"We're sinking": a qualitative interview-based study on stakeholder perceptions of structural and process limitations to the Canadian healthcare system.

BACKGROUND: Despite longstanding efforts and calls for reform, Canada's incremental approach to healthcare changes has left the country lagging behind other OECD nations. Reform to the Canadian healthcare system is essential to develop a higher performing system. This study sought to gain a deeper understanding of the views of Canadian stakeholders on structural and process deficiencies and strategies to improve the Canadian healthcare system substantially and meaningfully. METHODS: We conducted individual, ~ 45-minute, semi-structured virtual interviews from May 2022 to August 2022. Using existing contacts and snowball sampling, we targeted one man and one woman from five regions in Canada across four stakeholder groups: (1) public citizens; (2) healthcare leaders; (3) academics; and (4) political decision makers. Interviews centered on participants' perceptions of the state of the current healthcare system, including areas where major improvements are required, and strategies to achieve suggested enhancements; Donabedian's Model (i.e., structure, process, outcomes) was the guiding conceptual framework. Interviews were audio-recorded, transcribed verbatim, and de-identified, and inductive thematic analysis was performed independently and in duplicate according to published methods. RESULTS: The data from 31 interviews with 13 (41.9%) public citizens, 10 (32.3%) healthcare leaders, 4 (12.9%) academics, and 4 (12.9%) political decision makers resulted in three themes related to the structure of the healthcare system (1. system reactivity; 2. linkage with the Canadian identity; and 3. political and funding structures), three themes related to healthcare processes (1. staffing shortages; 2. inefficient care; and 3. inconsistent care), and three strategies to improve short- and long-term population health outcomes (1. delineating roles and revising incentives; 2. enhanced health literacy; 3. interdisciplinary and patient-centred care). CONCLUSION: Canadians in our sample identified important structural and process limitations to the Canadian healthcare system. Meaningful reforms are needed and will require addressing the link between the Canadian identity and our healthcare system to facilitate effective development and implementation of strategies to improve population health outcomes.

COVID-19 Vaccine's Speed to Market and Vaccine Hesitancy: A Cross-Sectional Survey Study.

Background: This paper aims to assess the extent to which the COVID-19 vaccine's speed to market affected Canadian residents' decision to remain unvaccinated. Method: A cross-sectional survey conducted in late 2021 asked participants whether they had received the vaccine and their reasons for abstaining. Results: Of the 2,712 participants who completed the survey, 8.9% remained unvaccinated. Unvaccinated respondents who selected "They made the vaccine too fast" (59.8%), were significantly more likely to identify as white, believe that the COVID-19 pandemic was not serious and have an unvaccinated social circle. Conclusion: Should the COVID-19 vaccine rapid regulatory process be expanded, more patients may refuse treatment than if traditional timelines are followed.

Risk of transmission of respiratory viruses during aerosol-generating medical procedures (AGMPs) revisited in the COVID-19 pandemic: a systematic review.

BACKGROUND: In many jurisdictions healthcare workers (HCWs) are using respirators for aerosol-generating medical procedures (AGMPs) performed on adult and pediatric populations with all suspect/confirmed viral respiratory infections (VRIs). This systematic review assessed the risk of VRIs to HCWs in the presence of AGMPs, the role respirators versus medical/surgical masks have on reducing that risk, and if the risk to HCWs during AGMPs differed when caring for adult or pediatric patient populations. MAIN TEXT: We searched MEDLINE, EMBASE, Cochrane Central, Cochrane SR, CINAHL, COVID-19 specific resources, and MedRxiv for English and French articles from database inception to September 9, 2021. Independent reviewers screened abstracts using pre-defined criteria, reviewed full-text articles, selected relevant studies, abstracted data, and conducted quality assessments of all studies using the ROBINS-I risk of bias tool. Disagreements were resolved by consensus. Thirty-eight studies were included; 23 studies on COVID-19, 10 on SARS, and 5 on MERS/ influenza/other respiratory viruses. Two of the 16 studies which assessed associations found that HCWs were 1.7 to 2.5 times more likely to contract COVID-19 after exposure to AGMPs vs. not exposed to AGMPs. Eight studies reported statistically significant associations for nine specific AGMPs and transmission of SARS to HCWS. Intubation was consistently associated with an increased risk of SARS. HCWs were more likely (OR 2.05, 95% CI 1.2-3.4) to contract human coronaviruses when exposed to an AGMP in one study. There were no reported associations between AGMP exposure and transmission of influenza or in a single study on MERS. There was limited evidence supporting the use of a respirator over a medical/surgical mask during an AGMP to reduce the risk of viral transmission. One study described outcomes of HCWs exposed to a pediatric patient during intubation. CONCLUSION: Exposure to an AGMP may increase the risk of transmission of COVID-19, SARS, and human coronaviruses to HCWs, however the evidence base is heterogenous and prone to confounding, particularly related to COVID-19. There continues to be a significant research gap in the epidemiology of the risk of VRIs among HCWs during AGMPs, particularly for pediatric patients. Further evidence is needed regarding what constitutes an AGMP.

The lived experience by patients and family members of extracorporeal membrane oxygenation: A qualitative study.

OBJECTIVE: To examine the lived experience of extracorporeal membrane oxygenation (ECMO) by patients and their families, and their relationship with intensive care clinicians. RESEARCH METHODOLOGY: Semi-structured interviews were conducted with six patients who had received ECMO and with four of their family members. The data were analysed narratively using a constant comparative method. SETTING: Patients were treated at a major acute care hospital in British Columbia between 2014 and 2021. ECMO was used either as a bridge to recovery or to organ transplant. Four had family members bedside throughout, while two had virtual visits due to COVID-19 infection control measures. FINDINGS: ECMO was experienced through a triad of relationships between the patient, key family members and key clinicians. The strength, directionality and focus of these relationships shifted during therapy and realigned once ECMO was removed. The largest shift involved family members. Post-ECMO, patients relied almost entirely on spouses, adult children and clinical team members to reconstruct their experience. The connection between families and clinical team members was limited and changed little. CONCLUSIONS: The lived experience of ECMO was complex in ways yet to be comprehensively reported in the literature. This technology had particular impact on family members when ECMO was used as a bridge to transplant and where run times extended to multiple weeks. COVID-19 infection control restrictions further complicated how this technology was experienced. Findings from this study highlight the importance of intensive care nurses recognising the critical role family members play as witnesses whose experiences later allow patients to make sense of their journey post-discharge.

A scoping review of opioid harm reduction interventions for equity-deserving populations.

Background: Morbidity and mortality associated with opioid use has become a North American crisis. Harm reduction is an evidence-based approach to substance use. Targeted harm reduction strategies that consider the needs of specific populations are required. The objective of this scoping review was to document the range of opioid harm reduction interventions across equity-deserving populations including racialized groups, Indigenous peoples, LGBTQIA2S+, people with disabilities, and women. Methods: Ten databases were searched from inception to July 5th, 2021. Terms for harm reduction and opioid use formed the central concepts of the search. We included studies that: (1) assessed the development, implementation, and/or evaluation of harm reduction interventions for opioid use, and (2) reported health-related outcomes or presented perspectives that directly related to experiences receiving or administering harm reduction interventions, (3) were completed within an equity-deserving population and (4) were completed in New Zealand, Australia, Canada or the US. A knowledge map was developed a-priori based on literature outlining different types of harm reduction interventions and supplemented by the expertise of the research team. Findings: 12,958 citations were identified and screened, with 1373 reviewed in full-text screening. Of these, 15 studies were included in the final dataset. The most common harm reduction program was opioid agonist treatment (OAT) (n = 11, 73%). The remaining four studies included: overdose prevention; drug testing equipment; and outreach, peer support, and educational programs for safer use. Nine studies focused on women, primarily pregnant/post-partum women, three focused on Indigenous peoples, and three studies included racialized groups. No studies were identified that provided any information on persons with a disability or members of the LGBTQIA2S+ population. Interpretation: The scant opioid specific harm reduction literature on equity-deserving populations to date has primarily focused on OAT programs and is focused primarily on women. There is a need for more targeted research to address the diverse social experiences of people who use drugs and the spectrum of harm reduction interventions that are needed. There is also a need to acknowledge the history of harm reduction as a drug-user activist movement aimed at challenging bio-medical paradigms of drug use. Further, there is a need to recognize that academic research may be contributing to health inequity by not prioritizing research with this lens. Funding: This research was funded by the Canadian Institutes of Health Research.

The effect of interventions targeting gut microbiota on depressive symptoms: a systematic review and meta-analysis.

BACKGROUND: Despite their popularity, the efficacy of interventions targeting gut microbiota to improve depressive symptoms is unknown. Our objective is to summarize the effect of microbiome-targeting interventions on depressive symptoms. METHODS: We conducted a systematic review and meta-analysis. We searched MEDLINE, Embase, PsycINFO, Database of Abstracts of Reviews of Effects, Cochrane Database of Systematic Reviews and the Cochrane Controlled Register of Trials from inception to Mar. 5, 2021. We included studies that evaluated probiotic, prebiotic, synbiotic, paraprobiotic or fecal microbiota transplant interventions in an adult population (age ≥ 18 yr) with an inactive or placebo comparator (defined by the absence of active intervention). Studies must have measured depressive symptoms with a validated scale, and used a randomized controlled trial study design. We conducted a random effects meta-analysis of change scores, using standardized mean difference as the measure of effect. RESULTS: Sixty-two studies formed the final data set, with 50 included in the meta-analysis. Probiotic, prebiotic, and synbiotic interventions on depressive symptoms showed statistically significant benefits. In the single studies evaluating each of fecal microbiota transplant and paraprobiotic interventions, neither showed a statistically significant benefit. INTERPRETATION: Despite promising findings of benefit of probiotic, prebiotic and synbiotic interventions for depressive symptoms in study populations, there is not yet strong enough evidence to favour inclusion of these interventions in treatment guidelines for depression. Critical questions about species administered, dosage and timing relative to other antidepressant medications remain to be answered. STUDY REGISTRATION: PROSPERO no. 143178.

Primary care physicians' perceptions of the role of alternative payment models in recruitment and retention in rural Alberta: a qualitative study.

BACKGROUND: Despite well-documented challenges in recruiting physicians to rural practice, few Canadian studies have described the role physician payment models may play in attracting and retaining physicians to rural practice. This study examined the perspectives of rural primary care physicians on the factors that attract and retain physicians in rural locations, including the role that alternative payment models (APMs) might play. METHODS: This was a qualitative study involving in-depth, open-ended interviews with rural primary care physicians practising under fee-for-service (FFS) models and APMs in Alberta, Canada. Participants were recruited from the Rural Health Professions Action Plan member list (consisting of physicians practising in rural or remote locations in Alberta) and the College of Physicians and Surgeons of Alberta online database. Interviews were conducted April to June 2020, and data were analyzed using a thematic framework approach. RESULTS: Fourteen physicians were interviewed. There were 5 themes identified: factors that attract physicians to rural practice, barriers and challenges associated with rural practice, the potential role of APMs in recruitment and retention, factors that physicians consider in deciding to change payment models, and physician perceptions of APMs compared with FFS models. Participants expressed that APMs may have some role to play in retaining rural physicians but identified professional challenges, and family-related and personal factors as key determinants. Most FFS physicians indicated that they were interested in exploring APMs provided specific concerns were addressed (e.g., clear and adequately compensated APM contracts, and physician involvement in the development of APMs). INTERPRETATION: Primary care physicians practising in rural regions in Alberta view payment models as one consideration among many in their decision to pursue rural practice. Alternative payment model contracts designed with the input of physicians may have a role to play in attracting and retaining physicians to rural practice.

Differences in transportation and leisure physical activity by neighborhood design controlling for residential choice.

BACKGROUND: Cross-sectional studies provide useful insight about the associations between the built environment and physical activity (PA), particularly when reasons for neighborhood choice are considered. Our study analyzed the relationship between levels of weekly transportation and leisure PA among 3 neighborhood designs, statistically adjusting for sociodemographic characteristics and reasons for neighborhood choice. METHODS: A stratified random sample of adults (age ≥20 years) living in Calgary (Canada) neighborhoods with different neighborhood designs (grid, warped-grid, and curvilinear) and socioeconomic status completed a self-administered questionnaire capturing PA, sociodemographic characteristics, and reasons for neighborhood choice (response rate = 10.1%; n = 1023). Generalized linear models estimated associations between neighborhood design and transportation and leisure PA outcomes (participation (any vs. none) and volume (metabolic equivalent: h/week)), adjusting for neighborhood socioeconomic status, sociodemographic characteristics (gender, age, ethnicity, education, household income, marital status, children, vehicle access, dog ownership, and injury), and reasons for neighborhood choice (e.g., proximity and quality of recreational and utilitarian destinations, proximity to work, highway access, aesthetics, and sense of community). RESULTS: Overall, 854 participants had resided in their neighborhood for at least 12 months and provided complete data. Compared with those living in curvilinear neighborhoods, grid neighborhood participants had greater odds (p < 0.05) of participating in any transportation walking (odds ratio (OR) = 2.17), transportation and leisure cycling (OR = 2.39 and OR = 1.70), active transportation (OR = 2.16), and high-intensity leisure PA (≥6 metabolic equivalent; OR = 1.74), respectively. There were no neighborhood differences in the volume of any transportation or leisure PA undertaken. Adjustment for neighborhood selection had minimal impact on the statistical or practical importance of model estimates. CONCLUSION: Neighborhood design is associated with PA patterns in adults, independent of reasons for neighborhood choice and sociodemographic factors.

Evidence synthesis - A systematized literature review on the associations between neighbourhood built characteristics and walking among Canadian adults. / Synthèse des données probantes - Associations entre les caractéristiques de l'environnement bâti du quartier et la marche chez les adultes canadiens : une revue systématisée de la littérature.

INTRODUCTION: Evidence to date suggests that the built environment has the potential to facilitate and even discourage physical activity. A limitation of previous reviews is that they have typically not been country-specific. We conducted a systematized literature review of quantitative studies that estimated associations between the built environment-which were objectively measured-and walking among Canadian adults. METHODS: Five scientific databases were searched for peer-reviewed studies published in all years up to December 31, 2016, that estimated the association between the built environment (i.e. objectively measured using audits and Geographic Information Systems [GIS]) and physical activity among a sample of Canadian adults. The database searches, title and abstract screen, full-text review and data extraction were undertaken by two reviewers. RESULTS: Of 4140 articles identified, 25 met the inclusion criteria. Most studies included data from a single Canadian province. All but two studies were cross-sectional. Most studies captured self-reported walking for transportation and walking for any purpose. Overall walkability and land use were consistently associated with walking for transportation, while proximity to destinations was associated with walking for any purpose. CONCLUSION: Our review findings suggest that the built environment is potentially important for supporting adult walking. Overall walkability, land use and proximity to destinations appear to be important given their association with transportation walking and walking for any purpose.

INTRODUCTION: Les données récentes semblent indiquer que l'environnement bâti peut faciliter comme décourager l'activité physique. Les revues de la littérature disponibles ont en général comme limite de ne pas être spécifiques à un pays. Nous avons effectué une revue systématisée des études quantitatives qui analysent les associations, mesurées objectivement, entre l'environnement bâti et la marche chez les adultes canadiens. MÉTHODOLOGIE: Nous avons effectué une recherche dans cinq bases de données scientifiques pour sélectionner les études évaluées par les pairs et publiées jusqu'au 31 décembre 2016 ayant analysé l'association entre l'environnement bâti (mesuré objectivement grâce à des vérifications et à un système d'information géographique [SIG]) et l'activité physique chez un échantillon d'adultes canadiens. Deux chercheurs ont effectué les recherches dans les bases de données, ont filtré les articles par titre et résumé, ont revu l'intégralité des textes sélectionnés et en ont extrait les données. RÉSULTATS: Parmi les 4 140 articles recensés, 25 respectaient nos critères d'inclusion. La plupart des études contenaient des données sur une seule province canadienne. Toutes les études sauf deux étaient transversales. La plupart des études disposaient d'information autodéclarée sur la marche comme mode de déplacement et la marche sans but spécifié. Le potentiel piétonnier global et l'occupation des sols ont été systématiquement associés à la marche comme mode de déplacement, alors que la proximité de la destination a été associée à la marche sans but spécifié. CONCLUSION: Les résultats de notre revue de littérature suggèrent que l'environnement bâti possède un fort potentiel susceptible d'encourager la marche chez les adultes. Ce sont surtout le potentiel piétonnier global, l'occupation des sols et la proximité de la destination qui sont importants, si l'on se fie à leur association à la marche comme mode de déplacement et à la marche sans but spécifié.