Patient transportation in Canada's northern territories: patterns, costs and providers' perspectives.

INTRODUCTION: Canada's northern territories are characterized by small, scattered populations separated by long distances. A major challenge to healthcare delivery is the reliance on costly patient transportation, especially emergency air evacuations (medevacs). The purpose of this study was to describe the patterns, costs and providers' perspectives on patient transportation, and identify potential factors associated with utilization and performance. METHODS: Secondary analyses of medical travel databases and an online survey of nurses in the communities and physicians in regional centers were undertaken. RESULTS: The proportion of the population living within 100 km of a hospital was 83% in Yukon, 63% in Northwest Territories (NWT) and 21% in Nunavut. In Nunavut and NWT, road access to a hospital was limited to residents of the cities where the hospitals were located, with the rest relying exclusively on air travel. Medevac rates varied among the three territories: 0.9 trips/1000 residents/year in Yukon, 32/1000 in NWT and 53/1000 in Nunavut. In Yukon, all communities except one are road-accessible whereas in Nunavut no communities are connected by roads. The relative absence of roads is a major reason why the patient transportation costs are high in Nunavut and NWT. The rate of medevacs originating from the remote, air-accessible-only communities varied greatly, which cannot be explained by the air distance from the nearest hospital, population size or frequency of health center visits. Medical travel accounts for 5% of the health expenditures in NWT and 20% in Nunavut. A medevac on average costs $218 per person per year in NWT and $700 in Nunavut. The providers survey detected only 66% or less in support of statements that nurses in the communities received timely access to clinical advice, whereas only 50% of physicians agreed with statements that the clinical information provided by the nurses was clear. CONCLUSION: Patient transportation, especially emergency air evacuations, is an essential but costly component of the healthcare system serving Canada's north. It is the 'glue' that binds an extensive network of facilities staffed by different categories of health professionals. While system design is largely dictated by geography, addressing human factors such as interprofessional communication is important for improving the system's effectiveness. This study is primarily descriptive and it points to additional areas for improved understanding of the performance of the system.

Tracking progress in suicide prevention in Indigenous communities: a challenge for public health surveillance in Canada.

Indigenous peoples in Canada experience disproportionate rates of suicide compared to non-Indigenous populations. Indigenous communities and organizations have designed local and regional approaches to prevention, and the federal government has developed a national suicide prevention framework. However, public health systems continue to face challenges in monitoring the population burden of suicide and suicidal behaviour. National health data systems lack Indigenous identifiers, do not capture data from some regions, and do not routinely engage Indigenous communities in data governance. These challenges hamper efforts to detect changes in population-level outcomes and assess the impact of suicide prevention activities. Consequently, this limits the ability to achieve public health prevention goals and reduce suicide rates and rate inequities.This paper provides a critical analysis of the challenges related to suicide surveillance in Canada and assesses the strengths and limitations of existing data infrastructure for monitoring outcomes in Indigenous communities. To better understand these challenges, we discuss the policy context for suicide surveillance and examine the survey and administrative data sources that are commonly used in public health surveillance. We then review recent data on the epidemiology of suicide and suicidal behaviour among Indigenous populations, and identify challenges related to national surveillance.To enhance capacity for suicide surveillance, we propose strategies to better track progress in Indigenous suicide prevention. Specifically, we recommend establishing an independent community and scientific governing council, integrating Indigenous identifiers into population health datasets, increasing geographic coverage, improving suicide data quality, comprehensiveness, and timeliness, and developing a platform for making suicide data accessible to all stakeholders. Overall, the strategies we propose can build on the strengths of the existing national suicide surveillance system by adopting a collaborative and inclusive governance model that recognizes the stake Indigenous communities have in suicide prevention.

Exploring fetal fibronectin testing as a predictor of labour onset: In parturient women from isolated communities.

OBJECTIVE: To investigate whether the fetal fibronectin assay would be useful for determining if a woman was close to a term delivery. If effective, this test would allow parturient women to stay in their communities longer. DESIGN: This feasibility study used a prospective cohort design to examine the negative predictive value of the fetal fibronectin test at term. SETTING: Iqaluit, NU. PARTICIPANTS: A total of 30 parturient women from rural and isolated communities in Nunavut. INTERVENTION: Starting at 36 weeks' gestation, women were tested every 2 days, and after 39 weeks this increased to every day until labour. MAIN OUTCOME MEASURES: The negative predictive value of the fetal fibronectin test was assessed. RESULTS: Women were no more likely to give birth at 7 or more days after their last negative fetal fibronectin test result relative to their likelihood of giving birth at 6 or fewer days after their last negative test result. Hence, the presence of fetal fibronectin in cervical secretion did not predict term delivery. CONCLUSION: This project indicated that the fetal fibronectin test did not have adequate sensitivity or specificity as a diagnostic measure to predict a delay of labour at term.

Strengthening child and youth programs: A look at inter-organizational mentoring strategies.

Community-based non-profit organizations rarely have access to research or evaluation evidence to inform their programs and often lack the capacity to gather or use this information independently. In 2016, Wisdom2Action-a network of knowledge mobilization (KMb) experts, policy makers and service providers across Canada-launched an inter-organizational mentorship program to facilitate the implementation and sharing of best and promising practices within community-based programs for young people. This article outlines the findings from a developmental evaluation of eight mentoring relationships. Drawing on the Promoting Action on Research in Health Sciences (PARiHS) model of KMb, we look at mentoring as a type of facilitation that supports the increased use of evidence and evaluation information by non-profit organizations and identify key themes that support effective organizational mentorship in this sector. Findings reinforce the importance of establishing connected relationships and understanding context in mentoring relationships, creating adaptive and responsive work plans, ensuring consistent communication, and maintaining a focus on capacity-building if knowledge mobilization is to occur.

Inuit women's health in Nunavut, Canada: a review of the literature.

OBJECTIVES: Inuit women face challenging health and wellness issues in Northern communities. Literature examining these contexts and the processes through which health is affected is virtually non-existent. The objective [corrected] of this review is to examine and consolidate the available literature on Inuit women's health issues from the last decade in order to identify priorities for future research. STUDY DESIGN: This study is a review of literature from the last decade. Inuit women's health issues that have been raised in the literature and in various reports are examined within a health-determinants framework. METHODS: Government reports and statistics, publications by Inuit organizations and publications available on MEDLINE were examined for this review. RESULTS: Inuit women's health is a crucial part of the health of their communities. Inuit women face serious health issues related to reproductive and sexual health, such as high rates of sexually transmitted infections and challenging circumstances surrounding childbirth. Wellness, suicide and stress are more significant issues for Inuit women compared with non-Inuit women. Food security and accessibility is an issue for all Northerners. Alcohol and substance abuse and exposure to violent situations endanger both the health and safety of Inuit women in many Northern communities. CONCLUSIONS: There exists an urgent need to better understand the mechanisms through which determinants of health affect Inuit women. As well as adding to the body of knowledge on health determinants in Canada, further examining these issues will provide valuable information for health policy decision-makers and program development in the North and facilitate the direction of resources to the necessary areas of health services provision in Nunavut.

Youth perspectives on sexually transmitted infections and sexual health in Northern Canada and implications for public health practice.

OBJECTIVE: High rates of sexually transmitted infections in the Arctic have been a focus of recent research, and youth are believed to be at greatest risk of infection. Little research has focused on understanding youth perspectives on sexual health. The goal of this study was to collect the perspectives of youth in Nunavut on sexual health and relationships with the intent of informing public health practice. METHOD: This qualitative research study was conducted within an Indigenous knowledge framework with a focus on Inuit ways of knowing. Data were collected through face-to-face interviews in three Nunavut communities with 17 youth between the ages of 14 and 19 years. Participants were asked open-ended questions about their experiences talking about sexual health and relationships with their family, peers, teachers or others in the community. RESULTS: There are four key findings, which are important for public health: (a) Parents/caregivers are the preferred source of knowledge about sexual health and relationships among youth respondents; (b) youth did not report using the Internet for sexual health information; (c) youth related sexual decision-making to the broader community context and determinants of health, such as poverty; and (d) youth discussed sexual health in terms of desire and love, which is an aspect of sexual health often omitted from the discourse. IMPLICATIONS AND CONTRIBUTION: The youth in this study articulated perspectives on sexual health, which are largely neglected in current public health practice in the North. The findings from this study underscore the important role of community-led participatory research in contributing to our understanding of the public health challenges in our communities today, and provide direction for future interventions and research.

Transforming Health Care in Remote Communities: report on an international conference.

An international conference titled "Transforming Health Care in Remote Communities" was held at the Chateau Lacombe Hotel in Edmonton, Canada, April 28-30, 2016. The event was organized by the University of Alberta's School of Public Health, in partnership with the Institute for Circumpolar Health Research in Yellowknife, Northwest Territories, and the Qaujigiartiit Health Research Centre in Iqaluit, Nunavut. There were 150 registrants from 7 countries: Canada (7 provinces and 3 territories), United States, Denmark, Iceland, Norway, Sweden, and Australia. They included representatives of academic institutions, health care agencies, government ministries, community organizations, and private industry. The Conference focused on developing solutions to address health care in remote regions. It enabled new networks to be established and existing ones consolidated.

A scoping review of Indigenous suicide prevention in circumpolar regions.

BACKGROUND: Suicide is a serious public health challenge in circumpolar regions, especially among Indigenous youth. Indigenous communities, government agencies and health care providers are making concerted efforts to reduce the burden of suicide and strengthen protective factors for individuals, families and communities. The persistence of suicide has made it clear that more needs to be done. OBJECTIVE: Our aim was to undertake a scoping review of the peer-reviewed literature on suicide prevention and interventions in Indigenous communities across the circumpolar north. Our objective was to determine the extent and types of interventions that have been reported during past decade. We want to use this knowledge to support community initiative and inform intervention development and evaluation. DESIGN: We conducted a scoping review of online databases to identify studies published between 2004 and 2014. We included articles that described interventions in differentiated circumpolar Indigenous populations and provided evaluation data. We retained grey literature publications for comparative reference. RESULTS: Our search identified 95 articles that focused on suicide in distinct circumpolar Indigenous populations; 19 articles discussed specific suicide-related interventions and 7 of these described program evaluation methods and results in detail. The majority of publications on specific interventions were found in North American countries. The majority of prevention or intervention documentation was found in supporting grey literature sources. CONCLUSION: Despite widespread concern about suicide in the circumpolar world and active community efforts to promote resilience and mental well-being, we found few recorded programs or initiatives documented in the peer-reviewed literature, and even fewer focusing specifically on youth intervention. The interventions described in the studies we found had diverse program designs and content, and used varied evaluation methods and outcomes. The studies we included consistently reported that it was important to use community-based and culturally guided interventions and evaluations. This article summarizes the current climate of Indigenous circumpolar suicide research in the context of intervention and highlights how intervention-based outcomes have largely remained outside of peer-reviewed sources in this region of the world.

Inuit parent perspectives on sexual health communication with adolescent children in Nunavut: "it's kinda hard for me to try to find the words".

BACKGROUND: For Inuit, the family unit has always played a central role in life and in survival. Social changes in Inuit communities have resulted in significant transformations to economic, political and cultural aspects of Inuit society. Where the family unit was once the setting for dialogue on family relations and sexuality, this has largely been replaced by teachings from the medical community and/or the school system. OBJECTIVE: The purpose of this study was to explore Inuit parent perspectives on sharing knowledge with teenage children about sexual health and relationships. METHOD: A qualitative Indigenous knowledge approach was used for this study with a focus on Inuit ways of knowing as described in the Piliriqattigiinniq Community Health Research Partnership Model. Interviews were conducted with 20 individual parents in 3 Nunavut communities in 2011. Parents were asked about whether and how they talk to their children about sexual health and relationships. An analytical approach building on the concept of Iqqaumaqatigiiniq ("all knowing coming into one"), which is similar to "immersion and crystallization," was used to identify story elements, groupings or themes in the data. The stories shared by parents are honoured, keeping their words intact as often as possible in the presentation of results. RESULTS: Parents shared stories of themselves, family members and observations of the community. Fifteen of 17 mothers in the study reported having experienced sexual abuse as children or adolescents. Parents identified the challenges that they have and continue to experience as a result of forced settlement, family displacement and the transition of Inuit society. They expressed a desire to teach their children about sexual health and relationships and identified the need for emotional support to do this in the wake of the trauma they have experienced. Parents highly valued elders and the knowledge they have about family relationships and childrearing. CONCLUSION: There are powerful, unresolved healing issues in Inuit communities. The traumatic experiences of the settlement and residential school era continue to have an impact on present-day family relationships. To support parent-child dialogue on sexual health and relationships, parents identified a need to repair relationships between youth and elders, and to provide culturally sensitive support to parents to heal from trauma.

Inuit family understandings of sexual health and relationships in Nunavut.

OBJECTIVE: To explore Inuit family understandings of sexual health and relationships in order to inform responsive public health interventions that are designed to meet the needs of Nunavummiut. METHOD: A qualitative indigenous knowledge approach was used for this study with a focus on Inuit epistemology and methodology, as described in the Piliriqatigiinniq Community Health Research Partnership Model. Interviews were conducted with 20 parents in three Nunavut communities in 2011. An immersion and crystallization analytical approach was used to analyze the data and to identify groupings or themes in the data. The stories shared by parents are honoured, keeping their words intact as often as possible in the presentation of results. RESULTS: Parents in this study largely discussed sexual health in the context of historical community events related to settlement and/or residential schools. Residential schools and forced settlement into communities were linked to trauma, family separation, hardship and grief. These experiences were prominent in participants' understandings of sexual health and perceptions of sexual health behaviours among youth in the community. CONCLUSION: This study highlights the complexity of the landscape of sexual health in Nunavut and the need for public health approaches that are inclusive of Inuit family perspectives on sexual health. Greater understanding of historical and community context can contribute to the development of pertinent, evidence-based public health interventions that will meet the needs of the population.

Doing the right thing! A model for building a successful hospital-based ethics committee in Nunavut.

BACKGROUND: There exists a need throughout the North to increase capacity to address issues of health ethics and for community members to better understand and share their perspectives on this topic. Ethics comes down to weighing rights and wrongs, evaluating differing needs and understandings, acknowledging the many shades of grey and doing our best to come up with the just, fair and moral approach to the question at hand. Northern regions must collaborate to share capacity, successes and experiences in order to meet the unique needs of northern health care institutions and move forward on this issue. While guidelines for ethical research with indigenous populations exist, little has been published about an Inuit approach to health ethics more broadly. DESIGN: To fill a critical need and to meet accreditation standards, the Qikiqtani General Hospital (QGH) in Iqaluit, Nunavut, Canada, is in the process of building an Ethics Committee. Capitalizing on partnerships with other bodies both in northern and southern Canada has proved an efficient and effective way to develop local solutions to challenges that have been experienced both at QGH and other jurisdictions. METHODS: The Ottawa Hospital Ethics Office and the active ethics committee at Stanton General Hospital in Yellowknife, NT, contributed expertise and experience, and helped provide some direction for the QGH ethics committee. At the local level, based on our shared commitment to health care ethics, the Qaujigiartiit Health Research Centre is an invaluable partner whose parallel efforts to develop a northern Health Research Ethics Board (REB) gives great synergy to the QGH Ethics Committee. RESULTS: Passion and commitment, as well as administrative support and endorsement from health care leaders, are the aspects of successful initiatives that we have identified to date. Using the information from both the experiences of other partners, as well as information gathered at a retreat held in Iqaluit in September 2011, we are working to develop a model for the QGH ethics committee that incorporates multi-level perspectives, from that of community to that of front-line worker. CONCLUSION: Ideally, the scope of the QGH Ethics Committee will grow over time to include ethics education, facilitation of clinical ethical consults, ethical review of policy, advice on governance issues and involvement and support of an external northern Health REB.

The development of a comprehensive maternal-child health information system for Nunavut-Nutaqqavut (Our Children).

OBJECTIVES: Nunavut is the most northerly jurisdiction in Canada of which 85% of inhabitants are Inuit. Although most infants are born healthy, Nunavut leads the country for adverse early child health outcomes such as infant mortality, rates of birth defects, prematurity and low birth weight. Public health and community efforts are needed to understand and improve outcomes. METHODS: To inform these issues, a combined University of British Columbia/Nunavut Public Health Strategy effort has initiated a comprehensive maternal-child health surveillance system (from 16 weeks gestation to age 5). A diverse group of professional and lay stakeholders were brought together initially to determine local interest. Following this, a series of small working groups were held to decide on potential prenatal, perinatal and early child health variables, to be documented. RESULTS: Over 100 Nunavut participants have now had some role in the development of the system which has been initiated. Pre-existing standard prenatal forms and well-child assessment forms have been modified to include "Nunavut specific" variables of nutrition, food and domestic security, exposures in pregnancy, birth defects, development, chronic diseases of childhood and paternal information. CONCLUSION: This comprehensive maternal-child health information system has been developed with the extensive input of health care providers and stakeholders, utilizing community and public health systems already in place. Careful assessment of local needs has contributed to database development, privacy protection, potential data utilization for health promotion and plans for dissemination of findings. It is hoped that this will be a user-friendly surveillance system, adaptable to other community and public health systems that will improve the understanding of Aboriginal maternal-child health determinants.