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Floating Catchment Area (FCA) methods are a popular tool to investigate accessibility to public facilities, in particular health care services. FCA approaches are attractive because, unlike other accessibility measures, they take into account the potential for congestion of facilities. This is done by 1) considering the population within the catchment area of a facility to calculate a variable that measures level of service, and then 2) aggregating the level of service by population centers subject to catchment area constraints. In this paper we discuss an effect of FCA approaches, an artifact that we term demand and level of service inflation. These artifacts are present in previous implementations of FCA methods. We argue that inflation makes interpretation of estimates of accessibility difficult, which has possible deleterious consequences for decision making. Next, we propose a simple and intuitive approach to proportionally allocate demandand and level of service in FCA calculations. The approach is based on a standardization of the impedance matrix, similar to approaches popular in the spatial statistics and econometrics literature. The result is a more intiuitive measure of accessibility that 1) provides a local version of the provider-to-population ratio; and 2) preserves the level of demand and the level of supply in a system. We illustrate the relevant issues with some examples, and then empirically by means of a case study of accessibility to family physicians in the Hamilton Census Metropolitan Area (CMA), in Ontario, Canada. Results indicate that demand and supply inflation/deflation affect the interpretation of accessibility analysis using existing FCA methods, and that the proposed adjustment can lead to more intuitive results. [ABSTRACT FROM AUTHOR]

Background: This study reports on physicians’ experiences with chronic pain management. For over a decade prescription opioids have been a primary treatment for chronic pain in North America. However, the current opioid epidemic has complicated long-standing practices for chronic pain management which historically involved prescribing pain medication. Caring for patients with chronic pain occurs within a context in which a growing proportion of patients suffer from chronic rather than acute conditions alongside rising social inequities. Methods: Our team undertook an ethnographic approach known as institutional ethnography in the province of Ontario, Canada in order to explore the social organization of chronic pain management from the standpoint of primary care physicians. This paper reports on a subset of this study data, specifically interviews with 19 primary care clinicians and 8 nurses supplemented by 40 hours of observations. The clinicians in our sample were largely primary care physicians and nurses working in urban, rural and Northern settings. Findings: In their reflections on providing care for patients with chronic pain, many providers describe being most challenged by the work involved in helping patients who also struggled with poverty, mental health and addiction. These frustrations were often complicated by concerns that they could lose their license for inappropriate prescribing, thus shifting their work from providing treatment and care to policing their patients for malingering and opioid abuse. Interpretation: Our findings show that care providers find the treatment of patients with chronic pain–especially those patients also experiencing poverty–to be challenging at best, and at worst frustrating and overwhelming. In many instances, their narratives suggested experiences of depersonalization, loss of job satisfaction and emotional exhaustion in relation to providing care for these patients, key dimensions of burnout. In essence, the work that they performed in relation to their patients’ social rather than medical needs seems to contribute to these experiences. Their experiences were further exacerbated by the fact that restricting and reducing opioid dosing in patients with chronic pain has become a major focus of care provision. [ABSTRACT FROM AUTHOR]

With the advent of continuous antiretroviral therapy, HIV has become a complex chronic, rather than acute, condition. The Chronic Care Model (CCM) provides an integrated approach to the delivery of care for people with chronic conditions that could therefore be applied to the delivery of care for people living with HIV. Our objective was to assess the alignment of HIV care settings with the CCM. We conducted a mixed methods study to explore structures, organization and care processes of Canadian HIV care settings. The quantitative results of phase one are published elsewhere. For phase two, we conducted semi-structured interviews with key informants from 12 HIV care settings across Canada. Irrespective of composition of the care setting or its location, HIV care in Canada is well aligned with several components of the CCM, most prominently in the areas of linkage to community resources and delivery system design with inter-professional team-based care. We propose the need for improvements in the availability of electronic clinical information systems and self-management support services to support better care delivery and health outcomes among people living with HIV in Canada. [ABSTRACT FROM AUTHOR]

Introduction: La Maison Bleue is a community-based perinatal health and social centre in Montreal that provides services during pregnancy up to age five to families living in vulnerable contexts. The study aimed to describe: 1) the challenges and protective factors that affect the well-being of migrant families receiving care at La Maison Bleue; and 2) how La Maison Bleue strengthens resilience among these families. Methods: We conducted a focused ethnography. Immigrants, refugees, asylum seekers and undocumented migrants were invited to participate. We collected data from November to December 2017 via semi-structured interviews and participant observation during group activities at La Maison Bleue. Data were thematically analysed. Results: Twenty-four mothers participated (9 interviewed, 17 observed). Challenges to well-being included family separation, isolation, loss of support, the immigration process, an unfamiliar culture and environment, and language barriers. Key protective factors were women’s intrinsic drive to overcome difficulties, their positive outlook and ability to find meaning in their adversity, their faith, culture and traditions, and supportive relationships, both locally and transnationally. La Maison Bleue strengthened resilience by providing a safe space, offering holistic care that responded to both medical and psychosocial needs, and empowering women to achieve their full potential towards better health for themselves and their families. Conclusion: Migrant mothers have many strengths and centres like La Maison Bleue can offer a safe space and be an empowering community resource to assist mothers in overcoming the multiple challenges that they face while resettling and raising their young children in a new country. [ABSTRACT FROM AUTHOR]

Non-consensual condom removal (NCCR) is the removal of a condom before or during sexual intercourse without one’s partner's consent. Despite considerable news and media attention devoted to the trend (as stealthing), little empirical research to date has examined people’s views of the practice. The present study aimed to contribute toward generating empirical evidence to guide the discussion surrounding NCCR. We asked participants about whether or not they felt NCCR is wrong, whether there should be consequences for its perpetration, and contextualized responses within legal context. A total of 592 undergraduate students took part in an online survey inquiring about their experiences with and views of NCCR. We used descriptive statistics to determine sample prevalence and outcomes of NCCR and qualitatively analyzed responses to open-ended questions asking about perceptions of NCCR. Of participants who had engaged in penetrative sexual intercourse with a male partner using an external condom, 18.7%, 95% CI [14.4, 22.7] reported that they had NCCR perpetrated against them. The majority of these participants reported that they experienced NCCR negatively and encountered related consequences; several reported contracting an STI, experiencing an unplanned pregnancy, or both. Nearly all participants expressed that NCCR is wrong, citing reasons that included the lack of consent, possibility of unplanned or unwanted outcomes, and a betrayal of trust. In this study, we found that there was agreement that NCCR is wrong, but variability in responses regarding the circumstances under which there should be consequences for the action. These perceptions reflect the current uncertainty in law. We recommend researchers refer to the phenomenon as NCCR (rather than stealthing) and discuss related issues to encourage future research to adopt consistent and accurate labels and definitions for NCCR. We hope that our findings will guide future research and spur public and legal discussion on NCCR. [ABSTRACT FROM AUTHOR]

Background: Attention to research and planning are increasingly being devoted to newcomer health, but the needs of newcomers with disabilities remain largely unknown. This information is difficult to determine since population-level data are rarely available on newcomers or on people with intellectual and developmental disabilities (IDD), although in Ontario, Canada these databases are accessible. This study compared the prevalence of IDD among first generation adult newcomers to adult non-newcomers in Ontario, and assessed how having IDD affected the health profile and health service use of newcomers. Methods: This population-based retrospective cohort study of adults aged 19–65 in 2010 used linked health and social services administrative data. Prevalence of IDD among newcomers (n = 1,649,633) and non-newcomers (n = 6,880,196) was compared. Among newcomers, those with IDD (n = 2,830) and without IDD (n = 1,646,803) were compared in terms of health conditions, and community and hospital service use. Results: Prevalence of IDD was lower in newcomers than non-newcomers (171.6 versus 898.3 per 100,000 adults, p<0.0001). Among newcomers, those with IDD were more likely than those without IDD to have comorbid physical health disorders, non-psychotic, psychotic and substance use disorders. Newcomers with IDD were also more likely to have psychiatry visits, and frequent emergency department visits and hospitalizations. Conclusion: First generation adult newcomers have lower rates of IDD than non-newcomers. How much of this difference is attributable to admission policies that exclude people expected to be high health service users versus how much is attributable to our methodological approach is unknown. Finding more medical and psychiatric comorbidity, and more health service use among newcomers with IDD compared to newcomers without IDD is consistent with patterns observed in adults with IDD more generally. To inform polices that support newcomers with IDD future research should investigate reasons for the prevalence finding, barriers and facilitators to timely health care access, and pathways to care. [ABSTRACT FROM AUTHOR]

Background: Patients with chronic obstructive pulmonary disease (COPD) are more likely to be readmitted than patients with other chronic medical conditions, yet knowledge regarding such readmissions is limited. We aimed to determine factors associated with readmission within 30 days of a COPD hospitalization or death with an emphasis on examining aspects of socioeconomic status and specific comorbidities. Methods: A population-based cohort study was conducted using health administrative data from Ontario, Canada. All hospitalizations for COPD between 2004 and 2014 were considered. The primary exposures were socioeconomic status as measured by residential instability (an ecologic variable), and comorbidities such as cardiovascular disease and cancer. Other domains of socioeconomic status were considered as secondary exposures. Logistic regression with generalized estimating equations was used to examine the effect of exposures, adjusting for other patient factors, on 30-day readmission or death. Results: There were 126,013 patients contributing to 252,756 index COPD hospitalizations from 168 Ontario hospitals. Of these hospitalizations, 19.4% resulted in a readmission and 2.8% resulted in death within 30 days. After adjusting for other factors, readmissions or death were modestly more likely among people with the highest residential instability compared to the lowest (OR 1.05, 95% CI 1.01–1.09). Comorbidities such as cardiovascular disease and cancer, as well as other aspects of low socioeconomic status also increased readmission or death risk. Interpretation: Socioeconomic status, measured in various ways, and many comorbidities predict 30-day readmission or death in patients hospitalized for COPD. Strategies that address these factors may help reduce readmissions and death. [ABSTRACT FROM AUTHOR]

Background: Population trends of disease prevalence and incidence over time measure burden of disease and inform healthcare planning. Neuromuscular disorders (NMD) affect muscle and nerve function with varying degrees of severity and disease progression. Objective: Using health administrative databases we described trends in incidence, prevalence, and mortality of adults and children with NMD. We also explored place of death and use of palliative care. Methods: Population-based (Ontario, Canada) cohort study (2003 to 2014) of adults and children with NMD identified using International Classification of Disease and health insurance billing codes within administrative health databases. Results: Adult disease prevalence increased on average per year by 8% (95% confidence interval (CI) 6% to 10%, P <.001), with the largest increase in adults18-39 years. Childhood disease prevalence increased by 10% (95% CI 8% to 11%, P <.0001) per year, with the largest increase in children 0 to 5 years. Prevalence increased across all diagnoses except amyotrophic lateral sclerosis and spinal muscular atrophy for adults and all diagnoses for children. Adult incidence decreased by 3% (95% CI -4% to -2%, P <.0001) but incidence remained stable in children. Death occurred in 34,336 (18.5%) adults; 21,236 (61.8%) of whom received palliative care. Death occurred in 1,009 (5.6%) children; 507 (50.2%) of whom received palliative care. Mortality decreased over time in adults (odds ratio (OR) 0.86, 95% CI 0.86–0.87, P <.0001) and children (OR 0.79, 95% CI 0.76–0.82, P <.0001). Use of palliative care over time increased for adults (OR 1.18, 95% CI 1.09 to 1.28, P <.0001) and children (OR 1.22, 95% CI 1.20 to 1.23, P <.0001). Conclusions: In both adults and children, NMD prevalence is rising and mortality rates are declining. In adults incidence is decreasing while in children it remains stable. This confirms on a population-based level the increased survival of children and adults with NMD. [ABSTRACT FROM AUTHOR]

Background: Food insecurity is associated with a wide array of negative health outcomes and higher health care costs but there has been no population-based study of the association of food insecurity and mortality in high-income countries. Methods: We use cross-sectional population surveys linked to encoded health administrative data. The sample is 90,368 adults, living in Ontario and respondents in the Canadian Community Health Survey (CCHS). The outcome of interest is all-cause mortality at any time after the interview and within four years of the interview. The primary variable of interest is food insecurity status, with individuals classed as “food secure”, “marginally food insecure”, “moderately food insecure”, or “severely food insecure”. We use logistic regression models to determine the association of mortality with food insecurity status, adjusting for other social determinants of health. Results: Using a full set of covariates, in comparison to food secure individuals, the odds of death at any point after the interview are 1.28 (CI = 1.08, 1.52) for marginally food insecure individuals, 1.49 (CI = 1.29, 1.73) for moderately food insecure individuals, and 2.60 (CI = 2.17, 3.12) for severely food insecure individuals. When mortality within four years of the interview is considered, the odds are, respectively, 1.19 (CI = 0.95, 1.50), 1.65 (CI = 1.37, 1.98), and 2.31 (CI = 1.81, 2.93). Interpretation: These findings demonstrate that food insecurity is associated with higher mortality rates and these higher rates are especially large for the most severe food insecurity category. Efforts to reduce food insecurity should be incorporated into broader public health initiatives to reduce mortality. [ABSTRACT FROM AUTHOR]

The recent emergence of West Nile virus (WNV) in North America highlights vulnerability to climate sensitive diseases and stresses the importance of preventive efforts to reduce their public health impact. Effective prevention involves reducing environmental risk of exposure and increasing adoption of preventive behaviours, both of which depend on knowledge and acceptance of such measures. When making operational decisions about disease prevention and control, public health must take into account a wide range of operational, environmental, social and economic considerations in addition to intervention effectiveness. The current study aimed to identify, assess and rank possible risk reduction measures taking into account a broad set of criteria and perspectives applicable to the management of WNV in Quebec under increasing transmission risk scenarios, some of which may be related to ongoing warming in higher-latitude regions. A participatory approach was used to collect information on categories of concern to relevant stakeholders with respect to WNV prevention and control. Multi-criteria decision analysis was applied to examine stakeholder perspectives and their effect on strategy rankings under increasing transmission risk scenarios. Twenty-three preventive interventions were retained for evaluation using eighteen criteria identified by stakeholders. Combined evaluations revealed that, at an individual-level, inspecting window screen integrity, wearing light colored, long clothing, eliminating peridomestic larval sites and reducing outdoor activities at peak times were top interventions under six WNV transmission scenarios. At a regional-level, the use of larvicides was a preferred strategy in five out of six scenarios, while use of adulticides and dissemination of sterile male mosquitoes were found to be among the least favoured interventions in almost all scenarios. Our findings suggest that continued public health efforts aimed at reinforcing individual-level preventive behaviours combined with the application of larvicides to manage the risk of WNV infection are the interventions most acceptable and effective at reaching current management objectives now and under future theoretical transmission risk. [ABSTRACT FROM AUTHOR]