Research Pillar: Population Health

Operations research applied to assess different strategies to reduce the public health and economic burdens of HIV/AIDS in British Columbia

Although traditional HIV prevention strategies — behaviour modification, condoms, needle exchange – have been very successful, their effect has reached a plateau since they are not always available, practical, or fully adhered to. In the past five years, research has shown that using antiretroviral therapy (ART) to treat those infected with HIV not only decreases mortality and morbidity but also decreases HIV transmission. Unfortunately, many individuals are still unaware that they are HIV-positive or that they should be on ART, since they have not been linked to our health-care system. These individuals will unnecessarily suffer from their disease and they will incur avoidable hospitalizations, physician visits, and costs.

Dr. Viviane Lima aims to identify different strategies to decrease the public health and economic burdens of HIV in British Columbia (BC). Since individuals living with HIV should follow the same continuum of care from infection until the time of first ART, diminishing the individual and economic burdens of HIV will require a combined effort of different players in our health-care system and the development of a comprehensive strategy to tackle each component in the continuum of care pathway. Lima’s research will employ innovative statistical and mathematical models to analyze these data and compare the potential effects of different complex strategies. This project will create great opportunities for trainees to be supported across a variety of disciplines, further enhancing BC’s competitive advantage in population-health and HIV research. The proposed methodology can also be applied to other diseases, conditions, and settings dealing with similar issues.

The dynamic interplay between women’s stress and reproductive axes across reproductive transitions: post-partum amenorrhea, the resumption of ovarian cyclicity and early pregnancy

Stress is often cited as having negative effects on women’s health. Most research, however, does not adequately account for the changes in stress physiology women experience as they transition between key reproductive phases (post-partum amenorrhea, resumption of ovarian cyclicity, and pregnancy). Reproductive function is modulated by the HPG (hypothalamic-pituitary-gonadal) axis, while stress response is controlled by the HPA (hypothalamic-pituitary-adrenal) axis. These two axes overlap and interact in manner a that affects both reproductive function and stress.

Dr. Pablo Nepomnaschy’s research focuses on investigating the relationship over time between the HPA and HPG axes. Understanding this relationship is paramount to all research focused on how stress affects women’s health and reproduction and their children’s development. The aims of this research are to: 1) produce the first longitudinal description of stress and reproductive hormones for healthy women as they transition across reproductive phases; 2) study the dynamic interactions between the HPA and HPG axes across those phases; 3) evaluate the role of psychosocial, energetic, and health stressors as modulators of reproductive transitions and the effect these transitions have on the physiologic responses to those stressors; 4) conduct an exploratory pilot study of the effects that peri-conceptional stress has on the development of the HPA axis in children.

Nepomnaschy will use data and bio-specimens from British Columbian and Guatemalan women and children. The socio-economic and ethnic homogeneity of the Guatemalan population provides a unique opportunity for the development of a basic model of the longitudinal relationship between the HPA and HPG axes. Those results will be used to develop studies to investigate stress-related health outcomes for women and children in BC, particularly among disenfranchised groups facing higher risk of stress exposure, such as BC’s Aboriginal population, new immigrants, and the homeless.

HIV risk environments among illicit drug users: A longitudinal ethno-spatial approach

Dr. Will Small’s research program will examine the influence of social, structural and physical environments upon illicit drug users’ HIV risk behaviour and HIV treatment-related outcomes. The study is nested within a larger program that includes three epidemiological cohort studies of adult drug users and street-involved youth. This approach integrates ethnographic observational fieldwork, in-depth interviews, and geo-spatial mapping techniques with quantitative laboratory and survey data to identify how the social, structural and physical features of drug-use scenes impact HIV outcomes.

Informed by ecological perspectives on health, and the HIV risk environment framework, this study will develop and pilot a novel ethno-spatial approach to identify the complex pathways and dynamics between contextual factors shaping the risk environments of drug use and HIV prevention and treatment for drug users. Building on 10 years of experience studying illicit drug use and HIV/AIDS in the local context, this program of ethno-spatial epidemiology seeks to address the following specific aims:

  1. Examine the influence of evolving social and physical features of “drug scenes” on HIV risk behaviours and HIV incidence among drug users.
  2. Assess the influence of evolving structural and physical factors on critical initiation and transitional events (e.g. initiation into drug use or sex work; transitions in drug use patterns) among drug users and inform epidemiological models of HIV risk.
  3. Examine the impact of evolving structural and physical factors on initiation and adherence to antiretroviral therapy and suppression of HIV-1 RNA among HIV-positive drug users.
  4. Create a platform for the ongoing ethno-spatial evaluation of future public health and public policy interventions targeting drug users.

Linking socioeconomic status to environmental pollution exposures over the life course: population-based research using biomarkers to investigate the effects of exposure on small for gestational age …

Dr. Scott Venners is studying the impact of exposures to environmental pollutants and their links to health inequalities between richer and poorer people, specifically small size at birth and diabetes in adulthood. As in many Canadian cities, babies born to mothers in socially and materially poorer parts of Vancouver are more likely to be born under-sized than those born in other parts of the city, and higher levels of second-hand smoke exposure may be a factor.

Venners will test exposure to second-hand smoke by measuring cotinine (a byproduct of nicotine) in serum (blood) samples from non-smoking pregnant women. He will then investigate whether non-smoking women with higher levels of serum cotinine (and thus with higher second-hand smoke exposures) are more likely to have a baby that is too small. The project will also test whether some babies are genetically more susceptible to adverse effects of second-hand smoke during pregnancy. Finally, Venners will test whether non-smoking pregnant women who live in poorer areas of Vancouver have higher levels of serum cotinine compared to others, which would suggest that they were exposed to more second-hand smoke. This evidence will provide a better understanding of whether reducing exposures to second-hand smoke will reduce disparities between poorer and richer areas in the likelihood a baby will be born too small.

In addition to passive smoking, the project will study other important classes of pollutants that may be linked to small size at birth. The project will also study the links between socioeconomic status, exposure to mixtures of persistent organic pollutants in adulthood, and inequalities in diabetes risk between richer and poorer Canadians.

Responding to the health crisis among street-involved youth in Vancouver: Evidence to inform interventions and policy responses

Street-involved youth are extremely vulnerable to health-related harms resulting from high rates of illegal drug use and sexually-risky behaviour, poverty, and neglect, as well as precarious living conditions, either on the street or in risky relationships. There is an estimated 150,000 street youth in Canada, with approximately 40 percent reporting injection drug use. This puts street youth at a very high risk for sexually transmitted infections (STI) and hepatitis C (HCV) infection.

Dr. DeBeck’s research seeks to address gaps that exist in our understanding of how street youth are initiated in illegal drug use and the dynamic of how STI and HCV are transmitted.

Her work will examine individual (e.g. stimulant use), social (e.g. childhood trauma), structural (e.g. access and coverage of addiction treatment), and environmental (e.g. homelessness) factors and how they intersect to promote a “risk environment” that elevates sexual risk and drug-related harms.

The outcome of her analysis will be a body of evidence that can support the development and evaluation of behavioural and structural interventions to prevent sexual and drug-related harms among street-involved youth. Her work will also support clinical trials to address critical issues in the diagnosis and treatment of hepatitis C among street-involved youth.

Ultimately, the results of her work will help prevent high-risk drug use, infectious diseases and other health harms among street-involved youth. It will also provide critical guidance for the effective management and treatment of infectious diseases among street involved youth.

End of Award Update – April 2024

 

Results

Having dedicated research time through a Michael Smith/Providence Health Care Research Institute-St. Paul’s Hospital Scholar Award allowed Dr. DeBeck to build research networks and engage in inclusive collaborations through the At-Risk Youth Study (ARYS) cohort platform. As a Michael Smith Scholar she published more than 160 peer reviewed publications, 55 of which research trainees were the first author and she was the senior author. Dr. DeBeck has also been able to publish with nine different co-authors with lived or living experiences of substance use, the majority of whom identify as Indigenous. Her Scholar Award gave her time to network and collaborate with organizations like the Western Aboriginal Harm Reduction Society, the First Nations Health Authority, Vancouver Coastal Health and the BC Ministry of Mental Health and Addictions. She was also able to facilitate the creation of a program of ARYS Peer Research Associates (PRA) and more recently an Indigenous Peer Collaborators Circle to lead research involving Indigenous people who use drugs.

 

Impact

Collectively, Dr. DeBeck’s activities as a Michael Smith Scholar have contributed to a scientific evidence-based model that demonstrates that prevailing models of drug law enforcement are ineffective and carry serious unintended harms for structurally marginalized populations. Her work has documented that the criminalization of drug use hinders HIV prevention; incarceration is linked to a decreased likelihood of quitting drug injection and an increased likelihood of relapse into substance use; and incarceration has been discriminatory, disproportionately affecting young Indigenous people in Vancouver. Cumulatively, this body of work provides evidence that despite continuing to receive significant government funding, drug law enforcement has not been demonstrated to be effective and has serious unintended negative harms. This paves the way for evidence-based policy reforms that are not punitive in nature.

Other research contributions include characterizing the early stages of problematic substance use which underscores the role of social determinants of health (e.g., adverse childhood events, child welfare exposure, and intergenerational trauma) as drivers of substance. Documenting the role of social determinants of substance use draws attention to the necessity of policy reforms that attend to social and structural drivers of risk and counters popular narratives of individual moral failings and individual responsibility for substance use.

Contributions during her Scholar Award also include work on addiction treatment engagement that inform responses to the drug toxicity poisoning crisis. The policy implications of this body of work are that addiction treatment, despite demonstrated clinical effectiveness for some people who use drugs, has limited overall reach and impact. Based on these studies, expansion of addiction treatment cannot be expected to adequately respond to the toxic drug crisis. Additional interventions that span prevention and harm reduction, including addressing the toxic drug supply, are needed. Monitoring and evaluating innovative models that make regulated drugs or “safer supply” available is a critical next step for drug policy development and one that the ARYS cohort is ideally positioned to contribute to.

Another impact of Dr. DeBeck’s Scholar Award was the opportunity to leverage drug consumption data from the ARYS cohort and be part of the working group that drafted the City of Vancouver’s 2021 application to Health Canada for the decriminalization of drug possession. The introduction of drug decriminalizing has been symbolically monumental as it reflects the growing understanding that drug criminalization has been ineffective and harmful and different approaches to substance use are needed.

 

Potential Influence

Holding a Scholar Award allowed the ARYS cohort research platform to thrive under the leadership of Dr. DeBeck. It also gave her the opportunity to build critical research networks and collaborations that positioned her to transition to a CIHR Applied Public Health Chair and Dorothy Killam Fellowship in 2024. With this foundation in place, she is well positioned to continue to generate responsive, high-quality data to inform substance use interventions and drug policy. Current priorities are to engage in community-based collaboration with people who use drugs and government partners, to evaluate interventions and inform policy responses to prevent toxic drug poisonings, increase service engagement, and promote health and wellness among street-involved young people who use drugs in Vancouver and beyond.

 

Next Steps

With a CIHR APHC and Dorothy Killam Fellowship Dr. DeBeck can continue a research-intensive trajectory. Collaboration with ARYS PRAs and a newly formed Indigenous Peer Collaborator Circle are ongoing. Data sharing with government and community partners is also continuing with multiple research products under development.

 

Useful Links

Health, Creative Arts, and Northern Communities

With the highest rates of premature mortality at 3.71/1,000 people, the Northern Health Authority has the lowest health status in BC. Dr. Sarah de Leeuw’s research seeks to address this issue by examining how creative arts and the humanities can help resolve health inequities experienced by Indigenous and non-Indigenous people in northern BC.

To do this, she will draw on her previous research as well as growing global evidence that shows how medical humanities and health-based creative arts can enhance well-being. She will also look at how social determinants of health frameworks can explain health disparities.

She will lead a team of northern BC community advisors, health researchers, and medical/health science students. The team will develop and deploy multi-disciplinary creative methods and methodologies to harness, document, translate, and disseminate existing northern strengths – especially First Nations’ – as a population health and wellness initiative.

Her research will:

  • Advance new methods, approaches, and models – anchored in creative arts and social determinants of health frameworks – that produce and translate innovative ways of addressing health inequities.
  • Promote rural, northern and First Nations communities through the creative arts as places where health service providers want to live and work.
  • Use creative arts to increase interest by locals – particularly First Nations – to pursue health and medical education and training within the region and to then stay in the region.
  • Encourage multi-disciplinary cross-community collaborations.
  • Augment northern health education curricula (nursing, social work, medicine, community health) with accessible, targeted, and affecting knowledge.
  • Circulate strengths-based evidence about populations in the Northern Health Authority – especially First Nations – beyond the borders of the health authority with the intent of encouraging southern, urban, and non-Indigenous British Columbians to feel vested in the wellness of BC’s northern populations.

Survival and Cause of Death in the British Columbian Multiple Sclerosis Population

Multiple sclerosis (MS) is a relatively common neurological disease. Because of its chronic nature and because it typically first appears in people in their mid 20s to 30s, people with MS are usually expected to live for many years following disease onset. Little is known about survival expectations, predictors of long-term survival, how survival is influenced by MS drug therapies, and causes of death in this population. Ever since immunomodulatory therapies first became available to Canadian MS patients in the mid 1990s, there has been a rapid uptake of these drugs. These medications appear to be at least partially effective in modifying some aspects of the disease, such as relapses, but they are associated with significant side effects, require frequent injections, and are expensive. The long-term impact of treatment is unknown and opportunities to study treatment-naïve patients have diminished over the years, as there are fewer patients with MS who have not taken these therapies. In British Columbia, we have a valuable data resource that includes both unexposed (untreated) and treated MS patients.

Dr. Elaine Kingwell is combining several large, powerful, clinical and administrative longitudinal datasets, including the population-based BC MS clinical database (containing data from approximately 7,000 MS patients over a 30-year period), BC Ministry of Health medical services plan registration data, BC Vital Statistics death data and BC Cancer Agency data. She will use this data set to determine the long-term health impacts of MS and how they are influenced by immunomodulatory drugs. She will specifically compare the causes of death (including cancer, suicide, heart disease and infection) between people with MS and the general population.

Dr. Kingwell will also investigate cancer survival of MS patients in comparison to the general population, which is an area of some controversy. She will determine how frequently MS is listed as an underlying or contributing cause of death, which will help to facilitate planning and interpretation of population-based studies of MS mortality trends. Findings from this study will further our understanding of the role that MS plays in long-term health outcomes, such as cancer survival, and will broaden our existing knowledge of factors associated with longevity in MS. These results will also provide a vital estimate of the impact of immunomodulatory therapy on survival and specific causes of death for MS. The findings from this research will have a profound impact on the care, monitoring and treatment of the disease.

A program of research to optimize public health immunization programs

Vaccines and immunization programs are the best way to prevent infectious diseases, improve child health, and save lives. According to the Public Health Agency of Canada, vaccines have saved the lives of more babies and children than any other medical intervention in the past 50 years. Through immunization, we have eliminated smallpox and have nearly eliminated eight other deadly diseases of childhood, including chickenpox and some kinds of pneumonia and meningitis. We need to continue to immunize all children so that we maintain high levels of protection throughout communities, which will prevent these diseases from re-emerging. Despite having province-wide immunization programs in place, not everyone gets vaccinated, as shown by several disease outbreaks in the past few years.

Dr. Julie Bettinger is working to address key questions about vaccines and immunization programs to ensure optimal disease protection in the population. Her research assesses the effectiveness of existing vaccination programs, evaluates the effectiveness of new vaccines, and also studies the best way to deliver them to children, adults and communities. Her approach uses quantitative and qualitative methods and includes collecting and analyzing surveillance data on select vaccine-preventable diseases and vaccine-adverse events from the Canadian Immunization Monitoring Program Active, an active surveillance network in 12 pediatric centers across Canada.

Dr. Bettinger’s research also focuses on evaluating the safety and effectiveness of vaccines through grant-funded clinical trials and observational studies and promoting improved immunization uptake through qualitative studies that assess the factors affecting vaccine use. Her work is used by local, provincial, and national public health decision makers, other research scientists, health care providers, and the public. This work, which is conducted at the Vaccine Evaluation Center at the Child and Family Research Institute and BC Children's Hospital, will create a centre for applied, population-based immunization research unique to BC and Canada.

Drug impaired driving: Evaluating the threat to traffic safety

Motor vehicle crashes cause 15,000 serious injuries and over 2,000 deaths in Canada annually. The contribution of drug-impaired driving to these tragedies is unknown, but suspected to be significant. This lack of knowledge hinders the development of effective traffic safety policies to prevent drug-impaired driving.

The research of Dr. Jeffrey Brubacher aims to prevent injuries and fatalities resulting from motor vehicle crashes. His research program consists of three inter-related themes:

  1. Cannabis and motor vehicle crashes. This five- year study will examine 3,000 injured drivers from five BC trauma centres to determine whether there was recent marijuana use before their crashes and whether or not the driver caused the crash. The study will provide important information about the role played by marijuana in causing car crashes.
  2. Prescription medications and motor vehicle crashes. This project will involve combining BC prescription data with BC driver records, including traffic accident reports, to determine whether or not drivers are more likely to be involved in a crash when they are taking prescription medications such as sleeping pills or pain medications.
  3. The Injured Driver Platform. This study will provide information on the motor vehicle crash risk associated with recreational drug use. Over an initial three-year period, medical data will be collected and interviews will be conducted with injured drivers at five BC trauma centres, and drivers will then be followed for two years after their original crash to determine how often they are responsible in other accidents or drive while impaired.

This project will help to identify risk factors for impaired driving which may be used to develop targeted interventions to prevent this risky behaviour. Dr. Brubacher's research will contribute to an international effort to understand the role played by prescription medications, marijuana, and other illegal drugs in causing motor vehicle accidents. He will present his findings to government officials so they are better able to develop effective road safety policy and public education campaigns targeting impaired drivers and, by doing so, to improve safety on our roads.