Peel Region Research Articles

Stated Preference Survey Pivoted on Revealed Preference Survey for Evaluating Employer-Based Travel Demand Management Strategies

This paper presents a study of commuters’ responses to various employer-based transportation demand management (TDM) strategies that was conducted in the Region of Peel, Ontario, Canada. The study involves design and implementation of a web-based survey of daily commuting mode choices and an efficient design-based stated preference (SP) experiment on the mode choice effects of potential employer-based TDM strategies. For the SP experiments, the survey also collected an elicited confidence rating from the respondents. The survey of 835 random commuters was conducted in fall 2014 and spring 2015. The paper uses empirical models of mode choices (revealed and stated) and an ordered probability model of the elicited confidence rating information to evaluate the data quality. The empirical models reveal that parking cost, monthly parking scheme, indoor parking facilities, emergency ride home, and bike share had higher impacts on commuting mode choices than did bike access facilities and a carshare strategy at the workplace. In relation to respondents’ confidence on SP responses, commuters with a higher number of cars in the household and with longer commuting distances seemed more certain and confident in their responses than did others. In addition, females were found to be more confident when answering SP choice questions.

Square-stalked St. John’s-wort, <i>Hypericum tetrapterum</i>, in Peel Region, Ontario: a New Non-native Vascular Plant Species for Eastern North America

The Eurasian Square-stalked St. John’s-wort (Hypericum tetrapterum Fr.: Hypericaceae) was found growing in an open Eastern White Cedar (Thuja occidentalis L.) swamp in Caledon, Regional Municipality of Peel, Ontario. This is the first record for eastern North America; previous North American occurrences have been on the Pacific coast in Vancouver, British Columbia, Canada (1991), and in Wahkiakum County, Washington State, USA (2003).

Mathematical assessment of the role of temperature and rainfall on mosquito population dynamics.

A new stage-structured model for the population dynamics of the mosquito (a major vector for numerous vector-borne diseases), which takes the form of a deterministic system of non-autonomous nonlinear differential equations, is designed and used to study the effect of variability in temperature and rainfall on mosquito abundance in a community. Two functional forms of eggs oviposition rate, namely the Verhulst-Pearl logistic and Maynard-Smith-Slatkin functions, are used. Rigorous analysis of the autonomous version of the model shows that, for any of the oviposition functions considered, the trivial equilibrium of the model is locally- and globally-asymptotically stable if a certain vectorial threshold quantity is less than unity. Conditions for the existence and global asymptotic stability of the non-trivial equilibrium solutions of the model are also derived. The model is shown to undergo a Hopf bifurcation under certain conditions (and that increased density-dependent competition in larval mortality reduces the likelihood of such bifurcation). The analyses reveal that the Maynard-Smith-Slatkin oviposition function sustains more oscillations than the Verhulst-Pearl logistic function (hence, it is more suited, from ecological viewpoint, for modeling the egg oviposition process). The non-autonomous model is shown to have a globally-asymptotically stable trivial periodic solution, for each of the oviposition functions, when the associated reproduction threshold is less than unity. Furthermore, this model, in the absence of density-dependent mortality rate for larvae, has a unique and globally-asymptotically stable periodic solution under certain conditions. Numerical simulations of the non-autonomous model, using mosquito surveillance and weather data from the Peel region of Ontario, Canada, show a peak mosquito abundance for temperature and rainfall values in the range [Formula: see text]C and [15-35] mm, respectively. These ranges are recorded in the Peel region between July and August (hence, this study suggests that anti-mosquito control effects should be intensified during this period).

Assessment of Fever Advisory Cards (FACs) as an Initiative to Improve Febrile Neutropenia Management in a Regional Cancer Center Emergency Department.

We aimed to improve the time to antibiotics (TTA) for patients treated with chemotherapy who present to the emergency department (ED) with febrile neutropenia (FN) by using standardized fever advisory cards (FACs). Patients treated with chemotherapy who visited the ED at the Peel Regional Cancer Center in Ontario, Canada, with suspected FN were identified, before (April 2012 to March 2013) and after (October 2013 to March 2014) FAC implementation. The primary outcome of interest was TTA. Additional process measures included Canadian Triage and Acuity Scale score, time to physician assessment, and FAC compliance. Outcomes were analyzed with descriptive statistics and control charts to determine whether the change in primary measures were within statistical control over time. Between the pre-FAC cohort (n = 239) and post-FAC cohort (n = 69), TTA did not change significantly post-FACs (195 v 244 min, P = .09), with monthly averages demonstrating normal variation by statistical process control methodology. The introduction of FACs increased the percentage of patients with correctly assigned Canadian Triage and Acuity Scale scores (87% v 100%) but did not affect time to physician assessment. Compliance with FACs among patients was not ideal, with only 62.5% using them as intended. The distribution of FACs was associated with an improved incidence of correct FN triaging but did not demonstrate a meaningful improvement in the quality of FN management. This may be explained by FAC use among patients not being ideal. Next steps in the continued effort toward high-quality FN care include redesign of FACs, reinforcement of provider and patient education, and ED outreach.

On-Premise Alcohol Establishments and Ambulance Calls for Trauma, Assault, and Intoxication.

Alcohol contributes to intentional and unintentional injury. We explored on-premise licensed alcohol establishments (LAEs) and emergency medical service (EMS) ambulance calls.We completed a retrospective population-based study in the Region of Peel, Ontario, 2005 to 2014, where alcohol sales are tightly regulated and healthcare is universally available. We included participants age ≥ 19 years. Longitude-latitude coordinates of all 696 LAEs and all 267,477 EMS ambulance calls were ascertained, and then assigned to 1 of 1568 dissemination areas (DA) in Peel. Relative risks (RRs) described the association between density of on-premise LAEs (by DA deciles) and the rate of EMS calls, adjusted for material deprivation, and density of beer/liquor stores in each DA.There was a curvilinear relation between LAE density and EMS calls for trauma, rising from 45.3 per 1000 in DAs with no LAEs to 381.0 per 1000 in decile-10 (adjusted RR 7.83, 95% confidence interval [CI] 6.15-9.97). This relation was more pronounced for alcohol-focused LAEs, and highest among younger males. Calls for assault (RR 2.67, 95% CI 1.26-5.65) and intoxication (RR 4.00, 95% CI 1.41-11.38) were more likely on the last day of the month and the day thereafter, compared to 1 week prior. At 02:00 hours, when LAEs must stop selling alcohol, there was a considerable rise in assault-related calls in DAs with LAE but not in DAs without LAEs.On-premise LAEs contribute to EMS calls for trauma and assault, especially among young males, around last call, and when monthly pay cheques are cashed.

Invasive Pneumococcal Disease in the Immunocompromised

Given the high morbidity and mortality from invasive pneumococcal disease (IPD), pneumococcal vaccines are especially important for immunocompromised patients. To better characterize this population, researchers analyzed 7604 episodes of IPD that occurred in metropolitan Toronto and the Peel region of Canada from 1995 to 2012. IPD incidence was 28% among immunocompromised patients, a statistically …

Invasive Pneumococcal Disease Among Immunocompromised Persons: Implications for Vaccination Programs.

In 2012/2013, a single dose of 13-valent pneumococcal conjugate vaccine (PCV13) was recommended for immunocompromised adults in the United States and Canada. To assess the potential benefits of this recommendation, we assessed the serotype-specific burden of invasive pneumococcal disease (IPD) among immunocompromised individuals. From 1995 to 2012, population-based surveillance for IPD was conducted in Metropolitan Toronto and Peel Region, Canada. Disease incidence and case fatality were measured in immunocompromised populations over time, and the contribution of different serotypes determined. Overall, 2115/7604 (28%) episodes of IPD occurred in immunocompromised persons. IPD incidence was 12-fold higher (95% confidence interval [CI], 8.7-15) in immunocompromised compared to immunocompetent persons; the case fatality rate was elevated in both younger (odds ratio [OR] 1.8) and older (OR 1.3) adults. Use of immunosuppressive medications was associated with a 2.1-2.7 fold increase in the risk of IPD. Five years after PPV23 program implementation, IPD incidence had declined significantly in immunocompromised adults (IRR 0.57, 95% CI, .40-.82). Ten years after pediatric PCV7 authorization, IPD due to PCV7 serotypes had decreased by 90% (95% CI, 77%-96%) in immunocompromised persons of all ages. In 2011/2012, 37% of isolates causing IPD in immunocompromised persons were PCV13 serotypes and 27% were PPV23/not PCV13 serotypes. Immunocompromised individuals comprised 28% of IPD. Both PPV23 and herd immunity from pediatric PCV7 were associated with reductions in IPD in immunocompromised populations. PCV13 vaccination of immunocompromised adults may substantially reduce the residual burden until herd immunity from pediatric PCV13 is fully established.

Using Knowledge Exchange to Build and Sustain Community Support to Reduce Cancer Screening Inequities.

"Knowledge exchange" (KE) refers to the interaction between knowledge users and researchers toward a goal of mutual learning and collaborative problem solving. Using a case study approach, this article describes how researchers leading a multiphase community engagement project, the Peel Cancer Screening Study (PCSS), used KE to engage a community advisory group (CAG) of knowledge users to build community support for interventions to reduce cancer screening inequities for South Asians in Peel Region, Ontario, Canada. As a result of KE activities (concept mapping, a CAG launch meeting, regular CAG meetings, workgroup meetings, a community report), there is currently a resident-targeted, community-level program being implemented and a provider-targeted intervention that is funded, with both ethnospecific and health service organizations involved. The process of KE received positive evaluations from advisory group members. The experiences of the PCSS illustrate the benefits of KE for researchers and community members.

Animal and human health is unlikely to be at risk when generations of sheep graze bauxite residue (Alkaloam®)-amended pastures

Bauxite residue (Alkaloam®) applied to pasture has been shown significantly to improve pasture production on sub-fertile soil, such as those found in south-west Western Australia, because it increases soil pH. There are concerns that animals grazing Alkaloam-amended pasture may suffer ill health through heavy metal accumulation in tissues, and that this effect could be amplified over generations. There are additional concerns that eating exposed animals, or direct exposure to Alkaloam, may be detrimental to human health. Although some literature exists there are no studies that address these issues when the application of Alkaloam occurred several years (20) before grazing. This investigation examined the heavy metal and trace element accumulation in the tissues of Dorper lambs (1 year old) and their dams, Dorper ewes (4–5 years old) grazing Alkaloam-amended pasture. The experiment was conducted on two sites grazed in the Peel region of Western Australia: one site in Coolup, the Control site (Site C), that had had no application of Alkaloam and one site in Wagerup, the Treatment site (Site T), that had had 20 tonnes per hectare of Alkaloam applied in 1993. Both sites had uniform soil and pasture type during the growing season. Samples of soil and pasture were collected at each site. Differences in trace element concentrations, pH and conductivity between sites were determined. Ten ewes and 10 lambs were randomly selected at each site, removed and killed on the same day for gross examination of the kidney, liver and lung tissue. Samples of the tissues were collected for histopathological examination and chemical analysis to determine concentrations of trace elements. Depending on the concentration of trace elements in each sample, a logistical regression with binomial regression or an ANOVA was performed to determine differences in concentrations between ages, sites and any interactions between age and site. Sheep from Site T had significantly higher concentrations of copper, manganese and molybdenum, whereas sheep from Site C had significantly higher concentrations of cobalt, iron, lead, nickel, selenium, strontium and zinc in tissues. Ewes had significantly higher concentrations of barium, cadmium, cobalt, iron and strontium whereas lambs had significantly higher concentrations of copper, manganese and molybdenum in tissues. Ewes had higher concentrations of cadmium in the kidney compared with lambs, and ewes from Site C had significantly higher concentrations than ewes from Site T. Ewes and lambs from Site C had significantly higher concentrations of selenium in the liver compared with ewes and lambs from Site T. Concentrations of heavy metals (As, Hg, Pb, Th and U) were low in tissues of all sheep. The results show that whereas there were different elemental tissue concentrations between sites and between ages of sheep, there were no detrimental trace element imbalances or accumulation of heavy metals that would cause ill health in any of the sheep that could be associated with the application of Alkaloam to pasture. It is unlikely that humans will suffer any ill effects as a consequence of eating exposed animals. This result supports the premise that bauxite residue can be safely applied to pasture to significantly improve pasture and animal production where animals graze pasture growing on sub-fertile soil.

Evaluating Patient Satisfaction after Implementation of the INSPIRES Nutrition Module at Carlo Fidani Peel Regional Cancer Centre's Radiation Therapy Department

Evaluating Patient Satisfaction after Implementation of the INSPIRES Nutrition Module at Carlo Fidani Peel Regional Cancer Centre's Radiation Therapy Department

An Investigation of Patient Education Experience and the Level of Preparedness for Endometrial Cancer Patients Receiving Vaginal Vault Brachytherapy at Carlo Fidani Peel Regional Cancer Centre (PRCC)

An Investigation of Patient Education Experience and the Level of Preparedness for Endometrial Cancer Patients Receiving Vaginal Vault Brachytherapy at Carlo Fidani Peel Regional Cancer Centre (PRCC)

Proximity to mosquito breeding habitat and Ross River virus risk in the Peel region of Western Australia.

It is intuitive that vector-borne disease exposure risk is related to proximity to sources of vector breeding, but this aspect rarely receives empirical testing. The population of Western Australia (WA) is increasing rapidly, with many new residential developments proposed in close proximity to mosquito breeding habitat. However, potential mosquito-borne disease risks for future residents are given little consideration by planning authorities. The Peel region is one of the fastest growing regions in WA and regularly experiences a large number of cases of the mosquito-borne Ross River virus (RRV) disease with epidemics occuring in the region every few years. A spatial analysis of RRV disease data in the Peel region was undertaken to determine the risk associated with proximity to a mosquito breeding habitat. Geographic Information Systems (GIS) software was used to create buffers between 1 and 6 km from the breeding habitat. The number of cases per 1000 dwellings in each buffer was calculated between 2002/03 to 2011/12 for years with >100 cases across all buffers (n=5) in addition to the cumulative rate over the entire period in each buffer. Residents living within 1 km of a mosquito breeding habitat had a significantly higher rate of RRV disease compared to the background rate across the Peel region in all individual years investigated. The cumulative data over the 10-year study period showed that residents in the 1- and 2-km buffers had a significantly higher rate, whereas those living between 3 and 6 km away did not. This study demonstrates an increased mosquito-borne disease risk associated with living in close proximity to a mosquito breeding habitat in a rapidly expanding region of WA and highlights the importance of considering mosquito-borne disease risks when planning authorities assess new residential development applications. Known mosquito breeding wetlands should be incorporated into land use planning scheme maps to ensure that they are accurately delineated and the implications are considered when planning decisions are made.

“But Many of These Problems are About Funds…”: The Challenges Immigrant Settlement Agencies (ISAs) Encounter in a Suburban Setting in Ontario, Canada

A large number of studies have focused on the neoliberal political and economic restructuring of non-profit immigrant settlement agencies (ISAs) through a policy analysis framework. While policy analysis is key to determining how resources are distributed among non-profit organizations, the challenges that ISAs encounter in planning and delivering services extend beyond limited financial resources in the sector. This research focuses on the system-level challenges ISAs encounter in planning and delivering services to newcomers in the suburban municipality of the Peel Region, Ontario, Canada. Twenty-one semi-structured interviews were conducted with frontline staff and executive directors in settlement organizations in Peel Region, Ontario, Canada, to understand the complex challenges they face within a highly federalized and neoliberal policy environment. The results indicate that although funding dollars are a large concern for ISAs, the conditions attached to funding, such as the types of programs settlement providers are able to offer, mandatory quotas, and restrictive eligibility criteria, hinder ISAs from being able to plan and implement programs that better respond to the needs of immigrants in Peel Region. The results also demonstrate that restrictive funding criteria contribute to competition with other ISAs for limited resources and challenge the structure and continuity of programs. Many of these challenges are exacerbated by the transportation system unique to suburban settings.

Incorporating consideration of health impacts into land use development approval processes: Development of a Health Background Study Framework.

This project involved development of a Health Background Study (HBS) Framework to support consideration of health impacts within municipalities' approval process for land use development. Peel Public Health and Toronto Public Health led the project with the participation of planners, urban designers, engineers, public health staff and development industry representatives. Historical growth in the Region of Peel and suburban Toronto has resulted in extensive low-density development, creating car-dependent communities with disconnected streets and segregated land uses. The inclusion of an HBS in developers' applications to municipalities is one approach by which health-related expectations for the built environment can be established within the approval process. Development of the HBS Framework used the six core elements of the built environment with the strongest evidence for impact on health and was informed by analysis of the provincial and local policy contexts, practices of other municipalities and stakeholder interviews. The Framework's contents were refined according to feedback from multidisciplinary stakeholder workshops. The HBS Framework identifies minimum standards for built environment core elements that developers need to address in their applications. The Framework was created to be simple and instructive with applicability to a range of development locations and scales, and to various stages of the development approval process. Peel Public Health is leading several initiatives to support the use of the HBS as a part of the development application process. The HBS Framework is a tool that public health and planning can use to support the consideration of health impacts within municipalities' land use development processes.

Perceptions of Radiation Therapists about Providing Psychosocial and Supportive Care to Patients at Peel Regional Cancer Center

BackgroundMany patients with cancer undergoing radiation treatment have unmet psychosocial and supportive care (PSOSC) needs. Radiation therapists (RTs) have a unique opportunity to provide PSOSC, but the published literature is limited regarding their perceptions and beliefs about delivering such care. A survey was designed to evaluate these aspects. MethodsA one-time, cross-sectional survey was distributed to 52 RTs at the Peel Regional Cancer Centre, Mississauga, Ontario, Canada. This survey contained six baseline questions and 34 item statements. The 34 statements spanned three themes: (1) convictions and motivations, (2) preparedness and execution, and (3) resources and facilitators. Participants were asked to rank statements on an eight-point scale, from “strongly disagree” to “strongly agree.” ResultsEighty-three percent of the RTs responded. Respondents reported they were engaged for 6.2 hours per week in supporting patients with PSOSC. This was despite a technical focus of organizing and delivering a course of radiotherapy for each patient, a relatively fixed schedule, and short-duration time slots booked per patient. Overall, respondents reported a moderately strong level of convictions and motivations for including PSOSC in practice. They perceived that they were not using all of their existing PSOSC skills and knowledge on the job and that supporting professional (eg, training and scheduling) and environmental (eg, screening tools, physical environment, and policies) infrastructures for PSOSC were not optimized. ConclusionsA majority of the respondents believed PSOSC to be an integral part of providing quality care to radiation oncology patients. Findings showed that staff members were highly motivated to provide this care and perceived that, with additional support, their capacity to provide such care in a way that is meaningful to patients would increase.

Availability, Location, and Format of Nutrition Information in Fast-food Chain Restaurants in Ontario, Canada.

To assess the availability, location, and format of nutrition information in fast-food chain restaurants in Ontario. Nutrition information in restaurants was assessed using an adapted version of the Nutrition Environment Measures Study for Restaurants (NEMS-R). Two raters independently visited 50 restaurants, 5 outlets of each of the top-10 fast-food chain restaurants in Canada. The locations of the restaurants were randomly selected within the Waterloo, Wellington, and Peel regions in Ontario, Canada. Descriptive results are presented for the proportion of restaurants presenting nutrition information by location (e.g., brochure), format (e.g., use of symbols), and then by type of restaurant (e.g., quick take-away, full-service). Overall, 96.0% (n = 48) of the restaurants had at least some nutrition information available in the restaurant. However, no restaurant listed calorie information for all items on menu boards or menus, and only 14.0% (n = 7) of the restaurants posted calorie information and 26.0% (n = 13) of restaurants posted other nutrients (e.g., total fat) for at least some items on menus boards or menus. The majority of the fast-food chain restaurants included in our study provided at least some nutrition information in restaurants; however, very few restaurants made nutrition information readily available for consumers on menu boards and menus.

Quality of febrile neutropenia management in a regional cancer center emergency department.

104 Background: ASCO's current guidelines for febrile neutropenia (FN) management support antibiotic administration within one hour of presentation to the emergency department (ED). Prompt initiation of antibiotic therapy is vital to decrease the likelihood of adverse outcomes. Many studies, however, have reported significant delays in antibiotic initiation with mean wait times far exceeding ASCO's guidelines. We aimed to assess the quality of FN management at a regional cancer centre ED. Methods: Patients undergoing chemotherapy who visited the ED at the Peel Regional Cancer Center in Ontario, Canada between 04/12 - 03/13 were identified using electronic medical records. Patients were excluded if there was no record of chemotherapy delivery within 30 days prior to ED visit. ICD-10 codes and chart data were used to identify patients who had presented for either fever or infection. The primary outcome measures were three major quality of health indicators; time to assessment by a physician, Canadian Triage and Acuity Scale (CTAS) score, and time to initiation of intravenous antibiotics. Results: In total 239 records were included in the analysis. CTAS score was concordant with recommendation for FN (level 1-2) in 85% of patients and did not vary based on primary cancer site (p = 0.17). The mean time to physician assessment was 97.2 min and the mean time to initiation of IV antibiotics was 194.7 min. Overall, 14.6% of patients received their first dose of antibiotic therapy within the recommended 1 hour window. Conclusions: Our audit identified a large margin for improvement in the time to initiation of antibiotic therapy for chemotherapy patients with suspected FN. Prompt recognition and initiation of standardized treatment pathways for FN in the ED may improve the time to initiation of antibiotic therapy. In an attempt to address this gap in quality we have developed and distributed a standardized wallet-sized fever card to all patients receiving cytotoxic chemotherapy within our regional cancer program. This card contains information pertaining to the current chemotherapy treatment and recommended ED treatment protocols for FN. An evaluation of the impact of these cards is ongoing.

Improving radiotherapy utilization rates in Ontario.

48 Background: Radiotherapy (RT) utilization is the proportion of patients (Pts) with a new diagnosis of carcinoma that receives at least one course of RT during the duration of their illness (MacKillop et al). In Ontario, the benchmark for utilization is 42%, and the target rate for Cancer Care Ontario (CCO) is 48%. However in 2005/06 Ontario’s utilization rate was only 35%. This shortfall implies that a significant number of Pts in Ontario were not receiving the best possible treatment. Methods: CCO has developed Capital Investments Strategies to take into account a growing population, an increased incidence of cancer (2.7% per annum), and changing demographics. The most recent (2012) has developed a plan for a gradual improvement in utilization at a rate of 0.5% per annum. With support from the Ministry of Health and Long-Term Care (MOHLTC), the amount of RT Units (RTUs) available increased from 77 (2005/06) to 103 (2013/14). In addition, the MOHLTC supported training programs for provincial Medical Physicists and Radiation Therapists to ensure effective staffing for increased RTUs. Results: Due to investments in RTUs and training, the number of Pts treated in Ontario has risen over 38% from 26,448 in 2005/06 to 36,613 in 2012/13. As a result, provincial utilization rates have risen from 35.1% in 2004/05 to 38.8% in 2012/13, closer to provincial targets. Notable improvements have been seen in centres such as The Carlo Fidani Peel Regional Cancer Centre, where the total number of RT Pts treated increased from 623 (2005/06) to 2532 (2012/13). Similar improvements are seen in other Local Health Integration Networks where comparable investments have been made. These improvements have been attained at the same time as provincial RT wait times have significantly improved from 80.2% (Jan 2010) to 91.6% (Dec 2012) of Pts seen within targets, exceeding provincial targets of 87%. Conclusions: The increase in RT utilization rates provincially demonstrates the success of developing a comprehensive capital investment strategy and coupling it with increased investments in human resource planning. The increased utilization rate has outpaced the increasing cancer incidence and demonstrates the success of these strategies, providing better access to care for cancer Pts in Ontario.

Socioeconomic status and recurrent emergency visits amongst chemotherapy patients.

106 Background: Multiple studies have found that cancer patients undergoing cytotoxic chemotherapy have a high rate of emergency department (ED) utilization throughout the course of their treatment and up to 20% of patients have recurrent ED visits. We assessed the effect of socioeconomic status (SES) on recurrent ED visits for infectious causes amongst chemotherapy patients. Methods: All patients who visited the Peel Regional Cancer Centre ED within 30 days of receiving cytotoxic chemotherapy between 04/12 - 3/13 were identified. Patients were included in the study if their primary reason for presentation was either fever or infection. Postal codes were cross-matched against 2011 census data from Statistics Canada to obtain estimates of income, education, and occupation. The impact of SES factors on the likelihood of multiple ED visits was analyzed. Results: 239 patients with at least 1 visit to the ED for infection were identified. Of these patients 103 (43.1%) had recurrent ED visits. Patients from areas with a higher proportion of arts, sports, culture, recreation, agriculture, and natural resources employment had a significantly (p<0.02) lower incidence of recurrent visits compared to single visits. Patients from areas with a lower proportion of healthcare, natural sciences, and applied sciences employment had a significantly (p<0.04) lower incidence of recurrent visits compared to single visits. Patients from areas with a greater proportion of people for whom the highest education completed was only high school had a significantly (p= 0.01) lower incidence of recurrent visits compared to single visits. Conclusions: Instead of observing a higher rate of ED visits for infection among patients with lower SES, patients residing in areas of lower education or in areas with a higher proportion of employment in fields associated with lower SES were less likely to have recurrent visits. It remains unclear if this represents decreased adherence to fever recommendations in patients with lower SES or over usage of ED services in patients with higher SES. Further studies are planned to better understand these observations to help inform educational interventions and community-based monitoring aimed at decreasing the risk of ED visits.

Citizen Science and Greenspace Planning in the Rouge River Watershed

The Rouge Park is a large 46-km2 protected greenspace situated in one of Canada's largest urbanized regions, the Greater Toronto Area (GTA), an area that covers the Region of Halton, Region of Peel, Region of York, Region of Durham, and the City of Toronto. This article highlights the actions and participation of civil society groups working in the park and how they have been successful in utilizing citizen science and ecologically based arguments to legitimize their case for conservation and thus build broad public support for their goals. Using a typology of key environmental planning case studies relevant to the park, the article identifies three distinct ways civil society groups utilized scientific expertise to facilitate and enforce a conservation narrative. First they identified and utilized existing scientific reports, second they published their own reports/studies, and third they applied a hands-on approach and initiated community-based restoration and monitoring programmes. This article concludes that in community-level environmental controversies, science represents a powerful tool for civil society in the planning and land management regime in Ontario.