The geographic distribution of un-immunized children in Ontario, Canada: Hotspot detection using Bayesian spatial analysis.

BACKGROUND: In Ontario, Canada, little is currently known about the extent to which un-immunized children may cluster geographically. Our objectives were to: describe the geographic distribution of fully un-immunized children; identify geographic clusters (hotspots) of un-immunized children; and to characterize the contribution of spatial effects and covariates on hotspots, where found. METHODS: Our analytic cohort consisted of Ontario students aged 7-17 years in the 2016-2017 school year. We defined students as un-immunized if they had zero doses of any vaccine and a non-medical exemption recorded in Ontario's registry. We calculated unadjusted proportions of un-immunized students by Census Subdivision (CSD) and then used a sequential approach to identify hotspots starting first with hotspot identification at the CSD level and then probed identified hotspots further by Dissemination Area (DA) and including covariates. Hotspots were identified using the Besag-York-Mollie Bayesian spatial model and were defined as areas with >95% probability of having two times the proportion of un-immunized students, relative to the province overall. RESULTS: We identified 15,208 (0.94%) un-immunized children within our cohort consisting of more than 1.61 million students. Unadjusted proportions of un-immunized students varied greatly by geography, ranging from 0% to 21.5% by CSD. We identified 16 hotspot CSDs which clustered in five distinct areas, all of which were located in southern Ontario. The contribution of covariates and spatial effects on the risk of having un-immunized students varied greatly across hotspot areas. CONCLUSIONS: Although the provincial proportion (0.94%) of un-immunized students is small, geographical clustering of such students is evident in Ontario and in some areas presents an important risk for future outbreaks. Further qualitative work within these hotspot areas would be a helpful next step to better characterize the factors associated with vaccine refusal in these communities.

Characteristics of immunized and un-immunized students, including non-medical exemptions, in Ontario, Canada: 2016-2017 school year.

BACKGROUND: Our objectives were: (1) to quantify and describe un-immunized students in Ontario, Canada and assess the extent to which these students have exemptions; and (2) to quantify and describe students with non-medical exemptions (NMEs), including what proportion have up-to-date immunizations. METHODS: We examined Ontario students 7 to 17 years-of-age in the 2016-2017 school year using information within a centralized immunization repository. We identified and described students with different immunization/exemption classifications by age, sex, school type, geography and area-level material deprivation using descriptive and multivariable logistic regression analyses. Finally, we assessed the immunization status of students with NMEs, by antigen. RESULTS: We found that students could be recorded as un-immunized with or without an NME, or be immunized with an NME. From a cohort of 1.65 million students, 2.9% of students had zero vaccine doses recorded, and of these 68% had no exemption of any kind. A total of 2.4% of students had an NME. Of these, 39% were un-immunized and 61% had received ≥1 vaccine. Among all students with NMEs, 19-48% had up-to-date immunizations, varying by antigen. Factors associated with increased odds of having a NME and being un-immunized included: attendance at private and 'other' schools, rural residence, and geography. Older age and greater area-level deprivation were associated with a reduced odds. CONCLUSIONS: Our assessment revealed that Ontario students with NMEs cannot be assumed to be un-immunized and at risk for all vaccine-preventable diseases. Conversely, not all un-immunized students had NMEs suggesting that future studies of un-immunized children in Ontario must consider additional factors beyond NME status alone. Other jurisdictions that use NME data to inform research and surveillance of vaccine hesitancy and risks for VPD outbreaks may wish to undertake a similar assessment to determine how well student NMEs correlate with student immunization status.

Use of Traditional Healing Practices in Two Ontario First Nations.

Colonization has negatively impacted Canada's Aboriginal people, with one of the consequences being loss of traditional knowledge, beliefs and practices, including traditional healing practices. In a study of two Ontario First Nations, the objectives of this research were to examine: (1) the extent of use of traditional healing practices, including traditional medicines and healers; (2) factors associated with their use and people's desire to use them; and (3) reasons for not using them among those who want to use them, but currently do not. Registered Band Members and volunteers from two First Nations communities (N = 613) participated in a well-being survey. About 15% of participants used both traditional medicines and healers, 15% used traditional medicines only, 3% used a traditional healer only, and 63% did not use either. Of those who did not use traditional healing practices, 51% reported that they would like to use them. Use was more common among men, older people, and those with more than high school education. Those who used traditional healing practices were found to have a stronger First Nations identity, better self-reported spiritual health, higher scores on historical loss and historical loss symptoms and higher levels of anxiety compared with people who did not use them. Common reasons for not using traditional practices were: not knowing enough about them, not knowing how to access or where to access them. These findings may be useful for promoting the use of traditional healing practices for the purpose of improving the health of First Nations people.

Dimensionality of the PTSD Checklist in a Canadian Aboriginal Sample.

BACKGROUND AND PURPOSE: The PTSD Checklist-Civilian Version (PCL-C) is a widely used screening instrument measuring posttraumatic stress disorder (PTSD). However, to our knowledge, the factor structure of the PCL-C has not been examined in an Aboriginal population. Considerable research indicates that PTSD symptoms are characterized by 4 factors, with both the "King model" and the "Simms model" supported by the literature. METHODS: Using confirmatory factor analysis on the PCL-C, we examined whether these models and the overall scale were supported in an Aboriginal community sample (N = 273). RESULTS: The data supported both models. However, the 4 factors were highly correlated, providing some support for a 1-factor model as well. CONCLUSIONS: Our data support use of the PCL-C in Aboriginal health research.

Psychometric properties and a latent class analysis of the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) in a pooled dataset of community samples.

The 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a brief measurement tool used cross-culturally to capture the multi-dimensional nature of disablement through six domains, including: understanding and interacting with the world; moving and getting around; self-care; getting on with people; life activities; and participation in society. Previous psychometric research supports that the WHODAS 2.0 functions as a general factor of disablement. In a pooled dataset from community samples of adults (N = 447) we used confirmatory factor analysis to confirm a one-factor structure. Latent class analysis was used to identify subgroups of individuals based on their patterns of responses. We identified four distinct classes, or patterns of disablement: (1) pervasive disability; (2) physical disability; (3) emotional, cognitive, or interpersonal disability; (4) no/low disability. Convergent validity of the latent class subgroups was found with respect to socio-demographic characteristics, number of days affected by disabilities, stress, mental health, and substance use. These classes offer a simple and meaningful way to classify people with disabilities based on the 12-item WHODAS 2.0. Focusing on individuals with a high probability of being in the first three classes may help guide interventions.

Increased Risk of Tinea Pedis and Onychomycosis Among Swimming Pool Employees in Netanya Area, Israel.

Tinea pedis and onychomycosis often co-occur in individuals. A relationship between swimming pools and tinea pedis exists; however, little research has investigated the relationship between onychomycosis, tinea pedis, and swimming pools. This study sought to examine the prevalence of tinea pedis and onychomycosis among swimming pool employees, a population that may be at risk of tinea infections. Samples were taken from 169 employees at 21 swimming pools in the Netanya area, Israel. KOH microscopy and culture was used to identify fungi. About 46 % of swimming pool employees had concurrent tinea pedis and onychomycosis, 30 % had tinea pedis only, and 6 % had onychomycosis only, compared to 10, 8, and 8 % of controls, respectively. After adjusting for age and gender, swimming pool employees were 20× more likely to have concurrent tinea pedis and onychomycosis, 15× more likely to have tinea pedis only, and 3× more likely to have onychomycosis only compared to controls. The present results are in agreement with previous research and support that swimming pools remain an important source of fungal contamination. More attention to hygienic guidelines and preventative measures may be needed in these settings.

Occurrence of multiple mental health or substance use outcomes among bisexuals: a respondent-driven sampling study.

BACKGROUND: Bisexual populations have higher prevalence of depression, anxiety, suicidality and substance use than heterosexuals, and often than gay men or lesbians. The co-occurrence of multiple outcomes has rarely been studied. METHODS: Data were collected from 405 bisexuals using respondent-driven sampling. Weighted analyses were conducted for 387 with outcome data. Multiple outcomes were defined as 3 or more of: depression, anxiety, suicide ideation, problematic alcohol use, or polysubstance use. RESULTS: Among bisexuals, 19.0 % had multiple outcomes. We did not find variation in raw frequency of multiple outcomes across sociodemographic variables (e.g. gender, age). After adjustment, gender and sexual orientation identity were associated, with transgender women and those identifying as bisexual only more likely to have multiple outcomes. Social equity factors had a strong impact in both crude and adjusted analysis: controlling for other factors, high mental health/substance use burden was associated with greater discrimination (prevalence risk ratio (PRR) = 5.71; 95 % CI: 2.08, 15.63) and lower education (PRR = 2.41; 95 % CI: 1.06, 5.49), while higher income-to-needs ratio was protective (PRR = 0.44; 0.20, 1.00). CONCLUSIONS: Mental health and substance use outcomes with high prevalence among bisexuals frequently co-occurred. We find some support for the theory that these multiple outcomes represent a syndemic, defined as co-occurring and mutually reinforcing adverse outcomes driven by social inequity.

Bisexuality, poverty and mental health: A mixed methods analysis.

Bisexuality is consistently associated with poor mental health outcomes. In population-based data, this is partially explained by income differences between bisexual people and lesbian, gay, and/or heterosexual individuals. However, the interrelationships between bisexuality, poverty, and mental health are poorly understood. In this paper, we examine the relationships between these variables using a mixed methods study of 302 adult bisexuals from Ontario, Canada. Participants were recruited using respondent-driven sampling to complete an internet-based survey including measures of psychological distress and minority stress. A subset of participants completed a semi-structured qualitative interview to contextualize their mental health experiences. Using information regarding household income, number of individuals supported by the income and geographic location, participants were categorized as living below or above the Canadian Low Income Cut Off (LICO). Accounting for the networked nature of the sample, participants living below the LICO had significantly higher mean scores for depression and posttraumatic stress disorder symptoms and reported significantly more perceived discrimination compared to individuals living above the LICO. Grounded theory analysis of the qualitative interviews suggested four pathways through which bisexuality and poverty may intersect to impact mental health: through early life experiences linked to bisexuality or poverty that impacted future financial stability; through effects of bisexual identity on employment and earning potential; through the impact of class and sexual orientation discrimination on access to communities of support; and through lack of access to mental health services that could provide culturally competent care. These mixed methods data help us understand the income disparities associated with bisexual identity in population-based data, and suggest points of intervention to address their impact on bisexual mental health.

Mental health and substance use among bisexual youth and non-youth in Ontario, Canada.

Research has shown that bisexuals have poorer health outcomes than heterosexuals, gays, or lesbians, particularly with regard to mental health and substance use. However, research on bisexuals is often hampered by issues in defining bisexuality, small sample sizes, and by the failure to address age differences between bisexuals and other groups or age gradients in mental health. The Risk & Resilience Survey of Bisexual Mental Health collected data on 405 bisexuals from Ontario, Canada, using respondent-driven sampling, a network-based sampling method for hidden populations. The weighted prevalence of severe depression (PHQ-9 ≥ 20) was 4.7%, possible anxiety disorder (OASIS ≥ 8) was 30.9%, possible post-traumatic stress disorder (PCL-C ≥ 50) was 10.8%, and past year suicide attempt was 1.9%. With respect to substance use, the weighted prevalence of problem drinking (AUDIT ≥ 5) was 31.2%, and the weighted prevalence of illicit polydrug use was 30.5%. Daily smoking was low in this sample, with a weighted prevalence of 7.9%. Youth (aged 16-24) reported significantly higher weighted mean scores on depression and post-traumatic stress disorder, and higher rates of past year suicidal ideation (29.7% vs. 15.2%) compared with those aged 25 and older. The burden of mental health and substance use among bisexuals in Ontario is high relative to population-based studies of other sexual orientation groups. Bisexual youth appear to be at risk for poor mental health. Additional research is needed to understand if and how minority stress explains this burden.