- Research article
- Open Access
- Open Peer Review
Substance use patterns and unprotected sex among street-involved youth in a Canadian setting: a prospective cohort study
BMC Public Healthvolume 16, Article number: 4 (2016)
Rates of sexually transmitted infections (STI) and unplanned pregnancy are high among youth. While the intersection between drug and alcohol use and unprotected sex is well recognized, few studies have examined the relationship between substance use patterns and unprotected sex among high risk-populations such as street-involved youth.
Data were derived from the At-Risk Youth Study (ARYS), a prospective cohort of street-involved youth from Vancouver, Canada. Generalized estimating equations (GEE) were used to examine substance use patterns that were independently associated with unprotected sex, defined as (vaginal or anal) sexual intercourse without consistent condom use.
Between September 2005 and May 2013, 1,026 youth were recruited into the ARYS cohort and 75 % (n = 766) reported engaging in recent unprotected sex at some point during the study period. In a multivariable analysis, female gender (adjusted odds ratio [AOR] = 1.46, 95 % confidence interval [CI]: 1.18-1.81), Caucasian ancestry (AOR = 1.38, 95 % CI: 1.13-1.68), being in a stable relationship (AOR = 4.64, 95 % CI: 3.82-5.65), having multiple sex partners (AOR = 2.60, 95 % CI: 2.18-3.10) and the following substance use patterns were all independently associated with recent unprotected sex: injection or non-injection crystal methamphetamine use (AOR = 1.21, 95 % CI: 1.03-1.43), injection or non-injection cocaine use (AOR = 1.20, 95 % CI: 1.02-1.41), marijuana use (AOR = 1.23, 95 % CI: 1.02-1.49), ecstasy use (AOR = 1.23, 95 % CI: 1.01-1.48) and alcohol use (AOR = 1.31, 95 % CI: 1.11-1.55) (all p < 0.05).
Unprotected sex was prevalent among street-involved youth in this setting, and independently associated with female gender and a wide range of substance use patterns. Evidence-based and gender-informed sexual health interventions are needed in addition to increased access to youth-centered addiction treatment services. STI testing and linkages to healthcare professionals remain important priorities for street-involved youth, and should be integrated across all health and social services.
Youth are at a critical stage of development as they initiate sexual and substance use behaviours that shape their health throughout adulthood . The evidence suggests, however, that this crucial transition period is often overlooked and not adequately addressed by healthcare providers in many settings . This is especially important for street-involved youth, who commonly experience trauma and abuse before entering street life , and adverse childhood events have been linked with an increased risk of illicit drug use  and, among women, sexual risk taking .
Despite efforts to increase safer sex practices among youth , in 2008 nearly half of all new sexually transmitted infections (STI) in the United States occurred among those aged 15–24 . Although condom use among Canadian youth has been estimated to be over 60 % since 2003 , the rate of condom use among Canadian street youth is estimated to hover around 50 % . The prevalence of chlamydia and gonorrhoea has also been found to be disproportionately higher among street-involved youth , with female youth generally having higher STI infection rates than males [9–11]. These differences in condom use and STI infection highlight the increased vulnerability of street-involved youth, and indicate that street-involved youth continue to experience disproportionate negative health outcomes and barriers to condom use.
The relationship between substance use and sexual activity in the general population is well-established, as previous studies have linked alcohol and illicit drug use with high-risk sexual behaviours such as increased frequency of intercourse, multiple sexual partners, and lower rates of condom use [12–15]. Despite increasing recognition of higher rates of STI among street-involved youth, less is known about substance use patterns and unprotected sex among street-involved youth who navigate a complex risk environment of danger on a daily basis . Given that few prospective longitudinal studies have examined unprotected sex and associated drug-related risk factors among this population, the present study was conducted to examine whether use of specific substances were associated with engaging in unprotected sex among street-involved youth.
Street-involved youth in Vancouver, Canada were recruited into a prospective cohort known as the At-Risk Youth Study (ARYS), which has previously been described in detail . Briefly, persons were eligible if they had used illicit drugs other than marijuana in the past 30 days, were between the ages 14 and 26, provided informed consent, and were ‘street-involved’ (defined as being temporarily or absolutely without housing in the preceding six months, or having accessed street-based youth services during that time). Participants who were unable to provide informed consent at the time due to intoxication, mental health issues, or inability to communicate in English were not enrolled into our study. At baseline and semi-annually, participants complete an interviewer-administered questionnaire and receive a stipend ($20 CDN) at each study visit. The Providence Health Care/University of British Columbia Research Ethics Board approved the study. Based on their street-involved status, youth under the age of 19 were considered emancipated minors and, consistent with provincial law allowing emancipated minors to consent to participate in research on their own behalf, were permitted to participate without parental consent.
This study included all participants who attended a study visit between September 2005 and May 2013. All participants were asked about their engagement in sexual activity over the last six months. For both same and opposite sex partnerships, participants were also asked to report how often a condom was used during vaginal and/or anal intercourse in the last six months. Possible responses included: always, usually, sometimes, occasionally, and never. In line with previous studies of condom use among street-involved youth , unprotected sex (yes vs. no) was defined based on reports of sexual activity and condom use. Specifically, unprotected sex was defined as reporting any insertive or receptive sex and “inconsistent” (i.e., usually, sometimes, occasionally, or never) condom use. No unprotected sex was defined as “always” reporting condom use during sexual encounters or reporting no sexual activity.
Explanatory variables of interest included the following socio-demographic information: female gender (yes vs. no); age (≥median age vs. <median age); ethnicity (Caucasian vs. other); currently being in a stable relationship, defined as being legally married, or common law, or having a regular partner (yes vs. no); and homelessness, defined as having no fixed address, sleeping on the street, couch surfing, or staying in a shelter or hostel (yes vs. no). Substance use variables included: any injection or non-injection use of crystal methamphetamine (yes vs. no); any injection or non-injection use of powder cocaine (yes vs. no); any injection or non-injection use of heroin (yes vs. no); any injection or non-injection use of crack cocaine (yes vs. no); any marijuana use (yes vs. no); any non-injection ecstasy use (yes vs. no); any alcohol use, defined as drinking beer, cider, coolers, wine, liquor, or other sources of alcohol (yes vs. no); binge drug use, defined as a period of using injection or non-injection drugs more often than usual based on participant responses to the following question: “In the past six months, did you go on runs or binges (that is, when you used non-injection drugs/injected drugs more than usual)” (yes vs. no); and any injection drug use (yes vs. no). Other risk characteristics included: multiple concurrent sexual partners (excluding those from sex work), based on responses to the following question: “In the last 6 months, how many different women/men have you had oral, vaginal or anal sex with, excluding those with whom you had sex in exchange for money or something else?” (>1 vs. ≤1); and engaging in sex work, defined as exchanging sex for money, shelter, drugs or other commodities (yes vs. no). Unless otherwise stated, all behavioural and risk variables refer to activities in the past six months.
First, we examined baseline characteristics from participants’ first study visit, stratified by unprotected sex, using Pearson’s χ2 test. Second, we examined reports of unprotected sex in the past six months during study follow-up using generalized estimating equations (GEE) with a logit link function and an exchangeable correlation structure for the analysis of correlated data . Bivariate GEE analyses were used to determine factors associated with unprotected sex. In order to adjust for potential confounding in the multivariable GEE analysis, variables significant at the p < 0.10 threshold in bivariate analyses were used in the backwards model selection process. The model with the best overall fit was determined by the lowest quasilikelihood under the independence model criterion (QIC) value . All statistical analyses were performed using the SAS software version 9.3 (SAS Institute, Cary, NC), and all p-values are two sided.
Availability of data and materials
The data from this study are not available in a public repository due to ethical concerns. Participants were assured during the informed consent process and throughout each study visit that their responses were confidential.
Between September 2005 and May 2013, 1,026 ARYS youths were eligible for this analysis. The median age at baseline was 21 (inter-quartile range [IQR]: 19-23), 327 (32 %) were female, and 698 (68 %) identified as Caucasian. Of this sample, 590 (58 %) youths reported engaging in unprotected sex at baseline, with an additional 176 (17 %) youths engaging in unprotected sex during follow-up. A total of 75 % of study participants reported unprotected sex over the study period. Participants contributed 3,605 observations during the study period, which included 1,903 (53 %) reports of unprotected sex. The median number of study visits was 3 (IQR: 1-5). Baseline descriptive frequencies and bivariate analyses of characteristics of this study sample, stratified by reports of unprotected sex at baseline, are displayed in Table 1.
The bivariate and multivariable GEE analyses of the socio-demographic, drug use, and risk factors that were associated with unprotected sex are displayed in Table 2. In the multivariable GEE analysis, factors that were positively and independently associated with having unprotected sex (p < 0.05) included: female gender (adjusted odds ratio [AOR] = 1.46, 95 % confidence interval [CI]: 1.18-1.81), Caucasian ancestry (AOR = 1.38, 95 % CI: 1.13-1.68), being in a stable relationship (AOR = 4.64, 95 % CI: 3.82-5.65), any injection or non-injection crystal methamphetamine use (AOR = 1.21, 95 % CI: 1.03-1.43), any injection or non-injection cocaine use (AOR = 1.20, 95 % CI: 1.02-1.41), any marijuana use (AOR = 1.23, 95 % CI: 1.02-1.49), any non-injection ecstasy use (AOR = 1.23, 95 % CI: 1.01-1.48), any alcohol use (AOR = 1.31, 95 % CI: 1.11-1.55), and having multiple sex partners (AOR = 2.60, 95 % CI: 2.18-3.10).
In the present study, 766 (75 %) youth reported recently engaging in unprotected sex during the study period and the majority of study observations included a report of recent unprotected sex. Female gender, Caucasian ancestry, substance use, monogamous relationships, and having multiple concurrent sex partners, were independently and positively associated with unprotected sex. The high prevalence of unprotected sex in this study aligns with previous findings that up to 25 % of street-youth have never used condoms and 56 % did not use condoms the last time they had sex under the influence of substances [10, 21]; this contrasts with a much higher proportion of condom use at last intercourse among the general youth population aged 20-24 in 2009/2010 (63 %) . It is unclear, however, if our study outcome of “any unprotected sex in the recent six months” is comparable to “unprotected sex at last sexual intercourse”.
A number of different drugs were positively and significantly associated with unprotected sex in our study. Experimentation with alcohol at an early age is common among young people , and this study found that youth who reported alcohol use were more likely to report having unprotected sex. Alcohol is known to lower inhibitions which increases the likelihood of engaging in sexual activities that one might not normally partake in, such as sexual encounters with strangers, anal intercourse, and sex without a condom [23–25].
The null findings for binge drug use and injection drug use in the current analysis indicate that youth in our sample who engage in unprotected sex are not more likely to engage in especially risky drug use patterns. However, crystal methamphetamine and cocaine use were significantly associated with engaging in unprotected sex in our analysis. This is consistent with previous research findings that stimulant drug use heightens sexual arousal and lowers inhibitions, resulting in a higher likelihood of engaging in risky sexual behavior [26, 27]. The link between stimulant drug use, increased sexual arousal and reduced inhibitions, resulting in lower condom use, is particularly well documented in the context of sexual health among men who have sex with men . The effect of stimulant use has also been found to increase risk of STI transmission among adults who use illicit drugs, in part by facilitating longer periods of sexual activity which can lead to increased risk of condom breakage [27, 29].
Our results provide further evidence that reducing stimulant drug use may prevent high levels of unprotected sex among this population. It is therefore of concern that vulnerable youth report high rates of difficulty accessing addiction treatment [30, 31]. Sustained efforts to improve engagement and retention in addiction treatment are warranted and can be expected to have positive health benefits beyond reductions in substance use [32, 33]. For youth who are unable or unwilling to reduce engagement in stimulant drug use, alternative interventions are needed. There is some evidence to suggest that low-threshold services such as supervised injection facilities  and needle exchange programs  may increase condom use; however, more studies to assess whether these secondary benefits would be realized with street-involved youth are needed. In addition, research indicates that the risks of HIV transmission through sexual intercourse can be reduced through expanded HIV testing and treatment . Consequently, STI and HIV testing for vulnerable youth who use stimulants should be a public health priority and integrated into all healthcare services.
It is noteworthy that ecstasy and marijuana use were each also positively and significantly associated with unprotected sex in this study. Ecstasy is known to induce feelings of euphoria, friendliness, and enhanced sensuality , and previous research has linked ecstasy use [38, 39] and marijuana use [40, 41] with sexual risk-taking. However, studies in this area have not been consistent and further investigation into the association between ecstasy and risky sexual behavior including inconsistent condom use is warranted . Similarly, the null findings for crack cocaine use and inconsistent condom use in the current study contrast with research in other settings among drug-using youth , suggesting more investigation is needed.
Study findings also show that female youth are significantly more likely to engage in unprotected sex, which is linked with complex interactions of gender inequality, power, and socio-structural context . Our results indicate that condoms are inconsistently used among participants in stable relationships and who have multiple concurrent sex partners (38 % and 63 % at baseline, respectively). The positive relationship between stable relationships and inconsistent condom use aligns with previous research [45, 46], however, the association between multiple concurrent sex partners and inconsistent condom use is novel. These results point to the need for tailored gender-informed interventions to support consistent condom use among sexually active street-involved youth [47, 48].
There are a number of study limitations. The absence of a probability sample limits the ability of this study to generalize to other settings, although our extensive recruitment efforts resulted in a similar sample to those found in other studies of Vancouver street-involved youth [49, 50]. Self-report surveys are also vulnerable to recall and socially-desirable response biases ; however, under-reporting of illicit drug use and sexual practices are expected to bias our results to the null.
This study demonstrates that unprotected sex remains highly prevalent among drug-using youth in this setting and a number of illicit drugs were independently associated with inconsistent condom use. Findings suggest that improving access to evidence-based and youth-centered addiction treatment to reduce problematic substance use can be expected to also prevent risky sexual behaviour . For those who continue to engage in substance use, better connections to healthcare services and STI testing are needed across the continuum of care. The heightened risk of unprotected sex among female youth in this study also highlights the need for gender-informed interventions to support consistent condom use among street-involved youth.
At-Risk Youth Study
Adjusted Odds Ratio
Generalized Estimating Equation
Sexually Transmitted Infection
Gilles K. Adolescence: A foundation for future health (Fact Sheet 1). In: Lancet Series on Adolescent Health Fact Sheets. Population Reference Bureau. Washington, D.C; 2014.
Kleinert S. Adolescent health: an opportunity not to be missed. Lancet. 2007;369(9567):1057–8.
Edidin JP, Ganim Z, Hunter SJ, Karnik NS. The mental and physical health of homeless youth: a literature review. Child Psychiat Hum D. 2012;43(3):354–75.
Dube SR, Felitti VJ, Dong M, Chapman DP, Giles WH, Anda RF. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: The adverse childhood experiences study. Pediatrics. 2003;111(3):564–72.
Hillis SD, Anda RF, Felitti VJ, Marchbanks PA. Adverse childhood experiences and sexual risk behaviors in women: A retrospective cohort study. Fam Plann Perspect. 2001;33(5):206–11.
Kirby D. Effective approaches to reducing adolescent unprotected Sex, pregnancy, and childbearing. J Sex Res. 2002;39(1):51–7.
Satterwhite CL, Torrone E, Meites E, Dunne EF, Mahajan R, Ocfemia MCB, et al. Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. Sex Transm Dis. 2013;40(3):187–93.
Rotermann M. Sexual behaviour and condom use of 15- to 24-year-olds in 2003 and 2009/2010. Health Reports (Statistics Canada). 2012;23(1):41–5.
Public Health Agency of Canada. Sexually Transmitted Infections in Canadian Street Youth: Findings from Enhanced Surveillance of Canadian Street Youth, 1999-2003. In. Ottawa: Government of Canada; 2006
Shields SA, Wong T, Mann J, Jolly AM, Haase D, Mahaffey S, et al. Prevalence and correlates of Chlamydia infection in Canadian street youth. J Adolesc Health. 2004;34(5):384–90.
Noell J, Rohde P, Ochs L, Yovanoff P, Alter MJ, Schmid S, et al. Incidence and prevalence of chlamydia, herpes, and viral hepatitis in a homeless adolescent population. Sex Transm Dis. 2001;28(1):4–10.
Ericksen KP, Trocki KF. Behavioral risk-factors for sexually-transmitted diseases in American households. Soc Sci Med. 1992;34(8):843–53.
Biglan A, Metzler CW, Wirt R, Ary D, Noell J, Ochs L, et al. Social and behavioral-factors associated with high-risk sexual-behavior among adolescents. J Behav Med. 1990;13(3):245–61.
Butcher AH, Manning DT, O’Neal EC. HIV-related sexual behaviors of college students. J Am Coll Health. 1991;40(3):115–8.
Lowry R, Holtzman D, Truman BI, Kann L, Collins JL, Kolbe LJ. Substance use and HIV-related sexual behaviors among US high school students: are they related? Am J Public Health. 1994;84(7):1116–20.
Fast D, Shoveller J, Shannon K, Kerr T. Safety and danger in downtown Vancouver: Understandings of place among young people entrenched in an urban drug scene. Health Place. 2010;16(1):51–60.
Wood E, Stoltz JA, Montaner JS, Kerr T. Evaluating methamphetamine use and risks of injection initiation among street youth: the ARYS study. Harm Reduct J. 2006;3:18.
de Carvalho FT, Neiva-Silva L, Ramos MC, Evans J, Koller SH, Piccinini CA, et al. Sexual and drug use risk behaviors among children and youth in street circumstances in Porto Alegre, Brazil. AIDS Behav. 2006;10(1):57–66.
Johnston CL, Callon C, Li K, Wood E, Kerr T. Offer of financial incentives for unprotected sex in the context of sex work. Drug Alcohol Rev. 2010;29(2):144–9.
Pan W. Akaike’s information criterion in generalized estimating equations. Biometrics. 2001;57(1):120–5.
Marshall BD. The contextual determinants of sexually transmissible infections among street-involved youth in North America. Cult Health Sex. 2008;10(8):787–99.
Jernigan D. Global status report: Alcohol and young people. Geneva: World Health Organization; 2001.
Schroder KE, Johnson CJ, Wiebe JS. An event-level analysis of condom use as a function of mood, alcohol use, and safer sex negotiations. Arch Sex Behav. 2009;38(2):283–9.
Patrick ME, O’Malley PM, Johnston LD, Terry-McElrath YM, Schulenberg JE. HIV/AIDS risk behaviors and substance use by young adults in the United States. Prev Sci. 2012;13(5):532–8.
Cooper ML, Orcutt HK. Alcohol use, condom use and partner type among heterosexual adolescents and young adults. J Stud Alcohol Drugs. 2000;61(3):413.
Gleghorn AA, Marx R, Vittinghoff E, Katz MH. Association between drug use patterns and HIV risks among homeless, runaway, and street youth in Northern California. Drug Alcohol Depend. 1998;51(3):219–27.
Zule WA, Costenbader E, Coomes CM, Meyer WJ, Riehman K, Poehlman J, et al. Stimulant use and sexual risk behaviors for HIV in rural North Carolina. J Rural Health. 2007;23(s1):73–8.
Mansergh G, Shouse R, Marks G, Guzman R, Rader M, Buchbinder S, et al. Methamphetamine and sildenafil (Viagra) use are linked to unprotected receptive and insertive anal sex, respectively, in a sample of men who have sex with men. Sex Transm Infect. 2006;82(2):131–4.
Quirk A, Rhodes T, Stimson G. ‘Unsafe protected sex’: qualitative insights on measures of sexual risk. AIDS Care. 1998;10(1):105–14.
Barker B, Kerr T, Nguyen P, Wood E, DeBeck K. Barriers to health and social services for street-involved youth in a Canadian setting. J Public Health Policy. 2015;36(3):350–63.
Phillips M, DeBeck K, Desjarlais T, Morrison T, Feng C, Kerr T, et al. Inability to access addiction treatment among street-involved youth in a Canadian setting. Subst Use Misuse. 2014;49(10):1233–40.
Williams RJ, Chang SY, Grp ACAR. A comprehensive and comparative review of adolescent substance abuse treatment outcome. Clin Psychol-Sci Pr. 2000;7(2):138–66.
Simpson DD, Joe GW, Brown BS. Treatment retention and follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychol Addict Behav. 1997;11(4):294–307.
Marshall BDL, Wood E, Zhang R, Tyndall MW, Montaner JSG, Kerr T. Condom use among injection drug users accessing a supervised injecting facility. Sex Transm Infect. 2009;85(2):121–6.
Bailey SL, Huo DZ, Garfein RS, Ouellet LJ. The use of needle exchange by young injection drug users. Jaids-J Acq Imm Def. 2003;34(1):67–70.
Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States - Implications for HIV prevention programs. Jaids-J Acq Imm Def. 2005;39(4):446–53.
Solowij N, Hall W, Lee N. Recreational MDMA use in Sydney: a profile of ‘Ecstacy’ users and their experiences with the drug. Br J Addict. 1992;87(8):1161–72.
Boyd CJ, McCabe SE, d’Arcy H. Ecstasy use among college undergraduates: gender, race and sexual identity. J Subst Abuse Treat. 2003;24(3):209–15.
Klitzman RL, Greenberg JD, Pollack LM, Dolezal C. MDMA (‘ecstasy’) use, and its association with high risk behaviors, mental health, and other factors among gay/bisexual men in New York City. Drug Alcohol Depend. 2002;66(2):115–25.
Andrade LF, Carroll KM, Petry NM. Marijuana use is associated with risky sexual behaviors in treatment-seeking polysubstance abusers. Am J Drug Alcohol Ab. 2013;39(4):266–71.
Bryan AD, Schmiege SJ, Magnan RE. Marijuana Use and risky sexual behavior among high-risk adolescents: trajectories, risk factors, and event-level relationships. Dev Psychol. 2012;48(5):1429–42.
McElrath K. MDMA and sexual behavior: Ecstasy users’ perceptions about sexuality and sexual risk. Subst Use Misuse. 2005;40(9-10):1461–77.
Chavoshi N, Christian W, Moniruzzaman A, Richardson C, Schechter M, Spittal P. The cedar project: understanding barriers to consistent condom Use over time in a cohort of young indigenous people who use drugs. Int J Sex Health. 2013;25(4):249–59.
Higgins JA, Hoffman S, Dworkin SL. Rethinking gender, heterosexual men, and women’s vulnerability to HIV/AIDS. Am J Public Health. 2010;100(3):435–45.
De Visser R, Smith A. Relationship between sexual partners influences rates and correlates of condom use. AIDS Educ Prev. 2001;13(5):413–27.
Tucker JS, Ober A, Ryan G, Golinelli D, Ewing B, Wenzel SL. To use or not to use: A stage-based approach to understanding condom use among homeless youth. Aids Care-Psychol Socio-Med Aspects Aids/Hiv. 2014;26(5):567–73.
Workowski KA, Berman SM. Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. Clin Infect Dis. 2007;44(Supplement 3):S73–6.
Exner TM, Dworkin SL, Hoffman S, Ehrhardt AA. Beyond the male condom: the evolution of gender-specific HIV interventions for women. Annu Rev Sex Res. 2003;14:114–36.
Miller CL, Strathdee SA, Kerr T, Li K, Wood E. Factors associated with early adolescent initiation into injection drug use: implications for intervention programs. J Adolesc Health. 2006;38(4):462–4.
Ochnio JJ, Patrick D, Ho M, Talling DN, Dobson SR. Past infection with hepatitis A virus among Vancouver street youth, injection drug users and men who have sex with men: implications for vaccination programs. Can Med Assoc J. 2001;165(3):293–7.
Podsakoff PM, MacKenzie SB, Lee J-Y, Podsakoff NP. Common method biases in behavioral research: a critical review of the literature and recommended remedies. J Appl Psychol. 2003;88(5):879.
National Institute on Drug Abuse. Principles of drug addiction treatment: A research-based guide. Second Edition. National Institutes of Health. Bethesda, Maryland; 2009.
The authors thank the study participants for their contribution to the research, as well as current and past researchers and staff. We would specifically like to thank Cody Callon, Deborah Graham, Peter Vann, Steve Kain, Tricia Collingham, Kristie Starr, and Carmen Rock for their research and administrative assistance. The study was supported by the US National Institutes of Health (U01DA038886) and the Canadian Institutes of Health Research (MOP–102742). This research was undertaken, in part, thanks to funding from the Canada Research Chairs program through a Tier 1 Canada Research Chair in Inner City Medicine which supports Dr. Evan Wood. Dr. Kora DeBeck is supported by a MSFHR/St. Paul’s Hospital Foundation‐Providence Health Care Career Scholar Award and a CIHR New Investigator Award. Funding sources had no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
The author(s) declare that they have no competing interests.
TC contributed to study design and the literature search, and was responsible for preparing the final draft of the manuscript. CJ contributed to study design, was responsible for managing the preliminary literature search, prepared the initial draft of the manuscript, and provided critical comments on the final draft and approved the final manuscript. TK contributed to study design, and the main content of the manuscript, provided critical comments on the final draft, and approved the final manuscript. PN was responsible for conducting the statistical analyses and contributing to the main content of the manuscript. He provided critical comments on the final draft, and approved the final manuscript. EW contributed to study design, statistical analyses, and the main content of the manuscript. He also provided critical comments on the final draft, and approved the final manuscript. KD contributed to study design, statistical analyses, and the main content of the manuscript. She also provided critical comments on the final draft and approved the final manuscript.