Identifying barriers to healthcare delivery and access in the Circumpolar North: important insights for health professionals

Challenges Experienced by Health Care Workers During Service Delivery in the Geographically Challenging Terrains of North-East India: Study Involving a Thematic Analysis

BACKGROUND

The public health landscape in North-East India is marked by the foundational principle of equitable health care provision, a critical endeavor considering the region's intricate geography and proximity to international borders. Health care workers grapple with challenges, such as treacherous routes, limited infrastructure, and diverse cultural nuances, when delivering essential medical services. Despite improvements since the National Rural Health Mission in 2005, challenges persist, prompting a study to identify health care workers' challenges and alternative strategies in Manipur and Nagaland.

OBJECTIVE

This study aims to document the challenges experienced by health care workers during service delivery in the geographically challenging terrains of North-East India.

METHODS

This study is part of the i-DRONE (Indian Council of Medical Research's Drone Response and Outreach for North East) project, which aims to assess the feasibility of drone-mediated vaccine and medical delivery. This study addresses the secondary objective of the i-DRONE project. In-depth interviews of 29 health care workers were conducted using semistructured questionnaires in 5 districts (Mokokchung and Tuensang in Nagaland, and Imphal West, Bishnupur, and Churachandpur in Manipur). Nineteen health facilities, including primary health care centers, community health centers, and district hospitals, were selected. The study considered all levels of health care professionals who were in active employment for the past 6 months without a significant vacation and those who were engaged in ground-level implementation, policy, and maintenance activities. Data were recorded, transcribed, and translated, and subsequently, codes, themes, and subthemes were developed using NVivo 14 (QSR International) for thematic analysis.

RESULTS

Five themes were generated from the data: (1) general challenges (challenges due to being an international borderline district, human resource constraints, logistical challenges for medical supply, infrastructural issues, and transportation challenges); (2) challenges during the COVID-19 pandemic (increased workload, lack of diagnostic centers, mental health challenges and family issues, routine health care facilities affected, stigma and fear of infection, and vaccine hesitancy and misinformation); (3) perception and awareness regarding COVID-19 vaccination; (4) alternative actions or strategies adopted by health care workers to address the challenges; and (5) suggestions provided by health care workers. Health care workers demonstrated adaptability by overcoming these challenges and provided suggestions for addressing these challenges in the future.

CONCLUSIONS

Health care workers in Manipur and Nagaland have shown remarkable resilience in the face of numerous challenges exacerbated by the pandemic. Despite infrastructural limitations, communication barriers, and inadequate medical supply distribution in remote areas, they have demonstrated adaptability through innovative solutions like efficient data management, vaccination awareness campaigns, and leveraging technology for improved care delivery. The findings are pertinent for not only health care practitioners and policymakers but also the broader scientific and public health communities. However, the findings may have limited generalizability beyond Manipur and Nagaland.

COVID-19 in a rural intensive care unit in Northern British Columbia: Descriptive analysis of outcomes and demands on rural resources

INTRODUCTION

This descriptive study reviews clinical outcomes of individuals admitted to a northern Canadian, rural intensive care unit (ICU) with severe COVID-19. It reports our site-specific data that is part of an ongoing global effort to gather data and guide therapy; the aims of this study were to describe participants admitted to our ICU with COVID-19 and illuminate challenges faced by rural and remote centres.

METHODS

This retrospective study examined data from participants admitted to the ICU with COVID-19 pneumonia between 24th November 2020 and 28th February 2022. Using data from electronic and hardcopy health records, data were obtained according to standardised forms developed for the Short Period Incidence Study of Severe Acute Respiratory Infection.

RESULTS

Eighty-five adult participants were admitted to our ICU with COVID-19. The median age of participants was 57 years old (range: 23-83 years); 49.4% were males and 50.6% were females. Of our cohort, 58.9% required mechanical ventilation at some point during their stay and the median duration of stay in our ICU was 5 days (range: 1-36 days). Amongst individuals included, 25.9% were discharged alive from our hospital on their index admission, 57.6% were transferred to another facility and 16.5% died in our facility.

CONCLUSION

COVID-19 significantly strained our local ICU resources, necessitating high numbers of patient transfers. However, despite limited resources, patients at our site received contemporary guideline-based care for COVID-19 pneumonia. Future pandemic and surge capacity planning must ensure that rural and remote communities receive adequate additional resources to meet the anticipated needs of their local populations.

INTRODUCTION

Cette étude descriptive examine les résultats cliniques des personnes admises dans une unité de soins intensifs rurale du nord du Canada avec une COVID-19 sévère. Elle rapporte des données spécifiques à notre site qui font partie d'un effort global en cours pour rassembler des données et guider la thérapie. Les objectifs de cette étude étaient de décrire les participants admis dans notre unité de soins intensifs avec la COVID-19 et d'éclairer les défis auxquels sont confrontés les centres ruraux et éloignés.

MTHODES

Cette étude rétrospective a examiné les données des participants admis à l'unité de soins intensifs pour une pneumonie due à la COIVD-19 entre le 24 novembre 2020 et le 28 février 2022. Les données ont été obtenues à partir de dossiers médicaux électroniques et papier, selon des formulaires standardisés développés pour l'étude d'incidence à court terme des infections respiratoires aiguës sévères (SPRINT-SARI).

RSULTATS

85 participants adultes ont été admis dans notre unité de soins intensifs avec la COVID-19. L'âge médian des participants était de 57 ans (intervalle: 23-83 ans); 49,4% étaient des hommes et 50,6% des femmes. Dans notre cohorte, 58,9% ont eu besoin d'une ventilation mécanique à un moment ou à un autre de leur séjour et la durée médiane du séjour dans notre unité de soins intensifs était de 5 jours (intervalle: 1-36 jours). Parmi les personnes incluses, 25,9% sont sorties vivantes de notre hôpital lors de leur admission initiale, 57,6% ont été transférées dans un autre établissement et 16,5% sont décédées dans notre établissement.

CONCLUSION

La COVID-19 a mis à rude épreuve les ressources de notre unité locale de soins intensifs, nécessitant un grand nombre de transferts de patients. Cependant, malgré des ressources limitées, les patients de notre site ont reçu des soins fondés sur des lignes directrices contemporaines pour la pneumonie due à la COVID-19. À l'avenir, la planification de la pandémie et de la capacité de pointe doit garantir que les communautés rurales et éloignées reçoivent des ressources supplémentaires adéquates pour répondre aux besoins anticipés de leurs populations locales.

Drug persistence in patients with rheumatic and musculoskeletal diseases during a major economic crisis: results from a nationwide cross-sectional online survey

To evaluate the drug persistence in patients with rheumatic and musculoskeletal diseases (RMDs) during the current economic crisis in Lebanon and to estimate predictors of persistence. A nationwide multicentric cross-sectional study using an online questionnaire was conducted in Lebanon with patients with chronic inflammatory rheumatic diseases (CIRDs) and non-inflammatory RMDs controls between July and October 2022. Disease-modifying antirheumatic drugs (DMARDs) were categorized as conventional synthetic (cs), biological (b), subcutaneous (SC) or intravenous (IV), and targeted synthetic (ts). Persistence was defined as "number of tablets or injections taken during the past month versus prescribed". The percentage of patients who discontinued or changed treatment due to cost or non-availability was reported. Factors associated with persistence were identified using multivariable linear regression. The study included 317 patients with RMDs (286 CIRDs); mean age 49.5 years, 68% females, 58% reporting currently low economic level. Persistence at one month was low for tsDMARDs (36%) and bDMARDs (SC55%, IV63%), and acceptable for csDMARDs (88%). A persistence ≥80% was found in 23.3% of patients on tsDMARDs, 42.9% on SC bDMARDs, 45.0% on IV bDMARDs, and 74.7% on csDMARDs. During the past 6 months, 55.8% of CIRD patients discontinued or changed treatment due to non-availability (45.3%) or cost (21.2%). Persistence was positively associated with finding alternative sources such as buying abroad (36%), depending on friends or families abroad (20%), charities (10%), and negatively associated with unemployment and low financial status. Persistence was significantly compromised for essential antirheumatic drugs and was mostly driven by treatment unavailability and cost.

Undergraduate Nursing Student Reflections on Indigenous Peoples' Experiences With the Canadian Health Care System

AIM

The aim of this study was to analyze nursing student level of knowledge and understanding of current experiences of Indigenous people within the Canadian health care system to identify curricular gaps that need to be addressed.

BACKGROUND

In response to the 2015 Truth and Reconciliation Commission of Canada, nursing schools have begun incorporating Indigenous health content into curricula. However, few studies about the implementation and effectiveness of this education exist.

METHOD

Students wrote a reflection and engaged with colleagues' reflections after watching a video from the Aboriginal Peoples Television Network. Fifteen reflections were selected using systematic, random sampling to undergo thematic analysis.

RESULTS

Two themes were identified: 1) students' understanding of barriers Indigenous populations face when accessing the health care system and 2) students' perceptions of strategies to ensure culturally safe care for Indigenous populations.

CONCLUSION

Analysis of students' learning through a reflection activity can improve the Indigenous health content curriculum.

Perceived barriers of access to health and nutrition services under drought and food insecurity emergency in north-east Uganda: a qualitative study

BACKGROUND

In the face of drought and food insecurity emergency, evidence on access to health and nutrition services is important. Karamoja is one of the regions that have experienced extreme drought and food insecurity emergency in Uganda. As a part of the drought and food insecurity emergency response, World Health Organization (WHO) with Ministry of Health (MoH) has designed and implemented a qualitative study in 15 districts that have experienced drought and food insecurity emergency in north-east Uganda. Thus, we aimed to explore the barriers of access to health and nutrition services in drought and food insecurity emergency affected districts in north-east Uganda.

METHODS

We employed a descriptive qualitative study design. We interviewed 30 patients and 20 Village Health Teams (VHT) from 15 districts. We employed an in-depth interview with semi-structured questions to collect data until information saturation reached. We used thematic data analysis approach by ATLAS.ti version 7.5.1.8 software.

RESULTS

Of the 30 interviewed subjects, 15 were female, and the median age of the subjects was 29 years with interquartile range (IQR) of 23 to 37 years. Majority (68.8%) of subjects reported that access to health and nutrition services was harder to them. Four themes: sociocultural and economic; environmental; health system, and individual related factors were identified as the barriers of access to health and nutrition services.

CONCLUSION

The present study identified several modifiable barriers that hinder access to health and nutrition services in drought and food insecurity affected districts. Comprehensive interventions aimed at addressing sociocultural, economic, environmental, health system and subject related challenges are required to improve access to health and nutrition services in drought and food insecurity affected setups.

Regional geographies and public health lessons of the COVID-19 pandemic in the Arctic

Objectives

This study examines the COVID-19 pandemic's spatiotemporal dynamics in 52 sub-regions in eight Arctic states. This study further investigates the potential impact of early vaccination coverage on subsequent COVID-19 outcomes within these regions, potentially revealing public health insights of global significance.

Methods

We assessed the outcomes of the COVID-19 pandemic in Arctic sub-regions using three key epidemiological variables: confirmed cases, confirmed deaths, and case fatality ratio (CFR), along with vaccination rates to evaluate the effectiveness of the early vaccination campaign on the later dynamics of COVID-19 outcomes in these regions.

Results

From February 2020 to February 2023, the Arctic experienced five distinct waves of COVID-19 infections and fatalities. However, most Arctic regions consistently maintained Case Fatality Ratios (CFRs) below their respective national levels throughout these waves. Further, the regression analysis indicated that the impact of initial vaccination coverage on subsequent cumulative mortality rates and Case Fatality Ratio (CFR) was inverse and statistically significant. A common trend was the delayed onset of the pandemic in the Arctic due to its remoteness. A few regions, including Greenland, Iceland, the Faroe Islands, Northern Canada, Finland, and Norway, experienced isolated spikes in cases at the beginning of the pandemic with minimal or no fatalities. In contrast, Alaska, Northern Sweden, and Russia had generally high death rates, with surges in cases and fatalities.

Conclusion

Analyzing COVID-19 data from 52 Arctic subregions shows significant spatial and temporal variations in the pandemic's severity. Greenland, Iceland, the Faroe Islands, Northern Canada, Finland, and Norway exemplify successful pandemic management models characterized by low cases and deaths. These outcomes can be attributed to successful vaccination campaigns, and proactive public health initiatives along the delayed onset of the pandemic, which reduced the impact of COVID-19, given structural and population vulnerabilities. Thus, the Arctic experience of COVID-19 informs preparedness for future pandemic-like public health emergencies in remote regions and marginalized communities worldwide that share similar contexts.

Providing rehabilitation services to major traumatic injury survivors in rural Australia: perspectives of rehabilitation practitioners and compensation claims managers

PURPOSE

The delivery of healthcare services in rural locations can be challenging. From the perspectives of rural rehabilitation practitioners and compensation claims managers, this study explored the experience of providing and coordinating rehabilitation services for rural major traumatic injury survivors.

MATERIALS AND METHODS

Semi-structured interviews with 14 rural rehabilitation practitioners and 10 compensation claims managers were transcribed, and reflexive thematic analysis was conducted.

RESULTS

Six themes were identified (1) Challenges finding and connecting with rural services, (2) Factors relating to insurance claims management, (3) Managing the demand for services, (4) Good working relationships, (5) Limited training and support, and (6) Client resilience and community. System-related barriers included a lack of available search resources to find rural rehabilitation services, limited service/clinician availability and funding policies lacking the flexibility to meet rehabilitation needs in a rural context. Strong peer and interdisciplinary relationships were viewed as crucial facilitators, which rural practitioners were particularly adept at developing.

CONCLUSIONS

Greater consideration of unique needs within rural contexts is required when developing service delivery models. Specifically, flexible and equitable funding policies; facilitating interdisciplinary connections, support and training for rehabilitation practitioners and compensation claims managers; and harnessing clients' resilience may improve the delivery of rural services.IMPLICATIONS FOR REHABILITATIONRural survivors of major traumatic injury often have ongoing health and rehabilitation needs and struggle to access required treatment services.Rehabilitation providers and compensation claims managers highlighted areas for improvement in rural areas, including resources for locating available services, funding the additional costs of rural service delivery, and greater service choice for clients.Building rural workforce capacity for treatment of major traumatic injury is needed, including improved clinician access to specialist training and support.Developing good working relationships between clients and clinicians, including interdisciplinary collaborations, and supporting client resilience and self-management should be promoted in future service delivery models.

Essential health services delivery and quality improvement actions under drought and food insecurity emergency in north-east Uganda

BACKGROUND

Essential health services can be disrupted due to several naturally occurring public health emergencies such as drought, flood, earthquake and outbreak of infectious diseases. However, little evidence exists on the status of essential health services delivery under the effect of drought and food insecurity. North-east Uganda is severely affected by prolonged drought that significantly affected the livelihood of the residents. Therefore, we aimed to determine the current status of essential health services and quality improvement (QI) actions in health facilities in north-east Uganda.

METHODS

We used a descriptive cross-sectional study design to assess the availability of essential health service and quality improvement activities in drought and food insecurity affected districts of north-east Uganda. We included a total of 150 health facilities from 15 districts with proportionated multistage sampling method. We interviewed health facilities' managers and services focal persons using structured questionnaire and observation checklist. We used a descriptive statistic to analyze the data with SPSS version 22.

RESULTS

A few health facilities (8.7%) had mental health specialist. There was also lack of capacity building training on essential health services. Considerable proportion of health facilities had no non-communicable diseases (38.3%), mental health (47.0%), and basic emergency obstetric care (40.3%) services. Stock out of essential medicines were observed in 20% of health facilities. There was lack of supportive supervision, and poor documentation of QI activities.

CONCLUSION

Essential health service and QI were suboptimal in drought and food insecure emergency affected districts. Human resource deployment (especially mental health specialist), provision of capacity building training, improving non-communicable diseases, mental health and basic emergency obstetric care services are required to improve availability of essential health services. Supporting supply chain management to minimize stock out of medicines, and promoting QI activities are also vital to assure quality of health service in drought and food insecurity affected districts in north-Eastern Uganda.

Cross-jurisdictional pandemic management: providers speaking on the experience of Nunavut Inuit accessing services in Manitoba during the COVID-19 pandemic

Across Canada, the COVID-19 pandemic placed considerable stress on territorial and provincial healthcare systems. For Nunavut, the need to continue to provide access to critical care to its citizens meant that medical travel to provincial points of care (Edmonton, Winnipeg and Ottawa) had to continue through the pandemic. This complexity created challenges related to the need to keep Nunavut residents safe while accessing care, and to manage the risk of outbreaks in Nunavut resultant from patients returning home. A number of strategies were adopted to mitigate risk, including the expansion of virtual care, self-isolation requirements before returning from Winnipeg, and a level of cross-jurisdictional coordination previously unprecedented. Structural limitations in Nunavut however limited opportunities to expand virtual care, and to allow providers from Manitoba to access the Nunavut's electronic medical records of patients requiring follow up. Thus, known and long-standing issues exacerbated vulnerabilities within the Nunavut healthcare system. We conclude that addressing cross-jurisdictional issues would be well served by the development of a more formal Nunavut-Manitoba agreement (with similar agreements with Ontario and Alberta), outlining mutual obligations and accountabilities.

Forensic psychiatry patients, services, and legislation in Nunavut and Greenland

Circumpolar regions face unique challenges in establishing and maintaining mental health care systems, including forensic psychiatry services. The scarcity of data and lack of evidence concerning the forensic psychiatry patient (FPP) populations of Nunavut and Greenland exacerbates the challenges of informing best practices and healthcare planning. By comparing the prevalence of forensic psychiatry patients, the mental health care services, and the legislation in these two relatively similar but unique regions, insight may be gained that can help inform healthcare planning. This cross-sectional study includes all forensic psychiatry in- and outpatients in one year from Nunavut (2018) and on February 29, 2020, in Greenland. The Greenland sample (n = 93) was nearly four times larger than the Nunavut sample (n = 15) at the population level. Despite considerable differences in forensic legislation and service supply, the forensic psychiatry patients in the two areas share several similarities. A total of 87% (n = 13) in the Nunavut sample were diagnosed with a DSM-5 schizophrenia spectrum disorder or other psychotic disorder. In Greenland, 82% (n = 76) were diagnosed with an ICD-10 F2 diagnosis (schizophrenia, schizotypal and delusional disorders). Approximately 2/3 of the patients in both populations were diagnosed with substance use disorder, and 60% of the Nunavut FPP received long-acting antipsychotic injections versus 62% in Greenland. Nearly half of the FPPs in both populations had never been convicted prior to entering the forensic psychiatry system; Nunavut 45% versus Greenland 47%. A substantial proportion of Greenlandic FPPs were outpatients compared to Nunavut (83% versus 47%). This study is an essential first step toward describing a Model of Care for forensic psychiatry patients in circumpolar regions; furthermore, the clinical similarities between the two populations provide support for future joint Arctic research and the inclusion of artic forensic patients in international studies.

The Integration of Clinical Decision Support Systems Into Telemedicine for Patients With Multimorbidity in Primary Care Settings: Scoping Review

BACKGROUND

Multimorbidity, the presence of more than one condition in a single individual, is a global health issue in primary care. Multimorbid patients tend to have a poor quality of life and suffer from a complicated care process. Clinical decision support systems (CDSSs) and telemedicine are the common information and communication technologies that have been used to reduce the complexity of patient management. However, each element of telemedicine and CDSSs is often examined separately and with great variability. Telemedicine has been used for simple patient education as well as more complex consultations and case management. For CDSSs, there is variability in data inputs, intended users, and outputs. Thus, there are several gaps in knowledge about how to integrate CDSSs into telemedicine and to what extent these integrated technological interventions can help improve patient outcomes for those with multimorbidity.

OBJECTIVE

Our aims were to (1) broadly review system designs for CDSSs that have been integrated into each function of telemedicine for multimorbid patients in primary care, (2) summarize the effectiveness of the interventions, and (3) identify gaps in the literature.

METHODS

An online search for literature was conducted up to November 2021 on PubMed, Embase, CINAHL, and Cochrane. Searching from the reference lists was done to find additional potential studies. The eligibility criterion was that the study focused on the use of CDSSs in telemedicine for patients with multimorbidity in primary care. The system design for the CDSS was extracted based on its software and hardware, source of input, input, tasks, output, and users. Each component was grouped by telemedicine functions: telemonitoring, teleconsultation, tele-case management, and tele-education.

RESULTS

Seven experimental studies were included in this review: 3 randomized controlled trials (RCTs) and 4 non-RCTs. The interventions were designed to manage patients with diabetes mellitus, hypertension, polypharmacy, and gestational diabetes mellitus. CDSSs can be used for various telemedicine functions: telemonitoring (eg, feedback), teleconsultation (eg, guideline suggestions, advisory material provisions, and responses to simple queries), tele-case management (eg, sharing information across facilities and teams), and tele-education (eg, patient self-management). However, the structure of CDSSs, such as data input, tasks, output, and intended users or decision-makers, varied. With limited studies examining varying clinical outcomes, there was inconsistent evidence of the clinical effectiveness of the interventions.

CONCLUSIONS

Telemedicine and CDSSs have a role in supporting patients with multimorbidity. CDSSs can likely be integrated into telehealth services to improve the quality and accessibility of care. However, issues surrounding such interventions need to be further explored. These issues include expanding the spectrum of medical conditions examined; examining tasks of CDSSs, particularly for screening and diagnosis of multiple conditions; and exploring the role of the patient as the direct user of the CDSS.

Current Use and Future Considerations for Concussion Telemedicine Healthcare in Canada

OBJECTIVE

To examine the use of telemedicine among Canadian concussion providers and clinics before and after the COVID-19 pandemic onset and identify barriers and facilitators for future use.

METHODS

Ninety-nine concussion clinics and healthcare providers across Canada that offered one or more clinical concussion-related service were identified using standardized online searches and approached to complete a cross-sectional online survey.

RESULTS

Thirty clinics or providers completed the survey and two completed subsections of the survey (response rate of 32.3%). Only 28.1% of respondents indicated that they used telemedicine to provide care prior to the COVID-19 pandemic. Providers most commonly using telemedicine prior to the pandemic were occupational therapists and physicians, while the most commonly used services were in-person videoconferencing and eConsultation. Most respondents (87%) indicated their clinic's use of telemedicine changed following the onset of the COVID-19 pandemic including new use of in-person video-conferencing, telephone calls, and eConsultation. Ninety-three percent indicated that they would consider using telemedicine to provide care to their concussion patients once the pandemic was over. Barriers needed to be overcome to facilitate use or greater use of telemedicine-based services were the inability to conduct a complete physical examination, lack of appropriate reimbursement, lack of start-up, and maintenance funding and medico-legal risk.

CONCLUSION

Telemedicine was used by a minority of Canadian concussion clinics and providers prior to the COVID-19 pandemic but was rapidly adopted by many facilities. This study provides important insight into the factors that must be considered to optimize use of telemedicine in concussion care in the future.

Employment, Education, and Income for Canadians with Developmental Disability: Analysis from the 2017 Canadian Survey on Disability

This study assessed needs and outcomes for people with developmental disability (DD) to understand the socioeconomic status of this group prior to implementation of the Accessible Canada Act in June 2019. The 2017 Canadian Survey on Disability (CSD) was used to analyze data for a sample of individuals with self-reported disability. Data related to employment, education, income, housing, caregivers, and use of government benefits is reported. Compared to the general Canadian public, persons with DD are less likely to: finish high-school or post-secondary education; participate in the labor force or be employed; and earn on average less/year in total income. To align with recent accessibility legislation, significant progress is needed to address disparities for people with DD.

Medical evacuations in Greenland in 2018: a descriptive study

Information regarding medical evacuations in Greenland is sparse. This study provides an overview of incidence, costs, and diagnoses leading to medical evacuations in Greenland in 2018. This is a retrospective, observational study. Patients with a valid Danish civil personal registration number were included. Data were obtained by scrutinising the itinerary of the Greenland travel coordination office and the medical records. 481 patients were identified. Forty-nine patients were excluded. 432 patients were analysed. Two-thirds of the evacuations were carried out within Greenland. The overall incidence of evacuations was 7.7 evacuations per 1,000 inhabitants per year. This differed, however, between the five different health regions. The cost of a medical evacuation ranged from less than 4,800 US dollars to more than 50,000 US dollars per case. Pregnancy and childbirth accounted for the majority of evacuations in women (31.2%) while diseases within the circulatory system and digestive tract accounted for the majority of evacuations in men (39.8%). The costs of medical evacuations may be reduced when combining evacuations of more than one patient. This indicates that combining evacuations of multiple patients from one health region by applying mandatory use of a central coordinating service may be beneficial.

Giving birth in rural Arctic Greenland results from an Eastern Greenlandic birth cohort

Eastern Greenland is one of the most remote areas in the world. Approximately 3,500 people lives in two small towns and five villages. There is limited information on birth outcomes in Eastern Greenland. A cohort of all birthing women from Eastern Greenland from 2000 to 2017 was established and pregnancy, birth, and neonatal outcomes were described. A total of 1,344 women and 1,355 children were included in the cohort where 14.5% of the women were 18 years or younger, and 36.2% were single parents. Most women, 84.8% gave birth in East Greenland and 92.9%, experienced a vaginal, non-instrumental birth. The overall caesarean section rate was 6.5%. The rate of premature births was 10.1% and 2.2% of the children were born with malformations. The rate of premature births was high, preventive initiatives such as midwifery-led continuity of care including a stronger focus on the pregnant woman's social and mental life situation may be recommended. Organisation of maternity services in East Greenland may benefit from a strong focus on public health, culture, and setting specific challenges, including the birth traditions of the society.

The second year of pandemic in the Arctic: examining spatiotemporal dynamics of the COVID-19 "Delta wave" in Arctic regions in 2021

The second year of the COVID-19 pandemic in the Arctic was dominated by the Delta wave that primarily lasted between July and December 2021 with varied epidemiological outcomes. An analysis of the Arctic's subnational COVID-19 data revealed a massive increase in cases and deaths across all its jurisdictions but at varying time periods. However, the case fatality ratio (CFR) in most Arctic regions did not rise dramatically and was below national levels (except in Northern Russia). Based on the spatiotemporal patterns of the Delta outbreak, we identified four types of pandemic waves across Arctic regions: Tsunami (Greenland, Iceland, Faroe Islands, Northern Norway, Northern Finland, and Northern Canada), Superstorm (Alaska), Tidal wave (Northern Russia), and Protracted Wave (Northern Sweden). These regionally varied COVID-19 epidemiological dynamics are likely attributable to the inconsistency in implementing public health prevention measures, geographical isolation, and varying vaccination rates. A lesson remote and Indigenous communities can learn from the Arctic is that the three-prong (delay-prepare-respond) approach could be a tool in curtailing the impact of COVID-19 or future pandemics. This article is motivated by previous research that examined the first and second waves of the pandemic in the Arctic. Data are available at https://arctic.uni.edu/arctic-covid-19.

Systematic Review and Meta-analysis: First Nations, Inuit, and Métis Youth Mental Health

OBJECTIVE

The ongoing effects of colonialism disproportionately place Indigenous youth at risk for mental health challenges. This meta-analysis examined lifetime and past-year prevalence estimates of mental health challenges among First Nations, Inuit, and Métis youth in Canada.

METHOD

Five electronic databases were searched from their inceptions until June 17, 2021. Studies were included if they assessed mental health challenges among First Nations, Inuit, and/or Métis youth (≤18 years old). Risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

A total of 28 articles were eligible. Sixteen studies contained data on First Nations, 2 on Inuit, one on Métis, and 10 aggregated Indigenous participants. Among First Nations participants, pooled prevalence estimates for past-year suicidality (8.9%), mood and/or anxiety (<2.9%), attention-deficit/hyperactivity (2.9%), oppositional defiant (8.8%), and conduct (12.8%) disorder diagnoses were identified. Limited studies containing Inuit, Métis, and aggregated Indigenous participants also found high levels of disruptive disorder symptoms. Data were very limited for lifetime prevalence estimates. Studies assessed to have a moderate or high methodological risk of bias (k = 19) or using measures that are not yet culturally validated (k = 25) may contribute to inaccuracies in prevalence estimates.

CONCLUSION

Existing data suggest that Indigenous youth have a low prevalence of mental health challenges, with the exception of disruptive behaviors. Future studies should use culturally validated tools and partner with Indigenous communities to ensure optimal identification of mental health challenges.

Longitudinal trends in incidence and health care use for pediatric concussion in Alberta, Canada

BACKGROUND

We described longitudinal trends in the incidence of episodes of care (EOC) and follow-up care for pediatric concussion in relation to age, sex, rurality of patient residence, point of care, and area-based socioeconomic status (SES) in Alberta, Canada.

METHODS

A retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients <18 years of age who received a diagnosis of concussion, other specified injuries of head, unspecified injury of head, or post-concussion syndrome between April 1, 2004 and March 31, 2018. Data were geospatially mapped.

RESULTS

Concussion EOCs increased 2.2-fold over the study period, follow-up visits 5.1-fold. Care was increasingly received in physician office (PO) settings. Concussion diagnoses in rural and remote areas occurred in emergency department (ED) settings more often than in metro centres or urban areas (76%/75% vs. 52%/60%). Proportion of concussion diagnoses was positively related to SES and age. Diagnosis and point of care varied geographically.

CONCLUSIONS

The shift in care to PO settings, increased incidence of all diagnoses, and the higher use of the ED by some segments of the population all have important implications for appropriate clinical management and the efficient provision of health care for pediatric concussion.

IMPACT

This is the first study to use EOC to describe longitudinal trends in incidence and follow-up care for pediatric concussion in relation to age, sex, rurality, point of care, and area-based SES. We report increased incidence of concussion in both emergency and outpatient settings and the proportion of diagnoses was positively related to SES and age. Patients increasingly received care for concussion in PO over time. Geospatial mapping indicated that the incidence of concussion and unspecified injury of head varied geographically and temporally. Results have important implications for appropriate clinical management and efficient provision of health care following pediatric concussion.

Factors associated with self-perceived health status in Portugal: Results from the National Health Survey 2014

Background

Self-perceived health is an important indicator of illness and mortality. This study aims at identifying a wide range of factors that can influence self-perceived health status among a representative sample in Portugal.

Methods

We used the 2014 National Health Survey (n = 17,057), whereby participants were required to assess their health status from "Very good," "Good," "Fair," "Poor" to "Very poor." We grouped the answers "Very good" and "Good," and "Poor" and "Very poor," respectively. Multinomial logistic regression was used to compare participants' characteristics across groups by computing odds ratio and corresponding 95% confidence intervals. Models included Socioeconomic/demographic characteristics, objective health status, healthcare use, functional disability, barriers to healthcare services utilization, lifestyle variables, mental health status, social support, and satisfaction with life as potential factors that can affect self-perceived health. Models were adjusted for sex, age, educational level, degree of urbanization, and presence of chronic diseases.

Results

About 45% of participants reported good/very good, 39% reported fair, while ~16% reported poor/very poor health perception. Poor/very poor health was more reported by women when compared to men (19.1 vs. 11.4%, respectively, p < 0.001). A higher prevalence of poor/very poor health status was reported by participants living in thinly populated areas or among older populations. Lower educational levels, lower income, as well as unemployment, were found to increase the risk of reporting poor/very poor health status. Utilizing healthcare services more frequently, experiencing barriers to access healthcare services, having depressive symptoms or activity limitations, or lacking social support were found to be significantly associated with poor/very poor self-perceived health.

Conclusion

Subjects living in Portugal tend to report less good/very good health status and more poor/very poor health when compared to the rest of Europe. This study stresses the importance of socioeconomic factors, chronic illness, barriers to access healthcare services, social isolation, and mental health status in influencing self-perceived health and highlights the urgent need for social-informed policies, strategies, and interventions to reduce health inequalities in Portugal.

An ecological approach to understanding Women's reproductive health and pregnancy decision making in Greenland

Using a community based participatory research framework and ecological systems theory we explored the experiences of reproductive health among Inuit women living in a remote Northwestern settlement in Greenland to understand the multiple diverse factors that influence their pregnancy outcomes. We conducted 15 in depth interviews with Inuit women between the ages of 19 and 45. Key factors influencing women's pregnancy decision making were: 1) precursors to pregnancy; 2) birth control use; 3) adoption and abortion; and 4) access to reproductive health care. Our results highlight the need to identify pathways through research, policy, health promotion, and health care practice that can support Inuit women in Greenland to be reproductively healthy and make informed decisions about pregnancy that resonate with their cultural beliefs as well as the realities of their everyday lives. We recommend the integration of cultural messaging into interdisciplinary approaches for preventive reproductive health care with women living in remote Arctic communities.

Tele-Active Rehabilitation for Youth With Concussion: Evidence-Based and Theory-Informed Intervention Development

BACKGROUND

Active rehabilitation involving subsymptom threshold exercise combined with education and support promotes recovery in youth with concussion but is typically delivered in person, which may limit accessibility for families because of a lack of services in their communities or logistical challenges to attending in-person sessions.

OBJECTIVE

This paper describes the evidence-based and theory-informed development of the Tele-Active Rehabilitation (Tele-AR) intervention for pediatric concussion, which was specifically designed for remote service delivery.

METHODS

The intervention was designed by clinician-researchers with experience in pediatric concussion rehabilitation following the Medical Research Council guidance for developing complex interventions. Development involved a critical review of the literature to identify existing evidence, the expansion of the theoretical basis for active rehabilitation, and the modeling of the intervention process and outcomes.

RESULTS

Tele-AR is a 6-week home exercise and education and support program facilitated through weekly videoconferencing appointments with a clinician. Exercise consists of low- to moderate-intensity subsymptom threshold aerobic activity and coordination drills that are individualized to participant needs and interests (prescribed for 3 days per week). Education includes the evidence-supported Concussion & You self-management program, which covers topics related to energy management, nutrition, hydration, sleep hygiene, and return to activity. Elements of self-determination theory are incorporated to support motivation and engagement. We present a logic model describing predicted intervention effects using a biopsychosocial conceptualization of outcomes after concussion.

CONCLUSIONS

The Tele-AR intervention may help to increase access to care that improves recovery and promotes a timely return to activity in youth with concussion. Future research is needed to evaluate the feasibility and efficacy of this approach.

Development of rehabilitation services in an Inuit sociocultural context: challenges, strategies and considerations for the future

In recent years, a new rehabilitation programme has been developed on the Hudson Bay coast of Nunavik. The purpose of this article is to reflect on the experience of an occupational and physical therapy programme development in an Inuit sociocultural context. To do so, the challenges encountered during the first years following the implementation of rehabilitation services and the strategies implemented by the professionals to overcome them were identified, examined in the light of the literature, and discussed with members of the rehabilitation team. The challenges encountered and strategies implemented were divided into 10 major themes: (1) diverse clinical needs; (2) communication issues; (3) acquisition of cross-cultural interaction and population-specific knowledge; (4) adaptation of clinical practice to Nunavimmiut; (5) client engagement in rehabilitation; (6) professional isolation; (7) lack of awareness around the objectives and scope of rehabilitation practice; (8) use of culturally safe assessment tools; (9) staff turnover; (10) large geographic area to be served. This exercise highlighted the need to adapt clinical rehabilitation practices to Nunavimmiut’s worldviews and culture, as well as to adopt a reflective practice in order to improve the quality, relevance and effectiveness of rehabilitation services.

Challenges facing Indigenous transplant patients living in Canada: exploring equity and utility in organ transplantation decision-making

Indigenous peoples in Canada and in the Circumpolar North face a higher disease burden leading to end-stage organ failure and face geographic and systemic barriers to accessing health-care services, including those for end-stage organ failure and organ donation and transplantation (ODT). To address these issues, I present a think tank model used in Saskatchewan, Canada, which focused on ODT and recommended research and policy changes that address inequitable Indigenous access to ODT, most specifically in northern and remote regions. Over the past three years, think tank members, comprised of Indigenous cultural leaders, elders, and persons with lived experience in ODT, and complemented by medical and advocacy exports, have highlighted equity and utility issues as key concerns, and discussed ways in which these issues can be addressed. Recommendations include culturally-safe methods for documenting and tracking Indigenous identity, development of training to address culturally specific needs, and additional funding to support Indigenous transplant donors and recipients.

Factors associated with follow-up care after pediatric concussion: A longitudinal population-based study in Alberta, Canada

BACKGROUND

Concussion is a common injury in children and adolescents. Current best practice guidelines indicate that recovery should be supervised through recurrent follow-up visits. A more detailed understanding of the system-level and individual factors that are associated with follow-up care is a critical step towards increasing evidence-based practice. The objective of this study was to identify predisposing, enabling, and need-based factors associated with follow-up care after pediatric concussion.

MATERIALS AND METHODS

A retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients <18 years of age with a diagnosis of concussion, other specified injuries of the head, unspecified injury of head, or post-concussion syndrome (PCS) between April 1, 2004 and March 31, 2018 in Alberta, Canada. The association between predisposing, enabling, and need-based factors and the receipt of follow-up care within a defined episode of care (EOC) was analyzed using logistic regression models for the entire cohort and for EOC that began with a concussion diagnosis. Predisposing factors included age and sex. Enabling factors included the community type of patient residence, area-based socioeconomic status (SES), and visit year. Need-based factors included where the EOC began (outpatient vs. emergency settings) and history of previous concussion-related EOC.

RESULTS

194,081 EOCs occurred during the study period but only 13% involved follow-up care (n = 25,461). Males and adolescents were more likely to receive follow-up care. Follow-up was less likely among patients who lived in remote communities or in areas of lower SES, while EOCs beginning in 2011 or later were more likely to involve follow-up care. Patients whose EOC began in outpatient settings, had more than one EOC, or a diagnosis of concussion were more likely to receive follow-up care.

CONCLUSION

Follow-up care for pediatric concussion has increased over time and is associated with patient age and sex, history of concussion-related EOC, where a patient lives (community type and area-based SES), and when and where the index visit occurs. A better understanding of which children are more likely to receive follow-up care, as well as how and when they do, is an important step in aligning practice with follow-up guidelines.

Global health radiology planning using Geographic Information Systems to identify populations with decreased access to care

Background

Communities throughout northern Canada face significant health care disparities including decreased access to radiology. A medical hybrid airship is under development which aims to serve remote populations, requiring strategic outreach planning. This study aims to use geographic information systems (GIS) to identify (1) high risk and medically underserved patient populations in northern Canada and (2) potential landing sites for a medical airship to allow for mobile delivery of radiology services.

Methods

The northern region of Canada extending from the Rocky Mountains to the Atlantic Ocean was analyzed using multi-variable, multi-weighted GIS modeling. Based on population distance from hospitals (50% weight), health centers (eg, clinic; 30% weight), remote communities (not connected to electric grid; 10% weight), and roads (10% weight), individuals were stratified into one of five health care accessibility index (HAI) categories (ranging from very low to very high severity). HAI (80% weight) was combined with population density (20%) to create a health care access severity index (HASI). Topographic and land cover data were used to identify suitable landing sites for the medical airship. A coordinate data set was made from georeferenced health care facilities, and infrastructure data was obtained from OpenStreetMap.

Results

GIS analyzed 815 772 Canadians. Of this population, 522 094 (64%) were found to live ≥60 km from a hospital, 326 309 (40%) were ≥45 km from the nearest health center, 65 262 (8%) were within 30 km of a remote community, and 57 104 (7%) lived ≥1 km from the nearest road. Combined, the HASI identified 44% of the population as having decreased access to care (high or very high severity). Lastly, 27.5% of land analyzed was found to be suitable for airship operations.

Conclusions

GIS identified medically underserved populations in northern Canada who may benefit from mobile radiology services. These techniques may help to guide future global health outreach efforts.

Experiences of cancer rehabilitation among patients in rural areas in northern Iceland: physical and psychosocial well-being, coping, quality of life, and satisfaction with care. A qualitative study

Physical rehabilitation and psychosocial support are a part of cancer patients well-being and their ability to cope. Physical geography and healthcare provider barriers may have negative influences on patients' health outcomes. To explore the perceptions and experiences of cancer rehabilitation in a rural area in northern Iceland. A further aim was to explore patients' physical and psychosocial well-being, coping and satisfaction with care. A qualitative study using semi-structured interviews and thematic analysis was completed with a purposive sample of 21 patients at a tertiary hospital in northern Iceland. Three main themes emerged: 1) Rehabilitation - the need for improved access support and continuity; 2) Coping and quality of life - balancing life as it was before cancer against the present situation in order to achieve normality; 3) Satisfaction - encountering caring behaviours enhances satisfaction and well-being. Specifically targeted rehabilitation programmes need to be included in the treatment options for cancer patients. Survival instinct, coping mechanisms and a strong urge to maintain general functionality are of paramount importance intertwined with patients' ability to cope with the disease and treatment, and their satisfaction with care.

Plan A, Plan B, and Plan C-OVID-19: adaptations for fly-in and fly-out mental health providers during COVID-19

Mental health providers have rapidly pivoted their in-person practices to teletherapy and telehealth interventions to address the increased demand for mental health services during the COVID-19 crisis. The change to service delivery has emphasised challenges for mental health service providers, particularly in regions that rely on fly-in and fly-out (FIFO) mental health service providers who are no longer able to travel to their places of work. In this qualitative study, we examined the impact of COVID-19 on the delivery of mental health services in Inuit Nunangat. Using a participatory action research methodology, we conducted semi-structured interviews with eight FIFO mental health service providers to understand their experiences and implement strategies to effectively deliver mental health services in a pandemic. We identified three themes through thematic analysis: 1) Service providers identify the challenges in adapting their practices to meet individual and community needs; 2) Service providers recognise the opportunities for enhancements to service delivery; 3) Service providers identify telemental health services as a potentially effective adjunct to in-person sessions. The findings support reconceptualising post-pandemic mental health service delivery to include both face-to-face and telemental health services.

"We Tried to Borrow Money, but No One Helped." Assessing the Three-Delay Model Factors Affecting the Healthcare Service Delivery among Dengue Patients during COVID-19 Surge in a Public Tertiary Hospital: A Convergent Parallel Mixed Methods Study

Identification of delay barriers to care is essential for an effective and efficient healthcare service delivery. In this study, we described the delay in care among parents of the patients seeking treatment for dengue. We also examined the factors affecting the severity of dengue (dengue with warning signs; severe dengue). A convergent parallel design mixed-method approach using Key Informant Interviews (KII) and a survey guided by the Three-Delay Model were conducted among 24 respondents at the National Children’s Hospital (NCH). Coding and thematic analysis using NVIVO and bivariable generalized linear models with a Poisson distribution and robust variance were utilized to analyze the KII transcripts and survey data, respectively. Results showed that financial constraints and previous dengue infection (first delay), mode of transportation, traffic density, and location (second delay), and hospital capacity (third delay) influenced the overall delay uncertainty in seeking care treatment for dengue infection. Furthermore, our bivariable analysis showed that travel time to NCH and place of residency, service given from previous health facilities, and parents’ educational background were associated and played a role in the severity of dengue infection. Interventions focused on the identified factors contributing to delayed care should be made to avoid unwanted clinical outcomes.

Hepatitis B virus elimination status and strategies in circumpolar countries, 2020

Hepatitis B virus (HBV) infection remains a global health threat. The World Health Organization (WHO) established a goal to eliminate HBV infection as a public health threat by 2030, and defined targets for key interventions to achieve that goal. We evaluated HBV burden and relevant national recommendations for progress towards WHO targets in circumpolar countries. Viral hepatitis experts of circumpolar countries were surveyed regarding their country’s burden of HBV, achievement of WHO targets and national public health authority recommendations for HBV prevention and control. Eight of nine circumpolar countries responded. All countries continue to see new HBV infections. Data about HBV prevalence and progress in reaching WHO 2030 elimination targets are lacking. No country was able to report data for all seven WHO target measures. All countries have recommendations targeting the prevention of mother-to-child transmission. Only the USA and Greenland recommend universal birth dose vaccination. Four countries have recommendations to screen persons at high risk for HBV. Existing recommendations largely address prevention; however, recommendations for universal birth dose vaccination have not been widely introduced. Opportunities remain for the development of trackable targets and national elimination planning to screen and treat for HBV to reduce incidence and mortality.

Forensic psychiatry services in Nunavut

There is a paucity of research on forensic psychiatry patients from Nunavut, including no published data concerning the prevalence and characterisation of patients in this territory. The lack of basic information hinders the evaluation of services and establishing best practices. The current paper aims to characterise forensic psychiatry patients from Nunavut and further the understanding of the challenges in organising forensic psychiatry healthcare in Nunavut. A retrospective chart review design was used to examine individuals from Nunavut who are engaged with the Ontario forensic psychiatry system. The sample included all Unfit to Stand Trial (26.7%) and Not Criminally Responsible (73.3%) patients (N = 15) under the jurisdiction of the Nunavut Review Board in a one-year period. The average distance between the patient’s place of residence in Nunavut and the Ontario facilities was 2,517 km. Overall, 26.7% were living in Nunavut, 60.0% remained in Ontario, and 13.3% resided in Alberta. Results are presented for sociodemographics, forensic status, personal and familial history, psychiatric and criminal history, diagnoses, index offence characteristics, treatment, assessment tools, and aggression. The prevalence and many characteristics of forensic psychiatry patients from Nunavut differ from the rest of Canada and have important implications for the delivery of services.

What factors affect patients' ability to access healthcare? An overview of systematic reviews

OBJECTIVES

This overview aims to synthesise global evidence on factors affecting healthcare access, and variations across low- and middle-income countries (LMICs) vs. high-income countries (HICs); to develop understanding of where barriers to healthcare access lie, and in what context, to inform tailored policies aimed at improving access to healthcare for all who need it.

METHODS

An overview of systematic reviews guided by a published protocol was conducted. Medline, Embase, Global Health and Cochrane Systematic Reviews databases were searched for published articles. Additional searches were conducted on the Gates Foundation, WHO and World Bank websites. Study characteristics and findings (barriers and facilitators to healthcare access) were documented and summarised. The methodological quality of included studies was assessed using an adapted version of the AMSTAR 2 tool.

RESULTS

Fifty-eight articles were included, 23 presenting findings from LMICs and 35 presenting findings from HICs. While many barriers to healthcare access occur in HICs as well as LMICs, the way they are experienced is quite different. In HICs, there is a much greater emphasis on patient experience; as compared to the physical absence of care in LMICs.

CONCLUSIONS

As countries move towards universal healthcare access, evaluation methods that account for health system and wider cultural factors that impact capacity to provide care, healthcare finance systems and the socio-cultural environment of the setting are required. Consequently, methods employed in HICs may not be appropriate in LMICs due to the stark differences in these areas.

First Nations and Metis peoples' access and equity challenges with early childhood oral health: a qualitative study

BACKGROUND

Inequities in early childhood oral health are evident amongst Indigenous peoples and communities in Manitoba, Canada. Early childhood caries (ECC) is decay in primary dentition in children under 6 years of age. A severe form of the disease occurs at a higher rate in Indigenous populations compared to the general population. ECC has been strongly associated with social determinants of health.

METHODS

Focus groups and sharing circles were conducted with four First Nations and Metis communities in urban and rural communities in Manitoba. There were eight groups in total of purposively sampled participants (n = 59). A grounded theory approach guided thematic analysis of audio recorded and transcribed data.

RESULTS

Indigenous participants experienced challenges similar to those found in the general population, such as encouraging and motivating parents and caregivers to establish regular oral hygiene routines for their children. However other challenges reported, disproportionately affect Indigenous communities. These include poor access to dental care, specifically no dental offices within 1 h driving radius and not having transportation to get there. Not having evidence-based oral health information to support good oral hygiene practices, preventing parents from making the best choices of oral hygiene products and oral health behaviours for their children. Poverty and food insecurity resulting in poor nutritional choices and leading to ECC. For example, feeding children sugary foods and beverages because those are more readily avialble than healthy options. Confusing or difficult encounters with dental professionals, highlighted as a factor that can erode trust, reduce compliance and impact continued attendance at dental offices.

CONCLUSION

Closing existing early childhood oral health gaps for First Nations and Metis peoples and communities requires equity-oriented healthcare approaches to address specific problems and challenges faced by these populations. Family, community and systemic level interventions that directly implement community recommendations are needed.

Cancer care reform in South Africa: A case for cancer care coordination: A narrative review

OBJECTIVE

This review provides an overview of the existing literature on the importance of care coordination for lung cancer care and other cancers in general. The review is inclusive of the burden of cancer, with a special reference to lung cancer, as well as challenges and achievements relating to cancer care coordination.

METHOD

We conducted a search of online databases of peer-reviewed studies published in the English language. The analysis for this review has been packaged into themes in order to generate results that can inform researchers and cancer health professionals, on the existing gaps necessary for developing appropriate intervention strategies and policy guidelines.

RESULTS

Cancer is a complex condition that often requires multiple interventions provided by a variety of health professionals within the healthcare continuum. This paper reviewed research studies that explored the supportive care needs of cancer patients. The results are presented in three superordinate themes, namely (a) cancer as a healthcare priority in South Africa (SA), (b) making a case for coordinated cancer care in SA, and (c) care coordination: a poorly defined, yet complex concept. One major need identified was the requirement of informational support. Other essential needs included referral, emotional, and financial support.

SIGNIFICANCE OF RESULTS

The identification of current obstacles has the potential to guide the development of a model to improve quality coordinated cancer health care. It remains that limited research exists around cancer services and cancer care in the South African region. This narrative review identified common elements and barriers to care for lung cancer patients and survivors, and offers recommendations for developing clinical care models.

Patient healthcare experiences in the Northwest Territories, Canada: an analysis of news media articles

The factors that influence patient healthcare experiences are complex and connected to place. In northern Canada, the socio-historical context and the inequitable distribution of health services are unique influences on patients. The objective of this study was to examine the characteristics of patient healthcare experiences as reported through news media in the Northwest Territories. We used a case series design to examine patient healthcare experiences reported in news media articles. We conducted a systematic search for articles published between 2008 and 2017 in the online database of a media outlet in the Northwest Territories. We used descriptive statistics to summarise the article characteristics and thematic analysis to understand patient experiences in 128 articles related to 71 cases. Most often, cases involved women, concerned mental health, suicidality, or chronic diseases, and were predominantly negative. Patient experiences included problems associated with medical travel, communication difficulties with providers, lack of cultural safety, and barriers in accessing care resulting in poor-quality care, particularly for Indigenous patients. Broadly, these experiences are rooted in the colonial history in the North. Understanding patient experiences and including Indigenous patients in health system decision-making can help focus policies and clinical care on cultural safety and equity.

The inverse care law re-examined: a global perspective

An inverse care law persists in almost all low-income and middle-income countries, whereby socially disadvantaged people receive less, and lower-quality, health care despite having greater need. By contrast, a disproportionate care law persists in high-income countries, whereby socially disadvantaged people receive more health care, but of worse quality and insufficient quantity to meet their additional needs. Both laws are caused not only by financial barriers and fragmented health insurance systems but also by social inequalities in care seeking and co-investment as well as the costs and benefits of health care. Investing in more integrated universal health coverage and stronger primary care, delivered in proportion to need, can improve population health and reduce health inequality. However, trade-offs sometimes exist between health policy objectives. Health-care technologies, policies, and resourcing should be subjected to distributional analysis of their equity impacts, to ensure the objective of reducing health inequalities is kept in sight.

Experiences of psychiatrists and support staff providing telemental health services to Indigenous peoples of Northern Quebec

Background

Due to regional, professional, and resource limitations, access to mental health care for Canada’s Indigenous peoples can be difficult. Telemental health (TMH) offers the opportunity to provide care across vast distances and has been proven to be as effective as face-to-face services. To our knowledge, there has been no qualitative study exploring the experiences of TMH staff serving the Indigenous peoples in Northern Quebec, Canada; which is the purpose of this study.

Methods

Using a qualitative descriptive design, the entire staff of a TMH clinic was recruited, comprising of four psychiatrists and four support staff. Individual semi-structured interviews were conducted through videoconferencing, and results were thematically analyzed.

Results

To address the mental health gap in Northern communities, all psychiatrists believe in the necessity of in-person care and note the synergistic effect of combining in-person care and TMH services. This approach to care allows psychiatrists to maintain both an insider and outsider identity. However, if a patient’s condition requires hospitalization, then the TMH staff face a new set of information sharing and communication challenges with the inpatient staff. TMH staff believe that the provision of culturally sensitive care to Northern patients at the inpatient unit is progressing; however, more work needs to be done. Despite the strong collegial atmosphere within the clinic and collective efforts to provide quality TMH services, all participants express a sense of frustration with the paper-based and scattered documentation system.

Conclusion

The TMH team works in cohesion to offer TMH services to Indigenous peoples; yet, automatization is needed to improve the workflow efficiency within the clinic and collaboration with the Northern clinics. More research is needed on the functioning of TMH teams and the separate but important roles of each team member.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06072-5.

Using Palliative Care Nurses in a Supportive Care Program to Reduce Hospital Utilization for Patients With Multiple Chronic Conditions

BACKGROUND

Health care organizations are designing comprehensive care programs to reduce hospital utilization by high-risk patients with multiple chronic illnesses.

LOCAL PROBLEM

A community hospital recognized patients with multiple chronic conditions had higher rates of inpatient stays and emergency department (ED) visits.

METHODS

Patients (n = 36) with multiple chronic conditions enrolled in a supportive care program. Researchers analyzed hospital utilization, inpatient stays, and ED visits preintervention and postgraduation for the participants enrolled. Palliative care nurses were assigned to patients enrolled in the supportive care program.

RESULTS

There was a statistically significant decrease in hospital utilization (Z = -2.540, P = .011) and inpatient stays (Z = -4.037, P < .001) following the implementation of the supportive care program.

CONCLUSIONS

The study met its aim of reducing hospital utilization and inpatient stays by creating a comprehensive approach to support high-risk patients in self-management of their chronic illnesses.

Spatiotemporal dynamics of the COVID-19 pandemic in the arctic: early data and emerging trends

Since February 2020 the COVID-19 pandemic has been unfolding in the Arctic, placing many communities at risk due to remoteness, limited healthcare options, underlying health issues and other compounding factors. Preliminary analysis of available COVID-19 data in the Arctic at the regional (subnational) level suggests that COVID-19 infections and mortality were highly variable, but generally remained below respective national levels. Based on the trends and magnitude of the pandemic through July, we classify Arctic regions into four groups: Iceland, Faroe Islands, Northern Norway, and Northern Finland with elevated early incidence rates, but where strict quarantines and other measures promptly curtailed the pandemic; Northern Sweden and Alaska, where the initial wave of infections persisted amid weak (Sweden) or variable (Alaska) quarantine measures; Northern Russia characterised by the late start and subsequent steep growth of COVID-19 cases and fatalities and multiple outbreaks; and Northern Canada and Greenland with no significant proliferation of the pandemic. Despite limitations in available data, further efforts to track and analyse the pandemic at the pan-Arctic, regional and local scales are crucial. This includes understanding of the COVID-19 patterns, mortality and morbidity, the relationships with public-health conditions, socioeconomic characteristics, policies, and experiences of the Indigenous Peoples.

Data used in this paper are available at https://arctic.uni.edu/arctic-covid-19.

Preliminary clinical algorithm to optimise remote delivery of paediatric concussion care in Canada's North

Concussion is a form of traumatic brain injury that affects thousands of children and adolescents across Canada annually. With timely access to comprehensive medical care, the majority of patients with acute concussion will recover within 1–4 weeks. Those who develop persistent post-concussion symptoms often benefit from early recognition and referral to multi-disciplinary concussion clinics that have the personnel and resources to meet their complex needs. Youth who live in remote and isolated communities within Canada’s North, a significant proportion of whom are Indigenous, face unique barriers and obstacles to accessing primary and specialised concussion care. Although telemedicine has recently emerged as a tool that can help address these gaps in care, there are presently no clinical guidelines or tools available to assist multi-disciplinary concussion clinics in providing remote concussion care to these medically underserved patients. Here we incorporate literature from a scoping review and our early institutional experience to present an evidence-informed preliminary clinical algorithm and resources to help guide and optimise remote paediatric concussion care delivery in Canada’s North. We also discuss how innovative technologies and partnerships can be leveraged to enhance the delivery of safe, equitable, cost-effective and culturally appropriate care to these communities.

Patient experience studies in the circumpolar region: a scoping review

OBJECTIVES

Patient experiences with health systems constitute a crucial pillar of quality care. Across the Arctic, patients' interactions with the healthcare system are influenced by challenges of access, historical inequities and social determinants. This scoping review sought to describe the range and nature of peer-reviewed literature on patient experience studies conducted within the circumpolar region.

DESIGN

In a partnership between Danish/Greenlandic, Canadian and American research teams, a scoping review of published research exploring patient experiences in circumpolar regions was undertaken.

DATA SOURCES

Seven electronic databases were queried: MEDLINE, Embase, Scopus, 'Global Health 1910 to 2019 Week 11', CINAHL, PsycINFO and SveMed+.

ELIGIBILITY CRITERIA

Articles were eligible for inclusion if they (a) took place in the circumpolar region, (b) reported patients' perspective and (c) were focussed primarily on patient experiences with care, rather than satisfaction with treatment outcome.

DATA EXTRACTION AND SYNTHESIS

Title and abstract screening, full-text review and data extraction was conducted by four researchers. Bibliometric information such as publication date and country of origin was extracted, as was information regarding study design and whether or not the article contained results relevant to the themes of Indigenous values, rural and remote context, telehealth and climate change. Two researchers then synthesised and characterised results relevant to these themes.

RESULTS

Of the 2824 articles initially found through systematic searches in seven databases, 96 articles were included for data extraction. Findings from the review included unique features related to Indigenous values, rural and remote health, telehealth and climate change.

CONCLUSIONS

The review findings provide an overview of patient experiences measures used in circumpolar nations. These findings can be used to inform health system improvement based on patient needs in the circumpolar context, as well as in other regions that share common features. This work can be further contextualized through Indigenous methodologies such as sharing circles and community based participatory methods.

Barriers to colonoscopy in remote northern Canada: an analysis of cancellations

Background: Colonoscopy is a critical diagnostic and therapeutic procedure that is challenging to access in northern Canada. In part, this is due to frequent cancellations. We sought to understand the trends and reasons for colonoscopy cancellations in the Northwest Territories (NWT).

Methods: A retrospective review of colonoscopy cancellations January, 2018 to May, 2019 was conducted at Stanton Territorial Hospital, NWT. Cancellation details and rationale were captured from the endoscopy cancellation logs. Thematic analysis was used to group cancellation reasons. Descriptive statistics were generated, and trends were analysed using run chart.

Results: Of the scheduled colonoscopies, 368(28%) were cancelled during the 16 month period, and cancellations occurred, on average, 27 days after booking. Cancellation reasons were grouped into 15 themes, encompassing personal, social, geographic and health system factors. The most frequently cited theme was work/other commitments (69 respondents; 24%). Cancellations due to travel and accommodation issues occurred more frequently in the winter.

Conclusion: Over one in four booked colonoscopies were cancelled and the reasons for cancellations were complex. Initiatives focusing on communication and support for patients with personal or occupational obligations could dramatically reduce cancellations. Ongoing collaborative efforts are needed to inform and optimise access to colonoscopy in this region.

Self-rated health and socio-economic status among older adults in Northern Iceland

Little is known about self-rated health (SRH) of older people living in more remote and Arctic areas. Iceland is a high-income country with one of the lowest rates of income inequality in the world, which may influence SRH. The research aim was to study factors affecting SRH, in such a population living in Northern Iceland. Stratified random sample according to the place of residency, age and gender was used and data collected via face-to-face interviews. Inclusion criteria included community-dwelling adults ≥65 years of age. Response rate was 57.9% (N = 175), average age 74.2 (sd 6.3) years, range 65–92 years and 57% were men. The average number of diagnosed diseases was 1.5 (sd 1.3) and prescribed medications 3.0 (sd 1.7). SRH ranged from 5 (excellent) to 1 (bad), with an average of 3.26 (sd 1.0) and no difference between the place of residency. Lower SRH was independently explained by depressed mood (OR = 0.88, 95% CI = 0.80–0.96), higher body mass index (OR = 0.93, 95% CI = 0.87–0.99), number of prescribed medications (OR = 0.88, 95% CI = 0.78–1.00) and perception of inadequate income (OR = 0.45, 95% CI = 0.21–0.98). The results highlight the importance of physical and mental health promotion for general health and for ageing in place and significance of economic factors as predictors of SRH.

Cardiac Surgery: Increasing Access in Low- and Middle-Income Countries

PURPOSE OF THE REVIEW

Low- and middle-income countries (LMICs) have long-battled communicable diseases, and now, a rise in non-communicable diseases (NCD) is conferring tremendous burden in these areas. Cardiovascular disease (CVD) remains the number one cause of death among NCDs across the globe. The current review provides insight regarding this disease burden and highlights challenges as well as strategies for establishing functional cardiac surgery centers and sustainable access to comprehensive cardiovascular care within LMICs.

RECENT FINDINGS

Without effective prevention and treatment strategies, estimates suggest that deaths from CVDs will reach 24 million by the year 2030. Surgery exists as a limited option for selected patients with advanced cardiac disease in LMICs in comparison with its availability in developed countries. Multi-lateral or public-private initiatives, government investment, philanthropic efforts, innovative financing systems to strengthen Universal Health Coverage, and expansion of training options through centers of excellence appear to be the way forward to broadening the availability of cardiovascular services, inclusive of surgery, to LMICs.

Is the closest health facility the one used in pregnancy care-seeking? A cross-sectional comparative analysis of self-reported and modelled geographical access to maternal care in Mozambique, India and Pakistan

BACKGROUND

Travel time to care is known to influence uptake of health services. Generally, pregnant women who take longer to transit to health facilities are the least likely to deliver in facilities. It is not clear if modelled access predicts fairly the vulnerability in women seeking maternal care across different spatial settings.

OBJECTIVES

This cross-sectional analysis aimed to (i) compare travel times to care as modelled in a GIS environment with self-reported travel times by women seeking maternal care in Community Level Interventions for Pre-eclampsia: Mozambique, India and Pakistan; and (ii) investigate the assumption that women would seek care at the closest health facility.

METHODS

Women were interviewed to obtain estimated travel times to health facilities (R). Travel time to the closest facility was also modelled (P) (closest facility tool (ArcGIS)) and time to facility where care was sought estimated (A) (route network layer finder (ArcGIS)). Bland-Altman analysis compared spatial variation in differences between modelled and self-reported travel times. Variations between travel times to the nearest facility (P) with modelled travel times to the actual facilities accessed (A) were analysed. Log-transformed data comparison graphs for medians, with box plots superimposed distributions were used.

RESULTS

Modelled geographical access (P) is generally lower than self-reported access (R), but there is a geography to this relationship. In India and Pakistan, potential access (P) compared fairly with self-reported travel times (R) [P (H₀: Mean difference = 0)] < .001, limits of agreement: [- 273.81; 56.40] and [- 264.10; 94.25] respectively. In Mozambique, mean differences between the two measures of access were significantly different from 0 [P (H₀: Mean difference = 0) = 0.31, limits of agreement: [- 187.26; 199.96]].

CONCLUSION

Modelling access successfully predict potential vulnerability in populations. Differences between modelled (P) and self-reported travel times (R) are partially a result of women not seeking care at their closest facilities. Modelling access should not be viewed through a geographically static lens. Modelling assumptions are likely modified by spatio-temporal and/or socio-cultural settings. Geographical stratification of access reveals disproportionate variations in differences emphasizing the varied nature of assumptions across spatial settings. Trial registration ClinicalTrials.gov, NCT01911494. Registered 30 July 2013, https://clinicaltrials.gov/ct2/show/NCT01911494.

The Potential of Telemedicine to Improve Pediatric Concussion Care in Rural and Remote Communities in Canada

Concussion is a form of mild traumatic brain injury that affects thousands of Canadian children and adolescents annually. Despite national efforts to harmonize the recognition and management of pediatric concussion in Canada, timely access to primary and specialized care following this injury remains a challenge for many patients especially those who live in rural and remote communities. To address similar challenges facing patients with stroke and other neurological disorders, physicians have begun to leverage advances in telemedicine to improve the delivery of specialized neurological care to those living in medically underserved regions. Preliminary studies suggest that telemedicine may be a safe and cost-effective approach to assist in the medical care of select patients with acute concussion and persistent post-concussion symptoms. Here we provide an overview of telemedicine, teleneurology, the principles of concussion assessment and management, as well as the current state of concussion care in Canada. Utilizing preliminary evidence from studies of telemedicine in concussion and experience from comprehensive systems of care for stroke, we outline steps that must be taken to evaluate the potential of telemedicine-based concussion networks to improve the care of pediatric concussion patients living in underserved rural and remote communities in Canada.