The Role of Social Capital in African Americans' Attempts to Reduce and Quit Cocaine Use

BACKGROUND:

Research examining substance users' recovery has focused on individual-level outcomes while paying limited attention to the contexts within which individuals are embedded, and the social processes involved in recovery.

OBJECTIVES:

This paper examines factors underlying African American cocaine users' decisions to reduce or quit cocaine use and uses practice theory to understand how lifestyle changes and shifts in social networks facilitate access to the capital needed to change cocaine use patterns.

METHODS:

The study, an in-depth analysis of substance-use life history interviews carried out from 2010 to 2012, included 51 currently not-in-treatment African American cocaine users in the Arkansas Mississippi Delta region. A blended inductive and deductive approach to data analysis was used to examine the socio-cultural and economic processes shaping cocaine use and recovery.

RESULTS:

The majority of participants reported at least one lifetime attempt to reduce or quit cocaine use; motivations to reduce use or quit included desires to meet social role expectations, being tired of using, and incarceration. Abstinence-supporting networks, participation in conventional activities, and religious and spiritual practices afforded access to capital, facilitating cocaine use reduction and sobriety.

CONCLUSIONS:

Interventions designed to increase connection to and support from nondrug using family and friends with access to recovery capital (e.g., employment, faith community, and education) might be ideal methods to reduce substance use among minorities in low-income, resource-poor communities.

Purchase full article at:   http://goo.gl/tu8pcE

By:  Cheney AM¹, Booth BM², Borders TF³, Curran GM⁴.

¹ Center for Healthy Communities , University of California Riverside , Riverside , California , USA.

² Division of Health Services Research , University of Arkansas for Medical Sciences , Little Rock , Arkansas , USA.

³ Department of Health Management and Policy , University of Kentucky , Lexington , Kentucky , USA.

⁴ Department of Pharmacy Practice , University of Arkansas for Medical Sciences , Little Rock , Arkansas , USA.

Subst Use Misuse. 2016 Apr 20:1-11.

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Barriers and Facilitators to Online Portal Use among Patients and Caregivers in a Safety Net Health Care System

Background

Patient portals have the potential to support self-management for chronic diseases and improve health outcomes. With the rapid rise in adoption of patient portals spurred by meaningful use incentives among safety net health systems (a health system or hospital providing a significant level of care to low-income, uninsured, and vulnerable populations), it is important to understand the readiness and willingness of patients and caregivers in safety net settings to access their personal health records online.

Objective

To explore patient and caregiver perspectives on online patient portal use before its implementation at San Francisco General Hospital, a safety net hospital.

Methods

We conducted 16 in-depth interviews with chronic disease patients and caregivers who expressed interest in using the Internet to manage their health. Discussions focused on health care experiences, technology use, and interest in using an online portal to manage health tasks. We used open coding to categorize all the barriers and facilitators to portal use, followed by a second round of coding that compared the categories to previously published findings. In secondary analyses, we also examined specific barriers among 2 subgroups: those with limited health literacy and caregivers.

Results

We interviewed 11 patients and 5 caregivers. Patients were predominantly male (82%, 9/11) and African American (45%, 5/11). All patients had been diagnosed with diabetes and the majority had limited health literacy (73%, 8/11). The majority of caregivers were female (80%, 4/5), African American (60%, 3/5), caregivers of individuals with diabetes (60%, 3/5), and had adequate health literacy (60%, 3/5). A total of 88% (14/16) of participants reported interest in using the portal after viewing a prototype. Major perceived barriers included security concerns, lack of technical skills/interest, and preference for in-person communication. Facilitators to portal use included convenience, health monitoring, and improvements in patient-provider communication. Participants with limited health literacy discussed more fundamental barriers to portal use, including challenges with reading and typing, personal experience with online security breaches/viruses, and distrust of potential security measures. Caregivers expressed high interest in portal use to support their roles in interpreting health information, advocating for quality care, and managing health behaviors and medical care.

Conclusions

Despite concerns about security, difficulty understanding medical information, and satisfaction with current communication processes, respondents generally expressed enthusiasm about portal use. Our findings suggest a strong need for training and support to assist vulnerable patients with portal registration and use, particularly those with limited health literacy. Efforts to encourage portal use among vulnerable patients should directly address health literacy and security/privacy issues and support access for caregivers.

Full article at:   http://goo.gl/60yyps

By:  Lina Tieu, MPH, ¹ Urmimala Sarkar, MD, MPH,¹ Dean Schillinger, MD,¹ James D Ralston, MD, MPH,² Neda Ratanawongsa, MD, MHS,¹ Rena Pasick, DrPH,³ and Courtney R Lyles, PhD¹

¹Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA, United States

²Group Health Research Institute, Seattle, WA, United States

³Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, United States

Lina Tieu, Division of General Internal Medicine, University of California, San Francisco, DGIM at SFGH, Box 1364, 1001 Potrero Ave, Bldg 10, Ward 13, San Francisco, CA, 94143, United States, Phone: 1 415 206 7878, Fax: 1 415 206 7880, Email: ude.fscu@ueiT.aniL.

J Med Internet Res. 2015 Dec; 17(12): e275.

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Perpetuating the Cycle of Violence in South African Low-Income Communities: Attraction to Violence in Young Men Exposed to Continuous Threat

BACKGROUND:

Life in the low-income urban communities of South Africa is imprinted by a cycle of violence in which young males predominantly are in the roles of both victim and perpetrator. There is some evidence that adolescents who show an attraction to cruelty can display high levels of psychosocial functioning despite the presence of posttraumatic stress symptoms. However, the role of appetitive aggression in the context of ongoing threats and daily hassles is not yet fully understood.

OBJECTIVE:

In this study, we examine the role of attraction to violence in areas of continuous traumatic stress exposure and its effect on posttraumatic stress disorder (PTSD) severity and violence perpetration.

METHOD:

A sample of 290 young males from two low-income Cape Town communities was surveyed. We assessed appetitive aggression with the Appetitive Aggression Scale (AAS), PTSD symptoms with the PTSD Symptom Scale-Interview, the number of witnessed and self-experienced traumatic event types with an adaptation of the Child Exposure to Community Violence questionnaire, and the number of perpetrated violence event types with an adapted offence checklist from the AAS.

RESULTS:

Appetitive aggression scores were predicted by witnessed as well as self-experienced traumatic events. Higher appetitive aggression scores resulted in higher levels of PTSD severity and perpetrated violence.

CONCLUSIONS:

Young males living in the low-income areas of South Africa may develop an attraction to cruelty in response to exposure to violence. Their willingness to fight in turn can increase the likelihood of continued violent behaviour. In contrast to previous research from postconflict areas, appetitive aggression and engagement in violence do not prevent the development of PTSD, but are instead associated with higher levels of posttraumatic stress. PTSD symptoms such as avoidance and hyperarousal, as well as an attraction to cruelty and thus the willingness to fight, might support survival in areas of ongoing conflict, but at the same time they could fuel the cycle of violence.

Frequencies of the different types of witnessed and self-experienced trauma events (n=290)

List of traumatic event types
Witnessed violence event types	Prevalence (%)
Have you ever witnessed someone being physically attacked by someone else?	98.6
Have you ever witnessed someone being attacked with a weapon by someone else?	95.2
Have you ever witnessed someone being threatened (to be harmed) by someone else?	91.7
Have you ever seen a dead body (besides at funerals)?	90.7
Was someone you know killed by another person?	81.4
Did someone close to you suffer from a serious illness?	73.7
Have you ever seen somebody being killed?	72.8
Have you ever witnessed a bad accident, like a very serious car accident?	67.8
Have you ever witnessed someone being tortured?	65.3
Have you ever witnessed a life-threatening fire or explosion?	63.8
Have you ever witnessed a family member being attacked by another family member?	59.0
Have you ever witnessed a painful and scary medical treatment (e.g., during an initiation)?	51.0
Have you ever witnessed a family member being threatened by another family member?	42.9
Have you ever witnessed a family member being attacked with a weapon by another family member?	36.8
Have you ever witnessed someone being sexually assaulted by someone else?	26.0
Have you ever witnessed sexual assault in your family by another family member?	2.4
Self-experienced violence event types	Prevalence (%)
Have you ever been threatened to be harmed by someone outside your family?	88.3
Have you ever been physically attacked by someone else?	86.2
Have you ever been attacked with a weapon by someone else?	84.5
Have you ever been physically attacked by someone in your family?	80.0
Have you ever lost a parent/caregiver?	58.5
Have your parents/caregivers regularly humiliated you verbally (e.g., insulted you; said you’re worthless or a bad child)?	55.0
Have you ever been attacked with a weapon (e.g., stick, stone, bottle, belt, knife, gun) by a family member?	51.7
Have you ever felt neglected by your parents/caregivers (e.g., they didn’t support you; didn’t send you to school even though they could have; didn’t care for you)?	49.1
Have you ever had a painful and scary medical treatment (e.g., during an initiation or in a hospital, when you were sick or badly injured)?	47.4
Have you ever been imprisoned?	41.9
Have you ever severely suffered from hunger, so that you worried about your health?	39.9
Have you ever been threatened to be harmed by someone in your family?	37.7
Have you ever been tortured?	37.2
Have you ever suffered from a serious illness?	27.4
Have you ever been in a bad accident, like a very serious car accident?	22.6
Have you ever been in a life-threatening fire or explosion?	14.2
Have you ever been in any kind of natural disaster (e.g., a fire, a tornado/hurricane, a flood, an earthquake)?	9.7
Have you ever been sexually assaulted by someone else?	5.6
Have you ever been sexually assaulted by a family member (e.g., abuse, doing something with your or their private parts that you didn’t want to, watching porn although you were too young or didn’t want to)?	2.1

Below:  Path model presenting the results of an AMOS path analysis, showing standardized regression weights and significance levels for the relationships between witnessed and self-experienced trauma event types, attraction to violence, PTSD symptom severity, and perpetrated violence types

Full article at:   http://goo.gl/zAVvXD

By:  Hinsberger M1, Sommer J2, Kaminer D3, Holtzhausen L4, Weierstall R2,5, Seedat S6, Madikane S7, Elbert T2.

• 1Department of Psychology, University of Konstanz, Reichenau, Konstanz, Germany; martina.hinsberger@uni-konstanz.de.
• 2Department of Psychology, University of Konstanz, Reichenau, Konstanz, Germany.
• 3Department of Psychology, University of Cape Town, Cape Town, South Africa.
• 4Department of Social Development, University of Cape Town, Cape Town, South Africa.
• 5Clinical Psychology and Psychotherapy, Medical School Hamburg, Hamburg, Germany.
• 6Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa.
• 7REALISTIC, Cape Town, South Africa. 

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Health-Related Outcomes among the Poor: Medicaid Expansion vs. Non-Expansion States

Introduction

States’ decisions not to expand Medicaid under the Affordable Care Act (ACA) could potentially affect access to care and health status among their low-income residents.

Methods

The 2010–2012 nationally representative Medical Expenditure Panel Survey data were analyzed in 2015 to compare 9755 low-income adults aged 18–64 years from Medicaid-expanding states with 7455 adults from nonexpanding states. Multivariate logistic regression models were fitted to evaluate the differences in access to care, receipt of preventive services, quality of care, attitudes about health and self-reported health status by Medicaid expansion status. The differences in care utilization and medical expenditures between the two groups were examined using a 2-part modeling approach.

Results

Compared to their counterparts in Medicaid expansion states, low income adults in the nonexpanding states were more likely to be black and reside in rural areas and were less likely to have a usual source of care (prevalence ratio[PR] 0.86, 95% confidence interval[CI] 0.82–0.91) and recommended preventive services such as dental checkups (PR = 0.86; CI = 0.79–0.94), routine checks (PR = 0.89; CI = 0.83–0.95), flu vaccinations (PR = 0.89; CI = 0.81–0.98), and blood pressure checks (PR = 0.96; CI = 0.94–0.99). They also had less care utilization, fewer prescriptions, and less medical expenditures, but more out-of-pocket expenditures (all p-value <0.05).

Conclusions

Low-income adults in Medicaid nonexpanding states, who are disproportionately represented by blacks and rural residents, were worse off for multiple health-related outcomes compared to their counterparts in Medicaid expanding states at the baseline of ACA implementation, suggesting that low income adults residing in nonexpanding states may benefit markedly from the expansion of Medicaid

Below:  Number of care utilization and expenditures by Medicaid expansion status among low income population aged 18–64 years

Full article at:   http://goo.gl/KCUJBx

By:   

Xuesong Han, Binh T. Nguyen, Jeffrey Drope, Ahmedin Jemal

Intramural Research, American Cancer Society, Atlanta, Georgia, United States of America

Xuesong Han, Ahmedin Jemal

Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America

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"Sex Is Sweet": Women from Low-Income Contexts in Uganda Talk About Sexual Desire and Pleasure

In many patriarchal societies in Africa, heterosexuality is privileged as the single legitimate form of sexual interaction; other sexualities are marginalised because they are perceived as un-African, abnormal, sinful and are repressed. Female sexuality too is subordinated and controlled with it being reduced to women's conventional mothering roles that are conflated with their reproductive capacities. However, there is evidence that women in heterosexual relations have the opportunity to assert themselves and to define pleasurable sex. 

Drawing on in-depth interviews and focus group discussions with married women in heterosexual unions the article examines the extent to which women from low-income contexts in Uganda express their sexual agency. 

The findings show that within heterosexual relations, these women are able to express their sexual desires freely and negotiate diverse options for pleasurable sexual experiences. The evidence indicates the need for acknowledging variations within heterosexual experiences and the possibility of positive heterosexual relationships that resist hegemonic masculinity and subordinated femininity.

Purchase full article at:   http://goo.gl/NaEW2q

By:   Muhanguzi FK1.

• 1Senior Lecturer, School of Women and Gender Studies, Makerere University, P.O. Box 7062, Kampala, UGANDA. Electronic address: floramuha@yahoo.com. 

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Posttraumatic Stress Disorder among Low-Income Women Exposed to Perinatal Intimate Partner Violence

Women exposed to intimate partner violence (IPV) and other forms of lifetime trauma may be at risk for negative mental health outcomes including posttraumatic stress disorder (PTSD). 

The purpose of this study was to examine potential predictors of PTSD among low-income women exposed to perinatal IPV. This study analyzed baseline cross-sectional data from 239 low-income pregnant women in the USA who participated in a nurse home visitation intervention between 2006 and 2012 after reporting recent IPV. PTSD was assessed with the Davidson Trauma Scale (DTS) in which participants answer questions about the most disturbing traumatic event (MDTE) in their lifetime that affected them the week before the interview. 

In total, 40 % of the women were identified as having PTSD (DTS ≥40). PTSD prevalence significantly increased with age to nearly 80 % of women ages 30 and older (n = 23). Age was also the strongest predictor of PTSD (p < 0.001). Most participants (65 %) identified non-IPV-related traumas as their MDTEs. Psychological (94 %), physical (82 %), and sexual (44 %) violence were not significantly associated with PTSD status. Despite recent exposure to IPV, most participants identified other traumatic events as more disturbing than IPV-related trauma. 

Further, the risk for PTSD increased with age, suggesting that the cumulative effect of trauma, which may include IPV, increases the risk for PTSD over a lifetime. 

Implementing comprehensive screening for trauma during prenatal care may lead to the early identification and treatment of PTSD during pregnancy in a community setting.

Purchase full article at:   http://goo.gl/nGqZeQ

By:   Kastello JC1, Jacobsen KH2, Gaffney KF3, Kodadek MP3, Bullock LC4, Sharps PW5.

• 1School of Nursing, University of Virginia, 202 Jeanette Lancaster Way, PO Box 800782, Charlottesville, VA, 222903, USA. jck9e@virginia.edu.
• 2Department of Global and Community Health, George Mason University, Fairfax, VA, USA.
• 3School of Nursing, George Mason University, Fairfax, VA, USA.
• 4School of Nursing, University of Virginia, 202 Jeanette Lancaster Way, PO Box 800782, Charlottesville, VA, 222903, USA.
• 5School of Nursing, Johns Hopkins University, Baltimore, MD, USA.  

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Rejection Sensitivity, Perceived Power, and HIV Risk in the Relationships of Low-Income Urban Women

The psychological processes associated with HIV infection in long-term relationships differ from those operative in casual sexual encounters, and relatively little research has considered the aspects of personality applicable in the ongoing heterosexual relationships in which women are at greatest risk. 

Sensitivity to rejection has been linked with efforts to prevent rejection at a cost to the self and, therefore, may be relevant to the health risks that many women incur in relationships. We examined the association of rejection sensitivity with women’s sexual risk behavior in a sample of women at heightened risk for HIV exposure. Women in long-term heterosexual relationships (N = 159) were recruited for study participation in the hospital emergency room serving a low-income neighborhood in New York City, in 2001–2003. Rejection sensitivity and known HIV risk factors were assessed using verbally administered questionnaires. 

Rejection sensitivity was associated with lower perceived relationship power and, in turn, more frequent unprotected sex with a partner perceived to be at risk for HIV. These results held when controlling for other HIV risk factors including partner violence, economic dependence, and substance use. 

Understanding the association of rejection concerns with lower perceived personal power in relationships may be important for HIV prevention.

Purchase full article at:  http://goo.gl/xYdECX

By:  Kathy R. Berenson PHD^a*, Christine Paprocki MA^b, Marget Thomas Fishman BA^c, Devika Bhushan MD^c, Nabila El-BasselDSW^d & Geraldine Downey PHD^c

• ^a Department of Psychology, Gettysburg College, Gettysburg, Pennsylvania, USA
• ^b Department of Psychology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
• ^c Department of Psychology, Columbia University, New York, New York, USA
• ^d School of Social Work, Columbia University, New York, New York, USA

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Mental Disorders and Disabilities among Low-Income Children

Children living in poverty are more likely to have mental health problems, and their conditions are more likely to be severe. Of the approximately 1.3 million children who were recipients of Supplemental Security Income (SSI) disability benefits in 2013, about 50% were disabled primarily due to a mental disorder. An increase in the number of children who are recipients of SSI benefits due to mental disorders has been observed through several decades of the program beginning in 1985 and continuing through 2010. Nevertheless, less than 1% of children in the United States are recipients of SSI disability benefits for a mental disorder. 

At the request of the Social Security Administration, Mental Disorders and Disability Among Low-Income Children compares national trends in the number of children with mental disorders with the trends in the number of children receiving benefits from the SSI program, and describes the possible factors that may contribute to any differences between the two groups. 

This report provides an overview of the current status of the diagnosis and treatment of mental disorders, and the levels of impairment in the U.S. population under age 18. The report focuses on 6 mental disorders, chosen due to their prevalence and the severity of disability attributed to those disorders within the SSI disability program: attention-deficit/hyperactivity disorder, oppositional defiant disorder/conduct disorder, autism spectrum disorder, intellectual disability, learning disabilities, and mood disorders. 

While this report is not a comprehensive discussion of these disorders, Mental Disorders and Disability Among Low-Income Children provides the best currently available information regarding demographics, diagnosis, treatment, and expectations for the disorder time course - both the natural course and under treatment.

Sections

The National Academies of SCIENCES • ENGINEERING • MEDICINE

COMMITTEE TO EVALUATE THE SUPPLEMENTAL SECURITY INCOME DISABILITY PROGRAM FOR CHILDREN WITH MENTAL DISORDERS

Reviewers

Preface

Acknowledgments

Acronyms and Abbreviations

Summary

I. Background and Context of the Supplemental Security Income Disability Benefit Program for Children

1. Introduction

2. The SSI Program for Children

3. National-Level Trends in the SSI Program for Children with Mental Disorders, 2004–2013

4. State Variation in the SSI Program for Children

5. Poverty and Childhood Disability

II. Clinical Characteristics of Selected Mental Disorders

6. Clinical Characteristics of Attention Deficit Hyperactivity Disorder

7. Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder

8. Clinical Characteristics of Autism Spectrum Disorder

9. Clinical Characteristics of Intellectual Disabilities

10. Clinical Characteristics of Learning Disabilities

11. Clinical Characteristics of Mood Disorders

III. Prevalence of Selected Mental Disorders

12. Prevalence of Attention Deficit Hyperactivity Disorder

13. Prevalence of Oppositional Defiant Disorder and Conduct Disorder

14. Prevalence of Autism Spectrum Disorder

15. Prevalence of Intellectual Disabilities

16. Prevalence of Learning Disabilities

17. Prevalence of Mood Disorders

IV. Medicaid Analytic eXtract Study

18. Medicaid Analytic eXtract Study

Appendixes

Via:  http://goo.gl/2MsaFD

By:  Committee to Evaluate the Supplemental Security Income Disability Program for Children with Mental Disorders; Board on the Health of Select Populations;Board on Children, Youth, and Families; Institute of Medicine; Division of Behavioral and Social Sciences and Education; The National Academies of Sciences, Engineering, and Medicine; Boat TF, Wu JT, editors.

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Experiences with Food Insecurity & Risky Sex among Low-Income People Living with HIV/AIDS in a Resource-Rich Setting

Forty-nine million individuals are food insecure in the United States, where food insecurity and HIV/AIDS are prevalent among the urban poor. Food insecurity is associated with risky sexual behaviours among people living with HIV/AIDS (PLHIV). No qualitative studies, however, have investigated the mechanisms underlying this relationship either in a resource-rich setting or among populations that include men who have sex with men (MSM).

Semi-structured in-depth interviews were conducted with 34 low-income PLHIV receiving food assistance in the San Francisco Bay Area. The interviews explored experiences with food insecurity and perceived associations with sexual risk behaviours. Interviews were conducted in English, audio-recorded and transcribed verbatim. Transcripts were coded and analyzed according to content analysis methods using an inductive-deductive approach.

Food insecurity was reported to be a strong contributor to risky sexual practices among MSM and female participants. Individuals described engaging in transactional sex for food or money to buy food, often during times of destitution. Participants also explained how food insecurity could lead to condomless sex despite knowledge of and desire to use safe sexual practices, largely because the need to obtain food in the short term was prioritized over the desire to use barrier protection.

Our data extend previous research by demonstrating that food insecurity contributes to transactional and unprotected sex among urban poor individuals in a resource-rich setting, including among MSM. These findings underscore the importance of public health and social intervention efforts focused on structural inequalities.

Full article at:  http://goo.gl/ssxcTA

By: Whittle HJ¹, Palar K², Napoles T², Hufstedler LL², Ching I³, Hecht FM², Frongillo EA⁴, Weiser SD^3,2,5.

¹Global Health Sciences, University of California, San Francisco (UCSF), San Francisco, CA, USA; harrywhittle@gmail.com.

²Division of HIV/AIDS, ID and Global Medicine, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA.

³Global Health Sciences, University of California, San Francisco (UCSF), San Francisco, CA, USA.

⁴Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, SC, USA.

⁵Center for AIDS Prevention Studies, University of California, San Francisco (UCSF), San Francisco, CA, USA

 

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Pathways and Trajectories Linking Housing Instability and Poor Health among Low-Income Women Experiencing Intimate Partner Violence (IPV): Towards a Conceptual Framework

We used grounded theory to understand pathways and trajectories to housing instability (HI) and poor health among low-income women with experiences of intimate partner violence (IPV). We conducted in-depth interviews during 2010-11 with 41 women (ages 18-45 years) living in Ontario, Canada. 

All women reported depressive symptoms in combination with other health problems. In addition to the direct pathway of IPV to poor health, thematic analysis revealed an indirect multi-tiered pathway with complex trajectories among IPV, HI and poor health. These trajectories included material HI (homelessness, high mobility, evictions, problems paying rent, hiding and landlord discrimination), psychological HI (feeling unsafe, low self-esteem, and poor control) and social trajectories (financial problems, loss of employment, income or social networks and leaving school). 

These trajectories elevated stress and decreased self-care (unhealthy behaviors, substance abuse, and reduced medical compliance) and exacerbated poor health already compromised by IPV. Depending on her specific context, each woman experienced these pathways and trajectories differently. Moreover, the women's experiences differed across three time periods: before, immediately after, and long after leaving an abusive relationship. Finally, we found that for these women, achieving stable housing was crucial for stabilizing their health.

Via: http://ht.ly/SaGQS 

By: Daoud N1,2, Matheson FI1,3,4, Pedersen C1, Hamilton-Wright S1, Minh A1, Zhang J1, O'Campo P1,4.

• 1a Centre for Research on Inner City Health , The Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , Ontario , Canada.
• 2b Department of Public Health, Faculty of Health Sciences , Ben-Gurion University , Beer Sheva , Israel.
• 3c Institute for Clinical Evaluative Sciences.
• 4d Dalla Lana School of Public Health , University of Toronto , Toronto , Ontario , Canada.