Family and community resilience: a Photovoice study.

BACKGROUND: Adverse childhood experiences (ACEs), in combination with adverse community environments, can result in traumatic stress reactions, increasing a person's risk for chronic physical and mental health conditions. Family resilience refers to the ability of families to withstand and rebound from adversity; it involves coping with disruptions as well as positive growth in the face of sudden or challenging life events, trauma, or adversities. This study aimed to identify factors contributing to family and community resilience from the perspective of families who self-identified as having a history of adversity and being resilient during the COVID-19 pandemic. METHODS: This study used Photovoice, a visual participatory research method which asks participants to take photographs to illustrate their responses to a research question. Participants consisted of a maximum variation sample of families who demonstrated family level resilience in the context of the pair of ACEs during the COVID-19 pandemic. Family members were asked to collect approximately five images or videos that illustrated the facilitators and barriers to well-being for their family in their community. Semi-structured in-depth interviews were conducted using the SHOWeD framework to allow participants to share and elucidate the meaning of their photos. Using thematic analysis, two researchers then independently completed line-by-line coding of interview transcripts before collaborating to develop consensus regarding key themes and interpretations. RESULTS: Nine families were enrolled in the study. We identified five main themes that enhanced family resilience: (1) social support networks; (2) factors fostering children's development; (3) access and connection to nature; (4) having a space of one's own; and (5) access to social services and community resources. CONCLUSIONS: In the context of additional stresses related to the COVID-19 pandemic, resilient behaviours and strategies for families were identified. The creation or development of networks of intra- and inter-community bonds; the promotion of accessible parenting, housing, and other social services; and the conservation and expansion of natural environments may support resilience and health.

Impacts of the COVID-19 pandemic on life and learning experiences of indigenous and non-Indigenous university and college students in Ontario, Canada: a qualitative study.

BACKGROUND: The years people spend attending university or college are often filled with transition and life change. Younger students often move into their adult identity by working through challenges and encountering new social experiences. These transitions and stresses have been impacted significantly by the COVID-19 pandemic, which has led to dramatic change in the post-secondary experience, particularly in the pandemic's early months when colleges and universities were closed to in person teaching. The goal of this study was to identify how COVID-19 has specifically impacted the postsecondary student population in Kingston, Ontario, Canada. METHODS: The Cost of COVID is a mixed methods study exploring the social and emotional impacts of the COVID-19 pandemic, with a focus on families, youth, and urban Indigenous People. The present analysis was completed using a subset of qualitative data including Spryng.io micronarrative stories from students in college and university, as well as in-depth interviews from service providers providing services to students. A double-coded phenomenological approach was used to collect and analyze data to explore and identify themes expressed by postsecondary students and service providers who worked with postsecondary students. RESULTS: Twenty-six micronarratives and seven in-depth interviews were identified that were specifically relevant to the post-secondary student experience. From this data, five prominent themes arose. Impacts of the COVID-19 pandemic on the use of technology was important to the post secondary experience. The pandemic has substantial educational impact on students, in what they chose to learn, how it was taught, and experiences to which they were exposed. Health and wellbeing, physical, psychological and emotional, were impacted. Significant impacts were felt on family, community, and connectedness aspects. Finally, the pandemic had important financial impacts on students which affected their learning and their experience of the pandemic. Impacts did differ for Indigenous students, with many of the traditional cultural supports and benefits of spaces of higher education no longer being available. CONCLUSION: Our study highlights important impacts of the pandemic on students of higher education that may have significant individual and societal implications going forward. Both postsecondary institutions and society at large need to attend to these impacts, in order to preserve the wellbeing of graduates, the Canadian labor market, and to ensure that the pandemic does not further exacerbate existing inequalities in post-secondary education in Canada.

Cost of COVID-19: Using life course theory as a lens to understand the consequences of the pandemic.

Context: The COVID-19 pandemic and associated countermeasures have had broad implications across society which will have implications for physical and mental health for years to come. Understanding these experiences through the lens of life course constructs may help communities, service providers including family doctors, and governments to recognize and respond more effectively to the lasting impacts. Objective: To use life course theory to explore the impacts of the COVID-19 pandemic and associated countermeasures on child and family mental, social, and emotional well-being. Study Design: Qualitative study including anonymous micro-narrative collection using Spryng.io software (n=210); in-depth interviews with health and social service providers (n=30). Directed content analysis was used to examine the experiences of the COVID-19 pandemic as they relate to key constructs in life course theory. Setting: Kingston, Frontenac, Lennox and Addington counties in South-Eastern Ontario (pop. 210,000). Population Studied: Participants were recruited to the micronarrative collection through convenience sampling using the online data collection tool, as well as through intentional sampling targeting Indigenous people and people experiencing socio economic deprivation and homelessness. Participants for the in-depth interviews were intentionally recruited as key informants from local health and social service organizations. Results: All of the key constructs of life course theory were relevant when applied to our findings. Our data identified meaningful impacts on life course trajectory components including transitions, turning points, and social pathways, as well as using the principles of agency, life span development, linked lives, timing, and time and place. Conclusions: Our data illustrate the pervasive impact of the COVID-19 pandemic on all aspects of the life course. While service providers and policy makers are attuned to the acute crises currently unfolding, the long term impacts of life course disruption will play out over years, or potentially over the entire lifespan of this cohort. Responses to the pandemic cannot limit themselves to crisis management in the next 12-18 months, but will need to integrate an understanding of life course theory to support long term healing of individuals and communities.

Food worry and mental health outcomes during the COVID-19 pandemic.

BACKGROUND: There is limited and inconsistent literature examining the relationship between food worry and mental health in the context of the COVID-19 pandemic. This study examined the association between food worry and mental health among community dwelling Canadian adults during the COVID-19 pandemic. METHODS: Adults age 16 years and older completed an anonymous online questionnaire between April 1, 2020 and November 30 2020. Measures of pre-pandemic and current food worry, depression (PHQ-2), anxiety (GAD-2), and sociodemographic variables were included. Multivariable logistic regression models were used to determine the association between food worry and symptoms of depression and anxiety. RESULTS: In total, 1605 participants were included in analyses. Worry about affording food was reported by 320 (14.78%) participants. In models adjusting for sociodemographic covariates, compared with people without food worry, participants who had food worry were 2.07 times more likely to report anxiety symptoms (aOR 2.07, 95% CI: 1.43 - 2.98, p < .001) and were 1.9 times more likely to report depressive symptoms (aOR 1.89, 95% CI: 1.39-2.57, p < .0001). Lower income, lower education, and pre-existing mental health conditions were significant predictors of symptoms of depression. Female gender, younger age, lower education, lower income, and pre-existing mental health condition were significant predictors of anxiety symptoms. CONCLUSION: Our study highlights the relationship between food worry and poor mental health. Policy supports such as improved income supports, clinical implications such as screening for food worry in primary care, referral to emergency food programs and support with meal planning may help mitigate mental health symptoms during the current pandemic, during future societal recovery from this pandemic and during future pandemics.

A systematic review of factors influencing participation in two types of malaria prevention intervention in Southeast Asia.

BACKGROUND: Multi-pronged malaria elimination strategies are increasingly being considered for accelerating efforts against malaria transmission in Southeast Asia. Two malaria prevention interventions used in in the region are insecticide-treated bed-nets (ITNs) and mass drug administration (MDA). Universal access to ITNs is recommended and high population coverage (e.g. above 80%) is needed during MDA initiatives to maximize the impact of these interventions. However, variability in ITN use and individual MDA participation exists. This systematic review aims to provide a summary and overview of literature discussing factors influencing uptake of these two malaria control strategies in Southeast Asian countries. METHODS: A search of OVID Embase, OVID MEDLINE, Cochrane Central Register of Controlled Trials, Web of Science, OpenGrey, ProQuest, and Google Scholar was undertaken in February 2020. English-language publications with any study design using data from any of the ten member countries of the Association of Southeast Asian Nations were eligible for inclusion. In addition, reference lists of identified articles were manually searched. Websites for relevant international agencies were also searched to identify related grey literature. RESULTS: The review identified thirty publications that met the inclusion and exclusion criteria. Most discussed ITN use (n = 18) and were relevant to populations in Myanmar (n = 14). All MDA studies were published after 2016, whereas included ITN studies spanned from 1998 to 2020. Seven main themes emerged across the studies. Knowledge of malaria and attitudes towards ITNs were emphasized as key factors associated with ITN use. For MDA participation, key factors included the importance of positive attitudes towards the program, the influence of indirect costs and incentives, and the tendency for group decision-making. CONCLUSIONS: As countries in Southeast Asia continue to work towards becoming malaria-free by 2030, the knowledge and attitudes of local population sub-groups should be assessed and incorporated into the planning and implementation of malaria prevention activities. The role of incentives and group decision making should also be considered particularly as they relate to MDA. There is need for ongoing involvement of health educators, the continuation of implementation research and the prioritization of community engagement efforts alongside malaria interventions in the region.

Reproductive health interventions for Inuit youth in the north: a scoping review.

BACKGROUND: Inuit have thrived in the northern regions of Canada and Alaska for thousands of years. Recent evidence suggests that Inuit in this region have experienced systemic barriers to reproductive health with resulting disparities in reproductive health-related outcomes including those among youth. Northern youth-focused reproductive health intervention research or evaluations have not to date been well summarized. The objective of this scoping review was to summarize the literature over the past twenty years focusing on reproductive health interventions for adolescents in northern Inuit communities. METHODS: English-language articles from 2000 to 2020 were identified from seven scientific databases, a general internet search and a review of relevant websites. Two reviewers screened titles, abstracts and full texts and included articles if they mentioned a reproductive health intervention and pertained, directly or indirectly, to reproductive health for Inuit aged 10-19 in northern communities. RESULTS: Seventeen articles met the inclusion criteria, across six themes: (1) Barriers to reproductive health interventions in the north; (2) Northern midwifery; (3) Northern birthing centres; (4) Fetal fibronectin tests for identifying high-risk pregnancies; (5) Prenatal education classes; and (6) Interventions to improve access to and quality of reproductive health supports. CONCLUSION: Overall there is relatively limited evidence base specific to reproductive health interventions and northern Inuit youth. What does exist largely focuses on maternal health interventions and is inclusive of but not specific to youth. There is some evidence that youth specific educational programs, participatory action research approaches and the promotion of northern birthing centres and midwifery can improve reproductive health for adolescents and young mothers in northern Inuit communities. Future initiatives should focus on the creation and evaluation of culturally relevant and youth specific interventions and increasing community and youth participation in intervention research for better reproductive health.

Experience of emergency department use among persons with a history of adverse childhood experiences.

BACKGROUND: Adverse childhood experiences (ACEs) are associated with increased morbidity and mortality, lower levels of distress tolerance, and greater emotional dysregulation, as well as with increased healthcare utilization. All these factors may lead to an increased use of emergency department (ED) services. Understanding the experience of ED utilization among a group of ED users with high ACE scores, as well as their experiences as viewed through the lens of a trauma and violence informed care (TVIC) framework, could be important to their provision of care. METHODS: This is the qualitative portion of a larger mixed methods study. Twenty-five ED users with high ACE scores completed in depth interviews. Thematic analysis of the interview transcripts was undertaken and directed content analysis was used to examine the transcripts against a TVIC framework. RESULTS: The majority of participants experienced excellent care although challenges to this experience were faced by many in the areas of registration and triage. Some participants did identify negative experiences of care and stigma when presenting with mental health conditions and pain crises, as did participants who perceived that they were considered "different" (dressed differently, living in poverty, young parents, etc.). Participants were thoughtful about their reasons for seeking ED care including lack of timely access to their family doctor, perceived urgency of their condition, or needs that fell outside the scope of primary care. Participants' experiences mapped onto a TVIC framework such that their needs and experiences could be framed using a TVIC lens. CONCLUSIONS: While the ED care experience was excellent for most participants, even those with a trauma history, there existed a subset of vulnerable patients for whom the principles of TVIC were not met, and for whom implementation of trauma informed care might have a positive impact on the overall experience of care. Recommendations include training around TVIC for ED leadership, staff and physicians, improved access to semi-urgent primary care, ED patient care plans integrating TVIC principles, and improved support for triage nurses and registration personnel.

Creating a locally driven research agenda for the ethnic minorities of Eastern Myanmar.

BACKGROUND: Research funding and production is inequitably distributed internationally, with emphasis placed on the priorities of funders and international partners. Research capacity development, along with agenda-setting for research priorities can create agency and self-sufficiency and should be inclusive of all relevant stakeholders. Myanmar is a fragile state, where decades of conflict have created a weakened healthcare system and health research sector. The population of Eastern Myanmar have long had their healthcare needs met by community-based organisations and ethnic health organisations operating within Eastern Myanmar and the adjoining Thai-Myanmar border. Despite a transition to civilian rule, the current context does not allow for a truly participatory health research capacity development and agenda-setting exercise between the health leaders of Eastern Myanmar and the government in Yangon. In this context, and with a desire to enhance the capacity, legitimacy and agency of their organisations, the health leaders of Eastern Myanmar are seeking to develop their own health research capacity and to take control of their own research agenda. METHODS: Approximately 60 participants from 15 organisations attended a 3-day forum with the goals of (1) developing research capacity and interest through a research conference and methods workshop; (2) using a nominal group technique (NGT) to develop a locally driven research agenda; and (3) supporting the development of local research projects through ongoing funding and mentorship. RESULTS: Participants were actively engaged in the workshops and NGT. Participants identified a broad range of health issues as priorities and were able to develop consensus around a list of 15 top priorities for the populations they serve. Despite availability of ongoing support, participants did not pursue the opportunity to engage in their own research projects emerging from this forum. CONCLUSIONS: The NGT was an effective way to achieve engagement and consensus around research priorities between a group of healthcare providers, researchers and policy-makers from a variety of ethnic groups. More active involvement of senior leadership must happen before the energy harnessed at such a forum can be implemented in ongoing research capacity development.

The history and promise of holism in health promotion.

Holism is an ancient theme concept that has resurfaced in recent literature, and that requires informed and intentional use in order to preserve its utility. This paper provides a historical and conceptual reintroduction of the notion of holism as it relates to health, with the hopes of informing the term's use in public health discourse. It also addresses the challenges that a lack of conceptual clarity about holistic health imposes on public health and health promotion discussions. It describes how the use and conceptualizations of holism are shifting in health promotion and argues that failing to accurately define and delineate its scope risks diluting its utility for future health promotion applications. We address these two problems, and build an argument for a rediscovery of the theory of holism in public health and health promotion, globally.

Later school start times for supporting the education, health, and well-being of high school students.

BACKGROUND: A number of school systems worldwide have proposed and implemented later school start times as a means of avoiding the potentially negative impacts that early morning schedules can have on adolescent students. Even mild sleep deprivation has been associated with significant health and educational concerns: increased risk for accidents and injuries, impaired learning, aggression, memory loss, poor self-esteem, and changes in metabolism. Although researchers have begun to explore the effects of delayed school start time, no one has conducted a rigorous review of evidence to determine whether later school start times support adolescent health, education, and well-being. OBJECTIVES: We aimed to assess the effects of a later school start time for supporting health, education, and well-being in high school students.Secondary objectives were to explore possible differential effects of later school start times in student subgroups and in different types of schools; to identify implementation practices, contextual factors, and delivery modes associated with positive and negative effects of later start times; and to assess the effects of later school start times on the broader community (high school faculty and staff, neighborhood, and families). SEARCH METHODS: We conducted the main search for this review on 28 October 2014 and updated it on 8 February 2016. We searched CENTRAL as well as 17 key electronic databases (including MEDLINE, Embase, ERIC, PsycINFO, and Sociological Abstracts), current editions of relevant journals and organizational websites, trial registries, and Google Scholar. SELECTION CRITERIA: We included any randomized controlled trials, controlled before-and-after studies, and interrupted time series studies with sufficient data points that pertained to students aged 13 to 19 years and that compared different school start times. Studies that reported either primary outcomes of interest (academic outcomes, amount or quality of sleep, mental health indicators, attendance, or alertness) or secondary outcomes (health behaviors, health and safety indicators, social outcomes, family outcomes, school outcomes, or community outcomes) were eligible. DATA COLLECTION AND ANALYSIS: At least two review authors independently determined inclusion and exclusion decisions through screening titles, abstracts, and full-text reports. Two review authors independently extracted data for all eligible studies. We presented findings through a narrative synthesis across all studies. When two or more study samples provided sufficient information to permit effect size calculations, we conducted random-effects meta-analyses to synthesize effects across studies. MAIN RESULTS: Our search located 17 eligible records reporting on 11 unique studies with 297,994 participants; the studies examined academic outcomes, amount and quality of sleep, mental health indicators, attendance, and student alertness. Overall, the quality of the body of evidence was very low, as we rated most studies as being at high or unclear risk of bias with respect to allocation, attrition, absence of randomization, and the collection of baseline data. Therefore, we cannot be confident about the effects of later school start times.Preliminary evidence from the included studies indicated a potential association between later school start times and academic and psychosocial outcomes, but quality and comparability of these data were low and often precluded quantitative synthesis. Four studies examined the association between later school start times and academic outcomes, reporting mixed results. Six studies examined effects on total amount of sleep and reported significant, positive relationships between later school start times and amount of sleep. One study provided information concerning mental health outcomes, reporting an association between decreased depressive symptoms and later school start times. There were mixed results for the association between later school start times and absenteeism. Three studies reported mixed results concerning the association between later school start times and student alertness. There was limited indication of potential adverse effects on logistics, as the qualitative portions of one study reported less interaction between parents and children, and another reported staffing and scheduling difficulties. Because of the insufficient evidence, we cannot draw firm conclusions concerning adverse effects at this time.It is important to note the limitations of this evidence, especially as randomized controlled trials and high-quality primary studies are difficult to conduct; school systems are often unwilling or unable to allow researchers the necessary control over scheduling and data collection. Moreover, this evidence does not speak to the process of implementing later school starts, as the included studies focused on reporting the effects rather than exploring the process. AUTHORS' CONCLUSIONS: This systematic review on later school start times suggests several potential benefits for this intervention and points to the need for higher quality primary studies. However, as a result of the limited evidence base, we could not determine the effects of later school start times with any confidence.

Harnessing opportunities for good governance of health impacts of mining projects in Mongolia: results of a global partnership.

BACKGROUND: The Sustainable Development Goals call for the effective governance of shared natural resources in ways that support inclusive growth, safeguard the integrity of the natural and physical environment, and promote health and well-being for all. For large-scale resource extraction projects -- e.g. in the mining sector -- environmental regulations and in particular environmental impact assessments (EIA) provide an important but insufficiently developed avenue to ensure that wider sustainable development issues, such as health, have been considered prior to the permitting of projects. METHODS: In recognition of the opportunity provided in EIA to influence the extent to which health issues would be addressed in the design and delivery of mining projects, an international and intersectoral partnership, with the support of WHO and public funds from Canadian sources, engaged over a period of six years in a series of capacity development activities and knowledge translation/dissemination events aimed at influencing policy change in the extractives sector so as to include consideration of human health impacts. RESULTS: Early efforts significantly increased awareness of the need to include health considerations in EIAs. Coupling effective knowledge translation about health in EIA with the development of networks that fostered good intersectoral partnerships, this awareness supported the development and implementation of key pieces of legislation. These results show that intersectoral collaboration is essential, and must be supported by an effective conceptual understanding about which methods and models of impact assessment, particularly for health, lend themselves to integration within EIA. CONCLUSIONS: The results of our partnership demonstrate that when specific conditions are met, integrating health into the EIA system represents a promising avenue to ensure that mining activities contribute to wider sustainable development goals and objectives.

Physical fighting, fighting-related injuries and family affluence among Canadian youth.

BACKGROUND: Physical fighting is an assaultive behaviour that can lead to injury. Family affluence is a health determinant that can influence injury. This study examines the relationship between family affluence and two outcomes: physical fighting and fighting-related injury in Canadian adolescents. Three measurements were used to represent family affluence and assess whether these measures demonstrated different associations with these outcomes. METHODS: Canadian data from the 2009/2010 Health Behaviour in School-aged Children Study were used. It consists of a nationally representative sample of 26,078 grade 6-10 students. A subset analysis of 10,429 grade 9-10 students was conducted to account for additional confounders. Modified Poisson regression was used to compare the risk of physical fighting and fighting-related injury in youth from different levels of family affluence. Three indicators were used to represent family affluence: self-perceived affluence, a family affluence scale (FAS), and area-level average household income. RESULTS: The overall prevalence was 35.6% for physical fighting and 2.7% for fighting-related injuries. Both outcomes were more frequent in males than females. An inverse gradient was present where risk for both outcomes increased with decreasing levels of affluence irrespective of the affluence measurement. The self-perceived affluence variable showed a significantly stronger gradient in girls than boys for both outcomes. For both outcomes, FAS showed a similar inverse gradient within females, but a threshold effect in males where there was a strong effect in the low FAS group, but a null effect in the moderate FAS group. The area-level income variable presented a significantly higher likelihood for physical fighting only in females (p = 0.001-0.075). For fighting-related injury, none of the area-level income models showed significant risk estimates with the exception of the bivariate association where low income females were twice as likely to report a fighting-related injury compared to higher income groups (p = 0.030). Post hoc power calculations indicate that there was not sufficient power to detect injury effects associated with the area level income measure. CONCLUSION: It appears that a socioeconomic gradient exists where lower affluence is associated with a higher risk of reporting a physical fight and fighting-related injury irrespective of the measure used. While the patterns were generally the same with all three measurements, the strength of this gradient varied across measures. This demonstrates that each indicator may measure different aspects of affluence. Further analyses are needed to explore concepts and mechanisms underlying each affluence measure.

Inequalities in the spiritual health of young Canadians: a national, cross-sectional study.

BACKGROUND: Spiritual health, along with physical, emotional, and social aspects, is one of four domains of health. Assessment in this field of research is challenging methodologically. No contemporary population-based studies have profiled the spiritual health of adolescent Canadians with a focus on health inequalities. In a 2014 nationally representative sample of Canadians aged 11-15 years we therefore: (1) psychometrically evaluated a series of items used to assess the perceived importance of spiritual health and its four potential sub-domains (connections with: self, others, nature and the natural environment, and the transcendent) to adolescents; (2) described potential inequalities in spiritual health within adolescent populations, overall and by spiritual health sub-domain, by key socio-demographic factors. METHODS: Cross-sectional analysis of survey reports from the 2014 (Cycle 7) of the Canadian Health Behaviour in School-aged Children study (weighted n = 25,036). Principal components analysis followed by confirmatory factor analysis were used to explore the psychometric properties of the spiritual health items and the associated composite scale describing perceived importance of spiritual health. Associations among this composite scale, its individual sub-domains, and key socio-demographic factors were then explored. RESULTS: The principal components analysis best supported a four-factor structure where the eight scale items loaded highly according to the original four domains. This was also supported in confirmatory factor analyses. We then combined the eight items into composite spiritual health score as supported by theory, principal components analysis findings, and acceptable tests of reliability. Further confirmatory factor analysis suggested the need for additional refinements to this scale. Based upon exploratory cross-sectional analyses, strong socio-demographic inequalities were observed in the spiritual health measures by age, gender, relative material wealth, immigration status, and province/territory. CONCLUSIONS: Study findings highlight potential inequalities in the spiritual health of young Canadians, as well as opportunities for methodological advances in the assessment of adolescent spiritual health in our population.

The Relationship Between Immigrant School Composition, Classmate Support and Involvement in Physical Fighting and Bullying among Adolescent Immigrants and Non-immigrants in 11 Countries.

Increasing numbers of migrant youth around the world mean growing numbers of heterogeneous school environments in many countries. Contradictory findings regarding the relationship between immigrant school composition (the percentage of immigrant versus non-immigrant students in a school) and adolescent peer violence necessitate further consideration. The current study examined the relationship between immigrant school composition and peer violence, considering classmate support as a potential moderator among 51,636 adolescents (50.1% female) from 11 countries. The findings showed that a higher percentage of immigrant adolescents in a school was related to higher levels of physical fighting and bullying perpetration for both immigrant and non-immigrant adolescents and lower levels of victimization for immigrants. In environments of low classmate support, the positive relationship between immigrant school composition and fighting was stronger for non-immigrants than in environments with high classmate support. In environments of low classmate support, the negative relationship between immigrant school composition and fighting and bullying victimization was stronger for immigrant adolescents than in environments with high classmate support. In general, the contribution of immigrant school composition was modest in comparison to the contribution of classmate support. The findings emphasize that it is not just the number of immigrants in a class per se, but rather the environment in the classroom which influences levels of peer violence. The results highlight a need for school intervention programs encouraging positive relations in schools with immigrant populations.

Critical examination of knowledge to action models and implications for promoting health equity.

INTRODUCTION: Knowledge and effective interventions exist to address many current global health inequities. However, there is limited awareness, uptake, and use of knowledge to inform action to improve the health of disadvantaged populations. The gap between knowledge and action to improve health equity is of concern to health researchers and practitioners. This study identifies and critically examines the usefulness of existing knowledge to action models or frameworks for promoting health equity. METHODS: We conducted a scoping review of existing literature to identify knowledge to action (KTA) models or frameworks and critiqued the models using a health equity support rubric. RESULTS: We identified forty-eight knowledge to action models or frameworks. Six models scored between eight and ten of a maximum 12 points on the health equity support rubric. These high scoring models or frameworks all mentioned equity-related concepts. Attention to multisectoral approaches was the factor most often lacking in the low scoring models. The concepts of knowledge brokering, integrative processes, such as those in some indigenous health research, and Ecohealth applied to KTA all emerged as promising areas. CONCLUSIONS: Existing knowledge to action models or frameworks can help guide knowledge translation to support action on the social determinants of health and health equity. There is a need to further test existing models or frameworks. This process should be informed by participatory and integrative research. There is room to develop more robust equity supporting models.

It still takes a village: an epidemiological study of the role of social supports in understanding unexpected health states in young people.

BACKGROUND: This study of adolescent Canadians examines two groups who are anomalous in their health experiences: (1) those with perceived low affluence yet who perceive themselves to have excellent general health status; (2) those of perceived high affluence but who are reporting poor health status. Our hope was to explore the role of social supports in explaining such anomalies. We hypothesized that cumulative levels of social support available to these young people would have an influence on their perceived health status, with more support being associated with better self reported health. METHODS: Young people (n = 26,078 from 436 schools) aged 11-15 years were administered a general health survey in classroom settings during the 2009-10 academic school year. Descriptive and regression-based cross-sectional analyses (with an affluence-social support interaction term) were used to relate both individual and cumulative levels of social support in homes, neighborhoods, schools, and peer groups to self-reported health status. RESULTS: Social supports and their cumulative availability indeed were strongly related to perceived health, with more supports being associated with better self-perceived health. Less affluent children were much more likely to report excellent health in the presence of numerous social supports. More affluent children were much more likely to report poor health in the absence of such supports. The strength and dose-dependent nature of the findings were consistent and striking. CONCLUSIONS: Study findings from this large, contemporary and national analysis affirm the importance of social supports as potential determinants of health for young people from both high and low affluent groups. Conceptually, findings affirm the wisdom of the ancient principle: "it takes a village to raise a child".

Youth injury prevention in Canada: use of the Delphi method to develop recommendations.

BACKGROUND: The Health Behaviour in School-aged Children Survey is one of very few cross-national health surveys that includes information on injury occurrence and prevention within adolescent populations. A collaboration to develop a Canadian youth injury report using these data resulted in, Injury among Young Canadians: A national study of contextual determinants. The objective of this study was to develop specific evidence-based, policy-oriented recommendations arising from the national report, using a modified-Delphi process with a panel of expert stakeholders. METHOD: Eight injury prevention experts and a 3-person youth advisory team associated with a Canadian injury prevention organization (Parachute Canada) reviewed, edited and commented on report recommendations through a three-stage iterative modified-Delphi process. RESULTS: From an initial list of 27 draft recommendations, the modified-Delphi process resulted in a final list of 19 specific recommendations, worded to resonate with the group(s) responsible to lead or take the recommended action. Two recommendations were rated as "extremely important" or "very important" by 100 % of the expert panel, two were deleted, a further two recommendations were deleted but the content included as text in the report, and four were merged with other existing recommendations. CONCLUSIONS: The modified-Delphi process was an appropriate method to achieve agreement on 19 specific evidence-based, policy-oriented recommendations to complement the national youth injury report. In providing their input, it is noted that the injury stakeholders each acted as individual experts, unattached to any organizational position or policy. These recommendations will require multidisciplinary collaborations in order to support the proposed policy development, additional research, programming and clear decision-making for youth injury prevention.

Replication of a whole school ethos-changing intervention: different context, similar effects, additional insights.

BACKGROUND: Whole school, ethos-changing interventions reduce risk behaviours in middle adolescence, more than curriculum-based approaches. Effects on older ages are not known. We set out to replicate one of these interventions, Australia's Gatehouse Project, in a rural Canadian high school. METHODS: A guided, whole school change process sought to make students feel more safe, connected, and valued by: changes in teaching practices, orientation processes, professional development of staff, recognition and reward mechanisms, elevating student voice, and strategies to involve greater proactivity and participation. We conducted risk behaviour surveys in grades 10 to 12 before the intervention and 2 years afterwards, and social network analyses with the staff. Changes in health and health risk behaviours were assessed using chi-square. Interactions between the intervention and gender and between the intervention and school engagement were assessed using interaction terms in logistic regression models. Changes in the density of relationships among staff were tested with methods analogous to paired t-tests. RESULTS: Like Gatehouse, there was no statistically significant reduction in depressive symptoms or bullying, though the trend was in that direction. Among girls, there was a statistically significant decrease in low school engagement (45% relative reduction), and decreases in drinking (46% relative reduction), unprotected sex (61% relative reduction) and poor health (relative reduction of 73%). The reduction in drinking matched the national trend. Reductions in unprotected sex and poor health went against the national trend. We found no statistically significant changes for boys. The effects coincided with statistically significant increases in the densities of staff networks, indicating that part of the mechanism may be through relationships at school. CONCLUSIONS: A non-specific, risk protective intervention in the social environment of the school had a significant impact on a cluster of risk behaviours for girls. Results were remarkably like reports from similar school environment interventions elsewhere, albeit with different behaviours being affected. It may be that this type of intervention activates change processes that interact highly with context, impacting different risks differently, according to the prevalence, salience and distribution of the risk and the interconnectivity of relationships between staff and students. This requires further exploration.

Assessment of lumbar puncture skill in experts and nonexperts using checklists and quantitative tracking of needle trajectories: implications for competency-based medical education.

UNLABELLED: CONSTRUCT: With the current shift toward competency-based education, rigorous assessment tools are needed for procedurally based tasks. BACKGROUND: Multiple tools exist to evaluate procedural skills, each with specific weaknesses. APPROACH: We sought to determine if quantitative needle tracking could be used as a measure of lumbar puncture (LP) performance and added discriminatory value to a dichotomous checklist. Thirty-two medical students were divided into 2 groups. One group was asked to practice an LP once (single practice [SP]) and the other 5 times (multiple practice [MP]). Experts (attending ER physicians, senior ER residents, and a junior anesthesia resident) were used as comparators. Medical students were assessed again at 1 month to assess skill retention. Groups were assessed performing an LP with an electromagnetic tracking device that allows the needle's 3-dimensional movements to be captured and analyzed, and a dichotomous checklist. RESULTS: Quantitative needle metrics as assessed by electromagnetic tracking showed a decreasing trend in needle movement distance with practice and with experience. The SP group made significantly more checklist mistakes initially as compared to the MP group (1.2 vs. 0.3, p <.05). At 1 month, there was a significant increase in both groups' mistakes (SP 3.4 vs. MP 1.3, p =.01). No correlation existed between individuals' needle motion and checklist mistakes. CONCLUSIONS: These findings suggest that quantitative needle tracking identifies students who struggle with needle insertion but are successful at completing the dichotomous checklist.

HPV vaccine acceptability in Africa: a systematic review.

OBJECTIVE: The objective of this study was to provide a systematic review of peer-reviewed literature on the factors associated with HPV vaccine acceptability among adults in African countries. METHODS: A systematic search was conducted across five electronic databases: EMBASE, PsychINFO, CINAHL, Global Health and Ovid MEDLINE, to identify studies related to HPV vaccination acceptability in African countries (August 2013). The Health Belief Model was used to guide data abstraction and synthesis. RESULTS: Fourteen unique studies representing ten sub-Saharan African countries were identified, with more than half published within the last two years. Acceptability of the HPV vaccine for daughters was high (range 59-100%); however, vaccine-related awareness and knowledge were low. Perceived barriers including accessibility and cost concerns were important for acceptance, as were cues to action from healthcare providers and governments. CONCLUSIONS: This review suggests that acceptability of the HPV vaccine in countries in this region will be high. Broad knowledge gaps were highlighted regarding HPV and cervical cancer and these should be addressed. Education on the vaccine's effectiveness and reducing perceived barriers to vaccination would also be useful. Public endorsement by governments and healthcare providers will likely also increase acceptance.