Canadian Urban Research Articles

Associations between long-term exposures to environmental factors and the development of amyotrophic lateral sclerosis: A matched case-control study

ObjectiveAmyotrophic lateral sclerosis (ALS) is a motor neuron disease in which the causes remain unclear, particularly the contribution of environmental factors. Thus, we created a multifactorial database to investigate the association between long-term exposure to urbanization, air pollution, water pollution, and the development of ALS. ApproachA matched case-control study was conducted in New Brunswick, Canada from January 2003 to February 2021. Study population included 304 ALS patients and 1207 controls with their historical postal codes from the New Brunswick Citizen Database linked to medical records and spatial environmental datasets from the Canadian Urban Environmental Heath Research Consortium. We compared their environmental exposures at place of residence prior to disease onset via conditional logistic regression models. ResultsOf the common air pollutants investigated, odds of ALS was significantly higher with increased SO2 exposure (OR = 4.369, 1.190-16.044 [95% CI], per 1 ppb increase of SO2) in adjusted models. No significant associations were observed for the investigated urbanization and water pollution-related exposures. ConclusionsThis is the first study to rigorously identify a potential environmental cause of ALS. Our findings suggest an association between long-term exposure to air pollutants, particularly SO2, and the development of ALS. Revision of SO2 emission regulations may be required. ImplicationsThe identification of SO2 exposure as an ALS environmental risk factor opens new prospects for identifying ALS therapeutic targets. Utilizing a similar data linking workflow to pre-existing disease registries found within data centres should be conducted to further investigate environmental influences on complex diseases.

Evaluation of weather and environmental factors and their association with cutaneous melanoma incidence: A national ecological study

BackgroundCutaneous melanoma (CM) is a significant contributor to skin cancer-related mortality globally and in Canada. Despite the well-established link between ultraviolet (UV) radiation exposure and skin cancer risk, there remains a gap in population-level interventions and persistent misconceptions about sun exposure and impact of environment on individual behavior. ObjectiveThe current study provides an ecological analysis using latest available data (2011-2017) to define geographic/environmental contributors to the CM landscape in Canada. MethodsUtilizing Canadian Cancer Registry (CCR) and Canadian Urban Environmental Health Research Consortium (CANUE) data, we analyzed 39,605 CM cases occurring in Canada from 2011-2017. Environmental data, including UV radiation, greenspace (NDVI), temperature, heat events, and precipitation was used to evaluate the effect of environment on CM incidence rates across Forward Sortation Area (FSA) postal codes. ResultsFSAs with increased CM incidence were associated with higher annual average temperature, snowfall, heat events, NDVI, and vitamin D-weighted UV exposure. Conversely, factors associated with decreased incidence included an increased annual highest temperature, rain precipitation, and a longer duration of heat events. LimitationsThis study is subject to ecological bias and findings should be interpreted with caution ConclusionThis study further substantiates associations between specific environmental factors and CM incidence.

Associations of neighborhood greenspace, and active living environments with autism spectrum disorders: A matched case-control study in Ontario, Canada

BackgroundIncreasing evidence links early life residential exposure to natural urban environmental attributes and positive health outcomes in children. However, few studies have focused on their protective effects on the risk of autism spectrum disorder (ASD). The aim of this study was to investigate the associations of neighborhood greenspace, and active living environments during pregnancy with ASD in young children (≤6 years). MethodsWe conducted a population-based matched case-control study of singleton term births in Ontario, Canada for 2012–2016. The ASD and environmental data was generated using the Ontario Autism Spectrum Profile, the Better Outcomes Registry & Network Ontario, and Canadian Urban Environmental Health Research Consortium. We employed conditional logistic regressions to estimate the odds ratio (OR) between ASD and environmental factors characterizing selected greenspace metrics and neighborhoods conducive to active living (i.e., green view index (GVI), normalized difference vegetation index (NDVI), tree canopy, park proximity and active living environments index (ALE)). ResultsWe linked 8643 mother-child pairs, including 1554 cases (18%). NDVI (OR 1.034, 0.944–1.024, per Inter Quartile Range [IQR] = 0.08), GVI (OR 1.025, 95% CI 0.953–1.087, per IQR = 9.45%), tree canopy (OR 0.992, 95% CI 0.903–1.089, per IQR = 6.24%) and the different categories of ALE were not associated with ASD in adjusted models for air pollution. In contrast, living closer to a park was protective (OR 0.888, 0.833–0.948, per 0.06 increase in park proximity index), when adjusted for air pollution. ConclusionsThis study reported mixed findings showing both null and beneficial effects of green spaces and active living environments on ASD. Further investigations are warranted to elucidate the role of exposure to greenspaces and active living environments on the development of ASD.

Environmental Injustice in Peel Region: A Cross-Sectional Analysis of Air Pollution and Social Vulnerability

Background: Nitrogen dioxide (NO2), a traffic-related air pollutant, is co-emitted with greenhouse gasses that contribute to climate change and negatively affect health. This research examines the relationship between air pollution exposure and social vulnerability to determine whether communities at a social disadvantage experience environmental injustice. Methods: The 2016 census measures for Peel Region were assessed. Peel Region has 1,381,739 people across Mississauga, Brampton, and Caledon; the spatial unit of analysis was the dissemination area (DA) with an average size of 837 people in Peel. Average ambient NO2 concentrations for 2016 came from the Canadian Urban Environmental Health Research Consortium and resampled to DAs. Social disadvantage was defined by the Ontario Marginalization Index (ON-Marg). Measures within index components came from the Canadian census. Environmental injustice was identified through correlation analysis between ON-Marg and NO2 exposure and an analysis of index components with exposure. Results: The 2016 annual NO2 concentrations were positively correlated with the overall ON-Marg quintiles (Spearman: 0.34, p < .001, 95% CI 0.29 to 0.37). The components and their correlations with NO2 were residential instability (Spearman: 0.37, p < .001, 95% CI 0.33 to 0.42), material deprivation (Spearman: 0.15, p < .001, 95% CI 0.10 to 0.19), dependency (Spearman: 0.31, p < .001, 95% CI 0.26 to 0.35), and ethnic concentration (Spearman: −0.06, p = .02, 95% CI −0.11 to −0.01). Conclusions: In Peel Region, a correlation exists between social vulnerability and air pollution, indicating inequitable exposure to NO2. Marginalized communities may not be able to choose their living environment. Environmental justice research in the context of NO2 will support policy aiming to reduce inequitable exposure.

Tree-Based Machine Learning to Identify Predictors of Psoriasis Incidence at the Neighborhood Level: A Populational Study from Quebec, Canada.

Psoriasis is a major global health burden affecting ~ 60 million people worldwide. Existing studies on psoriasis focused on individual-level health behaviors (e.g. diet, alcohol consumption, smoking, exercise) and characteristics as drivers of psoriasis risk. However, it is increasingly recognized that health behavior arises in the context of larger social, cultural, economic and environmental determinants of health. We aimed to identify the top risk factors that significantly impact the incidence of psoriasis at the neighborhood level using populational data from the province of Quebec (Canada) and advanced tree-based machine learning (ML) techniques. Adult psoriasis patients were identified using International Classification of Disease (ICD)-9/10 codes from Quebec (Canada) populational databases for years 1997-2015. Data on environmental and socioeconomic factors 1year prior to psoriasis onset were obtained from the Canadian Urban Environment Health Consortium (CANUE) and Statistics Canada (StatCan) and were input as predictors into the gradient boosting ML. Model performance was evaluated using the area under the curve (AUC). Parsimonious models and partial dependence plots were determined to assess directionality of the relationship. The incidence of psoriasis varied geographically from 1.6 to 325.6/100,000 person-years in Quebec. The parsimonious model (top 9 predictors) had an AUC of 0.77 to predict high psoriasis incidence. Amongst top predictors, ultraviolet (UV) radiation, maximum daily temperature, proportion of females, soil moisture, urbanization, and distance to expressways had a negative association with psoriasis incidence. Nighttime light brightness had a positive association, whereas social and material deprivation indices suggested a higher psoriasis incidence in the middle socioeconomic class neighborhoods. This is the first study to highlight highly variable psoriasis incidence rates on a jurisdictional level and suggests that living environment, notably climate, vegetation, urbanization and neighborhood socioeconomic characteristics may have an association with psoriasis incidence.

The Curtis Report as a critical juncture in Canadian urbanism

ABSTRACT Canada's post-Second World War policies on urbanism were first outlined in an obscure government document – the 1944 report of the Subcommittee on Housing and Community Planning of the federal government's Advisory Committee on Reconstruction (known colloquially as the ‘Curtis Report’). This article uses the tools of Historical Institutionalism and extensive archival research to analyse the Curtis Report. It examines antecedent conditions in the Depression and war; permissive conditions during the wartime housing crisis; the actors and choice of options at the critical juncture; the reactions during implementation and the path-dependent municipal planning and suburbanization outcomes of the report. The Curtis Report is identified as a critical juncture for major changes in housing and community planning that set Canada on a different course than the UK or the USA.

Advancing Population Health Through Open Environmental Data Platforms.

Data stand as the foundation for studying, evaluating, and addressing the multifaceted challenges within environmental health research. This chapter highlights the contributions of the Canadian Urban Environmental Health Research Consortium (CANUE) in generating and democratizing access to environmental exposure data across Canada. Through a consortium-driven approach, CANUE standardizes a variety of datasets - including air quality, greenness, neighborhood characteristics, and weather and climatic factors - into a centralized, analysis-ready, postal code-indexed database. CANUE's mandate extends beyond data integration, encompassing the design and development of environmental health-related web applications, facilitating the linkage of data to a wide range of health databases and sociodemographic data, and providing educational training and events such as webinars, summits, and workshops. The operational and technical aspects of CANUE are explored in this chapter, detailing its human resources, data sources, computational infrastructure, and data management practices. These efforts collectively enhance research capabilities and public awareness, fostering strategic collaboration and generating actionable insights that promote physical and mental health and well-being.

Toronto Outreach & The Dehumanization of Black People: Exploring Barth-Cone Theologies in a Canadian Urban Context

ABSTRACT The pastor of a church hosting a food bank, reflects on how context affects the similarities and dissimilarities of Karl Barth's and James H. Cone's theologies. This is done in order to gain a theological understanding of the propensity of dehumanization in Toronto, Canada. Both Barth and Cone expected theology to be the work of the Church; although in divergent ways, they both considered God's self-revelation in Christ to be the sign of God claiming humans as beloved. This comparative analysis requires theological and critical thinking on racism. While juxtaposing the Barth-Cone contexts and resulting theologies with the challenges of Black Canadians, one can appoint theological understanding to any church's mission and outreach that serves the marginalized.

The contributions of neighbourhood design in promoting metabolic health

The design and quality of the neighbourhood built environment can encourage health-supportive behaviours and support cardiometabolic health. However, despite the relationships between demographic and behavioural risk factors of metabolic syndrome being investigated by many studies, only some studies have directly estimated the associations between the built environment and metabolic syndrome. Using data from Canada, we examined the associations between the neighbourhood built environment and metabolic syndrome. Data from Alberta’s Tomorrow Project participants, conducted in Alberta, Canada, was used (n = 6718). Metabolic syndrome was defined as the presence of at least three clinical risk factors among lipid levels, blood pressure, and waist circumference. The normalised difference vegetation index was used to quantify the greenness of each participant’s neighbourhood. Built attributes of participants’ neighbourhoods associated with supporting physical activity, including dwelling density, intersection density, and the number of points of interest, were obtained via the Canadian Urban Environmental Health Research Consortium. Increases in the number of points of interest and total active living environment-friendliness of the neighbourhood were associated with having fewer metabolic syndrome risk factors (b = −0.11, 95% CI −0.16, −0.07 and b = −0.03, 95% CI −0.05, −0.01, respectively) and lower odds of metabolic syndrome (OR = 0.89, 95% CI 0.84, 0.094 and OR = 0.97, 95% CI 0.95, 0.99, respectively). Furthermore, higher dwelling density was associated with having fewer metabolic syndrome risk factors (b = −0.05, 95% CI −0.09, −0.01). Our findings highlight the importance of urban design to prevent and potentially manage metabolic syndrome and improve population health.

Third-Party Tracking in Online Public Library Environments in the United States and Canada: A Statistical Analysis

A Review of:Gardner, G. J. (2021). Aiding and abetting: Third-party tracking and (in)secure connections in public libraries. The Serials Librarian, 81(1), 69–87. https://doi.org/10.1080/0361526X.2021.1943105 Objective – To determine through statistical data collection the frequency of tracking by third parties in online public library environments along with the visibility and ease of discovery of online library policies and disclosures related to third-party tracking in particular and data privacy in general. Design – Online evaluation of public library websites. Setting – English-language public libraries in the United States and Canada. Subjects – 178 public library websites (133 in the United States and 45 in Canada). The libraries included in the study were intentionally selected for their membership in either the Canadian Urban Libraries Council (CULC) or the Urban Libraries Council (ULC) in the Unites States, since these libraries have some of the largest systems membership serving predominantly urban and suburban communities in both countries. The included Canadian libraries serve nearly 41% of the population in that country while the included libraries in the United States are positioned to serve 28% percent of the total population. The author notes that “These percentage figures serve as hypothetical, upper-bound estimates of the population affected by third-party tracking since not every member of these communities actually uses their local public library” (Gardner, 2021, p.72). Methods – In addition to evaluating the public library catalog and website in general with regards to third-party tracking and data privacy, 10 common content sources (databases) available at all of the included libraries were also included in the examination. Two browser add-ons designed to detect third-party tracking, Ghostery and Disconnect, were used in the study due to their popularity and incorporation into previous similar studies. In addition to third-party tracking the author executed word searches on library homepages using Ctrl-F for words commonly used to denote privacy or terms of use statements. No qualitative analysis was performed to determine if information shared regarding third-party tracking was accurate, and subpages were not examined. The data collection period lasted a total of three months beginning in March 2017 and running through May 2017. Main Results – The data gathered between March and May of 2017 clearly indicates a general disregard among most sampled public libraries regarding the protection of patron data gathered by third-party tracking. Of Canadian libraries included in the sample 89% (40) enabled third-party tracking, while libraries in the United States allowed it at a rate of 87% (116). Both Ghostery and Disconnect revealed an almost identical number of incidences of third-party tracking in library catalogs and in the 10 popular public library databases examined in the study. Certain OPACS were associated with higher tracking counts as were certain library databases. Libraries were found to be lax when it came to providing a link on the homepage potentially informing users of the presence of third-party tracking. Of the 156 total libraries with third-party tracking in their online catalogs, 69 (44%) included a homepage link while the rest did not. The author notes that the presence of a link was all that was examined, and not specific language used to disclose the level of third-party tracking or data privacy. In total, 8 of the 10 common content sources allowed third-party tracking. All 10 provided a link to either privacy or terms of service statements on their landing pages. Conclusion – Although patron privacy is an issue addressed in the American Library Association (ALA) Code of Ethics (American Library Association, 2021), the author concludes that “Together with previous research on usage of privacy-enhancing tools in public libraries, these results suggest that public libraries are accessories to third-party tracking on a large scale” (Gardner, 2021, p.69).

Association between annual exposure to air pollution and systolic blood pressure among adolescents in Montréal, Canada

In adults, chronic exposure to air pollution is associated with elevated blood pressure, but few studies have examined this relationship in youth. We investigated the association between annual ambient concentrations of air pollutants (fine particulate matter [PM2.5] and nitrogen dioxide [NO2]) and systolic blood pressure (SBP) among adolescents in Montréal, Canada. Participants were students aged 15 to 17 years who provided SBP and residential postal code data in 2004/05 through their enrolment in the Nicotine Dependence in Teens study. Annual estimates for 2004 of residential exposure to NO2 and PM2.5 were provided by the Canadian Urban Environmental Health Research Consortium and linked to participants' residential postal code. Elevated SBP was defined as SBP ≥ 90th percentile adjusted for age, sex and height. Logistic regression was used to estimate odds ratios and 95% confidence intervals (CIs) for each pollutant with respect to elevated SBP, adjusted for relevant confounders. The sample consisted of 508 adolescents (mean age: 16.9, 46% male); 4% had elevated SBP. Although estimates were not statistically significant, there were generally modest positive associations between pollutant levels and SBP. The adjusted prevalence odds ratio of elevated SBP was 1.33 (95% CI: 0.64, 3.05) for every interquartile range (IQR) increase in residential PM2.5 levels (2.1μg/m3). Similarly, the adjusted prevalence odds ratio of elevated SBP was 1.17 (95% CI: 0.47, 2.70) for every IQR increase in residential NO2 levels (10.2 ppb). Findings support a possible relationship between exposure to air pollutants and increased SBP in adolescents, warranting further investigation for this important public health concern.

Impact of Neighborhood Deprivation on Aging Sexual Minority People's Depression: Results from the CANUE and CLSA data

As the aging population grows across the world, exploring the impact of social environment on minority populations’ aging and well-being would be an essential step towards building an inclusive society. Using the Canadian Longitudinal Study on Aging (CLSA) and Canadian Urban Environmental Health Research Consortium (CANUE) data, the study investigated the relationship between deprivation and depression level in aging sexual minority people to examine how neighborhood level social and material deprivation influence mental health. 48,792 survey respondents were included in our analyses and the average age was 62.9. The study had 47,792 heterosexual, 760 gay/lesbian, and 240 bisexual individuals (23,977 men and 24,815 women). Regression analyses were conducted while controlling for age in each model. Results revealed that neighborhood material deprivation has a significant impact on mental health outcomes of aging lesbian women and bisexual men. The study provides an opportunity for intervention considerations for materially deprived neighborhoods to serve the aging sexual minority people residing in such areas.

Air pollution and the onset of balance problems: The Canadian longitudinal study on aging.

To understand the relationship between ambient air pollution and the onset of balance problems. Population-based prospective cohort study. Baseline and 3-year follow-up data were used from the Canadian Longitudinal Study on Aging. The Comprehensive Cohort included adults aged 45-85 years old recruited from 11 sites across 7 provinces. Data on air pollution came from the Canadian Urban Environmental Health Research Consortium. Annual mean levels of ozone, fine particulate matter (PM2.5), and sulfur dioxide for each participant's postal code were estimated from satellite data. Balance was measured at both time points using the one-leg balance test with those who could not stand on one leg for at least 60s defined as failing the balance test. Our outcome was the new development of failing the balance test at follow-up in those who passed the balance test at baseline. Logistic regression was used. Of the 12,158 people who could stand for 60s on one leg at baseline, 18% were unable to do so 3 years later. In single pollutant models, living in an area with higher ozone levels was associated with the 3-year onset of balance problems (odds ratio (OR)=1.13 per interquartile range of ozone, 95% CI 1.02, 1.24) after adjustment for demographic, lifestyle, and health variables. In a multipollutant model, the association with ozone increased slightly (OR=1.16, 95% CI 1.04, 1.30). There were no associations with PM2.5 or sulfur dioxide. Our findings provide longitudinal evidence that higher ozone levels are associated with the odds of developing balance problems over a 3-year period. Further work should attempt to confirm our findings and explore the potential mechanism of action.

Multimorbidity in Large Canadian Urban Centres

Abstract Introduction Although health outcomes are related to the characteristics of the geographic areas in which people live, there is limited knowledge on how the prevalence of multimorbidity varies within and across major Canadian urban centres. Our goal was to assess the level of between-neighbourhood variation in the prevalence of multimorbidity in Canada's large urban centres, controlling for compositional effects associated with demographic and socioeconomic factors. Methods Cross-sectional data from the 2015-2018 cycles of the Canadian Community Health Survey (CCHS) were used. Respondents (20 years and older) residing in one of the 35 census metropolitan areas (CMAs) were included (N = 100,803). Census tracts (CTs), relatively small and stable geographic areas nested within CMAs, were used as a measure of neighbourhood. To assess the between-neighbourhood differences in multimorbidity prevalence, we fitted sequential random intercept logistic regression models. Results During the 2015-2018 period, 8.1% of residents of large urban centres in Canada had multimorbidity. The results from the unadjusted model indicate that 13.4% of the total variance in multimorbidity could be attributed to the between-neighbourhood differences. After adjustment for overall characteristics of the CMAs in which these neighbourhoods are located, as well as for individual-level demographic and socioeconomic factors related to compositional effects, 11.0% of the individual variance in multimorbidity could still be attributed to the between-neighbourhood differences. Discussion and Conclusions There is significant and substantial geographic variation in multimorbidity prevalence across neighbourhoods in Canada's large urban centres. Residing in some neighbourhoods could be associated with increased odds of having multimorbidity, even after accounting for overall characteristics of the CMAs in which these neighbourhoods are located, as well as individual-level factors.

A View from the South: Canadian Urban History in North American and Global Context

This essay reflects on the current state of the field in Canadian urban history compared to American urban history and in the context of emerging trends toward global urban history. It suggests that Canadian urban historians have been slower to engage with global frameworks than their counterparts in the United States and United Kingdom.

The Location of Canadian Urban History: Sex, Environment, Indigeneity

This article is a response to Richard Harris’s diagnosis that urban history in Canada is in a “parlous condition,” published as part of the 50th anniversary issue of the Urban History Review / Revue d’histoire urbaine. It reviews recent publications in the historical subfields of sex and sexuality, environment, and Indigeneity to reveal how, in fact, urban history in Canada is still thriving.

A comprehensive evaluation of built-environment as a risk factor for sleep disruption

Background/ Aim Sleep disruption is a significant public health issue, given its high prevalence and links to both injury and chronic disease. Interventions for improving sleep often focus on individual-level behaviour change. Modifying aspects of the built environment may be a strategy for population-level improvements. Few studies have evaluated the impacts of built environment on sleep. We assessed relationships between the built environment and sleep disruption using a well-characterized, population-based cohort. Methods Analyses were conducted among participants of the British Columbia Generations Project (BCGP) with complete data on built environment factors and self-reported sleep duration and quality(n=23,556). Measures of air pollution (PM₂.₅, NO₂), greenness (density within 250-metres) and intensity of light-at-night (LAN) were obtained from the Canadian Urban Environmental Research Consortium (CANUE), and linked to participants residential postal codes. Logistic regression analysis, adjusted for age and sex, was used to estimate the association between each built environment factor and self-reported sleep duration (<7 hours, ≥7 hours) and difficulty in falling or staying asleep (sometimes/most of the time/ always vs. rarely/never). Results Increased PM₂.₅ was associated with lower odds of insufficient sleep duration (OR=0.85/5µg/m³; 0.74-0.97) and greater odds of difficulty falling/staying asleep (OR 1.54/5µg/m³; 1.37-1.74). Increased LAN intensity was associated with greater odds of insufficient sleep (OR=1.04/10-unit; 1.02-1.07) but not with difficulty falling/staying asleep. Greenness exposure in the top quartile was associated with reduced odds of insufficient sleep (OR=0.92; 0.86-0.99) and difficulty staying/falling asleep (OR=0.97; 0.95-0.99) compared to those in the bottom quartile. Greenness, LAN and PM₂.₅ were moderately correlated (-0.5 < r < 0.5). Conclusions BCGP’s rich data enabled a comprehensive evaluation of the built-environment as a modifiable determinant of sleep disruption. Further analyses will elucidate the mediating effects of sleep on the links between built-environment and chronic disease. Keywords Sleep; Built Environment; Air Pollution; Greenness; Light pollution

Analysis of Geographic and Environmental Factors and Their Association with Cutaneous Melanoma Incidence in Canada

Background: Over 90% of skin cancers including cutaneous melanoma (CM) are related directly to sun exposure. Despite extensive knowledge on ultraviolet radiation’s (UVR) detrimental impact, many still fail to implement sun protection/sun avoidance. Human behavior, attitudes, and cultural norms of individuals and communities heavily depend on the surrounding climate/environment. In many instances, the climate shapes the culture/norms of the society. Canada has vast geographic/environmental differences. Methods: In the current ecological study, we sought to examine the relationship between various geographic and environmental factors and the distribution of CM incidence by Forward Sortation Area (FSA) postal code across Canada. CM incidence data were extracted from the Canadian Cancer Registry, while environmental data were extracted from the Canadian Urban Environmental Health Research Consortium (greenspace, as measured by the normalized difference vegetation index; annual highest temperature; absolute number and average length of yearly heat events; annual total precipitation [rain and snow]; absolute number and average length of events with precipitation [rain and snow]; and summer UVR index). The above geographic/environmental data by FSA were correlated with the respective CM incidence employing negative binomial regression model. Results: Our analysis highlights that increases in annual average temperature, summer UVR, and greenspace were associated with higher expected incidence of CM cases, while higher number of annual heat events together with highest annual temperature and higher average number of annual rain events were associated with a decrease in CM incidence rate. This study also highlights regional variation in environmental CM risk factors in Canada. Conclusions: This national population-based study presents clinically relevant conclusions on weather/geographic variations associated with CM incidence in Canada and will help refine targeted CM prevention campaigns by understanding unique weather/geographic variations in high-risk regions.

Decision Needs and Preferred Strategies for Shared Decision-Making in Rheumatoid Arthritis: Perspectives of Canadian Urban Indigenous Women.

ObjectiveDecision‐making for treatment of rheumatoid arthritis (RA) is complex, with multiple beneficial medication options available, but with the potential for treatment‐related adverse effects and significant economic considerations. Indigenous patients make treatment decisions informed by an interplay of clinical, family, and societal factors. Shared decision‐making may represent an approach to support treatment decisions in a culturally congruent manner. Our objective was to identify aspects of arthritis care that Indigenous participants found relevant for shared decision‐making and to explore preferences for shared decision‐making strategies.MethodsA purposive sampling from rheumatology clinics that provide services to Indigenous patients in a Canadian urban center was used to recruit participants for interviews. Seven participants were recruited to reach content saturation. Interview content was coded by 2 individuals, including an Indigenous patient with RA, and the data were analyzed via thematic analysis.ResultsParticipants were all women ages 37–61 years living with RA. Participants supported the idea that shared decision‐making would be beneficial, primarily to support decisions around treatment plans and medication changes. Shared decision‐making approaches would need to reflect Indigenous‐specific content areas, such as benefits and risks of therapy informed by data from Indigenous patient populations and inclusion of traditional modes of healing. All participants were interested in having a decision coach and preferred that decision aids be in both paper and electronic formats for accessibility.ConclusionThis study advances knowledge in the priority areas and specific content needed in the shared decision‐making process and the preferences of shared decision‐making strategies relevant and appropriate for urban Indigenous women living with RA in Canada.

Mothers Who Use Drugs: Closing the Gaps in Harm Reduction Response Amidst the Dual Epidemics of Overdose and Violence in a Canadian Urban Setting.

Objectives. To identify key gaps in overdose prevention interventions for mothers who use drugs and the paradoxical impact of institutional practices that can increase overdose risk in the context of punitive drug policies and a toxic drug supply. Methods. Semistructured interviews were conducted with 40 women accessing 2 women-only, low-barrier supervised consumption sites in Greater Vancouver, British Columbia, Canada, between 2017 and 2019. Our analysis drew on intersectional understandings of structural, everyday, and symbolic violence. Results. Participants' substance use and overdose risk (e.g., injecting alone) was shaped by fear of institutional and partner scrutiny and loss (or feared loss) of child custody or reunification. Findings indicate that punitive policies and institutional practices that frame women who use drugs as unfit parents continue to negatively shape the lives of women, most significantly among Indigenous participants. Conclusions. Nonpunitive policies, including access to safe, nontoxic drug supplies, are critical first steps to decreasing women's overdose risk alongside gender-specific and culturally informed harm-reduction responses, including community-based, peer-led initiatives to maintain parent-child relationships. (Am J Public Health. 2022;112(S2):S191-S198. https://doi.org/10.2105/AJPH.2022.306776).