Evaluation of the gap in delivery of opioid agonist therapy among individuals with opioid-related health problems: a population-based retrospective cohort study.

AIMS: Although opioid-related harms have reached new heights across North America, the size of the gap in opioid agonist therapy (OAT) delivery for opioid-related health problems is unknown in most jurisdictions. This study sought to characterize the gap in OAT treatment using a cascade of care framework, and determine factors associated with engagement and retention in treatment. DESIGN: A population-based retrospective cohort study. SETTING: Ontario, Canada. PARTICIPANTS: Individuals who sought medical care for opioid-related health problems or died from an opioid-related cause between 2005 and 2019. MEASUREMENTS: Monthly treatment status for buprenorphine/naloxone or methadone OAT between 2013 and 2019 (i.e. 'off OAT', 'retained on OAT < 6 months', 'retained on OAT ≥ 6 months'). FINDINGS: Of 122 811 individuals in the cohort, 97 516 (79.4%) received OAT at least once during the study period. There was decreasing 6-month treatment retention over time. Model results indicated that males had higher odds of being on OAT each month [odds ratio (OR) = 1.26, 95% confidence interval (CI) = 1.23-1.28] but lower odds of OAT retention (OR = 0.90, 95% CI = 0.88-0.92), while the reverse was observed for older individuals (monthly: OR = 0.76 per 10-year increase, 95% CI = 0.76-0.77; retention: OR = 1.36 per 10-year increase, 95% CI = 1.34-1.38) and individuals with higher neighbourhood income (e.g. highest income quintile, monthly: OR = 0.79, 95% CI = 0.77-0.82; highest income quintile, retention: OR = 1.15, 95% CI = 1.11-1.20). Individuals residing in rural areas and with a history of mental health diagnoses had poorer outcomes overall, including lower odds of being on OAT each month (rural: OR = 0.75, 95% CI = 0.73-0.78; mental health: OR = 0.89, 95% CI = 0.87-0.92) and OAT retention (rural: OR = 0.79, 95% CI = 0.77-0.82; mental health: OR = 0.81, 95% CI = 0.78-0.83), as well as higher risk of starting/stopping OAT [rural, starting OAT: hazard ratio (HR) = 1.07, 95% CI = 1.05-1.10; mental health, starting OAT: HR = 1.20, 95% CI: 1.18-1.23; rural, stopping OAT: HR = 1.24, 95% CI: = 1.22-1.26; mental health, stopping OAT: HR = 1.11, 95% CI = 1.09-1.13]. Individuals with a history of mental health diagnoses also had a higher risk of death, regardless of OAT status (off OAT death: HR = 1.49, 95% CI = 1.33-1.66; on OAT death: HR = 1.20, 95% CI = 1.09-1.31). CONCLUSIONS: Factors influencing engagement and declining retention in treatment with opioid agonist therapy in Ontario's health system include age, sex and neighbourhood income, as well as mental health diagnoses or residing in rural regions.

Population-Based Teacher-Rated Assessment of Anxiety Among Canadian Kindergarten Children.

Despite anxiety being a prevalent mental health problem in children, little data exist on the pervasiveness and levels of anxiety symptoms in kindergarteners. Data from the Early Development Instrument, a teacher-completed, population-level measure of child development, were collected across Canada from 2004 to 2015. The final analytic sample consisted of 974,319 children of whom 2.6% were classified as "highly anxious". Compared to children who exhibited "few to none" anxious behaviors, highly anxious children were more likely to be male, have English/French as a second language, and have a special needs designation. Furthermore, compared with their less anxious peers, highly anxious children had between 3.5 and 6.1 higher odds of scoring below the 10th percentile cut-off in physical, social, language/cognitive and communication domains. Our findings suggest that anxious behaviors are related to children's overall health and illustrate the consistency and extensiveness of anxiety at a very young age among Canadian children.

Supporting community overdose response planning in Ontario, Canada: Findings from a situational assessment.

BACKGROUND: Many communities across North America are coming together to develop comprehensive plans to address and respond to the escalating overdose crisis, largely driven by an increasingly toxic unregulated drug supply. As there is a need to build capacity for successful implementation, the objective of our mixed methods study was to identify the current planning and implementation practices, needs, and priority areas of support for community overdose response plans in Ontario, Canada. METHODS: We used a situational assessment methodology to collect data on current planning and implementation practices, needs, and challenges related to community overdose response plans in Ontario, consisting of three components. Between November 2019 to February 2020, we conducted ten semi-structured key informant interviews, three focus groups with 25 participants, and administered an online survey (N = 66). Purposeful sampling was used to identify professionals involved in coordinating, supporting, or partnering on community overdose response plans in jurisdictions with relevant information for Ontario including other Canadian provinces and American states. Key informants included evaluators, representatives involved in centralised supports, as well as coordinators and partners on community overdose response plans. Focus group participants were coordinators or leads of community overdose response plans in Ontario. RESULTS: Sixty-six professionals participated in the study. The current planning and implementation practices of community overdose response plans varied in Ontario. Our analysis generated four overarching areas for needs and support for the planning and implementation of community overdose response plans: 1) data and information; 2) evidence and practice; 3) implementation/operational factors; and 4) partnership, engagement, and collaboration. Addressing stigma and equity within planning and implementation of community overdose response plans was a cross-cutting theme that included meaningful engagement of people with living and lived expertise and meeting the service needs of different populations and communities. CONCLUSIONS: Through exploring the needs and related supports for community overdose response plans in Ontario, we have identified key priority areas for building local capacity building to address overdose-related harms. Ongoing development and refinement, community partnership, and evaluation of our project will highlight the influence of our supports to advance the capacity, motivation, and opportunities of community overdose response plans.

Socioeconomic position and consumption of sugary drinks, sugar-sweetened beverages and 100% juice among Canadians: a cross-sectional analysis of the 2015 Canadian Community Health Survey-Nutrition.

OBJECTIVE: The aim of this study was to describe sugary drink (beverages with free sugars), sugar-sweetened beverage (beverages with added sugars, SSB) and 100% juice (beverages with natural sugars) consumption across socioeconomic position (SEP) among Canadians. METHODS: We conducted a cross-sectional analysis of 19,742 respondents of single-day 24-h dietary recalls in the nationally representative 2015 Canadian Community Health Survey-Nutrition. Poisson regressions were used to estimate the prevalence of consuming each beverage type on a given day. Among consumers on a given day, linear regressions were used to estimate mean energy intake. Models included household education, food security and income quintiles as separate unadjusted exposures. Sex-specific models were estimated separately for children/adolescents (2-18 years) and adults (19 +). RESULTS: Among female children/adolescents, the prevalence of consuming sugary drinks and, separately, SSB ranged from 11 to 21 and 8 to 27 percentage-points higher among lower education compared to 'Bachelor degree or above' households. In female adults, the prevalence of consuming sugary drinks and, separately, SSB was 10 (95% CI: 1, 19) and 14 (95% CI: 2, 27) percentage-points higher in food insecure compared to secure households. In males, the prevalence of consuming 100% juice was 9 (95% CI: - 18, 0) percentage-points lower among food insecure compared to secure households. Social inequities in energy intake were observed in female adult consumers, among whom mean energy from sugary drinks was 27 kcal (95% CI: 3, 51) higher among food insecure compared to secure and 35 kcal (95% CI: 2, 67) higher from 100% juice among 'less than high school' education compared to 'Bachelor degree or above' households. CONCLUSION: Social inequities in sugary drink consumption exist in Canada. The associations differed by SEP indicator. Equitable interventions to reduce consumption are warranted.

RéSUMé: OBJECTIF: Dresser le portrait de la consommation de boissons sucrées (boissons contenant des sucres libres), de boissons contenant du sucre ajouté et de jus purs à 100 % (boissons contenant des sucres naturels) chez la population canadienne en fonction du statut socioéconomique. MéTHODE: Nous avons effectué une analyse transversale des rappels alimentaires de 24 heures réalisés par 19 742 personnes dans le cadre de l'Enquête sur la santé dans les collectivités canadiennes ­ Nutrition 2015, laquelle est représentative de la population nationale. Nous avons utilisé la régression de Poisson pour estimer la prévalence de la consommation de chaque type de boisson durant un jour donné. Pour calculer l'apport énergétique quotidien moyen, nous avons utilisé des régressions linéaires. Les modèles d'analyse traitent la scolarité, la sécurité alimentaire et les quintiles de revenu des ménages comme des expositions non ajustées distinctes. L'analyse en fonction du sexe est divisée en deux groupes, soit les enfants et adolescents (2 à 18 ans) et les adultes (19 ans et plus). RéSULTATS: Chez les filles et les adolescentes, la prévalence de la consommation de boissons sucrées et de boissons contenant du sucre ajouté est plus élevée (de 11 à 21 points de pourcentage et de 8 à 27 points de pourcentage, respectivement) dans les ménages moins scolarisés que dans les ménages plus scolarisés (baccalauréat et études supérieures). Chez les femmes vivant de l'insécurité alimentaire, la prévalence de la consommation de boissons sucrées et de boissons contenant du sucre ajouté est plus élevée de 10 points de pourcentage (IC de 95 % : 1, 19) et de 14 points de pourcentage (IC de 95 % : 2, 27), respectivement, que chez celles qui n'en vivent pas. Chez les sujets masculins, la prévalence de consommation des jus purs à 100 % est moins élevée de 9 points de pourcentage (IC de 95 % : -18, 0) dans les ménages vivant de l'insécurité alimentaire. Nous avons remarqué des disparités sur le plan social dans l'apport énergétique chez les femmes; l'apport moyen provenant de boissons sucrées est plus élevé de 27 kcal (IC de 95% : 3, 51) dans les ménages vivant de l'insécurité alimentaire, et l'apport moyen provenant de jus pur à 100 % est plus élevé de 35 kcal (IC de 95 % : 2, 67) dans les ménages moins scolarisés (pas de diplôme d'études secondaires) que chez les ménages plus scolarisés (baccalauréat et études supérieures). CONCLUSION: Il existe des disparités sur le plan social dans la consommation de boissons sucrées au Canada. Les résultats variaient en fonction de l'indicateur de statut économique. Nous recommandons des interventions équitables pour réduire la consommation de ces boissons.

Exploring Factors Contributing to the Implementation of Ontario's Healthy Kids Community Challenge: Surveys and Key Stakeholder Interviews with Program Providers.

(1) Background: To explore factors contributing to the Healthy Kids Community Challenge (HKCC) program implementation; (2) Methods: Data were collected through a quantitative survey (n = 124) and in-depth telephone interviews (n = 16) with program providers. Interviews were recorded and transcribed for thematic analysis using NVivo; (3) Results: Provincial funding and in-kind support from community partners were key. Initiatives were feasible to implement, and key messages were well-received by communities. Specific practices and process were commonly discussed, and strong local program leadership was crucial to implementation; (4) Conclusions: Results have implications for planning and implementing future multi-component, community-based health promotion programs that include similar partnerships.

Ontario dentists' ease to discuss sensitive health issues with their patients: A cross-sectional study.

OBJECTIVES: With consistent calls for a more integrated approach to improve the healthcare system's effectiveness, the scope of practice for dentists has expanded; dentists are now seen to positively intervene to address several sensitive health issues among their patients. However, it is not clear how comfortable dentists feel in doing so. This study endeavored to assess self-perceived ease of dentists to discuss various sensitive health issues and if their socio-demographics influence their ease. METHODS: A self-administered online survey was sent to Ontario dentists (n = 9975) to assess their self-perceived ease in discussing five sensitive health issues with their patients: eating disorders, substance abuse, sexually transmitted infections (STIs), sexual behaviors, and physical abuse. Ordinal logistic regressions were performed along with descriptive analyses. RESULTS: The response rate was 9.3%. Over 50% of participants indicated difficulty discussing STIs, sexual behaviors and physical abuse. Younger dentists, female practitioners, dentists practicing in private settings, and those practicing in rural areas perceived more difficulty to discuss all five health issues. Place of training was also a significant predictor: internationally trained dentists perceived it easier to discuss eating disorders, substance abuse, and physical abuse while Canadian trained were more at ease to discuss STIs and sexual behaviors. CONCLUSION: This exploratory study identified that a large proportion of dentists are not comfortable discussing sensitive health issue with their patients. There are numerous opportunities for intervention in Canadian dental curriculums, continuing education programs, and communication practices to support dentists' discussions with patients about these important health concerns.

The Equity and Effectiveness of Achieving Canada's Voluntary Sodium Reduction Guidance Targets: A Modelling Study Using the 2015 Canadian Community Health Survey-Nutrition.

Background: High sodium intake is a leading modifiable risk factor for cardiovascular diseases. This study estimated full compliance to Canada's voluntary sodium reduction guidance (SRG) targets on social inequities and population sodium intake. Methods: We conducted a modeling study using n = 19,645, 24 h dietary recalls (Canadians ≥ 2 years) from the 2015 Canadian Community Health Survey-Nutrition (2015 CCHS-N). Multivariable linear regressions were used to estimate mean sodium intake in measured (in the 2015 CCHS-N) and modelled (achieving SRG targets) scenarios across education, income and food security. The percentage of Canadians with sodium intakes above chronic disease risk reduction (CDRR) thresholds was estimated using the US National Cancer Institute (NCI) method. Results: In children aged 2-8, achieving SRG targets reduced mean sodium intake differences between food secure and insecure households from 271 mg/day (95%CI: 75,468) to 83 mg/day (95%CI: -45,212); a finding consistent across education and income. Mean sodium intake inequities between low and high education households were eliminated for females aged 9-18 (96 mg/day, 95%CI: -149,341) and adults aged 19 and older (males: 148 mg/day, 95%CI: -30,327; female: -45 mg/day, 95%CI: -141,51). Despite these declines (after achieving the SRG targets) the majority of Canadians' are above the CDRR thresholds. Conclusion: Achieving SRG targets would eliminate social inequities in sodium intake and reduce population sodium intake overall; however, additional interventions are required to reach recommended sodium levels.

Domestic violence and abuse related emergency room visits in Ontario, Canada.

BACKGROUND: Hospitals' emergency rooms (ERs) are generally the first point of contact of domestic violence and abuse (DVA) victims to the health care system. For efficient management and resource allocation for ERs to manage DVA-related emergencies in Canada, it is important to quantify and assess the pattern of these visits. METHODS: Aggregate DVA-related ER visits data, using relevant ICD-10-CA codes, from 2012 to 2016 were retrieved from IntelliHealth Ontario. The 2011 ON-Marg (Ontario Marginalization) indices were linked at the Dissemination Area level to ER data. Descriptive analyses including total number and rate of visits per 100,000 people were calculated, stratified by age and sex. The Slope Index of Inequality (SII) and Relative Index of Inequality (RII) were also assessed. RESULTS: From 2012 to 2016, 10,935 (81.2% by females and 18.8% by males) DVA-related visits were made to ERs in Ontario. An annual average of 25.5 visits per 100,000 females and 6.1 visits per 100,000 males was observed. Residential instability and deprivation were significant predictors of DVA-related ER visits. No particular site of injury was indicated in 38.5% of visits, 24.7% presented with cranio-maxillofacial (CMF) trauma in isolation, 28.9% presented with non-CMF injuries, and 7.9% visits presented with both CMF and non-CMF injuries. CONCLUSION: This study identified that the burden of DVA-related ER visits is large enough to warrant timely public health interventions, and observed that certain populations in Ontario experience more DVA and/or are more prone to its impact. Our findings have important implications for various stakeholders involved in planning and implementing relevant policies and programs.

Determinants of dentists' readiness to assess HPV risk and recommend immunization: A transtheoretical model of change-based cross-sectional study of Ontario dentists.

OBJECTIVES: To evaluate dentists' readiness to assess the history of human papilloma virus (HPV) infections and recommend immunization among their patients. MATERIALS AND METHODS: A link to a self-administered questionnaire was emailed to Ontario dentists. Dentists' readiness and its determinants were assessed based on Transtheoretical Model's 'stages' and 'processes' of change, respectively. Based on their current practices, dentists were either assigned to 'pre-action' or 'action+' stages. RESULTS: Of the 9,975 dentists contacted, 932 completed the survey; 51.9% participants were in action stage to assess the history of HPV infections and 20.5% to recommend immunization. Internationally-trained and those whose office's physical layout was not a concern to discuss patients' sexual history were more likely to assess the history. Dentists with higher knowledge about HPV vaccines, not concerned about the HPV vaccine safety, comfortable discussing sex-related topics with patients, or willing to exceed their scope of practice were more ready to recommend HPV immunization to their patients. CONCLUSION: Improving Ontario dentists' knowledge and communication skills and changing their self-perceived role regarding HPV infections and vaccination can increase their capacity to minimize the burden of HPV infections.

Teacher-Reported Prevalence of FASD in Kindergarten in Canada: Association with Child Development and Problems at Home.

The prevalence of Fetal Alcohol Spectrum Disorder (FASD) may be underestimated as it can be difficult to diagnose in early childhood possibly reflecting unique developmental trajectories relative to other Neurodevelopmental Disabilities (NDDs). Using data collected via the Early Development Instrument (EDI) between 2010 and 2015, we examined the prevalence of kindergarten children with FASD and their concurrent developmental outcomes. We found that the prevalence of FASD ranged from 0.01 to 0.31%. A greater percentage of children with FASD had teacher-reported home problems that interfered with their classroom functioning. Overall children with FASD had higher mean scores on the developmental domains compared to children with NDDs. Results of the current study can inform strategies and policies for early identification and intervention.

Strengthening public health nutrition: findings from a situational assessment to inform system-wide capacity building in Ontario, Canada.

OBJECTIVE: To assess public health nutrition practice within the public health system in Ontario, Canada to identify provincial-wide needs for scientific and technical support. DESIGN: A qualitative descriptive study was conducted to identify activities, strengths, challenges and opportunities in public health nutrition practice using semi-structured key informant interviews (n 21) and focus groups (n 10). Recorded notes were analysed concurrently with data generation using content analysis. System needs were prioritised through a survey. SETTING: Public health units. PARTICIPANTS: Eighty-nine practitioners, managers, directors, medical officers of health, researchers and other stakeholders were purposively recruited through snowball and extreme case sampling. RESULTS: Five themes were generated: (i) current public health nutrition practice was broad, complex, in transition and collaborative; (ii) data/evidence/research relevant to public health needs were insufficiently available and accessible; (iii) the amount and specificity of guidance/leadership was perceived to be mismatched with strong evidence that diet is a risk factor for poor health; (iv) resources/capacity were varied but insufficient and (v) understanding of nutrition expertise in public health among colleagues, leadership and other organisations can be improved. Top ranked needs were increased understanding, visibility and prioritisation of healthy eating and food environments; improved access to data and evidence; improved collaboration and coordination; and increased alignment of activities and goals. CONCLUSIONS: Collective capacity in the public health nutrition can be improved through strategic system-wide capacity-building interventions. Research is needed to explore how improvements in data, evidence and local contexts can bridge research and practice to effectively and efficiently improve population diets and health.

Identifying contexts and mechanisms in multiple behavior change interventions affecting smoking cessation success: a rapid realist review.

BACKGROUND: Smoking continues to be a leading cause of preventable chronic disease-related morbidity and mortality, excess healthcare expenditure, and lost work productivity. Tobacco users are disproportionately more likely to be engaging in other modifiable risk behaviours such as excess alcohol consumption, physical inactivity, and poor diet. While hundreds of interventions addressing the clustering of smoking and other modifiable risk behaviours have been conducted worldwide, there is insufficient information available about the context and mechanisms in these interventions that promote successful smoking cessation. The aim of this rapid realist review was to identify possible contexts and mechanisms used in multiple health behaviour change interventions (targeting tobacco and two or more additional risk behaviours) that are associated with improving smoking cessation outcome. METHODS: This realist review method incorporated the following steps: (1) clarifying the scope, (2) searching for relevant evidence, (3) relevance confirmation, data extraction, and quality assessment, (4) data analysis and synthesis. RESULTS: Of the 20,423 articles screened, 138 articles were included in this realist review. Following Michie et al.'s behavior change model (the COM-B model), capability, opportunity, and motivation were used to identify the mechanisms of behaviour change. Universally, increasing opportunities (i.e. factors that lie outside the individual that prompt the behaviour or make it possible) for participants to engage in healthy behaviours was associated with smoking cessation success. However, increasing participant's capability or motivation to make a behaviour change was only successful within certain contexts. CONCLUSION: In order to address multiple health behaviours and assist individuals in quitting smoking, public health promotion interventions need to shift away from 'individualistic epidemiology' and invest resources into modifying factors that are external from the individual (i.e. creating a supportive environment). TRIAL REGISTRATION: PROSPERO registration number: CRD42017064430.

Behavior Change Techniques Included in Reports of Social Media Interventions for Promoting Health Behaviors in Adults: Content Analysis Within a Systematic Review.

BACKGROUND: Social media are an increasingly commonly used platform for delivering health promotion interventions. Although recent research has focused on the effectiveness of social media interventions for health promotion, very little is known about the optimal content within such interventions, and the active ingredients to promote health behavior change using social media are not clear. Identifying which behavior change techniques (BCTs) are reported may help to clarify the content of interventions using a generalizable terminology that may facilitate future intervention development. OBJECTIVE: This study aimed to identify which BCTs are reported in social media interventions for promoting health behavior change in adults. METHODS: We included 71 studies conducted with adult participants (aged ≥18 years) and for which social media intervention was considered interactive in a Cochrane review of the effectiveness of such interventions. We developed a coding manual informed by the Behavior Change Technique Taxonomy version 1 (BCTTv1) to identify BCTs in the included studies. We identified BCTs in all study arms (including control) and described BCTs in the group and self-directed components of studies. We characterized the dose of delivery for each BCT by low and high intensity. We used descriptive analyses to characterize the reported BCTs. RESULTS: Our data consisted of 71 studies published from 2001 to 2017, mainly conducted in high-income countries (n=65). Most studies (n=31) used tailored, interactive websites to deliver the intervention; Facebook was the most used mainstream platform. In developing our coding manual, we adapted some BCTTv1 instructions to better capture unique nuances of how BCTs were operationalized in social media with respect to likes, retweets, smiles, congratulations, and badges. Social support (unspecified), instruction on how to perform the behavior, and credible source were most frequently identified BCTs in intervention arms of studies and group-delivery settings, whereas instruction on how to perform the behavior was most commonly applied in self-directed components of studies, control arms, and individual participant settings. Instruction on how to perform the behavior was also the most frequently reported BCT in both intervention and control arms simultaneously. Instruction on how to perform the behavior, social support (unspecified), self-monitoring of behavior, information about health consequences, and credible source were identified in the top 5 BCTs delivered with the highest intensity. CONCLUSIONS: This study within a review provides a detailed description of the BCTs and their dose to promote behavior change in web-based, interactive social media interventions. Clarifying active ingredients in social media interventions and the intensity of their delivery may help to develop future interventions that can more clearly build upon the existing evidence.

Cow's Milk Fat Obesity pRevention Trial (CoMFORT): a primary care embedded randomised controlled trial protocol to determine the effect of cow's milk fat on child adiposity.

INTRODUCTION: Cow's milk is a dietary staple for children in North America. Though clinical guidelines suggest children transition from whole (3.25% fat) milk to reduced (1% or 2%) fat milk at age 2 years, recent epidemiological evidence supports a link between whole milk consumption and lower adiposity in children. The purpose of this trial is to determine which milk fat recommendation minimises excess adiposity and optimises child nutrition and growth. METHODS AND ANALYSIS: Cow's Milk Fat Obesity pRevention Trial will be a pragmatic, superiority, parallel group randomised controlled trial involving children receiving routine healthcare aged 2 to 4-5 years who are participating in the TARGet Kids! practice-based research network in Toronto, Canada. Children (n=534) will be randomised to receive one of two interventions: (1) a recommendation to consume whole milk or (2) a recommendation to consume reduced (1%) fat milk. The primary outcome is adiposity measured by body mass index z-score and waist circumference z-score; secondary outcomes will be cognitive development (using the Ages and Stages Questionnaire), vitamin D stores, cardiometabolic health (glucose, high-sensitivity C-reactive protein, non-high density lipoprotein (non-HDL), low density lipoprotein (LDL), triglyceride, HDL and total cholesterol, insulin and diastolic and systolic blood pressure), sugary beverage and total energy intake (measured by 24 hours dietary recall) and cost effectiveness. Outcomes will be measured 24 months postrandomisation and compared using analysis of covariance (ANCOVA), adjusting for baseline measures. ETHICS AND DISSEMINATION: Ethics approval has been obtained from Unity Health Toronto and The Hospital for Sick Children. Results will be presented locally, nationally and internationally and published in a peer-reviewed journal. The findings may be helpful to nutrition guidelines for children in effort to reduce childhood obesity using a simple, inexpensive and scalable cow's milk fat intervention. TRIAL REGISTRATION NUMBER: NCT03914807; pre-results.

How can we support best practice? A situational assessment of injury prevention practice in public health.

BACKGROUND: To effectively impact the significant population burden of injury, we completed a situational assessment of injury prevention practice within a provincial public health system to identify system-wide priorities for capacity-building to advance injury prevention in public health. METHODS: A descriptive qualitative study was used to collect data on the current practice, challenges and needs of support for injury prevention. Data was collected through semi-structured interviews (n = 20) and focus groups (n = 19). Participants included a cross-section of injury prevention practitioners and leadership from public health units reflecting different population sizes and geographic characteristics, in addition to public health researchers and experts from academia, public health and not-for-profit organizations. Thematic analysis was used to code all of the data by one reviewer, followed by a second independent reviewer who coded a random selection of interview notes. Major codes and sub codes were identified and final themes were decided through iterations of coding comparisons and categorization. Once data were analysed, we confirmed the findings with the field, in addition to participating in a prioritization exercise to surface the top three needs for support. RESULTS: Major themes that were identified from the data included: current public health practice challenges; capacity and resource constraints, and; injury as a low priority area. Overall, injury prevention is a broad, complex topic that competes with other areas of public health. Best practices are challenged by system-wide factors related to resources, direction, coordination, collaboration, and emerging injury public health issues. Injury is a reportedly under prioritized and under resourced public health area of practice. Practitioners believe that increasing access to data and evidence, and improving collaboration and networking is required to promote best practice. CONCLUSIONS: The results of this study suggest that there are several system level needs to support best practice in public health injury prevention in Ontario including reducing research to practice gaps and supporting opportunities for collaboration. Our research contributes to the literature of the complexity of public health practice, and presents several mechanisms of support to increase capacity at a system level to improve injury prevention practice, and eventually lessen the population burden of injury.

Assessing the impact of the 2015 introduction of increased penalties and enhanced public awareness and enforcement activities on texting while driving among adults in Ontario, Canada.

Objective: Texting while driving (TWD) is considered a particularly hazardous form of distracted driving. It is highly prevalent among young drivers, but fewer studies of TWD among adult drivers exist and these prevalence rates may approach those of younger drivers. The effectiveness of measures to prevent distracted driving, and TWD specifically, is unclear. On September 1, 2015, Ontario introduced increased penalties for distracted driving accompanied by public education programs to increase public awareness of the new regulations. Provincial police also introduced enhanced enforcement efforts. The current study examined self-reported TWD in a representative sample of Ontario adults before and after introduction of the new legislation and the enhanced public education and enforcement efforts.Methods: Data were based on telephone interviews with 1,846 respondents who reported having driven in the past year. Data were derived from the 2015-2016 cycles of the Centre for Addiction and Mental Health (CAMH) Monitor, an ongoing cross-sectional telephone survey of adults aged 18+ years in Ontario, Canada. A binary logistic regression analysis of TWD in the previous 30 days was conducted, adjusting for demographic characteristics (sex, age), driving exposure, and introduction of the legislation (before versus after).Results: The proportion of the sample reporting TWD declined significantly from 37.6% before the law was introduced to 24.2% after the law was introduced. The impact appeared to be most pronounced among drivers who reported TWD more frequently. Adjusted odds of TWD declined 42% following introduction of the legislation and associated enhanced public education and enforcement.Conclusions: These results identify a decrease in TWD following the introduction of enhanced penalties with corresponding public education and enforcement efforts, adding to the existing evaluative evidence base to inform transportation safety policy. These results also support the need to examine TWD and its determinants among all age groups.

Dentists' Capacity to Mitigate the Burden of Oral Cancers in Ontario, Canada.

BACKGROUND: In Canada, although the incidence of smoking-related oral cavity cancers has decreased, oropharyngeal cancers associated with human papilloma virus (HPV) are on the rise. During their routine interactions with patients, dentists have the opportunity to intervene. This study was conducted to assess dentists' capacity to prevent and detect oral cancers and to identify the barriers and facilitators that affect this capacity. METHODS: A 25-item, self-administered questionnaire was emailed to Ontario dentists through their regulatory body. It aimed to assess their perceptions about various aspects of oral cancer prevention and detection, including their knowledge, attitudes and practices. A binary logistic regression model was constructed for each modifiable risk factor (smoking, alcohol use, HPV) to identify the predictors of dentists' readiness to discuss with patients the connection between risk factors and oral cancers. RESULTS: Of the 9975 dentists contacted, 932 completed the survey. Most respondents (92.4%) believed that they are adequately trained to recognize the early signs and symptoms of oral cancer. However, only 35.4% of respondents said that they are adequately trained to obtain biopsy samples from suspected lesions. In addition, only a small proportion (< 40%) of the dentists believed that they are adequately trained to address relevant risk factors. Compared with dentists who said that they are adequately trained and currently assess a given risk factor, the odds of discussing the risk factor were consistently and significantly lower among those who said that they are inadequately trained (OR: smoking 0.11, alcohol 0.52, HPV 0.36) and among those who do not currently assess that risk factor (OR: smoking 0.12, alcohol 0.22, HPV 0.23). CONCLUSIONS: This study suggests that the capacity of Ontario dentists to detect and prevent oral cancers is limited by lack of training in using oral cancer screening tools and addressing risk factors. To mitigate this barrier, dentists' capacity could be enhanced by improving their training in detecting oral cancers and their readiness to assess and address the risk factors.

Supporting public health practice in healthy growth and development in the Province of Ontario, Canada.

BACKGROUND: As public health services are modernized in Ontario, Canada, there is a need to inform the system-level roles and responsibilities of government agencies. The aim of this study was to identify how Public Health Ontario (PHO) can optimally support evidence-based planning and programming in Healthy Growth and Development (HGD) across Ontario. METHODS AND DESIGN: A situational assessment was conducted with key informants from public health and other HGD fields. SAMPLE: Key informants were identified using purposeful snowball sampling and included public health nurses, health promoters, and medical officers of health. Analytic strategy: Twenty telephone interviews and seven focus groups were used to collect data. A thematic analysis was conducted concurrently with data collection. RESULTS: Five themes were identified: (a) Transition to the new Ontario Public Health Standards (OPHS) included experiences of adopting the new OPHS within local public health units (PHUs). (b) Collaborating and networking referred to the ability to work with community partners. (c) Data, evidence, and research described the presence of data, evidence, and research to support practice. (d) Decision making, planning, and priority setting described resources available that influenced decision making. (e) Current and emerging issues in HGD included high-priority topics. CONCLUSION: Public health practice in HGD is complex with many challenges in data and evidence, and making programming decisions without adequate or measurable indicators. A specialized position at PHO is an opportunity to support some of these system-wide needs.

One-Year Mortality After Emergency Department Visit for Nonfatal Opioid Poisoning: A Population-Based Analysis.

STUDY OBJECTIVE: We aim to characterize the incidence and risk factors for opioid-related and all-cause mortality in the year after an emergency department (ED) visit for nonfatal opioid poisoning by conducting a population-based study. METHODS: We used linked health care databases in Ontario, Canada, to identify individuals who attended an ED for nonfatal opioid poisoning between January 1, 2015, and December 31, 2016. Using Cox proportional hazards regression, we examined predictors of mortality in the year after discharge (ED or hospital, if admitted). RESULTS: In this cohort (n=6,140), 327 individuals (5.3%) died of any cause and 118 (1.9%) died of opioid-related causes within 1 year. Adjusting for other covariates, we found that health service use in the first week was not protective for opioid-related death (hazard ratio [HR] 0.70; 95% confidence interval [CI] 0.47 to 1.06) or all-cause mortality (HR 0.98; 95% CI 0.78 to 1.24). In exploring other covariates, predictors of opioid-related mortality included male sex (HR 1.98; 95% CI 1.32 to 2.97) and using opioid agonist therapy (HR 1.79; 95% CI 1.15 to 2.80) or benzodiazepine (HR 1.54; 95% CI 1.02 to 2.31) in the 12 months before the index event. Assessment by a family physician in the previous 12 months was associated with a lower risk of opioid-related and all-cause mortality (HR 0.58, 95% CI 0.39 to 0.86; and HR 0.63, 95% CI 0.49 to 0.82, respectively). CONCLUSION: We identified predictors of opioid-related and all-cause mortality after ED presentation for opioid poisoning. Several predictors of mortality may facilitate targeted interventions.

Is neighbourhood walkability related to body mass index among different age groups? A cross-sectional study of Canadian urban areas.

BACKGROUND: Studies of neighbourhood walkability and body mass index (BMI) have shown mixed results, possibly due to biases from self-reported outcomes or differential effects across age groups. Our objective was to examine relationships between walkability and objectively measured BMI in various age groups, in a nationally representative population. METHODS: The study population came from the 2007-2011 Canadian Health Measures Survey, a cross-sectional survey of a nationally representative Canadian population. In our covariate-adjusted analyses, we included survey respondents aged 6-79 who were not pregnant, did not live in rural areas, were not missing data and were not thin/underweight. We used objectively measured height and weight to calculate BMI among adults aged 18-79 and zBMI among children aged 6-17. We categorised respondents into walkability quintiles based on their residential Street Smart Walk Score values. We performed linear regression to estimate differences between walkability quintiles in BMI and zBMI. We analysed adults and children overall; age subgroups 6-11, 12-17, 18-29, 30-44, 45-64 and 65-79; and sex subgroups. RESULTS: The covariate-adjusted models included 9265 respondents overall. After adjustment, differences between walkability quintiles in BMI and zBMI were small and not statistically significant, except for males aged 6-17 in the second-highest walkability quintile who had significantly lower zBMIs than those in the lowest quintile. CONCLUSION: After accounting for confounding factors, we did not find evidence of a relationship between walkability and BMI in children or adults overall, or in any age subgroup with sexes combined. However, post hoc analysis by sex suggested males aged 6-17 in more walkable areas may have lower zBMIs.