Ontario Public Health Units Research Articles

The evolution of social networks through the implementation of evidence-informed decision-making interventions: a longitudinal analysis of three public health units in Canada.

BackgroundWe studied the evolution of information-seeking networks over a 2-year period during which an organization-wide intervention was implemented to promote evidence-informed decision-making (EIDM) in three public health units in Ontario, Canada. We tested whether engagement of staff in the intervention and their EIDM behavior were associated with being chosen as information source and how the trend of inter-divisional communications and the dominance of experts evolved over time.MethodsLocal managers at each health unit selected a group of staff to get engage in Knowledge Broker-led workshops and development of evidence summaries to address local public health problems. The staff were invited to answer three online surveys (at baseline and two annual follow-ups) including name generator questions eliciting the list of the staff they would turn to for help integrating research evidence into practice. We used stochastic actor-oriented modeling to study the evolution of networks. We tested the effect of engagement in the intervention, EIDM behavior scores, organizational divisions, and structural dynamics of social networks on the tendency of staff to select information sources, and the change in its trend between year 1 and year 2 of follow-up.ResultsIn all the three health units, and especially in the two units with higher levels of engagement in the intervention, the network evolved towards a more centralized structure, with an increasing significance of already central staff. The staff showed greater tendencies to seek information from peers with higher EIDM behavior scores. In the public health unit that had highest engagement and stronger leadership support, the engaged staff became more central. In all public health units, the engaged staff showed an increasing tendency towards forming clusters. The staff in the three public health units showed a tendency towards limiting their connections within their divisions.ConclusionsThe longitudinal analysis provided us with a means to study the microstructural changes in public health units, clues to the sustainability of the implementation. The hierarchical transformation of networks towards experts and formation of clusters among staff who were engaged in the intervention show how implementing organizational interventions to promote EIDM may affect the knowledge flow and distribution in health care communities, which may lead to unanticipated consequences.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-015-0355-5) contains supplementary material, which is available to authorized users.

Assessment of Quality Improvement in Ontario Public Health Units

Assessment of Quality Improvement in Ontario Public Health Units

A comparison of West Nile virus surveillance using survival analyses of dead corvid and mosquito pool data in Ontario, 2002–2008

The aim of this study was to improve understanding of the relative performance of the use of dead wild corvids and mosquito pools infected with West Nile virus (WNv) in surveillance for WNv activity in the environment. To this end, all records on dead corvid submissions and mosquito pools tested in Public Health Units (PHUs) in Ontario, from 2002 to 2008, were explored. Survival analyses were employed using the first-WNv-positive cases detected each year for each PHU, and censored observations for PHUs which did not detect WNv during a given year using each data source (504 observations). Survival analyses were employed to compare the number of surveillance weeks before WNv was detected by either data source, and the influence of temporal, geographic and sociodemographic factors on these data. The outcome measurement for the final accelerated failure time (AFT) model with log-logistic distribution was a time ratio, which represents the ratio of the survival time of one group relative to another. Dead corvid surveillance was faster at detecting WNv than testing mosquito pools during the early years of WNv incursion into Ontario, while mosquito testing found WNv more quickly later in the study period. There was also regional variation in time-to-detection of WNv, by modality, as well as for various types of urban/rural settings. In comparison to mosquito surveillance, West Nile virus was detected more quickly using dead corvid surveillance in sparsely populated regions. These areas may benefit from collection of dead corvids to optimize detection and direct early surveillance efforts. When we compared the time-to-detection of WNv using dead corvids and the onset of human cases in PHUs, we found that dead corvid surveillance was predictive of West Nile activity in health units that reported human cases during the first 3 years of the incursion into Ontario.

Knowledge change associated with participation in prenatal education programs in Ontario: A cohort study.

The primary objective was to examine how participation in prenatal programs delivered by Ontario public health units influences pregnant women's pregnancy-related knowledge. Secondary objectives were to examine the socio-demographic characteristics of women participating in these programs and assess program satisfaction. A cohort study was conducted of 511 adult pregnant women who were registered for a prenatal program within one of seven Ontario public health units. Participants completed a pre-program survey, which examined socio-demographic and pregnancy characteristics, and baseline pregnancyrelated knowledge. After finishing the program, participants completed a post-program survey investigating pregnancy-related knowledge and program satisfaction. Pregnancy-related knowledge was assessed using the Healthy Pregnancies Knowledge Survey, which captures knowledge within three subtopic areas: healthy pregnancies, healthy lifestyles and breastfeeding. Participants demonstrated a significant increase in mean knowledge scores, both overall and across each subtopic area. Most participants reported that their program satisfied their questions either mostly or very well across all content areas examined. This study is the first large-scale effort to examine the ability of prenatal programs offered through Ontario public health units to influence clients' pregnancy-related knowledge. These findings contribute to the evidence base for prenatal education program planning.

Examining public health nurses’ documentary practices: the impact of criminalizing HIV non-disclosure on inscription styles

In Canada, there has been a rise in criminal HIV non-disclosure cases where public health records have been subpoenaed for use in police investigations and criminal court proceedings. In particular, public health nurses’ written counseling notes, originally collected for the purposes of creating a record of treatment and a plan of care, have been used as evidence against their clients. This article engages sociologically with this issue by analyzing whether and how this criminal law development has affected public health nurses’ reasoning and documentary practices in settings of HIV post-test counseling sessions. The paper argues that variations in nurses’ inscription styles result in part from considerations about the criminal law, which indicates the influence of ‘medico-legal’ relations that connect health care and the criminal justice system. Implications for nursing practice and the broader goals of HIV prevention are discussed. Data are drawn from interviews with thirty nurses working at four public health units in Ontario.

Working Through and Around: Exploring Rural Public Health Nursing Practices and Policies To Promote Rural Women’s Health

Purpose : To discuss findings from research in Ontario, Canada, that addresses the following objectives: 1) identify organizational attributes and local and provincial health policies that enable or impede the work of Ontario public health nurses to improve rural women's health, and 2) critically examine roles, job descriptions, and practices of Ontario PHNs that will improve rural women's health. Sample: 20 frontline PHNs and 14 supervisors and managers in three Ontario public health units that serve people who live in rural locations. Method : Six focus group interviews were conducted with PHNs and PHN managers in three rural Ontario public health units. Study participants were asked to describe policies and practices that guided their practice regarding rural women's health, identify organizational attributes that enable or impede public health nursing practice regarding rural women's health, and indicate roles and practices for PHNs to improve rural women's health. Findings : 1) Policies address rural women's health and rural public health minimally or not at all, 2) PHN practice is primarily focused on child bearing women and children to the exclusion of other populations of rural women such as seniors, 3) PHNs work through and around policies to address rural women' s health more effectively, and 4) institutional, government, community, professional, and personal factors play significant roles in shaping public health nursing practice and policy regarding rural women's health. Conclusions : This research facilitates understanding regarding policies, contexts, and values that shape rural PHN practice, and provides evidence for policies and practices that enhance and support public health nursing for more effective promotion of rural women's health. Clearly, more investigation is needed; this research forms the basis for ongoing inquiry in this area. Keywords : rural public health nursing, rural women's health, policy, practice, Canada DOI : h ttp://dx.doi.org/10.14574/ojrnhc.v15i1.342

Understanding action on the social determinants of health: a critical realist analysis of in-depth interviews with staff of nine Ontario public health units.

BackgroundAddressing the social determinants of health (SDH) is identified as a role for local public health units (PHUs) in the province of Ontario. Despite this authorization to do so there is wide variation in PHU practice. In this article we consider the factors that shape local PHU action on the SDH through a critical realist analysis.MethodsInterviews with Medical Officers of Health (MOHs) and lead staff from nine PHUs in Ontario identify the structures and powers that allow PHUs to address the SDH as well as the many factors that either activate or inhibit these structures and powers.ResultsWe found that personal backgrounds and attitudes of MOHs and leading staff people as well as local jurisdictional characteristics shape whether and how PHUs carry out SDH-related activities.ConclusionsAction on the SDH is a result of a complex interplay of micro-, meso- and macro-level factors that requires recognition of the contested nature of public health, presence of Ministry of Health mandates, local jurisdictional characteristics, and politics. The most effective way to assure PHU action on the SDH is for the Ministry of Health and Long-Term Care to mandate such activities and develop accountability mechanisms that assure implementation.

Establishment of Culex (Melanoconion) erraticus (Diptera: Culicidae) in Southern Ontario, Canada.

Culex (Melanoconion) erraticus (Dyar and Knab) is now established in southern Ontario, Canada. This species was first discovered in 2002 during a province-wide adult mosquito surveillance program for West Nile virus. Using CO2-baited CDC miniature light traps, a few Cx. erraticus were collected from 2002 to 2011, but the total number increased during the 2012 and 2013 seasons. The number of Ontario Public Health Units with records for Cx. erraticus has also increased since 2002, demonstrating that the geographic distribution of this species is expanding northward. Cx. erraticus is a potential arboviral bridge vector for a number of pathogens and its establishment in Ontario should be considered a potential public health concern.

Creating, Synthesizing, and Sharing: The Management of Knowledge in Public Health.

To better understand the applicability of knowledge management (KM) in public health (PH) as a strategy to improve planning and decision making. The study was designed as a narrative inquiry; a form of storytelling research. Qualitative data were collected through interviews designed to gain participants' stories about planning processes. Twenty-four participants from six PH Units in Ontario, Canada. We performed a secondary analysis to better understand the use of KM strategies, techniques, and approaches. Findings were compared to a preliminary KM framework supporting knowledge processes within a dynamic, interactive context. Analysis showed that while KM strategies are supported informally, it is most often done in an ad hoc manner. Participants acknowledged a gap in their knowledge sharing practices. PH professionals are ready to apply KM in PH as an approach to facilitate planning and decision making. The proposed KM framework incorporates partnerships to adapt to the realities of PH context. Consideration of KM strategies can improve information organization, partnerships and decision making, as well as contribute to current PH reforms aimed at strengthening the health care system. This presents an opportunity to integrate formalized methods of knowledge use and knowledge sharing among PH employees using a KM approach.

Examining inequities in children’s environmental health: results of a survey on the risk perceptions and protective actions of new mothers

Young children are more highly exposed and vulnerable to environmental health hazards than adults due to a variety of physiological and behavioural factors. Despite the significant responsibility mothers typically bear in managing their children’s health, little is known about how they perceive and negotiate these risks in their day-to-day lives. To better understand mothers’ environmental health risk perceptions and associated protective actions across socio-economic and geographic contexts, a telephone survey was conducted among new mothers (n = 606) recruited through two Public Health Units in Ontario, Canada. Analyses revealed that approximately half of the respondents were moderately or highly concerned about environmental health risks, ranging in nature from household products to outdoor air contaminants. Factors affecting the likelihood of experiencing concern included lower income and lower levels of perceived control. With regard to protective actions, 43% reported taking three or more actions to reduce environmental health risks to their children, with the likelihood of taking action being negatively affected by factors including low income and first language other than English or French, and positively affected by being a first-time parent (primiparous). This study contributes to our understanding of environmental health risk perceptions and associated protective behaviours among new mothers, and has implications for the development of more context-focused risk management and communication strategies.

Discussing the Limits of Confidentiality: The Impact of Criminalizing HIV Nondisclosure on Public Health Nurses' Counseling Practices

In Canada, there have been a growing number of criminal HIV nondisclosure cases where public health records have been subpoenaed to aid in police investigations and/or to be presented in court as evidence against HIVpositive persons. This has led some to suggest that nurses provide explicit warnings about the limits of confidentiality in relation to crimes related to HIV nondisclosure, while others maintain that a robust account of the limits of confidentiality will undermine the nurse–client relationship and the public health goals of reducing HIV/ sexually transmitted infection transmission. This article engages with this issue by exploring whether and how public health nurses endeavor to control information about the limits of confidentiality at the outset of HIV posttest counseling. The data indicate variation in practices, as nurses pragmatically balance ethical and professional concerns; although some nurses intentionally withhold information about the risk of subpoena, others report talking to clients about confidentiality in ways that focus on the risk of harm associated with criminalization. The discussion argues that practice variation also illuminates medico-legal relations between health care and the criminal justice system. Data are drawn from qualitative interviews with 30 nurses working at four public health units in Ontario.

Ideological and organizational components of differing public health strategies for addressing the social determinants of health.

Despite a history of conceptual contributions to reducing health inequalities by addressing the social determinants of health (SDH), Canadian governmental authorities have struggled to put these concepts into action. Ontario's-Canada's most populous province-public health scene shows a similar pattern. In statements and reports, governmental ministries, professional associations and local public health units (PHUs) recognize the importance of these issues, yet there has been varying implementation of these concepts into public health activity. The purpose of this study was to gain insight into the key features responsible for differences in SDH-related activities among local PHUs. We interviewed Medical Officers of Health (MOH) and key staff members from nine local PHUs in Ontario varying in SDH activity as to their understandings of the SDH, public health's role in addressing the SDH, and their units' SDH-related activities. We also reviewed their unit's documents and their organizational structures in relation to acting on the SDH. Three clusters of PHUs are identified based on their SDH-related activities: service-delivery-oriented; intersectoral and community-based; and public policy/public education-focused. The two key factors that differentiate PHUs are specific ideological commitments held by MOHs and staff and the organizational structures established to carry out SDH-related activities. The ideological commitments and the organizational structures of the most active PHUs showed congruence with frameworks adopted by national jurisdictions known for addressing health inequalities. These include a structural analysis of the SDH and a centralized organizational structure that coordinates SDH-related activities.

Electronic immunization data collection systems: application of an evaluation framework

BackgroundEvaluating the features and performance of health information systems can serve to strengthen the systems themselves as well as to guide other organizations in the process of designing and implementing surveillance tools. We adapted an evaluation framework in order to assess electronic immunization data collection systems, and applied it in two Ontario public health units.MethodsThe Centers for Disease Control and Prevention’s Guidelines for Evaluating Public Health Surveillance Systems are broad in nature and serve as an organizational tool to guide the development of comprehensive evaluation materials. Based on these Guidelines, and informed by other evaluation resources and input from stakeholders in the public health community, we applied an evaluation framework to two examples of immunization data collection and examined several system attributes: simplicity, flexibility, data quality, timeliness, and acceptability. Data collection approaches included key informant interviews, logic and completeness assessments, client surveys, and on-site observations.ResultsBoth evaluated systems allow high-quality immunization data to be collected, analyzed, and applied in a rapid fashion. However, neither system is currently able to link to other providers’ immunization data or provincial data sources, limiting the comprehensiveness of coverage assessments. We recommended that both organizations explore possibilities for external data linkage and collaborate with other jurisdictions to promote a provincial immunization repository or data sharing platform.ConclusionsElectronic systems such as the ones described in this paper allow immunization data to be collected, analyzed, and applied in a rapid fashion, and represent the infostructure required to establish a population-based immunization registry, critical for comprehensively assessing vaccine coverage.

Adaptation of a Best Practice Guideline to Strengthen Client‐Centered Care in Public Health

Best practice guidelines (BPGs) were developed by the Registered Nurses Association of Ontario (RNAO) to support evidence-based nursing practice. One Ontario public health unit chose to implement the BPG on client-centered care (CCC). A critical review of this BPG revealed issues that would hinder successful implementation within a public health setting. These included a focus on the client as an individual, the predominance of acute care exemplars and training resources that were not representative of public health nursing practice, and the need to reconcile the enforcement roles of public health with the BPG principles. The purpose of this article is to describe the process of adapting the CCC BPG to more accurately reflect the broad scope of public health nursing practice. A model for CCC in public health nursing context is presented and processes for implementing, evaluating, and sustaining CCC are described.

Epistemological barriers to addressing the social determinants of health among public health professionals in Ontario, Canada: a qualitative inquiry

To date, Ontario public health units (PHUs) have generally neglected the social determinants of health (SDH) concept in favor of risk aversion and behaviorally oriented health promotion approaches. Addressing SDH and responding to the presence of health inequities is required under the Ontario Public Health Standards and is a component of provincial public health documents and reports. Nevertheless, units vary in their understanding and application of the SDH concept in their activities. The authors conducted 18 interviews with Medical Officers of Health and lead staff persons from nine Ontario PHUs, in order to better understand how these differences in addressing the SDH among health units come about. The findings suggest that differences in practice largely result from epistemological variations: conceptions of the SDH; the perceived role of public health in addressing them; and understandings concerning the validity of differing forms of evidence and expected outcomes. Drawing from Bachelard’s concept of epistemological barriers and Raphael’s seven discourses on the SDH, we examine the ways in which the participating units discuss and apply the SDH concepts. We argue that a substantial barrier to further action on the SDH is the internalization of discourses and traditions that treat health as individualized and depoliticized.

Improving Collaboration between Public Health and Family Health Teams in Ontario

To identify and explore areas where responsibilities may overlap between family health teams (FHTs) and public health units (PHUs); to identify facilitators or barriers to collaboration; and to identify priority areas for increased collaboration. DESIGN AND CONTEXT: Cross-sectional mixed-methods study of FHTs and PHUs in Ontario, Canada, consisting of a postal survey, key informant interviews and a roundtable meeting. The survey response rate was 46%. Direct client-based services such as giving immunizations, promoting prenatal health and nutrition, and counselling related to smoking cessation were identified as the top three areas of perceived overlap. The greatest interest in collaboration was expressed in the areas of emergency planning and preparedness, immunization, and prenatal health and nutrition. Good communication with a clear understanding of roles and functions was the most important facilitator, and lack of resources and absence of a clear provincial mandate and direction to collaborate were identified as significant barriers. Small, simple client-based projects of interest to both kinds of organization would be the best way to move forward in the short term. Improving communication between FHTs and PHUs, understanding of roles and functions, the use of shared or interoperable information systems and greater clarity from government on the ways in which these two key sectors of the healthcare system are intended to work together were identified as important for the success of increased collaboration.

Spatial and environmental impacts on adverse birth outcomes in Ontario

This study assesses the overall spatial variations and neighbourhood‐level “hot spots” of low birth weight and preterm birth incidence within three public health units in Ontario, Canada. The analysis uses a stepwise approach of intra‐class correlation analysis, a spatial scan statistic, and multilevel spatial modeling. Results show that neighbourhood level variation accounts for only 2–3 percent of the total variation of adverse birth outcomes in the study area. However, strong spatial autocorrelation is observed at the neighbourhood level, and spatial clusters of relatively high adverse birth outcome rates exist in areas that are associated with environmental risks, including pollution sources and proximity to highways. Thus, although estimated neighbourhood impacts on adverse birth outcomes are small compared with those of individual‐level risks, local high potential environmental risk areas are identifiable. Environmental surveillance and spatial statistical analysis should be conducted regularly by local health authorities to identify and monitor the impact of environmental changes on health in general and on birth outcomes in particular. Specific community‐oriented health interventions may be required to reduce observed local health impacts.

Integration of Primary Health Care and Public Health During a Public Health Emergency

We have provided a detailed evaluation of how collaboration between an Ontario public health unit and its primary care providers facilitated an optimal response to the 2009 H1N1 influenza pandemic. Family health teams (integrated, interdisciplinary teams that provide a range of care options) provided flu assessment centers, with public health as a partner providing infection control advice, funding, coordination, antiviral medication, clinical care guidelines, supplemental nurse staffing, and arrangement of communication strategies with the public. The family health team structure offers a new capacity for timely, coordinated, and comprehensive response to public health emergencies, in partnership with public health, and provides a promising new direction for healthcare organization.

Exploring the feasibility of integrating barcode scanning technology into vaccine inventory recording in seasonal influenza vaccination clinics

In response to the need for improved quality of vaccine inventory and client immunization records, barcodes containing a unique identifier and lot number will be placed on all vaccine vials in Canada. We conducted feasibility studies to examine integration of barcode scanning into inventory recording workflow for mass immunization clinics. During the 2010-2011 seasonal influenza vaccination campaign, Ontario public health units (PHUs) using an electronic immunization system were randomized to record clinic inventory data (including vaccine lot number and expiry date) through: (i) barcode scanning of vials; or (ii) drop-down menus. A third group of PHUs recording vaccine inventory on paper served as an observation arm. We visited a sample of clinics within each PHU to assess barcode readability, method efficiency and data quality. Clinic staff completed a survey examining method perceptions. We observed 20 clinics using barcode scanning to record inventory data (eight PHUs), 20 using drop-down menus (eight PHUs), and 21 using paper forms (five PHUs). Mean time spent recording data per vial was 4.3s using barcode scanners with 1.3 scan attempts per vial, 0.5s using drop-down menus, and 1.7s using paper. Few errors were observed. Sixty-four perception surveys were completed by inventory staff; barcode scanning users indicated fairly strong overall satisfaction with the method (74%), and the majority agreed that barcode scanning improved client safety (84%) and inventory record accuracy (77%). However, 38% of barcode scanning users felt that individually scanning vials took longer than the other approaches and 26% indicated that this increased time would discourage them from adopting the method. Our study demonstrated good readability of barcodes but scanning individual vials for high-volume clinics was time-consuming; modifying the process will improve feasibility to facilitate adoption in Canada, while serving as an example for other countries considering this technology.

A cost comparison of electronic and hybrid data collection systems in Ontario during pandemic and seasonal influenza vaccination campaigns

BackgroundDuring the pandemic (H1N1) 2009 influenza vaccination campaign, health regions in Canada collected client-level immunization data using fully electronic or hybrid systems, with the latter comprising both electronic and paper-based elements. The objective of our evaluation was to compare projected five-year costs associated with implementing these systems in Ontario public health units (PHUs) during pandemic and seasonal influenza vaccination campaigns.MethodsSix PHUs provided equipment and staffing costs during the pandemic (H1N1) 2009 influenza vaccination campaign and staffing algorithms for seasonal campaigns. We standardized resources to population sizes 100,000, 500,000 and 1,000,000, assuming equipment lifetime of five years and public health vaccine administration rates of 18% and 2.5% for H1N1 and seasonal campaigns, respectively. Two scenarios were considered: Year 1 pandemic and Year 1 seasonal campaigns, each followed by four regular influenza seasons. Costs were discounted at 5%.ResultsAssuming a Year 1 pandemic, the five-year costs per capita for the electronic system decrease as PHU population size increases, becoming increasingly less costly than hybrid systems ($4.33 vs. $4.34 [100,000], $4.17 vs. $4.34 [500,000], $4.12 vs. $4.34 [1,000, 000]). The same trend is observed for the scenario reflecting five seasonal campaigns, with the electronic system being less expensive per capita than the hybrid system for all population sizes ($1.93 vs. $1.95 [100,000], $1.91 vs. $1.94 [500,000], $1.87 vs. $1.94 [1,000, 000]). Sensitivity analyses identified factors related to nurse hours as affecting the direction and magnitude of the results.ConclusionsFive-year cost projections for electronic systems were comparable or less expensive than for hybrid systems, at all PHU population sizes. An intangible benefit of the electronic system is having data rapidly available for reporting.