Community-based screening and triage connecting First Nations children and youth to local supports: a cross-sectional study.

BACKGROUND: First Nations children in Canada experience health inequities. We aimed to determine whether a self-report health app identified children's needs for support earlier in their illness than would typically occur. METHODS: Children (aged 8 to 18 yr) were recruited from a rural First Nation community. Children completed the Aaniish Naa Gegii: the Children's Health and Well-being Measure (ACHWM) and then met with a local mental health worker who determined their risk status. ACHWM Emotional Quadrant Scores (EQS) were compared between 3 groups of children: healthy peers (HP) who were not at risk, those with newly identified needs (NIN) who were at risk and not previously identified, and a typical treatment (TT) group who were at risk and already receiving support. RESULTS: We included 227 children (57.1% girls), and the mean age was 12.9 (standard deviation [SD] 2.9) years. The 134 children in the HP group had a mean EQS of 80.1 (SD 11.25), the 35 children in the NIN group had a mean EQS of 67.2 (SD 13.27) and the 58 children in the TT group had a mean EQS of 66.2 (SD 16.30). The HP group had significantly better EQS than the NIN and TT groups (p < 0.001). The EQS did not differ between the NIN and TT groups (p = 0.8). INTERPRETATION: The ACHWM screening process identified needs for support among 35 children, and the associated triage process connected them to local services; the similarity of EQS in the NIN and TT groups highlights the value of community screening to optimize access to services. Future research will examine the impact of this process over the subsequent year in these groups.

Associations between exposure to adverse childhood experiences and biological aging: Evidence from the Canadian Longitudinal Study on Aging.

People exposed to adverse childhood experiences (ACEs) suffer from an increased risk of chronic disease and shorter lifespan. These individuals also tend to exhibit accelerated reproductive development and show signs of advanced cellular aging as early as childhood. These observations suggest that ACEs may accelerate biological processes of aging through direct or indirect mechanisms; however, few population-based studies have data to test this hypothesis. We analysed ACEs and biological aging data from the Canadian Longitudinal Study on Aging (CLSA; n = 23,354 adults aged 45-85) and used the BioAge R package to compute three indices of biological aging from blood-chemistry and organ-function data: Klemera-Doubal method (KDM) biological age, phenotypic age (PA), and homeostatic dysregulation (HD). Adults with ACEs tended to be biologically older than those with no ACEs, although the observed effect-sizes were small (Cohen's d<0.15), with the exception of neglect (d=0.35 for KDM and PA). Associations were similar for men and women and tended to be smaller for older as compared to midlife participants. Subtypes of ACEs perceived as being more severe (e.g., being pushed or kicked, experiencing forced sexual activity, witnessing physical violence) and more frequent and diverse exposures were associated with relatively larger effect-sizes. These findings support the hypothesis that ACEs contribute to accelerated biological aging, although replication is needed in studies with access to prospective records of ACEs and cellular-level measurements of biological aging. Furthermore, future work to better understand the degree to which associations between ACEs and biological aging are moderated by specific life-course pathways, and mediated by lifestyle and socioeconomic factors is warranted.

Associations of Adverse Childhood Experiences with Frailty in Older Adults: A Cross-Sectional Analysis of Data from the Canadian Longitudinal Study on Aging.

INTRODUCTION: Frailty in older adults, characterized by a decline in multiple physiological systems and increasing vulnerability to loss of independence, disability, and death, is a public health priority in developed countries. Etiology of frailty extends across the lifespan and may begin in early life, but empirical evidence for this association is scarce. In this study, we examined whether adverse childhood experiences (ACEs) are associated with frailty in later life. METHODS: We conducted a cross-sectional analysis of data for a population-based sample of 27,748 adults aged 45-85 years from the Canadian Longitudinal Study on Aging. The frailty index (FI) was computed with 76 health-related characteristics of physical and cognitive performance, self-rated health, chronic conditions, visual and hearing ability, activities of daily living, and well-being. Self-reported exposure to ACEs included physical, emotional, and sexual abuse, neglect, and witnessing intimate partner violence prior age of 16 and parental death, divorce, and living with a family member with mental illness prior age of 18. Generalized linear regression models with gamma error distribution and identity link function, adjusted for age and sex, were used to examine associations of each ACE type and the number of ACE types (0, 1, 2, or 3+) reported by an individual with FI. All models were adjusted for income, education, smoking, and alcohol consumption in sensitivity analysis. RESULTS: Individuals exposed to ACEs had elevated levels of FI (mean = 0.13, SD = 0.09) than those unexposed, with the largest difference observed for neglect (B [95% CI]: 0.05 [0.04, 0.06]) and the smallest for parental death and divorce (0.015 [0.01,0.02]). The ACE count was associated with frailty in a graded manner, with the FI difference reaching 0.04 [0.037, 0.044] for participants exposed to 3+ ACE types. The association between ACEs and frailty tended to be stronger for women than men and for men aged 45-64 years than older men. CONCLUSIONS: Our study supports previous studies showing that exposure to ACEs is associated with frailty in adults. Our findings suggest that screening for ACEs involving childhood maltreatment may be useful for identifying individuals at risk of frailty and prevention of ACEs may have long-term benefits for healthy aging.

Respiratory Symptoms Are Associated With Frailty in Older Adults With Normal Spirometry, Independent of Smoking, in the Canadian Longitudinal Study of Aging.

BACKGROUND: Recent studies have demonstrated that even in the absence of lung impairment as determined by spirometry, smoking and respiratory symptoms are associated with poor overall health and well-being. However, this relationship is not well defined; and it remains unclear the degree to which symptoms are related to poor health, independent of smoking. This is of particular importance to older adults, as they are more likely to exhibit respiratory symptoms and are, therefore, at risk of not receiving appropriate treatment if they have never smoked and have normal spirometry. METHODS: We performed a cross-sectional analysis of data from the Canadian Longitudinal Study on Aging to delineate the associations of respiratory symptoms and smoking on the health of participants age 45-86 who exhibited normal spirometry. Participant health was estimated using a frailty index, a multidimensional measure of vulnerability to adverse outcomes that has been validated in numerous health settings. RESULTS: Of the 21,293 participants included in our analysis, 87% exhibited a normal FEV1, FVC, and FEV1/FVC; of those, 45% reported at least one respiratory symptom, and 50% were former or current smokers. Both respiratory symptoms and smoking were independently associated with frailty (median interquartile range [IQR] = 0.11 [0.07-0.15]), the most substantial associations observed for those having at least one respiratory symptom (adjusted ß 0.023, 95% CI 0.022-0.025) and current smokers with > 10 pack-year exposure (adjusted ß 0.014, 95% CI [0.010-0.019). Not only was the association between symptoms and frailty evident in never smokers, a significant proportion of the total effect of smoking on frailty was observed to be mediated by symptoms. CONCLUSIONS: Our data show that respiratory symptoms, regardless of smoking history, were a significant correlate of frailty in older adults with normal spirometry. Hence, they should not be simply regarded as a benign by-product of aging.

Epigenetic age is associated with baseline and 3-year change in frailty in the Canadian Longitudinal Study on Aging.

BACKGROUND: The trajectory of frailty in older adults is important to public health; therefore, markers that may help predict this and other important outcomes could be beneficial. Epigenetic clocks have been developed and are associated with various health-related outcomes and sociodemographic factors, but associations with frailty are poorly described. Further, it is uncertain whether newer generations of epigenetic clocks, trained on variables other than chronological age, would be more strongly associated with frailty than earlier developed clocks. Using data from the Canadian Longitudinal Study on Aging (CLSA), we tested the hypothesis that clocks trained on phenotypic markers of health or mortality (i.e., Dunedin PoAm, GrimAge, PhenoAge and Zhang in Nat Commun 8:14617, 2017) would best predict changes in a 76-item frailty index (FI) over a 3-year interval, as compared to clocks trained on chronological age (i.e., Hannum in Mol Cell 49:359-367, 2013, Horvath in Genome Biol 14:R115, 2013, Lin in Aging 8:394-401, 2016, and Yang Genome Biol 17:205, 2016). RESULTS: We show that in 1446 participants, phenotype/mortality-trained clocks outperformed age-trained clocks with regard to the association with baseline frailty (mean = 0.141, SD = 0.075), the greatest of which is GrimAge, where a 1-SD increase in ΔGrimAge (i.e., the difference from chronological age) was associated with a 0.020 increase in frailty (95% CI 0.016, 0.024), or ~ 27% relative to the SD in frailty. Only GrimAge and Hannum (Mol Cell 49:359-367, 2013) were significantly associated with change in frailty over time, where a 1-SD increase in ΔGrimAge and ΔHannum 2013 was associated with a 0.0030 (95% CI 0.0007, 0.0050) and 0.0028 (95% CI 0.0007, 0.0050) increase over 3 years, respectively, or ~ 7% relative to the SD in frailty change. CONCLUSION: Both prevalence and change in frailty are associated with increased epigenetic age. However, not all clocks are equally sensitive to these outcomes and depend on their underlying relationship with chronological age, healthspan and lifespan. Certain clocks were significantly associated with relatively short-term changes in frailty, thereby supporting their utility in initiatives and interventions to promote healthy aging.

Tracking Indigenous Applicants Through the Admissions Process of a Socially Accountable Medical School.

PURPOSE: To describe the admissions process and outcomes for Indigenous applicants to the Northern Ontario School of Medicine (NOSM), a Canadian medical school with the mandate to recruit students whose demographics reflect the service region's population. METHOD: The authors examined 10-year trends (2006-2015) for self-identified Indigenous applicants through major admission stages. Demographics (age, sex, northern and rural backgrounds) and admission scores (grade point average [GPA], preinterview, multiple mini-interview [MMI], final), along with score-based ranks, of Indigenous and non-Indigenous applicants were compared using Pearson chi-square and Mann-Whitney tests. Binary logistic regression was used to assess the relationship between Indigenous status and likelihood of admission outcomes (interviewed, received offer, admitted). RESULTS: Indigenous qualified applicants (338/17,060; 2.0%) were more likely to be female, mature (25 or older), or of northern or rural background than non-Indigenous applicants. They had lower GPA-based ranks than non-Indigenous applicants (P < .001) but had comparable preinterview-, MMI-, and final-score-based ranks across all admission stages. Indigenous applicants were 2.4 times more likely to be interviewed and 2.5 times more likely to receive an admission offer, but 3 times less likely to accept an offer than non-Indigenous applicants. Overall, 41/338 (12.1%) Indigenous qualified applicants were admitted compared with 569/16,722 (3.4%) non-Indigenous qualified applicants. CONCLUSIONS: Increased representation of Indigenous peoples among applicants admitted to medical school can be achieved through the use of socially accountable admissions. Further tracking of Indigenous students through medical education and practice may help assess the effectiveness of NOSM's social accountability admissions process.

How underserviced rural communities approach physician recruitment: changes following the opening of a socially accountable medical school in northern Ontario.

INTRODUCTION: The Northern Ontario School of Medicine (NOSM) opened in 2005 with a social accountability mandate to address a long history of physician shortages in northern Ontario. The objective of this qualitative study was to understand the school's effect on recruitment of family physicians into medically underserviced rural communities of northern Ontario. METHODS: We conducted a multiple case study of 8 small rural communities in northern Ontario that were considered medically underserviced by the provincial ministry of health and had successfully recruited NOSM-trained physicians. We interviewed 10 people responsible for physician recruitment in these communities. Interview transcripts were analyzed by means of an inductive and iterative thematic method. RESULTS: All 8 communities were NOSM medical education sites with populations of 1600-16 000. Positive changes, linked to collaboration with NOSM, included achieving a full complement of physicians in 5 communities with previous chronic shortages of 30%-50% of the physician supply, substantial reduction in recruitment expenditures, decreased reliance on locums and a shift from crisis management to long-term planning in recruitment activities. The magnitude of positive changes varied across communities, with individual leadership and communities' active engagement being key factors in successful physician recruitment. CONCLUSION: Locating medical education sites in underserviced rural communities in northern Ontario and engaging these communities in training rural physicians showed great potential to improve the ability of small rural communities to recruit family physicians and alleviate physician shortages in the region.

INTRODUCTION: L'École de médecine du Nord de l'Ontario (EMNO), qui a ouvert ses portes en 2005, a pour mandat social de combler la pénurie d'effectifs médicaux qui sévit depuis longtemps dans le Nord de l'Ontario. L'objectif de cette étude qualitative était d'étudier l'effet qu'a eu l'école sur le recrutement des médecins de famille dans des communautés rurales mal desservies dans cette région de la province. METHODS: Nous avons procédé à une étude de cas multiples auprès de 8 petites communautés rurales du Nord de l'Ontario considérées comme mal desservies par le ministère de la Santé provincial sur le plan des effectifs médicaux et ayant réussi à recruter des médecins formés à l'EMNO. Nous avons interrogé 10 personnes responsables du recrutement des médecins dans ces communautés. La transcription des entrevues a été analysée au moyen d'une méthode thématique inductive et itérative. RESULTS: La formation médicale de l'EMNO était offerte dans les 8 communautés, dont la population variait de 1600 à 16 000 habitants. Parmi les améliorations reliées à la collaboration avec l'EMNO, mentionnons : le recrutement de médecins dans 5 communautés où sévissaient auparavant des pénuries chroniques de l'ordre de 30 % à 50 %, une réduction substantielle des dépenses liées au recrutement, une diminution interdu recours à des remplaçants et la transition des activités de recrutement pour passer d'une situation de gestion de crise à une situation de planification à long terme. L'ampleur des améliorations a varié selon les communautés; le leadership individuel et la participation active des communautés ont été des facteurs clés de la réussite du recrutement des médecins. CONCLUSION: La prestation d'une formation dans de petites communautés rurales mal desservies du Nord de l'Ontario et la mobilisation des communautés visées à l'endroit de la formation des médecins en milieu rural ont révélé leur fort potentiel d'amélioration de la capacité de recruter des médecins de famille et de corriger les pénuries d'effectifs médicaux dans la région.

An examination of retention factors among registered nurses in Northeastern Ontario, Canada: Nurses intent to stay in their current position.

BACKGROUND: The purpose of the study was to examine factors related to the retention of registered nurses in northeastern Ontario, Canada. OBJECTIVE/METHOD: A cross-sectional survey of registered nurses working in northeastern Ontario, Canada was conducted. Logistic regression analyses were used to consider intent to stay in current employment in relation to the following: 1) demographic factors, and 2) occupation and career satisfaction factors. RESULTS: A total of 459 (29.8% response rate) questionnaires were completed. The adjusted odds logistic regression analysis of RNs who intended to remain in their current position for the next five years, demonstrated that respondents in the 46 to 56 age group (OR: 2.65; 95% CI: 1.50 to 4.69), the importance of staff development in the organization (OR: 3.04; 95% CI: 1.13 to 8.13) northeastern Ontario lifestyle (OR: 2.61; 95% CI: 1.55 to 4.40), working in nursing for 14 to 22.5 years (OR: 2.55; 95% CI: 1.10 to 5.93), and working between 0 to 1 hour of overtime per week (OR: 1.20; 95% CI: 1.20 to 4.64) were significant factors in staying in their current position for the next five years. CONCLUSIONS: This study shows that a further understanding of the work environment could assist with developing retention for rural nurses. Furthermore, employers may use such information to ameliorate the working conditions of nurses, while researchers may use such evidence to develop interventions that are applicable to improving the working conditions of nurses.

The importance of tailoring physicians' trauma care training needs in rural environments.

SUMMARY: Gaps in the provision of care exist in the initial evaluation and management of patients first cared for in the most rural settings. We designed a survey to explore what unmet educational needs might exist so as to improve the care of patients before transfer. Here we discuss opportunities for tailored training that will enhance learning capacity, narrow the trauma education gap and improve trauma care, particularly in rural environments.

Does better access to FPs decrease the likelihood of emergency department use? Results from the Primary Care Access Survey.

OBJECTIVE: To determine whether better access to FP services decreases the likelihood of emergency department (ED) use among the Ontario population. DESIGN: Population-based telephone survey. SETTING: Ontario. PARTICIPANTS: A total of 8502 Ontario residents aged 16 years and older. MAIN OUTCOME MEASURES: Emergency department use in the 12 months before the survey. RESULTS: Among the general population, having a regular FP was associated with having better access to FPs for immediate care (P < .001) but was not associated with a decreased likelihood of ED visits (odds ratio [OR] = 1.49, P = .03). Better actual access to FP services for immediate care was associated with a decreased likelihood of ED use (OR = 0.62, P < .001) among the general population. Among those with chronic diseases, having a regular FP was associated with a decreased likelihood of ED use (OR = 0.47, P = .01). Of the Ontario population, 39.3% wanted to see FPs for immediate care at least once a year; 63.1% of them had seen FPs without difficulties and were significantly less likely to use EDs than those who did not see FPs or had difficulties accessing physicians when needed (OR = 0.62, P < .001). Having a chronic health condition, recent immigrant status, residence in rural and northern parts of Ontario, and lower educational and income levels were significant predictors of a higher likelihood of ED use, independent of access to FPs (P < .05). CONCLUSION: A decreased likelihood of ED use is strongly associated with having a regular FP among those with chronic diseases and with having access to FPs for immediate care among the general population. Further research is needed to understand what accounts for a higher likelihood of ED use among those with regular FPs, new immigrants, residents of northern and rural areas of Ontario, and people with low socioeconomic status when actual access and sociodemographic characteristics have been taken into consideration. More important, this study demonstrates a need of distinguishing between potential and actual access to care, as having a regular FP and having timely and effective access to FP care might mean different things and have different effects on ED use.

Nurse practitioners in Ontario primary healthcare: referral patterns and collaboration with other healthcare professionals.

The purpose of this study is to examine referrals of nurse practitioners providing primary healthcare (PHC NPs) to better understand how PHC NPs collaborate with other healthcare professionals and contribute to interprofessional care. The analysis is based on the data from a survey of 378 PHC NPs registered in Ontario, Canada in 2008. Overall, 69% of PHC NPs made referrals to family physicians (FPs) and 67% of PHC NPs received referrals from FPs. Almost 50% of PHC NPs had bidirectional referrals between them and FPs. Eighty-nine percent of PHC NPs made referrals to specialist physicians. Bidirectional referrals between PHC NPs and social workers and mental health workers were common in family health teams and community health centers. Patterns of referrals (bidirectional, unidirectional and no referrals) between PHC NPs and FPs, social workers, mental and allied health workers in various practice settings indicate development of collaborative relationships between PHC NPs and other healthcare professionals and reflect the influence of practice models on delivery of interprofessional care. These findings are discussed in light of the development of NPs' role and integration of PHC NPs in the Ontario healthcare system. Implications for policy changes and future research are also suggested.

Postgraduate specialty training in northeastern Ontario and subsequent practice location.

INTRODUCTION: Physician specialists are under-represented in communities in northern Ontario, even in larger communities of approximately 100 000 population. The positive association between postgraduate training in northern or rural areas and eventual practice in these locations has been well documented in the literature, but only for family medicine/general practice. Few, if any, studies have explored the association for other specialties. The objective of this study was to determine if there was an association between northern training and northern practice location for physicians who were enrolled in the Northeastern Ontario Postgraduate Specialty (NOPS) program, which offers placements in northeastern Ontario in specialties such as anesthesiology, internal medicine and surgery. METHODS; A national medical human resources database provided the 31 December 2006 practice location of all 50 participants in the NOPS program since its inception in 2000 until 2006. Program records provided data on participants' specialty rotations in northeastern Ontario, including number, location, and duration of rotations. Non-NOPS participants (n=50) were randomly selected for comparison, matched one for one to the NOPS group on sex, year of birth, language, medical school, year of graduation from medical school, age at the time of graduation, and specialty. Hierarchical log-linear models and 2 tests were used to assess differences between NOPS and non-NOPS participants in geographic location and population size of practice community. Chi-square tests were used to analyze the relationship between the duration of northeastern rotations and practice location of NOPS participants. RESULTS: NOPS and the matched non-NOPS groups did not differ significantly for age or age at graduation from medical school (paired t-tests, p>0.80) and matched exactly for sex, medical school location and specialty group. Forty-six percent of NOPS participants were female and 80% came from Ontario residency programs. Seventy-two percent of the program participants were enrolled in medical specialties (the remainder were in surgical specialties) and this differed significantly by sex: 83% of females vs 63% of males (Χ (2)=4.76, df=1, p=0.03). A majority completed residency training at 31-35 years of age. Fifty percent of NOPS participants obtained medical degrees from Ontario universities, 34% from other Canadian universities and 16% from other universities. Significantly more NOPS participants than non-participants were located in northeastern Ontario (9 vs 0), significantly fewer were in other provinces (13 vs 22) and identical numbers were located in southern Ontario (28 vs 28) (=11.61, df=2, p<0.01). Significantly more NOPS participants than non-participants were practicing in communities of 10 000-99 999 people (15 vs 4), approximately equal numbers in communities of 100 000-499 999 (9 vs11) and non-significantly fewer were practicing in areas of 500 000 or more (26 vs 35) (Χ (2)=7.90, df=2, p=0.02), though this interaction was not significant in the hierarchical log-linear model. The NOPS participants located in northeastern Ontario were more likely to have longer northeastern rotations (>4 weeks) than those located in southern Ontario (Χ (2)=7.81, df=2, p=0.02). However, a longer northeastern rotation was no guarantee of a northeastern practice location because roughly equal numbers of participants with longer rotations were spread throughout the 3 geographic practice locations. Conversely, a shorter rotation was strongly associated with a southern Ontario practice location (18/25). The NOPS participants located in communities of ≥ 500 000 people were more likely to have shorter rotations than longer rotations, but this difference was only marginally statistically significant Χ (2)=5.13, df=2, p=0.08). CONCLUSIONS: The study found that specialists who participated in NOPS postgraduate specialty training in northeastern Ontario were more likely to practice in northeastern Ontario than non-participants. There was also a strong association between the duration of training in the northeast and northeastern practice and avoidance of practice in metropolitan areas. It is not clear yet whether longer northeastern rotations encourage northeastern practice or whether this reflects an existing disposition; it is clear, however, that specialists with longest specialty training rotations in the northeast were more likely to practice in the northeast. The results from this study provide the first empirical evidence of positive association between postgraduate specialty training in the northeast and eventual practice in northeastern Ontario and smaller cities.

Integration of nurse practitioners into Ontario's primary health care system: variations across practice settings.

Annual tracking surveys of nurse practitioners in the Canadian province of Ontario conducted by the Centre for Rural and Northern Health Research for the Ministry of Health and Long-Term Care provide a picture of current employment and practice. The authors present an update on the most recent survey of primary health care nurse practitioners (PHC NPs), conducted in 2008.The study sample consisted of 378 NPs registered in Ontario in 2008 and practising in PHC. Differences in demographic, employment, and practice characteristics in a variety of practice settings are explored. Geographic distribution, education, autonomy of the NP, and the practice profiles varied across settings. The findings document the integration of NPs into Ontario's health-care system and suggest a need to further describe the models of practice and their impact on PHC outcomes.