A preprint of our work on multiple-cause mortality is now available.

Peters, P. A.; Klym, M.; Lopez Barrios, M.; McGaughey, T. Cause-Related Mortality in Canada by Income Quintile: Examining the Impact of Multiple Causes before and after the COVID-19 Pandemic. Preprints 2024, 2024092342.

Abstract

Mortality rates are fundamental to understanding the overall health of a population. However, statistics are usually reported using the primary underlying cause of death, overlooking potentially relevant contributing causes listed on death certificates. This paper presents indicators for multiple cause-related mortality in Canada from 2000 – 2022. Deaths from the Canadian Vital Statistics Database (2000 – 2022) were merged with multiple cause files and classified into 136 cause of death groupings. Summary statistics for multiple causes were calculated, including the Standardized Ratio of Multiple to Underlying (SRMU), which is also calculated by neighbourhood income quintile. Age-Standardized Mortality Rates (ASMR) were calculated for the underlying cause of death (ASMRUC) and compared to rates including any mention of each respective cause (ASMRAM). These were then compared to ASMRs based on a contributing-cause weighting scheme (ASMRW). The average number of causes reported on death certificates has increased from 2.79 in 2002 to 3.19 in 2021. Those in the lowest income quintiles have a higher average number of causes (3.31 in 2021) compared to those in the highest income quintile (3.09 in 2021). When employing multiple cause weighting strategies, the rank order of age-standardized mortality rates is significantly elevated for conditions including renal failure, hypertension, pneumonia, septicemia, arterial fibrillation, and artery diseases. Multiple cause-of-death approaches provide further insight into the patterns of mortality and highlight conditions that become leading causes using weighted approaches. This provides evidence to support efforts to address these conditions. There are also differences in multiple causes of death reporting by income quintile which warrants further investigation.

Keywords

multiple causes of death; comorbidity; mortality; mortality determinants; COVID-19; chronic diseases; population health; demography

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Presentation to Central OHT Collaborative June 13, 2024.

The link between communities, places, and health is well-established in the scientific and public health literature. Differences in the characteristics of places can help explain differences in health inequalities. Place-based analysis offers a lends to better understand the health needs of local communities, evaluate gaps in health service accessibility, and show where opportunities to intervene exist. Access to care should not be determined by where people live.

As part of our collaboration between the and ‘s , we presented to representatives of Ontario Health Teams from across the province. This work demonstrates a pilot project for our place-based geographic analysis of the factors influencing mammography screening at the local level, and builds on our prior collaborations.

The objective of this project was to see how geoanalytic results can be used in health system planning and point-of-care, with the goal of improving the health of local populations. For this project, the mammography screening use-case makes use of existing data that can be integrated with local-level data on social determinants and health accessibility. Building from our prior work with geographically weighted regression, this project facilitated the creation of an interactive geospatial visualization tool to provide OHTs a resource for developing upstream engagement strategies.

The project demonstrated how a data-centred, place-based approach enhances understanding of an OHT’s attributable population.

The mammography screening interactive tool is .

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Dissanayake A, Dupuis A, Burton CL, Soreni N, Peters PA, Gajaria A, Arnold P, Crosbie J, & R Schachar. (2024) “Racial/Ethnic Disparities in Youth Mental Health Traits and Diagnoses within a Community-based Sample.” Canadian Journal of Psychiatry. .

Abstract

Objective

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Sheppard-Perkins M, McGaughey T, Peters PA & F Darroch. (2024) “Exploring the Use of Geographic Methods to Understand Sexual- and Gender-based Violence: A Scoping Review.” Gender, Place & Culture. .

This research was led by Dr. Francine Darroch of the Health and Wellness Equity Research Group.

Abstract

Geographic methods of inquiry are being increasingly employed to discern and visualize geographical patterns associated with increased risk of sexual- and gender-based violence (SGBV). As such, this scoping review systematically collated academic literature and subsequently synthesised (1) the time trend of studies employing geographic methods to understand SGBV, (2) the context in which geographic methods are being used to understand SGBV (i.e. objectives), (3) study characteristics, and (4) the methods and data sources used. A total of six databases were searched: Gender Studies, PsychINFO, Scopus, PudMed, Cochrane, and Campbell. Following title-abstract (n = 3354) and full-text screening (n = 159), 42 studies met data extraction criteria. From our review, there is clear momentum in the use of geographic methods to understand trends in SGBV. The majority of studies stated objectives aligning with assessing risk of SGBV (n = 35, 83.3%), while the remaining aimed to assess SGBV service availability. As research expands, there is notable focus on urban and suburban areas and a dominant dependence on institutional data sources (e.g. hospitals and police data), which hold certain caveats when it comes to structural barriers to SGBV data collection, such as fear of reporting and historic distrust in institutional services. Dovetailing the employment of big data sources with community-facilitated SGBV data collection methods may be a promising avenue for neighbourhood-specific efforts to inform policy and practice.

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Health Service Implementation and Antifragile Characteristics: A Dirt Research Approach

Petrie S & PA Peters. (2023) “Health Service Implementation and Antifragile Characteristics in Rural Communities: A Dirt Research Approach.” International Journal of Environmental Research and Public Health. 20(14): 6418.

Abstract

The implementation of health and care services within rural communities requires necessary sensitivity to the unique facets of rural places. Often, rural service implementation is executed with inappropriate frameworks based on assumptions derived from urban centres. To understand the characteristics of rural communities that can facilitate successful program implementation better, ethnographic accounts of rural health and care services were compiled in rural communities within Canada, Australia, and Iceland. Ethnographic accounts are presented in the first and third person, with an accompanying reflexive analysis immediately following these accounts. Antifragility was the guiding concept of interest when investigating rural implementation environments, a concept that posits that a system can gain stability from uncertainty rather than lose integrity. These ethnographic accounts provide evidence of antifragile operators such as optionality, hybrid leadership, starting small, nonlinear evaluation, and avoiding suboptimisation. It is shown that the integration of these antifragile operators allows programs to function better in complex rural systems. Further, the presence of capable individuals with sufficient knowledge in several disciplines and with depth in a single discipline allows for innovative local thinking initiatives.

Keywords: rural health; health services; ethnography; electronic health; place-based health; antifragility

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Addressing Health Inequities and Enhancing Population Health Management Strategies Through GeoAnalytics

The link between communities, places, and health is well established in the scientific and public health literature, and differences in the characteristics of places can help explain differences in health inequalities. Place-based analysis, as illustrated in this project, offers a lens to better understand the health needs of local communities, evaluate gaps in health service accessibility, and show where opportunities to intervene exist.

The Ontario health system has become more locally oriented with the introduction of , providing a vital link between health policy makers, health service providers, and local communities. OHTs are sources of expertise in data collection, analysis, and evidence-based approaches to improve population health and health equity. As such, there is tremendous potential for these organizations to conduct analyses that are relevant and impactful for local health services and health outcomes.

This project reviewed the potential role of geoanalytics for Ontario Health Teams via an examination of place-based analytic approaches at the local level, examination of use-case scenarios for emergency department visits and mammography screening, and an evaluation of the potential for geoanalytics within a population health framework.

Importantly, we are concerned here with how the analytic results can be used in health system planning and point-of-care, with the goal of improving the health of local populations. For this project, use-cases have been selected to make use of existing data available to and for those that can lead to impactful interventions and upstream engagement strategies in the short-term.

The final evaluation further discusses the potential for spread and scale of the analytic frameworks, data systems, and tools at the Provincial level. Looking towards future digital infrastructure, a geoanalytics approach has strong potential to integrate with existing health data systems and provide a much-needed link between often-inaccessible health administrative data and locally relevant population statistics.

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GeoAnalytics Project Evaluation

ArcGIS StoryMap

– this StoryMap presents the geoanalytic results for the emergency department and mammography screening use-case scenarios. This StoryMap was created as part of the Rural R:ISK project funded by the Social Sciences and Humanities Research Councile (SSHRC).

Health geoanalytics can support public health organizations such as OHTs in making informed decisions, optimizing resource allocation, and improving the efficiency of their operations. This may lead to cost savings by reducing waste, targeting interventions effectively, and improving overall health outcomes in the population.

Infographics of Health Indicators for Southlake Community OHT

Steering Committee Members

This project was guided with the expert input from a steering committee and contributing stakeholders.

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ShelterCare: The Integration of Health and Housing Services as an Evidence-Based Shelter Model

Ayshia Baile, April 23, 2023

Homelessness is a multifaceted issue which is incredibly prevalent across Canada. It was estimated in 2016 that at least 35 000 individuals experience homelessness on any given night, with more than 235 000 Canadians every year (Gaetz et al., 2016). This estimate does not include ‘hidden homelessness’ which is thought to be up to 50,000 people per night nationwide encompassing those who do not have permanent housing and temporarily stay with friends, relatives, in their vehicles, or other undocumented spaces, avoiding unsheltered homelessness (Gaetz et al., 2013). Due to the Covid-19 pandemic, routine homelessness enumerations have been delayed, although studies have projected a rising incidence in homelessness since the onset of the pandemic with estimated continued growth considering the impeding recession if no effective interventions are implemented (Falvo, 2020). This issue runs deeper than lack of stable housing as there are many social, economic, and systemic barriers faced by individuals who experience homelessness, making it a complex problem which requires comprehensive solutions. Of utmost concern, are the severe health impacts of poor housing and homelessness. Homeless populations have been described in literature as being vulnerable to the ‘tri-morbidity’ of social marginalization being mental illness, addiction, and physical illness highlighting the main health risks associated with homelessness (Gicas et al., 2020). Lack of stable housing decreases overall quality of life, exacerbates chronic health conditions and medical complications, and presents significant barriers to health access which negatively impacts individuals who experience homelessness and public healthcare systems. Homelessness requires immediate interventions and should be a priority for all governing bodies in Canada but, as housing is a key social determinant of health, it should be a critical priority for health and healthcare decision makers. With the multitude of proposed models and pilot projects being conducted to address health inequities afflicting the homeless population, which solutions have promising measurable benefits and should be prioritized by health policymakers?

ShelterCare is a housing intervention that was originally thought to be a utopian model for ending chronic homelessness but was given the opportunity to demonstrate its potential as an incredibly impactful evidence-based intervention due to the COVID-19 pandemic. These pilot projects have exemplified the need for the program to address systemic barriers to housing for homeless populations and drastically improve the health of marginalized individuals. Demonstrating similar positive outcomes to other evidence-based housing interventions like Housing First, but while considering the state of housing and escalating opioid crisis, this model can fill significant gaps and better support individuals who have experienced chronic homelessness to secure and maintain permanent housing.

This paper reviews current housing and shelter interventions and evaluate the overall improvements to health and quality of life of the homeless population. Based on currently piloted housing initiatives and comparing to previously explored solutions, the ShelterCare model will be reviewed in-depth for its impact on health. The perspectives and impact of key stakeholders will be considered including municipal and provincial governing bodies, regional public health, hospital, and community health officials, related non-profit and community advocacy leaders, social services sector, and clients themselves, as cross-sector collaboration is required to effectively implement this intervention. An approach to engaging with these stakeholders as well as a model for continuous evaluation of its impacts will be outlined, highlighting the gaps this service would fill and how it could be implemented effectively.

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ShelterCare Final Paper

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Characteristics of High-Resource Health System Users in Rural and Remote Regions: A Scoping Review

LeBlanc M, McGaughey T, & PA Peters. (2023) “Characteristics of High-Resource Health System Users in Rural and Remote Regions: A Scoping Review.” International Journal of Environmental Research and Public Health. 20(7): 5385. .

Abstract

A small proportion of health care users are recognized to use a significantly higher proportion of health system resources, largely due to systemic, inequitable access and disproportionate health burdens. These high-resource health system users are routinely characterized as older, with multiple comorbidities, and reduced access to adequate health care. Geographic trends also emerge, with more rural and isolated regions demonstrating higher rates of high-resource use than others. Despite known geographical discrepancies in health care access and outcomes, health policy and research initiatives remain focused on urban population centers. To alleviate mounting health system pressure from high-resource users, their characteristics must be better understood within the context in which i arises. To examine this, a scoping review was conducted to provide an overview of characteristics of high-resource users in rural and remote communities in Canada and Australia. In total, 21 papers were included in the review. Using qualitative thematic coding, primary findings characterized rural high-resource users as those of an older age; with increased comorbid conditions and condition severity; lower socioeconomic status; and elevated risk behaviors.

Keywords: health care; rural health; healthcare inequalities; public health systems research; health care costs; health services research

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A National Epidemic with Severe Local Implications: A Global to Local Review of Substance Use to Analyze the State of Addictions in Rural Eastern Ontario

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A National Epidemic with Severe Local Implications

This research (summarized below) is also presented as an interactive ArcGIS Storymap available at the following link..

Substance Use in Canada

The dramatic rise in substance-use disorder prevalence across North America has become an urgent and escalating health issue in need of rapid intervention. In 2012, Statistics Canada conducted a study concluding that 6 million Canadians met the criteria for substance-use disorder, but even this value is thought to be an underestimate (1). It is likely this statistic has increased greatly since 2012 when considering the surging overdose crisis and significant increase in opioid-use, as well as opioid-related deaths in the past three years (2). In 2017, the cost of substance use was calculated to be $46 billion, a 5.4% increase since 2015, which factored for associated healthcare, lost productivity, criminal justice, and other direct costs (3). Substance use and addictions in Canada is therefore multifactorial, involving social, health, and economic implications.

Substance use and addiction is a global public health crisis that has rapidly escalated over the last decade. Substance use disorder is one of the most prevalent causes of morbidity and mortality internationally (4), with alcohol- and opioid-related harms being of most concern. The United States of America and Canada have historically had the highest prevalence of opioid drug use mostly due to the availability of such drugs when compared to less developed countries and have both seen an even greater increase in use since the emergence of Covid-19. Of greatest concern, is the spike in opioid deaths which has also more than doubled since 2010 (5). Canada and the United States have the highest rates of prescribed opioids worldwide, and although the US sees considerably more opioid-related deaths, per capita opioid use, and alcohol-attributed health deficits, recent data shows Canada is paralleling increases in these areas which is a cause of great concern (6). Continuing health professions education programs have begun to gain a hold on prescription opioids and their potentially harmful effects, but there has been a major increase in non-pharmaceutical opioid use across Canada which accounted for 90% of apparent opioid deaths from January to June 2021 (7).

The life expectancy of Canada has levelled for the first time since World War II, with one of the main contributors being opioid-related deaths. This negative trend was first observed in British Columbia, which has been in a declared public health emergency since 2016 due to significant opioid-related deaths, but life expectancy has since begun to plateau for all of Canada. Most deaths seen in the past five years have been males between the ages of 20-49, which therefore has a significant impact on life expectancy, with alcohol and drug use identified as the most important risk factor among young adults (7).

Alcohol and opioid use are currently a major focus for substance use disorder harms, as these sectors have seen the greatest increase in associated harms and affect the most individuals, although it should be noted that an increase in stimulant use as well as polysubstance use has been observed in the past few years. Substantially less mortality is seen with these substances, and toxic supply is less of a concern, but many of the initiatives and treatment options addressing the opioid crisis can also benefit those impacted by stimulant addiction and polysubstance use. Other addiction disorders such as gambling can also have detrimental effects on overall health and wellbeing of Canadians, but this report will have a greater focus on drug addiction and substance use disorder, specifically regarding opioid use, as it is an incredibly urgent public health crisis causing the death of thousands and therefore requires immediate intervention.

Our interactive ArcGIS Storymap provides further analysis of this epidemic for rural Eastern Ontario, highlighting both the harms and the services available in this region.

Link to the complete Storymap: .

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What a Pandemic Has Taught Us �Ӱ�ԭ�� the Potential for Innovation in Rural Health: Commencing an Ethnography in Canada, the United States, Sweden, and Australia

Petrie S, Carson D, Peters PA, Hurtig A-K, LeBlanc M, Simpson H, Barnabe J, Young M, Ostafichuk M, Hodge H, Glademan J, Smale M, & M Gonzalez Garcia. (2021) “What a Pandemic Has Taught Us �Ӱ�ԭ�� the Potential for Innovation in Rural Health: Commencing an Ethnography in Canada, the United States, Sweden, and Australia.” Frontiers in Public Health. 9: 768624 .

Abstract

The COVID-19 pandemic coincided with a multi-national federally funded research project examining the potential for health and care services in small rural areas to identify and implement innovations in service delivery. The project has a strong focus on electronic health (eHealth) but covers other areas of innovation as well. The project has been designed as an ethnography to prelude a realist evaluation, asking the question under what conditions can local health and care services take responsibility for designing and implementing new service models that meet local needs? The project had already engaged with several health care practitioners and research students based in Canada, Sweden, Australia, and the United States. Our attention is particularly on rural communities with fewer than 5,000 residents and which are relatively isolated from larger service centres. Between March and September 2020, the project team undertook ethnographic and auto-ethnographic research in their own communities to investigate what the service model responses to the pandemic were, and the extent to which local service managers were able to customize their responses to suit the needs of their communities. An initial program theory drawn from the extant literature suggested that “successful” response to the pandemic would depend on a level of local autonomy, “absorptive capacity,*” strong service-community connections, an “anti-fragile†” approach to implementing change, and a realistic recognition of the historical barriers to implementing eHealth and other innovations in these types of rural communities. The field research in 2020 has refined the theory by focusing even more attention on absorptive capacity and community connections, and by suggesting that some level of ignorance of the barriers to innovation may be beneficial. The research also emphasized the role and power of external actors to the community which had not been well-explored in the literature. This paper will summarize both what the field research revealed about the capacity to respond well to the COVID-19 challenge and highlight the gaps in innovative strategies at a managerial level required for rapid response to system stress.

*Absorptive Capacity is defined as the ability of an organization (community, clinic, hospital) to adapt to change. Organizations with flexible capacity can incorporate change in a productive fashion, while those with rigid capacity take longer to adapt, and may do so inappropriately.

†Antifragility is defined as an entities’ ability to gain stability through stress. Biological examples include building muscle through consistent use, and bones becoming stronger through subtle stress. Antifragility has been used as a guiding principle in programme implementation in the past.

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