Prevalence of cannabis use and the frequency, types, and sources of cannabis products used in northern remote territories of the Canadian legal cannabis market

OBJECTIVE

The Cannabis Policy Study in the Territories (CPST) is an annual repeat cross-sectional study aiming to evaluate the impacts of cannabis legalization in the Canadian territories (Yukon, Northwest Territories, and Nunavut), where there is a paucity of data on cannabis use. This current study's objective was to describe the 2022 CPST, including methods, population prevalence estimates of cannabis use, and legal cannabis sources and perceptions in the territories.

METHODS

The 2022 CPST includes 2462 respondents (aged 16 +) residing in the territories who either use or do not use cannabis. Respondents were recruited through mail-push-to-web invitations sent via licensed mailing lists, sampling from a near census of households in the territories. Population-weighted indicators of cannabis use are described.

RESULTS

Past 12-month cannabis use was self-reported by 46.1%, and 21.8% self-reported daily/almost daily use. The most commonly used product types among past 12-month consumers were dried flower (73.4%), edibles (59.0%), and vape oils (35.7%). On average, 74.8% of cannabis products used in the past 12 months were from legal sources, though legal sourcing varied by product type (54.4‒92.2%). Cannabis consumers reported favourable perceptions of legal compared to illegal cannabis products regarding quality, convenience, and safety, but a lesser extent for price.

CONCLUSION

Cannabis use is highly prevalent in the territories, particularly daily/almost daily use, and legal market penetration is high despite region remoteness. Following cannabis legalization, monitoring cannabis use prevalence and patterns in remote regions is important for informing the development of harm reduction and prevention initiatives that consider the unique needs of these regions.

Targeted HIV Self-Testing Identifies Persons with Undiagnosed HIV and Active Engagement Links them to Care: The GetaKit Study

Current international HIV testing guidelines recommend that HIV negative persons from HIV priority groups complete repeat screening every 3-6 months; local guidelines in our jurisdiction recommend that such retesting should occur every 3 months. Such an approach allows for timely HIV diagnosis and linkage to care - and aligns with the UNAIDS 95-95-95 targets to have 95% of undiagnosed persons be aware of their HIV status. To meet these aims, new approaches to HIV testing have been developed, including our HIV self-testing initiative, GetaKit.ca, which uses an online screening algorithm to determine eligibility and has built in pathways for re-test reminders, linkage HIV prevention care, and rapid follow-up for positive test results. To understand self-testing frequency in relation to our local recommendations for resting every 3 months, we evaluated data from participants who ordered repeat HIV self-tests through GetaKit.ca. Descriptive analyses were performed on participant characteristics and chi-square tests were performed on aggregated participant risk data. During the study period, 5235 HIV self-tests were distributed to 3627 participants, of whom, 26% ordered more than once and 27% belonged to an HIV priority population. Participants who retested were more likely to have been white, male, and part of an HIV priority population; they were also more likely to have completed prior STI or HIV testing or had a prior STI diagnosis, compared to those who did not. We identified 16 new HIV diagnoses, 2 of which were among repeat testers. Our results suggest that HIV self-testing can be useful to help meet UNAIDS targets to identify undiagnosed infections; however, such efforts are less likely to be successful without adequate linkage to follow-up services, including HIV treatment and prevention care.

A thematic content analysis of 2010-2015 state tobacco control legislation in the United States: Bill rationales and priority populations

Objective

Tobacco use causes numerous types of cancers, heart diseases, and chronic illnesses, and is responsible for nearly 1 in every 5 deaths in the United States (U.S.) annually. This study assessed whether tobacco control laws introduced in state legislatures between 2010 and 2015 provided a rationale for the proposed bill and/or specified priority population groups, and we then examined emerging themes in the text that did so.

Methods

Using LexisNexis® State Net®, we identified tobacco control bills introduced in all states and coded their bill rationales and population category. We then conducted qualitative thematic analysis on a sample of bills with rationales or specified populations.

Results

Of the 2815 tobacco control bills introduced in state legislatures in the analysis period, 422 (15.0%) included a bill rationale, and 1309 (46.5%) specified at least one priority population. Four overarching themes emerged: 1) Addressing tobacco-related health harms and financial costs incurred to society; 2) Protecting the public from tobacco-related harms as a government responsibility; 3) Providing services to priority populations; 4) Exempting or preempting some population groups and localities.

Conclusions

Rationalizing tobacco control legislation by focusing on both health and cost implications was a key feature of tobacco policy bill text we analyzed; given the history of this approach, it is likely to remain so in the future. Our study may serve as a benchmark for tracking current and future tobacco control legislation to examine whether there is a growth in prioritizing populations experiencing unjust burdens of tobacco use and related disease.

Understanding PrEP Acceptability Among Priority Populations: Results from a Qualitative Study of Potential Users in Central Uganda

Daily oral pre-exposure prophylaxis (PrEP) can safely and effectively prevent HIV acquisition in HIV-negative individuals. However, uptake of PrEP has been suboptimal in sub-Saharan Africa. The goal of this qualitative study was to identify facilitators of and barriers to PrEP acceptability among target users not taking PrEP. Fifty-nine individuals belonging to Ugandan priority populations participated in a single in-depth interview. Participants perceived themselves as being at high risk for HIV acquisition, and expressed interest in PrEP as an HIV prevention strategy. Two forms of stigma emerged as potential barriers to PrEP use: (1) misidentification as living with HIV; and (2) disclosure of membership in a priority population. Acceptability of PrEP was dampened for this sample of potential PrEP users due to anticipated stigmatization. Mitigating stigma should be a key component of effective PrEP delivery to reach UNAIDS goal of ending the AIDS epidemic by 2030.

Constructing an ethical framework for priority allocation of pandemic vaccines

Background

Allocation of scarce resources during a pandemic extends to the allocation of vaccines when they eventually become available. We describe a framework for priority vaccine allocation that employed a cross-disciplinary approach, guided by ethical considerations and informed by local risk assessment.

Methods

Published and grey literature was reviewed, and augmented by consultation with key informants, to collate past experience, existing guidelines and emerging strategies for pandemic vaccine deployment. Identified ethical issues and decision-making processes were also included. Concurrently, simulation modelling studies estimated the likely impacts of alternative vaccine allocation approaches. Assembled evidence was presented to a workshop of national experts in pandemic preparedness, vaccine strategy, implementation and ethics. All of this evidence was then used to generate a proposed ethical framework for vaccine priorities best suited to the Australian context.

Findings

Published and emerging guidance for priority pandemic vaccine distribution differed widely with respect to strategic objectives, specification of target groups, and explicit discussion of ethical considerations and decision-making processes. Flexibility in response was universally emphasised, informed by real-time assessment of the pandemic impact level, and identification of disproportionately affected groups. Model outputs aided identification of vaccine approaches most likely to achieve overarching goals in pandemics of varying transmissibility and severity. Pandemic response aims deemed most relevant for an Australian framework were: creating and maintaining trust, promoting equity, and reducing harmful outcomes.

Interpretation

Defining clear and ethically-defendable objectives for pandemic response in context aids development of flexible and adaptive decision support frameworks and facilitates clear communication and engagement activities.

Implementation of the Health Equity Impact Assessment (HEIA) tool in a local public health setting: challenges, facilitators, and impacts

SETTING

The Simcoe Muskoka District Health Unit (SMDHU) is a local public health agency in Ontario, serving the County of Simcoe and District of Muskoka's population of over 540,000 people in a mixed urban-rural environment. SMDHU has had a strategic focus on the determinants of health since 2007.

INTERVENTION

The use of the Health Equity Impact Assessment (HEIA) tool was encouraged throughout SMDHU. An online survey was conducted to assess the implementation of mitigation strategies identified through the HEIAs; in particular, the facilitators and barriers/challenges, and the impacts at both the program level and the level of priority populations, themselves, were assessed.

OUTCOMES

Agency programs reported 40 HEIAs conducted between 2013 and 2017. While three of the 40 HEIAs were at an early stage, the remaining 37 were at an advanced stage of implementing mitigation strategies, or beyond. Reports from these 37 advanced-stage HEIAs indicated that 30 of them observed or measured impacts on their programs, services, and/or policies (i.e., program-level impacts), following the implementation of HEIA mitigation strategies. These impacts included improved collaboration with external partners, development of more accessible and inclusive communication, increased availability of information and population health data, increased access to services for priority populations, reduced financial barriers for accessing services, and increased staff training on health equity and priority populations. However, few respondents had measured or purposefully assessed impacts on target populations themselves (i.e., population-level impacts); therefore, such impacts are unknown. Key facilitators to the implementation of mitigation strategies were availability of staff, collaboration and support from other areas of the organization, sufficient time, collaboration with community partners, and the inclusion of HEIAs in program operational plans. Absence of these facilitators was identified as a barrier to implementation of mitigation strategies.

IMPLICATIONS FOR POLICY AND PRACTICE

The use of HEIAs served as a catalyst for change in this local public health agency, leading to equity-oriented impacts on public health programming, planning, service delivery, and organizational policy. Support and capacity-building for measuring and evaluating impacts of mitigation strategies on intended priority populations themselves are recommended, to ensure more robust learning and improvement.

Influence of revised public health standards on health equity action: a qualitative study in Ontario, Canada

Background

In 2008, a revised set of public health standards was released in the province of Ontario, Canada. The updated Ontario Public Health Standards (OPHS) introduced a new policy mandate that required local public health units (PHUs) to identify “priority populations” for public health programs and services. The aim of this study was to understand how this Priority Populations Mandate (PPM) facilitated or hindered action on health equity or the social determinants of health through PHUs in Ontario.

Methods

This study used two sets of qualitative data that were part of a larger study. The first set of data was 16 semi-structured key informant interviews with policymakers involved in developing the OPHS and public health practitioners. The second set of data was the qualitative component of a role-based survey sent out to all the 36 PHUs in Ontario. Thematic content analysis was conducted to iteratively develop themes to answer the research question.

Results

We identified six factors that both facilitated and hindered action on health equity and social determinants of health action in the province resulting from the OPHS and PPM. These six factors were grouped into three categories or themes: OPHS policy attributes (1. introducing new terminology, 2. allowing flexibility in implementation and 3. ensuring evidence-informed decision-making), health sector context into which the PPM was introduced (4. different understandings of health equity and 5. variability in existing partnerships) and implementation by PHUs (6. requirement to address the PPM).

Conclusions

Although the revised OPHS and the PPM facilitated action on health equity and the social determinants of health, on the whole, this objective could have been better met. The mandate within the OPHS could have been strengthened with respect to promoting action on health equity and the social determinants of health through more clearly defined terminology, conveying a guiding health equity vision and uniting different PHU approaches to addressing health equity.