Cardiovascular disease (CVD) is increasing in Sub-Saharan Africa (SSA). Overweight/obesity and tobacco use are modifiable CVD risk factors, however literature about the spatiotemporal dynamics of these risk factors in the region at subnational or local scales is lacking. We describe the spatiotemporal trends of overweight/obesity and tobacco use at subnational levels over a 13-year period (2003 to 2016) in five East African nations.Cross-sectional, nationally representative Demographic and Health Surveys (DHS) were used to explore the subnational spatiotemporal patterns of overweight/obesity and tobacco use in Burundi, Kenya, Rwanda, Tanzania, and Uganda, five East African Community (EAC) nations with unique cultural landscapes influencing CVD risk factors. Adaptive kernel density estimation and logistic regression were used to determine the spatial distribution and change over time of CVD risk factors on a subnational and subpopulation  scale.Subnational analysis shows that regional and national level analysis masks important trends in CVD risk factor prevalence. Overweight/obesity and tobacco use trends were not similar: overweight/obesity prevalence increased across most nations included in the study and the inverse was true for tobacco use prevalence. Urban populations in each nation were more likely to be overweight/obese than rural populations, but the magnitude of difference varied widely between nations. Spatial analysis revealed that although the prevalence of overweight/obesity increased over time in both urban and rural populations, the rate of change differed between urban and rural areas. Rural populations were more likely to use tobacco than urban populations, though the likelihood of use varied substantially between nations. Additionally, spatial analysis showed that tobacco use was not evenly distributed across the landscape: tobacco use increased in and around major cities and urban centers but declined in rural areas.We highlight the importance of de-homogenizing CVD risk factor research in SSA. Studies of national or regional prevalence trends mask important information about subpopulation and place-specific behavior and drivers of risk factor prevalence. Spatially explicit studies should be considered as a vital tool to understand local drivers of health, disease, and associated risk factor trends, especially in highly diverse yet low-resourced, marginalized, and often homogenized regions. Cardiovascular disease (CVD) is a significant global health issue, contributing to high mortality, disability, and reduced quality of life. While high-income countries (HICs) have experienced a decline in CVD mortality since 2000, the burden of CVD is increasingly shifting to low- and middle-income countries (LMICs) . In 2019CVD is a continuum, starting with behavioral risk factors, such as tobacco use and unhealthy diet choices that lead to CVD risk conditions, such as hypertension and overweight/obesity, and culminate with ischemic heart disease or stroke . EffectiThe LMICs that constitute sub-Saharan Africa (SSA) bear a significant burden of global CVD morbidity and mortality, where the onset of CVD and associated mortality occur at younger ages , 17. UrbOverweight/obesity and tobacco use are significant and modifiable CVD risk factors in SSA , 23, 24 This study addresses these knowledge gaps by analyzing cross-sectional nationally representative survey data from five East African countries over a 13-year period. The study employs regression and adaptive kernel density estimation methods to explore the subnational spatial and temporal patterns of overweight/obesity and tobacco use in an East African context. By going beyond administrative boundaries and creating continuous surfaces, the study captures local variations in disease distribution and trends. The five East African Community (EAC) nations—Burundi, Kenya, Rwanda, Tanzania, and Uganda—were selected to showcase the subnational and subpopulation variability in CVD risk factor trends which are often masked in national or regional trends.The objective of this study is to describe the spatiotemporal trends of overweight/obesity and tobacco use at subnational levels over the 13-year period (2003 to 2016) by asking the following question: How does the prevalence of CVD risk factors (overweight/obesity and tobacco use) change over time (2003 to 2016), within subpopulations , and across the national landscape? By providing insights into the geographic variations of CVD risk factors observed within SSA countries, this study informs the development of context-specific and locally appropriate intervention strategies to address the burden of CVD in the region , 29. AddBurundi, Rwanda, Kenya, Tanzania, and Uganda are member states of the East African Community (EAC) organization in the African Great Lakes region of eastern Africa Fig. . The EACData was obtained from Demographic and Health Surveys from 2010 to 2016 in Burundi and from 2003 to 2016 in Kenya, Tanzania, Rwanda, and Uganda . The DemIn most surveys since the early 2000s, DHS provides geographical coordinates (latitude and longitude) for each sample cluster. Households sampled within a cluster are assigned the same coordinates which are offset by two kilometers in urban areas and five kilometers in rural areas to maintain respondent confidentiality. Urban and rural areas are defined by national statistical boards and may vary from country to country. As there is no standard, universally accepted metric to define urban–rural areas, they may be defined by population density or infrastructure or both . Data fr2 is overweight and BMI ≥ 30 kg/m2 is obese. To ensure enough statistical power for the analysis, overweight and obesity were combined to form one category, overweight/obese.Overweight/obesity and tobacco use, CVD risk factors, were derived from the DHS. Interviewers collected anthropometric measures, height and weight, for women using a digital scale and measuring board. BMI data was not collected for men. Therefore, the prevalence of overweight/obesity in this study refers only to women between 15 and 49 years old who were not pregnant. Overweight and obesity categories were assigned using the World Health Organization (WHO) definition, where BMI ≥ 25 kg/mA)(Yes or No) in some surveys this question was asked as: Do you currently smoke cigarettes every day, somedays, or not at all? Do you currently smoke cigarettes? B)(Yes or No) in some surveys this question was asked as: Do you currently smoke or use any other type of tobacco every day, somedays, or not at all? Do you currently smoke or use any other type of tobacco? C)What other type of tobacco do you currently smoke or use? The DHS collects self-reported data on tobacco use habits of both sexes, therefore women between 15 and 49 years old and men between 15 and 49 years old were included in this portion of the study. Smoking and smokeless tobacco were combined into one category to ensure enough statistical power. The prevalence of tobacco use, in any form, was determined using the following DHS questions:All affirmative answers were coded as one and summed to create an index that ranged from 0 to 3. A tobacco use variable was then created by coding respondents with a 0 score as “0” for no tobacco use and respondents with a 1 to 3 score as “1” for yes.R using the survey package for complex survey analysis [Survey-weighted means were used to provide an estimate of the proportion of the national, rural, and urban populations with CVD risk factors (overweight/obesity or tobacco use). Each CVD risk factor was analyzed separately in each country, and results were stratified by survey period. This method allows for spatial  and temporal (survey periods) comparison of CVD risk factor prevalence within nations while accounting for the DHS complex survey design and weighting. A survey-design based Kruskal–Wallis test statistic was used to determine if CVD risk factor prevalence were significantly different across survey periods in national, rural, and urban populations within each country. All statistical analysis was performed in analysis , 34.Kernel density estimation (KDE) is an interpolation method that uses features within a neighborhood  to estimate the value of raster cells . AdaptivprevR) which uses Gaussian kernel estimators with an adaptive bandwidth of equal number of observations to interpolate prevalence surfaces from DHS data [prevR, where the optimal N value is a function of the observed national prevalence, the number of people sampled, and the number of survey clusters [prevR KDE method with adaptive bandwidths has been used to map health and disease outcomes, model disease risk, equity, and social vulnerability [The GIS data provided by the DHS links multiple individual observations to one spatial location, the sample cluster. The number of observations per sample cluster varies by location, where clusters in densely populated urban areas often have more observations than clusters in rural areas. Larmarange et al. developed a CRAN R spatial interpolation package  within nations across two survey periods (around 2010 and 2015). To illustrate the subnational change of CVD risk factor prevalence across the landscape, raster math was used to calculate a ratio of CVD risk factor prevalence between the latter survey map (around 2015) and the first survey map (around 2010). Spatial analysis was conducted in R using packages , 47, 48. Desktop .Only women between 15 and 49 years old, who were not pregnant during the survey were included in the overweight/obesity portion of the study. A total of 182,310 women were included in the 2003 to 2016 DHS surveys. Pregnant women  were excluded to reduce potential bias from pregnancy related weight gain, resulting in an analytical dataset of 166,932 women. The number of participants varied by country. Uganda had the lowest number of participants in this study [Overweight/obesity varied across the region and within national, urban, and rural populations of women aged 15 to 49 years in East Africa. Across all countries, there is an increasing trend in overweight/obesity prevalence over time. Generally, the prevalence appears to be higher in more recent survey periods compared to earlier ones. On a regional level, overweight/obesity prevalence was highest in Kenya (ranging from 23.17% in 2003 to 32.76% in 2014) and lowest in Burundi (ranging from 7.57% in 2010 and 7.9% in 2016)  is increasing as countries progress through stages of epidemiological and obesity transitions –52. In tUrban populations in each nation were more likely to be overweight/obese than rural populations, although the magnitude of overweight/obesity difference varied widely between nations. Urban populations in the lowest income nation of the group, Burundi, were almost 6 to 7 times more likely to be overweight/obese compared to rural populations. Yet in Kenya, the nation with the highest GDP in the group, urban populations were 2 to 3 times more likely to be overweight/obese compared to rural populations. Although the prevalence of overweight/obesity increased over time in both urban and rural populations, spatial analysis revealed that the rate of change was not equal across all urban and rural areas. While urban areas had higher prevalence rates at the start and end of the study, the greatest magnitude of change over time occurred in rural areas. These findings not only illustrate how analysis at broader scales, i.e., regional or national, mask variation in space and obscure the place specific indicators and drivers of overweight/obesity prevalence but may also signify obesity transition in East Africa.Jaacks et al. , propose four stages of obesity transition as a model for the global obesity epidemic . In the The urban–rural overweight/obesity gap is likely linked to higher economic development in urban areas which lead to changes in employment, income, food access, physical activity, and transportation. However, as illustrated in this study and others, the rate of overweight/obesity is increasing at a higher rate in rural compared to urban areas . As LMICnot decreasing across the entire landscape. Prevalence estimate maps reveal that tobacco use increased in and around major cities and urban centers in all the nations, except Burundi, but declined in rural areas.In contrast to the urban/rural patterns of overweight/obesity, rural populations were more likely to use tobacco compared to urban populations and the likelihood of use varied substantially between nations. Adults in rural Burundi were 5 to 6 times more likely to use tobacco than their urban counterparts, while rural adults in Kenya were 2 to 3 times more likely to use tobacco than urban adults. The rate of tobacco use declined in both subpopulations, however, spatial analysis showed that tobacco use was Although the national prevalence of tobacco use declined over time in all the nations, which aligns with studies about global and national tobacco use trends, spatial analysis showed that the decline in tobacco use was not true for all places with the nations –60. CurrAlthough this study was able to illustrate spatial and temporal variations in overweight/obesity and tobacco use prevalence using secondary data, there were several limitations. DHS surveys provide standardized data and large sample sizes; however, the observed trends were not longitudinal and were derived from a series of cross-section analyses of multiple surveys, which represent different sample years and sizes. Second, there are issues inherent with the definition of urbanicity in the DHS, due to a lack of a universally accepted definition of urban and rural areas, there urban and rural areas determined by national statistical offices and may differ across nations and time , 65. Thinot fit all. Studies of national prevalence trends for overweight/obesity or tobacco use, which constitute most of the CVD risk factor literature in SSA, mask important information about subpopulation and place-specific behavior and drivers of risk factor prevalence. As shown in this study, although the national prevalence of tobacco use declined in all the nations, place-specific trends differed and, in some cases, increased. This type of understanding is not only vital to increase knowledge at local scales but can be a starting point for studies to understand local drivers of risk factor trends which can in turn inform policy and public health intervention.To the best of the authors’ knowledge, this is the first study to explore the spatiotemporal trends of overweight/obesity and tobacco use prevalence at a subnational level in this region of SSA. Findings highlight the importance of de-homogenizing studies about CVD risk factors, such as tobacco use and overweight/obesity, in not only SSA but in other parts of the world in epidemiological transition. One question, one method, and one conclusion at regional or national levels does It is imperative that as nations transition to higher levels of cardiovascular and chronic conditions, which are strongly impacted by place and culture, epidemiological analysis should occur at subnational levels and include spatial analysis, especially in regions where administrative boundaries are not static. As illustrated, spatial analysis also provides another means to understand subpopulation behavior, for instance, CVD risk factor trends in urban and rural spaces were place specific and therefore did not experience similar growth or decline patterns. Findings from this study offer insight on (1) the use of existing data, such as DHS or other national surveys, to analyze spatial trends in areas with low data resources and (2) potential future directions for research on how to utilize this type of de-homogenized analysis to build policy and create public health interventions that tailored to and appropriate for specific areas of needs.


To examine differences in mental health-related service contacts between immigrant, refugee, racial and ethnic minoritized children and youth, and the extent to which social, and economic characteristics account for group differences.The sample for analyses includes 10,441 children and youth aged 4–17 years participating in the 2014 Ontario Child Health Study. The primary caregiver completed assessments of their child's mental health symptoms, perceptions of need for professional help, mental health-related service contacts, experiences of discrimination and sociodemographic and economic characteristics.Adjusting for mental health symptoms and perceptions of need for professional help, children and youth from immigrant, refugee and racial and ethnic minoritized backgrounds were less likely to have mental health-related service contacts (adjusted odds ratios ranged from 0.54 to 0.79), compared to their non-immigrant peers and those who identified as White. Group differences generally remained the same or widened after adjusting for social and economic characteristics. Large differences in levels of perceived need were evident across non-migrant and migrant children and youth.Lower estimates of mental health-related service contacts among immigrant, refugee and racial and ethnic minoritized children and youth underscore the importance and urgency of addressing barriers to recognition and treatment of mental ill-health among children and youth from minoritized backgrounds. Less than one-third of these children and youth will have contact with a specialized mental healthcare provider. These mental health treatment gaps highlight the need to identify population subgroups less likely to receive mental healthcare and address barriers to recognition and treatment.In Ontario, it is estimated that 18% to 22% of children and youth aged 4 to 17 years will have a mental disorder, at any given time, associated with substantial distress and impairment.314 Lower levels of service use for mental healthcare have been consistently documented for females, children living in poverty and with lower parental education levels, families with 2 biological parents and youth from immigrant and racial and ethnic minoritized backgrounds.314Evidence from Canada and the United States designed to identify factors associated with disparities in mental health service use among youth point to a variety of sociodemographic and family factors including gender, migrant status, racial and ethnic minoritized background, poverty, parental education, and family structure.14 Evidence syntheses and systematic reviews follow the same trend: children and youth from migrant families are much less likely to access mental health services compared to individuals native to the country being examined.16 Migration can often fuel health inequities by exposing families to economic decline, limited access to healthcare and education, and poor living and work conditions.1719 Even within migrant subgroups differences in mental health have been documented, with refugees exhibiting increased mental health symptom severity and hospitalization.2022 Refugees are distinct from immigrants and should be examined in this way as their resettlement in Canada is considered involuntary and a result of fear of persecution, war or armed conflict.In Canada, children and youth from immigrant and refugee (hereafter referred to as migrant) backgrounds are much less likely to receive mental healthcare, compared to non-migrant peers. It posits that the causal pathway to the use of health services begins with predisposing characteristics , then personal and community enabling factors  and lastly, the need for health services . In the context of children's pathway to mental health services, parents are conceptually identified as facilitating the initiating step to seek service through their ability to perceive the need for help for emotional and behavioural symptoms in their children.26 To comprehensively conceptualize need for mental health services, it is important to account for mental health symptoms , as well as a parent-reported perceived need for services. It can be maintained that social context plays an important role in perceptions. For instance, perceived discrimination has often been cited as an important social contextual stressor accounting for differences in mental health disparities among racial and ethnic minoritized populations.2830 However, its influence on mental health service utilization within migrant groups is lacking. We hypothesize that predisposing factors , personal/community enabling resources  and need for services  represent important correlates of mental health help-seeking behaviours among children, youth and their families in Ontario.Andersen's behavioural model fits within the paradigm of variance in service use by conceptualizing the determinants into 3 broad categories.22 Moreover, our understanding is primarily based on health administrative data, which is limited to physician-based contacts, including outpatient and inpatient settings. Therein, we are unable to account for the level of mental health need, as well as services provided outside of hospitalization and physician-based services. Evidence documenting patterns of mental health service use across sectors and settings clearly demonstrates that youth frequently utilize services outside of the healthcare system.32 Sole reliance on administrative data results in a significant proportion of mental health-related service contacts being missed, while also restricting our evidence to a subset of adolescents who received care from a mental health professional for mental health-related concerns. Identifying correlates of mental health service-related contacts and quantifying disparities requires a comprehensive approach that incorporates all relevant settings and sectors that deliver mental healthcare to children and youth and those who have, and have not, accessed care. Most available evidence on the sector and setting specific correlates of mental healthcare has been derived from the United States and Australia, with limited applicability to a Canadian context due to variations in healthcare systems, financing and policies.32While evidence shows that the use of specialized mental healthcare among children and youth with mental disorders is low, the factors contributing to these disparities, particularly among immigrant, refugee, racial and ethnic minoritized children and youth in a Canadian context remain largely unknown. Specifically, the study objectives are to (1) quantify differences in mental health-related service contacts between immigrant, refugee, racial and ethnic minoritized children and youth relative to non-migrants; and (2) examine the extent to which social and economic characteristics account for group differences. With Canada's changing population landscape, it is necessary to understand not only the magnitude of mental healthcare disparities in migrant subgroups, but also the social determinants contributing to them to achieve equitable access to mental healthcare in Ontario.The present study uses general population data to examine correlates of mental health-related service contacts among children and youth aged 4 to 17 years in Ontario.Ethics approval for all study procedures was obtained through the Hamilton Integrated Research Ethics Committee at McMaster University  and final ethics was obtained from the Research Ethics Board. The data are stored and accessible in Canada through the Statistics Canada Research Data Centres program.35Data for analyses come from the 2014 Ontario Child Health Study (OCHS). The OCHS is a general population provincial epidemiologic study of child and youth health and mental disorder. Sampling for the OCHS was based on a 3-stage stratified, random cluster design using the 2014 Canada Child Tax Benefit (CCTB) file as a sampling frame to identify households with children aged 4 to 17 years. Data were collected from the person most knowledgeable (PMK) about the household and child (98.6% identified as the parent of a selected child). Between October 2014 and September 2015, a total of 10,802 children and youth aged 4 to 17 years nested in 6,537 families and 484 neighbourhoods (50.8% response) agreed to participate. Additional information on survey design, content, and data collection is available elsewhere.Mental health service contact. The outcome of interest was the parent report of whether the child had a service contact regarding mental health concerns in the past 6 months. Parents were asked if they or their child saw or spoke to general healthcare providers , mental health providers , school guidance counsellor or teacher/other adults at school, a combination of complementary/alternative medicine providers  or phone helpline or crisis hotline regarding their child's mental health in the past 6 months. Parents were also asked whether their child had gone to any of the following settings for mental health concerns: walk-in clinic, urgent care clinic or hospital, or an agency that provides mental health or addiction services for youth. A binary indicator of any service contact was derived indicating either no service contact or contact with at least 1 provider or in at least 1 service setting for mental health concerns . To examine the distribution of where children and youth are seeking care and from whom, service setting/sector and type of professional were classified into the following categories, as defined in Georgiades et al. (1) school (school-based setting), (2) specialized mental health , (3) general healthcare , and (4) other .Migrant status. The migrant group was based on parent-reported country of birth and migration class. Respondents were classified as (1) immigrant, at least 1 parent arrived in Canada as a landed immigrant, (2) refugee, at least 1 parent came to Canada as a refugee, and (3) non-migrant, both parents were born in Canada.Sociodemographic factors. Sociodemographic variables assessed in the OCHS are based on harmonized content developed by Statistics Canada. They include age (in years), sex , parent racial and ethnic background (White = 0), Asian , West Asian , Black , Other , family structure , 2 parents , single parent), household income below the low-income measure (0 = above low income), receipt of social assistance (no = 0), parental education level  and employment , urban–rural residency .Internalizing and externalizing symptoms. Internalizing and externalizing symptoms were measured through dimensional ratings from the 2014 OCHS-Emotional Behavioural Scales (OCHS-EBS). It was administered to the PMK describing their child's feelings and behaviours in the past 6 months rated on a 3-point Likert scale. Internalizing behaviours include 27 items measuring the frequency of symptoms of a generalized anxiety disorder (6 items), separation anxiety disorder (7 items), major depressive disorder (9 items), and social phobia/social anxiety disorder (5 items). Externalizing behaviours are derived from items measuring the frequency of symptoms of attention deficit hyperactivity disorder (8 items), oppositional defiant disorder (6 items), and conduct disorder (11 items). The OCHS-EBS has undergone psychometric evaluation and the reliability and validity of the scale have been well established. Subscale scores are calculated by summing together the coded responses across items within each disorder to produce a summative score. A higher score is indicative of greater symptom severity.Perception of need. Parents were asked whether they felt their child needed professional help for emotional and/or behavioural problems (no = 0).Experienced discrimination. Parents were asked to indicate whether they experienced discrimination or have been treated unfairly by others in Canada because of their ethnicity, culture, race, skin colour, language, accent, or religion (no = 0).n = 10,802). Restricting the sample to complete data across study variables resulted in a 3.3% reduction in the study sample . Comparison between complete cases and those with missing data on all study variables showed no statistically significant differences.Children and youth aged 4 to 17 years old were eligible for inclusion in the analysis  and chi-square tests, as appropriate.Sequential logistic regression analyses were undertaken to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between mental health service contact and study variables and to understand the extent to which these variables account for group differences. To examine associations between sociodemographic factors and mental health symptoms on service contact, Model 1 included youth demographic characteristics (age and sex), mental health symptoms and need , migrant status and racial and ethnic background. In Model 2, family socio-economic and demographic characteristics were added: family structure, low income, receipt of social assistance, rural–urban residence, parental education and parental employment. Experienced discrimination was added in Model 3. Sampling weights were also applied to all analyses to generate estimates that are representative of the target population of children and youth in Ontario. All analyses were conducted in the STATA statistical software system package version 14.0 .Due to the complex sample design of the 2014 OCHS, a total of 1,000 mean bootstrap weights generated by Statistics Canada were applied with an adjustment factor of 5 to obtain accurate standard errors.n = 5,974, 57.4%), immigrant children represented 37.3% of the sample, while refugee children and youth represented 5.5% of the total study sample. White children and youth comprised the largest group (62.6%), with immigrants (45.6%) and refugees (42.3%) predominately identifying as East, Southeast or South Asian. Despite immigrant and refugee parents exhibiting higher education levels, a significantly higher proportion were low income . Compared to non-immigrants, immigrant and refugee families were twice as likely to experience discrimination . Non-immigrant children and youth had higher levels of parent-reported mental health symptoms. Internalizing symptoms were significantly higher in non-immigrants compared to immigrant children and youth (Cohen's d = 0.13) and compared to refugees (d = 0.17). Similar patterns are observed in externalizing symptoms with non-immigrant children and youth exhibiting higher levels than immigrant (d = 0.20) and refugee (d = 0.22) children and youth. The prevalence of perceived need for help for emotional and behavioural concerns was also higher among non-immigrants (15.2%), compared to immigrants (5.9%) and refugees (5.6%).The distribution of sociodemographic characteristics and mental healthcare needs by migrant status are presented in One-quarter (25.3%) of the sample made a contact with a professional for mental health concerns, with twice the number of non-immigrant children and youth making contact (32.4%) compared to their immigrant and refugee counterparts . Schools were the most prevalent setting/sector for service contact among non-immigrant (20.1%) and immigrant (7.6%) children and youth, however, children from refugee families most often frequented specialized mental healthcare (7.5%).Higher mental health need was associated with mental health-related service contact. Children with increased internalizing and externalizing symptoms were significantly more likely to make contact for mental health concerns . Perceived need for professional help for emotional and/or behavioural problems was the strongest predictor of mental health-related service contact .In Model 2, family sociodemographic characteristics were added. Low income families and those who s received social assistance had increased odds of having a service contact for mental health concerns. Compared to families with 2 biological parents, children and youth living with either 2 adoptive parents or 1 biological parent and 1 adoptive/foster  and those living with a single parent had higher odds of mental health-related service contact . The magnitude of the ORs associated with immigrant and refugee backgrounds remained relatively unchanged with the addition of sociodemographic variables in the sequential models. The final model included parental experiences of discrimination. After adjusting for all other study variables, the association between experiences of discrimination and mental health-related service contacts was not statistically significant .This study enhances our understanding of the prevalence and determinants of mental health-related service contacts among children and youth in Ontario. We found higher levels of mental health symptoms and a perceived need for professional help for mental health concerns among non-immigrants, compared to immigrant children and youth. After adjusting for these group differences, our results highlight disparities in mental health-related service utilization among migrant groups, with immigrant children and youth less likely to seek services. A similar pattern was observed among racial and ethnic families, where they are almost 40% to 50% less likely to make contact compared to self-identified White families. Social and economic factors did not account for the observed disparities, pointing to the need to identify other underlying considerations that are contributing to differential help-seeking behaviours across underserved population subgroups.40Importantly, we found children and youth living in low income households, receiving social assistance, and having a single or no biological parent in the home were more likely to have mental health-related service contacts. The mechanisms contributing to these group differences are unclear, however, other studies with similar findings have prompted careful consideration of stressful social circumstances in the lives of vulnerable children and youth, and the importance of the family environment in forming mental health treatment patterns.42 Caution is warranted when interpreting these results given the sole reliance on a single item to assess experiences of discrimination that were not specific to the healthcare context. It is also important to note that experiences of discrimination were added to our final analytic model which controlled for a number of sociodemographic and economic characteristics. Indeed, in unadjusted analyses reports of discrimination were associated with a reduced likelihood of mental health-related service contacts .Large group differences were documented in experiences of discrimination with nearly one-quarter of immigrant and refugee families reporting experiences of discrimination compared to one-tenth of non-immigrant families. While experiences of discrimination have been associated with mental health disparities, our findings suggest that parents who have experienced discrimination or unfair treatment were not less likely to access mental healthcare for their child.8 Of note, perception of a need for professional help for emotional and/or behavioural problems was the strongest predictor of service contact, independent of mental health symptom severity. Our results are in line with Canadian,44 European46 and Australian48 findings indicating a self-reported perceived need for mental health treatment is an important determinant of mental health service utilization. Negligible attenuation of the magnitude of the association of perceived need and mental health service contact after accounting for social and economic variables suggests there are other factors at play influencing parent identification of the need for help. Large differences in levels of perceived need were evident across non-migrant and migrant groups, highlighting the importance of adjusting for these in our analysis. Evidence suggests mental health literacy and social stigma are important factors giving rise to these group differences.47Consistent with previous studies, mental health symptom severity was associated with increased odds of mental health-related service contacts.32 This highlights the importance of schools in addressing mental health concerns but also in acting as the first point of contact in a potential pathway of referrals, all of which are vital for early identification and intervention.Schools were the most frequented setting accessed by children and youth, as seen in previous literature.21 This could be because previous reports exclusively relied on physician-based administrative records , thereby capturing a limited proportion of children and youth and an even smaller number of refugee children and youth. The present study included a comprehensive range of settings and sectors where mental healthcare is delivered and thus included a broader cross-section of children and youth receiving mental health-related services, in addition to capturing adolescents in need who did not receive help. This is particularly important in the context of minority mental healthcare services research, given that these population subgroups have been shown to be consistently underserved. We found that a general population sample screened for perceived need and mental health service use are exhibiting a high need for professional help, yet underutilization of services. This treatment gap prompts the need for routine screening of treatable mental health conditions to identify and target high-risk adolescents.Interestingly, disparities in access across immigrant and refugee subgroups were found to be comparable in magnitude, contrary to prior evidence demonstrating overutilization among refugees, relative to immigrants.within migrant subgroups, future studies that have adequate sample coverage should take a more refined approach to examine within-group differences by migrant class , recency of arrival in Canada and more homogenous racial and ethnic subgroups.This is the first study to our knowledge that has taken a comprehensive approach to examining disparities in mental healthcare across migrant subgroups, race and ethnicity, while accounting for between-group differences in mental health symptom severity and perceptions of the need for professional help. However, it is not without limitations. Generalizability of the findings outside of Ontario must be made with caution due to provincial and international variations in immigration policies, and healthcare and education systems. Another limitation lies in the reporting of outcomes as the results of this study were based on parent reports which may not accurately capture children's and youth's perceptions. Additionally, our assessment should not be equated with the receipt of treatment. We undertook a broad approach to capture any service contact for mental health concerns, as such, we are unable to characterize the nature of those contacts in relation to assessment, treatment referral, and intervention. The sampling strategy and eligibility criteria of the OCHS resulted in an absence of certain migrant groups such as non-English/French speaking children and youth, children without a CCTB tax file, as well as children living on reserves and institutions. Due to this, it is plausible that our results are an underestimation of the true magnitude of disparities in mental healthcare access. Given heterogeneity Insights from this work could be used to implement programs and policies designed to reduce disparities in mental healthcare and promote mental health. To respond to the increasing diversity of immigrant, refugee and racial and ethnic minoritized populations in Canada, approaches to improve uptake and overcome barriers are needed, such as culturally tailored mental health training for service providers and community-based programs to improve mental health literacy. Equitable access to care requires investments in approaches that facilitate early identification and access to interventions across sectors and settings, as well as targeted outreach for immigrant, refugee and racial and ethnic minoritized children and youth.Click here for additional data file.Supplemental material, sj-docx-1-cpa-10.1177_07067437221144630 for Social Disparities in Mental Health Service Use Among Children and Youth in Ontario: Evidence From a General, Population-Based Survey by Mahdis Kamali, Jordan Edwards and Laura N. Anderson, Eric Duku, Katholiki Georgiades in The Canadian Journal of Psychiatry


Major advances in different cancer treatment modalities have been made, and people are now living longer with cancer. However, patients with cancer experience a range of physical and psychological symptoms during and beyond cancer treatment. New models of care are needed to combat this rising challenge. A growing body of evidence supports the effectiveness of eHealth interventions in the delivery of supportive care to people living with the complexities of chronic health conditions. However, reviews on the effects of eHealth interventions are scarce in the field of cancer-supportive care, particularly for interventions with the aim of empowering patients to manage cancer treatment–related symptoms. For this reason, this protocol has been developed to guide a systematic review and meta-analysis to assess the effectiveness of eHealth interventions for supporting patients with cancer in managing cancer-related symptoms.This systematic review with meta-analysis is conducted with the aim of identifying eHealth-based self-management intervention studies for adult patients with cancer and evaluating the efficacy of eHealth-based self-management tools and platforms in order to synthesize the empirical evidence on self-management and patient activation through eHealth.A systematic review with meta-analysis and methodological critique of randomized controlled trials is conducted following Cochrane Collaboration methods. Multiple data sources are used to identify all potential research sources for inclusion in the systematic review: (1) electronic databases such as MEDLINE, (2) forward reference searching, and (3) gray literature. The PRISMA  guidelines for conducting the review were followed. The PICOS  framework is used to identify relevant studies.The literature search yielded 10,202 publications. The title and abstract screening were completed in May 2022. Data will be summarized, and if possible, meta-analyses will be performed. It is expected to finalize this review by Winter 2023.The results of this systematic review will provide the latest data on leveraging eHealth interventions and offering effective and sustainable eHealth care, both of which have the potential to improve quality and efficiency in cancer-related symptoms.PROSPERO 325582; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=325582DERR1-10.2196/38758 The incidence of cancer is rising, and it is estimated that by 2040, globally, more than 28 million people will experience cancer as new cancer cases . It is eGlobally, there is recognition that patients benefit from being actively engaged in their own health . Active eHealth interventions could potentially enhance the clinical, organizational, and relational aspects of care by integrating patient databases for individualized treatment and real-time decision support. Moreover, it has been reported that electronic technology, by identifying decision support, care coordination, and continuity of care, could improve cancer care delivery . This apEven though there is empirical evidence that substantiates the role of eHealth interventions in the delivery of supportive care to people living with the complexities of chronic health conditions -19, the Reviews on the effects of eHealth interventions are scarce in the field of cancer supportive care, particularly for interventions to increase patient activation and empower patients to self-manage cancer-related symptoms. There is substantial evidence that patients who have the appropriate information and skills are more likely to engage actively in their care and effectively manage the consequences of treatment, including their physical and psychological symptoms ,22. FurtWe propose to conduct a systematic review with meta-analysis and methodological critique of the literature to answer the following PICO  research question: What is the efficacy in cancer populations  of eHealth interventions (intervention) compared to usual care or other active intervention (comparison) on symptom severity, psychological distress, self-management behaviors, health outcomes, and health use .This review aims to explore usage and effectiveness of eHealth interventions designed to support patients with cancer in managing cancer-related symptoms and the effects on outcomes. The findings could inform and promote evidence-informed oncology practice for eHealth interventions targeted at cancer and advance science in the field.This systematic review to identify randomized controlled trials (RCTs) and meta-analyses follows methods as specified by the Cochrane Collaboration  and the Are eHealth interventions (or programs) effective in reducing the physical or psychological effects of cancer and its treatment or improving other health outcomes  compared with usual care or other active treatment?Does effectiveness (effect sizes [ESs]) of eHealth interventions (or programs) differ by patient or disease characteristics , that is, effect modifiers?Does effectiveness (ESs) of eHealth interventions (or programs) differ based on intervention design (delivery setting) or methods , training and qualities of the interventionist, intervention components, length of the intervention, or other potential mediators, that is, adherence to the intervention?The search strategy was developed with assistance from a library information specialist. A computerized search of electronic databases will be conducted from January 2000 until January 2022 as follows: The Cochrane Central Registry of Controlled Trials (CENTRAL), Cochrane Library and Trials Registry and the Database of Abstracts of Reviews of Effectiveness (DARE), MEDLINE (2000 to January 2022), Embase (2000 to January 2022), CINAHL (2000 to January 2022), PSYCHINFO (2000 to January 2022), and CancerLit (2000 to January 2022). In addition, the gray literature databases, EAGLE (2000 to January 2022), openSIGLE (2000 to January 2022), and PsychEXTRA (2000 to January 2022) will be searched. The reasons for limiting the literature search from 2000 onwards are the development of internet technology and the use of internet-based support programs in the delivery of supportive care over the past 22 years .The search for eligible studies will include search terms: self-manage* or “self-manage*” or self-car* or “self-care*”, behave* or cognitive* or train* or instruct* or patient education or “patient education” or “management plan*” or “management program* (AND) ehealth* or mHealth* or “mobile Health*” or Telehealth* (AND) terms for neoplasms, cancers, or cancer symptoms  and sensitive search terms for identifying randomized trials as subject headings specified by Cochrane . The iniEligible studies will be identified based on the inclusion or exclusion criteria described below.The following inclusion criteria were used:RCTs, quasi-randomized, or controlled clinical trials with an intervention group and a comparison patient group (receiving another intervention or standard care)Interventions using eHealth technology Interventions targeted at improving self-management or patient activation in managing physical symptoms or psychological distressInclude one of the following outcomes: physical health status or symptoms, psychological health status or psychological symptoms or health distress, quality of lifeComparisons were made with usual care or another active interventionAdults (18 years or older) at any stage or type of cancerThe following exclusion criteria were used:Studies without an eHealth intervention in the self-management of cancerStudies that did not include usual care controls or active intervention controlsStudies published in non-English languageInterventions that do not include a formal analysis of effects or use valid instrumentsWe will be studying the following primary outcomes:Self-reported measures of physical health status or symptoms on valid and reliable scalesSelf-reported measures for psychological health status or symptoms, that is, depression or anxietyQuality of life or functioning is measured with valid and reliable scalesWe will be studying the following secondary outcomes:Patient characteristics, including demographic and clinical data, and the intervention Participant’s withdrawal from the studiesSubjective and objective measures of physical function or disabilitySymptom limitations or interferenceHealthcare utilization , and other health care or social costsStudies will be selected using Covidence software based on a review of the title, keywords, and abstract and coded using the following criteria: (1) include: an RCT, with a focus on cancer patient activation or self-management; (2) exclude: no self-management focus. Selecting studies includes these steps: (1) using a reference management software to merge search results and remove duplicates; (2) examine all titles initially to remove articles that are clearly not eHealth, followed by an abstract review ; and (3) retrieve the full study reports and assess compliance with eligibility criteria independently by 2 reviewers. Agreement will be examined using interrater agreement (<75 nonagreement); disagreements will be resolved by consensus or in consultation with a third reviewer. Authors| will clarify study eligibility criteria or missing data results if necessary. Interventions with more than 1 article will also be retrieved and reviewed to complement the data abstraction and quality assessment of the study .Data will be abstracted using a data abstraction form developed for the review based on Cochrane methods. Data abstraction is independently assessed by 2 reviewers with reliability of coding assessed by computing Kappa, or percentage agreement, for categorical data and the intraclass correlation for continuous data. If any aspect of the study design and conduct is unclear, the study authors will be contacted to complete data abstraction. Two other review authors will check a random sample of the abstractions. Disagreements will be resolved by discussion, with arbitration by a third author if necessary, following an independent review of the study report in question. The data abstraction form will be pretested on a minimum of 5 studies. The abstracted data will include categories as per Cochrane: (1) source and setting; (2) methods; (3) participants; (4) experimental interventions ; (5) control treatment; (6) analysis; (7) adverse events; (8) outcome measures; (9) results; (10) conclusions of study authors; and (11) miscellaneous, that is, funding sources.A quality assessment will be performed by 2 review authors and checked by another author. A methodological quality assessment of studies will be conducted based on an adapted version of the Cochrane Collaboration Back Review Group criteria , which wAuthors will be contacted with 2 reminders to complete missing data. Reviewers will be blinded to the authors of study reports. For each of these potential sources of bias, a judgment of yes (low risk of bias), no (high risk of bias), or unclear is assigned to each study (number of yeses is the single score or study). A summary table of the risk of bias across studies will be developed for reporting purposes.Outcomes will be analyzed as continuous or dichotomous variables depending on data reporting using standard statistical techniques. For continuous data , a standardized mean difference with 95% CIs will be calculated as appropriate to facilitate comparison between intervention and controls with correction for differences in the direction of the scale. If reported as medians with ranges, means and SDs will be calculated . For dicAs per Cochrane, clinical heterogeneity  ,34 will The following subgroup analysis will be conducted if the number of studies available for the analysis is adequate (10 studies for each characteristic modeled by participant characteristics and intervention components) as described below and based on the research questions posed:Study intervention characteristics: The potential effect modifiers examined may include the characteristics of the intervention .Study participant characteristics: Subgroup analysis will be conducted for disease stage (early and advanced), sex , and disease subtype, as some types of cancer may be associated with higher mortality.g. [g cannot be computed directly from means and SDs based on the source paper, it will be computed indirectly from the available test statistics, for example, t, based on Rosenthal [g will be corrected for small-sample bias [A summary of findings table will be completed to synthesize the reporting of common primary outcomes: physical effects (function and symptoms), psychological effects , and secondary outcomes  using the GRADEpro software. ES computations will be calculated using Hedges g. . Where gosenthal . The estple bias . Given tA sensitivity analysis will be conducted to evaluate the robustness of the meta-analysis, that is, the effects of methodological quality on study outcomes, by assessing for associations between individual items in the methodological quality checklist and the study outcomes. When data can be pooled, sensitivity analysis will be conducted by pooling the “yes” versus “no” responses to risk. When the data cannot be pooled, the sensitivity analysis will be performed using a chi-square analysis as per Cochrane.The literature search and data collection started in October 2017, after making a work plan to design and run the systematic search strategies in databases and the timeframe for delivery of the search results with the Library and Information Services within the University Health Network. However, to provide a comprehensive snapshot of knowledge since the time of incorporation of data from studies identified during the first search, a second literature search was conducted in February 2022 to ensure new studies were included and increase the validity of the review. The literature search yielded a total of 10,202 publications. Data will be summarized, and if possible, meta-analyses will be performed to evaluate the effectiveness of eHealth interventions on the outcomes. Results are expected to be published in winter 2023..Recent literature has highlighted the utility of eHealth interventions with promising outcomes in cancer care, although mixed and inconclusive results were also presented . The mai


Background: Neurological disorders with dyskinesia would seriously affect older people’s daily activities, which is not only associated with the degeneration or injury of the musculoskeletal or the nervous system but also associated with complex linkage between them. This study aims to review the relationship between motor performance and cortical activity of typical older neurological disorder patients with dyskinesia during walking and balance tasks.Methods: Scopus, PubMed, and Web of Science databases were searched. Articles that described gait or balance performance and cortical activity of older Parkinson’s disease (PD), multiple sclerosis, and stroke patients using functional near-infrared spectroscopy were screened by the reviewers. A total of 23 full-text articles were included for review, following an initial yield of 377 studies.Results: Participants were mostly PD patients, the prefrontal cortex was the favorite region of interest, and walking was the most popular test motor task, interventional studies were four. Seven studies used statistical methods to interpret the relationship between motor performance and cortical activation. The motor performance and cortical activation were simultaneously affected under difficult walking and balance task conditions. The concurrent changes of motor performance and cortical activation in reviewed studies contained the same direction change and different direction change.Conclusion: Most of the reviewed studies reported poor motor performance and increased cortical activation of PD, stroke and multiple sclerosis older patients. The external motor performance such as step speed were analyzed only. The design and results were not comprehensive and profound. More than 5 weeks walking training or physiotherapy can contribute to motor function promotion as well as cortices activation of PD and stroke patients. Thus, further study is needed for more statistical analysis on the relationship between motor performance and activation of the motor-related cortex. More different type and program sports training intervention studies are needed to perform. Neurological disorders encompass diseases of the brain and nervous system are the leading cause of disability  and contThe abnormal motor performance of stroke, PD, and MS patients, such as the step speed, step length, step width, step frequency, gait variability, stance time has been investigated . HoweverThe recent advancement in technologies such as Functional near-infrared spectroscopy (fNIRS), and portable electroencephalography has allowed for the investigation of brain function during realtime human movements in the natural environment freely. fNIRS is a non-invasive, repeatable, and reliable functional neuroimaging technology based on the theory of neurovascular coupling and optical spectroscopy . An incrCortical activation and gait characteristics of PD patients , stroke Two independent researchers performed a systematic literature search in Scopus, PubMed, and Web of Science databases to identify all relevant studies published from 1 January 2012 to 30 December 2022 after the fNIRS became popular . The 202Search and screening process is shown in However, studies were deemed irrelevant based on the following criteria: 1) it was non-experimental studies , 2) participants were healthy people only, people with other diseases or animal, 3) other cortical activation test equipment , was used, 4) main results were not kinematics and cortical activation, 5) the full text of study was not available, 6) a brain-computer interface was used, 7) studies were the conferences, or case reports.A stepwise process was used to identify articles to be selected for inclusion in this review. Two authors independently screened titles, followed by abstracts, and then full texts. Reviewers  extracted the data and synthesized it into pre-designed tables. If any disagreement arose regarding the inclusion or exclusion of single studies, it would be resolved through consultation and confirmed by the reviewers (ZC and YT).2 level of region of interest.The following items were extracted from each included study; the name of author and published year; the type of neurological disorders , age and degree of dyskinesia ; the number of fNIRS channels and region of interest; type of motor task and task paradigms ; intervention time; motor performance and cortical activation results including statistical correlation results, gait characteristics, balance score, and HbOEach full-text article was assessed by two independent reviewers and scored using the PEDro scale. Any discrepancies were resolved by discussion and consensus. The PEDro scale was developed to measure methodological quality and internal validity of randomized studies . Each ofAs shown in Among the 23 studies, walking was used as a test task in 20 studies, including straight walking (N = 15), turning (N = 5), obstacles (N = 5), and treadmill walking (N = 4). Meanwhile, the balance was used as a test task in the other three studies, including normal standing (N = 1) and postural intervention standing (N = 2). Gait and posture stability were the primary behavioral outcomes of walking and balance tasks. PFC was the most popular region of interest (N = 19) which was tested by 2–32 channels in fNIRS systems. Other region of interest in the frontal and parietal cortices were tested by six channels (N = 2) or more than 40 channels in the fNIRS system (N = 4).Scores on the PEDro scale ranged from five to eight for the selected articles . Twenty via Pearson’s correlation methods  and its relationship with cortical activation were left behind.Our review results showed that motor performance has improved after sports training or occupational therapy intervention. However, the type of sports training was simple, the difficulty, intensity, time interval of sports training intervention needs further study. The expanded and specific study would promote the clinical rehabilitation intervention therapy of neurological disorder patient with dyskinesia.From the 23 included publications, four were interventional studies, seven studies used statistical methods to interpret the relationship between motor performance and cortical activation, participants were mostly PD patients, PFC was the favorite region of interest, and walking was the most popular test motor task. The motor performance and cortical activation of frontal and parietal cortices were simultaneously affected during difficult walking and balance tasks of the neurological disorder patients with dyskinesia. Most reviewed studies reported poor motor performance and increased cortical activation of PD, stroke and MS older patients, compare with healthy older adults or difficult motor task conditions. Few studies discussed the exact relationship of motor performance and cortical activation by statistical analysis. The design and results were not comprehensive and profound. The sports biomechanics variables and its relationship with cortical activation variables were left behind. More than 5 weeks of walking training or physiotherapy can contribute to motor function promotion as well as frontal and parietal cortices activation of PD and stroke patients.There are several limitations in the present review. Firstly, it was limited to studies published in English. As such, studies with relevant findings may have been ommited. Secondly, the search time period for this review was the recent 10 years while fNIRS became popular. As such, we might not identify all relevant articles. Thirdly, it was limited to studies containing walking and balance motor tasks. As such, studies relevant to upper extremity motor tasks were excluded. Fourthly, the other cortical activation detected methods, such as portable electroencephalography were not included in this review, it is not known if a different detected method could have different results. Last but not least, the various study design made it difficult to summarize and discuss the different neural pathway changes of walking and balance control.Further study is needed to do more statistical analysis on the relationship between motor performance and activation of motor-related cortex. It would help analyze their relationship accurately. And dual task walking, obstacle walking and turning might be used as a sports training method. Intervention studies should be conducted to distinguish the intervention time, intensity and effects of dual-task walking, obstacle walking, over ground walking, and treadmill walking for neurological disorder patients with dyskinesia. It would help to look for new sport rehabilitation methods for those patients. Meanwhile, body performance such as trunk or head movement, electromyography, and ground reaction force should be synchronized with cortical activation test to evaluate the posture control of patients during walking and balance task. It would help to investigate the common change in musculoskeletal and nervous system, then further discuss their collaboration. Finally, the relationship between the different neural pathways of movement and the corresponding motor performance should be considered. It would help to investigate the different coordinate mechanisms of the musculoskeletal and nervous system in diverse patients movements.


Harmful use of alcohol consumption in Australia is a serious socio-political and public health issue that is exacerbated by exploitative marketing campaigns by the alcohol industry. In Indigenous populations harmful alcohol use is directly related to the legacy of colonisation that has led to complex social issues and adverse intergenerational trauma. To effectively address alcohol-related harm in Australia, it is necessary to critically apply the ‘Three Pillars of Harm Minimisation’, which are demand reduction, supply reduction, and harm reduction. This can be facilitated through approaches such as the ‘Interplay Wellbeing Framework’, which situates concepts of wellbeing and risky alcohol use within the context of systemic inequities across all social determinants of health. Culturally responsive approaches embody a holistic view of community, mutually respectful collaboration, culture, healing, and self-determined change. This is underpinned by Indigenous leadership that promotes existing resistance, resilience, interpersonal relationships, and strengths that instil healing to counter the harms associated with alcohol use. It is necessary to develop appropriate initiatives to reduce alcohol-related harm for Aboriginal and Torres Strait Islander communities, which can be evaluated against value-based domains such as those of culture, empowerment, and community.,,,,,Intergenerational trauma manifests as poor psychological wellbeing and is interlinked with risky alcohol consumption for some Indigenous Australians in contemporary Australia.,,The Northern Territory (NT) has the lowest population of people within any state or territory in Australia and has a tenfold proportion of Indigenous Australians.,,,The public health message of harm associated with exposure to alcohol consumption in Australia is diluted by a deliberate attempt by the alcohol industry to control health warnings.In Australia, the legal age to purchase and consume alcohol is 18 years and consumption is largely unrestrained due to social acceptance, which includes overt alcohol advertising and marketing.(p6) To counter widespread social acceptance of alcohol consumption in Australian society in addition to a reduced awareness of alcohol-related harm, harm reduction strategies are paramount throughout all stages of the life-span. For example, a recent harm reduction campaign was launched by The Foundation for Alcohol Research and Education (FARE)–the National Awareness Campaign for Pregnancy and Breastfeeding Women (the Campaign) from July 2020 to September 2024.The National Alcohol Strategy 2019–2028 outlines that many people who drink at risky levels do not consider themselves as heavy drinkers and nor do they attribute alcohol use as a cause of ‘cancer, cerebrovascular, cardio-vascular, liver and digestive disease’.,,,Harm reduction strategies are also necessary to prevent the 1452 premature deaths that were attributed to alcohol in 2020; 396 were female and 1056 were male deaths.,To reduce alcohol-related harm in some Indigenous Australian communities, Alcohol Management Plans (AMPs) were developed using varying and inconsistent approaches.,,,,,,,AMPs initially provided beneficial outcomes. An evaluation of the impacts and effectiveness of AMPs  in two distinct Cape York communities showed a dramatic reduction in violence against women (Community A: 39.2% and Community B 48.2%).,Reaching consensus regarding ongoing management of alcohol in Indigenous communities has been a deeply polarising issue, as seen recently in Alice Springs in the NT.,This reflects a long-standing community concern that whilst a place exists for supply restriction policies (as characterised by AMPs) to reduce alcohol-related harms, these measures alone do nothing to address underlying issues such as intergenerational trauma, poverty, housing, education, unemployment, access to alternative activities, access to adequate health care, and racial discrimination.,It is evident state and federal government policies have undermined efforts by local communities to control alcohol use, disrupting the plans of communities and exacerbating alcohol-related harms experienced by drinkers and other community members.,,The development of the Interplay Wellbeing Framework in remote communities found that reductions in alcohol use were linked with the strength of culture, empowerment, and community.For instance, several studies have examined the essential elements of culturally responsive residential rehabilitation services, which promote recovery and sobriety from alcohol.(p973) Despite a high attrition rate, an evaluation of the program provided evidence that it led to improvements in self-efficacy in refusing alcohol, decreases in psychological distress, and feelings of emotional empowerment.(p979)Further research examined the role and value of culture, healing, emotional empowerment, and psycho-social wellbeing, over a 16-week program at Oolong House in New South Wales.The value of culture on Country was also qualitatively evaluated within a healing model of care to promote effective rehabilitation.The devastating impact of colonisation and ongoing racially discriminatory government policies has left a trail of destruction, such that in the present day a predatory alcohol industry continues to capitalise on traumatised Indigenous Australian communities and exacerbate risky drinking behaviour. Whilst a place may exist for AMPs to reduce alcohol-related harms in some Indigenous communities, prohibition alone will not address the underlying social determinants of health and racialised health and justice systems, which impede holistic wellbeing for Indigenous Australians and their communities. Until the complex underlying issues are addressed in conjunction with harmful alcohol use, future policy making presents as an ineffective superficial band-aid that is unable to mend or heal broken lives impacted by alcohol dependence. Indigenous-led and sustainable social change needs to incorporate a holistic view of community, as demonstrated within the Interplay Wellbeing Framework. Such an approach acknowledges two-way respectful partnerships with Indigenous Australians and the value of Country, culture, healing, empowerment, and self-determination to address alcohol-related harm.LH drafted the manuscript. All other authors contributed to editing and revisions. All authors have approved the final manuscript for submission.Lorelle Holland would like to acknowledge the financial support provided to her as a recipient of a National Health and Medical research Council (NHMRC) Post Graduate Scholarship (PGS) and the Australian Academy of Science Douglas and Lola Douglas Scholarship in Medical Science during her PhD studies (Grant number 2014148). We declare no conflicts of interest in the writing or content of the manuscript.


A transformative change grounded in a commitment to antiracism and racial and health equity is underway at the University of California, Berkeley, School of Public Health. Responding to a confluence of national, state, and local circumstances, bold leadership, and a moral and disciplinary imperative to name and address racism as a root cause of health inequities, our community united around a common vision of becoming an antiracist institution. Berkeley Public Health has a long history of efforts supporting diversity, equity, inclusion, belonging, and justice. Building upon those efforts, we pursued an institution-wide initiative, one that creates a more equitable and inclusive school of public health that models and supports the development of future public health leaders, practitioners, scholars, and educators. Grounded in the principles of cultural humility, we recognized that our vision was a journey, not a destination. This article describes our efforts from June 2020 through June 2022 in developing and implementing ARC4JSTC , a comprehensive, multiyear antiracist change initiative encompassing faculty and workforce development, student experience, curriculum and pedagogy, community engagement outreach, and business processes. Our work is data informed, grounded in principles of change management, and focused on building internal capacity to promote long-term change. Our discussion of lessons learned and next steps helps to inform our ongoing work and antiracist institutional change efforts at other schools and programs of public health. Schools and programs of public health (SPPH) have a moral, ethical, and disciplinary imperative to address problems that undermine our collective mission to improve health and well-being for all. Many SPPH have declared racism a public health crisis, but little guidance exists in the published literature for addressing racism, including structural racism, in academic public health.We describe ARC4JSTC, an inclusive data-informed initiative at the University of California, Berkeley, School of Public Health, for actively working toward becoming an antiracist institution.We conclude with a discussion of lessons learned and next steps to inform antiracist institutional change efforts in SPPH.disaccumulation of protective resources and hyperaccumulation of risk  with the tools for antiracist transformation  23–28).–28.23–28Useful guidance for such efforts has been published by SPPH, other institutions of higher education, and health equity scholars ,21,29–33Social justice is a deeply rooted pillar of BPH, guiding our organizational mission, values, principles of community, and our ongoing diversity, equity, inclusion, and belonging (DEIB) efforts. Over the years, these efforts included hiring our first-ever director of diversity in 2005 which resulted, in part, from student advocacy and aligned with campuswide efforts to support DEIB at the local level  with demonstrated impacts in increasing underrepresented minorities in applicant pools and in matriculation; creating a diversity services office in 2005, which expanded into the Diversity, Respect, Equity, Action, Multiculturalism (DREAM) Office in 2015 with an explicit focus on inclusion and belonging, intensified efforts to increase diversity of the student body , and consultation regarding admissions policies and improving faculty diversity; student-led town halls on racism, power, and privilege in 2015; creating the Diversity, Inclusion, Community, Equity Committee in 2015 — a voluntary collective of students, staff, faculty, and alumni addressing equity issues at BPH — which was the result of student activism and an outgrowth of the student-led town halls; conducting surveys to monitor BPH climate starting in 2015; developing new curricular competencies that address structural inequities in 2016 ; adding course evaluation questions on classroom climate and respectful student engagement starting in 2018; training faculty and staff on having courageous conversations about race, understanding and addressing racial microaggressions, and bystanderism (not intervening despite witnessing or being aware of a racist act) in 2019; and hiring a full-time Dean’s Cabinet–level chief of DEIB (2021). These are tremendous successes. However, like many schools, we have faced challenges: for example, continued reports of microaggressions and other experiences that hinder inclusion, sense of belonging, and schoolwide ownership of DEIB.On June 9, 2020, Dean Michael Lu issued a statement condemning racism and all forms of White supremacy and declaring racism a significant determinant of health. The statement — drafted in collaboration with several faculty and staff, including those from underrepresented racial and ethnic minority groups — drew broad support across BPH constituencies and catalyzed the groundswell for creating a more equitable and inclusive school of public health. The resulting schoolwide advocacy for intensifying our institutional commitment to antiracist change aligned with the efforts of a large group of faculty, students, and staff already working on antiracist efforts. The “Solidarity Against Racism During Covid-19” group organized because of racist hate emails received by a faculty member who spoke nationally about the disproportionate harms of COVID-19 among racial and ethnic minorities. The group issued a call to action and organized around several efforts, including a collaboration between faculty and students to develop a BPH website highlighting evidence that documented the effects of structural racism on health. The objective of the website was to ensure that the BPH community itself understood these fundamentals and could turn to this resource in their own research, teaching, mentoring, and community and professional service.In a follow-up to his June 9th statement and against a backdrop of already lively antiracism activities, Dean Lu created 4 workgroups: 1) building an antiracist curriculum; 2) antiracism and racial justice training for faculty and staff; 3) expansion of supports for underrepresented students, faculty, and staff; and 4) collaboration between finance and development to identify existing funds and generate additional resources to sustain BPH antiracism efforts. Each group was cochaired by a member of the Dean’s Cabinet to ensure institution-level engagement and accountability .system of structuring opportunity that confers unfair advantage and disadvantage by race across multiple levels, from structural and institutional policies, practices, and norms, including (control over) collective and individual discourses  to consider what actions they might take to support the school’s antiracism goals. We define racism as a scourses  — systemscourses .We faced a unique window of opportunity, and because of a confluence of factors, we were ready to meet the moment. One major factor was our new dean. Less than a year into his deanship, at a BPH faculty meeting in November 2019, Michael Lu named social inequality as one of the “most pressing issues of our time.” He made it a focus of his leadership at BPH and 1 of 4 priority areas for the school. With the right leadership, the strong national, local, and disciplinary imperative to address structural racism as a public health issue, and an already activated community, we were primed for change.The initial burst of activities (summer 2020) was relatively uncoordinated; action was disaggregated at multiple levels, which risked inefficiency  and burnout, impeding co-learning, and ultimately undermining long-term success. To address this concern, our executive associate dean (A.M.A.), also chair of ARC4JSTC, convened the cochairs of each workgroup, a division chair representative, several student representatives, the school’s equity advisor, and the chief of curriculum and instruction to discuss a coordinated effort. This initial group grew organically, adding voices and perspectives that were missing from early discussions. We were deliberate about creating a steering committee that was as inclusive as possible while avoiding overlap to ensure efficiency. For example, it was essential to have a representative cross-section of various divisions , offices, committees, and operational roles; student (undergraduate and graduate), staff, faculty, and alumni representatives; registered student organizations; and racial and ethnic diversity as well as diversity in other forms of social identity; community representation; and dean’s office representatives to ensure continued institutional commitment. Ex-officio members were also available to ensure alignment with relevant campus initiatives and support co-learning with other campus units; these individuals had operational roles needed for successful implementation . After 6 months of sharing insights from different perspectives about organizational goals, strengths, challenges, opportunities, and potential threats, we had a 23-member steering committee that represented the knowledge and perspectives, skill sets, and operational areas integral to seeding change. We asked each committee member the following questions: 1) What future do you imagine for an antiracist BPH? 2) What do you believe is most important for us to keep in mind with this work moving forward? and 3) What will help you stay committed to this work moving forward? Responses were integrated into a set of guiding principles .1. Striving for a new identity as an antiracist institution — identified both internally and externally — is an ongoing journey, not a destination.2. Leading for antiracist change means full integration and normalization of antiracist praxis.3. Racism is structural — deeply entrenched into organizational policies, practices, and norms — therefore, antiracist efforts must also be structural.4. Identifying and remediating institutional racism is a marathon, not a sprint; it requires educating (learning and unlearning), organizing, nurturing, and holding each other accountable for meaningful change.5. Knowledge of racism, power, and privilege; deep understanding of marginalizing experiences; and both individual and collective action are all critical to antiracist transformation and are the foundation for developing an equity and social justice–oriented praxis.6. The process of antiracist change will challenge deeply held beliefs about power and privilege and require confronting resistance at the individual, interpersonal, and institutional levels.7. Perseverance will require acknowledging and celebrating progress along the way.8. Antiracist praxis will be new for some and will sharpen growth edges for others; and will require balancing accountability, empathy, and compassion among all.9. The antiracist changes we make today are an investment in our future identity (see first guiding principle).Recognizing the need for project management, we enlisted the support of our campus Business Process Management Office. Their investment in supporting the university’s goal of becoming an antiracist campus created a mutually beneficial partnership. We received 3 forms of support:Project management — managing and organizing work, meeting timelines, coaching project sponsor and project chair, and tracking progressChange management — creating a management structure to demonstrate the organization’s commitment to change and creating a resistance management plan including coaching project leaders on communications and managing internal relationshipsSurvey design and testing — optimizing user experience via item formatting and ordering and managing alpha and beta testing.Given the need to align our strategies with the needs of our community ,36, we cEach workgroup then created a project charter that outlined short-, intermediate-, and long-term goals, objectives, strategies, and metrics for evaluating success. Informed by our data collection  and steering committee and project management discussions, our project structure changed from 4 workgroups  to 4 popBusiness process and practice — faculty and staff recruitment policies and practices, purchasing practicesData and evaluation — collection, analysis, and dissemination of data to support planning and evaluation effortsVoice and visibility — improvement in understanding of the health consequences of racism and communicating the antiracism work being done in the school for all BPH community membersChange management – creation of an environment in which project management and change management converge to achieve organizational objectives.Committee members raised concerns about the term “steering committee” being hierarchical and antithetical to our goals of creating a more inclusive community. To foster community ownership of the work, we invited everyone in the school to provide recommendations for renaming the steering committee. We received 150 responses and found consensus on several terms and phrases, which resulted in a new name for the program and the steering committee: the Anti-racist Community for Justice and Social Transformative Change (ARC4JSTC) and the ARC4JSTC-Action Team (ARC4JSTC-AT), respectively.In March 2021, the ARC4JSTC-AT conducted a listening tour to communicate and solicit feedback on the change vision and plan throughout the school. Feedback was overwhelmingly positive. In the interest of developing short-term wins to motivate continued engagement and growth, we prioritized activities that 1) would build internal capacity, 2) could be implemented quickly and with current resources, 3) would have high visibility , and 4) would have recognizable and sustainable impact. After finalizing the plan, the ARC4JSTC-AT provided the dean with a budget request, met with campus groups and offices to communicate our plan for antiracist transformation, and secured additional funds and other in-kind support .Data collection revealed several growth areas for the BPH community. The most obvious were racial literacy, bystanderism, and the skills and confidence to implement antiracist praxis. Previous climate survey data showed that although most survey respondents indicated experiencing BPH as welcoming , respectful , supportive , inclusive , and diverse , more than one-quarter of respondents reported perceived and experienced racial and other forms of bias and discrimination, most commonly caused by faculty.Each project team undertook multiple projects . FollowiIn late spring and early summer 2021, BPH implemented its inaugural Antiracist Pedagogy Faculty Leadership Academy. The Academy was designed to follow up on an initial set of mandatory introductory racial literacy faculty workshops  for faculty interested in further developing their antiracist praxis and to create an early adopter group of antiracist champions to support ongoing curricular transformation. Part I (early summer) consists of five 2-hour didactic and active learning sessions focused on applying historical and contemporary, conceptual, and practical lenses to the subject of racism, antiracism, and antiracist pedagogy while developing an opportunity for collaborative learning and strategizing. Participants learn foundational theories and frameworks for understanding structural racism, particularly in higher education; connect this scholarship to their teaching through reflection and discussion with colleagues; create and adapt strategies to redesign their syllabus; and develop and practice pedagogic skills that foster inclusive classroom environments. Part II, “Implementing Your Antiracist Curriculum,” consists of monthly Community of Practice Learning Laboratories during the fall and spring semesters. These sessions provide an opportunity for faculty to discuss their overall classroom environment, including events occurring in the classroom related to DEIB and racism and antiracism more generally, troubleshoot, and continue to work on developing antiracist pedagogy skills.For our inaugural Academy, we invited selected faculty members (N = 39) to maximize the number of students impacted and ensure faculty training for a cross-section of our programs and divisions. This included faculty from our core and breadth classes, leadership classes, interdisciplinary programs , and graduate student instructor pedagogy course. We conducted surveys after each session to assess the effectiveness of the material and the instructor and a presurvey and postsurvey to assess the effectiveness of the Academy in supporting the development of antiracist pedagogy skills. Responses indicated that the Academy helped improve participants’ perceived knowledge, skills, readiness, and confidence in a range of antiracist pedagogy practices. We also held a post-Academy listening session via Zoom and received helpful feedback for session logistics and for modifying our evaluation strategy, including the frequency of surveys. Participants indicated that completing a survey after each session was burdensome. Participant feedback was positive overall: “This training was essential and foundational.”“Gave me space to be so much braver in my classes. It was almost like magic. This semester has been one of my most fulfilling semesters of teaching.”A new graduate student elective course teaches students how to develop an antiracist analysis of public health, present a set of antiracist public health tools, and build skills necessary for advancing an antiracist agenda in the field. The course consists of 4 competencies and multiple learning objectives  and was Our workforce development team created a work plan based on a series of planning and brainstorming sessions during the 2020–2021 academic year. As a result, a series of voluntary trainings and community building circles was held in collaboration with an outside vendor (race-work.com) and our campuswide Restorative Justice Center . CommuniThe goal of the community engagement project team is to help ensure community voices are represented in BPH’s decision making and efforts to become an antiracist institution. The initial project was to develop plans for a schoolwide community advisory board and to reimagine what community engagement can or should be. To ensure community voice during the planning process, we recruited 5 community members through an open call for applications to serve on the planning team, each receiving a $3,000 stipend for their participation. Planning is ongoing. Next steps are to ensure alignment with the vision of school leadership and other constituency groups .Three major projects are underway. The first is to develop a set of antiracist competencies, or habits of heart and mind  — instinSecond, we are in the final stages of developing a bias reporting form. The form will provide an opportunity for anonymous reporting of bias and discrimination of any sort and will also be designed to capture examples of positive experiences. Our goals are to 1) monitor our progress (we expect the number of reports to decline over time as we become more antiracist) and 2) develop a library of cases that we can use as a resource for future trainings. Third, we are also in the final stages of seeking feedback on our new schoolwide DEIB plan. The plan includes a set of goals, objectives, and current and future strategies in 4 focus areas: teaching and learning, social impact, belonging, and infrastructure. Next steps are to develop a set of metrics to evaluate success. The plan rests on 2 pillars — antiracism and social justice — and aims to advance our efforts toward becoming an antiracist institution.doing antiracism, there exists deep and well-tested knowledge on a plethora of practices for creating antiracist institutional change. Racial literacy . This is a question of epistemology: whose knowledge is valued and considered as valid data to help understand the phenomenon of interest? Experiential knowledge is a central tenet of critical race theory, as is understanding that an individual need not be overtly prejudiced or commit acts of prejudice for racism to flourish  ; and theAntiracism praxis uses a structural approach to identify and address how racism operates within systems, going above the level of the individual to address change at the institutional level . Both a


Youth suicide is a significant public health problem resulting in a major social and economic burden for communities and a devastating impact on families.The present study, which is part of a continuing research on attempted suicide among adolescents conducted in Northern Greece since 1990, explored the circumstances and characteristics of adolescent suicide attempters, comparing them with a clinical sample of adolescents with no suicidal behavior.N = 160) and we compared them with our sample of adolescent suicide attempters (N = 182).We retrospectively studied medical records and collected clinical data, sociodemographic and family characteristics of adolescents  referred to the Adolescent Unit of the AHEPA General Hospital for assessment and treatment between 2008 and 2018 . Chi-square analyses showed that, compared with patients with no suicidal behavior, attempters were more frequently diagnosed with personality disorder and mood disorder. No differences were found between groups for substance-use disorder, psychosis, eating disorder and somatic symptom disorder. Attempters were also living in more problematic circumstances, such as such as severe family dysfunction and/or impairment, reported significantly more conflict with parents, had more school problems and had experienced romantic disappointment (see Table 1).Of the 342 cases reviewed, 71.6% were female and aged 12 to 19 years (These findings highlight risk factors for suicide attempts and inform the development of suicide models that improve identification of adolescents at greatest risk to making a suicide attempt.None Declared