An Exploratory Study on the Impacts of Individual Skills and Health Information Exposure on Perceptions of Cancer Control and Expert Competence.

People's perceptions of control over their risk of cancer, and their perceptions of health experts' abilities to manage cancer risks, shape their beliefs about the effectiveness of expert-recommended cancer-preventive behaviors and actions. The aims of this exploratory study were to investigate the impact of individual skills and sources of health information on (i) internal locus of cancer control (ILOC) and (ii) perceived expert competence. Using a cross-sectional survey (n = 172), we collected data on individual health expertise, numeracy, health literacy, amounts of health information received from various sources, ILOC for cancer prevention and perceived expert competence (i.e., believing that health experts have the knowledge to correctly estimate cancer risks). Significant associations between health expertise and ILOC, and between health literacy and ILOC, were not observed in this study (OR = 2.15, 95%CI = 0.96-5.98; OR = 1.78, 95%CI = 0.97-3.63, respectively). Participants who received more health information from the news were more likely to perceive experts as competent (OR = 1.86, 95%CI = 1.06-3.57). Logistic regression analyses suggested that higher levels of health literacy among individuals with lower numeracy may promote ILOC but discourage expert competence beliefs. Analyses by gender suggested females with low educational attainment and lower numeracy may especially benefit from educational interventions to improve health literacy and promote ILOC. Our findings build off existing literature that point to a possible interaction between numeracy and health literacy. This research, with follow up work, may have practical implications for health educators aiming to promote specific cancer beliefs that lead to the uptake of expert-recommended cancer-preventive behaviors.

Defining and classifying public health systems: a critical interpretive synthesis.

BACKGROUND: The introduction of the determinants of health has caused a shift towards understanding health from a holistic perspective as well as increased recognition of public health's contributions to the health of the population. Several frameworks exist to conceptualise healthcare systems, highlighting the stark contrast of frameworks unique to public health systems. The objectives of this study were to define public health systems and assess differences between healthcare systems and public health systems within established health systems frameworks. METHODS: A critical interpretive synthesis was conducted. Databases searched included EBSCOhost, OVID, Scholars Portal, Web of Science, Cochrane Library and Health Systems Evidence. Data extraction, coding and analysis followed a best-fit framework analysis method. Initial codes were based on a current leading health systems and policy classification scheme - health systems arrangements (governance, financial and delivery arrangements). RESULTS: A total of 5933 unique documents were identified and 67 were included in the analysis. Definitions of public health and public health systems varied significantly as did their roles and functions across jurisdictions. Public health systems arrangements generally followed those of health systems, with the addition of partnerships (community and inter-sectoral) and communication playing a larger role in public health. A public health systems framework and conceptualisation of how public health currently fits within health systems are presented. CONCLUSIONS: Public health systems are unique and vital entities within health systems. In addition to examining how public health and public health systems have been defined within the literature, this review suggests that establishing the scope of public health is crucial to understanding its role within the larger health system and adds to the discourse around the relationship between public health, healthcare and population health. More broadly, this study addresses an important gap in understanding public health systems and provides conceptual and practical contributions as well as areas for future research.

Test-retest reliability, internal consistency, construct validity and factor structure of a falls risk perception questionnaire in older adults with type 2 diabetes mellitus: a prospective cohort study.

BACKGROUND: Older adults with type 2 diabetes (DM2) are at increased risk of falling due to complications including: diabetic peripheral neuropathy, diabetic retinopathy, autonomic neuropathy and diabetic foot ulcers. The purpose of this study was to determine the test-retest reliability, internal consistency, construct validity and to perform factor analysis of a new falls Risk Perception Questionnaire (RPQ) in older community-dwelling adults with DM2. METHODS: A prospective cohort of 30 community-dwelling older adults, ≥ 55 years, with DM2 was assembled. At baseline, perceived risk of falling, fear of falling and physical activity were measured. At time 2 (T2), at least 2 days later, perceived risk of falling was assessed again to determine the test-retest reliability of the RPQ. At time 3 (T3), approximately six weeks later, and time 4 (T4), at least 2 days after T3, perceived risk of falling was assessed by phone to determine the test-retest reliability of the RPQ when administered by phone. RESULTS: The RPQ demonstrated excellent test-retest reliability when delivered in person (ICC = 0.78, 95% Confidence Interval, CI: 0.59-0.89) and by phone (ICC = 0.82, 95% CI: 0.65-0.91), good internal consistency (α = 0.78) and adequate construct validity (r = 0.52, 95% CI: 0.20-0.74, p = 0.003) in older adults with DM2. CONCLUSION: Given the good psychometric properties in this sample of persons with Diabetes, the RPQ has the potential to be used in clinical practice as a risk assessment and fall prevention tool. However, further testing needs to be done using a larger sample.

Dying to Learn: A Scoping Review of Breast and Cervical Cancer Studies Focusing on Black Canadian Women.

BACKGROUND: In Canada, data on race/ethnicity are not routinely collected. Black Canadian women may be under-screened for cervical/breast cancer and may be predisposed to worse outcomes, however data are difficult to find. OBJECTIVES: A scoping review was conducted to identify common themes and gaps in the literature regarding cervical/breast cancer prevention and management in Black Canadian women. METHODS: Medline, Embase, the Cochrane Library, CINAHL, PsycINFO, and Scopus databases (2003-2018) and grey literature were searched. Relevant studies were selected, data were charted, and themes were extracted. RESULTS: Twenty-three studies met inclusion criteria. Women from sub-Saharan Africa appear to have lower cervical and breast cancer screening rates; those of Caribbean/Latin American origin appear to have screening rates comparable to the general population; no studies reported prevalence or mortality rates for Black Canadian women. CONCLUSION: There is a paucity of health research on breast and cervical cancer specific to Black Canadian women.

Family medicine residents' knowledge of, attitudes toward, and clinical practices related to environmental health: Multi-program survey.

OBJECTIVE: To assess family medicine residents' knowledge of, attitudes toward, and clinical practices related to environmental health (EH). DESIGN: Two-part study with questionnaire construction using a modified Delphi method, and a Web-based questionnaire administered to family medicine residents between November 2015 and January 2016. SETTING: All Canadian family medicine programs (for questionnaire construction) and 4 Ontario family medicine training programs (for questionnaire administration). PARTICIPANTS: First- to third-year family medicine residents (for questionnaire administration). MAIN OUTCOME MEASURES: Responses to 93 survey items that measured family medicine residents' knowledge of, attitudes toward, and clinical practices related to EH. RESULTS: For the final administered questionnaire, 203 of 887 (22.9%) family medicine residents responded. Although 92.0% of respondents somewhat or strongly believed that taking an environmental exposure history was important, only 18.1% of them had specific training in taking environmental exposure history, and 48.4% believed that taking an exposure history takes up too much time in office practice. While 82.9% of residents correctly identified recreational water use as a cause of gastroenteritis, only 60.2% correctly identified radon as a cause of lung cancer and 37.6% knew that elevated ground-level ozone is associated with asthma. Only 10.8% believed their supervisors had a good understanding of environmental exposures. Residents who believed their supervisors understood environmental exposures were more likely to take exposure histories for patients with uncontrolled asthma (P < .05), and those who discussed EH exposure with supervisors frequently, or thought environmental exposure histories were very important, were more likely to provide patients with EH education materials (P < .01). CONCLUSION: Although family medicine residents are aware of the importance of assessing patients' environmental exposures, they lack training and mentorship in EH. As a health determinant of critical importance, EH should be a high priority for inclusion in postgraduate family medicine education.

Low prioritization of latent tuberculosis infection-A systemic barrier to tuberculosis control: A qualitative study in Ontario, Canada.

BACKGROUND: Eliminating tuberculosis (TB) in low-incidence countries is an important global health priority, and Canada has committed to achieve this goal. The elimination of TB in low-incidence countries requires effective management and treatment of latent tuberculosis infection (LTBI). This study aimed to understand and describe the system-level barriers to LTBI treatment for immigrant populations in the Greater Toronto and Hamilton Area, Ontario, Canada. METHODS: A qualitative study that used purposive sampling to recruit and interview health system advisors and planners (n = 10), providers (n = 13), and clients of LTBI health services (n = 9). Data were recorded, transcribed verbatim, and analyzed using content analysis. RESULTS: Low prioritization of LTBI was an overarching theme that impacted four dimensions of LTBI care: management, service delivery, health literacy, and health care access. These factors explained, in part, inequities in the system that were linked to variations in health care quality and health care access. While some planners and providers at the local level were attempting to prioritize LTBI care, there was no clear pathway for information sharing. CONCLUSIONS: This multiperspective study identified barriers beyond the typical socioeconomic determinants and highlighted important upstream factors that hinder treatment initiation and adherence. Addressing these factors is critical if Canada is to meet the WHO's global call to eradicate TB in all low incidence settings.

Ko-Pamoja: the feasibility of a lay health educator-led breast and cervical screening program for Black women in Ontario, Canada (short report).

BACKGROUND: Effective strategies are needed to actively encourage Black women in Canada to adhere to breast and cervical cancer screening and follow-up. In this study, we describe "Ko-Pamoja," a pilot peer education program for breast and cervical cancer screening targeted specifically at Black women in Toronto, Canada. METHODS: We used an Afrocentric lens to design the program, whose purpose was to increase awareness of cancer susceptibility and the benefits of screening for breast and cervical cancer for Black women. Participants were recruited through three Black-predominant churches. We used pre- and post-session questionnaires to assess changes in participant awareness of cancer susceptibility and screening guidelines, and changes in screening self-efficacy. RESULTS: 30 women attended sessions. Ko-Pamoja was able to increase awareness of cancer susceptibility, awareness of screening guidelines, and screening self-efficacy. Two months after the last session, four women had been screened for breast cancer at a participating mammogram site. CONCLUSIONS: Building on the successes of Ko-Pamoja, future versions are being developed in the region. These versions will be adapted to take into account our lessons learned while maintaining the Afrocentric lens and community-focussed approach, in order to promote cancer screening and ultimately improve outcomes.

Assessing Continuous Quality Improvement in Public Health: Adapting Lessons from Healthcare.

CONTEXT: Evidence of the effect of continuous quality improvement (CQI) in public health and valid tools to judge that such effects are not fully formed. OBJECTIVE: The objective was to adapt and apply Shortell et al.'s (1998) four dimensions of CQI in an examination of a public health accountability and performance management initiative in Ontario, Canada. METHODS: In total, 24 semi-structured, in-depth interviews were conducted with informants from public health units and the Ministry of Health and Long-Term Care. A web survey of public health managers in the province was also carried out. RESULTS: A mix of facilitators and barriers was identified. Leadership and organizational cultures, conducive to CQI success were evident. However, limitations in performance measurement and managerial discretion were key barriers. CONCLUSION: The four dimensions of CQI provided insight into both facilitators and barriers of CQI adoption in public health. Future research should compare the outcomes of public health CQI initiatives to the framework's stated facilitators and barriers.

Hopes and realities of public health accountability policies.

Holding local boards of health accountable presents challenges related to governance and funding arrangements. These challenges result in (a) multiple accountability pressures, (b) population health outcomes whose change is measureable only over long time periods and (c) board of health activity that is often not the key immediate direct contributor to achieving desired outcomes. We examined how well these challenges are addressed in Ontario, Canada at early stages of implementation of a new accountability policy. Findings reveal that senior and middle management are open to being held accountable to the Ministry of Health and Long-Term Care (MOHLTC), but are more oriented to local boards of health and local/regional councils. These managers perceive the MOHLTC system as compliance oriented, and find internal accountability systems most helpful for performance improvement. Like health-care system accountability metrics, performance indicators are largely focused on structures and processes owing to the challenges of attributing population health outcomes to public health unit (PHU) activities. MOHLTC is in the process of responding to these challenges.

High gestational weight gain and the risk of preterm birth and low birth weight: a systematic review and meta-analysis.

OBJECTIVE: Many women have high gestational weight gain (GWG), but potential neonatal consequences are not yet well quantified. We sought to determine the relationship between high GWG and preterm birth (PTB) and low birth weight (LBW) in singleton births. DATA SOURCES: We searched Medline and Embase and reference lists. STUDY SELECTION: Two assessors independently performed all steps. We selected studies assessing high total or weekly GWG on PTB (< 37 weeks) and LBW (< 2500 grams). DATA EXTRACTION AND SYNTHESIS: Thirty-eight studies, 24 cohort and 14 case-control, were included involving 2 124 907 women. Most contained unadjusted data. Women with high total GWG had a decreased risk overall of PTB < 37 weeks (relative risk [RR] 0.75; 95% CI 0.60 to 0.96), PTB 32 to 36 weeks (RR 0.70; 95% CI 0.70 to 0.71), and < 32 weeks (RR 0.87; 95% CI 0.85 to 0.90). High GWG was associated with lower risk of LBW (RR 0.64; 95% CI 0.53 to 0.78). Women with the highest GWG had lower risks of LBW (RR 0.55; 95% CI 0.32 to 0.94) than women with moderately high GWG (RR 0.73; 95% CI 0.60 to 0.89). Women with the highest weekly GWG had greater risks of PTB (RR 1.51; 95% CI 1.47 to 1.55) than women with moderately high weekly GWG (RR 1.09; 95% CI 1.05 to 1.13). Women with high weekly GWG were at increased risk of PTB 32 to 36 weeks (RR 1.14; 95% CI 1.10 to 1.17 and < 32 weeks (RR 1.81; 95% CI 1.73 to 1.90). CONCLUSION: Although women with high total GWG have lower unadjusted risks of PTB and LBW, high weekly GWG is associated with increased PTB, and more adjusted studies are needed, as are more studies in obese women. Potential benefits of high GWG for the infant must be balanced against maternal risks and other known infant risks such as high birth weight.

Integration of community health teaching in the undergraduate medicine curriculum at the University of Toronto.

BACKGROUND: In 1999, Determinants of Community Health was introduced at the Faculty of Medicine, University of Toronto. The course spanned all 4 years of the undergraduate curriculum and focused on addressing individual patient and community needs, prevention and population health, and diverse learning contexts. PURPOSE: To demonstrate the value of an integrated, longitudinal approach to the efficiency of delivering a public health curriculum. DESIGN: Time-series comparing the curricular change over two periods of time. SETTING/PARTICIPANTS: Undergraduate medical students from 1993 to 2009. INTERVENTION: Using a spiral curriculum, the educational materials are integrated across all 4 years, based on the concept of medical decision making in a community context. MAIN OUTCOME MEASURES: This study compares measures of student satisfaction and national rankings of the University of Toronto with the other 16 Canadian medical schools for the "Population Health, Ethical, Legal, and Organizational aspects of the practice of medicine" component of the Medical Council of Canada Qualifying Examination Part 1. RESULTS: The University of Toronto has been ranked either first or second place nationally, in comparison to lower rankings in previous years (p<0.02 on the Kruskal-Wallis test). Student ratings indicated the course was comparable to others in the curriculum. CONCLUSIONS: For the same amount of curricular time, an integrated spiral curriculum for teaching public health appears to be more effective than traditional approaches.

Healthy fish consumption and reduced mercury exposure: counseling women in their reproductive years.

OBJECTIVE: To provide family physicians with a practical, evidence-based approach to counseling women about healthy fish eating. SOURCES OF INFORMATION: MEDLINE was searched for articles published between 1999 and 2008. Most studies described in this article provide level II or III evidence. MAIN MESSAGE: Fish is an important component of a healthy diet for women in their reproductive years owing to the beneficial effects of omega-3 fatty acids on the neurologic development of the fetus. However, some fish species contain considerable methylmercury, which crosses the placenta and has harmful effects on neurobehavioural development. As many jurisdictions have issued fish consumption advisories, which can be confusing, women would benefit from individualized assistance from a trusted source, their family physicians, to clarify the risks and benefits of eating fish. CONCLUSION: We recommend that family physicians counsel women in their reproductive years about healthy choices regarding fish in their diet, and provide appropriate resources.

Intention to become pregnant and low birth weight and preterm birth: a systematic review.

Increased stress, psychosocial problems, economic disadvantages, and lack of prenatal care are proposed to explain discrepancies in the outcome of unintended pregnancies. Studies of maternal intention and pregnancy outcomes have yielded varied results. Objective is to review studies of the risk of low birth weight (LBW)/preterm births (PTB) associated with unintended pregnancies ending in a live birth. We reviewed studies reporting on maternal intentions and outcomes from Medline, Embase, CINAHL, and bibliographies of identified articles. An unintended pregnancy was further classified as mistimed (not intended at that time) or unwanted (not desired at any time). Studies reporting an association between pregnancy intention and any of the outcomes were included. Study quality was assessed for biases in selection, exposure assessment, confounder adjustment, analyses, outcomes assessment, and attrition. Unadjusted and adjusted data from included studies were extracted by two reviewers. There were significantly increased odds of LBW among unintended pregnancies [odds ratio (OR) 1.36, 95% confidence interval (CI) 1.25, 1.48] ending in a live birth. Within the unintended category, mistimed (OR 1.31, 95% CI 1.13, 1.52) and unwanted (OR 1.51, 95% CI 1.29, 1.78) pregnancies were associated with LBW. There were statistically significantly increased odds of PTB among unintended (OR 1.31, 95% CI 1.09, 1.58), and unwanted (OR 1.50, 95% CI 1.41, 1.61) but not for mistimed (OR 1.36, 95% CI 0.96, 1.93) pregnancies. Unintended, unwanted, and mistimed pregnancies ending in a live birth are associated with a significantly increased risk of LBW and PTB.

Work and life stressors and psychological distress in the Canadian working population: a structural equation modelling approach to analysis of the 1994 National Population Health Survey.

Work stressors are increasingly recognized as potentially important determinants of mental health status. We examined such relationships using a structural equation modelling approach with data on adult, working Canadians who participated in the first wave of the National Population Health Survey (NPHS). Work stressors formed a composite construct with paths from psychological demands, decision latitude, work social support and job insecurity, each measured through a reduced version of the Job Content Questionnaire. Life stressors also formed a composite construct composed of chronic stressors and recent life events. Psychological distress was the outcome, mediated by the latent effect constructs of mastery and self-esteem. Work stressors had consistently positive total effects on distress (sum of standardized path coefficients from 0.004 to 0.153 across gender-occupation strata), with all of these effects mediated through reduced self-esteem and mastery (work stressors to these mediators: -0.188 to -0.413). Life stressors had larger positive total effects on distress (0.462 to 0.536), with the majority of these effects direct.

Dietary intakes and plasma organochlorine contaminant levels among Great Lakes fish eaters.

Nutritional intakes and contaminant burdens should be assessed jointly in individuals who are at high risk of environmental exposures to contaminants through food. In this study, the authors used shore surveys and community contacts to recruit 91 individuals who frequently consumed Great Lakes fish. These individuals provided dietary intake information and fasting blood samples for lipid and contaminant analyses. Participants ate an annual median of 88 meals of Great Lakes fish. Asian-Canadians consumed more total fish meals (i.e., Great Lakes, non-Great Lakes, and other) (medians = 213.0 females, 223.0 males) than Euro-Canadians (medians = 131.0 females, 137.5 males). The higher total fish consumption by Asian-Canadians was associated with a lower percentage of energy derived from fat, higher protein and iron intakes, and higher plasma concentrations of omega-3 essential fatty acids (e.g., median docosahexaenoic acid levels [microgram/l] in Asian-Canadian females = 5.48, males = 4.38; in Euro-Canadian females = 2.93, males = 2.27). Plasma organochlorine contaminant lipid weight concentrations varied by country of origin and by gender (e.g., median total polychlorinated biphenyls [microgram/kg] in Asian-Canadian females = 490.6, males = 729.0; in Euro-Canadian females = 339.6, males = 355.5). Age was the most consistent predictor (+ve) of contaminant concentrations, followed by years spent in Canada (for Asian-Canadians). Associations with sport fish consumption variables were less consistent than for the aforementioned predictors. Given both the health benefits and potential risks of fish consumption, policies that address diverse ethnocultural groups should support continued consumption of sport fish, but from less-contaminated sources than are currently used.