Testing the effectiveness of a sexual assault resistance programme in 'real-world' implementation.

Background: In a multi-site randomized controlled trial (RCT), the EAAA programme designed for first year university women (17-24 years old) was shown to reduce the likelihood of any (attempted and completed) rape in the next year by 50% (Senn, C. Y., Eliasziw, M., Barata, P. C., Thurston, W. E., Newby-Clark, I. R., Radtke, H. L., & Hobden, K. L. (2015). Efficacy of a sexual assault resistance program for university women. New England Journal of Medicine, 372(24), 2326-2335). Through a non-profit organization, EAAA has been available to universities globally since 2016 using a Train-the-Trainer model. Observations of the 'real world' implementation suggested that universities often altered eligibility criteria (especially year of study and age) in their recruitment.Objective: The current study (2017-2021) evaluated whether EAAA was effective when implemented by universities in Canada outside of the constraints of an RCT.Method: Five universities participated. Women students who signed up to take the EAAA programme on their campuses were recruited for the research. Participants completed surveys at 1-week pre-program and 1-week and 6-months post-programme. Compared to the RCT, participant eligibility was broader, the sample was more diverse in terms of race and sexual identity and had a higher proportion of survivors. Programme fidelity was adequate.Results: Comparisons in this quasi-experimental design, between students who took the programme and students in the control group (i.e. those who signed up but did not attend the programme), confirmed the effectiveness of the EAAA programme. Reduction of any rape exceeded the a priori benchmark of 37.5%. Completed rape was significantly reduced by 57.3% at 6-months. Reduction in attempted rape of 32.9% was lower than in the RCT likely due to the somewhat older (average age 22 vs 18) sample. Positive changes to previously established mediators of the programme effects were all replicated.Conclusions: These findings suggest that the EAAA is highly effective when implemented by universities even when eligibility for students in terms of year of study and age is broadened.

This study evaluates whether the EAAA programme is effective when implemented by university staff at five Canadian universities outside of the constraints of an RCT.Women-identified students who attended the EAAA programme experienced a 57.3% reduction in completed rape and other benefits including increased confidence and reductions in rape myth beliefs when compared to a comparable group of students who signed up but didn't attend the programme.These reductions in sexual victimization in the 'real-world' implementation of the EAAA programme in a sample of diverse undergraduate and graduate students enhances our confidence in its ability to reduce the pervasive public health issue of sexual violence experienced by women in university.

An Evaluation of Strategies Used to Maximize Intervention Fidelity in a Randomized Controlled Trial of a Sexual Assault Resistance Program for University Women.

In this paper, we describe and evaluate the strategies used to maximize intervention fidelity in a randomized controlled trial to examine the efficacy of a sexual assault resistance intervention. The EAAA program was based on the best available theory and evidence on how women can successfully resist sexual coercion from male acquaintances. Extensive protocols for hiring, training, and supervising facilitators were established a priori. Detailed intervention manuals were developed that clearly described program goals, learning objectives, core elements, troubleshooting tips, sections that must be delivered verbatim, adaptations that could be made if necessary, and the ideal and minimum dose. Program sessions were audio-recorded, and a subsample of recordings were scored for adherence to the manuals using detailed Intervention Fidelity Checklists (IFC) developed specifically for this research. The Gearing et al. (2011) Comprehensive Intervention Fidelity Guide (CFIG) was employed retrospectively to provide objectivity to our analysis and help identify what we did well and what we could have done better. The SARE (Sexual Assault Resistance Education) Trial received high scores (38 out of 44 (86%) from each of the first two authors on the CFIG, suggesting a high level of intervention fidelity. Although a potential for bias on the part of the two raters was an obvious limitation, as was our neglection to include measures of implementation receipt, which Gearing et al. (2011) recommended, our analysis underscores the utility in employing methods recommended to enhance intervention fidelity when developing and evaluating evidence-based interventions.

The Complexities of Intimate Partner Violence: Mental Health, Disabilities, and Child Abuse History for White, Indigenous, and Other Visible Minority Canadian Women.

This research examines how mental health issues associated with intimate partner violence (IPV) relate to women's intersecting identities of race/ethnicity, disability status, and child abuse history. Data (N = 595) from a Canadian triprovincial study included women who were White (n = 263, 44.8%), Indigenous (n = 292, 49.7%), or visible minority (n = 32, 5.5%). Few demographic differences were found. None of the mental health measures (Symptom Checklist-Short Form [SCL-10], Centre for Epidemiological Studies-Depression [CES-D-10], Posttraumatic Stress Disorder [PTSD] Checklist) were in the clinical ranges. In a MANCOVA on the mental health scales, with IPV severity, racial group, disability status, and child abuse history as variables, only disability was significantly associated with more mental health symptoms.

The Mental Health and Well-Being of Canadian Indigenous and Non-Indigenous Women Abused by Intimate Partners.

Intimate partner violence (IPV), mental health, disabilities, and child abuse history were examined for 292 Indigenous compared with 295 non-Indigenous Canadian women. IPV was assessed by the Composite Abuse Scale and mental health by the Symptom Checklist-10, Center for Epidemiological Studies-Depression 10, the Posttraumatic Stress Disorder (PTSD) Checklist, and Quality of Life Questionnaire. Scores did not differ nor were they in the clinical ranges for the two groups. In a MANCOVA on the mental health/well-being scales, with IPV severity as a covariate, only disability was significantly associated with more severe mental health symptoms. Suggestions for service providers are presented.

Everything Is Related and It All Leads Up to My Mental Well-Being: A Qualitative Study of the Determinants of Mental Wellness Amongst Urban Indigenous Elders.

Indigenous peoples in Canada often experience a greater burden of poor health and wellness relative to non-Indigenous Canadians due to a legacy of colonisation and racism. However, Indigenous mental wellness outcomes vary by community, and it is essential to understand how a community has been impacted by the determinants to improve mental wellness outcomes. This article shares insight from a research partnership with the Ki-Low-Na Friendship Society, an urban Indigenous community service organisation. The study used a decolonising, qualitative methodology in which urban Indigenous Elders shared their knowledge of mental wellness and experiences of services and supports. Elders described mental wellness holistically, connected to their relationships, land, language and culture. They described several determinants of wellness including identity, poverty, transportation, abuse and trauma. Elders shared experiences of culturally unsafe care and identified colonisation as root causes of poor mental wellness. They shared how some determinants affect urban Indigenous communities uniquely. This included limited transportation to cultural activities outside urban centres, such as medicine picking, the importance of urban organisations (such as Aboriginal Friendship Centres) in developing social support networks, and the role of discrimination, racism and inequitable care as barriers to accessing services in urban centres.

Stepping Stones to Resiliency following a community-based two-generation Canadian preschool programme.

Early intervention programmes are designed to address complex inequities for Canadian families living with low income, affecting social relationships, well-being and mental health. However, there is limited understanding of resiliency and change in families living with low income over time. We conducted a mixed methods study with recent immigrant, other Canadian-born, and Aboriginal families living with low income, who attended a two-generation preschool programme (CUPS One World) between 2002 and 2008. The aim of this study was to develop an understanding of the processes of change. We included 134 children and their caregivers living with low income, and experiencing mental health problems, addiction or social isolation. Children's receptive language, a proxy for school readiness, was measured at programme intake, exit, and age 10 years using the Peabody Picture Vocabulary Test 3rd Edition (PPVT-III). In Phase I (quantitative), we identified children with receptive language scores in the top and bottom 25th percentile, informing participant selection for Phase II. In Phase II (qualitative), we engaged in constructivist grounded theory to explore experiences of 14 biological mothers, after their children (n = 25) reached age 10 years. Interviews were conducted between June and September 2015. The core category, Stepping Stones to Resiliency, encompassed Perceptions of Family, Moving Forward, Achieving Goals, and Completely Different. Perceptions of Family influenced families' capabilities to move across the Stepping Stones to Resiliency. Stepping Stones to Resiliency provides a lens from which to view others in their daily challenges to break free of painful intergenerational cycles. It is a reminder of our struggle, our shared humanness, and that movement towards resiliency is more difficult for some than others. Our findings challenge traditional episodic, biomedical treatment paradigms for low-income families also experiencing intergenerational cycles of mental health problems, addictions, social isolation, and family violence.

Knowledge of and Adherence to the Cyanide Code Among Small-scale Gold Miners in Northern Tanzania.

BACKGROUND: Tanzania has seen explosive development in small scale gold mining (SGM) operations. Recently, the use of cyanide has become more common in SGM, especially in the reprocessing of mercury-amalgamated tailings from artisanal mining sites. OBJECTIVES: The primary objective of this study was to examine the level of knowledge and adherence to the Cyanide Code among workers and managers at SGM operations in northwestern Tanzania that use cyanide for gold extraction, focusing on workers' safety. METHODS: A cross-sectional study of workers and managers at 17 selected SGM sites was conducted. A random-cluster approach was used to recruit 215 mine workers and 23 mine managers who worked at the same sites for more than three months. Individuals participated in structured face-to-face interviews. Site evaluation checklists were also administered to assess adherence. RESULTS: The majority of the SGM workers (61.4%, n=132) were not aware of the Cyanide Code. Among the mine managers, 64.2% (n=15) were aware of the Cyanide Code. Fifty-four percent of workers and 39.1% of managers did not adhere to the Cyanide Code. Workers who reported being trained on the Cyanide Code were significantly more likely to have knowledge about the Cyanide Code guidelines compared to untrained workers (adjusted odds ratio =20.3, confidence interval: 7.5 - 54.8). DISCUSSION: Wide variations in knowledge of and adherence to the Cyanide Code were found. A manager's knowledge of Cyanide Code was significantly associated with workers' knowledge. High worker and manager knowledge was associated with increased site safety performance. Even though all the SGM sites were physically visited, some potentially hazardous practices may not have been revealed by managers and workers because of fear of possible regulatory actions due to disclosure of concerns related to their operation's safety compliance. CONCLUSIONS: The limited knowledge of the Cyanide Code among workers and managers, combined with poor adherence to cyanide waste management practices, indicates that there is a need for education, health promotion and sensitization among workers and managers to improve worker safety and minimize environmental health impacts. PARTICIPANT CONSENT: Obtained. ETHICS APPROVAL: Ethical approval was obtained from the Conjoint Catholic University of Health and Allied Sciences and Bugando Medical Centre Research Review and Ethics Committee (Ref. BREC/001/35/2014). Permission to conduct research in Geita District was obtained from the respective authorities at the regional and district levels and from owners of the SGM sites.

Secondary and 2-Year Outcomes of a Sexual Assault Resistance Program for University Women.

We report the secondary outcomes and longevity of efficacy from a randomized controlled trial that evaluated a novel sexual assault resistance program designed for first-year women university students. Participants (N = 893) were randomly assigned to receive the Enhanced Assess, Acknowledge, Act (EAAA) program or a selection of brochures (control). Perception of personal risk, self-defense self-efficacy, and rape myth acceptance was assessed at baseline; 1-week postintervention; and 6-, 12-, 18-, and 24-month postrandomization. Risk detection was assessed at 1 week, 6 months, and 12 months. Sexual assault experience and knowledge of effective resistance strategies were assessed at all follow-ups. The EAAA program produced significant increases in women's perception of personal risk, self-defense self-efficacy, and knowledge of effective (forceful verbal and physical) resistance strategies; the program also produced decreases in general rape myth acceptance and woman blaming over the entire 24-month follow-up period. Risk detection was significantly improved for the intervention group at post-test. The program significantly reduced the risk of completed and attempted rape, attempted coercion, and nonconsensual sexual contact over the entire follow-up period, yielding reductions between 30% and 64% at 2 years. The EAAA program produces long-lasting changes in secondary outcomes and in the incidence of sexual assault experienced by women students. Universities can reduce the harm and the negative health consequences that young women experience as a result of campus sexual assault by implementing this program. Online slides for instructors who want to use this article for teaching are available on PWQ's website at http://journals.sagepub.com/page/pwq/suppl/index.

The Intersection of Gender and Other Social Institutions in Constructing Gender-Based Violence in Guangzhou China.

Although violence against women is illegal in China, few studies have been published concerning this issue in that country. This article is part of a program of research undertaken in one province of China. The purpose of this study was to understand, from the perspectives of women who have experienced gender-based violence (GBV), the intersections of gender and other social institutions in constructing GBV in Guangzhou, China. The research question was as follows: For women who have been unfortunate enough to be with a partner who is willing to use abuse, how is gender revealed in their discussion of the experience? Women participants (N = 13) were all over the age of 21, had experienced some form of abuse in an intimate relationship, and had lived in Guangzhou at least for a year prior to data collection. They had a variety of backgrounds and experiences. The majority spoke of GBV as common. "Saving face" was connected to fear of being judged and socially stigmatized which had emotional as well as material consequences. Eight situations in which social stigma existed and caused women to lose face were identified. Gender role expectations and gendered institutions played a part in family relationships and the amount of support a woman could expect or would ask for. The women in this study received very little support from systems in their society. A high proportion (67%) revealed symptoms of mental strain, and three talked about having depression or being suicidal. The results are discussed in terms of identifying the mechanisms by which systems interlock and perpetuate GBV.

Mapping the role of structural and interpersonal violence in the lives of women: implications for public health interventions and policy.

BACKGROUND: Research on interpersonal violence towards women has commonly focused on individual or proximate-level determinants associated with violent acts ignores the roles of larger structural systems that shape interpersonal violence. Though this research has contributed to an understanding of the prevalence and consequences of violence towards women, it ignores how patterns of violence are connected to social systems and social institutions. METHODS: In this paper, we discuss the findings from a scoping review that examined: 1) how structural and symbolic violence contributes to interpersonal violence against women; and 2) the relationships between the social determinants of health and interpersonal violence against women. We used concept mapping to identify what was reported on the relationships among individual-level characteristics and population-level influence on gender-based violence against women and the consequences for women's health. Institutional ethics review was not required for this scoping review since there was no involvement or contact with human subjects. RESULTS: The different forms of violence-symbolic, structural and interpersonal-are not mutually exclusive, rather they relate to one another as they manifest in the lives of women. Structural violence is marked by deeply unequal access to the determinants of health (e.g., housing, good quality health care, and unemployment), which then create conditions where interpersonal violence can happen and which shape gendered forms of violence for women in vulnerable social positions. Our web of causation illustrates how structural factors can have negative impacts on the social determinants of health and increases the risk for interpersonal violence among women. CONCLUSION: Public health policy responses to violence against women should move beyond individual-level approaches to violence, to consider how structural and interpersonal level violence and power relations shape the 'lived experiences' of violence for women.

Primary healthcare needs and barriers to care among Calgary's homeless populations.

BACKGROUND: Despite Canada's universal healthcare system, significant barriers impede individuals experiencing homelessness from accessing health services. Furthermore, there is a paucity in the qualitative literature describing how Canadians experiencing homelessness access health care services. Our objective was to qualitatively explore perceived healthcare needs and barriers among individuals experiencing homelessness in one large Canadian city - Calgary, Alberta. METHODS: We conducted a qualitative descriptive study that included open-ended interviews and focus groups with a variety of stakeholders who are involved in healthcare among Calgary's homeless populations. These included individuals experiencing homelessness (n = 11) as well as employees from several healthcare service providers for those experiencing homelessness (n = 11). Transcripts from these interviews were thematically analyzed by two analysts. RESULTS: Stakeholder interviews yielded several pervasive themes surrounding the health care needs of the homeless and barriers to accessing care. Some of the primary health care needs which were identified included mental health, addictions, and allied health as well as care that addresses the social determinants of health. Notably, it was difficult for many stakeholders to pinpoint specific health care priorities, as they identified that the health care needs among Calgary's homeless populations are diverse and complex, often even describing the needs as overwhelming. Types of barriers to primary care that were identified by stakeholders included: emotional, educational, geographical, financial and structural barriers, as well as discrimination. CONCLUSIONS: Our findings highlight the diverse primary health care needs of Calgary's homeless populations. Despite the fact that Canada has a universal publicly funded health care system, individuals experiencing homelessness face significant barriers in accessing primary care.

Efficacy of a sexual assault resistance program for university women.

BACKGROUND: Young women attending university are at substantial risk for being sexually assaulted, primarily by male acquaintances, but effective strategies to reduce this risk remain elusive. METHODS: We randomly assigned first-year female students at three universities in Canada to the Enhanced Assess, Acknowledge, Act Sexual Assault Resistance program (resistance group) or to a session providing access to brochures on sexual assault, as was common university practice (control group). The resistance program consists of four 3-hour units in which information is provided and skills are taught and practiced, with the goal of being able to assess risk from acquaintances, overcome emotional barriers in acknowledging danger, and engage in effective verbal and physical self-defense. The primary outcome was completed rape, as measured by the Sexual Experiences Survey-Short Form Victimization, during 1 year of follow-up. RESULTS: A total of 451 women were assigned to the resistance group and 442 women to the control group. Of the women assigned to the resistance group, 91% attended at least three of the four units. The 1-year risk of completed rape was significantly lower in the resistance group than in the control group (5.2% vs. 9.8%; relative risk reduction, 46.3% [95% confidence interval, 6.8 to 69.1]; P=0.02). The 1-year risk of attempted rape was also significantly lower in the resistance group (3.4% vs. 9.3%, P<0.001). CONCLUSIONS: A rigorously designed and executed sexual assault resistance program was successful in decreasing the occurrence of rape, attempted rape, and other forms of victimization among first-year university women. (Funded by the Canadian Institutes of Health Research and the University of Windsor; SARE ClinicalTrials.gov number, NCT01338428.).

Sexual violence in the lives of first-year university women in Canada: no improvements in the 21st century.

BACKGROUND: Summarizes the frequency, type, and context of sexual assault in a large sample of first-year university women at three Canadian universities. METHODS: As part of a randomized controlled trial assessing the efficacy of a sexual assault resistance education program, baseline data were collected from women between ages of 17 and 24 using computerized surveys. Participants' experience with sexual victimization since the age of 14 years was assessed using the Sexual Experiences Survey--Short Form Victimization (SES-SFV). RESULTS: Among 899 first-year university women (mean age = 18.5 years), 58.7% (95% CI: 55.4%, 62.0%) had experienced one or more forms of victimization since the age of 14 years, 35.0% (95% CI: 31.9%, 38.3%) had experienced at least one completed or attempted rape, and 23.5% (95% CI: 20.7%, 26.4%) had been raped. Among the 211 rape victims, 46.4% (95% CI: 39.7%, 53.2%) had experienced more than one type of assault (oral, vaginal, anal) in a single incident or across multiple incidents. More than three-quarters (79.6%; 95% CI: 74.2%, 85.1%) of the rapes occurred while women were incapacitated by alcohol or drugs. One-third (33.3%) of women had previous self-defence training, but few (4.0%) had previous sexual assault education. CONCLUSIONS: Findings from the first large Canadian study of university women since the 1990s indicate that a large proportion of women arrive on campuses with histories of sexual victimization, and they are generally unprepared for the perpetrators they may face during their academic years. There is an urgent need for effective rape prevention programs on university campuses. TRIAL REGISTRATION: ClinicalTrials.gov NCT01338428. Registered 13 April 2011.

Discordant indigenous and provider frames explain challenges in improving access to arthritis care: a qualitative study using constructivist grounded theory.

INTRODUCTION: Access to health services is a determinant of population health and is known to be reduced for a variety of specialist services for Indigenous populations in Canada. With arthritis being the most common chronic condition experienced by Indigenous populations and causing high levels of disability, it is critical to resolve access disparities through an understanding of barriers and facilitators to care. The objective of this study was to inform future health services reform by investigating health care access from the perspective of Aboriginal people with arthritis and health professionals. METHODS: Using constructivist grounded theory methodology we investigated Indigenous peoples' experiences in accessing arthritis care through the reports of 16 patients and 15 healthcare providers in Alberta, Canada. Semi-structured interviews were conducted between July 2012 and February 2013 and transcribed verbatim. The patient and provider data were first analyzed separately by two team members then brought together to form a framework. The framework was refined through further analysis following the multidisciplinary research team's discussions. Once the framework was developed, reports on the patient and provider data were shared with each participant group independently and participants were interviewed to assess validity of the summary. RESULTS: In the resulting theoretical framework Indigenous participants framed their experience with arthritis as 'toughing it out' and spoke of racism encountered in the healthcare setting as a deterrent to pursuing care. Healthcare providers were frustrated by high disease severity and missed appointments, and framed Indigenous patients as lacking 'buy-in'. Constraints imposed by complex healthcare systems contributed to tensions between Indigenous peoples and providers. CONCLUSION: Low specialist care utilization rates among Indigenous people cannot be attributed to cultural and social preferences. Further, the assumptions made by providers lead to stereotyping and racism and reinforce rejection of healthcare by patients. Examples of 'working around' the system were revealed and showed potential for improved utilization of specialist services. This framework has significant implications for health policy and indicates that culturally safe services are a priority in addressing chronic disease management.

The role of a student-run clinic in providing primary care for Calgary's homeless populations: a qualitative study.

BACKGROUND: Despite the increasing popularity of Student-Run Clinics (SRCs) in Canada, there is little existing literature exploring their role within the Canadian healthcare system. Generalizing American literature to Canadian SRCs is inappropriate, given significant differences in healthcare delivery between the two countries. Medical students at the University of Calgary started a SRC serving Calgary's homeless population at the Calgary Drop-In and Rehabilitation Centre (CDIRC). This study explored stakeholders' desired role for a SRC within Calgary's primary healthcare system and potential barriers it may face. METHODS: Individual and group semi-structured interviews were undertaken with key stakeholders in the SRC project: clients (potential patients), CDIRC staff, staff from other stakeholder organizations, medical students, and faculty members. Convenience sampling was used in the recruitment of client participants. Interview transcripts were analyzed using a coding template which was derived from the literature. RESULTS: Participants identified factors related to the clinic and to medical students that suggest there is an important role for a SRC in Calgary. The clinic was cited as improving access to primary healthcare for individuals experiencing homelessness. It was suggested that students may be ideally suited to provide empathetic healthcare to this population. Barriers to success were identified, including continuity of care and the exclusion of some subsets of the homeless population due to location. CONCLUSIONS: SRCs possess several unique features that may make them a potentially important primary healthcare resource for the homeless. Participants identified numerous benefits of the SRC to providing primary care for homeless individuals, as well as several important limitations that need to be accounted for when designing and implementing such a program.

Sexual assault resistance education for university women: study protocol for a randomized controlled trial (SARE trial).

BACKGROUND: More than one in six women will be sexually assaulted in their lifetimes, most by men they know. The situation on university campuses is even more startling, with as many as 1 in 4 female students being victims of rape or attempted rape. The associated physical and mental health effects are extensive and the social and economic costs are staggering. The aim of this randomized controlled trial is to determine whether a novel, small-group sexual assault resistance education program can reduce the incidence of sexual assault among university-attending women, when compared to current university practice of providing informational brochures. METHODS/DESIGN: The trial will evaluate a theoretically and empirically sound four-unit, 12-hour education program that has been demonstrated in pilot studies to have short-term efficacy. Three of the four units provide information, skills, and practice aimed at decreasing the time needed for women to assess situations with elevated risk of acquaintance sexual assault as dangerous and to take action, reducing emotional obstacles to taking action, and increasing the use of the most effective methods of verbal and physical self-defense. The fourth unit focuses on facilitating a stronger positive sexuality from which women may resist sexual coercion by male intimates more successfully. The trial will extend the pilot evaluations by expanding the participant pool and examining the long term efficacy of the program. A total of 1716 first-year female students (age 17 to 24 years) from three Canadian universities will be enrolled. The primary outcome is completed sexual assault, measured by The Sexual Experiences Survey - Short Form Victimization instrument. Secondary outcomes include changes in knowledge, attitudes, and skills related to the process of sexual assault resistance. Outcomes will be measured at baseline, 1 week, 6, 12, 18, and 24 months. DISCUSSION: The results of the trial will be used to produce a maximally effective sexual assault resistance education program that can be adopted by universities, to assess whether aspects of the program need to be strengthened, and also to indicate how long the effects of the program last and at which point in time refresher sessions may be necessary. TRIAL REGISTRATION: ClinicalTrials.gov NCT01338428.

Intersections between interprofessional practice, cultural competency and primary healthcare.

The concepts of interprofessional collaborative practice (IPCP), cultural competency and primary healthcare (PHC) appear to be linked in theory and practice. This discussion article provides arguments explicating the potential linkages between IPCP and cultural competency. We argue that cultural competency is an important component of IPCP both for relationships with patients and/or communities in which providers work and between team members. Organizational structures also play an important role in facilitating IPCP and cultural competency. The integration of both IPCP and cultural competency has the potential to enhance positive health outcomes. Furthermore, we argue IPCP and cultural competency have important implications for PHC service design, given interprofessional teams are a key component of PHC systems. Linking these concepts in providing PHC services can be essential for impacting outcomes at all levels of primary healthcare, including patient, provider and systems.

Causes of death among an urban homeless population considered by the medical examiner.

Those who are homeless face illness and death, however, live in places not conducive to provision of end-of-life care. Limited information exists on causes of death among this group of people. To characterize causes of death, data were requested from the Office of the Chief Medical Examiner for Alberta Justice, Canada, for people determined to be homeless in the period 2007-2009. One hundred and thirty-two deaths were reported. Most deaths that could be classified were attributed to drug and alcohol use/abuse and to natural causes. For many, end-of-life circumstances may have been improved through provision of palliative care delivered in a hospice setting.

A pilot study of the impact of bovine spongiform encephalopathy on the futures of rural youth and Canadian farming.

There is an abundance of literature examining the economic impact of Canada's bovine spongiform encephalopathy (BSE) outbreak, but few studies examined the impact of such a crisis on health at the individual, family, or community levels. In particular, rural youth represent an under-researched population despite being at risk for a unique set of social and health concerns. In this pilot study, our objectives were to explore how rural youth responded to Canada's BSE crisis and how they perceived themselves, their families, and their communities to have been impacted. Seven youths (n = 7), recruited from within a university setting using a snowball sampling method, were interviewed. They represent a segment of rural, agriculturally based youth who are resilient due to good parental support. Although they reported high stress in their families during the immediate crisis in 2003, they did not report lasting high levels of stress or negative health effects due to BSE. They did report a decline in rural community health, identifying a reduction in community activities and in the participation of families in community activities. Participants identified elements that discourage youth from pursuing farming as a career and expressed concern for the future of family farming. The results are discussed in terms of the ability of agriculturally based youth to make the transition to adulthood. The implications have importance for future research and policy that addresses the structural supports for choice making, the long-term success for rural youth in transitioning to adult status, and the future of agriculture.

Implementation of universal screening for domestic violence in an urgent care community health center.

Given the morbidity and mortality associated with domestic violence (DV), there is international recognition that the health sector has a responsibility to prevent violence. In North America, the health sector has commonly responded by developing protocols for identifying victims of abuse. This utilization-focused evaluation describes the process involved in the implementation of a universal DV screening protocol undertaken by nurses in the urgent care clinic of a community health center. Dealing with the challenges of the urgent care setting, the strong and supportive urgent care team approach helped integrate the screening procedure into routine nursing practice. Understanding the purpose of asking about DV, quickly recognizing problems, validating staff concerns, and adapting procedures resulted in a strong commitment to implementation. This research has implications for others looking to implement or evaluate screening protocols in other health care settings.