Long-term evaluation of a Canadian back pain mass media campaign.

PURPOSE: This paper evaluates the long-term impact of a Canadian mass media campaign on general public beliefs about staying active when experiencing low back pain (LBP). METHODS: Changes in beliefs about staying active during an episode of LBP were studied using telephone and web-based surveys. Logistic regression analysis was used to investigate changes in beliefs over time and the effect of exposure to campaign messaging. RESULTS: The percentage of survey respondents agreeing that they should stay active through LBP increased annually from 58.9 to ~72.0%. Respondents reporting exposure to campaign messaging were statistically significantly more likely to agree with staying active than respondents who did not report exposure to campaign messaging (adjusted OR, 95% CI = 1.96, 1.73-2.21). CONCLUSION: The mass media campaign had continued impact on public LBP beliefs over the course of 7 years. Improvements over time were associated with exposure to campaign messaging.

Epidemiology of pertussis in Alberta, Canada 2004-2015.

BACKGROUND: We describe the epidemiology of pertussis in Alberta, Canada by person, place, and time between 2004 and 2015, identify outbreak years, and examine vaccination coverage and vaccination timeliness. METHODS: We used health data from Alberta's Communicable Disease Registry System for the period of January 1, 2004 through August 31, 2015 to identify unique cases of pertussis. Unique cases were deterministically linked to data in Alberta's immunization repository and health care insurance plan registry. Population estimates and vaccination coverage were extracted from Alberta's online Interactive Health Data Application. We estimated pertussis incidence rates per 100,000 persons by year, age group, gender, and health zone. Outbreak years were identified using a one-sided cumulative sum (CUSUM) analysis by comparing annual incidence rates to baseline rates. RESULTS: Over the period, 3510 cases of pertussis were confirmed by laboratory testing or epidemiological linkage. Incidence rates per 100,000 persons were highest in 2004 (20.5), 2005 (13.6), and 2015 (10.4) for all age groups. Incidence rates were highest among the youngest age groups and decreased as age groups increased. Based on CUSUM analysis, 2008 and 2012 met the criteria for outbreak years. Vaccination coverage was over 90% among the general population, however only 61% of cases received at least one dose. About 60% of cases were diagnosed 5+ years after receiving the vaccine. Approximately 87-91% of vaccinated cases did not receive the first three vaccine doses in a timely manner. CONCLUSION: Pertussis incidence rates fluctuated over the period across all age groups. The majority of cases had no record of vaccination or were delayed in receiving vaccines. CUSUM analysis was an effective method for identifying outbreaks.

Impact of a 3-year multi-centre community-based intervention on risk factors for chronic disease and obesity among free-living adults: the Healthy Alberta Communities study.

BACKGROUND: Healthy Alberta Communities (HAC) was a 3-year community-based intervention to reduce lifestyle-related risk factors for chronic disease and obesity at a population-level. The current paper examines changes in blood pressure (BP) and anthropometric indicators within HAC communities compared to secular trends. METHODS: Between 2006 and 2009, this community-academic partnership sought to create environments supportive of healthier dietary and physical activity behaviours within four diverse communities in Alberta, Canada. Height, weight, waist and hip circumference and BP were measured among 1554 and 1808 community residents at baseline (2006) and follow-up (2009), respectively. A comparison sample was drawn from a representative national survey. Samples were stratified by age and change between pre- and post-intervention was assessed using t-tests. Changes in parameters over time between groups were compared using meta-analysis. The net difference in change in outcomes (change in intervention communities minus change in comparison group) represented the effect of the intervention. RESULTS: Adjusted systolic (SBP) and diastolic (DBP) BP declined within most age groups in HAC communities from pre- to post-intervention. The net decline in SBP was 1 mmHg in 20-39 year olds (p = 0.006) and 2 mmHg in 40-59 year olds (p = 0.001), while the net decline in DBP was 3 mmHg in 20-39 year olds (p < 0.001), 2 mmHg in 40-59 year olds (p < 0.001) and 3 mmHg in 60-79 year olds (p < 0.001). The net increase in the proportion of individuals with normal BP was 5.9 % (p < 0.001), while the net decline in the proportion of individuals with stage 1 hypertension was 4.5 % (p < 0.001). BMI and body weight were unchanged. There was a significant net increase in waist and hip circumference among 20-39 year olds within intervention communities. CONCLUSIONS: Findings suggest HAC succeeded in shifting the population distribution of BP in a leftward direction. By contrast, anthropometric parameters remained unchanged or worsened within intervention communities. Therefore, while improvements in some clinical risk factors can be achieved through relatively diffuse and shorter-term community-level environmental changes, improvements in others may require interventions of greater intensity and duration. Evaluating the success of community-based interventions based on their efficacy in changing individual-level clinical indicators may, however, underestimate their potential.

The intersection of health and wealth: association between personal bankruptcy and myocardial infarction rates in Canada.

BACKGROUND: We examined the association between personal bankruptcy filing and acute myocardial infarction (AMI) rates in Canada. METHODS: Between 2002 and 2009, aggregate and yearly bankruptcy and AMI rates were estimated for 1,155 forward sortation areas of Canada. Scatter plot and correlations were used to assess the association of the aggregate rates. Cross-lagged structural equation models were used to explore the longitudinal relationship between bankruptcy and AMI after adjustment for socio-economic factors. RESULTS: A cross-lagged structural equation model estimated that on average, an increase of 100 in bankruptcy filing count is associated with an increase of 1.5 (p = 0.02) in AMI count in the following year, and an increase of 100 in AMI count is associated with an increase of 7 (p < 0.01) in bankruptcy filing count. CONCLUSIONS: We found that regions with higher rates of AMI corresponded to those with higher levels of economic and financial stress, as indicated by personal bankruptcy rate, and vice-versa.

Multiple Sclerosis Mortality Rates in Canada, 1975-2009.

BACKGROUND: This study examined mortality due to multiple sclerosis (MS) in Canada, 1975-2009 to determine whether there has been a change in age at death relative to the general population and decrease in MS mortality rates. METHODS: Mortality rates/100,000 population for MS and all causes were calculated using data derived from Statistics Canada, age-standardized to the 2006 population. RESULTS: The average annual Canadian MS mortality rate, 1975-2009 was 1.23/100,000. Five-year rates for 1975-79, 1980-84, 1985-89, 1990-94, 1995-99, 2000-04, 2005-09 were: 1.16, 0.94, 1.01, 1.16, 1.30, 1.43, 1.33. Trend analysis showed mortality rates over the entire 35 years were stable (average annual percent change of less than one percent). The average annual 1975-2009 rates for females and males were 1.45 and 0.99. Five-year female rates were always higher than males. Regardless of gender, there was a decrease in MS mortality rates in the 0-39 age group and increases in the 60-69, 70-79, and 80+ groups over time. In contrast, there were decreases in all-cause mortality rates across each age group. The highest MS mortality rates for 1975-2009 were consistently in the 50-59 and 60-69 groups for both genders, while the highest all-cause mortality rates were in the 80+ group. CONCLUSIONS: Changes in the age distribution of MS mortality rates indicate a shift to later age at death, possibly due to improved health care. However MS patients remain disadvantaged relative to the general population and changes in age at death are not reflected in decreased mortality rates.

Racial discrimination, post-traumatic stress and prescription drug problems among Aboriginal Canadians.

OBJECTIVES: 1) To examine associations between racial discrimination and drug problems among urban-based Aboriginal adults; and 2) to determine whether these associations are best explained by symptoms of psychological stress, distress or post-traumatic stress disorder (PTSD). METHODS: Data were collected through in-person surveys with a community-based sample of Aboriginal adults (N = 372) living in a mid-sized city in western Canada in 2010. Associations were examined using bootstrapped linear regression models adjusted for confounders, with continuous prescription and illicit drug problem scores as outcomes. Mediation was examined using the cross-products of coefficients method. RESULTS: More than 80% of Aboriginal adults had experienced racial discrimination in the past year, with the majority reporting high levels in that period. Past-year discrimination was a risk factor for PTSD symptoms and prescription drug problems in models adjusted for confounders and other forms of psychological trauma. In mediation models, PTSD symptoms explained the association between discrimination and prescription drug problems; psychological stress and distress did not. PTSD symptoms also explained this association when the covariance between mediators was controlled. The results also indicate that participation in Aboriginal cultural traditions was associated with increased discrimination. CONCLUSIONS: Most efforts to address Aboriginal health inequities in Canada have focused on the role Aboriginal people play in these disparities. The current findings combine with others to call for an expanded focus. Non-Aboriginal Canadians may also play a role in the health inequities observed. The findings of this study suggest efforts to reduce discrimination experienced by Aboriginal adults in cities may reduce PTSD symptomology and prescription drug problems in these populations.

Osteoarthritis prevalence and modifiable factors: a population study.

BACKGROUND: This study's objectives were to investigate the prevalence of self-reported knee and hip osteoarthritis (OA) stratified by age and sex and to examine the association of modifiable factors with knee and hip OA prevalence. The study was conducted using randomly sampled data gathered from four communities in the province of Alberta, Canada. METHODS: A large adult population sample (N = 4733) of individuals ≥18 years were selected. Health-related information was collected through telephone interviews and community measurement clinics for which a sub-sample (N = 1808) attended. Participants self-reported OA during telephone interviews. Clinic interviews further assessed if the diagnosis was made by a health care professional. Statistical analyses compared prevalence of OA between sexes and across age categories. Associations between modifiable factors for OA and the prevalence of knee and hip OA were assessed using binary logistic regression modelling. RESULTS: Overall prevalence of self-reported OA in the total sample was 14.8 %, where 10.5 % of individuals reported having knee OA and 8.5 % reported having hip OA. Differences in prevalence were found for males and females across age categories for both knee and hip OA. In terms of modifiable factors, being obese (BMI >30 kg/m2) was significantly associated with the prevalence of knee (OR: 4.37; 95 % CI: 2.08,9.20) and hip (OR: 2.52; 95 % CI: 1.17,5.43) OA. Individuals who stand or walk a lot, but do not carry or lift things during their occupational activities were 2.0 times less likely to have hip OA (OR: 0.50; 95 % CI: 0.26,0.96). Individuals who usually lift or carry light loads or have to climb stairs or hills were 2.2 times less likely to have hip OA (OR: 0.45; 95 % CI: 0.21,0.95). The odds of having hip OA were 1.9 times lower in individuals consuming recommended or higher vitamin C intake (OR: 0.52; 95 % CI: 0.29,0.96). Significant differences in prevalence were found for both males and females across age categories. CONCLUSION: The prevalence of knee and hip OA obtained in this study is comparable to other studies. Females have greater knee OA prevalence and a greater proportion of women have mobility limitations as well as hip and knee pain; it is important to target this sub-group.

HIV counseling and testing for the prevention of mother-to-child transmission of HIV in Swaziland: a multilevel analysis.

HIV counseling and voluntary testing during antenatal care have been proven to reduce the risk of HIV transmission from mother to child, through increasing knowledge about safe behaviors, ascertaining HIV status and increasing coverage of effective antiretroviral regimens. However, it remains that, in developing countries where 95 % of mother-to-child HIV transmissions (MTCT) take place, such interventions are not widely accessible or available. Using a nationally representative cross-sectional household survey, the present study aimed to examine individual- and contextual-level influences on the receipt of HIV pre-test counseling and uptake of HIV testing during the antenatal care period in Swaziland, a country highly burdened by HIV/AIDS. The study sample was restricted to women aged 15-49 years with a live birth in the past five years preceding the survey and who received antenatal care for the most recent birth. The findings of this study indicated that only 62 % of women received pre-test counseling for the prevention of MTCT and no more than 56 % of women consented to be tested for HIV during antenatal care. The multilevel regression analysis revealed that the likelihood of receiving HIV pre-test counseling increases significantly with higher parity, education level, household wealth and antenatal visits while it is lower in areas where poverty is pervasive (OR = 0.474) and in rural regions (OR = 0.598) as well. Beyond all the significant predictors, undergoing pre-test counseling has emerged as an important determinant of HIV testing. Receiving pre-test counseling increases the odds of accepting an HIV test by 77 %. Evidence from this analysis underscores bottlenecks and challenges that persist in increasing the need for and uptake of HIV preventive and treatment services to stop new HIV infections among children.

Evaluation of antiretroviral treatment programme monitoring in Eastern Cape, South Africa.

INTRODUCTION: The provision of antiretroviral treatment (ART) for HIV infection is a key strategy in addressing the high burden of HIV/AIDS in South Africa and improving the quality and length of life for those infected. Information produced from routine monitoring is essential for evidence-based decision-making within ART programmes. An evaluation of the ART programme data system in Eastern Cape, South Africa was conducted to determine the causes of irregular reporting and to make recommendations to improve data quality. METHODS: Data audits and semi-structured interviews were performed in facilities that initiate and provide ART. Thirty-two facilities in three sub-districts were audited. RESULTS: The number of adults receiving ART was over-reported by 36.6% (P < 0.05) on the District Health Information System. The interviews of nurses and administrators revealed various factors that contributed to the inaccuracy of the data including training, staffing levels, use of registers, data verification processes, and standardization with programme partners. CONCLUSIONS: Recommendations to address the inaccuracy of ART programme data include improving knowledge translation during training of ART programme staff, ensuring the implementation of established data verification policies and procedures, rethinking the design of the programme to reduce the burden on health facilities and personnel, and standardizing information management procedures amongst the various governmental and non-governmental stakeholders. The challenges with reporting in the Eastern Cape may be shared by other South African provinces as well as other low-middle income countries that require high quality data to inform well-designed and well-implemented interventions in the fight against HIV/AIDS.

Parental concern about vaccine safety in Canadian children partially immunized at age 2: a multivariable model including system level factors.

Children who begin but do not fully complete the recommended series of childhood vaccines by 2 y of age are a much larger group than those who receive no vaccines. While parents who refuse all vaccines typically express concern about vaccine safety, it is critical to determine what influences parents of 'partially' immunized children. This case-control study examined whether parental concern about vaccine safety was responsible for partial immunization, and whether other personal or system-level factors played an important role. A random sample of parents of partially and completely immunized 2 y old children were selected from a Canadian regional immunization registry and completed a postal survey assessing various personal and system-level factors. Unadjusted odds ratios (OR) and adjusted ORs (aOR) were calculated with logistic regression. While vaccine safety concern was associated with partial immunization (OR 7.338, 95% CI 4.138-13.012), other variables were more strongly associated and reduced the strength of the relationship between concern and partial immunization in multivariable analysis (aOR 2.829, 95% CI 1.151-6.957). Other important factors included perceived disease susceptibility and severity (aOR 4.629, 95% CI 2.017-10.625), residential mobility (aOR 3.908, 95% CI 2.075-7.358), daycare use (aOR 0.310, 95% CI 0.144-0.671), number of needles administered at each visit (aOR 7.734, 95% CI 2.598-23.025) and access to a regular physician (aOR 0.219, 95% CI 0.057-0.846). While concern about vaccine safety may be addressed through educational strategies, this study suggests that additional program and policy-level strategies may positively impact immunization uptake.

The pot calling the kettle black: the extent and type of errors in a computerized immunization registry and by parent report.

BACKGROUND: Accurate classification of children's immunization status is essential for clinical care, administration and evaluation of immunization programs, and vaccine program research. Computerized immunization registries have been proposed as a valuable alternative to provider paper records or parent report, but there is a need to better understand the challenges associated with their use. This study assessed the accuracy of immunization status classification in an immunization registry as compared to parent report and determined the number and type of errors occurring in both sources. METHODS: This study was a sub-analysis of a larger study which compared the characteristics of children whose immunizations were up to date (UTD) at two years as compared to those not UTD. Children's immunization status was initially determined from a population-based immunization registry, and then compared to parent report of immunization status, as reported in a postal survey. Discrepancies between the two sources were adjudicated by review of immunization providers' hard-copy clinic records. Descriptive analyses included calculating proportions and confidence intervals for errors in classification and reporting of the type and frequency of errors. RESULTS: Among the 461 survey respondents, there were 60 discrepancies in immunization status. The majority of errors were due to parent report (n = 44), but the registry was not without fault (n = 16). Parents tended to erroneously report their child as UTD, whereas the registry was more likely to wrongly classify children as not UTD. Reasons for registry errors included failure to account for varicella disease history, variable number of doses required due to age at series initiation, and doses administered out of the region. CONCLUSIONS: These results confirm that parent report is often flawed, but also identify that registries are prone to misclassification of immunization status. Immunization program administrators and researchers need to institute measures to identify and reduce misclassification, in order for registries to play an effective role in the control of vaccine-preventable disease.

Understanding older adults' usage of community green spaces in Taipei, Taiwan.

As the world's population ages, there is an increasing need for community environments to support physical activity and social connections for older adults. This exploratory study sought to better understand older adults' usage and perceptions of community green spaces in Taipei, Taiwan, through direct observations of seven green spaces and nineteen structured interviews. Descriptive statistics from observations using the System for Observing Play and Recreation in Communities (SOPARC) confirm that older adults use Taipei's parks extensively. Our analyses of interviews support the following recommendations for age-friendly active living initiatives for older adults: make green spaces accessible to older adults; organize a variety of structured activities that appeal to older adults particularly in the morning; equip green spaces for age-appropriate physical activity; and, promote the health advantages of green spaces to older adults.

Relating built environment to physical activity: two failures to validate.

The Irvine-Minnesota Inventory (IMI) is an audit tool used to record properties of built environments. It was designed to explore the relationships between environmental features and physical activity. As published, the IMI does not provide scoring to support this use. Two papers have since been published recommending methods to form scales from IMI items. This study examined these scoring procedures in new settings. IMI data were collected in two urban settings in Alberta in 2008. Scale scores were calculated using the methods presented in previous papers and used to test whether the relationships between IMI scales and walking behaviors were consistent with previously reported results. The scales from previous work did not show expected relationships with walking behavior. The scale construction techniques from previous work were repeated but scales formed in this way showed little similarity to previous scales. The IMI has great potential to contribute to understanding relationships between built environment and physical activity. However, constructing reliable and valid scales from IMI items will require further research.

Healthy Alberta Communities: impact of a three-year community-based obesity and chronic disease prevention intervention.

OBJECTIVE: To assess the impact of a 3 year (2006-2009) community-based intervention for obesity and chronic disease prevention in four diverse "Healthy Alberta Communities" (HAC). METHODS: Targeted intervention development incorporated the ANGELO conceptual framework to help community stakeholders identify environmental determinants of obesity amenable to intervention. Several inter-related initiatives were implemented. To evaluate, we surveyed separate samples of adults in HAC communities before and after the interventions and compared responses to identical survey questions asked of adults living in Alberta in two waves of the Canadian Community Health Survey (CCHS). RESULTS: The HAC sample included 4761 (2006) and 4733 (2009) people. The comparison sample included 9775 and 9784 respondents in 2005 and 2009-10 respectively. Self-reported body mass index showed no change, and neither were there significant changes in behaviors relative to secular trends. Most significant outcomes were relevant to social conditions, specifically sense of belonging to community in the intervention communities. CONCLUSION: Health outcome indicators at the community level may not be sufficiently sensitive to capture changes which, over a relatively short term, would only be expected to be incremental, given that interventions were directed primarily to creating environmental conditions supportive of changes in behavioral outcomes rather than toward health outcome change directly.

Adjusting divergences between self-reported and measured height and weight in an adult Canadian population.

OBJECTIVE: To develop algorithm equations that could be used to adjust self-reported height and weight to elicit better estimates of actual BMI. METHODS: Linear regression analyses were performed to generate equations that could predict actual height and weight from self-reported data collected through telephone interviews on a representative sample of Canadians aged 18 years or older. RESULTS: There were systematic biases in self-reported height and weight, leading to an underestimation of BMI. The application of our calibration equations to self-reported data produced closer estimates to actual rates of overweight and obesity. DISCUSSION: We advocate the use of our correction equation whenever dealing with self-reported height and weight from telephone surveys to avoid potential distortions in estimating obesity prevalence.

Attitudes to aging mediate the relationship between older peoples' subjective health and quality of life in 20 countries.

BACKGROUND: With ever-increasing life expectancy globally, it is imperative to build knowledge of how older peoples' views of their own aging, considering their health-related circumstances, affect quality of life for practitioners and policy-makers alike. Based on our literature review, we wanted to determine whether older adults' attitudes toward their own aging would partly mediate the effect of their health satisfaction ratings upon their quality of life. Furthermore, would these attitudes mediate the relationship between health satisfaction and quality of life in the same way when we account for older adults' country of origin, and their age and gender? METHODS: This was a secondary analysis of cross-sectional survey data collected in 20 countries taking part in the 2003 WHOQOL-OLD Field study. The study sample consisted of 4593 adults whom were, on average, 72.10 years of age (range = 60 to 100 years of age); 42.8% were female. The WHOQOL-BREF measured quality of life and health satisfaction. The Attitudes to Aging Questionnaire measured participants' attitudes toward physical change, psychosocial loss, and psychological growth. All items in both questionnaires were measured on a 5-point Likert scale. Questionnaire responses were analyzed using multilevel modeling and path analysis. RESULTS: All three attitudes to aging partly mediated the relationship between health satisfaction and physical, psychological, social, environmental, and global quality of life. These partial mediations manifested in the same way across all 20 country samples, regardless of age or gender. Attitudes toward physical change were the strongest mediator of health satisfaction upon global and domain-specific quality of life, followed by psychosocial loss and psychosocial growth. CONCLUSIONS: Our study is the first cross-cultural study with a large sample to show that quality of life judgements, between 60 to 100 years of age, are a product of older men's and women's perceptions of health-related circumstances, and attitudes toward physical and psychosocial aspects of the aging self. A prospective study of the linkages between older peoples' subjective views of health and attitudes toward the aging self over time using multiple subjective measures of health is warranted. Understanding these linkages may help practitioners and policy makers consider strategies to enhance quality of life.

Illicit and prescription drug problems among urban Aboriginal adults in Canada: the role of traditional culture in protection and resilience.

Illicit and prescription drug use disorders are two to four times more prevalent among Aboriginal peoples in North America than the general population. Research suggests Aboriginal cultural participation may be protective against substance use problems in rural and remote Aboriginal communities. As Aboriginal peoples continue to urbanize rapidly around the globe, the role traditional Aboriginal beliefs and practices may play in reducing or even preventing substance use problems in cities is becoming increasingly relevant, and is the focus of the present study. Mainstream acculturation was also examined. Data were collected via in-person surveys with a community-based sample of Aboriginal adults living in a mid-sized city in western Canada (N = 381) in 2010. Associations were analysed using two sets of bootstrapped linear regression models adjusted for confounders with continuous illicit and prescription drug problem scores as outcomes. Psychological mechanisms that may explain why traditional culture is protective for Aboriginal peoples were examined using the cross-products of coefficients mediation method. The extent to which culture served as a resilience factor was examined via interaction testing. Results indicate Aboriginal enculturation was a protective factor associated with reduced 12-month illicit drug problems and 12-month prescription drug problems among Aboriginal adults in an urban setting. Increased self-esteem partially explained why cultural participation was protective. Cultural participation also promoted resilience by reducing the effects of high school incompletion on drug problems. In contrast, mainstream acculturation was not associated with illicit drug problems and served as a risk factor for prescription drug problems in this urban sample. Findings encourage the growth of programs and services that support Aboriginal peoples who strive to maintain their cultural traditions within cities, and further studies that examine how Aboriginal cultural practices and beliefs may promote and protect Aboriginal health in an urban environment.

Community Health and the Built Environment: examining place in a Canadian chronic disease prevention project.

The Community Health and the Built Environment (CHBE) project investigated the role of place in interventions for chronic disease prevention in order to identify contextual factors that may foster or inhibit intervention success. This paper presents a project model comprising objective-outsider and subjective-insider perspectives in a multi-method, community-based participatory research approach with an emphasis on knowledge exchange. The collaborative process generated valuable lessons concerning effective conduct of community-based research. The CHBE project model contributes a mechanism for investigating how place influences health behaviours and the outcomes of health promotion interventions.

Racial discrimination, post traumatic stress, and gambling problems among urban Aboriginal adults in Canada.

Little is known about risk factors for problem gambling (PG) within the rapidly growing urban Aboriginal population in North America. Racial discrimination may be an important risk factor for PG given documented associations between racism and other forms of addictive behaviour. This study examined associations between racial discrimination and problem gambling among urban Aboriginal adults, and the extent to which this link was mediated by post traumatic stress. Data were collected via in-person surveys with a community-based sample of Aboriginal adults living in a mid-sized city in western Canada (N = 381) in 2010. Results indicate more than 80 % of respondents experienced discrimination due to Aboriginal race in the past year, with the majority reporting high levels of racism in that time period. Past year racial discrimination was a risk factor for 12-month problem gambling, gambling to escape, and post traumatic stress disorder (PTSD) symptoms in bootstrapped regression models adjusted for confounders and other forms of social trauma. Elevated PTSD symptoms among those experiencing high levels of racism partially explained the association between racism and the use of gambling to escape in statistical models. These findings are the first to suggest racial discrimination may be an important social determinant of problem gambling for Aboriginal peoples. Gambling may be a coping response that some Aboriginal adults use to escape the negative emotions associated with racist experiences. Results support the development of policies to reduce racism directed at Aboriginal peoples in urban areas, and enhanced services to help Aboriginal peoples cope with racist events.

The relationship between the use of the partograph and birth outcomes at Korle-Bu teaching hospital.

OBJECTIVE: maternal mortality represents the single greatest health disparity between high and low income countries. This inequity is especially felt in low income countries in sub Saharan Africa and Southeast Asia where 99% of the global burden of maternal death is borne. A goal of MDG 5 is to reduce maternal mortality and have a skilled attendant at every birth by 2015. A critical skill is ongoing intrapartum monitoring of labour progress and maternal/fetal well-being. The WHO partograph was designed to assess these parameters. DESIGN AND SETTING: a retrospective review of charts (n=1,845) retrieved consecutively over a 2 month period in a tertiary teaching hospital in Ghana was conducted to assess the adequacy of partograph use by skilled birth attendants and the timeliness of action taken if the action line was crossed. WHO guidelines were implemented to assess the adequacy of partograph use and how this affected maternal neonatal outcomes. Further, the timeliness and type of action taken if action line was crossed was assessed. FINDINGS: partographs were adequately completed in accordance with WHO guidelines only 25.6% (472) of the time and some data appeared to be entered retrospectively. Partograph use was associated with less maternal blood loss and neonatal injuries. When the action line was crossed (464), timely action was taken only 48.7% of the time and was associated with less assisted delivery and a fewer low Apgar scores and NICU admissions. CONCLUSION: when adequately used and timely interventions taken, the partograph was an effective tool. Feasibility of partograph use requires more scrutiny; particularly identification of minimum frequency for safe monitoring and key variables as well as a better understanding of why skilled attendants have not consistently 'bought in' to partograph use. Frontline workers need access to ongoing and current education and strategically placed algorhythims.