Follow the Arrows: Using a Co-Created Causal Loop Diagram to Explore Leverage Points to Strengthen Population Physical Activity Promotion in British Columbia, Canada.

BACKGROUND: Population physical activity promotion (PPAP) is one of the most effective noncommunicable disease prevention strategies, yet coordination is lacking around the world. Whole-of-system approaches and complex systems methods are called for to advance PPAP. This paper reports on a project which (1) used an Attributes Framework with system mapping (group model building and causal loop diagramming of feedback loops) and (2) identified potential leverage points to address the challenge of effective coordination of multisectoral PPAP in British Columbia. METHODS: Key findings from stakeholder interviews and workshops described the current system for PPAP in terms of attributes and dimensions in the framework. These were translated into variables and used in group model building. Participants prioritized the importance of variables to address the coordination challenge and then created causal loop diagrams in 3 small groups. One collective causal loop diagram was created, and top priority variables and associated feedback loops were highlighted to explore potential leverage points. RESULTS: Leverage points included the relationships and feedback loops among priority variables: political leadership, visible policy support and governance, connectivity for knowledge translation, collaborative multisector grants, multisector collaboration, and integrating co-benefits. Leveraging and altering "vicious" cyclical patterns to increase coordinated multisector PPAP are key. CONCLUSIONS: The Attributes Framework, group model building and causal loop diagrams, and emergent feedback loops were useful to explore potential leverage points to address the challenge of multisectoral coordination of PPAP. Future research could apply the same methods in other jurisdictions and compare and contrast resultant frameworks, variables, feedback loops, and leverage points.

Cohort profile: the British Columbia COVID-19 Cohort (BCC19C)-a dynamic, linked population-based cohort.

Purpose: The British Columbia COVID-19 Cohort (BCC19C) was developed from an innovative, dynamic surveillance platform and is accessed/analyzed through a cloud-based environment. The platform integrates recently developed provincial COVID-19 datasets (refreshed daily) with existing administrative holdings and provincial registries (refreshed weekly/monthly). The platform/cohort were established to inform the COVID-19 response in near "real-time" and to answer more in-depth epidemiologic questions. Participants: The surveillance platform facilitates the creation of large, up-to-date analytic cohorts of people accessing COVID-19 related services and their linked medical histories. The program of work focused on creating/analyzing these cohorts is referred to as the BCC19C. The administrative/registry datasets integrated within the platform are not specific to COVID-19 and allow for selection of "control" individuals who have not accessed COVID-19 services. Findings to date: The platform has vastly broadened the range of COVID-19 analyses possible, and outputs from BCC19C analyses have been used to create dashboards, support routine reporting and contribute to the peer-reviewed literature. Published manuscripts (total of 15 as of July, 2023) have appeared in high-profile publications, generated significant media attention and informed policy and programming. In this paper, we conducted an analysis to identify sociodemographic and health characteristics associated with receiving SARS-CoV-2 laboratory testing, testing positive, and being fully vaccinated. Other published analyses have compared the relative clinical severity of different variants of concern; quantified the high "real-world" effectiveness of vaccines in addition to the higher risk of myocarditis among younger males following a 2nd dose of an mRNA vaccine; developed and validated an algorithm for identifying long-COVID patients in administrative data; identified a higher rate of diabetes and healthcare utilization among people with long-COVID; and measured the impact of the pandemic on mental health, among other analyses. Future plans: While the global COVID-19 health emergency has ended, our program of work remains robust. We plan to integrate additional datasets into the surveillance platform to further improve and expand covariate measurement and scope of analyses. Our analyses continue to focus on retrospective studies of various aspects of the COVID-19 pandemic, as well as prospective assessment of post-acute COVID-19 conditions and other impacts of the pandemic.

Health trends in Canada 1990-2019: An analysis for the Global Burden of Disease Study.

OBJECTIVE: Monitoring trends in key population health indicators is important for informing health policies. The aim of this study was to examine population health trends in Canada over the past 30 years in relation to other countries. METHODS: We used data on disability-adjusted life years (DALYs), years of life lost (YLL), years lived with disability, life expectancy (LE), and child mortality for Canada and other countries between 1990 and 2019 provided by the Global Burden of Disease Study. RESULTS: Life expectancy, age-standardized YLL, and age-standardized DALYs all improved in Canada between 1990 and 2019, although the rate of improvement has leveled off since 2011. The top five causes of all-age DALYs in Canada in 2019 were neoplasms, cardiovascular diseases, musculoskeletal disorders, neurological disorders, and mental disorders. The greatest increases in all-age DALYs since 1990 were observed for substance use, diabetes and chronic kidney disease, and sense organ disorders. Age-standardized DALYs declined for most conditions, except for substance use, diabetes and chronic kidney disease, and musculoskeletal disorders, which increased by 94.6%, 14.6%, and 7.3% respectively since 1990. Canada's world ranking for age-standardized DALYs declined from 9th place in 1990 to 24th in 2019. CONCLUSION: Canadians are healthier today than in 1990, but progress has slowed in Canada in recent years in comparison with other high-income countries. The growing burden of substance abuse, diabetes/chronic kidney disease, and musculoskeletal diseases will require continued action to improve population health.

RéSUMé: OBJECTIF: La surveillance des tendances des indicateurs clés de la santé de la population est importante pour éclairer les politiques de santé. Dans cette étude, nous avons examiné les tendances de la santé de la population au Canada au cours des 30 dernières années par rapport à d'autres pays. MéTHODES: Nous avons utilisé des données sur les années de vie ajustées en fonction de l'incapacité (DALY), les années de vie perdues (YLL), les années vécues avec un handicap, l'espérance de vie (LE) et la mortalité infantile pour le Canada et d'autres pays entre 1990 et 2019, fournies par l'Étude mondiale sur le fardeau de la maladie. RéSULTATS: L'espérance de vie, les YLL ajustées selon l'âge et les DALY ajustées selon l'âge ont tous connu une amélioration au Canada entre 1990 et 2019, bien que le taux d'amélioration se soit stabilisé depuis 2011. Les cinq principales causes des DALY pour tous les âges au Canada en 2019 étaient les néoplasmes, les maladies cardiovasculaires, les affections musculosquelettiques, les affections neurologiques et les troubles mentaux. Les plus fortes augmentations des DALY pour tous les âges depuis 1990 ont été observées pour l'usage de substances, le diabète et les maladies rénales chroniques, ainsi que les troubles des organes sensoriels. Les DALY ajustées selon l'âge ont diminué pour la plupart des conditions, à l'exception de l'usage de substances, du diabète et des maladies rénales chroniques, ainsi que des troubles musculosquelettiques, qui ont augmenté de 94,6 %, 14,6 % et 7,3 % respectivement depuis 1990. Le classement mondial du Canada pour les DALY ajustées selon l'âge est diminué de la 9ième place en 1990 à la 24ième place en 2019. CONCLUSION: Les Canadiens sont en meilleure santé aujourd'hui qu'en 1990, mais les progrès se sont ralentis ces dernières années par rapport à d'autres pays à revenu élevé. La croissance du fardeau lié à l'abus de substances, au diabète/maladies rénales chroniques et aux affections musculosquelettiques exigera des actions continues pour améliorer la santé de la population.

Elusive boundaries: using an attribute framework to describe systems for population physical activity promotion.

The cost of physical inactivity is alarming, and calls for whole-of-system approaches to population physical activity promotion (PPAP) are increasing. One innovative approach to PPAP is to use a framework of interdependent attributes and associated dimensions of effective systems for chronic disease prevention. Describing system boundaries can be an elusive task, and this article reports on using an attribute framework as a first step in describing and then assessing and strengthening a provincial system for PPAP in British Columbia, Canada. Interviews were conducted with provincial stakeholders to gather perspectives regarding attributes of the system. Following this, two workshops were facilitated to document important stories about the current system for PPAP and link story themes with attributes. Results from interviews and workshops were summarized into key findings and a set of descriptive statements. One hundred and twenty-one statements provide depth, breadth and scope to descriptions of the system through the lens of an adapted framework including four attributes: (i) implementation of desired actions, (ii) resources, (iii) leadership and (iv) collaborative capacity. The attribute framework was a useful tool to guide a whole-of-system approach and turn elusive boundaries into rich descriptors of a provincial system for PPAP. Immediate implications for our research are to translate descriptive statements into variables, then assess the system through group model building and identify leverage points from a causal loop diagram to strengthen the system. Future application of this approach in other contexts, settings and health promotion and disease prevention topics is recommended.

Association of COVID-19 Infection With Incident Diabetes.

Importance: SARS-CoV-2 infection may lead to acute and chronic sequelae. Emerging evidence suggests a higher risk of diabetes after infection, but population-based evidence is still sparse. Objective: To evaluate the association between COVID-19 infection, including severity of infection, and risk of diabetes. Design, Setting, and Participants: This population-based cohort study was conducted in British Columbia, Canada, from January 1, 2020, to December 31, 2021, using the British Columbia COVID-19 Cohort, a surveillance platform that integrates COVID-19 data with population-based registries and administrative data sets. Individuals tested for SARS-CoV-2 by real-time reverse transcription-polymerase chain reaction (RT-PCR) were included. Those who tested positive for SARS-CoV-2 (ie, those who were exposed) were matched on sex, age, and collection date of RT-PCR test at a 1:4 ratio to those who tested negative (ie, those who were unexposed). Analysis was conducted January 14, 2022, to January 19, 2023. Exposure: SARS-CoV-2 infection. Main Outcomes and Measures: The primary outcome was incident diabetes (insulin dependent or not insulin dependent) identified more than 30 days after the specimen collection date for the SARS-CoV-2 test with a validated algorithm based on medical visits, hospitalization records, chronic disease registry, and prescription drugs for diabetes management. Multivariable Cox proportional hazard modeling was performed to evaluate the association between SARS-CoV-2 infection and diabetes risk. Stratified analyses were performed to assess the interaction of SARS-CoV-2 infection with diabetes risk by sex, age, and vaccination status. Results: Among 629 935 individuals (median [IQR] age, 32 [25.0-42.0] years; 322 565 females [51.2%]) tested for SARS-CoV-2 in the analytic sample, 125 987 individuals were exposed and 503 948 individuals were unexposed. During the median (IQR) follow-up of 257 (102-356) days, events of incident diabetes were observed among 608 individuals who were exposed (0.5%) and 1864 individuals who were not exposed (0.4%). The incident diabetes rate per 100 000 person-years was significantly higher in the exposed vs nonexposed group (672.2 incidents; 95% CI, 618.7-725.6 incidents vs 508.7 incidents; 95% CI, 485.6-531.8 incidents; P < .001). The risk of incident diabetes was also higher in the exposed group (hazard ratio [HR], 1.17; 95% CI, 1.06-1.28) and among males (adjusted HR, 1.22; 95% CI, 1.06-1.40). The risk of diabetes was higher among people with severe disease vs those without COVID-19, including individuals admitted to the intensive care unit (HR, 3.29; 95% CI, 1.98-5.48) or hospital (HR, 2.42; 95% CI, 1.87-3.15). The fraction of incident diabetes cases attributable to SARS-CoV-2 infection was 3.41% (95% CI, 1.20%-5.61%) overall and 4.75% (95% CI, 1.30%-8.20%) among males. Conclusions and Relevance: In this cohort study, SARS-CoV-2 infection was associated with a higher risk of diabetes and may have contributed to a 3% to 5% excess burden of diabetes at a population level.

A scoping review of complex systems methods used in population physical activity research: do they align with attributes of a whole system approach?

BACKGROUND: Complex systems approaches are increasingly used in health promotion and noncommunicable disease prevention research, policy and practice. Questions emerge as to the best ways to take a complex systems approach, specifically with respect to population physical activity (PA). Using an Attributes Model is one way to understand complex systems. We aimed to examine the types of complex systems methods used in current PA research and identify what methods align with a whole system approach as reflected by an Attributes Model. METHODS: A scoping review was conducted and two databases were searched. Twenty-five articles were selected and data analysis was based upon the following: the complex systems research methods used, research aims, if participatory methods were used and evidence of discussion regarding attributes of systems. RESULTS: There were three groups of methods used: system mapping, simulation modelling and network analysis. System mapping methods appeared to align best with a whole system approach to PA promotion because they largely aimed to understand complex systems, examined interactions and feedback among variables, and used participatory methods. Most of these articles focused on PA (as opposed to integrated studies). Simulation modelling methods were largely focused on examining complex problems and identifying interventions. These methods did not generally focus on PA or use participatory methods. While network analysis articles focused on examining complex systems and identifying interventions, they did not focus on PA nor use participatory methods. All attributes were discussed in some way in the articles. Attributes were explicitly reported on in terms of findings or were part of discussion and conclusion sections. System mapping methods appear to be well aligned with a whole system approach because these methods addressed all attributes in some way. We did not find this pattern with other methods. CONCLUSIONS: Future research using complex systems methods may benefit from applying the Attributes Model in conjunction with system mapping methods. Simulation modelling and network analysis methods are seen as complementary and could be used when system mapping methods identify priorities for further investigation (e.g. what interventions to implement or how densely connected relationships are in systems).

Risk factors for COVID-19 hospitalization after COVID-19 vaccination: a population-based cohort study in Canada.

OBJECTIVES: With the uptake of COVID-19 vaccines, there is a need for population-based studies to assess risk factors for COVID-19-related hospitalization after vaccination and how they differ from unvaccinated individuals. METHODS: We used data from the British Columbia COVID-19 Cohort, a population-based cohort that includes all individuals (aged ≥18 years) who tested positive for SARS-CoV-2 by real-time reverse transcription-polymerase chain reaction from January 1, 2021 (after the start of vaccination program) to December 31, 2021. We used multivariable logistic regression models to assess COVID-19-related hospitalization risk by vaccination status and age group among confirmed COVID-19 cases. RESULTS: Of the 162,509 COVID-19 cases included in the analysis, 8,546 (5.3%) required hospitalization. Among vaccinated individuals, an increased odds of hospitalization with increasing age was observed for older age groups, namely those aged 50-59 years (odds ratio [OR] = 2.95, 95% confidence interval [CI]: 2.01-4.33), 60-69 years (OR = 4.82, 95% CI: 3.29, 7.07), 70-79 years (OR = 11.92, 95% CI: 8.02, 17.71), and ≥80 years (OR = 24.25, 95% CI: 16.02, 36.71). However, among unvaccinated individuals, there was a graded increase in odds of hospitalization with increasing age, starting at age group 30-39 years (OR = 2.14, 95% CI: 1.90, 2.41) to ≥80 years (OR = 41.95, 95% CI: 35.43, 49.67). Also, comparing all the age groups to the youngest, the observed magnitude of association was much higher among unvaccinated individuals than vaccinated ones. CONCLUSION: Alongside a number of comorbidities, our findings showed a strong association between age and COVID-19-related hospitalization, regardless of vaccination status. However, age-related hospitalization risk was reduced two-fold by vaccination, highlighting the need for vaccination in reducing the risk of severe disease and subsequent COVID-19-related hospitalization across all population groups.

Mental Health and Substance Use Associated with Hospitalization among People with COVID-19: A Population-Based Cohort Study.

This study identified factors associated with hospital admission among people with laboratory-diagnosed COVID-19 cases in British Columbia. The study used data from the BC COVID-19 Cohort, which integrates data on all COVID-19 cases with data on hospitalizations, medical visits, emergency room visits, prescription drugs, chronic conditions and deaths. The analysis included all laboratory-diagnosed COVID-19 cases in British Columbia to 15 January 2021. We evaluated factors associated with hospital admission using multivariable Poisson regression analysis with robust error variance. Of the 56,874 COVID-19 cases included in the analysis, 2298 were hospitalized. Factors associated with increased hospitalization risk were as follows: male sex (adjusted risk ratio (aRR) = 1.27; 95% CI = 1.17-1.37), older age (p-trend < 0.0001 across age groups increasing hospitalization risk with increasing age [aRR 30-39 years = 3.06; 95% CI = 2.32-4.03, to aRR 80+ years = 43.68; 95% CI = 33.41-57.10 compared to 20-29 years-old]), asthma (aRR = 1.15; 95% CI = 1.04-1.26), cancer (aRR = 1.19; 95% CI = 1.09-1.29), chronic kidney disease (aRR = 1.32; 95% CI = 1.19-1.47), diabetes (treated without insulin aRR = 1.13; 95% CI = 1.03-1.25, requiring insulin aRR = 5.05; 95% CI = 4.43-5.76), hypertension (aRR = 1.19; 95% CI = 1.08-1.31), injection drug use (aRR = 2.51; 95% CI = 2.14-2.95), intellectual and developmental disabilities (aRR = 1.67; 95% CI = 1.05-2.66), problematic alcohol use (aRR = 1.63; 95% CI = 1.43-1.85), immunosuppression (aRR = 1.29; 95% CI = 1.09-1.53), and schizophrenia and psychotic disorders (aRR = 1.49; 95% CI = 1.23-1.82). In an analysis restricted to women of reproductive age, pregnancy (aRR = 2.69; 95% CI = 1.42-5.07) was associated with increased risk of hospital admission. Older age, male sex, substance use, intellectual and developmental disability, chronic comorbidities, and pregnancy increase the risk of COVID-19-related hospitalization.

Implementation of Physical Activity Interventions in Rural, Remote, and Northern Communities: A Scoping Review.

Compared with urban centers, rural, remote, and northern communities face substantial health inequities and increased rates of noncommunicable disease fuelled, in part, by decreased participation in physical activity. Understanding how the unique sociocultural and environmental factors in rural, remote, and northern communities contribute to implementation of physical activity interventions can help guide health promotion policy and practice. A scoping review was conducted to map literature describing the implementation of physical activity interventions in rural, remote, and/or northern communities. Databases MEDLINE, PsycINFO, EMBASE, CINAHL, and SPORTDiscus were searched using a predetermined search strategy. Outcomes of interest included community demographics, program characteristics, intervention results, measures of implementation, and facilitators or barriers to implementation. A total of 1672 articles were identified from a search of databases, and 8 from a targeted hand search. After screening based on inclusion and exclusion criteria, 12 articles were summarized in a narrative review. Prominent barriers to physical activity program implementation included transportation, lack of infrastructure, sociocultural factors, and weather. Facilitators of program success included flexibility and creativity on the part of the implementation team, leveraging community relationships, and shared resources. Few papers reported on traditional implementation outcomes such as fidelity, dose, and quality. There is a lack of rigorous implementation evaluations of physical activity interventions delivered in rural, remote, or northern communities. Positive aspects of rural life, such as social cohesion and willingness to share resources, appear to contribute to successful program implementation.

Decreasing antibiotic use, the gut microbiota, and asthma incidence in children: evidence from population-based and prospective cohort studies.

BACKGROUND: Childhood asthma incidence is decreasing in some parts of Europe and North America. Antibiotic use in infancy has been associated with increased asthma risk. In the present study, we tested the hypothesis that decreases in asthma incidence are linked to reduced antibiotic prescribing and mediated by changes in the gut bacterial community. METHODS: This study comprised population-based and prospective cohort analyses. At the population level, we used administrative data from British Columbia, Canada (population 4·7 million), on annual rates of antibiotic prescriptions and asthma diagnoses, to assess the association between antibiotic prescribing (at age <1 year) and asthma incidence (at age 1-4 years). At the individual level, 2644 children from the Canadian Healthy Infant Longitudinal Development (CHILD) prospective birth cohort were examined for the association of systemic antibiotic use (at age <1 year) with the diagnosis of asthma (at age 5 years). In the same cohort, we did a mechanistic investigation of 917 children with available 16S rRNA gene sequencing data from faecal samples (at age ≤1 year), to assess how composition of the gut microbiota relates to antibiotic exposure and asthma incidence. FINDINGS: At the population level between 2000 and 2014, asthma incidence in children (aged 1-4 years) showed an absolute decrease of 7·1 new diagnoses per 1000 children, from 27·3 (26·8-28·3) per 1000 children to 20·2 (19·5-20·8) per 1000 children (a relative decrease of 26·0%). Reduction in incidence over the study period was associated with decreasing antibiotic use in infancy (age <1 year), from 1253·8 prescriptions (95% CI 1219·3-1288·9) per 1000 infants to 489·1 (467·6-511·2) per 1000 infants (Spearman's r=0·81; p<0·0001). Asthma incidence increased by 24% with each 10% increase in antibiotic prescribing (adjusted incidence rate ratio 1·24 [95% CI 1·20-1·28]; p<0·0001). In the CHILD cohort, after excluding children who received antibiotics for respiratory symptoms, asthma diagnosis in childhood was associated with infant antibiotic use (adjusted odds ratio [aOR] 2·15 [95% CI 1·37-3·39]; p=0·0009), with a significant dose-response; 114 (5·2%) of 2182 children unexposed to antibiotics had asthma by age 5 years, compared with 23 (8·1%) of 284 exposed to one course, five (10·2%) of 49 exposed to two courses, and six (17·6%) of 34 exposed to three or more courses (aOR 1·44 [1·16-1·79]; p=0·0008). Increasing α-diversity of the gut microbiota, defined as an IQR increase (25th to 75th percentile) in the Chao1 index, at age 1 year was associated with a 32% reduced risk of asthma at age 5 years (aOR for IQR increase 0·68 [0·46-0·99]; p=0·046). In a structural equation model, we found the gut microbiota at age 1 year, characterised by α-diversity, ß-diversity, and amplicon sequence variants modified by antibiotic exposure, to be a significant mediator between outpatient antibiotic exposure in the first year of life and asthma diagnosis at age 5 years (ß=0·08; p=0·027). INTERPRETATION: Our findings suggest that the reduction in the incidence of paediatric asthma observed in recent years might be an unexpected benefit of prudent antibiotic use during infancy, acting via preservation of the gut microbial community. FUNDING: British Columbia Ministry of Health, Pharmaceutical Services Branch; Canadian Institutes of Health Research; Allergy, Genes and Environment (AllerGen) Network of Centres of Excellence; Genome Canada; and Genome British Columbia.

Move the north: evaluation of a regional stakeholder engagement initiative to support the development of a community-partnered physical activity research agenda.

BACKGROUND: Although it is generally accepted that engaging with members of the public contributes to more actionable and relevant research, there are a limited number of reported evaluations of community engagement initiatives. Certain populations, such as those with lower socioeconomic status and those who live in rural or dispersed communities, tend to face increased barriers to engagement. For researchers and community members alike, it is important to understand and evaluate engagement initiatives to support participatory research methods, particularly when working with underserved or hard to reach populations. METHODS: Over 2-days in October 2018, we hosted a Research Agenda Development Workshop and Physical Activity Summit with relevant researchers, health professionals, and community partners. The objectives of this initiative were to develop a physical activity research agenda based on community-identified priorities, create networking opportunities, and understand factors impacting physical activity participation in communities across northern British Columbia (BC). An evaluation plan was created early in the planning process to understand the reach of the event based on representation targets. Stakeholder satisfaction with the event was evaluated with a post-meeting survey. RESULTS: The event was successful in engaging community members from a broad geographic region with at least 90 people in attendance from 11 different northern BC communities, representing 46 different organizations. Meeting attendees indicated they were satisfied with the event and felt their perspectives were heard. To advance physical activity in the region, the most commonly desired outcome from the event was the need for ongoing communication channels to support knowledge translation and capacity building in the low-resourced communities of northern BC. There were some gaps in representation targets present at the event. Namely, there were a limited number of people representing Indigenous organizations, and the education and private sectors. CONCLUSIONS: This two-day event was successful at achieving its objectives and engaged a diverse group of stakeholders from a broad geographic region. The outcomes from this event are being used to develop a community-partnered physical activity research agenda and contribute to ongoing learning by the research team to understand contextual factors influencing physical activity in the communities of northern BC. This model of engagement could be used by other researchers interested in engaging with a diverse, multi-sector group of academics, health professionals and community members to support community-centered population health research.

The association of material deprivation component measures with injury hospital separations in British Columbia, Canada.

BACKGROUND: This study examines social disparities across neighbourhood levels of income, education and employment in relation to overall injury hospital separations in the province of British Columbia, Canada. Further, the study examines the relationships of social disparities to a set of three injury prevention priorities in British Columbia, namely, transport (motor vehicle occupant, pedestrian and cyclist), falls among older adults, and youth self-harm. The goal being to better understand area-based injury incidence with a view to precision prevention initiatives, particularly for more vulnerable populations. METHODS: Acute hospital separations from the Discharge Abstract Database were identified for all causes of injury and the three BC injury prevention priorities for the period April 1, 2009 to March 31, 2014, inclusive. An ecological approach was applied where each hospital separation case was attributed with the income, education and employment level according to the injured individual's area of residence, derived from the 2011 CensusPlus data. RESULTS: Injury hospital separation data were available for 191 Forward Sortation Areas in BC. Between April 1, 2009 and March 31, 2014, there was a total of 177,861 injury-related hospital separations, averaging 35,572 hospital separations per year and an annual rate of 779 injury hospital separations per 100,000 population. Injury hospital separation rates varied with the measured neighbourhood area socioeconomic status variables. Injury hospital separation rates demonstrated an inverse relationship with neighbourhood levels of income and education. Neighbourhood area socioeconomic status differences were also associated with the injury hospital separation rates for falls among older adults, motor vehicle crashes involving motor vehicle occupants, pedestrians, cyclists and young drivers, and youth self-harm. CONCLUSIONS: The study results show that neighbourhood levels of income, education and employment are associated with the risk of injury hospital separation. In particular, low education levels in FSAs was associated with increased risk of injury hospital separation, mainly for motor vehicle occupants, pedestrians, young drivers, and youth self-harm. The results of this study provide useful information for implementing injury prevention initiatives and interventions in BC to align with the provincial public health system and road safety strategy goals, particularly for identified priorities.

Area-based socioeconomic disparities in mortality due to unintentional injury and youth suicide in British Columbia, 2009-2013. / Disparités socioéconomiques et spatiales dans les décès attribuables au suicide chez les jeunes et aux blessures non intentionnelles en Colombie-Britannique (2009-2013).

INTRODUCTION: The association between health outcomes and socioeconomic status (SES) has been widely documented, and mortality due to unintentional injuries continues to rank among the leading causes of death among British Columbians. This paper quantified the SES-related disparities in the mortality burden of three British Columbia's provincial injury prevention priority areas: falls among seniors, transport injury, and youth suicide. METHODS: Mortality data (2009 to 2013) from Vital Statistics and dissemination area or local health area level socioeconomic data from CensusPlus 2011 were linked to examine age-standardized mortality rates (ASMRs) and disparities in ASMRs of unintentional injuries and subtypes including falls among seniors (aged 65+) and transport-related injuries as well as the intentional injury type of youth suicide (aged 15 to 24). Disparities by sex and geography were examined, and relative and absolute disparities were calculated between the least and most privileged areas based on income, education, employment, material deprivation, and social deprivation quintiles. RESULTS: Our study highlighted significant sex differences in the mortality burden of falls among seniors, transport injury, and youth suicide with males experiencing significantly higher mortality rates. Notable geographic variations in overall unintentional injury ASMR were also observed across the province. In general, people living in areas with lower income and higher levels of material deprivation had increasingly higher mortality rates compared to their counterparts living in more privileged areas. CONCLUSION: The significant differences in unintentional and intentional injury-related mortality outcomes between the sexes and by SES present opportunities for targeted prevention strategies that address the disparities.

Discriminatory Performance of the Calcaneal Quantitative Ultrasound and Osteoporosis Self-Assessment Tool to Select Older Women for Dual-Energy X-ray Absorptiometry.

The objective of this cross-sectional study was to evaluate the accuracy of the calcaneal quantitative ultrasound (QUS) and the Osteoporosis Self-Assessment Tool (OST) in identifying older women with osteoporosis as defined by dual-energy X-ray absorptiometry (DXA), and to establish optimal cutoffs to determine risk. We assessed bone mineral density of the femoral neck and lumbar spine using DXA and subsequent calcaneal QUS and OST measurements in 174 women aged 50-80 years. Pearson product correlation coefficients between QUS, OST, and DXA parameters were calculated. Receiver operating characteristic curves were constructed and areas under the curves (AUCs) and optimal thresholds for QUS and OST were defined based on sensitivity, specificity, and likelihood ratio analysis. The ability of calcaneal QUS to identify women with a T-score ≤-2.5 at the femoral neck (AUC = 0.892) consistently outperformed a T-score ≤-2.5 at the lumbar spine (AUC = 0.696) and OST at both the femoral neck and lumbar spine (AUC = 0.706-0.807). Stiffness index cutoff values that fall between 65 and 78 were found to warrant DXA screening, with a cutoff <65 indicating high likelihood of osteoporosis. Further prospective research is needed to examine the gender-related differences of QUS and OST diagnostic performance and their usefulness in clinical practice.

Life expectancy ranking of Canadians among the populations in selected OECD countries and its disparities among British Columbians.

BACKGROUND: Canada is among the world's leading nations with the longest life expectancy at birth (LE0), and British Columbia (BC) ranks top among Canadian provinces and territories for LE0 in both men and women. This paper examined recent data as well as projected trends in LE0 of Canadian men and women and explored the geographic and socioeconomic disparities in LE0 specific to BC. METHODS: Using retrospective data on LE0 and age-standardized mortality rates, Canada was compared to 11 other Organization for Economic Cooperation and Development (OECD) countries with the longest LE0. Projections were made using linear regression modelling to the year of 2023. The association between regional LE0 and regional socioeconomic status (SES) was examined for the province of BC using its Local Health Area (LHA) level data on SES and LE0. RESULTS: In 2009, Canadian men (LE0: 78.7 years) and women (LE0: 83.3 years) ranked 7(th) and 8(th), respectively among the 12 OECD nations under comparison. Significantly smaller annual gains in LE0 contributed to the losing of their top ranks in LE0 for Canadian men and women in recent years, which was projected to sustain. Higher mortality risks, particularly for lung cancer and external causes of mortality among women was found for Canada compared to leading countries on these measures. Geographic variations were evident in LE0 in BC, and there was a significant gap of 3.6 years in the average LE0 for BC's LHAs in the lowest SES tertile (78.6 years, 95% CI: 78.0-79.3) compared to those in the highest SES tertile (82.2 years, 95% CI: 81.6-82.8). CONCLUSIONS: Canada continues to remain one of the OECD countries with longest living population. With the highest LE0 in the country, British Columbia has an opportunity to address socio-economic disparities in LE0.

Differences in fall injury hospitalization and related survival rates among older adults across age, sex, and areas of residence in Canada.

BACKGROUND: Falls are the leading cause of injury-related hospital admissions in Canadian older adults, accounting for 85 % of injury hospitalizations among older adults aged over 65 years. While many of these injuries can lead to death, the survival rates of fall-related injuries are rarely examined. This surveillance study examined the fall injury hospitalization and survival rates among older adults in the context of place. METHODS: Saskatchewan's health administrative data on injury hospitalizations among individuals aged 65 years and over (n = 39,867) was utilized for this study. Variables of interest included age group, sex, and the geographical area of residence at the time of hospitalization (rural, urban, north). Logistic regression analysis was applied to determine the association of variables of interest (age group, sex, and area of residence at the time of hospitalization as the covariate) with frequency of fall injury hospitalizations. Probable time to death due to fall-related injury hospitalization was determined by survival analysis. RESULTS: Three key findings that emerged from the present study are the following: (1) fall injury hospitalizations accounted for 77 % of all injury hospitalizations; (2) fall injury hospitalization rates varied by age group, sex, and area of residence, with advancing age, women, and certain geographical areas showing higher rates; and (3) survival rates also varied by sex and area of residence. Women had longer survival estimates after a fall injury hospitalization compared to men, and those living in the north have the shortest survival estimates. CONCLUSIONS: The findings from the study highlighted the high rate of fall-related injury hospitalization among older adults varying with their age group, sex, and area of residence. These factors need to be considered in injury surveillance and fall prevention research as well as programs and policies that support the reduction of falls.

Enhancing capacity for risk factor surveillance at the regional/local level: a follow-up review of the findings of the Canadian Think Tank Forum after 4 years.

BACKGROUND: National health surveys are sometimes used to provide estimates on risk factors for policy and program development at the regional/local level. However, as regional/local needs may differ from national ones, an important question is how to also enhance capacity for risk factor surveillance regionally/locally. METHODS: A Think Tank Forum was convened in Canada to discuss the needs, characteristics, coordination, tools and next steps to build capacity for regional/local risk factor surveillance. A series of follow up activities to review the relevant issues pertaining to needs, characteristics and capacity of risk factor surveillance were conducted. RESULTS: Results confirmed the need for a regional/local risk factor surveillance system that is flexible, timely, of good quality, having a communication plan, and responsive to local needs. It is important to conduct an environmental scan and a gap analysis, to develop a common vision, to build central and local coordination and leadership, to build on existing tools and resources, and to use innovation. CONCLUSIONS: Findings of the Think Tank Forum are important for building surveillance capacity at the local/county level, both in Canada and globally. This paper provides a follow-up review of the findings based on progress over the last 4 years.

Surveillance of ischemic heart disease should include physician billing claims: population-based evidence from administrative health data across seven Canadian provinces.

BACKGROUND: Canadian provinces and territories routinely collect health information for administrative purposes. This study used Canadian medical and hospital administrative data for population-based surveillance of diagnosed ischemic heart disease (IHD). METHODS: Hospital discharge abstracts and physician billing claims data from seven provinces were analyzed to estimate prevalence and incidence of IHD using three validated algorithms: a) one hospital discharge abstract with an IHD diagnosis or procedure code (1H); b) 1H or at least three physician claims within a one-year period (1H3P) and c) 1H or at least two physician claims within a one-year period (1H2P). Crude and age-standardized prevalence and incidence rates were calculated for Canadian adults aged 20 +. RESULTS: IHD prevalence and incidence varied by province, were consistently higher among males than females, and increased with age. Prevalence and incidence were lower using the 1H method compared to using the 1H2P or 1H3P methods in all provinces studied for all age groups. For instance, in 2006/07, crude prevalence by province ranged from 3.4%-5.5% (1H), from 4.9%-7.7% (1H3P) and from 6.0%-9.2% (1H2P). Similarly, crude incidence by province ranged from 3.7-5.9 per 1,000 (1H), from 5.0-6.9 per 1,000 (1H3P) and from 6.1-7.9 per 1,000 (1H2P). CONCLUSIONS: Study findings show that incidence and prevalence of diagnosed IHD will be underestimated by as much as 50% using inpatient data alone. The addition of physician claims data are needed to better assess the burden of IHD in Canada.

Warm weather transport of broiler chickens in Manitoba. II. Truck management factors associated with death loss in transit to slaughter.

This observational study was conducted to identify the cause of death and load level factors associated with mortality in 1 090 733 Manitoba broiler chickens transported to slaughter in spring and early summer. Death loss in transit was 0.346% and accounted for 19% of the total carcass condemnation. The death loss pattern was clearly bimodal, with a low death loss in 180 of 198 shipments. Cumulative death loss during the growing phase of production was consistently associated with increased transport mortalities in load level models and when comparing high death loss with low death loss truckloads. High ambient temperature at the time of slaughter and loading density of the truck were the major factors associated with exceptional death loss.