Attitudes, subjective norms and perceived behavioural control factors influencing Canadian secondary school students' milk and milk alternatives consumption.

OBJECTIVE: The research objectives were to evaluate factors that influence Canadian secondary school students' milk and milk alternatives (MMA) consumption and to explore associations through age and gender lenses. DESIGN: A qualitative design was used, consisting of semi-structured interviews and photo-elicitation methods. Analysis was guided by the Theory of Planned Behaviour (TPB). Deductive and inductive thematic analyses were used to generate themes, charting data based on attributes such as gender and age. SETTING: Interviews were held virtually or via telephone. PARTICIPANTS: Participants were twenty-eight high school students from Ontario, Canada, diverse in terms of gender and age. RESULTS: Both desirable and undesirable beliefs about the health outcomes of consuming MMA were commonly discussed. These included health benefits such as strong bones, muscular strength, and growth, and health consequences like unwanted skin conditions, weight gain, and diseases. While boys and girls associated MMA consumption with muscular strength, boys predominantly considered this favourable, while girls discussed outcomes like unwanted skin conditions and weight gain more often. Adolescents' perspectives on taste/perceived enjoyment, environmentally friendly choices and animal welfare also influenced their MMA preferences. Parental influences were most cited among social factors, which appeared to be stronger during early adolescence. Factors involving cost, time and accessibility affected adolescents' beliefs about how difficult it was to consume MMA. CONCLUSIONS: Recommendations for shifting attitudes towards MMA are provided to address unfavourable beliefs towards these products. Interventions to increase MMA consumption among adolescents should include parents and address cost barriers.

Turning the tide on inequity through systematic equity action-analysis.

BACKGROUND: Collective agreement about the importance of centering equity in health research, practice, and policy is growing. Yet, responsibility for advancing equity is often situated as belonging to a vague group of 'others', or delegated to the leadership of 'equity-seeking' or 'equity-deserving' groups who are tasked to lead systems transformation while simultaneously navigating the violence and harms of oppression within those same systems. Equity efforts also often overlook the breadth of equity scholarship. Harnessing the potential of current interests in advancing equity requires systematic, evidence-guided, theoretically rigorous ways for people to embrace their own agency and influence over the systems in which they are situated. ln this article, we introduce and describe the Systematic Equity Action-Analysis (SEA) Framework as a tool that translates equity scholarship and evidence into a structured process that leaders, teams, and communities can use to advance equity in their own settings. METHODS: This framework was derived through a dialogic, critically reflective and scholarly process of integrating methodological insights garnered over years of equity-centred research and practice. Each author, in a variety of ways, brought engaged equity perspectives to the dialogue, bringing practical and lived experience to conversation and writing. Our scholarly dialogue was grounded in critical and relational lenses, and involved synthesis of theory and practice from a broad range of applications and cases. RESULTS: The SEA Framework balances practices of agency, humility, critically reflective dialogue, and systems thinking. The framework guides users through four elements of analysis (worldview, coherence, potential, and accountability) to systematically interrogate how and where equity is integrated in a setting or object of action-analysis. Because equity issues are present in virtually all aspects of society, the kinds of 'things' the framework could be applied to is only limited by the imagination of its users. It can inform retrospective or prospective work, by groups external to a policy or practice setting (e.g., using public documents to assess a research funding policy landscape); or internal to a system, policy, or practice setting (e.g., faculty engaging in a critically reflective examination of equity in the undergraduate program they deliver). CONCLUSIONS: While not a panacea, this unique contribution to the science of health equity equips people to explicitly recognize and interrupt their own entanglements in the intersecting systems of oppression and injustice that produce and uphold inequities.

Economic burden of food allergy in Canada: Estimating costs and identifying determinants.

BACKGROUND: Limited data exist on the economic burden of food allergy (FA). OBJECTIVE: To assess FA-related direct (healthcare and out-of-pocket) and indirect (lost productivity) costs and their determinants in Canadian children and adults self-reporting FA. METHODS: FA-individuals self-reporting a convincing history or physician diagnosis were recruited through FA registries, an anaphylaxis registry, and advocacy associations, and electronically surveyed regarding FA-related healthcare use, out-of-pocket expenditures, and time lost from paid and unpaid labor. Direct and indirect costs (2020 Canadian dollars [CAD]) were stratified on severe reaction vs mild, moderate or no reaction, and children vs adults; multivariate regressions assessed the association between costs and sociodemographic and disease characteristics. RESULTS: Between May 2018 and July 2019, 2692 eligible individuals responded (2189 convincing history and 503 physician diagnosis only); 1020 experienced a severe reaction; 1752 were children. Per FA-individual, annual healthcare, out-of-pocket, and indirect costs were $1267, $2136, and $7950. Those with a severe reaction had higher healthcare and out-of-pocket costs than those with mild, moderate or no reaction. FA-children vs FA-adults had higher healthcare and out-of-pocket costs, and lower indirect costs. Multivariate results showed that lower age, a severe reaction ever, multiple FAs, and fair or poor general health were associated with higher healthcare and out-of-pocket costs. Higher age, lower household education and income, and fair or poor general health were associated with higher indirect costs. CONCLUSION: The economic burden of FA in Canada is substantial, particularly for those with a severe reaction ever, multiple FAs, and fair or poor general health. It is crucial that those most adversely affected are allocated appropriate resources to support disease management.

Socioeconomic factors and bacillary dysentery risk in Jiangsu Province, China: a spatial investigation using Bayesian hierarchical models.

Bacillary dysentery (BD) is an acute diarrheal disease prevalent in areas affected by socioeconomic disparities. We investigated BD risk and its associations with socioeconomic factors at the county-level in Jiangsu province, China using epidemiological and socioeconomic data from 2011-2014. We fitted four Bayesian hierarchical models with various prior specifications for random effects. As all model comparison criteria values were similar, we presented results from a reparameterized Besag-York-Mollié model, which addressed issues with the identifiability of variance captured by spatial and independent effects. Our model adjusted for year and socioeconomic status showed 18-65% decreased BD risk compared to 2011. We found a high relative risk in the northwestern and southwestern counties. Increasing the percentage of rural households, rural income per capita, health institutions per capita, or hospital beds per capita decreases the relative risk of BD, respectively. Our findings can be used to improve infectious diarrhea surveillance and enhance existing public health interventions.

Geospatial analysis of cholera patterns in Nigeria: findings from a cross-sectional study.

BACKGROUND: Persistence of cholera outbreaks in developing countries calls for concern and more targeted intervention measures for long-term control. This research undertook spatial analysis of cholera incidence in Nigeria over a seventeen-year period to determine the existence of regional hotspots and predictors. METHODS: A cross-sectional study design was used for the research. Cholera data for each of the thirty-six states and the federal capital territory (FCT) were obtained from the Nigeria Centre for Disease Control (NCDC) of the Federal Ministry of Health, Nigeria. Socioeconomic data including proportion of households using solid waste disposal (unapproved dumpsite, refuse burying, refuse burning, public dumpsite, and refuse collectors), water sources (pipe borne water, well, borehole, rain water, surface waters and water vendors), sewage disposal (water closet, pit latrines, bucket/pan, public toilet and nearby bush/stream), living in a single room and earning less than minimum wage (18,000 naira) were obtained from National Population Commission. On the other hand, proportion of illiterate adults (15 years and above) and poor people; and population density were obtained from National Bureau of Statistics. Each socioeconomic data was obtained at state level. Cholera patterns were analysed at state level using Global Moran's I while specific locations of cholera clusters were determined using Local Moran's I. Stepwise multiple regression was used to determine socioeconomic predictors of cholera incidence. RESULTS: Local Moran's I revealed significant cluster patterns in 1999, 2001, 2002, 2009 and 2010 in Adamawa, Gombe, Katsina, Bauchi, Borno, Yobe, and Kano states. Households using surface water was the significant predictor (23%) of the observed spatial variations in cholera incidence. CONCLUSIONS: Persistence of cholera outbreaks in some north east and north western states calls for more targeted, long-term and effective intervention measures especially on provision of safe sources of water supply by government and other stakeholders.

The value of hackathons in integrated knowledge translation (iKT) research: Waterlupus.

BACKGROUND: Despite a growing movement toward a knowledge-user-driven research process, our understanding of the generation, implementation and evaluation of specific approaches in the integrated knowledge translation (iKT) toolbox that aim to engage health and healthcare knowledge users is limited. Health hackathons offer an innovative approach with potential to generate direct and indirect health-related outcomes benefitting participants, knowledge users and the broader population. In May 2019, our research team hosted Waterlupus, a health hackathon to improve the economic lives of individuals with systemic lupus erythematosus (SLE) in Canada. Waterlupus was held with a multi-stakeholder group of 50 participants that included advocacy organization representatives, policy-makers, researchers, physicians, individuals with lived experience and students. While the hackathon generated viable solutions with the potential to positively impact the lives of individuals with SLE, understanding how participants perceived the hackathon as an iKT tool is critical in the planning and implementation of future iKT research. METHODS: Semi-structured in-depth telephone interviews were conducted with Waterlupus participants (n = 13) between August and November 2019 to (1) explore participant experiences of the hackathon; (2) investigate participant-identified hackathon outcomes; and (3) elicit recommendations for future iKT research using health hackathons. RESULTS: Participants provided feedback on the format and organization of Waterlupus, and identified direct and indirect outcomes to knowledge users, students and researchers beyond the innovations generated at the event. While the majority (n = 11) had never participated in a hackathon prior to Waterlupus, all 13 stated they would participate in future hackathons. Positive outcomes identified include connecting with students and other SLE stakeholders, the formation of professional and support networks, increased awareness of SLE, as well as the innovations generated. Participant recommendations for future health hackathons include the addition of stakeholders from industry or technology, and the need for clear and designated roles for stakeholders to ensure efficient use of resources. CONCLUSIONS: This work contributes to a limited literature regarding the use of health hackathons for social innovation, and offers knowledge-user suggestions relevant to the implementation of future iKT events, and hackathons specifically.

Water risk perceptions across the life-course of women in Kenya.

Inadequate access to water, sanitation and hygiene (WaSH) exposes many vulnerable populations, especially women and girls, to preventable diseases around the world. This paper reports findings from a photovoice project that explored water-related risk perceptions and health outcomes among women in Nyanchwa, Kenya. Thirteen women in four age categories were recruited for this study in July 2016 using the 'snowball' technique. From the results, inadequate access to WaSH was associated with increased water collection burden on women and children; environmental pollution; poor educational outcomes; loss of time due to water collection and poor sanitation infrastructure. Some barriers to change identified include financial barriers and inadequate government support. The identified risks and barriers are important considerations for the design, evaluation and mainstreaming of WaSH programs in resource constrained settings.

Trajectories of Depressive Symptoms and Perceived Stress From Pregnancy to the Postnatal Period Among Canadian Women: Impact of Employment and Immigration.

Objectives. To identify trajectory patterns of maternal depressive symptoms and perceived stress from midpregnancy to 2 years postpartum and determine relationships with selected sociodemographic factors including income, education, immigration, and postpartum employment. Methods. Pregnant women (n = 3307) recruited from the general population in 4 regions in Canada provided 6 waves of data from pregnancy to 2 years postpartum. The study was conducted from 2009 to 2015. Results. We determined 5 trajectory groups distinguished by time and magnitude for both depressive symptoms and perceived stress. Immigrants living in Canada for more than 5 up to 10 years, but not more recent arrivals, were at higher risk for persistent stress and depression independent of income status. Being employed at 1 year postpartum was associated with a lower likelihood of postpartum depression and perceived stress, while mothers reporting work exhaustion were substantially more likely to experience persistent depression and stress. Conclusions. The study highlighted the heterogeneous nature of depressive symptoms and perceived stress. Targeting interventions toward women 5 to 10 years after immigration and those experiencing exhaustion from postpartum work may be particularly beneficial.

Risk for Maternal Depressive Symptoms and Perceived Stress by Ethnicities in Canada: From Pregnancy Through the Preschool Years.

OBJECTIVE: Past cross-sectional studies have reported that mothers from ethnic minorities experience higher levels of prenatal and post-partum psychosocial distress compared with mothers from ethnic majorities. However, no studies have examined how the pattern varies longitudinally in a Canadian population of heterogeneous ethnicity. METHODS: We analyzed data from 3,138 mothers participating in the Canadian Healthy Infant Longitudinal Development (CHILD) Study, a longitudinal multi-center study incorporating 10 distinct waves of psychosocial data collection from pregnancy until the index child was aged 5 y. Maternal self-identified ethnicity was grouped as White Caucasian, First Nations, Black, Southeast Asian, East Asian, South Asian, Middle Eastern, Hispanic and mixed ethnicity. We performed a multi-level regression to determine whether mothers of specific minority ethnicities were more likely to experience higher levels of distress (i.e. depressive symptoms and perceived stress) compared to white Caucasian mothers. RESULTS: Mothers self-identifying as Black or First Nations had consistently higher distress scores than mothers from other ethnicities across all data collection times. After adjusting for relevant variables (history of depression, education, household income, marital status, and social support), First Nations mothers had a 20% increase in the mean scores of depressive symptoms compared to White Caucasian Mothers. CONCLUSIONS: Increased levels of perinatal and post-partum distress were seen in only some ethnic minority groups. Studies should avoid collapsing all categories into ethnic minority or majority and may need to consider how ethnicity interacts with other sociodemographic factors such as poverty.

Can knowledge exchange support the implementation of a health-promoting schools approach? Perceived outcomes of knowledge exchange in the COMPASS study.

BACKGROUND: Despite the potential population-level impact of a health-promoting schools approach, schools face challenges in implementation, indicating a gap between school health research and practice. Knowledge exchange provides an opportunity to reduce this gap; however, there has been limited evaluation of these initiatives. This research explored researchers' and knowledge users' perceptions of outcomes associated with a knowledge exchange initiative within COMPASS, a longitudinal study of Canadian secondary students and schools. Schools received annual tailored summaries of their students' health behaviours and suggestions for action and were linked with knowledge brokers to support them in taking action to improve student health. METHODS: Qualitative semi-structured interviews were conducted with COMPASS researchers (n = 13), school staff (n = 13), and public health stakeholders (n = 4) to explore their experiences with COMPASS knowledge exchange. Key issues included how knowledge users used school-specific findings, perceived outcomes of knowledge exchange, and suggestions for change. RESULTS: Outcomes for both knowledge users and researchers were identified; interestingly, knowledge users attributed more outcomes to using school-specific findings than knowledge brokering. School and public health participants indicated school-specific findings informed their programming and planning. Importantly, knowledge exchange provided a platform for partnerships between researchers, schools, and public health units. Knowledge brokering allowed researchers to gain feedback from knowledge users to enhance the study and a better understanding of the school environment. Interestingly, COMPASS knowledge exchange outcomes aligned with Samdal and Rowling's eight theory-driven implementation components for health-promoting schools. Hence, knowledge exchange may provide a mechanism to help schools implement a health-promoting schools approach. CONCLUSIONS: This research contributes to the limited literature regarding outcomes of knowledge brokering in public health and knowledge exchange in school health research. However, since not all schools engaged in knowledge brokering, and not all schools that engaged discussed these outcomes, further research is needed to determine the amount of engagement required for change and examine the process of COMPASS knowledge brokering to consider how to increase school engagement.

"Now What?" Perceived Factors Influencing Knowledge Exchange in School Health Research.

Increasing the uptake of school health research into practice is pivotal for improving adolescent health. COMPASS, a longitudinal study of Ontario and Alberta secondary students and schools (2012-2021), used a knowledge exchange process to enhance schools' use of research findings. Schools received annual summaries of their students' health behaviors and suggestions for action and were linked with a knowledge broker to support them in making changes to improve student health. The current research explored factors that influenced COMPASS knowledge exchange activities. Semistructured interviews were conducted with researchers (n = 13), school staff (n = 13), and public health stakeholders (n = 4). Interestingly, knowledge users focused more on factors that influenced their use of COMPASS findings than factors that influenced knowledge brokering. The factors identified by participants are similar to those that influence implementation of school health interventions (e.g., importance of school champions, competing priorities, inadequate resources). While knowledge exchange offers a way to reduce the gap between research and practice, schools that need the most support may not engage in knowledge exchange; hence, we must consider how to increase engagement of these schools to ultimately improve student health.

Psychosocial impacts of the lack of access to water and sanitation in low- and middle-income countries: a scoping review.

The lack of access to safe water and adequate sanitation has implications for the psychosocial well-being of individuals and households. To review the literature on psychosocial impacts, we completed a scoping review of the published literature using Medline, Embase, and Scopus. Fifteen studies met the inclusion criteria and were reviewed in detail. Of the included studies, six were conducted in India, one in Nepal, one in Mexico, one in Bolivia, two in Ethiopia, one in Zimbabwe, one in South Africa, and two in Kenya. Four interrelated groups of stressors emerged from the review: physical stressors, financial stressors, social stressors, and stressors related to (perceived) inequities. Further, gender differences were observed, with women carrying a disproportionate psychosocial burden. We argue that failure to incorporate psychosocial stressors when estimating the burden or benefits of safe water and sanitation may mask an important driver of health and well-being for many households in low- and middle-income countries. We propose further research on water-related stressors with particular attention to unique cultural norms around water and sanitation, short and long term psychosocial outcomes, and individual and collective coping strategies. These may help practitioners better understand cumulative impacts and mechanisms for addressing water and sanitation challenges.

Food, health, and complexity: towards a conceptual understanding to guide collaborative public health action.

BACKGROUND: What we eat simultaneously impacts our exposure to pathogens, allergens, and contaminants, our nutritional status and body composition, our risks for and the progression of chronic diseases, and other outcomes. Furthermore, what we eat is influenced by a complex web of drivers, including culture, politics, economics, and our built and natural environments. To date, public health initiatives aimed at improving food-related population health outcomes have primarily been developed within 'practice silos', and the potential for complex interactions among such initiatives is not well understood. Therefore, our objective was to develop a conceptual model depicting how infectious foodborne illness, food insecurity, dietary contaminants, obesity, and food allergy can be linked via shared drivers, to illustrate potential complex interactions and support future collaboration across public health practice silos. METHODS: We developed the conceptual model by first conducting a systematic literature search to identify review articles containing schematics that depicted relationships between drivers and the issues of interest. Next, we synthesized drivers into a common model using a modified thematic synthesis approach that combined an inductive thematic analysis and mapping to synthesize findings. RESULTS: The literature search yielded 83 relevant references containing 101 schematics. The conceptual model contained 49 shared drivers and 227 interconnections. Each of the five issues was connected to all others. Obesity and food insecurity shared the most drivers (n = 28). Obesity shared several drivers with food allergy (n = 11), infectious foodborne illness (n = 7), and dietary contamination (n = 6). Food insecurity shared several drivers with infectious foodborne illness (n = 9) and dietary contamination (n = 9). Infectious foodborne illness shared drivers with dietary contamination (n = 8). Fewer drivers were shared between food allergy and: food insecurity (n = 4); infectious foodborne illness (n = 2); and dietary contamination (n = 1). CONCLUSIONS: Our model explicates potential interrelationships between five population health issues for which public health interventions have historically been siloed, suggesting that interventions targeted towards these issues have the potential to interact and produce unexpected consequences. Public health practitioners working in infectious foodborne illness, food insecurity, dietary contaminants, obesity, and food allergy should actively consider how their seemingly targeted public health actions may produce unintended positive or negative population health impacts.

Eczema in early childhood, sociodemographic factors and lifestyle habits are associated with food allergy: a nested case-control study.

BACKGROUND: Studies suggest an increase in food allergy prevalence over the last decade, but the contributing factors remain unknown. The aim of this study was to evaluate the association between the most common food allergies and atopic history, sociodemographic characteristics and lifestyle habits. METHODS: We conducted a case-control study nested within the SPAACE study (Surveying Prevalence of Food Allergy in All Canadian Environments) ­ a cross-Canada, random telephone survey. Cases consisted of individuals with probable food allergy (self-report of convincing symptoms and/or physician diagnosis) to milk, egg, peanut, tree nut, shellfish, fish, wheat, soy, or sesame. Controls consisted of nonallergic individuals, matched for age. Cases and controls were queried on personal and family history of atopy, sociodemographic characteristics and lifestyle habits. Multivariate logistic regression was used to evaluate the association between atopy, sociodemographic characteristics and lifestyle habits with probable food allergy. RESULTS: Between September 2010 and September 2011, 480 cases and 4,950 controls completed the questionnaire. For all 9 allergens, factors associated with a higher risk of probable allergy were as follows: (1) personal history of eczema (in the first 2 years of life), asthma or hay fever (odds ratio, OR 2.3, 95% CI 1.6-3.5; OR 2.8, 95% CI 2.2-3.6, and OR 2.3, 95% CI 1.8-3.0, respectively), (2) maternal, paternal or sibling's food allergy (OR 3.7, 95% CI 2.5-5.6; OR 3.0, 95% CI 1.8-5.1, and OR 3.1, 95% CI 2.2-4.2), (3) high household income (top 20%; OR 1.5, 95% CI 1.2-2.0). Males and older individuals were less likely to have food allergy (OR 0.7, 95% CI 0.6-0.9, and OR 0.99, 95% CI 0.99-1.00). Eczema in the first 2 years of life was the strongest risk factor for egg, peanut, tree nut and fish allergy. CONCLUSIONS: This is the largest population-based nested case-control study exploring factors associated with food allergies. Our results reveal that, in addition to previously reported factors, eczema in the first 2 years of life is consistently associated with food allergies.

Examining local-level factors shaping school nutrition policy implementation in Ontario, Canada.

OBJECTIVE: Increasing numbers of overweight and obese youth draw attention to the school as an important setting for targeted nutrition interventions, given that it is where they spend a majority of their waking time. The objective of the present study was to explore local-level factors shaping the implementation of a school nutrition policy. DESIGN: In-depth, semi-structured interviews were conducted in person or via the telephone (a maximum of 60 min). An interview guide was informed by the Analysis Grid for Environments Linked to Obesity (ANGELO) framework, research objectives and literature. Key themes centred on policy implementation, including facilitators and barriers (i.e. resources, capacity), user satisfaction (i.e. students) and communication strategies. SETTING: Secondary schools in Ontario, Canada. SUBJECTS: Twenty-two participants from local agencies supporting school nutrition programming (n 8) and secondary-school principals, vice principals and teachers (n 14) from nine schools across three Ontario school boards. RESULTS: Results are organized according to environments outlined in the ANGELO framework. The cost of healthy food for sale, revenue loss (economic), proximity of schools to off-site food outlets (physical), the restrictive nature of policy, the role of key stakeholders (political), the role of stigma and school culture (sociocultural) act as local-level barriers to policy implementation. CONCLUSIONS: Gaps in policy implementation include the high cost of food for sale and subsequent revenue generation, the close proximity of internal and external food environments, the need for consultation and communication between stakeholders, and strategies to reduce stigma and improve the school nutrition culture.

The COMPASS study: a longitudinal hierarchical research platform for evaluating natural experiments related to changes in school-level programs, policies and built environment resources.

BACKGROUND: Few researchers have the data required to adequately understand how the school environment impacts youth health behaviour development over time. METHODS/DESIGN: COMPASS is a prospective cohort study designed to annually collect hierarchical longitudinal data from a sample of 90 secondary schools and the 50,000+ grade 9 to 12 students attending those schools. COMPASS uses a rigorous quasi-experimental design to evaluate how changes in school programs, policies, and/or built environment (BE) characteristics are related to changes in multiple youth health behaviours and outcomes over time. These data will allow for the quasi-experimental evaluation of natural experiments that will occur within schools over the course of COMPASS, providing a means for generating "practice based evidence" in school-based prevention programming. DISCUSSION: COMPASS is the first study with the infrastructure to robustly evaluate the impact that changes in multiple school-level programs, policies, and BE characteristics within or surrounding a school might have on multiple youth health behaviours or outcomes over time. COMPASS will provide valuable new insight for planning, tailoring and targeting of school-based prevention initiatives where they are most likely to have impact.

Exploring the school nutrition policy environment in Canada using the ANGELO framework.

Excess body weight has become a major public health issue. Given the link between poor nutrition, obesity, and chronic disease in youth, increasing attention is being paid to the school as an ideal setting for promoting nutritious eating practices. Informed by the ANGELO (Analysis Grid for Environments Linked to Obesity) framework, we employ a documentary analysis to investigate the context of school nutrition in Canada, particularly the relationship between regional- and upper-level policies. In doing so, we examine policy documents and technical reports across three levels. We used mixed methods to analyze relevant English language policy documents and technical reports across Canada (n = 58), published between 1989 and 2011. Results reveal distinct differences across federal, provincial, and regional levels. The availability of nutritious food in schools and having nutrition education as part of the curriculum were key components of the physical environment across federal and provincial levels. Federal and provincial priorities are guided by a health promotion framework and adopting a partnership approach to policy implementation. Gaps in regional-level policy include incorporating nutrition education in the curriculum and making the link between nutrition and obesity. Policy implications are provided, in addition to future research opportunities to explore the connections between these environments at the local level.

Exploring Implementation of the Ontario School Food and Beverage Policy at the Secondary-School Level: A Qualitative Study.

PURPOSE: The purpose of this study was to explore the implementation of the Ontario School Food and Beverage Policy (P/PM 150) from the perspective of secondary-school students. METHODS: This research, informed by the ANGELO framework, undertook three focus groups with secondary students (n = 20) in 2 school boards representing both high- and low-income neighbourhoods in fall 2012. Focus groups were transcribed verbatim for subsequent analysis. Key themes were generated deductively from the research objectives and inductively as they emerged from transcripts. RESULTS: Perceived impacts of P/PM 150 included high-priced policy-compliant food for sale, lower revenue generation, and food purchased off-campus. Limited designated eating spaces, proximity to external, nonpolicy-compliant food, and time constraints acted as key local level barriers to healthy eating. CONCLUSIONS: Pricing strategies are needed to ensure that all students have access to nutritious food, particularly in the context of vulnerable populations. Recognition of the context and culture in which school nutrition policies are being implemented is essential. Future research to explore the role of public health dietitians in school nutrition policy initiatives and how to leverage local resources and stakeholder support in low income, rural and remote populations is needed.

Climate change, biodiversity loss, and Indigenous Peoples' health and wellbeing: a systematic umbrella review protocol.

BACKGROUND: Research that examines the intersections of Indigenous Peoples' health and wellbeing with climate change and biodiversity loss is abundant in the global scholarship. A synthesis of this evidence base is crucial in order to map current pathways of impact, as well as to identify responses across the global literature that advance Indigenous health and wellbeing, all while centering Indigenous voices and perspectives. This protocol details our proposed methodology to systematically conduct an umbrella review (or review of reviews) of the synthesized literature on climate change, biodiversity loss, and the health and wellbeing of Indigenous Peoples globally. METHODS: A multidisciplinary team of Indigenous and non-Indigenous scholars will conduct the review, guided by an engagement process with an Indigenous Experts group. A search hedge will be used to search PubMed®, Scopus®, Web of Science™, CINAHL (via EBSCOHost®), and Campbell Collaboration databases and adapted for use in grey literature sources. Two independent reviewers will conduct level one (title/abstract) and level two (full-text) eligibility screening using inclusion/exclusion criteria. Data will be extracted from included records and analyzed using quantitative (e.g., basic descriptive statistics) and qualitative methods (e.g., thematic analysis, using a constant comparative method). DISCUSSION: This protocol outlines our approach to systematically and transparently review synthesized literature that examines the intersections of climate change, biodiversity loss, and Indigenous Peoples' health and wellbeing globally. SYSTEMATIC REVIEW REGISTRATION: This protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on April 24, 2023 (registration number: CRD42023417060).