Developing an AI Tool to Derive Social Determinants of Health for Primary Care Patients: Qualitative Findings From a Codesign Workshop.

PURPOSE: Information about social determinants of health (SDOH) is essential for primary care clinicians in the delivery of equitable, comprehensive care, as well as for program planning and resource allocation. SDOH are rarely captured consistently in clinical settings, however. Artificial intelligence (AI) could potentially fill these data gaps, but it needs to be designed collaboratively and thoughtfully. We report on a codesign process with primary care clinicians to understand how an AI tool could be developed, implemented, and used in practice. METHODS: We conducted semistructured, 50-minute workshops with a large urban family health team in Toronto, Ontario, Canada asking their feedback on a proposed AI-based tool used to derive patient SDOH from electronic health record data. An inductive thematic analysis was used to describe participants' perspectives regarding the implementation and use of the proposed tool. RESULTS: Fifteen participants contributed across 4 workshops. Most patient SDOH information was not available or was difficult to find in their electronic health record. Discussions focused on 3 areas related to the implementation and use of an AI tool to derive social data: people, process, and technology. Participants recommended starting with 1 or 2 social determinants (income and housing were suggested as priorities) and emphasized the need for adequate resources, staff, and training materials. They noted many challenges, including how to discuss the use of AI with patients and how to confirm their social needs identified by the AI tool. CONCLUSIONS: Our codesign experience provides guidance from end users on the appropriate and meaningful design and implementation of an AI-based tool for social data in primary care.

Addressing Social Determinants of Health in Family Medicine Practices.

Primary care practices are under pressure to address patients' social determinants of health (SDOH). However, the extent to which these practices have this ability remains unknown. The objective of this study was to examine the association between physician, practice, and community characteristics and the ability of family medicine practices to address patients' SDOH. This cross-sectional study used data from the American Board of Family Medicine Continuing Certification Questionnaire from 2017 to 2019, with a 100% response rate. Respondents rated their practice's ability to address SDOH, which was dichotomized as high or low. Sequential multivariate logistic regression determined the association of the reported ability to address SDOH with physician, practice, and community characteristics. Among 19,300 respondents, 55.6% reported a high ability to address patients' SDOH. Across models controlling for different groups of variables, characteristics persistently positively associated with ability to address SDOH included employment at a federally qualified health center (Odds Ratios [OR] = 2.111-3.012), federally funded clinic (OR = 1.999-2.897), managed care organization (OR = 2.038-2.303), and working collaboratively with a social worker (OR = 2.000-2.523) or care coordinator (OR = 1.482-1.681). Characteristics persistently negatively associated with the ability to address SDOH were practicing at an independently owned (OR = 0.726-0.812) or small practice (OR = 0.512-0.863). While results varied across models, these findings are important for developing evidence-based policies and recommendations for resource sharing and allocation in clinics and communities. Ensuring availability and access to allied health professionals and community resources may be key components in Family Medicine clinics addressing SDOH.

Relationship between the presence of primary care physicians and health-related quality of life.

Background: The supply of primary care physicians is associated with better health outcomes and a lower total cost of health services. However, the effect of the presence or absence of primary care physicians on health-related quality of life (QOL) is unknown. We comparatively investigated the health-related QOL of ordinary citizens according to the presence or absence of a primary care physician. Methods: We conducted an observational cross-sectional study using a propensity score analysis. A questionnaire on health-related QOL (SF-36v2, age, gender, presence or absence of a primary care physician, and chronic disease status) was mailed to 2200 individuals identified through stratified random sampling. We used propensity scores to compensate for covariates and analyzed three component SF-36 summary scores and subscale scores of the "primary care physician" and "no primary care physician" groups. Results: Valid responses were received from 1095 individuals (49.8%). The "primary care physician group" comprised 653 individuals (59.6%). The physical health component scores of the "primary care physician group" were significantly lower than those of the "no primary care physician group," and the "mental health component" scores were significantly higher (p = 0.032, p = 0.009). For the subscales, scores for "vitality" and "mental health" were significantly higher in the "primary care physician group" (p = 0.014, p = 0.018). Conclusions: Patients who had a primary care physician with whom they could comfortably consult at any time had a high mental health component score, and low physical health component score in the health-related QOL.

Describing the Health Status of Women Experiencing Violence or Abuse: An Observational Study Using Claims Data.

INTRODUCTION: Violence against women (VAW) can result in long-term and varied sequela for survivors, making it difficult to evaluate healthcare intervention. This study seeks to improve understanding of the healthcare experiences of women survivors prior to a violence-related diagnosis, allowing healthcare systems to better design strategies to meet the needs of this population. METHODS: Using population-based data from 2016 to 2019, this cross-sectional observational study presents healthcare spending, utilization, and diagnostic patterns of privately insured women, age 18 or older, in the 10-months prior to an episode of care for a documented experience of violence (DEV). RESULTS: Of 12 624 764 women meeting enrollment criteria, 10 980 women had DEV. This group had higher general medical complexity, despite being 10 years younger than the comparison group (mean age 32.7 vs 43.5). These relationships held up when comparing participants in each cohort by age. Additional key findings including higher numbers of medical visits across clinical settings and higher total cost ($10 138-$4585). CONCLUSIONS: The study utilized population-based data, to describe specific areas of health and medical cost for women with DEV. Increased medical complexity and utilization patterns among survivors broaden the understanding of the health profiles and healthcare touchpoints of survivors to inform and optimize strategies for medical system engagement and resource allocation for this public health crisis.

Cumulative protective factors are associated with decreased risk for prescription opioid misuse among high school students.

BACKGROUND: Multiple protective factors at the individual and environmental levels have been associated with prescription opioid misuse (POM) among adolescents. The literature may benefit by extending this research to consider the association between cumulative protective factors and current (ie, within the past 30 days) POM. METHODS: The 2017 Virginia Youth Survey (part of the Youth Risk Behaviour Surveillance System) (N=3697) was used to investigate recent POM and the presence of individual and cumulative protective factors among high school students. Youth were asked to indicate whether they had engaged POM within the past 30 days. A set of protective factors representing youths' internal assets (eg, aspirational plans for education) and external resources (eg, family meals, safe school environment) were investigated as predictors of current POM, followed by testing of a cumulative protective factor score. Logistic regression models estimated ORs and 95% CIs. RESULTS: When including demographics and risk factors in the model, none of the individual protective factors were significantly associated with current POM. Alternatively, the cumulative protective factor score was significantly associated with a decrease in the odds of current POM. CONCLUSIONS: The cumulative protective factor score was significantly associated with a decrease in the odds of current POM among high school students in Virginia. Programmes designed to provide multiple forms of support may be effective strategies for preventing current POM.

Relationship between loneliness, social isolation and modifiable risk factors for cardiovascular disease: a latent class analysis.

BACKGROUND: There is growing research into the effects of psychological and social factors such as loneliness and isolation on cardiovascular disease (CVD). However, it is unclear whether individuals with particular clusters of CVD risk factors are more strongly affected by loneliness and isolation. This study aimed to identify latent clustering of modifiable risk factors among adults aged 50+ and explore the relationship between loneliness, social isolation and risk factor patterns. METHODS: Data from 8218 adults of English Longitudinal Study of Ageing were used in latent class analyses to identify latent classes of cardiovascular risk factors and predictors of class membership. RESULTS: There were four latent classes: low-risk (30.2%), high-risk (15.0%), clinical-risk (42.6%) and lifestyle-risk (12.2%) classes. Loneliness was associated with a greater risk of being in the high-risk class (relative risk ratio (RRR) 2.40, 95% CI 2.40 to 1.96) and lifestyle-risk class (RRR 1.36, 95% CI 1.10 to 1.67) and a lower risk of being in the clinical-risk class (RRR 0.84, 95% CI 0.72 to 0.98) relative to the low-risk class. Social disengagement, living alone and low social contact were also differentially associated with latent class memberships. CONCLUSION: These findings supplement our existing knowledge of modifiable risk factors for CVD by showing how risk factors cluster together and how the risk patterns are related to social factors, offering important implications for clinical practice and preventive interventions.

Under capital's thumb: longitudinal associations between relational social class and health.

BACKGROUND: We used a relational social-class measure based on property ownership and managerial authority to analyse the longitudinal relationships between class, self-rated health (SRH) and mental illness. To our knowledge, this is the first study using a relational social-class measure to evaluate these relationships longitudinally. METHODS: Using Panel Study of Income Dynamics data from 1984 to 2017, we first assigned respondents aged 25-64 to the not in the labour force (NILF), worker, manager, petit bourgeois (PB) or capitalist classes based on business ownership, managerial authority and employment status. Next, using Cox models, we estimated the confounder-adjusted associations between 2-year-lagged class and incidence of poor/fair SRH and serious mental illness. We also tested whether the associations varied by gender, whether they persisted after more-fully adjusting for traditional socioeconomic-status measures (education and income) and how they changed temporally. RESULTS: We identified large inequities in poor/fair SRH. NILFs had the greatest hazard, followed by workers, PBs, managers and capitalists. We also identified large inequities in serious mental illness; NILFs and workers had the greatest hazard, while capitalists had the lowest. Class inequities in both outcomes lessened but remained considerable after confounder and socioeconomic-status adjustment, and we found some evidence that the class-SRH relationship varied by gender, as being NILF was more harmful among men than women. Additionally, class inequities in the outcomes decreased somewhat over time. CONCLUSION: We identified substantial class inequities in SRH and mental illness. Our findings demonstrate the importance of using relational social-class measures to deepen understanding of health inequities' root causes.

Sociodemographic correlates of eating disorder subtypes among men and women in France, with a focus on age.

BACKGROUND: On the population level, the association of age and other sociodemographic factors with eating disorders (ED) is unclear. METHODS: We used cross-sectional data from the French general population-based NutriNet-Santé e-cohort (n=49 603 adults; 76.3% women; mean age=50.4±14.6 years). ED were evaluated in 2014 with the 5-item SCOFF screening questionnaire and the Expali algorithmic tool. Likely cases of restrictive, bulimic, hyperphagic and other ED were the dependent variables. Age, marital status, education, occupation, physical activity and smoking were the independent variables. Associations were estimated via gender-stratified multivariable polytomous logistic regression. RESULTS: Among women, age displayed inverse linear associations with both restrictive and bulimic ED, underscoring 18-25 years as the most vulnerable period (adjusted OR=3.37, 95% CI: 2.24 to 5.08 for restrictive ED; adjusted OR=2.98, 95% CI: 2.37 to 3.74 for bulimic ED, respectively). A similar association was observed in men regarding bulimic ED. In women, age was not associated with hyperphagic ED for which living alone, low education, low physical activity, being a homemaker/disabled/unemployed/retired, a manual worker or a former/current smoker had increased importance. In men, 18-39 years emerged as the least vulnerable period regarding hyperphagic ED (adjusted OR=0.74, 95% CI: 0.56 to 0.99). Across gender, having postsecondary education had significant inverse associations with all except restrictive ED, whereas being a student had a significant positive association with restrictive ED. CONCLUSIONS: The findings support gender-specific associations of age with four ED subtypes and could inform future prevention initiatives targeting specific ED among specific age groups. TRIAL REGISTRATION NUMBER: NCT03335644; Pre-results.

Association of nursery and early school attendance with later health behaviours, biomedical risk factors, and mortality: evidence from four decades of follow-up of participants in the 1958 birth cohort study.

BACKGROUND: Although early life education for improved long-term health and the amelioration of socioeconomically generated inequalities in chronic disease is advocated in influential policy statements, the evidence base is very modest. AIMS: To address this dearth of evidence using data from a representative UK national birth cohort study. METHODS: The analytical sample comprised men and women in the 1958 birth cohort study with prospectively gathered data on attendance at nursery or primary school before the age of 5 years who had gone on to participate in social survey at 42 years (n=11 374), or a biomedical survey at 44/5 years of age (n=9210), or had data on vital status from 18 to 55 years (n=17 657). RESULTS: Relative to study members who had not attended nursery, in those who had, there was in fact a higher prevalence of smoking and high alcohol intake in middle age. Conversely, nursery attenders had more favourable levels of lung function and systolic blood pressure in middle age. This apparent association between nursery attendance and lower systolic blood pressure was confined to study members from more deprived social backgrounds of origin (P value for interaction 0.030). There was no apparent link between early school attendance and any behavioural or biological risk factor. Neither nursery nor early school attendance was clearly related to mortality risk. CONCLUSIONS: We found no clear evidence for an association of either attendance at nursery or primary school before the age of 5 years and health outcomes around four decades later.

Voces actuales en el fenómeno de pasantes de drogas ilícitas en Colombia / Current voices in the phenomenon of illicit drug couriers in Colombia / Vozes atuais no fenômeno dos passantes de drogas ilícitas na Colômbia

Resumen Este documento se deriva del análisis realizado a las narrativas de los pasantes de drogas ilícitas denominados popularmente como "mulas"; de manera especial, resalta su mirada localizada sobre el fenómeno del tráfico ilegal de drogas en Colombia. El escrito tiene como objetivo: primero, caracterizar la multiplicidad de conceptos que se utilizan para describir este fenómeno y proponer una definición que abarque diferentes acepciones, y segundo, presentar categorías conceptuales que se desprenden de las narrativas de los pasantes de drogas. Como metodología se utilizó el análisis de contenido, para describir, sistematizar y analizar los testimonios voluntarios de 42 personas imputadas y condenadas como pasantes de drogas ilícitas en Colombia. Esta investigación argumenta que uno de los elementos para entender el fenómeno de los pasantes de drogas ilícitas y su experiencia es su condición de vulnerabilidad. Por un lado, los pasantes ocupan un lugar periférico en las organizaciones narcotraficantes; por otro, son altamente vulnerables al sistema socio-técnico establecido por el Estado para prevenir el transporte de drogas ilícitas. Este estudio muestra que las narrativas de los pasantes de drogas se pueden categorizar en cuatro dicotomías, que sirven como elementos retóricos para la ruptura del binario legalidad/ilegalidad.

Abstract This document derives from the analysis carried out on the accounts and narratives of illegal drug carriers popularly known as "pasantes", more generally as mules, and in a special way, it stresses the view focused on the phenomenon of illicit drug trafficking in Colombia. The article's objectives are: firstly to characterize the multiplicity of concepts used to describe this phenomenon and offer a definition capable of encompassing different meanings, and secondly to show conceptual categories stemming from the illicit drug accounts. The methodology used content analysis to describe, systematize and analyze the voluntary testimonies of 42 individuals accused and convicted in Colombia as illegal drug carriers. In this research it is argued that one of the various elements helping understand the mule phenomenon and their experience is their vulnerability conditions. On the one hand, they have a peripheral place in drug trafficker's organizations. On the other hand, their vulnerability to the social-technical system established by the State to prevent illicit-drug transportation is very high. . This study shows that the mule's narratives can be categorized into four dichotomies serving as rhetoric elements for the breaking of the legality/illegality binary.

Resumo Este documento é derivado da análise feita às narrativas dos passantes de drogas ilícitas chamadas popularmente "mulas"; da maneira especial, destaca sua olhada localizada no fenômeno do tráfego ilegal de drogas está na Colômbia. O escrito tem como o objetivo: primeiramente, caracterizar a multiplicidade dos conceitos que são usados descrever este fenômeno e propor uma definição que abrange diferentes acepções, e segundo, apresentar categorias conceituais que se desprendem das narrativas dos passantes das drogas. Enquanto a metodologia foi usada a análise de conteúdo, para descrever, sistematizar e analisar os testemunhos voluntários de 42 pessoas imputadas e condenadas como passantes de drogas ilícitas na Colômbia. Esta investigação argumenta que um dos elementos para compreender o fenômeno dos passantes de drogas ilícitas e de sua experiência é sua condição da vulnerabilidade. De um lado, os passantes ocupam um lugar periférico nas organizações narcotraficantes; por outro, são altamente vulneráveis ao sistema sócio-técnico estabelecido pelo Estado para impedir o transporte com drogas ilícitas. Este estudo amostra que as narrativas dos passantes das drogas podem se categorizar em quatro dicotomias, que funcionam como elementos retóricos para a ruptura do binário legalidade/ilegalidade.

Community vulnerability and symptoms of acute respiratory infection among preschool age children in the Democratic Republic of Congo, Malawi and Nigeria: evidence from Demographic and Health Surveys.

BACKGROUND: As a consequence of the global spread of HIV infection in sub-Saharan Africa, the impact of the AIDS pandemic has contributed to more than 40 million orphaned and vulnerable children (OVC) in sub-Saharan Africa. The children's vulnerability is hypothesised to increase the risk of acute respiratory infection (ARI), which remains one of the major infectious causes of child mortality and morbidity in this region. This study examines the linkages between children's vulnerability and ARI symptoms, with a focus on the individual as well as community levels. METHODS: Using population-based Demographic and Health Surveys of preschool age children (0-59 months old) from the Democratic Republic of Congo (n=7755), Malawi (n=17 559) and Nigeria (n=28 049), multilevel logistic models were conducted to establish the relationships between ARI symptoms among OVC and community-level vulnerability, adjusting for children's and household characteristics and a season variation. RESULTS: The child's OVC status and community vulnerability were shown to be significantly associated with an increased likelihood of the child suffering from ARI symptoms in three countries. In contrast, the relationship between ARI symptoms and some selected variables associated with community development was not consistent across the 3 countries. CONCLUSIONS: Community vulnerability demonstrates a significant influence on whether or not the child exhibits ARI symptoms. Being OVC contributes to differences in children's likelihood of ARI symptoms between communities. In addition to industrial pollution, specific components, such as community development, vary in their associations with the ARI symptoms across different countries. The large differences in childhood ARI symptoms across countries suggests that policies aimed at promoting child health need to be context specific.

Health literacy and the use of healthcare services in Belgium.

BACKGROUND: Most of the existing studies demonstrating the relationships between health literacy and health service use have been conducted outside Europe and cannot be generalised to European healthcare systems. Moreover, the majority of studies measure healthcare use via self-reports. This study investigated whether health literacy is related to the use of health services measured objectively via patient records in a European country. METHODS: 9617 members of a Belgian health insurance fund (59% females, ages 18-88 years, mean age 55.8 years) completed an online questionnaire including the 16-item European Health Literacy Survey Questionnaire (HLS-EU-Q) and agreed to have their responses linked to the insurance fund's health service use records. A two-part model approach was used to assess the association between health literacy and the use of healthcare services and the costs related, adjusting for personal and behavioural characteristics. RESULTS: Low health literacy is associated with more admissions to 1-day clinics, general practitioner (GP) home consultations, psychiatrist consultations and ambulance transports, and with longer stays in general hospitals. Associations with psychiatric hospitalisations and specialist consultations are also found but are not significant when correction for multiple comparisons is applied. In contrast, health literacy is not significantly related to the number of GP consultations, admissions to 1-day surgical clinics or emergency consultations. The relationship between health literacy and medication use is inconsistent. CONCLUSION: The results partly confirm that low health literacy is associated with greater use of healthcare services, and especially of more specialised services. Improving the health literacy of the population can be an effective strategy to promote a more (cost)-effective use of the healthcare services and thus contribute to population health.

Are adolescent orphans more likely to be HIV-positive? A pooled data analyses across 19 countries in sub-Saharan Africa.

BACKGROUND: Despite extensive resources and numerous programmes directed towards orphans in sub-Saharan Africa, evidence of their disadvantage is surprisingly limited. While initial research suggests that orphans are at greater risk of being HIV-positive, the evidence is limited in geographic scope. METHODS: To rigorously test disparities in HIV prevalence related to orphanhood and parental HIV status in sub-Saharan Africa, we used Demographic and Health Survey data from 19 countries in sub-Saharan Africa. We conducted pooled multilevel logistic regression on adolescents aged 15-17 years with HIV test results (N=22 837 girls and 20 452 boys). RESULTS: Regardless of their gender, orphans who lost their mother, lost both parents or had an HIV-infected mother were two to three times more likely to test positive for HIV infection (ORs 1.87-3.17). The loss of a father was also associated with HIV infection risk for females, but of slightly lower magnitude (OR 1.63). CONCLUSIONS: To better inform interventions, future research is needed to quantify the relative contribution of perinatally-acquired and sexually-acquired infections, and to investigate the specific mechanisms that may account for disparities in the latter. In the meantime, programmes serving HIV-infect adults as well as those serving orphaned and vulnerable children should invest in family-based HIV testing in order to identify adolescents in need of treatment.

A novel housing-based socioeconomic measure predicts hospitalisation and multiple chronic conditions in a community population.

BACKGROUND: Socioeconomic status (SES) is an important predictor for outcomes of chronic diseases. However, it is often unavailable in clinical data. We sought to determine whether an individual housing-based SES index termed HOUSES can influence the likelihood of multiple chronic conditions (MCC) and hospitalisation in a community population. METHODS: Participants were residents of Olmsted County, Minnesota, aged >18 years, who were enrolled in Mayo Clinic Biobank on 31 December 2010, with follow-up until 31 December 2011. Primary outcome was all-cause hospitalisation over 1 calendar-year. Secondary outcome was MCC determined through a Minnesota Medical Tiering score. A logistic regression model was used to assess the association of HOUSES with the Minnesota tiering score. With adjustment for age, sex and MCC, the association of HOUSES with hospitalisation risk was tested using the Cox proportional hazards model. RESULTS: Eligible patients totalled 6402 persons (median age, 57 years; 25th-75th quartiles, 45-68 years). The lowest quartile of HOUSES was associated with a higher Minnesota tiering score after adjustment for age and sex (OR (95% CI) 2.4 (2.0 to 3.1)) when compared with the highest HOUSES quartile. Patients in the lowest HOUSES quartile had higher risk of all-cause hospitalisation (age, sex, MCC-adjusted HR (95% CI) 1.53 (1.18 to 1.98)) compared with those in the highest quartile. CONCLUSIONS: Low SES, as assessed by HOUSES, was associated with increased risk of hospitalisation and greater MCC health burden. HOUSES may be a clinically useful surrogate for SES to assess risk stratification for patient care and clinical research.

Evictions and suicide: a follow-up study of almost 22,000 Swedish households in the wake of the global financial crisis.

BACKGROUND: Millions of families across the world are evicted every year. However, very little is known about the impact that eviction has on their lives. This lack of knowledge is also starting to be noticed within the suicidological literature, and prominent scholars are arguing that there is an urgent need to explore the extent to which suicides may be considered a plausible consequence of being faced with eviction. METHOD: The present study's sample consists of all persons served with an application for execution of an eviction order during 2009-2012. This group is compared to a random 10% sample of the general Swedish population, ages 16 years and over. The analysis is based on penalised maximum likelihood logistic regressions. RESULTS: Those who had lost their legal right to their dwellings and for whom the landlord had applied for the eviction to be executed were approximately four times more likely to commit suicide than those who had not been exposed to this experience (OR=4.42), controlling for several demographic, socioeconomic and mental health conditions prior to the date of the judicial decision. CONCLUSIONS: Home evictions have a significant and detrimental impact on individuals' risk of committing suicide, even when several other well-known suicidogenic risk factors are controlled for. Our results reinforce the importance of ongoing attempts to remove the issue of evictions from its status as a hidden and neglected social problem.

Primary care physician insights into a typology of the complex patient in primary care.

PURPOSE: Primary care physicians play unique roles caring for complex patients, often acting as the hub for their care and coordinating care among specialists. To inform the clinical application of new models of care for complex patients, we sought to understand how these physicians conceptualize patient complexity and to develop a corresponding typology. METHODS: We conducted qualitative in-depth interviews with internal medicine primary care physicians from 5 clinics associated with a university hospital and a community health hospital. We used systematic nonprobabilistic sampling to achieve an even distribution of sex, years in practice, and type of practice. The interviews were analyzed using a team-based participatory general inductive approach. RESULTS: The 15 physicians in this study endorsed a multidimensional concept of patient complexity. The physicians perceived patients to be complex if they had an exacerbating factor-a medical illness, mental illness, socioeconomic challenge, or behavior or trait (or some combination thereof)-that complicated care for chronic medical illnesses. CONCLUSION: This perspective of primary care physicians caring for complex patients can help refine models of complexity to design interventions or models of care that improve outcomes for these patients.

Factors associated with pregnancy among adolescents in low-income and lower middle-income countries: a systematic review.

BACKGROUND: Pregnancy-related morbidity and mortality is much more prevalent among adolescents than adults. Adolescent pregnancy is therefore a significant public health problem. Most births to adolescents (95%) occur in resource-constrained countries. OBJECTIVE: The aim was to review the available evidence about the factors associated with adolescent pregnancy in low-income and lower middle-income countries. METHODS: The review used the PRISMA procedure of identification, screening and eligibility of publications. PubMed, OVID MEDLINE, SCOPUS and CINAHL plus were searched systematically for peer-reviewed English language papers published before December 2013. FINDINGS: In total, 2005 articles were identified and 12 met the inclusion criteria and were reviewed. Despite varied methods, there was substantial consistency in the findings. Limited education, low socioeconomic position, insufficient access to and non-use of contraception were consistently found to be risks for pregnancy among adolescents. There was some evidence that early marriage, living in a rural area, early sexual initiation, belonging to an ethnic and religious minority group also increased the risk of adolescent pregnancy. Higher education, access to income-generating work and family support were found to protect against adolescent pregnancy. CONCLUSIONS: In resource-constrained countries, as in well-resourced countries, low socioeconomic position appears to increase the risk of pregnancy among adolescents. Additional risks specific to these contexts include cultural traditions such as early marriage and inaccurate beliefs about contraception. It is unlikely that strategies to reduce pregnancy among women aged less than 20 years will be effective unless these are addressed directly.

The relationship between social, policy and physical venue features and social cohesion on condom use for pregnancy prevention among sex workers: a safer indoor work environment scale.

BACKGROUND: This study aims to report on a newly developed Safer Indoor Work Environmental Scale that characterises the social, policy and physical features of indoor venues and social cohesion; and using this scale, longitudinally evaluate the association between these features on sex workers' (SWs') condom use for pregnancy prevention. METHODS: Drawing on a prospective open cohort of female SWs working in indoor venues, a newly developed Safer Indoor Work Environment Scale was used to build six multivariable models with generalised estimating equations (GEE), to determine the independent effects of social, policy and physical venue-based features and social cohesion on condom use. RESULTS: Of 588 indoor SWs, 63.6% used condoms for pregnancy prevention in the last month. In multivariable GEE analysis, the following venue-based features were significantly correlated with barrier contraceptive use for pregnancy prevention: managerial practices and venue safety policies (adjusted OR (AOR)=1.09; 95% CI 1.01 to 1.17), access to sexual and reproductive health services/supplies (AOR=1.10; 95% CI 1.00 to 1.20), access to drug harm reduction (AOR=1.13; 95% CI 1.01 to 1.28) and social cohesion among workers (AOR=1.05; 95% CI 1.03 to 1.07). Access to security features was marginally associated with condom use (AOR=1.13; 95% CI 0.99 to 1.29). CONCLUSIONS: The findings of the current study highlight how work environment and social cohesion among SWs are related to improved condom use. Given global calls for the decriminalisation of sex work, and potential legislative reforms in Canada, this study points to the critical need for new institutional arrangements (eg, legal and regulatory frameworks; labour standards) to support safer sex workplaces.