Master Theses & Projects (FHSCI)
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Item SDTDMn0 : a multidimensional distributed data mining framework supporting time series data analysis for critical care research(2011-04-01) Dhanoa, Agam; McGregor, Carolyn; James, Andrew; Calley, ChristinaPremature birth is one of the major perinatal health issues across the world. In 2007, the estimated Canadian preterm birth rate was 8.1 % (CIHI, 2009). Recent research has shown that conditions, such as nosocomial infections or apnoeas, exhibit certain variations in the baby's physiological parameters which can indicate the onset of the event before it can be detected by physicians and nurses. Neonatal Intensive Care Units are some of the highest information producing areas in hospitals. The multidimensional and distributed nature of the data further adds another layer of complexity as physiological changes can occur in one data stream or can be cross-correlated between several streams. With the collection and storage of electronic data becoming a global trend, there is an opportunity to analyse the collected data in order to extract meaningful information and improve healthcare. The aforementioned properties of the data motivate the need for a framework that supports analysis and trend detection in a multidimensional and distributed environment.Item STDMn+p0: a multidimensional patient oriented data mining framework for critical care research(2011-04-01) Smith, Kathleen Patricia; McGregor, Carolyn; Catley, Christina; Eklund, Mikael; James, AndrewIn the neonatal intensive care unit (NICU) environment, critical care and treatment directly correlate to the multidimensional development of an infant and are influenced by attributes such as gender and gestational age (GA). Recent literature on guidelines developed for neonatal intensive care; do not take the gender or the GA of the infant into account. The exponential activity of a growing neonate in its early stages of life needs to be captured and embedded into algorithms designed to extract patterns of predictive temperament within the NICU domain. The STDMn+p0 framework presents an extended multidimensional approach with the ability to create patient characteristic clinical rules. Further defining NICU algorithms, through the extended use of attributes to include gender and GA, and using these new algorithms in clinical decision support systems increases the accuracy and thereby minimizes the risk of adverse events.Item Experiences and satisfaction with methadone maintenance treatment (MMT) health services: views from a small Ontario city(2011-04-01) Taylor, Lorri; Weaver, Robert; Byrne, Carolyn; Grant, JudithAddiction to opiates is a complex public health issue affecting thousands of Canadians. Methadone Maintenance Treatment (MMT) is considered the gold standard in Canada, and the world, for treating opiate dependence. In the past, Canadian research into opiate addiction and the effectiveness of MMT has mostly focused on larger cities: Toronto, Montreal, and Vancouver. This community based research study employed a mixed method approach to gain understanding of the experiences and satisfaction with MMT and other health services available to opiate users in Belleville, Ontario (population 48,000). Surveys (N = 53), focus groups, participant-observation methods and key informant interviews were used to gather data. The results provide an overall picture of the quality of life for opiate users and MMT clients, the quality of care clients receive, and the perceptions of community members regarding MMT. Challenges related to smaller locales are identified along with recommendations for improving MMT health services.Item Development of instruments to access physiological and physical neck pain risk factors(2011-07-01) Gray, Diana; Murphy, BernadetteNeck pain has the potential to result in altered afferent input to the central nervous system which may thereby result in altered sensorimotor integration and eventually further disability. One “at risk” population for neck pain may be university students, particularly given the growing use of laptop computers in the university setting. This thesis presents two pilot studies which aim to develop and assess instruments to use as screening tools for risk factors associated with neck pain. The first study explores the environment in which university students utilize their laptop computers and the relationship to known risk factors for neck pain. A new questionnaire, The Student Laptop Use and Neck Pain Risk Questionnaire (SLUNPRQ) was created to measure the presence of risk factors known to increase the risk of developing neck pain. This questionnaire was piloted for reliability using test- retest measures. Results indicated that the SLUNPRQ had good reliability based on Cohen’s Kappa scores. A modified questionnaire was developed based on questions with either low reliability or ambiguous answers and is ready for further testing. The second study sought to determine if dual somatosensory evoked potential (SEP) ratios changed with long term chiropractic care. This was part of the overall goal of finding neural markers that could identify those who are at risk for developing neck pain. This study sought to determine the feasibility of using dual SEPs to evaluate changes in neural markers of sensorimotor integration after 12 weeks of chiropractic care and demonstrated that dual SEPs shows potential as a marker to screen individuals at risk of neck pain as the SEP markers showed improvement after long term chiropractic care.Item Alterations in neck muscle performance and proprioception with fatique, altered posture and recurrent neck pain(2011-07-01) Barker, Ian; Murphy, BernadetteAltered neuromuscular processing and motor output as both a risk and perpetuating factor for chronic neck pain is a relative new area of study. The cervical flexion relaxation response (FRR) is a reproducible and reliable marker of differences in neuromuscular function between neck pain patients and controls. Change in joint position sense (JPS) of upper limb joints has also been linked to chronic neck pain. Studies in this thesis sought to develop an experimental model in humans to investigate whether the FRR and JPS can be altered by fatigue and/or postural stress. Additionally a pilot study on the effect of three months of chiropractic treatment on the FRR was conducted. The studies revealed that muscular fatigue is a modulator of the FRR and may play a large role in spine stabilization. Minor postural alterations in the neck can impact joint position error at the elbow and 12 weeks of chiropractic care is a useful therapy to improve chronic and recurrent neck pain as well as improving the cervical FRR.Item Is Yang style Tai Chi a “one size fits all” fall prevention exercise program for older adults?(2011-08-01) Gonsalves, Rohan; Lemonde, ManonFalls among Canadian older adults is a growing problem, not only in terms of incident rates and its impacts, but most importantly, the vast scope of preventable morbidity and mortality. A decline in age-related physical function is acknowledged as a risk factor of falls. Community-based group exercise programs such as Yang style tai chi may help to reduce fall risk by improving components of physical function. To investigate, a pretest-posttest experimental design was conducted. Post-intervention assessments revealed Yang style tai chi practiced three times a week over eight weeks improved balance, muscle strength and muscle endurance. These findings suggest Yang style tai chi is moderately effective in reducing fall risk but further research is needed to determine the true effectiveness of tai chi as a fall prevention strategy. This study provides directions for future research guided by a proposed conceptual framework and offers some tentative recommendations for community health practice.Item Professors’ views on mental health nursing education in the baccalaureate nursing programs of Ontario: a grounded theory approach(2011-08-01) Boyko, Olga Viktorivna; Stanyon, WendyAccording to the Canadian Nurses’ Association (2005), mental health (MH) nursing is currently undervalued in the nursing profession. The Education Committee of the Canadian Federation of Mental Health Nurses (CFMHN) (2009) reports that the length of MH theory and practicum varies enormously in the undergraduate nursing programs of Ontario and across the country. Interviews with 19 nursing professors representing programs with different MH components show a variation in their opinions about topics such as the degree of importance of a mandatory stand-alone MH component, whether MH nursing education should be students’ or professors’ responsibility, how professors relate themselves to the MH component, and their familiarity with and assessment of their program’s MH education. It remains unclear the extent to which these factors contribute to program design and, in turn, students’ knowledge of MH nursing. Further research in this area is required.Item The shift from “muffins” to mangoes: child, family, and organizational impacts of an after-school snack program(2011-08-01) Bham, Salma A.; Vogel, EllenIn 2009 alarming rates of childhood obesity resulted in the Government of Ontario launching a province-wide initiative through the Ministry of Health Promotion & Sport. This study focused on Eastview Boys and Girls Club (Eastview unit) in Oshawa, Ontario and examined immediate impacts of an after-school snack program involving close to 100-children daily. Data collection included key informant interviews (n=7); one focus group interview with parents (n=8); three interactive children‟s sessions, and document review. Findings identified changes in children‟s eating behaviours (e.g., willingness to try new foods) and shifts in staff attitudes (e.g., role-modelling). Facilitators included staff commitment, strong partnerships, and previous program accreditation. Organizational barriers included gaps in nutrition-related knowledge/skills of staff and insufficient program-specific training and resources. Recommendations call for building capacities at individual-, organizational- and community-levels to strengthen the nutritional component of the after-school initiative. Future research should evaluate long-term outcomes of the snack program.Item An in-depth analysis of the workforce characteristics of registered dietitians in Ontario(2011-08-01) Miller, Andrea; Vogel, EllenThe purpose of this study was to examine workforce characteristics of RDs in Ontario from 2003-2009. Descriptive statistics were used to determine: (1) What does the profession of dietetics look like? (2) What are the employment transition trends of RDs? Data analysis revealed two themes: (1) Succession planning for mid-career RDs- what are the priorities? (2) The shift to the community- who is paying the moving costs? Findings indicate the workforce of RDs aged 40-59 years has declined; these RDs represent the smallest proportion of the workforce with graduate-level education. There has been a shift of RDs out of government and public health settings into LTC/CCAC‟s and FHTs. Results indicate that while hospitals are the most attractive work setting, there are few RDs in the FSAD practice area. Recommendations include development of retention strategies for mid-career RDs and increasing understandings of RD workforce transition trends for future HHR planning.Item "Walking the talk" in the integration of chronic disease prevention management: dietitians' perspectives regarding diabetes management in adult peritoneal dialysis programs in Ontario(2011-08-01) Vaillancourt, Christina; Vogel, EllenOntario’s Chronic Disease and Prevention Framework (CDPM) is a framework aimed at improving health outcomes and reducing costs. Currently, there is a paucity of data examining diabetes management (DM) in peritoneal dialysis (PD) programs. This study, carried out in 2010-11, describes dietitians’ perspectives regarding DM in PD programs in Ontario. Purposeful sampling of dietitians employed in PD programs (n=18)resulted in a response rate of 86.6%. A web-based survey collected data on demographic characteristics of PD clients, program models, and program-specific data regarding facilitators and barriers to provision of dialysis-specific diabetes education. Statistical analysis was completed and responses to open-ended questions examined using thematic open coding. Findings suggest three major themes: “walking the CDPM talk”, dietitians as “unrecognized CDPM champions” and “the missing pieces to the CDPM puzzle”. Results suggest that while many dietitians have embraced CDPM, their capacity to fully integrate it into their practices is limited by organizational- and system-level barriers.Item The role of interprofessional collaboration on the discharge planning in the neonatal intensive unit(2011-10-01) Manogaran, Myuri; Gamble, BrendaRationale: Interprofessional collaboration (IPC) occurs when “multiple health workers from different professional backgrounds work together with patients, families, careers and communities to deliver the highest quality of care” (WHO, 2010, p. 13). Successful discharge planning for patients from hospitals is dependent upon IPC (Shepperd et al., 2004). The purpose of this study is to identify and examine barriers or facilitators to IPC as they pertain to discharge planning on a neonatal intensive care unit (NICU). Methods: Case study design using an online survey, participant observation and semi-structured interviews for data collection. Healthcare workers on a NICU at a large Canadian teaching hospital were surveyed to determine their views on the discharge planning process, leadership and IPC. Participant observations took place during the weekly IPC rounds to observe the healthcare workers when discussing discharge plans and to identify key informants for interviews. Based on these observations, 10 health care workers were selected to interview to gain a more in depth understanding of IPC in the discharge planning. Data collection occurred from December 2010 to February 2011. Results: Survey results (n=66) indicate that the majority of healthcare workers on the NICU support IPC. However, the interview data demonstrated that problems arose during an emergency discharge. An emergency discharge occurs when an existing patient on the NICU needs to be discharged to another unit in order to provide a bed for a new admission. The lack of effective communication, role clarity issues, and a need for mutual respect act as barriers to the full participation of all members of the interprofessional team in an emergency discharge. Conclusions: Defining the context is important; IPC works well in a non-emergency situation on the NICU. The level of involvement of the healthcare workers in IPC varies due to previous experience working on interprofessional teams (IPT). The medical lead is responsible for making the decision about a discharge. However, what has been identified as important is an IPC leader who is responsible for ensuring that all information from the IPT members is accessible to inform the medical lead.Item Exploring Black-Canadian parent-youth sex communication(2012-01-01) Lee-Foon, Nakia; George, ClemonBlack-Canadian populations are disproportionately affected by HIV/AIDS. In particular, Black-Canadian youth are noted to be at a greater risk of HIV infection due to their sexual risk behaviours. Many international studies indicate that open parent-youth sex communication may counter the potentially negative impact of peers, mass media and inadequate sexual health education programs on youth sexual risk behaviour. However, there is a paucity of Canadian studies on Black-Canadian parent-youth sex communication and ways to enhance this communication. As such, a qualitative based exploratory study was conducted using a community based research approach to determine the state of Black-Canadian parent-youth sex communication in Toronto, Ontario. Data was collected through 17 Key Informant interviews; that is individuals who work in Black Toronto communities and are knowledgeable about the subject matter. The results noted several factors which affect Black-Canadian parent-youth sex communication such as religion and cultural taboos surrounding the discussion of sexual health. The impact of these factors along with potential implications of this study on Black-Canadian populations and recommendations to enhance Black-Canadian parent- youth sex communication are discussed.Item Tuberculosis screening in a cohort of individuals diagnosed with HIV in Ontario during 2001 to 2009(2012-04-01) Afzal, Arsalan; George, ClemonTuberculosis (TB) is a preventable and a treatable disease yet it is considered to be one of the most common infections seen in HIV. People who are infected with HIV are 20 times more likely to develop TB than those without HIV. Globally, there are nearly 40 million people living with HIV and at least one-third of them are infected with TB. Ontario accounts for the highest number of TB cases in Canada yet HIV-TB co-infection in Ontario is not well described. Despite the close relationship between TB and HIV and increasing efforts to fight both concurrently, TB continues to create economic and social burden in HIV infections. Our study estimates the prevalence of active and latent TB and identifies risk factors associated with TB in a cohort of individuals living with HIV in Ontario. Cases diagnosed with HIV during 2001 to 2009 were extracted from the Ontario HIV Treatment Network Cohort Study (OCS). Reviewing Mantoux test results, diagnoses and medication history, identified active and latent TB cases. Period prevalence was estimated by proportion with TB and multivariate analyses were performed to identify associated factors. One thousand two hundred and ninety-three cases (1293) met our selection criteria. Three hundred and eighty four (384; 29.7%) were 29 years or younger, 805 (62.3%) aged between 30 years and 50 years and 104 (8.0%) aged 50 years or older. One thousand and nine (1009; 78.0%) were males. Four hundred and sixty six (466; 36.0%) had at least one record of a Mantoux skin test. The prevalence of active TB was 76/1293 = 0.0587 or 5.87% (95% CI 4.6% to 7.0%) whereas the prevalence of latent TB varied from 5.26% (68/1293 = 0.0526) 95% (CI 4.0% - 6.5%) to 11.37% (53/466 = 0.1137) 95% CI (8.2% to 13.7%) depending on the methodology. In the multivariate analysis, factors associated with active TB were age and birthplace. Individuals 50 years and older were more likely to have active TB than individuals 30 years and younger (OR 4.3 CI (1.7-12.7), p <0.01). Individuals born in Africa were more likely to have active TB than Canadian born (OR 14; 95% CI (5.9 – 32.8) p < 0.001). Factors associated with latent TB were sex and birthplace. Females were more likely to have latent TB than males (OR 2.4; 95% CI (1.1 – 5.2) p < 0.05). Individuals born in Africa were more likely to have latent TB than Canadian born (OR 12.3; 95% CI (4.7 – 32.1) p < 0.001). TB remains a major problem in persons infected with HIV with rates disproportionally high among the foreign born population. Low rates of Mantoux tests in OCS present a missed opportunity for active TB prevention among individuals with HIV. To identify individuals with higher risk of having TB after HIV diagnosis, better screening tools to identify latent TB are needed. Consideration should be given to data capture systems that would ideally be linked between Public Health and HIV clinics.Item Educating students about mental illness: ethnic students' perspective of the effectiveness of a web-based educational tool(2012-04-01) Syed, Atiquah; Stanyon, WendyRationale: Mental health (MH) issues are increasing on post-secondary campuses particularly with ethnic students. This study aimed to establish the effectiveness of web-based MH education. Methods: A three-phase design was used with non-random sampling. An interest questionnaire addressed students’ (n=42) interest/preferred method of MH education in the first phase. In the second phase, a pre/post knowledge test/attitude scale assessed Mindsight’s (a web-based tool for MH education) effectiveness with ethnic students from the initial sample (n=13). In the final phase, ethnic students provided feedback on Mindsight’s effectiveness during focus groups/telephone interviews. Results: Most students considered MH education important and would use web-based tools. All students showed an increase in MH knowledge and most showed a decrease in stigmatizing attitudes. Mindsight was considered easy to use and interactive, however lacked in ethnic sensitivity. Conclusion: Web-based MH education has potential; however, ethnic sensitivity needs to be addressed.Item Tamil mental health system consumers’ views on the utilization of community mental health resources(2012-04-01) Suthaharan, Sivajini; Gamble, BrendaThe goal of this study was to examine the views and perspectives of Tamil mental health outpatients and mental health care workers on the impact social activities and social network has on mentally ill patients’ general and mental health. The study was conducted at an outpatient mental health program at a Canadian hospital, using the grounded theory approach. Data were collected through questionnaires, document review and semi-structured interviews. Results showed that the mental health program had a positive impact on the mental health outpatients’ quality of life, including improvement in mental health, physical health, social network and social skills. The importance of cultural integration in mental health programs was discussed. Furthermore, barriers in accessing and utilizing mental health resources were highlighted and recommendations for program development were provided. Mental health programs can be effective in helping to improve the quality of life for Tamil consumers of outpatient mental health services.Item Investigating the relationship between modifiable environmental risk factors and incidence of colorectal cancer: a community based study(2012-06-01) Sritharan, Jeavana; Sanchez, OttoColorectal cancer is the third most diagnosed cancer and second leading cause of cancer related deaths in Canada. As Ontario has the largest population in Canada, it also has great disparities in colorectal cancer incidence. The region of Timiskaming has the highest incidence for colorectal cancer, while the region of Peel has the lowest incidence for colorectal cancer in Ontario. The purpose of this study is to identify the dominant non-nutritional modifiable environmental risk factors in the region of Timiskaming compared to the region of Peel that may be associated with diverging colorectal cancer incidence rates. The three objectives of the study included performing a systematic review on available published literature, creating an assessment questionnaire tool regarding environmental exposures, and utilizing the questionnaire assessment tool within a pilot study group while expanding it into the communities of interest. Findings indicate that there are dominant non-nutritional modifiable environmental risk factors in the regions of Timiskaming and Peel that may be associated with colorectal cancer. The dominant factors identified are tobacco/smoking, alcohol use, pesticides/organochlorines, and metal toxins. Following this study, it is imperative that recommendations are directed at a community level and relate to the assessment of potential non-nutritional modifiable environmental risk factors. Future research should accompany a larger sample size, multiple participant communities, and catering of the questionnaire tool towards the communities of interest.Item Program evaluation of the chronic pain self-management workshop in the workplace(2012-06-01) Stein, Matthew; Lemonde, ManonChronic pain conditions can be extremely challenging to deal with in the workplace. The implications of these conditions extend far beyond the employees themselves and can create significant organizational impacts. The Chronic Pain Self-Management Program was developed by Dr. Sandra LeFort, and was originally based on the generic Stanford model of self-management. The six-week program, delivered weekly, is designed to explore and instruct those with chronic pain on different aspects of their condition. This pilot study used a mixed method design to evaluate the effectiveness of Chronic Pain Self-Management Program in the workplace. The quantitative measures for this study were unable to demonstrate the effectiveness of the workshop due to a lack of statistical significance. Through the qualitative measures it was possible to delve into how the chronic pain condition manifests itself in the workplace and what support systems are available for those with chronic pain. There are definitely some positive implications from this pilot research, but through further research it is possible to truly understand how people live with chronic pain in the workplace and how their conditions can be made more manageable.Item Motor training and cervical spine manipulation: effects on sensorimotor integration(2012-07-01) Bosse, Jessica; Murphy, BernadetteAltered afferent input resulting from neck joint dysfunction has become a growing area of study. Cervical spine manipulation, specifically in individuals with subclinical neck pain (SNCP); induces neurological changes, suggesting it has a positive neuromodulatory effect on brain processing. The effects of manipulation on motor learning in individuals with SCNP have not been investigated until now. Studies in this thesis sought to develop and investigate a novel motor training task to be coupled with cervical spine manipulation to investigate its effects on individual’s ability to process new task information. The studies revealed significant changes in neural activity specific to the cerebellum and sensorimotor integration following a complex motor training task as compared to a simple repetitive task, suggesting that those specific regions are involved in processing of more complex motor skill learning tasks. This novel task was then coupled with manipulation which revealed significant activation increases in cortical and decreases in subcortical brain regions following manipulation. Regions specific to sensorimotor integration (SMI) showed increased activation in both the manipulation and passive head movement control groups, corroborating with the results from the first study. The use of a complex motor training task is a useful tool for determining intervention effects on neural processing in individuals with SCNP.Item The effect of experimental pain on motor training performance and sensorimotor integration(2012-07-01) Dancey, Erin Margaret; Yielder, Paul; Murphy, BernadetteSensorimotor integration (SMI) is the ability of the central nervous system (CNS) to integrate afferent (incoming) information from different body parts and formulate appropriate motor output to muscles. Effective sensorimotor integration is essential when learning new skills and when performing tasks at home and in the workplace (Rothwell &Rosenkranz, 2005). The overall aim of this thesis is to investigate the effect of acute experimental pain on sensorimotor processing. The primary outcome is the effect of acute experimental pain on somatosensory evoked potential (SEP) peaks. Secondary outcomes include the effect of pain on motor performance and the interactive effect of pain and motor training on SEP peaks. As expected for the placebo condition, no significant differences were found in any of the post-placebo peaks. Contrary to what was expected for the placebo condition, the only peak to be significantly different post-motor learning was the N24 peak. Contrary to what was expected, there were no significant differences for any of the peaks following capsaicin application. One of the secondary outcomes was the interactive effect of pain and motor learning on SEP peaks. The only peak to show any significant differences post-intervention/post-motor learning was the N24 peak. Another secondary outcome was the effect of pain on motor performance. In terms of accuracy, no significant differences were found for either condition following motor learning. However, the data does show a trend towards improved accuracy for the subjects in the intervention group while the subjects in the placebo show a trend towards decreased accuracy. As expected, there was a significant decrease in reaction time for both conditions post-motor learning. However, contrary to what was expected, reaction time decreased to a greater extent in the intervention condition as compared to the placebo condition. It was anticipated that the reaction time would decrease to a greater extent in the placebo condition as it was hypothesized that pain would negatively impact motor performance. It is suspected that the effect of the pain induced by the capsaicin made the motor training task more difficult and participants would have had to focus greater attentional resources to learn the task which lead to the enhanced performance following motor training.Item Durham Region healthy sex youthality project: youth's perspectives of sexual health needs in Durham Region(2012-07-01) Higginson, Alyssa; George, ClemonAccording to Durham Region Public Health Department, 40% of youth, aged 15-19 years, living in Durham Region said that they had engaged in sexual intercourse in the last year, with 570 youth becoming pregnant. In Durham Region 2.3/100,000 youth between the ages of 15 and 24 years are infected with HIV/AIDS annually. Chlamydia rates have also been steadily increasing with 1,250 cases reported in 2009 in Durham Region, with the rates of STIs in Canada being the highest in youth ages 15 to 24 years. This study was undertaken as a capacity building venture to engage youth in Durham Region and allow them to identify their sexual needs and priorities for HIV prevention and healthy sexual development. The study also had four objectives: (1) To assess whether youth know about the sexual health services that are available to them; (2) To discover how youth perceive the sexual health services they are aware of; (3) To identify where youth currently receive sexual health resources; and (4) To understand where, how and from whom youth would like to receive sexual health resources. The Durham Region Healthy SexYouthality Project was a community-based research study conducted by the Durham Region Healthy SexYouthality Coalition. The Project was a qualitative research study that employed focus group sessions to engage youth in discussions pertaining to their sexual health. The study sample included 32 participants ranging from 15 to 24 years of age, with the mean age of 18.96 years. Of the 32 participants, 19 were female, 12 were male and 1 identified as transgender. The coalition identified four populations within Durham Region; urban, rural, semi-rural and LGBTQ youth, which resulted in 10 focus groups. The size of each meeting ranged from four to nine participants and each was audiotaped. The data was transcribed and then analyzed using open coding with the NVivo 9 software. Several themes about sexual health services emerged from the study. They include: lack of knowledge of services, the need for increased awareness; the perceptions youth have about health services including that they are inaccessible, not anonymous, not confidential, not knowledgeable, are judgemental but are youth-friendly; where youth currently receive information including the internet, media, friends/peers, school, parents and health professionals; and how youth would prefer to receive sexual health education such as through trustworthy internet sources, improved sexual education in schools and new community programs. In conclusion, youth in Durham Region need more information about the sexual health services that are available to them and changes need to be made to make them more accessible, anonymous and confidential. Youth also prefer to access information about sexual health through convenient and reliable sources and it is up to organizations working with youth to ensure that these needs are best being met.