Longitudinal study of pregnancy intention and its association with pregnancy occurrence among female sex workers in Benin and Mali.

BACKGROUND: The intention of becoming pregnant has an evident impact on the prenatal and postnatal period. For female sex workers (FSWs) in West Africa, among whom pregnancies are frequent as are HIV and sexually transmitted infections, a better understanding of their pregnancy intention and its influence on pregnancy occurrence could help prevent unwanted pregnancies and adverse effects on wanted pregnancies. METHODS: We recruited 330 FSWs in Benin and 322 in Mali and followed them for 12 months. We evaluated their pregnancy intention at recruitment and 6-month follow-up, using a multidimensional prospective measure that we developed. We assessed pregnancy occurrence with a pregnancy test and a retrospective questionnaire at 6 and 12 months. A Cox proportional hazard model was used to estimate the association between intention and pregnancy. We carried out an analysis to take losses to follow-up into account using the inverse of probability of censoring weights and a cluster analysis to corroborate that the multidimensional measure of pregnancy intention fitted the data. RESULTS: 407 FSWs were included in the first 6-month analysis and 284 at 12 months. Mean age was 30.9 years. The pregnancy intention distribution was similar between the two periods: 15.2% in the first period and 16.3% in the second had a positive intention. One out of four were ambivalent and almost 60% (57.7% and 56.3%) had a negative intention. For 38.2% of the FSWs, the intention changed between the two periods. The global incidence rate (to first event) was 19.1 pregnancies per 100 person-years. There was a borderline significant trend (p = 0.0529) of decreased pregnancy incidence with decreasing intention. Compared to positive intention, the adjusted hazard ratio (aHR) for ambivalent and negative intentions were 0.71 [95% confidence interval (95% CI) 0.32-1.60] and 0.46 (95% CI 0.21-1.01), respectively. CONCLUSION: The level of pregnancy intention influences its occurrence among FSWs and nearly one out of six wants a baby despite working in the sex trade. Programmatically, early identification of these women could facilitate provision of quality antenatal and postnatal care. Given other health risks associated with sex work this care may decrease potential risks of adverse maternal, fetal and neonatal outcomes.

The intention of becoming pregnant has an evident impact on the prenatal and postnatal period. For female sex workers (FSWs) in West Africa, among whom pregnancies are frequent, a better understanding of their pregnancy intention and its influence on pregnancy occurrence could help prevent unwanted pregnancies and adverse effects of wanted pregnancies. We recruited 330 FSWs in Benin and 322 in Mali and we followed them for 12 months. We evaluated their pregnancy intention at recruitment and at 6-month follow-up. We assessed pregnancy occurrence with a pregnancy urine test and with a retrospective questionnaire asking on pregnancy occurrence at 6 and 12 months. With these data we estimated the association between intention and pregnancy. 407 FSWs were included in the first 6-month analysis and 284 at 12 months. Sixteen percent of the FSWs had a positive intention of having a pregnancy in the next 6 months in both the first 6-month and 12 months. One out of four were ambivalent and almost 60% had a negative intention. For 38.2% of the FSWs the intention changed between the two periods. Women with an ambivalent intention compared to those with positive intention, had 30% less pregnancies whereas for negative intention, women had 54% less pregnancies during the study follow-up. As for any woman, the level of pregnancy intention influences its occurrence. Moreover, nearly one out of six FSWs wants a baby despite working in the sex trade. Programmatically, early identification of these women could facilitate provision of quality antenatal and postnatal care.

A population-based combination strategy to improve the cervical cancer screening coverage rate in Bamako, Mali.

INTRODUCTION: Cervical cancer screening coverage rate is <5% in Sub-Saharan Africa and <2% in French- speaking African countries. In 2016, we implemented strategies to improve cervical cancer screening in Bamako, the "Weekend70 program". The present study objectives are to determine the effect of this program on women's participation in cervical cancer screening in Bamako, and to estimate the cervical cancer screening coverage rate in Bamako. MATERIAL AND METHODS: From 1 January 2016 to 31 July 2020, we conducted an operational research by developing several strategies to improve the cervical cancer screening coverage rate among adolescents and women ≥15 years old in Bamako, Mali. The strategies consisted of awareness-raising activities, strengthening of screening practices in healthcare facilities and cost-free cervical cancer screening during the weekend. Descriptive statistics were presented. The cervical cancer coverage rate was calculated by dividing the number of women screened by the total number of women ≥20 years old, based on Mali demographic data. RESULTS: The total number of women screened was 289 924. Residents from Bamako represented 91.9% (266 436/289 924) vs 8.1% (23 488/289 924) who lived outside Bamako. The mean age was 33.2 (± 11.5) years old. Around 46.1% of participants attending the cervical cancer screening were between 30 and 49 years old (World Health Organization prioritized target age for cervical cancer screening). Women ≥60 years old represented <5%. Cervical cancer screening participation increased significantly, from <800 women screened per week before the implementation of the program to a peak of 4100 women screened per week during the "Weekend70 program". Overall, the cervical cancer screening coverage rates at the end of the study among women ≥20 years old was 47.3%, and 56.9% in the WHO target population. CONCLUSION: In an impoverished context, a multi-component strategy significantly increases cervical cancer screening participation.

Prevalence and Factors Associated With HIV and Sexually Transmitted Infections Among Female Sex Workers in Bamako, Mali.

BACKGROUND: We aimed to (1) estimate the prevalence of HIV and other sexually transmitted infections (STIs) among female sex workers (FSWs) in Bamako, Mali, and (2) identify factors associated with STIs including HIV infection in this population. METHODS: We analyzed baseline data from a prospective observational cohort study on cervical cancer screening, human papillomavirus, and HIV infections among FSWs 18 years or older recruited in Bamako. Multivariable log-binomial regression was used to estimate the adjusted prevalence ratios (APRs) with 95% confidence interval (95% CI) for HIV infection and STIs versus associated factors. RESULTS: Among 353 women participating in the study, mean age was 26.8 (±7.6) years. HIV prevalence was 20.4%, whereas 35.1% of the FSWs had at least one STI. Factors significantly associated with HIV were older age (P < 0.0001, test for trend), duration of sex work ≥6 years (APR, 1.92; 95% CI, 1.22-3.02), uneducated status (APR, 2.24; 95% CI, 1.16-4.34), less than 10 clients in the last 7 days (APR, 1.55; 95% CI, 1.02-2.34), and gonococcal (APR, 1.85; 95% CI, 1.21-2.82) and chlamydial (APR, 2.58; 95% CI, 1.44-4.62) infections. Younger age (P = 0.018, test for trend), having ≥10 clients in the last week (APR, 1.47; 95% CI, 1.11-1.94), and HIV infection (APR, 2.00; 95% CI, 1.49-2.69) were significantly associated with STIs. CONCLUSIONS: HIV and curable STI prevalence are high among FSWs in Bamako. There is thus a need to enhance the efficiency of interventions toward FSWs in Mali to reduce the burden of HIV and STIs among them and prevent HIV spread to the general population.

Portrait of rural emergency departments in Québec and utilization of the provincial emergency department management Guide: cross sectional survey.

BACKGROUND: Rural emergency departments (EDs) constitute crucial safety nets for the 20% of Canadians who live in rural areas. Pilot data suggests that the province of Québec appears to provide more comprehensive access to services than do other provinces. A difference that may be attributable to provincial policy/guidelines "the provincial ED management Guide". The aim of this study was to provide a detailed description of rural EDs in Québec and utilization of the provincial ED management Guide. METHODS: We selected EDs offering 24/7 medical coverage, with hospitalization beds, located in rural or small towns. We collected data via telephone, paper, and online surveys with rural ED/hospital staff. Data were also collected from Québec's Ministry of Health databases and from Statistics Canada. We computed descriptive statistics, ANOVA and t-tests were used to examine the relationship between ED census, services and inter-facility transfer requirements. RESULTS: A total of 23 of Québec's 26 rural EDs (88%) consented to participate in the study. The mean annual ED visits was 18 813 (Standard Deviation = 6 151). Thirty one percent of ED physicians were recent graduates with fewer than 5 years of experience. Only 6 % had residency training or certification in emergency medicine. Teams have good local access (24/7) to diagnostic equipment such as CT scanner (74%), intensive unit care (78%) and general surgical services (78%), but limited access to other consultants. Sixty one percent of participants have reported good knowledge of the provincial ED management Guide, but only 23% of them have used the guidelines. Furthermore, more than 40% of EDs were more than 300 km from levels 1 to 2 trauma centers, and only 30% had air transport access. CONCLUSIONS: Rural EDs in Québec are staffed by relatively new graduates working as solo physicians in well-resourced and moderately busy (by rural standards) EDs. The provincial ED management Guide may have contributed to this model of service attribution. However, the majority of rural ED staff report limited knowledge or use of the provincial ED management Guide and increased efforts at disseminating this Guide are warranted.

Violence, condom breakage, and HIV infection among female sex workers in Benin, West Africa.

OBJECTIVE: To examine the relationship between violence, condom breakage, and HIV prevalence among female sex workers (FSWs). METHODS: Data were obtained from the 2012 cross-sectional integrated biological and behavioral survey conducted in Benin. Multivariable log-binomial regression was used to estimate the adjusted prevalence ratios of HIV infection and condom breakage in relation to violence toward FSWs. A score was created to examine the relationship between the number of violence types reported and HIV infection. RESULTS: Among the 981 women who provided a blood sample, HIV prevalence was 20.4%. During the last month, 17.2%, 13.5%, and 33.5% of them had experienced physical, sexual, and psychological violence, respectively. In addition, 15.9% reported at least 1 condom breakage during the previous week. There was a significant association between all types of violence and HIV prevalence. The adjusted prevalence ratios of HIV were 1.45 (95% confidence interval [95% CI], 1.05-2.00), 1.42 (95% CI, 1.02-1.98), and 1.41 (95% CI, 1.08-1.41) among those who had ever experienced physical, sexual, and psychological violence, respectively. HIV prevalence increased with the violence score (P = 0.002, test for trend), and physical and sexual violence were independently associated with condom breakage (P = 0.010 and P = 0.003, respectively). CONCLUSIONS: The results show that violence is associated with a higher HIV prevalence among FSWs and that condom breakage is a potential mediator for this association. Longitudinal studies designed to analyze this relationship and specific interventions integrated to current HIV prevention strategies are needed to reduce the burden of violence among FSWs.

Through the big top: An exploratory study of circus-based artistic knowledge translation in rural healthcare services, Québec, Canada.

BACKGROUND: The conventional methods and strategies used for knowledge translation (KT) in academic research often fall short in effectively reaching stakeholders, such as citizens, practitioners, and decision makers, especially concerning complex healthcare issues. In response, a growing number of scholars have been embracing arts-based knowledge translation (ABKT) to target a more diverse audience with varying backgrounds and expectations. Despite the increased interest, utilization, and literature on arts-based knowledge translation over the past three decades, no studies have directly compared traditional knowledge translation with arts-based knowledge translation methods. Thus, our study aimed to evaluate and compare the impact of an arts-based knowledge translation intervention-a circus show-with two traditional knowledge translation interventions (webinar and research report) in terms of awareness, accessibility, engagement, advocacy/policy influence, and enjoyment. METHODS: To conduct this exploratory convergent mixed method study, we randomly assigned 162 participants to one of the three interventions. All three knowledge translation methods were used to translate the same research project: "Rural Emergency 360: Mobilization of decision-makers, healthcare professionals, patients, and citizens to improve healthcare and services in Quebec's rural emergency departments (UR360)." RESULTS: The findings revealed that the circus show outperformed the webinar and research report in terms of accessibility and enjoyment, while being equally effective in raising awareness, increasing engagement, and influencing advocacy/policy. Each intervention strategy demonstrates its unique array of strengths and weaknesses, with the circus show catering to a diverse audience, while the webinar and research report target more informed participants. These outcomes underscore the innovative and inclusive attributes of Arts-Based Knowledge translation, showcasing its capacity to facilitate researchers' engagement with a wider array of stakeholders across diverse contexts. CONCLUSION: As a relevant first step and a complementary asset, arts-based knowledge translation holds immense potential in increasing awareness and mobilization around crucial health issues.

Type-specific incidence, persistence and factors associated with human papillomavirus infection among female sex workers in Benin and Mali, West Africa.

OBJECTIVES: This study in female sex workers (FSWs) aimed to: (1) estimate type-specific incidence and persistence of human papillomavirus (HPV) infection in Cotonou (Benin) and Bamako (Mali); and (2) identify the factors associated with type-specific incidence and persistence of high-risk HPV (HR-HPV) infection. METHODS: A 1-year prospective cohort study on cervical cancer screening, and HPV and human immunodeficiency virus (HIV) infections was conducted among FSWs in Cotonou and Bamako from 2017 to 2019. Poisson regression models assessed factors associated with the incidence of HR-HPV infection, while log-binomial regression was performed to identify factors associated with the persistence of HR-HPV infection. Adjusted relative risks (ARR) and 95% confidence intervals (95% CI) were estimated. RESULTS: The incidence of HR-HPV infection was 46.98 per 1000 women-months (predominant types HPV16, HPV35 and HPV59). Factors associated with the incidence of HR-HPV infection were age <20 years (ARR 15.10; 95% CI 3.29-69.19), age at sexual debut <18 years (ARR 6.92; 95% CI 1.97-24.27) and sex work duration ≤1 year (ARR 7.40; 95% CI 1.84-29.69). The persistence of HR-HPV infection at 12 months was 38.7% (most persistent types HPV59, HPV52 and HPV51). Persistence of HR-HPV infection was higher in women with chlamydia (P = 0.031), HIV infection (P < 0.001) and multiple-type HPV infections (P < 0.001). CONCLUSION: FSWs in West Africa are at high risk of incident and persistent HR-HPV infection, suggesting an urgent need for cervical cancer screening in this population.

Human papillomavirus genotype distribution and factors associated among female sex workers in West Africa.

OBJECTIVES: This study aimed to: (1) Estimate HPV prevalence and genotype distribution among female sex workers (FSWs) in Mali and Benin as well as the prevalence of multiple HPV type infections in this group, and (2) Identify potential risk factors associated with high-risk (HR) HPV infections. METHODS: We analyzed baseline data of 665 FSWs aged ≥ 18 years recruited during a prospective cohort of cervical cancer screening in Cotonou (Benin) and Bamako (Mali) from 2017 to 2018. The Linear Array HPV genotyping test was used to identify HPV genotypes. Descriptive statistics and multivariate log-binomial regression were used. Adjusted prevalence ratios (APR) with 95% confidence intervals (95%CI) were estimated to identify risk factors associated with HR-HPV infections. RESULTS: HPV data were available for 659 FSWs (Benin: 309; Mali: 350). The mean age was 35.0 years (± 10.7) in Benin and 26.8 years (± 7.6) in Mali. The overall HPV prevalence rates were 95.5% in Benin and 81.4% in Mali. About 87.7% and 63.4% of FSWs harbored ≥ 2 HPV types in Benin and Mali, respectively. The top three prevalent HR-HPV among FSWs in Benin were: HPV58 (37.5%), HPV16 (36.6%) and HPV52 (28.8%). Corresponding patterns in Mali were HPV16 (15.7%), HPV51 (14.3%) and HPV52 (12.9%). In Benin, the main factors associated with HR-HPV were vaginal douching (APR = 1.17; 95%CI:1.02-1.34) and gonococcal infection (APR = 1.16; 95%CI:1.04-1.28), while in Mali they were sex work duration ≤ 1 year (APR = 1.35; 95%CI:1.10-1.65) and HIV infection (APR = 1.26; 95%CI: 1.06-1.51). CONCLUSION: Our study found a very high prevalence of HPV infection as well as high frequency of multiple HPV type infections in FSWs in two countries in West Africa. These findings suggest the necessity to emphasize cervical cancer prevention in this high-risk group.

Assessing Motor Function in Congenital Muscular Dystrophy Patients Using Accelerometry.

BACKGROUND: When tested in a controlled clinic environment, individuals with neuromuscular-related symptoms may complete motor tasks within normal predicted ranges. However, measuring activity at home may better reflect typical motor performance. The accuracy of accelerometry measurements in individuals with congenital muscular dystrophy (CMD) is unknown. We aimed to compare accelerometry and manual step counts and assess free-living physical activity intensity in individuals with CMD using accelerometry. METHODS: Ambulatory pediatric CMD participants (n = 9) performed the 6-minute walk test in clinic while wearing ActiGraph GT3X accelerometer devices. During the test, manual step counting was conducted to assess concurrent validity of the ActiGraph step count in this population using Bland-Altman analysis. In addition, activity intensity of 6 pediatric CMD participants was monitored at home with accelerometer devices for an average of 7 days. Cut-point values previously validated for neuromuscular disorders were used for data analysis. RESULTS: Bland-Altman and intraclass correlation analyses showed no concurrent validity between manual and ActiGraph-recorded step counts. Fewer steps were recorded by ActiGraph step counts compared with manual step counts (411 ± 74 vs 699 ± 43, respectively; P = .004). Although improved, results were in the same direction with the application of low-frequency extension filters (587 ± 40 vs 699 ± 43, P = .03). ActiGraph step-count data did not correlate with manual step count (Spearman ρ = 0.32, P = .41; with low-frequency extension: Spearman ρ = 0.45, P = .22). Seven-day physical activity monitoring showed that participants spent more than 80% of their time in the sedentary activity level. CONCLUSIONS: In a controlled clinic setting, step count was significantly lower by ActiGraph GT3X than by manual step counting, possibly because of the abnormal gait in this population. Additional studies using triaxial assessment are needed to validate accelerometry measurement of activity intensity in individuals with CMD. Accelerometry outcomes may provide valuable measures and complement the 6-minute walk test in the assessment of treatment efficacy in CMD.

Randomized controlled trial of N-acetylcysteine therapy for RYR1-related myopathies.

OBJECTIVE: To investigate the efficacy of N-acetylcysteine (NAC) for decreasing elevated oxidative stress and increasing physical endurance in individuals with ryanodine receptor 1-related myopathies (RYR1-RM). METHODS: In this 6-month natural history assessment (n = 37) followed by a randomized, double-blinded, placebo-controlled trial, 33 eligible participants were block-randomized (1:1) to receive NAC (n = 16) or placebo (n = 17), orally for 6 months (adult dose 2,700 mg/d; pediatric dose 30 mg/kg/d). The primary endpoint was urine 15-F2t isoprostane concentration and the clinically meaningful co-primary endpoint was 6-minute walk test (6MWT) distance. RESULTS: When compared to the general population, participants had elevated baseline 15-F2t isoprostane concentrations and most had a decreased 6MWT distance (mean ± SD 3.2 ± 1.5 vs 1.1 ± 1.7 ng/mg creatinine and 468 ± 134 vs 600 ± 58 m, respectively, both p < 0.001). 15-F2t isoprostane concentration and 6MWT distance did not change over the 6-month natural history assessment (p = 0.98 and p = 0.61, respectively). NAC treatment did not improve 15-F2t isoprostane concentration (least squares means difference 0.1 [95% confidence interval [CI] -1.4 to 1.6] ng/mg creatinine, p = 0.88) or 6MWT distance (least squares means difference 24 [95% CI -5.5 to 53.4] m, p = 0.11). NAC was safe and well-tolerated at the doses administered in this study. CONCLUSION: In ambulatory RYR1-RM-affected individuals, we observed stable disease course, and corroborated preclinical reports of elevated oxidative stress and decreased physical endurance. NAC treatment did not decrease elevated oxidative stress, as measured by 15-F2t isoprostane. CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that, for people with RYR1-RM, treatment with oral NAC does not decrease oxidative stress as measured by 15-F2t isoprostane. CLINICALTRIALSGOV IDENTIFIER: NCT02362425.

Profile of trauma mortality and trauma care resources at rural emergency departments and urban trauma centres in Quebec: a population-based, retrospective cohort study.

OBJECTIVES: As Canada's second largest province, the geography of Quebec poses unique challenges for trauma management. Our primary objective was to compare mortality rates between trauma patients treated at rural emergency departments (EDs) and urban trauma centres in Quebec. As a secondary objective, we compared the availability of trauma care resources and services between these two settings. DESIGN: Retrospective cohort study. SETTING: 26 rural EDs and 33 level 1 and 2 urban trauma centres in Quebec, Canada. PARTICIPANTS: 79 957 trauma cases collected from Quebec's trauma registry. PRIMARY AND SECONDARY OUTCOME MEASURES: Our primary outcome measure was mortality (prehospital, ED, in-hospital). Secondary outcome measures were the availability of trauma-related services and staff specialties at rural and urban facilities. Multivariable generalised linear mixed models were used to determine the relationship between the primary facility and mortality. RESULTS: Overall, 7215 (9.0%) trauma patients were treated in a rural ED and 72 742 (91.0%) received treatment at an urban centre. Mortality rates were higher in rural EDs compared with urban trauma centres (13.3% vs 7.9%, p<0.001). After controlling for available potential confounders, the odds of prehospital or ED mortality were over three times greater for patients treated in a rural ED (OR 3.44, 95% CI 1.88 to 6.28). Trauma care setting (rural vs urban) was not associated with in-hospital mortality. Nearly all of the specialised services evaluated were more present at urban trauma centres. CONCLUSIONS: Trauma patients treated in rural EDs had a higher mortality rate and were more likely to die prehospital or in the ED compared with patients treated at an urban trauma centre. Our results were limited by a lack of accurate prehospital times in the trauma registry.

Longitudinal changes in clinical outcome measures in COL6-related dystrophies and LAMA2-related dystrophies.

OBJECTIVE: To identify the rate of change of clinical outcome measures in children with 2 types of congenital muscular dystrophy (CMD), COL6-related dystrophies (COL6-RDs) and LAMA2-related dystrophies (LAMA2-RDs). METHODS: Over the course of 4 years, 47 individuals (23 with COL6-RD and 24 with LAMA2-RD) 4 to 22 years of age were evaluated. Assessments included the Motor Function Measure 32 (MFM32), myometry (knee flexors and extensors, elbow flexors and extensors), goniometry (knee and elbow extension), pulmonary function tests, and quality-of-life measures. Separate linear mixed-effects models were fitted for each outcome measurement, with subject-specific random intercepts. RESULTS: Total MFM32 scores for COL6-RDs and LAMA2-RDs decreased at a rate of 4.01 and 2.60 points, respectively, each year (p < 0.01). All muscle groups except elbow flexors for individuals with COL6-RDs decreased in strength between 1.70% (p < 0.05) and 2.55% (p < 0.01). Range-of-motion measurements decreased by 3.21° (p < 0.05) at the left elbow each year in individuals with LAMA2-RDs and 2.35° (p < 0.01) in right knee extension each year in individuals with COL6-RDs. Pulmonary function demonstrated a yearly decline in sitting forced vital capacity percent predicted of 3.03% (p < 0.01) in individuals with COL6-RDs. There was no significant change in quality-of-life measures analyzed. CONCLUSION: Results of this study describe the rate of change of motor function as measured by the MFM32, muscle strength, range of motion, and pulmonary function in individuals with COL6-RDs and LAMA2-RDs.

Organisation des services dans une urgence rurale éloignée : réflexions autour du cas de Fermont, Québec.

INTRODUCTION: The goal of this study was to meet a small, remote emergency department's need to reflect on the minimum threshold of services to offer. The study's main objectives were to 1) provide a statistical profile of the emergency services in Fermont, Quebec, 2) assess the staff's and users' perception of the threshold of services offered and 3) propose solutions for improving care and services. METHODS: This case study was conducted with a participatory approach and a mixed methodology. We compared the results from a questionnaire on the emergency services that was validated during a previous study with the results concerning the other rural emergency services in Quebec as well as with national and provincial recommendations. The questionnaire concerned users' sociodemographic characteristics, the hospital's and the emergency services' descriptors, the services available locally, and the physician and nurse staff. Interviews were also carried out with 33 people (health care professionals, policy-makers and citizens). RESULTS: Fermont's emergency department is smaller than the average rural emergency department in Quebec. They have resources that are in some respects comparable to those of other emergency departments and in line with the recommendations; in other respects, their resources are rather limited. Respondents emphasized how important it is to take into account the environment's specific features when establishing the minimum threshold of services. The proposed solutions would promote collaboration, break down silos within professional practice and focus on training. CONCLUSION: Fermont's case aside, this exploratory case study highlights how important it is to adopt a pluralistic, participatory and local approach in order to support reflection on the minimum threshold of services in remote emergency departments and to improve their overall performance.

INTRODUCTION: Cette étude visait à répondre au besoin d'une petite urgence éloignée d'assoir sa réflexion autour d'un seuil minimum de services à offrir. Les principaux objectifs de l'étude étaient de : 1) dresser le portrait statistique de l'urgence de Fermont, Québec, 2) évaluer la perception du personnel et des usagers en lien avec le seuil de services offert et 3) énoncer des solutions permettant d'améliorer les soins et les services. METHODS: Cette étude de cas a été réalisée avec une approche participative et une méthodologie mixte. Nous avons comparée les données d'un questionnaire sur l'urgence qui a été validé lors d'une étude précédente aux données des autres urgences rurales québécoises et à des recommandations nationales et provinciales. Le questionnaire portait sur les caractéristiques sociodémographiques des usagers, les descripteurs du centre hospitalier et de l'urgence, les services disponibles localement et les effectifs médicaux et infirmiers. Des entrevues ont aussi été réalisées auprès de 33 personnes (professionnels de la santé, décideurs et citoyens). RESULTS: L'urgence de Fermont est plus petite que la moyenne des urgences rurales québécoises et dotée de ressources à certains égards comparables aux autres urgences et aux recommandations et à d'autres égards limités. Les répondants ont souligné l'importance de tenir compte des particularités du milieu dans l'établissement d'un seuil minimum de services. Les solutions proposées concernent l'importance de favoriser la collaboration, de décloisonner la pratique professionnelle et de miser sur la formation. CONCLUSION: Au-delà du cas de Fermont, cette étude de cas exploratoire a permis de souligner l'importance d'adopter une approche pluraliste, participative et locale pour soutenir la réflexion autour du seuil minimum de services à offrir dans les urgences éloignées et pour améliorer la performance générale des urgences rurales.

Rural versus urban academic hospital mortality following stroke in Canada.

INTRODUCTION: Stroke is one of the leading causes of death in Canada. While stroke care has improved dramatically over the last decade, outcomes following stroke among patients treated in rural hospitals have not yet been reported in Canada. OBJECTIVES: To describe variation in 30-day post-stroke in-hospital mortality rates between rural and urban academic hospitals in Canada. We also examined 24/7 in-hospital access to CT scanners and selected services in rural hospitals. MATERIALS AND METHODS: We included Canadian Institute for Health Information (CIHI) data on adjusted 30-day in-hospital mortality following stroke from 2007 to 2011 for all acute care hospitals in Canada excluding Quebec and the Territories. We categorized rural hospitals as those located in rural small towns providing 24/7 emergency physician coverage with inpatient beds. Urban hospitals were academic centres designated as Level 1 or 2 trauma centres. We computed descriptive data on local access to a CT scanner and other services and compared mean 30-day adjusted post-stroke mortality rates for rural and urban hospitals to the overall Canadian rate. RESULTS: A total of 286 rural hospitals (3.4 million emergency department (ED) visits/year) and 24 urban hospitals (1.5 million ED visits/year) met inclusion criteria. From 2007 to 2011, 30-day in-hospital mortality rates following stroke were significantly higher in rural than in urban hospitals and higher than the Canadian average for every year except 2008 (rural average range = 18.26 to 21.04 and urban average range = 14.11 to 16.78). Only 11% of rural hospitals had a CT-scanner, 1% had MRI, 21% had in-hospital ICU, 94% had laboratory and 92% had basic x-ray facilities. CONCLUSION: Rural hospitals in Canada had higher 30-day in-hospital mortality rates following stroke than urban academic hospitals and the Canadian average. Rural hospitals also have very limited local access to CT scanners and ICUs. These rural/urban discrepancies are cause for concern in the context of Canada's universal health care system.

Lack of CT scanner in a rural emergency department increases inter-facility transfers: a pilot study.

OBJECTIVE: Rural emergency departments (EDs) are an important gateway to care for the 20% of Canadians who reside in rural areas. Less than 15% of Canadian rural EDs have access to a computed tomography (CT) scanner. We hypothesized that a significant proportion of inter-facility transfers from rural hospitals without CT scanners are for CT imaging. Our objective was to assess inter-facility transfers for CT imaging in a rural ED without a CT scanner. RESULTS: We selected a rural ED that offers 24/7 medical care with admission beds but no CT scanner. Descriptive statistics were collected from 2010 to 2015 on total ED visits and inter-facility transfers. Data was accessible through hospital and government databases. Between 2010 and 2014, there were respectively 13,531, 13,524, 13,827, 12,883, and 12,942 ED visits, with an average of 444 inter-facility transfers. An average of 33% (148/444) of inter-facility transfers were to a rural referral centre with a CT scan, with 84% being for CT scan. Inter-facility transfers incur costs and potential delays in patient diagnosis and management, yet current databases could not capture transfer times. Acquiring a CT scan may represent a reasonable opportunity for the selected rural hospital considering the number of required transfers.

Portrait of trauma care in Quebec's rural emergency departments and identification of priority intervention needs to improve the quality of care: a study protocol.

INTRODUCTION: Trauma remains the primary cause of death in individuals under 40 years of age in Canada. In Quebec, the Trauma Care Continuum (TCC) has been demonstrated to be effective in decreasing the mortality rate among trauma victims. Although rural citizens are at greater risk for trauma and trauma death, no empirical data concerning the effectiveness of the TCC for the rural population in Quebec are available. The emergency departments (EDs) are important safety nets for rural citizens. However, our data indicate that access to diagnostic support services, such as intensive care units and CT is limited in rural areas. The objectives are to (1) draw a portrait of trauma services in rural EDs; (2) explore geographical variations in trauma care in Quebec; (3) identify adaptable factors that could reduce variation; and (4) establish consensus solutions for improving the quality of care. METHODS AND ANALYSIS: The study will take place from November 2015 to November 2018. A mixed methodology (qualitative and quantitative) will be used. We will include data (2009-2013) from all trauma victims treated in the 26 rural EDs and tertiary/secondary care centres in Quebec. To meet objectives 1 and 2, data will be gathered from the Ministry's Database of the Quebec Trauma Registry Information System. For objectives 3 and 4, the project will use the Delphi method to develop consensus solutions for improving the quality of trauma care in rural areas. Data will be analysed using a Poisson regression to compare mortality rate during hospital stay or death on ED arrival (objectives 1 and 2). Average scores and 95% CI will be calculated for the Delphi questionnaire (objectives 3 and 4). ETHICS AND DISSEMINATION: This protocol has been approved by CSSS Alphonse-Desjardins research ethics committee (Project MP-HDL-2016-003). The results will be published in peer-reviewed journals.

The challenges of measuring quality-of-care indicators in rural emergency departments: a cross-sectional descriptive study.

BACKGROUND: Evidence-based indicators of quality of care have been developed to improve care and performance in Canadian emergency departments. The feasibility of measuring these indicators has been assessed mainly in urban and academic emergency departments. We sought to assess the feasibility of measuring quality-of-care indicators in rural emergency departments in Quebec. METHODS: We previously identified rural emergency departments in Quebec that offered medical coverage with hospital beds 24 hours a day, 7 days a week and were located in rural areas or small towns as defined by Statistics Canada. A standardized protocol was sent to each emergency department to collect data on 27 validated quality-of-care indicators in 8 categories: duration of stay, patient safety, pain management, pediatrics, cardiology, respiratory care, stroke and sepsis/infection. Data were collected by local professional medical archivists between June and December 2013. RESULTS: Fifteen (58%) of the 26 emergency departments invited to participate completed data collection. The ability to measure the 27 quality-of-care indicators with the use of databases varied across departments. Centres 2, 5, 6 and 13 used databases for at least 21 of the indicators (78%-92%), whereas centres 3, 8, 9, 11, 12 and 15 used databases for 5 (18%) or fewer of the indicators. On average, the centres were able to measure only 41% of the indicators using heterogeneous databases and manual extraction. The 15 centres collected data from 15 different databases or combinations of databases. The average data collection time for each quality-of-care indicator varied from 5 to 88.5 minutes. The median data collection time was 15 minutes or less for most indicators. INTERPRETATION: Quality-of-care indicators were not easily captured with the use of existing databases in rural emergency departments in Quebec. Further work is warranted to improve standardized measurement of these indicators in rural emergency departments in the province and to generalize the information gathered in this study to other health care environments.

Differences in access to services in rural emergency departments of Quebec and Ontario.

INTRODUCTION: Rural emergency departments (EDs) are important safety nets for the 20% of Canadians who live there. A serious problem in access to health care services in these regions has emerged. However, there are considerable geographic disparities in access to trauma center in Canada. The main objective of this project was to compare access to local 24/7 support services in rural EDs in Quebec and Ontario as well as distances to Levels 1 and 2 trauma centers. MATERIALS AND METHODS: Rural EDs were identified through the Canadian Healthcare Association's Guide to Canadian Healthcare Facilities. We selected hospitals with 24/7 ED physician coverage and hospitalization beds that were located in rural communities. There were 26 rural EDs in Quebec and 62 in Ontario meeting these criteria. Data were collected from ministries of health, local health authorities, and ED statistics. Fisher's exact test, the t-test or Wilcoxon-Mann-Whitney test, were performed to compare rural EDs of Quebec and Ontario. RESULTS: All selected EDs of Quebec and Ontario agreed to participate in the study. The number of EDs visits was higher in Quebec than in Ontario (19 322 ± 6 275 vs 13 446 ± 8 056, p = 0.0013). There were no significant differences between Quebec and Ontario's local population and small town population density. Quebec's EDs have better access to advance imaging services such as CT scanner (77% vs 15%, p < .0001) and most the consultant support and ICU (92% vs 31%, p < .0001). Finally, more than 40% of rural EDs in Quebec and Ontario are more than 300 km away from Levels 1 and 2 trauma centers. CONCLUSIONS: Considering that Canada has a Universal health care system, the discrepancies between Quebec and Ontario in access to support services are intriguing. A nationwide study is justified to address this issue.

The Quebec rural emergency department project: a cross-sectional study of a potential two-pronged strategy in the knowledge transfer process.

INTRODUCTION: Health services research generates useful knowledge. Promotion of implementation of this knowledge in medical practice is essential. Prior to initiation of a major study on rural emergency departments (EDs), we deployed two knowledge transfer strategies designed to generate interest and engagement from potential knowledge users. The objective of this paper was to review: 1) a combined project launch and media press release strategy, and 2) a pre-study survey designed to survey potential knowledge users' opinions on the proposed study variables. MATERIALS AND METHODS: We evaluated the impact of the project launch (presentation at two conferences hosted by key stakeholders) and media press release via a survey of participants/stakeholders and by calculating the number of media interview requests and reports generated. We used a pre-study survey to collect potential key stakeholder' opinions on the study variables. RESULTS: Twenty-one of Quebec's 26 rural EDs participated in the pre-study survey (81% participation rate). The press release about the study generated 51 press articles and 20 media request for interviews, and contributed to public awareness of a major rural research initiative. In the pre-study survey, thirteen participants (46%) mentioned prior knowledge of the research project. Results from the pre-study survey revealed that all of the potential study variables were considered to be relevant for inclusion in the research project. Respondents also proposed additional variables of interest, including factors promoting retention of human resources. CONCLUSIONS: The present study demonstrated the potential utility of a two-pronged knowledge transfer strategy, including a combined formal launch and press release, and a pre-study survey designed to ensure that the included variables were of interest to participants and stakeholders.