Using Heart Rate Variability Methods for Health-Related Outcomes in Outdoor Contexts: A Scoping Review of Empirical Studies.

Heart rate variability (HRV) is a psychophysiological variable that is often used in applied analysis techniques to indicate health status because it provides a window into the intrinsic regulation of the autonomic nervous system. However, HRV data analysis methods are varied and complex, which has led to different approaches to data collection, analysis, and interpretation of results. Our scoping review aimed to explore the diverse use of HRV methods in studies designed to assess health outcomes in outdoor free-living contexts. Four database indexes were searched, which resulted in the identification of 17,505 candidate studies. There were 34 studies and eight systematic reviews that met the inclusion criteria. Just over half of the papers referenced the 1996 task force paper that outlined the standards of measurement and physiological interpretation of HRV data, with even fewer adhering to recommended HRV recording and analysis procedures. Most authors reported an increase in parasympathetic (n = 23) and a decrease in systematic nervous system activity (n = 20). Few studies mentioned methods-related limitations and challenges, despite a wide diversity of recording devices and analysis software used. We conclude our review with five recommendations for future research using HRV methods in outdoor and health-related contexts.

Validating the Remote First Aid Self-Efficacy Scale for Use in Evaluation and Training of First Responders in Remote Contexts.

INTRODUCTION: The purpose of this study was to investigate the psychometric properties of the remote first aid self-efficacy scale (RFA SES). The RFA SES is a 30-item self-report scale developed in response to emerging evidence showing that self-efficacy is predictive of performance. METHODS: Trained alumni from Wilderness Medical Associates (WMA) training courses and less trained students from Laurentian University (LU) were recruited via email to complete an online questionnaire at 2 different periods (T1 and T2). The questionnaire included demographic questions, the 30-item RFA SES, the 10-item Connor-Davidson resilience scale (CD-RISC), and the 10-item generalized self-efficacy scale (GSES). Data analysis included assessment of the dimensionality, reliability, and validity of the scale. RESULTS: There were 448 alumni from WMA and 1106 students from LU who participated in the study. The RFA SES demonstrated a clear unidimensional structure. The mean interitem correlation was 0.75 at T1. Test-retest reliability (T1 to T2) was high for both the LU group (intraclass correlation [ICC]=0.90) and the WMA group (ICC=0.92). Moderate correlations were found between RFA SES and CD-RISC (r=0.42, P<0.001), a general measure of resilience, and the GSES (r=0.48, P<0.001), a general measure of self-efficacy. Wilderness Medical Associates participants showed higher mean scores than LU students at T1 (t [569]=16.2, P<0.001). CONCLUSIONS: The RFA SES is a unidimensional, reliable, and potentially valid scale. Further research should focus on item reduction followed by additional tests of reliability and validity.

Emergency care with lay responders in underserved populations: a systematic review.

OBJECTIVE: To assess the individual and community health effects of task shifting for emergency care in low-resource settings and underserved populations worldwide. METHODS: We systematically searched 13 databases and additional grey literature for studies published between 1984 and 2019. Eligible studies involved emergency care training for laypeople in underserved or low-resource populations, and any quantitative assessment of effects on the health of individuals or communities. We conducted duplicate assessments of study eligibility, data abstraction and quality. We synthesized findings in narrative and tabular format. FINDINGS: Of 19 308 papers retrieved, 34 studies met the inclusion criteria from low- and middle-income countries (21 studies) and underserved populations in high-income countries (13 studies). Targeted emergency conditions included trauma, burns, cardiac arrest, opioid poisoning, malaria, paediatric communicable diseases and malnutrition. Trainees included the general public, non-health-care professionals, volunteers and close contacts of at-risk populations, all trained through in-class, peer and multimodal education and public awareness campaigns. Important clinical and policy outcomes included improvements in community capacity to manage emergencies (14 studies), patient outcomes (13 studies) and community health (seven studies). While substantial effects were observed for programmes to address paediatric malaria, trauma and opioid poisoning, most studies reported modest effect sizes and two reported null results. Most studies were of weak (24 studies) or moderate quality (nine studies). CONCLUSION: First aid education and task shifting to laypeople for emergency care may reduce patient morbidity and mortality and build community capacity to manage health emergencies for a variety of emergency conditions in underserved and low-resource settings.

Conceptual framework for task shifting and task sharing: an international Delphi study.

BACKGROUND: Task shifting and sharing (TS/S) involves the redistribution of health tasks within workforces and communities. Conceptual frameworks lay out the key factors, constructs, and variables involved in a given phenomenon, as well as the relationships between those factors. Though TS/S is a leading strategy to address health worker shortages and improve access to services worldwide, a conceptual framework for this approach is lacking. METHODS: We used an online Delphi process to engage an international panel of scholars with experience in knowledge synthesis concerning TS/S and develop a conceptual framework for TS/S. We invited 55 prospective panelists to participate in a series of questionnaires exploring the purpose of TS/S and the characteristics of contexts amenable to TS/S programmes. Panelist responses were analysed and integrated through an iterative process to achieve consensus on the elements included in the conceptual framework. RESULTS: The panel achieved consensus concerning the included concepts after three Delphi rounds among 15 panelists. The COATS Framework (Concepts and Opportunities to Advance Task Shifting and Task Sharing) offers a refined definition of TS/S and a general purpose statement to guide TS/S programmes. COATS describes that opportunities for health system improvement arising from TS/S programmes depending on the implementation context, and enumerates eight necessary conditions and important considerations for implementing TS/S programmes. CONCLUSION: The COATS Framework offers a conceptual model for TS/S programmes. The COATS Framework is comprehensive and adaptable, and can guide refinements in policy, programme development, evaluation, and research to improve TS/S globally.

Epidemiologic features of medical emergencies in remote First Nations in northern Ontario: a cross-sectional descriptive study using air ambulance transport data.

BACKGROUND: For about 25 000 Ontarians living in remote northern First Nations communities, seeing a doctor in an emergency department requires flying in an airplane or helicopter. This study describes the demographic and epidemiologic characteristics of patients transported from these communities to access hospital-based emergency medical care. METHODS: In this cross-sectional descriptive study, we examined primary medical data on patient transportation from Ornge, the provincial medical air ambulance service provider, for 26 remote Nishnawbe Aski Nation communities in northern Ontario from 2012 to 2016. We described these transports using univariate descriptive statistics. RESULTS: Over the 5-year study period, 10 538 patients (mean 2107.6 per year) were transported by Ornge from the 26 communities. Transport incidence ranged from 9.2 to 9.5 per 100 on-reserve population per year. Women aged 65 years or more had the highest transport incidence (25.9 per 100). Girls aged 5-9 years had the lowest mean incidence (2.1 per 100). Gastrointestinal issues accounted for 13.3% of transfers. Neurologic issues, respiratory issues and trauma each accounted for about 11% of transfers, and cardiac issues for 9.6%. Patients with obstetric issues accounted for 7.6% of transfers per year, and toxicologic emergencies for 7.5%. INTERPRETATION: This study provides the epidemiologic foundation to improve emergency care and emergency transport from remote First Nation communities in Ontario.

Conceptualizing and Managing Medical Emergencies Where No Formal Paramedical System Exists: Perspectives from a Remote Indigenous Community in Canada.

(1) Background: Remote communities in Canada lack an equitable emergency medical response capacity compared to other communities. Community-based emergency care (CBEC) training for laypeople is a model that has the potential to enhance the medical emergency response capacity in isolated and resource-limited contexts. The purpose of this study was to understand the characteristics of medical emergencies and to conceptualize and present a framework for what a medical emergency is for one remote Indigenous community in northwestern Ontario, in order to inform the development of CBEC training. (2) Methods: This study adhered to the principles of community-based participatory research and realist evaluation; it was an integrated component of the formative evaluation of the second Sachigo Lake Wilderness Emergency Response Education Initiative (SLWEREI) training course in 2012. Twelve members of Sachigo Lake First Nation participated in the training course, along with local nursing staff, police officers, community Elders, and course instructors (n = 24 total), who participated in interviews, focus groups, and a collaborative discussion of local health issues in the development of the SLWEREI. (3) Results: The qualitative results are organized into sections that describe the types of local health emergencies and the informal response system of community members in addressing these emergencies. Prominent themes of health adversity that emerged were an inability to manage chronic conditions and fears of exacerbations, the lack of capacity for addressing mental illness, and the high prevalence of injury for community members. (4) Discussion: A three-point framework of what constitutes local perceptions of an emergency emerged from the findings in this study: (1) a sense of isolation; (2) a condition with a potentially adverse outcome; and (3) a need for help.

Health effects of training laypeople to deliver emergency care in underserviced populations: a systematic review protocol.

INTRODUCTION: The Disease Control Priorities Project recommends emergency care training for laypersons in low-resource settings, but evidence for these interventions has not yet been systematically reviewed. This review will identify the individual and community health effects of educating laypeople to deliver prehospital emergency care interventions in low-resource settings. METHODS AND ANALYSIS: This systematic review addresses the following question: in underserviced populations and low-resource settings (P), does first aid or emergency care training or education for laypeople (I) confer any individual or community health benefit for emergency health conditions (O), in comparison with no training or other forms of education (C)? We restrict this review to studies reporting quantitatively measurable outcomes, and search 12 electronic bibliographic databases and grey literature sources. A team of expert content and methodology reviewers will conduct title and abstract screening and full-text review, using a custom-built online platform. Two investigators will independently extract methodological variables and outcomes related to patient-level morbidity and mortality and community-level effects on resilience or emergency care capacity. Two investigators will independently assess external validity, selection bias, performance bias, measurement bias, attrition bias and confounding. We will summarise the findings using a narrative approach to highlight similarities and differences between the gathered studies. ETHICS AND DISSEMINATION: Formal ethical approval is not required. RESULTS: The results will be disseminated through a peer-reviewed publication and knowledge translation strategy. REVIEW REGISTRATION NUMBER: CRD42014009685.

Assessing children's interpretations of the Aboriginal Children's Health and Well-Being Measure (ACHWM).

BACKGROUND: There are emerging opportunities to improve the health of Aboriginal children and youth. The Aboriginal Children's Health and Well-being Measure (ACHWM) was developed to enable Aboriginal communities to obtain group-level data from the perspectives of their children 8 to 18 years of age. The survey was developed in collaboration with children, based on the Medicine Wheel framework. The purpose of this study was to ensure that children and youth interpreted the ACHWM questions consistently and accurately and to establish the face validity of the survey. METHODS: Children and parents/caregivers from the Wikwemikong Unceded Indian Reserve (Canada) participated in a detailed interview process as they completed the ACHWM, in 2012. Each participant worked through their thought process verbally, to enable the interviewer to identify questions that were misinterpreted or inconsistently interpreted. Questions were revised based on feedback from the participants, and reviewed with new participants until a stable version was established. The resulting version was reviewed by health care providers and community members to further ensure cultural relevance and face validity within the community. RESULTS: A total of 18 interviews, with 9 children and 9 caregivers, were required to achieve a stable version of the survey. The children ranged in age from 8 to 18 years. Revisions were required for 19 questions. Most of these revisions were minor linguistic changes. In addition, 6 questions were deleted due to consistent problems and 4 questions were created to address gaps identified during the process. Community members confirmed the appropriateness of the measure for their community and communicated their pride in their youth's role in the development of this survey. CONCLUSIONS: The result was a 58-question version of the ACHWM that was consistently interpreted and culturally appropriate, and had face validity confirmed by experts from the community, children and their parents/caregivers. The ACHWM is ready to be assessed for relevance to other Aboriginal communities.

Community-based participatory research with indigenous communities: the proximity paradox.

Community-based participatory research (CBPR) is a promising approach used with increasing prevalence in health research with underserviced Indigenous communities in rural and remote locations. This case comparison used CBPR principles to examine the characteristics of two collaborative research projects in Canada. Both projects reflected CBPR principles in unique ways with particular differences related to community access and proximity of collaborating partners. CBPR principles are often used and recommended for partnerships involving remote underserviced communities, however many of these principles were easier to follow for the collaboration with a relatively well serviced community in close proximity to researchers, and more challenging to follow for a remote underserviced community. The proximity paradox is an apparent contradiction in the increasing application of CBPR principles for use in distal partnerships with remote Indigenous communities when many of these same principles are nearly impossible to follow. CBPR principles are much easier to apply in proximal partnerships because they afford an environment where collaborative relationships can be developed and sustained.

A process for creating the Aboriginal children's health and well-being measure (ACHWM).

OBJECTIVES: The purpose of this study was to identify concepts of health and well-being important to Aboriginal children and youth. These concepts were necessary for the development of a culturally appropriate measure of health. METHODS: We completed 4 community consultation sessions, 4 advisory committee meetings, and 6 full-day focus groups within the Wikwemikong Unceded Indian Reserve. The focus groups engaged Aboriginal children and youth via relevant cultural teachings, a photography exercise combined with a community bicycling tour, and detailed discussions of health and well-being using photovoice. The process was guided by a conceptual model: the Medicine Wheel. The participants placed their photos on a wall mural and identified their most important concepts. These concepts were synthesized through expert consensus into items and reviewed by the broader community. RESULTS: The participants ranged in age from 8.2 to 17.7 years (mean age=12.3). Through innovative methods, children and youth identified 206 concepts representing the 4 quadrants of the Medicine Wheel: emotional, spiritual, physical and mental. These concepts were refocused, in collaboration with the community, to create a new 60-item measure of health and well-being that was primarily positive in focus. CONCLUSION: This study demonstrates the success of implementing a unique process of photovoice in combination with bicycling and informed by an Aboriginal framework. The results confirm the distinct conceptualization of health and well-being in this population and underscore the necessity for a culturally appropriate measure. This study also produced a first draft of the Aboriginal Children's Health and Well-being Measure (ACHWM).