Opportunities to improve asthma and COPD prevention and care: insights from the patient journey obtained through focus groups.

BACKGROUND: The healthcare experiences of patients hold valuable insights for improving the quality of services related to their well-being. We therefore invited and explored the perspectives of patients living with asthma and chronic obstructive pulmonary disease (COPD) on their interaction with the systems supporting health, in order to identify opportunities to improve services to prevent, treat and manage these conditions. METHODS: Two virtual focus groups were held in August 2021, one for adult asthma and one for COPD, to learn of patients' experiences receiving care for these conditions in the Vancouver Coastal Health (VCH) region of British Columbia. Participants were recruited through online postings or their clinician. We discussed the care pathway for each condition and invited participants to share their experiences of the past 5 years, specifically their reflections on the process, including feelings, points of praise and frustration, and opportunities for improvement in this context. Composite patient journey maps were developed for each condition to reflect the experiences shared. Audio recordings of the focus groups were transcribed and used in qualitative data analysis. RESULTS: Thematic analysis revealed the following as possible areas for improvement: low public awareness of asthma and COPD and associated risk factors, non-standardised diagnosis pathways that delay diagnosis, and inconsistency in delivering valued aspects of care such as supports for self-management, trust-inspiring acute care, empowering patient communication and timely access to care. CONCLUSION: We successfully used focus groups to generate composite journey maps of the experiences of patients living with asthma (n=8) and COPD (n=9) to identify features that these patients consider important for improving the healthcare system for asthma and COPD in VCH. Health professionals, decision makers and patient advocates in VCH and beyond can consider these insights when evaluating, and planning changes to, current practices and policies in service delivery.

Engaging interested parties to optimize wildfire smoke communication in Canada: challenges with initiating change.

Background: In February 2022, an online Wildfire Smoke Communication Workshop series identified priorities and strategies to improve wildfire smoke communication in Canada. We evaluated the engagement methods, the workshop series and workshop summary report, to determine if participants/organizations initiated changes identified in the workshop to optimize wildfire smoke communication plans. Methods: Three evaluation surveys were developed using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework dimensions and PRISM (Practical, Robust, Implementation, and Sustainability Model) contextual domains to measure the engagement impact. Surveys 1, 2, and 3 were disseminated to workshop participants between February 2022 (post-workshop series), May 2022 (pre-wildfire season), and September 2022 (post-wildfire season). Likert survey responses were analyzed descriptively using means and standard deviations. Open-ended written responses were analyzed using deductive reasoning and response proportions. Results: Of 69 workshop participants, 28, 19, and 13 responded to surveys 1, 2, and 3, respectively. Workshop participation helped survey 1 respondents consider optimizing wildfire smoke communication (M = 3.93, SD = 0.88). Workshop participation and the summary report helped survey 2 respondents consider new actions to optimize wildfire smoke communication (M = 3.84, SD = 0.74). The most intended action in survey 2 (68%, n = 13) and the most common action taken in survey 3 (62%, n = 8) was to simplify message content. The primary limitation to optimization was capacity. Conclusion: The engagement methods, particularly the summary report, were beneficial for organizations to take action to optimize wildfire smoke communication in Canada. Future engagement methods should examine persisting system-level issues and capacity limitations as they undermine the ability to optimize wildfire smoke communication in Canada.

Disparities in self-reported healthcare access for airways disease in British Columbia, Canada, during the COVID-19 pandemic. Insights from a survey co-developed with people living with asthma and chronic obstructive pulmonary disease.

Patients' perspectives on the impact of the COVID-19 pandemic on their access to asthma and COPD healthcare could inform better, more equitable care delivery. We demonstrate this topic using British Columbia (BC), Canada, where the impact of the pandemic has not been described. We co-designed a cross-sectional survey with patient partners and administered it to a convenience sample of people living with asthma and COPD in BC between September 2020 and March 2021. We aimed to understand how access to healthcare for these conditions was affected during the pandemic. The survey asked respondents to report their characteristics, access to healthcare for asthma and COPD, types of services they found disrupted and telehealth (telephone or video appointment) use during the pandemic. We analysed 433 responses and found that access to healthcare for asthma and COPD was lower during the pandemic than pre-pandemic (p < 0.001). Specialty care services were most frequently reported as disrupted, while primary care, home care and diagnostics were least disrupted. Multivariable logistic regression revealed that access during the pandemic was positively associated with self-assessed financial ability (OR = 22.0, 95% CI: 7.0 - 84.0, p < 0.001, reference is disagreeing with having financial ability) and living in medium-sized urban areas (OR = 2.3, 95% CI: 1.0 - 5.2, p = 0.04, reference is rural areas). These disparities in access should be validated post-pandemic to confirm whether they still persist. They also indicate the continued relevance of exploring approaches for more equitable healthcare.

Public Health Messaging for Wildfire Smoke: Cast a Wide Net.

Wildfire smoke events are increasing in British Columbia (BC), Canada and environmental and public health agencies are responsible for communicating the health-related risks and mitigation strategies. To evaluate and identify opportunities for improving public communications about wildfire smoke and associated health risks we collaborated with end-users and developed a 32-question online survey. The survey was deployed province-wide from 29 September to 31 December 2020 following a severe wildfire smoke episode, which impacted large parts of BC. Using a convenience sample, we disseminated the survey through email lists, radio advertisements, a provincial research platform, and snowball methods. There were 757 respondents, who were generally representative of provincial demographics. Respondents indicated that they receive wildfire smoke messages from diverse sources, including: websites, social media, radio, and television. Radio was identified as the most important source of information for populations that may have increased exposure or health risks, including Indigenous respondents and those working in the trades. Respondents with lower educational attainment expressed that messaging should be simplified. Environmental and public health agencies should continue to share wildfire smoke messages using diverse methods, ideally tailoring the messages and methods to specific populations at risk for exposure and health effects.

Better Together: Launching and Nurturing a Community Stakeholder Committee to Enhance Care and Research for Asthma and COPD.

Partnering with patients and community stakeholders to identify, design, undertake, and evaluate research is increasingly common. We describe our experience with creating and developing an ongoing Community Stakeholder Committee to guide lung health research for disease prevention and health care improvement. This committee is central to the integrated knowledge translation approach of Legacy for Airway Health, which is dedicated to preventing and improving care for lung diseases. Patient Engagement in Research (PEIR) aims to improve the relevance, quality, and implementation of research activities. Meaningful patient and community engagement in research remains challenging to enact. The committee was established in October 2019, just before the COVID-19 pandemic, and quickly adapted from in-person to virtual engagement activities. This change led to an increased focus on relationship-building and mutual support alongside other research and training activities. We conducted a baseline evaluation survey after 1 year (October 2020), using a modified version of the Patient Engagement in Research Scale (PEIRS-22). Whereas individual scores suggested varied levels of meaningful engagement within the committee, overall results indicated strong personal relationships and a sense of feeling valued and respected, as well as a desire for increased opportunities to contribute to research within the program. Overall, this experience offers lessons learned about the importance of spending time and effort to build relationships, particularly in a virtual context, and shows that meaningful engagement can be achieved even when personal contact is limited. These efforts are illustrated in successful grant applications, research involvement, and stronger personal relationships.

Glossary of health equity in the context of environmental public health practice.

Health equity is increasingly present as an overarching goal in public health policy frameworks across the globe. Public health actions to support health equity are challenging because solutions to the root causes of health inequities often lie outside of the health sector, and a specific role for environmental public health practitioners has not been clearly articulated. The regulatory nature of the environmental public health profession means that their role is particularly ambiguous. Still, environmental public health practitioners are well situated to identify and respond to factors that contribute to health inequities because of their role as front-line professionals who interact with a wide cross-sector of the population. This Glossary, rooted primarily in the Canadian context but drawing on lessons from elsewhere, describes environmental public health regulatory practice in relation to health equity, including approaches that practitioners can use to contribute to addressing the social determinants of health.

Fish for Dinner? Balancing Risks, Benefits, and Values in Formulating Food Consumption Advice.

Many and complex factors underlie seemingly simple decisions about what to eat. This is particularly so for foods such as fish, which present consumers with both risks and benefits. Advice about what type of and how much fish to consume is abundant, but that advice is often confusing or contradictory, reflecting the differing mandates and orientations of those advising. We survey a range of issues that can and should be incorporated into dietary advice, and offer tools for health agencies tasked with providing it. We argue that risks and benefits should not be limited to direct physical health. Rather, socioeconomic and community factors, unintended or indirect effects, and nonhuman-health outcomes such as animal welfare and planetary health should also be considered and weighed. We provide examples of existing fish consumption guidance to highlight the conflicting messages that emerge when different sources of advice with singular aims of avoiding risk, gaining nutritional benefit, or sustaining fish populations are juxtaposed. We then offer tools borrowed from health and other fields to guide health agencies toward developing more comprehensive advice and targeting that advice for specific populations.

Portable air cleaners should be at the forefront of the public health response to landscape fire smoke.

Landscape fires can produce large quantities of smoke that degrade air quality in both remote and urban communities. Smoke from these fires is a complex mixture of fine particulate matter and gases, exposure to which is associated with increased respiratory and cardiovascular morbidity and mortality. The public health response to short-lived smoke events typically advises people to remain indoors with windows and doors closed, but does not emphasize the use of portable air cleaners (PAC) to create private or public clean air shelters. High efficiency particulate air filters and electrostatic precipitators can lower indoor concentrations of fine particulate matter and improve respiratory and cardiovascular outcomes. We argue that PACs should be at the forefront of the public health response to landscape fire smoke events.

Policy options for healthier retail food environments in city-regions.

Public policy is central to health promotion: it determines the distribution of resources in a society and establishes the structural context for the actions of both corporations and consumers. With this in mind, the purpose of this paper is to begin a discussion on promising policy options for a health-promoting retail food environment. Drawing on specific municipal examples, we examine four groups of policy options for healthier retail food environments in city-regions: planning for health; transforming consumer environments; economic and fiscal instruments; and a culture of transparency and participation. We introduce examples of policy options that are receiving increasing attention in the public health and urban planning literature and that function at the municipal level. We also highlight how public health professionals have an important role to play in policy that shapes retail food environments, especially in making explicit the linkages between health and other policy goals. In doing so, this commentary aims to motivate public health practitioners in a variety of community contexts to consider the policy supports they need to advance their exploration, development, testing and evaluation of interventions for healthier retail food environments.

What role for environmental public health practitioners in promoting healthy built environments?

Spaces that encourage better health are increasingly seen as key to reducing the burden of chronic disease: many larger Canadian public health departments now include built environment (BE) teams, which work with municipalities and land use planners to promote and/or require the development of health-encouraging spaces. In many public health agencies, it is environmental health practitioners who have assumed the new healthy BE role, but at what cost to existing mandates? We argue that reinventing roles to increase BE capacities within environmental health practice would reinforce health protection mandates while building capacity in chronic disease prevention. Significant expansion into the design of healthier built environments may require some reallocation of resources. However, we anticipate that healthier built environments will reduce threats to health and so lessen the need for conventional health protection, while encouraging activities and behaviours that lead to greater population wellness.

Uptake of cadmium from Pacific oysters (Crassostrea gigas) in British Columbia oyster growers.

BACKGROUND: Pacific oysters along the North American coast from Washington to Alaska contain concentrations of cadmium (Cd) that are high by comparison with Atlantic oysters, frequently exceeding 2mug/g wet weight, but it is unclear whether this Cd is absorbed by consumers. OBJECTIVES: To determine the effect of oyster consumption on Cd in blood and urine among a group with high oyster consumption. METHODS: Sixty-one non-smoking oyster growers and family members with a mean age of 47.3+/-7.6 years (range 33-64) were interviewed by telephone to assess their oyster consumption and other sources of Cd exposure at present and 5 years prior to the start of oyster farming. Their blood and urine Cd concentrations were measured. RESULTS: The geometric mean Cd concentration in blood was 0.83mug/L and in urine was 0.76mug/g creatinine. Thirty-six percent of participants had urinary Cd levels above 1mug/g creatinine and 5% were above 2mug/g creatinine. Recent (last 12 months) and long-term oyster consumptions were positive predictors of blood Cd but did not directly predict urinary Cd. The optimal model for predicting the variance in blood Cd included recent intake of oyster-derived Cd, serum iron concentration and recent ketchup consumption (R(2)=0.34, p=0.00004), with the latter two variables showing a protective effect. The factors found to predict urinary Cd were blood Cd concentration and duration of oyster farming. A rise in blood Cd was observed after 12 years of farming oysters, likely caused by higher consumption of oysters during this period. CONCLUSIONS: Oyster-derived Cd is bioavailable and affects body stores of the metal.

Food sales outlets, food availability, and the extent of nutrition policy implementation in schools in British Columbia.

BACKGROUND: The purpose of this study was to determine the number and types of different food sales outlets, the types of foods offered for sale in all school food outlets, and the extent of nutrition policy implementation in schools in British Columbia. We also directly measured the number and types of snack foods available for sale in each vending machine at each school. METHODS: Based on a thorough literature review and guided by an expert panel of nutritionists, we developed an instrument to measure the quantity and types of foods offered for sale in vending machines, the types of food for sale in all school food outlets, and the extent of nutrition policy development. RESULTS: The survey response rate was approximately 70%. Approximately 60% of surveyed schools had a permanent food sales outlet. Snack and beverage vending machines were most common in secondary schools, while tuck shops and food-based fundraisers were more common in elementary schools. While few snack vending machines were present in elementary schools, tuck shops stocked items commonly found in snack machines. Approximately 25% of schools had a formal group responsible for nutrition. These schools were more likely to have nutrition policies in place. CONCLUSION: "Junk" foods were widely available in elementary, middle, and secondary schools through a variety of outlets. Although snack machines are virtually absent in elementary schools, tuck shops and school fundraisers sell foods usually found in snack machines, largely cancelling the positive effect of the absence of snack machines in these schools. Schools with a group responsible for nutrition appear to have a positive impact on nutrition policy implementation.

Trace element levels in adults from the west coast of Canada and associations with age, gender, diet, activities, and levels of other trace elements.

The purpose of this study was to assess trace element levels in whole blood, serum and urine of 61 non-smoking adults living on the west coast of Canada and to determine their association with the following variables: age, gender, diet, participation in certain hobby and/or occupational activities, and levels of other trace elements. Participants or their spouses were employed as oyster growers and were originally recruited to study the absorption of cadmium from oyster consumption. Trace elements were measured using inductively-coupled plasma mass spectrometry. A telephone interview was used to assess participant's intake of selected foods and the amount of time they have spent on certain activities over the lifetime. Comparison of results to previous studies revealed that blood lead, blood mercury, serum nickel, serum selenium and urine molybdenum levels were generally higher in this study than have previously been measured, possibly due to higher consumption of seafood in this sample. Men had statistically higher levels of serum iron, blood lead, and serum selenium, while women had statistically higher levels of serum copper and blood manganese. Blood lead levels increased with age. Diet had a statistically significant association with several elements. Consumption of spinach, seaweed, organ meats, and shellfish tended to be positively correlated with trace element concentrations and consumption of various forms of potatoes tended to be negatively correlated. Several statistically significant correlations were also observed between trace elements.

Bringing home the right to food in Canada: challenges and possibilities for achieving food security.

We offer a critique of Canada's approach to domestic food security with respect to international agreements, justiciability and case law, the breakdown of the public safety net, the institutionalisation of charitable approaches to food insecurity, and the need for 'joined-up' food and nutrition policies. We examined Canada's commitments to the right to food, as well as Canadian policies, case law and social trends, in order to assess Canada's performance with respect to the human right to food. We found that while Canada has been a leader in signing international human rights agreements, including those relating to the right to food, domestic action has lagged and food insecurity increased. We provide recommendations for policy changes that could deal with complex issues of state accountability, social safety nets and vulnerable populations, and joined-up policy frameworks that could help realise the right to adequate food in Canada and other developed nations.

Putting food on the public health table: Making food security relevant to regional health authorities.

Food security is emerging as an increasingly important public health issue. The purpose of this paper is to describe a conceptual model and five classes of food security indicators for regional health authorities (RHAs): direct, indirect, consequence, process, and supra-regional. The model was developed after a review of the food security literature and interviews with British Columbia community nutritionists and public health officials. We offer this conceptual model as a practical tool to help RHAs develop a comprehensive framework and use specific indicators, in conjunction with public health nutritionists and other community stakeholders. We recommend using all five classes of indicator together to ensure a complete assessment of the full breadth of food security. This model will be useful for Canadian health authorities wishing to take a holistic community-based approach to public health nutrition to develop more effective policies and programs to maximize food security. The model and indicators offer a rational process that could be useful for collaborative multi-stakeholder initiatives to improve food security.

Potential for increased human foodborne exposure to PCDD/F when recycling sewage sludge on agricultural land.

Sewage sludge from municipal wastewater treatment is used in agriculture as a nutrient source and to aid in moisture retention. To examine the potential impact of sludge-amended soil on exposures to polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs) from plant and animal foods, we conducted a review of published empirical data from international sources. Levels of PCDD/F in municipal sewage sludge ranged from 0.0005 to 8300 pg toxic equivalents (TEQ)/g. Background levels in soil ranged from 0.003 to 186 pg TEQ/g. In sludge-amended soils, levels of PCDD/F ranged from 1.4 to 15 pg TEQ/g. Studies that measured levels before and after sludge treatment showed an increase in soil concentration after treatment. Relationships between PCDD/F levels in soil and resulting concentrations in plants were very weakly positive for unpeeled root crops, leafy vegetables, tree fruits, hay, and herbs. Somewhat stronger relationships were observed for plants of the cucumber family. In all cases, large increases in soil concentration were required to achieve a measurable increase in plant contamination. A considerably stronger positive relationship was observed between PCDD/F in feed and resulting levels in cattle tissue, suggesting bioaccumulation. Although PCDD/Fs are excreted in milk, no association was found between feed contamination and levels of PCDD/Fs measured in milk. There is a paucity of realistic data describing the potential for entry of PCDD/Fs into the food supply via sewage sludge. Currently available data suggest that sewage sludge application to land used for most crops would not increase human exposure. However, the use of sludge on land used to graze animals appears likely to result in increased human exposure to PCDD/F.

Politics and partnerships: challenges and rewards of partnerships in workplace health research in the healthcare sector of British Columbia, Canada.

In British Columbia (BC), Canada, a partnership of researchers, healthcare employers, and healthcare unions reduced high injury rates through examining determinants of healthy workplaces and designing, implementing, and evaluating interventions. Over 51 million dollars (Canadian) was saved from the BC healthcare budget over two years, largely attributable to the collaborative effort. Challenges and rewards of the process were determined from interviews and workshops with researchers and community stakeholders, and by obtaining direct input to this report. Challenges included maintaining communication and trust between partners, preserving partnerships during restructuring and labor disputes, and maintaining involvement and support of front-line workers and senior management. As all partners recognized the importance of the research agenda, the stakeholders remained committed to working through the challenges, and have consequently achieved considerable success.