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IntroductionNeighbourhoods have the potential to influence population-wide modifiable risk factors such as physical inactivity and obesity. Built environments that encourage active living hold promise as a policy lever for reducing health care burden, particularly that related to cardiometabolic disease.
Objectives and ApproachWe examined the role of active living environments on hospitalization risk, frequency, and cumulative length of stay for all-causes and cardiometabolic diseases. The linked dataset is a combination of survey data from Canadian respondents aged 45+, records from a national census of acute hospitalizations, and the Canadian Active Living Environment (Can-ALE) - a 5-class measure of how conducive one's neighbourhood is to active living based on street connectivity, points of interest, and population density. We modelled the risk of all-cause and cardiometabolic hospitalizations for respondents living in more and less favourable environments using logistic regression. Frequency and cumulative length of stay were modelled using truncated negative binomial regression. Models were adjusted for individual-level factors and proximity to a hospital. An offset variable was included to account for different follow-up times.
Results232,000 respondents were included with a mean follow-up time of 5.37 years. Those living in progressively more favourable active living environments (classes 2, 3, 4, and 5) exhibited incrementally lower risk of hospitalization compared to those living in the least favourable (class 1). Relative to respondents living in the least favourable environments (class 1), odds ratios were 0.84 (95% CI 0.76-0.93) for all-cause hospitalization and 0.80 (95% CI 0.68-0.93) for cardiometabolic hospitalization for respondents living in the most favourable environments (class 5). There was little evidence of similar associations for hospitalization frequency and cumulative length of stay.
Conclusion / ImplicationsLiving in neighbourhoods that are more conducive to active living are associated with lower risk of all-cause and cardiometabolic hospitalization.

IntroductionThe built environment can shape modifiable risk factors such as obesity, poor diet, and physical inactivity, and could be a policy lever for the reduction of chronic disease. In Canada, the health care costs related to chronic disease continue to rise and there have been few policy options offered.
Objectives and ApproachWe examine the role of the built environment in hospital burden and premature mortality, with an emphasis on one of the highest burden diseases, Type 2 Diabetes (T2D). Neighbourhood built environment measures for active living were derived using geographic information systems for respondents of the Canadian Community Health Survey, for whom we have linked hospitalization and mortality records. A combination of ICD codes, self-reported diabetes status, as well as a population-based algorithm identifying those at higher risk of developing diabetes were used to identify cases. Differences in hospitalization frequency, cumulative length of stay, and mortality are investigated.
ResultsOver half a million hospitalization records were identified in our cohort of roughly 450,000 survey respondents. Key factors such as age, gender, race, and socioeconomic status are accounted for in modelling the association between neighborhood environment and hospitalization. Hospital burden and mortality in T2D patients are much higher than that of patients who do not report having the condition, and those at elevated risk of T2D display intermediate levels of hospitalization. Two-part hurdle models show evidence of an association between more walkable neighborhoods and lower hospitalization risk in non-T2D patients as well as those at elevated risk of developing T2D. The relationship between neighborhoods and the volume of chronic-disease related episodes as well as mortality is unclear, and under further investigation.
Conclusion/ImplicationsElucidating the role of neighbourhood built environments on hospital burden and premature mortality for individuals with diabetes will provide insight as to the full range of clinical and non-clinical interventions that could feasibly address the needs of some the highest health care system users.

ABSTRACTObjectivesTo demonstrate the methodology and results for linking measures of neighbourhood walking-friendliness or "walkability" to Canadian health surveys and Canadian health surveys linked to administrative health care records.
ApproachWe linked multiple measures of neighbourhood walkability to hundreds of thousands of 6-digit postal codes of respondents to three large Canadian surveys using geographic information systems and anonymized banks of postal codes.
ResultsLong term exposure to walkable neighbourhoods was associated with increased reporting of walking for utilitarian purposes. Moving to a high walkable neighbourhood from a low walkable neighbourhood was associated with a full unit decrease in the body mass index of Canadian men over a 12-year follow-up. In a linkage of walkability measures to respondents who wore biosensors for a one-week period in several Canadian cities, we found that neighbourhood walkability was associated with increased reporting of utilitarian walking but not overall physical activity and step counts as measured by biosensors.
ConclusionThere is potential for walkable neighbourhoods to influence physical activity and body weight of Canadians which is more evident when individuals are followed for long periods of time.

ABSTRACTObjectivesBirth and delivery in hospital is one of the most common medical procedures in Canadian hospitals, and can be used to assess equity in the delivery of health care. This study investigates the association between socioeconomic status and hospital burden for childbirth using linked Canadian survey and administrative databases, accounting for a wide array of other individual and health-care related characteristics.
ApproachA population-based record linkage between national health survey data and the Canadian Discharge Abstract Database (a census of all Canadian hospital separations) allowed the tracking of hospital utilization between 2005 and 2009 for which individual-level socioeconomic and demographic factors were also available. Length of stay for delivery, risk of pre-delivery hospitalization within 30 days of admission for delivery, and risk of maternal readmission within 30 days of discharge for delivery were the three measures of hospital utilization modeled.
ResultsComplete information for 7,163 deliveries of 5,568 women was available and used in the models of length of stay and risk of maternal admission pre- and post-delivery. In fully adjusted models, predicted length of stay was graded by household income with longest stays for lowest income women (2.79 days, 95% CI 2.61-2.92), followed by middle income women (2.63 days, 95% CI 2.50-2.76) and high income women (2.56 days, 95% CI 2.49-2.63). Factors intrinsic to routine hospital care and protocol such as province and vaginal versus Cesarean section delivery were stronger predictors of length of stay than income. Additionally, Aboriginal status, compounded with residing in a rural setting was associated with higher predicted probability of maternal readmission.
ConclusionsLow income women have marginally longer stays in hospital following birth events than do middle and high-income women in Canada that persist after adjustment for strong drivers of length of stay (parity and birth mode). While this may suggest that more complicated cases are benefiting from longer stays in hospital, it provokes the question as to whether there may be additional reductions in length of stay that could be achieved through resource redistribution to the prenatal period. Overall, the results suggest that equity goals of the Canadian health care system are being achieved for birth-related hospitalizations, and the availability of these linked data will be key for further comprehensive evaluation of population health status.

ObjectivesHypertension is a leading cause of cardiovascular disease and premature death. Neighbourhoods characterized by a high proportion of fast-food outlets may contribute to hypertension in residents; however, limited research has explored these associations. The objectives of this study were to assess associations between neighbourhood fast-food environments, measured and self-reported hypertension.
ApproachWe used data from 10,700 adults who participated in six cycles of the Canadian Health Measures Survey (CHMS). Measured hypertension was defined as having an average systolic blood pressure (BP) of ≥140, a diastolic BP ≥90 mm Hg or being on BP lowering medication. Participants were also asked if they had been diagnosed with high BP or if they take BP lowering medication (i.e., self-reported hypertension). We characterized the fast-food environment of each participant's neighbourhood using the Canadian Food Environment Dataset (Can-FED). We considered the proportion of fast-food outlets relative to fast-food outlets and full-service restaurants as a continuous variable.
ResultsThe mean proportion of fast-food outlets was 23.3% (SD 26.8%). A one standard deviation (SD) increase in the proportion to fast-food outlets was associated with higher odds of measured hypertension in the full sample (OR=1.17, 95% CI 1.05 to 1.31) and in sex-specific models (women: OR=1.14, 95% CI 1.01 to 1.29; and men: OR=1.21, 95% CI 1.03 to 1.43). A one standard deviation (SD) increase in the proportion to fast-food outlets was associated with higher odds of self-reported hypertension in the full sample (OR=1.13, 95% CI 1.02 to 1.24); however, associations were inconclusive in sex-specific models (women: OR=1.11, 95% CI 0.99 to 1.26; and men: OR=1.14, 95% CI 0.99 to 1.33).
ConclusionBy linking neighbourhood food environment measures that were created from an administrative data source (the Statistics Canada Business Register) to individual-level data from the CHMS, we were able to demonstrate that reducing the proportion of fast-food outlets in neighbourhoods may reduce rates of hypertension and support individually targeted interventions.

Clothing, dress, and ornamentation are crucial parts of individual and communal religious life and practice, yet they are too often overlooked. This book convenes leading scholars to explore the roles of attire and adornment in the creation and communication of religious meaning, identity, and community. Contributors investigate aspects of religious dress in North America in the nineteenth, twentieth, and twenty-first centuries, considering adornment practices in a wide range of religious traditions and among individuals who straddle religious boundaries. The collection is organized around four frameworks for understanding the material culture of religion: theological interpretation, identity formation, negotiation of tradition, and activism.Religion, Attire, and Adornment in North America features essays on topics such as Black Israelites' use of African fabrics, Christian religious tattoos, Wiccan ritual nudity, Amish "plain dress," Mormon sacred garments, Hare Krishna robes, and the Church of Body Modification. Spanning the diversity of religious practice and expression, this book is suitable for a range of undergraduate courses and offers new insights for scholars in many disciplines

Public health in the early 21st century increasingly considers how social inequalities impact on individual health, moving away from the focus on how disease relates to the individual person. This 'new public health' identifies how social, economic and political factors affect the level and distribution of individual health, through their effects on individual behaviours, the social groups people belong to, the character of relationships to others and the characteristics of the societies in which people live. The rising social inequalities that can be seen in nearly every country in the world today present not just a moral danger, but a mortal danger as well. Social inequality and public health brings together the latest research findings from some of the most respected medical and social scientists in the world. It surveys four pathways to understanding the social determinants of health: differences in individual health behaviours; group advantage and disadvantage; psychosocial factors in individual health; and healthy and unhealthy societies, shedding light on the costs and consequences of today's high-inequality social models. This exciting book brings together leaders in the field discussing their latest research and is a must-read for anyone interested in public health and social inequalities internationally