Impact of the COVID-19 pandemic on inbound air travel to Canada

Background

Commercial air travel can result in global dispersal of infectious diseases. During the coronavirus disease 2019 (COVID-19) pandemic, many countries implemented border measures, including restrictions on air travel, to reduce the importation risk of COVID-19. In the context of inbound air travel to Canada, this study aimed to: 1) characterize travel trends before and during the pandemic, and 2) statistically assess the association between travel volumes and travel restrictions during the pandemic.

Methods

Monthly commercial air travel volume data from March 2017 to February 2023 were obtained from the International Air Transport Association (IATA). National and airport-level travel trends to Canada were characterized by inbound travel volumes, the number of countries contributing travellers and the ranking of the top ten countries contributing travellers across the study period, by six year-length subperiod groupings (three pre-pandemic and three pandemic). Using seasonal autoregressive integrated moving average (SARIMA) models, interrupted time series (ITS) analyses assessed the association between major travel restrictions and travel volumes by including variables to represent changes to the level and slope of the time series.

Results

The pre-pandemic inbound travel volume increased by 3% to 7% between consecutive subperiods, with three seasonal peaks (July-August, December-January, March). At the onset of the pandemic, travel volume decreased by 90%, with the number of contributing countries declining from approximately 200 to 140, followed by a slow recovery in volume and seasonality. A disruption in the ranking of countries that contributed travellers was also noticeable during the pandemic. Results from the ITS analysis aligned with the timing of travel restrictions as follows: implementation in March 2020 coincided with a sharp reduction in volumes, while the easing of major restrictions, starting with the authorization of fully vaccinated travellers from the United States to enter Canada in August 2021, coincided with an increase in the slope of travel volumes. Descriptive and statistical results suggest a near-return of pre-pandemic travel patterns by the end of the study period.

Conclusion

Study results suggest resilience in commercial air travel into Canada. Although the COVID-19 pandemic led to a disruption in travel trends, easing of travel restrictions appeared to enable pre-pandemic trends to re-emerge. Understanding trends in air travel volumes, as demonstrated here, can provide information that supports preparedness and response regarding importation risk of infectious pathogens.

Enablers and barriers to primary health care access for Indigenous adolescents: a systematic review and meta-aggregation of studies across Australia, Canada, New Zealand, and USA

BACKGROUND

Indigenous adolescents access primary health care services at lower rates, despite their greater health needs and experience of disadvantage. This systematic review identifies the enablers and barriers to primary health care access for Indigenous adolescents to inform service and policy improvements.

METHODS

We systematically searched databases for publications reporting enablers or barriers to primary health care access for Indigenous adolescents from the perspective of adolescents, their parents and health care providers, and included studies focused on Indigenous adolescents aged 10-24 years from Australia, Canada, New Zealand, and United States of America. Results were analyzed against the WHO Global standards for quality health-care services for adolescents. An additional ninth standard was added which focused on cultural safety.

RESULTS

A total of 41 studies were included. More barriers were identified than enablers, and against the WHO Global standards most enablers and barriers related to supply factors - providers' competencies, appropriate package of services, and cultural safety. Providers who built trust, respect, and relationships; appropriate package of service; and culturally safe environments and care were enablers to care reported by adolescents, and health care providers and parents. Embarrassment, shame, or fear; a lack of culturally appropriate services; and privacy and confidentiality were common barriers identified by both adolescent and health care providers and parents. Cultural safety was identified as a key issue among Indigenous adolescents. Enablers and barriers related to cultural safety included culturally appropriate services, culturally safe environment and care, traditional and cultural practices, cultural protocols, Indigenous health care providers, cultural training for health care providers, and colonization, intergenerational trauma, and racism. Nine recommendations were identified which aim to address the enablers and barriers associated with primary health care access for Indigenous adolescents.

CONCLUSION

This review provides important evidence to inform how services, organizations and governments can create accessible primary health care services that specifically meet the needs of Indigenous adolescents. We identify nine recommendations for improving the accessibility of primary health care services for Indigenous adolescents.

Assessing primary health care provider and organization readiness to address family violence in Alberta, Canada: development of a Delphi consensus readiness tool

BACKGROUND

Family violence, which includes intimate partner abuse, child abuse, and elder abuse, is a serious public health concern. Primary healthcare (PHC) offers a vital opportunity to identify and address family violence, yet barriers prevent the effective implementation of family violence interventions in PHC settings. The purpose of this study is to improve family violence identification and response in Alberta's PHC settings by exploring readiness factors.

METHODS

An integrated knowledge translation approach, combining implementation science and participatory action research, was employed to develop a readiness assessment tool for addressing family violence within PHC settings in Alberta. The research involved three phases: phase 1 involved a rapid evidence assessment, phase 2 engaged a panel of healthcare and family violence experts to explore readiness components in the Alberta context, and phase 3 utilized a 3-round Delphi consensus-building process to refine readiness indicators.

RESULTS

Phase 1 findings from a rapid evidence assessment highlighted five main models/tools for assessing readiness to implement family violence interventions in PHC settings. In phase 2, additional concepts were identified through exploration with healthcare and family violence expert panel members, resulting in a total of 16 concepts for assessing family violence readiness within the Alberta PHC context. The 3-round Delphi consensus-building process in Phase 3 involved nine panelists, who collectively agreed on the inclusion of all concepts and indicators, yielding a total of 60 items for the proposed readiness assessment tool for addressing family violence in PHC within Alberta.

CONCLUSION

The current study lays the groundwork for future family violence intervention programs, offering insights into key components that promote readiness for implementing comprehensive programs and supporting PHC organizations in effectively addressing family violence.

Implementation opportunities and challenges to piloting a community-based drug-checking intervention for sexual and gender minority men in Vancouver, Canada: a qualitative study

BACKGROUND

In response to the overdose crisis, a collaborative group of two community-based organizations, a health authority and a research institute in Vancouver, Canada, implemented a pilot community-based drug checking (CBDC) intervention for sexual and gender minority (SGM) men. This study identified key factors that influenced the implementation of the CBDC intervention, including opportunities and challenges.

METHODS

We conducted semi-structured interviews with seven pertinent parties involved in the CBDC, including policymakers, researchers and representatives from community-based organizations. These interviews were coded and analyzed using domains and constructs of the Consolidated Framework for Implementation Research.

RESULTS

While drug-related stigma was identified as a challenge to deliver drug checking services, participants described the context of the overdose crisis as a key facilitator to engage collaboration between relevant organizations (e.g., health authorities, medical health officers, community organizations) to design, resource and implement the CBDC intervention. The implementation of the CBDC intervention was also influenced by SGM-specific needs and resources (e.g., lack of information about the drug supply). The high level of interest of SGM organizations in providing harm reduction services combined with the need to expand drug checking into community spaces represented two key opportunities for the CBDC intervention. Here, SGM organizations were recognized as valued partners that fostered a broader culture of harm reduction. Participants' emphasis that knowing the composition of one's drugs is a "right to know", particularly in the context of a highly contaminated illicit drug market, emerged as a key implementation factor. Lastly, participants emphasized the importance of involving SGM community groups at all stages of the implementation process to ensure that the CBDC intervention is appropriately tailored to SGM men.

CONCLUSIONS

The context of the overdose crisis and the involvement of SGM organizations were key facilitators to the implementation of a drug checking intervention in SGM community spaces. This study offers contextualized understandings about how SGM knowledge and experiences can contribute to implement tailored drug checking interventions.

"We're sinking": a qualitative interview-based study on stakeholder perceptions of structural and process limitations to the Canadian healthcare system

BACKGROUND

Despite longstanding efforts and calls for reform, Canada's incremental approach to healthcare changes has left the country lagging behind other OECD nations. Reform to the Canadian healthcare system is essential to develop a higher performing system. This study sought to gain a deeper understanding of the views of Canadian stakeholders on structural and process deficiencies and strategies to improve the Canadian healthcare system substantially and meaningfully.

METHODS

We conducted individual, ~ 45-minute, semi-structured virtual interviews from May 2022 to August 2022. Using existing contacts and snowball sampling, we targeted one man and one woman from five regions in Canada across four stakeholder groups: (1) public citizens; (2) healthcare leaders; (3) academics; and (4) political decision makers. Interviews centered on participants' perceptions of the state of the current healthcare system, including areas where major improvements are required, and strategies to achieve suggested enhancements; Donabedian's Model (i.e., structure, process, outcomes) was the guiding conceptual framework. Interviews were audio-recorded, transcribed verbatim, and de-identified, and inductive thematic analysis was performed independently and in duplicate according to published methods.

RESULTS

The data from 31 interviews with 13 (41.9%) public citizens, 10 (32.3%) healthcare leaders, 4 (12.9%) academics, and 4 (12.9%) political decision makers resulted in three themes related to the structure of the healthcare system (1. system reactivity; 2. linkage with the Canadian identity; and 3. political and funding structures), three themes related to healthcare processes (1. staffing shortages; 2. inefficient care; and 3. inconsistent care), and three strategies to improve short- and long-term population health outcomes (1. delineating roles and revising incentives; 2. enhanced health literacy; 3. interdisciplinary and patient-centred care).

CONCLUSION

Canadians in our sample identified important structural and process limitations to the Canadian healthcare system. Meaningful reforms are needed and will require addressing the link between the Canadian identity and our healthcare system to facilitate effective development and implementation of strategies to improve population health outcomes.

Inequities in access to palliative and end-of-life care in the black population in Canada: a scoping review

BACKGROUND

Improving equity and early access to palliative care for underserved populations in Canada is a priority. Little is known regarding access to palliative and end-of-life care in the Black population.

METHODS

We undertook a scoping review using the framework by Arksey and O'Malley to identify knowledge, access gaps, and experiences of palliative and end-of-life care among Blacks living with life-limiting illnesses in Canada. Primary studies, discussion papers, books, and reports were considered eligible. We followed a comprehensive search strategy developed by an information scientist. Searches were performed in the following bibliographic databases: Medline, EMBASE, PsycINFO via OVID, CINAHL via EBSCOhost, Scopus and Cochrane Library via Wiley. The search strategy was derived from three main concepts: (1) Black people; (2) Canada and Canadian provinces; (3) Palliative, hospice, or end-of-life care. No publication date or language limits were applied. Titles and abstracts were screened for eligibility by one reviewer and full text by two independent reviewers.

RESULTS

The search yielded 233 articles. Nineteen articles were selected for full-text review, and 7 articles met the inclusion criteria. These studies were published between 2010 and 2021, and conducted in the provinces of Ontario and Nova Scotia only. Studies used both quantitative and qualitative methods and included cancer decedents, next of kin, family caregivers and religious leaders. Sample sizes in various studies ranged from 6 - 2,606 participants. Included studies reported a general lack of understanding about palliative and end-of-life care, positive and negative experiences, and limited access to palliative and end-of-life care for Blacks, across all care settings.

CONCLUSION

Findings suggest limited knowledge of palliative care and inequities in access to palliative and end-of-life care for Blacks living with life-limiting illnesses in 2 Canadian provinces. There is an urgent need for research to inform tailored and culturally acceptable strategies to improve understanding and access to palliative care and end-of-life care among Blacks in Canada.

Law, Blood, and Custody: Sexual Minority Mothers and Heteronormativity

This article analyzes how couples made up of two mothers redefine their roles when they break up as well as how legal professionals frame the custodial arrangements of these former same-sex couples. To do so, we focus on the case of Quebec, Canada, where parentage equality between mothers was attained as early as in 2002. We rely on individual semi-structured interviews with mothers' (N = 17) and legal professionals' accounts (N = 23) as well as on court records regarding physical custody arrangements. We find that the legal recognition of both mothers favors coparenting practices, and especially joint physical custody. However, the heteronormative frame of custody arrangements lingers. Sexual minority mothers struggle with the valorization of birth motherhood and with the standard of gendered parental complementarity. Indeed, professionals can still fall back on heteronormative norms, notably by assigning to non-birth mothers a "paternal" role. In the end, the inexperience of many professionals on LGBTQ+ issues, the embeddedness of heteronormativity in day-to-day relations, as well as the permanence of heteronormative legal categories and professional practices are all factors that set these families apart.

Cancer Care Supportive Text Messaging Program (Text4Hope) for People Living With Cancer and Their Caregivers During the COVID-19 Pandemic: Longitudinal Observational Study

BACKGROUND

Cancer is the leading cause of death in Canada, and living with cancer generates psychological demands, including depression and anxiety among cancer survivors and caregivers. Text4Hope-Cancer Care SMS text messaging-based service was provided to people with cancer and caregivers during the COVID-19 pandemic to support their mental health.

OBJECTIVE

The aim of this study is to examine the clinical effectiveness of and satisfaction with Text4Hope-Cancer Care in addressing mental health conditions among people living with cancer and caregivers.

METHODS

The study was conducted in Alberta, Canada. People who were diagnosed or receiving cancer treatment and caregivers self-subscribed to receive 3-months daily supportive cognitive behavioral therapy-based SMS text messages and a web-based survey was sent at designated time points to collect clinical and nonclinical data. The Hospital Anxiety and Depression scale (HADS) was used to examine changes in anxiety and depression symptoms after receiving the service. Satisfaction with the service was assessed using a survey with a Likert scale. Descriptive and inferential statistics were used, and test significance was considered with P≤.05.

RESULTS

Overall, 107 individuals subscribed to the service, and 93 completed the program (completion rate 93/107, 86.9%). A significant improvement in the anxiety symptoms (HADS-Anxiety [HADS-A] subscale) was reported after 3 months of Text4Hope-Cancer Care (t11=2.62; P=.02), with medium effect size (Hedges g=0.7), but not depression symptoms (HADS-Depression [HADS-D] subscale). Subscribers expressed high satisfaction and agreed that the service has helped them to cope with mental health symptoms and improve their quality of life. Most subscribers read the SMS text messages more than once (30/30, 100%); took time to reflect or took a beneficial action after reading the messages (27/30, 90%); and highly agreed (27/30, >80%) with the value of the received supportive SMS text messages as being relevant, succinct, affirmative, and positive. All subscribers recommended SMS text messaging for stress, anxiety, and depression and for cancer care support (30/30, 100%).

CONCLUSIONS

Text4Hope-Cancer Care was well-perceived and effectively addressed anxiety symptoms among people living with cancer and caregivers during the peak of the COVID-19 pandemic. This study provides evidence-based support and insight for policy and stakeholders to implement similar convenient, economic, and accessible mental health services that support vulnerable populations during crises.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/20240.

"The Children Are Not Controllable Because They Follow Western Values" - Narratives of the Parenting Experiences of African Immigrants in Alberta, Canada

African immigrants are moving to high-income nations such as Canada in greater numbers in search of a better life. These immigrants frequently struggle with several issues, including limited social support, shifts in gender roles/status, cultural conflicts with their children, and language barriers. We used participatory action research (PAR) to gather data about Sub-Saharan African immigrants residing in Alberta, Canada, with a focus on their viewpoints, difficulties, and experiences of parenting children in Canada. We contextualized our study and its findings using both postcolonial feminism and transnationalism approaches. Study findings show African immigrant parents place a high priority on respect between generations. The absence of assistance, conflicts caused by culture, and language barriers are notable difficulties they encountered in parenting. An additional factor is a lack of acquaintance with and comprehension of the culture of their new home nation. Several implications stem from our findings, including the need for interventional research that explores effective, culturally relevant strategies for enhancing parenting among African immigrants. Our findings demonstrate the need for culturally sensitive policies and practices that support the transition and integration of African immigrant families into Canadian society. It is imperative for health care providers and policy makers to develop and revise culturally appropriate policies that take into consideration the importance of African immigrants in destination countries. Adopting culturally relevant policies and practices will improve the wellbeing of this growing but underprivileged minority of Canadians.

A methodology for estimating SARS-CoV-2 importation risk by air travel into Canada between July and November 2021

BACKGROUND

Estimating rates of disease importation by travellers is a key activity to assess both the risk to a country from an infectious disease emerging elsewhere in the world and the effectiveness of border measures. We describe a model used to estimate the number of travellers infected with SARS-CoV-2 into Canadian airports in 2021, and assess the impact of pre-departure testing requirements on importation risk.

METHODS

A mathematical model estimated the number of essential and non-essential air travellers infected with SARS-CoV-2, with the latter requiring a negative pre-departure test result. The number of travellers arriving infected (i.e. imported cases) depended on air travel volumes, SARS-CoV-2 exposure risk in the departure country, prior infection or vaccine acquired immunity, and, for non-essential travellers, screening from pre-departure molecular testing. Importation risk was estimated weekly from July to November 2021 as the number of imported cases and percent positivity (PP; i.e. imported cases normalised by travel volume). The impact of pre-departure testing was assessed by comparing three scenarios: baseline (pre-departure testing of all non-essential travellers; most probable importation risk given the pre-departure testing requirements), counterfactual scenario 1 (no pre-departure testing of fully vaccinated non-essential travellers), and counterfactual scenario 2 (no pre-departure testing of non-essential travellers).

RESULTS

In the baseline scenario, weekly imported cases and PP varied over time, ranging from 145 to 539 cases and 0.15 to 0.28%, respectively. Most cases arrived from the USA, Mexico, the United Kingdom, and France. While modelling suggested that essential travellers had a higher weekly PP (0.37 - 0.65%) than non-essential travellers (0.12 - 0.24%), they contributed fewer weekly cases (62 - 154) than non-essential travellers (84 - 398 per week) given their lower travel volume. Pre-departure testing was estimated to reduce imported cases by one third (counterfactual scenario 1) to one half (counterfactual scenario 2).

CONCLUSIONS

The model results highlighted the weekly variation in importation by traveller group (e.g., reason for travel and country of departure) and enabled a framework for measuring the impact of pre-departure testing requirements. Quantifying the contributors of importation risk through mathematical simulation can support the design of appropriate public health policy on border measures.

Honour, acculturation and well-being: Evidence from the UK and Canada

Adopting a social psychological approach, across three studies (N = 927) in two western immigrant-receiving societies (UK and Canada), we examined the role of honour in acculturation variables (i.e., immigrants' heritage and mainstream cultural orientation and well-being), controlling for some of the commonly studied predictors of immigrant adaptation. We assessed honour as concern (Studies 1 and 2) and as a desired attribute for men and women (Study 3) and studied well-being in terms of acculturative stress (Study 1) and subjective evaluation of one's life (Studies 1 and 3). We examined our questions among groups of immigrants originating from honour (Studies 1 and 2) and dignity cultural groups (Study 1) and from first- and second-generation immigrants (Study 3). Overall, despite some significant associations at the bivariate level between honour and acculturation outcomes, findings provided mixed support for the claim that honour (measured as concerns and cultural codes) plays a significant role in immigrant acculturation above and beyond commonly studied predictors of immigrant adaptation.

Alternative Food Practices as Pathways to Cope with Climate Distress

Experiences of distress and challenging emotions in response to the climate crisis are increasingly common, particularly among young adults. These experiences can include challenging emotions caused by the harmful environmental impacts of conventional food systems, as their contributions to greenhouse gas emissions have become more widely known. While recent studies have examined various experiences of climate distress, the interaction between climate distress and food practice remains poorly understood. In this research, we turn to this intersection by examining the experiences of climate distress of young adults who have alternative food practices, and the interaction between their climate distress and their alternative food practices. Guided by an exploratory, single case study research approach, this research draws from 20 semi-structured interviews conducted with young adults located in urban centres in the Southeastern Prairie Region of Canada. Thematic analysis of the findings reveals that participants experience a variety of climate emotions and a personal responsibility to act in response to the climate crisis. The findings suggest that because of their ability to facilitate a meaningful and practical environmental impact, alternative food practices represent significant climate actions and may be pathways to facilitate coping or managing climate distress among young adults. Results demonstrate the psychological impacts of the climate crisis on young adults, highlighting the need for action on climate change and climate distress. Increasing the accessibility of alternative food practices may support young adults in coping with challenging climate emotions.

User-Centered Development of a Patient Decision Aid for Choice of Early Abortion Method: Multi-Cycle Mixed Methods Study

BACKGROUND

People seeking abortion in early pregnancy have the choice between medication and procedural options for care. The choice is preference-sensitive-there is no clinically superior option and the choice depends on what matters most to the individual patient. Patient decision aids (PtDAs) are shared decision-making tools that support people in making informed, values-aligned health care choices.

OBJECTIVE

We aimed to develop and evaluate the usability of a web-based PtDA for the Canadian context, where abortion care is publicly funded and available without legal restriction.

METHODS

We used a systematic, user-centered design approach guided by principles of integrated knowledge translation. We first developed a prototype using available evidence for abortion seekers' decisional needs and the risks, benefits, and consequences of each option. We then refined the prototype through think-aloud interviews with participants at risk of unintended pregnancy ("patient" participants). Interviews were audio-recorded and documented through field notes. Finally, we conducted a web-based survey of patients and health care professionals involved with abortion care, which included the System Usability Scale. We used content analysis to identify usability issues described in the field notes and open-ended survey questions, and descriptive statistics to summarize participant characteristics and close-ended survey responses.

RESULTS

A total of 61 individuals participated in this study. Further, 11 patients participated in think-aloud interviews. Overall, the response to the PtDA was positive; however, the content analysis identified issues related to the design, language, and information about the process and experience of obtaining abortion care. In response, we adapted the PtDA into an interactive website and revised it to include consistent and plain language, additional information (eg, pain experience narratives), and links to additional resources on how to find an abortion health care professional. In total, 25 patients and 25 health care professionals completed the survey. The mean System Usability Scale score met the threshold for good usability among both patient and health care professional participants. Most participants felt that the PtDA was user-friendly (patients: n=25, 100%; health care professionals: n=22, 88%), was not missing information (patients: n=21, 84%; health care professionals: n=18, 72%), and that it was appropriate for patients to complete the PtDA before a consultation (patients: n=23, 92%; health care professionals: n=23, 92%). Open-ended responses focused on improving usability by reducing the length of the PtDA and making the website more mobile-friendly.

CONCLUSIONS

We systematically designed the PtDA to address an unmet need to support informed, values-aligned decision-making about the method of abortion. The design process responded to a need identified by potential users and addressed unique sensitivities related to reproductive health decision-making.

Quality improvement lessons from Canadian thyroid and parathyroid surgery legal decisions

BACKGROUND

This is the first study of Canadian thyroid and parathyroid surgery legal decisions, and the first study of surgical malpractice using the Canadian Legal Information Institute (CanLII) database. The objective was to identify quality improvement opportunities in surgical practice, to increase patient safety and satisfaction.

METHODS

Legal decisions relating to thyroid and parathyroid surgery in the CanLII database were screened. Cases were included if a surgeon was listed as applicant or respondent; they related to pre-, intra-, or post-operative management of thyroid or parathyroid disease; and malpractice was alleged. Cases were excluded if surgery was mentioned incidentally or for non-surgical focus.

RESULTS

Of the 347 unique legal decisions screened, 14 met inclusion and exclusion criteria. Surgeries occurred between 1976 and 2012, with 13 thyroid surgeries, 1 parathyroidectomy, and 4 mortalities.

CONCLUSIONS

Quality improvement lessons include communication, pre-operative patient education and documentation of risks discussed, and in-person assessment of complications.

Exploring the Impact of Length of Residence and Food Insecurity on Weight Status Among Canadian Immigrants

PURPOSE

While the individual impacts of long-term residence and food insecurity on overweight/obesity are well-documented, their combined effect on immigrants' weight status is less understood. This study examines the interaction between length of residence and food insecurity in predicting overweight/obesity among immigrants and investigates whether this relationship is gender-specific.

DESIGN

A national cross-sectional survey.

SETTING

The 2017-2018 Canadian Community Health Survey.

SUBJECTS

Immigrants aged 18 and older (N = 13 680).

MEASURES

All focal variables were self-reported.

ANALYSIS

Logistic regression models were employed.

RESULTS

Long-term immigrants were more likely to report overweight/obesity than their short-term counterparts (OR = 1.39; P < .001). Moreover, immigrants from food-insecure households were at a higher risk of reporting overweight/obesity (OR = 1.27; P < .05) compared to those from food-secure households. The analysis further revealed that food insecurity exacerbated the detrimental association between length of residence and overweight/obesity in men (OR = 2.63; P < .01) but not in women (OR = .66; P > .05).

CONCLUSION

The findings suggest that long-term immigrant men may be especially susceptible to the compounded chronic stressors of extended residence and food insecurity. Health professionals and policymakers should advocate for psychosocial resources to help mitigate these adverse effects and support the well-being of immigrant populations.

Relationships Between Measures of the Physical Activity-Related Built Environment and Excess Weight in Preschoolers: A Retrospective, Population-Level Cohort Study

Background: The built environment can impact health outcomes. Our purpose was to examine relationships between built environment variables related to physical activity and excess weight in preschoolers. Methods: In this retrospective, population-level study of 4- to 6-year-olds, anthropometric measurements were taken between 2009 and 2017 in Calgary and Edmonton, Alberta, Canada. Based on BMI z-scores (BMIz), children were classified as normal weight (-2 ≤ BMIz <1) or excess weight (BMIz ≥1; overweight and obesity). Physical activity-related built environment variables were calculated (distances to nearest playground, major park, school; street intersection density; number of playgrounds and major parks within an 800 m buffer zone). Binomial logistic regression models estimated associations between physical activity-related built environment variables and excess weight. Results: Our analysis included 140,368 participants (females: n = 69,454; Calgary: n = 84,101). For Calgary, adjusted odds ratios (aORs) showed the odds of excess weight increased 1% for every 100-intersection increase [1.010 (1.006-1.015); p < 0.0001] and 13.6% when there were ≥4 playgrounds (vs. 0 or 1) within an 800 m buffer zone [1.136 (1.037-1.243); p = 0.0059]. For Edmonton, aORs revealed lower odds of excess weight for every 100 m increase in distances between residences to nearest major park [0.991 (0.986-0.996); p = 0.0005] and school [0.992 (0.990-0.995); p < 0.0001]. The odds of excess weight decreased as the number of major parks within the 800 m buffer zone increased from 0 to 1 [0.943 (0.896-0.992); p = 0.023] and from 0 to ≥3 [0.879 (0.773-0.999); p = 0.048]. Conclusion: The physical activity-related built environment was associated with excess weight in preschoolers, although relationships varied between cities that differed demographically and geographically.

Crafting British medicine in the Empire: the establishment of medical schools in India and Canada, 1763-1837

In the early nineteenth century, medical schools became a growing means of regulating medicine in the British Empire, both in the metropole and in two colonies: India and Canada. By examining the establishment of medical schools in Calcutta, Bombay, Madras, Quebec City, Montreal and Toronto between the end of the Seven Years' War and the beginning of the Victorian era, this article argues that the rise of the British Empire was a key factor in the gradual replacement of private medical apprenticeships with institutional medical education. Although the imperial state did not implement a uniform medical policy across the British Empire, the medical schools established under its jurisdiction were instrumental in devising a curriculum that emphasised human dissection, bedside training in hospitals and organic chemistry as criteria of medical competence.

Politics, ecologies and professional regulation: The case of British Columbia's Professional Governance Act

A variety of theories have been proposed to explain why states pass legislation to regulate professional groups, and why, more recently, they have acted to curtail professional privileges. While these theories have drawn attention to the importance of power dynamics and public protection, among other factors, the role of political interests has been downplayed. This article builds on ecological theory to argue that, with some modifications, the theory illuminates the centrality of state-profession relations and politics to regulatory change. The theory is applied to a case study of regulatory change in British Columbia, Canada impacting resources-sector professions, with particular attention to the controversies and political considerations that shaped reform. The case study suggests that when the political and professions ecologies are overlapping and symbiotic, as they were in BC, a challenge in the political ecology can implicate professions, prompting a solution that brings change within both ecologies.

The Challenges of Advance Care Planning for Acute Care Registered Nurses

STUDY BACKGROUND

The practice of acute care nurses is shaped by organizational factors such as lack of privacy, heavy workloads, unclear roles, lack of time, and lack of specific policies and procedures. We know little about the social and organizational structures and processes that influence nurses' uptake of valuable patient-centered discussions like advance care planning (ACP). ACP is beneficial for patients, their substitute decision makers, and healthcare providers.

PURPOSE

To describe the operational, organizational, and societal influences shaping nurses' ACP work in acute care settings.

METHODS

This ethnographic study purposively sampled 14 registered nurses and 9 administrators who worked in two acute care hospitals in Northeastern Ontario. Methods consisted of 23 open-ended, semi-structured interviews, 20 hours of observational fieldwork, and a collection of publicly available organizational documents. Data were inductively analyzed using an iterative constant comparative approach.

RESULTS

Nurses were challenged to meet multiple competing demands, leaving them to scramble to manage complex and critically ill acute care patients while also fulfilling organizational tasks aligned with funding metrics, accreditation, and strategic planning priorities. Such factors limited nurses' capacity to engage their patients in ACP.

CONCLUSIONS

Acute care settings that align patient values and medical treatment need to foster ACP practices by revising organizational policies and processes to support this outcome, analyzing the tasks of healthcare providers to determine who might best address it, and budgeting how to support it with additional resources.

Survival, treatment patterns, and costs of HER2+ metastatic breast cancer patients in Ontario between 2005 to 2020

BACKGROUND

To enable the integration of novel therapies, it is critical to understand current long-term outcomes in HER2-positive metastatic breast cancer (mBC), including survival, treatment patterns, and costs. We sought to define these outcomes among patients with mBC in Ontario.

METHODS

We conducted a retrospective population-level study in Ontario women diagnosed with breast cancer of any stage between January 1, 2005 and December 31, 2019, with follow-up until December 31, 2020. HER2-positivity was based on receipt of a HER2-targeted therapy (HER2-TT) in the first line (1L) metastatic setting. Administrative databases at ICES were used to assess outcomes.

RESULTS

In Ontario, 2557 patients were diagnosed with mBC and received a HER2-TT, and of these 1606 were diagnosed with early-stage (stage I-III) that became metastatic (recurrent), while 951 were diagnosed with late stage/de novo mBC (stage IV). The average age of all patients was 54.8 years ± 12.7 years. Treatment regimens that included pertuzumab and trastuzumab (cohort name: pert_tras) were the most frequently used HER2-TT for 1L mBC (51.4%), while T-DM1 was the most frequent therapy (87.5%) in second line (2L). The median overall survival (mOS) from initiation of 1L pert_tras was not reached, whereas mOS from initiation of T-DM1 in 2L was 18.7 months. The overall mean cost per patient on pert_tras during 1L was $267,282. The main cost drivers were the cost of systemic therapy, followed by cancer clinic visits, with a mean cost per patient at $158,961 and $73,882, respectively.

CONCLUSION

The baseline characteristics and treatment patterns for patients who received HER2-TT in our study align with previously reported results. However, the mOS observed for 2L T-DM1 was shorter than that found in pivotal, clinical trial literature. As expected, anti-cancer systemic therapy costs were the main contributor to the over quarter-million dollar mean cost per patient on pert_tras in 1L.

Survey of Canadian Physician Use of Botulinum Toxin A (BoNT-A) for Paratonia: Real World Insights

Paratonia is a form of hypertonia characterized by an inability to relax muscles in the setting of cognitive impairment. Paratonia results in pain, refusal of care, and caregiver burden. We sent surveys to 67 Canadian physiatrists and neurologists regarding their experience treating paratonia with botulinum toxin A (BoNT-A). Twenty-seven survey respondents were included in the analysis. Thirteen percent of survey respondents treating paratonia with BoNT-A reported a significant clinically relevant improvement; 74% endorsed a moderately clinically relevant improvement; 13% endorsed a slight clinically relevant improvement. Ninety percent of survey respondents endorsed significant barriers in treating paratonia with BoNT-A.

Estimating the impacts of nonoptimal temperatures on mortality: A study in British Columbia, Canada, 2001-2021

Background

Studies show that more than 5.1 million deaths annually are attributed to nonoptimal temperatures, including extreme cold and extreme heat. However, those studies mostly report average estimates across large geographical areas. The health risks attributed to nonoptimal temperatures in British Columbia (BC) are reported incompletely or limit the study area to urban centers. In this study, we aim to estimate the attributable deaths linked to nonoptimal temperatures in all five regional health authorities (RHAs) of BC from 2001 to 2021.

Methods

We applied the widely used distributed lag nonlinear modeling approach to estimate temperature-mortality association in the RHAs of BC, using daily all-cause deaths and 1 × 1 km gridded daily mean temperature. We evaluated the model by comparing the model-estimated attributable number of deaths during the 2021 heat dome to the number of heat-related deaths confirmed by the British Columbia Coroners Service.

Results

Overall, between 2001 and 2021, we estimate that 7.17% (95% empirical confidence interval = 3.15, 10.32) of deaths in BC were attributed to nonoptimal temperatures, the majority of which are attributed to cold. On average, the mortality rates attributable to moderate cold, moderate heat, extreme cold, and extreme heat were 47.04 (95% confidence interval [CI] = 45.83, 48.26), 0.94 (95% CI = 0.81, 1.08), 2.88 (95% CI = 2.05, 3.71), and 3.10 (95% CI = 1.79, 4.4) per 100,000 population per year, respectively.

Conclusions

Our results show significant spatial variability in deaths attributable to nonoptimal temperatures across BC. We find that the effect of extreme temperatures is significantly less compared to milder nonoptimal temperatures between 2001 and 2021. However, the increased contribution of extreme heat cannot be ruled out in the near future.

Indigenous people's experiences of primary health care in Canada: a qualitative systematic review

INTRODUCTION

Indigenous people in Canada encounter negative treatment when accessing primary health care (PHC). Despite several qualitative accounts of these experiences, there still has not been a qualitative review conducted on this topic. In this qualitative systematic review, we aimed to explore Indigenous people's experiences in Canada with PHC services, determine urban versus rural or remote differences and identify recommendations for quality improvement.

METHODS

This review was guided by the Joanna Briggs Institute's methodology for systematic reviews of qualitative evidence. MEDLINE, CINAHL, PubMed, PsycInfo, Embase and Web of Science as well as grey literature and ancestry sources were used to identify relevant articles. Ancestry sources were obtained through reviewing the reference lists of all included articles and determining the ones that potentially met the eligibility criteria. Two independent reviewers conducted the initial and full text screening, data extraction and quality assessment. Once all data were gathered, they were synthesized following the meta-aggregation approach (PROSPERO CRD42020192353).

RESULTS

The search yielded a total of 2503 articles from the academic databases and 12 articles from the grey literature and ancestry sources. Overall, 22 articles were included in this review. Three major synthesized findings were revealed-satisfactory experiences, discriminatory attitudes and systemic challenges faced by Indigenous patients-along with one synthesized finding on their specific recommendations.

CONCLUSION

Indigenous people value safe, accessible and respectful care. The discrimination and racism they face negatively affect their overall health and well-being. Hence, it is crucial that changes in health care practice, structures and policy development as well as systemic transformation be implemented immediately.

Detection and Phylogenetic Analysis of Orf Virus and Muskox Rhadinovirus 1 from Muskoxen (Ovibos moschatus) in the Canadian Arctic

Orf virus (genus Parapoxvirus) has been associated with gross skin lesions on muskoxen (Ovibos moschatus) from Victoria Island, Nunavut, Canada, where muskox populations are experiencing population declines. Orf virus causes painful proliferative and necrotizing dermatitis upon viral replication and shedding, which may lead to animal morbidity or mortality through secondary infections and starvation. Herpesvirus, known to cause gross lesions on skin and mucosa during active viral replication, has also been documented in muskoxen but to date has not been associated with clinical disease. Our objective was to characterize the variation of orf virus and herpesvirus in wild muskoxen of the Canadian Arctic. Tissue samples including gross skin lesions from the nose, lips, and/or legs were opportunistically collected from muskoxen on Victoria Island, Nunavut and Northwest Territories, and mainland Nunavut, Canada, from 2015 to 2017. Sampled muskoxen varied in age, sex, location, hunt type, and body condition. Tissues from 60 muskoxen were tested for genetic evidence of orf virus and herpesvirus infection using PCR targeting key viral genes. Tissues from 38 muskoxen, including 15 with gross lesions, were also examined for histological evidence of orf virus and herpesvirus infection. Eleven muskoxen (10 from Victoria Island and one from mainland Nunavut) with gross lesions had microscopic lesions consistent with orf virus infection. Muskox rhadinovirus 1, a gammaherpesvirus endemic to muskoxen, was detected in 33 (55%) muskoxen including 17 with gross lesions. In all tissues examined, there was no histological evidence of herpesvirus-specific disease. Sequencing and characterization of amplified PCR products using phylogenetic analysis indicated that a strain of orf virus, which appears to be unique, is likely to be endemic in muskoxen from Victoria Island and mainland Nunavut. Many of the muskoxen are also subclinically infected with a known muskox-endemic strain of herpesvirus.

The contributions of avoidable causes of death to gender gap in life expectancy and life disparity in the US and Canada: 2001-2019

OBJECTIVES

This study measures public health policies' and healthcare system's influence, by assessing the contributions of avoidable deaths, on the gender gaps in life expectancy and disparity (GGLD and GGLD, respectively) in the United States (US) and Canada from 2001 to 2019.

METHODS

To estimate the GGLE and GGLD, we retrieved age- and sex-specific causes of death from the World Health Organization's mortality database. By employing the continuous-change model, we decomposed the GGLE and GGLD by age and cause of death for each year and over time using females as the reference group.

RESULTS

In Canada and the US, the GGLE (GGLD) narrowed (increased) by 0.9 (0.2) and 0.2 (0.3) years, respectively. Largest contributor to the GGLE was non-avoidable deaths in Canada and preventable deaths in the US. Preventable deaths had the largest contributions to the GGLD in both countries. Ischemic heart disease contributed to the narrowing GGLE/GGLD in both countries. Conversely, treatable causes of death increased the GGLE/GGLD in both countries. In Canada, "treatable & preventable" as well as preventable causes of death narrowed the GGLE while opposite was seen in the US. While lung cancer contributed to the narrowing GGLE/GGLD, drug-related death contributed to the widening GGLE/GGLD in both countries. Injury-related deaths contributed to the narrowing GGLE/GGLD in Canada but not in the US. The contributions of avoidable causes of death to the GGLE declined in the age groups 55-74 in Canada and 70-74 in the US, whereas the GGLE widened for ages 25-34 in the US.

CONCLUSION

Canada experienced larger reduction in the GGLE compared to the US attributed mainly to preventable causes of death. To narrow the GGLE and GGLD, the US needs to address injury deaths. Urgent interventions are required for drug-related death in both countries, particularly among males aged 15-44 years.