The rights and interests of First Nations, Métis, and Inuit in debates over deemed consent legislation for deceased organ donation in Canada: calls to action.

Nova Scotia, Canada is the first jurisdiction in North America to pass deemed consent legislation for organ donation. Individuals medically suitable to be deceased organ donors are considered to have authorised post-mortem organ removal for transplantation unless they opt out of the system. While governments do not have a legal duty to consult Indigenous nations before passing health legislation, this does not diminish Indigenous interests and rights in relation to the legislation. This analysis discusses impacts of the legislation, specifically intersectionality with Indigenous rights, trust in the healthcare system, transplant inequities, and distinctions-based health legislation. How governments engage Indigenous groups about the legislation is yet to unfold. Consultation with Indigenous leaders and engagement and education of Indigenous peoples is, however, key to moving forward legislation that respects Indigenous rights and interests. What happens in Canada is being watched globally, as deemed consent is debated as a solution to organ transplant shortages.

Contraflows and cycling safety: Evidence from 22 years of data involving 508 one-way streets.

Contraflow cycling on one-way streets is a low cost intervention that research shows can improve the cycling experience and increase participation. Evidence from several studies suggest that cyclists on contraflows have a lower crash risk. However, implementing contraflow cycling is often controversial, including in the United Kingdom (UK). In this paper we examine whether contraflow cycling on one-way streets alters crash or casualty rates for pedal cyclists. Focusing on inner London boroughs between 1998 and 2019, we identified 508 road segments where contraflow cycling was introduced on one-way streets. We identified road traffic crashes occurring within 10 m of these segments and labelled them as pre-contraflow, contraflow or contraflow removed crashes. We calculated rates using the number of crashes or casualties divided by the time exposed and generated 95 % confidence intervals using bootstrap resampling. We adjusted the rates for changes in cordon cycling volume and injury severity reporting. There were 1498 crashes involving pedal cyclists: 788 pre-contraflow, 703 contraflow and 7 following contraflow removal. There was no change in adjusted overall pedal cyclist crash or casualty rates when contraflow cycling was introduced. Proximity to a junction doubled the crash rate. The crash rate when pedal cyclists were travelling contraflow was the same as those travelling with flow. We have found no evidence that introducing contraflow cycling increases the crash or casualty rate for pedal cyclists. It is possible that such rates may indeed fall when contraflow cycling is introduced if more accurate spatio-temporal cycling volume data was available. We recommend all one-way streets are evaluated for contraflow cycling but encourage judicious junction design and recommend UK legislative change for mandatory-two-way cycling on one-way streets unless exceptional circumstances exist.

Severe and Fatal Cycling Crash Injury in Britain: Time to Make Urban Cycling Safer.

Pedal cycling is advocated for increasing physical activity and promoting health and wellbeing. However, whilst some countries have achieved zero cyclist deaths on their roads, this is not the case for Great Britain (GB). A retrospective cross-sectional analysis was conducted of STATS19 cyclist crash data, a dataset of all police-reported traffic crashes in GB. Information about crash location, casualty, driver and vehicles involved were included as predictors of casualty severity (fatal or severe vs. slight). Sixteen thousand one hundred seventy pedal cycle crashes were reported during 2018. Severe or fatal cyclist crash injury was associated with increasing age of the cyclist (35-39 years, OR 1.38, 95% CI 1.11 to 1.73; 55-59 years, OR 1.73, 95% CI 1.35 to 2.2; 70 years and over, OR 2.87, 95% CI 2.12 to 3.87), higher road speed limits (50 MPH OR 2.10, 95% CI 1.43 to 3.07; 70 MPH OR 4.12, 95% CI 2.12 to 8.03), the involvement of goods vehicles (OR 2.08, 95% CI 1.30 to 3.33) and the months of May and June (OR 1.34 to 1.36, 95% CI 1.06 to 1.73). Urban planning that includes physical separation of pedal cyclists from other road users, raising awareness around the risks from goods vehicles and reducing road speed should be the urgent focus of interventions to increase the benefits and safety of cycling.

Challenges facing Indigenous transplant patients living in Canada: exploring equity and utility in organ transplantation decision-making.

Indigenous peoples in Canada and in the Circumpolar North face a higher disease burden leading to end-stage organ failure and face geographic and systemic barriers to accessing health-care services, including those for end-stage organ failure and organ donation and transplantation (ODT). To address these issues, I present a think tank model used in Saskatchewan, Canada, which focused on ODT and recommended research and policy changes that address inequitable Indigenous access to ODT, most specifically in northern and remote regions. Over the past three years, think tank members, comprised of Indigenous cultural leaders, elders, and persons with lived experience in ODT, and complemented by medical and advocacy exports, have highlighted equity and utility issues as key concerns, and discussed ways in which these issues can be addressed. Recommendations include culturally-safe methods for documenting and tracking Indigenous identity, development of training to address culturally specific needs, and additional funding to support Indigenous transplant donors and recipients.

Should we be moving to a national standardized non-gadolinium MR imaging protocol for the surveillance of vestibular schwannomas?

OBJECTIVES:: To examine whether the model of Getting It Right First Time (GIRFT) could be relevant to the surveillance of non-operated vestibular schwannomas (vs) by testing the following hypotheses: (1) in the UK there is a great variation in the imaging protocol for the follow-up of vs; (2) high-resolution, T 2 weighted MRI (HRT 2W-MRI) has an equivalent accuracy to gadolinium-enhanced T 1 weighted MRI (Gd-MRI) in the assessment of vs size and; (3) imaging with HRT 2W-MRI rather than Gd-MRI could offer financial savings. METHODS:: Two neuroradiologists independently performed measurements of 50 vs imaged with HRT 2W-MRI and Gd-MRI. Differences in mean tumour measurements between HRT 2W-MRI and Gd-MRI were determined, as were intra- and interobserver concordance. Level of agreement was measured using Bland-Altman plots. Consultant neuroradiologists within 30 adult neurosurgical units in the UK were contacted via email and asked to provide the MRI protocol used for the surveillance of non-operated vs in their institution. The financial difference between scanning with HRT 2W-MRI and Gd-MRI was determined within Leeds Teaching Hospitals NHS Trust. RESULTS:: There was no statistically significant difference in the mean diameter of vs size, measured on HRT 2W-MRI and Gd-MRI (p = 0.28 & p = 0.74 for observers 1 and 2 respectively). Inter- and intraobserver concordance were excellent (Interclass correlation coefficient = 0.99, Interclass correlation coefficient ≥ 0.98 respectively). Differences between the two sequences were within limits of agreement. 26 of 30 UK neuroscience centres (87 % response rate) provided imaging protocols. 16 of the 26 (62%) centres use Gd-MRI for the surveillance of vs. HRT 2-MRI is £36.91 cheaper per patient than Gd-MRI. CONCLUSION:: Variation exits across UK centres in the imaging surveillance of non-operated vs. HRT 2W-MRI and Gd-MRI have equivalent accuracy when measuring vs. Imaging with HRT 2W-MRI rather than Gd-MRI offers potential financial savings. ADVANCES IN KNOWLEDGE:: This study highlights the potential health and economic benefits of a national standardized imaging protocol for the surveillance of non-operated vs.

Canadian response to need for transformation of youth mental health services: ACCESS Open Minds (Esprits ouverts).

AIM: Youth mental health is of paramount significance to society globally. Given early onset of mental disorders and the inadequate access to appropriate services, a meaningful service transformation, based on globally recognized principles, is necessary. The aim of this paper is to describe a national Canadian project designed to achieve transformation of mental health services and to evaluate the impact of such transformation on individual and system related outcomes. METHOD: We describe a model for transformation of services for youth with mental health and substance abuse problems across 14 geographically, linguistically and culturally diverse sites, including large and small urban, rural, First Nations and Inuit communities as well as homeless youth and a post-secondary educational setting. The principles guiding service transformation and objectives are identical across all sites but the method to achieve them varies depending on prevailing resources, culture, geography and the population to be served and how each community can best utilize the extra resources for transformation. RESULTS: Each site is engaged in community mapping of services followed by training, active stakeholder engagement with youth and families, early case identification initiatives, providing rapid access (within 72 hours) to an assessment of the presenting problems, facilitating connection to an appropriate service within 30 days (if required) with no transition based on age within the 11 to 25 age group and a structured evaluation to track outcomes over the period of the study. CONCLUSIONS: Service transformation that is likely to achieve substantial change involves very detailed and carefully orchestrated processes guided by a set of values, principles, clear objectives, training and evaluation. The evidence gathered from this project can form the basis for scaling up youth mental health services in Canada across a variety of environments.

Improving household surveys and use of data to address health inequities in three Asian cities: protocol for the Surveys for Urban Equity (SUE) mixed methods and feasibility study.

INTRODUCTION: As rapid urbanisation transforms the sociodemographic structures within cities, standard survey methods, which have remained unchanged for many years, under-represent the urban poorest. This leads to an overly positive picture of urban health, distorting appropriate allocation of resources between rural and urban and within urban areas. Here, we present a protocol for our study which (i) tests novel methods to improve representation of urban populations in household surveys and measure mental health and injuries, (ii) explores urban poverty and compares measures of poverty and 'slumness' and (iii) works with city authorities to understand, and potentially improve, utilisation of data on urban health for planning more equitable services. METHODS AND ANALYSIS: We will conduct household surveys in Kathmandu, Hanoi and Dhaka to test novel methods: (i) gridded population sampling; (ii) enumeration using open-access online maps and (iii) one-stage versus two-stage cluster sampling. We will test reliability of an observational tool to categorise neighbourhoods as slum areas. Within the survey, we will assess the appropriateness of a short set of questions to measure depression and injuries. Questionnaire data will also be used to compare asset-based, consumption-based and income-based measures of poverty. Participatory methods will identify perceptions of wealth in two communities in each city. The analysis will combine quantitative and qualitative findings to recommend appropriate measures of poverty in urban areas. We will conduct qualitative interviews and establish communities of practice with government staff in each city on use of data for planning. Framework approach will be used to analyse qualitative data allowing comparison across city settings. ETHICS AND DISSEMINATION: Ethical approvals have been granted by ethics committees from the UK, Nepal, Bangladesh and Vietnam. Findings will be disseminated through conference papers, peer-reviewed open access articles and workshops with policy-makers and survey experts in Kathmandu, Hanoi and Dhaka.

The lived experience of paroled offenders with fetal alcohol spectrum disorder and comorbid psychiatric disorder.

This case study presents the life history and postincarceration experiences of two forensic psychiatric patients diagnosed with comorbid mental illness and fetal alcohol spectrum disorder (FASD). The men first met in prison and a few years after their release became roommates at the suggestion of their community support worker and parole officer. With shared and coordinated clinical and mentorship supports, the men were able to establish stability in their lives and manage their mental illness. However, changes in support and gaps within the continuum of care contributed to a sudden breakdown in their stability. The life history and experiences of the two men illustrate the importance in establishing and maintaining positive social networks and coordinated supports for the postincarceration success of offenders living with FASD and comorbid mental illness. The findings highlight areas of patient and system vulnerability that should be addressed to reduce recidivism and strengthen the stability in the lives of these individuals.

Resituating the ethical gaze: government morality and the local worlds of impoverished Indigenous women.

BACKGROUND: Over generations, government policies have impacted upon the lives of Indigenous peoples of Canada in unique and often devastating ways. In this context, Indigenous women who struggle with poverty, mental illness, trauma and substance abuse are among the most vulnerable, as are Indigenous children involved in child welfare systems. OBJECTIVE: By examining the life history of Wanda, a First Nations woman, this article examines the intergenerational role that government policies play in the lives of impoverished Indigenous women and their families. Questions of moral governance and responsibility and the need for ethical policies are raised. DESIGN: The life narrative presented in this article is part of a larger qualitative research programme that has collected over 100 life histories of Indigenous women with addictions and who have involvement with the child welfare system, as children or adults. Wanda's life story exemplifies the impact of government policies that is characteristic of vulnerable Indigenous women and draws attention to the lack of ethical standards in government policymaking in child welfare, public health and mental health/addictions. RESULTS: The path to recovery for Canadian Indigenous women in need of treatment for co-occurring mental disorders and substance addiction is too frequently characterized by an inadequate and ever shifting continuum of care. For those who feel intimidated, suspicious or have simply given up on seeking supports, a profound invisibility or forgetting of their struggle exists in areas of government policy and programming provision. Living outside the scope of mental health and addiction priorities, they become visible to the human service sector only if they become pregnant, their parenting draws the attention of child and family services (CFS), they need emergency health care, or are in trouble with the law. The intergenerational cycle of substance abuse, mental illness and poverty is commonly associated with child welfare involvement, specifically practices that place the health and well-being of Indigenous children at risk. In order to break this cycle, close attention to implementation of ethically based policies and best practice interventions is required. CONCLUSIONS: From an ethical policy perspective, the focus of government policies and the practices they generate must be first and foremost to ensure that individuals, families and groups are not left worse off than prior to a government policy impacting upon their life. Furthermore, the impact of living a life determined by multiple government policies should not be a story of individual and family devastation, and government policies should not be the most significant determinant of health for any group of people.

Health sciences research and Aboriginal communities: pathway or pitfall?

OBJECTIVE: To provide health researchers and clinicians with background information and examples regarding Aboriginal health research challenges, in an effort to promote effective collaborative research with Aboriginal communities. METHODS: An interdisciplinary team of experienced Aboriginal-health researchers conducted a thematic analysis of their planning meetings regarding a community-based Aboriginal health research training project and of the text generated by the meetings and supplemented the analysis with a literature review. RESULTS: Four research challenges are identified and addressed: (1) contrasting frameworks of Western science and indigenous knowledge systems; (2) the impact of historic colonialist processes upon the interface between health science research and Aboriginal communities; (3) culturally relevant frameworks and processes for knowledge generation and knowledge transfer; and (4) Aboriginal leadership, governance, and participation. CONCLUSION: Culturally appropriate and community-controlled collaborative research can result in improved health outcomes in Aboriginal communities and contribute new insights and perspectives to the fields of public health and medicine in general.

Knowledge translation and indigenous knowledge.

OBJECTIVE: We wanted to evaluate the interface between knowledge translation theory and Indigenous knowledge. DESIGN: Literature review supplemented by expert opinion was carried out. METHOD: Thematic analysis to identify gaps and convergences between the two domains was done. RESULTS: The theoretical and epistemological frameworks underlying Western scientific and Indigenous knowledge systems were shown to have fundamental differences. CONCLUSION: Knowledge translation methods for health sciences research need to be specifically developed and evaluated within the context of Aboriginal communities.