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Scruton S, Wong G, Babinski S, Squires LR, Berlin A, Easley J, McGee S, Noel K, Rodin D, Sussman J, Urquhart R, Bender JL. Optimizing Virtual Follow-Up Care: Realist Evaluation of Experiences and Perspectives of Patients With Breast and Prostate Cancer. J Med Internet Res 2025; 27:e65148. [PMID: 39752659 PMCID: PMC11748426 DOI: 10.2196/65148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Revised: 10/28/2024] [Accepted: 11/07/2024] [Indexed: 01/24/2025] Open
Abstract
BACKGROUND Virtual follow-up (VFU) has the potential to enhance cancer survivorship care. However, a greater understanding is needed of how VFU can be optimized. OBJECTIVE This study aims to examine how, for whom, and in what contexts VFU works for cancer survivorship care. METHODS We conducted a realist evaluation of VFU among patients with breast cancer and prostate cancer at an urban cancer center during the COVID-19 pandemic. Realist evaluations examine how underlying causal processes of an intervention (mechanisms) in specific circumstances (contexts) interact to produce results (outcomes). Semistructured interviews were conducted with a purposive sample of patients ≤5 years after diagnosis. Interviews were audio-recorded and analyzed using a realist logic of analysis. RESULTS Participants (N=24; n=12, 50% with breast cancer and n=12, 50% with prostate cancer) had an average age of 59.6 (SD 10.7) years. Most participants (20/24, 83%) were satisfied with VFU and wanted VFU options to continue after the COVID-19 pandemic. However, VFU impacted patient perceptions of the quality of their care, particularly in terms of its effectiveness and patient centeredness. Whether VFU worked well for patients depended on patient factors (eg, needs, psychosocial well-being, and technological competence), care provider factors (eg, socioemotional behaviors and technological competence), and virtual care system factors (eg, modality, functionality, usability, virtual process of care, and communication workflows). Key mechanisms that interacted with contexts to produce positive outcomes (eg, satisfaction) were visual cues, effective and empathetic communication, and a trusting relationship with their provider. CONCLUSIONS Patients value VFU; however, VFU is not working as well as it could for patients. To optimize VFU, it is critical to consider contexts and mechanisms that impact patient perceptions of the patient centeredness and effectiveness of their care. Offering patients the choice of in-person, telephone, or video visits when possible, coupled with streamlined access to in-person care when required, is important. Prioritizing and addressing patient needs; enhancing physician virtual socioemotional behaviors and technology competency; and enhancing VFU functionality, usability, and processes of care and communication workflows will improve patient perceptions of the patient centeredness and effectiveness of virtual care.
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Affiliation(s)
- Sarah Scruton
- Cancer Rehabilitation and Survivorship, Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Stephanie Babinski
- Cancer Rehabilitation and Survivorship, Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Lauren R Squires
- Cancer Rehabilitation and Survivorship, Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- TECHNA Institute, University Health Network, Toronto, ON, Canada
| | - Julie Easley
- Department of Medical Education, Dr Everett Chalmers Regional Hospital, Horizon Health Network, Fredericton, NB, Canada
| | - Sharon McGee
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, ON, Canada
| | - Ken Noel
- The Walnut Foundation, Brampton, ON, Canada
| | - Danielle Rodin
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jonathan Sussman
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Robin Urquhart
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, ON, Canada
| | - Jacqueline L Bender
- Cancer Rehabilitation and Survivorship, Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Shapiro GK, Santiago AT, Pittman T, Iwano K, Rodin G, Cole H, Zeman K, Sellmann S, Oza AM, Jones J, Rosenthal M, Conti RM, Rodin D. Disparities in clinical trial enrollment at a Canadian comprehensive cancer center: A 15-year retrospective study. Cancer 2024; 130:2782-2794. [PMID: 38662430 DOI: 10.1002/cncr.35331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/26/2024] [Accepted: 03/22/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION Disparities in clinical trials (CTs) enrollment perpetuate inequities in treatment access and outcomes, but there is a paucity of Canadian data. The objective of this study was to examine disparities in cancer CT enrollment at a large Canadian comprehensive cancer center. METHODS Retrospective study of CT enrollment among new patient consultations from 2006 to 2019, with follow-up to 2021 (N = 154,880), with the primary outcome of enrollment as a binary variable. Factors associated with CT enrollment were evaluated using multivariable Bayesian hierarchical logistic regression with random effects for most responsible physician (MRP) and geography, adjusted for patient characteristics (sex, age, language, geography, and primary care provider [PCP]), area-level marginalization (residential instability, material deprivation, dependency, and ethnic concentration), disease (cancer site and stage), and MRP (department, sex, language, and training). A sensitivity analysis of the cumulative incidence of enrollment was conducted to account for differences in disease type and follow-up length. RESULTS CT enrollment was 11.2% overall, with a 15-year cumulative incidence of 18%. Lower odds of enrollment were observed in patients who were female (adjusted odds ratio [AOR], 0.82; 95% confidence interval [CI], 0.78-0.86), ≥65 years (AOR vs. <40, 0.61; 95% CI, 0.56-0.66), non-English speakers (0.72; 95% CI, 0.67-0.77), living ≥250 km away (AOR vs. <15 km, 0.71; 95% CI, 0.62-0.80), and without a PCP. Disease characteristics accounted for the largest proportion of observed variation (20.8%), with significantly greater odds of enrollment in patients with genitourinary cancers and late-stage disease. CONCLUSION Significant sociodemographic disparities were observed, suggesting the need for targeted strategies to increase diversity in access to cancer CTs in Canada.
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Affiliation(s)
- Gilla K Shapiro
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Anna T Santiago
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Tyler Pittman
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Kai Iwano
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Heather Cole
- Cancer Clinical Research Unit, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Katherine Zeman
- Cancer Clinical Research Unit, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Susanna Sellmann
- Cancer Clinical Research Unit, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Amit M Oza
- Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Jones
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Meredith Rosenthal
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Rena M Conti
- Department of Markets, Public Policy, and Law, Boston University Questrom School of Business, Boston, Massachusetts, USA
| | - Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
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Bai X, Zhang H, Jiao Y, Yuan C, Ma Y, Han L. Digital Health Interventions for Chronic Wound Management: A Systematic Review and Meta-Analysis. J Med Internet Res 2024; 26:e47904. [PMID: 39012684 PMCID: PMC11289581 DOI: 10.2196/47904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/16/2023] [Accepted: 05/24/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Digital health interventions (DHIs) have shown promising results for the management of chronic wounds. However, its effectiveness compared to usual care and whether variability in the type of intervention affects wound outcomes are unclear. OBJECTIVE The main objective was to determine the effectiveness of DHIs on wound healing outcomes in adult patients with chronic wounds. The secondary objectives were to assess if there was any variation in wound healing outcomes across the various types of DHIs. METHODS In total, 9 databases were searched for the literature up to August 1, 2023. Randomized controlled trials (RCTs), cohort studies, and quasi-experimental studies comparing the efficacy of DHIs with controls in improving wound outcomes in adult patients with chronic wounds were included. Study selection, data extraction, and risk of bias assessment were conducted independently by 2 reviewers. We assessed the quality of each RCT, cohort study, and quasi-experimental study separately using the Cochrane risk of bias tool, ROBINS-I, and the Joanna Briggs Institute Critical Appraisal tools checklists. Relative risks (RRs) and 95% CIs were pooled using the random effects model, and heterogeneity was assessed by the I2 statistic. Subgroup analysis and sensitivity analysis were also performed. RESULTS A total of 25 studies with 8125 patients were included in this systematic review, while only 20 studies with 6535 patients were included in the meta-analysis. Efficacy outcomes in RCTs showed no significant differences between the DHIs and control groups in terms of wound healing (RR 1.02, 95% CI 0.93-1.12; P=.67) and all-cause mortality around 1 year (RR 1.08, 95% CI 0.55-2.12; P=.83). Compared with the control group, the use of DHIs was associated with significant changes in adverse events (RR 0.44, 95% CI 0.22-0.89; P=.02). Subgroup analysis suggested a positive effect of the digital platforms in improving wound healing (RR 2.19, 95% CI 1.35-3.56; P=.002). Although meta-analysis was not possible in terms of wound size, cost analysis, patient satisfaction, and wound reporting rates, most studies still demonstrated that DHIs were not inferior to usual care in managing chronic wounds. CONCLUSIONS The findings of our study demonstrate the viability of adopting DHIs to manage chronic wounds. However, more prominent, high-quality RCTs are needed to strengthen the evidence, and more detailed clinical efficacy research is required. TRIAL REGISTRATION PROSPERO CRD42023392415; https://tinyurl.com/4ybz6bs9.
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Affiliation(s)
- Xinrui Bai
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu, China
| | - Hongyan Zhang
- Department of Nursing, Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Yanxia Jiao
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu, China
| | - Chenlu Yuan
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu, China
| | - Yuxia Ma
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu, China
| | - Lin Han
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu, China
- Department of Nursing, Gansu Provincial Hospital, Lanzhou, Gansu, China
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Wagner RW, Natori A, Prinsloo S, Otto AK, Saez-Clarke E, Ochoa JM, Tworoger SS, Ulrich CM, Hathaway CA, Ahmed S, McQuade JL, Peoples AR, Antoni MH, Penedo FJ, Cohen L. The role of area deprivation index in health care disruptions among cancer survivors during the SARS-CoV-2 pandemic. Public Health 2024; 232:52-60. [PMID: 38735226 PMCID: PMC12122008 DOI: 10.1016/j.puhe.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 02/20/2024] [Accepted: 04/05/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE To examine the associations between demographic/medical and geographic factors with follow-up medical care and health-related quality of life (HRQoL) among cancer survivors during the SARS-CoV-2 pandemic. STUDY DESIGN Cross-sectional survey. METHODS An online survey was sent to cancer survivors between May 2020 and January 2021, exploring their experience with SARS-CoV-2, follow-up care, and HRQoL. PolicyMap was used to geocode home addresses. Both geographic and demographic/medical factors were examined for their associations with SARS-CoV-2 experience, follow-up care, and HRQoL (FACT-G7). RESULTS Geographic data were available for 9651 participants. Patients living in the highest area deprivation index (ADI) neighborhoods (most deprived) had higher odds of avoiding in-person general (odds ratio [OR] = 7.20; 95% confidence interval [CI] = 2.79-18.60), cancer (OR = 8.47; 95% CI = 3.73-19.30), and emergency (OR = 14.2; 95% CI = 5.57-36.30) medical care, as well as lower odds of using telemedicine (OR = 0.61; 95% CI = 0.52-0.73) compared to the lowest ADI group. Race/ethnicity was not associated with follow-up care after controlling for ADI. The effect of ADI on HRQoL was generally in the expected direction, with higher ADI being associated with worse HRQoL. CONCLUSIONS ADI influenced follow-up medical care more than age, race/ethnicity, or health insurance type. Healthcare providers and institutions should focus on decreasing barriers to in-person and telemedicine health care that disproportionally impact those living in more deprived communities, which are exacerbated by health care disruptions like those caused by the SARS-CoV-2 pandemic.
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Affiliation(s)
- R W Wagner
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A Natori
- Division of Medical Oncology, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - S Prinsloo
- Department of Palliative, Rehabilitation and Integrative Medicine, Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A K Otto
- Memory Keepers Medical Discovery Team, University of Minnesota Medical School, Duluth Campus, Duluth, MN, USA
| | - E Saez-Clarke
- Department of Psychology, College of Arts and Sciences, University of Miami, FL, USA
| | - J M Ochoa
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S S Tworoger
- Division of Oncological Sciences, Knight Cancer Institute, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - C M Ulrich
- Huntsman Cancer Institute, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - C A Hathaway
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - S Ahmed
- Department of Lymphoma and Myeloma, Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J L McQuade
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A R Peoples
- Huntsman Cancer Institute, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - M H Antoni
- Department of Psychology, College of Arts and Sciences, University of Miami, FL, USA; Department of Psychiatry and Behavioral Sciences, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - F J Penedo
- Department of Psychology, College of Arts and Sciences, University of Miami, FL, USA; Department of Medicine & Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - L Cohen
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Jolidon V, Eicher M, Peytremann-Bridevaux I, Arditi C. Inequalities in patients' experiences with cancer care: the role of economic and health literacy determinants. BMC Health Serv Res 2024; 24:733. [PMID: 38877526 PMCID: PMC11179203 DOI: 10.1186/s12913-024-11174-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 06/05/2024] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND Patients with fewer socioeconomic and health literacy resources are disadvantaged in their access and use of healthcare, which may give rise to worse experiences with care and thus inequalities in patient experiences. However, only a limited number of studies have examined how socioeconomic and health literacy factors shape inequalities in patients' experiences with cancer care. OBJECTIVE To examine whether patients' experiences with cancer care differ according to their economic status and health literacy. METHODS Secondary analysis of data on 2789 adult patients diagnosed with cancer from the Swiss Cancer Patient Experiences-2 (SCAPE-2) study, a cross-sectional survey conducted in eight hospitals across Switzerland from September 2021 to February 2022. Regression analysis was applied to examine the independent effect of patients' economic status and health literacy on various outcomes of experiences with cancer care, covering eight different dimensions of patient-centred care, controlling for confounding factors. RESULTS Adjusted regression analysis showed that patients with lower economic status reported significantly worse experiences with cancer care in 12 out of 29 specific care experiences, especially in the dimensions of 'respect for patients' preferences' and 'physical comfort' where all items of experiences were associated with economic status. Additionally, lower health literacy was associated with worse patient experiences in 23 specific care experiences. All items in the dimensions of 'respect for patients' preferences', 'physical comfort' and 'emotional support' were associated with health literacy. DISCUSSION This study revealed significant inequalities in experiences with cancer care shaped by the economic status and health literacy of patients across different dimensions of patient-centred care. It is essential to address the needs of more disadvantaged patients who face obstacles in their access and use of the healthcare system, not only to mitigate inequalities in cancer care but also to avoid inequalities in health outcomes.
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Affiliation(s)
- Vladimir Jolidon
- Unisanté, University Center for Primary Care and Public Health, Department of Epidemiology and Health Systems, University of Lausanne, CH-1011 Lausanne, Switzerland
| | - Manuela Eicher
- Institute of Higher Education and Research in Healthcare (IUFRS), Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Department of Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Isabelle Peytremann-Bridevaux
- Unisanté, University Center for Primary Care and Public Health, Department of Epidemiology and Health Systems, University of Lausanne, CH-1011 Lausanne, Switzerland
| | - Chantal Arditi
- Unisanté, University Center for Primary Care and Public Health, Department of Epidemiology and Health Systems, University of Lausanne, CH-1011 Lausanne, Switzerland.
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Kureshi N, Abidi SSR, Clarke DB, Zeng W, Feng C. Spatial Hotspots and Sociodemographic Profiles Associated With Traumatic Brain Injury in Nova Scotia. J Neurotrauma 2024; 41:844-861. [PMID: 38047531 DOI: 10.1089/neu.2023.0257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability, primarily caused by falls and motor vehicle collisions (MVCs). Although many TBIs are preventable, there is a notable lack of studies exploring the association of geographically defined TBI hotspots with social deprivation. Geographic information systems (GIS) can be used to identify at-risk neighborhoods (hotspots) for targeted interventions. This study aims to determine the spatial distribution of TBI by major causes and to explore the sociodemographic and economic characteristics of TBI hotspots and cold spots in Nova Scotia. Patient data for TBIs from 2003 to 2019 were obtained from the Nova Scotia Trauma Registry. Residential postal codes were geocoded and assigned to dissemination areas (DA). Area-based risk factors and deprivation status (residential instability [RI], economic dependency [ED], ethnocultural composition [EC], and situational vulnerability [SV]) from the national census data were linked to DAs. Spatial autocorrelation was assessed using Moran's I, and hotspot analysis was performed using Getis-Ord Gi* statistic. Differences in risk factors between hot and cold spots were evaluated using the Mann-Whitney U test for numerical variables and the χ2 test or Fisher's exact test for categorical variables. A total of 5394 TBI patients were eligible for inclusion in the study. The distribution of hotspots for falls exhibited no significant difference between urban and rural areas (p = 0.71). Conversely, hotspots related to violence were predominantly urban (p = 0.001), whereas hotspots for MVCs were mostly rural (p < 0.001). Distinct dimensions of deprivation were associated with falls, MVCs, and violent hotspots. Fall hotspots were significantly associated with areas characterized by higher RI (p < 0.001) and greater ethnocultural diversity (p < 0.001). Conversely, the same domains exhibited an inverse relationship with MVC hotspots; areas with low RI and ethnic homogeneity displayed a higher proportion of MVC hotspots. ED and SV exhibited a strong gradient with MVC hotspots; the most deprived quintiles displayed the highest proportion of MVC hotspots compared with cold spots (ED; p = 0.002, SV; p < 0.001). Areas with the highest levels of ethnocultural diversity were found to have a significantly higher proportion of violence-related hotspots than cold spots (p = 0.005). This study offers two significant contributions to spatial epidemiology. First, it demonstrates the distribution of TBI hotspots by major injury causes using the smallest available geographical unit. Second, we disentangle the various pathways through which deprivation impacts the risk of main mechanisms of TBI. These findings provide valuable insights for public health officials to design targeted injury prevention strategies in high-risk areas.
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Affiliation(s)
- Nelofar Kureshi
- Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - David B Clarke
- Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada
- Brain Repair Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Weiping Zeng
- Super GeoAI Technology Inc. Saskatoon, Saskatchewan, Canada
| | - Cindy Feng
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
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