The impact of the COVID-19 pandemic on people who use drugs in three Canadian cities: a cross-sectional analysis

BACKGROUND

The COVID-19 pandemic had a disproportionate impact on the health and wellbeing of people who use drugs (PWUD) in Canada. However less is known about jurisdictional commonalities and differences in COVID-19 exposure and impacts of pandemic-related restrictions on competing health and social risks among PWUD living in large urban centres.

METHODS

Between May 2020 and March 2021, leveraging infrastructure from ongoing cohorts of PWUD, we surveyed 1,025 participants from Vancouver (n = 640), Toronto (n = 158), and Montreal (n = 227), Canada to describe the impacts of pandemic-related restrictions on basic, health, and harm reduction needs.

RESULTS

Among participants, awareness of COVID-19 protective measures was high; however, between 10 and 24% of participants in each city-specific sample reported being unable to self-isolate. Overall, 3-19% of participants reported experiencing homelessness after the onset of the pandemic, while 20-41% reported that they went hungry more often than usual. Furthermore, 8-33% of participants reported experiencing an overdose during the pandemic, though most indicated no change in overdose frequency compared the pre-pandemic period. Most participants receiving opioid agonist therapy in the past six months reported treatment continuity during the pandemic (87-93%), however, 32% and 22% of participants in Toronto and Montreal reported missing doses due to service disruptions. There were some reports of difficulty accessing supervised consumption sites in all three sites, and drug checking services in Vancouver.

CONCLUSION

Findings suggest PWUD in Canada experienced difficulties meeting essential needs and accessing some harm reduction services during the COVID-19 pandemic. These findings can inform preparedness planning for future public health emergencies.

Substance use care innovations during COVID-19: barriers and facilitators to the provision of safer supply at a toronto COVID-19 isolation and recovery site

BACKGROUND

Early in the COVID-19 pandemic, there was an urgent need to establish isolation spaces for people experiencing homelessness who were exposed to or had COVID-19. In response, community agencies and the City of Toronto opened COVID-19 isolation and recovery sites (CIRS) in March 2020. We sought to examine the provision of comprehensive substance use services offered to clients on-site to facilitate isolation, particularly the uptake of safer supply prescribing (prescription of pharmaceutical opioids and/or stimulants) as part of a spectrum of comprehensive harm reduction and addiction treatment interventions.

METHODS

We conducted in-depth, semi-structured interviews with 25 clients and 25 staff (including peer, harm reduction, nursing and medical team members) from the CIRS in April-July 2021. Iterative and thematic analytic methods were used to identify key themes that emerged in the interview discussions.

RESULTS

At the time of implementation of the CIRS, the provision of a safer supply of opioids and stimulants was a novel and somewhat controversial practice. Prescribed safer supply was integrated to address the high risk of overdose among clients needing to isolate due to COVID-19. The impact of responding to on-site overdoses and presence of harm reduction and peer teams helped clinical staff overcome hesitation to prescribing safer supply. Site-specific clinical guidance and substance use specialist consults were crucial tools in building capacity to provide safer supply. Staff members had varied perspectives on what constitutes 'evidence-based' practice in a rapidly changing, crisis situation.

CONCLUSION

The urgency involved in intervening during a crisis enabled the adoption of prescribed safer supply, meeting the needs of people who use substances and assisting them to complete isolation periods, while also expanding what constitutes acceptable goals in the care of people who use drugs to include harm reduction approaches.

Randomized controlled trial demonstrates novel tools to assess patient outcomes of Indigenous cultural safety training

BACKGROUND

Health care routinely fails Indigenous peoples and anti-Indigenous racism is common in clinical encounters. Clinical training programs aimed to enhance Indigenous cultural safety (ICS) rely on learner reported impact assessment even though clinician self-assessment is poorly correlated with observational or patient outcome reporting. We aimed to compare the clinical impacts of intensive and brief ICS training to control, and to assess the feasibility of ICS training evaluation tools, including unannounced Indigenous standardized patient (UISP) visits.

METHOD

Using a prospective parallel group three-arm randomized controlled trial design and masked standardized patients, we compared the clinical impacts of the intensive interactive, professionally facilitated, 8- to10-h Sanyas ICS training; a brief 1-h anti-bias training adapted to address anti-Indigenous bias; and control continuing medical education time-attention matched to the intensive training. Participants included 58 non-Indigenous staff physicians, resident physicians and nurse practitioners from family practice clinics, and one emergency department across four teaching hospitals in Toronto, Canada. Main outcome measures were the quality of care provided during UISP visits including adjusted odds that clinician would be recommended by the UISP to a friend or family member; mean item scores on patient experience of care measure; and clinical practice guideline adherence for NSAID renewal and pain assessment.

RESULTS

Clinicians in the intensive or brief ICS groups had higher adjusted odds of being highly recommended to friends and family by standardized patients (OR 6.88, 95% CI 1.17 to 40.45 and OR 7.78, 95% CI 1.05 to 58.03, respectively). Adjusted mean item patient experience scores were 46% (95% CI 12% to 80%) and 40% (95% CI 2% to 78%) higher for clinicians enrolled in the intensive and brief training programs, respectively, compared to control. Small sample size precluded detection of training impacts on clinical practice guideline adherence; 100% of UISP visits were undetected by participating clinicians.

CONCLUSIONS

Patient-oriented evaluation design and tools including UISPs were demonstrated as feasible and effective. Results show potential impact of cultural safety training on patient recommendation of clinician and improved patient experience. A larger trial to further ascertain impact on clinical practice is needed.

TRIAL REGISTRATION

Clinicaltrials.org NCT05890144. Retrospectively registered on June 5, 2023.

The potential benefits of "community champions" in the healthcare system

In a study to understand acceptability and uptake of Human Papilloma Virus (HPV) self-sampling, we engaged community champions to lead recruitment and other study activities. This article describes qualitative findings relevant to the role of the community champion. We found that community champions were critical to promoting awareness about and encouraging cervical screening and HPV self-sampling. They were well-connected community members who had healthcare backgrounds, which created trust in their messages. They were highly effective at encouraging screening because of their education and cultural congruency, combined with the time for thorough and clear explanations. Women had an inherent level of comfort with the community champions that often did not exist with their physician. The community champions were seen as being able to address some of the barriers that exist within the healthcare system. We encourage health leaders to consider how this role can be sustainably and meaningfully incorporated into the healthcare system.

Systematic review of Indigenous cultural safety training interventions for healthcare professionals in Australia, Canada, New Zealand and the United States

OBJECTIVE

To synthesise and appraise the design and impact of peer-reviewed evaluations of Indigenous cultural safety training programmes and workshops for healthcare workers in Australia, Canada, New Zealand and/or the United States.

DESIGN

Systematic review.

DATA SOURCES

Ovid Medline, Embase, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Bibliography of Indigenous Peoples in North America, Applied Social Sciences Index & Abstracts, ERIC (Education Resources Information Center), International Bibliography of the Social Sciences, ProQuest Dissertations & Theses Global, Sociological Abstracts, and Web of Science's Social Sciences Citation Index and Science Citation Index from 1 January 2006 to 12 May 2022.

ELIGIBILITY CRITERIA

Studies that evaluated the outcomes of educational interventions for selecting studies: designed to improve cultural safety, cultural competency and/or cultural awareness for non-Indigenous adult healthcare professionals in Canada, Australia, New Zealand or the United States.

DATA EXTRACTION AND SYNTHESIS

Our team of Indigenous and allied scientists tailored existing data extraction and quality appraisal tools with input from Indigenous health service partners. We synthesised the results using an iterative narrative approach.

RESULTS

2442 unique titles and abstracts met screening criteria. 13 full texts met full inclusion and quality appraisal criteria. Study designs, intervention characteristics and outcome measures were heterogeneous. Nine studies used mixed methods, two used qualitative methods and two used quantitative methods. Training participants included nurses, family practice residents, specialised practitioners and providers serving specific subpopulations. Theoretical frameworks and pedagogical approaches varied across programmes, which contained overlapping course content. Study outcomes were primarily learner oriented and focused on self-reported changes in knowledge, awareness, beliefs, attitudes and/or the confidence and skills to provide care for Indigenous peoples. The involvement of local Indigenous communities in the development, implementation and evaluation of the interventions was limited.

CONCLUSION

There is limited evidence regarding the effectiveness of specific content and approaches to cultural safety training on improving non-Indigenous health professionals' knowledge of and skills to deliver quality, non-discriminatory care to Indigenous patients. Future research is needed that advances the methodological rigour of training evaluations, is focused on observed clinical outcomes, and is better aligned to local, regional,and/or national Indigenous priorities and needs.

Altered expression, but small contribution, of the histone demethylase KDM6A in obstructive uropathy in mice

Epigenetic processes have emerged as important modulators of kidney health and disease. Here, we studied the role of KDM6A (a histone demethylase that escapes X-chromosome inactivation) in kidney tubule epithelial cells. We initially observed an increase in tubule cell Kdm6a mRNA in male mice with unilateral ureteral obstruction (UUO). However, tubule cell knockout of KDM6A had relatively minor consequences, characterized by a small reduction in apoptosis, increase in inflammation and downregulation of the peroxisome proliferator-activated receptor (PPAR) signaling pathway. In proximal tubule lineage HK-2 cells, KDM6A knockdown decreased PPARγ coactivator-1α (PGC-1α) protein levels and mRNA levels of the encoding gene, PPARGC1A. Tubule cell Kdm6a mRNA levels were approximately 2-fold higher in female mice than in male mice, both under sham and UUO conditions. However, kidney fibrosis after UUO was similar in both sexes. The findings demonstrate Kdm6a to be a dynamically regulated gene in the kidney tubule, varying in expression levels by sex and in response to injury. Despite the context-dependent variation in Kdm6a expression, knockout of tubule cell KDM6A has subtle (albeit non-negligible) effects in the adult kidney, at least in males.

Implementation of a Cervical Cancer Screening Intervention for Under- or Never-Screened Women in Ontario, Canada: Understanding the Acceptability of HPV Self-Sampling

With appropriate screening, cervical cancer can be prevented. In Ontario, Canada, some groups of women have low screening rates. South Asian, Middle Eastern and North African women are particularly at risk of under-screening. Currently, cytology-based screening is used in Ontario, although the growing evidence and adoption of HPV testing for cervical screening has encouraged many jurisdictions around the world to move towards HPV testing, with the option of self-sampling. We conducted an intervention beginning in June 2018, where we recruited over 100 under- or never-screened (UNS) women who identify as South or West Asian, Middle Eastern or North African from the Greater Toronto Area, to understand the uptake and acceptability of HPV self-sampling as an alternative to a Pap test. Participants self-selected if they tried the kit or not and completed both quantitative and qualitative research activities. This paper focuses on the qualitative arm of the study, where follow-ups and five focus groups were conducted with those who tried the kit (three groups) and those who did not (two groups), as well as eight key informant interviews with community champions and others who were involved in our recruitment. We used the Consolidated Framework for Implementation Research (CFIR) to guide our data collection and analysis. Major themes around convenience, privacy and comfort came from the data as important drivers of the uptake of the intervention. The role of community champions and peers in engaging and educating UNS women, as well as having self-confidence to collect the sample, also came out as factors impacting uptake and plans for continued use. Overall, the intervention showed that HPV self-sampling is an acceptable alternative to a Pap test for some but not all UNS women in Ontario.

Differential Patterns by Area-Level Social Determinants of Health in Coronavirus Disease 2019 (COVID-19)-Related Mortality and Non-COVID-19 Mortality: A Population-Based Study of 11.8 Million People in Ontario, Canada

BACKGROUND

Social determinants of health (SDOH) have been associated with coronavirus disease 2019 (COVID-19) outcomes. We examined patterns in COVID-19-related mortality by SDOH and compared these patterns to those for non-COVID-19 mortality.

METHODS

Residents of Ontario, Canada, aged ≥20 years were followed from 1 March 2020 to 2 March 2021. COVID-19-related death was defined as death within 30 days following or 7 days prior to a positive COVID-19 test. Area-level SDOH from the 2016 census included median household income; proportion with diploma or higher educational attainment; proportion essential workers, racially minoritized groups, recent immigrants, apartment buildings, and high-density housing; and average household size. We examined associations between SDOH and COVID-19-related mortality, and non-COVID-19 mortality using cause-specific hazard models.

RESULTS

Of 11 810 255 individuals, we observed 3880 COVID-19-related deaths and 88 107 non-COVID-19 deaths. After accounting for demographics, baseline health, and other area-level SDOH, the following were associated with increased hazards of COVID-19-related death (hazard ratio [95% confidence interval]: lower income (1.30 [1.04-1.62]), lower educational attainment (1.27 [1.07-1.52]), higher proportions essential workers (1.28 [1.05-1.57]), racially minoritized groups (1.42 [1.08-1.87]), apartment buildings (1.25 [1.07-1.46]), and large vs medium household size (1.30 [1.12-1.50]). Areas with higher proportion racially minoritized groups were associated with a lower hazard of non-COVID-19 mortality (0.88 [0.84-0.92]).

CONCLUSIONS

Area-level SDOH are associated with COVID-19-related mortality after accounting for demographic and clinical factors. COVID-19 has reversed patterns of lower non-COVID-19 mortality among racially minoritized groups. Pandemic responses should include strategies to address disproportionate risks and inequitable coverage of preventive interventions associated with SDOH.

Genetics Adviser: a protocol for a mixed-methods randomised controlled trial evaluating a digital platform for genetics service delivery

INTRODUCTION

The high demand for genetic tests and limited supply of genetics professionals has created a need for alternative service delivery models. Digital tools are increasingly being used to support multiple points in the genetic testing journey; however, none are transferable across multiple clinical specialties and settings nor do they encompass the entire trajectory of the journey. We aim to evaluate the effectiveness of the Genetics Adviser, an interactive, patient-facing, online digital health tool that delivers pre-test counselling, provides support during the waiting period for results, and returns results with post-test counselling, encompassing the entire patient genetic testing journey.

METHODS AND ANALYSIS

We will compare the Genetics Adviser paired with a brief genetic counselling session to genetic counselling alone in a randomised controlled trial. One hundred and forty patients who previously received uninformative genetic test results for their personal and family history of cancer will be recruited from familial cancer clinics in Toronto and offered all clinically significant results from genomic sequencing. Participants randomised into the intervention arm will use the Genetics Adviser to learn about genomic sequencing, receive pre-test counselling, support during the waiting period and results, supplemented with brief counselling from a genetic counsellor. Participants in the control arm will receive standard pre-test and post-test counselling for genomic sequencing from a genetic counsellor. Our primary outcome is decisional conflict following pre-test counselling from the Genetics Adviser+genetic counsellor or counsellor alone. Secondary outcomes include: knowledge, satisfaction with decision-making, anxiety, quality of life, psychological impact of results, empowerment, acceptability and economic impact for patients and the health system. A subset of patients will be interviewed to assess user experience.

ETHICS AND DISSEMINATION

This study has been approved by Clinical Trials Ontario Streamlined Research Ethics Review System (REB#20-035). Results will be shared through stakeholder workshops, national and international conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04725565.

Understanding income-related differences in distribution of child growth, behaviour and development using a cross-sectional sample of a clinical cohort study

OBJECTIVES

Children from low-income households are at an increased risk of social, behavioural and physical health problems. Prior studies have generally relied on dichotomous outcome measures. However, inequities may exist along the range of outcome distribution. Our objective was to examine differences in distribution of three child health outcomes by income categories (high vs low): body mass index (BMI), behaviour difficulties and development.

DESIGN AND SETTING

This was a cross-sectional study using data from a primary care-based research network with sites in three Canadian cities, and 15 practices enrolling participants.

PARTICIPANTS, INDEPENDENT VARIABLE AND OUTCOMES

The independent variable was annual household income, dichotomised at the median income for Toronto (<$C80 000 or ≥$C80 000). Outcomes were: (1) growth (BMI z-score (zBMI) at 5 years, 1628 participants); (2) behaviour (Strengths and Difficulties Questionnaire (SDQ) at 3-5 years, 649 participants); (3) development (Infant Toddler Checklist (ITC) at 18 months, 1405 participants). We used distributional decomposition to compare distributions of these outcomes for each income group, and then to construct a counterfactual distribution that describes the hypothetical distribution of the low-income group with the predictor profile of the higher-income group.

RESULTS

We included data from 1628 (zBMI), 649 (SDQ) and 1405 (ITC) children. Children with lower family income had a higher risk distribution for all outcomes. For all outcomes, thecounterfactual distribution, which represented the distribution of children with lower-income who were assigned the predictor profile of the higher-income group, was more favourable than their observed distributions.

CONCLUSION

Comparing the distributions of child health outcomes and understanding different risk profiles for children from higher-income and lower-income groups can offer a deeper understanding of inequities in child health outcomes. These methods may offer an approach that can be implemented in larger datasets to inform future interventions.

Improved SARS-CoV-2 PCR detection and genotyping with double-bubble primers

A new approach for improved RT-PCR is described. It is based on primers designed to form controlled stem-loop and homodimer configurations, hence the name 'double-bubble' primers. The primers contain three main regions for efficient RT-PCR: a 3' short overhang to allow reverse transcription, a stem region for hot start and a template-specific region for PCR amplification. As proof of principle, GAPDH, SARS-CoV-2 synthetic RNA and SARS-CoV-2 virus-positive nasopharyngeal swabs were used as templates. Additionally, these primers were used to positively confirm the N501Y mutation from nasopharyngeal swabs. Evidence is presented that the double-bubble primers offer fast, specific, robust and cost-effective improvement in RT-PCR amplification for detection of gene expression in general and for diagnostic detection and genotyping of SARS-CoV-2 in particular.

Exploring different methods to evaluate the impact of basic income interventions: a systematic review

BACKGROUND

Persistent income inequality, the increase in precarious employment, the inadequacy of many welfare systems, and economic impact of the COVID-19 pandemic have increased interest in Basic Income (BI) interventions. Ensuring that social interventions, such as BI, are evaluated appropriately is key to ensuring their overall effectiveness. This systematic review therefore aims to report on available methods and domains of assessment, which have been used to evaluate BI interventions. These findings will assist in informing future program and research development and implementation.

METHODS

Studies were identified through systematic searches of the indexed and grey literature (Databases included: Scopus, Embase, Medline, CINAHL, Web of Science, ProQuest databases, EBSCOhost Research Databases, and PsycINFO), hand-searching reference lists of included studies, and recommendations from experts. Citations were independently reviewed by two study team members. We included studies that reported on methods used to evaluate the impact of BI, incorporated primary data from an observational or experimental study, or were a protocol for a future BI study. We extracted information on the BI intervention, context and evaluation method.

RESULTS

86 eligible articles reported on 10 distinct BI interventions from the last six decades. Workforce participation was the most common outcome of interest among BI evaluations in the 1960-1980 era. During the 2000s, studies of BI expanded to include outcomes related to health, educational attainment, housing and other key facets of life impacted by individuals' income. Many BI interventions were tested in randomized controlled trials with data collected through surveys at multiple time points.

CONCLUSIONS

Over the last two decades, the assessment of the impact of BI interventions has evolved to include a wide array of outcomes. This shift in evaluation outcomes reflects the current hypothesis that investing in BI can result in lower spending on health and social care. Methods of evaluation ranged but emphasized the use of randomization, surveys, and existing data sources (i.e., administrative data). Our findings can inform future BI intervention studies and interventions by providing an overview of how previous BI interventions have been evaluated and commenting on the effectiveness of these methods.

REGISTRATION

This systematic review was registered with PROSPERO (CRD 42016051218).

Associations between essential medicines and health outcomes for cardiovascular disease

BACKGROUND

National essential medicines lists are used to guide medicine reimbursement and public sector medicine procurement for many countries therefore medicine listings may impact health outcomes.

METHODS

Countries' national essential medicines lists were scored on whether they listed proven medicines for ischemic heart disease, cerebrovascular disease and hypertensive heart disease. In this cross sectional study linear regression was used to measure the association between countries' medicine coverage scores and healthcare access and quality scores.

RESULTS

There was an association between healthcare access and quality scores and health expenditure for ischemic heart disease (p ≤ 0.001), cerebrovascular disease (p ≤ 0.001) and hypertensive heart disease (p ≤ 0.001). However, there was no association between medicine coverage scores and healthcare access and quality scores for ischemic heart disease (p = 0.252), cerebrovascular disease (p = 0.194) and hypertensive heart disease (p = 0.209) when country characteristics were accounted for.

CONCLUSIONS

Listing more medicines on national essential medicines lists may only be one factor in reducing mortality from cardiovascular disease and improving healthcare access and quality scores.