Canadian Community Health Survey Cycle Research Articles

Sexual Identity and Heavy Drinking Among Adults in Canada by Racially Minoritized Status and Income, 2015-2020.

Purpose: Our objective was to estimate inequities in heavy drinking between heterosexual, gay or lesbian, and bisexual or pansexual individuals, by sex/gender, and to determine whether this association is heterogeneous across racially minoritized status and income groups in Canadians aged 15 and older. Methods: We pooled three Canadian Community Health Survey cycles (2015-2020) and used separate modified Poisson regressions to explore the sex/gender-specific association between sexual identity and heavy drinking prevalence by racially minoritized status, and income, adjusted for survey cycle, age, marital status, and region. Results: With racially minoritized status, and income categories collapsed, heavy drinking was 1.3 times higher (95% confidence interval [CI] = 1.0-1.7) among bisexual or pansexual women compared with heterosexual women, with no differences among men. Among racially minoritized women, heavy drinking was 2.9 (95% CI = 1.3-6.4) times higher among bisexual or pansexual women and 1.9 (95% CI = 0.7-5.2) times higher among gay or lesbian women compared with heterosexual women. Among racially minoritized men, heavy drinking was 1.9 (95% CI = 0.9-4.0) times higher among gay men compared with heterosexual men. No differences were observed across sexual identity in White men or women. Bisexual or pansexual women reported increased heavy drinking relative to heterosexual women across income quintiles. Conclusion: Heavy drinking is distributed heterogeneously across sexual identity, sex/gender, racially minoritized status, and income. These results encourage equity-focused interventions to reduce heavy drinking among intersecting sociodemographic groups experiencing a greater burden of heavy drinking.

Ascertaining the Francophone population in Ontario: validating the language variable in health data

BackgroundLanguage barriers can impact health care and outcomes. Valid and reliable language data is central to studying health inequalities in linguistic minorities. In Canada, language variables are available in administrative health databases; however, the validity of these variables has not been studied. This study assessed concordance between language variables from administrative health databases and language variables from the Canadian Community Health Survey (CCHS) to identify Francophones in Ontario.MethodsAn Ontario combined sample of CCHS cycles from 2000 to 2012 (from participants who consented to link their data) was individually linked to three administrative databases (home care, long-term care [LTC], and mental health admissions). In total, 27,111 respondents had at least one encounter in one of the three databases. Language spoken at home (LOSH) and first official language spoken (FOLS) from CCHS were used as reference standards to assess their concordance with the language variables in administrative health databases, using the Cohen kappa, sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV).ResultsLanguage variables from home care and LTC databases had the highest agreement with LOSH (kappa = 0.76 [95%CI, 0.735–0.793] and 0.75 [95%CI, 0.70–0.80], respectively) and FOLS (kappa = 0.66 for both). Sensitivity was higher with LOSH as the reference standard (75.5% [95%CI, 71.6–79.0] and 74.2% [95%CI, 67.3–80.1] for home care and LTC, respectively). With FOLS as the reference standard, the language variables in both data sources had modest sensitivity (53.1% [95%CI, 49.8–56.4] and 54.1% [95%CI, 48.3–59.7] in home care and LTC, respectively) but very high specificity (99.8% [95%CI, 99.7–99.9] and 99.6% [95%CI, 99.4–99.8]) and predictive values. The language variable from mental health admissions had poor agreement with all language variables in the CCHS.ConclusionsLanguage variables in home care and LTC health databases were most consistent with the language often spoken at home. Studies using language variables from administrative data can use the sensitivity and specificity reported from this study to gauge the level of mis-ascertainment error and the resulting bias.

Measuring the Health Co-Benefits of Air Pollution Interventions on Premature Deaths in Canadian Cities

Background: Climate change has significant consequences on human health. Cities are especially vulnerable, where air pollution is a major environmental health risk. Premature mortality (i.e., deaths before age 75) is a robust population health outcome amenable to targeted policy and programmatic interventions. We used the Premature Mortality Population Risk Tool augmented with environmental data (PreMPoRT-ENV) to predict the 5-year incidence of premature deaths under air pollution reduction policies. Methods: PreMPoRT-ENV is a sex-specific Weibull accelerated failure time survival model that uses the Canadian Community Health Survey (CCHS) linked to the Canadian Vital Statistics Death Database and environmental data. We applied PreMPoRT-ENV to the 2016–2017 CCHS cycles and simulated Canadian Ambient Air Quality Standards targets to predict their impact on premature mortality across Canadian census metropolitan areas. We simulated capping annual mean particulate matter 2.5 microns or less in diameter (PM2.5) and nitrogen dioxide (NO2), as well as reducing air pollutants by 10% and 25% plus capping. Results: The weighted sample included 9,240,000 females and 9,260,000 males. Capping PM2.5 to 8.8 μg/m3 and NO2 to 12.0 ppb resulted in 12 per 100,000 fewer predicted premature deaths than observed exposures over 5 years (1,110 fewer absolute premature deaths). Reducing air pollutants by 10% and 25% plus capping resulted in even fewer predicted premature deaths. Conclusion: Our study highlights how to use a model that predicts premature mortality to provide estimates of the health impacts of environmental vulnerabilities. Results suggest that more aggressive targets may be needed to further realize population health benefits.

Tractors, Talk, Mindset, Mantras, Detachment, and Distraction: A Mixed-Methods Investigation of Coping Strategies Used by Farmers in Canada

Characterized by high unpredictability and little control, everyday factors make farming one of the most stressful occupations globally. Indeed, farmers around the world and in Canada score more severely on measures of perceived stress and negative mental health outcomes like anxiety and depression, and suicide ideation among farmers is disproportionately high. Research investigating effective ways of coping with everyday stress within the time and workload constraints of farming is scarce. This mixed-methods study explores the ways farmers in Ontario and Canada cope with daily farming stressors. Qualitative data from 75 in-depth interviews with farmers and industry professionals in Ontario, Canada, were analyzed to investigate farming-specific coping strategies within the farming context. Quantitative survey responses from 1167 farmers across Canada to the 14-item Ways of Coping measure developed for the Canadian Community Health Survey Cycle 1.2 were analyzed to determine which coping strategies Canadian farmers use most in relation to the representative national population. The ways of coping endorsed by farmers are presented in this paper, including adaptations of positive coping strategies in the farming context. The descriptions of positive and negative coping strategies used provide direction for effective avenues to reduce stress and boost farmers’ well-being.

School nutrition policy and diet quality of children and youth: a quasi-experimental study from Canada.

We investigated the impact of mandatory school nutrition policy on diet quality of Canadian school children using a quasi-experimental study design. Using 24-h dietary recall data from the 2004 Canadian Community Health Survey (CCHS) Cycle 2.2 and 2015 CCHS - Nutrition, we constructed the Diet Quality Index (DQI). We used multivariable difference-in-differences regressions to quantify the DQI scores associated with school nutrition policy. We conducted stratified analyses by sex, school grade, household income, and food security status to gain additional insights into the impact of nutrition policy. We found that mandatory school nutrition policy was associated with an increased DQI score by 3.44 points (95% CI: 1.1, 5.8) during school-hours in intervention provinces relative to control provinces. DQI score was higher among males (3.8 points, 95% CI: 0.6, 7.1) than among females (2.9 points, 95% CI: -0.5, 6.3), and the score among students in elementary schools was higher (5.1 points, 95% CI: 2.3, 8.0) than that among high school students (0.4 points, 95% CI: -3.6, 4.5). We also found that DQI scores were higher for middle-high income and food secure households. Provincial mandatory school nutrition policy was associated with better diet quality among children and youth in Canada. Our findings suggest that other jurisdictions may consider implementing mandatory school nutrition policy.

Dietary Patterns of Off-Reserve Indigenous Peoples in Canada and Their Association with Chronic Conditions

Nationally representative nutrition surveys (Canadian Community Health Survey (CCHS) Cycle 2.2, Nutrition 2004 and 2015) were used to examine dietary patterns and their association with socioeconomic/sociodemographic factors and chronic conditions in off-reserve Indigenous population in Canada. A cluster analysis was used to identify dietary patterns (DPs), and the Nutrient Rich Food Index (NRF 9.3) was used as the diet quality score and stratified by age/gender groups. In 2004 (n = 1528), the dominant DPs among Indigenous adults (age = 41 ± 2.3) were "Mixed" (mean NRF = 450 ± 12) and "Unhealthy" among men (mean NRF = 426 ± 18), "Fruits" among women (mean NRF = 526 ± 29), and "High-Fat/High-Sugar" among children (age = 10.2 ± 0.5) (mean NRF = 457 ± 12). In 2015 (n = 950), the dominant DPs were "Unhealthy" (mean NRF = 466 ± 6), "Mixed" (mean NRF = 485 ± 21), Healthy-Like (mean NRF = 568 ± 37), and "Mixed" (mean NRF = 510 ± 9) among adults (age = 45.6 ± 2.2), men, women, and children (age = 10.9 ± 0.3) respectively. The majority of Indigenous peoples had the "Unhealthy" DP with a low diet quality, which may contribute to a high prevalence of obesity and chronic diseases. The income level and smoking status among adults and physical inactivity among children were recognized as important factors that may be associated with the dietary intake of off-reserve Indigenous population.

Vaping and Health Service Use: A Canadian Health Survey and Health Administrative Data Study.

Rationale: Emerging research suggests that e-cigarette (EC) use may have detrimental health effects, increasing the burden on healthcare systems. Objectives: To determine whether young EC users had increased asthma, asthma attacks, and health services use (HSU). Methods: This cohort study used the linked Canadian Community Health Survey (cycles 2015-16 and 2017-18) and health administrative data (January 2015-March 2018). A propensity score method matched self-reported EC users to up to five control subjects. Matched multivariable logistic and negative binomial regressions were used to calculate odds ratios, rate ratios (RRs), and 95% confidence intervals (CIs) with EC use as the exposure and asthma, asthma attacks, and all-cause HSU as the outcomes. Results: Analyses included 2,700 matched Canadian Community Health Survey participants (15-30 yr), 505 (2.4% of 20,725 participants) EC users matched to 2,195 nonusers. After adjusting for confounders, EC users with asthma had over twofold higher odds of having an asthma attack in the last 12 months (odds ratio, 2.30; 95% CI, 1.29-4.12). Dual EC and conventional tobacco users had a twofold increased all-cause HSU rate compared with nonusers who never smoked tobacco (RR, 2.13; 95% CI, 1.53-2.98). This rate was greater than that for EC users who never smoked tobacco (RR, 1.73; 95% CI, 1.00-3.00) and non-EC users who regularly smoke tobacco (RR, 1.72; 95% CI, 1.29-2.29). Compared with male nonusers, female EC users had the highest increased all-cause HSU (RR, 1.94; 95% CI, 1.39-2.69) over male EC users and female nonusers (RR, 1.13; 95% CI, 0.86-1.48; RR, 1.41; 95% CI, 1.16-1.71, respectively). Conclusions: Current EC use is associated with significantly increased odds of having an asthma attack. Furthermore, concurrent EC use and conventional cigarette smoking are associated with a higher rate of all-cause HSU. The odds of asthma attack and all-cause HSU were highest among women. Thus, EC use may be an epidemiological biomarker for youth and young adults with increased health morbidity.

Adherence to emerging plant-based dietary patterns and its association with cardiovascular disease risk in a nationally representative sample of Canadian adults.

ObjectivesLittle is known about the role of emerging plant-based dietary patterns in cardiovascular disease (CVD) at the national population level. The objectives of this research were to assess the validity and reliability of newly-established plant-based dietary indices, and to evaluate their associations with CVD risk among Canadian adults.
 ApproachData were obtained from repeated 24-hour dietary recalls of adult participants in the cross-sectional, nationally representative Canadian Community Health Survey cycle 2004 linked to vital statistics (n=12,323) and cycle 2015 (n=14,026). Plant-based diet quality was assessed with a revised Plant-based Dietary Index (PDI), EAT-Lancet Reference Diet (ERD) score and the latest Dietary Guidelines for Americans Adherence Index (DGAI) 2020. Weighted multivariate analyses were used for testing associations between diet quality and lifestyle characteristics, and weighted multivariable-adjusted Cox proportional-hazards models for associations with CVD risk.
 ResultsConstruct validity was confirmed for the revised PDI and DGAI 2020 (but not ERD) as participants in the highest (healthiest) quartile, compared to those in the lowest (least healthy), were more likely to be female (52.63±1.27% compared to 44.8±1.65% for revised PDI; 59.37±2.01% compared to 40.84±1.71% for DGAI 2020), older (50.55±0.39 compared to 45.56±0.43 for revised PDI; 51.57±0.39 compared to 46.35±0.54 for DGAI 2020), to have post-secondary education (32.36±1.55% compared to 21.12±1.31% for revised PDI; 34.17±2.69% compared to 17.87±0.98% for DGAI 2020), and less likely to be daily smokers (8.21±1% compared to 17.06±1.45% for revised PDI; 7.36±1.71% compared to 21.53±1.58% for DGAI 2020) (P-trend<0.0001). No significant associations were observed between dietary index scores and CVD risk.
 ConclusionsRevised PDI and DGAI 2020 provided valid and meaningful measures of plant-based eating among Canadians, while validity of ERD was not directly confirmed. Adherence to the plant-based dietary patterns was not associated with CVD risk. Future large-scale analyses are necessary to further evaluate the role of plant-based eating in CVD prevention.

Adherence to emerging plant-based dietary patterns and its association with cardiovascular disease risk in a nationally representative sample of Canadian adults

Little is known about the role of emerging plant-based dietary patterns in cardiovascular disease (CVD) risk at the national population level. The objectives of this research were to assess the validity and reliability of newly established plant-based dietary indices, and to evaluate their associations with CVD risk among Canadian adults. Data were obtained from repeated 24-h dietary recalls of adult participants in the cross-sectional, nationally representative Canadian Community Health Survey cycle 2004 linked to health administrative databases (n=12,323) and cycle 2015 (n=14,026). Plant-based diet quality was assessed with a revised Plant-based Dietary Index (PDI), EAT-Lancet Reference Diet (ERD) score, and the latest Dietary Guidelines for Americans Adherence Index (DGAI) 2020. Weighted multivariate analyses were used for testing associations between diet quality and lifestyle characteristics, and weighted multivariable-adjusted Cox proportional hazards models for associations with CVD risk. Construct validity was confirmed for the revised PDI and DGAI 2020 (but not the ERD) because participants in the highest (healthiest) quartile, compared to those in the lowest (least healthy), were more likely to be female (mean±SE: 52.63%±1.27% compared with 44.80%±1.65% for revised PDI; 59.37%±2.01% compared with 40.84%±1.71% for DGAI 2020), older (mean±SE: 50.55±0.39 y compared with 45.56±0.43 y for revised PDI; 51.57±0.39 y compared with 46.35±0.54 y for DGAI 2020), to have postsecondary education (mean±SE: 32.36%±1.55% compared with 21.12%±1.31% for revised PDI; 34.17%±2.69% compared with 17.87%±0.98% for DGAI 2020), and less likely to be daily smokers (mean±SE: 8.21%±1.0% compared with 17.06%±1.45% for revised PDI; 7.36%±1.71% compared with 21.53%±1.58% for DGAI 2020) (P-trend<0.0001). No significant associations were observed between dietary index scores and CVD risk. The revised PDI and DGAI 2020 provided valid and meaningful measures of plant-based eating among Canadians, whereas the validity of the ERD was not directly confirmed. Adherence to the plant-based dietary patterns was not associated with CVD risk. Future large-scale studies are necessary to further evaluate the role of plant-based eating in CVD prevention.

Trends in obesity across Canada from 2005 to 2018: a consecutive cross-sectional population-based study.

Background:Obesity is increasingly prevalent worldwide and is becoming an epidemic in many countries, including Canada. We sought to describe and analyze temporal obesity trends in the Canadian adult population from 2005 through 2018 at the national and provincial or territorial levels.Methods:We conducted a consecutive, cross-sectional study using data from 7 sequential Canadian Community Health Survey (CCHS) cycles (2005 to 2017/18). We included data from Canadian adults (age ≥ 18 yr) who participated in at least 1 of the 7 consecutive CCHS cycles and who had body mass index values (calculated by Statistics Canada based on respondents’ self-reported weight and height). Obesity prevalence (adjusted body mass index ≥ 30) was a primary outcome variable. We analyzed temporal trends in obesity prevalence using Pearson χ2 tests with Bonferroni adjustment, and the Cochran–Armitage test of trend.Results:We included data from 746 408 (403 582 female and 342 826 male) CCHS participants. Across Canada, the prevalence of obesity increased significantly between 2005 and 2017/18, from 22.2% to 27.2% (p < 0.001). We observed increases across both sexes, all age groups and all Canadian provinces and territories (p < 0.001). In 2017/18, the prevalence of obesity was higher among males than females (28.9% v. 25.4%; p < 0.001); the prevalence among adults aged 40–69 years exceeded 30%. In 2017/18, Newfoundland and Labrador had the highest prevalence (39.4%), and British Columbia had the lowest (22.8%) prevalence of obesity. Over the 14-year study period, Quebec and Alberta exhibited the largest relative increases in obesity.Interpretation:In 2017/18, more than 1 in 4 adult Canadians lived with obesity, and from 2005 to 2017/18, the prevalence of obesity among adults in Canada increased substantially across sexes, age groups and all Canadian provinces and territories to 27.2%. Our findings call for urgent actions to identify, implement and evaluate solutions for obesity prevention and management in all Canadian provinces and territories.

A comparison of household food insecurity rates in Newfoundland and Labrador in 2011-2012 and 2017-2018.

The prevalence of household food insecurity in Newfoundland and Labrador (NL) fell sharply between 2007 and 2011, but it appears to have risen since then. Our objective was to compare the prevalence of food insecurity between 2011-2012 and 2017-2018 in relation to population socio-demographic characteristics. Our analytic sample comprised all NL households in the Canadian Community Health Survey (CCHS) cycles 2011-2012 and 2017-2018, n = 6800. We stratified the prevalence of household food insecurity for each cycle by socio-demographic characteristics and applied multivariable logistic regression models to determine food insecurity odds in 2017-2018 compared with 2011-2012 after controlling for socio-demographic covariates. Interactions of covariates with survey cycle were tested and models stratified when warranted. The prevalence of food insecurity rose from 12.0% (95% CI 10.5, 13.6) in 2011-2012 to 14.7% (95% CI 13.1, 16.6) in 2017-2018. After adjusting for household socio-demographic variables, the odds of food insecurity was 1.49 (95% CI 1.27, 1.75) in 2017-2018. The prevalence of food insecurity had increased significantly among unattached individuals, renters, households with low educational attainment, and households with income above the Low Income Measure, with concomitant increases in the contribution of these groups to the total provincial prevalence of food insecurity in 2017-2018 compared with that in 2011-2012. The odds of food insecurity among NL households increased significantly from 2011-2012 to 2017-2018. Given the serious negative health implications of household food insecurity, the province should draw on the lessons from its earlier success in food insecurity reduction to reverse the current trend.

Initiation or cessation: what keeps the prevalence of smoking higher in Quebec than in the rest of Canada?

We compared smoking initiation and cessation in Quebec versus the rest of Canada as possible underpinnings of the continued higher cigarette smoking prevalence in Quebec. Data were drawn from the Canadian Community Health Survey (CCHS). We compared average and sex-stratified prevalence estimates of (1) current cigarette smoking in persons aged 15 years and older; (2) past-year initiation of cigarette smoking in those aged 12 to 17 and 18 to 24 years; and (3) past-year cessation in adults aged 25 years and older in Quebec versus the other nine Canadian provinces in each two-year CCHS cycle from 2007/08 to 2017/18. The prevalence of current smoking decreased from 25% to 18% among adults aged 15 years and older in Quebec from 2007/08 to 2017/18, and from 22% to 16% in the rest of Canada. Initiation among those aged 12 to 17 years decreased from 9% to 5% in Quebec, and from 7% to 3% in the rest of Canada. Neither initiation among people aged 18 to 24 (at 6% and 7%, respectively) nor cessation among adults aged 25 and older (approximately 8%) changed over time in Quebec or in the rest of Canada. In each two-year CCHS cycle, past-year initiation among those 12 to 17 years of age was consistently higher in Quebec than in the rest of Canada, but there were no substantial or sustained differences in initiation among people aged 18 to 24 or in past-year cessation. Findings were similar when stratified by sex. Higher levels of smoking initiation among youth aged 12 to 17 years could be a proximal underpinning of the continuing higher prevalence of smoking in Quebec versus the rest of Canada.

Trends and Regional Variation in Prevalence of Cardiovascular Risk Factors and Association With Socioeconomic Status in Canada, 2005-2016

Cardiovascular disease remains the second leading cause of death in Canada. Monitoring and tracking the trends and disparities in major cardiovascular risk factors could provide benchmarks for future cardiovascular health strategies. To investigate the temporal trends, regional variations, and socioeconomic disparities in major cardiovascular risk factors in Canada from 2005 to 2016. This repeated cross-sectional survey study included adults aged 20 years and older from 6 Canadian Community Health Survey cycles between 2005 and 2016. Cardiovascular risk factors included hypertension, diabetes, obesity, and current smoking. Socioeconomic status was measured using equivalized household income. Data analysis was performed from September 2019 to April 2020. A total of 112 health regions and socioeconomic status. Age- and sex-adjusted prevalence of hypertension, diabetes, obesity, and current smoking by year; health regions; and socioeconomic status. Absolute numbers were rounded to base 100 for confidentiality purposes, and percentages were based on weighted numbers. Slope index of inequality (SII) and relative index of inequality (RII) were calculated to assess absolute and relative socioeconomic inequalities, respectively. A total of 670 000 respondents (329 000 [49.1%] men; 341 000 [50.9%] women) aged 20 years and older from 6 survey cycles were enrolled for this study. The largest age group was those aged 40 to 59 years (eg, 2005 cycle: 40.2% [95% CI, 39.9%-40.6%]). In the 2015/2016 cycle, the overall age- and sex-adjusted prevalence rates of hypertension, diabetes, obesity, and current smoking were 20.7% (95% CI, 20.4%-21.1%), 7.2% (95% CI, 7.0%-7.5%), 20.1% (95% CI, 19.7%-20.6%), and 17.8% (95% CI, 17.4%-18.2%), respectively. From 2005 to 2016, there was a significant increase in the prevalence of hypertension, diabetes, and obesity (eg, prevalence of diabetes in both sexes, 2005: 5.8% [95% CI, 5.6%-6.0%]; 2015/2016: 7.2% [95% CI, 7.0%-7.5%]; P < .001) but a significant decrease in the prevalence of current smoking (both sexes, 2005: 22.1% [95% CI, 21.7%-22.5%]; 2015/2016: 17.8% [95% CI, 17.4%-18.2%]; P < .001). The prevalence of all the risk factors varied widely across health regions (eg, obesity, Vancouver Health Service Delivery Area: 6.7% [95% CI, 4.5%-9.0%]; Miramichi Area: 36.8% [95% CI, 27.3%-46.3%]). In addition to obesity among men, all risk factors tended to be more common among those with lower income (eg, prevalence of hypertension in both sexes, 2015/2016, lowest income group: 23.2% [95% CI, 22.4%-24.0%]; highest income group: 18.4% [95% CI, 17.7%-19.1%]). The SII and RII indicated consistent absolute and relative socioeconomic inequalities in hypertension, diabetes, and current smoking over time (eg, RII for hypertension in both sexes, 2005: 1.25; 95% CI, 1.18-1.33; 2015/2016: 1.34; 95% CI, 1.26-1.43). However, the phenomenon of absolute and relative socioeconomic inequalities in obesity was only observed among women (eg, RII for 2015/2016 for obesity in women; 1.74 (95% CI, 1.56-1.93); men: 1.09; 95% CI, 0.99-1.21). During the study period, the prevalence of hypertension, diabetes, and obesity significantly increased, while the prevalence of current smoking significantly decreased. Geographic and socioeconomic gaps should be considered and addressed in future interventions and policies targeted at reducing these cardiovascular risk factors in Canada.

Black-white racial disparities in household food insecurity from 2005 to 2014, Canada.

ObjectivesTo understand the differential vulnerability to household food insecurity of the Black population as compared with white counterparts in Canada.MethodsUsing data for households with Black and white respondents in pooled Canadian Community Health Survey cycles from 2005 to 2014, the 18-question Household Food Security Survey Module was analyzed (N = 491,400). Bivariate and multivariate logistic and multinomial regression models were run using respondent’s race, immigration status, and six well-established predictors of household food insecurity in the general population. Additional multivariable logistic regression models were run, with race interacted with each predictor individually to yield predicted probabilities.ResultsThe weighted prevalence of household food insecurity was 10.0% for white respondents and 28.4% for Black respondents. The odds of Black households being food-insecure as compared with white households fell from 3.56 (95% CI: 3.30–3.85) to 1.88 (95% CI: 1.70–2.08) with adjustment for household socio-demographic characteristics. In contrast with white households, there was relative homogeneity of risk of food insecurity among Black subgroups defined by immigration status, household composition, education, and province of residence. Homeownership was associated with lower probabilities of food insecurity for Black and white households, but the probability among Black owners was similar to that for white renters (14.7% vs. 14.3%). Black households had significantly higher predicted probabilities of food insecurity than their white counterparts across all main sources of household income except child benefits and social assistance.ConclusionBeing racialized as Black appears to be an overriding factor shaping vulnerability to food insecurity for the Black population in Canada. Future research and public policy on food insecurity should seriously consider the role of racism at the systemic and institutional levels.

Cchsflow: an open science approach to transform and combine population health surveys

SettingThe Canadian Community Health Survey (CCHS) is one of the world’s largest ongoing cross-sectional population health surveys, with over 130,000 respondents every two years or over 1.1 million respondents since its inception in 2001. While the survey remains relatively consistent over the years, there are differences between cycles that pose a challenge to analyze the survey over time.InterventionA program package called cchsflow was developed to transform and harmonize CCHS variables to consistent formats across multiple survey cycles. An open science approach was used to maintain transparency, reproducibility and collaboration.OutcomesThe cchsflow R package uses CCHS survey data between 2001 and 2014. Worksheets were created that identify variables, their names in previous cycles, their category structure, and their final variable names. These worksheets were then used to recode variables in each CCHS cycle into consistently named and labelled variables. Following, survey cycles can be combined. The package was then added as a GitHub repository to encourage collaboration with other researchers.ImplicationThe cchsflow package has been added to the Comprehensive R Archive Network (CRAN) and contains support for over 160 CCHS variables, generating a combined data set of over 1 million respondents. By implementing open science practices, cchsflow aims to minimize the amount of time needed to clean and prepare data for the many CCHS users across Canada.

Using external data to incorporate unmeasured confounders: A plasmode simulation study comparing alternative approaches to impute body mass index in a study of the relationship between osteoarthritis and cardiovascular disease

Background: Administrative databases do not contain Body Mass Index (BMI) informa- tion. In proportion-based imputation (PBI) technique, a BMI category is assigned to an individual according to the proportions observed in external survey data. Alternatively, BMI can be imputed using Multiple Imputation (MI). Objectives: To compare MI with PBI to impute BMI variable in osteoarthritis (OA)- cardiovascular disease (CVD) relationship. Research Design: plasmode simulation study. Subjects: used publicly available data from the Canadian Community Health Survey (CCHS) cycles 1.1, 2.1, and 3.1. Measures: BMI was set missing for everyone in the 500 simulated data created from CCHS 3.1 data. Dataset compiled from CCHS cycles 1.1 and 2.1 served as the external data (BMI observed). BMI missing in copies of simulated data was imputed using MI and PBI accessing observed BMI information in external data. After imputation, distribution of BMI variable and the adjusted odds ratio (aOR) estimated from multivariable logistic regression model were compared. Results: Compared to PBI, MI produced proportions of individuals closer to the known proportions across the BMI categories except for the overweight category. Considering the known aOR of 1.59 (1.36, 1.82), BMI imputed using MI introduced less bias in OA- CVD association compared to PBI, the aOR was 1.62 (1.39, 1.86) and 1.66 (1.41, 1.90), respectively. Conclusions: This is the first study to compare MI with PBI in the context of imputing BMI information that is not recorded at the database level. MI was superior to imputation method based on population-level proportions in imputing BMI missing for everyone in the simulated datasets.

Major Depressive Episodes and Employment Earnings Trajectories over the Following Decade among Working-aged Canadian Men and Women

Quantify the association between experiencing a major depressive episode (MDE) and employment earnings over the following decade among working-aged Canadian men and women. Ten national Canadian Community Health Survey (CCHS 2003-2014) cycles were linked to administrative tax records (1997-2016) for individuals 18-54 years old with information on past year MDE defined by the Composite International Diagnostic Interview Short Form (n=85,155) measured at baseline. Subsequent earnings were measured annually two to ten years post-MDE. MDE cases were matched with adult controls without MDE using 1:1 greedy nearest-neighbour without replacement propensity score matching for women and men. Using random-effects longitudinal modelling, among women (n=6,974) in the matched cohort (average initial earnings ~$52,119/annum, 2016 Canadian real dollars), experiencing an MDE was associated with average earnings of $4,473 less in the year the MDE was reported (95%CI=-$3,215,-$5,731) and an additional $363 less/year over the following decade (95%CI=-$132,-$594). Among men (n=3,620, average initial earnings ~$76,110/annum), an MDE was associated with an initial reduction in earnings of $5,023 (95%CI=-$2,453,-$7,593) followed by an earnings decline starting with $730/year, increasing to ~$1,810/year at ten years post-MDE. Residual confounding by measures excluded from the propensity score. Only one MDE measurement limited exploring earnings trajectories of those with multiple episodes. Consistently lower earnings were seen for ten years after experiencing one MDE. The magnitude of earnings difference immediately after the MDE was similar for men and women. Findings reveal the critical period surrounding an MDE where effective clinical treatment and labor policy may help buffer longstanding earnings loss.

Rationale and Methodology of the 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS): A 16-year Follow-up Survey: Raison D'être Et Méthodologie De L'enquête De Suivi Sur La Santé Mentale Des Membres Des Forces Armées Canadiennes Et Des Anciens Combattants, 2018 (ESSMFACM).

Objective:Knowledge is limited regarding the longitudinal course and predictors of mental health problems, suicide, and physical health outcomes among military and veterans. Statistics Canada, in collaboration with researchers at the University of Manitoba and an international team, conducted the Canadian Armed Forces Members and Veterans Mental Health Follow-Up Survey (CAFVMHS). Herein, we describe the rationale and methods of this important survey.Method:The CAFVMHS is a longitudinal survey design with 2 time points (2002 and 2018). Regular Force military personnel who participated in the first Canadian Community Health Survey Cycle 1.2—Mental Health and Well-Being, Canadian Forces Supplement (CCHS-CFS) in 2002 (N = 5,155) were reinterviewed in 2018 (n = 2,941). The World Mental Health Survey–Composite International Diagnostic Interview was used with the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria.Results:The CAFVMHS includes 2,941 respondents (66% veterans; 34% active duty) and includes data on mental disorder diagnoses, physical health conditions, substance use, medication use, general health, mental health services, perceived need for care, social support, moral injury, deployment experiences, stress, physical activity, military-related sexual assault, childhood experiences, and military and sociodemographic information.Conclusions:The CAFVMHS provides a unique opportunity to further understand the health and well-being of military personnel in Canada over time to inform intervention and prevention strategies and improve outcomes. The data are available through the Statistics Canada Research Data Centres across Canada and can be used cross-sectionally or be longitudinally linked to the 2002 CCHS-CFS data.

A study protocol for a predictive algorithm to assess population-based premature mortality risk: Premature Mortality Population Risk Tool (PreMPoRT)

BackgroundPremature mortality is an important population health indicator used to assess health system functioning and to identify areas in need of health system intervention. Predicting the future incidence of premature mortality in the population can facilitate initiatives that promote equitable health policies and effective delivery of public health services. This study protocol proposes the development and validation of the Premature Mortality Risk Prediction Tool (PreMPoRT) that will predict the incidence of premature mortality using large population-based community health surveys and multivariable modeling approaches.MethodsPreMPoRT will be developed and validated using various training, validation, and test data sets generated from the six cycles of the Canadian Community Health Survey (CCHS) linked to the Canadian Vital Statistics Database from 2000 to 2017. Population-level risk factor information on demographic characteristics, health behaviors, area level measures, and other health-related factors will be used to develop PreMPoRT and to predict the incidence of premature mortality, defined as death prior to age 75, over a 5-year period. Sex-specific Weibull accelerated failure time models will be developed using a Canadian provincial derivation cohort consisting of approximately 500,000 individuals, with approximately equal proportion of males and females, and about 12,000 events of premature mortality. External validation will be performed using separate linked files (CCHS cycles 2007–2008, 2009–2010, and 2011–2012) from the development cohort (CCHS cycles 2000–2001, 2003–2004, and 2005–2006) to check the robustness of the prediction model. Measures of overall predictive performance (e.g., Nagelkerke’s R2), calibration (e.g., calibration plots), and discrimination (e.g., Harrell’s concordance statistic) will be assessed, including calibration within defined subgroups of importance to knowledge users and policymakers.DiscussionUsing routinely collected risk factor information, we anticipate that PreMPoRT will produce population-based estimates of premature mortality and will be used to inform population strategies for prevention.

Changes in income‐related inequalities in oral health status in Ontario, Canada

Oral health inequalities impose a substantial burden on society and the healthcare system across Canadian provinces. Monitoring these inequalities is crucial for informing public health policy and action towards reducing inequalities; however, trends within Canada have not been explored. The objectives of this study are as follows: (a) to assess trends in income-related inequalities in oral health in Ontario, Canada's most populous province, from 2003 to 2014, and (b) to determine whether the magnitude of such inequalities differ by age and sex. Data representative of the Ontario population aged 12years and older were sourced from the Canadian Community Health Survey (CCHS) cycles 2003 (n=36,182), 2007/08 (n=36,430) and 2013/14 (n=41,258). Income-related inequalities in poor self-reported oral health (SROH) were measured using the Slope Index of Inequality (SII) and Relative Index of Inequality (RII) and compared across surveys. All analyses were sample-weighted and performed with STATA 15. The prevalence of poor SROH was stable across the CCHS cycles, ranging from 14.1% (2003 cycle) to 14.8% (2013/14 cycle). SII estimates did not change (18.7-19.0), while variation in RII estimates was observed over time (2003=3.85; 2007/08=4.47; 2013/14=4.02); differences were not statistically significant. SII and RII were lowest among 12- to 19-year-olds and gradually higher among 20- to 64-year-olds. RII was slightly higher among females in all survey years. Absolute and relative income-related inequalities in SROH have persisted in Ontario over time and are more severe among middle-aged adults. Therefore, oral health inequalities in Ontario require attention from key stakeholders, including governments, regulators and health professionals.