Building CapaCITY/É for sustainable transportation: protocol for an implementation science research program in healthy cities

INTRODUCTION

Improving sustainable transportation options will help cities tackle growing challenges related to population health, congestion, climate change and inequity. Interventions supporting active transportation face many practical and political hurdles. Implementation science aims to understand how interventions or policies arise, how they can be translated to new contexts or scales and who benefits. Sustainable transportation interventions are complex, and existing implementation science frameworks may not be suitable. To apply and adapt implementation science for healthy cities, we have launched our mixed-methods research programme, CapaCITY/É. We aim to understand how, why and for whom sustainable transportation interventions are successful and when they are not.

METHODS AND ANALYSIS

Across nine Canadian municipalities and the State of Victoria (Australia), our research will focus on two types of sustainable transportation interventions: all ages and abilities bicycle networks and motor vehicle speed management interventions. We will (1) document the implementation process and outcomes of both types of sustainable transportation interventions; (2) examine equity, health and mobility impacts of these interventions; (3) advance implementation science by developing a novel sustainable transportation implementation science framework and (4) develop tools for scaling up and scaling out sustainable transportation interventions. Training activities will develop interdisciplinary scholars and practitioners able to work at the nexus of academia and sustainable cities.

ETHICS AND DISSEMINATION

This study received approval from the Simon Fraser University Office of Ethics Research (H22-03469). A Knowledge Mobilization Hub will coordinate dissemination of findings via a website; presentations to academic, community organisations and practitioner audiences; and through peer-reviewed articles.

Clinical Practice Guideline Recommendations in Pediatric Mild Traumatic Brain Injury: A Systematic Review

STUDY OBJECTIVE

Our primary objectives were to identify clinical practice guideline recommendations for children with acute mild traumatic brain injury (mTBI) presenting to an emergency department (ED), appraise their overall quality, and synthesize the quality of evidence and the strength of included recommendations.

METHODS

We searched MEDLINE, EMBASE, Cochrane Central, Web of Science, and medical association websites from January 2012 to May 2023 for clinical practice guidelines with at least 1 recommendation targeting pediatric mTBI populations presenting to the ED within 48 hours of injury for any diagnostic or therapeutic intervention in the acute phase of care (ED and inhospital). Pairs of reviewers independently assessed overall clinical practice guideline quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The quality of evidence on recommendations was synthesized using a matrix based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework.

RESULTS

We included 11 clinical practice guidelines, of which 6 (55%) were rated high quality. These included 101 recommendations, of which 34 (34%) were based on moderate- to high-quality evidence, covering initial assessment, initial diagnostic imaging, monitoring/observation, therapeutic interventions, discharge advice, follow-up, and patient and family support. We did not identify any evidence-based recommendations in high-quality clinical practice guidelines for repeat imaging, neurosurgical consultation, or hospital admission. Lack of strategies and tools to aid implementation and editorial independence were the most common methodological weaknesses.

CONCLUSIONS

We identified 34 recommendations based on moderate- to high-quality evidence that may be considered for implementation in clinical settings. Our review highlights important areas for future research. This review also underlines the importance of providing strategies to facilitate the implementation of clinical practice guideline recommendations for pediatric mTBI.

Social determinants of health and disparities in pediatric trauma care: protocol for a systematic review and meta-analysis

BACKGROUND

Social determinants of health (SDH), including "the conditions in which individuals are born, grow, work, live and age" affect child health and well-being. Several studies have synthesized evidence about the influence of SDH on childhood injury risks and outcomes. However, there is no systematic evidence about the impact of SDH on accessing care and quality of care once a child has suffered an injury. We aim to evaluate the extent to which access to care and quality of care after injury are affected by children and adolescents' SDH.

METHODS

Using Cochrane methodology, we will conduct a systematic review including observational and experimental studies evaluating the association between social/material elements contributing to health disparities, using the PROGRESS-Plus framework: place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, and social capital and care received by children and adolescents (≤ 19 years of age) after injury. We will consult published literature using PubMed, EMBASE, CINAHL, PsycINFO, Web of Science, and Academic Search Premier and grey literature using Google Scholar from their inception to a maximum of 6 months prior to submission for publication. Two reviewers will independently perform study selection, data extraction, and risk of bias assessment for included studies. The risk of bias will be assessed using the ROBINS-E and ROB-2 tools respectively for observational and experimental study designs. We will analyze data to perform narrative syntheses, and if enough studies are identified, we will conduct a meta-analysis using random effects models.

DISCUSSION

This systematic review will provide a synthesis of evidence on the association between SDH and pediatric trauma care (access to care and quality of care) that clinicians and policymakers can use to better tailor care systems and promote equitable access and quality of care for all children. We will share our findings through clinical rounds, conferences, and publication in a peer-reviewed journal.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023408467.

Association Between First Attempt Buffalo Concussion Treadmill Test and Days to Recovery in 855 Children With Sport-Related Concussion: A Historical Cohort Study and Prognostic Factors Analysis

OBJECTIVE

Little is known about the prognostic value of the Buffalo Concussion Treadmill Test (BCTT) after the acute phase of sport-related concussion (SRC). We examined the added prognostic value of the BCTT performed 10 to 21 days after SRC in children, in addition to participant, injury, and clinical process characteristics on days to recovery.

DESIGN

Historical clinical cohort study.

SETTING

Network of approximately 150 Canadian multidisciplinary primary-care clinics.

PARTICIPANTS

855 children (mean age 14 years, range 6-17 years, 44% female) who presented between January 2016, and April 2019 with SRC.

ASSESSMENT OF RISK FACTORS

Participant, injury, and clinical process characteristics, with focus on BCTT exercise intolerance assessed 10 to 21 days after injury.

OUTCOME

Days to clinical recovery.

RESULTS

Children who were exercise intolerant experienced an increase of 13 days to recovery (95% CI, 9-18 days). Each additional day between SRC and first BCTT was associated with a recovery delay of 1 day (95% CI, 1-2 days), and prior history of concussion was associated with a recovery delay of 3 days (95% CI, 1-5 days). Participant, injury, and clinical process characteristics, and the first attempt BCTT result explained 11% of the variation in recovery time, with 4% accounted for by the BCTT.

CONCLUSION

Exercise-intolerance assessed 10 to 21 days after SRC was associated with delayed recovery. However, this was not a strong prognostic factor for days to recovery.

High-'n'-dry? A comparison of cannabis and alcohol use in drivers presenting to hospital after a vehicular collision

DESIGN

This was a prospective observational study.

BACKGROUND AND AIMS

The characteristics of cannabis-involved motor vehicle collisions are poorly understood. This study of injured drivers identifies demographic and collision characteristics associated with high tetrahydrocannabinol (THC) concentrations.

SETTING

The study was conducted in 15 Canadian trauma centres between January 2018 and December 2021.

CASES

The cases (n = 6956) comprised injured drivers who required blood testing as part of routine trauma care.

MEASUREMENTS

We quantified whole blood THC and blood alcohol concentration (BAC) and recorded driver sex, age and postal code, time of crash, crash type and injury severity. We defined three driver groups: high THC (THC ≥ 5 ng/ml and BAC = 0), high alcohol (BAC ≥ 0.08% and THC = 0) and THC/BAC-negative (THC = 0 = BAC). We used logistic regression techniques to identify factors associated with group membership.

FINDINGS

Most injured drivers (70.2%) were THC/BAC-negative; 1274 (18.3%) had THC > 0, including 186 (2.7%) in the high THC group; 1161 (16.7%) had BAC > 0, including 606 (8.7%) in the high BAC group. Males and drivers aged less than 45 years had higher adjusted odds of being in the high THC group (versus the THC/BAC-negative group). Importantly, 4.6% of drivers aged less than 19 years had THC ≥ 5 ng/ml, and drivers aged less than 19 years had higher unadjusted odds of being in the high THC group than drivers aged 45-54 years. Males, drivers aged 19-44 years, rural drivers, seriously injured drivers and drivers injured in single-vehicle, night-time or weekend collisions had higher adjusted odds ratios (aORs) for being in the high alcohol group (versus THC/BAC-negative). Drivers aged less than 35 or more than 65 years and drivers involved in multi-vehicle, daytime or weekday collisions had higher adjusted odds for being in the high THC group (versus the high BAC group).

CONCLUSIONS

In Canada, risk factors for cannabis-related motor vehicle collisions appear to differ from those for alcohol-related motor vehicle collisions. The collision factors associated with alcohol (single-vehicle, night-time, weekend, rural, serious injury) are not associated with cannabis-related collisions. Demographic factors (young drivers, male drivers) are associated with both alcohol and cannabis-related collisions, but are more strongly associated with cannabis-related collisions.

Road safety, health equity, and the built environment: perspectives of transport and injury prevention professionals in five Canadian municipalities

BACKGROUND

Concerns regarding health equity (HE) and the built environment (BE) are well established in the Canadian urban context. Transport and injury prevention professionals across sectors, such as transportation and public health, are involved in designing and implementing BE interventions that enhance the safety of vulnerable road users (VRUs). Results from a larger study examining barriers and facilitators to BE change are used to illustrate how transport and injury prevention professionals perceive HE concerns in their work in five Canadian municipalities. Broadening our understanding of how HE influences the professional BE change context is crucial when advocating for modifications that enhance the safety of equity-deserving VRUs and groups who experience marginalization.

METHODS

Interview and focus group data were gathered from transport and injury prevention professionals working in policy/decision-making, transport, police services, public health, non-profit organizations, schools/school boards, community associations, and private sectors across five Canadian urban municipalities: Vancouver, Calgary, Peel Region, Toronto, and Montréal. Data were analyzed using thematic analysis (TA) to illustrate how equity considerations were perceived and applied in participants' BE change work.

RESULTS

The results of this study illustrate transport and injury prevention professionals' awareness of the varying needs of VRUs, as well as the inadequacies of current BEs in the Canadian urban context and consultation processes utilized to guide change. Participants emphasized the importance of equitable community consultation strategies, as well as specific BE changes that would support the health and safety of VRUs. Overall, the results highlight how HE concerns inform transport and injury prevention professionals' BE change work in the Canadian urban context.

CONCLUSION

For professionals working in urban Canadian transport and injury prevention sectors HE concerns influenced their perspectives of the BE and BE change. These results illustrate a growing need for HE to guide BE change work and consultation processes. Further, these results contribute to ongoing efforts in the Canadian urban context to ensure that HE is at the forefront of BE policy change and decision-making, while promoting existing strategies to ensure that the BE, and related decision-making processes, are accessible and informed by a HE lens.

Modelling prevalent cardiovascular disease in an urban Indigenous population

OBJECTIVE

Studies have highlighted the inequities between the Indigenous and non-Indigenous populations with respect to the burden of cardiovascular disease and prevalence of predisposing risks resulting from historical and ongoing impacts of colonization. The objective of this study was to investigate factors associated with cardiovascular disease (CVD) within and specific to the Indigenous peoples living in Toronto, Ontario, and to evaluate the reliability and validity of the resulting model in a similar population.

METHODS

The Our Health Counts Toronto study measured the baseline health of Indigenous community members living in Toronto, Canada, using respondent-driven sampling. An iterative approach, valuing information from the literature, clinical insight and Indigenous lived experiences, as well as statistical measures was used to evaluate candidate predictors of CVD (self-reported experience of discrimination, ethnic identity, health conditions, income, education, age, gender and body size) prior to multivariable modelling. The resulting model was then validated using a distinct, geographically similar sample of Indigenous people living in Hamilton, Ontario, Canada.

RESULTS

The multivariable model of risk factors associated with prevalent CVD included age, diabetes, hypertension, body mass index and exposure to discrimination. The combined presence of diabetes and hypertension was associated with a greater risk of CVD relative to those with either condition and was the strongest predictor of CVD. Those who reported previous experiences of discrimination were also more likely to have CVD. Further study is needed to determine the effect of body size on risk of CVD in the urban Indigenous population. The final model had good discriminative ability and adequate calibration when applied to the Hamilton sample.

CONCLUSION

Our modelling identified hypertension, diabetes and exposure to discrimination as factors associated with cardiovascular disease. Discrimination is a modifiable exposure that must be addressed to improve cardiovascular health among Indigenous populations.

Clinical practice guideline recommendations for pediatric injury care: protocol for a systematic review

INTRODUCTION

Evidence suggests the presence of deficiencies in the quality of care provided to up to half of all paediatric trauma patients in Canada, the USA and Australia. Lack of adherence to evidence-based recommendations may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aim to systematically review CPG recommendations for paediatric injury care and appraise their quality.

METHODS AND ANALYSIS

We will identify CPG recommendations through a comprehensive search strategy including Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, Cochrane library, Web of Science, ClinicalTrials and websites of organisations publishing recommendations on paediatric injury care. We will consider CPGs including at least one recommendation targeting paediatric injury populations on any diagnostic or therapeutic intervention from the acute phase of care with any comparator developed in high-income countries in the last 15 years (January 2007 to a maximum of 6 months prior to submission). Pairs of reviewers will independently screen titles, abstracts and full text of eligible articles, extract data and evaluate the quality of CPGs and their recommendations using Appraisal of Guidelines Research and Evaluation (AGREE) II and AGREE Recommendations Excellence instruments, respectively. We will synthesise evidence on recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework and present results within a recommendations matrix.

ETHICS AND DISSEMINATION

Ethics approval is not a requirement as this study is based on available published data. The results of this systematic review will be published in a peer-reviewed journal, presented at international scientific meetings and distributed to healthcare providers.

PROSPERO REGISTRATION NUMBER

International Prospective Register of Systematic Reviews (CRD42021226934).

Healthcare utilization and costs following non-fatal powdered and non-powdered firearm injuries for children and youth

Little is known about the healthcare and economic burdens of non-fatal firearm injuries for children/youth beyond the initial admission. This study sought to estimate healthcare utilization and total direct healthcare costs of non-fatal powdered and non-powdered (air gun) firearm injuries 1-year post-injury. Using administrative data from 2003 to 2018 on all children/youth 0-24 years old in Ontario, Canada, a matched 1:2 cohort study was conducted to compare children/youth who experienced powdered and non-powdered firearm injuries with those who did not. Mean and median number of healthcare encounters and costs, and respective 95% confidence intervals (CIs) and interquartile ranges (IQRs), were estimated for both weapon type groups and controls and by intent. Children/youth who experienced a powdered and non-powdered firearm injury had a higher number of healthcare encounters and costs per year than those who did not. Mean 1-year costs for those with powdered and non-powdered firearm injuries were $8825 ($8007-$9643) and $2349 ($2118-$2578), respectively, versus $812 ($567-$1058) and $753 ($594-$911), respectively, for those without. Mean 1-year costs were highest for handgun injuries ($12,875 [95% CI $9941-$15,808]), and for intentional assault-related ($13,498 [$11,843-$15,153]; $3287 [$2213-$4362]), and intentional self-injuries ($14,773 [$6893-$22,652]; $6005 [$2193-$9817]) for both powdered and non-powdered firearm injuries, respectively.   Conclusion: Firearm injuries have substantial healthcare and economic burdens beyond the initial injury-related admission; this should be accounted for when examining the overall impact of firearm injuries. What is Known: • Child/youth firearm injuries have significant health and economic burdens. • However, existing work has mainly examined healthcare utilization and costs of initial admissions and/or have been limited to single-center studies and no studies have provide cost estimates by weapon type and intent. What is New: • Children/youth who suffered powdered firearm injuries had higher mean healthcare utilization and costs than those with non-powdered firearm injuries as well as comparable healthy children/youth. • Mean 1-year costs were highest for handgun injuries ($12,875), and for intentional assault-related ($13,498; $3287), and intentional self-injuries ($14,773; $6005) for powdered and non-powdered firearm injuries, respectively.

Body checking in non-elite adolescent ice hockey leagues: it is never too late for policy change aiming to protect the health of adolescents

OBJECTIVES

The objective of this study is to evaluate the effect of policy change disallowing body checking in adolescent ice hockey leagues (ages 15-17) on reducing rates of injury and concussion.

METHODS

This is a prospective cohort study. Players 15-17 years-old were recruited from teams in non-elite divisions of play (lower 40%-70% by division of play depending on year and city of play in leagues where policy permits or prohibit body checking in Alberta and British Columbia, Canada (2015-18). A validated injury surveillance methodology supported baseline, exposure-hours and injury data collection. Any player with a suspected concussion was referred to a study physician. Primary outcomes include game-related injuries, game-related injuries (>7 days time loss), game-related concussions and game-related concussions (>10 days time loss).

RESULTS

44 teams (453 player-seasons) from non-body checking and 52 teams (674 player-seasons) from body checking leagues participated. In body checking leagues there were 213 injuries (69 concussions) and in non-body checking leagues 40 injuries (18 concussions) during games. Based on multiple multilevel mixed-effects Poisson regression analyses, policy prohibiting body checking was associated with a lower rate of injury (incidence rate ratio (IRR): 0.38 (95% CI 0.24 to 0.6)) and concussion (IRR: 0.49; 95% CI 0.26 to 0.89). This translates to an absolute rate reduction of 7.82 injuries/1000 game-hours (95% CI 2.74 to 12.9) and the prevention of 7326 injuries (95% CI 2570 to 12083) in Canada annually.

CONCLUSIONS

The rate of injury was 62% lower (concussion 51% lower) in leagues not permitting body checking in non-elite 15-17 years old leagues highlighting the potential public health impact of policy prohibiting body checking in older adolescent ice hockey players.

Firearm injury epidemiology in children and youth in Ontario, Canada: a population-based study

BACKGROUND AND OBJECTIVE

Despite firearms contributing to significant morbidity and mortality globally, firearm injury epidemiology is seldom described outside of the USA. We examined firearm injuries among youth in Canada, including weapon type, and intent.

DESIGN

Population-based, pooled cross-sectional study using linked health administrative and demographic databases.

SETTING

Ontario, Canada.

PARTICIPANTS

All children and youth from birth to 24 years, residing in Ontario from 1 April 2003 to 31 March 2018.

EXPOSURE

Firearm injury intent and weapon type using the International Classification of Disease-10 CM codes with Canadian enhancements. Secondary exposures were sociodemographics including age, sex, rurality and income.

MAIN OUTCOMES

Any hospital or death record of a firearm injury with counts and rates of firearm injuries described overall and stratified by weapon type and injury intent. Multivariable Poisson regression stratified by injury intent was used to calculate rate ratios of firearm injuries by weapon type.

RESULTS

Of 5486 children and youth with a firearm injury (annual rate: 8.8/100 000 population), 90.7% survived. Most injuries occurred in males (90.1%, 15.5/100 000 population). 62.3% (3416) of injuries were unintentional (5.5/100 000 population) of which 1.9% were deaths, whereas 26.5% (1452) were assault related (2.3/100 00 population) of which 18.7% were deaths. Self-injury accounted for 3.7% (204) of cases of which 72.0% were deaths. Across all intents, adjusted regression models showed males were at an increased risk of injury. Non-powdered firearms accounted for half (48.6%, 3.9/100 000 population) of all injuries. Compared with handguns, non-powdered firearms had a higher risk of causing unintentional injuries (adjusted rate ratio (aRR) 14.75, 95% CI 12.01 to 18.12) but not assault (aRR 0.84, 95% CI 0.70 to 1.00).

CONCLUSIONS

Firearm injuries are a preventable public health problem among youth in Ontario, Canada. Unintentional injuries and those caused by non-powdered firearms were most common and assault and self-injury contributed to substantial firearm-related deaths and should be a focus of prevention efforts.

Public Response on Social Media to a Social Marketing Campaign for Influencing Attitudes towards Boating Safety

The purpose of this research paper is to assess the response on Facebook to a social marketing campaign for recreational boating safety. The campaign ran for the 2018 and 2019 boating seasons in British Columbia, Canada. Messages related to boating safety were delivered in multi-media formats, including ten Facebook posts. All public comments on the campaign Facebook page in response to the ads were included in the analysis. Comments were reviewed for tone and subject; those that related directly to the campaign or boating safety-related topics, such as alcohol use or enforcement, were labeled positive, negative or neutral in tone. Metrics such as likes and shares were also noted. The overall engagement rate (defined as engagements over people reached) was 4.1%. The posts were liked >7000 times and received 901 shares. A total of 219 comments were analysed. Almost half of the comments were positive (n = 106, 48.4%). Fifty comments were off-topic (22.8%), 45 were neutral (20.5%) and 18 were negative (8.2%). The majority of comments were positive, indicating that the campaign performed as planned and was generally well received by the people for whom it was intended. Comments illuminated prevailing attitudes towards risks, injuries and safety practices related to recreational boating. Positive comments valued safety as an aspect of having a pleasant experience, rather than a barrier. Negative comments were about perceiving reduced fun of boating, rather than objecting to the campaign itself. As a component of a multi-media social marketing strategy, Facebook can be a source of instant feedback from the campaign audience.

A review of reported network degree and recruitment characteristics in respondent driven sampling implications for applied researchers and methodologists

OBJECTIVE

Respondent driven sampling (RDS) is an important tool for measuring disease prevalence in populations with no sampling frame. We aim to describe key properties of these samples to guide those using this method and to inform methodological research.

METHODS

In 2019, authors who published respondent driven sampling studies were contacted with a request to share reported degree and network information. Of 59 author groups identified, 15 (25%) agreed to share data, representing 53 distinct study samples containing 36,547 participants across 12 countries and several target populations including migrants, sex workers and men who have sex with men. Distribution of reported network degree was described for each sample and characteristics of recruitment chains, and their relationship to coupons, were reported.

RESULTS

Reported network degree is severely skewed and is best represented by a log normal distribution. For participants connected to more than 15 other people, reported degree is imprecise and frequently rounded to the nearest five or ten. Our results indicate that many samples contain highly connected individuals, who may be connected to at least 1000 other people.

CONCLUSION

Because very large reported degrees are common; we caution against treating these reports as outliers. The imprecise and skewed distribution of the reported degree should be incorporated into future RDS methodological studies to better capture real-world performance. Previous results indicating poor performance of regression estimators using RDS weights may be widely generalizable. Fewer recruitment coupons may be associated with longer recruitment chains.

E-cigarettes: A new hazard for children and adolescents

Objectives

Electronic cigarettes and fluid (e-cigarettes, e-fluid) are hazardous materials that when inhaled or ingested may pose significant health risks to children and adolescents. The objective of this work was to explore the spectrum of injury related to e-cigarette exposure among Canadian children and adolescents.

Methods

A one-time survey was sent to all paediatricians in Canada. Information was collected on children and adolescents who presented with e-cigarette exposure (inhalation and ingestion cases) in the previous 12 months. Questions included the number of injuries and symptoms, in addition to age, sex, treatment setting, intentional e-cigarette use, and how the products were accessed.

Results

A total of 520 surveys were completed and returned, identifying 35 cases. Symptoms related to inhalation were present in 30 cases and in 5 ingestion cases (5 unintentional, 0 intentional). For inhalation cases, most were male, ages 15 to 19 years, who sought treatment for nausea/vomiting, cough, throat irritation, or acute nicotine toxicity in an outpatient clinic/office. Most inhalation cases reported e-cigarette use 2 to 3 days/week, and e-cigarettes purchases from a mall kiosk/store. For ingestion cases, most were male, ages 1 to 4 years presenting to an emergency department with nausea/vomiting, cough, or respiratory irritation. Younger cases accessed e-fluid at home, older cases purchased in a mall kiosk/store. E-fluid flavours reported consumed were fruit, candy, and tobacco.

Conclusions

E-cigarettes, recently introduced into the North American market are hazardous to children and adolescents. Given the low response rate to the survey, further investigation into the true burden of injury, as well as the risks that e-cigarettes pose, together with ways to reduce exposure, is needed.

Does disallowing body checking in non-elite 13- to 14-year-old ice hockey leagues reduce rates of injury and concussion? A cohort study in two Canadian provinces

OBJECTIVE

To compare rates of injury and concussion among non-elite (lowest 60% by division of play) Bantam (ages 13-14 years) ice hockey leagues that disallow body checking to non-elite Bantam leagues that allow body checking.

METHODS

In this 2-year cohort study, Bantam non-elite ice hockey players were recruited from leagues where policy allowed body checking in games (Calgary/Edmonton 2014-2015, Edmonton 2015-2016) and where policy disallowed body checking (Kelowna/Vancouver 2014-2015, Calgary 2015-2016). All ice hockey game-related injuries resulting in medical attention, inability to complete a session and/or time loss from hockey were identified using valid injury surveillance methodology. Any player suspected of having concussion was referred to a study physician for diagnosis and management.

RESULTS

49 body checking (608 players) and 33 non-body checking teams (396 players) participated. There were 129 injuries (incidence rate (IR)=7.98/1000 hours) and 54 concussions (IR=3.34/1000 hours) in the body checking teams in games. After policy change, there were 31 injuries (IR=3.66/1000 hours) and 17 concussions (IR=2.01/1000 hours) in games. Policy disallowing body checking was associated with a lower rate of all injury (adjusted incidence rate ratio (IRR)=0.44; 95% CI: 0.27 to 0.74). The point estimate showed a lower rate of concussion (adjusted IRR=0.6; 95% CI: 0.31 to 1.18), but this was not statistically significant.

CONCLUSION

Policy change disallowing body checking in non-elite Bantam ice hockey resulted in a 56% lower rate of injury. There is growing evidence that disallowing body checking in youth ice hockey is associated with fewer injuries.

Association of Immigrant and Refugee Status With Risk Factors for Exposure to Violent Assault Among Youths and Young Adults in Canada

IMPORTANCE

Immigrant populations continue to grow across Western countries. Such populations may face vulnerabilities that contribute to the risk of experiencing violent injury. Youths are at disproportionate risk compared with other age groups, and such violence may be preventable with appropriately targeted injury prevention strategies.

OBJECTIVE

To examine the association of immigrant or refugee status and immigration-related factors with the experience of assault.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used linked health and administrative databases in Ontario, Canada, where health services are funded through a universal, single-payer health insurance plan. All youths and young adults aged 10 to 24 years (hereafter referred to as youths) residing in Ontario from January 1, 2008, to December 31, 2016, were eligible to participate. Data were analyzed from April 13, 2017, to January 6, 2020.

EXPOSURES

The main exposure was immigrant status. Secondary exposures were immigration-related factors, including visa class, time since immigration, and region and country of origin.

MAIN OUTCOMES AND MEASURES

The main outcome consisted of violent injuries requiring acute care (emergency department visit or hospitalization) or causing death. Poisson regression models were used to estimate rate ratios for injuries.

RESULTS

A total of 22 969 443 person-years were included in the analysis (51.3% male and 48.7% female participants). Compared with nonimmigrants, a greater proportion of immigrants lived in the lowest neighborhood income quintile (30.5% vs 18.2%) and urban areas (98.9% vs 87.7%). Among immigrants, 17.9% were refugees. Rates of violent injuries experienced were 549.0 (95% CI, 545.7-552.2) per 100 000 person-years in nonimmigrant youth, 225.0 (95% CI, 219.4-230.7) per 100 000 person-years in nonrefugee immigrant youth, and 525.4 (95% CI, 507.2-544.1) per 100 000 person-years in refugee immigrant youth. The rates of violent injury among nonrefugee and refugee immigrants were lower than among nonimmigrants (nonrefugee adjusted rate ratio [aRR], 0.41 [95% CI, 0.38-0.43]; refugee aRR, 0.82 [95% CI, 0.76-0.89]). Older age (oldest vs youngest aRR, 6.90 [95% CI, 6.53-7.29]), male sex (aRR, 2.60 [95% CI, 2.52-2.68]), and low neighborhood income (aRR, 2.42 [95% CI, 2.32-2.53]) were associated with violent injury risk. Rates of experiencing assault were lowest among South Asian (aRR, 0.33 [95% CI, 0.30-0.37]) and East Asian (aRR, 0.23 [95% CI, 0.19-0.26]) immigrants. Only Somali immigrants experienced higher assault rates (712.0 [95% CI, 639.3-805.3] per 100 000 person-years) compared with nonimmigrants. Most injuries (79.9%) were from being struck, followed by being cut (5.9%).

CONCLUSIONS AND RELEVANCE

The low rates of assault experienced by immigrants, including refugees, compared with nonimmigrants suggests that Canadian immigrant settlement supports and cultural factors may be protective against the risk of experiencing assault.

Implementing a junior high school-based programme to reduce sports injuries through neuromuscular training (iSPRINT): a cluster randomised controlled trial (RCT)

Objective

To evaluate the effectiveness of a junior high school-based sports injury prevention programme to reduce injuries through neuromuscular training (NMT).

Methods

This was a cluster randomised controlled trial. Students were recruited from 12 Calgary junior high schools (2014–2017). iSPRINT is a 15 min NMT warm-up including aerobic, agility, strength and balance exercises. Following a workshop, teachers delivered a 12-week iSPRINT NMT (six schools) or a standard-of-practice warm-up (six schools) in physical education classes. The definition of all recorded injuries included injuries that resulted in participants being unable to complete a sport and recreation (S&R) session, lost time from sport and/or seek medical attention. Incidence rate ratios (IRRs) were estimated based on multiple multilevel Poisson regression analyses (adjusting for sex (considering effect modification) and previous injury, offset by S&R participation hours, and school-level and class-level random effects were examined) for intent-to-treat analyses.

Results

1067 students (aged 11–16) were recruited across 12 schools (6 intervention schools (22 classes), 6 control schools (27 classes); 53.7% female, 46.3% male). The iSPRINT programme was protective of all recorded S&R injuries for girls (IRR=0.543, 95% CI 0.295 to 0.998), but not for boys (IRR=0.866, 95% CI 0.425 to 1.766). The iSPRINT programme was also protective of each of lower extremity injuries (IRR=0.357, 95% CI 0.159 to 0.799) and medical attention injuries (IRR=0.289, 95% CI 0.135 to 0.619) for girls, but not for boys (IRR=1.055, 95% CI 0.404 to 2.753 and IRR=0.639, 95% CI 0.266 to 1.532, respectively).

Conclusion

The iSPRINT NMT warm-up was effective in preventing each of all recorded injuries, lower extremity injuries and medically treated S&R injuries in female junior high school students.

Trial registration number

NCT03312504

Impact of applying different resting blood pressure cut-points to clear for maximal exercise

OBJECTIVE

The purpose of this study was to examine the impact of applying six commonly-used and two proposed resting blood pressure (BP) cut-points to clear individuals for maximal exercise in non-clinical health, wellness, commercial fitness agencies and physically demanding occupation test sites.

METHODS

Participants (n = 1670) completed the Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) and had their resting BP measured. Individuals with a BP >160/90 mmHg were further screened for contraindications to exercise using the ePARMed-X+ (www.eparmedx.com), all 1670 were cleared. There were no adverse events during or post exercise.

RESULTS

The percentages of participants cleared for each BP cut-point were: <130/80 mmHg (85.3%), <140/90 mmHg (93.4%), <144/90 mmHg (94.6%), <144/94 mmHg (96.3%), <150/100 mmHg (98.6%), <160/90 mmHg (95.6%), <160/94 mmHg (97.8%) and <160/100 mmHg (99.5%). Individuals who would not have been cleared without further screening were significantly older, had a higher BMI, or had a lower maximal oxygen consumption.

CONCLUSIONS

Conservative or lower resting BP cut-points currently applied to clear individuals for maximal exercise provide an unnecessary barrier. For individuals categorized as low-to- moderate risk by evidence-based screening tools such as the PAR-Q+ and ePARmed-X+, we recommend a resting BP cut-point of <160/94 mmHg to clear for maximal exercise until sufficient evidence is amassed to support the increase to <160/100 mmHg.

Societal determinants of violent death: The extent to which social, economic, and structural characteristics explain differences in violence across Australia, Canada, and the United States

In this ecological study, we attempt to quantify the extent to which differences in homicide and suicide death rates between three countries, and among states/provinces within those countries, may be explained by differences in their social, economic, and structural characteristics. We examine the relationship between state/province level measures of societal risk factors and state/province level rates of violent death (homicide and suicide) across Australia, Canada, and the United States. Census and mortality data from each of these three countries were used. Rates of societal level characteristics were assessed and included residential instability, self-employment, income inequality, gender economic inequity, economic stress, alcohol outlet density, and employment opportunities). Residential instability, self-employment, and income inequality were associated with rates of both homicide and suicide and gender economic inequity was associated with rates of suicide only. This study opens lines of inquiry around what contributes to the overall burden of violence-related injuries in societies and provides preliminary findings on potential societal characteristics that are associated with differences in injury and violence rates across populations.

•

This study opens lines of inquiry around what contributes to the overall burden of violence-related injuries in societies.

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Differences in homicide and suicide death between and within countries may be explained by social, economic, and structural characteristics.

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Residential instability, self-employment, and income inequality were associated with rates of both homicide and suicide.

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Gender economic inequity was associated with rates of suicide only.

Factors associated with the timing of the first prenatal ultrasound in Canada

Background

The aim of this study was to investigate the factors associated with the timing of the first prenatal ultrasound in Canada.

Methods

This was a secondary data analysis of the Maternity Experiences Survey, a cross-sectional survey covering different aspects of pregnancy, labour, birth and the post-partum period. Bivariate and multivariate multinomial logistic regressions were performed to assess the relationship between timing of first prenatal ultrasound and different independent variables.

Results

68.4% of Canadian women received an optimally timed first prenatal ultrasound, 27.4% received early ultrasounds and 4.3% received late ultrasound. The highest prevalence of early ultrasound was in Ontario (33.3%) and the lowest was in Manitoba (13.3%). The highest prevalence of late ultrasound was found in Manitoba (12.1%) and the lowest was in British Columbia and Ontario (3.5% each). The highest prevalence of optimal timing of first prenatal ultrasound was in Quebec (77%) and the lowest was in Ontario (63.2%). Factors influencing the timing of ultrasound included: Early – maternal age < 20 (adjusted OR = 0.54, 95%CI:0.34–0.84), alcohol use during pregnancy (adjusted OR = 0.69, 95%CI:0.53–0.90), history of premature birth (adjusted OR = 1.41, 95%CI:1.06–1.89), multiparity (adjusted OR = 0.67, 95%CI:0.57–0.78), born outside of Canada (adjusted OR = 0.82, 95%CI:0.67–0.99), prenatal care in Newfoundland and Labrador (adjusted OR = 1.66, 95%CI:1.20–1.30), Nova Scotia (adjusted OR = 1.68, 95%CI:1.25–2.28), Ontario (adjusted OR = 2.16, 95%CI:1.76–2.65), Saskatchewan (adjusted OR = 1.50, 95%CI:1.05–2.14), Alberta (adjusted OR = 1.37, 95%CI:1.05–1.77) British Columbia (adjusted OR = 1.90, 95%CI:1.45–2.50) and Manitoba (adjusted OR = 0.66, 95%CI:0.45–0.98) Late – unintended pregnancy (adjusted OR = 1.89, 95%CI:1.38–2.59), born outside of Canada (adjusted OR = 1.75, 95%CI:1.14–2.68), prenatal care in Manitoba (adjusted OR = 2.88, 95%CI:1.64–5.05) and the Territories (adjusted OR = 4.50, 95%CI:2.27–8.93). An interaction between history of miscarriage and having ‘other’ prenatal care provider significantly affected timing of ultrasound (adjusted OR = 0.31, 95%CI:0.14–0.66).

Conclusion

Only 68% of Canadian women received an optimally timed prenatal ultrasound which was influenced by several factors including province of prenatal care, maternal age and country of birth, and an interaction effect between prenatal care provider and history of miscarriage. These findings establish a baseline of factors influencing the timing of prenatal ultrasound in Canada, which can be built upon by future studies.

Metrics to assess injury prevention programs for young workers in high-risk occupations: a scoping review of the literature

INTRODUCTION

Despite legal protections for young workers in Canada, youth aged 15-24 are at high risk of traumatic occupational injury. While many injury prevention initiatives targeting young workers exist, the challenge faced by youth advocates and employers is deciding what aspect(s) of prevention will be the most effective focus for their efforts. A review of the academic and grey literatures was undertaken to compile the metrics-both the indicators being evaluated and the methods of measurement-commonly used to assess injury prevention programs for young workers. Metrics are standards of measurement through which efficiency, performance, progress, or quality of a plan, process, or product can be assessed.

METHODS

A PICO framework was used to develop search terms. Medline, PubMed, OVID, EMBASE, CCOHS, PsychINFO, CINAHL, NIOSHTIC, Google Scholar and the grey literature were searched for articles in English, published between 1975-2015. Two independent reviewers screened the resulting list and categorized the metrics in three domains of injury prevention: Education, Environment and Enforcement.

RESULTS

Of 174 acquired articles meeting the inclusion criteria, 21 both described and assessed an intervention. Half were educational in nature (N=11). Commonly assessed metrics included: knowledge, perceptions, self-reported behaviours or intentions, hazardous exposures, injury claims, and injury counts. One study outlined a method for developing metrics to predict injury rates.

CONCLUSION

Metrics specific to the evaluation of young worker injury prevention programs are needed, as current metrics are insufficient to predict reduced injuries following program implementation. One study, which the review brought to light, could be an appropriate model for future research to develop valid leading metrics specific to young workers, and then apply these metrics to injury prevention programs for youth.

What are the risk factors for injuries and injury prevention strategies for skiers and snowboarders in terrain parks and half-pipes? A systematic review

OBJECTIVE

To synthesise the current evidence regarding the risk factors, the injury prevention strategies and the profile of injured skiers and snowboarders in terrain parks (TPs) and half-pipes (HPs).

DESIGN

Systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

DATA SOURCES

Literature searches from six electronic databases and manual searches were performed.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Inclusion criteria were: (1) publication based on original data; (2) injuries sustained in TPs or HPs; (3) recreational skiing or snowboarding injuries; (4) observational or experimental study design with a comparison group.

RESULTS

No study explored the risk factors in HPs or the prevention strategies in TPs or HPs. From the literature retrieved, there is strong evidence that skiing or snowboarding in a TP is a risk factor for head, neck, back and severe injuries. Two papers assessed the risk factors for injuries in TPs, mainly demonstrating that features promoting aerial manoeuvres or a large drop to the ground were associated with higher feature-specific injury rates. The profile of injured skiers and snowboarders in TPs described in the literature suggested some evidence of associations between factors including activity, sex, skill level, helmet use, age and TP injuries.

SUMMARY/CONCLUSIONS

This systematic review demonstrates the need for studies identifying the risk factors for injuries to skiers and snowboarders and on interventions to reduce the risk of injury in TPs and HPs. Studies addressing the issue of TP design should be considered.

PROSPERO REGISTRATION NUMBER

CRD42016045206.

E-cigarettes: A new hazard for children and adolescents

OBJECTIVES

Electronic cigarettes and fluid (e-cigarettes, e-fluid) are hazardous materials that when inhaled or ingested may pose significant health risks to children and adolescents. The objective of this work was to explore the spectrum of injury related to e-cigarette exposure among Canadian children and adolescents.

METHODS

A one-time survey was sent to all paediatricians in Canada. Information was collected on children and adolescents who presented with e-cigarette exposure (inhalation and ingestion cases) in the previous 12 months. Questions included the number of injuries and symptoms, in addition to age, sex, treatment setting, intentional e-cigarette use and how the products were accessed.

RESULTS

A total of 520 surveys were completed and returned, identifying 220 cases. Symptoms related to inhalation were present in 135 cases (43 unintentional, 92 intentional) and in 85 ingestion cases (35 unintentional, 50 intentional). For inhalation cases, most were male, aged 15 to 19 years, who sought treatment for nausea/vomiting, cough, throat irritation or acute nicotine toxicity in an outpatient clinic/office. Most inhalation cases reported e-cigarette use 2 to 3 days/week, and e-cigarettes purchases from a mall kiosk/store. For ingestion cases, most were male, aged 1 to 4 years presenting to an emergency department with nausea/vomiting, cough or respiratory irritation. Younger cases accessed e-fluid at home, older cases purchased in a mall kiosk/store. E-fluid flavours reported consumed were fruit, candy, and tobacco.

CONCLUSIONS

E-cigarettes, recently introduced into the North American market are hazardous to children and adolescents. Further investigation into the risks that e-cigarettes pose and ways to reduce exposure is needed to minimize injury.

Mental Health Consultation Among Ontario's Immigrant Populations

To determine the prevalence rates and characteristics of past-year mental health consultation for Ontario's adult (18 + years old) immigrant populations. The Canadian Community Health Survey (CCHS) 2012 was used to calculate the prevalence rates of past-year mental health consultation by service provider type. Characteristics associated with mental health consultation were determined by carrying out multivariable logistic regression analysis on merged CCHS 2008-2012 data. Adult immigrant populations in Ontario (n = 3995) had lower estimated prevalence rates of past-year mental health consultation across all service provider types compared to Canadian-born populations (n = 14,644). Amongst those who reported past-year mental health consultation, 57.89% of Ontario immigrants contacted their primary care physician, which was significantly higher than the proportion who consulted their family doctor from Canadian-born populations (45.31%). The factors of gender, age, racial/ethnic background, education level, working status, food insecurity status, self-perceived health status, smoking status, alcohol drinking status, years since immigration, and age at time of immigration were significantly associated with past-year mental health consultation for immigrant populations. Ontario's adult immigrant populations most commonly consult their family doctor for mental health care. Potential exists for expanding the mental health care role of primary care physicians as well as efforts to increase accessibility of specialized mental health services. Integrated, coordinated care where primary care physicians, specialized mental health professionals, social workers, and community educators, etc. working together in a sort of "one-stop-shop" may be the most effective way to mitigate gaps in the mental health care system. In order to effectively tailor mental health policy, programming, and promotion to suit the needs of immigrant populations initiatives that focus on the connection between physical and mental health and migration variables such as length of stay in Canada, years since immigration, and other important migration variables (beyond the scope of the CCHS which require further study) need to be developed. Examination of the social determinants of mental health is critical to understand how we can best serve the mental health needs of Ontario's immigrant populations.

A systematic review of the risk factors and interventions for the prevention of playground injuries

OBJECTIVES

The primary objectives of this work were to (1) identify the risk and/or protective factors associated with playground injuries among children less than 18 years of age and (2) identify interventions/programs/policies aimed at preventing playground-related injuries among children less than 18 years of age. Secondary objectives include a summary of the data that reflect alignment with current playground standards.

METHODS

For the primary outcome, 4 databases and 12 online resources were systematically searched to include observational and experimental studies examining risk and/or protective factors or interventions associated with playground injury or outcomes related to playground injury (e.g., risky playground behaviour). Data extraction included study design, participants, outcome, exposure or intervention, data analysis, and effect estimates. The quality of evidence for all studies was assessed using the Downs and Black criteria.

RESULTS

This review included studies of moderate quality, revealing a number of risk factors and effective interventions for playground injury. Risk factors included absence of handrails and guardrails on playground equipment, non-impact-absorbing surfacing, and critical fall heights. Effective interventions included modifying playground surfacing and reducing equipment height to less than 1.5 m.

CONCLUSION

Equipment- and structure-based playgrounds should adhere to and maintain playground standards in order to reduce the risk of serious injury. Organizations responsible for installing and maintaining playgrounds should consider alternative play spaces that allow children to play outdoors, in a natural environment that supports healthy child development and promotes physical activity.

The effect of informal caregiver support on utilization of acute health services among home care clients: a prospective observational study

BACKGROUND

Emergency department visits and hospitalizations (EDVH) place a large burden on patients and the health care system. The presence of informal caregivers may be beneficial for reducing EDVH among patients with specific diagnoses. Our objective was to determine whether the presence of an informal caregiver was associated with the occurrence of an EDVH among clients 50 years of age or older.

METHODS

Using a database accessed through the Toronto Central Community Care Access Centre (CCAC), we identified 479 adults over 50 years of age who received home care in Toronto, Canada. Exposure variables were extracted from the interRAI health assessment form completed at the time of admission to the CCAC. EDVH data were linked to provincial records through the CCAC database. Data on emergency room visits were included for up to 6 months after time of admission to home care. Multiple logistic regression analysis was used to identify factors associated with the occurrence of an EDVH.

RESULTS

Approximately half of all clients had an EDVH within 180 days of admission to CCAC home care. No significant association was found between the presence of an informal caregiver and the occurrence of an EDVH. Significant factors associated with an EDVH included: Participants having a poor perception of their health (adjusted OR = 1.68, 95% CI: 1.11-2.56), severe cardiac disorders (adjusted OR = 1.54, 95% CI: 1.04-2.29), and pulmonary diseases (adjusted OR = 1.99, 95% CI: 1.16-3.47).

CONCLUSIONS

The presence of an informal caregiver was not significantly associated with the occurrence of an EDVH. Future research should examine the potential associations between length of hospital stay or quality of life and the presence of an informal caregiver. In general, our work contributes to a growing body of literature that is increasingly concerned with the health of our aging population, and more specifically, health service use by elderly patients, which may have implications for health care providers.

Annual Trends in Follow-Up Visits for Pediatric Concussion in Emergency Departments and Physicians' Offices

OBJECTIVE

To assess whether children and youth with concussion receive follow-up visits in accordance with the recommended guidelines.

STUDY DESIGN

We conducted a retrospective, population-based study using linked health administrative data from all concussion-related visits to emergency department and physician offices by children aged 5 through 18 years (range, 5.00-18.99) in Ontario between 2003 and 2013. We analyzed the percentage of children and youth seen for follow-up. The Mann-Kendall test for trends was used to assess a monotonic increasing trend over time in concussion follow-up visits.

RESULTS

A total of 126 654 children and youth were evaluated for an index concussion visit. The number of children and youth assessed for concussion follow-up (N = 45 155) has increased significantly over time (P < .001). In 2003, 781 of 7126 patients (11.0%; 95% CI, 10.3-11.7) with an index visit for concussion had a follow-up assessment. By 2013, 6526 of 21 681 (30.1%; 95% CI, 29.5-30.7) patients received follow-up care.

CONCLUSIONS

The proportion of children and youth receiving follow-up after an acute concussion has significantly increased between 2003 and 2013. Nevertheless, more than two-thirds of all patients do not seek medical follow-up or clearance as recommended by current concussion guidelines, suggesting that ongoing efforts to improve and monitor compliance with recommended guidelines by patients and physicians are important.

Unintentional injuries among refugee and immigrant children and youth in Ontario, Canada: a population-based cross-sectional study

BACKGROUND

Unintentional injuries are a leading reason for seeking emergency care. Refugees face vulnerabilities that may contribute to injury risk. We aimed to compare the rates of unintentional injuries in immigrant children and youth by visa class and region of origin.

METHODS

Population-based, cross-sectional study of children and youth (0-24 years) from immigrant families residing in Ontario, Canada, from 2011 to 2012. Multiple linked health and administrative databases were used to describe unintentional injuries by immigration visa class and region of origin. Poisson regression models estimated rate ratios for injuries.

RESULTS

There were 6596.0 and 8122.3 emergency department visits per 100 000 non-refugee and refugee immigrants, respectively. Hospitalisation rates were 144.9 and 185.2 per 100 000 in each of these groups. The unintentional injury rate among refugees was 20% higher than among non-refugees (adjusted rate ratio (ARR) 1.20, 95% CI 1.16, 1.24). In both groups, rates were lowest among East and South Asians. Young age, male sex, and high income were associated with injury risk. Compared with non-refugees, refugees had higher rates of injury across most causes, including for motor vehicle injuries (ARR 1.51, 95% CI 1.40, 1.62), poisoning (ARR 1.40, 95% CI 1.26, 1.56) and suffocation (ARR 1.39, 95% CI 1.04, 1.84).

INTERPRETATION

The observed 20% higher rate of unintentional injuries among refugees compared with non-refugees highlights an important opportunity for targeting population-based public health and safety interventions. Engaging refugee families shortly after arrival in active efforts for injury prevention may reduce social vulnerabilities and cultural risk factors for injury in this population.

Trends in the leading causes of injury mortality, Australia, Canada, and the United States, 2000-2014

OBJECTIVES

The aim of this study was to highlight the differences in injury rates between populations through a descriptive epidemiological study of population-level trends in injury mortality for the high-income countries of Australia, Canada and the United States.

METHODS

Mortality data were available for the US from 2000 to 2014, and for Canada and Australia from 2000 to 2012. Injury causes were defined using the International Classification of Diseases, Tenth Revision external cause codes, and were grouped into major causes. Rates were direct-method age-adjusted using the US 2000 projected population as the standard age distribution.

RESULTS

US motor vehicle injury mortality rates declined from 2000 to 2014 but remained markedly higher than those of Australia or Canada. In all three countries, fall injury mortality rates increased from 2000 to 2014. US homicide mortality rates declined, but remained higher than those of Australia and Canada. While the US had the lowest suicide rate in 2000, it increased by 24% during 2000-2014, and by 2012 was about 14% higher than that in Australia and Canada. The poisoning mortality rate in the US increased dramatically from 2000 to 2014.

CONCLUSION

Results show marked differences and striking similarities in injury mortality between the countries and within countries over time. The observed trends differed by injury cause category. The substantial differences in injury rates between similarly resourced populations raises important questions about the role of societal-level factors as underlying causes of the differential distribution of injury in our communities.

Characteristics of patients receiving midwife-led prenatal care in Canada: results from the Maternity Experiences Survey (MES)

Background

The aim of this study was to determine the characteristics of women in Canada who received care from a midwife during their prenatal period.

Methods

The findings of this study were drawn from the Maternity Experiences Survey (MES), which was a cross-sectional survey that assessed the experiences of women who gave birth between November 2005 and May 2006. The main outcome variable for this study was the prenatal care provider (i.e. midwife versus other healthcare providers). Demographic, socioeconomic, as well as health and pregnancy factors were evaluated using bivariate and multivariate models of logistic regression.

Results

A total of 6421 participants were included in this analysis representing a weighted total of 76,508 women. The prevalence of midwife-led prenatal care was 6.1%. The highest prevalence of midwife-led prenatal care was in British Columbia (9.8%), while the lowest prevalence of midwife-led prenatal care was 0.3% representing the cumulative prevalence in Nova Scotia, Prince Edward Island, Newfoundland and Labrador, New Brunswick, Saskatchewan, and Yukon. Factors showing significant association with midwife-led prenatal care were: Aboriginal status (OR = 2.26, 95% CI: 1.41–3.64), higher education with bachelor and graduate degree attainment having higher ORs when compared to high-school or less (OR = 2.71, 95% CI: 1.71–4.31 and OR = 3.17, 95% CI: 1.81–5.55, respectively), and alcohol use (OR = 1.63, 95% CI: 1.17–2.26). Age, marital status, immigrant status, work during pregnancy, household income, previous pregnancies, perceived health, maternal Body Mass Index (BMI), and smoking during the last 3 months of pregnancy were not significantly associated with midwife care.

Conclusions

In general, women who were more educated, have aboriginal status, and/or are alcohol drinkers were more likely to receive care from midwives. Since MES is the most recent resource that includes information about national midwifery utilization, future studies can provide more up-to-date information about this important area. Moreover, future research can aim at understanding the reasons that lead women to opt for midwife-led prenatal care.

Risk of firearm injuries among children and youth of immigrant families

BACKGROUND

Firearm injuries contribute to substantial morbidity and mortality. The immigrant paradox suggests that, despite being more socially disadvantaged, immigrants are less likely than nonimmigrants to have poor outcomes. We tested the association of immigrant characteristics with firearm injuries among children and youth.

METHODS

We conducted a population-based cohort study involving residents of Ontario aged 24 years and younger from 2008-2012 using health and administrative databases. We estimated rate ratios of unintentional and assault-related firearm injuries by immigrant status using Poisson regression models with Generalized Estimating Equations.

RESULTS

We included 15 866 954 nonimmigrant and 4 551 291 immigrant person-years in our analysis. Nonimmigrant males had 1032 unintentional (12.4 per 100 000, 95% confidence interval [CI] 11.7-13.2) and 304 assault-related (3.6 per 100 000, 95% CI 3.2-4.0) firearm injuries. Immigrant males had 148 unintentional (7.2 per 100 000, 95% CI 6.1-8.5) and 113 assault-related (5.5 per 100 000, 95% CI 4.5-6.6) firearm injuries. Compared with nonimmigrants, immigrants had a lower rate of unintentional firearm injury (adjusted rate ratio 0.5, 95% CI 0.4-0.6) but a similar rate of assault-related firearm injury. Among immigrants, refugees had a 43% higher risk of assault-related firearm injury compared with nonrefugees (adjusted rate ratio 1.4, 95% CI 1.0-2.0). Immigrants from Central America and Africa accounted for 68% of immigrants with assault-related firearm injuries.

INTERPRETATION

Compared with nonimmigrants, immigrant children and youth had a lower risk of unintentional firearm injury, although the risk of assault-related firearm injury was higher among refugees and immigrants from Central America and Africa. The results suggest that prevention strategies for firearm safety should target nonimmigrant youth as well as these newly identified high-risk immigrant populations.

School environments and social risk factors for child pedestrian-motor vehicle collisions: A case-control study

BACKGROUND

Child pedestrian-motor vehicle collisions (PMVCs) have decreased in Canada in the past 20 years. Many believe this trend is explained by the rise in automobile use for all travel. Initiatives to increase walking to school need to consider PMVC risk. Potential risk factors related to walking to school, the built environment and social factors were examined for schools with historically high child PMVC rates.

METHODS

Child PMVCs (age 4-12 years) from 2000 to 2013 and built environment features were mapped within school attendance boundaries in the City of Toronto, Canada. Case and control schools were in the highest and lowest PMVC quartiles respectively. Observational counts of travel mode to school were conducted. Logistic regression evaluated walking to school, built environment and social risk factors for higher PMVC rates, stratified by geographic location (downtown vs. inner suburbs).

RESULTS

The mean PMVC rates were 18.8/10,000/year (cases) and 2.5/10,000/year (controls). One-way street density (OR=4.00), school crossing guard presence (OR=3.65) and higher social disadvantage (OR=1.37) were associated with higher PMVCs. Higher residential land use density had a protective effect (OR=0.56). More walking was not a risk factor. While several built environment risk factors were identified for the inner suburbs; only social disadvantage was a risk factor within older urban neighbourhoods.

CONCLUSIONS

Several modifiable environmental risk factors were identified for child PMVCs. More walking to school was not associated with increased PMVCs after controlling for the environment. School social disadvantage was associated with higher PMVCs with differences by geographic location. These results have important implications for the design of roadways around schools.

Unintentional injuries in children and youth from immigrant families in Ontario, Canada: a population-based cross-sectional study

BACKGROUND

Unintentional injury is the leading cause of childhood death. Injury is associated with a number of sociodemographic characteristics, but little is known about risk in immigrants. Our objective was to examine the association between family immigrant status and unintentional injury in children and youth.

METHODS

We performed a population-based, cross-sectional study involving children and youth (age 0-24 yr) residing in Ontario from 2008 to 2012. Multiple linked health and administrative databases were used to describe unintentional injuries by family immigrant status. Unintentional injury events (e.g., emergency department visits, admissions to hospital, deaths) were analyzed using Poisson regression models to estimate rate ratios (RRs) for injury by immigrant status.

RESULTS

Annualized injury rates were 11 749 emergency department visits per 100 000 population, 267 hospital admissions per 100 000 population and 12 deaths per 100 000 population. Injury rates were lower among immigrants across all causes of unintentional injury (adjusted RR 0.56, 95% confidence interval [CI] 0.54-0.59). Among nonimmigrants, lowest neighbourhood income quintile was associated with the highest rates (RR 1.13, 95% CI 1.08-1.18, quintile 5 v. 1); among immigrants, lowest income quintile was associated with the lowest rates of injury (RR 0.88, 95% CI 0.82-0.94, quintile 5 v. 1). Highest rates of injury for nonimmigrants were among adolescents (age 10-14 yr, RR 1.23, 95% CI 1.18-1.28; v. 20-24 yr), but for immigrants, was highest among young children (0-4 yr RR 1.23, 95% CI 1.16-1.31; v. 20-24 yr).

INTERPRETATION

Rates of unintentional injury are lower among immigrant than among Canadian-born children, supporting a healthy immigrant effect. Socioeconomic status and age have different associations with injury risk, suggesting alternative causal pathways for injuries in immigrant children and youth.

Trends in unintentional injury mortality in Canadian children 1950-2009 and association with selected population-level interventions

OBJECTIVES

To examine unintentional injury mortality rates in children (0-19 years) in Canada from 1950 to 2009 against national population-level injury prevention interventions.

METHODS

Injury mortality rates were age and sex adjusted. Changes in trend and level of mortality rates were assessed at pre-specified intervention periods using segmented linear regression analyses for interrupted time series. Maximum likelihood estimation was used with a second order autoregressive error process.

RESULTS

From 1950 to 2009, the overall unintentional injury mortality rate decreased by 86%. Males had consistently higher mortality rates compared to females; however, the standardized rate ratio decreased from 2.37:1 in 1950 to 1.97:1 in 2009. Substantial declines in choking/suffocation deaths were noted in children less than 1 year of age, predominantly during the period 1970-1988 when the Hazardous Products Act and Crib Regulations were implemented. For burns, significant changes in slope were noted comparing 1972-1994 to pre-1971 (introduction of the Hazardous Products Act - Flammability Regulations), where the greatest decline was noted in children ages 1-4 years (Est. = -0.03, 95% CI = -0.02, -0.04). For 15-19 year olds, there was a 408% increase in motor vehicle collision-related mortality rates between 1950 and 1971; however a significant change in slope was noted during the period 1978-1985, compared to 1972-1977 (Est. = -0.10, 95% CI = -0.20, -0.007) across all age groups.

CONCLUSION

While this study is not a cause and effect analysis, there is a strong association with implementation of safety campaigns and legislative changes related to child safety and a dramatic decline in childhood fatalities related to injury.

The effect of concussion history on cognitive-motor integration in elite hockey players

AIM

To observe the effects of concussion history on cognitive-motor integration in elite-level athletes.

METHODS

The study included 102 National Hockey League draft prospects (n = 51 concussion history [CH]; n = 51 no history [NC]). Participants completed two computer-based visuomotor tasks, one involved 'standard' visuomotor mapping and one involved 'nonstandard' mapping in which vision and action were decoupled.

RESULTS

We observed a significant effect of group on reaction time (CH slower) and accuracy (CH worse), but a group by condition interaction only for reaction time (p < 0.05). There were no other deficits found. We discussed these findings in comparison to our previous work with non-elite athletes.

CONCLUSION

Previously concussed elite-level athletes may have lingering neurological deficits that are not detected using standard clinical assessments.