The Nova Scotia Community Cancer Matrix: A geospatial tool to support cancer prevention.

Globally, cancer is a leading cause of death and morbidity and its burden is increasing worldwide. It is established that medical approaches alone will not solve this cancer crisis. Moreover, while cancer treatment can be effective, it is costly and access to treatment and health care is vastly inequitable. However, almost 50% of cancers are caused by potentially avoidable risk factors and are thus preventable. Cancer prevention represents the most cost-effective, feasible and sustainable pathway towards global cancer control. While much is known about cancer risk factors, prevention programs often lack consideration of how place impacts cancer risk over time. Maximizing cancer prevention investment requires an understanding of the geographic context for why some people develop cancer while others do not. Data on how community and individual level risk factors interact is therefore required. The Nova Scotia Community Cancer Matrix (NS-Matrix) study was established in Nova Scotia (NS), a small province in Eastern Canada with a population of 1 million. The study integrates small-area profiles of cancer incidence with cancer risk factors and socioeconomic conditions, to inform locally relevant and equitable cancer prevention strategies. The NS-Matrix Study includes over 99,000 incident cancers diagnosed in NS between 2001 and 2017, georeferenced to small-area communities. In this analysis we used Bayesian inference to identify communities with high and low risk for lung and bladder cancer: two highly preventable cancers with rates in NS exceeding the Canadian average, and for which key risk factors are high. We report significant spatial heterogeneity in lung and bladder cancer risk. The identification of spatial disparities relating to a community's socioeconomic profile and other spatially varying factors, such as environmental exposures, can inform prevention. Adopting Bayesian spatial analysis methods and utilizing high quality cancer registry data provides a model to support geographically-focused cancer prevention efforts, tailored to local community needs.

Paramedic Endotracheal Intubation Success Rates Before and After an Intensive Airway Management Education Session.

Introduction Advanced airway management by paramedics is potentially life-saving, but carries a significant risk to patient safety and can be associated with poor clinical outcome if performed incorrectly. Previously, our team had found that an intensive education intervention demonstrated an improvement in paramedic performance on a written exam and increased confidence in airway skills. This study measured intubation success and the number of attempts per patient before and after intensive paramedic airway management education intervention. Methods A 10-hour mandatory course was taken by all advanced life support (ALS) paramedics in a provincial system (2009/04-07, n=~395). The course was done during semi-annual continuing education Emergency Health Services (EHS) in-services. These day-long courses were held in person over four months. The electronic charting database was queried for intubation attempts and successful placements 12 months before the training, during the four months of training, and 12 months post-training. The primary outcome is the difference in success rates between the before (pre-intervention) and after (post-intervention) periods. The secondary outcome is the number of attempts per patient. Stationarity of success in pre- and post-periods was tested. The model was fit tested using Maximum Likelihood regression, and variables were tested using the Wald test. Results A sample size of 476 intubation attempts in each of the pre- and post-periods was required to detect a 10% improvement with the pre-intervention success of 60%. A total of 1421 intubation attempts occurred; 674 pre-intervention, 604 post-intervention, and 143 during teaching. Seven attempts were excluded (success unknown). Intubation success rates improved, from 0.68 (95% CI 0.64-0.71) to 0.75 (95% CI 0.72-0.78); a difference of 0.076 (95% CI 0.03-0.12) (p = 0.001). Intubation success rates in the pre-intervention and post-intervention periods were found to be static. A significant decrease was found in the number of attempts per patient in the post-period (p = 0.005). Conclusion Intubation success increased from 68% to 75% and was maintained over the 12-month post-period. There is a potential that judgment may also have improved, based on the decreased number of attempts per patient. Limitations include missing values, paramedics' self-reported number of attempts, and the definition of what is considered to be an attempt. In addition to previously demonstrated improvements in paramedic exam and scenario performance, this airway education intervention appears to have made a significant improvement to patient outcomes. These findings support the value of such education interventions to improve performance.

Availability and affordability of healthy and less healthy food in Nova Scotia: where you shop may affect the availability and price of healthy food.

OBJECTIVE: The present study aimed to examine the availability and price of healthier compared with less healthy foods by geography, store category and store type for convenience stores, and by store size for grocery stores in Nova Scotia. DESIGN: A cross-sectional study that examined differences in the overall availability and price of healthier compared to less healthy foods in grocery and convenience stores in Nova Scotia. The Nova Scotia Consumer Food Environment project was part of a larger initiative of the Nova Scotia government (Department of Health and Wellness) to assess the food and beverage environment in Nova Scotia in 2015/16. SETTING: Four geographic zones (Nova Scotia Health Authority Management Zones) in Nova Scotia, Canada. PARTICIPANTS: A sample of forty-seven grocery stores and fifty-nine convenience stores were selected from a list of 210 grocery stores and 758 convenience stores in Nova Scotia to ensure geographic and store type representation in our sample. RESULTS: Findings indicate that rurality had a significant effect on food availability as measured by the Nutrition Environment Measures Surveys (NEMS) score (P < 0·01); there was a higher availability of healthy foods in rural compared to urban areas for convenience stores but not grocery stores. Healthier foods were also more available in chain stores compared to independent stores (P < 0·01) and in large stores compared to small and medium stores (P < 0·001 and P < 0·01, respectively). CONCLUSIONS: The availability of and accessibility to less healthy foods in Nova Scotia food environment suggests that there is a need for government policy action to support a food environment that contributes to healthier diets.

In-store food environment for adults and children in Nova Scotia, Canada.

OBJECTIVES: This paper examines the retail food environment in grocery and convenience stores across Nova Scotia with specific attention to prominence and promotion of foods and beverages, as well as in-store promotion of foods and beverages to children. METHODS: A descriptive cross-sectional analysis of data on the availability, price, prominence, and promotion of foods and beverages classified as "healthier" and "less healthy" was undertaken as a part of a Nova Scotia Consumer Food Environment (NS-CFE) project. Data were collected in a random stratified sample of 47 grocery stores and 59 convenience stores by trained research assistants working in pairs using adapted Nutrition Environment Measures Survey Toronto grocery store (NEMS-S) and NEMS Corner Store (NEMS-CS) tools. RESULTS: "Less healthy" snack foods and sugar-sweetened beverages were more prominently displayed than "healthier" options with an exception of cereal, at both grocery and convenience stores (all p < 0.001). Coke™ and fruit juice were more expensive than water in both grocery and convenience stores (both p ≤ 0.05). Significantly more child-specific strategies were used to promote "less healthy" compared with "healthier" options in both grocery and convenience stores (both p < 0.001). CONCLUSION: Results of this study demonstrate that "less healthy" options are significantly more prominently displayed and more heavily marketed to all Nova Scotians, including children, in the retail food environment compared with items classified as "healthier". These findings indicate that there is a need for comprehensive structural changes to the retail food environment in Nova Scotia, to support population health.

RéSUMé: OBJECTIFS: Notre article porte sur l'environnement alimentaire au détail des épiceries et des dépanneurs en Nouvelle-Écosse, en particulier sur l'emplacement et la promotion des aliments et boissons et sur la promotion sur le lieu de vente des aliments et boissons destinés aux enfants. MéTHODE: Dans le cadre d'un projet sur l'environnement alimentaire de consommation en Nouvelle-Écosse (Nova Scotia Consumer Food Environment, NS-CFE), nous avons mené une analyse transversale descriptive des données sur la disponibilité, le prix, l'emplacement et la promotion d'aliments et de boissons catégorisés comme étant « plus sains ¼ et « moins sains ¼. Les données ont été collectées dans un échantillon aléatoire stratifié de 47 épiceries et de 59 dépanneurs par des adjoints à la recherche formés travaillant deux par deux à l'aide de deux outils de sondage adaptés : le NEMS-S (Nutrition Environment Measures Survey Toronto Grocery Store) et le NEMS-CS (NEMS Corner Store). RéSULTATS: Les grignotines et les boissons édulcorées au sucre « moins saines ¼ étaient placées plus en vue que les options « plus saines ¼, à l'exception des céréales, dans les épiceries comme dans les dépanneurs (tous, p < 0,001). Le Coke™ et les jus de fruits étaient plus chers que l'eau dans les épiceries comme dans les dépanneurs (les deux, p ≤ 0,05). Un nombre sensiblement plus élevé de stratégies visant expressément les enfants étaient employées pour promouvoir les options « moins saines ¼ que les options « plus saines ¼ dans les épiceries comme dans les dépanneurs (les deux, p < 0,001). CONCLUSION: Les résultats de cette étude montrent que les options « moins saines ¼ sont placées plus en vue et sont plus intensivement commercialisées aux Néo-Écossais, y compris aux enfants, dans l'environnement alimentaire au détail, que les articles catégorisés comme étant « plus sains ¼. Ces constatations montrent qu'il est nécessaire d'apporter des changements structurels globaux à l'environnement alimentaire au détail de la Nouvelle-Écosse pour favoriser la santé de la population.

Correlation of age and rurality with low-urgency use of emergency medical services (LUEMS): A geographic analysis.

OBJECTIVES: Studies suggest that addressing the needs of the older population in rural areas may substantially reduce their low-urgency use of emergency medical services (LUEMS). It may ultimately also help improve the efficiency in our health system. There is, however, a dearth of evidence substantiating geographic patterns in LUEMS by different age cohorts. This exploratory study was aimed to clarify the understanding of emergency medical services (EMS) use in Nova Scotia through a geographic analysis. METHODS: Records with Canadian Triage and Acuity Scale of 4 and 5 were considered as LUEMS. We assessed the distribution of LUEMS incidence rates (proportion of LUEMS out of all EMS uses) by age and rurality, using descriptive statistics and Geographic Information Systems mapping. RESULTS: Nearly half of all EMS transports were individuals of 65+ years of age; 35% of those were LUEMS. The rates increased along with the level of rurality, and the older cohort had the highest incidence rates in non-metro communities. High rates were seen primarily in some rural communities farthest away from the capital/tertiary care centre. CONCLUSION: High LUEMS incidence rates are rural phenomena but not specific to the older population. However, the absolute number of LUEMS by the older cohort is significant, and elder-specific interventions in rural regions could still lead to effective cost savings. Further investigation of other factors, such as distance to the emergency department, availability of public transportation, and socioeconomic conditions of EMS users, is needed.

Misclassification errors from postal code-based geocoding to assign census geography in Nova Scotia, Canada.

OBJECTIVES: Postal codes are often the only available geographic identifiers in many sources of health data in Canada. In order to conduct geographic analyses, postal codes are routinely geocoded to census geography to link to ecological data. Despite common use of this method, the extent of geographic misclassification errors is poorly understood. We estimated misclassification errors in the geocoding of postal codes to assign census geography in Nova Scotia, Canada. METHODS: We examined differences between counts and match rates for postal-code geocoded and actual locations of buildings in Nova Scotia at two census administrative area levels: dissemination areas (DAs) and census subdivisions (CSDs). Actual locations were based on the data collected by the provincial government containing actual latitude/longitude of buildings. Variation in misclassification by rurality, using Statistics Canada's classification, was also assessed. RESULTS: Outside two urban areas (Halifax Metro and Sydney) which had <10% differences in counts, many DAs had >30% differences. Match rates showed similar patterns, with the vast majority of non-urban DAs having <40% match rates. Even in major urban areas, 10% of DAs had large misclassification errors. Misclassification errors at the CSD level were still too great to estimate counts or rates without further area aggregation. CONCLUSION: Routine use of postal code geocoding should be replaced with geocoding of location information using additional identifiers such as civic addresses or latitude and longitude. If data holders did this in-house before providing data to researchers, the accuracy and capacity of geographic analysis would be enhanced while protecting confidentiality.

A small-area analysis of inequalities in chronic disease prevalence across urban and non-urban communities in the Province of Nova Scotia, Canada, 2007-2011.

BACKGROUND: Small-area studies of health inequalities often have an urban focus, and may be limited in their translatability to non-urban settings. Using small-area units representing communities, this study assessed the influence of living in different settlement types (urban, town and rural) on the prevalence of four chronic diseases (heart disease, cancer, diabetes and stroke) and compared the degrees of associations with individual-level and community-level factors among the settlement types. METHODS: The associations between community-level and individual-level characteristics and prevalence of the chronic diseases were assessed using logistic regression (multilevel and non-multilevel) models. Individual-level data were extracted from the Canadian Community Health Survey (2007-2011). Indices of material deprivation and social isolation and the settlement type classification were created using the Canadian Census. RESULTS: Respondents living in towns were 21% more likely to report one of the diseases than respondents living in urban communities even after accounting for individual-level and community-level characteristics. Having dependent children appeared to have protective effects in towns, especially for males (OR: 0.49 (95% CI 0.27 to 0.90)). Unemployment had a strong association for all types of communities, but being unemployed appeared to be particularly damaging to health of males in urban communities (OR: 2.48 (95% CI 1.43 to 4.30)). CONCLUSIONS: The study showed that those living in non-urban settings, particularly towns, experience extra challenges in maintaining health above and beyond the socioeconomic condition and social isolation of the communities, and individual demographic, behavioural and socioeconomic attributes. Our findings also suggest that health inequality studies based on urban-only settings may underestimate the risks by some factors. Ways to devise meaningful small-area units comparable in all settlement types are necessary to help plan effective provision of chronic disease-related health services and programmes on a regional scale.

What type of rural? Assessing the variations in life expectancy at birth at small area-level for a small population province using classes of locally defined settlement types.

BACKGROUND: Although efforts have been made to articulate rural-urban health inequalities in recent years, results have been inconsistent due to different geographical scales used in these studies. Small-area level investigations of health inequalities will likely show more detailed pictures of health inequalities among diverse rural communities, but they are difficult to conduct, particularly in a small population region. The objectives of this study were: 1) to compare life expectancy at birth for females and males across small-areas classified by locally defined settlement types for a small province in Canada; 2) to assess whether any of the settlement types explains variations in life expectancy over and above the extent of socioeconomic disadvantage and social isolation; and 3) to examine variations in life expectancies within a (larger) area unit used as the basis of health inequality investigations in previous studies. METHODS: Seven settlement types were determined for the 'community' units based on population per-kilometre-road density and settlement forms. Mean life expectancies at birth for both genders were compared by settlement type, both for the entire province and within the Halifax Regional Municipality--the province's only census designated metropolitan area, but also contains rural settlements. Linear regression analyses were conducted to assess the statistical associations between life expectancy and the settlement types, adjusting for indicators of community-level deprivation. RESULTS: While types of communities considered as 'rural' generally had lower life expectancy for both genders, the effects of living in any settlement type were attenuated once adjusted for socioeconomic deprivation and social isolation. An exception was the village and settlement cluster type, which had additionally negative effects on health for females. There were some variations observed within the Halifax Regional Municipality, suggesting the importance of further investigating a variety of health and disease outcomes at smaller area-levels than those employed in previous studies. CONCLUSIONS: This paper highlighted the importance of further articulating the differences in the characteristics of rural at finer area-levels and the differential influence they may have on health. Further efforts are desirable to overcome various data challenges in order to extend the investigation of health inequalities to hard-to-study provinces.

Can emergency medical services use turnaround time as a proxy for measuring ambulance offload time?

BACKGROUND: "Offload delay" occurs when the transfer of care from paramedics to the emergency department (ED) is prolonged. Accurately measuring the delivery interval or "offload" is important, because it represents the time patients are waiting for definitive care. Because recording this interval presents a significant challenge, most emergency medical services systems only measure the complete at-hospital time or "turnaround interval," and most offload delay research and policy is based on this proxy. OBJECTIVE: This study sought to test the validity of using the turnaround interval as a surrogate for the delivery interval. METHODS: This observational study examined levels of correspondence, or correlation, between delivery interval and turnaround interval, to assess whether turnaround is a reasonable surrogate for delivery. Delivery and turnaround intervals were logged by Richmond Ambulance Authority (RAA) in Richmond, Virginia, United States from April 1 to December 31, 2008. A total of 1732 ambulance runs from RAA were included. RESULTS: Pearson's correlation analysis showed a good correlation between turnaround and actual offload time (delivery), with a coefficient (r) of 0.753. A post hoc analysis explored patterns in the relationship, which is quite complex. CONCLUSION: The results show that the correlation between the delivery and turnaround intervals is good. However, there remains much to be learned about the at-hospital time intervals and how to use these data to make decisions that will improve resource utilization and patient care. Efforts to establish a method to accurately record the delivery interval and to understand the at-hospital portion of the ambulance response are necessary.

Should we enhance the commonly used deprivation index for a regional context?

BACKGROUND/OBJECTIVES: Versions of deprivation indices have been increasingly used to monitor patterns and magnitudes of inequality in health. For policy-makers, it is of interest to assess whether they need to construct regionally tailored indices, or whether the existing indices perform sufficiently in detecting inequalities in their respective jurisdiction. Few studies have explored the benefits of constructing a more tailored index for a regional context. METHODS: The study examined, in linear regression models, the proportion of variance (adjusted R2) explained in age-standardized cardiovascular disease (CVD) incidence rate ratios by an index emulating a now-widely-used multiple deprivation index created in Quebec (INSPQI), and a newly created index for Nova Scotia with additional census variables. The magnitudes of inequality were compared by the differences between mean incidences of most and least deprived groups. RESULTS: The newly created deprivation index did not explain as well as the INSPQI-like index the community-level variability in CVD incidences. The gap in mean CVD incidences between the most and least deprived groups was somewhat narrower with the new index, indicating that the new index is not necessarily more sensitive to the inequality attributed to community social disadvantages. CONCLUSIONS: Complicating the indices may not necessarily be of benefit when used for surveillance of population health inequalities. For public health practitioners and decision makers who need to make quick decisions in provisions of services and programs, a generic, well-established deprivation index such as INSPQI can serve well in a regional context.

Coalfield health effects: variation in health across former coalfield areas in England.

Regions affected by deindustrialisation are often characterised by unfavourable local health profiles. This was the situation in coalfield areas in England, where the scale and suddenness of the job losses in the 1980s and 1990s left these communities experiencing difficult socioeconomic conditions, and associated poor health status. Using data from the Health Survey for England, this paper examines whether poorer health outcomes still characterise coalfield areas today. Findings confirm a 'coalfield health effect' related to limiting long-term illness. With regards to self reported general health and mental health outcomes, results are less clear. The population health profile of coalfield communities is not homogeneous, with some coalfield communities faring worse than others, indicating more localised health issues.

Fast food and deprivation in Nova Scotia.

OBJECTIVE: To examine the relationship between density of fast food restaurants and measures of social and material deprivation at the community level in Nova Scotia, Canada. METHODS: Census information on population and key variables required for the calculation of deprivation indices were obtained for 266 communities in Nova Scotia. The density of fast food restaurants per 1000 individuals for each community was calculated and communities were divided into quintiles of material and psychosocial deprivation. One-way analysis of variance was used to investigate associations between fast food outlet densities and deprivation scores at the community level. RESULTS: A statistically significant inverse association was found between community-level material deprivation and the mean number of fast food restaurants per 1000 people for Nova Scotia (p < 0.000). Significant positive relationships were found between density of fast food restaurants and psychosocial deprivation (p < 0.000). Both associations were principally linear with greater fast food outlet density occurring as material deprivation decreased and as psychosocial deprivation increased. INTERPRETATION: Community-level deprivation in Nova Scotia is associated with fast food outlet density and lends support for environmental explanations for variations in the prevalence of obesity. Such findings are valuable to population health intervention initiatives targeting the modification of environmental determinants of obesity.

Quantifying the spatial and temporal variation of ground-level ozone in the rural Annapolis Valley, Nova Scotia, Canada using nitrite-impregnated passive samplers.

The spatiotemporal variability of ground-level ozone (GLO) in the rural Annapolis Valley, Nova Scotia was investigated between August 29, 2006, and September 28, 2007, using Ogawa nitrite-impregnated passive diffusion samplers (PS). A total of 353 PS measurements were made at 17 ambient and 1 indoor locations over 18 sampling periods ranging from 2 to 4 weeks. The calculated PS detection limit was 0.8 +/- 0.02 parts per billion by volume (ppbv), for a 14-day sampling period. Duplicate samplers were routinely deployed at three sites and these showed excellent agreement (R2 values of 0.88 [n = 11], 0.95 [n = 17], and 0.96 [n = 17]), giving an overall PS imprecision value of 5.4%. Comparisons between PS and automated continuous ozone analyzers at three sites also demonstrated excellent agreement with R2 values of 0.82, 0.95, and 0.95, and gradients not significantly different from unity. The minimum, maximum, and mean (+/- 1 sigma) ambient annual GLO concentrations observed were 7.7, 72.1, and 34.3 +/- 10.1 ppbv, respectively. The three highest sampling sites had significantly greater (P = 0.032) GLO concentrations than three Valley floor sites, and there was a strong correlation between concentration and elevation (R2 = 0.82). Multivariate models were used to parameterize the observed GLO concentrations in terms of prevailing meteorology at an elevated site found at Kejimkujik National Park and also at a site on the Valley floor. Validation of the multivariate models using 30 months of historical meteorological data at these sites yielded R2 values of 0.70 (elevated site) and 0.61 (Valley floor). The mean indoor ozone concentration was 5.4 +/- 3.3 ppbv and related to ambient GLO concentration by the equation: indoor = 0.34 x ambient - 5.07. This study has demonstrated the suitability of PS for long-term studies of GLO over a wide geographic area and the effect of topographical and meteorological influences on GLO in this region.

A population-based analysis of the health experience of African Nova Scotians.

BACKGROUND: People of African descent living in Britain and the United States have higher rates of morbidity from chronic disease than among the general population. We investigated whether the same applied to people of African descent living in a Canadian province. METHODS: We used administrative data to calculate 10-year cumulative incidence rate ratios for the period 1996-2005 for treated circulatory disease, diabetes mellitus and psychiatric disorders in Preston (population 2425), a community of predominantly African Nova Scotians. We used data for the province of Nova Scotia as a whole as the population reference standard. We also calculated 10-year incidence rate ratios for visits to family physicians and specialists and for admissions to hospital. We compared these findings with those in 7 predominantly white communities in Nova Scotia with otherwise similar socio-economic characteristics. RESULTS: In the province as a whole, we identified 787,787 incident cases for the 3 disease groups over the 10-year period. Incidence rate ratios for the community of interest relative to the provincial population were significantly elevated for the 3 diseases: circulatory disease (1.19, 95% CI 1.08-1.29), diabetes (1.43, 95% CI 1.21-1.64) and psychiatric disorders (1.13, 95% CI 1.06-1.20). Incidence rate ratios in the community of interest were also higher than those in the comparison communities. Visits to family physicians and specialists for circulatory disease and diabetes were similarly elevated, but the pattern was less clear for visits for psychiatric disorders and hospital admissions. INTERPRETATION: African Nova Scotians had higher morbidity levels associated with treated disease, which could not be explained by socio-economic characteristics, recent immigration or language. Apart from psychiatric disorders, use of specialist services was consistent with morbidity. Further study is needed to investigate the relative contribution of genetic, biological, behavioural, psychosocial and environmental factors.