Behavioural interventions delivered through interactive social media for health behaviour change, health outcomes, and health equity in the adult population.

BACKGROUND: Social networking platforms offer a wide reach for public health interventions allowing communication with broad audiences using tools that are generally free and straightforward to use and may be combined with other components, such as public health policies. We define interactive social media as activities, practices, or behaviours among communities of people who have gathered online to interactively share information, knowledge, and opinions. OBJECTIVES: We aimed to assess the effectiveness of interactive social media interventions, in which adults are able to communicate directly with each other, on changing health behaviours, body functions, psychological health, well-being, and adverse effects. Our secondary objective was to assess the effects of these interventions on the health of populations who experience health inequity as defined by PROGRESS-Plus. We assessed whether there is evidence about PROGRESS-Plus populations being included in studies and whether results are analysed across any of these characteristics. SEARCH METHODS: We searched CENTRAL, CINAHL, Embase, MEDLINE (including trial registries) and PsycINFO. We used Google, Web of Science, and relevant web sites to identify additional studies and searched reference lists of included studies. We searched for published and unpublished studies from 2001 until June 1, 2020. We did not limit results by language. SELECTION CRITERIA: We included randomised controlled trials (RCTs), controlled before-and-after (CBAs) and interrupted time series studies (ITSs). We included studies in which the intervention website, app, or social media platform described a goal of changing a health behaviour, or included a behaviour change technique. The social media intervention had to be delivered to adults via a commonly-used social media platform or one that mimicked a commonly-used platform. We included studies comparing an interactive social media intervention alone or as a component of a multi-component intervention with either a non-interactive social media control or an active but less-interactive social media comparator (e.g. a moderated versus an unmoderated discussion group). Our main outcomes were health behaviours (e.g. physical activity), body function outcomes (e.g. blood glucose), psychological health outcomes (e.g. depression), well-being, and adverse events. Our secondary outcomes were process outcomes important for behaviour change and included knowledge, attitudes, intention and motivation, perceived susceptibility, self-efficacy, and social support. DATA COLLECTION AND ANALYSIS: We used a pre-tested data extraction form and collected data independently, in duplicate. Because we aimed to assess broad outcomes, we extracted only one outcome per main and secondary outcome categories prioritised by those that were the primary outcome as reported by the study authors, used in a sample size calculation, and patient-important. MAIN RESULTS: We included 88 studies (871,378 participants), of which 84 were RCTs, three were CBAs and one was an ITS. The majority of the studies were conducted in the USA (54%). In total, 86% were conducted in high-income countries and the remaining 14% in upper middle-income countries. The most commonly used social media platform was Facebook (39%) with few studies utilising other platforms such as WeChat, Twitter, WhatsApp, and Google Hangouts. Many studies (48%) used web-based communities or apps that mimic functions of these well-known social media platforms. We compared studies assessing interactive social media interventions with non-interactive social media interventions, which included paper-based or in-person interventions or no intervention. We only reported the RCT results in our 'Summary of findings' table. We found a range of effects on health behaviours, such as breastfeeding, condom use, diet quality, medication adherence, medical screening and testing, physical activity, tobacco use, and vaccination. For example, these interventions may increase physical activity and medical screening tests but there was little to no effect for other health behaviours, such as improved diet or reduced tobacco use (20,139 participants in 54 RCTs). For body function outcomes, interactive social media interventions may result in small but important positive effects, such as a small but important positive effect on weight loss and a small but important reduction in resting heart rate (4521 participants in 30 RCTs). Interactive social media may improve overall well-being (standardised mean difference (SMD) 0.46, 95% confidence interval (CI) 0.14 to 0.79, moderate effect, low-certainty evidence) demonstrated by an increase of 3.77 points on a general well-being scale (from 1.15 to 6.48 points higher) where scores range from 14 to 70 (3792 participants in 16 studies). We found no difference in effect on psychological outcomes (depression and distress) representing a difference of 0.1 points on a standard scale in which scores range from 0 to 63 points (SMD -0.01, 95% CI -0.14 to 0.12, low-certainty evidence, 2070 participants in 12 RCTs). We also compared studies assessing interactive social media interventions with those with an active but less interactive social media control (11 studies). Four RCTs (1523 participants) that reported on physical activity found an improvement demonstrated by an increase of 28 minutes of moderate-to-vigorous physical activity per week (from 10 to 47 minutes more, SMD 0.35, 95% CI 0.12 to 0.59, small effect, very low-certainty evidence). Two studies found little to no difference in well-being for those in the intervention and control groups (SMD 0.02, 95% CI -0.08 to 0.13, small effect, low-certainty evidence), demonstrated by a mean change of 0.4 points on a scale with a range of 0 to 100. Adverse events related to the social media component of the interventions, such as privacy issues, were not reported in any of our included studies. We were unable to conduct planned subgroup analyses related to health equity as only four studies reported relevant data. AUTHORS' CONCLUSIONS: This review combined data for a variety of outcomes and found that social media interventions that aim to increase physical activity may be effective and social media interventions may improve well-being. While we assessed many other outcomes, there were too few studies to compare or, where there were studies, the evidence was uncertain. None of our included studies reported adverse effects related to the social media component of the intervention. Future studies should assess adverse events related to the interactive social media component and should report on population characteristics to increase our understanding of the potential effect of these interventions on reducing health inequities.

Migration and diabetes in British Columbia and Quebec: prevalence and health service utilization.

OBJECTIVES: This study describes prevalence of diabetes among immigrants and health service utilization among diabetic immigrants in British Columbia (BC) and Quebec (QC). METHODS: Immigrants to BC and QC between 1985 and 1999 were identified. Using age-standardized rate ratios, they were compared with a matched comparison group with respect to their diabetes prevalence and, among those with diabetes, physician service utilization. RESULTS: Immigrant women in both provinces and men in BC had higher rates of diabetes compared to the matched comparison group. Rates varied by region of birth and language ability. Diabetes prevalence rate ratios increased with length of stay in BC. Diabetic immigrants had lower rates of physician visits than diabetic comparisons. This gap decreased commensurate with immigrants' length of stay in BC. Diabetic immigrants who spoke neither official language had similar or higher rates of physician visits compared with immigrants who spoke one or both official languages. CONCLUSIONS: Genetic predisposition, lifestyle changes, acculturation, resettlement stress and differential health care access may explain increased prevalence of diabetes among many immigrants. These results can inform diabetes prevention and management programs tailored to the needs of specific immigrant groups. The gap in health service use between diabetic immigrants and comparisons does not appear to be related to language ability. Further studies are required to identify reasons.

Migration and health in Canada: health in the global village.

BACKGROUND: Immigration has been and remains an important force shaping Canadian demography and identity. Health characteristics associated with the movement of large numbers of people have current and future implications for migrants, health practitioners and health systems. We aimed to identify demographics and health status data for migrant populations in Canada. METHODS: We systematically searched Ovid MEDLINE (1996-2009) and other relevant web-based databases to examine immigrant selection processes, demographic statistics, health status from population studies and health service implications associated with migration to Canada. Studies and data were selected based on relevance, use of recent data and quality. RESULTS: Currently, immigration represents two-thirds of Canada's population growth, and immigrants make up more than 20% of the nation's population. Both of these metrics are expected to increase. In general, newly arriving immigrants are healthier than the Canadian population, but over time there is a decline in this healthy immigrant effect. Immigrants and children born to new immigrants represent growing cohorts; in some metropolitan regions of Canada, they represent the majority of the patient population. Access to health services and health conditions of some migrant populations differ from patterns among Canadian-born patients, and these disparities have implications for preventive care and provision of health services. INTERPRETATION: Because the health characteristics of some migrant populations vary according to their origin and experience, improved understanding of the scope and nature of the immigration process will help practitioners who will be increasingly involved in the care of immigrant populations, including prevention, early detection of disease and treatment.

A meta-analysis of randomized control trials of home-based secondary prevention programs for coronary artery disease.

BACKGROUND: A variety of different types of secondary prevention programs for coronary heart disease (CHD) exist. Home-based programs have become more common and may be more accessible or preferable to some patients. This review compared the benefits and costs of home-based programs with usual care and cardiac rehabilitation. METHODS: A meta-analysis following a systematic search of 19 databases, existing reviews, and references was designed. Studies evaluated home-based interventions that addressed more than one main CHD risk factor using a randomized trial with a usual care or cardiac rehabilitation comparison group with data extractable for CHD patients only and reported in English as a full article or thesis. RESULTS: Thirty-nine articles reporting 36 trials were reviewed. Compared with usual care, home-based interventions significantly improved quality of life [weighted mean difference: 0.23; 95% confidence interval (95% CI): 0.02-0.45], systolic blood pressure (weighted mean difference: -4.36 mmHg; 95% CI: -6.50 to -2.22), smoking cessation (difference in proportion: 14%; 95% CI: 0.02-0.26), total cholesterol (standardized mean difference: -0.33; 95% CI: -0.57 to -0.08), and depression (standardized mean difference: -0.33; 95% CI: -0.59 to -0.07). Effect sizes were small to moderate and trials were of low-to-moderate quality. Comparisons with cardiac rehabilitation could not be made because of the small number of trials and high levels of heterogeneity. CONCLUSION: Home-based secondary prevention programs for CHD are an effective and relatively low-cost complement to hospital-based cardiac rehabilitation and should be considered for stable patients less likely to access or adhere to hospital-based services.

Age- and sex-related prevalence of diabetes mellitus among immigrants to Ontario, Canada.

BACKGROUND: The majority of immigrants to Canada originate from the developing world, where the most rapid increase in prevalence of diabetes mellitus is occurring. We undertook a population-based study involving immigrants to Ontario, Canada, to evaluate the distribution of risk for diabetes in this population. METHODS: We used linked administrative health and immigration records to calculate age-specific and age-adjusted prevalence rates among men and women aged 20 years or older in 2005. We compared rates among 1,122,771 immigrants to Ontario by country and region of birth to rates among long-term residents of the province. We used logistic regression to identify and quantify risk factors for diabetes in the immigrant population. RESULTS: After controlling for age, immigration category, level of education, level of income and time since arrival, we found that, as compared with immigrants from western Europe and North America, risk for diabetes was elevated among immigrants from South Asia (odds ratio [OR] for men 4.01, 95% CI 3.82-4.21; OR for women 3.22, 95% CI 3.07-3.37), Latin America and the Caribbean (OR for men 2.18, 95% CI 2.08-2.30; OR for women 2.40, 95% CI: 2.29-2.52), and sub-Saharan Africa (OR for men 2.31, 95% CI 2.17-2.45; OR for women 1.83, 95% CI 1.72-1.95). Increased risk became evident at an early age (35-49 years) and was equally high or higher among women as compared with men. Lower socio-economic status and greater time living in Canada were also associated with increased risk for diabetes. INTERPRETATION: Recent immigrants, particularly women and immigrants of South Asian and African origin, are at high risk for diabetes compared with long-term residents of Ontario. This risk becomes evident at an early age, suggesting that effective programs for prevention of diabetes should be developed and targeted to immigrants in all age groups.

Dietary vitamin C, E, and carotenoid intake and risk of renal cell carcinoma.

OBJECT: The study examines the association between dietary intake of vitamin C, E, and carotenoids and the risk of renal cell carcinoma (RCC). METHODS: Between 1994 and 1997 in 8 Canadian provinces, mailed questionnaires were completed by 1,138 incident, histologically confirmed cases of RCC and 5,039 population controls, including information on socio-economic status, lifestyle habits and diet. A 69-item food frequency questionnaire provided data on eating habits 2 years before data collection. Odds ratios (OR) and 95% confidence intervals (CI) were computed using unconditional logistic regression. RESULTS: Dietary intake of beta-carotene and lutein/zeaxanthin was inversely associated with the risk of RCC. The ORs for the highest versus the lowest quartile were 0.74 (95% CI, 0.59-0.92) and 0.77 (95% CI, 0.62-0.95), respectively. The significant inverse association with beta-carotene and lutein/zeaxanthin was more pronounced in women, and in overweight or obese subjects. The relation of lutein/zeaxanthin to RCC was stronger in ever smokers. No clear association was observed with vitamin C and E, beta-cryptozanthin, and lycopene. CONCLUSION: The findings provide evidence that a diet rich in beta-carotene and lutein/zeaxanthin may play a role in RCC prevention.

Energy intake, physical activity, energy balance, and cancer: epidemiologic evidence.

Energy intake, physical activity, and obesity are modifiable lifestyle factors. This chapter reviews and summarizes the epidemiologic evidence on the relation of energy intake, physical activity, and obesity to cancer. High energy intake may increase the risk of cancers of colon-rectum, prostate (especially advanced prostate cancer), and breast. However, because physical activity, body size, and metabolic efficiency are highly related to total energy intake and expenditure, it is difficult to assess the independent effect of energy intake on cancer risk. There are sufficient evidences to support a role of physical activity in preventing cancers of the colon and breast, whereas the association is stronger in men than in women for colon cancer and in postmenopausal than in premenopausal women for breast cancer. The evidence also suggests that physical activity likely reduces the risk of cancers of endometrium, lung, and prostate (to a lesser extent). On the other hand, there is little or no evidence that the risk of rectal cancer is related to physical activity, whereas the results have been inconsistent regarding the association between physical activity and the risks of cancers of pancreas, ovary and kidney. Epidemiologic studies provide sufficient evidence that obesity is a risk factor for both cancer incidence and mortality. The evidence supports strong links of obesity with the risk of cancers of the colon, rectum, breast (in postmenopausal women), endometrium, kidney (renal cell), and adenocarcinoma of the esophagus. Epidemiologic evidence also indicates that obesity is probably related to cancers of the pancreas, liver, and gallbladder, and aggressive prostate cancer, while it seems that obesity is not associated with lung cancer. The role of obesity in other cancer risks is unclear.

Individual, social, environmental, and physical environmental correlates with physical activity among Canadians: a cross-sectional study.

BACKGROUND: The identification of various individual, social and physical environmental factors affecting physical activity (PA) behavior in Canada can help in the development of more tailored intervention strategies for promoting higher PA levels in Canada. This study examined the influences of various individual, social and physical environmental factors on PA participation by gender, age and socioeconomic status, using data from the 2002 nationwide survey of the Physical Activity Monitor. METHODS: In 2002, 5,167 Canadians aged 15-79 years, selected by random-digit dialling from household-based telephone exchanges, completed a telephone survey. The short version of the International Physical Activity Questionnaire was used to collect information on total physical activity. The effects of socio-economical status, self-rated health, self-efficacy, intention, perceived barriers to PA, health benefits of PA, social support, and facility availability on PA level were examined by multiple logistic regression analyses. RESULTS: Self-efficacy and intention were the strongest correlates and had the greatest effect on PA. Family income, self-rated health and perceived barriers were also consistently associated with PA. The effects of the perceived health benefits, education and family income were more salient to older people, whereas the influence of education was more important to women and the influence of perceived barriers was more salient to women and younger people. Facility availability was more strongly associated with PA among people with a university degree than among people with a lower education level. However, social support was not significantly related to PA in any subgroup. CONCLUSION: This study suggests that PA promotion strategies should be tailored to enhance people's confidence to engage in PA, motivate people to be more active, educate people on PA's health benefits and reduce barriers, as well as target different factors for men and women and for differing socio-economic and demographic groups.

Rural-urban disparities in health: how does Canada fare and how does Canada compare with Australia?

OBJECTIVE: To analyse rural-urban and intra-rural disparities in health status in Canada and to compare Canada with Australia with respect to such disparities. DESIGN: Four indicators were used to show rural-urban and intra-rural differences in health status: (i) mortality due to circulatory diseases, (ii) mortality due to cancer, (iii) injury-related mortality; and (iv) all-cause mortality. Rural was disaggregated into finer categories based on degree of remoteness, using the Metropolitan Influence Zone classification in Canada and the Accessibility/Remoteness Index of Australia. Comparisons were made using age-standardised mortality rates and standardised mortality ratios. PARTICIPANTS: Rural and urban populations of Canada and Australia. RESULTS: The study confirmed previous findings that rural Canadians tended to have poorer health status than their urban counterparts. However, when rural was disaggregated into finer categories, different health status patterns emerged. Although the most rural areas tended to have the worst health status, the least rural areas generally enjoyed good health. The Canada-Australia comparisons revealed convergence and divergence. CONCLUSIONS: The similarities between Canada and Australia show that rural-urban disparities in health status are not limited to a particular country. For several causes of death, whereas the mortality risks in Rural 1 areas in Canada are significantly lower than in urban areas, the opposite is true in Australia, suggesting that although there are some common patterns across the two countries in relation to rural-urban health status disparities, nation-specific uniqueness is to be expected.

Nutrient and fiber intake and risk of renal cell carcinoma.

This study examines the association between nutrient and fiber intake and the risk of renal cell carcinoma (RCC). Between 1994 and 1997 in 8 Canadian provinces, mailed questionnaires were completed by 1,138 incident, histologically confirmed cases of RCC and 5,039 population controls. Measurement included information on socioeconomic status, lifestyle habits, and diet. A 69-item food frequency questionnaire provided data on eating habits 2 yr before data collection. Odds ratios (ORs) and 95% confidence intervals were derived through unconditional logistic regression. Intakes of total fat, saturated fat, monounsaturated fat, trans-fat, and cholesterol were associated with the risk of RCC; the ORs for the highest vs. the lowest quartile were 1.67, 1.53 and 1.46, 1.31, and 1.48, respectively. The positive association was apparently stronger in women, overweight or obese, and never smokers. Sucrose was related to the risk of RCC. High fiber intake was inversely associated with RCC risk. No association was found with intake of total protein and polyunsaturated fat, n-3 and n-6 polyunsaturated fatty acids, and total carbohydrates. The results were consistent across strata of sex, tobacco, and BMI. The findings suggest that a diet low in fats and cholesterol and rich in fiber could favorably affect the risk of RCC.

Supporting knowledge into action: The Canadian Best Practices Initiative for Health Promotion and Chronic Disease Prevention.

Public health practitioners and policy-makers working to address the burden of chronic disease are increasingly seeking to use best practices given the need to make thoughtful program and policy choices with limited resources. While the evidence base in chronic disease prevention is growing through a number of different information sources, there is often a disconnect between the desire to use best practices and their implementation. This is related not only to individual and organizational barriers in terms of time and resources, but also to lack of agreement on what constitutes best practice and what sources of evidence are valid guides for practice. This is compounded by lack of user-friendly and streamlined access to credible best practice evidence and decision making/practice supports. In response to these needs, six years ago Canadian researchers, policy-makers and practitioners came together to begin working on creating a best practice system in Canada for health promotion and chronic disease prevention. This article presents an overview of the development of the Canadian Best Practices Portal and in particular how an evolution in thinking about best practice methodology and evidence will contribute to an enriched knowledge base for health promotion and chronic disease prevention policy, practice and research.

Diet and vitamin or mineral supplementation and risk of colon cancer by subsite in Canada.

The study assesses the association of diet and vitamin or mineral supplementation with risk of proximal or distal colon cancer. Mailed questionnaires were completed by 1723 newly diagnosed, histologically confirmed colon cancer cases and 3097 population controls between 1994 and 1997 in seven Canadian provinces. Measurement included information on socio-economic status, physical activity, smoking habits, alcohol use, diet and vitamin or mineral supplementation. Odds ratios and 95% confidence intervals were derived through unconditional logistic regression. Linear regression was used to examine that dietary factors affect body mass index. The strongest positive associations between colon cancer risk and increasing total fat intake were observed for proximal colon cancer in men and for distal colon cancer in both men and women. Increased consumption of vegetables, fruit and whole-grain products did not reduce the risk of colon cancer. A modest reduction in distal colon cancer risk was noted in women who consumed yellow-orange vegetables. Significant positive associations were observed between proximal colon cancer risk in men and consumption of red meat and dairy products, and between distal colon cancer risk in women and total intake of meat and processed meat. We also saw strong associations between bacon intake and both subsites of colon cancer in women. When men were compared with women directly by subsite however, the results did not show a corresponding association. A significantly reduced risk of distal colon cancer was noted in women only with increasing intake of dairy products and of milk. Among men and women taking vitamin and mineral supplements for more than 5 years, significant inverse associations with colon cancer were most pronounced among women with distal colon cancer. These findings suggest that dietary risk factors for proximal colon cancer may differ from those for distal colon cancer.

Non-communicable disease and injury-related mortality in rural and urban places of residence: a comparison between Canada and Australia.

BACKGROUND: Few published studies looking at cross-national comparisons of rural-urban health status are available. As a first step towards addressing the lack of information on how rural populations in Canada compare with rural populations elsewhere in the world, this paper examines and contrasts Canadian mortality risks of selected diseases in rural and urban areas with those of Australia. METHODS: Age-standardized mortality ratios for selected causes of deaths were calculated at the national level and broken down into place of residence categories using country-specific definitions of rurality (Metropolitan Influence Zones in Canada and the Australian Standard Geographical Classification [ASGC] Remoteness in Australia). RESULTS: Patterns of rural-urban mortality risk were mostly similar in both countries. However, depending on the causes of death examined, important differences were found. Mortality from motor vehicle accidents, suicide and a few cancer sites showed similar urban-rural gradients in both Canada and Australia. Notable differences were found for diabetes, all cancers combined, as well as lung and colorectal cancer. Rural Australians were at higher risk of dying from these diseases than their urban counterparts, whereas rural Canadians were at lower risk than urban Canadians. DISCUSSION: Overall, the patterns that have emerged from this comparison of Canadian and Australian mortality risks suggest that health status disparities between rural and urban populations are not limited to a specific country or region of the world. However, there are also important differences between the two countries, as the geographic mortality patterns varied according to sex and according to disease category. This analysis is an initial step in promoting discussion of rural health in an international context.

Obesity, high energy intake, lack of physical activity, and the risk of kidney cancer.

The authors conducted a population-based case-control study of 810 cases with histologically confirmed incident kidney cancer and 3,106 controls to assess the effect of obesity, energy intake, and recreational physical activity on renal cell and non-renal cell cancer risk in Canada from 1994 to 1997. Compared with normal body mass index (BMI; 18.5 to <25.0 kg/m2), obesity (BMI, >or=30.0 kg/m2) was associated with multivariable-adjusted odds ratios (OR) and 95% confidence intervals (95% CI) of 2.57 (2.02-3.28) for renal cell cancer and 2.79 (1.70-4.60) for non-renal cell cancer. The OR (95% CI) associated with the highest quartiles of calorie intake was 1.30 (1.02-1.66) for renal cell cancer and 1.53 (0.92-2.53) for non-renal cell cancer. Compared with the lowest quartile of total recreational physical activity, the highest quartile of total activity was associated with an OR (95% CI) of 1.00 (0.78-1.28) and 0.79 (0.46-1.36) for the two subtypes. There were no apparent differences between men and women about these associations. The influence of obesity and physical activity on the risk of renal cell and non-renal cell cancer did not change by age, whereas the effect of excess energy intake was stronger among older people. No significant effect modifications of physical activity on BMI among both genders and of energy intake on BMI among men were observed, with a synergic effect of obesity and high energy intake on renal cell cancer risk found among women. This study suggests that obesity and excess energy intake are important etiologic risk factors for renal cell and non-renal cell cancer. The role of physical activity needs further investigation.

Mortality: life and health expectancy of Canadian women.

HEALTH ISSUE: The sex differences in mortality, life expectancy, and, to a lesser extent, health expectancy, are well recognized in Canada and internationally. However, the factors explaining these differences between women and men are not well understood. This chapter explores the contribution of various causes of death (such as preventable, and sex-specific deaths) on these differences between women and men. KEY FINDINGS: "External" preventable causes of death (e.g. smoking-related, injuries, etc.) were responsible for a large portion of the sex gap in mortality and life expectancy. When excluding these causes from the calculations, the sex gap in life expectancies were largely reduced, decreasing from approximately 5.5 years (life expectancy being 81.4, years in women, and 75.9 years in men) to approximately 2.2 years (84.9 in women and 82.7 in men). Sex gaps in corresponding health expectancies entirely disappeared when these preventable causes of death were excluded. Moreover, a larger death burden was observed among women than men for sex-specific causes of death (eg. excess breast cancer, gynaecological cancers, maternal mortality). Significant disparities were also observed in the mortality rates of various subgroups of women by geographic regions of Canada. DATA GAPS AND RECOMMENDATIONS: These results indicate that women do not appear to have a large biological survival advantage but, rather, are at lower risk of preventable deaths. They also provide additional information needed for the development of policies aimed at reducing disparities in life and health expectancies in Canada and other developed countries.

Morbidity Experiences and Disability Among Canadian Women.

HEALTH ISSUE: Women are more frequently affected by chronic conditions and disability than men. Although some of these sex differences have been in part attributed to biological susceptibility, social determinants of health and other factors, these gaps have not been fully explained in the current literature. This chapter presents comparisons of hospitalization rates, and the prevalence of chronic conditions and physical disability between Canadian women and men and between various subgroups of women, adjusting for selected risk factors. The Canadian Hospital Morbidity Database (2000-2001) and Canadian Community Health Survey (2000-2001) were used to examine inpatient hospital morbidity, prevalence of chronic conditions and disability. KEY FINDINGS: Hospitalization rates were 20% higher among women than men. This was due to the large number of hospitalizations for pregnancies and childbirth. When "normal" deliveries were excluded, hospitalization rates remained higher among women. Women had slightly lower rates of hospitalizations for ambulatory-care sensitive conditions than men. Prevalence of activity limitation (mild and severe) was higher among women than men, and differences remained after adjusting for age, chronic conditions, socio-economic status, and smoking. Women who reported a disability were less likely than men to be in a partnered relationship, have less tangible social support, and have lower income and employment rates. DATA GAPS AND RECOMMENDATIONS: The impact of morbidity and disability on Canadian women is substantial. These results identify areas for interventions among more vulnerable subgroups, and point to the need for further research in the area of risk factors for the prevention of morbidity and disability in the population.

Chronic Pain: The Extra Burden on Canadian Women.

HEALTH ISSUE: Chronic pain is a major health problem associated with significant costs to both afflicted individuals and society as a whole. These costs seem to be disproportionately borne by women, who generally have higher prevalence rates for chronic pain than do men. KEY FINDINGS: Data obtained from 125,574 respondents to the Canadian Community Health Survey (2000-2001) indicated that 18% of Canadian women suffered from chronic pain, compared to 14% of men. This gender discrepancy, however, seemed to be linked primarily to differences in age, income, and education between adult men and women in this large sample. Age, income, depression and functional interference with activities were strongly associated with chronic pain in general. No gender differences were found in the intensity of pain experienced. Ethnicity was not strongly associated with chronic pain prevalence, although Asians were the group with the highest chronic pain prevalence in the over-65 age group and Aboriginal Canadians had the highest prevalence in the under-65 age group. DATA GAPS AND RECOMMENDATIONS: Current gaps in our knowledge include the types of chronic pain women experience, their impact on domestic responsibilities and parenting and health care utilization patterns of women with chronic pain. Data sources such as provincial databases of billing claims may be useful in the future to enrich our knowledge of health care utilization and analgesic medication use. Enhanced surveillance, assessment, and early identification of pain disorders are recommended to improve outcomes. Considering current demographic patterns toward an older population, there is also some urgency to the development of patient education and self-management programs.

Factors Associated with Women's Medication Use.

HEALTH ISSUE: Research has consistently shown that while women generally live longer than men, they report more illness and use of health care services (including medication). In the literature, the reasons for women's elevated medication use are not clear. This paper investigates the associations between over-the-counter (OTC) and prescription (Rx) medication use and selected social and demographic variables in men and women. KEY FINDINGS: While a larger proportion of women than men used medication throughout the study, the proportion of people using medication did not increase. The use of OTC and Rx medication increased by number of physician visits for women and men.Medication use increased with age, chronic disease and number of physician visits, and decreased with the perception of good to excellent health. The relationship with other factors varied for women and men depending on their education level, income and social roles. For women, the social roles of being married or previously married, being employed or being a parent did not increase their likelihood of medication use. Reported income adequacy is not associated with the chances of mediation use among highly educated women, but for women with low levels, medication use increases as income adequacy decreases. DATA GAPS AND RECOMMENDATIONS: More complete data are needed about social roles and their relation to mediation use. Data that would allow an assessment of the appropriateness of OTC and Rx drug use or the reasons for such use need to be collected. More research is needed to better understand the distribution and determinants of specific medication use.

Integrating Socio-Economic Determinants of Canadian Women's Health.

HEALTH ISSUE: The association between a number of socio-economic determinants and health has been amply demonstrated in Canada and elsewhere. Over the past decades, women's increased labour force participation and changing family structure, among other changes in the socio-economic environment, have altered social roles considerably and lead one to expect that the pattern of disparities in health among women and men will also have changed. Using data from the CCHS (2000), this chapter investigates the association between selected socio-economic determinants of health and two specific self-reported outcomes among women and men: (a) self-perceived health and (b) self-reports of chronic conditions. KEY FINDINGS: The descriptive picture demonstrated by this CCHS dataset is that 10% of men aged 65 and over report low income, versus 23% of women within the same age bracket. The results of the logistic regression models calculated for women and men on two outcome variables suggest that the selected socio-economic determinants used in this analysis are important for women and for men in a differential manner. These results while supporting other results illustrate the need to refine social and economic characteristics used in surveys such as the CCHS so that they would become more accurate predictors of health status given that there are personal, cultural and environmental dimensions to take into account. RECOMMENDATIONS: Because it was shown that socio economic determinants of health are context sensitive and evolve over time, studies should be designed to examine the complex temporal interactions between a variety of social and biological determinants of health from a life course perspective. Examples are provided in the chapter.

Integrating Ethnicity and Migration As Determinants of Canadian Women's Health.

HEALTH ISSUE: This chapter investigates (1) the association between ethnicity and migration, as measured by length of residence in Canada, and two specific self-reported outcomes: (a) self-perceived health and (b) self-reports of chronic conditions; and (2) the extent to which these selected determinants provide an adequate portrait of the differential outcomes on Canadian women's self-perceived health and self-reports of chronic conditions. The 2000 Canadian Community Health Survey was used to assess these associations while controlling for selected determinants such as age, sex, family structure, highest level of education attained and household income. KEY FINDINGS: * Recent immigrant women (2 years or less in Canada) are more likely to report poor health than Canadian-born women (OR = 0.48 CI: 0.30-0.77). Immigrant women who have been in Canada 10 years and over are more likely to report poor health than Canadian-born women (OR = 1.31 CI: 1.18-1.45).* Although immigrant women are less likely to report chronic conditions than Canadian-born women, this health advantage decreased over time in Canada (OR from 0.35 to 0.87 for 0-2 years to 10 years and above compared with Canadian born women). DATA GAPS AND RECOMMENDATIONS: * Migration experience needs to be conceptualized according to the results of past studies and included as a social determinant of health above and beyond ethnicity and culture. It is expected that the upcoming longitudinal survey of immigrants will help enhance surveillance capacity in this area.* Variables need to be constructed to allow women and men to best identify themselves appropriately according to ethnic identity and number of years in the host country; some of the proposed categories used as a cultural group may simply refer to skin colour without capturing associated elements of culture, ethnicity and life experiences.