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Features
Understanding how Socioeconomic and Environmental Factors Contribute to Asthma Risk and Treatment in Children
By Nayaab Punjani
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Asthma is an inflammatory lung condition that affects one in four Canadian children.1,2 Certain triggers may increase the incidence of asthma attacks - which involve wheezing and shortness of breath - resulting in hospital admissions.1 Currently, 2.3 million Ontarians are diagnosed with asthma, with 50 000 new cases in 2020 alone.2
These statistics prompted Dr. Teresa To’s research pursuit into the epidemiology of respiratory diseases, with an emphasis on childhood asthma. Dr. To is currently a professor of Biostatistics and Epidemiology at the Dalla Lana School of Public Health with an IMS cross-appointment. She is a Senior Scientist in the Department of Child Health Evaluative Sciences at The Hospital for Sick Children, while also serving as a Senior Adjunct Scientist for ICES, an organization that compiles databases examining patterns of healthcare access and use in Ontario.
When Dr. Teresa To was first hired by ICES, no one was focused on pediatrics, so Dr. To partnered with The Hospital for Sick Children to study the conditions responsible for hospital admissions. While examining the data from emergency department admissions, she mentions, “One of the top reasons for children being admitted, was asthma…I repeated my analysis to ensure findings were accurate, and it came out the same and it sort of blew my mind, why would kids, even in the late 90s… be admitted for something so treatable?” Over the years she realized the situation is quite complex, requiring consideration of social determinants and access to Canada’s healthcare system.
Dr. To’s research began through the examination of asthma epidemiology to understand factors relating to the incidence of cases, hospital admissions, and causes of death. Dr. To features findings of this research in a website known as OASIS–the Ontario Asthma Surveillance Information System (https://lab.research.sickkids.ca/oasis/).
Dr. To found that one of the key factors contributing to asthma is socioeconomic status. Despite having universal health care access in Canada, we do not have a universal drug plan. She explains,
involvement as a Tier 1 Canada Research Chair for Asthma, and a Lead for the Environmental Health Platform of the Canadian Respiratory Research Network. The environmental focus of her work aims to examine the influence of air pollution on the exacerbation of asthma symptoms. One of her published studies found that when exposed to air pollutants, people with asthma were three times more likely to develop chronic obstructive pulmonary disease (COPD), also known as asthma-COPD overlap syndrome (ACOS), which is associated with worsened lung functioning and a significantly higher need for health care services.3
For children, Dr. To aimed to study early life exposures to air pollution and lung health, as the lungs continue to mature until the early 20s. Early life exposure to pollutants - such as nitrogen dioxide and ozone - resulted in a 17% elevation in the risk of asthma development among a cohort of newborns that were followed for an average of 17 years.4 Therefore, Dr. To suggests that being aware of the conditions of the ambient environment (such as air quality level and temperature) will help guide the time and level of outdoor activities. For example, simple lifestyle changes such as avoiding walking with children in high-traffic streets during poor air quality hours, may help protect these children’s delicate immature organs.
Since asthma is a chronic condition, taking medications daily is critical to manage it and prevent asthma attacks. However, people tend to take their medications on an “as-needed” basis. Dr. To aims to help individuals be better informed about asthma and modifiable factors, such as smoking. She employs the use of infographics released via social media to improve outreach and education for youth.
Dr. To also works with health care providers to optimize the quality of care provided to patients. This involves promoting the use of individualized action plans that have three zones—green, yellow, and red. With the red zone indicating severe symptoms and the need to seek emergency medical treatment. She has also developed the Asthma Quality of Care Indicator checklist that ensures consistent quality of care for patients, while also providing doctors with feedback. Furthermore, Dr. To has helped develop a mobile application called BREATHE, which helps patients track their symptoms with a symptom diary and indicates to the user the air pollution levels in the area. There is also a built-in action plan that informs patients the zone (i.e., green, yellow, or red) of their asthma control.
Dr. To’s research involves integrating various techniques and sources of data. This includes statistics generated by linking multiple annual population-level databases housed at ICES, including data on hospital admissions, emergency department visits, outpatient visits, and laboratory testing. She also linked health administrative data to air pollution data obtained from Environment Canada and Health Canada. Through all her research findings, Dr. To aims to advocate for patients and inform the government of the needs of the asthma population. She also joins forces with the Lung Health Foundation every year to lobby at the parliament “for better coverage, for medication, for better care for people with asthma.”
In terms of the future of her research, Dr. To aims to explore a few emerging areas in respiratory health; 1) examine the impact of COVID-19 in people with asthma, 2) better understand and manage severe asthma, 3) focus on the development and progression of asthma in the pediatric population in order to reduce hospitalizations and 4) look at the effect of vaping on the frequency of asthma attacks and exacerbations in younger populations, with funding from the Canadian Institutes of Health Research (CIHR). Her latest findings showed that one in eight e-cigarette users had asthma, and those with asthma had nearly 24% increased odds of having an asthma attack within 12 months. Dr. To hopes to use findings from this research to raise the awareness of the potential harmful health effects of vaping and develop and implement evidence-based strategies to prevent and reduce e-cigarette use, especially in youth.5
Dr. To leaves a few pieces of advice for future graduates and researchers. Regardless of the specific research question that you are trying to answer, it is important to employ an evidence-based approach. Building one’s research foundation based on strong data collection methods, sound analytical tools, and formal research training are all paramount. Furthermore, one needs to appreciate the relevance of “knowledge translation.” Its impact relies on how effective and efficient research findings are translated and transferred to the general public, including patients, health care providers, and the government. “It is not ideal to simply do research and publish papers…that is old school now…it is also our responsibility to pass the findings and information to the public…to the people who need it [and] who can benefit from it,” while also helping contribute to systemic change at the government level.
Dr. Teresa To
Professor in Biostatistics and Epidemiology at the Dalla Lana School of Public Health
Professor at the Institute of Health Policy, Management and Evaluation (IHPME)
Cross appointed Professor with the Institute of Medical Science (IMS)
Senior Scientist, Child Health Evaluative Sciences, The Hospital for Sick Children
Senior Adjunct Scientist ICES/ Scientific Lead from Sick Kids for ICES UofT
Tier 1 Canada Research Chair, Asthma
Lead, Environmental Health Platform, Canadian Respiratory Research Network Associate Editor, Canadian Journal of Respiratory, Critical Care and Sleep Medicine
Photo credit: Dr. To
References
1. Asthma Canada. Understanding Asthma [Internet]. Asthma Canada. [cited 2021 May 25]. Available from: https://asthma.ca/get-help/understanding-asthma/ 2. SickKids. THE ONTARIO ASTHMA SURVEILLANCE SYSTEM (OA-
SIS) [Internet]. OASIS. 2021 [cited 2021 May 25]. Available from: https:// lab.research.sickkids.ca/oasis/ 3. To T, Zhu J, Larsen K, et al. Progression from Asthma to Chronic 4. Obstructive Pulmonary Disease. Is Air Pollution a Risk Factor? Am J
Respir Crit Care Med. 2016 Aug 15; 194(4): 429–38. 5. To T, Zhu J, Stieb D, et al. Early life exposure to air pollution and incidence of childhood asthma, allergic rhinitis and eczema. Eur Respir J. 2020 Feb; 55(2):1900913. 6. To T, Zhang K, Terebessy E, et al. Does Vaping Increase the Odds of Asthma? A Canadian Community Health Survey Study. Session TP16: Clinical and research updates on tobacco cessation, vaping, and e-cigarettes. ATS 2021 International Conference, 14-19 May.
A Population in Flux: Interventions in the Youth Homelessness Space
By Beatrix Wang
Youth aged 13 to 24 comprise roughly 12% of Canada’s populace, but account for 20% of its homeless population.1 This disparity underscores youth homelessness as a major concern within Canada, with young people representing one of its fastest growing homeless populations.2
Though a largely overlooked issue in the past, a growing body of research has recently begun to shed light on the complex, intersecting forces that result in young people experiencing homelessness. Dr. Sean Kidd, Clinical Psychologist, Senior Scientist, and Division Chief of Psychology at the Centre for Addiction and Mental Health (CAMH) and Associate Professor in the Department of Psychiatry, is a leading expert within this space.
“We can sometimes think about youth homelessness as this binary sort of thing,” Dr. Kidd says. “Like there’s a bad situation at home … or a young person has a mental health crisis or a justice interaction, then they’re homeless. And that’s really not how it works for the vast majority. For most, it’s a long trajectory of challenge, marginalization, and interacting problems.” These factors include poverty, discrimination, and intergenerational trauma. Consequently, there is an overrepresentation of 2SLGBTQ+ and Indigenous youth among those experiencing homelessness.
The lack of safe, stable housing has farreaching consequences. Not having an address can prevent individuals from obtaining employment and accessing services. Housing instability can increase the chance of young people being in environments wherein abuse and sex trafficking are risks. Safe housing, furthermore, is a vital determinant of health—both mental and physical—and its absence makes wellness difficult to achieve in innumerable ways.
However, for many, the story does not end when they obtain housing. This was something Dr. Kidd saw firsthand in research performed with colleagues at the University of Dalhousie, which followed the trajectories of 51 youth transitioning out of homelessness for a year.3 The outcomes, to put it mildly, were not good. “It was a very depressing study to run,” Dr. Kidd says. “In that year, we saw about a quarter were street homeless again. And you could count on one hand the number that were flourishing.” For many who retained housing, the team observed continued marginalization, mental health crises, and trouble engaging with work and school.
There was a silver lining to this study, however. These findings, though bleak, demonstrated a need for continued support for youth exiting homelessness, and led Dr. Kidd to embark on a research journey wherein he has worked to develop a critical time intervention called the “Housing Outreach Program Collaboration” (HOP-C).4
With HOP-C, Dr. Kidd and his colleagues are asking an essential question: If youth who have experienced homelessness have difficulty succeeding within the current system, even when they do obtain housing, can their chances of success be increased by intervening in the right ways and at the right time? of homelessness and housing insecurity. “You’ve got a moment,” Dr. Kidd says, “when a young person has some housing, some stability. It’s very precarious. But if you can double down on supports at that transition time, you have a chance of improving their outcomes such that they’re keeping their housing and flourishing more.”
HOP-C, a multi-agency collaboration between CAMH, LOFT Community Services, Covenant House, the Wellesley Institute, and others, combines outreach, case management, peer support, and mental health services in a team-based approach that provides programming for youth in this window of time. Initial pilot and feasibility studies in Toronto showed high levels of engagement and improved short-term outcomes in education, employment, and housing. Dr. Kidd and his colleagues next partnered
DR. SEAN KIDD
Associate Professor in the Department of Psychiatry, Associate Member of IMS, Associate Faculty in the Department of Psychological Clinical Science at the University of Toronto Scarborough
with Lakehead University and Dilico Anishinabek Family Care to co-develop and pilot an extremely successful Indigenous-led HOP-C program in Thunder Bay.
These successes led to a substantial CIHR grant, totalling nearly $1 million, which will fund a fully powered HOP-C randomized control trial in Toronto starting in September 2021. In the largest application of the program yet, over 100 youth will experience the intervention for a year and their outcomes will be followed for six months afterwards.
Part of what has made HOP-C so unique is how it redefines what peer support can be. After seeing the effectiveness of the initial study in Toronto, the team, led by youth with lived experiences of homelessness, wanted to do even more. “Later in the project,” recalls Mardi Daley, a HOP-C peer specialist, “there was the question of, how can we build something? How do we build a product to show what we’ve done in this housing intervention?” With this goal in mind, the team hired HOP-C participants to create something that imparted knowledge that would have helped them at the onsets of their journeys. What resulted was the MY Guide, a 90-page booklet filled with encouragement, tips, recipes, and activities to aid youth transitioning out of homelessness in Toronto and beyond.
This process, which gave participants the opportunity to produce something impactful for their peers, proved to be empowering. “Homelessness is so highly stigmatised, especially for young people, that a lot of them are written off before they’ve even had a chance to try things,” Daley says. “So it’s key to allow them to learn how to be leaders for themselves, to see that they’re capable beyond the stereotypes and limitations of being homeless. Plus, having young people lead younger people shows that you, too, can do this, even if you’ve been homeless; that there’s a future for you after this.”
The guides have since been distributed worldwide, and this concept—youth empowering other youth—has grown into what is now the “By Youth For Youth” (BYFY) Initiative.5 In Thunder Bay, Indigenous young people have developed their own culturally-grounded BYFY guide with consultation from community elders. In Nicaragua, the initiative has taken the form of graffiti art, a hip-hop video, and a theatre piece. More projects are on the horizon as BYFY continues to expand. Owing to such initiatives, significant progress is beginning to be made. Over the course of his career, Dr. Kidd has watched and helped the field shift from its humble beginnings to its current form, which is increasingly rich in policy- and intervention-based research. Much work remains to be done, however. “A whole system’s response is what we need to end ongoing chronic youth homelessness in Canada,” Dr. Kidd says. “And what I’m trying to do is carve out one part of that and really validate, with a good amount of evidence, that one piece of the picture.” The monumental task of ending youth homelessness requires effort on a massive scale to evolve the current system into something less crisis-oriented and more geared towards prevention and continued support for youth. In recent years, this has taken the form of a national coalition called A Way Home Canada, in which dedicated individuals are engaged across a broad range of sectors to make this aim a reality.6 It is in this manner that the field is coming together, engaging policymakers, and bringing about systemwide transformation.
MARDI DALEY
A peer support worker in the HOP-C program and a BYFY initiative leader
Photo credit: Mardi Daley
References
1. Gaetz S, Gulliver T, Richter T. The State of Homelessness in Canada: 2014. In Toronto: The Homeless Hub Press; 2014. 2. Laird G. Shelter: homelessness in a growth economy : Canada’s 21st century paradox : a report for the Sheldon Chumir Foundation for
Ethnics in Leadership [Internet]. Calgary, Alta.: Sheldon Chumir
Foundation for Ethics in Leadership; 2007. Available from: http:// epe.lac-bac.gc.ca/100/200/300/sheldon_chumir_foundation/shelter/
LAIRD_Homelessness_Report.pdf 3. Kidd SA, Frederick T, Karabanow J, et al. A Mixed Methods Study of Recently Homeless Youth Efforts to Sustain Housing and Stability. Child Adolesc Soc Work J. 2016 Jun 1;33(3):207–18. 4. HOP-C: Housing Outreach Program Collaborative [Internet]. The
Homeless Hub. [cited 2021 Jun 26]. Available from: https://www. homelesshub.ca/HOP-C 5. By Youth For Youth Initiative [Internet]. The Homeless Hub. [cited 2021 Jun 13]. Available from: https://www.homelesshub.ca/byyouth-for-youth-initiative 6. A Way Home Canada [Internet]. A Way Home Canada. [cited 2021
Jun 26]. Available from: https://awayhome.ca/
By Sonja Elsaid
“It is like you are an athlete, and you go to being a couch potato.” These are the words commonly heard from patients with osteoarthritis, describing the consequences of their symptoms.
Osteoarthritis (OA) is the most common form of joint disease occurring in the knee, hip, and joints. It is associated with abnormal joint load or injury and the body’s inability to repair joint tissue. As a result, joint tissue breaks down over time, causing inflammation, immobility, and pain. The older we get, the more likely we are to develop OA.1 Research shows that over 23% of people suffer from OA between ages 65-69.2 However, by the time people reach 80 years, a staggering half will be affected.2 Unfortunately, OA has no cure. The current treatment is purely to control the symptoms.1,2
Initially, with mild OA, people start experiencing joint stiffness, and some pain; however, the pain becomes more severe with time, causing functional limitations. Eventually, the walking speed gets slower, going up and down the stairs becomes problematic, and the constant feeling of pain ultimately leads to generalized fatigue and depression.1,3 Avoiding pain and activities causes most patients afflicted with OA to become ‘couch potatoes.’
“But, what if I told you that the very same cause of pain could make the pain go away?” said Dr. Aileen Davis, Professor Emeritus at the Department of Physical Therapy and Surgery, and the Graduate Departments of Rehabilitation Science, Health Policy, Management and Evaluation, and the Institute of Medical Science at the University of Toronto. Contrary to popular belief that movement and exercise could wear out or even cause damage to joints affected by OA, teaching patients how to align their joints properly during exercise could mitigate the joint pain. “It is a paradox! It tells us that when we use proper nutrition, manage our weight and engage in a supervised exercise making the affected cartilage as healthy as possible; we are reducing and not increasing the pain.”
Dr. Davis, who is also recently retired from the Senior Scientist position at the Healthcare and Outcomes Research division of Krembil Research Institute (formerly Toronto Western Research Institute) at the University Health Network, was referring to the outcomes of one of her most notable achievements, which is bringing GoodLife with osteoArthritis in Denmark (GLA: D®) to Canada.
Access to the right type of healthcare programs is one of the most important social determinants of health. GLA:D is an education and targeted exercise program for people with OA of the knee and hip. The program originated from the University of Southern Denmark.3 The idea of implementing such a program in Canada surfaced in 2014 by Dr. Davis — then the Director of Osteoarthritis Research at Bone and Joint Canada, which had a mandate to address a huge gap in provision of social determinants of health to Canadians—a program that addresses conservative management of OA. Given that GLA:D is an evidencedbased program for managing OA, it seemed like a good idea to bring this program to Canada.3
With the help of her colleagues at the Holland Centre at Sunnybrook Hospital, Dr. Davis conducted a pilot study initially testing the program only in Toronto. Subsequently, after receiving a three-year Trillium Foundation grant with Bone and Joint Canada, the research project expanded to include several sites in Ontario and eventually British Columbia and Alberta due to its popularity. As of January 2020, the program is no longer just a research project, but a fully implemented community-based clinical program.
Essentially, GLA:DTM Canada (http:// gladcanada.ca/)3 consists of three main elements. The first element is a certifiable education program for healthcare workers willing to implement the GLA:D program in their practice. Initially taught by Dr. Davis herself across Canada, the course is currently being delivered by knee and hip OA experts to physiotherapists, regulated kinesiologists, and chiropractors.
The second element of the GLA:D program is patient education and exercise. During the two- to three-day education session, patients learn how to keep their OA-affected cartilage as healthy as possible by engaging in proper nutrition and
improving muscle strength to minimize the load to the affected joints.3 “One of the aims of patient education is to help them learn the importance of healthy weight management and how simply losing 5-10 lbs could significantly reduce pain,” Dr. Davis explained.
“The six-to-eight-week supervised exercise program”, continued Dr. Davis, “follows the educational component of GLA:D. Under ordinary circumstances, patients with OA receive a picture with a diagram of the types of exercises they should engage in at home. However, exercising alone may be particularly challenging for those who have never been active. For this reason, GLA:D program offers in-person instruction on exercising correctly during the 12 sessions. The key feature of the exercise program is to supervise the initial stages of learning how to exercise.”
“The third component of the GLA:D program”, emphasized Dr. Davis, “is the quality monitoring part.” At this stage, patient outcomes are evaluated and recorded in the national electronic GLA:D registry. Namely, patient-reported, validated outcome measures and functional tests are assessed at baseline, at three months—after completing the program—and at 12-month follow-up. Among other outcomes, pain, quality of life, and mobility/function are tracked throughout the three-time points.
According to the GLA:DTM Canada outcomes data, significant improvements in functional abilities have been demonstrated by 65% of hip and 73% of knee patients.3 The survey tracked 1,601 patients with hip and 2,774 with knee OA across 209 Canadian sites between 2016 and 2019.3 Moreover, clinically significant improvements in quality of life and walking speed were observed.3
The most striking results were recorded with the 30%-improvement in pain. It was noted that in nearly half of patients with knee and hip OA that pain markedly improved one year after enrolling in the program.3 Furthermore, compared to the baseline, at both three and 12-month timepoints, knee patients indicated using fewer intra-articular injections to manage pain. Significant decreases were also seen in the percentage of patients being afraid of damaging their joints by exercise.3
Overall, the program addresses one of the social determinants of health—improving access to healthcare—as it significantly improved OA patient health outcomes. Although Dr. Davis retired in June 2020, the GLA:D program remains her legacy, passed on to her colleagues at the Schroeder Arthritis Institute, and Bone and Joint Canada to cultivate, expand and evolve it further. During the COVID-19 pandemic, the program has already moved to the online platform to accommodate the mandated social isolation during the lockdown. As for Dr. Davis, many of her former colleagues are enormously grateful that they get to carry on her legacy of showing the world how science can improve lives.
Dr. Aileen Davis
Ph.D. Professor Emeritus at the Department of Physical Therapy and Surgery and the Graduate Departments of Rehabilitation Science, Health Policy, Management and Evaluation, and the Institute of Medical Science at the University of Toronto.
Photo credit: Dr. Davis
References
1. Cramer P and Hochberg MC. Osteoarthritis. Lancet. 1997;350:503-09. 2. Public Health Agency of Canada (PHAC). Osteoarthritis in Canada.
Ottawa (ON): PHAC; 2019 [cited 2021 Jun 01]. Available from:https:// www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases-conditions/osteoarthritis/osteoarthritis-factsheet.pdf 3. Zywiel MG and McGlasson R. GLA:DTM Canada Implementation and Outcomes: 2019 Annual Report. Bone and Joint Canada. [Internet] 2020 June 1 [cited 2021 June 1]. Available from: http://gladcanada.ca/
