Large Canadian City Research Articles

50 Co-designing an intervention with asylum seeking youth to improve access to healthcare in Canada using human-centered design

Abstract Background Asylum seeking youth in Canada and the United States face multiple barriers to accessing healthcare, leaving them at greater risk of worse health outcomes. In a previous study, we found that limited knowledge of the Canadian health care system and few navigation supports were a key barrier to care for asylum seeking youth, yet no youth-developed intervention existed to support this population. Human-centered design (HCD) develops meaningful interventions with communities who have been historically marginalized. Objectives This study sought to co-design an intervention to increase youth empowerment and access to health care for asylum seeking youth in Canada. Design/Methods This was a community-based participatory-action research (CBPAR) study, and combined human-centered design (HCD) methodologies. We obtained research ethics board approval for this study (#SMH REB 22-117). In partnership with two community organizations that supported asylum seeking youth in a large Canadian city, a youth advisory board was created. In multiple co-creation sessions over a calendar year, an intervention was developed in rapid prototyping sessions and refined with feedback, to develop a final pilot intervention. Results A total of 7 asylum-seeking youth participated in the youth advisory board, ranging in age from 12-19, representing 3 different languages and included youth who self-identified with chronic medical conditions. Over a 15-month period, they participated in 6 co-creation sessions to develop a multi-lingual, web-based tool; youth specifically stated they did not believe an app would be helpful, but rather a resource that could be easily accessed. The youth advisory board shared they had limited understanding of the Canadian healthcare system, as well as interim and provincial health insurance. Youth felt the tool should answer questions about how health insurance worked, be brightly colored, use dyslexia-friendly font and be easily saved on a smartphone as an image. A multi-lingual wallet card was developed for youth to easily present at healthcare encounters, particularly if they did not have provincial health insurance, to help youth communicate their coverage, language and needs. Conclusion To our knowledge, we developed the first co-designed tool in Canada for youth asylum seekers, by youth, to improve and empower youth to receive health care services they are entitled to through navigation support. Given the high degree of marginalization faced by asylum seeking youth, this intervention has the promise to improve health outcomes. Feasibility and acceptability of this study will be evaluated in subsequent studies.

Adjudication of Codes for Identifying Sepsis in Hospital Administrative Data by Expert Consensus*

OBJECTIVES: Refine the administrative data definition of sepsis in hospitalized patients, including less severe cases. Design and Setting: For each of 1928 infection and 108 organ dysfunction codes used in Canadian hospital abstracts, experts reached consensus on the likelihood that it could relate to sepsis. We developed a new algorithm, called AlgorithmL, that requires at least one infection and one organ dysfunction code adjudicated as likely or very likely to be related to sepsis. AlgorithmL was compared with four previously described algorithms, regarding included codes, population-based incidence, and hospital mortality rates—separately for ICU and non-ICU cohorts in a large Canadian city. We also compared sepsis identification from these code-based algorithms with the Centers for Disease Control’s Adult Sepsis Event (ASE) definition. SUBJECTS: Among Calgary’s adult population of 1.033 million there were 61,632 eligible hospitalizations. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: AlgorithmL includes 720 infection codes and 50 organ dysfunction codes. Comparison algorithms varied from 42–941 infection codes to 2–36 organ codes. There was substantial nonoverlap of codes in AlgorithmL vs. the comparators. Annual sepsis incidence rates (per 100,000 population) based on AlgorithmL were 91 in the ICU and 291 in the non-ICU cohort. Incidences based on comparators ranged from 28–77 for ICU to 11–266 for non-ICU cohorts. Hospital sepsis mortality rates based on AlgorithmL were 24% in ICU and 17% in non-ICU cohorts; based on comparators, they ranged 27–38% in the ICU cohort and 18–47% for the non-ICU cohort. Of AlgorithmL-identified cases, 41% met the ASE criteria, compared with 42–82% for the comparator algorithms. CONCLUSIONS: Compared with other code-based algorithms, AlgorithmL includes more infection and organ dysfunction codes. AlgorithmL incidence rates are higher; hospital mortality rates are lower. AlgorithmL may more fully encompass the full range of sepsis severity.

Confidence, Training, and Barriers for Canadian Law Enforcement in Cases of Luring, Sexual Abuse, and Child Sexual Abuse Imagery

The exponential growth of Internet access has generated new platforms for child sexual abuse. The Internet serves as a platform for luring children to engage in sexual activity and also for accessing, distributing or producing sexually explicit material featuring children (“child sexual abuse imagery” (CSAI)). Both types of offenses have been criminalized in various jurisdictions around the world, compelling law enforcement professionals to detect, identify, investigate, and refer such offenses for prosecution. This study was conducted to understand law enforcement training, confidence, and barriers to responding to three categories of criminal activity involving the online sexual exploitation of children: (1) luring, (2) creation and distribution of CSAI, and (3) sexual abuse. This study surveyed two separate police units responsible for investigating sex crimes and/or child abuse in two large Canadian cities. More participants reported encountering a suspected or confirmed case of child sexual abuse within the last year than a case of luring or CSAI (57%, 45%, and 35%, respectively). Participants indicated they had received more formal training on investigating sexual abuse than luring or CSAI and felt less confident in their ability to investigate crimes involving technology and online platforms than other types of investigations. Participants were also more likely to encounter barriers relating to the “soft skills” of working with youth and their families relative to the “hard skills” of investigating criminal activity. Due to the exponential growth of online sexual abuse and the need for nimble and technologically savvy investigative responses, law enforcement should receive more formal training in all areas of online child sexual exploitation, including the criminal offenses of luring and CSAI.

The impacts of extreme heat events on non-accidental, cardiovascular, and respiratory mortality: An analysis of 12 Canadian cities from 2000 to 2020.

Extreme heat has significant impacts on mortality. In Canada, past research has analyzed the degree to which non-accidental mortality increases during single extreme heat events; however, few studies have considered multiple causes of death and the impacts of extreme heat events on mortality over longer time periods. Daily death counts attributable to non-accidental, cardiovascular, and respiratory causes were retrieved for the 12 most populous cities in Canada from 2000 to 2020. Generalized additive models were applied to quantify daily mortality risks for people aged younger than 65 years and for those aged 65 years and older in each city and for each cause of death. Model results were used to calculate the change in mortality risks and the number of excess deaths attributable to extreme heat during extreme heat events. Elevated mortality risks were observed during extreme heat events in most cities for non-accidental and respiratory causes. The impacts of extreme heat on non-accidental mortality were typically greater for people aged 65 and older than for those aged younger than 65. Significantly higher non-accidental mortality risks were observed during extreme heat events for people aged 65 and older in Montréal, the city of Québec, Surrey, and Toronto. For cardiovascular and respiratory causes, people aged 65 and older had significantly higher mortality risks during extreme heat events in Montréal, and both Montréal and Toronto, respectively. In the 12 cities, approximately 670 excess non-accidental deaths, 115 excess cardiovascular deaths, and 115 excess respiratory deaths were attributable to extreme heat events during the study period. Mortality risks during extreme heat events were generally higher in cities with larger proportions of renter households and fewer extreme heat events. This study estimates the longer-term impacts of extreme heat events on three mortality outcomes in a set of large Canadian cities. As climate change causes more frequent and intense extreme heat events, and as policy makers aim to reduce the health impacts of heat, it is important to understand how and where extreme heat affects health.

Gastroenterologist and surgeon perceptions of recommendations for optimal endoscopic localization of colorectal neoplasms

National consensus recommendations have recently been developed to standardize colorectal tumour localization and documentation during colonoscopy. In this qualitative semi-structured interview study, we identified and contrast the perceived barriers and facilitators to using these new recommendations according to gastroenterologists and surgeons in a large central Canadian city. Interviews were analyzed according to the Consolidated Framework for Implementation Research (CFIR) through directed content analysis. Solutions were categorized using the Expert Recommendations for Implementing Change (ERIC) framework. Eleven gastroenterologists and ten surgeons participated. Both specialty groups felt that the new recommendations were clearly written, adequately addressed current care practice tensions, and offered a relative advantage versus existing practices. The new recommendations appeared appropriately complex, applicable to most participants, and could be trialed and adapted prior to full implementation. Major barriers included a lack of relevant external or internal organizational incentives, non-existing formal feedback processes, and a lack of individual familiarity with the evidence behind some recommendations. With application of the ERIC framework, common barriers could be addressed through accessing new funding, altering incentive structures, changing record systems, educational interventions, identifying champions, promoting adaptability, and employing audit/feedback processes. Future research is needed to test strategies for feasibility and effectiveness.

Barriers to primary care among immigrants and refugees in Peterborough, Ontario: a qualitative study of provider perspectives

BackgroundCanada’s immigrants and refugees have often settled in large Canadian cities, but this is changing with rising costs of living and rural settlement initiatives. However, little consideration is made regarding systemic changes needed to accommodate this distribution, particularly in healthcare in medium-sized cities or smaller communities. For most Canadians, primary care is an entry point into the healthcare system but immigrants and refugees face unique barriers to accessing care compared to the general Canadian population. This project aimed to better understand the barriers to accessing primary care among newcomers in Peterborough, Ontario from the perspective of newcomer service providers.MethodologyParticipants were recruited from community organizations identified by the local settlement agency, the New Canadians Centre, as having regular interactions with newcomer clients including clinics, not-for-profit organizations, and volunteer groups. Four focus groups were completed, each with three participants (n=12). A coding grid was deductively developed to guide thematic analysis by adapting Levesque et al.’s conceptual framework defining access to healthcare with five specific dimensions: approachability, acceptability, availability and accommodation, affordability, and appropriateness.ResultsParticipants identified lack of awareness of the healthcare system, stigma, competing priorities, and direct costs as some of the barriers for newcomers. Participants highlighted barriers unique to Peterborough including proximity to services, social isolation, and a shortage of family physicians. The results also highlighted strengths in the community such as its maternal-child health programming.ConclusionThe results provide a glimpse of the challenges to accessing primary care among newcomers in medium-sized communities and identify opportunities to prepare for changing settlement patterns.

Sources of Wintertime Atmospheric Organic Pollutants in a Large Canadian City: Insights from Particle and Gas Phase Measurements

Sources of Wintertime Atmospheric Organic Pollutants in a Large Canadian City: Insights from Particle and Gas Phase Measurements

Sources, spatial-distributions and fluxes of PAH-contaminated dusts in the Athabasca oil sands region

Atmospheric deposition of polycyclic aromatic hydrocarbons (PAHs) has increased in northern Alberta, Canada, due to industrial development in the Athabasca oil sands region (AOSR). However, the sources, summertime deposition fluxes and associated spatial patterns are poorly characterized, and the magnitude of contamination has not been directly contrasted with comparable measurements around large Canadian cities. PAHs were measured in Sphagnum moss collected from 30 bogs in the AOSR and compared with reference moss collected from various remote, rural and near-urban sites in Alberta and Ontario. At all 39 locations, strong correlations between depositional fluxes of PAHs and accumulation rates of ash (n = 117, r = 0.877, p < 0.001) implied that the main source of PAHs to moss was atmospheric deposition of particles. Average PAH concentrations at near-field AOSR sites (mean [SD], 62.4 [24.3] ng/g) were significantly higher than at far-field AOSR sites (44.9 [20.8] ng/g; p = 0.038) or the 7 reference sites in Alberta (20.6 [3.5] ng/g; p < 0.001). In fact, average PAH concentrations across the entire AOSR (7,850 km2) were approximately twice as high as in London, Ontario, or near petroleum upgrading and major traffic corridors in Edmonton, Alberta. A chemical mass balance model estimated that both delayed petcoke (33 % of PAHs) and fine tailings (38 % of PAHs) were the major sources of PAHs in the AOSR. Over the 2015 summer growing season, we estimate that 101–110 kg of PAHs (on 14,300–17,300 tonnes of PAH-containing dusts) were deposited to the AOSR within a 50 km radius of surface mining. Given that the highest PAH deposition was to the northern quadrant of the AOSR, which includes the First Nations community of Fort MacKay, further dust control measures should be considered to protect human and environmental health in the region.

‘Robocops’ in the Making: Reframing Police–Citizen Interactions Through the Lens of Body-Worn Cameras

Abstract This paper examines new meanings that police–citizen interactions take on when officers make sense of them through the lens of body-worn cameras (BWCs). Drawing on 30 interviews with frontline police officers in a large Canadian city, we analyse the embodied character of BWCs to show how officers reframe their role and the subtleties of their approach in dealing with the public as more robotic. First, the participants believe BWCs curb their ability to build rapport with citizens, and therefore dehumanize interactions. Second, they report a need to operate more mechanically to follow protocol for case-building and use-of-force. Still, 100 per cent of participants remain in favour of BWC use—in an era of high visibility and pressure for accountability, video recording technology offers protection.

PB0325 How Rare is Rare? The First Epidemiological Study of Thrombotic Thrombocytopenic Purpura (TTP) in a Large Canadian City

PB0325 How Rare is Rare? The First Epidemiological Study of Thrombotic Thrombocytopenic Purpura (TTP) in a Large Canadian City

How do South Asian seniors in a large Canadian city perceive long-term care?

To understand how community-dwelling South Asian older adults understand and envision long-term care (LTC). Descriptive qualitative study. The Region of Waterloo in Ontario. Participants included 3 key informants (geriatrician, social worker, and medical translator, all South Asian), 1 family caregiver, and 15 community-dwelling South Asian adults aged 65 and older. In-depth interviews and focus groups were recorded, transcribed verbatim, and analyzed using a framework analysis approach. High-level themes included the emotional impacts of failure to provide culturally competent care, such as fear and isolation; a desire for a model of culturally competent care with an emphasis on food and language; and the need for LTC to be more integrated with the broader community and connected to families. As the delivery of LTC is rethought in this country, there is the potential to deliver on the promise of culturally competent care for this growing population. These findings are among the first to communicate the LTC care needs of South Asian older adults in their own words.

HIV prevalence among a retrospective clinical cohort of transgender women in Canada: Results of the Montreal-Toronto Trans study, collected 2018-2019.

HIV prevalence data among transgender (trans) people are not routinely collected in national estimates, including Canada, contributing to gender-based inequities. We examined HIV prevalence and associated factors among trans women in clinical care in two large Canadian cities. Retrospective chart data of trans women aged 16+ were collected from six family medicine and/or HIV clinics in Montreal and Toronto, Canada, 2018-2019. Multinomial logistic regression was used to analyze factors associated with documented HIV positive or missing HIV status relative to documented HIV negative status. Among 1,059 patients, 7.5% were HIV positive, 54.4% HIV negative, and 38.1% missing HIV data. Findings showed lower odds of being HIV positive for those <30years or 30-50 years (vs. >50 years); higher odds were seen for those: of Black race/ethnicity (vs. white), landed immigrant or refugee (vs. Canadian citizen), receiving social assistance (vs. not), and whom ever having used recreational drugs. Albeit high, the prevalence of HIV was lower than expected based on global estimates. Missing HIV status data suggest gaps in testing. Findings highlight socioeconomic and clinical realities among trans women in Canada and inform future HIV prevention and support.

How ‘smart’ are smart cities? Resident attitudes towards smart city design

The growth in the international smart city market over the past decade has been tremendous. Fuelled by private vendors and consultants, adoption of smart city technology in many cities has been rapid. How well does the adoption of this technology and the overall design of smart cities align with the needs and preferences of residents? In this paper we examine this question using data from a unique survey of residents in three large Canadian cities: Vancouver, Montreal and Toronto. The survey includes perceptions of both the importance and maturity of 23 policy or service areas, grouped along four dimensions (Services, Governance, Social and Economic). The results indicate that there is a misalignment in certain service and policy areas between the types of projects that cities are pursuing and the preferences of residents, indicating the need for broader and deeper engagement with the community in the design and implementation of smart city plans.

P.030 Antibody testing for autoimmune encephalitis: a multisite study examining clinical practices in a large Canadian city

Background: Antibody panels are one diagnostic tool within the comprehensive evaluation of suspected autoimmune encephalitis (AIE). Over-reliance on antibody panels contributes to misdiagnosis and inflated healthcare costs. Methods: Inpatients or outpatients who had AIE antibody testing ordered from one of four adult hospitals in Calgary between January 2018 – January 2020 were included. Medical records of 150 individuals were reviewed, including those with positive antibodies or testing sent to Mayo Clinic, plus a random sample. Results: AIE antibody panels were sent for 469 individuals during the 2-year period; 42 were positive (9.0%) of which 10 were pathogenic. Of 150 individuals included in chart review, 27 (18.0%) met criteria for possible AIE at presentation and 16 (10.8%) met criteria for definite AIE at final diagnosis. Overall, antibody testing was ordered in both serum and CSF in 36.3% (versus 69.2% meeting possible AIE criteria); MRI brain was performed in 92.7% (possible AIE 92.6%), EEG in 78.7% (possible AIE 100.0%), and lumbar puncture in 66.7% (possible AIE 96.3%). A sizable proportion did not receive malignancy screening (overall 48.7%; possible AIE 29.6%). Conclusions: Antibody panels are overemphasized in the assessment for AIE and often performed unnecessarily, while other recommended clinical tests are not consistently completed.

Memories of structured input become increasingly distorted across development.

Trajectories of cognitive and neural development suggest that, despite early emergence, the ability to extract environmental patterns changes across childhood. Here, 5- to 9-year-olds and adults (N = 211, 110 females, in a large Canadian city) completed a memory test assessing what they remembered after watching a stream of shape triplets: the particular sequence in which the shapes occurred and/or their group-level structure. After accounting for developmental improvements in overall memory, all ages remembered specific transitions, while memory for group membership was only observed in older children and adults (age by test-type interaction η2 = .05). Thus, while young children form memories for specifics of structured experience, memory for derived associations is refined later-underscoring that adults and young children form different memories despite identical experience.

Integrating Bicycling and Public Transport in North America

This paper provides an overview of bike-transit integration in large American and Canadian cities. It begins with an analysis of national trends in bike-and-ride programs such as the provision of bike racks on buses, accommodation of bikes on rail vehicles, and bike parking at rail stations and bus stops. Most of the paper, however, is devoted to case studies of bike-transit integration in six large American cities (San Francisco, Portland, Minneapolis, Chicago, Washington, and New York) and two Canadian cities (Vancouver and Toronto). Much progress has been made over the past decade in coordinating cycling with public transport, but the demand for bike-and-ride far exceeds the supply of facilities in some cities. More funding, in particular, is needed to provide more secure, sheltered bike parking at rail stations and to increase bike-carrying capacity on rail vehicles.

Exploring the impact of COVID-19 on families of children with developmental disabilities: A community-based formative study.

COVID-19 continues to disproportionately impact families of children with developmental disabilities (DD). There is an urgent need to understand these families' experiences, particularly those that face economic or social marginalization. This qualitative study sought to identify the experiences of families of children with DD during the COVID-19 pandemic. Using phenomenology, in-depth interviews (IDIs) were conducted with caregivers and health care providers of children with DD living in a large urban Canadian city. Interviews were recorded, transcribed, and coded using inductive coding methods by two independent coders. Transcripts were analyzed within and across stakeholder groups using thematic analysis. A total of 25 IDIs were conducted in 2020. 3 main themes and 7 sub-themes emerged related to the experiences of parents and health care providers for children with DD: families reported difficulty adhering to public health measures leading to isolation and increased parental stress; restricted access to in-person services worsened behaviour and development; and worsened household financial security in already marginalized families. Our study demonstrates that families of children with DD have been negatively impacted by the evolving environment from the COVID-19 pandemic, and even more so in those who face social and economic challenges. Public health restrictions have impaired the daily lives of these families and our study suggests that limitations to accessing in-person services may have long-lasting impacts on the well-being of families of children with DD. It is imperative that the unique needs of these families be considered and centred for future interventions.

The effectiveness of phasic, family-based, trauma-informed treatment within a Canadian community mental health center

Interpersonal trauma affects children and families in multiple domains and leads to wide a wide range of symptoms. Those at higher risk of trauma and its impact tend to be those with limited access to quality mental health treatment and frequently served at community mental health clinics. Despite the nuances of trauma treatment and prevalence of trauma in these underserved populations, rarely do community mental health settings house dedicated trauma treatment teams. The purpose of this study was to examine the effectiveness of a triphasic, family-based trauma treatment for children provided by a dedicated trauma team within a community mental health setting. This retroactive case-review study involved 31 families presenting for trauma treatment at a community mental health setting in a large Canadian city. T-tests and reliable change indices were used to compare pre- and posttreatment means across various domains. Treatment gains were large and statistically significant across all domains and reliable change from pre- to posttreatment was likewise found across all domains. These findings suggest that tri-phasic, family-based trauma treatment for children provided by a dedicated trauma team in a community mental health setting is a promising and effective option to address the chronically underserved high-risk and low-­resourced segments of the population.

Physician Perspectives on the Implementation of a Trauma Informed Care Initiative in the Maternity Care Setting

Objectives: To explore the barriers and facilitators from the perspective of family physicians on the implementation of a pilot trauma-informed care (TIC) initiative to promote resilience, with particular emphasis on asking about adverse childhood experiences (ACEs), in a maternity care clinic.Methods: Using an exploratory qualitative design, in-depth semi-structured interviews were conducted with family physicians who were practicing in a maternity clinic in a large Canadian city. Interviews were audio-recorded and transcribed verbatim. Transcripts were reviewed by three coders and themes were extracted using thematic analysis.Results: The analysis of 10 interviews yielded six thematic domains. Three domains pertained to perceived barriers to obtaining an ACEs history including: (1) concern about time management, (2) initial lack of physician comfort with TIC, and (3) cultural limitations of using the ACEs questionnaire. Three themes pertained to perceived facilitators of obtaining an ACEs history including: (1) the importance of a physician champion, (2) a supportive and flexible clinic environment, and (3) improved patient-physician relationships.Implications: In the context of a broader TIC initiative within a maternity care setting, asking patients about ACEs was generally perceived positively by physicians. Ensuring a supportive clinic environment and adequate staff training may be critical factors that contribute to successful implementation. Future research focused on diverse physician experiences in different settings are needed.

Neighbourhood rebuilding and affordable housing in Canadian cities

ABSTRACT A growing affordability problem in Canadian cities has prompted a renewed commitment of the federal government, complemented with provincial and municipal programs, to increase the supply of affordable rental housing. Recently, large Canadian cities have joined their efforts with non-profit and private organisations to provide affordable rental housing in mixed-income experimental projects. In this context, the research addresses a significant gap in the evaluation of partnerships, focusing on the nature of multi-agency collaborations in the provision process (design, build, finance, operate). Partnerships capitalise on the effective role of the public sector in the mobilization of resources, the efficiencies of private agencies in the development process (design, build) and the hybridity of the non-profit institutions (management, service delivery). The research develops a conceptual framework, based on the political market model to explain adoption of planning and housing policies by municipalities. It presents a typology of affordable housing partnerships using highlights from case studies in large Canadian cities – Toronto, Vancouver and Montreal.