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Malnutrition in medical and surgical inpatients is an on-going problem. More-2-Eat (M2E) Phase 1 demonstrated that improved detection and treatment of hospital malnutrition could be embedded into routine practice using an intensive researcher-facilitated implementation process. Yet, spreading and sustaining new practices in diverse hospital cultures with minimal researcher support is unknown.To demonstrate that a scalable model of implementation can increase three key nutrition practices (admission screening; Subjective Global Assessment (SGA); and medication pass (MedPass) of oral nutritional supplement) in diverse acute care hospitals to detect and treat malnutrition in medical and surgical patients.Ten hospitals participated in this pretest post-test time series implementation study from across Canada, including 21 medical or surgical units (Phase 1 original units (n = 4), Phase 1 hospital new units (n = 9), Phase 2 new hospitals and units (n = 8)). The scalable implementation model included: training champions on implementation strategies and providing them with education resources for teams; creating a self-directed audit and feedback process; and providing mentorship. Standardized audits of all patients on the study unit on an audit day were completed bi-monthly to track nutrition care activities since admission. Bivariate comparisons were performed by time period (initial, mid-term and final audits). Run-charts depicted the trajectory of change and qualitatively compared to Phase 1.5158 patient charts were audited over the course of 18-months. Admission nutrition screening rates increased from 50% to 84% (p 0.0001). New Phase 1 units more readily implemented screening than Phase 2 sites, and the original Phase 1 units generally sustained screening practices from Phase 1. SGA was a sustained practice at Phase 1 hospitals including in new Phase 1 units. The new Phase 2 units improved completion of SGA but did not reach the levels of Phase 1 units (original or new). MedPass almost doubled over the time periods (7%-13% of all patients p 0.007). Other care practices significantly increased (e.g. volunteer mealtime assistance).Nutrition-care activities significantly increased in diverse hospital units with this scalable model. This heralds the transition from implementation research to sustained changes in routine practice. Screening, SGA, and MedPass can all be implemented, improve nutrition care for all patients, spread within an organization, and for the most part, sustained (and in the case of original Phase 1 units, for over 3 years) with champion leadership.

Summary Background Poor food intake is common in hospital patients and is associated with adverse patient and healthcare outcomes; diverse mealtime barriers to intake often undermine clinical nutrition care. Aim This study determines whether implementation of locally adaptable nutrition care activities as part of uptake of the Integrated Nutrition Pathway for Acute Care (INPAC) reduced mealtime barriers and improved other patient outcomes (e.g. length of stay; LOS) when considering other covariates. Methods 1250 medical patients from 5 Canadian hospitals were recruited for this before-after time series design. Mealtime barriers were tallied with the Mealtime Audit Tool after a meal, while proportion of the meal consumed was assessed with the My Meal Intake Tool. Implementation of new standard care activities occurred over 12 months and three periods (pre-, early, and late) of implementation were compared. Regression analyses determined the effect of time period while adjusting for key covariates. Results Mealtime barriers were reduced over time periods (Period 1 = 2.5 S.D. 2.1; Period 3 = 1.8 S.D. 1.7) and site differences were noted. This decrease was statistically significant in regression analyses (−0.28 per time period; 95% CI -0.44, −0.11). Within and across site changes were also observed over time in meal intake and LOS; however, after adjusting for covariates, time period of implementation was not significantly associated with these outcomes. Discussion Mealtime barriers can be reduced and sustained by implementing improved standard care procedures for patients. The More-2-Eat study provides an example of how to implement changes in practice to support the prevention and treatment of malnutrition. Trial registration Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304 , June 7, 2016.

BACKGROUND Decreased physical functioning is associated with malnutrition and common in acute care patients; determining loss of function is often considered part of a comprehensive nutrition assessment. Handgrip strength (HGS) and 5-meter timed walk (5m) are functional measures used in a variety of settings. This analysis sought to determine which functional measure could be added to a hospital nutrition assessment, based on its feasibility and capacity to discriminate patient subgroups. METHODS Eligible medical patients (no delirium/dementia, admitted from community; n = 1250), recruited from 5 hospitals that participated in a previous multisite action research study, provided data on demographics, HGS, 5m, nutrition status, perceived disability, and other characteristics. RESULTS Significantly more patients (z = 17.39, P < .00001) were able to complete HGS than 5m (92% versus 43%, respectively). Median HGS was 28.0 kg for men and 14.7 kg for women. Of patients who completed the 5m, mean completion time was 8.98 seconds (median, 6.79 seconds, SD = 6.59). 5m and HGS scores were significantly worse with patient-perceived disability (z = -9.56, t = 10.69, respectively; P < .0001; 95% confidence interval [CI], [7.33, 10.63]; [1.76, 3.18]). HGS was associated with nutrition status (t = 4.13, P < .001; 95% CI [2.02, 5.67]), although it showed poor validity as a single nutrition indicator. CONCLUSIONS These data indicate that HGS is a more useful functional measure than 5m when added to a hospital nutrition assessment. Determination of HGS cutpoints to identify low strength in acute care patients will promote its use.

Summary Background Handgrip strength (HGS) is a practical measure of strength and physical function that can be used to identify frailty among hospitalized patients, but its utility in this setting is unclear. To be considered useful, any functional measure needs to provide pertinent information on the patient and predict relevant outcomes such as health-care utilization (e.g., length of stay (LOS)) and patient-reported quality of life (QOL). The purpose of this study was to determine if HGS predicted LOS and QOL. A second aim was to examine the best sensitivity (SE) and specificity (SP) for predicting length of stay (>7 or >13 days) using previously published cut-points for HGS. Methodology HGS was measured on 1136 medical patients shortly after admission with a Lafayette dynamometer. QOL was assessed with the self-reported SF-12 completed with an interviewer during hospitalization and 30- days after discharge via telephone. Physical (PCS) and mental (MCS) component scores of SF-12 were calculated. A variety of covariates were assessed (e.g., nutritional status). Multivariate analyses stratified by sex were completed. Results The mean LOS was 12.71 days (median = 8.00; SD = 13.20), 12.88 days (SD = 13.82) for males, and 12.58 days (SD = 12.68) for females. Lower admission HGS scores were associated with longer LOS (male X2 = 7.85, p Conclusion Admission HGS adds predictive value for both LOS and physical components of QOL and is worth pursuing in practice to identify potential frailty and the need for proactive steps to mitigate further functional decline during hospitalization. However, HGS cut-points for LOS specific to acute care patients need to be defined and tested.

Decreased physical functioning is associated with malnutrition and common in acute care patients; determining loss of function is often considered part of a comprehensive nutrition assessment. Handgrip strength (HGS) and 5-meter timed walk (5m) are functional measures used in a variety of settings. This analysis sought to determine which functional measure could be added to a hospital nutrition assessment, based on its feasibility and capacity to discriminate patient subgroups.Eligible medical patients (no delirium/dementia, admitted from community; n = 1250), recruited from 5 hospitals that participated in a previous multisite action research study, provided data on demographics, HGS, 5m, nutrition status, perceived disability, and other characteristics.Significantly more patients (z = 17.39, P.00001) were able to complete HGS than 5m (92% versus 43%, respectively). Median HGS was 28.0 kg for men and 14.7 kg for women. Of patients who completed the 5m, mean completion time was 8.98 seconds (median, 6.79 seconds, SD = 6.59). 5m and HGS scores were significantly worse with patient-perceived disability (z = -9.56, t = 10.69, respectively; P.0001; 95% confidence interval [CI], [7.33, 10.63]; [1.76, 3.18]). HGS was associated with nutrition status (t = 4.13, P.001; 95% CI [2.02, 5.67]), although it showed poor validity as a single nutrition indicator.These data indicate that HGS is a more useful functional measure than 5m when added to a hospital nutrition assessment. Determination of HGS cutpoints to identify low strength in acute care patients will promote its use.

In-hospital malnutrition and inadequate food intake have been associated with negative outcomes (e.g., prolonged length of stay, readmission, mortality, and increased hospital costs). Studies examining the factors associated with low food intake in hospital, commonly defined as the consumption of ≤50% of meals, have produced mixed results. We examined the correlates of food intake including patient socioeconomic, demographic, and health characteristics, institutional factors, and common clinical strategies in 1129 medical patients from 5 Canadian hospitals. Low food intake was found in 35% of patients (41% of females and 29% of males) (p < 0.001). In multivariate analyses, sex, socioeconomic status, demographics, and diagnoses were not significantly related to food intake. Patients assessed as malnourished (subjective global assessment (SGA) B/C) (odds ratio (OR), 2.41; p = 0.003) or as not at risk of malnutrition (OR, 1.67; p = 0.040) were more likely to have low intake when compared with those assessed as well nourished (SGA A). Patient reports of mealtime challenges (OR, 2.70; p < 0.001) and barriers to food intake (OR, 1.11; p = 0.008) were positively related to low intake throughout the study sample. Higher 12-Item Short Form Health Survey Mental Component Summary scores were related to better food intake (OR, 0.98; p < 0.001). Clinical strategies such as between-meal snacks lowered the likelihood of low food intake (OR, 0.55; p = 0.037), whereas a group of “other strategies” increased the odds (OR, 2.77; p = 0.001). These results offer a better understanding of the correlates of in-hospital low food intake. The conclusion discusses some avenues for improving food intake in the clinical setting, such as better mealtime monitoring and a reduction in barriers to food intake.

Many international medical graduates (IMGs) are unable to find residency positions in Canada. A growing proportion are “Canadians studying abroad” (CSAs) trying to return to Canada. We examine the characteristics and practice intentions of residents in Canada: IMGs excluding CSAs, CSAs, and Canadian medical school graduates (CMGs). CSAs and CMGs appear to be similar, but IMGs do not in key instances. IMGs are substantially less likely to state that they intend to practise where they trained or in Canada, controlling for characteristics. This adds support to previous findings indicating that regions relying on IMGs to provide health care may experience ongoing challenges.

Many patients leave hospital in poor nutritional states, yet little is known about the post-discharge nutrition care in which patients are engaged. This study describes the nutrition-care activities 30-days post-discharge reported by patients and what covariates are associated with these activities. Quasi-randomly selected patients recruited from 5 medical units across Canada (n = 513) consented to 30-days post-discharge data collection with 48.5% (n = 249) completing the telephone interview. Use of nutrition care post-discharge was reported and bivariate analysis completed with relevant covariates for the two most frequently reported activities, following recommendations post-discharge or use of oral nutritional supplements (ONS). A total of 42% (n = 110) received nutrition recommendations at hospital discharge, with 65% (n = 71/110) of these participants following those recommendations; 26.5% (n = 66) were taking ONS after hospitalization. Participants who followed recommendations were more likely to report following a special diet (p = 0.002), different from before their hospitalization (p = 0.008), compared to those who received recommendations, but reported not following them. Patients taking ONS were more likely to be at nutrition risk (p < 0.0001), malnourished (p = 0.0006), taking ONS in hospital (p = 0.01), had a lower HGS (p = 0.0013; males only), and less likely to believe they were eating enough to meet their body’s needs (p = 0.005). This analysis provides new insights on nutrition-care post-discharge.

Socioeconomic inequality, or the socioeconomic status (SES) gradient, is arguably one of the most-studied phenomena in health. The gradient in health is apparent in objective and subjective measures, across virtually all countries, and is evident at individual and population levels. There is no longer much debate over the relationship between SES and health. However, exact causal pathways remain elusive. Advocating for strong policy to reduce or eliminate the SES-health gradient necessitates understanding the causal pathways, from intervention to outcome. While economists are not convinced that there is a clear enough understanding of the causal pathways of the SES-health gradient, they have produced a substantial body of work from which to move forward. The article briefly discusses the theoretical underpinnings used by economists as a basis for the study of the causal pathways for the health gradient. That presentation is followed by a concise overview of some of the evidence that economists have produced. The paper concludes with a discussion of how current economic evidence may be used to help policymakers advocate for interventions to limit the SES gradient in noncommunicable diseases.La desigualdad socioeconómica, o el gradiente según la situación socioeconómica, es posiblemente uno de los fenómenos más estudiados en el campo de la salud. El gradiente de la salud es evidente en mediciones objetivas y subjetivas, en prácticamente todos los países y tanto a nivel individual como poblacional. Ya no se debate mucho la relación entre la situación socioeconómica y la salud. Sin embargo, las vías causales exactas siguen siendo difíciles de definir. A fin de promover políticas enérgicas que reduzcan o eliminen el gradiente socioeconómico de la salud, es necesario entender las vías causales, de la intervención al resultado. Si bien los economistas no están convencidos de que se conozcan suficientemente las vías causales del gradiente socioeconómico de la salud, han producido un volumen sustancial de trabajo a partir del cual avanzar. En este artículo se comentan brevemente los fundamentos teóricos usados por los economistas como base para estudiar las vías causales del gradiente de salud. Luego se brinda un panorama conciso de algunos de los datos científicos generados por los economistas. El artículo concluye con una discusión de cómo pueden usarse los datos científicos económicos actuales para ayudar a los responsables de formular políticas a proponer intervenciones que limiten el gradiente socioeconómico en materia de enfermedades no transmisibles.A desigualdade socioeconômica, ou o gradiente socioeconômico, é possivelmente um dos fenômenos mais estudados em saúde. O gradiente em saúde é evidente nas medidas objetivas e subjetivas em praticamente todos os países e é evidente ao nível do indivíduo e de população. Já não existe muito debate sobre a relação entre nível socioeconômico e saúde, mas as exatas vias causais continuam mal definidas. Defender uma firme política para reduzir ou eliminar o gradiente socioeconômico em saúde requer conhecer as vias causais, da intervenção ao resultado. Por não estarem convencidos de que existe um entendimento claro razoável das vias causais do gradiente socioeconômico em saúde, os economistas produziram um volume substancial de estudos que servem de base. O artigo aborda resumidamente os princípios teóricos para embasar o estudo das vias causais do gradiente em saúde e apresenta de forma concisa o panorama das evidências geradas pelos economistas. Por fim, se discute como as evidências econômicas atuais podem ser empregadas para ajudar os responsáveis pelas políticas a defender intervenções visando reduzir o gradiente socioeconômico nas doenças não transmissíveis.

Staff play key roles in the prevention, detection, and treatment of hospital malnutrition. Understanding staff knowledge, attitudes, and practices (KAP) is important for developing and evaluating change management strategies.The More-2-Eat project improved nutrition care in 5 Canadian hospitals by implementing the Integrated Nutrition Pathway for Acute Care (INPAC). To understand staff views before (T1) and after 1 year of implementation (T2), a reliable KAP questionnaire, based on INPAC, was administered. T2 included questions about involvement in implementation. The mean difference between T2 and T1 responses was calculated, and t tests were used for comparisons.The questionnaire was completed at T1 (n = 189) and T2 (n = 147) (unpaired); 57 staff completed both questionnaires (paired). A significant increase in total score was seen in unpaired results at T2 (from 93.6/128 [range, 51-124] to 99.5/128 [range, 54-119]; t = 5.97, P.0001), with an increase in knowledge/attitudes (KA) (t = 2.4, P = .016) and practice (t = 3.57, P.0001) components. There were no statistically significant changes in paired responses. Seventy percent (n = 102/147) noticed positive changes in practices, 12% (n = 18) noticed positive/negative changes, 1% (n = 1) noticed negative change, and 17% (n = 25) noticed no change. Fifty-nine percent (n = 86) felt involved in the change, and these staff had higher KA and KAP scores than those who did not feel involved.Staff involvement is important in the implementation process for improving nutrition care.

Nous savons peu de choses sur les facteurs liesa la duree de la pauvrete au Canada et sur des facteurs qui pourraient avoir un effet different chez les hommes et chez les femmes. De plus, la recherche s’interesse peu a tout ce qui entoure la sortie de la pauvrete au Canada : par exemple, certains Canadiens ne s’eloignent que legerement du seuil de pauvrete, alors que d’autres reussissenta avoir un revenu reellement superieur au seuil de pauvrete. Dans cet article, nous explorons les determinants de la duree de la pauvrete chez les hommes et chez les femmes au Canada. L’une des contributions majeures de cette recherche est que nous y examinons la duree de la pauvrete en lien avec differents scenarios de sortie de la pauvrete, vers un revenu legerement au-dessus du seuil de pauvrete et vers un revenu reellement superieur au seuil de pauvrete. Nous montrons que pres d’un quart des periodes de pauvrete se terminent par une sortie qui se situe autour de 110 pour cent du seuil de pauvrete (donc tres pres de la pauvrete) ; et plusieurs Canadiens qui en sortent de cette facon vivent de nombreuxepisodes de pauvrete.Nos resultats, previsibles, indiquent qu’un degre superieur de scolarite augmente la probabilite d’une sortie de la pauvrete vers un revenu reellement superieur au seuil de pauvrete, mais que peu de facteurs sont associesa une sortie de la pauvrete vers un revenu legerement au-dessus du seuil de pauvrete. Par ailleurs, plus les periodes de pauvrete sont longues, plus la probabilite d’en sortir est faible, et particulierement vers un revenu reellement superieur au seuil de pauvrete. De plus, les coefficients ne permettent pas d’etablir de reelles differences entre les sexes ; il y a toutefois des differences dans les caracteristiques associeesa une sortie de la pauvrete vers un revenu legerement au-dessus du seuil de pauvrete et vers un revenu reellement superieur au seuil de pauvrete. Abstract: Little is understood about the factors associated with poverty duration in Canada, or which factors, if any, may affect women and men differently. Moreover, research pays scant attention to how far Canadians transition out of poverty. For example, some may exit poverty only marginally, while others exit much further above the poverty line. We investigate the determinants of poverty duration among women and men in Canada. A major contribution of this article is the examination of poverty duration across different exit destinations (competing risks): exits to just above the poverty line versus exits to further above the poverty line. We find that nearly one-quarter of poverty spells end within 110 percent of the poverty line (near poverty). Many of those who exit to near poverty experience multiple spells. As expected, we find that higher education increases the probability of transitioning further out of poverty, but very little is correlated with exits to near poverty relative to remaining in poverty. The longer the poverty spell, the lower the probability of exit, particularly to higher income levels. We find few significant gender differences in the coefficient estimates. Differences are present in the characteristics associated with exits close to or further away from the poverty line.

Hospital malnutrition has been established as a critical, prevalent, and costly problem in many countries. Many cost studies are limited due to study population or cost data used. The aims of this study were to determine: the relationship between malnutrition and hospital costs; the influence of confounders on, and the drivers (medical or surgical patients or degree of malnutrition) of the relationship; and whether hospital reported cost data provide similar information to administrative data. To our knowledge, the last two goals have not been studied elsewhere.Univariate and multivariate analyses were performed on data from the Canadian Malnutrition Task Force prospective cohort study combined with administrative data from the Canadian Institute for Health Information. Subjective Global Assessment was used to assess the relationship between nutritional status and length of stay and hospital costs, controlling for health and demographic characteristics, for 956 patients admitted to medical and surgical wards in 18 hospitals across Canada.After controlling for patient and hospital characteristics, moderately malnourished patients' (34% of surveyed patients) hospital stays were 18% (p = 0.014) longer on average than well-nourished patients. Medical stays increased by 23% (p = 0.014), and surgical stays by 32% (p = 0.015). Costs were, on average, between 31% and 34% (p-values 0.05) higher than for well-nourished patients with similar characteristics. Severely malnourished patients (11% of surveyed patients) stayed 34% (p = 0.000) longer and had 38% (p = 0.003) higher total costs than well-nourished patients. They stayed 53% (p = 0.001) longer in medical beds and had 55% (p = 0.003) higher medical costs, on average. Trends were similar no matter the type of costing data used.Over 40% of patients were found to be malnourished (1/3 moderately and 1/10 severely). Malnourished patients had longer hospital stays and as a result cost more than well-nourished patients.

A plethora of literature links socioeconomic status (SES) to health and health care utilization. Recent anecdotal evidence indicates that Canadians believe their access to health care is diminishing. This study describes health care utilization patterns for services provided under public health insurance (physicians, specialists, and hospitals) in Canada between 1978 and 2003. The relationship between SES and utilization, controlling for health and demographic characteristics, is examined to investigate whether changes in the equity of utilization have occurred over time. Results indicate that SES inequities in utilization are apparent, appearing to be more relevant in initial contact with the system than in the number of visits. Specialists' services are particularly problematic and becoming more so over time.

The evolution of measured poverty may reflect socio-economic developments, particular measurement choices or the effect (or lack of effect) of policy initiatives. We report a “case study” of child poverty in Canada between 1986 and 2000, a period when the elimination of child poverty was a stated policy goal, but reported child poverty rates did not change significantly. We find that the apparent persistence of child poverty in Canada is remarkably robust to measurement choices, and cannot easily be explained by socioeconomic developments.

OBJECTIVE: To determine the association of socio-economic (SES) factors with risk behaviours among adolescents. METHODS: A cross-sectional survey was carried out on students in four high schools in northern Nova Scotia, Canada. Associations between SES variables and substance use behaviours, having early intercourse and suicide attempt in the past year were examined using multivariate analysis (logit regression). Negative binomial regression was performed for associations of SES with a total risk score summing risk behaviours. RESULTS: Participants included 2,198 students (48% males; 52% females) ranging in age from 14 to 20 years. Almost 25% of youth smoked regularly, 19% of males smoked marijuana > or = 10 times monthly, more than 40% of males regularly drank excessively, and 10% of students > 14 years old had had intercourse before age 15. Smoking was the behaviour most often associated with lower SES in both genders. Mother's not being employed was protective against all substance use variables except driving after drinking. Living both with lone mother and in any family arrangement other than with both parents was associated with smoking, using marijuana, and early sex. Higher risk score was associated with living with a lone mother or other family arrangement. Lower risk score was associated with father having more than high school education and mother not working. INTERPRETATION: Lower socio-economic status is associated with adolescent risk behaviours. These findings point to the importance of these factors to risk-taking in youth, their relevance to social policy, and also their importance as factors to consider in targeted interventions. Language: en

Examined the mutual influence on maternal depressive symptoms and child adjustment problems and their antecedent-consequence conditions across 3 cycles of panel data collected over a 4-year period in the National Longitudinal Survey of Children and Youth (NLSCY). Results indicated stability in, and relations between, maternal and child outcomes. Cross-lagged panel correlations showed that maternal depressive symptoms tended to precede child aggression and hyperactivity but tended to follow child emotional problems. Temporal relations were interpreted in the context of mechanisms that transmit risk between mothers and children. Logistic regression analysis showed bidirectional risk between maternal mood and child adjustment after earlier symptoms were statistically controlled. These findings indicate that maternal depression increases the risk of adjustment problems in children, and vice versa, underscoring the intergenerational transmission of psychopathology.

The upbringing of children is modeled as a modified principal agent problem in which children attempt to maximize their own well-being when faced with a parenting strategy chosen by the parent, to maximize parent's perception of family well-being. Thus, children as well as parents are players, but children have higher discount rates than parents. The simultaneity of parenting and child behaviour is confirmed using the 1994 Canadian National Longitudinal Survey of Children.

We use data from the Ontario Child Health Study (OCHS) to provide the first Canadian estimates of how the empirical association between child health and both low-income and family status (lone-mother versus two-parent) changes when we re-estimate the model with pooled data. Two waves of data provide a better indication of the family's long-run level of economic resources than does one wave. Our measures of health status include categorical indicators and the health utility score derived from the Health Utilities Index Mark 2 (HUI2) system. Consistent with findings from other countries, we find that most outcomes are more strongly related to low-average income (in 1982 and 1986) than to low-current income in either year. Unlike some previous research, we find the quantitative impact of low-income on child health to be modest to large. Lone-mother status is negatively associated with most outcomes, but the lone-mother coefficients did not change significantly when we switched from low-current income to low-average income. This implies that the lone-mother coefficient in single cross-sections is not just a proxy for low-permanent income.

An educational hearing conservation program (HCP) emphasizing student participation and supplemental in-class activities led by a teacher was presented in two 1-hour sessions to two classes of fourth-grade children enrolled in regular education programs. Questionnaires assessing their knowledge of hearing, noise-induced hearing loss, and hearing conservation practices were administered before and after the HCP. Significant increases in knowledge concerning noise-induced hearing loss and hearing conservation practices were seen in both classes, with greater gain seen among students receiving more extensive supplemental activities. Post-HCP responses revealed that the majority of the children intend to use ear protection when engaged in noisy activities. Teachers indicated they would increase coverage of hearing and hearing conservation in their classrooms and use hearing protection when exposed to loud noise.

This comparative study of the relationship between family economic background and adult outcomes in the United States and Canada addresses three questions. First, is there something to explain? We suggest that the existing literature finds that there are significant differences in the degree of intergenerational economic mobility between these two countries, relative mobility being lower in the United States. This is the result of lower mobility at the very top and the very bottom of the earnings distribution. Second, does this reflect different underlying values of the citizens in these countries? Findings from comparable public opinion polls suggest that this is not the case. The citizens of both countries have a similar understanding of a successful life, one that is rooted in individual aspirations and freedom. They also have similar views on how these goals should be attained, but with one important exception: Americans differ in that they are more likely to see the State hindering rather than helping the attainment of these goals. Finally, how do the investments these countries make in the future of their children through the family, the labour market, and public policy actually differ? Using a number of representative household surveys we find that the configuration of all three sources of investment and support for children differs significantly, disadvantaged American children living in much more challenging circumstances, and the role of public policy not as strong in determining outcomes.

In Canada's publicly funded health care system, policy is governed by the Canada Health Act whose primary objective is to “protect, promote, and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health care services without financial or other barriers” (Canada Health Act 1984, c.6, s.3). “Reasonable access,” while not explicitly defined by the Act, is generally assumed to have been achieved by the removal of the direct cost of health care at the point of delivery (Birch and Abelson 1993; Birch, Eyles, and Newbold 1993; Newbold, Eyles, and Birch 1995). A number of Canadian studies have examined access to general practitioner (GP) services in relation to income with conflicting results. While most conclude that there is no association between income and incidence of GP utilization when assessed over a 1-year period (Broyles et al. 1983; Birch, Eyles, and Newbold 1993; McIsaac, Goel, and Naylor 1997; Dunlop, Coyte, and McIsaac 2000; Finkelstein 2001), the association between income and volume of GP utilization is less clear. Several studies have reported an inverse association even after adjustment for need (Broyles et al. 1983; McIsaac, Goel, and Naylor 1997; Dunlop, Coyte, and McIsaac 2000), while others have reported no differential utilization by income level (Birch, Eyles, and Newbold 1993; Finkelstein 2001). In general, most studies that were unable to use direct measures to control for medical need found an expected inverse association between income and utilization of GP services (Roos and Mustard 1997; Kephart, Thomas, and MacLean 1998; Veugelers and Yip 2003); however, a recent study by Roos et al. (2004) observed lower than expected use of physician services among individuals from poorer neighborhoods. While the literature examining equity of access to GP services in Canada contains many studies of the relationship between income and access to physician services, comparatively little attention has been given to other potential barriers to access (Birch and Abelson 1993; Birch, Eyles, and Newbold 1993). It has been suggested that opportunity costs associated with attending medical appointments may render some individuals less likely to access care than others (Broyles et al. 1983; Birch, Eyles, and Newbold 1993). There are reasons to believe that employment-related opportunity costs may influence an individual's ability to access GP services. Because the ability to attend ambulatory medical appointments is time dependent, “time crunch” imposed by work may operate as a barrier to utilization (Boaz and Muller 1989) in that it reduces opportunities to access medical appointments (Nishiyama and Johnson 1997). Lost wages for time off work may also deter some workers from accessing care (Broyles et al. 1983; Boaz and Muller 1989). Studies of work hours and health have largely focused on the effect of long work hours on illness, injury, and health behavior (Caruso et al. 2004); however, the relationship between work hours and use of health care services has not been well studied. Only one qualitative study (Wellstood, Wilson, and Eyles 2006), and no quantitative studies were identified that have specifically assessed whether work hours act as a barrier to accessing GP services. The purpose of this study, therefore, was to examine the relationship between work hours and utilization of ambulatory GP services in order to assess the extent to which work hours may act as a barrier to access.

While the empirical evidence for the effect of geography on health is compelling, to make further progress it is necessary to revisit the scientific basis for asking questions about the influence of places on health. This chapter addresses this conceptual question. It first reviews existing evidence on location and health, then offers two perspectives from the past—one from sociology and one from epidemiology—that clarify the motivations for studying place effects and that help to chart a path forward. It concludes with a discussion of the challenges and possibilities for future study on the connections between location, social environment, and health, as well as the potential policy implications.

This chapter examines the question of whether research evidence regarding early childhood development and population health has actually contributed to the development of policies that affect children's health and well-being. To explore the role that research played in the development of child policy, it examines recently implemented child policies in three countries: the National Children's Agenda in Canada, the State Children's Health Insurance Program in the United States, and the Early Childhood Education and Care Policy in Norway. It contextualizes each of these policies with a discussion of family policy and social attitudes towards family and children in each country. The chapter concludes that while research evidence played a central role in the development of each of these policies, the political, cultural, and historical environment, along with the core social values of the population, shaped policy specifics.

Examined temporal relations between maternal mood and disruptive child behaviour using daily assessments of 30 mother-child dyads carried out over 8 consecutive weeks (623 pooled observations). Pooled time-series analyses showed synchronous fluctuation in child behaviour and maternal distress. Time-lagged models showed temporal relations between maternal and child outcomes that changed according to the type of maternal mood and child behaviour being reported. Controlling for cross-sectional relations, maternal anger and fatigue were related to previous child inattentive/impulsive/overactive behaviour (IO) and maternal confusion related to previous child oppositional/defiant behaviour (OD). However, maternal depression, low vigour, anger, and anxiety each predicted subsequent child IO and maternal confusion and anxiety each predicted subsequent child OD. Mutual influences on maternal and child functioning were interpreted in the context of interpersonal mechanisms that mediate psychological problems within families and their implications for treatment.

The unconditional health status of lone mothers is worse than that of married mothers in Canada but not in Norway. Even controlling for demographic characteristics and health behaviours in Canada, the health status of lone mothers is worse. Only after we control for income does the differential in health status between married and lone mothers in Canada disappear. An important difference between the countries is that lone mothers are much less likely to be poor in Norway because they receive more generous social transfers. A simulation which involves 'giving Canadian mothers Norwegian transfers,' illustrates the possibility of significant gains in socioeconomic status and health of poor mothers in Canada.

In this paper, we use the Canadian National Longitudinal Survey of Children and Youth data to examine the links between child well-being and neighbourhood 'quality.' This study adds to the literature by (i) investigating the relationship between neighbourhood quality and child health, (ii) by utilizing subjective assessments by individuals familiar with the neighbourhood (i.e., the survey respondent and interviewer), and (iii) by utilizing multiple assessments of neighbourhood quality, and (iv) by investigating several measures of health. Other work has found that controlling for family level characteristics reduces or eliminates the apparent association between neighbourhood quality and health. We find, measuring both child well-being and neighbourhood quality multi-dimensionally, that even after controlling for family level characteristics neighbourhood quality has strong associations with child well-being.

Often undetected and poorly managed, maternal depression and child adjustment problems are common health problems and impose significant burden to society. Studies show evidence of mutual influences on maternal and child functioning, whereby depression in mothers increases risk of emotional and behavioral problems in children and vice versa. Biological mechanisms (genetics, in utero environment) mediate influences from mother to child, while psychosocial (attachment, child discipline, modeling, family functioning) and social capital (social resources, social support) mechanisms mediate transactional influences on maternal depression and child adjustment problems. Mutual family influences in the etiology and maintenance of psychological problems advance our understanding of pathways of risk and resilience and their implications for clinical interventions. This article explores the dynamic interplay of maternal and child distress and provides evidence for a biopsychosocial model of mediating factors with the aim of stimulating further research and contributing to more inclusive therapies for families.

This study focuses on the health status of women with children, particularly lone mothers, the beneficiaries of many policies. Data from the 1994 Statistics Canada's National Population Health Survey indicate that lone mothers have, on average, consistently lower unconditional health status than married mothers. However, lone mothers also have, on average, lower levels of health inputs. Once age, income, education, lifestyle factors, family size, and other recognized determinants of health are controlled for, lone mothers are at least no worse off than married mothers when it comes to health status. This evidence points toward promoting policies directed at increasing the education, income and lifestyle factors of lone mothers if we wish to improve their health status.

A statistical association between poor child health and low family income has been well established by Lipman, Offord and Boyle (1994, 1995) and Dooley and Lipman (1995) in a series of papers using data from the Ontario Child Health Study (OCHS). The incidence of psychiatric disorders and poor school performance is higher among children of poor families than among children of non-poor families. The OCHS data generally show that children in one parent families have more problems than do children in two parent families, but this finding is less robust than that for low income. Most previous, however, has been done with the initial 1983 wave of the OCHS and little been done with the data from both the 1983 and 1987 surveys. Our objective in the proposed paper is to investigate these relationships using both waves of the OCHS data. We are particularly interested in the relationship between child health and “permanent low income” as measured by the income data from both waves. We will investigate the possibility that there is a lagged relationship between family status and child health. Cross tabular and multivariate methods will be used to analyse the relationship between socioeconomic status and child health status. We will use ordinal and cardinal measures of child health derived from the Health Utilities Index Mark 2 (Feeny et al., 1992 and Torrence et al., 1992). This HUI system affords one means of assessing the overall impact of socioeconomic status on child health status and health-related quality of life. The longitudinal results indicate that lone motherhood (both current and long-term status) was negatively associated with all outcome measures except cognition. Most notable was the fact that current low income exhibited a much weaker relationship with our health outcome measures than did longer term low income. In most cases the marginal effect on child health of long term poverty was equal to or greater than the marginal effect of ever having lived in a lone-mother family. We believe this demonstrates the necessity of obtaining measures of permanent income rather than current income levels when investigating child health status.

The primary goal of this paper is to improve our understanding of the link between the health of Canadian children and a variety of socioeconomic factors. Both researchers and policy makers have a long standing interest in this topic. There is broad agreement that environmental factors have an impact on health outcomes. Until recently, however, there has been little or no Canadian data with which to assess the nature and magnitude of the role which socioeconomic factors play in the incidence and severity of such problems.