Research Pillar: Health Services

Improving health equity through cross-cultural collaboration: Learning from Indigenous-developed programs to strengthen public health systems in preventing the harms of substance use in BC

A function of public health systems and services is to reduce health inequities. The harms of substance use impact British Columbians differently based on their social position and access to resources. Over the last decade, BC has had renewed interest in health equity as demonstrated by several key policy documents. Initial research findings however, have demonstrated that the application of a health equity lens is a challenge for public health decision makers and practitioners. However, for many public health service providers, First Nations and Aboriginal health organizations and service providers are seen as leaders in the understanding and application of health equity principles.

Accordingly, there is an immense opportunity in BC for collaboration and learning with First Nations and Aboriginal health partners to optimize health equity for all British Columbians. Despite these opportunities, little is known about the synergies between Indigenous knowledge and health equity strategies related to the reduction of harms of substance use in BC. In particular, more research is needed to understand if Indigenous approaches to health and wellness can be imported into the current BC public health system and to  explore how Indigenous-developed programs and services can inform health equity strategies related to reducing the harms of substance use in BC public health systems and services.

This research project will be one of the first to systematically examine how health equity strategies in the BC public health system could benefit from Indigenous knowledge and worldviews. This project has the potential to impact the health of all British Columbians by informing the development of more equitable health programs and services. In addition, by prioritizing Indigenous ontologies and processes, this project also has implications for how Aboriginal communities in BC are perceived and esteemed, thereby having the potential also to specifically improve the well-being of those communities. In addition, this prioritization has the potential to mitigate epistemological colonialism and shift power relations which are integral in promoting health equity for Indigenous peoples.

Dr. Shahram received a 2017 Health Policy Fellowship to promote Indigenous health in BC’s southern interior by integrating cultural safety and health equity assessments into the fabric of the Interior Health. Her 2016 Trainee Award will placed on hold during her health policy fellowship assignment.

CALOR: Cooling Autoinflammation with cLinically Oriented Research

MSFHR/Cassie and Friends Society for Children with Juvenile Arthritis and Other Rheumatic Diseases Scholar Award

Childhood rheumatic diseases such as juvenile arthritis, lupus, vasculitis and fever syndromes are the most common childhood chronic illnesses. In Canada, the diseases affect approximately 10,000 children and youth. The affected children have recurrent attacks of inflammation in joints, muscles, and critical organs due to inappropriate activation of blood cells and molecules in the immune system.  Some rheumatic diseases are life- or organ-threatening and all have significant potential for lifelong poor health and disability. There are no cures and few treatments that are specific and safe for a growing child.

This project, CALOR (Cooling Auto-inflammation with CLinically Oriented Research), aims to develop ways to better measure inflammation in these diseases, especially low levels of inflammation that, if present, may justify continuation or re-starting of therapy to stave off an inflammatory attack. The project uses advanced informatics and a systems biology approach, including novel cellular phenotyping of first responder cells of the innate immune system, to find markers of inflammation.

Project outcomes may include sensitive measures of subclinical inflammation that better direct treatment decisions for children with a rheumatic disease. Central to the approach is early engagement of clinicians and patients to establish research priorities, to connect affected families with each other, and ultimately to identify ways to support BC family doctors so that ongoing patient care can be close to home. The CALOR project is founded on a recently developed Canadian Auto-inflammation Disease Registry and a nucleus of invested clinicians, researchers and families at BC’s Children’s Hospital.

End of Award Update: September 2022

Most exciting outputs

The major goal of our research program is to improve the lives of children with rare diseases that cause inflammation in the bones, muscles and joints. Vasculitis is one of these diseases caused by inflammation in the blood vessels of major organs. This is a very rare disease in children, affecting approximately 1 in 250,000 children. One of the exciting things that we have been able to do is create the largest database of clinical information (from over 600 affected kids) and frozen samples (from over 250 affected kids) that allows us to do meaningful studies on this disease. Before this, studies described no more than 25 children with vasculitis. Even more exciting, we were able to identify nine children that were originally diagnosed with vasculitis but had a newly discovered (as of 2014) disease, called DADA2. This is important because the treatment for vasculitis and for DADA2 is different.

Impacts so far

The Michael Smith Health Research BC/ Cassie and Friends Society Scholar Award has given us the opportunity to develop a connection with Cassie + Friends Society, a national organization dedicated to advancing research, information, connection and support for children living with a rheumatic disease. This relationship has helped shape our research program (are we asking research questions that are meaningful to patients and families?) and educated our trainees about the challenges for families and patients in everyday life and as part of a research study. In the lab, we have established two tests to help physicians diagnose two rare childhood syndromes, called DADA2 and ‘Type I Interferonopathy (Type 1 IFN). Kids with these diseases benefit from particular biologic therapy, therefore, it is important that they get diagnosed and started on the correct treatment as soon as possible. In the first two years that we offered these tests, we were consulted up to three times monthly and proceeded with testing for 20 children from around the province who were referred to various subspecialties at British Columbia Children’s Hospital. Results of our testing was conclusive in all but one case, affirming the suspected disease in five cases, and supporting a change in treatment for six patients.

Potential future influence

Since 2015, we have had 42 aspiring researchers, from high school students through to postdoctoral fellows, contribute to our program of research. For the vast majority, this was their first exposure to patient-oriented research in a health care setting, and in the study of rheumatic diseases that affect children. Our alumni have pursued a variety of academic and health related careers, and we trust that in those pursuits they will share their knowledge and experience with others in order to generate continued support and enthusiasm for patient-centric studies, especially rare diseases that affect children.

 

Next steps

The Michael Smith Health Research BC/ Cassie and Friends Society Scholar Award has allowed us to build a solid foundation of infrastructure, resources, and key collaborations with Cassie + Friends Society and the Rheumatology Health Care Team at BC Children’s Hospital. We have secured new funding from the Canadian Institutes of Health Research and the (US) National Institutes of Health to continue to advance our understanding of rheumatic diseases in a way that will improve the lives of affected children.

 

Useful links

Respiratory Evaluation Sciences Program: Innovations in analytic approaches to improve efficiency in respiratory care

Asthma and chronic obstructive pulmonary disease (COPD) are among the most prevalent chronic diseases in Canada. This research program aims to improve patient outcomes and the efficiency of health care delivery in chronic respiratory diseases like asthma and COPD. The outputs of this research program will help enable evidence-informed decision making at all levels of care.

I analyze existing health data to gain insight into disease burden and gaps in care. I also perform economic evaluations that translate such knowledge into policy-relevant messages on cost-effectiveness of interventions, programs, and policies. Together, these components complete a logical pathway from answering "how big the problem is", to "what the available options are to tackle the problem", and to "what intervention provides the best health value for the resources it consumes".

The project that showcases this program of research is the Evaluation Platform in COPD (EPIC). Through this project, I am leading a pan-Canadian team of experts to develop a computer model of COPD that can be used to predict the outcomes of interventions and policies. EPIC will be capable of modeling the health and cost consequences of many different interventions along the entire pathway of care for COPD (e.g. smoking cessation programs, treatments for COPD, providing better community care, etc.).

Knowledge translation activities through this program will be aimed at raising awareness and usage of analytical decision making in resource allocation. This will be approached through a policy-practice-research partnership, an ongoing interaction between policy makers, best practice experts, and my research team. An established patient advisory committee is ensuring my research remains patient-oriented.

By improving our ability to make evidence-informed decisions at multiple levels of care, this program aims to provide a lasting benefit to the health of Canadians with lung disease and the efficiency of our healthcare system.

Responding to HIV and other blood-borne pathogens among people who use illicit drugs

The intertwined pandemics of addiction and HIV/AIDS remain a public health crisis. Among people who use drugs, a substantial number live with HIV/AIDS and many experience suboptimal treatment outcomes.

Efforts to control the spread of HIV/AIDS through scale-up of HIV testing and treatment has been shown to be effective in the general population. However, the strategy has yet to be fully evaluated among groups of people who use drugs. To control the spread of HIV/AIDS in these groups most effectively, more information is needed about the effects on them of social/ structural exposures such as criminalization, marginalization and impoverishment.

This five-year program aims to produce scientific evidence to improve the health of people who are addicted to illicit drugs by targeting the associated blood-borne infections, in particular HIV and hepatitis C, along the following framework:

  1. Identifying modifiable social/structural and environmental barriers to optimal outcomes for HIV and hepatitis C treatment, informed by the risk environment framework. 
  2. Modelling model social/ structural and environmental factors that affect HIV viral load and new HIV infections at the community level, in the context of BC's province-wide HIV treatment-as-prevention effort.
  3. Evaluating the effects on outcomes of HIV treatment of various aspects of the local healthcare systems, such as harm-reduction-based outpatient ART adherence support interventions, using causal inference approaches.
  4. Evaluating the uptake and effectiveness of DAA and identifying barriers to successful treatment among drug users infected with both HIV and hepatitis C.

The ultimate goal is to control the spread of HIV/AIDS and improve the health of British Columbians by combining clinical and social epidemiologic approaches to identify the social-structural drivers of ill health and effective evidence-based healthcare interventions.

A Research Program to Ensure the Effective Delivery of Substance Use Treatment Across Acute and Community Care Settings

Substance use disorders are a major contributor to preventable illness and death, including HIV and hepatitis C infection. An effective response to this public health crisis depends on using evidence-based practices in acute and community care settings (addiction health care) to understand factors that influence access to health services and people’s drug use.

This program examines health care and substance use through three interconnected lines of inquiry:

  1. Collaborating with peer-based support organizations in the community to explore social, structural, and physical influences shaping access to and engagement with substance use treatment.
  2. Employing implementation science approaches to examine individual, social, and structural influences on the uptake of evidence-based practices in addiction health care through examining a) local and regional implementation of newly released regional guidelines for the clinical management of opioid dependence, and b) the recent integration of evidence-based practices in addiction health care in a range of settings.
  3. Examining the perspectives and experiences of people who use drugs in relation to evidence-based practices in addiction health care and the impacts of these practices upon a) substance use treatment access and retention; b) addiction health services access and engagement, including HIV and hepatitis C treatment; and c) overdose risks.

Ultimately, this project seeks to integrate community-based and implementation science approaches to inform how we can increase the responsiveness of substance use treatment programs to the needs of people who use drugs and of health care professionals.

Integrating HCV and addiction treatment to improve individual and population HCV outcomes among people who inject drugs

Hepatitis C (HCV) remains a significant challenge that affects an estimated 60,000 British Columbians. Many more, in particular, people who inject drugs (PWID), remain highly vulnerable to HCV infection. Recently, there have been dramatic developments in the treatment of HCV with the arrival of direct acting antivirals (DAAs). These drug regimens are highly effective, offering vastly superior cure rates over past HCV treatments. Interferon-free regimens with DAA-based regimens are also simpler and better tolerated. While there is immense optimism regarding future HCV treatment efforts, concerns remain regarding issues of access, treatment adherence, and potential reinfection following treatment. Further, recent evidence from phylogenetic analyses reveal that the core transmitters of HCV within British Columbia tend to be PWID with active addiction and who remain outside of conventional treatment programs.

Accordingly, there is now a pressing need to optimize the delivery of addiction treatment to ensure the success of HCV treatment in order to reduce HCV-associated morbidity and mortality, prevent forward transmission and protect valuable health resources. Vancouver offers an ideal setting in which to undertake research focused on identifying how to best integrate addiction and HCV treatment efforts. The BC Centre for Excellence in HIV/AIDS (BC CfE) is home to two large ongoing US National Institutes of Health-funded prospective cohort studies of PWID with a HCV prevalence of 90%. The BC CfE is also home to a CIHR and NIH-funded addiction clinical trials network, and is leading efforts to deliver DAAs to marginalized populations, including PWID.

Using prospective cohort methods, this postdoctoral program of research will seek to identify barriers to and facilitators of access and adherence to DAAs, as well as risk factors for HCV reinfection, with a focus on the role that addiction treatment plays in shaping HCV outcomes (e.g., sustained virological response). With the advent of safer and more efficacious HCV treatments, as well as the research infrastructure afforded by the BC CfE, I will be uniquely positioned to undertake innovative research with high potential to improve population health outcomes in British Columbia.

Influence of community rehabilitation services on community reintegration and health utilization after stroke

Stroke is a leading cause of long-term disability in adults, and community reintegration is the pivotal outcome of successful rehabilitation.

Physical and cognitive impairments after stroke impact reintegration of patients into the community and place a burden on caregivers. The current system seeks to address this with health care services aimed at improving physical and cognitive functioning, as well as providing access to information and resources to facilitate improvement. These services are costly, and it is not known if such services benefit community reintegration or could potentially reduce the usage and cost of other health and social services.

The primary purpose of this study is to determine the impact of rehabilitation services on community reintegration and health after stroke.

This study will include 100 community-dwelling stroke patients and their caregivers. They will be assessed at several timepoints following stroke, and the hours and type of community rehabilitation services will be documented within this 12-month period. We will use the framework from the World Health Organization International Classification of Functioning to assess impairments and activity. We will compare the extent of the use and cost of health and social services, community services, and medications used by the patient with their degree of community reintegration.

The study protocol has been reviewed and approved by the local Clinical Research Ethics Board.

The results from this research could help to inform the effective delivery of health care services for stroke survivors.

Mirrored integrated patient practitioner journey mapping for addressing persistent health inequities lived by Aboriginal people in Northern British Columbia

Aboriginal people in northern BC live with persistent health service inequities. This research asks:

  1. What is the current character of the interface between health provision institutions and Aboriginal communities in the rapidly evolving social, cultural and political climate?
  2. In the diverse landscape of Aboriginal communities, what are the common gaps in health services and programs, and how can they be addressed in a holistic way to renew the health and well-being of Aboriginal people and communities?     

Research design heavily incorporating Indigenous methodologies, ways of knowing, and decolonizing methodologies will be used to develop a model for integrated health and a well-being journey mapping integrating both sides of the patient/practitioner interface with specific attention to:

  • Socio-cultural determinants of health.
  • The specific context of Aboriginal communities in urban, rural and remote northern BC.
  • Attention to applied methodologies and Knowledge To Action (KTA), Aboriginal KT (AKT), and integrated Knowledge Translation (iKT) strategies.

This work will:

  • Describe the nature of the current paradigm shift in health services and program provision for Aboriginal communities and identify emerging streams of new vision and work to improve their health and wellbeing.
  • Identify and explore community-driven mechanisms to renew trust at the community-institutional interface and to expand access to culturally safer programs in Aboriginal communities.

The cost effectiveness of personalized medicine: Using a biomarker-driven treatment strategy for Rheumatoid Arthritis

Rheumatoid arthritis is a common lifelong disease. People with the disease suffer swelling and pain as the disease damages their joints. This leads to disabilities that can affect their ability to do day to day tasks in their personal and work lives.

The best way to slow down the damage caused by the disease is to treat it early. There are many different treatments available, but there are many people for whom each of these treatments does not work. New tests are being developed in laboratories to try and understand which treatments are likely to work for each person with the disease. These tests offer the hope that only the people who are likely to benefit from a treatment will be treated, saving money, and giving patients effective treatment earlier. What is not known is whether these tests can actually improve patient outcomes and save costs in real life.

This study plans to estimate the value to patients and the health system of paying for additional tests to determine which treatments people are given and when.

Supporting women’s sexual and reproductive health and rights through Treatment as Prevention: Investigating the impact of structural and interpersonal violence on HIV and reproductive health inequities among women living with HIV in British Columbia

BC's ambitious "90-90-90" target for 2020 aims to ensure that: 1) 90 percent of people living with HIV/AIDS are aware of their status; 2) 90 percent of those diagnosed receive sustained treatment; and 3) 90 percent of those being treated achieve viral suppression. Access and uptake from all affected groups in BC would be needed to achieve this. This work aims to identify and study barriers to HIV testing and treatment and reproductive health services (e.g. cervical screening, mammograms, fertility and pregnancy services) among marginalized women living with HIV/AIDS (WLWHA) in BC.

Specific areas of study will include:

  • Investigating the impact on disclosure of HIV status to health care providers and intimate partners of social factors such as:
    • criminalization of drug use and sex work
    • gender-based violence
  • Investigating the spatial distribution and accessibility of sexual and reproductive health services and their impact on reproductive health outcomes (e.g. contraceptive usage, cervical screening, unintended pregnancy)
  • Exploring challenges faced by WLWHA with families, including how caregiving demands and gender-based violence affect treatment access and compliance.

The intended outcome of the work is to recommend improved service delivery methods for HIV testing, treatment and reproductive health care with an ultimate goal of informing policies and programming.