Supporting Ontario public health units to address adverse childhood experiences in pandemic recovery planning: A priority-setting exercise.

BACKGROUND: Adverse childhood experiences (ACEs) are potentially traumatic exposures experienced during childhood, for example, neglect. There is growing evidence that the coronavirus disease 2019 (COVID-19) pandemic and related socioeconomic conditions contributed to an increased risk of ACEs. As public health programs/services are re-evaluated and restored following the state of emergency, it is important to plan using an ACEs-informed lens. The aim of this study was to identify and prioritize initiatives or activities that Public Health Ontario (PHO) could undertake to support Ontario public health units' work towards ACEs-informed pandemic recovery plans. METHODS: The Child Health and Nutrition Research Initiative method was adapted to conduct a priority-setting exercise (May-October 2022). Two online surveys were administered with members of the Healthy Growth and Development (HGD) Evidence Network, comprised of public health unit staff working in child and family health/HGD from Ontario's 34 public health units. In the first survey, participants were asked to propose activities or initiatives that PHO could undertake to support Ontario public health units' work towards ACEs-informed planning. In the second survey, participants were asked to score the final list of options against pre-determined prioritization criteria (for example, relevance). Responses were numerically coded and used to calculate prioritization scores, which were used to rank the options. RESULTS: In all, 76% of public health units (n = 26) responded to the first survey to identify options. The 168 proposed ideas were consolidated into a final list of 13 options, which fall under PHO's scientific and technical support mandate areas (data and surveillance, evidence synthesis, collaboration and networking, knowledge exchange and research). A total of 79% of public health units (n = 27) responded to the follow-up survey to prioritize options. Prioritization scores ranged from 76.4% to 88.6%. The top-ranked option was the establishment of a new provincial ACEs community of practice. CONCLUSIONS: Over three quarters of public health units contributed to identifying and ranking 13 options for PHO to support public health units in considering and addressing ACEs through pandemic recovery planning. In consultation with the ACEs and Resilience Community of Practice, recently formed on the basis of this exercise, PHO will continue to use the ranked list of options to inform work-planning activities/priorities.

The Core Competencies for Public Health in Canada: Opportunities and Recommendations for Modernization.

CONTEXT: The 2008 Public Health Agency of Canada's (PHAC's) "Core Competencies for Public Health in Canada" (the "Canadian core competencies") outline the skills, attitudes, and knowledge essential for the practice of public health. The core competencies represent an important part of public health practice, workforce development, and education in Canada and internationally. However, the core competencies are considered outdated and are facing calls for review, expansion, and revision. OBJECTIVE: To examine the literature on public health competencies to identify opportunities and recommendations for consideration when reviewing and updating the Canadian core competencies. METHODS: This narrative literature review included 4 components: 3 literature searches conducted between 2021 and 2022 using similar search strategies, as well as an analysis of competency frameworks from comparable jurisdictions. The 3 searches were conducted in collaboration with the Health Library to identify core competency-relevant scholarly and gray literature published in English since 2007. Reference lists of sources identified were also reviewed. During the data extraction process, one researcher screened each source, extracted competency-relevant information, and categorized these data into key findings. RESULTS: After identifying 2392 scholarly and gray literature sources, 166 competency-relevant sources were included in the review. Findings from these sources were synthesized into 3 main areas: (1) competency framework methodology and structure; (2) competencies to add; and (3) competencies to modify. DISCUSSION: These findings demonstrate that updates to Canada's core competencies are needed and overdue. Recommendations to support this process include establishing a formal governance structure for the competencies' regular review, revision, and implementation, as well as ensuring that priority topics applicable across all competency categories are integrated as overarching themes. Limitations of the evidence include the potential lack of applicability and generalizability to the Canadian context, as well as biases associated with the narrative literature review methodology.

Traffic-Calming Measures and Road Traffic Collisions and Injuries: a Spatiotemporal Analysis.

Traffic-calming measures (TCMs) are physical modifications to the road network aimed at making the roads safer. Although studies have reported reductions in road crashes and injuries tied to the presence of TCMs, they have been criticized for their pre-post designs. This study aims to complement our knowledge of TCMs effectiveness by assessing their impact using a longitudinal design. The implementation of eight TCMs, including curb extensions and speed humps, was evaluated at the intersections and census tract levels in Montreal, Canada from 2012 to 2019. The primary outcome was fatal or serious collisions among all road users. Inference was performed using a Bayesian implementation of Conditional Poisson regression in which random effects were used to account for the spatiotemporal variation in collisions. TCMs were generally implemented on local roads, although most collisions occurred on arterial roads. Overall, there was weak evidence that TCMs were associated with study outcomes. However, subgroup analyses of intersections on local roads suggested a reduction in collision rates due to TCMs (median IRR: 0.31; 95% Credible Interval: 0.12 - 0.86). To improve road safety, effective counterparts of TCMs on arterial roads must be identified and implemented.

COVID-19-related global health governance and population health priorities for health equity in G20 countries: a scoping review.

Since the declaration of the COVID-19 pandemic, the promotion of health equity including the health of various population sub-groups has been compromised, human rights jeopardised, and social inequities further exacerbated. Citizens worldwide, including in the Group of 20 (G20) countries, were affected by both global health governance (GHG) processes and decisions and public health measures taken by governments to respond to COVID-19. While it is critical to swiftly respond to COVID-19, little is known about how and to what extent the GHG is affecting population health priorities for health equity in global economies such as the G20 countries. This scoping review synthesised and identified knowledge gaps on how the COVID-19-related GHG is affecting population health priorities for policy, programme, and research in G20 countries. We followed the five-stage scoping review methodology promoted by Arksey and O'Malley and the PRISMA Extension for Scoping Reviews guidelines. We searched four bibliographic databases for references conducted in G20 countries and regions and published in English and French, between January 2020 and April 2023. Out of 4,625 references and after two phases of screening, 14 studies met the inclusion criteria. G20 countries included in the review were Australia, Brazil, Canada, China, France, India, Italy, Japan, Russia, South Africa, the United Kingdom, the United States of America, and the European Union. We found insufficient collaboration and coordination and misalignment among governance actors at multiple levels. In most cases, equity considerations were not prioritised while unequal consequences of COVID-19 public health measures on population groups were widely reported. COVID-19-related population health priorities mainly focused on upstream and midstream determinants of health. Our scoping review showed the stark inequities of COVID-19 public health outcomes, coupled with a prevalent lack of coherent collaboration and coordination among governance actors. Moreover, governance as an object of empirical study is still emerging when examining its intersection with global health and population health policy, programme, and research. An urgent shift is required to effectively act upon structural health determinants that include transformative and comprehensive policies for prevention, equity, resilience, and sustainable health.

Household food insecurity is prevalent in a cohort of postpartum women who registered in the Canada Prenatal Nutrition Program in Toronto.

OBJECTIVE: To assess the prevalence, severity and socio-demographic predictors of household food insecurity among vulnerable women accessing the Canada Prenatal Nutrition Program (CPNP) and to examine associations between household food insecurity and breastfeeding practices to 6 months. DESIGN: Cohort investigation pooling data from two studies which administered the 18-item Household Food Security Survey Module at 6 months postpartum and collected prospective infant feeding data at 2 weeks and 2, 4 and 6 months. Household food insecurity was classified as none, marginal, moderate or severe. Logistic regression analyses were performed to assess predictors of household food insecurity and associations between household food security (any and severity) and continued and exclusive breastfeeding. SETTING: Three Toronto sites of the CPNP, a federal initiative targeting socially and/or economically vulnerable women. PARTICIPANTS: 316 birth mothers registered prenatally in the CPNP from 2017 to 2020. RESULTS: Household food insecurity at 6 months postpartum was highly prevalent (44 %), including 11 % in the severe category. Risk of household food insecurity varied by CPNP site (P < 0·001) and was higher among multiparous participants (OR 2·08; 95 % CI 1·28, 3·39). There was no association between the prevalence or severity of food insecurity and continued or exclusive breastfeeding to 6 months postpartum in the adjusted analyses. CONCLUSIONS: Household food insecurity affected nearly half of this cohort of women accessing the CPNP. Further research is needed on household food insecurity across the national CPNP and other similar programmes, with consideration of the implications for programme design, service delivery and policy responses.

School attendance and sexual and reproductive health outcomes among adolescent girls in Kenya: a cross-sectional analysis.

BACKGROUND: Given the high burden of adverse sexual and reproductive health outcomes (SRH) and low levels of school attendance among adolescent girls in Kenya, this study sought to elucidate the association between school attendance and SRH outcomes among adolescent girls in Homa Bay and Narok counties. METHODS: This study uses baseline quantitative data from the mixed-methods evaluation of the In Their Hands (ITH) program which occurred between September to October 2018 in Homa Bay and Narok counties. In total, 1840 adolescent girls aged 15-19 years participated in the baseline survey, of which 1810 were included in the present analysis. Multivariable logistic regression models were used to assess the association between school attendance (in- versus out-of-school) and ever having sex, condom use during last sex, and ever pregnant, controlling for age, orphan status, income generation, religion, county, relationship status, and correct SRH knowledge. RESULTS: Across the 1810 participants included in our study, 61.3% were in-school and 38.7% were out-of-school. Compared to adolescent girls who were in-school, those out-of-school were more likely (AOR 5.74 95% CI 3.94, 8.46) to report ever having sex, less likely (AOR: 0.21, 95% CI 0.16, 0.31) to have used a condom during their last sexual intercourse, and more likely (AOR: 6.98, 95% CI 5.04, 9.74) to have ever been pregnant. CONCLUSIONS: School attendance plays an integral role in adolescent girls' SRH outcomes, and it is imperative that policy actors coordinate with the government and community to develop and implement initiatives that support adolescent girls' school attendance and education.

Adolescent girls in Kenya experience poor sexual and reproductive health outcomes (SRH) and have low levels of educational attainment. In this study, we aimed to examine if school attendance was associated with sexual and reproductive health outcomes among adolescent girls aged 15 to 19 years in Homa Bay and Narok counties in Kenya. The study used data from the evaluation of the In Their Hands (ITH) program which occurred between September to October 2018. A total of 1840 adolescent girls years participated in the baseline survey, of which 1810 were included in this study. We found that compared to adolescent girls in-school, those who were out-of-school were significantly more likely to report ever having sex, less likely to have used a condom during their last intercourse, and more likely to have ever been pregnant. This study found that attending school plays an important protective role in the SRH of adolescent girls. Therefore, it is important to develop and implement initiatives to support adolescent girls' school attendance, and ultimately their education attainment.

Quality of care in the context of universal health coverage: a scoping review.

INTRODUCTION: Universal health coverage (UHC) is an emerging priority of health systems worldwide and central to Sustainable Development Goal 3 (target 3.8). Critical to the achievement of UHC, is quality of care. However, current evidence suggests that quality of care is suboptimal, particularly in low- and middle-income countries. The primary objective of this scoping review was to summarize the existing conceptual and empirical literature on quality of care within the context of UHC and identify knowledge gaps. METHODS: We conducted a scoping review using the Arksey and O'Malley framework and further elaborated by Levac et al. and applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews reporting guidelines. We systematically searched MEDLINE, EMBASE, CINAHL-Plus, PAIS Index, ProQuest and PsycINFO for reviews published between 1 January 1995 and 27 September 2021. Reviews were eligible for inclusion if the article had a central focus on UHC and discussed quality of care. We did not apply any country-based restrictions. All screening, data extraction and analyses were completed by two reviewers. RESULTS: Of the 4128 database results, we included 45 studies that met the eligibility criteria, spanning multiple geographic regions. We synthesized and analysed our findings according to Kruk et al.'s conceptual framework for high-quality systems, including foundations, processes of care and quality impacts. Discussions of governance in relation to quality of care were discussed in a high number of studies. Studies that explored the efficiency of health systems and services were also highly represented in the included reviews. In contrast, we found that limited information was reported on health outcomes in relation to quality of care within the context of UHC. In addition, there was a global lack of evidence on measures of quality of care related to UHC, particularly country-specific measures and measures related to equity. CONCLUSION: There is growing evidence on the relationship between quality of care and UHC, especially related to the governance and efficiency of healthcare services and systems. However, several knowledge gaps remain, particularly related to monitoring and evaluation, including of equity. Further research, evaluation and monitoring frameworks are required to strengthen the existing evidence base to improve UHC.

Learning from intersectoral initiatives to respond to the needs of refugees, asylum seekers, and migrants without status in the context of COVID-19 in Quebec and Ontario: a qualitative multiple case study protocol.

BACKGROUND: Refugees, asylum seekers, and migrants without status experience precarious living and working conditions that disproportionately expose them to coronavirus disease 2019 (COVID-19). In the two most populous Canadian provinces (Quebec and Ontario), to reduce the vulnerability factors experienced by the most marginalized migrants, the public and community sectors engage in joint coordination efforts called intersectoral collaboration. This collaboration ensures holistic care provisioning, inclusive of psychosocial support, assistance to address food security, and educational and employment assistance. This research project explores how community and public sectors collaborated on intersectoral initiatives during the COVID-19 pandemic to support refugees, asylum seekers, and migrants without status in the cities of Montreal, Sherbrooke, and Toronto, and generates lessons for a sustainable response to the heterogeneous needs of these migrants. METHODS: This theory-informed participatory research is co-created with socioculturally diverse research partners (refugees, asylum seekers and migrants without status, employees of community organizations, and employees of public organizations). We will utilize Mirzoev and Kane's framework on health systems' responsiveness to guide the four phases of a qualitative multiple case study (a case being an intersectoral initiative). These phases will include (1) building an inventory of intersectoral initiatives developed during the pandemic, (2) organizing a deliberative workshop with representatives of the study population, community, and public sector respondents to select and validate the intersectoral initiatives, (3) interviews (n = 80) with community and public sector frontline workers and managers, municipal/regional/provincial policymakers, and employees of philanthropic foundations, and (4) focus groups (n = 80) with refugees, asylum seekers, and migrants without status. Qualitative data will be analyzed using thematic analysis. The findings will be used to develop discussion forums to spur cross-learning among service providers. DISCUSSION: This research will highlight the experiences of community and public organizations in their ability to offer responsive services for refugees, asylum seekers, and migrants without status in the context of a pandemic. We will draw lessons learnt from the promising practices developed in the context of COVID-19, to improve services beyond times of crisis. Lastly, we will reflect upon our participatory approach-particularly in relation to the engagement of refugees and asylum seekers in the governance of our research.

Evaluating the quality of research co-production: Research Quality Plus for Co-Production (RQ + 4 Co-Pro).

BACKGROUND: Co-production is an umbrella term used to describe the process of generating knowledge through partnerships between researchers and those who will use or benefit from research. Multiple advantages of research co-production have been hypothesized, and in some cases documented, in both the academic and practice record. However, there are significant gaps in understanding how to evaluate the quality of co-production. This gap in rigorous evaluation undermines the potential of both co-production and co-producers. METHODS: This research tests the relevance and utility of a novel evaluation framework: Research Quality Plus for Co-Production (RQ + 4 Co-Pro). Following a co-production approach ourselves, our team collaborated to develop study objectives, questions, analysis, and results sharing strategies. We used a dyadic field-test design to execute RQ + 4 Co-Pro evaluations amongst 18 independently recruited subject matter experts. We used standardized reporting templates and qualitative interviews to collect data from field-test participants, and thematic assessment and deliberative dialogue for analysis. Main limitations include that field-test participation included only health research projects and health researchers and this will limit perspective included in the study, and, that our own co-production team does not include all potential perspectives that may add value to this work. RESULTS: The field test surfaced strong support for the relevance and utility of RQ + 4 Co-Pro as an evaluation approach and framework. Research participants shared opportunities for fine-tuning language and criteria within the prototype version, but also, for alternative uses and users of RQ + 4 Co-Pro. All research participants suggested RQ + 4 Co-Pro offered an opportunity for improving how co-production is evaluated and advanced. This facilitated our revision and publication herein of a field-tested RQ + 4 Co-Pro Framework and Assessment Instrument. CONCLUSION: Evaluation is necessary for understanding and improving co-production, and, for ensuring co-production delivers on its promise of better health.. RQ + 4 Co-Pro provides a practical evaluation approach and framework that we invite co-producers and stewards of co-production-including the funders, publishers, and universities who increasingly encourage socially relevant research-to study, adapt, and apply.

How does informal employment affect health and health equity? Emerging gaps in research from a scoping review and modified e-Delphi survey.

INTRODUCTION: This article reports on the results from a scoping review and a modified e-Delphi survey with experts which aimed to synthesize existing knowledge and identify research gaps on the health and health equity implications of informal employment in both low- and middle-income countries (LMICs) and high-income countries (HICs). METHODS: The scoping review included peer-reviewed articles published online between January 2015 and December 2019 in English. Additionally, a modified e-Delphi survey with experts was conducted to validate our findings from the scoping review and receive feedback on additional research and policy gaps. We drew on micro- and macro-level frameworks on employment relations and health inequities developed by the Employment Conditions Knowledge Network to synthesize and analyze existing literature. RESULTS: A total of 540 articles were screened, and 57 met the eligibility criteria for this scoping review study, including 36 on micro-level research, 19 on macro-level research, and 13 on policy intervention research. Most of the included studies were conducted in LMICs while the research interest in informal work and health has increased globally. Findings from existing literature on the health and health equity implications of informal employment are mixed: informal employment does not necessarily lead to poorer health outcomes than formal employment. Although all informal workers share some fundamental vulnerabilities, including harmful working conditions and limited access to health and social protections, the related health implications vary according to the sub-groups of workers (e.g., gender) and the country context (e.g., types of welfare state or labour market). In the modified e-Delphi survey, participants showed a high level of agreement on a lack of consensus on the definition of informal employment, the usefulness of the concept of informal employment, the need for more comparative policy research, qualitative health research, and research on the intersection between gender and informal employment. CONCLUSIONS: Our results clearly identify the need for more research to further understand the various mechanisms through which informal employment affects health in different countries and for different groups of informal workers.

Probing key informants' views of health equity within the World Health Organization's Urban HEART initiative.

To date, no studies have assessed how those involved in the World Health Organization's (WHO) work understand the concept of health equity. To fill the gap, this research poses the question, "how do Urban Health Equity Assessment and Response Tool (Urban HEART) key informants understand the concept of health equity?", with Urban HEART being selected given the focus on health equity. To answer this question, this study undertakes synchronous electronic interviews with key informants to assess how they understand health equity within the context of Urban HEART. Key findings demonstrate that: (i) equity is seen as a core value and inequities were understood to be avoidable, systematic, unnecessary, and unfair; (ii) there was a questionable acceptance of need to act, given that political sensitivity arose around acknowledging inequities as "unnecessary"; (iii) despite this broader understanding of the key aspects of health inequity, the concept of health equity was seen as vague; (iv) the recognized vagueness inherent in the concept of health equity may be due to various factors including country differences; (v) how the terms "health inequity" and "health inequality" were used varied drastically; and (vi) when speaking about equity, a wide range of aspects emerged. Moving forward, it would be important to establish a shared understanding across key terms and seek clarification, prior to any global health initiatives, whether explicitly focused on health equity or not.

Early Impacts of the COVID-19 Pandemic on Public Health Systems and Practice in 3 Canadian Provinces From the Perspective of Public Health Leaders: A Qualitative Study.

CONTEXT: The COVID-19 pandemic has impacted health systems worldwide. Studies to date have largely focused on the health care system with less attention to the impact on public health systems and practice. OBJECTIVE: To describe the early impacts of COVID-19 on public health systems and practice in 3 Canadian provinces from the perspective of public health system leaders and synthesize lessons learned. DESIGN: A qualitative study using semistructured virtual interviews with public health leaders between October 2020 and April 2021. The World Health Organization's essential public health operations framework guided data collection and analysis. SETTING: This study involved the Canadian provinces of Alberta, Ontario, and Québec. These provinces were chosen for their large populations, relatively high COVID-19 burden, and variation in public health systems. PARTICIPANTS: Public health leaders from Alberta (n = 21), Ontario (n = 18), and Québec (n = 19) in organizations with a primary mandate of stewardship and/or administration of essential public health operations (total n = 58). RESULTS: We found that the COVID-19 pandemic led to intensified collaboration in public health systems and a change in workforce capacity to respond to the pandemic. This came with opportunities but also challenges of burnout and disruption of non-COVID-19 services. Information systems and digital technologies were increasingly used and there was greater proximity between public health leaders and other health system leaders. A renewed recognition for public health work was also highlighted. CONCLUSIONS: The COVID-19 pandemic impacted several aspects of public health systems in the provinces studied. Our findings can help public health leaders and policy makers identify areas for further investment (eg, intersectoral collaboration, information systems) and develop plans to address challenges (eg, disrupted services, workforce burnout) that have surfaced.

High levels of breastmilk feeding despite a low rate of exclusive breastfeeding for 6 months in a cohort of vulnerable women in Toronto, Canada.

Exclusive breastfeeding (EBF) for 6 months is a global public health goal, but measuring its achievement as a marker of population breastmilk feeding practices is insufficient. Additional measures are needed to understand variation in non-EBF practices and inform intervention priorities. We collected infant feeding data prospectively at seven time points to 6 months post-partum from a cohort of vulnerable women (n = 151) registered at two Canada Prenatal Nutrition Program sites in Toronto, Canada. Four categories of breastmilk feeding intensity were defined. Descriptive analyses included the (i) proportion of participants in each feeding category by time point, (ii) use of formula and non-formula supplements to breastmilk, (iii) proportion of participants practising EBF continuously for at least 3 months; and (iv) frequency of transitions between feeding categories. All participants initiated breastmilk feeding with 70% continuing for 6 months. Only 18% practised EBF for 6 months, but 48% did so for at least 3 continuous months. The proportion in the EBF category was highest from 2 to 4 months post-partum. Supplemental formula use was highest in the first 3 months; early introduction of solids and non-formula fluids further compromised EBF at 5 and 6 months post-partum. Most participants (75%) transitioned between categories of breastmilk feeding intensity, with 35% making two or more transitions. Our data show high levels of breastmilk provision despite a low rate of EBF for 6 months. Inclusion of similar analyses in future prospective studies is recommended to provide more nuanced reporting of breastmilk feeding practices and guide intervention designs.

Scoping review of the World Health Organization's underlying equity discourses: apparent ambiguities, inadequacy, and contradictions.

BACKGROUND AND OBJECTIVE: Given the heightened rhetorical prominence the World Health Organization has afforded to equity in the past half-century, it is important to better understand how equity has been referred to and its conceptual underpinning, which may have broader global implications. ELIGIBILITY CRITERIA: Articles were included if they met inclusion criteria - chiefly the explicit discussion of the WHO's concept of health equity, for example in terms of conceptualization and/or definitions. Articles which mentioned health equity in the context of WHO's programs, policies, and so on, but did not discuss its conceptualization or definition were excluded. SOURCES OF EVIDENCE: We focused on peer-reviewed literature by scanning Ovid MEDLINE and SCOPUS databases, and supplementing by hand-search. RESULTS: Results demonstrate the WHO has held - and continues to hold - ambiguous, inadequate, and contradictory views of equity that are rooted in different theories of social justice. CONCLUSIONS: Moving forward, the WHO should revaluate its conceptualization of equity and normative position, and align its work with Amartya Sen's Capabilities Approach, as it best encapsulates the broader views of the organization. Further empirical research is needed to assess the WHO interpretations and approaches to equity.

Breastfeeding rates are high in a prenatal community support program targeting vulnerable women and offering enhanced postnatal lactation support: a prospective cohort study.

BACKGROUND: In Canada, 91% of all mothers initiate breastfeeding, but 40-50% stop by 6 months and only 34% breastfeed exclusively for 6 months, with lower rates among socially and/or economically vulnerable women. The Canada Prenatal Nutrition Program (CPNP) aims to support breastfeeding among vulnerable women, but there is no formal framework or funding for sites to integrate proactive postnatal breastfeeding support. This research aimed to i) describe infant feeding practices among clients of one Toronto CPNP site using charitable funds to offer a lactation support program (in-home lactation consultant visits, breast pumps); ii) determine whether breastfeeding outcomes at 6 months differ based on maternal sociodemographics and food insecurity; and iii) assess utilization of the lactation support program. METHODS: Infant feeding practices were collected prospectively at 2 weeks, 2, 4 and 6 months postpartum via telephone questionnaires (n = 199). Maternal sociodemographics were collected at 2 weeks and food insecurity data at 6 months postpartum. Program monitoring records were used to determine utilization of the lactation support program. RESULTS: Ninety-one percent of participants were born outside of Canada; 55% had incomes below the Low-Income Cut-Off; and 55% reported food insecurity. All participants initiated breastfeeding, 84% continued for 6 months and 16% exclusively breastfed for 6 months. Among breastfed infants, ≥76% received vitamin D supplementation. Approximately 50% of infants were introduced to solids before 6 months. Only high school education or less and food insecurity were associated with lower breastfeeding rates. Overall, 75% of participants received at least one visit with a lactation consultant and 95% of these received a breast pump. CONCLUSIONS: This study provides initial evidence that postnatal lactation support can be delivered within a CPNP site, with high uptake by clients. While all participants initiated breastfeeding and 84% continued for 6 months, adherence to the recommended 6 months of exclusive breastfeeding was low. Further research is needed to better understand the barriers to exclusive breastfeeding and how to support this practice among vulnerable women. Study registered at clinicaltrials.gov as NCT03400605 .

The critical intersection of environmental and social justice: a commentary.

The global crises of ecological degradation and social injustice are mutually reinforcing products of the same flawed systems. Dominant human culture is morally obliged to challenge and reconstruct these systems in order to mitigate future planetary harm. In this commentary, we argue that doing so requires a critical examination of the values and narratives which underlie systems of oppression and power. We argue for the moral necessity of a socially just approach to the ecological crisis.

Artificial intelligence for good health: a scoping review of the ethics literature.

BACKGROUND: Artificial intelligence (AI) has been described as the "fourth industrial revolution" with transformative and global implications, including in healthcare, public health, and global health. AI approaches hold promise for improving health systems worldwide, as well as individual and population health outcomes. While AI may have potential for advancing health equity within and between countries, we must consider the ethical implications of its deployment in order to mitigate its potential harms, particularly for the most vulnerable. This scoping review addresses the following question: What ethical issues have been identified in relation to AI in the field of health, including from a global health perspective? METHODS: Eight electronic databases were searched for peer reviewed and grey literature published before April 2018 using the concepts of health, ethics, and AI, and their related terms. Records were independently screened by two reviewers and were included if they reported on AI in relation to health and ethics and were written in the English language. Data was charted on a piloted data charting form, and a descriptive and thematic analysis was performed. RESULTS: Upon reviewing 12,722 articles, 103 met the predetermined inclusion criteria. The literature was primarily focused on the ethics of AI in health care, particularly on carer robots, diagnostics, and precision medicine, but was largely silent on ethics of AI in public and population health. The literature highlighted a number of common ethical concerns related to privacy, trust, accountability and responsibility, and bias. Largely missing from the literature was the ethics of AI in global health, particularly in the context of low- and middle-income countries (LMICs). CONCLUSIONS: The ethical issues surrounding AI in the field of health are both vast and complex. While AI holds the potential to improve health and health systems, our analysis suggests that its introduction should be approached with cautious optimism. The dearth of literature on the ethics of AI within LMICs, as well as in public health, also points to a critical need for further research into the ethical implications of AI within both global and public health, to ensure that its development and implementation is ethical for everyone, everywhere.

Building the field of food systems research: commentary on a research funder's role.

BACKGROUND: The Food, Environment, and Health (FEH) program of the International Development Research Centre (IDRC) aims to improve the health of low- and middle-income country populations by generating evidence, innovations, and policies that reduce the health and economic burdens of preventable chronic and infectious diseases. A predominant focus of the FEH program is research related to consumer food environments that promote or enable healthy and sustainable shifts in consumption. An evaluation of the FEH program, led by the University of Toronto, provided an opportunity to analyse the approach and role of a development funder in building the field of food systems research. DISCUSSION: In this commentary, we provide an external evaluator's perspective on the IDRC's contributory role in building the field of food systems research, based on a secondary analysis of findings from a recent FEH program evaluation. We used the field-building framework outlined in Di Ruggiero et al. (Health Res Policy System, 2017) to highlight the strengths and challenges of the FEH's approach to field-building and determined that the program aligns with six of the seven features of the framework. The FEH program has enhanced support and awareness for food systems research, provided organized funding and capacity-building opportunities, multilevel activity to support research and its use, and strong scientific leadership, and set significant standards and exemplars. However, we also found that not all sociopolitical environments have fully recognized or valued food systems research and its use for policy change. CONCLUSION: The FEH program's field-building approach can be situated within the field-building framework, and it has been successful in laying the groundwork for building the field of food systems, particularly consumer food environments research. However, supportive external environments and further investments may be needed to achieve a critical mass of capacity, continue building communities of practice, and influence policy. The FEH program approach may serve as an exemplar and comparator for other research funding agencies looking to develop strategic research programming in the field of food systems research.

Vulnerable mothers' experiences breastfeeding with an enhanced community lactation support program.

The Canada Prenatal Nutrition Program (CPNP) provides a variety of health and nutrition supports to vulnerable mothers and strongly promotes breastfeeding but does not have a formal framework for postnatal lactation support. Breastfeeding duration and exclusivity rates in Canada fall well below global recommendations, particularly among socially and economically vulnerable women. We aimed to explore CPNP participant experiences with breastfeeding and with a novel community lactation support program in Toronto, Canada that included access to certified lactation consultants and an electric breast pump, if needed. Four semistructured focus groups and 21 individual interviews (n = 46 women) were conducted between September and December 2017. Data were analysed using inductive thematic analysis. Study participants reported a strong desire to breastfeed but a lack of preparation for breastfeeding-associated challenges. Three main challenges were identified by study participants: physical (e.g., pain and low milk supply), practical (e.g., cost of breastfeeding support and maternal time pressures), and breastfeeding self-efficacy (e.g., concern about milk supply and conflicting information). Mothers reported that the free lactation support helped to address breastfeeding challenges. In their view, the key element of success with the new program was the in-home visit by the lactation consultant, who was highly skilled and provided care in a non-judgmental manner. They reported this support would have been otherwise unavailable due to cost or travel logistics. This study suggests value in exploring the addition of postnatal lactation support to the well-established national CPNP as a means to improve breastfeeding duration and exclusivity among vulnerable women.

The health of workers in the global gig economy.

BACKGROUND: The "gig" economy connects consumers with contractors (or workers) through online platform businesses to perform tasks (or "gigs"). This innovation in technology provides businesses and consumers access to low-cost, on-demand labour, but gig workers' experiences are more complex. They have access to very flexible, potentially autonomous work, but also deal with challenges caused by the nature of the work, its precariousness, and their relationships with the platform businesses. Workers in the Global North and South may also experience these challenges very differently. Based on our report "Towards an Understanding of Canadian Workers in the Global Gig Economy", we present a commentary on the implications of a globalized online platform labour market on the health of gig workers in Canada and globally. MAIN BODY: Based on our scoping review of peer and grey literature, we categorized gig worker vulnerabilities in three ways: 1) occupational vulnerabilities, 2) precarity, and 3) platform-based vulnerabilities. Occupational vulnerabilities are connected to the work being performed (e.g. driving a car or computer work) and are not specific to platform labour. Precarity refers to the short-term, contingent nature of the work, characteristics that may be shared with other forms of work. Some examples of precariousness are lack of health insurance, collective bargaining, or career training and promotion. Finally, platform-based vulnerabilities are particular to the way platform labour is structured. These vulnerabilities include worker misclassification, information asymmetries, and the culture of surveillance. We suggest that, together, these vulnerabilities challenge gig workers' right to health. CONCLUSIONS: We propose that the experience of gig workers around the world must be understood in the context of neoliberalism, which has increased both the globalization and precaritization of work. While gig workers share some vulnerabilities, which have important negative consequences on their health, with other workers, the platform-specific vulnerabilities of workers require further inquiry. In particular, the specific health and overall experience of gig workers in different regions of the world - with different labour policies and sociopolitical contexts for work - must be disentangled as workers in the Global North and South experience this work very differently.