Exploring the association between income inequality and sleep in Canadian adolescents: A path analysis approach.

OBJECTIVES: An estimated 30% of Canadian adolescents do not get the recommended 8-10hours of sleep. No prior study has examined the role of income inequality, the gap between rich and poor within a society, in adolescent sleep. The aim of this study is to examine the association between income inequality and sleep duration among Canadian adolescents, how this association differs by gender, and whether depressive symptoms, anxiety, and social cohesion mediate this relationship. METHODS: Multilevel path models were conducted using cross-sectional survey data from 74,501 adolescents who participated in the Cannabis, Obesity, Mental health, Physical activity, Alcohol use, Smoking, and Sedentary behavior (COMPASS) study in 2018-2019. Income inequality was measured at the census division level and sleep duration, gender, depressive symptoms, anxiety, and social cohesion were measured at the individual level. RESULTS: A 1% increase in income inequality was associated with a 3.67-minute decrease in sleep duration (95% CI=-5.64 to -1.70). The cross-level interactions between income inequality and gender were significant, suggesting that income inequality has more adverse associations with sleep among females than males. Both depressive symptoms and anxiety were significant mediators, wherein greater income inequality was associated with higher levels of depressive symptoms and anxiety, which were in turn, associated with a shorter sleep duration. CONCLUSION: Interventions that reduce income inequality may prevent depressive symptoms and anxiety and improve sleep in adolescents. Reducing societal income gaps may improve adolescent sleep especially in those attending school in high income inequality areas, females, and those experiencing depressive symptoms and anxiety.

Income inequality and deaths of despair risk in Canada, identifying possible mechanisms.

BACKGROUND: Declines in life expectancy in developed countries have been attributed to increases in drug-related overdose, suicide, and liver cirrhosis, collectively referred to as deaths of despair. Income inequality is proposed to be partly responsible for increases in deaths of despair rates. This study investigated the associations between income inequality, deaths of despair risk in Canada, and potential mechanisms (stress, social cohesion, and access to health services). METHODS: We obtained data from the Canadian Community Health Survey and the Canadian Vital Statistics Database from 2007 to 2017. A total of 504,825 Canadians were included in the analyses. We used multilevel survival analyses, as measured by the Gini coefficient, to examine the relationships between income inequality and mortality attributed to drug overdose, suicide, death of despair, and all-cause. We then used multilevel path analyses to investigate whether each mediator (stress, social cohesion, and access to mental health professionals), which were investigated using separate mediation models, influenced the relationship between income inequality and drug overdose, suicide, deaths of despair, and all-cause death. RESULTS: Adjusted multilevel survival analyses demonstrated significant relationships between a one-SD increase in Gini coefficient was associated with an increased hazard for drug overdose (HRadj. = 1.28; 95 CI = 1.05, 1.55), suicide (HRadj. = 1.24; 95 CI = 1.06, 1.46), deaths of despair (HRadj. = 1.26; 95 CI = 1.12, 1.40), and all-cause death (HRadj. = 1.04; 95 CI = 1.02, 1.07). Adjusted path analyses indicated that stress, social cohesion, and access to mental health professionals significantly mediated the association between income inequality and mortality outcomes. CONCLUSION: Income inequality is associated with deaths of despair and this relationship is mediated by stress, social cohesion, and access to mental health professionals. Findings should be applied to develop programs to address income inequality in Canada.

An investigation into the relationship between community engagement and maternal mental health in Calgary, Alberta using the All Our Families cohort.

INTRODUCTION: Existing literature shows that increased community engagement is associated with decreased depressive symptoms. To our knowledge, no existing studies have investigated the relationship between community engagement and adverse mental health among mothers in a Canadian context, nor has this relationship been studied over time. The current study aims to address these gaps by modelling the association between community engagement and anxiety and depression longitudinally using a cohort of prenatal and postnatal mothers living in Calgary, Alberta. METHODS: We used data from the All our Families (AOF) study, a prospective cohort study of expectant and new mothers in Calgary, Alberta from 2008 to 2017 across seven timepoints. We used three-level latent growth curves to model the relationship between individual-level community engagement and maternal depression and anxiety scores, while adjusting for both individual and neighborhood-level characteristics. RESULTS: The study sample consisted of 2129 mothers across 174 neighborhoods in Calgary. Adjusted latent growth curve models demonstrated that community engagement was associated with lower depression (b = - 0.28, 95% CI - 0.33, - 0.23) and anxiety (b = - 0.07, 95% CI - 0.12, - 0.02) scores among mothers over time. DISCUSSION: Adjusted results show that community engagement has a protective effect against depression and anxiety amongst mothers. The results of this study are in line with existing evidence suggesting that social cohesion, civic participation, and community engagement are protective against adverse mental health outcomes.

Income Inequality and the Odds of Online Gambling Among a Large Sample of Adolescents in Canada.

Consistent evidence points to the detrimental effects of income inequality on population health. Income inequality may be associated with online gambling, which is of concern since gambling is a risk factor for adverse mental health conditions, such as depression and suicide ideation. Thus, the overall objective of this study is to study the role of income inequality on the odds of participating in online gambling. Data from 74,501 students attending 136 schools participating in the 2018/2019 Cannabis, Obesity, Mental health, Physical activity, Alcohol, Smoking, and Sedentary behaviour (COMPASS) survey were used. The Gini coefficient was calculated based on school census divisions (CD) using the Canada 2016 Census linked with student data. We used multilevel modeling to explore the association between income inequality and self-reported participation in online gambling in the last 30 days, while controlling for individual- and area-level characteristics. We examined whether mental health (depressive and anxiety symptoms, psychosocial wellbeing), school connectedness, and access to mental health programs mediate this relationship. Adjusted analysis indicated that a standardized deviation (SD) unit increase in Gini coefficient (OR = 1.17, 95% CI 1.05, 1.30) was associated with increased odds of participating in online gambling. When stratified by gender, the association was significant only among males (OR = 1.12, 95% CI 1.03, 1.22). The relationship between higher income inequality and greater odds for online gambling may be mediated by depressive and anxiety symptoms, psychosocial well-being, and school connectedness. Evidence points to further health consequences, such as online gambling participation, stemming from exposure to income inequality.

Association Between Area-Level Income Inequality and Health-Related School Absenteeism: Evidence From the COMPASS Study.

BACKGROUND: Income inequality is theorized to impact health. However, evidence among adolescents is limited. This study examined the association between income inequality and health-related school absenteeism (HRSA) in adolescents. METHODS: Participants were adolescents (n = 74,501) attending secondary schools (n = 136) that participated in the 2018-2019 wave of the COMPASS study. Chronic (missing ≥3 days of school in the previous 4 weeks) and problematic (missing ≥11 days of school in the previous 4 weeks) HRSA was self-reported. Income inequality was assessed via the Gini coefficient at the census division (CD) level. Multilevel modeling was used. RESULTS: Greater income inequality was associated with a higher likelihood of chronic and problematic HRSA (chronic: OR = 1.17, 95% CI: 1.06, 1.30; problematic: OR = 1.29, 95% CI 1.11 to 1.50). Increased predicted probabilities for Problematic HRSA were observed at greater degrees of income inequality among students who identified as either white, black, Latinx, or mixed, while protective associations were observed among students who identified as Asian or other. No associations were modified by gender. CONCLUSION: Income inequality demonstrated unfavorable associations with HRSA, which was modified by racial identity.

Exploring the longitudinal associations between census division income inequality and BMI trajectories among Canadian adolescent: Is gender an effect modifier?

Background: Income inequality is a structural determinant of health linked to increased risk of overweight and obesity, although its links to the health of adolescent populations are not well understood. This study investigated the longitudinal associations between census-division-level (CD) income inequality and BMI trajectories among Canadian adolescents, and determine if these associations vary by gender. Methods: Study data are from the Cannabis use, Obesity, Mental health, Physical Activity, Alcohol use, Smoking, and Sedentary behaviour (COMPASS) cohort of adolescents attending secondary schools in Canada. Our sample included 14,675 adolescents who were followed up across three waves of the COMPASS study (2016-2017, 2017-2018, and 2018-2019) and linked to 30 CDs. Measures of income inequality and other area-level covariates were derived and linked to COMPASS participants using data from the 2016 Canadian Census. We utilized multilevel mixed-effects linear regression modelling to quantify the associations between income inequality and BMI and test for effect modification by gender. Sensitivity analyses were run excluding those with BMI scores in the range considered overweight or obesity at baseline. Results: Higher CD income inequality was significantly associated with higher z-transformed BMI scores (ß = 0.11, 95% CI = 0.034 to 0.19). The interaction term between income inequality and time was not statistically significant, indicating that this association remained constant over time. Once stratified by gender, the association between inequality and BMI became stronger for males (ß = 0.14, 95% CI = 0.060 to 0.022) and attenuated for females (ß = 0.063, 95% CI = -0.047 to 0.17). Conclusion: Attending schools in CDs with higher income inequality was associated with higher BMI scores among male but not female adolescents. Further work is needed to investigate this discrepancy and identify the structural mechanisms that mediate the relationship between inequality and adolescent health.

Income inequality and mental health in adolescents during COVID-19, results from COMPASS 2018-2021.

INTRODUCTION: Understanding the inequitable impacts of the ongoing COVID-19 pandemic on youth mental health are leading priorities. Existing research has linked income inequality in schools to adolescent depression, however, it is unclear if the onset of the pandemic exacerbated the effects of income inequality on adolescent mental health. The current study aimed to quantify the association between income inequality and adolescent mental health during COVID-19. MATERIAL AND METHODS: Longitudinal data were taken from three waves (2018/19 to 2020/21) of the Cannabis, Obesity, Mental health, Physical activity, Alcohol, Smoking, and Sedentary behaviour (COMPASS) school-based study. Latent Growth Curve modelling was used to assess the association between Census District (CD)-level income inequality and depressive symptoms before and after the onset of COVID-19. RESULTS: The study sample included 29,722 students across 43 Census divisions in British Columbia, Alberta, Ontario, and Quebec. The average age of the sample at baseline was 14.9 years [standard deviation (SD) = 1.5] and ranged between 12 and 19 years of age. Most of the sample self-reported as white (76.3%) and female (54.4%). Students who completed the COMPASS survey after the onset of COVID reported 0.20-unit higher depressive scores (95% CI = 0.16, 0.24) compared to pre-COVID. The adjusted analyses indicated that the association between income inequality on anxiety scores was strengthened following the onset of COVID-19 (ß = 0.02, 95% CI = 0.0004, 0.03), indicating that income inequality was associated with a greater increase in anxiety scores during COVID-19. DISCUSSION: The adjusted results indicate that the association between income inequality and adolescent anxiety persisted and was heightened at the onset of COVID-19. Future studies should use quasi-experimental methods to strengthen this finding. The current study can inform policy and program discussions regarding the effects of the COVID-19 pandemic and pandemic recovery for young Canadians and relevant social policies for improving adolescent mental health.

Income inequality and 'hospitalisations of despair' in Canada: a study on longitudinal, population-based data.

BACKGROUND: Rates of drug overdoses, alcohol-related liver disease and suicide attempts represent a major public health burden in Canada. While the existing literature does highlight some evidence of association between income inequality and mental health and deaths of despair, no existing research has investigated more intermediate events. As such, the objective of the current study is to investigate the association between income inequality and hospitalisations of despair over time. METHODS: Data from the 2006 Canadian Census, the 2007/2008 Canadian Community Health Survey and the 2007-2018 Discharge Abstract Database were linked. Data were analysed using Cox proportional hazards modelling accounting for robust standard errors at the area level to investigate associations between income inequality at baseline and hazards for hospitalisations of despair, hospitalisations attributable to drug overdose, alcohol-related liver disease and suicide attempts, and all-cause hospitalisations, while controlling for sociodemographics characteristics (including income) and relevant area-level variables. RESULTS: The results highlighted statistically significant associations between income inequality and hazard of hospitalisations of despair (HR 1.38, 95% CI 1.06 to 1.80), hospitalisations related to drug overdose (HR 1.51, 95% CI 1.07 to 2.13) and all-cause hospitalisations (HR 1.17, 95% CI 1.05 to 1.30). The association between income inequality and hospitalisations related to alcohol-related liver disease and suicide attempts/self-harm were not statistically significant. CONCLUSION: Overall, the results showed evidence of associations between income inequality and hospitalisations of despair, drug overdose-related hospitalisations and all-cause hospitalisations. These findings are applicable to upstream policy discussion regarding reducing income inequality and identify potential points of intervention for prevention of drug overdose, alcohol-related liver disease and suicide attempts/self-harm.

Inequality's on Tap: A Longitudinal Study of Area-Level Income Inequality and Alcohol Consumption Among Canadian Adolescents.

PURPOSE: To determine if income inequality at the census division level is associated with alcohol consumption and abuse among junior high and high school students. METHODS: Data on adolescents are from the Cannabis use, Obesity, Mental health, Physical activity, Alcohol use, Smoking, and Sedentary behavior (COMPASS) study. Participant data (n = 19,759) were collected during three survey waves (2016-2017, 2017-2018, and 2018-2019) and linked to 30 census divisions within four Canadian provinces. Data on income inequality and other area-level factors were derived from the 2016 Canadian census. Multilevel logistic regression modelling was used to quantify the associations between income inequality, monthly alcohol consumption, and binge drinking. RESULTS: After adjusting for covariates, students living in census divisions within the second and third quintiles of income inequality experienced an average 80% (OR = 1.80, 95% CI = 1.08-3.02) and 92% (OR = 1.92, 95% CI = 1.05-3.51) increased odds of engaging in monthly binge drinking, respectively, compared to those living in the first quintile. Similarly, adolescents living in census divisions within the second inequality quintile experienced an average 169% (OR = 2.69, 95% CI = 1.45, 4.99) increased odds of engaging in weekly binge drinking, compared to those living in the first quintile. There was no significant association between higher income inequality and current monthly alcohol consumption. DISCUSSION: Moderate area-level income inequality within census divisions was adversely associated with alcohol consumption among adolescents. Future work should investigate the potential mechanisms that mediate this relationship.

The association between income inequality and adolescent body mass index: findings from the COMPASS study (2016-2019).

OBJECTIVES: Income inequality has been linked to high and unhealthy body mass index (BMI), though there is a dearth of evidence in adolescents. Therefore, this study examines the association between income inequality and BMI in a large sample of Canadian adolescents. METHODS: A pooled cross-sectional design was used. Participants were adolescents (n = 101,901) from 157 Canadian secondary schools participating in the 2016-2017, 2017-2018, or 2018-2019 waves of the Cannabis, Obesity, Mental health, Physical activity, Alcohol, Smoking, and Sedentary behaviour (COMPASS) study. BMI was calculated from self-reported height and weight and converted to World Health Organization (WHO) z-BMI scores. Gini coefficients were calculated at the census division level (n = 49) using data from the 2016 Canadian Census. Multilevel modelling was performed to account for the clustering of students nested within schools, which were nested within census divisions. Interactions were included to determine whether associations were heterogeneous for males and females. RESULTS: Income inequality demonstrated a non-linear association with WHO z-BMI score (z-Gini: ß = 0.05, 95%CI: 0.02, 0.08; z-Gini2: ß = -0.02, 95% CI: -0.04, -0.01) among adolescents after adjusting for student-, school-, and census division-level covariates. This association was more pronounced among females. CONCLUSION: The association between income inequality and BMI, being overweight, or having obesity appears to be non-linear. Public health units and schools may benefit from incorporating upstream factors such as income inequality into their interventions attempting to promote healthy weights.

RéSUMé: OBJECTIFS: L'inégalité des revenus a été liée à un indice de masse corporelle (IMC) élevé et malsain, bien qu'il y ait un manque de preuves chez les adolescents. Par conséquent, la présente étude examine l'association entre l'inégalité des revenus et l'IMC dans un vaste échantillon d'adolescents canadiens. MéTHODES: Un devis comprenant des études transversales groupées a été utilisé. Les participants étaient des adolescents (n = 101 901) de 157 écoles secondaires canadiennes participant aux vagues 2016-2017, 2017-2018 ou 2018-2019 de l'étude COMPASS (Cannabis, Obésité, Santé mentale, Activité physique, Alcool, Tabagisme et Comportement sédentaire). L'IMC a été calculé à partir de la taille et du poids auto-déclarés et convertis en scores z selon l'Organisation mondiale de la santé (OMS). Les coefficients de Gini ont été calculés à l'échelle du secteur de recensement (n = 49) en utilisant les données du Recensement canadien de 2016. Des modèles multiniveaux ont été effectués pour tenir compte du regroupement des élèves dans les écoles, qui elles-mêmes étaient incluses dans les secteurs de recensement. Des variables d'interactions ont été incluses dans les modèles afin de permettre une comparaison des paramètres estimés entre les hommes et les femmes. RéSULTATS: L'inégalité des revenus a démontré une association non linéaire avec le score de l'IMC z de l'OMS (z-Gini : ß = 0,05, IC à 95 % : 0,02, 0,08; z-Gini2 : ß = -0,02, IC à 95 % : -0,04, -0,01) chez les adolescents après ajustement pour tenir compte des covariables au niveau des élèves, de l'école et des divisions de recensement. Cette association était plus prononcée chez les femmes. CONCLUSION: L'association entre l'inégalité des revenus et l'IMC, l'embonpoint ou l'obésité semble être non linéaire. Les bureaux de santé publique et les écoles pourraient tirer profit de l'intégration de facteurs en amont comme l'inégalité des revenus dans leurs interventions visant à promouvoir le poids santé.

The association between social fragmentation and deaths attributable to alcohol, drug use, and suicide: Longitudinal evidence from a population-based sample of Canadian adults.

BACKGROUND: Social fragmentation has been theorized and empirically associated with suicide in prior research. However, less is known about whether social fragmentation is associated with deaths attributed to alcohol use or drug use. This research examined the association between social fragmentation and risk for deaths attributable to alcohol use, drug use, and suicide (collectively known as deaths of despair) among Canadian adults. METHODS: A weighted sample representing 15,324,645 Canadians within 288 census divisions between 2006 and 2019 was used. Mortality data from the Canadian Vital Statistics Database (alcoholic liver disease, drug use, and suicide) was linked with census division socioeconomic data from the 2006 Canadian census using the Canadian Census Health and Environment Cohorts. Social fragmentation at the census division was created based on the Congdon Index. Cox-proportional hazard regression with survey weights and the sandwich estimator were used to account for clustering of individuals (level-1) nested within census divisions (level-2). RESULTS: After adjusting for individual and census division confounders, social fragmentation was positively associated with all-cause mortality (HR = 1.04; 95% CI: 1.02, 1.07), suicide (HR = 1.09; 95%CI: 1.01, 1.18), drug overdose related mortality (HR = 1.13; 95%CI: 1.03, 1.24), and deaths of despair (HR = 1.10; 95% CI: 1.04, 1.16), and not significantly associated with alcohol related liver disease (HR = 1.06; 95% CI: 0.91, 1.23). CONCLUSION: Social fragmentation is associated with an increased hazard of deaths of despair among Canadian adults. Efforts to improve social cohesion in areas that are highly socially fragmented need to be evaluated.

Housing for vulnerable populations-identifying system cost implications: an analytic literature review.

We explored how investments in housing for vulnerable populations (including those experiencing homelessness) are described as leading to cost containment for the health, justice, and social service systems; the nature of any costs and benefits; and variations by housing type and over time. A structured search of peer-reviewed academic research focused on the core concepts of economic benefit, public housing programs, and vulnerable populations. Findings from 42 articles reporting on cost containment specific to health, justice, and social service systems at the municipal, regional, and/or state/provincial level were synthesized. Most of the studies focused on supportive housing interventions, targeted adults (mainly men) experiencing chronic homelessness in the USA, and reported results over 1-5 years. Approximately half of the articles reported on the costs required to house vulnerable populations. About half reported on funding sources, which is critical information for leadership decisions in cost containment for supportive housing. Most of the studies assessing program cost or cost-effectiveness reported a reduction in service costs and/or greater cost-effectiveness. Studies mostly reported impacts on health services, with hospital/inpatient care and emergency service use typically decreasing across the intervention types. All the studies that assessed cost impacts on the justice system reported a decrease in expenditures. Housing vulnerable populations was also found to decrease shelter service use and engagement with the foster care/welfare systems. Housing interventions may offer cost-savings in the short- and medium-term, with a limited evidence base also demonstrating long term benefit.

The impact of the COVID-19 pandemic on inequalities in lifestyle behaviours and mental health and wellbeing of elementary school children in northern Canada.

Objectives: The COVID-19 pandemic has negatively affected children's lifestyle behaviours and mental health and wellbeing, and concerns have been raised that COVID-19 has also increased health inequalities. No study to date has quantified the impact of COVID-19 on health inequalities among children. We compared pre-pandemic vs. post-lockdown inequalities in lifestyle behaviours and mental health and wellbeing among children living in rural and remote northern communities. Methods: We surveyed 473 grade 4-6 students (9-12 years of age) from 11 schools in rural and remote communities in northern Canada in 2018 (pre-pandemic), and 443 grade 4-6 students from the same schools in 2020 (post-lockdown). The surveys included questions on sedentary behaviours, physical activity, dietary intake, and mental health and wellbeing. We measured inequality in these behaviors using the Gini coefficient, a unitless measure ranging from 0 to 1 with a higher value indicating greater inequality. We used temporal changes (2020 vs. 2018) in Gini coefficients to assess the impact of COVID-19 on inequalities in lifestyle behaviours and mental health and wellbeing separately among girls and boys. Results: Inequalities in all examined lifestyle behaviours increased between 2018 and 2020. Inequalities in watching TV, playing video games, and using a cell phone increased among girls, while inequalities in playing video games, using computers and tablets, and consumption of sugar, salt, saturated fat and total fat increased among boys. Changes in inequalities in mental health and wellbeing were small and not statistically significant. Conclusion: The findings suggest that the COVID-19 pandemic has exacerbated inequalities in lifestyle behaviours among children living in rural and remote northern communities. If not addressed, these differences may translate into exacerbated inequalities in future health. The findings further suggest that school health programs can help mitigate the negative impact of the pandemic on lifestyle behaviours and mental health and wellbeing.

The association between reproductive rights and access to abortion services and mental health among US women.

Background: This study examines whether living in US states with (1) restrictive reproductive rights and (2) restrictive abortion laws is associated with frequent mental health distress among women. Methods: We operationalize reproductive rights using an overall state-level measure of reproductive rights as well as a state-level measure of restrictive abortion laws. We merged data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) with these state-level exposure variables and other state-level information. We used multilevel logistic regression to assess the relationship between these two measures and the likelihood of reporting 14 or more days of frequent mental health distress. We also tested whether associations differed across race, household income, education, and marital status. Results: In the adjusted models, a standard deviation-unit increase in the reproductive rights score was significantly associated with decreased odds of reporting frequent mental health distress (OR = 0.95, 95% CI = 0.91, 0.99). Women in states with very hostile abortion restrictions had higher odds of frequent mental health distress. Associations between state-level abortion restrictions were larger among women 25-34 years old and women with a high school degree. For example, women aged 25-34 years residing in moderate (OR = 1.54, 95% CI = 1.14, 2.04), hostile (OR = 1.59, 95% CI = 1.15, 2.18), and very hostile (OR = 1.29, 95% CI = 1.02, 1.64) states were more likely to report frequent mental health distress than women living in states with less restrictive abortion policies. Conclusion: We found the association between state-level restrictions on reproductive rights and abortion access and frequent mental health distress differed by age and socioeconomic status. These results suggest abortion rights restrictions may contribute to mental health inequities among women.

Income inequality and daily use of cannabis, cigarettes, and e-cigarettes among Canadian secondary school students: Results from COMPASS 2018-19.

INTRODUCTION: Cannabis, cigarette, and e-cigarette use among Canadian adolescents is a major public health concern. Income inequality has been associated with adverse mental health among youth and may contribute to the risk of frequent cannabis, cigarette, and e-cigarette use. We tested the association between income inequality and the risk of daily cannabis, cigarette, and e-cigarette use among Canadian secondary school students. METHODS: We used individual-level survey data from Year 6 (2018/19) of Cannabis, Obesity, Mental health, Physical activity, Alcohol use, Smoking, and Sedentary Behavior (COMPASS) and area-level data from the 2016 Canadian Census. Three-level logistic models were used to assess the relationship between income inequality and adolescent daily and current cannabis use, cigarette smoking, and e-cigarette use. RESULTS: The analytic sample included 74,501 students aged 12-19. Students were most likely to report being male (50.4%), white (69.1%), and having weekly spending money over $100 (23.5%). We found that a standard deviation unit increase in Gini coefficient was significantly associated with increased likelihood of daily cannabis use (OR=1.25, 95% CI = 1.01-1.54) when adjusting for relevant covariates. We found no significant relationship between income inequality and daily smoking. While Gini was not significantly associated with daily e-cigarette use, we observed a significant interaction between Gini and gender (OR=0.87, 95% CI= 0.80-0.94), indicating that increased income inequality was associated with higher risk of reporting daily e-cigarette use among females only. DISCUSSION: An association between income inequality and the likelihood of reporting daily cannabis use across all students and daily e-cigarette use in females were observed. Schools in higher income inequality areas may benefit from targeted prevention and harm reduction programs. Results emphasize the need for upstream discussion on policies that can mitigate the potential effects income inequality.

A Longitudinal Study of Income Inequality and Mental Health Among Canadian Secondary School Students: Results From the Cannabis, Obesity, Mental Health, Physical Activity, Alcohol, Smoking, and Sedentary Behavior Study (2016-2019).

PURPOSE: Depression and anxiety among adolescents are major public health concerns. Findings indicate that income inequality was associated with increased risk for depression and anxiety among adolescents; however, this has not been tested longitudinally. We aim to quantify the longitudinal association between income inequality and depression and anxiety among Canadian adolescents. METHODS: We used longitudinal data on 21,141 students from three waves (2016/17-2018/19) of the Cannabis, Obesity, Mental health, Physical activity, Alcohol, Smoking, and Sedentary behavior (COMPASS) school-based study. Multilevel modeling was used to assess the association between census division (CD)-level income inequality and depressive and anxiety symptoms and odds for depression and anxiety over time. RESULTS: Across CDs, the mean Gini coefficient was 0.37 (range: 0.30, 0.46). Attending schools in CDs with higher levels of income inequality was associated with higher depressive scores (ß = 0.08; 95% confidence interval [CI] = 0.02, 0.14) and an increased odds for depression (odds ratio = 1.55, 95% CI = 1.06, 2.28) over time. Income inequality was not significantly associated with anxiety symptoms or experiencing anxiety over time. Additional analyses showed that income inequality was associated with higher depressive scores among females (ß = 0.10; 95% CI = 0.01, 0.18) and males (ß = 0.08, 95% CI = 0.01, 0.15) and for anxiety scores among females (ß = 0.13, 95% CI = 0.04, 0.22), but not among males (ß = -0.01, 95% CI = -0.09, 0.06). DISCUSSION: Findings from this study indicated that income inequality is associated with depression over time among adolescents. This study highlights key points of intervention for the prevention of mental illness in adolescents.

An action-oriented public health framework to reduce financial strain and promote financial wellbeing in high-income countries.

BACKGROUND: Perceived financial security impacts physical, mental, and social health and overall wellbeing at community and population levels. Public health action on this dynamic is even more critical now that the COVID-19 pandemic has exacerbated financial strain and reduced financial wellbeing. Yet, public health literature on this topic is limited. Initiatives targeting financial strain and financial wellbeing and their deterministic effects on equity in health and living conditions are missing. Our research-practice collaborative project addresses this gap in knowledge and intervention through an action-oriented public health framework for initiatives targeting financial strain and wellbeing. METHODS: The Framework was developed using a multi-step methodology that involved review of theoretical and empirical evidence alongside input from a panel of experts from Australia and Canada. In an integrated knowledge translation approach, academics (n = 14) and a diverse group of experts from government and non-profit sectors (n = 22) were engaged throughout the project via workshops, one-on-one dialogues, and questionnaires. RESULTS: The validated Framework provides organizations and governments with guidance for the design, implementation, and assessment of diverse financial wellbeing- and financial strain-related initiatives. It presents 17 priority actionable areas (i.e., entry points for action) likely to have long-lasting, positive effects on people's financial circumstances, contributing to improved financial wellbeing and health. The 17 entry points relate to five domains: Government (All Levels), Organizational & Political Culture, Socioeconomic & Political Context, Social & Cultural Circumstances, and Life Circumstances. CONCLUSIONS: The Framework reveals the intersectionality of root causes and consequences of financial strain and poor financial wellbeing, while also reinforcing the need for tailored actions to promote socioeconomic and health equity for all people. The dynamic, systemic interplay of the entry points illustrated in the Framework suggest opportunities for multi-sectoral, collaborative action across government and organizations towards systems change and the prevention of unintended negative impacts of initiatives.

A Policy-Ready Public Health Guidebook of Strategies and Indicators to Promote Financial Well-Being and Address Financial Strain in Response to COVID-19.

INTRODUCTION: The COVID-19 pandemic has adversely affected the financial well-being of populations globally, escalating concerns about links with health care and overall well-being. Governments and organizations need to act quickly to protect population health relative to exacerbated financial strain. However, limited practice- and policy-relevant resources are available to guide action, particularly from a public health perspective, that is, targeting equity, social determinants of health, and health-in-all policies. Our study aimed to create a public health guidebook of strategies and indicators for multisectoral action on financial well-being and financial strain by decision makers in high-income contexts. METHODS: We used a multimethod approach to create the guidebook. We conducted a targeted review of existing theoretical and conceptual work on financial well-being and strain. By using rapid review methodology informed by principles of realist review, we collected data from academic and practice-based sources evaluating financial well-being or financial strain initiatives. We performed a critical review of these sources. We engaged our research-practice team and government and nongovernment partners and participants in Canada and Australia for guidance to strengthen the tool for policy and practice. RESULTS: The guidebook presents 62 targets, 140 evidence-informed strategies, and a sample of process and outcome indicators. CONCLUSION: The guidebook supports action on the root causes of poor financial well-being and financial strain. It addresses a gap in the academic literature around relevant public health strategies to promote financial well-being and reduce financial strain. Community organizations, nonprofit organizations, and governments in high-income countries can use the guidebook to direct initiative design, implementation, and assessment.

Investigating the association between income inequality in youth and deaths of despair in Canada: a population-based cohort study from 2006 to 2019.

BACKGROUND: Deaths due to suicide, drug overdose and alcohol-related liver disease, collectively known as 'deaths of despair', have been markedly increasing since the early 2000s and are especially prominent in young Canadians. Income inequality has been linked to this rise in deaths of despair; however, this association has not yet been examined in a Canadian context, nor at the individual level or in youth. The study objective was to examine the association between income inequality in youth and deaths of despair among youth over time. METHODS: We conducted a population-based longitudinal study of Canadians aged 20 years or younger using data from the Canadian Census Health and Environment Cohorts. Baseline data from the 2006 Canadian Census were linked to the Canadian Vital Statistics Database up to 2019. We employed multilevel survival analysis models to quantify the association between income inequality in youth and time-to deaths of despair. RESULTS: The study sample included 1.5 million Canadians, representing 7.7 million Canadians between the ages of 0 and 19 at baseline. Results from the weighted, adjusted multilevel survival models demonstrated that income inequality was associated with an increased hazard of deaths of despair (adjusted HR (AHR) 1.35; 95% CI 1.04 to 1.75), drug overdose (AHR 2.38; 95% CI 1.63 to 3.48) and all-cause deaths (AHR 1.10; 95% CI 1.04 to 1.18). Income inequality was not significantly associated with suicide deaths (AHR 1.23, 95% CI 0.93 to 1.63). CONCLUSION: The results show that higher levels of income inequality in youth are associated with an increased hazard of all-cause death, deaths of despair and drug overdose in young Canadians. This study is the first to reveal the association between income inequality and deaths of despair in youth and does so using a population-based longitudinal cohort involving multilevel data. The results of this study can inform policies related to income inequality and deaths of despair in Canada.