Evaluating the Utility of a Psychoeducational Serious Game (SPARX) in Protecting Inuit Youth From Depression: Pilot Randomized Controlled Trial.

BACKGROUND: Inuit youth in Northern Canada show considerable resilience in the face of extreme adversities. However, they also experience significant mental health needs and some of the highest adolescent suicide rates in the world. Disproportionate rates of truancy, depression, and suicide among Inuit adolescents have captured the attention of all levels of government and the country. Inuit communities have expressed an urgent imperative to create, or adapt, and then evaluate prevention and intervention tools for mental health. These tools should build upon existing strengths, be culturally appropriate for Inuit communities, and be accessible and sustainable in Northern contexts, where mental health resources are often scarce. OBJECTIVE: This pilot study assesses the utility, for Inuit youth in Canada, of a psychoeducational e-intervention designed to teach cognitive behavioral therapy strategies and techniques. This serious game, SPARX, had previously demonstrated effectiveness in addressing depression with Maori youth in New Zealand. METHODS: The Nunavut Territorial Department of Health sponsored this study, and a team of Nunavut-based community mental health staff facilitated youth's participation in an entirely remotely administered pilot trial using a modified randomized control approach with 24 youths aged 13-18 across 11 communities in Nunavut. These youth had been identified by the community facilitators as exhibiting low mood, negative affect, depressive presentations, or significant levels of stress. Entire communities, instead of individual youth, were randomly assigned to an intervention group or a waitlist control group. RESULTS: Mixed models (multilevel regression) revealed that participating youth felt less hopeless (P=.02) and engaged in less self-blame (P=.03), rumination (P=.04), and catastrophizing (P=.03) following the SPARX intervention. However, participants did not show a decrease in depressive symptoms or an increase in formal resilience indicators. CONCLUSIONS: Preliminary results suggest that SPARX may be a good first step for supporting Inuit youth with skill development to regulate their emotions, challenge maladaptive thoughts, and provide behavioral management techniques such as deep breathing. However, it will be imperative to work with youth and communities to design, develop, and test an Inuit version of the SPARX program, tailored to fit the interests of Inuit youth and Elders in Canada and to increase engagement and effectiveness of the program. TRIAL REGISTRATION: ClinicalTrials.gov NCT05702086; https://www.clinicaltrials.gov/ct2/show/NCT05702086.

The association between diabetes type, age of onset, and age at natural menopause: a retrospective cohort study using the Canadian Longitudinal Study on Aging.

OBJECTIVES: With growing incidence of type 1 diabetes (T1D), type 2 diabetes (T2D), and gestational diabetes, more women are expected to spend a larger proportion of their reproductive years living with a diabetes diagnosis. It is important to understand the long-term implications of premenopausal diabetes type on women's reproductive health including their age at natural menopause (ANM). METHODS: Baseline data from the Comprehensive Cohort of Canadian Longitudinal Study on Aging were used. Females who reported premenopausal diagnosis of diabetes were considered exposed. Kaplan-Meier cumulative survivorship estimates and multivariable Cox regression models were used to assess the association between diabetes types and ANM. Sociodemographic, lifestyle, and premenopausal clinical factors were adjusted in the final model as covariates. RESULTS: The sample comprised 11,436 participants, weighted to represent 1,474,412Canadian females aged 45 to 85 years. The median ANM was 52 years. After adjusting for ethnicity, education, smoking, and premenopausal clinical factors, early age of diagnosis of both T1D (<30 years) and T2D (30-39 years) were associated with earlier menopause (T1D, <30: hazard ratio [HR], 1.55; 95% confidence interval [CI], 1.05-2.28; T2D, 30-39: HR, 1.82; 95% CI, 1.12-2.94), as compared with nondiabetics. In addition, later age of diagnosis of T2D (≥40 years) was associated with later ANM (T2D: HR, 0.63; 95% CI, 0.50-0.80). No significant association between gestational diabetes and ANM was noted. CONCLUSIONS: Our results point to early menopause among young women living with a diabetes diagnosis. These findings should allow for more focused research geared toward understanding the long-term health implications of diabetes on women's reproductive health and aging.

A Web-Based Cognitive Behavioral Therapy, Mindfulness Meditation, and Yoga Intervention for Posttraumatic Stress Disorder: Single-Arm Experimental Clinical Trial.

BACKGROUND: Posttraumatic stress disorder (PTSD) is a debilitating, undertreated condition. The web-based delivery of cognitive behavioral therapy supplemented with mindfulness meditation and yoga is a viable treatment that emphasizes self-directed daily practice. OBJECTIVE: This study aims to examine the effectiveness of a web-based cognitive behavioral therapy, mindfulness, and yoga (CBT-MY) program designed for daily use. METHODS: We conducted an 8-week, single-arm, experimental, registered clinical trial on adults reporting PTSD symptoms (n=22; aged 18-35 years). Each participant received web-based CBT-MY content and an hour of web-based counseling each week. Pre-post outcomes included self-reported PTSD symptom severity, depression, anxiety, chronic pain, and mindfulness. Pre-post psychophysiological outcomes included peak pupil dilation (PPD) and heart rate variability (HRV). HRV and PPD were also compared with cross-sectional data from a non-PTSD comparison group without a history of clinical mental health diagnoses and CBT-MY exposure (n=46). RESULTS: Pre-post intention-to-treat analyses revealed substantial improvements in PTSD severity (d=1.60), depression (d=0.83), anxiety (d=0.99), and mindfulness (d=0.88). Linear multilevel mixed models demonstrated a significant pre-post reduction in PPD (B=-0.06; SE=0.01; P<.001; d=0.90) but no significant pre-post change in HRV (P=.87). Overall, participants spent an average of 11.53 (SD 22.76) min/day on self-directed mindfulness practice. CONCLUSIONS: Web-based CBT-MY was associated with clinically significant symptom reductions and significant PPD changes, suggesting healthier autonomic functioning. Future randomized controlled trials are needed to further examine the gains apparent in this single-arm study. TRIAL REGISTRATION: ClinicalTrials.gov NCT03684473; https://clinicaltrials.gov/ct2/show/NCT03684473.

Urinary Fluoride Levels among Canadians with and without Community Water Fluoridation.

Drinking water is a major source of dietary fluoride intake in communities with water fluoridation. We examined the association between urinary fluoride adjusted for specific gravity (UFSG) and tap water fluoride levels, by age and sex, among individuals living in Canada. Participants included 1629 individuals aged 3 to 79 years from Cycle 3 (2012-2013) of the Canadian Health Measures Survey. We used multiple linear regression to estimate unique associations of tap water fluoride levels, age, sex, ethnicity, body mass index (BMI), use of fluoride-containing dental products, smoking in the home, and tea consumption with UFSG. UFSG concentration was significantly higher among participants who received fluoridated drinking water (mean = 1.06 mg/L, standard deviation = 0.83) than among those who did not (M = 0.58 mg/L, SD = 0.47), p < 0.01. UFSG increased over adulthood (ages 19 to 79). Higher UFSG concentration was associated with being female, tea drinking, and smoking in the home. In conclusion, community water fluoridation is a major source of contemporary fluoride exposure for Canadians. Lifestyle factors including tea consumption, as well as demographic variables such as age and sex, also predict urinary fluoride level, and are therefore important factors when interpreting population-based fluoride biomonitoring data.

Fluoride exposure and duration and quality of sleep in a Canadian population-based sample.

BACKGROUND: Fluoride from dietary and environmental sources may concentrate in calcium-containing regions of the body such as the pineal gland. The pineal gland synthesizes melatonin, a hormone that regulates the sleep-wake cycle. We examined associations between fluoride exposure and sleep outcomes among older adolescents and adults in Canada. METHODS: We used population-based data from Cycle 3 (2012-2013) of the Canadian Health Measures Survey. Participants were aged 16 to 79 years and 32% lived in communities supplied with fluoridated municipal water. Urinary fluoride concentrations were measured in spot samples and adjusted for specific gravity (UFSG; n = 1303) and water fluoride concentrations were measured in tap water samples among those who reported drinking tap water (n = 1016). We used multinomial and ordered logistic regression analyses (using both unweighted and survey-weighted data) to examine associations of fluoride exposure with self-reported sleep outcomes, including sleep duration, frequency of sleep problems, and daytime sleepiness. Covariates included age, sex, ethnicity, body mass index, chronic health conditions, and household income. RESULTS: Median (IQR) UFSG concentration was 0.67 (0.63) mg/L. Median (IQR) water fluoride concentration was 0.58 (0.27) mg/L among participants living in communities supplied with fluoridated municipal water and 0.01 (0.06) mg/L among those living in non-fluoridated communities. A 0.5 mg/L higher water fluoride level was associated with 34% higher relative risk of reporting sleeping less than the recommended duration for age [unweighted: RRR = 1.34, 95% CI: 1.03, 1.73; p = .026]; the relative risk was higher, though less precise, using survey-weighted data [RRR = 1.96, 95% CI: 0.99, 3.87; p = .05]. UFSG was not significantly associated with sleep duration. Water fluoride and UFSG concentration were not significantly associated with frequency of sleep problems or daytime sleepiness. CONCLUSIONS: Fluoride exposure may contribute to sleeping less than the recommended duration among older adolescents and adults in Canada.

Association of water fluoride and urinary fluoride concentrations with attention deficit hyperactivity disorder in Canadian youth.

BACKGROUND: Exposure to fluoride has been linked with increased prevalence of attention deficit hyperactivity disorder (ADHD) in the United States and symptoms of inattention in Mexican children. We examined the association between fluoride exposure and attention outcomes among youth living in Canada. METHOD: We used cross-sectional data collected from youth 6 to 17 years of age from the Canadian Health Measures Survey (Cycles 2 and 3). Urinary fluoride concentration adjusted for specific gravity (UFSG) was available for 1877 participants. Water fluoride concentration measured in tap water samples was available for 980 participants. Community water fluoridation (CWF) status was determined by viewing reports on each city's website or contacting the water treatment plant. We used logistic regression to test the association between the three measures of fluoride exposure and ADHD diagnosis. Linear regression was used to examine the relationship between the three measures of fluoride exposure and the hyperactivity/inattention score on the Strengths and Difficulties Questionnaire (SDQ). RESULTS: UFSG did not significantly predict ADHD diagnosis or hyperactive/inattentive symptoms. A 1 mg/L increase in tap water fluoride level was associated with a 6.1 times higher odds of an ADHD diagnosis (95% CI = 1.60, 22.8). A significant interaction between age and tap water fluoride level (p = .03) indicated a stronger association between tap water fluoride and hyperactivity/inattention symptoms among older youth. A 1 mg/L increase in water fluoride level was associated with a 1.5 SDQ score increase (95% CI: 0.23, 2.68, p = .02) for youth at the 75th percentile of age (14 years old). Similarly, there was a significant interaction between age and CWF. At the 75th percentile of age (14 years old), those living in a fluoridated region had a 0.7-point higher SDQ score (95% CI = 0.34, 1.06, p < .01) and the predicted odds of an ADHD diagnosis was 2.8 times greater compared with youth in a non-fluoridated region (aOR = 2.84, 95% CI: 1.40, 5.76, p < .01). DISCUSSION: Exposure to higher levels of fluoride in tap water is associated with an increased risk of ADHD symptoms and diagnosis of ADHD among Canadian youth, particularly among adolescents. Prospective studies are needed to confirm these results.

Factors associated with the timing of the first prenatal ultrasound in Canada.

BACKGROUND: The aim of this study was to investigate the factors associated with the timing of the first prenatal ultrasound in Canada. METHODS: This was a secondary data analysis of the Maternity Experiences Survey, a cross-sectional survey covering different aspects of pregnancy, labour, birth and the post-partum period. Bivariate and multivariate multinomial logistic regressions were performed to assess the relationship between timing of first prenatal ultrasound and different independent variables. RESULTS: 68.4% of Canadian women received an optimally timed first prenatal ultrasound, 27.4% received early ultrasounds and 4.3% received late ultrasound. The highest prevalence of early ultrasound was in Ontario (33.3%) and the lowest was in Manitoba (13.3%). The highest prevalence of late ultrasound was found in Manitoba (12.1%) and the lowest was in British Columbia and Ontario (3.5% each). The highest prevalence of optimal timing of first prenatal ultrasound was in Quebec (77%) and the lowest was in Ontario (63.2%). Factors influencing the timing of ultrasound included: Early - maternal age < 20 (adjusted OR = 0.54, 95%CI:0.34-0.84), alcohol use during pregnancy (adjusted OR = 0.69, 95%CI:0.53-0.90), history of premature birth (adjusted OR = 1.41, 95%CI:1.06-1.89), multiparity (adjusted OR = 0.67, 95%CI:0.57-0.78), born outside of Canada (adjusted OR = 0.82, 95%CI:0.67-0.99), prenatal care in Newfoundland and Labrador (adjusted OR = 1.66, 95%CI:1.20-1.30), Nova Scotia (adjusted OR = 1.68, 95%CI:1.25-2.28), Ontario (adjusted OR = 2.16, 95%CI:1.76-2.65), Saskatchewan (adjusted OR = 1.50, 95%CI:1.05-2.14), Alberta (adjusted OR = 1.37, 95%CI:1.05-1.77) British Columbia (adjusted OR = 1.90, 95%CI:1.45-2.50) and Manitoba (adjusted OR = 0.66, 95%CI:0.45-0.98) Late - unintended pregnancy (adjusted OR = 1.89, 95%CI:1.38-2.59), born outside of Canada (adjusted OR = 1.75, 95%CI:1.14-2.68), prenatal care in Manitoba (adjusted OR = 2.88, 95%CI:1.64-5.05) and the Territories (adjusted OR = 4.50, 95%CI:2.27-8.93). An interaction between history of miscarriage and having 'other' prenatal care provider significantly affected timing of ultrasound (adjusted OR = 0.31, 95%CI:0.14-0.66). CONCLUSION: Only 68% of Canadian women received an optimally timed prenatal ultrasound which was influenced by several factors including province of prenatal care, maternal age and country of birth, and an interaction effect between prenatal care provider and history of miscarriage. These findings establish a baseline of factors influencing the timing of prenatal ultrasound in Canada, which can be built upon by future studies.

Changes in adiposity and other factors in relation to age at natural menopause: analyses from the coronary artery risk development (CARDIA) study.

OBJECTIVE: The age at natural menopause has subsequent health implications. Earlier age at natural menopause is a risk factor for cardiovascular disease, atherosclerosis, and stroke. Despite extensive study, no clear and conclusive association between anthropometric measures and age at natural menopause has emerged. This study aims to assess whether baseline and/or longitudinal changes in adiposity are associated with age at natural menopause. METHODS: In all, 2,030 premenopausal women from the Coronary Artery Risk Development in Young Adults study-a prospective study with 25 years follow-up-were included for analysis from 1985 to 1986 until menopause was attained. Anthropometry included body mass index and waist circumference. Discrete-time survival analysis was then used to determine the association between anthropometric measures at baseline, and also their changes with age at natural menopause, while adjusting for various time-varying and invariant covariates in separate models for body mass index and waist circumference. RESULTS: Multivariate Cox regression analysis showed that baseline body mass index (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.94-0.98) and baseline waist circumference (HR 0.98, 95% CI 0.97-0.99) significantly increased the risk of later age at natural menopause. Neither time-varying body mass index nor waist circumference indicating change across time associated with age at natural menopause. Premenopausal hypertension was strongly associated with an earlier age at natural menopause. CONCLUSION: These findings show that age at natural menopause is partly determined by modifiable factors such as premenopausal hypertension and baseline adiposity. These results highlight the importance of both control and prevention of cardiovascular risk factors such as excess weight in early to mid-adulthood before menopause onset.

Fluoride exposure and thyroid function among adults living in Canada: Effect modification by iodine status.

BACKGROUND: Fluoride exposure has the potential to disrupt thyroid functioning, though adequate iodine intake may mitigate this effect. This is the first population-based study to examine the impact of chronic low-level fluoride exposure on thyroid function, while considering iodine status. The objective of this study was to determine whether urinary iodine status modifies the effect of fluoride exposure on thyroid stimulating hormone (TSH) levels. METHODS: This cross-sectional study utilized weighted population-based data from Cycle 3 (2012-2013) of the Canadian Health Measures Survey (CHMS). Information was collected via a home interview and a visit to a mobile examination centre. The weighted sample represented 6,914,124 adults in Canada aged 18-79 who were not taking any thyroid-related medication. Urinary fluoride concentrations were measured in spot samples using an ion selective electrode and adjusted for specific gravity (UFSG). Serum TSH levels provided a measure of thyroid function. Multivariable regression analyses examined the relationship between UFSG and TSH, controlling for covariates. RESULTS: Approximately 17.8% of participants fell in the moderately-to-severely iodine deficient range. The mean (SD) age of the sample was 46.5 (15.6) years and the median UFSG concentration was 0.74 mg/L. Among iodine deficient adults, a 1 mg/L increase in UFSG was associated with a 0.35 mIU/L increase in TSH [95% CI: 0.06, 0.64; p = 0.01, one-tailed]. CONCLUSIONS: Adults living in Canada who have moderate-to-severe iodine deficiencies and higher levels of urinary fluoride may be at an increased risk for underactive thyroid gland activity.

The Relationships Between the Geriatric Practice Environment, Nursing Practice, and the Quality of Hospitalized Older Adults' Care.

PURPOSE: To test the relationships between the geriatric practice environment, geriatric nursing practice, and overall quality of care for older adults and their families as reported by nurses working in hospitals, while controlling for nurse and hospital characteristics. DESIGN: A cross-sectional tailored survey design was employed. A questionnaire was mailed to a randomly selected sample of nurses whose primary practice area was medicine, surgery, geriatrics, emergency, or critical care in acute care hospitals in Ontario, Canada. METHODS: Participants (N = 2,005) working in 148 hospitals responded to validated measures of the geriatric practice environment, geriatric nursing practice, overall quality of care for older adults and their families, and nurse and hospital characteristics. The relationships were tested using structural equation modeling. FINDINGS: Controlling for nurse and hospital characteristics, the geriatric practice environment had a statistically significant positive relationship of large magnitude with both geriatric nursing practice (ß = 0.52) and overall quality of care (ß = 0.92); however, the indirect relationship between the geriatric practice environment and overall quality of care, mediated by geriatric nursing practice, was not significant (ß = -0.02). Final model fit was acceptable, with the root mean square error of approximation = 0.07, comparative fit index = 0.93, and Tucker-Lewis Index = 0.87. CONCLUSIONS: A strong geriatric practice environment positively and directly influences geriatric nursing practice and overall quality of care for older adults and their families but does not appear to influence overall quality of care indirectly through geriatric nursing practice. CLINICAL RELEVANCE: The results can be used as the basis for promoting practice environments that support overall quality of care and geriatric nursing practice in acute care hospitals.

Perceived acceptability and preferences for low-intensity early activity interventions of older hospitalized medical patients exposed to bed rest: a cross sectional study.

BACKGROUND: Hospitalized older patients spend most of their time in bed, putting them at risk of experiencing orthostatic intolerance. Returning persons to their usual upright activity level is the most effective way to prevent orthostatic intolerance but some older patients have limited activity tolerance, supporting the need for low-intensity activity interventions. Consistent with current emphasis on patient engagement in intervention design and evaluation, this study explored older hospitalized patients' perceived acceptability of, and preference for, two low-intensity early activity interventions (bed-to-sitting and sitting-to-walking), and characteristics (gender, illness severity, comorbidity, illnesses and medications with orthostatic effects, and baseline functional capacity) associated with perceived acceptability and preference. METHODS: A convenience sample was recruited from in-patient medical units of two hospitals in Ontario, Canada and included 60 cognitively intact adults aged 65+ who were admitted for a medical condition within the past 72 h, spent ≥ 24 consecutive hours on a stretcher or in bed, presented with ≥ 2 chronic diseases, understood English, and were able to ambulate before admission. A cross-sectional observational design was used. Participants were presented written and oral descriptions and a 2-min video of each intervention. The sequence of the interventions' presention was randomized. Following the presentation, a research nurse administered measures of perceived acceptability and preference, and collected health and demographic data. Perceived acceptability and preference for the interventions were measured using the Treatment Acceptability and Preferences Scale. Illness severity was measured using the Modified Early Warning Score. Comorbidity was assessed with the Age Adjusted Charlson Comorbidity Scale and the Cumulative Illness Rating Scale - for Geriatrics. Baseline functional capacity was measured using the Duke Activity Status Index. RESULTS: Participants' perceived acceptability of both interventions clustered above the scale midpoint. Most preferred the sitting-to-walking intervention (n = 26; 43.3%). While none of the patient characteristics were associated with intervention acceptability, illness severity (odds ratio = 1.9, p = 0.04) and medications with orthostatic effects (odds ratio = 9.9, p = 0.03) were significantly associated with intervention preference. CONCLUSIONS: The interventions examined in this study were found to be acceptable to older adults, supporting future research examining their feasibility and effectiveness.

Age at natural menopause and its associated factors in Canada: cross-sectional analyses from the Canadian Longitudinal Study on Aging.

BACKGROUND: Early onset of menopause is associated with long-term disease and higher mortality risks. Research suggests that age at natural menopause (ANM) varies across populations. Little is known about factors that affect ANM in Canadian women. OBJECTIVE: This study aims to estimate the median ANM and examine factors associated with earlier ANM among Canadian women. METHODS: Baseline data from the Tracking cohort of the Canadian Longitudinal Study on Aging was used for this analysis. The relation of sociodemographic, lifestyle, and health-related factors with ANM was examined among 7,719 women aged 40 and above. Nonparametric Kaplan-Meier cumulative survivorship estimates were used to assess the timing of natural menopause. Univariate and multivariate Cox proportional hazard regression models were used to characterize ANM and its association with relevant covariates. RESULTS: Overall, median ANM was 51 years. Having no partner, low household income and education levels, current and former smoking, and cardiovascular disease were all associated with an earlier ANM, whereas current employment, alcohol consumption, and obesity were associated with later ANM. CONCLUSIONS: These findings provide a national estimate of ANM in Canada and show the importance of lifestyle factors and health conditions in determining menopausal age. These factors might help in risk assessment, prevention and early management of chronic disease risk during the menopausal transition.

A Multi-Method Study of the Geriatric Learning Needs of Acute Care Hospital Nurses in Ontario, Canada.

Older people are at risk of experiencing functional decline and related complications during hospitalization. In countries with projected increases in age demographics, preventing these adverse consequences is a priority. Because most Canadian nurses have received little geriatrics content in their basic education, understanding their learning needs is fundamental to preparing them to respond to this priority. This two-phased multi-method study identified the geriatrics learning needs and strategies to address the learning needs of acute care registered nurses (RNs) and registered practical nurses (RPNs) in the province of Ontario, Canada. In Phase I, a survey that included a geriatric nursing knowledge scale was completed by a random sample of 2005 Ontario RNs and RPNs. Average scores on the geriatric nursing knowledge scale were in the "neither good nor bad" range, with RNs demonstrating slightly higher scores than RPNs. In Phase II, 33 RN and 24 RPN survey respondents participated in 13 focus group interviews to help confirm and expand survey findings. In thematic analysis, three major themes were identified that were the same in RNs and RPNs: (a) geriatric nursing is generally regarded as simple and custodial, (b) older people's care is more complex than is generally appreciated, and (c) in the current context, older people's care is best learned experientially and in brief on-site educational sessions. Healthcare providers, policy-makers, and educators can use the findings to develop educational initiatives to prepare RNs and RPNs to respond to the needs of an aging hospital population.