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Greenspace and socioeconomic status are known correlates of diabetes prevalence, but their combined effects at the sub-neighborhood scale are not yet known. This study derives, maps, and validates a combined socioeconomic/greenspace index of individual-level diabetes risk at the sub-neighborhood scale, without the need for clinical measurements. In two Canadian cities (Vancouver and Hamilton), we computed 4 greenspace variables from satellite imagery and extracted 11 socioeconomic variables from the Canadian census. We mapped 5125 participants from the Prospective Urban and Rural Epidemiology Study by their residential address and used age- and sex-dependent walking speeds to estimate individual exposure zones to local greenspace and socioeconomic characteristics, which were then entered into a principal component analysis to derive a novel diabetes risk index (DRI-GLUCoSE). We mapped index scores in both study areas and validated the index using fully adjusted logistic regression models to predict individual diabetes status. Model performance was then compared to other non-clinical diabetes risk indices from the literature. Diabetes prevalence among participants was 9.9%. The DRI-GLUCoSE index was a significant predictor of diabetes status, exhibiting a small non-significant attenuation with the inclusion of dietary and physical activity variables. The final models achieved a predictive accuracy of 75%, the highest among environmental risk models to date. Our combined index of local greenspace and socioeconomic factors demonstrates that the environmental component of diabetes risk is not sufficiently explained by diet and physical activity, and that increasing urban greenspace may be a suitable means of reducing the burden of diabetes at the community scale.

Quantifying the severity of traumatic injury has been foundational for the standardization of outcomes, quality improvement research, and health policy throughout the evolution of trauma care systems. Many injury severity scores are difficult to calculate and implement, especially in low- and middle-income countries (LMICs) where human resources are limited. The Kampala Trauma Score (KTS)-a simplification of the Trauma Injury Severity Score-was developed in 2000 to accommodate these settings. Since its development, numerous instances of KTS use have been documented, but extent of adoption is unknown. More importantly, does the KTS remain useful for determining injury severity in LMICs? This review aims to better understand the legacy of the KTS and assess its strengths and weaknesses. Three databases were searched to identify scientific papers concerning the KTS. Google Scholar was searched to identify grey literature. The search returned 357 papers, of which 199 met inclusion criteria. Eighty-five studies spanning 16 countries used the KTS in clinical settings. Thirty-seven studies validated the KTS, assessing its ability to predict outcomes such as mortality or need for admission. Over 80% of these studies reported the KTS equalled or exceeded more complicated scores at predicting mortality. The KTS has stood the test of time, proving itself over the last twenty years as an effective measure of injury severity across numerous contexts. We recommend the KTS as a means of strengthening trauma systems in LMICs and suggest it could benefit high-income trauma systems that do not measure injury severity.

Running can improve physical health and psychological wellbeing. However, the characteristics of conducive running environments are relatively unknown. This study determines neighborhood factors that attract running and explores how age and gender mediate built environment preferences. Spatial patterns of runners in Metro Vancouver were identified using crowdsourced fitness data from Strava, a popular application for tracking physical activities. The influence of socio-economic status (SES), green and/or blue space, and urbanicity on route popularity was assessed using a Generalized Linear Model (GLM). The influence of these neighborhood variables was also calculated for runners by age and gender. The results show high neighborhood SES, the presence of green and/or blue space, and high population density are associated with increased running activities in all age and gender groups. This study contributes a novel approach to understanding conducive running environments by demonstrating the utility of crowdsourced data in combination with data about urban environments. The patterns of this large group of runners can be used to inform planning for cities that promote running, as well as seek to encourage equal participation among different ages and genders.

Blood pressure measurement is a marker of antenatal care quality. In well resourced settings, lower blood pressure cutoffs for hypertension are associated with adverse pregnancy outcomes. We aimed to study the associations between blood pressure thresholds and adverse outcomes and the diagnostic test properties of these blood pressure cutoffs in low-resource settings.We did a secondary analysis of data from 22 intervention clusters in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials (NCT01911494) in India (n=6), Mozambique (n=6), and Pakistan (n=10). We included pregnant women aged 15-49 years (12-49 years in Mozambique), identified in their community by trained community health workers, who had data on blood pressure measurements and outcomes. The trial was unmasked. Maximum blood pressure was categorised as: normal blood pressure (systolic blood pressure [sBP]120 mm Hg and diastolic blood pressure [dBP]80 mm Hg), elevated blood pressure (sBP 120-129 mm Hg and dBP80 mm Hg), stage 1 hypertension (sBP 130-139 mm Hg or dBP 80-89 mm Hg, or both), non-severe stage 2 hypertension (sBP 140-159 mm Hg or dBP 90-109 mm Hg, or both), or severe stage 2 hypertension (sBP ≥160 mm Hg or dBP ≥110 mm Hg, or both). We classified women according to the maximum blood pressure category reached across all visits for the primary analyses. The primary outcome was a maternal, fetal, or neonatal mortality or morbidity composite. We estimated dose-response relationships between blood pressure category and adverse outcomes, as well as diagnostic test properties.Between Nov 1, 2014, and Feb 28, 2017, 21 069 women (6067 in India, 4163 in Mozambique, and 10 839 in Pakistan) contributed 103 679 blood pressure measurements across the three CLIP trials. Only women with non-severe or severe stage 2 hypertension, as discrete diagnostic categories, experienced more adverse outcomes than women with normal blood pressure (risk ratios 1·29-5·88). Using blood pressure categories as diagnostic thresholds (women with blood pressure within the category or any higher category vs those with blood pressure in any lower category), dose-response relationships were observed between increasing thresholds and adverse outcomes, but likelihood ratios were informative only for severe stage 2 hypertension and maternal CNS events (likelihood ratio 6·36 [95% CI 3·65-11·07]) and perinatal death (5·07 [3·64-7·07]), particularly stillbirth (8·53 [5·63-12·92]).In low-resource settings, neither elevated blood pressure nor stage 1 hypertension were associated with maternal, fetal, or neonatal mortality or morbidity adverse composite outcomes. Only the threshold for severe stage 2 hypertension met diagnostic test performance standards. Current diagnostic thresholds for hypertension in pregnancy should be retained.University of British Columbia, the BillMelinda Gates Foundation.

As data science gains traction, it often brings quantitative approaches and positivist epistemologies. While these can generate powerful insights, we argue for methodological hybridity in modern data science. We demonstrate the power of complementary qualitative approaches and flexible ontologies. Using an example of classifying segments™ on Strava, neither quantitative nor qualitative approaches alone were adequate to meaningfully classify segments, but together allowed accurate, useful, and intuitive categories to emerge. Drawing on this experience, we discuss qualitative data science and argue the ontological discussions within Critical GIS from the 1990s and 2000s are increasingly relevant and informative amidst our platial paradigms.

Running is one of the most popular forms of physical activity. To date, no literature explores association between the features of the built environment and running. A limited amount of literature uses walkability as a proxy for runnability, thereby misjudging the differing goals of walking and running: leisure, sport or commute. We create a rough runnability index using an affordance-based framework as a conceptual and methodological attempt to quantify features of the built environment that facilitate or hinder running as a form of leisure or sport activity. Three indices are created in the City of Surrey, British Columbia, Canada using pixelated edges. We find that areas in the downtown core and near high traffic routes show low safety and general runnability, whereas areas near parks and in low traffic, residential areas show higher safety for runners. Representing runnability using pixelated edges allows for sub-block level analysis of runnability as experienced by runners.

Background: Socioeconomic status (SES) has been shown to influence the outcomes of surgical pathologies in areas with unequal access to health care. The purpose of this study was to measure the effect of SES on the urgency for inguinal hernia repair in an area with purported equitable access to health care in the context of a universal health care system. Methods: We included all adult patients who underwent surgical management of an inguinal hernia between 2012 and 2016 at 2 urban academic centres. We measured the SES using the Vancouver Area Neighbourhood Deprivation Index ( VANDIX) score. Results: We included 2336 patients: 98 emergency surgery and 294 elective surgery cases. We matched patients without replacement on age, sex and American Society of Anesthesiology score, using optimized propensity score matching at a ratio of 1 case to 3 controls. We found no significant correlation between lower SES and emergency surgical management (p = 0.122). Secondary analysis assessed the impact of SES on morbidity and length of stay. We found no significant difference in the rate of complications, length of stay and recurrence by SES category. Patients from lower SES brackets had increased odds for readmission (odds ratio 1.979; 95% confidence interval 1.111-4.318). Conclusion: We found no correlation between a low SES and the need for emergency inguinal hernia repair, but found an increased rate of readmission in patients from lower SES brackets. This finding should be further scrutinized through a deeper dive into the barriers to access to nonacute care settings, such as home care.

Summary Background To overcome the three delays in triage, transport and treatment that underlie adverse pregnancy outcomes, we aimed to reduce all-cause adverse outcomes with community-level interventions targeting women with pregnancy hypertension in three low-income countries. Methods In this individual participant-level meta-analysis, we de-identified and pooled data from the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised controlled trials in Mozambique, Pakistan, and India, which were run in 2014–17. Consenting pregnant women, aged 12–49 years, were recruited in their homes. Clusters, defined by local administrative units, were randomly assigned (1:1) to intervention or control groups. The control groups continued local standard of care. The intervention comprised community engagement and existing community health worker-led mobile health-supported early detection, initial treatment, and hospital referral of women with hypertension. For this meta-analysis, as for the original studies, the primary outcome was a composite of maternal or perinatal outcome (either maternal, fetal, or neonatal death, or severe morbidity for the mother or baby), assessed by unmasked trial surveillance personnel. For this analysis, we included all consenting participants who were followed up with completed pregnancies at trial end. We analysed the outcome data with multilevel modelling and present data with the summary statistic of adjusted odds ratios (ORs) with 95% CIs (fixed effects for maternal age, parity, maternal education, and random effects for country and cluster). This meta-analysis is registered with PROSPERO, CRD42018102564. Findings Overall, 44 clusters (69 330 pregnant women) were randomly assigned to intervention (22 clusters [36 008 pregnancies]) or control (22 clusters [33 322 pregnancies]) groups. 32 290 (89·7%) pregnancies in the intervention group and 29 698 (89·1%) in the control group were followed up successfully. Median maternal age of included women was 26 years (IQR 22–30). In the intervention clusters, 6990 group and 16 691 home-based community engagement sessions and 138 347 community health worker-led visits to 20 819 (57·8%) of 36 008 women (of whom 11 095 [53·3%] had a visit every 4 weeks) occurred. Blood pressure and dipstick proteinuria were assessed per protocol. Few women were eligible for methyldopa for severe hypertension (181 [1%] of 20 819) or intramuscular magnesium sulfate for pre-eclampsia (198 [1%]), of whom most accepted treatment (162 [89·5%] of 181 for severe hypertension and 133 [67·2%] of 198 for pre-eclampsia). 1255 (6%) were referred to a comprehensive emergency obstetric care facility, of whom 864 (82%) accepted the referral. The primary outcome was similar in the intervention (7871 [24%] of 32 290 pregnancies) and control clusters (6516 [22%] of 29 698; adjusted OR 1·17, 95% CI 0·90–1·51; p=0·24). No intervention-related serious adverse events occurred, and few adverse effects occurred after in-community treatment with methyldopa (one [2%] of 51; India only) and none occurred after in-community treatment with magnesium sulfate or during transport to facility. Interpretation The CLIP intervention did not reduce adverse pregnancy outcomes. Future community-level interventions should expand the community health worker workforce, assess general (rather than condition-specific) messaging, and include health system strengthening. Funding University of British Columbia, a grantee of the Bill & Melinda Gates Foundation.

Individual socioeconomic status is known to correlate with multimorbidity, but the role of neighbourhood-level socioeconomic deprivation is uncertain. Participants from five cities (n = 16,313) fro...

Qualitative geographic information systems (GIS) have come a long way since the original call from critical GIS scholars in the 1990s. The invention of the geoweb as well as big data sources for qu...

Supplemental Digital Content is available in the text., In pregnancy in well-resourced settings, limited data suggest that higher blood pressure (BP) visit-to-visit variability may be associated with adverse pregnancy outcomes. Included were pregnant women in 22 intervention clusters of the CLIP (Community-Level Interventions for Preeclampsia) cluster randomized trials, who had received at least 2 prenatal contacts from a community health worker, including standardized BP measurement. Mixed-effects adjusted logistic regression assessed relationships between pregnancy outcomes and both BP level (median [interquartile range]) and visit-to-visit variability (SD and average real variability [ARV], adjusted for BP level), among all women and those who became hypertensive. The primary outcome was the CLIP composite of maternal and perinatal mortality and morbidity. Among 17 770 pregnancies, higher systolic and diastolic BP levels were associated with increased odds of the composite outcome per 5 mm Hg increase in BP (odds ratio [OR], 1.05 [95% CI, 1.03–1.07] and OR, 1.08 [1.06–1.11], respectively). Higher BP visit-to-visit variability was associated with increased odds, per a SD increase in BP variability measure, of (1) hypertension (systolic: OR, 2.09 [1.98–2.21] for SD and 1.52 [1.45–1.60] for ARV; diastolic: OR, 2.70 [2.54–2.87] for SD and 1.86 [1.76–1.96] for ARV); and (2) the composite outcome (systolic: OR, 1.10 [1.06–1.14] for SD and 1.06 [1.02–1.10] for ARV; diastolic: OR, 1.07 [1.03–1.11] for SD and 1.06 [1.02–1.09] for ARV). In 3 less-developed countries, higher BP level and visit-to-visit variability predicted adverse pregnancy outcomes, providing an opportunity for high-definition medicine.

Objective This study aimed to identify the association between the food environment and obesity. Methods BMI and waist circumference (WC) were measured in 8,076 participants from three cities. The number of fast-food restaurants, full-service restaurants, bars/pubs, markets, and liquor stores within 500 m of each participant was documented. The association between the food environment (ratio of fast-food to full-service restaurants, ratio of bars/pubs to liquor stores, and presence of markets) with obesity (BMI ≥ 30 kg/m2 ) and abdominal obesity (WC ≥ 102 cm for males or WC ≥ 88 cm for females) was investigated, adjusted for age, sex, education level, neighborhood deprivation, neighborhood type, and total hours per week of walking and taking into account city-level clustering. Results The ratios of fast-food to full-service restaurants and of bars/pubs to liquor stores were positively associated with obesity (OR = 1.05 [CI: 1.02-1.09] and OR = 1.08 [CI: 1.04-1.13], respectively). The ratio of bars/pubs to liquor stores was positively associated with abdominal obesity (OR = 1.10 [CI: 1.05-1.14]). There was no association between markets and either obesity or abdominal obesity. Conclusions Features of the food environment have varying associations with obesity. These features have an additive effect, and future studies should not focus on only one feature in isolation.

Trauma is a leading contributor to the burden of disease in Canada, accounting for more than 15 000 deaths annually. Although caring for injured patients at designated trauma centres (TCs) is consistently associated with survival benefits, it is unclear how travel time to definitive care influences outcomes. Using a population-based sample of trauma patients, we studied the association between predicted travel time (PTT) to TCs and mortality for patients assigned to ground transport.Victims of penetrating trauma or motor vehicle collisions (MVCs) in Nova Scotia between 2005 and 2014 were identified from a provincial trauma registry. We conducted cost distance analyses to quantify PTT for each injury location to the nearest TC. Adjusted associations between TC access and injury-related mortality were then estimated using logistic regression.Greater than 30 minutes of PTT to a TC was associated with a 66% increased risk of death for MVC victims (p = 0.045). This association was lost when scene deaths were excluded from the analysis. Sustaining a penetrating trauma greater than 30 minutes from a TC was associated with a 3.4-fold increase in risk of death. Following the exclusion of scene deaths, this association remained and approached significance (odds ratio 3.48, 95% confidence interval 0.98–14.5, p = 0.053).Predicted travel times greater than 30 minutes were associated with worse outcomes for victims of MVCs and penetrating injuries. Improving communication across the trauma system and reducing prehospital times may help optimize outcomes for rural trauma patients.Les traumatismes contribuent pour une bonne part au fardeau de la maladie au Canada; on leur attribue plus de 15 000 décès annuellement. Même si les soins prodigués aux patients victimes de traumatismes dans les centres de traumatologie désignés (CTD) sont toujours associés à des gains au plan de la survie, on ignore quelle est l’influence du temps de transfert vers le CTD sur l’issue. À partir d’un échantillon de patients polytraumatisés basé dans la population, nous avons analysé le lien entre le temps de transfert prévu (TTP) vers le CTD et la mortalité des patients transportés par voie terrestre.On a identifié les victimes de traumatismes pénétrants ou d’accidents de la route en Nouvelle-Écosse entre 2005 et 2014 à partir d’un registre provincial de traumatologie. Nous avons analysé la distance de coût pour quantifier le TTP à partir de chaque scène vers le CTD le plus proche. Les liens ajustés entre l’accès au CTD et la mortalité liée au traumatisme ont ensuite été estimés par régression logistique.Un délai de TTP de plus de 30 minutes pour arriver au CTD a été associé à un accroissement de 66 % du risque de décès chez les patients polytraumatisés (p = 0,045). Ce lien s’annulait si on excluait de l’analyse les décès survenus sur la scène de l’accident. Subir un traumatisme ouvert à plus de 30 minutes de distance d’un CTD a été associé à une augmentation par un facteur de 3,4 du risque de décès. Une fois les décès sur la scène de l’accident exclus, ce lien a persisté et s’est rapproché du seuil de signification (rapport des cotes 3,48, intervalle de confiance de 95 % 0,98–14,5, p = 0,053).Des temps de transfert prévus supérieurs à 30 minutes ont été associés une issue plus défavorable pour les victimes d’accidents de la route et de traumatismes pénétrants. L’amélioration de la communication entre les divers éléments du système de traumatologie et la réduction du temps préhospitalier pourrait optimiser l’issue pour les patients victimes de traumatismes en région rurale.

Recreational road running is growing in popularity and has been linked to numerous mental and physical health benefits. However, we know little about what environmental preferences or concerns runners have regarding participation in the sport, and whether differences exist across age and gender. We conducted a cross-sectional survey on recreational road runners to investigate the type of built and natural environments road runners prefer, as well as the safety and health concerns that may affect runners’ choice of environment. Responses were analyzed by age and gender. A total of 1228 road runners responded to the survey, 59.6% of respondents were women and 32.1% of respondents were men. Most respondents preferred to run on asphalt or sidewalk surfaces, and preferred well-lit, tree-lined routes. Major concerns for both men and women include animals and dangerous road conditions. Men and women differed significantly in their responses to the importance of running around others and their primary concerns while running. Results of this study serve to deepen our understanding of recreational road runners’ environmental preferences and concerns, providing valuable information for public health officials and city planners alike. This information must be considered if we are to continue to encourage uptake of running as a sport and reap its health effects.

Critical Practice of Grant Application and Administration

COVID-19 emerged as a deadly pandemic disease that has spread to nearly every country worldwide. In response to this pandemic, maps of the disease’s spread and health outcomes were being produced in near real time. Maps can serve as an effective tool in communicating disease progression to policy analysts, decision makers, and the public. However, initial maps illustrating COVID-19 events largely overemphasized their usefulness for tracking the progression of the disease and developing appropriate responses. Messy and inconsistent health data was a big part of this problem, as was the paucity of high-resolution spatial data. Lack of GIS and cartographic training by the purveyors of these maps was another key factor. This chapter will examine the various geographic visualizations of COVID-19 that have arisen, including examples that have fallen short and others that have proven resoundingly successful.

Background Incomplete vital registration systems mean that causes of death during pregnancy and childbirth are poorly understood in low-income and middle-income countries. To inform global efforts to reduce maternal mortality, we compared physician review and computerised analysis of verbal autopsies (interpreting verbal autopsies [InterVA] software), to understand their agreement on maternal cause of death and circumstances of mortality categories (COMCATs) in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials. Methods The CLIP trials took place in India, Pakistan, and Mozambique, enrolling pregnant women aged 12-49 years between Nov 1, 2014, and Feb 28, 2017. 69 330 pregnant women were enrolled in 44 clusters (36 008 in the 22 intervention clusters and 33 322 in the 22 control clusters). In this secondary analysis of maternal deaths in CLIP, we included women who died in any of the 22 intervention clusters or 22 control clusters. Trained staff administered the WHO 2012 verbal autopsy after maternal deaths. Two physicians (and a third for consensus, if needed) reviewed trial surveillance data and verbal autopsies, and, in intervention clusters, community health worker-led visit data. They determined cause of death according to the WHO International Classification of Diseases-Maternal Mortality (ICD-MM). Verbal autopsies were also analysed by InterVA computer models (versions 4 and 5) to generate cause of death. COMCAT analysis was provided by InterVA-5 and, in India, by physician review of Maternal Newborn Health Registry data. Causes of death and COMCATs assigned by physician review, Inter-VA-4, and InterVA-5 were compared, with agreement assessed with Cohen's κ coefficient. Findings Of 61 988 pregnancies with successful follow-up in the CLIP trials, 143 maternal deaths were reported (16 deaths in India, 105 in Pakistan, and 22 in Mozambique). The maternal death rate was 231 (95% CI 193-268) per 100 000 identified pregnancies. Most deaths were attributed to direct maternal causes (rather than indirect or undetermined causes as per ICD-MM classification), with fair to good agreement between physician review and InterVA-4 (κ=0·56 [95% CI 0·43-0·66]) or InterVA-5 (κ=0·44 [0·30-0·57]), and InterVA-4 and InterVA-5 (κ=0·72 [0·60-0·84]). The top three causes of death were the same by physician review, InterVA-4, and InterVA-5 (ICD-MM categories obstetric haemorrhage, non-obstetric complications, and hypertensive disorders); however, attribution of individual patient deaths to obstetric haemorrhage varied more between methods (physician review, 38 [27%] deaths; InterVA-4, 69 [48%] deaths; and InterVA-5, 82 [57%] deaths), than did attribution to non-obstetric causes (physician review, 39 [27%] deaths; InterVA-4, 37 [26%] deaths; and InterVA-5, 28 [20%] deaths) or hypertensive disorders (physician review, 23 [16%] deaths; InterVA-4, 25 [17%] deaths; and InterVA-5, 24 [17%] deaths). Agreement for all nine ICD-MM categories was fair for physician review versus InterVA-4 (κ=0·48 [0·38-0·58]), poor for physician review versus InterVA-5 (κ=0·36 [0·27-0·46]), and good for InterVA-4 versus InterVA-5 (κ=0·69 [0·59-0·79]). The most commonly assigned COMCATs by InterVA-5 were emergencies (68 [48%] of 143 deaths) and health systems (62 [43%] deaths), and by physician review (India only) were health systems (seven [44%] of 16 deaths) and inevitability (five [31%] deaths); agreement between InterVA-5 and physician review (India data only) was poor (κ=0·04 [0·00-0·15]). Interpretation Our findings indicate that InterVA-5 is less accurate than InterVA-4 at ascertaining causes and circumstances of maternal death, when compared with physician review. Our results suggest a need to improve the next iteration of InterVA, and for researchers and clinicians to preferentially use InterVA-4 when recording maternal deaths. Funding University of British Columbia (grantee of the Bill & Melinda Gates Foundation).

Background The implementation of trauma registries has proven a highly effective means of injury control. However, many low and middle-income countries lack trauma registries. Those that have trauma registries vary widely in terms of both implementation and structure. We sought to identify the most common barriers that stand in the way of sustainable trauma registry implementation, and the types of strategies that have proven successful in overcoming these barriers. Methods We conducted a questionnaire of trauma registry stewards and researchers in LMICs. Results Twenty-two individuals responded to the questionnaire representing trauma registry experiences across thirteen LMICs. The most common barriers to trauma registry implementation identified included staffing, funding, and stakeholder engagement. Many different strategies for addressing these barriers were discussed. Those mentioned by multiple respondents included the need for a trauma registry champion, fostering strong stakeholder relationships, and improving efficiency of data collection. Conclusions Though trauma registry implementation and structure may differ from place to place, there are many shared barriers and facilitators that can be learned from. Identifying these common experiences can help create a repository of knowledge that can better serve those looking to implement their own trauma registries in similar settings.