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Beyond Recidivism: Changes in Health and Social Service Involvement Following Exposure to Drug Treatment Court

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2015
Abstract: 

Background

The majority of Drug Treatment Court (DTC) research has examined the impact of DTCs on criminal recidivism. Comparatively little research has addressed the association between DTC participation and engagement with community-based health and social services. The present study investigated changes in participant involvement with outpatient healthcare and income assistance within a DTC cohort. We hypothesized that involvement with community-based (outpatient) health and social services would increase post-DTC participation, and that service levels would be higher among program graduates and offenders with histories of co-occurring mental and substance use disorders.

Methods

Participants were 631 offenders at the DTC in Vancouver, Canada (DTCV). Administrative data representing hospital, outpatient medical care, and income assistance were examined one-year pre/post program to assess differences over time. Generalized estimating equations were used to investigate the association between changes in service use and program involvement. We also examined the relationship between level of service use and offender characteristics.

Results

Members of the cohort were disproportionately Aboriginal (33 %), had been sentenced 2.7 times in the 2 years preceding their index offence, and 50 % had been diagnosed with a non substance-related mental disorder in the five years preceding the index offence. The mean number of outpatient services post DTCV was 51, and the mean amount of social assistance paid was $5,897. Outpatient service use increased following exposure to DTCV (Adjusted Rate Ratio (ARR) = 1.45) and was significantly higher among women (ARR = 1.47), program graduation (ARR = 1.23), and those previously diagnosed with concurrent substance use and mental disorders (ARR = 4.92). Overall, hospital admissions did not increase post-program, although rates were significantly higher among women (ARR = 1.76) and those with concurrent disorders (ARR = 2.71). Income assistance increased significantly post program (ARR = 1.16), and was significantly higher among women (ARR = 1.03), and those diagnosed with substance use disorders (ARR = 1.42) and concurrent disorders (ARR = 1.72).

Conclusions

These findings suggest that the DTCV was a catalyst for increased participant engagement with community health and social supports, and that rates of service use were consistently higher among women and individuals with concurrent disorders. Research is needed to investigate the potential link between health and social support and reductions in recidivism associated with DTCs.

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Article
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British Columbia Healthy Connections Project Process Evaluation: A Mixed Methods Protocol to Describe the Implementation and Delivery of the Nurse-Family Partnership in Canada

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2015
Abstract: 

Background

The Nurse-Family Partnership is a home visitation program for first-time, socially and economically disadvantaged mothers. The effectiveness of this public health intervention has been well established in the United States; however, whether the same beneficial outcomes will be obtained within the Canadian context is unknown. As part of the British Columbia Healthy Connections Project, which includes a trial comparing Nurse-Family Partnership’s effectiveness with existing services in British Columbia, we are conducting a process evaluation to describe and explain how the intervention is implemented and delivered across five regional Health Authorities.

Methods

A convergent parallel mixed methods research design will be used to address the process evaluation objectives. The principles of interpretive description will guide all sampling, data collection and analytic decisions in the qualitative component of the study. The full population of public health nurses and supervisors (n = 71) will discuss their experiences of implementing and delivering the program in interviews (or focus groups). Managers (n  = 5–15) responsible for this portfolio will also be interviewed annually. Fidelity reports with quantitative data on the reach and the dose of the intervention will be collected and analyzed. Summaries of team meetings and supervisory sessions will be analyzed. Data will be used to compare, corroborate and explain results and variances across the five regional Health Authorities.

Discussion

The process evaluation results will be of immediate instrumental use to the program implementers to inform intervention delivery. Findings will contribute to the emerging body of evidence surrounding: 1) professional nurse home visitation practice issues; 2) best practices for meeting the needs of families living in rural and remote communities; 3) a deeper understanding of how health and social issues such as mental health problems including substance misuse and exposure to intimate partner violence affect a young mother’s capacity to parent; and 4) strategies to support professionals from the primary care, public health and child welfare sectors to work collaboratively to meet the needs of children and families who are at risk or experiencing maltreatment.

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Article
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Suicide Related Ideation and Behavior Among Canadian Gay and Bisexual Men: A Syndemic Analysis

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2015
Abstract: 

Background

While several studies have demonstrated that gay and bisexual men are at increased risk of suicide less attention has been given to the processes that generate the inherent inequity with the mainstream population. This study tested whether syndemic theory can explain the excess suicide burden in a sample of Canadian gay and bisexual men. Syndemic theory accounts for co-occurring and mutually reinforcing epidemics suffered by vulnerable groups due to the effects of social marginalization.

Methods

This study used data from Sex Now 2011, a cross-sectional survey of Canadian gay and bisexual men (n  = 8382). The analysis measured the extent to which anti-gay marginalization and several psychosocial health problems are associated with suicide related ideation and attempts. Since psychosocial health problems were hypothesized to have an additive effect on suicide related ideation and attempts, the analysis calculated the effect of accumulated psychosocial health problems on suicide behavior.

Results

Suicide ideation and attempts were positively associated with each individual marginalization indicator (verbal violence, physical violence, bullying, sexual violence and work discrimination) and psychosocial health problems (smoking, party drugs, depression, anxiety, STIs, HIV risk and HIV). Furthermore, prevalence of suicide ideation and attempts increased with each added psychosocial health problem. Those who reported 3 or more had 6.90 (5.47–8.70) times the odds of experiencing suicide ideation and 16.29 (9.82–27.02) times the odds of a suicide attempt compared to those with no psychosocial health problems.

Conclusions

This investigation suggests that syndemics is a useful theory for studying suicide behavior among gay and bisexual men. Moreover, the findings highlight a need to address gay and bisexual men’s health problems holistically and the urgent need to reduce this population’s experience with marginalization and violence.

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Article
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Emergency Department Use and Hospitalizations Among Homeless Adults With Substance Dependence and Mental Disorders

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2015
Abstract: 

Background

Homelessness, substance use, and mental disorders each have been associated with higher rates of emergency department (ED) use and hospitalization. We sought to understand the correlation between ED use, hospital admission, and substance dependence among homeless individuals with concurrent mental illness who participated in a ‘Housing First’ (HF) intervention trial.

Methods

The Vancouver At Home study consisted of two randomized controlled trials addressing homeless individuals with mental disorders who have “high” or “moderate” levels of need. Substance dependence was determined at baseline prior to randomization, using the Mini International Neuropsychiatric Interview diagnostic tool, version 6.0. To assess health service use, we reviewed the number of ED visits and the number of hospital admissions based on administrative data for six urban hospitals. Negative binomial regression modeling was used to test the independent association between substance dependence and health service use (ED use and hospitalization), adjusting for HF intervention, age, gender, ethnicity, education, duration of lifetime homelessness, mental disorders, chronic health conditions, and other variables that were selected a priori to be potentially associated with use of ED services and hospital admission.

Results

Of the 497 homeless adults with mental disorders who were recruited, we included 381 participants in our analyses who had at least 1 year of follow-up and had a personal health number that could be linked to administrative health data. Of this group, 59% (n = 223) met criteria for substance dependence. We found no independent association between substance dependence and ED visits or hospital admissions [rate ratio (RR) = 0.85; 95% CI 0.62–1.17 and RR = 1.21; 95% CI 0.83–1.77, respectively]. The most responsible diagnoses (defined as the diagnosis that accounts for the length of stay) for hospital admissions were schizo-affective disorder, schizophrenia-related disorder, or bipolar affective disorder; collectively reported in 48% (n = 263) of admissions. Fifteen percent (n = 84) of hospital admissions listed substance dependence as the most responsible diagnosis.

Conclusions

Substance dependence was not independently associated with ED use or hospital admission among homeless adults with mental disorders participating in an HF trial. Hospital admissions among this cohort were primarily associated with severe mental disorders.

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Article
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Inbound Medical Tourism to Barbados: A Qualitative Examination of Local Lawyers’ Prospective Legal and Regulatory Concerns

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2015
Abstract: 

Background

Enabled by globalizing processes such as trade liberalization, medical tourism is a practice that involves patients’ intentional travel to privately obtain medical care in another country. Empirical legal research on this issue is limited and seldom based on the perspectives of destination countries receiving medical tourists. We consulted with diverse lawyers from across Barbados to explore their views on the prospective legal and regulatory implications of the developing medical tourism industry in the country.

Methods

We held a focus group in February 2014 in Barbados with lawyers from across the country. Nine lawyers with diverse legal backgrounds participated. Focus group moderators summarized the study objective and engaged participants in identifying the local implications of medical tourism and the anticipated legal and regulatory concerns. The focus group was transcribed verbatim and analyzed thematically.

Results

Five dominant legal and regulatory themes were identified through analysis: (1) liability; (2) immigration law; (3) physician licensing; (4) corporate ownership; and (5) reputational protection.

Conclusions

Two predominant legal and ethical concerns associated with medical tourism in Barbados were raised by participants and are reflected in the literature: the ability of medical tourists to recover medical malpractice for adverse events; and the effects of medical tourism on access to health care in the destination country. However, the participants also identified several topics that have received much less attention in the legal and ethical literature. Overall this analysis reveals that lawyers, at least in Barbados, have an important role to play in the medical tourism sector beyond litigation – particularly in transactional and gatekeeper capacities. It remains to be seen whether these findings are specific to the ecology of Barbados or can be extrapolated to the legal climate of other medical tourism destination countries.

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Article
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High-Frequency Use of Corrections, Health, and Social Services, and Association With Mental Illness and Substance Use

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2015
Abstract: 

Background

A subgroup of individuals becomes entrenched in a “revolving door” involving corrections, health, and social welfare services. Little research has investigated the numbers of people that are in frequent contact with multiple public agencies, the costs associated with these encounters, or the characteristics of the people concerned. The present study used linked administrative data to examine offenders who were also very frequent users of health and social services. We investigated the magnitude and distribution of costs attributable to different categories of service for those in the top 10 % of sentences to either community or custodial settings. We hypothesized that the members of these subgroups would be significantly more likely to have substance use and other mental disorders than other members of the offender population.

Methods

Data were linked across agencies responsible for services to the entire population of British Columbia spanning justice, health, and income assistance. Individuals were eligible for inclusion in the study if they were sentenced at least once in the Vancouver Provincial Court between 2003 and 2012. We examined the subset of participants who fell within the top 10 % of sentences and at least two of the following service categories: community physician services; hospital days; pharmaceutical costs; or income assistance between 2007 and 2012. We examined two groups of offenders separately (those in the top ten percent sentenced to community supervision or to custody) due to differences in time at risk and availability to receive community-based services.

Results

From more than 14,000 offenders sentenced in Vancouver’s Downtown Eastside, very High Frequency service users associated with community (n = 216) and custody (n = 107) sentences incurred average attributable public service costs of id="mce_marker"68,000 and $247,000 respectively over a 5-year period of observation. Health-related costs for both groups were over $80,000 per person, primarily associated with hospital admissions. Across both groups, 99 % had been diagnosed with at least one mental disorder and over 80 % had co-occurring substance use and another mental disorder.

Conclusions

A subset of offenders with concurrent psychiatric disorders receives extremely high levels of service from health, social welfare, and justice sectors in close temporal succession. Members of this subpopulation require targeted supports in order to produce positive outcomes and prevent the perpetuation of a costly and ineffective revolving door.

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Article
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Older Adults’ Outdoor Walking and the Built Environment: Does Income Matter?

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2015
Abstract: 

Background

Our aim was to examine the association between Street Smart Walk Score® and self-reported outdoor walking among older Canadians, and to determine whether socioeconomic status modifies this association.

Methods

We linked objective walkability data with cross-sectional survey data from the Canadian Community Health Survey Healthy-Aging 2008–2009 Cycle for a sample of 1309 British Columbians aged ≥ 65 years. We examined associations between Street Smart Walk Score and meeting physical activity guidelines (≥150 min of moderate to vigorous activity/week) through self-reported outdoor walking using multivariable logistic regression, and tested for significant interactions with household income.

Results

A ten point higher Street Smart Walk Score was associated with a 17 % higher odds of meeting physical activity guidelines through walking outside (95 % CI: 1.07,1.27). In addition, older adults living in neighbourhoods categorised as Walker’s Paradise were over three times more likely to meet guidelines than those living in Car-dependent/Very car dependent neighbourhoods. We found no evidence that household income moderated the effect of Walk Score on walking outside.

Conclusions

Neighbourhood design may be one avenue whereby physical activity levels of older people can be enhanced through outdoor walking, with benefit across socioeconomic strata.

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Article
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Suburbanisation of Oral Cavity Cancers: Evidence From a Geographically-Explicit Observational Study of Incidence Trends in British Columbia, Canada, 1981–2010

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2015
Abstract: 

Background

Recent studies have demonstrated an elevated risk of oral cavity cancers (OCC) among socioeconomically deprived populations, whose increasing presence in suburban neighbourhoods poses unique challenges for equitable health service delivery. The majority of studies to date have utilised aspatial methods to identify OCC. In this study, we use high-resolution geographical analyses to identify spatio-temporal trends in OCC incidence, emphasising the value of geospatial methods for public health research.

Methods

Using province-wide population incidence data from the British Columbia Cancer Registry (1981–2009, N  = 5473), we classify OCC cases by census-derived neighbourhood types to differentiate between urban, suburban, and rural residents at the time of diagnosis. We map geographical concentrations by decade and contrast trends in age-adjusted incidence rates, comparing the results to an index of socioeconomic deprivation.

Results

Suburban cases were found to comprise a growing proportion of OCC incidence. In effect, OCC concentrations have dispersed from dense urban cores to suburban neighbourhoods in recent decades. Significantly higher age-adjusted oral cancer incidence rates are observed in suburban neighbourhoods from 2006 to 2009, accompanied by rising socioeconomic deprivation in those areas. New suburban concentrations of incidence were found in neighbourhoods with a high proportion of persons aged 65+ and/or born in India, China, or Taiwan.

Conclusions

While the aging of suburban populations provides some explanation of these trends, we highlight the role of the suburbanisation of socioeconomically deprived and Asia-born populations, known to have higher rates of risk behaviours such as tobacco, alcohol, and betel/areca consumption. Specifically, betel/areca consumption among Asia-born populations is suspected to be a primary driver of the observed geographical shift in incidence from urban cores to suburban neighbourhoods. We suggest that such geographically-informed findings are complementary to potential and existing place-specific cancer control policy and targeting prevention efforts for high-risk sub-populations, and call for the supplementation of epidemiological studies with high-resolution mapping and geospatial analysis.

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Article
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Canadian Research Ethics Board Members’ Attitudes Toward Benefits From Clinical Trials

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2015
Abstract: 

Background

While ethicists have for many years called for human subject trial participants and, in some cases, local community members to benefit from participation in pharmaceutical and other intervention-based therapies, little is known about how these discussions are impacting the practice of research ethics boards (REBs) that grant ethical approval to many of these studies.

Methods

Telephone interviews were conducted with 23 REB members from across Canada, a major funder country for human subject research internationally. All interviews were digitally recorded and transcribed verbatim. After coding, the data was analyzed to identify central themes and topics. Themes were identified, application of the themes was confirmed, and these themes were then used to populate the findings of this manuscript.

Results

Our analysis of the interviews identified two primary themes when considering what benefits are owed to research participants and their communities. 1) Most study participants felt that given that these studies are led by persons in the role of researcher rather than health care provider, they had a limited obligation to provide benefits to study participants. 2) These REB members were all working in Canada, a high income country where most residents enjoy high levels of access to health care. As a result of this context, the study participants tended to focus on ethical concerns including obtaining informed consent and avoiding undue inducement to participate in research rather than ensuring that study participants directly benefit from successful trials.

Conclusions

Research on REB members’ attitudes toward what benefits are owed to study participants and community members is needed in other countries in order to determine how context affects these attitudes.

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Article
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Factors Associated With the Frequency of Monitoring of Liver Enzymes, Renal Function and Lipid Laboratory Markers Among Individuals Initiating Combination Antiretroviral Therapy: A Cohort Study

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2015
Abstract: 

Background

As the average age of the HIV-positive population increases, there is increasing need to monitor patients for the development of comorbidities as well as for drug toxicities.

Methods

We examined factors associated with the frequency of measurement of liver enzymes, renal function tests, and lipid levels among participants of the Canadian Observational Cohort (CANOC) collaboration which follows people who initiated HIV antiretroviral therapy in 2000 or later. We used zero-inflated negative binomial regression models to examine the associations of demographic and clinical characteristics with the rates of measurement during follow-up. Generalized estimating equations with a logit link were used to examine factors associated with gaps of 12 months or more between measurements.

Results

Electronic laboratory data were available for 3940 of 7718 CANOC participants. The median duration of electronic follow-up was 3.5 years. The median (interquartile) rates of tests per year were 2.76 (1.60, 3.73), 2.55 (1.44, 3.38) and 1.42 (0.50, 2.52) for liver, renal and lipid parameters, respectively. In multivariable zero-inflated negative binomial regression models, individuals infected through injection drug use (IDU) were significantly less likely to have any measurements. Among participants with at least one measurement, rates of measurement of liver, renal and lipid tests were significantly lower for younger individuals and Aboriginal Peoples. Hepatitis C co-infected individuals with a history of IDU had lower rates of measurement and were at greater risk of having 12 month gaps between measurements.

Conclusions

Hepatitis C co-infected participants infected through IDU were at increased risk of gaps in testing, despite publicly funded health care and increased risk of comorbid conditions. This should be taken into consideration in analyses examining factors associated with outcomes based on laboratory parameters.

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Article
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