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While recent evidence indicates that the generation of reactive oxygen species (ROS) and associated oxidative damage are frequently observed in fish populations with exposure to pulp and paper mill effluents, the potential for ROS generation from municipal sewage effluents has not been addressed. This study investigates the utility of measures of oxidative stress in delineating the effects of both pulp and paper mill and municipal sewage discharges. Longnose sucker (Catostomus catostomus) were collected below three pulp and paper mill and two municipal sewage effluent discharges over a 3-year period within the Wapiti and Athabasca River systems in northern Alberta. Biochemical responses in longnose sucker varied between the two rivers systems, with more pronounced changes occurring within the Wapiti River. Of the suite of biochemical parameters examined, fatty acyl-CoA oxidase (FAO) activity was the most sensitive indicator of pulp and paper mill exposure, but was only infrequently induced with exposure to municipal sewage effluent. Hepatic and gonadal 2-thiobarbituric acid reactive substances, lipid hydroperoxides, and hepatic free iron were less consistently elevated with exposure to pulp and paper mill effluent than FAO activity, and were also only infrequently altered with sewage effluent exposure. Hepatic ascorbic acid, liver somatic index, and condition factor were consistently altered with exposure to both sewage and pulp and paper mill effluents. While specific biochemical and organismal responses varied with effluents and time, the collective suite of oxidative stress endpoints proved to be useful tools in identifying relative influences of municipal sewage and pulp and paper mill effluent on fish populations in adjacent receiving waters.

The latitudinal herbivory-defense hypothesis (LHDH) predicts that plants near the equator will be more heavily defended against herbivores than are plants at higher latitudes. Although this idea is widely found in the literature, recent studies have called this biogeographic pattern into question. We sought to evaluate the LHDH in a high-latitude terrestrial ecosystem where fire and mammalian herbivores may contribute to selection for higher levels of defensive chemistry. To address this objective, we collected seeds of Alaska paper birch (Betula neoalaskana) from nine locations along two north-south transects between 55 degrees N and 62 degrees N latitudes in western, interior Canada. The birch seeds were planted in pots in a common garden in Madison, Wisconsin, USA. From the resulting seedlings, we determined levels of chemical defense by assessing the density of resin glands, which have been shown to be negatively correlated with browsing. To assess plant architectural traits such as height, mean individual leaf area, and root-to-shoot ratio, we harvested a subset of the birch seedlings. Further, we used these traits to examine growth-defense trade-offs. Contrary to the LHDH, we found a positive correlation between chemical defense and latitude. Investigating relationships with fire, we found a strong positive correlation between resin gland density and percentage of area annually burned (PAAB) around each collection location and also between PAAB and latitude. Additionally, birch seedlings originating from higher latitudes were shorter, smaller-leaved, and rootier than their lower-latitude counterparts. Growth-defense trade-offs were observed in negative correlations between resin gland density and height and leaf size. Seedlings with higher resin gland densities also allocated less biomass to shoots and more to roots. These results further call into question the LHDH and provide specific information about latitudinal trends in plant defense at high, northern latitudes where fire is a major ecosystem driver and mammals are the main herbivores of deciduous trees such as birches. We propose that these interconnected relationships are the key drivers of the positive correlation between defense and latitude in B. neoalaskana. Understanding patterns of boreal plant defense and growth is especially important because high latitude ecosystems are particularly susceptible to climate change. Key words: Alaska paper birch; Betula neoalaskana; biogeography; chemical defense; grotvth-defense trade-offs; inherent growth rate; latitude; latitudinal herbivory-defense hypothesis; papyr'feric acid; plant ar- chitecture; resin glands; root-to-shoot ratio.

Nursing on paper: therapeutic letters in nursing practice This paper offers a selected piece of interpretive research extracted from the context of a larger research study. The hermeneutic research inquiry described in this paper involved the examination of the nursing and family therapy intervention of therapeutic letters. It incorporated the textual interpretation of 11 therapeutic letters, clinical sessions with three families, clinical team discussions, and research interviews with four family members and three nurse clinicians who participated in the writing of the letters. This particular paper extracts segments of the research related to the letters received by two participants, as well as some general findings, with a focus on the possibilities and influences of therapeutic letters in nursing practice. The findings of this research offer suggestions, not as a template, but as an inspiration and evocation to write therapeutic letters that address the obligation of meeting people experiencing illness at the point of their suffering, with words and questions that invite relationship, reflection, and are large enough to sustain a meeting.

The HIV/AIDS epidemic disproportionately involves socially vulnerable populations. Since 2001, the proportion of foreign-born patients served by the Northern Alberta HIV Program has increased. Our study aimed to evaluate antiretroviral therapy (ART) outcomes among HIV-infected foreign-born patients in northern Alberta, Canada, prescribed once-daily ART.We utilized a two-part retrospective cohort study to compare ART outcomes of foreign-born and Canadian-born Aboriginal patients compared to Canadian-born non-Aboriginal patients. Part 1 utilized logistic regression to compare the odds of experiencing initial virological suppression of foreign-born (40%) and Canadian-born Aboriginal patients (27%) compared with Canadian-born non-Aboriginal patients (33%). Part 2 used survival analysis to compare the rate of ART failure by country of origin among patients who achieved initial virological suppression in Part 1.Our study sample included 322 treatment-naïve patients (122 foreign-born). For Part 1, 261 patients achieved initial virological suppression within six months of initiating ART. After controlling for age, treatment regimen, HIV risk exposure, and calendar year compared to Canadian-born non-Aboriginal patients, the odds of achieving initial virological suppression were significantly lower for Canadian-born Aboriginal patients (OR=0.44, 95% CI: 0.20-0.96); and similar for foreign-born patients (OR=0.76, 95% CI: 0.33-1.73). Part 2 included 261 patients who were followed for 635.1 person-years. Adjusting for age, sex, baseline CD4 cell count, and drug regimen, compared to Canadian-born non-Aboriginal patients, Canadian-born Aboriginal and foreign-born patients had similar rates of virological failure after achieving initial virological suppression (HR=1.54, 95% CI: 0.38-6.18; HR=0.49, 95% CI: 0.11-2.20, respectively).Our study indicated that ART outcomes among Alberta-based foreign-born patients are similar to those among Canadian-born non-Aboriginal patients. Our results, however, suggested that Canadian-born Aboriginal patients had poorer treatment outcomes compared to Canadian-born non-Aboriginal patients. It is imperative, therefore, that clinicians, researchers and community members better understand reasons for poor ART outcomes among Canadian-born Aboriginal patients in northern Alberta.

The COVID-19 pandemic has tested the resilience of health systems broadly and primary care (PC) specifically. This paper begins by distinguishing the technical and political aspects of resilience and then draws on a documentary analysis and qualitative interviews with health system and PC stakeholders to examine competing resilience-focused responses to the pandemic in Alberta, Canada. We describe the pre-existing linkages between the province's central service delivery agency and its independent PC clinics. Together, these central and independent elements make up Alberta's broader health system, with the focus of this paper being on PC's particular vision of how resilience ought to be achieved. We describe two specific, pandemic-affected areas of activity by showing how competing visions of resilience emerged in the central service delivery agency and independent PC responses as they met at the system's points of linkage. At the first point of linkage, we describe the centralized activation of an incident management system and the replies made by independent PC stakeholders. At the second point of linkage, we describe central efforts to disseminate infection prevention and control guidance to PC clinics and the improvisational efforts of staff at those independent clinics to operationalize the guidance and ensure continuity of operations. We identify gaps between the resilience visions of the central agency and independent PC, drawing broadly applicable policy lessons for improving responses in present and future public health emergencies. Finding ways to include PC in centralized resilience policy planning is a priority.

The COVID-19 pandemic exposed primary care (PC), and policies aimed at integrating it into provincial health systems, to a “shock test.” This paper draws on documentary analysis and qualitative interviews with PC and health system stakeholders to examine shifts in Alberta's pre-pandemic PC integration model during the first nine months of the pandemic. We begin with an account of three elements of the province's pre-pandemic model: finance, health authority activity and community activity. We describe these elements as they shifted, focusing on two indicators of change: novel virtual care billing codes and personal protective equipment (PPE) distribution channels. We draw out policy planning lessons for improving PC integration under normal and future pandemic conditions, namely, by facilitating rapid updates of virtual care billing codes, analyses of the impact of care delivery and backstopping of PPE markets and supply chains for PC.

Objective:Increasing evidence links unhealthy food environments with diet quality and overweight/obesity. Recent evidence has demonstrated that relative food environment measures outperform absolute measures. Few studies have examined the interplay between these two measures. We examined the separate and combined effects of the absolute and relative densities of unhealthy food outlets within 1600 m buffers around elementary schools on children’s diet- and weight-related outcomes.Design:This is a cross-sectional study of 812 children from thirty-nine schools. The Youth Healthy Eating Index (Y-HEI) and daily vegetables and fruit servings were derived from the Harvard Food Frequency Questionnaire for Children and Youth. Measured heights and weights determined BMI Z-scores. Food outlets were ranked as healthy, somewhat healthy and unhealthy according to provincial paediatric nutrition guidelines. Multilevel mixed-effects regression models were used to assess the effect of absolute (number) and relative (proportion) densities of unhealthy food outlets within 1600 m around schools on diet quality and weight status.Setting:Two urban centres in the province of Alberta, Canada.Participants:Grade 5 students (10–11 years).Results:For children attending schools with a higher absolute number (36+) of unhealthy food outlets within 1600 m, every 10 % increase in the proportion of unhealthy food outlets was associated with 4·1 lower Y-HEI score and 0·9 fewer daily vegetables and fruit.Conclusions:Children exposed to a higher relative density of unhealthy food outlets around a school had lower diet quality, specifically in areas where the absolute density of unhealthy food outlets was also high.

Objective:To further understandings of household food insecurity in First Nations communities in Canada and its relationship with obesity.Design:Analysis of a cross-sectional dataset from the First Nations Food, Nutrition and Environment Study representative of First Nations communities south of the 60th parallel. Multivariate logistic regression was used to assess associations between food insecurity and sociodemographic factors, as well as the odds of obesity among food-insecure households adjusting for sociodemographic characteristics.Setting:Western and Central Canada.Participants:First Nations peoples aged ≥19 years.Results:Forty-six percent of First Nations households experienced food insecurity. Food insecurity was highest for respondents who received social assistance; had ≤10 years of education; were female; had children in the household; were 19–30 years old; resided in Alberta; and had no year-round road access into the community. Rates of obesity were highest for respondents residing in marginally food-insecure households (female 56·6 %; male 54·6 %). In gender-specific analyses, the odds of obesity were highest among marginally food-insecure households in comparison with food-secure households, for both female (OR 1·57) and male (OR 1·57) respondents, adjusting for sociodemographic variables. For males only, those in severely food-insecure (compared with food-secure) households had lower odds of obesity after adjusting for confounding (OR 0·56).Conclusions:The interrelated challenges of food insecurity and obesity in First Nations communities emphasise the need for Indigenous-led, culturally appropriate and food sovereign approaches to food security and nutrition in support of holistic wellness and prevention of chronic disease.

Background Concordance between Common Drug Review (CDR) recommendations and provincial plans has been studied previously. However, no study has, to the best of the authors' knowledge, examined the characteristics of CDR recommendations that may be associated with concordance. Methods Recommendation-decision pairs were collected from the CDR and the provincial plans of Ontario, British Columbia and Alberta. Concordance was evaluated by province. Characteristics of each CDR recommendation were collected, and associations with concordance were evaluated by logistic regression. Results Recommendation-listing concordance was high. Positive references to cost and clinical outcomes compared to placebo were statistically associated with concordance. Negative references to cost and to the consistency and certainty of economic evidence were statistically associated with discordance. However, these findings were inconsistent across the jurisdictions studied. Conclusion Although concordance was high, the ability of recommendation characteristics to explain the relationship between province and CDR listing decisions was limited. This exploratory study highlights the complexity of the reimbursement process and possible reasons for drug listing differences across jurisdictions.

Paleopathology, or the study of ancient injuries and diseases, can enable the ecology and life history of extinct taxa to be deciphered. Large‐bodied ornithopods are the dinosaurs with the highest frequencies of paleopathology reported to‐date. Among these, the crested hadrosaurid Parasaurolophus walkeri is one of the most famous, largely due to its dramatic elongated and tubular nasal crest. The holotype of Parasaurolophus walkeri at the Royal Ontario Museum, Canada, displays several paleopathologies that have not been discussed in detail previously: a dental lesion in the left maxilla, perhaps related to periodontal disease; callus formation associated with fractures in three dorsal ribs; a discoidal overgrowth above dorsal neural spines six and seven; a cranially oriented spine in dorsal seven, that merges distally with spine six; a V‐shaped gap between dorsal spines seven and eight; and a ventral projection of the pubic process of the ilium which covers, and is fused with, the lateral side of the iliac process of the pubis. These lesions suggest that the animal suffered from one or more traumatic events, with the main one causing a suite of injuries to the anterior aspect of the thorax. The presence of several lesions in a single individual is a rare observation and, in comparison with a substantial database of hadrosaur paleopathological lesions, has the potential to reveal new information about the biology and behavior of these ornithopods. The precise etiology of the iliac abnormality is still unclear, although it is thought to have been an indirect consequence of the anterior trauma. The discoidal overgrowth above the two neural spines also seems to be secondary to the severe trauma inflicted on the ribs and dorsal spines, and probably represents post‐traumatic ossification of the base of the nuchal ligament. The existence of this structure has previously been considered in hadrosaurs and dinosaurs more generally through comparison of origin and insertion sites in modern diapsids (Rhea americana, Alligator mississippiensis, Iguana iguana), but its presence, structure, and origin‐attachment sites are still debated. The V‐shaped gap is hypothesized as representing the point between the stresses of the nuchal ligament, pulling the anterior neural spines forward, and the ossified tendons pulling the posterior neural spines backward. Different reconstructions of the morphology of the structure based on the pathological conditions affecting the neural spines of ROM 768 are proposed. Finally, we review the history of reconstructions for Parasaurolophus walkeri showing how erroneous misconceptions have been perpetuated over time or have led to the development of new hypotheses, including the wide neck model supported in the current research., The fossilized lesions in Parasaurolophus walkeri comprise periodontal disease, fractured ribs, and myositis ossificans traumatica in a number of vertebral dorsal spines and in the ilium.The injuries appear to have been caused by one or more non‐threatening events.The discoidal overgrowth on the dorsal spines m ight represent a pathological correlate for the origin of the nuchal ligament thereby enabling the morphology of the neck to be ascertained.

The need for a baseline information system derives from the diversity and inconsistencies in the existing data sources in the province, in the data itself, in the collecting procedures and regarding accessibility. In addition, we were required to investigate the feasibility of establishing a set of ''social indicators'' for the Fort McMurray study area. In this background Paper we set out the results of our examination, and our conclusions. We propose a framework within which to collect and order base data. And we suggest the socio-economic data which might comprise the data system.

A collection of working papers that helped inform the final report and recommendations, including: • Recommended Models for Calculating Diffusion From Point Sources With Applications to the Athabasca Bituminous Sands Area Western Research & Development Ltd • Meteorological Aspects of the Athabasca Tar Sands Study Geoscience Research Associates Limited • Research on Waste Disposal and Waste Deposits Research Council of Alberta • Utilities Technology and Energy Aspects Intercontinental Engineering Ltd. • Athabasca Tar Sands Baseline Study British Columbia Research • The Environmental Impact of In-Situ Technology Research Council of Alberta • Direct Coking of Alberta Bitumen In A Fluidized Solids Bed Dr. P.E. Gishler • Forest Survey - Athabasca Tar Sands Area, 1972 British Columbia Research

Species profile for Betula papyrifera: paper birch, western birch, white birch, canoe birch

Objective Despite well-documented data on the mixed impact of physician payment models, there is limited evidence on how to enhance existing payment model designs. This study examines the approaches to optimizing payment models from the perspective of specialist physicians to better support patient and physician experience and other health system objectives. Method Semi-structured interviews were conducted with 32 specialist physicians across Alberta, Canada. Data from the interviews were analyzed using a framework approach. Results Respondents emphasized the need to incentivize physicians with the right blend of financial and non-financial incentives, including physician wellness. Respondents also highlighted the need for physician involvement and accountability to optimize the value of physician payment models. Conclusion To optimize physician payment models, it may be useful to include a blend of financial and non-financial incentives with clear accountability measures as this may better align physician practice with health system priorities.

Background The development of a successful COVID-19 control strategy requires a thorough understanding of the trends in geographic and demographic distributions of disease burden. In terms of the estimation of the population prevalence, this includes the crucial process of unravelling the number of patients who remain undiagnosed. Objective This study estimates the period prevalence of COVID-19 between March 1, 2020, and November 30, 2020, and the proportion of the infected population that remained undiagnosed in the Canadian provinces of Quebec, Ontario, Alberta, and British Columbia. Methods A model-based mathematical framework based on a disease progression and transmission model was developed to estimate the historical prevalence of COVID-19 using provincial-level statistics reporting seroprevalence, diagnoses, and deaths resulting from COVID-19. The framework was applied to three different age cohorts (< 30; 30-69; and ≥70 years) in each of the provinces studied. Results The estimates of COVID-19 period prevalence between March 1, 2020, and November 30, 2020, were 4.73% (95% CI 4.42%-4.99%) for Quebec, 2.88% (95% CI 2.75%-3.02%) for Ontario, 3.27% (95% CI 2.72%-3.70%) for Alberta, and 2.95% (95% CI 2.77%-3.15%) for British Columbia. Among the cohorts considered in this study, the estimated total number of infections ranged from 2-fold the number of diagnoses (among Quebecers, aged ≥70 years: 26,476/53,549, 49.44%) to 6-fold the number of diagnoses (among British Columbians aged ≥70 years: 3108/18,147, 17.12%). Conclusions Our estimates indicate that a high proportion of the population infected between March 1 and November 30, 2020, remained undiagnosed. Knowledge of COVID-19 period prevalence and the undiagnosed population can provide vital evidence that policy makers can consider when planning COVID-19 control interventions and vaccination programs.

This paper discusses findings from a high-level scan of the contextual factors and actors that influenced policies on team-based primary healthcare in three Canadian provinces: British Columbia, Alberta and Saskatchewan. The team searched diverse sources (e.g., news reports, press releases, discussion papers) for contextual information relevant to primary healthcare teams. We also conducted qualitative interviews with key health system informants from the three provinces. Data from documents and interviews were analyzed qualitatively using thematic analysis. We then wrote narrative summaries highlighting pivotal policy and local system events and the influence of actors and context. Our overall findings highlight the value of reviewing the context, relationships and power dynamics, which come together and create "policy windows" at different points in time. We observed physician-centric policy processes with some recent moves to rebalance power and be inclusive of other actors and perspectives. The context review also highlighted the significant influence of changes in political leadership and prioritization in driving policies on team-based care. While this existed in different degrees in the three provinces, the push and pull of political and professional power dynamics shaped Canadian provincial policies governing team-based care. If we are to move team-based primary healthcare forward in Canada, the provinces need to review the external factors and the complex set of relationships and trade-offs that underscore the policy process.

Background In March 2020, Text4Hope—a community health service—was provided to Alberta residents. This free service aims to promote psychological resilience and alleviate pandemic-associated stress, anxiety, and depression symptoms during the COVID-19 pandemic. Objective This study aimed to evaluate the feedback, satisfaction, experience, and perceptions of Text4Hope subscribers and to examine any differences based on gender after subscribers received 6 weeks of daily supportive text messages. Additionally, this study examined subscribers’ anticipated receptivity to technology-based medical services that could be offered during major crises, emergencies, or pandemics. Methods Individuals self-subscribed to Text4Hope to receive daily supportive text messages for 3 months. Subscribers were invited to complete a web-based survey at 6 weeks postintervention to provide service satisfaction–related information. Overall satisfaction was assessed on a scale of 0-10, and satisfaction scores were analyzed using a related-measures t test. Likert scale satisfaction responses were used to assess various aspects of the Text4Hope program. Gender differences were analyzed using one-way analysis of variance (ANOVA) and Chi-square analyses. Results A total of 2032 subscribers completed the baseline and 6-week surveys; 1788 (88%) were female, 219 (10.8%) were male, and 25 (1.2%) were other gender. The mean age of study participants was 44.58 years (SD 13.45 years). The mean overall satisfaction score was 8.55 (SD 1.78), suggesting high overall satisfaction with Text4Hope. The ANOVA analysis, which was conducted using the Welch test (n=1716), demonstrated that females had significantly higher mean satisfaction scores than males (8.65 vs 8.11, respectively; mean difference=0.546; 95% CI 0.19 to 0.91; P Conclusions Respondents affirmed the high quality of the text messages with their positive feedback. Technology-based services can provide remotely accessible and population-level interventions that align with the recommended physical distancing practices for pandemics. Text4Hope subscriber feedback revealed high satisfaction and acceptance at 6 weeks postintervention. International Registered Report Identifier (IRRID) RR2-10.2196/19292

Background Despite a doubling of osteoarthritis-targeted mobile health (mHealth) apps and high user interest and demand for health apps, their impact on patients, patient outcomes, and providers has not met expectations. Most health and medical apps fail to retain users longer than 90 days, and their potential for facilitating disease management, data sharing, and patient-provider communication is untapped. An important, recurrent criticism of app technology development is low user integration design. User integration ensures user needs, desires, functional requirements, and app aesthetics are responsive and reflect target user preferences. Objective This study aims to describe the co-design process for developing a knee osteoarthritis minimum viable product (MVP) mHealth app with patients, family physicians, and researchers that facilitates guided, evidence-based self-management and patient-physician communication. Methods Our qualitative co-design approach involved focus groups, prioritization activities, and a pre-post quality and satisfaction Kano survey. Study participants included family physicians, patient researchers and patients with knee osteoarthritis (including previous participants of related collaborative research), researchers, key stakeholders, and industry partners. The study setting was an academic health center in Southern Alberta. Results Distinct differences exist between what patients, physicians, and researchers perceive are the most important, convenient, desirable, and actionable app functional requirements. Despite differences, study participants agreed that the MVP should be electronic, should track patient symptoms and activities, and include features customized for patient- and physician-identified factors and international guideline-based self-management strategies. Through the research process, participants negotiated consensus on their respective priority functional requirements. The highest priorities were a visual symptom graph, setting goals, exercise planning and daily tracking, and self-management strategies. The structured co-design with patients, physicians, and researchers established multiple collaborative processes, grounded in shared concepts, language, power, rationale, mutual learning, and respect for diversity and differing opinions. These shared team principles fostered an open and inclusive environment that allowed for effective conceptualization, negotiation, and group reflection, aided by the provision of tangible and ongoing support throughout the research process, which encouraged team members to question conventional thinking. Group-, subgroup-, and individual-level data helped the team reveal how and for whom perspectives about individual functional requirements changed or remained stable over the course of the study. This provided valuable insight into how and why consensus emerged, despite the presence of multiple and differing underlying rationales for functional requirement prioritization. Conclusions It is feasible to preserve the diversity of perspectives while negotiating a consensus on the core functional requirements of an mHealth prototype app for knee osteoarthritis management. Our study sample was purposely constructed to facilitate high co-design interactivity. This study revealed important differences between the patient, physician, and researcher preferences for functional requirements of an mHealth app that did not preclude the development of consensus.

Background South Asian Canadians are at high risk of developing cardiovascular disease and diabetes. Consumer-oriented health information technology may help mitigate lifestyle risk factors and improve chronic disease self-management. Objective This study aims to explore the prevalence, patterns, and predictors of the use of the internet, digital devices, and apps for health purposes as well as preferences for future use of eHealth support in South Asian Canadians. Methods We conducted a cross-sectional, mixed-mode survey in a convenience sample of 831 South Asian adults recruited at faith-based gathering places, health care settings, and community events in Edmonton, Alberta, in 2014. The 706 responders (mean age 47.1, SD 17.6 years; n=356, 50.4% female; n=509, 72.1% Sikh) who provided complete sociodemographic information were included in the analysis, and the denominators varied based on the completeness of responses to each question. Multivariate logistic regression was used to determine sociodemographic and health status predictors of internet use, being a web-based health information seeker, smartphone or tablet ownership, health app use, and willingness to use various modes of eHealth support. Results Of all respondents, 74.6% (527/706) were internet users and 47.8% (336/703) were web-based health information seekers. In addition, 74.9% (527/704) of respondents owned a smartphone or tablet and 30.7% (159/518) of these had a health and fitness app. Most internet users (441/527, 83.7%) expressed interest in using ≥1 mode of eHealth support. Older age, being female, having less than high school education, preferring written health information in languages other than English, and lacking confidence in completing medical forms predicted lack of internet use. Among internet users, factors that predicted web-based health information seeking were being female, use of the internet several times per day, being confident in completing medical forms, and preferring health information in English. Predictors of not owning a smartphone or tablet were being older, preferring health information in languages other than English, having less than high school education, living in Canada for Conclusions eHealth-based chronic disease prevention and management interventions are feasible for South Asian adults, but digital divides exist according to language preference, education, age, sex, confidence in completing medical forms, and number of years lived in Canada. Community-based, culturally tailored strategies targeting these factors are required to address existing divides and increase the uptake of credible web-based and app-based resources for health purposes.

Objectives Of the several barriers associated with uptake and adherence to hearing services, cost is the most commonly identified barrier in Canada. This study evaluated health insurance plans for hearing care coverage within Alberta, Canada, and subsequent out-of-pocket expenses that would result if an individual chose to pursue treatment. Methods An investigation of eight companies that provide supplementary health coverage in Alberta was conducted. Categories of health service coverage included hearing, vision, speech-language pathology (S-LP), physical therapy related (PT-R; including massage therapy and chiropractic therapy) and alternative medicine related (AM-R; including osteopathy, acupuncture and naturopathy). All coverage amounts were corrected to a four-year term for comparison purposes. Results For a four-year term, the coverage amounts for hearing services were CAD 300-750; for vision services were CAD 0-900; for S-LP services were CAD 0-2,400; for PT-R services were CAD 1,400-10,200; and for AM-R services were CAD 0-10,200 per four-year term. The expected out-of-pocket expense for vision ranged from CAD 0 to CAD 2,766, whereas for hearing, it ranged from CAD 250 to CAD 11,700. Conclusion A considerable range and discrepancy were reported between hearing care and most paramedical services. In addition, the coverage amounts for hearing care were inconsistent with treatment costs, resulting in considerable out-of-pocket expenses for most consumers. The potential implications of such cost-related barriers on public health are an important consideration as our understanding of the impact of untreated hearing impairment continues to increase.

ObjectiveThe World Cancer Research Fund (WCRF) and the American Institute for Cancer Research (AICR) publish recommendations for cancer prevention. The present study aimed to estimate the association between adherence to these cancer-specific prevention recommendations and subsequent development of cancer in a prospective cohort.DesignA composite adherence score was constructed based on questionnaire data to reflect overall adherence to WCRF/AICR lifestyle-related recommendations on body fatness, physical activity, diet and alcoholic drinks. Multivariable Cox proportional hazard regression models were used to assess the association (hazard ratio; 95 % CI) between the adherence score and risk of developing cancer.SettingAlberta’s Tomorrow Project, a prospective cohort study.ParticipantsMen and women (n25 100, mean age at enrolment 50·5 years) recruited between 2001 and 2009 with no previous cancer diagnosis were included in analyses.ResultsCancer cases (n2066) were identified during a mean follow-up of 11·7 years. Participants who were most adherent to the selected WCRF/AICR recommendations (composite score: 4–6) were 13 % (0·87; 0·78, 0·98) less likely to develop cancer compared with those who were least adherent (composite score: 0–2). Each additional recommendation met corresponded to a 5 % (0·95; 0·91, 0·99) reduction in risk of developing cancer. When stratified by sex, the associations remained significant for women, but not for men.ConclusionsAdherence to lifestyle-related cancer prevention recommendations was associated with reduced risk of developing cancer over the follow-up term in this Canadian cohort.

With provincial policy changing institutional care provision for older adults who are unable to safely remain at home, supportive living represents a new middle-ground to provide care for older adults. We compared characteristics of supportive living staff and residents to those in long-term care (LTC), using facility and staff surveys, as well as administrative Resident Assessment Instrument (RAI) data, to describe differences and similarities between facility types. Data analysis included t-tests, chi-square tests, ridit analyses and odds ratios. Participants from 15 supportive living facilities were compared to participants from eight LTC homes. Supportive living healthcare aides were younger, worked fewer years and were more likely to work full time than LTC healthcare aides. LTC residents were more likely than supportive living residents to have: cognitive impairment, medical instability, and activities of daily living dependence. This knowledge, which situates supportive living in the new care continuum, is useful for policy makers and administrators deciding on interventions and clinical guidelines for care groups.

Background Inequities in access to health services are a global concern and a concern for Canadian populations living in rural areas. Rural children hospitalized at tertiary children’s hospitals have higher rates of medical complexity and experience more expensive hospitalizations and more frequent readmissions. The 2 tertiary pediatric hospitals in Alberta, Canada, have already been operating above capacity, but the pediatric beds at regional hospitals are underused. Such imbalance could lead to poor patient safety and increased readmission risk at tertiary pediatric hospitals and diminish the clinical exposure of regional pediatric health care providers, erode their confidence, and compel health systems to further reduce the capacity at regional sites. A Telemedicine Rounding and Consultation for Kids (TRaC-K) model was proposed to enable health care providers at Alberta Children’s Hospital to partner with their counterparts at Medicine Hat Regional Hospital to provide inpatient clinical care for pediatric patients who would otherwise have to travel or be transferred to the tertiary site. Objective The aim of this study is to identify perceived barriers and enablers to implementing the TRaC-K model. Methods This study was guided by the Theoretical Domains Framework (TDF) and used qualitative methods. We collected qualitative data from 42 participants from tertiary and regional hospitals through 31 semistructured interviews and 2 focus groups. These data were thematically analyzed to identify major subthemes within each TDF domain. These subthemes were further aggregated and categorized into barriers or enablers to implementing the TRaC-K model and were tabulated separately. Results Our study identified 31 subthemes in 14 TDF domains, ranging from administrative issues to specific clinical conditions. We were able to merge these subthemes into larger themes and categorize them into 4 barriers and 4 enablers. Our findings showed that the barriers were lack of awareness of telemedicine, skills to provide virtual clinical care, unclear processes and resources to support TRaC-K, and concerns about clear roles and responsibilities. The enablers were health care providers’ motivation to provide care closer to home, supporting system resource stewardship, site and practice compatibility, and motivation to strengthen tertiary–regional relationships. Conclusions This systematic inquiry into the perceived barriers and enablers to the implementation of TRaC-K helped us to gain insights from various health care providers’ and family members’ perspectives. We will use these findings to design interventions to overcome the identified barriers and harness the enablers to encourage successful implementation of TRaC-K. These findings will inform the implementation of telemedicine-based interventions in pediatric settings in other parts of Canada and beyond. International Registered Report Identifier (IRRID) RR2-10.1186/s12913-018-3859-2

ObjectiveTo quantify associations of the dietary share of ultra-processed foods (UPF) with the overall diet quality of First Nations peoples.DesignA cross-sectional analysis of data from the First Nations Food, Nutrition and Environment Study, designed to contribute to knowledge gaps regarding the diet of First Nations peoples living on-reserve, south of the 60th parallel. A multistage sampling of communities was conducted. All foods from 24 h dietary recalls were categorized into NOVA categories and analyses were performed to evaluate the impact of UPF on diet quality.SettingWestern and Central Canada.SubjectsFirst Nations participants aged 19 years or older.ResultsThe sample consisted of 3700 participants. UPF contributed 53·9 % of energy. Compared with the non-UPF fraction of the diet, the UPF fraction had 3·5 times less vitamin A, 2·4 times less K, 2·2 times less protein, 2·3 times more free sugars and 1·8 times more Na. As the contribution of UPF to energy increased so did the overall intakes of energy, carbohydrate, free sugar, saturated fat, Na, Ca and vitamin C, and Na:K; while protein, fibre, K, Fe and vitamin A decreased. Diets of individuals who ate traditional First Nations food (e.g. wild plants and game animals) on the day of the recall were lower in UPF.ConclusionsUPF were prevalent in First Nations diets. Efforts to curb UPF consumption and increase intake of traditional First Nations foods and other fresh or minimally processed foods would improve diet quality and health in First Nations peoples.

ObjectiveTo explore cross-sectional adherence to cancer prevention recommendations by adults enrolled in a prospective cohort in Alberta, Canada.DesignQuestionnaire data were used to construct a composite cancer prevention adherence score for each participant, based on selected personal recommendations published by the World Cancer Research Fund/American Institute for Cancer Research (2007). Data were self-reported on health and lifestyle, past-year physical activity and past-year FFQ. The scores accounted for physical activity, dietary supplement use, body size, and intakes of alcohol, fruit, vegetables and red meat. Tobacco exposure was also included. Scores ranged from 0 (least adherent) to 7 (most adherent).SettingAlberta’s Tomorrow Project; a research platform based on a prospective cohort.SubjectsAdult men and women (n24 988) aged 35–69 years recruited by random digit dialling and enrolled in Alberta’s Tomorrow Project between 2001 and 2009.ResultsOf the cohort, 14 % achieved adherence scores ≥5 and 60 % had scores ≤3. Overall adherence scores were higher in women (mean (sd): 3·4 (1·1)) than in men (3·0 (1·2)). The extent of overall adherence was also associated with level of education, employment status, annual household income, personal history of chronic disease, family history of chronic disease and age.ConclusionsReported adherence to selected personal recommendations for cancer prevention was low in this cohort of adults. In the short to medium term, these results suggest that more work is required to identify behaviours to target with cancer prevention strategies at a population level. Future work will explore the associations between adherence scores and cancer risk in this cohort.

ObjectiveIn 2011, Dietitians of Canada added ‘My Goals’ to its website-based nutrition/activity tracking program (eaTracker®,http://www.eaTracker.ca/); this feature allows users to choose ‘ready-made’ or ‘write-your-own’ goals and to self-report progress. The purpose of the present study was to document experiences and perceptions of goal setting and My Goals, and report users’ feedback on what is needed in future website-based goal setting/tracking tools.DesignOne-on-one semi-structured interviews were conducted with (i) My Goals users and (ii) dietitians providing a public information support service, EatRight Ontario (ERO).SettingMy Goals users from Ontario and Alberta, Canada were recruited via an eaTracker website pop-up box; ERO dietitians working in Ontario, Canada were recruited via ERO.SubjectsMy Goals users (n23; age 19–70 years; 91 % female;n5 from Alberta/n18 from Ontario) and ERO dietitians (n5).ResultsDietitians and users felt goal setting for nutrition (and activity) behaviour change was both a beneficial and a challenging process. Dietitians were concerned about users setting poor-quality goals and users felt it was difficult to stick to their goals. Both users and dietitians were enthusiastic about the My Goals concept, but felt the current feature had limitations that affected use. Dietitians and users provided suggestions to improve My Goals (e.g. more prominent presence of My Goals in eaTracker; assistance with goal setting; automated personalized feedback).ConclusionsDietitians and users shared similar perspectives on the My Goals feature and both felt goal use was challenging. Several suggestions were provided to enhance My Goals that are relevant to website-based goal setting/tracking tool design in general.

Objective:Little is known about the diet quality of preschool children in Canada. We adapted an established diet quality index for European preschool children to align with the Canadian context and applied the index to dietary data of 3-year-old children to assess patterns of diet quality.Design:Our diet quality index (DQI-C) consists of four components that align with Canada’s Food Guide (Vegetables and Fruit, Grain Products, Milk and Alternatives and Meat and Alternatives) and two components that account for less healthy intakes (Candy/Snacks, and Sugar-Sweetened Beverages (SSB)). The ratio between consumption v. recommended intakes is calculated for each component and summed to give a total score from 0 to 6.Setting:Alberta, Canada.Participants:The DQI-C was applied to FFQ data from 1260 3-year-old children.Results:Mean DQI-C was 3·69 (sd 0·6). Most children met recommendations for Vegetables and Fruit (73 %) and Meat and Alternatives (70 %); however, fewer met recommendations for Milk and Alternatives (38 %) and Grain Products (13 %). Children in the lowest quartile for DQI-C score consumed a mean of 82 g of Candy/Snacks and 193 g of SSB daily, whereas those in the highest quartile consumed 45 g/d and 17 g/d of Candy and Snacks and SSB, respectively.Conclusion:This DQI-C score is useful for ranking Canadian preschool children according to their overall diet quality. There is room for improvement for consumptions of Grain Products, Meat and Alternatives, Candy/Snacks and SSB, which could be a target for initiatives to improve diet quality of preschool children in Canada.

ObjectiveTo assess and compare the favourability of healthy public policy options to promote healthy eating from the perspective of members of the general public and policy influencers in two Canadian provinces.DesignThe Chronic Disease Prevention Survey, administered in 2016, required participants to rank their level of support for different evidence-based policy options to promote healthy eating at the population level. Pearson’sχ2significance testing was used to compare support between groups for each policy option and results were interpreted using the Nuffield Council on Bioethics’ intervention ladder framework.SettingAlberta and Québec, Canada.ParticipantsMembers of the general public (n2400) and policy influencers (n302) in Alberta and Québec.ResultsGeneral public and policy influencer survey respondents were more supportive of healthy eating policies if they were less intrusive on individual autonomy. However, in comparing levels of support between groups, we found policy influencers indicated significantly stronger support overall for healthy eating policy options. We also found that policy influencers in Québec tended to show more support for more restrictive policy options than their counterparts from Alberta.ConclusionsThese results suggest that additional knowledge brokering may be required to increase support for more intrusive yet impactful evidence-based policy interventions; and that the overall lower levels of support among members of the public may impede policy influencers from taking action on policies to promote healthy eating.

Predicting the magnitude of the annual seasonal peak in influenza-like illness (ILI)-related emergency department (ED) visit volumes can inform the decision to open influenza care clinics (ICCs), which can mitigate pressure at the ED. Using ILI-related ED visit data from the Alberta Real Time Syndromic Surveillance Net for Edmonton, Alberta, Canada, we developed (training data, 1 August 2004–31 July 2008) and tested (testing data, 1 August 2008–19 February 2014) spatio-temporal statistical prediction models of daily ILI-related ED visits to estimate high visit volumes 3 days in advance. Our Main Model, based on a generalised linear mixed model with random intercept, incorporated prediction residuals over 14 days and captured increases in observed volume ahead of peaks. During seasonal influenza periods, our Main Model predicted volumes within ±30% of observed volumes for 67%–82% of high-volume days and within 0.3%–21% of observed seasonal peak volumes. Model predictions were not as successful during the 2009 H1N1 pandemic. Our model can provide early warning of increases in ILI-related ED visit volumes during seasonal influenza periods of differing intensities. These predictions may be used to support public health decisions, such as if and when to open ICCs, during seasonal influenza epidemics.

Laboratory-scale experiments were carried out to test a mathematical model of the nitrogen dynamics in a composting process. The main ingredients of composting materials were wheat straw and dairy manure. The influence of (a) two carbon amendments, i.e. molasses and office paper, and (b) two chemicals forming buffer solutions on ammonia volatilization were investigated. Nitrogen losses amounted to 12-25% of initial nitrogen, in which ammonia volatilization accounted for 60-99%. Addition of molasses, a readily available form of carbon, reduced cumulative ammonia emissions substantially, but office paper, i.e. cellulose, had only a small influence. The addition of buffering chemicals did not significantly reduce ammonia volatilization.

BackgroundThe COVID-19 global pandemic has disrupted structures and communities across the globe. Numerous regions of the world have had varying responses in their attempts to contain the spread of the virus. Factors such as public health policies, governance, and sociopolitical climate have led to differential levels of success at controlling the spread of SARS-CoV-2. Ultimately, a more advanced surveillance metric for COVID-19 transmission is necessary to help government systems and national leaders understand which responses have been effective and gauge where outbreaks occur.ObjectiveThe goal of this study is to provide advanced COVID-19 surveillance metrics for Canada at the country, province, and territory level that account for shifts in the pandemic including speed, acceleration, jerk, and persistence. Enhanced surveillance identifies risks for explosive growth and regions that have controlled outbreaks successfully.MethodsUsing a longitudinal trend analysis study design, we extracted 62 days of COVID-19 data from Canadian public health registries for 13 provinces and territories. We used an empirical difference equation to measure the daily number of cases in Canada as a function of the prior number of cases, the level of testing, and weekly shift variables based on a dynamic panel model that was estimated using the generalized method of moments approach by implementing the Arellano-Bond estimator in R.ResultsWe compare the week of February 7-13, 2021, with the week of February 14-20, 2021. Canada, as a whole, had a decrease in speed from 8.4 daily new cases per 100,000 population to 7.5 daily new cases per 100,000 population. The persistence of new cases during the week of February 14-20 reported 7.5 cases that are a result of COVID-19 transmissions 7 days earlier. The two most populous provinces of Ontario and Quebec both experienced decreases in speed from 7.9 and 11.5 daily new cases per 100,000 population for the week of February 7-13 to speeds of 6.9 and 9.3 for the week of February 14-20, respectively. Nunavut experienced a significant increase in speed during this time, from 3.3 daily new cases per 100,000 population to 10.9 daily new cases per 100,000 population.ConclusionsCanada excelled at COVID-19 control early on in the pandemic, especially during the first COVID-19 shutdown. The second wave at the end of 2020 resulted in a resurgence of the outbreak, which has since been controlled. Enhanced surveillance identifies outbreaks and where there is the potential for explosive growth, which informs proactive health policy.

This study aimed to investigate the efficacy of private septic systems retrofitted into aerobic bioreactors with ‘SludgeHammer’ technology. In addition, the study attempted to characterize the strength of domestic wastewater released from ‘green’ households practicing water conservation strategies. Ten retrofitted onsite septic systems were studied in the Edmonton area, Alberta (AB) Canada during winter. These systems could remove BOD5 and TSS by 92 ± 5 and 92 ± 6% respectively which, according to Albertan regulatory standards, were characteristic removal efficiencies of the secondary treatment in the subsequent drain field. These removal efficiencies were remarkable given the strength of the influent wastewater. The raw wastewater carried significantly high pollutant concentrations (1160 ± 350 mg BOD5/L, 1653 ± 1174 mg TSS/L, 99 ± 19 mg NH4+-N/L, 100 ± 56 mg TN/L, and 39 ± 28 mg PO43−-P/L), characterizing it as high-strength domestic wastewater. Mixing provided by the aerator could only suspend 1/34th (3% m/m) of the solids in the bioreactor and consequently released significantly low solid concentrations (195 ± 206 mg TSS/L) into the final treatment component. As such, this technology did not impair the natural function of septic tanks or did not create any unintended excessive solid loading on drain field as a consequence of the added mixing energies provided by the active aeration. Nitrogen balance suggested the possibility of simultaneous nitrification and denitrification (SND) in the aerobic bioreactors. In some cases, PO43−-P removal efficiency was as high as that in enhanced biological phosphate removal (EBPR) process (81–97%). Phosphorus balance estimated that non-assimilative pathways (i.e., EBPR + biologically induced phosphate precipitation (BIPP)) contributed 50–99% to overall phosphorus removal in the system. Long HRTs, high influent BOD5 and anaerobic/aerobic zoning in the bioreactor most likely provided favorable conditions for SND and high phosphorus removal efficiencies in the retrofitted onsite wastewater treatment systems (OWTS).

SUMMARYPatients with methicillin-resistant Staphylococcus aureus (MRSA) clones, which were traditionally seen in the community setting (USA400/CMRSA7 and USA300/CMRSA10), are often identified as hospital-acquired (HA) infections using Infection Prevention and Control (IPC) surveillance definitions. This study examined the demographics and healthcare risk factors of patients with HA-MRSA to help understand if community MRSA clones are from a source internal or external to the hospital setting. Despite USA300/CMRSA10 being the predominant clone in Alberta, hospital clones (USA100/CMRSA2) still dominated in the acute care setting. In the Alberta hospitalized population, patients with USA400/CMRSA7 and USA300/CMRSA10 clones were significantly younger, had fewer comorbidities, and a greater proportion had none or ambulatory care-only healthcare exposure. These findings suggest that there are two distinct populations of HA-MRSA patients, and the patients with USA400/CMRSA7 and USA300/CMRSA10 clones identified in hospital more greatly resemble patients affected by those clones in the community. It is possible that epidemiological assessment overidentifies HA acquisition of MRSA in patients unscreened for MRSA on admission to acute care.