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Helping children with depression

Peer reviewed: 
No, item is not peer reviewed.
Date created: 
2017
Abstract: 

Background: For children who develop depression, timely and effective treatments are essential — to minimize both symptoms and distress, and to help them return to healthy lives.

Methods: We used systematic review methods to identify randomized control trials (RCTs) evaluating interventions for depressed children and youth. Applying our inclusion criteria to the 99 studies identified from our searches, we accepted 14 RCTs.

Results: Cognitive-Behavioural Therapy (CBT) stood out as a robust treatment for childhood depression, whether delivered individually, in groups, or by computer. As well, the medications clomipramine, escitalopram and fluoxetine reduced symptoms but were also associated with significant side effects.  

Conclusions: Strong evidence suggests CBT is the best among the psychosocial interventions for depression and comes with no side effects. All children with depression should offered this intervention. Among the medications, the evidence is most robust for fluoxetine. Any young person prescribed an antidepressant needs regular monitoring for both benefits and side effects.

Preventing problematic substance use among youth

Peer reviewed: 
No, item is not peer reviewed.
Date created: 
2019
Abstract: 

Background: Risk and protective factors for substance use disorders do not occur equally among young people. We identify factors that influence the development of substance use disorders as well as programs with the best potential for helping young people at risk.    

Methods: We used systematic review methods to identify randomized control trials (RCTs) evaluating interventions aimed to prevent problematic substance use among at-risk youth. Applying our inclusion criteria to the 82 studies identified from our searches, we accepted six RCTs evaluating five prevention interventions.

Results: Three programs made a significant impact on substance use. CHAT reduced the negative consequences of young people’s alcohol and cannabis use. Middle School Success reduced the frequency of girls’ cannabis use. Across the two Preventure RCTs, the program reduced alcohol use and binge drinking frequency, drug use frequency and number of drugs used as well as alcohol use problems. In contrast, Brief Intervention and Strengthening Families did not have a significant impact on substance use. 

Conclusions: Even though many young people experiment with alcohol or cannabis, most do not develop problematic use. For those who are at-risk for their use escalating, there are effective interventions to curtail substance use. Moreover, by investing in effective prevention programs, unnecessary costs for young people, their families and society can be avoided.

Pregnancy Incidence and Intention after HIV Diagnosis among Women Living With HIV in Canada

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2017-07-20
Abstract: 

Background

Pregnancy incidence rates among women living with HIV (WLWH) have increased over time due to longer life expectancy, improved health status, and improved access to and HIV prevention benefits of combination antiretroviral therapy (cART). However, it is unclear whether intended or unintended pregnancies are contributing to observed increases.

Methods

We analyzed retrospective data from the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS). Kaplan-Meier methods and GEE Poisson models were used to measure cumulative incidence and incidence rate of pregnancy after HIV diagnosis overall, and by pregnancy intention. We used multivariable logistic regression models to examine independent correlates of unintended pregnancy among the most recent/current pregnancy.

Results

Of 1,165 WLWH included in this analysis, 278 (23.9%) women reported 492 pregnancies after HIV diagnosis, 60.8% of which were unintended. Unintended pregnancy incidence (24.6 per 1,000 Women-Years (WYs); 95% CI: 21.0, 28.7) was higher than intended pregnancy incidence (16.6 per 1,000 WYs; 95% CI: 13.8, 20.1) (Rate Ratio: 1.5, 95% CI: 1.2–1.8). Pregnancy incidence among WLWH who initiated cART before or during pregnancy (29.1 per 1000 WYs with 95% CI: 25.1, 33.8) was higher than among WLWH not on cART during pregnancy (11.9 per 1000 WYs; 95% CI: 9.5, 14.9) (Rate Ratio: 2.4, 95% CI: 2.0–3.0). Women with current or recent unintended pregnancy (vs. intended pregnancy) had higher adjusted odds of being single (AOR: 1.94; 95% CI: 1.10, 3.42), younger at time of conception (AOR: 0.95 per year increase, 95% CI: 0.90, 0.99), and being born in Canada (AOR: 2.76, 95% CI: 1.55, 4.92).

Conclusion

Nearly one-quarter of women reported pregnancy after HIV diagnosis, with 61% of all pregnancies reported as unintended. Integrated HIV and reproductive health care programming is required to better support WLWH to optimize pregnancy planning and outcomes and to prevent unintended pregnancy.

Document type: 
Article
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Child Mortality, Hypothalamic-Pituitary-Adrenal Axis Activity and Cellular Aging in Mothers

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2017-05-25
Abstract: 

Psychological challenges, including traumatic events, have been hypothesized to increase the age-related pace of biological aging. Here we test the hypothesis that psychological challenges can affect the pace of telomere attrition, a marker of cellular aging, using data from an ongoing longitudinal-cohort study of Kaqchikel Mayan women living in a population with a high frequency of child mortality, a traumatic life event. Specifically, we evaluate the associations between child mortality, maternal telomere length and the mothers’ hypothalamic-pituitary-adrenal axis (HPAA), or stress axis, activity. Child mortality data were collected in 2000 and 2013. HPAA activity was assessed by quantifying cortisol levels in first morning urinary specimens collected every other day for seven weeks in 2013. Telomere length (TL) was quantified using qPCR in 55 women from buccal specimens collected in 2013. Results: Shorter TL with increasing age was only observed in women who experienced child mortality (p = 0.015). Women with higher average basal cortisol (p = 0.007) and greater within-individual variation (standard deviation) in basal cortisol (p = 0.053) presented shorter TL. Non-parametric bootstrapping to estimate mediation effects suggests that HPAA activity mediates the effect of child mortality on TL. Our results are, thus, consistent with the hypothesis that traumatic events can influence cellular aging and that HPAA activity may play a mediatory role. Future large-scale longitudinal studies are necessary to confirm our results and further explore the role of the HPAA in cellular aging, as well as to advance our understanding of the underlying mechanisms involved.

Document type: 
Article
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Structural Determinants of Health among Im/Migrants in the Indoor Sex Industry: Experiences of Workers and Managers/Owners in Metropolitan Vancouver

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2017-01-31
Abstract: 

Background

Globally, im/migrant women are overrepresented in the sex industry and experience disproportionate health inequities. Despite evidence that the health impacts of migration may vary according to the timing and stage of migration (e.g., early arrival vs. long-term migration), limited evidence exists regarding social and structural determinants of health across different stages of migration, especially among im/migrants engaged in sex work. Our aim was to describe and analyze the evolving social and structural determinants of health and safety across the arrival and settlement process for im/migrants in the indoor sex industry.

Methods

We analyzed qualitative interviews conducted with 44 im/migrant sex workers and managers/owners working in indoor sex establishments (e.g., massage parlours, micro-brothels) in Metropolitan Vancouver, Canada in 2011; quantitative data from AESHA, a larger community-based cohort, were used to describe socio-demographic and social and structural characteristics of im/migrant sex workers.

Results

Based on quantitative data among 198 im/migrant workers in AESHA, 78.3% were Chinese-born, the median duration in Canada was 6 years, and most (86.4%) serviced clients in formal indoor establishments. Qualitative narratives revealed diverse pathways into sex work upon arrival to Canada, including language barriers to conventional labour markets and the higher pay and relative flexibility of sex work. Once engaged in sex work, fear associated with police raids (e.g., immigration concerns, sex work disclosure) and language barriers to sexual negotiation and health, social and legal supports posed pervasive challenges to health, safety and human rights during long-term settlement in Canada.

Conclusions

Findings highlight the critical influences of criminalization, language barriers, and stigma and discrimination related to sex work and im/migrant status in shaping occupational health and safety for im/migrants engaged in sex work. Interventions and policy reforms that emphasize human rights and occupational health are needed to promote health and wellbeing across the arrival and settlement process.

Document type: 
Article
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A Randomized Trial Examining Housing First in Congregate and Scattered Site Formats

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2017-01-11
Abstract: 

Objective

No previous experimental trials have investigated Housing First (HF) in both scattered site (SHF) and congregate (CHF) formats. We hypothesized that CHF and SHF would be associated with a greater percentage of time stably housed as well as superior health and psychosocial outcomes over 24 months compared to treatment as usual (TAU).

Methods

Inclusion criteria were homelessness, mental illness, and high need for support. Participants were randomised to SHF, CHF, or TAU. SHF consisted of market rental apartments with support provided by Assertive Community Treatment (ACT). CHF consisted of a single building with supports equivalent to ACT. TAU included existing services and supports.

Results

Of 800 people screened, 297 were randomly assigned to CHF (107), SHF (90), or TAU (100). The percentage of time in stable housing over 24 months was 26.3% in TAU (reference; 95% confidence interval (CI) = 20.5, 32.0), compared to 74.3% in CHF (95% CI = 69.3, 79.3, p<0.001) and 74.5% in SHF (95% CI = 69.2, 79.7, p<0.001). Secondary outcomes favoured CHF but not SHF compared to TAU.

Conclusion

HF in scattered and congregate formats is capable of achieving housing stability among people experiencing major mental illness and chronic homelessness. Only CHF was associated with improvement on select secondary outcomes.

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Article
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Methadone Maintenance Treatment and Mortality in People with Criminal Convictions: A Population-Based Retrospective Cohort Study from Canada

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2018-07-31
Abstract: 

Background

Individuals with criminal histories have high rates of opioid dependence and mortality. Excess mortality is largely attributable to overdose deaths. Methadone maintenance treatment (MMT) is one of the best evidence-based opioid substitution treatments (OSTs), but there is uncertainty about whether methadone treatment reduces the risk of mortality among convicted offenders over extended follow-up periods. The objective of this study was to investigate the association between adherence to MMT and overdose fatality as well as other causes of mortality.

Methods and findings

We conducted a retrospective cohort study involving linked population-level administrative data among individuals in British Columbia (BC), Canada with a history of conviction and who filled a methadone prescription between January 1, 1998 and March 31, 2015. Participants were followed from the date of first-dispensed methadone prescription until censoring (date of death or March 31, 2015). Methadone was divided into medicated (methadone was dispensed) and nonmedicated (methadone was not dispensed) periods and analysed as a time-varying exposure. Hazard ratios (HRs) with 95% CIs were estimated using multivariable Cox regression to examine mortality during the study period. All-cause and cause-specific mortality rates were compared during medicated and nonmedicated methadone periods. Participants (n = 14,530) had a mean age of 34.5 years, were 71.4% male, and had a median follow-up of 6.9 years. A total of 1,275 participants died during the observation period. The overall all-cause mortality rate was 11.2 per 1,000 person-years (PYs). Participants were significantly less likely to die from both nonexternal (adjusted HR [AHR] 0.27 [95% CI 0.23–0.33]) and external (AHR 0.41 [95% CI 0.33–0.51]) causes during medicated periods, independent of sociodemographic, criminological, and health-related factors. Death due to infectious diseases was 5 times lower (AHR 0.20 [95% CI 0.13–0.30]), and accidental poisoning (overdose) deaths were nearly 3 times lower (AHR 0.39 [95% CI 0.30–0.50]) during medicated periods. A competing risk regression demonstrated a similar pattern of results. The use of a Canadian offender population may limit generalizability of results. Furthermore, our observation period represents community-based methadone prescribing and may omit prescriptions administered during hospital separations. Therefore, the magnitude of the protective effects of methadone from nonexternal causes of death should be interpreted with caution.

Conclusions

Adherence to methadone was associated with significantly lower rates of death in a population-level cohort of Canadian convicted offenders. Achieving higher rates of adherence may reduce overdose deaths and other causes of mortality among offenders and similarly marginalized populations. Our findings warrant examination in other study centres in response to the crisis of opiate-involved deaths.

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Article
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Qualitative Analysis of the Dynamics of Policy Design and Implementation in Hospital Funding Reform

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2018-01-26
Abstract: 

Background  As in many health care systems, some Canadian jurisdictions have begun shifting away from global hospital budgets. Payment for episodes of care has begun to be implemented. Starting in 2012, the Province of Ontario implemented hospital funding reforms comprising three elements: Global Budgets; Health Based Allocation Method (HBAM); and Quality-Based Procedures (QBP). This evaluation focuses on implementation of QBPs, a procedure/diagnosis-specific funding approach involving a pre-set price per episode of care coupled with best practice clinical pathways. We examined whether or not there was consensus in understanding of the program theory underpinning QBPs and how this may have influenced full and effective implementation of this innovative funding model.

Methods  We undertook a formative evaluation of QBP implementation. We used an embedded case study method and in-depth, one-on-one, semi-structured, telephone interviews with key informants at three levels of the health care system: Designers (those who designed the QBP policy); Adoption Supporters (organizations and individuals supporting adoption of QBPs); and Hospital Implementers (those responsible for QBP implementation in hospitals). Thematic analysis involved an inductive approach, incorporating Framework analysis to generate descriptive and explanatory themes that emerged from the data.

Results  Five main findings emerged from our research: (1) Unbeknownst to most key informants, there was neither consistency nor clarity over time among QBP designers in their understanding of the original goal(s) for hospital funding reform; (2) Prior to implementation, the intended hospital funding mechanism transitioned from ABF to QBPs, but most key informants were either unaware of the transition or believe it was intentional; (3) Perception of the primary goal(s) of the policy reform continues to vary within and across all levels of key informants; (4) Four years into implementation, the QBP funding mechanism remains misunderstood; and (5) Ongoing differences in understanding of QBP goals and funding mechanism have created challenges with implementation and difficulties in measuring success.

Conclusions  Policy drift and policy layering affected both the goal and the mechanism of action of hospital funding reform. Lack of early specification in both policy goals and hospital funding mechanism exposed the reform to reactive changes that did not reflect initial intentions. Several challenges further exacerbated implementation of complex hospital funding reforms, including a prolonged implementation schedule, turnover of key staff, and inconsistent messaging over time. These factors altered the trajectory of the hospital funding reforms and created confusion amongst those responsible for implementation. Enacting changes to hospital funding policy through a process that is transparent, collaborative, and intentional may increase the likelihood of achieving intended effects.

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Article
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Measuring Sexual Relationship Power Equity among Young Women and Young Men South Africa: Implications for Gender-Transformative Programming

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2019-09-25
Abstract: 

Introduction Measures used to assess equitable relationship dynamics, including the sexual relationship power scale (SRPS) have previously been associated with lower HIV-risk among young women, and reduced perpetration of intimate partner violence among men. However, few studies describe how the SRPS has been adapted and validated for use within global youth sexual health studies. We examined gender-specific psychometric properties, reliability, and validity of a SRPS used within a South African youth-engaged cohort study.

Methods Young men and women (16–24 years) enrolled in community-based cohorts in Durban and Soweto (2014–2016) reporting a primary partner at 6-month follow-up completed a 13-item (strongly agree/agree/disagree/strongly disagree) South African adaptation of Pulerwitz’s SRPS (range 13–52, higher scores indicating greater sexual relationship power [SRP] equity). SRPS modifications were made using gender-specific exploratory factor analyses (EFAs), removing items with factor loadings <0.3. Cronbach alphas were conducted for full and modified scales by gender. Using modified scales, unadjusted and adjusted regression models examined associations between 1. relevant socio-demographic and relationship determinants and SRP equity, and 2. SRP equity and sexual relationship related outcomes. All models adjusted for education, age, site, and current employment.

Results 235 sexually-active youth (66% women, median age = 20) were included. Mean scores across all 13 scale items were 2.71 (SD 0.30) for women and 2.70 (SD 0.4) for men. Scale Cronbach’s alphas were 0.63 for women and 0.64 for men. EFAs resulted in two gender-specific single-factor SRPS. Modified SRPS Cronbach alphas increased to 0.67 for women (8-items) and 0.70 for men (9-items). After adjusting for age, site and current employment, higher education remained associated with SRP equity across genders. In adjusted models, correlates of SRP equity included primary partnerships that were age-similar (<5 years older) and <2 years in length for women and living in Soweto and younger age for men. Greater SRP equity among women was also independently associated with no recent partner violence.

Conclusions Results highlight important gender differences in SRP equity measures and associations, highlighting the critically need for future research to examine gendered constructions of SRP equity in order to accurately develop, validate and use appropriate measures within quantitative surveys.

Document type: 
Article
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Plain Language to Minimize Cognitive Load: A Social Justice Perspective

Author: 
Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2017-11-17
Abstract: 

This tutorial explores ethical implications of cognitive load theory and intersectional theory on technical and professional communication, and proposes plain language as an ethical imperative to redress social inequities. Key concepts: When the cognitive load of a learning task is too high and overwhelms working memory, learning is impaired. The greater stress and mental burden that marginalized populations experience can leave less working memory available for reading and learning. Using plain language to reduce cognitive load can be considered a political act that increases marginalized populations' opportunities to understand. Key lessons: 1. Consider whether marginalized populations are part of your audience. 2. Using personas to represent those populations, audit their mental burden to exercise cognitive empathy. 3. Consider reducing cognitive load via plain language an ethical imperative. Implications for practice: Assessing the presence and absence of specific marginalized groups is iterative and takes practice, but developing plain-language communications that accommodate these audiences reduces cognitive load for all readers. And although personas are useful for developing cognitive empathy, nothing replaces user testing in determining your communication's effectiveness.

Document type: 
Article
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