evidence of the social determinants of health affecting FIT uptake (e.g., place of residence, race/ethnicity/culture/language, gender and/or sex). CONCLUSIONS: Findings from this rapid review suggest multicomponent interventions combined with tailored strategies addressing the diverse, unique needs and priorities of the population with no regular healthcare provider or limited access to the healthcare system may be more effective in increasing FIT screening. Decision-makers and practitioners should consider equity and social factors when developing resources and coordinating efforts in the delivery and implementation of FIT screening strategies.

Geospatial analysis and participant characteristics associated with colorectal cancer screening participation in Alberta, Canada: a population-based cross-sectional study.

BACKGROUND: Colorectal cancer (CRC) is a leading cause of death in Canada and early detection can prevent deaths through screening. However, CRC screening in Alberta, Canada remains suboptimal and varies by sociodemographic and health system characteristics, as well as geographic location. This study aimed to further the understanding of these participant and health system characteristics associated with CRC screening in Alberta and identify clusters of regions with higher rates of overdue or unscreened individuals. METHODS: We included Albertans aged 52 to 74 as of December 31, 2019 (index date) and we used data from administrative health data sources and linked to the Alberta Colorectal Cancer Screening Program database to determine colorectal cancer screening rates. We used multivariable multinomial logistic regression analysis to investigate the relationship between sociodemographic, health system characteristics and participation in CRC screening. We used optimized Getis-Ord Gi* hot-spot analysis to identify hot and cold-spots in overdue for and no record of CRC screening. RESULTS: We included 919,939 Albertans, of which 65% were currently up to date on their CRC screening, 21% were overdue, and 14% had no record of CRC screening. Compared to Albertans who were currently up to date, those who were in older age groups, those without a usual provider of care, those who were health system non-users, and those living in more deprived areas were more likely to have no record of screening. Areas with high number of Albertans with no record of screening were concentrated in the North and Central zones. CONCLUSIONS: Our study showed important variation in colorectal cancer screening participation across sociodemographic, health system and geographical characteristics and identified areas with higher proportions of individuals who have no record of screening or are under-screened in Alberta, Canada.

Developing non-response weights to account for attrition-related bias in a longitudinal pregnancy cohort.

BACKGROUND: Prospective cohorts may be vulnerable to bias due to attrition. Inverse probability weights have been proposed as a method to help mitigate this bias. The current study used the "All Our Families" longitudinal pregnancy cohort of 3351 maternal-infant pairs and aimed to develop inverse probability weights using logistic regression models to predict study continuation versus drop-out from baseline to the three-year data collection wave. METHODS: Two methods of variable selection took place. One method was a knowledge-based a priori variable selection approach, while the second used Least Absolute Shrinkage and Selection Operator (LASSO). The ability of each model to predict continuing participation through discrimination and calibration for both approaches were evaluated by examining area under the receiver operating curve (AUROC) and calibration plots, respectively. Stabilized inverse probability weights were generated using predicted probabilities. Weight performance was assessed using standardized differences of baseline characteristics for those who continue in study and those that do not, with and without weights (unadjusted estimates). RESULTS: The a priori and LASSO variable selection method prediction models had good and fair discrimination with AUROC of 0.69 (95% Confidence Interval [CI]: 0.67-0.71) and 0.73 (95% CI: 0.71-0.75), respectively. Calibration plots and non-significant Hosmer-Lemeshow Goodness of Fit Tests indicated that both the a priori (p = 0.329) and LASSO model (p = 0.242) were well-calibrated. Unweighted results indicated large (> 10%) standardized differences in 15 demographic variables (range: 11 - 29%), when comparing those who continued in the study with those that did not. Weights derived from the a priori and LASSO models reduced standardized differences relative to unadjusted estimates, with the largest differences of 13% and 5%, respectively. Additionally, when applying the same LASSO variable selection method to develop weights in future data collection waves, standardized differences remained below 10% for each demographic variable. CONCLUSION: The LASSO variable selection approach produced robust weights that addressed non-response bias more than the knowledge-driven approach. These weights can be applied to analyses across multiple longitudinal waves of data collection to reduce bias.

Unmet Primary Health Care Needs among Nepalese Immigrant Population in Canada.

BACKGROUND: Immigrants represent over one-fifth (21.9%) of the Canadian population, which is an increasing trend. Primary care is a gateway to accessing the healthcare system for the majority of Canadians seeking medical services; however, Canada reported a growing shortage of healthcare providers, mainly primary care practitioners. Canadians, including immigrants, encounter many unmet healthcare needs due to various reasons. This study aimed to assess unmet healthcare (UHC) needs and associated factors among Nepalese immigrants residing in Calgary. METHODS: A cross-sectional study using a self-administered questionnaire was conducted in 2019. UHC needs were measured based on a single-item question: "During the past 12 months, was there ever a time that you felt you needed medical help, but you did not receive it". A follow-up question was asked to learn about associated unmet needs factors, and the responses were categorized into availability, accessibility, and acceptability. Descriptive and multivariable logistic regression was employed to assess the association between UHC needs and its predictors by using STATA version 14.2. RESULTS: Of 401 study participants, nearly half of the participants (n = 187; 46.63%) reported UHC needs, which was not significantly different among male and female participants (p = 0.718). UHC needs were nearly two times higher among those aged 26-45 (AOR 1.93) and those ≥56 years (AOR 2.17) compared to those under 25 years of age. The top reasons reported for unmet needs were long waits to access care (67.91%), healthcare costs (57.22%), and lack of knowing where to get help (31.55%). Overall, "services availability when required" was a leading obstacle that accounted for UHC needs (n = 137, 73.26%). Nearly two-thirds (n = 121, 64.71%) of participants reported that "accessibility of services" was a barrier, followed by "acceptability (n = 107, 57.22%). Those who reported UHC needs also reported an impact on their lives personally and economically. The most commonly reported personal impact was mental health impact, including worry, anxiety, and stress (67.38%). The most common economic impact reported due to UHC needs was increased use of over-the-counter drugs (33.16%) and increased healthcare costs (17.20%). CONCLUSIONS: UHC needs are presented in the Nepalese immigrant population. Accessibility to healthcare is limited for several reasons: waiting time, cost, distance, and unavailability of services. UHC needs impact individuals' personal health, daily life activities, and financial capacity. Strategies to improve access to PHC for disadvantaged populations are crucial and need to be tackled effectively.

Women's Mental Health up to Eight Years after Childbirth and Associated Risk Factors: Longitudinal Findings from the All Our Families Cohort in Canada.

OBJECTIVE: This study examined the prevalence of elevated maternal anxiety and/or depression symptoms up to eight years after childbirth and the association between role and relationship strains during parenting and mental health challenges from three to eight years after childbirth. METHODS: This study used data from the All Our Families longitudinal pregnancy cohort. Role and relationship strain factors and anxiety and depression symptoms were measured at repeated time points from four months to eight years after childbirth. The proportion of women with elevated anxiety and/or depression was calculated at each available time point. Generalized estimating equation models were used to examine the association between role and relationship strain factors and anxiety and/or depression from three to eight years after childbirth. Predicted probability of having anxiety and/or depression was estimated across those with and without challenges with roles and relationships. The models were adjusted for known risk factors such as maternal income and perinatal anxiety and/or depression. RESULTS: The prevalence of elevated anxiety and/or depression ranged from 18.8% (at four months) to 26.2% (at eight years). The adjusted odds ratio of anxiety and/or depression was 3.5 (95% CI = 2.9, 4.3) for those juggling family responsibilities and 2.4 (95% CI = 2.0, 3.0) for those with stressful partner relationship compared to their counterparts. Similarly, experiencing financial crunch and poor partner relationship were associated with increased mental health difficulties. Women without challenges in roles or relationships had a 23% lower predicted probability of anxiety and/or depression than those with the challenges. CONCLUSIONS: Monitoring mothers for anxiety and depression beyond the postpartum period and strategies that address role and relationship challenges may be valuable to women at risk of anxiety and depression.

Implementing Screening, Brief Intervention and Referral Intervention for Health Promotion and Disease Prevention in Hospital Settings in Alberta: A Pilot Study.

Objective: This study assessed the feasibility of implementing screening, brief intervention and referral (SBIR) intervention in hospital settings. Methods: This cross-sectional study evaluated the implementation of the SBIR intervention in a hospital in Alberta for tobacco use, alcohol intake, physical inactivity, and insufficient vegetable and fruit consumption. Patients were interviewed approximately 4-month later to collect data on the acceptability and effectiveness of the intervention received (n = 108). The data were primarily analyzed using descriptive statistics. Results: Of 108 patients, >80% agreed that "they were ok with being screened" for the risk factors during their hospital visit. Up to 68% of patients recalled the provider's brief education. At the follow-up, 20% of patients quit tobacco, 50% reduced alcohol use, 30% increased physical activity, and 25% increased vegetable and fruit intake. Conclusion: Risk factor screening was acceptable for patients. Patients recalled the brief education they received from healthcare providers. Patients reported risk-reducing changes in their risk factors. Our future work will integrate the SBIR approach within the Electronic Clinical Information System and use robust research methods to investigate the impact of SBIR on patients' behavior change.

Childhood Adversity and Mental Health Outcomes Among University Students: A Longitudinal Study.

BACKGROUND: Mental health concerns are common among university students and maybe elevated among those with specific risk exposures. The study examined the association between childhood adversities and mental health outcomes among undergraduate university students and assessed whether psychosocial and behavioral factors mediate those associations. METHODS: The Queen's University Student Well-Being and Academic Success Survey identified two large cohorts of first-year undergraduate students entering university in Fall 2018 and 2019 (n = 5,943). At baseline, students reported sociodemographic information, family-related mental health history, childhood physical abuse, sexual abuse, peer bullying, and parental separation or divorce. Baseline and follow-up surveys in Spring 2019, Fall 2019, and Spring 2020 included validated measures of anxiety (7-item Generalized Anxiety Disorder) and depressive symptoms (9-item Patient Health Questionnaire ), non-suicidal self-harm, and suicidality, along with psychological processes and lifestyle variables. Repeated measures logistic regression using Generalized Estimating Equations was used to characterize the associations between childhood adversities and mental health outcomes and examine potential mediation. RESULTS: Adjusting for age, gender, ethnicity, familial mental illness, and parental education, any childhood abuse (odds ratio: 2.89; 95% confidence interval, 2.58 to 3.23) and parental separation or divorce (odds ratio: 1.29; 95% confidence interval, 1.12 to 1.50) were significantly associated with a composite indicator of mental health outcomes (either 9-item Patient Health Questionnaire score ≥10 or 7-item Generalized Anxiety Disorderscore ≥10 or suicidality or self-harm). The association with childhood abuse weakened when adjusted for perceived stress, self-esteem, and insomnia (odds ratio: 2.05; 95% confidence interval, 1.80 to 2.34), and that with parental divorce weakened when adjusted for self-esteem (odds ratio: 1.17; 95% confidence interval, 1.00 to 1.36). CONCLUSION: Childhood abuse and parental separation or divorce were associated with mental health concerns among university students. Childhood adversities may impact later mental health through an association with stress sensitivity, self-esteem, and sleep problems. The findings suggest that prevention and early intervention focusing on improving sleep, self-esteem, and coping with stress while considering the individual risk profile of help-seeking students may help support student mental health.

Patient-Identified Solutions to Primary Care Access Barriers in Canada: The Viewpoints of Nepalese Immigrant Community Members.

BACKGROUND: Accessing healthcare for immigrants in Canada is complicated by many difficulties. With the continued and upward trend of immigration to Canada, it is crucial to identify the solutions to the barriers from the perspectives of different immigrant communities as they encounter them including the relatively smaller and less studied population groups of immigrants. As such, Nepalese immigrants in Canada are a South Asian ethnic group who have their own distinct language, culture, and socio-economic backgrounds, however, their experience with accessing healthcare in Canada is scarce in the literature. METHODS: We conducted 12 focus group discussions with first-generation Nepalese immigrants who had experiences with primary care use in Canada. Informed consent and demographic information were obtained before each focus group discussion. The verbatim transcription of the focus groups was analyzed using thematic analysis. RESULTS: The participants expressed a range of potential solutions to overcome the barriers, which we presented using the socio-ecological framework into 4 different levels. This includes individual-, community-, service provider-, and government/policy-levels. Individual-level actions included improving self-awareness and knowledge of health in general and navigating the healthcare system and proactively improving the language skills and assimilating into the Canadian culture. Examples of community-level actions included community events to share health information with immigrants, health literacy programs, and driving/carpooling to clinics or hospitals. Actions at the service provider level were mainly focused on enhancing communications, cultural competency training for providers, and ensuring to hire primary care workforce representing various ethnocultural backgrounds. Overall, focus group participants believed that the provincial and federal government, as appropriate, should increase support for dental and vision care support and take actions to increase the healthcare capacity, particularly by employing internationally graduated health professionals. CONCLUSIONS: Access to primary care is essential for the health of immigrant populations in Canada. Individuals, community organizations, health service providers, and governments need to work both individually and collaboratively to improve immigrants' primary care access.

Interventions to Increase Colorectal Cancer Screening Uptake in Primary Care: A Systematic Review.

OBJECTIVE: We systematically reviewed and summarized previous studies that examined facilitators and barriers to implementing interventions to increase CRCS uptake in primary care practice. METHODS: We searched PubMed, Medline (EBSCO), and CINAHL databases, from the inception of these databases to April 2020. The search strategy combined a set of terms related to facilitators/barriers, intervention implementation, CRCS, and uptake/participation. A priori set inclusion and exclusion criteria were used during both title/abstract screening and full-text screening phases to identify the eligible studies. Quality of the included studies was appraised using quality assessment tools, and data were extracted using a predetermined data extraction tool. We classified facilitators and barriers according to the Consolidated Framework for Implementation Research domains and constructs and identified the common facilitators and barriers looking at how common they were across studies. RESULTS: A total of 12 studies were included in the review. Engagement of the clinic team, leadership team, and partners, clinics' motivation to improve CRCS rates, use of the EMR system, continuous monitoring and feedback system, and having a supportive environment for implementation were the most commonly reported implementation facilitators. Limited time for the clinic team to devote to a new project, challenges in getting accurate, timely data related to CRCS, limited capacity/support to use the EMR system, and disconnect between clinic team members were the most commonly reported implementation barriers. CONCLUSIONS: The synthesized findings improve our understanding of facilitators of and barriers to the implementation of interventions to increase CRCS participation in primary care practice, and inform the customized implementation strategies. Many of the included studies had limited use of rigorous implementation science frameworks to guide their implementation and evaluation, which precludes a comprehensive understanding of the implementation factors specific to CRCS interventions in primary care. Future studies assessing the CRCS intervention implementation factors would benefit from the use of implementation science frameworks.

Patterns of up-to-date status for colorectal cancer screening in Alberta: a cross-sectional study using survey data.

BACKGROUND: Regular screening for colorectal cancer (CRC) reduces its mortality. We explored patterns of use of different CRC screening modalities and quantified the association between having a regular primary care provider and being up to date for CRC screening in a community-based population in Alberta, Canada. METHODS: We conducted a cross-sectional study of adults between 50 and 74 years of age in Alberta, using Canadian Community Health Survey data (2015-2016). We defined being up to date for CRC screening as having completed a fecal occult blood test (FOBT) or fecal immunochemical test (FIT) within the previous 2 years, or having a colonoscopy or sigmoidoscopy in the previous 5 years before the survey. We analyzed data using multivariable logistic regression models. RESULTS: Of 4600 surveyed adults, 62.6% were up to date for CRC screening, with 45.1% having completed a FIT or FOBT (45.1%), and 34.1% having undergone a colonoscopy or sigmoidoscopy. The adjusted odds ratio of being up to date for CRC screening was 0.25 (95% confidence interval 0.17-0.38) and the absolute probability of being up to date for CRC screening was 34.4% lower for adults who had no regular primary care provider, compared with those who had. This pattern was observed in both male and female subgroups. INTERPRETATION: Our findings suggest a suboptimal uptake of CRC screening overall in Alberta, with high disparity between adults with and without a regular primary care provider. The use of customized, multicomponent intervention strategies that are shown to be effective in increasing participation in CRC screening may address this issue.

Cesarean Deliveries Among Immigrant and Canadian-Born Women in a Representative Community Population in Canada: A Retrospective Cohort Study.

OBJECTIVE: To examine differences in the rate of cesarean delivery between Canadian-born women and immigrants to Canada and by duration of time in Canada and rate of cesarean delivery in their country-of-origin. METHODS: We used linked data from hospitalization records and the Canadian Community Health Survey for all deliveries after 20 weeks gestation between 2002 and 2017 in Canada (excluding Québec). Odds of cesarean delivery in recent immigrants (<5 y in Canada) and non-recent immigrants (≥5 y in Canada) were compared with those of Canadian-born women using multivariable logistic regression. Immigrants were further categorized using the cesarean delivery rate in their country-of-origin as low (<10%), medium (≥10 to <35%), or high (≥35%). RESULTS: Of the 53 505 women included, 89% were Canadian-born, 4% were recent immigrants and 7% were non-recent immigrants. Overall, 28.6% of women had a cesarean delivery. After adjusting for medical and socio-economic factors, the odds of cesarean delivery among recent immigrants (OR 1.12; 95% CI 0.95-1.34) and non-recent immigrants (OR 1.11; 95% CI 0.98-1.25) did not differ statistically from those of Canadian-born women. Recent immigrants from countries with lower cesarean delivery rates had higher odds of cesarean delivery (OR 1.34; 95% CI 1.05-1.70), whereas the odds of cesarean for recent immigrants from medium- and high-rate countries did not differ from those of Canadian-born women. CONCLUSION: After accounting for demographic and medical factors, few differences remained in cesarean delivery rates between immigrants and Canadian-born women. Country-of-origin practices are unlikely to reflect preferences for cesarean delivery in immigrant women in Canada.

Data harmonization and data pooling from cohort studies: a practical approach for data management.

Data pooling from pre-existing datasets can be useful to increase study sample size and statistical power in order to answer a research question. However, individual datasets may contain variables that measure the same construct differently, posing challenges for data pooling. Variable harmonization, an approach that can generate comparable datasets from heterogeneous sources, can address this issue in some circumstances. As an illustrative example, this paper describes the data harmonization strategies that helped generate comparable datasets across two Canadian pregnancy cohort studies: All Our Families; and the Alberta Pregnancy Outcomes and Nutrition. Variables were harmonized considering multiple features across the datasets: the construct measured; question asked/response options; the measurement scale used; the frequency of measurement; timing of measurement, and the data structure. Completely matching, partially matching, and completely un-matching variables across the datasets were determined based on these features. Variables that were an exact match were pooled as is. Partially matching variables were harmonized or processed under a common format across the datasets considering the frequency of measurement, the timing of measurement, the measurement scale used, and response options. Variables that were completely unmatching could not be harmonized into a single variable. The variable harmonization strategies that were used to generate comparable cohort datasets for data pooling are applicable to other data sources. Future studies may employ or evaluate these strategies, which permit researchers to answer novel research questions in a statistically efficient, timely, and cost-efficient manner that could not be achieved using a single data source.

Birth outcomes, pregnancy complications, and postpartum mental health after the 2013 Calgary flood: A difference in difference analysis.

BACKGROUND: In June 2013, the city of Calgary, Alberta and surrounding areas sustained significant flooding which resulted in large scale evacuations and closure of businesses and schools. Floods can increase stress which may negatively impact perinatal outcomes and mental health, but previous research is inconsistent. The objectives of this study are to examine the impact of the flood on pregnancy health, birth outcomes and postpartum mental health. METHODS: Linked administrative data from the province of Alberta were used. Outcomes included preterm birth, small for gestational age, a new diagnoses of preeclampsia or gestational hypertension, and a diagnosis of, or drug prescription for, depression or anxiety. Data were analyzed using a quasi-experimental difference in difference design, comparing flooded and non-flooded areas and in affected and unaffected time periods. Multivariable log binomial regression models were used to estimate risk ratios, adjusted for maternal age. Marginal probabilities for the difference in difference term were used to show the potential effect of the flood. RESULTS: Participants included 18,266 nulliparous women for the pregnancy outcomes, and 26,956 women with infants for the mental health analysis. There were no effects for preterm birth (DID 0.00, CI: -0.02, 0.02), small for gestational age (DID 0.00, CI: -0.02, 0.02), or new cases of preeclampsia (DID 0.00, CI: -0.01, 0.01). There was a small increase in new cases of gestational hypertension (DID 0.02, CI: 0.01, 0.03) in flood affected areas. There were no differences in postpartum anxiety or depression prescriptions or diagnoses. CONCLUSION: The Calgary 2013 flood was associated with a minor increase in gestational hypertension and not other health outcomes. Universal prenatal care and magnitude of the disaster may have minimized impacts of the flood on pregnant women.

Assessment of anxiety during pregnancy: are existing multiple anxiety scales suitable and comparable in measuring anxiety during pregnancy?

BACKGROUND: This study examined the performance of multiple anxiety scales in measuring anxiety during pregnancy, an important issue due to the possible effect of pregnancy-related symptoms on the measurement of anxiety. METHODS: Secondary data on anxiety, measured by the State-Trait Anxiety Inventory-State (STAI-S) 20-item and six-item scales, the Edinburgh Postnatal Depression Scale-Anxiety Subscale (EPDS-3A) and the Symptoms Checklist-90-Anxiety Subscale (SCL-90), were obtained from two pregnancy cohort studies. Both cohorts completed the EPDS-3A, while 3341 women completed the STAI-S and 2187 women completed the SCL-90, with 231 women participating in both cohorts. Data were analyzed using confirmatory factor analysis and Spearman correlation. RESULTS: The STAI-6 had adequate model fit, while the STAI-20 and the SCL-90 had inadequate model fit. Model fitness for the EPDS-3A could not be assessed due to its low number of items. The correlation between the STAI-20 and STAI-6 was excellent (r = 0.93). The correlation of EPDS-3A with other anxiety scales was low to moderate (r (STAI-20) = 0.57, r (STAI-6) = 0.53 and r (SCL-90) = 0.44). The correlation of SCL-90 with both STAI-20 and STAI-6 was low (r < 0.50). CONCLUSION: Findings indicate that these scales do not measure anxiety as a single dimension and that these scales are incomparable and may conceptualize anxiety differently.

A Viewpoint: Validation of Self-Reported Anxiety Screening Scales in Perinatal Populations- Outstanding Issues in the Validation Research Agenda.

In the absence of perinatal anxiety screening, clinically significant symptoms of anxiety remain under-detected and undertreated during perinatal period. Perinatal anxiety has a significant and far reaching impact on mothers and their children. There are well established recommendations for routine mental health screening during the perinatal period, yet less than one in five of providers routinely screen and one in seven women receive the mental health intervention they need. The validity of anxiety screening scales needs to be ascertained by criterion validity parameters such as sensitivity, specificity, and predictive values. Criterion validity, which is assessed against a reference standard, allows clear interpretation of screening results, supporting their integration with clinical care pathways. However, few existing validation studies of anxiety scales in perinatal populations examined criterion validity. Construct validity of anxiety scales, the focus of existing validation studies, does not use reference standard; thus, it lacks clear clinical interpretability for screening application. Future validation studies should focus on assessing the criterion validity of anxiety scales in perinatal populations. This will help nurses, midwives, and other members of interdisciplinary teams to clarify scale validity, interpretation, and utility for screening women for anxiety in the perinatal period.

Variation in characteristics of people with mental disorders across smoking status in the Canadian general population.

INTRODUCTION: People with mental disorders are less successful in smoking cessation efforts. This study compared the characteristics of current smokers and former smokers with mental disorders. METHODS: This was a cross-sectional study that used the Public Use Microdata File of the Canadian Community Health Survey 2012. Survey respondents with any mental health disorder in the last 12 months (n=2700), identified using the World Health Organization Composite International Diagnostic Interview instrument, were included in the analysis. Smoking status was classified based on self-report responses as current, former and never smoker. Logistic regression models were used to analyze the data. RESULTS: The odds of quitting smoking were significantly lower among people who were single or never married (widowed/divorced/separated/single) compared to those who were married or had a common-law partner (adjusted odds ratio, AOR=0.6, 95% CI: 0.4-0.9). Similarly, significantly lower odds of quitting smoking were observed among people with less than post-secondary education compared to those with post-secondary education (AOR=0.4, 95% CI: 0.3- 0.6). Also, the odds of quitting were significantly lower among immigrants, young adults, and middle-aged adults. CONCLUSIONS: People who are young or middle-aged, single or never married, less educated, and immigrants, are less likely to quit smoking. This pattern underscores the socioeconomic disparities in quitting smoking among people with mental disorders. Future research should investigate why these groups continue to smoke more often than their counterparts. This will help design the smoking cessation support that address the challenges experienced by vulnerable populations and reduce the disparities.

Mental disorders and subsequent suicide events in a representative community population.

OBJECTIVE: This study examined the patterns of association between mental disorders and subsequent suicide in a community sample representative of the Canadian household population. METHODS: This retrospective cohort study used data from the Canadian Community Health Survey 2002 linked to the Death Database 2000-2011 and the Hospitalization Database 1999/2000-2012/2013) (n=27,000). Mental disorders (past year major depressive episodes (MDE), bipolar disorders (BPD), anxiety disorders (AD), and substance dependence (SD)) and subsequent suicide events (deaths or hospitalizations for suicide attempts) were identified. Competing risk regression models were used to analyze the time-to-event data, adjusting for age, sex, marital status, and educational attainment. RESULTS: Past year mental disorders were diagnosed in 11.38% of the cohort and 0.41% had suicide events. An increased hazard of suicide events associated with MDE, SD and AD weakened over-time, but this was not observed for BPD. For example, the HR of suicide events for MDE was 6.02 (95% confidence interval (CI)=2.65, 13.68) in the first 4 years, whereas, it was 2.03 (95% CI=0.91, 4.53) after 4 years. Whereas, the HRs of suicide events for BPD were 16.95 (95% CI=6.88, 41.75) and 15.81 (95% CI=5.89, 42.45) before and after 4 years. LIMITATIONS: Diagnostic data are likely to underestimate the prevalence of suicide events. CONCLUSIONS: The risk of suicide events declined over time for MDE, SA and AD, but remained high for BPD. This may reflect improvement over time in MDE, SA and AD, but indicates that people living with BPD have a persistent elevated hazard of suicide events.

Monitoring maternal near miss/severe maternal morbidity: A systematic review of global practices.

There is international interest in monitoring severe events in the obstetrical population, commonly referred to as maternal near miss or severe maternal morbidity. These events can have significant consequences for individuals in this population and further study can inform practices to reduce both maternal morbidity and mortality. Numerous surveillance systems exist but we lack a standardized approach. Given the current inconsistencies and the importance in monitoring these events, this study aimed to identify and compare commonly used surveillance methods. In June 2018, we systematically searched MEDLINE, EMBASE, and CINAHL using terms related to monitoring/surveillance and maternal near miss/severe maternal morbidity. We included papers that used at least three indicators to monitor for these events and collected data on specific surveillance methods. We calculated the rate of maternal near miss/severe maternal morbidity in hospitalization data obtained from the 2016 US National Inpatient Sample using five common surveillance methods. Of 18,832 abstracts, 178 papers were included in our review. 198 indicators were used in studies included in our review; 71.2% (n = 141) of these were used in <10% of included studies and only 6.1% (n = 12) were used in >50% of studies included in our review. Eclampsia was the only indicator that was assessed in >80% of included studies. The rate of these events in American hospitalization data varied depending on the criteria used, ranging from 5.07% (95% CI = 5.02, 5.11) with the Centers for Disease Control criteria and 7.85% (95% CI = 7.79, 7.91) using the Canadian Perinatal Surveillance System. Our review highlights inconsistencies in monitoring practices within and between developed and developing countries. Given the wide variation in monitoring approaches observed and the likely contributing factors for these differences, it may be more feasible for clinical and academic efforts to focus on standardizing approaches in developed and developing countries independently at this time. PROSPERO Registration: CRD42018096858.