Employing Community-based Participatory Research Approaches to Improve Local Influenza Pandemic Preparedness in Remote and Isolated Canadian First Nations Communities

Background: Public health emergencies, such as influenza pandemics, continue to disproportionately impact Aboriginal Canadians (First Nations, Inuit, and Métis), especially those populations residing in geographically remote areas. Previous influenza pandemic plans reflected inadequacies with regards to addressing the pre-existing inequalities and special needs of Aboriginal Canadians during an influenza pandemic, and this may be attributed to their limited participation during preparedness efforts. Significant barriers hinder the ability of Aboriginal Canadians to effectively participate in preparedness efforts and there is a limited amount of information of how to operationalize their participation. By addressing the identified barriers to participation, community-based participatory research (CBPR) offers a promising framework and strategy to facilitate the effective participation of Aboriginal Canadians in influenza pandemic preparedness efforts. Objectives: The overall objective of this dissertation was to explore the use of CBPR approaches to engage community members in directing how to improve local influenza pandemic preparedness in remote and isolated Canadian First Nations communities. This dissertation consisted of five manuscripts grouped into three overarching studies; all of which employed a CBPR approach. The objectives for Study I were to qualitatively identify the needs and explore the potential of using a collaborative health informatics system (CHIS) to improve the delivery of health care services during an influenza pandemic response while also identifying any perceived barriers of implementing such a system. Study II used a qualitative questionnaire to examine the experiences, perceptions, and recommendations regarding implementing measures to mitigate the effects of an influenza pandemic. Study III was a cross-sectional survey conducted to gain an understanding of the bird harvesting practices and knowledge, risk perceptions, and attitudes regarding avian influenza among subsistence hunters and discussed related implications to future influenza pandemic plans. Methods: The initial needs assessment of Study I involved conducting semi-directed interviews with community-based health care professionals (n=9) residing in three remote and isolated Canadian First Nations communities to explore the use of the CHIS. The second needs assessment of Study I was conducted with one of the initial three study communities and involved semi-directed interviews and focus groups with community-based health care professionals (n=16). Questions were specifically developed to further explore issues that emerged from the initial needs assessment. Interviews were transcribed verbatim and open, axial, and selective coding were used to create the emerging concepts and categories. Study II involved conducting interviewer-administered questionnaires with community-based health care professionals (n=9) residing in three remote and isolated Canadian First Nations communities to explore the experiences, perceptions, and recommendations regarding forty-one mitigation measures. The collected qualitative data were transcribed verbatim and deductively analyzed following a template organizing approach. The cross-sectional survey of Study III was conducted with subsistence hunters (n=106) residing in a remote and isolated First Nations community. The survey employed twenty closed-ended questions related to bird harvesting practices, knowledge, risk perceptions, and attitudes about hunting influenza-infected birds. Two open-ended questions allowed for participants to describe their risk perceptions of avian influenza as well as any additional concerns. Simple descriptive statistics, cross-tabulations, and analysis of variance (ANOVA) were used to examine the distributions and relationships between variables. Written responses were transcribed verbatim and deductively analyzed following a template organizing approach. Results: For the initial needs assessment of Study I, the fifty-five emerging concepts were organized into five categories, including: general issues, potential benefits, potential uses, useful technical functions and suggested technical modifications, and concerns. Participants stated that the CHIS could improve the delivery of health care services by tracking and mapping the occurrence of disease outbreaks, along with facilitating communication and health information sharing between the involved health care organizations. Some concerns of the CHIS were noted, namely the concern of accessibility safeguards considering that confidential health information would be inputted, stored, and presented. For the second needs assessment of Study I, one hundred and thirty eight emerging concepts were organized into four overarching categories, including: level of intra- and inter-government agency communication and collaboration, health information sharing within and between government agencies, patient charting and reporting, and solutions. It was noted that having different jurisdictions responsible for providing health care services hindered the ability to share patient’s health information and provide quality health care. Participants stated that the CHIS could potentially be utilized to help manage a response by facilitating inter-agency communication, collaboration, and health information sharing. For Study II, participants reported that thirty mitigation measures were used during their response to the 2009 H1N1 influenza pandemic (A(H1N1)pdm09). Although participants reported that most measures were modified or altered when being implemented to address the unique characteristics of their communities. All of the mitigation measures implemented during A(H1N1)pdm09 were considered to be effective, along with three measures that were not used and one additional measure suggested by a participant. Measures were considered to be effective particularly if the measure aided in decreasing virus transmission, protecting their high-risk population, and increasing community awareness about influenza pandemics. Participants reported that lack of resources, minimal community awareness, overcrowding in homes, and inadequate health care infrastructure hindered the implementation of some mitigation measures. The list of community-informed recommended mitigation measures created from the collected data revealed many discrepancies when compared to national recommendations and existing literature. For Study III, the findings indicated that subsistence hunters partook in some practices while harvesting wild birds that could potentially expose them to avian influenza, although appropriate levels of compliance with some protective measures were reported. More than half of the respondents were generally aware of avian influenza, with fewer being aware of key signs and symptoms, and almost one third perceived a risk of becoming infected with avian influenza while harvesting birds. Participants aware of avian influenza were more likely to perceive a risk of being infected with avian influenza while harvesting birds. The results suggested that knowledge of avian influenza positively influenced the use of a recommended protective measure. Regarding attitudes about hunting influenza-infected birds, the results revealed that the percentage of hunters who would cease harvesting birds increased as avian influenza was detected in birds in more nearby geographic areas. Conclusions: Study I highlighted that the CHIS was viewed as being a useful and valuable tool to improve the delivery of health care, among other potential functions, during an influenza pandemic response. Study II highlighted the perceived barriers to implementing nationally recommended mitigation measures and supports the notion of recommending pandemic control strategies in remote and isolated Canadian First Nations communities that may not be supported in other communities. And Study III revealed a need for more education that is culturally-appropriate about avian influenza and precautions First Nations subsistence hunters can take to reduce the possibility of being exposed to avian influenza while harvesting wild birds. Moreover, the inclusion of First Nations subsistence hunters as an avian influenza risk group with associated special considerations in future influenza pandemic plans seems warranted. In general, the three overarching studies of this dissertation display the importance and value of employing CBPR approaches to engage locally impacted populations in improving influenza pandemic preparedness. The CBPR processes used and findings revealed throughout this dissertation can be used to inform future influenza pandemic preparedness efforts to improve the response capacity and health outcomes of Canadian First Nations residing in remote and isolated communities during the next influenza pandemic

The 2009 H1N1 Health Sector Pandemic Response in Remote and Isolated First Nation Communities of Sub-Arctic Ontario, Canada

On June 11, 2009, the World Health Organization declared a global influenza pandemic due to a novel influenza A virus subtype of H1N1. Public health emergencies, such as an influenza pandemic, can potentially impact disadvantaged populations disproportionately due to underlying social factors. Canada’s First Nation population was severely impacted by the 2009 H1N1 influenza pandemic. Most First Nation communities suffer from poor living conditions, impoverished lifestyles, lack of access to adequate health care, and uncoordinated health care delivery. Also, there are vulnerable populations who suffer from co-morbidities who are at a greater risk of falling ill. Moreover, First Nation communities that are geographically remote (nearest service center with year-round road access is located over 350 kilometers away) and isolated (only accessible by planes year-round) face additional challenges. For example, transportation of supplies and resources may be limited, especially during extreme weather conditions. Therefore, remote and isolated First Nation communities face unique challenges which must be addressed by policy planners in order to mitigate the injustice that may occur during a public health emergency. The Assembly of First Nations noted that there has been very little inclusion of First Nations’ input into current federal and provincial pandemic plans. Disadvantaged groups know best how they will be affected by a public health emergency and are able to identify barriers and solutions. Therefore, the objective of my research was to gain retrospective insight into the barriers faced by three remote and isolated First Nation communities of sub-arctic Ontario (i.e., Fort Albany, Attawapiskat, and Kashechewan) during their 2009 H1N1 pandemic response. Culturally-appropriate community-based suggestions for improvement of existing community-level pandemic plans were also elicited. Collected data informed modifications to community-level pandemic plans, thereby directly applying research findings. Being a qualitative community-based participatory study, First Nation community members were involved in many aspects of this research. Semi-directed interviews were conducted with adult key informants (n=13) using purposive sampling of participants representing the three main sectors responsible for health care services (i.e., federal health centers, provincial hospitals, and Band Councils). Data were manually transcribed and coded using deductive and inductive thematic analysis to reveal similarities and differences experienced within and between each community (and government body) regarding their respective pandemic response. Another round of semi-directed interviews (n=4) and community pandemic committee meetings were conducted to collect additional information to guide the modifications to the community-level pandemic plans. Reported barriers due to being geographically remote and isolated included the following: overcrowding in houses, insufficient human resources, and inadequate community awareness. Primary barriers faced by government bodies responsible for health care delivery were reported as follows: receiving contradicting governmental guidelines and direction from many sources, lack of health information sharing, and insufficient details in community-level pandemic plans. Suggested areas for improvement included increasing human resources (i.e., nurses and trained health care professionals), funding for supplies, and community awareness. Additionally, participants recommended that complementary communication plans should be developed. As suggested by participants, community-specific information was added to update community-level pandemic plans. Remote and isolated First Nation communities faced some barriers during their 2009 H1N1 health sector pandemic response. Government bodies should focus efforts to provide more support in terms of human resources, monies, and education. In addition, various government organizations should collaborate to improve housing conditions, timely access to resources, and the level of coordination regarding health care delivery. Furthermore, as pandemic plans are dynamic, government bodies should continue to aide First Nation communities with updating their community-level pandemic plans to satisfy their evolving needs. These recommendations should be addressed so that remote and isolated western James Bay First Nation communities and other similar communities can be better prepared for the next public health emergency.1 yea

Designing Assignments to Establish a Foundation for Evidenceâ Based Practice in an Undergraduate Clinical Nursing Course

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/142903/1/wvn12198.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142903/2/wvn12198_am.pd

Recommended Mitigation Measures for an Influenza Pandemic in Remote and Isolated First Nations Communities of Ontario, Canada: A Community-Based Participatory Research Approach

Influenza pandemics disproportionately impact remote and/or isolated Indigenous communities worldwide. The differential risk experienced by such communities warrants the recommendation of specific mitigation measures. Interviewer-administered questionnaires were conducted with adult key health care informants from three remote and isolated Canadian First Nations communities of sub-Arctic Ontario. Forty-eight mitigation measures (including the setting, pandemic period, trigger, and duration) were questioned. Participants’ responses were summarized and collected data were deductively and inductively coded. The participants recommended 41 of the questioned mitigation measures, and often differed from previous literature and national recommendations. Results revealed that barriers, such as overcrowded housing, limited supplies, and health care infrastructure, impacted the feasibility of implementing mitigation measures. These findings suggest that pandemic plans should recommend control strategies for remote and isolated Canadian First Nations communities that may not be supported in other communities. These findings highlight the importance of engaging locally impacted populations using participatory approaches in policy decision-making processes. Other countries with remote and/or isolated Indigenous communities are encouraged to include recommendations for mitigation measures that specifically address the unique needs of such communities in an effort to improve their health outcomes during the next influenza pandemic

Health care experiences of mothers of children with bronchiectasis in Counties Manukau, Auckland, New Zealand

Abstract Background Bronchiectasis is a worsening public health problem in New Zealand. This study aimed to explore the health care experiences of mothers of children with bronchiectasis in the Counties Manukau District Health Board area of Auckland, New Zealand. Methods Semi-structured interviews were undertaken with ten mothers of children with bronchiectasis. Data were analysed using thematic analysis. Results Five themes emerged: 1) Searching for answers, describing mothers’ search for a diagnosis; 2) (Dis)empowerment, describing mothers’ acquisition of knowledge, leading to empowerment; 3) Health care and relationships, describing the impact of relationships on the mother’s health care experiences; 4) A juggling act, describing the challenges of juggling health care with school, work and family; 5) Making it work, describing how mothers overcome barriers to access health care for their child. Conclusions The health provider-parent relationship was crucial for fostering positive health care experiences. Mothers’ acquisition of knowledge facilitated empowerment within those relationships. Additionally, mothers’ perceptions of the quality and benefit of health services motivated them to overcome barriers to accessing care. Study findings may help to improve health care experiences for parents of children with bronchiectasis if identified issues are addressed

Childhood vaccination uptake among children born in Aotearoa New Zealand based on parental nationality

Migrants and refugees generally experience immunization inequities compared to their host populations. Childhood vaccination coverage rates are influenced by a complex set of interrelated factors, including child and parental nativity. Coverage rates for MMR, pertussis, and HPV vaccines were compared among children born in Aotearoa New Zealand (NZ) of overseas-born parents or NZ-born parents. A nationwide retrospective cohort study was conducted using linked, de-identified data. Logistic regression models examined the most influential factors contributing to differences in timely vaccine uptake. Of the total study population who had received all scheduled vaccines (N = 760,269), 32.9% were children of migrant parents. Children of migrant parents had higher rates of complete and timely uptake for MMR, pertussis, and HPV vaccinations compared to non-migrant children. NZ-born children of migrant parents were significantly more likely to receive MMR and pertussis-containing vaccines on-time compared to those of non-migrants. All included factors, except for the child’s gender and parents’ English ability, significantly influenced vaccine uptake. Among NZ-born children of migrant parents, additional logistic modeling found significant differences based on parental duration of residence, visa group, and region of nationality. Findings point to the importance of differentiating between parent versus child nativity when examining immunization coverage. While vaccination rates were higher for NZ-born children of migrant parents, compared to non-migrant parents, timely coverage rates across both groups were below national targets. Continued efforts are needed to improve timely immunization service delivery to address suboptimal and inequitable coverage

Vaccine hesitancy and its determinants among refugee parents resettled in Aotearoa New Zealand

Vaccine hesitancy is an important factor underpinning suboptimal vaccine uptake and evidence on marginalized subgroups, such as refugees, is limited. This cross-sectional survey was conducted in 2020/21 with former refugee parents who resettled in Aotearoa New Zealand (NZ). The Parent Attitudes about Childhood Vaccines (PACV) was offered in Somali, Oromo, Arabic, and English languages, and the reliability of the four versions were evaluated. The prevalence of parental vaccine hesitancy was explored and the association between vaccine hesitancy and sociodemographic factors was examined using logistic regression. One hundred and seventy-eight responses were included in the analysis. The Cronbach’s alpha scores for Somali, Oromo, Arabic, and English PACV were 0.89, 0.64, 0.53, and 0.77, respectively. The rate of parental vaccine hesitancy was 16.3%, 95% CI (10.7, 21.3). Most caregivers were concerned about vaccine side effects (47%), safety (43%), and efficacy (40%). Less than a quarter (21%) of parents had delayed their child receiving a vaccine and 12% had refused to vaccinate their child for reasons other than medical exemptions. After adjusting for covariate/s, parents’ primary source of information and education status were significantly associated with vaccine hesitancy. Media as a primary source of vaccine information and low education status were associated with higher vaccine hesitancy. Vaccine hesitancy is relatively low among former refugees and is influenced by modifiable factors, including educational level and primary source of vaccine information. Vaccine information tailored to former refugee parents’ concerns are required to reduce vaccine hesitancy and improve vaccine uptake

The challenges and opportunities of translating best practice immunisation strategies among low performing general practices to reduce equity gaps in childhood immunisation coverage in New Zealand

Abstract Background Immunisation coverage rates vary considerably at the local level across New Zealand and challenges remain with effectively translating best available research evidence into public health practice. This study aimed to translate best practices from high performing general practices into strategies to improve childhood immunisation coverage among low performing practices. Methods An intervention study was undertaken of general practices with low immunisation coverage rates and a high percentage of the enrolled population being of Māori ethnicity. Intervention groups received customised action plans and support for a 12 month period while control groups received ‘business as usual’ support. Structured interviews were conducted with key informants from all participating practices to understand current aspects related to childhood immunisation delivery and surveys were conducted to understand how the intervention worked. Collected data were thematically analysed. Results Ten sites were randomised to either intervention (n = 6) or control group (n = 4). Positive aspects of childhood immunisation delivery included high prioritisation at the practice and staff being pro-immunisation and knowledgeable. Key challenges experienced included inaccurate family contact information and discrepancies with referral processes to other providers. Other challenges noted were building rapport with families and vaccine hesitancy. The action plans included various strategies aimed to improve processes at the practice, contact and engagement with parents, and partnership development with local service providers. Conclusions Creating customised action plans and providing support to providers were considered as helpful approaches when attempting to improve childhood immunisation coverage rates. Our study supports the notion that one strategy will not solely by itself improve childhood immunisation rates and highlights the importance of having a toolkit of strategies from which to draw from

Exploring immunisation inequities among migrant and refugee children in New Zealand

Migrants may experience immunisation inequities compared with the host population related to barriers with accessing immunisations in their home countries, while migrating and/or post-arrival. This retrospective cohort study explored vaccination rates among migrant and non-migrant children in New Zealand (NZ). Linked de-identified data from various government sources from 1 January 2006 to 31 December 2015 were analysed using Statistic NZ’s Integrated Data Infrastructure. Vaccination rates were compared between three cohorts of children aged up to 5 years: foreign-born children who migrated to NZ; children born in NZ of migrant mothers; and a comparator group of children born in NZ to non-migrant mothers. Less than half of foreign-born children (46%) had a record in the NZ National Immunisation Register compared with 95% and 96% among migrant and non-migrant NZ-born children, respectively. Foreign-born migrant children had lower age-appropriate reported vaccination rates by vaccine of interest, ethnicity and visa category compared with NZ-born children. Migrant children from Pacific ethnicities had lower reported coverage than other ethnicities. High rates of not age-appropriately vaccinated were noted among foreign-born children on refugee, Pacific and humanitarian visa schemes. This study highlights possible shortfalls around immunisation data, particularly about recording vaccinations given overseas for foreign-born children, and potential challenges around engagement with immunisation services for migrant children. However, results highlight the successful engagement of quota refugee children as part of NZ’s refugee orientation programme. It is important to monitor vaccination coverage by migrant and refugee background to inform improvements to policy and practice for wider population health benefits

Bird harvesting practices and knowledge, risk perceptions, and attitudes regarding avian influenza among Canadian First Nations subsistence hunters: implications for influenza pandemic plans

Abstract Background There is concern of avian influenza virus (AIV) infections in humans. Subsistence hunters may be a potential risk group for AIV infections as they frequently come into close contact with wild birds and the aquatic habitats of birds while harvesting. This study aimed to examine if knowledge and risk perception of avian influenza influenced the use of protective measures and attitudes about hunting influenza-infected birds among subsistence hunters. Methods Using a community-based participatory research approach, a cross-sectional survey was conducted with current subsistence hunters (n = 106) residing in a remote and isolated First Nations community in northern Ontario, Canada from November 10–25, 2013. Simple descriptive statistics, cross-tabulations, and analysis of variance (ANOVA) were used to examine the distributions and relationships between variables. Written responses were deductively analyzed. Results ANOVA showed that males hunted significantly more birds per year than did females (F1,96 = 12.1; p = 0.001) and that those who hunted significantly more days per year did not perceive a risk of AIV infection (F1,94 = 4.4; p = 0.040). Hunters engaged in bird harvesting practices that could expose them to AIVs, namely by cleaning, plucking, and gutting birds and having direct contact with water. It was reported that 18 (17.0%) hunters wore gloves and 2 (1.9%) hunters wore goggles while processing birds. The majority of hunters washed their hands (n = 105; 99.1%) and sanitized their equipment (n = 69; 65.1%) after processing birds. More than half of the participants reported being aware of avian influenza, while almost one third perceived a risk of AIV infection while harvesting birds. Participants aware of avian influenza were more likely to perceive a risk of AIV infection while harvesting birds. Our results suggest that knowledge positively influenced the use of a recommended protective measure. Regarding attitudes, the frequency of participants who would cease harvesting birds was highest if avian influenza was detected in regional birds (n = 55; 51.9%). Conclusions Our study indicated a need for more education about avian influenza and precautionary behaviours that are culturally-appropriate. First Nations subsistence hunters should be considered an avian influenza risk group and have associated special considerations included in future influenza pandemic plans