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.

Employing the equity lens to understand multisectoral partnerships: lessons learned from a mixed-method study in Canada.

BACKGROUND: Multisectoral approaches to health are collaborations between stakeholders across multiple sectors, usually formed to address issues that affect health but go beyond the purview of one particular sector. The significance of multisectoral partnerships to attain health equity has been widely acknowledged. However, the extent which equity can be attained depends upon the perceptions of various stakeholders. We examine how multisectoral partnerships promoting healthy eating and active living conceptualized and employed an equity lens in their work. METHOD: This study is part of a larger pan-Canadian mixed-method research and knowledge sharing program entitled MUSE (Multisectoral Urban Systems for health and Equity in Canadian cities). Data collected from both quantitative and qualitative sources for two sites of the MUSE project-Saskatoon and Toronto were analyzed. In the qualitative part, 30 semi-structured key informant interviews were conducted with key stakeholders from six different multisectoral partnerships based in Saskatoon and Toronto. Data were analyzed in an inductive way. In the quantitative part, a survey with 37 representatives of stakeholder organizations was carried out. Simple descriptive statistics (means and percentages) were used to observe the distribution of data and to complement the qualitative analysis. RESULTS: Equity was not a central component in program design although participants addressing equity, did so by discussing accessibility. How much consideration was given to equity varied as a function of the type of partnership. Most participants emphasized geographical accessibility but a few mentioned financial accessibility. Collaborative leadership style facilitated a participatory decision-making process, and thereby upholding equity in the partnership decision-making process. Communication, networking, and negotiation skills were found to be core competencies of a leader that contributed in upholding equity in partnership dynamics. The study also showed some challenges to embed equity in partnership works, such as the lack of comprehensive understanding of population health and its equity tenet. CONCLUSIONS: Findings indicate that multisectoral partnerships aimed at promoting healthy eating and physical activity experience several challenges to attain equity within the partnership as well as in the partnership-based works aimed at reducing health equity in populations. Factors identified can support decision makers commit to and work to attaining equity within their partnerships as well as in the partnership-based work in the community and beyond.

Comparative inequalities in child dental caries across four countries: Examination of international birth cohorts and implications for oral health policy.

Child dental caries (i.e., cavities) are a major preventable health problem in most high-income countries. The aim of this study was to compare the extent of inequalities in child dental caries across four high-income countries alongside their child oral health policies. Coordinated analyses of data were conducted across four prospective population-based birth cohorts (Australia, n = 4085, born 2004; Québec, Canada, n = 1253, born 1997; Rotterdam, the Netherlands, n = 6690, born 2002; Southeast Sweden, n = 7445, born 1997), which enabled a high degree of harmonization. Risk ratios (adjusted) and slope indexes of inequality were estimated to quantify social gradients in child dental caries according to maternal education and household income. Children in the least advantaged quintile for income were at greater risk of caries, compared to the most advantaged quintile: Australia: AdjRR = 1.18, 95%CI = 1.04-1.34; Québec: AdjRR = 1.69, 95%CI = 1.36-2.10; Rotterdam: AdjRR = 1.67, 95%CI = 1.36-2.04; Southeast Sweden: AdjRR = 1.37, 95%CI = 1.10-1.71). There was a higher risk of caries for children of mothers with the lowest level of education, compared to the highest: Australia: AdjRR = 1.18, 95%CI = 1.01-1.38; Southeast Sweden: AdjRR = 2.31, 95%CI = 1.81-2.96; Rotterdam: AdjRR = 1.98, 95%CI = 1.71-2.30; Québec: AdjRR = 1.16, 95%CI = 0.98-1.37. The extent of inequalities varied in line with jurisdictional policies for provision of child oral health services and preventive public health measures. Clear gradients of social inequalities in child dental caries are evident in high-income countries. Policy related mechanisms may contribute to the differences in the extent of these inequalities. Lesser gradients in settings with combinations of universal dental coverage and/or fluoridation suggest these provisions may ameliorate inequalities through additional benefits for socio-economically disadvantaged groups of children.

Household income and maternal education in early childhood and activity-limiting chronic health conditions in late childhood: findings from birth cohort studies from six countries.

BACKGROUND: We examined absolute and relative relationships between household income and maternal education during early childhood (<5 years) with activity-limiting chronic health conditions (ALCHC) during later childhood in six longitudinal, prospective cohorts from high-income countries (UK, Australia, Canada, Sweden, Netherlands, USA). METHODS: Relative inequality (risk ratios, RR) and absolute inequality (Slope Index of Inequality) were estimated for ALCHC during later childhood by maternal education categories and household income quintiles in early childhood. Estimates were adjusted for mother ethnicity, maternal age at birth, child sex and multiple births, and were pooled using meta-regression. RESULTS: Pooled estimates, with over 42 000 children, demonstrated social gradients in ALCHC for high maternal education versus low (RR 1.54, 95% CI 1.28 to 1.85) and middle education (RR 1.24, 95% CI 1.11 to 1.38); as well as for high household income versus lowest (RR 1.90, 95% CI 1.66 to 2.18) and middle quintiles (RR 1.34, 95% CI 1.17 to 1.54). Absolute inequality showed decreasing ALCHC in all cohorts from low to high education (range: -2.85% Sweden, -13.36% Canada) and income (range: -1.8% Sweden, -19.35% Netherlands). CONCLUSION: We found graded relative risk of ALCHC during later childhood by maternal education and household income during early childhood in all cohorts. Absolute differences in ALCHC were consistently observed between the highest and lowest maternal education and household income levels across cohort populations. Our results support a potential role for generous, universal financial and childcare policies for families during early childhood in reducing the prevalence of activity limiting chronic conditions in later childhood.

Association between area-level material deprivation and incidence of hospitalization among children with SARS-CoV-2 in Montreal.

Background: Although sociodemographic factors have been linked with SARS-CoV-2 infection and hospitalizations in adults, there are little data on the association between sociodemographic characteristics and SARS-CoV-2-related hospitalization in children. The objective of this study was to determine the association between area-level material deprivation and incidence of hospitalization with SARS-CoV-2 among children. Methods: We conducted a retrospective cohort study of all children (0 to 17 years of age) with a PCR-confirmed SARS-CoV-2 infection March 1, 2020 through May 31, 2021 at a tertiary-care paediatric hospital, in Montreal, Canada. Data were collected through chart review and included age, sex, and postal code, allowing linkage to dissemination area-level material deprivation, measured with the Pampalon Material Deprivation Index (PMDI) quintiles. We examined the association between PMDI quintiles and hospitalization using Poisson regression. Results: During the study period, 964 children had a positive PCR-confirmed SARS-CoV-2 test and 124 were hospitalized. Children living in the most deprived quintile of PMDI represented 40.7% of hospitalizations. Incidence rate ratio of hospitalization for this group compared to the most privileged quintile was 2.42 (95%CI: 1.33; 4.41). Conclusion: Children living in the most materially deprived areas had more than twice the rate of hospitalizations for COVID-19 than children living in most privileged areas. Special efforts should be deployed to protect children who live in disadvantaged areas, especially pending vaccination of younger children.

Quarantots, quarankids, and quaranteens: how research can contribute to mitigating the deleterious impacts of the COVID-19 pandemic on health behaviours and social inequalities while achieving sustainable change.

The adoption and maintenance of healthy behaviours including age-appropriate amounts of physical activity, limited sedentary and screen time, and healthy eating are the foundations for youth development and thriving. In reviewing extant evidence, we observe that the COVID-19 pandemic has been associated with marked reductions in physical activity, increased sedentary and screen time, and increased food intake and unhealthy snacking. Deleterious effects in movement behaviours appear to be more pronounced among vulnerable groups and food insecurity has become more widespread. To contribute to mitigating these impacts, we advocate for strengthened evidence-based public health. Towards this end, ongoing surveillance should be intensified and augmented with additional indicators of social inequalities. More importantly, substantial efforts must be devoted to developing, implementing, and evaluating complex interventions aimed at equitably promoting recommended 24-hour movement behaviours and healthy eating guidelines in home, childcare, school, and neighbourhood settings.

RéSUMé: L'adoption et le maintien de saines habitudes de vie telles des niveaux d'activité physique appropriés pour l'âge, des durées limitées d'activités sédentaires et de temps d'écran, de même qu'une alimentation saine, sont des piliers pour le développement et l'épanouissement des enfants et des jeunes. Après avoir recensé les écrits disponibles, nous constatons que la pandémie de COVID-19 a été associée avec une réduction marquée de l'activité physique, une augmentation de la durée des activités sédentaires et du temps d'écran et une augmentation de la consommation de nourriture et de collations sucrées. Les effets délétères sur les comportements d'activité physique semblent plus prononcés parmi les groupes vulnérables et l'insécurité alimentaire est davantage répandue. Afin de contribuer à atténuer ces impacts, nous proposons le renforcement d'une santé publique fondée sur les données probantes. Nous recommandons une intensification et une bonification des activités de surveillance par l'ajout de nouveaux indicateurs pour mesurer les inégalités sociales de santé. De plus, des efforts considérables doivent être investis dans le développement, l'implantation et l'évaluation d'interventions complexes visant à promouvoir équitablement les directives canadiennes relatives au mouvement sur 24 heures et les saines habitudes alimentaires dans les familles, milieux de garde, écoles et quartiers résidentiels.

Understanding and attenuating pandemic-related disruptions: a plan to reduce inequalities in child development.

The Secretary General of the United Nations described the impact of COVID-19-related school closures as a "generational catastrophe." What will be the legacy of the 2020-2021 pandemic-related disruptions in 5, 10, 20 years from now, as regards education and well-being of children and youth? Addressing the disproportionate impact on those growing up in socio-economically disadvantaged areas or on those with pre-existing learning challenges is key to sustainable recovery. This commentary builds on the four literature reviews presented in this Special Section on a Pandemic Recovery Plan for Children and proposes strategies to understand and attenuate the impact of pandemic-related lockdown measures. Importantly, we need a monitoring strategy to assess indicators of child development in three areas of functioning: education and learning, health, and well-being (or mental health). Surveillance needs to begin in the critical prenatal period (with prenatal care to expectant parents), and extend to the end of formal high school/college education. Based on child development indicators, a stepped strategy for intervention, ranging from all-encompassing population-based health and education promotion initiatives to targeted prevention programs and targeted remedial/therapeutic interventions, can be offered. As proposed in the UN plan for recovery, ensuring healthy present and future generations involves a concerted and intensive intersectoral effort from the education, health, psychosocial services, and scientific communities.

RéSUMé: Selon les Nations Unis, les perturbations scolaires associées à la pandémie de COVID-19 pourraient mener à une « catastrophe générationnelle ¼ en gaspillant un potentiel humain incalculable, sapant des décennies de progrès et exacerbant des inégalités bien ancrées. Le déploiement du vaccin chez les moins de 12 ans n'a pas débuté avant la rentrée scolaire 2021, ce qui laisse présager de nombreuses perturbations pour cette 3e année scolaire pandémique. Quel sera le legs des perturbations entrainées par la pandémie de COVID-19 en matière d'éducation et de bien-être dans 5, 10, ou 20 ans? Une relance durable dépendra des mesures prises pour prévenir l'impact négatif disproportionné sur les enfants/adolescents de milieux socioéconomiques défavorisés et ceux qui ont des défis d'apprentissage préexistants. Ce commentaire propose des stratégies pour comprendre et atténuer l'impact des perturbations pandémiques en se fondant sur les quatre articles de la présente « Section spéciale sur un plan de relance pour les enfants suite à la pandémie ¼. Trois lignes d'action prioritaires émergent à la lumière des connaissances scientifiques actuelles. Premièrement, le contexte pandémique met en évidence la nécessité d'accéder à données intersectorielles (éducation, santé, services psychosociaux) permettant de distinguer les conséquences à court et à long terme. Deuxièmement, il faut être prêt à déployer une stratégie interventionnelle par étape, avec des interventions universelles en promotion, jusqu'aux interventions plus ciblées et intensives. Troisièmement, il faudra mettre en place des programmes particuliers pour les enfants/adolescents de milieux défavorisés et pour ceux qui présentent des facteurs de risque personnels (défis de santé mentale, retards d'apprentissage). À titre d'exemple, le tutorat scolaire devrait être facilement accessible dans tous les milieux défavorisés. Tel que proposé dans le plan de relance de l'ONU, un effort concerté, intensif et intersectoriel de la part des sciences de l'éducation, de la santé, et des services psychosociaux sera nécessaire pour assurer la santé et l'éducation des générations présentes et futures.

An Ecological Momentary Assessment Study of Pain Intensity Variability: Ascertaining Extent, Predictors, and Associations With Quality of Life, Interference and Health Care Utilization Among Individuals Living With Chronic Low Back Pain.

This ecological momentary assessment (EMA) study examined the extent of pain intensity variability among 140 individuals with chronic low back pain and explored predictors of such variability and psychosocial and health care utilization outcomes. Individuals completed momentary pain intensity reports (0-10 numeric rating scale) several times daily for two periods of seven consecutive days, one month apart. Participants also completed online questionnaires at baseline which tapped into pain characteristics, pain-related catastrophization, kinesiophobia, activity patterns, and depression and anxiety symptoms. Questionnaires assessing quality of life and health care utilization were administered online one month after completion of the last EMA report. Data were analyzed using linear hierarchical location-scale models. Results showed that pain intensity fluctuated over the course of a week as shown by an average standard deviation of 1.2. The extent of variability in pain intensity scores was heterogeneous across participants but stable over assessment periods. Patients' baseline characteristics along with psychosocial and health care utilization outcomes were not significantly associated with pain intensity variability. We conclude that pain intensity variability differs across patients yet correlates remain elusive. There is an important gap in our knowledge of what affects this variability. Future EMA studies should replicate and extend current findings. PERSPECTIVE: This study provides evidence indicating that there is substantial variability in momentary reports of pain intensity among individuals living with chronic low back pain. However, risk and protective factors for greater lability of pain are elusive as is evidence that greater pain intensity variability results in differential health care utilization.

On successfully avoiding communication inequalities and instilling positive impacts: The experience of the 2012-2016 WIXX campaign in Québec.

Communication campaigns can contribute to promoting physical activity (PA) among children. However, health inequalities can ensue from this type of public health intervention. Using a pre-test posttest design, we examined the effects of social disadvantage on the large-scale WIXX communication campaign and whether or not social disadvantage moderated WIXX's impact on PA. Parents of youths were identified using random digit dialing procedures and asked permission for their child to participate in a telephone survey. Surveys were conducted each year between 2012 and 2016. Moderating effects of individual-level and area-based indicators of social disadvantage on campaign effectiveness were examined. Self-reported levels of PA and trying new PAs were the outcomes. Exposure was defined as a function of ads recall and brand awareness. Logistic regression analyses controlling for survey periods, screen time, language, school grade, and attitudes toward PA were performed in 2020. Among girls, no significant interaction effects were observed for household income, parental education, and material deprivation. A significant interaction effect was observed for minority group status on PA (OR = 2.4; 95%CIs: 1.2, 4.9) and trying of new activities (OR = 2.5; 95%CIs: 1.2, 5.1). A significant interaction effect between social deprivation and exposure was observed for trying new activities among girls (OR = 1.8; 95%CIs: 1.0, 3.2). Among boys, no significant interaction effects were observed for any indicators. Results suggest no clear evidence of communication inequalities as a result of the WIXX campaign but reveal positive impacts of the campaign among more socially disadvantaged girls.

NutriQuébec: a unique web-based prospective cohort study to monitor the population's eating and other lifestyle behaviours in the province of Québec.

INTRODUCTION: The epidemic of non-communicable diseases including cardiovascular diseases and type 2 diabetes is attributable in large part to unhealthy eating and physical inactivity. In the fall of 2016, the Québec government launched its first-ever Government Health Prevention Policy (Politique gouvernementale de prévention en santé (PGPS)) to influence factors that lead to improved health status and quality of life as well as reduced social inequalities in health in the population of Québec. NutriQuébec is a web-based prospective open cohort study whose primary aim is to provide essential data for the evaluation of the PGPS on the Québec population's eating and other lifestyle behaviours over time. METHODS AND ANALYSIS: Over a first phase of 3 years, NutriQuébec will enrol 20 000 adults living in the province of Québec in Canada through a multimedia campaign designed to reach different segments of the population, including subgroups with lower socioeconomic status. Participants will be invited to complete on a web platform nine core questionnaires on a yearly basis. Questionnaires will assess several dimensions related to lifestyle, including eating and physical activity behaviours, as well as a large number of personal characteristics and global health status. Temporal trends in eating and lifestyle behaviours will be analysed in relation to the implementation of the PGPS to provide essential data for its evaluation at a population level. Data analyses will use sociodemographic weights to adjust responses of participants to achieve, so far as is possible, representativeness of the adult Québec population. ETHICS AND DISSEMINATION: Université Laval Research Ethics Board approved the NutriQuébec project. Data analysis, presentations in conferences and publication of manuscripts are scheduled to start in 2020. TRIAL REGISTRATION NUMBER: NCT04140071.

Smoking in Young Adults: A Study of 4-Year Smoking Behavior Patterns and Residential Presence of Features Facilitating Smoking Using Data From the Interdisciplinary Study of Inequalities in Smoking Cohort.

INTRODUCTION: Young adults have the highest prevalence of smoking among all age groups in most industrialized countries and exhibit great variability in smoking behavior. Differences in associations between features in residential environments and smoking initiation, prevalence, and cessation have been extensively examined in the literature. Nonetheless, in many cases, findings remain inconsistent. This paper proposes that a potential driver of these inconsistencies is an almost exclusive focus on point-specific smoking outcomes, without consideration for the different behavior patterns that this age group may experience over time. AIMS AND METHODS: Based on data from the Interdisciplinary Study of Inequalities in Smoking cohort of 18- to 25-year-old Montreal residents (n = 1025), we examined associations between 4-year smoking patterns measured at three timepoints and proximal presence/density of tobacco retail outlets and presence of smoker accommodation facilities in Montreal, Canada. Associations were tested using two-level multinomial and logistic models. RESULTS: In fully adjusted models, compared to never-smokers, residents of areas with a higher density of tobacco retail were more likely to (1) be characterized as established smokers, (2) have experienced repeated changes in smoking status (being "switchers") during the 4-year study period, and (3) be former smokers. CONCLUSIONS: From a conceptual standpoint, these findings highlight the importance of acknowledging and examining smoking behavior patterns among young adults. Furthermore, specific pattern-feature associations may point to unique mechanisms by which features could influence smoking behavior patterns. These findings require replication and extension, including testing hypotheses regarding tobacco retail density's role in sustaining smoking and in influencing changes in smoking status. IMPLICATIONS: Results from this study highlight the importance of describing and examining different young adult smoking behavior patterns and how they may be influenced by residential environment features such as the density of tobacco retail. Findings suggest that young adults residing in areas with a higher density of tobacco retailers are more likely to have experienced repeated changes in smoking status and to be established smokers. Further research in this area is needed to advance knowledge of the putative mechanisms by which residential features may influence smoking behavior patterns and to ultimately orient policy and interventions seeking to curb smoking at the local level.

Does Place Matter? An International Comparison of Early Childhood Development Outcomes between the Metropolitan Areas of Melbourne, Australia and Montreal, Canada.

There is strong consensus about the importance of early childhood development (ECD) for improving population health and closing the health inequity gap. Environmental features and public policies across sectors and jurisdictions are known to influence ECD. International comparisons provide valuable opportunities to better understand the impact of these ecological determinants on ECD. This study compared ECD outcomes between metropolitan Melbourne (Australia) and Montreal (Canada), and contrasted disparities across demographic and socioeconomic characteristics. Methods: Population wide surveys using the Early Development Instrument (EDI) were conducted among 4-6 years-old children in both Montreal and Melbourne in 2012, measuring five domains of ECD: 1-Physical Health/Well-Being (PHYS); 2-Social Competence (SOC); 3-Emotional Maturity (EMOT); 4-Language/Cognitive Development (COGN); and 5-Communication Skills/General Knowledge (COMM). Descriptive analyses of summary EDI indicators and domain indicators (including median scores and interquartile ranges) were compared between metropolitan areas, using their respective 95% confident intervals (CIs). Analyses were performed using Stata software (v14). Results: The proportion of children developmentally vulnerable in at least one domain of ECD was 26.8% (95% CIs: 26.2, 27.3) in Montreal vs. 19.2% (95% CIs: 18.8, 19.5) in Melbourne. The Melbourne advantage was greatest for EMOT and COGN (11.5% vs. 6.9%; 13.0% vs. 5.8%). In both Montreal and Melbourne, boys, immigrants, children not speaking the language of the majority at home, and those living in the most deprived areas were at greater risk of being developmentally vulnerable. Relative risks as a function of home language and area-level deprivation subgroups were smaller in Montreal than in Melbourne. Conclusion: This study shows that Melbourne's children globally experience better ECD outcomes than Montreal's children, but that inequity gaps are greater in Melbourne for language and area-level deprivation subgroups. Further research is warranted to identify the environmental factors, policies, and programs that account for these observed differences.

The Overall Awareness and Impact of the WIXX Multimedia Communication Campaign, 2012-2016.

Background: Evidence regarding the impact of physical activity (PA) communication campaigns among children is scarce. This study was aimed at examining the reach of the WIXX campaign and its impact on children's PA beliefs and behaviors. Methods: This study adopted a pre-posttest design. Children (9-13 y old) were recruited using a random digit dialing procedure. Self-reported outcomes included PA beliefs, trying new PAs, and meeting PA guidelines. WIXX awareness and survey periods were the treatment variables. Logistic regression analyses were conducted to examine the main effect of treatment variables and the time-specific impact of WIXX. Results: The campaign reached 80.3% of the children. Fully adjusted results showed that girls with high (odd ratio = 1.4; 95% confidence interval, 1.0-2.0) and moderate (odd ratio = 1.4; 95% confidence interval, 1.0-1.8) awareness were more likely to have tried new PAs. Results from the sensitivity analyses suggested that this positive result was due to strategies implemented during the second year of the campaign. No other significant association between exposure and outcomes was observed. Conclusions: The WIXX campaign was successful in reaching a significant proportion of children. Although some encouraging results were observed among girls, WIXX awareness was not associated with changes on the examined outcomes among boys.

Residential environments and smoking behaviour patterns among young adults: A prospective study using data from the Interdisciplinary Study of Inequalities in Smoking cohort.

Young adults have the highest prevalence of smoking among all age groups. Studies have shown associations between presence/density of tobacco retail and presence of smoker accommodation and smoking prevalence. However, little is known about their potential to influence different smoking patterns including initiation, maintenance, or cessation. This is important because smoking behaviour patterns in young adults may be subject to ongoing changes. Moreover, smoking pattern determinants may be different to those of smoking prevalence, and feature-pattern associations may be scale-dependent, requiring the consideration of different analytical spatial units. We examined associations between prospectively-measured smoking behaviour patterns and presence/density of tobacco retail, and presence of smoker accommodation facilities across 2 nested spatial units in Montreal, Canada. Data were from 18 to 25 year-old Montreal residents who had participated in the Interdisciplinary Study of Inequalities in Smoking cohort both at baseline in 2011-2012 and follow-up in 2014 and resided in the same area at follow-up. 2-year smoking behaviour patterns were assessed for 2 cohorts based on participants' smoking status at baseline. Associations were examined using multilevel logistic models. Young adults who were smokers at baseline residing in areas with higher local-level presence of tobacco retail were less likely to quit smoking (i.e.: to be non-smokers for fewer than 2 years). Higher presence of smoker accommodation was not associated with smoking patterns at any scale. Findings provide evidence of scale-specific associations between residential environment features and smoking behaviour patterns in young adults, which may point to specific exposure-outcome processes underlying these associations.

INTERACT: A comprehensive approach to assess urban form interventions through natural experiments.

BACKGROUND: Urban form interventions can result in positive and negative impacts on physical activity, social participation, and well-being, and inequities in these outcomes. Natural experiment studies can advance our understanding of causal effects and processes related to urban form interventions. The INTErventions, Research, and Action in Cities Team (INTERACT) is a pan-Canadian collaboration of interdisciplinary scientists, urban planners, and public health decision makers advancing research on the design of healthy and sustainable cities for all. Our objectives are to use natural experiment studies to deliver timely evidence about how urban form interventions influence health, and to develop methods and tools to facilitate such studies going forward. METHODS: INTERACT will evaluate natural experiments in four Canadian cities: the Arbutus Greenway in Vancouver, British Columbia; the All Ages and Abilities Cycling Network in Victoria, BC; a new Bus Rapid Transit system in Saskatoon, Saskatchewan; and components of the Sustainable Development Plan 2016-2020 in Montreal, Quebec, a plan that includes urban form changes initiated by the city and approximately 230 partnering organizations. We will recruit a cohort of between 300 and 3000 adult participants, age 18 or older, in each city and collect data at three time points. Participants will complete health and activity space surveys and provide sensor-based location and physical activity data. We will conduct qualitative interviews with a subsample of participants in each city. Our analysis methods will combine machine learning methods for detecting transportation mode use and physical activity, use temporal Geographic Information Systems to quantify changes to urban intervention exposure, and apply analytic methods for natural experiment studies including interrupted time series analysis. DISCUSSION: INTERACT aims to advance the evidence base on population health intervention research and address challenges related to big data, knowledge mobilization and engagement, ethics, and causality. We will collect ~ 100 TB of sensor data from participants over 5 years. We will address these challenges using interdisciplinary partnerships, training of highly qualified personnel, and modern methodologies for using sensor-based data.

Cervical cancer screening in Montreal: Building evidence to support primary care and policy interventions.

In Canada, over 40% of invasive cervical cancers occur among women who have never been screened. Although 12% of Canadian women have never been screened, this number can be as high as 43% among certain social groups. Little is published on factors associated with screening uptake and inequalities among women residing in Quebec. Four waves of the Canadian Community Health Survey (2003, 2005, 2008, 2012, N = 6393) were utilized to assess lifetime screening and screening in the previous 3 years among women residing in Montreal. Chi-squared statistics were calculated, Poisson regression was utilized to model prevalence ratios, and prevalence differences were calculated. In total, 13.6% of women had never been screened and 12.1% had not been screened in the previous 3 years. Immigrant status was the strongest predictor of never being screened [recent vs non-immigrant: Prevalence Ratio (PR), 3.9 (95% Confidence Interval (CI): 2.9-5.4)] and not having a primary care physician (PCP) was the strongest predictors of not being screened recently [PR = 3.0 (95% CI: 2.3-3.9)]. The two most common reasons for not being screened were not "know[ing] it was necessary" and not "get[ting] around to it." These results provide a description of sub-populations which might benefit from cervical screening interventions: immigrants and women without a PCP. Interventions targeting access to PCPs, expanding training of non-physicians to conduct screening, organized screening, or autoadministered screening test may mitigate inequalities. Future work should assess their acceptability and feasibility, and evaluate the impact of these types of primary care and policy interventions.

Impacts of Bicycle Infrastructure in Mid-Sized Cities (IBIMS): protocol for a natural experiment study in three Canadian cities.

INTRODUCTION: Bicycling is promoted as a transportation and population health strategy globally. Yet bicycling has low uptake in North America (1%-2% of trips) compared with European bicycling cities (15%-40% of trips) and shows marked sex and age trends. Safety concerns due to collisions with motor vehicles are primary barriers.To attract the broader population to bicycling, many cities are making investments in bicycle infrastructure. These interventions hold promise for improving population health given the potential for increased physical activity and improved safety, but such outcomes have been largely unstudied. In 2016, the City of Victoria, Canada, committed to build a connected network of infrastructure that separates bicycles from motor vehicles, designed to attract people of 'all ages and abilities' to bicycling.This natural experiment study examines the impacts of the City of Victoria's investment in a bicycle network on active travel and safety outcomes. The specific objectives are to (1) estimate changes in active travel, perceived safety and bicycle safety incidents; (2) analyse spatial inequities in access to bicycle infrastructure and safety incidents; and (3) assess health-related economic benefits. METHODS AND ANALYSIS: The study is in three Canadian cities (intervention: Victoria; comparison: Kelowna, Halifax). We will administer population-based surveys in 2016, 2018 and 2021 (1000 people/city). The primary outcome is the proportion of people reporting bicycling. Secondary outcomes are perceived safety and bicycle safety incidents. Spatial analyses will compare the distribution of bicycle infrastructure and bicycle safety incidents across neighbourhoods and across time. We will also calculate the economic benefits of bicycling using WHO's Health Economic Assessment Tool. ETHICS AND DISSEMINATION: This study received approval from the Simon Fraser University Office of Research Ethics (study no. 2016s0401). Findings will be disseminated via a website, presentations to stakeholders, at academic conferences and through peer-reviewed journal articles.

Estimating the health benefits of planned public transit investments in Montreal.

BACKGROUND: Since public transit infrastructure affects road traffic volumes and influences transportation mode choice, which in turn impacts health, it is important to estimate the alteration of the health burden linked with transit policies. OBJECTIVE: We quantified the variation in health benefits and burden between a business as usual (BAU) and a public transit (PT) scenarios in 2031 (with 8 and 19 new subway and train stations) for the greater Montreal region. METHOD: Using mode choice and traffic assignment models, we predicted the transportation mode choice and traffic assignment on the road network. Subsequently, we estimated the distance travelled in each municipality by mode, the minutes spent in active transportation, as well as traffic emissions. Thereafter we estimated the health burden attributed to air pollution and road traumas and the gains associated with active transportation for both the BAU and PT scenarios. RESULTS: We predicted a slight decrease of overall trips and kilometers travelled by car as well as an increase of active transportation for the PT in 2031 vs the BAU. Our analysis shows that new infrastructure will reduce the overall burden of transportation by 2.5 DALYs per 100,000 persons. This decrease is caused by the reduction of road traumas occurring in the inner suburbs and central Montreal region as well as gains in active transportation in the inner suburbs. CONCLUSION: Based on the results of our study, transportation planned public transit projects for Montreal are unlikely to reduce drastically the burden of disease attributable to road vehicles and infrastructures in the Montreal region. The impact of the planned transportation infrastructures seems to be very low and localized mainly in the areas where new public transit stations are planned.

Correlates of Initial Recall of a Multimedia Communication Campaign to Promote Physical Activity among Tweens: the WIXX Campaign.

This study examined factors associated with children's and parents' recall of a communication campaign aimed at promoting children's physical activity. A cross-sectional population-based telephone survey was conducted among 1001 children and their parents. Respondents were recruited through a random digit dialing procedure. Respondents' recall of the campaign, beliefs, sociodemographics as well as levels of physical activity and sedentary behaviors were self-reported. Logistic regression analyses were conducted for tweens and their parents separately. Girls (odds ratio [OR] = 2.1; 95%confidence interval (CI): 1.3, 3.5) were more likely to have unaided recall when compared to boys. Tweens in primary school (OR = 1.9; 95%CI: 1.0, 3.4 and OR = 2.1; 95%CI: 1.4, 3.0) and those speaking French (OR = 3.3; 95%CI: 1.4, 8.1 and OR = 2.9; 95%CI: 1.8, 4.7) were more likely to have unaided and aided recall, respectively. Among parents, tweens' unaided (OR = 12.0; 95%CI: 5.2, 28.1) and aided (OR = 3.3; 95%CI: 1.5, 7.3) recall, obesity status (OR = 2.6; 95%CI: 1.3, 5.3), and low income (OR = 5.2; 95%CI: 1.9, 14.3) were positively associated with recall. Additional beliefs were associated with tweens' and parents' recall of the campaign. The association between sex, language, and recall is in line with the branding strategy adopted and no clear evidence for communication inequalities was observed.

Short-Term Impact of a Multimedia Communication Campaign on Children's Physical Activity Beliefs and Behavior.

To examine the short-term impact of the WIXX multimedia communication campaign on children's physical activity (PA) beliefs and behaviors, 3 repeated cross-sectional telephone surveys were conducted before, 9 months after, and 21 months after the launch of the campaign. A random-digit dialing procedure was used to recruit children ages 9 to 13 years. Children's PA beliefs, behaviors, and recall of the WIXX ads were self-reported. Logistic regression models showed that girls exposed to the WIXX ads were more likely to believe that PA would help to make new friends (odds ratio [OR] = 1.4, 95% confidence interval [CI] [1.0, 1.9]) and that they can be active even if too busy (OR = 1.4, 95% CI [1.0, 1.8]) compared to girls not exposed. Boys exposed were more likely to believe that PA would help to spend time with friends (OR = 1.4, 95% CI [1.1, 1.9]). Boys (OR = 1.5, 95% CI [1.1, 2.0.]) and girls (OR = 1.4, 95% CI [1.1, 1.8]) exposed were more likely to report having tried new PAs. No significant impact of the campaign was observed on overall PA after we controlled for confounders. Recall of the WIXX ads was associated with a significant, albeit modest, impact on some PA beliefs and intermediate PA behaviors.