Interim Federal Health Program: Survey of use of supplemental benefits by paediatric health care providers.

Objectives: The Interim Federal Health Program (IFHP) provides temporary healthcare coverage to refugees and refugee claimants. Previous research demonstrates that paediatric healthcare providers poorly utilize the IFHP, with low registration rates and limited understanding of the program. The objective of this study was to examine paediatric provider use of IFHP-covered supplemental benefits, and their experience with trying to access these benefits. Methods: A one-time survey was administered via the Canadian Paediatric Surveillance Program in February 2020. Of those who had provided care to IFHP-eligible patients, descriptive tables and statistics were created looking at provider demographics, and experience using the IFHP supplemental benefits. A multinomial logistic regression was built to look at provider characteristics associated with trying to access supplemental benefits. Results: Of the 2,753 physicians surveyed, there were 1,006 respondents (general paediatricians and subspecialists). Of the respondents, 526 had recently provided care to IFHP-eligible patients. Just over 30% of those who had recently provided care did not access supplemental benefits as they did not know they were covered by the IFHP. Of those who had tried to access supplemental benefits, over 80% described their experience as difficult, or very difficult. Conclusions: Paediatric providers have a poor understanding of IFHP-covered supplemental benefits, which is cited as a reason for not trying to access supplemental benefits. Of those who do try to access these benefits, they describe the process as difficult. Efforts should be made to improve provider knowledge and streamline the process to improve access to healthcare for refugee children and youth.

Interim Federal Health Program: Survey of access and utilization by paediatric health care providers.

Background: The Interim Federal Health Program (IFHP) provides health care coverage to refugees and refugee claimants, yet remains underused by providers. The objective of this study was to assess Canadian paediatricians' current understanding and utilization of the IFHP, and perceived barriers to utilization. Methods: A one-time survey was administered via the Canadian Paediatric Surveillance Program in February 2020. In addition to descriptive statistics, multinomial logistic regressions were built to examine paediatrician use of the IFHP, and characteristics associated with registration and use. Results: Of the 2,753 physicians surveyed, there were 1,006 respondents (general paediatricians and subspecialists). 52.2% of respondents had provided care to IFHP-eligible patients in the previous 6 months. Of those participants, only 26.4% were registered IFHP providers, and just 16% could identify 80% or more of IFHP-covered services. Knowledge of 80% or more of IFHP-covered services was associated with registration status (adjusted odds ratio [aOR] 1.92; 95%CI 1.09 to 3.37). Among those who knew they were not registered, 70.2% indicated they did not know they had to register. aOR demonstrated that those with fewer years of practice had higher odds of not knowing that they had to register (aOR 1.22; 95%CI 1.01 to 1.49). Conclusions: We demonstrate that IFHP is poorly utilized by paediatric providers, with low registration rates and poor understanding of IFHP-covered supplemental services, even among those who have recently provided care to IFHP-eligible patients. Efforts to improve registration and knowledge of IFHP are essential to improving access to health care for refugee children and youth.

Gender and racial disparities in adherence to statin therapy: a meta-analysis.

BACKGROUND: Significant disparities exist in cardiovascular outcomes based on race/ethnicity and gender. Rates of evidence-based medication use and long-term medication adherence also appear to be lower in racial subgroups and women but have been subject to little attention. Our objective was to evaluate the effect of race/ethnicity and gender on adherence to statin therapy for primary or secondary prevention. METHODS AND RESULTS: Studies were identified through a systematic search of MEDLINE, EMBASE, ClinicalTrials.gov, and the Cochrane Database of Systematic Reviews (through April 1, 2010) and manual examination of references in selected articles. Studies reporting on adherence to statins by men and women or patients of white and nonwhite race were included. Information on study design, adherence measurement, duration, geographic location, sample size, and patient demographics was extracted using a standardized protocol. From 3,022 potentially relevant publications, 53 studies were included. Compared with men, women had a 10% greater odds of nonadherence (odds ratio 1.10, 95% confidence interval [CI], 1.07-1.13). Nonwhite race patients had a 53% greater odds of nonadherence than white race patients (odds ratio 1.53, 95% CI 1.25-1.87). There was significant heterogeneity in the pooled estimate for gender (I(2) 0.95, P value for heterogeneity <.001) and race (I(2) 0.98, P value for heterogeneity <.001). The overall results remained unchanged in those subgroups that had significantly less heterogeneity. CONCLUSIONS: Among patients prescribed statins, women and nonwhite patients are at increased risk for nonadherence. Further research is needed to identify interventions best suited to improve adherence in these populations.

For the Parent, by the Parent: Creating a Program to Empower Parents of Refugee Background in Canada Using Novel Participatory Approaches.

BACKGROUND: Families of refugee background have complex, multigenerational mental health and developmental needs that are not accounted for in current programming frameworks in Canada. Providing appropriate support services and educational resources that address the unique concerns of families of refugee background will allow for improved family cohesion and developmental outcomes for children. Parenting programs have been shown to be successful in improving parental stress, parental efficacy, and children's mental health and well-being. This study gathers data about the experiences of caregivers of refugee background in order to develop a novel, multi-dimensional parenting program model using Community-Based Participatory Research (CBPR) principles. METHODOLOGY: This was a qualitative, CBPR study using a formative research framework. In-depth interviews (IDIs) were conducted with caregivers of refugee background and service providers that work closely with this population. Data were recorded, transcribed, and coded using deductive and inductive coding methods by two independent coders. RESULTS: A total of 20 IDIs were conducted (7 caregivers and 13 service providers). The main topics that were identified to be incorporated into the program include: features of child development, how to address resettlement issues, child advocacy, and parenting after resettlement. Participants felt that tackling language barriers, addressing the overlapping responsibilities of caregivers attending the sessions, providing incentives, increasing awareness of the program, and using an anti-racist and anti-oppressive approach was key to the program's success. Participants emphasized the need for trauma-informed mental health supports within the program model. CONCLUSION: This study describes the key considerations for a novel parenting program for families of refugee background, by engaging them as key stakeholders in the program design process. Future iterations of this project would involve a pilot and evaluation of the program.

A systematic review of adherence to cardiovascular medications in resource-limited settings.

BACKGROUND: Medications are a cornerstone of the prevention and management of cardiovascular disease. Long-term medication adherence has been the subject of increasing attention in the developed world but has received little attention in resource-limited settings, where the burden of disease is particularly high and growing rapidly. To evaluate prevalence and predictors of non-adherence to cardiovascular medications in this context, we systematically reviewed the peer-reviewed literature. METHODS: We performed an electronic search of Ovid Medline, Embase and International Pharmaceutical Abstracts from 1966 to August 2010 for studies that measured adherence to cardiovascular medications in the developing world. A DerSimonian-Laird random effects method was used to pool the adherence estimates across studies. Between-study heterogeneity was estimated with an I(2) statistic and studies were stratified by disease group and the method by which adherence was assessed. Predictors of non-adherence were also examined. FINDINGS: Our search identified 2,353 abstracts, of which 76 studies met our inclusion criteria. Overall adherence was 57.5% (95% confidence interval [CI] 52.3% to 62.7%; I(2) 0.98) and was consistent across study subgroups. Studies that assessed adherence with pill counts reported higher levels of adherence (62.1%, 95% CI 49.7% to 73.8%; I(2) 0.83) than those using self-report (54.6%, 95% CI 47.7% to 61.5%; I(2) 0.93). Adherence did not vary by geographic region, urban vs. rural settings, or the complexity of a patient's medication regimen. The most common predictors of poor adherence included poor knowledge, negative perceptions about medication, side effects and high medication costs. INTERPRETATION: Our study indicates that adherence to cardiovascular medication in resource-limited countries is sub-optimal and appears very similar to that observed in resource-rich countries. Efforts to improve adherence in resource-limited settings should be a priority given the burden of heart disease in this context, the central role of medications in their management, and the clinical and economic consequences of non-adherence.

Evaluation of the effectiveness of the Global Medical Student Partnership program in undergraduate medical education.

BACKGROUND: The Global Medical Student Partnership (GMSP) is a medical student-led international initiative to promote accessible global health learning. This study aims to evaluate the effectiveness of the GMSP program in meeting its learning objectives. METHODS: Canadian and international medical student pairs met online monthly (January-May 2018) to discuss global health-related medical cases. Students then reviewed cases with local GMSP peers and faculty experts. A mixed-methods study was performed to evaluate whether the objectives of the program had been achieved. 26 of 32 (81.3%) students completed a questionnaire, and 13 (40.6%) also participated in one-on-one semi-structured interviews. Descriptive statistics and thematic analysis were used to analyze students' perspectives on skill development through GMSP. RESULTS: GMSP students agreed or strongly agreed that international collaboration and communication skills were more important to them following program participation (92.3%, 92.3% respectively). Many expressed that after GMSP, they knew more about their healthcare system, practices abroad and how to solve complex health issues (92.3%, 84.6%, 61.5% respectively). Qualitative data showed GMSP improved students' communication and presentation skills, provided a foundation for international relationships, fostered appraisal of diverse health systems, and furthered students' understanding of health advocacy. CONCLUSIONS: Our findings demonstrate that GMSP met its original objectives by providing students with opportunities to engage in international collaborations and to further develop their skills in advocacy, communication, and health-systems research. This program may be an important addition to medical education as it makes use of technology and peer-to-peer exchange to enable global health learning.

CONTEXTE: Le Global Medical Student Partnership (GMSP) est une initiative d'envergure internationale menée par des étudiants en médecine qui vise à favoriser la formation en santé mondiale. La présente étude consiste à évaluer l'efficacité du programme GMSP pour atteindre ses objectifs d'apprentissage. MÉTHODOLOGIE: Des paires d'étudiants en médecine canadiens et étrangers se sont rencontrés en ligne tous les mois, entre janvier et mai 2018, pour discuter de situations cliniques en santé mondiale. Après la rencontre, ces situations cliniques ont été revues par des pairs locaux du programme GMSP et des experts du corps professoral. On a effectué une étude à devis mixte pour déterminer si les objectifs du programme avaient été atteints. 26 des 32 (81,3 %) étudiants ont répondu à un questionnaire et 13 (40,6 %) ont aussi pris part à des entrevues individuelles semi-dirigées. Des statistiques descriptives et une analyse thématique ont été utilisées analyser les perceptions des étudiants sur le développement d'habiletés par le programme GMSP. RÉSULTATS: Les étudiants participant au programme GMSP étaient d'accord ou très en accord pour dire que les habiletés à la collaboration internationale et à la communication étaient plus importantes à leurs yeux après la participation au programme (92.3%, 92,3%, respectivement). Bon nombre ont affirmé qu'après le programme GMSP, ils en connaissaient plus sur leur système de soins de santé, les pratiques à l'étranger et les façons de résoudre des problèmes de santé complexes (92,3 %, 84,6 %, 61,5 % respectivement). Des données qualitatives ont montré que le programme GMSP a amélioré les aptitudes à la communication et des techniques de présentation. Elles ont servi à établir des relations à l'international, à évaluer divers systèmes de soins de santé et à mieux comprendre la promotion de la santé et à militer en faveur de celle-ci. CONCLUSIONS: Nos résultats montrent que le programme GMSP a atteint ses objectifs de départ puisqu'il a donné aux étudiants des occasions de collaboration internationale et leur a permis de développer davantage leurs habiletés en matière de défense des droits, de communication, et de recherche sur les systèmes de soins de santé. Ce programme pourrait s'avérer un important complément à la formation médicale parce qu'il utilise la technologie et des échanges pairs-pairs pour l'apprentissage des enjeux de santé mondiaux.

Meta-analysis of the efficacy and safety of clopidogrel plus aspirin as compared to antiplatelet monotherapy for the prevention of vascular events.

Antiplatelet agents are central to the treatment and prevention of cardiovascular disease. Although aspirin is the most widely used agent, randomized trials have assessed whether adding clopidogrel to aspirin ("dual-antiplatelet therapy") offers additional benefit with acceptable safety. Unfortunately, these trials have reached conflicting results, in part because of the heterogenous populations they studied. To clarify the role of dual-antiplatelet therapy for patients with vascular disease, a systematic review and meta-analysis of randomized controlled trials was performed. Medline and the Cochrane Collaboration and American College of Physicians Journal Club databases were searched for trials published from 1966 to August 2006 that compared aspirin and clopidogrel with antiplatelet monotherapy. Only trials that presented clinically relevant efficacy and safety outcomes were included. From each trial, demographic data and outcomes were recorded. Summary odds ratios and 95% confidence intervals (CIs) were calculated using a random-effects model. Eight trials comprising 91,744 patients were included. Mean follow-up ranged from 28 days to 18 months. Compared with aspirin alone, dual therapy with aspirin and clopidogrel reduced the odds ratio of the composite outcome of death, reinfarction, and stroke by 15% (95% CI 23% to 6%) in patients with acute coronary syndromes and by 34% (95% CI 44% to 22%) in patients who underwent percutaneous coronary intervention. Dual therapy also significantly reduced the odds of fatal and nonfatal reinfarction in these patient groups but did not significantly reduce the odds of all-cause mortality. Dual therapy was associated with significantly increased risk for major bleeding in studies >1 month in duration (odds ratio 1.80, 95% CI 1.40 to 2.30). In conclusion, combining aspirin and clopidogrel significantly reduces the odds of major cardiovascular events in patients with acute coronary syndromes or those who undergo percutaneous coronary intervention but at the expense of significant increases in the risk for bleeding.

The Burden of Cardiovascular Disease in Low- and Middle-Income Countries: Epidemiology and Management.

Cardiovascular disease (CVD) is the second leading cause of mortality worldwide, accounting for 17 million deaths in 2013. More than 80% of these cases were in low- and middle-income countries (LMICs). Although the risk factors for the development of CVD are similar throughout the world, the evolving change in lifestyle and health behaviours in LMICs-including tobacco use, decreased physical activity, and obesity-are contributing to the escalating presence of CVD and mortality. Although CVD mortality is falling in high-income settings because of more effective preventive and management programs, access to evidence-based interventions for combating CVD in resource-limited settings is variable. The existing pressures on both human and financial resources impact the efforts of controlling CVD. The implementation of emerging innovative interventions to improve medication adherence, introducing m-health programs, and decentralizing the management of chronic diseases are promising methods to reduce the burden of chronic disease management on such fragile health care systems.