Eric Crighton

Progression from Asthma to Chronic Obstructive Pulmonary Disease. Is Air Pollution a Risk Factor

RATIONALE Individuals with asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS), have more rapid decline in lung function, more frequent exacerbations, and poorer quality of life than those with asthma or COPD alone. Air pollution exposure is a known risk factor for asthma and COPD; however, its role in ACOS is not as well understood. OBJECTIVES To determine if individuals with asthma exposed to higher levels of air pollution have an increased risk of ACOS. METHODS Individuals who resided in Ontario, Canada, aged 18 years or older in 1996 with incident asthma between 1996 and 2009 who participated in the Canadian Community Health Survey were identified and followed until 2014 to determine the development of ACOS. Data on exposures to fine particulate matter (PM2.5) and ozone (O3) were obtained from fixed monitoring sites. Associations between air pollutants and ACOS were evaluated using Cox regression models. MEASUREMENTS AND MAIN RESULTS Of the 6,040 adults with incident asthma who completed the Canadian Community Health Survey, 630 were identified as ACOS cases. Compared with those without ACOS, the ACOS population had later onset of asthma, higher proportion of mortality, and more frequent emergency department visits before COPD diagnosis. The adjusted hazard ratios of ACOS and cumulative exposures to PM2.5 (per 10 μg/m(3)) and O3 (per 10 ppb) were 2.78 (95% confidence interval, 1.62-4.78) and 1.31 (95% confidence interval, 0.71-2.39), respectively. CONCLUSIONS Individuals exposed to higher levels of air pollution had nearly threefold greater odds of developing ACOS. Minimizing exposure to high levels of air pollution may decrease the risk of ACOS.

Evidence-based performance indicators of primary care for asthma: a modified RAND Appropriateness Method

PURPOSE To develop evidence-based performance indicators that measure the quality of primary care for asthma. DATA SOURCES Cochrane Database of Systematic Reviews, MEDLINE, EMBASE and CINAHL for peer-reviewed articles published in 1998-2008 and five national/global asthma management guidelines. STUDY SELECTION Articles with a focus on current asthma performance indicators recognized or used in community and primary care settings. Data extraction Modified RAND Appropriateness METHOD was used. The work described herein was conducted in Canada in 2008. Five clinician experts conducted the systematic literature review. Asthma-specific performance indicators were developed and the strength of supporting evidence summarized. A survey was created and mailed to 17 expert panellists of various disciplines, asking them to rate each indicator using a 9-point Likert scale. Percentage distribution of the Likert scores were generated and given to the panellists before a face-to-face meeting, which was held to assess consensus. At the meeting, they ranked all indicators based on their reliability, validity, availability and feasibility. RESULTS Literature search yielded 1228 articles, of which 135 were used to generate 45 performance indicators in five domains: access to care, clinical effectiveness, patient centeredness, system integration and coordination and patient safety. The top five ranked indicators were: Asthma Education from Certified Asthma Educator, Pulmonary Function Monitoring, Asthma Control Monitoring, Controller Medication Use and Asthma Control. CONCLUSION The top 15 ranked indicators are recommended for implementation in primary care to measure asthma care delivery, respiratory health outcomes and establish benchmarks for optimal health service delivery over time and across populations.

The relationship between socio-economic and geographic factors and asthma among Canada's Aboriginal populations

Objectives. To examine the prevalence, exacerbations and management of asthma among Canada’s Aboriginal populations, and its relationship to socio-economic and geographic factors. Study design. Secondary analysis of a national cross-sectional questionnaire survey. Methods. Data were collected in 2000 and 2001 through a survey of Aboriginal children and adults residing on-and off-reserve as part of the 2001 Aboriginal People’s Survey (APS). The asthma related outcome variables — physician-diagnosed asthma, attack in past year and regular use of inhalants — were examined in relation to socio-economic and geographic factors such as income, education, housing and location of residence. Statistical analyses were based on weighted univariate and multivariate logistic regressions. Results. The results show variations in asthma diagnosis, attacks and inhalant use across geographic location, socio-economic and demographic characteristics. Geographic location was found to be significantly associated with asthma for both adults and children, with those living in the northern territories, on-reserve or rural locations being the least likely to be diagnosed. Geographic location and Aboriginal identity were also found to be significantly associated with asthma medication use. Conclusions. While these findings may suggest a “healthier” population in more remote locations, they alternatively point to a general pattern of under-diagnosis, potentially due to poor health care access, as is typical in more remote locations.

Perceptions and experiences of environmental health risks among new mothers: a qualitative study in Ontario, Canada

There is a growing awareness and concern in contemporary societies about potential health impacts of environmental contaminants on children. Mothers are traditionally more involved than other family members in managing family health and household decisions and thus targeted by public health campaigns to minimise risks. However little is known about how new mothers perceive and experience environmental health risks to their children. In 2010, we undertook a parallel case study using qualitative, in-depth interviews with new mothers and focus groups with public health key informants in two Public Health Units in Ontario Province, Canada. We found that the concern about environmental hazards among participants ranged from having no concerns to actively incorporating prevention into daily life. Overall, there was a common perception among participants that many risks, particularly in the indoor environment, were controllable and therefore of little concern. But environmental risks that originate outside the home were viewed as less controllable and more threatening. In response to such threats, mothers invoked coping strategies such as relying on the capacity of childrens bodies to adapt. Regardless of the strategies adopted, actions (or inactions) were contingent upon active information seeking. We also found an optimistic bias in which new mothers reported that other children were at greater risk despite similar environmental circumstances. The findings suggest that risk communication experts must attend to the social and environmental contexts of risk and coping when designing strategies around risk reducing behaviours.

Mapping as a knowledge translation tool for Ontario Early Years Centres: views from data analysts and managers

BackgroundLocal Ontario Early Years Centres (OEYCs) collect timely and relevant local data, but knowledge translation is needed for the data to be useful. Maps represent an ideal tool to interpret local data. While geographic information system (GIS) technology is available, it is less clear what users require from this technology for evidence-informed program planning. We highlight initial challenges and opportunities encountered in implementing a mapping innovation (software and managerial decision-support) as a knowledge translation strategy.MethodsUsing focus groups, individual interviews and interactive software development events, we taped and transcribed verbatim our interactions with nine OEYCs in Ontario, Canada. Research participants were composed of data analysts and their managers. Deductive analysis of the data was based on the Ottawa Model of Research Use, focusing on the innovation (the mapping tool and maps), the potential adopters, and the environment.ResultsChallenges associated with the innovation included preconceived perceptions of a steep learning curve with GIS software. Challenges related to the potential adopters included conflicting ideas about tool integration into the organization and difficulty with map interpretation. Lack of funds, lack of availability of accurate data, and unrealistic reporting requirements represent environmental challenges.ConclusionDespite the clear need for mapping software and maps, there remain several challenges to their effective implementation. Some can be modified, while other challenges might require attention at the systemic level. Future research is needed to identify barriers and facilitators related to using mapping software and maps for decision-making by other users, and to subsequently develop mapping best practices guidelines to assist community-based agencies in circumventing some challenges, and support information equity across a region.

Maternal exposure to ambient air pollution and risk of early childhood cancers: A population-based study in Ontario, Canada

BACKGROUND There are increasing concerns regarding the role of exposure to ambient air pollution during pregnancy in the development of early childhood cancers. OBJECTIVE This population based study examined whether prenatal and early life (<1year of age) exposures to ambient air pollutants, including nitrogen dioxide (NO2) and particulate matter with aerodynamic diameters ≤2.5μm (PM2.5), were associated with selected common early childhood cancers in Canada. METHODS 2,350,898 singleton live births occurring between 1988 and 2012 were identified in the province of Ontario, Canada. We assigned temporally varying satellite-derived estimates of PM2.5 and land-use regression model estimates of NO2 to maternal residences during pregnancy. Incident cases of 13 subtypes of pediatric cancers among children up to age 6 until 2013 were ascertained through administrative health data linkages. Associations of trimester-specific, overall pregnancy and first year of life exposures were evaluated using Cox proportional hazards models, adjusting for potential confounders. RESULTS A total of 2044 childhood cancers were identified. Exposure to PM2.5, per interquartile range increase, over the entire pregnancy, and during the first trimester was associated with an increased risk of astrocytoma (hazard ratio (HR) per 3.9μg/m3=1.38 (95% CI: 1.01, 1.88) and, HR per 4.0μg/m3=1.40 (95% CI: 1.05-1.86), respectively). We also found a positive association between first trimester NO2 and acute lymphoblastic leukemia (ALL) (HR=1.20 (95% CI: 1.02-1.41) per IQR (13.3ppb)). CONCLUSIONS In this population-based study in the largest province of Canada, results suggest an association between exposure to ambient air pollution during pregnancy, especially in the first trimester and an increased risk of astrocytoma and ALL. Further studies are required to replicate the findings of this study with adjustment for important individual-level confounders.

Asthma and Chronic Obstructive Pulmonary Disease (COPD) Prevalence and Health Services Use in Ontario Métis: A Population-Based Cohort Study

Introduction Chronic respiratory diseases cause a significant health and economic burden around the world. In Canada, Aboriginal populations are at increased risk of asthma and chronic obstructive pulmonary disease (COPD). There is little known, however, about these diseases in the Canadian Métis population, who have mixed Aboriginal and European ancestry. A population-based study was conducted to quantify asthma and COPD prevalence and health services use in the Métis population of Ontario, Canada’s largest province. Methods The Métis Nation of Ontario Citizenship Registry was linked to provincial health administrative databases to measure and compare burden of asthma and COPD between the Métis and non-Métis populations of Ontario between 2009 and 2012. Asthma and COPD prevalence, health services use (general physician and specialist visits, emergency department visits, hospitalizations), and mortality were measured. Results Prevalences of asthma and COPD were 30% and 70% higher, respectively, in the Métis compared to the general Ontario population (p<0.001). General physician and specialist visits were significantly lower in Métis with asthma, while general physician visits for COPD were significantly higher. Emergency department visits and hospitalizations were generally higher for Métis compared to non-Métis with either disease. All-cause mortality in Métis with COPD was 1.3 times higher compared to non-Métis with COPD (p = 0.01). Conclusion There is a high burden of asthma and COPD in Ontario Métis, with significant prevalence and acute health services use related to these diseases. Lower rates of physician visits suggest barriers in access to primary care services.

What Have We Learned? A Review of the Literature on Children’s Health and the Environment in the Aral Sea Area

ObjectivesTo review the published literature examining the impacts of the Aral Sea disaster on children’s health.MethodsA systematic review of the English language literature.ResultsThe literature search uncovered 26 peer-reviewed articles and four major reports published between 1994 and 2008. Anemia, diarrheal diseases, and high body burdens of toxic contaminants were identified as being among the significant health problems for children. These problems are associated either directly with the environmental disaster or indirectly via the deterioration of the region’s economy and social and health care services. While links between persistent organic pollutant exposures and body burdens are clear, health impacts remain poorly understood. No clear evidence for the link between dust exposure and respiratory function was identified.ConclusionWhile important questions about the nature of the child health and environment relationships remain to be answered, the literature unequivocally illustrates the seriousness of the public health tragedy and provides sufficient evidence to justify immediate action. Regrettably, international awareness of the crisis continues to be poor, and the level of action addressing the situation is wholly inadequate.

If you build it, they still may not come: outcomes and process of implementing a community-based integrated knowledge translation mapping innovation

BackgroundMaps and mapping tools through geographic information systems (GIS) are highly valuable for turning data into useful information that can help inform decision-making and knowledge translation (KT) activities. However, there are several challenges involved in incorporating GIS applications into the decision-making process. We highlight the challenges and opportunities encountered in implementing a mapping innovation as a KT strategy within the non-profit (public) health sector, reflecting on the processes and outcomes related to our KT innovations.MethodsA case study design, whereby the case is defined as the data analyst and manager dyad (a two-person team) in selected Ontario Early Year Centres (OEYCs), was used. Working with these paired individuals, we provided a series of interventions followed by one-on-one visits to ensure that our interventions were individually tailored to personal and local decision-making needs. Data analysis was conducted through a variety of qualitative assessments, including field notes, interview data, and maps created by participants. Data collection and data analysis have been guided by the Ottawa Model of Research Use (OMRU) conceptual framework.ResultsDespite our efforts to remove all barriers associated with our KT innovation (maps), our results demonstrate that both individual level and systemic barriers pose significant challenges for participants. While we cannot claim a causal association between our project and increased mapping by participants, participants did report a moderate increase in the use of maps in their organization. Specifically, maps were being used in decision-making forums as a way to allocate resources, confirm tacit knowledge about community needs, make financially-sensitive decisions more transparent, evaluate programs, and work with community partners.ConclusionsThis project highlights the role that maps can play and the importance of communicating the importance of maps as a decision support tool. Further, it represents an integrated knowledge project in the community setting, calling to question the applicability of traditional KT approaches when community values, minimal resources, and partners play a large role in decision making. The study also takes a unique perspective--where research producers and users work as dyad-pairs in the same organization--that has been under-explored to date in KT studies.

Equity-focused knowledge translation: a framework for ''reasonable action'' on health inequities

ObjectivesTo identify gaps in procedural approaches to knowledge translation and outline a more relational approach that addresses health inequities based on creating collaborative environments for reasonable action.MethodsA literature review encompassing approaches to critical inquiry of the institutional conditions in which knowledge is created combined with a process for encouraging reflexive professional practice provide the conceptual foundation for our approach, called equity-focused knowledge translation (EqKT).ResultsThe EqKT approach creates a matrix through which teams of knowledge stakeholders (researchers, practitioners, and policymakers) can set common ground for taking collaborative action on health inequities.ConclusionsOur approach can contribute to the call by the WHO Commission on the Social Determinants of Healths for more reasonable action on health inequities by being incorporated into numerous public health settings and processes. Further steps include empirical applications and evaluations of EqKT in real world applications.