Characteristics of High-Resource Health System Users in Rural and Remote Regions: A Scoping Review.

A small proportion of health care users are recognized to use a significantly higher proportion of health system resources, largely due to systemic, inequitable access and disproportionate health burdens. These high-resource health system users are routinely characterized as older, with multiple comorbidities, and reduced access to adequate health care. Geographic trends also emerge, with more rural and isolated regions demonstrating higher rates of high-resource use than others. Despite known geographical discrepancies in health care access and outcomes, health policy and research initiatives remain focused on urban population centers. To alleviate mounting health system pressure from high-resource users, their characteristics must be better understood within the context in which i arises. To examine this, a scoping review was conducted to provide an overview of characteristics of high-resource users in rural and remote communities in Canada and Australia. In total, 21 papers were included in the review. Using qualitative thematic coding, primary findings characterized rural high-resource users as those of an older age; with increased comorbid conditions and condition severity; lower socioeconomic status; and elevated risk behaviors.

Patient and provider perspectives on eHealth interventions in Canada and Australia: a scoping review.

INTRODUCTION: Despite the promises of universal health care in most developed countries, health inequities remain prevalent within and between rural and remote communities. Remote health technologies are often promoted as solutions to increase health system efficiency, to enhance quality of care, and to decrease gaps in access to care for rural and remote communities. However, there is mixed evidence for these interventions, particularly related to how they are received and perceived by health providers and by patients. Health technologies do not always adequately meet the needs of patients or providers. To examine this, a broad-based scoping review was conducted to provide an overview of patient and provider perspectives of eHealth initiatives in rural communities. The unique objective of this review was to prioritize the voices of patients and providers in discussing the disparities between health interventions and needs of people in rural communities. eHealth initiatives were reviewed for rural communities of Australia and Canada, two countries that have similar geographies and comparable health systems at the local level. METHODS: Searches were performed in PubMed, Scopus, and Web of Science with results limited from 2000 to 2018. Keywords included combinations of 'eHealth', 'telehealth', 'telemedicine', 'electronic health', and 'rural/remote'. Individual patient and provider perspectives on health care were identified, followed by qualitative thematic coding based on the type of intervention, the feedback provided, the affected population, geographic location, and category of individual providing their perspective. Quotes from patients and providers are used to illustrate the identified benefits and disadvantages of eHealth technologies. RESULTS: Based on reviewed literature, 90.1% of articles reported that eHealth interventions were largely positive. Articles noted decreased travel time (18%), time/cost saving (15.1%), and increased access to services (13.9%) as primary benefits to eHealth. The most prevalent disadvantages of eHealth were technological issues (24.5%), lack of face-to-face contact (18.6%), limited training (10.8%), and resource disparities (10.8%). These results show where existing eHealth interventions could improve and can inform policymakers and providers in designing new interventions. Importantly, benefits to eHealth extend beyond geographic access. Patients reported ancillary benefits to eHealth that include reduced anxiety, disruption on family life, and improved recovery time. Providers reported closer connections to colleagues, improved support for complex care, and greater eLearning opportunity. Barriers to eHealth are recognized by patient and providers alike to be largely systemic, where lack of rural high-speed internet and unreliability of installed technologies were significant. CONCLUSION: Regional and national governments are seen as the key players in addressing these technical barriers. This scoping review diverges from many reviews of eHealth with the use of first-person perspectives. It is hoped that this focus will highlight the importance of patient voices in evaluating important healthcare interventions such as eHealth and associated technologies.

Alcohol distribution reforms and school proximity to liquor sales outlets in New Brunswick.

OBJECTIVES: The purpose of this project was to evaluate how changes to the sale of alcohol in New Brunswick would be distributed across urban and rural communities, and low- and high-income neighbourhoods. The study objectives were to 1) estimate the population living close to alcohol outlets before and after liquor distribution reforms, 2) identify communities or regions that would be more or less affected, and 3) determine whether expanding access to alcohol products would reduce school proximity to retailers. METHODS: Data from Statistics Canada, Desktop Mapping Technologies Inc. (DMTI), and geocoded publicly available information were spatially linked and analyzed using descriptive statistics. The populations living within 499 m, 500-999 m and 1-5 km of an outlet were estimated, and the distances from schools to stores were examined by geographic characteristics and neighbourhood socio-economic status. RESULTS: Permitting the sale of alcohol in all grocery stores throughout the province would increase the number of liquor outlets from 153 to 282 and would increase the population residing within 499 m of an outlet by 97.49%, from 19 886 to 39 273 residents. The sale of alcohol in grocery stores would result in an additional 35 liquor sales outlets being located within 499 m of schools. Low-income neighbourhoods would have the highest number and proportion of stores within 499 m of schools. CONCLUSION: The findings of this study demonstrate the importance of considering social, economic and health inequities in the context of alcohol policy reforms that will disproportionately affect low-income neighbourhoods and youth living within these areas.

The influence of community well-being on mortality among Registered First Nations people.

BACKGROUND: Living in a community with lower socioeconomic status is associated with higher mortality. However, few studies have examined associations between community socioeconomic characteristics and mortality among the First Nations population. DATA AND METHODS: The 1991-to-2006 Census Mortality and Cancer Cohort follow-up, which tracked a 15% sample of Canadians aged 25 or older, included 57,300 respondents who self-identified as Registered First Nations people or Indian band members. The Community Well-Being Index (CWB), a measure of the social and economic well-being of communities, consists of income, education, labour force participation, and housing components. A dichotomous variable was used to indicate residence in a community with a CWB score above or below the average for First Nations communities. Age-standardized mortality rates (ASMRs) were calculated for First Nations cohort members in communities with CWB scores above and below the First Nations average. Cox proportional hazards models examined the impact of CWB when controlling for individual characteristics. RESULTS: The ASMR for First Nations cohort members in communities with a below-average CWB was 1,057 per 100,000 person-years at risk, compared with 912 for those in communities with an above-average CWB score. For men, living in a community with below-average income and labour force participation CWB scores was associated with an increased hazard of death, even when individual socioeconomic characteristics were taken into account. Women in communities with below-average income scores had an increased hazard of death. INTERPRETATION: First Nations people in communities with below-average CWB scores tended to have higher mortality rates. For some components of the CWB, effects remained even when individual socioeconomic characteristics were taken into account.

Data resource profile: 1991 Canadian Census Cohort.

The 1991 Canadian Census Cohort is the largest population-based cohort in Canada (N=2,734,835). Prior to the creation of this Cohort, no national population-based Canadian cohort was available to examine mortality by socioeconomic indicators. The 1991 Canadian Census Cohort was created via the linkage of a sub-sample of respondents from the mandatory 1991 Canadian Census long-form to historical tax summary files, Canadian Mortality Database, Canadian Cancer Database, 1991 Health and Activity Limitation Survey and a sub-sample of the Longitudinal Worker File. Overall ascertainment of mortality and cancer is anticipated to be nearly complete and the Cohort is broadly representative of most groups in the Canadian population. The Cohort has been used to examine mortality outcomes by different indicators of socioeconomic status, occupational categories, ethnic groups, educational attainment, and for exposure to ambient air pollution. Results have shown that the estimated remaining years of life at age 25 differed substantially by income adequacy quintile, educational attainment, housing type and Aboriginal ancestry.

Mortality among children and youth in high-percentage First Nations identity areas, 2000-2002 and 2005-2007.

INTRODUCTION: Many First Nations children live in communities that face diverse social and health challenges compared with their non-Aboriginal peers, including some of the most socio-economically challenging situations in Canada. These differences can be seen in broad indicators of the social determinants of health. Studies of mortality in Aboriginal populations across Canada are often restricted by the lack of Aboriginal identifiers on national death records. While some studies have utilised a record-linkage approach, this is often not possible for the entire country or for recent data. Some researchers have adopted a geographic approach and examined mortality and morbidity in areas that have a high percentage of Aboriginal identity residents, and have uniformly reported elevated rates of mortality and morbidity compared with other areas. The purpose of this article was to examine child and youth mortality (aged 1 to 19 years) in areas where a high percentage of the population identified as First Nations in comparison with areas where there is a low percentage of Aboriginal identity residents. METHODS: Using a geographic threshold table approach, areas with a high percentage of Aboriginal identity peoples were classified as either First Nations, Métis, or Inuit communities based on the predominant identity group. The upper one-third of the total Aboriginal population distribution was used as a cut-off for high percentage First Nations areas, where 97.7% of the population aged 1-19 were of First Nations identity in 2006 (N=140 779). Mortality rates were then calculated for high-percentage First Nations identity areas and compared with low-percentage Aboriginal identity areas, excluding high-percentage Métis or Inuit identity areas. Deaths were aggregated for the 3 years surrounding the 2001 and 2006 census periods, and a total of 473 deaths were recorded for 2000-2002 and 493 deaths for 2005-2007. Analysis was facilitated via the correspondence of six-digit residential postal codes on vital statistics records to census geographical areas using automated geo-coding software (Statistics Canada; PCCF+). RESULTS: Age-standardized mortality rates for children and youth in high-percentage First Nations identity areas were significantly higher than in low-percentage Aboriginal identity areas. The rate ratio for all-cause mortality for boys was 3.2 (CI: 2.9-3.6) for 2005-2007 and 3.6 (CI: 3.2-4.2) for girls. Mortality rates for injuries had the largest difference, with rate ratios of 4.7 (CI: 4.0-5.5) and 5.3 (CI:4.5-6.3) for boys in 2000-2002 and 2005-2007 and 5.5 (CI: 4.4-6.8) and 8.3 (CI: 6.8-10.1) for girls in the same period. CONCLUSION: A strength of this study is that it is the first to use national-level vital statistics registration data across two time periods to report mortality by cause for children and youth living in high-percentage First Nations areas. Vital events were geographically coded to high-percentage First Nations identity areas and compared with low-percentage Aboriginal identity areas at the Dissemination Areas level. This area-based methodology allows for mortality to be calculated for children and youth by sex and by detailed cause of death for multiple time periods. The results provide key evidence for the persistent differences in the causes of death for children and youth living in high-percentage First Nations identity areas.

Geozones: an area-based method for analysis of health outcomes.

BACKGROUND: Administrative datasets often lack information about individual characteristics such as Aboriginal identity and income. However, these datasets frequently contain individual-level geographic information (such as postal codes). This paper explains the methodology for creating Geozones, which are area-based thresholds of population characteristics derived from census data, which can be used in the analysis of social or economic differences in health and health service utilization. DATA AND METHODS: With aggregate 2006 Census information at the Dissemination Area level, population concentration and exposure for characteristics of interest are analysed using threshold tables and concentration curves. Examples are presented for the Aboriginal population and for income gradients. RESULTS: The patterns of concentration of First Nations people, Métis, and Inuit differ from those of non-Aboriginal people and between urban and rural areas. The spatial patterns of concentration and exposure by income gradients also differ. INTERPRETATION: The Geozones method is a relatively easy way of identifying areas with lower and higher concentrations of subgroups. Because it is ecological-based, Geozones has the inherent strengths and weaknesses of this approach.

Community-driven alcohol policy in Canada's northern territories 1970-2008.

OBJECTIVE: To describe community-driven alcohol policy for 78, primarily First Nations, Métis and Inuit, communities in Canada's three northern territories (Yukon, Northwest Territories and Nunavut) between 1970 and 2008. This is a first step to understanding the policy-oriented prevention system that has evolved in these areas over time. METHODS: Regulatory data were compiled from Part II of the Territorial Gazette Indices and the Revised Statutes and Regulations of each territory. Regulations were categorized as open, restricted, prohibited or other. RESULTS: The number of communities with some form of regulation has increased steadily over time with half of the sample communities adopting some form of regulation between 1970 and 2008. The use of prohibition as a policy choice peaked in 1980 but has remained relatively steady since that time. There has been a steady increase in the adoption of other kinds of restrictions. Communities with regulations tend to have smaller and younger populations, a greater percentage of people with First Nations, Métis or Inuit origin and are more geographically isolated than those with no regulation. CONCLUSIONS: This is the first time alcohol control policies have been compiled and described for the Canadian north. The dataset records the collective energies being put into community problem solving and provides a means to interpret the prevalence of health and social problems linked to alcohol use in these communities over time.