PS62 Psychiatry Toronto Notes 2023

Canadian Legal Issues

Common Forms

• the legislation is specific to each province, as are the types and numbers of forms, but the principles

are common across Canada

Table 23. Common Forms Under the Mental Health Act (in Ontario)

Expiration Date Right of Patient Options Before

to Review Board Form Expires

Hearing

Form Who Signs When

Form1: Application for Psychiatric

Assessment

. Filled out when patients are

thought to be in imminent danger

to harm themselves (suicide) or

others(homicide), or when they

are incapable of self-care (e.g. not

dressed for freezing weather) and

are suffering from an apparent

mental disorder

• Based on any combination of the

physician'

s own observations and

facts communicated by others

. Box A or Box B completed

• Box A:Serious Harm Test

• The Past/Present Test assesses

current betiaviours/threats/attempts

. The Future Test assessesthe

liketihood of serious harm occurring

as a result of the presenting mental

disorder.In thissection,one should

document evidence of the mental

disorder and concerning behaviours/

thoughts

. Box B:Patients with a known mental

disorder who are incapable of

consenbng to treatment (substitute

decision-maker needed), have

previously received treatment and

improved, and are currently at risk of

serious harm due to the same mental

disorder

Within 7 d after having 72 halter

examined the patient hospitalization

Void il not

implemented

within 7 d

Form 3and 30 or

voluntary admission

Form1: Application by

physician to bring a patient

to hospital (schedule!

facility) for psychiatric

assessment against

patient's will (Form 42 given

to patient)

Form 2:Order by Justice

of the Peace to bring

patient to a hospital for

an examination against

patient's will

Any physician No

or

send home t

follow-up

Justice of the Peace No statutory lime

restriction

7 dlromwhen

completed

Purpose of form

is complete once

patient brought to

hospital

Form land 42 or

voluntary admission

or send home

t follow-up

No

Form 3:Certificate of

involuntary admission to a

schedule!facility (Form 30

given to patient, notice to

rights advisor)

Form 4:Certificate of

renewal of involuntary

admission to a schedule!

facility ( Form 30 given to

patient, notice to rights

advisor)

Form 4a:Certificate of

continuation of involuntary

admission to a schedule!

facility ( Form 30 given to

patient, notice to rights

advisor. Form!7 sent to

the Capacity and Consent

Board, copies to chart)

Form 5:Change to informal/

voluntary status

Any physician other Before expiration of

than physician who Form!

completed Form 1 Anytimetochange

status of a voluntary

inpatient

Prior to expiration of

Form 3

14 d Yes Form 4 and 30

or voluntary

admission

(Form 5)

Form 4 and 30 or

voluntary admission

(Form 5)

Any physician,

usually the

attending physician

following patient

on Form 3

First:1mo

Second:2 mo

Third:3 mo (max)

Yes

Prior to expiration of

the third Form 4

Any physician, 3 mo

usually the

attending physician

following patient

on Form 4

Mandatory review

board hearing

Another Form 4a or

voluntary admission

Any physician,

usually the

attending physician the criteria for

following patient involuntary admission

onform 3/4/4a under the Mental

Health Act arc no

longci fulfilled)

Physician issuing Whenever Form

the form 3/4/4a 3/4/4a filled

Whenever deemed N .'A N /A N/A

appropriate (i.e.

Form 30: Notice to patient

that patient is now under

involuntary admission

on either form 3.4.or 4a

(original to patient, copy

to chart)

Form 33: Notice to patient

that patient isincapable of

consenting to treatment of

a mentaldisorder,and/or

management of property

and/or disclosure of health

information (original to

patient, notice to rights

advisor, copy to chart)

Form 42: Notice to the

patient that patientis now

on a From land the reason

forthis change (original to

patient,copy to chart)

N /A Yes N /A

Attending physician Whenevei deemed N /A Yes N /A

appropriate

Physician who is

signing Form!

Whenever Form1

filled

N /A No

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PS63Psychiatry Toronto Notes 2023

Consent

• see Ethical, Legal, and Organizational Medicine. FLOM11

Community Treatment Order (CTO)

• purpose: a community treatment order(CTO)orders a person suffering from a serious mental

disorder to receive treatment and supervision in the community.Based on a comprehensive plan

outlining medications, appointments, and other care believed necessary to allow the person to live in

the community (vs.in a psychiatric facility,where conditions are more restrictive)

• intended for those who:

due to their serious mental disorder, experience a pattern of admission to a psychiatric facility

where condition is usually stabilized

• after being released, these patients often stop treatment,leading to destabilization

• due to the destabilization of their condition, these patients usually require readmission to

hospital

if CTO violated (i.e.treatment not taken,does not comply with follow up),the physician can issue

a Form 47 which is an order for examination that allows the police to bring the patient to the

hospital for an examination (usually the patient is examined and the treatment will continue as

per theCTO)

• criteria for a physician to issue a CIO

patient with a prior history of psychiatric hospitalization (cumulative >30 d over >2

hospitalizations in the past 3 yr),or the person has been subject to a previousCTO in the past 3yr

a community treatment plan for the person has been made

examination by a physician within the previous 72 h before entering into theCTO plan

• ability of the person subject to theCTO to comply with it

consultation with a rights advisor and consent of the person or the person’

ssubstitute decision

maker

• CTOs are valid for 6 mo unless they are renewed or terminated at an earlier date such as

when the person or his/hersubstitute decision-maker withdraws consent to the community

treatment plan

• CTO processis consent-based and allstatutory protections governing informed consent apply

• the rights of a person subject to a CTO include

the right to a review by the Consent and Capacity Board with appeal to the courts each time a

CI'

O isissued or renewed

a mandatory'review by the Consent and Capacity Board every second time a CTO is renewed

the right to request a re-examination by the issuing physician to determine if the CTO isstill

necessary for the person to live in the community

the right to review findings of incapacity'to consent to treatment

provisionsfor rights advice

CTO Legislature

• Ontario passed CTO legislature

on December 1.2000 (known as

"Brian’

slaw")

. Similar CTOs have been implemented

in Saskatchewan (1995), Manitoba

(1997), and British Columbia (1999)

Duty to Inform/Warn

• see Ethical, Legal, and Organizational Medicine, ELOM10

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PS6!Psychiatr\

T

Toronto Notes 2023

Landmark Psychiatry Clinical Trials

Trial Reference Results

Schizophrenia

CATIE Psychiatr Serv 2008;59(5):500-506 Title:What CATIE Found:Results From the Schizophrenia Trial

Purpose:Compare the effectiveness of a proxy first-generation antipsychotic (perphenazine) toseveral second-generation

antipsycholics.

Methods:1460 patients with chronic schizophrenia were randomly assigned in a double-blind study to receive one of

perphenazine,olanzapine,quetiapine.risperidone, or ziprasidone for up to 18 mo.

Results:Perphenazine did not differ significantly in overal effectiveness or benehts compared to the second-generation

antipsycholics.Perphenazine was the most cost-effective drug.Individual clinical circumstances impacted drug effectiveness.

Patients who have a poor response to an initial medication may tolerate and see greater effectiveness with a different medication.

Conclusions:First and second-generation antipsychotics did not differin overall effectiveness.Patient factors must be considered

when prescribing antipsychotic medications.

Major Depressive Oisorder

TRANSFORMS Am J Psychiatry 2019,176|6):428-438 Title: Efficacy and Safety of Flexibly Dosed Esketamine Nasal Spray Combined with a Newly Initiated Oral Antidepressant in

Treatment-Resistant Depression:A Randomized Double-Blind Active-Controlled Study

Purpose:Evaluate the efficacy and safety of flexibly dosed esketamine nasal spray for patients with treatment-resistant

depression.

Methods:Patients with treatment-resistant depression vrere randomly assigned treatment of esketamine nasal spray witha

newly initiated antidepressant or a placebo nasal spray with a newly initiated antidepressant.

Results:197 participants completed the study. Patients receiving the esketamine nasal spray plus antidepressant treatment

demonstrated a change in Montgomery-Asberg Depression Rating Scale score that was signifrcantly greater than placebo nasal

spray plus antidepressant atd 28. Clinically meaningful improvements were found in the esketamine group earlier in the study

timeline.

Conclusions:Esketamine nasal spray was a safe,rapid-acting, and efficacious therapy for treatment-resistant depression.

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PS65 Psvchiatn Toronto Notes 2023

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Public Health and Preventive Medicine

Jenny Cho and Muhammad Maaz, chapter editors

Ming Li and Dorrin Zarrin Khat, associate editors

Vijithan Sugumar, KBM editor

Dr. Andrew Pinto and Dr. Jason Pennington,staff editors

Acronyms

Public Health Context

Public Health in Canada

Legislation and Public Health in Canada

Determinants of Health

Concepts of Health

Groups Facing Systemic Barriers. Discrimination,and Structural

Violence

Indigenous Health in Canada

Disease Prevention

Measurements of Health and Disease in a Population PH12

Epidemiology.

Interpreting Test Results

Effectiveness of Interventions

Types of Study Design

Qualitative vs. Quantitative

Observational Study Designs

Experimental Study Designs

Summary Study Designs

Methods of Analysis

Distributions

Data Analysis

Common Statistical Tests

Causation

Assessing Evidence

Health System Planning and Quality.

Continuous Quality Improvement

Economic Evaluation

Managing Disease Outbreaks

Definitions

Steps to Control an Outbreak

Infection Control Targets

Environmental Health

Environmental Risk Assessment

PH2

PH2

PH3

PH13

PH16

PH19

PH22

.PH23

PH24

PH26

Air

Water

Soil

Food

Environmental Racism

Occupational Health

Taking an OccupationalHealth History

Occupational Hazards.

Workplace Legislation

Workplace Health Promotion

WorkplacePrimary Prevention

Workplace Secondary Prevention

Workplace Tertiary Prevention

Appendix - Mandatory Reporting.

Reportable Diseases

Other Reportable Conditions

Landmark Public Health and Preventive Medicine Trials...PH32

References

PH29

PH30

PH31

,PH33

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PHI Public Health and Preventive Medicine Toronto Notes 2023

PH2 Public Health and Preventive Medicine Toronto Notes 2023

Acronyms

ADLs activities of daily living

attributable risk

CAS Children’s Aid Society

cost benefit analysis

CEA cost effectiveness analysis

CFR case fatality rate

CTFPHC Canadian Task Force on

Preventive Health Care

disability adjusted life year

DDT dichlorodiphenyltrichloroethane MOH

EBM evidence-based medicine

FP false positives

false negatives

FOOT fecal occult blood test

IMR infant mortality ratio

ITT intention-to-treat analysis

IICO low income cut-off

MERS Middle East respiratory

syndrome

Medical Health Officer

Medical Officer of Health

MMR maternal mortality ratio

NNH number needed to harm

N NT number needed to beat

NPV negative predictivevalue

OR odds ratio

PFT pulmonary function test

PHAC Public Health Agency of Canada TP

per protocol analysis

PPV positive predictive value

PSA prostate screening antigen

potential years of life lost

OALY quality adjusted life year

quality improvement

relative risk

SARS severe acute respiratory

syndrome

SOS safety data sheets

SMR standardized mortality ratio

true positives

TN true negatives

WHMIS Workplace Hazardous Materials

Information System

WHO World Health Organization

WSIB Workplace Safety and Insurance

2:

=

"

At FN

L b A

PP

DALY MHO PYU

01

RR

Public Health Context

•see

the

Ethical

organization

. Lenal,

of

and

health

Organizational

care in Canada

Medicine

including

.Overview

the legal

of Canadian

foundation

Healthcare

and historical

System

context

.ELOM2 for m

Definitions

•population health

refers to the health of defined groups of people,their health determinants,trendsin health, and

health inequalities

influenced by: physical, biological,social,environmental, and economic factors;personal health

behaviours; access to and quality of healthcare services

broader scope compared to public health;accountsfor socioeconomic,policy,and historical

issues

•public health

an organized effort by society to promote, protect, improve, and when necessary,restore the

health of individuals,specified groups,or the entire population

a combination of sciences,skills, and values that function through collective societal activities

and involve programs,services,and institutions aimed at protecting and improving the health of

population as a whole

public health services in many provinces (e.g.Ontario) are administered,funded, and delivered

entirely separately from healthcare services

•epidemiology’

“study of the distribution|...] of determinants of disease, health-related states, and eventsin

populations”

•Public Health and Preventive Medicine (formerly called Community Medicine)

the medical specialty that focuses on population rather than individuals’health

works with diverse populationsto improve population health, addresssocial determinants of

health, and promote health equity

5yr Royal College training in medical skills and knowledge,epidemiology,statistics,social

sciences, public administration, policy development, program management, and leadership

Sources:Shah, CP. Chapter 2 Measurementand Investigation.Public Health and Preventive Medicine in Canada]

"

5e.Toronto:Elsevier.2003

Shah, CP.Chapler15 Community Health Services. Public Health and Preventive Medicinein Canada. Se.Toronto:Elsevier,2003

Preparing for the LMCC

The AFMC Primer on Population Health

isthe core textfor the LMCC and is

available as an online resource on the

AFMC website (http://phprimer.afmc.ca)

For the LMCC exam,it is recommended

that you also read Chapter15 in Shah CP.

Public health and preventive medicine in

Canada.5th ed.Toronto:Elsevier.2003

Historical

G

Perspective

Over the last century,the focus of pubic

health has evolved:

. Infectious diseases:a prominent

issue in low- and middle-income

countries and higher income

countries aike:includes emergent

dseases caused by unfamiliar

or new pathogens,inefficient or

inappropriate antibiotic use.travel

global wanning (eg.HV.drugresistant TB.C0V1D-19).and the

manufactured conditions of crisis

and/or routineconditions of poverty

imposed on Indigenous.Black,and

other communities of colour

• Chronic diseases:have increased

morbidity and mortality (e g.heart

disease and cancer due to risk

factors and'or exposures) and

disproportionatety affect Indigenous

populations throughout the world

• Social determinants of health:

driven by a growing body of evidence

since the1980sthat universal

accessto health care services did

not ameliorate health inequalities,

and thatsignificant improvements

in health could only be achieved

by going '

upstream 'with action on

policies

the

Public Health in Canada

The public health service in Canada is composed of various agencies at the federal (Public Health Agency

of Canada), provincial (Public Health Ontario), and municipal/local levels (local public health units).

The organization of the public health system in each province varies widely and is usually separate from

the healthcare system.

Mission of the Public Health Agency of Canada (federal only):to promote and protect the health of

Canadiansthrough leadership, partnership, innovation, preparedness, and action in public health

•local public health units and services within regional health authorities(in most provinces except

Ontario, where local public health units are either autonomous or within local government) provide

programs and activities for health protection, promotion, and disease prevention at local and regional

levels

•catchment-area populations range widely (hundredsto millions), covering areas of 15-1.5 million km -

•the “core functions" of public health include six essential activities

The Association of Faculties of Medicine of Canada Public Health Educators' Network. AFMC Primer on Population Health[Internet).The organization of

health servicesin Canada;[cited 2006 Mar 25[. Available from https://phpriiner.afnic.ca/enl

1. health protection:measurestaken to address potential health risks at the population level

through regulation and advising government (e.g.safe water and food supply)

2. health surveillance: monitoring and predicting health outcomes and determinants with

systematic,longitudinal data collection

3. disease and injury prevention:addressing infectious disease through preventive (e.g.

vaccination, droplet protection) and control (e.g. quarantine) measures;reduce morbidity

through lifestyle improvement

Example of a Municipal Health Unit

The Middlesex-London Health Unit

• Serves 450000 people living,

working,visiting,and studying in the

city of London and Middesex county

• 275 fulFtime staff indudingMOHs

(physicians), public health nurses,

epidemiologists, health promotion

educators,dental hygiene managers.

etc

• Servicesindude infectious disease

control,ensuring environmental

health standards, health promotion,

and providing family health programs

+

PH3 Public Health and Preventive Medicine Toronto Notes 2023

4. population health assessment:studying and engaging with a community to understand their

needs and improve policies and services

5. health promotion: advocating for improved health through broad community and

government measures (e.g.policy, interventions,community organizations)

6. emergency preparedness and response: developing protocols and infrastructure for natural

(e.g.hurricane) and man-made (e.g. opioid crisis) disasters. In many types of health-related

disasters, public health leads the disaster response

Sources:Shah.CP.Chapter 15Community HealthServices.Public Health and Preventive Medicine inCanada. 5e.Toronto:Elsevier,2003

the Association of Faculties olMedicine of Canada Public HealthEducators' Network.AFMC Primer onPopulation Health[Internet],The organization of

healthservices inCanada:[cited 2006 Mar 25].Available from https://phprimer.afmc.ca/en/

Chief Public Health Officer (CPHO) of

Canada

• Responsible for the Public Health

Agency of Canada (PHAQ and

reports to the Minister of Health

• As the federal government’s lead

public health professional,provides

advice to the Minister of Health

and Government of Canada and

collaborates with other governments,

jurisdictions,agencies,organizations,

and countries on health matters

• Communicates public health

information to health professionals,

stakeholders,and the public

• In an emergency,such as an

outbreak or natural disaster,directs

PHAC staff,including medical

professionals,scientists,and

epidemiologists,to coordinate

emergency response

Sauce:Government ol Canada:the role ol the chief

public health ollicer[Internet!- Government olCanada:

[updated 2016 Feb 8;cited 2022 July[:[about too

screere[.Avaiable Irom:htlps:

' wvbw.cdradd.ca

en'

public-health.'corporatefccganuatioral-structure.'

canada-chiel-pubic-heaHh-ollicerirole-chel-Fwbfichealth-olfker.html

Legislation and Public Health in Canada

Table 1. Legislation and Public Health in Canada

Federal Provincial Municipal (Ontario)

Health Canada

• Provides health services to the Canadian

military and velerans

• Provides non-insured health benefits

|NIH8) to status First Nations peoples and

Inuit.and is responsible for the funding of

healthcare services on reserve

• Approves new drugs and medical devices

• Food Guide

Public Health Agency of Canada|main

Government of Canada agency responsible for

public heallh)

• An independent body created post-SARS

to strengthen public health capacity and

response

• Focuses on preventing chronic diseases,

preventing injuries,and responding to

public health emergencies and infectious

disease outbreaks

• Activities include CIFPHC guideline

secretarial,knowledge brokers

• Oversees immigration screening,protects

Canadian borders (e.g.airporlheallh

inspection)

• Liaises with the WHO on global health

issues

Canadian Food Inspection Agency

• Regulates food labeling

• Deals wilh animal-related infections

Canadian Institutes of HeallhResearch

(CIHR)

• Formed in 2000 to support research to

improve heallhand the health care system

Each province has its own Public Health Act

or equivalent (e.g.the Heallh Protection and

PromotionPel in Ontario) and agencies (e.g.

Public Health Ontario)

• Designates the creation of geographic

areas for the provision of public health

services

• Gives powers to the Chief Medical Officer

olHealth to control public health hazards

• Specifies diseases to he reported to public

health units by physicians,laboratories,

and hospitals (seeytppem/M. PH31)

• Mandates programs that address public

health issues,environmental health,and

chronic disease prevention

Local public health units (e.g. MiddlesexLondon Health Unit) deliver programs

mandated by provincial, municipal,or regional

legislation and are responsible for the delivery

of most public health services,such as:

• Infectious disease control,including

the follow-up of reported diseases and

management of local outbreaks

• Inspection of food premises,including

those in hospitals,nursing homes, and

restaurants

• Family health services,including preconception,preschool,school-aged,and

adult health programs

• Tobaccocontrol legislation enforcement

• Assessment and management ollocal

environmental health risks

• Collection and dissemination of local

health status reports

• Oral health

• By-laws may be approved by municipal

governments to facilitate public health

issues

Medical Officer of Health (MOH)

(Ontario)

May be called “Medical Health Officer"

(MHO) in other provinces

Appointed to each public health unit by

the board of health

Position held by a Public Health and

Preventive Medicine specialist physician

Responsibilities include oversight of a

multidisciplinary team who:

• Collect and analyze epidemiological

data

• Provide occupational and

environmental health surveillance

• Implement health programs,

including tobacco use prevention

inspections (restaurants,physician's

offices,tattoo parlors) and prenatal

courses

The MOH.by tew.ten require en irdrndujlpremne

egency to take «refraui hem any action due to a public

healthhazard (Section 13 and 22 ot the Health Protection

andPromotion Act)

Determinants of Health

Concepts of Health Determinants of Health

Income and social status

Employment and working conditions

Education and literacy

Childhood oeperiences

Physical environments

Social supports and coping skills

Healthy behaviours

Access to health services

Biology and genetic endowment

Gender

Culture

Exposure to colonization and racialized

prejudice

Racism

Soiree Social iMermirunlicl hcuKh and health

int

’

qujAlici,Internd,.Govumnwnt olCanada:[mcdlud

2022 June 14;cited June 2022].Available hemhltpv

«Yvw.canjda.u'vn/publK-hejnh,Servlcevhealthpiomotlcn'populjUcn-heallh'whal.dvleriTurei-heanh.

• wellness: “state of dynamic physical, mental, social, and spiritual well-being that enables a person to

achieve full potential and have an enjoyable life”

• disease: “abnormal, medically-defined changes in the structure or function of the human body"

• illness: “an individual'

s experience or subjective perception of a lack of physical or mental well-being

and consequent inability to function normally in social roles"

• illness behaviour: an individual’s actions resulting from and responding to their illness, including

their interactions with, or avoidance of, the healthcare system

• sickness: views the individual and their society hold towards a health condition, affecting their

thoughts and actions

• impairment: “any loss or abnormality of psychological, physiological, or anatomical structure or

function"

• disability: “any restriction or lack of ability to perform an activity within the range considered

normal for a human being”

• handicap: a disadvantage for an individual arising from impairment or disability

“limits or prevents the fulfillment of an individual's normal role as determined by society and

depends on age,sex,social, and cultural factors"

I

-

If

+

PH I Public Health and Preventive Medicine Toronto Notes 2023

•health equity: when all people have “ the opportunity to attain their full health potential" and no

one is “disadvantaged from achieving this potential because of their social position or other socially

determined circumstance.

" Health inequities are systematic differences in the health of individuals/

groups which are considered unjust

•health equality: defined as where populations have equal or similar health status. Health inequalities

systematic differences in the health of groups that do not necessarily carry a moral judgement

Source:ACC Institute olHuman Services.Special Needs Education.Impanmrnl.Disability,andHandicap: what'

s the dillerence

’

llnlcrnetf Instituted

Human Services: 2018 Nov 9 Idled 2020 Apr 281Available lioni:hHps://acc.cdu.sipen/linpalinicnl ^

^dlsablllly aiid handicap whats the difference/

Definitions olHealth

• Multidimensional definition ol health,

as defined by the WHO in1948:

"state ol complete physical,menial

and social well being and not merely

the absence ol disease or infirmity"

• WHO updated the definition (socioecological definition) of health In

1986:"The ability to Identify and to

realize aspirations,to satisfy needs,

and to change or cope with the

environment. Health is therefore

a resource for everyday life,not

the objective of living.Health is a

positive concept emphasizing social

and personal resources,as well as

physical capacities"(Ottawa Charter

for Health Promotion)

• Other definitions of health have since

been proposed that incorporate

other dimensions of health

• "Health is a social, economic,

and political issue and above all a

fundamental human right”- The

People's Charter for Health

• "Health is the continuous and

harmonious interaction and balance

between the physical,emotional,

spiritual,and mental/intellectual

realms" The National Aboriginal

Health Organization

are s

Determinants of Health

• I 974: the Honourable Marc Lalonde, federal Minister of Health, publishes A New Perspective on the

Health of Canadians which outlines four factors that determine health: “human biology, environment,

lifestyle, and health care organizations.

"The idea of determinants of health has since been expanded

and refined to include many additional factors

Sources:Shah.CP. Concepts. Determinants,and Promotion ol Health.PublicHealth and Preventive Medicine in Canada. Se. Toronto:Elsevier.2003

The Association of Faculties of Medicine of Canada Public HealthEducators’Network.AFMC primer on population health [Internet].Chapter 1.Concepts of

health andillness [cited Jul 2022);[about 7p.|.Available from https://phprimer.afmc.ca/en/part-i/chapter-1/

Water and

sanitation Health care

services

/ General

socioeconomic,cultural,

and environmental/^

conditions /

Unemployment

Housing

Living and working

conditions

Social and community

Work environment networks

Individual lifestylu

factors /

Education

Age. sex.and

Agriculture hereditary factors and

food production

<K> Cassandra Cetlm 2015 j

Figure 1. Population health model

Adapted from Dalilgrecn G,Whitehead M. European strategies lor tackling social inequities in health:Leveling upPurl 2.World Health Organization. 2006 Stale ol the ArtBcview:Poverty and the

Developing(rain

Pediatrics 2016:13(4):c201S30)S

Socioeconomic stalus ISIS) plays an important

role inportable bum development, lower SES is

associated with developmental delay,lower academic

achievement,and morebelravioural andemotional

problems.SES has been found loinfluence brain

regions that support memury.emotion regulation,

r.ighei ordei cognitive functioning,and regions

that support language and literacy.Some passible

mechanisms underlying these changes include

ep genetics,material deprivation (e.g.cognitive

stimulation,nutrient deficiencies!, stress (e.g.

-egathre parenting behaviours),and environmental

toxins.There is a needlor primary care providers to

build capacity to address poverty in their practice

and facilitate referral to evidence based community

intervention programs.

• cultural humility: an approach to health care based on humble acknowledgement of oneself as a

learner when it comes to understanding a person'

s experience, This is a life-long process of learning

and being self-reflexive

• culturalsafety:

developed by Ur. lrihapeti Ramsden, a Maori nurse scientist, in the 1980s and is “concerned with

the power relationships between nurses and those in their care. The recipients of nursing care are

empowered to decide what is culturally safe rather than complying passively with the authority of

nurses or other health professionals"

- Cancer Australia

“an approach that considers how social and historical contexts, as well asstructural and

interpersonal power imbalances,shape health and health care experiences. Practitioners are selfreflective/self-aware with regards to their position of power and the impact of this role in relation

to patients” - HeretoHelp British Columbia

• cultural awareness: an attitude that includes awareness about differences between cultures

• culturalsensitivity: an attitude that recognizes the differences between cultures and that these

differences are important to acknowledge in health care

• cultural competency: an approach that focuses on practitioners’attaining skills, knowledge, and

attitudesto work in more effective and respectful ways with Indigenous patients and people of

different cultures Ottawa Charier for Health Promotion

(1986)

• Health promotion: the process of

enabling people to increase control

over, and improve their health

• Some health promotion can be

achieved through clinical interactions

with patients,but most health

promotion is done at the population

level by public health professionals

and agencies through engaging

stakeholders,formulating policy, and

influencing upstream factors

• The Ottawa Charter is a framework

for thinking about health promotion

• The Ottawa Charter states that

governments and health care

providers should be involved in

a health promotion process that

includes:

1. Building healthy public policy

2. Creating supportive environments

3. Strengthening community action

4. Developing personal skills

5. Re-orienting health services

Groups Facing Systemic Barriers, Discrimination, and

Structural Violence

• certain groups are at greater risk for poorer health outcomes not due to their identity, but rather due

to systemic barriers, discrimination, and structural violence (e.g. harmful policies, historic, and

contemporary factors). The readers are strongly cautioned against pathologizing entire groups and

are encouraged to further read into the historical factors that have contributed to creating systemic

barriers which perpetuate inequities

• see Colonization ami Healthcare, PH7; l.lhical. Lenal, and Organizational Medicine, Indigenous

Disproportionate Over-Representation of Biological, Psychological and Social Co-Morbidities, BLOM27;

Indigenous Health, BLOM24

r T

L J

+

PH5 Public Health and Preventive Medicine Toronto Notes 2023

Table 2. Equity-Seeking Groups Facing Systemic Barriers

Definition Physical Environmental Personal Risk Factors Population-Specific

Interventions

Indigenous Peoples three distinct groups:First

Nations (status and non-status

Indians as per (lie Indian Acl|,

Metis,andlnuit

the original inhabitants ol the

land now tailedCanada

AllIndigenous communities

and individuals experience

the eflccts ol(oloniralion.but

sometimes in very dilfcicnt

ways

A history ol surviving

coloniralion and genocide

Systemic racism

lower income

Higher risk ol experiencing

violence and unemployment

Homelessness

limited overcrowded housing

in disrepair incommunity

Homelessness oil-reserve

exposures to environmental

toxins (poor drinking water)

duelo land dispossession

and loss ol environmental

stewardship

lifestyle adaptation,loss

ol traditional livelihood,

unemployment,andlack of

facilities

Movements towards

decolonization and addressing

the tecommendalions ol

the truth andReconciliation

Obesity (higher SMI) secondary Commission

lopoorer access to high quality Menial health awaicness and

nutrition flood insecurity)

Higher rales of smoking.

substance misuse,and suicide disease management,

secondary tomtergeneiational including DM

trauma

increasing health literacy

Indigenous-specific chronic

Culturally appiopriate and

interdisciplinary harm

reduction,substance use

treatment,and smoking

cessation piograms

Cultural continuity

(language and cultural

programs ate protective

against depression and

suicide)

Incorporation ol Traditional

Medicine intothe care

plan (wellness journey) for

Indigenous patients v/ho want

Uns lobe part of their care

Health practitioner training in

cultural humility and safety

Black Individuals and

Communities

Sub-Saharan African Ancestry,

diverse culturesand histories

(people may self-identity

by geographic or ancestral

regions(e.g.Caribbean.

Ghanaian.Somali,African

American.Black Canadian,

etc.)but socially classified

by society based on hair/skin

phenotype as 'Black')

3rd largest“visible minority"

group inCanada

43 o Canadian-born

Anti-Black systemic racism

in Canada (officially

acknowledged by the United

Nations, the CanadianPublic

Health Association,and

Higher risk DM and HTN

Ipoor data quality for

identifying disparities

inCanada due to lack of

collection of race-based data)

Cullurally-specific and safe

practices

Anti- racist approaches to care,

policy,andprogramming

Movements toreallocate police

funding to more appropriate

social services to curb police

violence through transparency

and public oversight

Variable,depending on

socioeconomic status and

immigrant statusi'history in

Canada

The Nova Scotian Black

population has been in Canada several provincial and local

for centuries;historically governments) has led ID

displaced intorural settings physical and mental health

Newer immigrants tend to live inequities

in urban centres High BMI

Higher risk DM and HTN

(poor data quality for

identifying disparities

in Canada due to lack of

collection of race-based data)

Isolated Seniors Individuals »65 yr Aging in place of choice

Falls andinjury prevention

Menial health promotion

Preventing abuse and neglect

Improvements in (amity income

most significant

Access locally childhood

education

Access lo sale housing

Eldei abuse

lack ol emotional support

Isolation

Low hazard tolerance

Higher rates of

Institutionalization

Mobility issues

Housing availability

Unsafe housing

Lack of recreational space

Inactivity

Polypharmacy

Medical comorbiditics

Individuals/Children in

Poverty

Based onllCOs Poor supervision

Food insecurity

High- risk behaviours

low income

Family dysfunction

Lackol educational

opportunities

IICOis an income threshold

below which a family will likely

devote a larger share olits

income on thenecessities ol

food,shelter,and clothing than

the aveiagc lamily

Includes impaiiments.activity

limitations,and participation

lesliklions

People with Disabilities Substance misuse

Poor nutrition

Inactivity

Dependency lorADls

Institutionalization

Barriers to access

Transportation challenges

Transportation support

Multidisciplinary care

Unique suppoit lor individuals

with specific disabilities (c.g.

trisomy 21)

Women'shealth

Mental health

Comprehensive medical exam

Dental and vision screening

Vaccinations

Cancer screening

Receive language and

employment training

Support integrating into local

community

Benefit from culturally

appropriate and culturally

safe interventions,ideally

developed in collaboration

with the specific target

communities

low income

low education status

Discrimination

Stigma

New Immigrants Person born outside

of Canada who has been

granted the light to live in

Canada permanently by

immigration authorities

Access to community services Exposure lo diseases and

Cultural perspectives

(including reliance on

alternative health practices)

Unstable or precarious housing (e.g.smoke Irom wood fires.

incidence of TB)

Barriers finding employment

conditions in country ol origin, that matches skills and

in current country of residence, qualifications

or during immigration process Exposure to cultural

discrimination and isolation

which can impact health

English language learner

Healthy immigrant effect

(health worsens over time

to match that of the general

population)

Cultural or religious

expectations

r->

L J

Nate:this chart delineates themajor challenges lacedby each group,but the issues listed are not unique tD each papulation.

+

Sources:Shah.CP.The Health of Vulnerable Groups.Public Health and Preventive Medicine in Canada. 5e.Toronto: Elsevier.2003.

PH6 Public Health and Preventive Medicine Toronto Notes 2023

Table 2. Equity-Seeking Groups Facing Systemic Barriers

Definition Physical Environmental Personal Risk Factors Population-Specific

Interventions

Persons Experiencing

Homelessness

Higher ratesof adverse

childhood events and

subsequent substance use

Greater risk of experiencing

violence due to lack of housing

and protection

An individual who lacks

permanent housing or

adequate housing

low income

Food insecurity

Mental illness

A history of colonial

subjugation and land

expropriation

Eiposure to temperature

extremes

Eiposure to communicable

diseases inshelters

HousingFirst policies

Sale housing

Addictions support

Mental health

Refugees Forced to flee country of origin Post-traumatic stress disorders

because of a well-founded Depression

fear of persecution and given Adjustment problems

protection by the Government Partial health coverage

via Interim Federal Health

Refugee claimant:arrive Program

in Canada and ask to be

considered refugee

Diseases and condrbons in Employment

country of origin (e.g.malaria. English language learner

IB.onchocerciasis,etc.)

Direct and indirect effects

of war

Vaccinations

Women's health

Mental health

Comprehensive medical eiam

Dental and vision screening

Political advocacy

Language training

Support for transitioning into

the workplace

Support integrating into local

community

If possible and when

requested,offer patients a

healthcare provider of the

same gender

Provide accessible multi-faith

spaces and chaplainservices in

the hospital

Instill a culture of inclusion

beyond tolerance and provide

religious accommodation

where possible

Proactively consulthealthcare

workers if they require

alternative scheduling for

religious holidaysor fasting

Collaborate with religious

leaders and chaplains in

supporting the health of their

respective communities

Apply anintersectional lens

to understand LGBTI02S

populations (racialued.

gender-diverse,traditional'

cultural roles asin 2S)

Gender-neutral language

and the avoidance of

heteronormativeassumptions

to invite patients to selfidentity as gender or seiual

minorities

Increased awareness of the

broader social,legal,and

medical context inwhich

LGBTI02S individuals live

Improve recognition that

individuals who belong

tomultiplemarginalded

communities may face

additional barriers to

maintaining good health

Longstanding prior lack of

access to healthcare

(chronically

neglected problems)

Cultural or religious

expectations

of Canada

Religious Minorities Religious minorities are

those who do not practice the

statistically dominant faith

It varies by country,but in

Canada,religious minorities

are currently those who are not and court workers from

affiliated with one of the major wearing religious symbols like

Christian denominations hijabs.turbans,and kippahs

Not allmembers of a minority

faithpractice and degree

of identification varies by

individual

Reduced employment options

inOuebec due to laws banning

government workers such

as teachers,police officers,

publicly employed lawyers.

At risk of experiencinghate Poorer mental health

crimes,especially those who Suboptimal health and carewear visible re :g ous symbols, seeking behaviours

such asMuslim women.Sikh

men.and Jewish men

Over-representation in youth

homeless population

Violence,harassment,and

discrimination when seeking

stable housing,employment,

health,or social services

Higher ratesof depression,

anxiety,obsessive-compulsive

andphobicdisorders,

suicidality,and self-harm

Increased risk of alcohol,

tobacco,and other substance

misuse

Double the risk for posttraumatic stress disorder than

heterosexual people

Greater participation in highrisk sexual practices related to

HIV infection

Deterioration of mental

health due to multiple factors

(internalized queerphobia.

limited sociomedical

infrastructure perpetuating!

instigating underlying

comorbidities)

LGBTI02S Individuals Those who identify aslesbian

(a homosexualwoman),

gay (a homosexual person

iirespective of gender),

bisexual (a person who is

attracted to both genders),

trans (a person whose core motivatedby sexual

gender identity andfor gender orientation and/or gender

expression does not align with identity:higher prevalence of

the sex-assigned gender at hale crimesagainst racialued

birth;the sexuality of trans communities with greater

persons is independent of their fatality

gender diversity),intersex

(an umbrella term to describe

bodies that fall outside the

strict maleifemale binary),

questioning (regarding one's

sexual or gender identity),

queer (a historically reclaimed

pejorative that is an umbrella

term to encompass allsexual

and gender diversities),

two-spirited (a pan-indigenous

term acknowledging gender

diversity inuniquely traditional

rotes as distinct from western

gender diverse identities),and

asexual (a person who does not

experiencesexual attraction

to others as distinct from

celibacy:asexual individuals

may stillhave sex

family violence

Lower income

Identity documents lacking

correct name or sex

designations

Victims of hate crimes

Note:thischart delineates the major challenges faced by each group,but the issues listed are not unique to each population.

Sources:Shah.CP.TheHealth of Wlnerable Groups.Public Healthand Preventive Medicine in Canada.5e.Toronto:Elsevier.2003.

r T

L.J

+

PH7 Public Health and Preventive Medicine Toronto Notes 2023

Screening for Poverty

• poverty is not always apparent despite being widespread (20% of families in Ontario live in poverty)

• poverty is a risk factor for many chronic diseases, cancer, and mental illness

• women, Indigenous peoples, new immigrants, and LGBTQ+ are some of the groups at highest risk of

living in poverty

• primary healthcare providers should intervene,such as by asking the following two questions:

step 1: “Do you ever have difficulty making ends meet at the end of the month?”

for living below the poverty line,sensitivity 98% and specificity 40%

step 2: “Have you filled out and sent in your tax forms?"

tax returns are required for accessing many income security benefits like GST/HST credit,

working income tax benefits, property tax credits, child benefits, etc.

connect your patientsto a free community tax clinic to assist them

New Immigrants to Canada

• Mandatory medical exams on entry

to Canada by a designated medical

practitioner

• Complete medical examination for

persons of all ages

. Chest x-ray and report for persons

>11 yr

t Urinalysis for persons 25 yr

• Syphilis serology for persons 215 yr

• HIV testing for applicants 215 yr.as

well as for those children who have

received blood or blood products,

have a known HIV-positive mother,or

have an identified risk. An ELISA HIV

screening test should be done for

HIV land HIV 2

• Serum creatinine for persons 215 yr.

and children with a history of HIN

(resting BP >150/90 mmHg).DM.

kidney disease,or signs of impaired

renal function

• Provide compassionate psychosocial

assessment,be aware of increased

prevalence of mental health issues

(c.g.PTSD. depression,intimate

partner violence)

. Assess Immunization documents and

develop catch-up schedule

Sou»:CltUamMp anilIraniyalkn Canada Handbook

|M«l»l|. townm.nl cl Canada [rmHM 2022

Sapl 20;. Avodcbt.lien Mtpu.’wwwxiiudt MWV

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Indigenous Health in Canada

Definitions

•Indigenous peoples represent approximately 4.9% of the total population of Canada in 2016 and speak

over 70 Indigenouslanguages

•3 distinct groups of Indigenous peoples in Canada (per sec. 35 of the Constitution Act 1982): first

Nations (status and non-status), Metis, and lnuit

• f irst Nations: includes over 600 diverse communities in Canada;status vs. non-status refers to

the registration of first Nations peoples under the Indian Act (1876), which, in addition to the

establishment of the Department of Indian Affairs, was originally established by the government

to administcr/manage Treaty commitments, and to remove self-governing and traditional

practice rights.

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Ihe Indian Act impacts the lives of countless Indigenous peoples, families and

communitiesfrom birth to death

• Metis: descendants of the first Nations and European settlers; nearly 2/3 residing in cities,

greatest percentage in Ontario

• lnuit: roughly 75% of this population of 70000 resides in the 4 Canadian Regions known as lnuit

Nunangat, the lnuit Homeland. These include: Nunavut, Nunavik ( N. Quebec), Nunatsiavut

(Labrador), and Inuvialuit (Northwest Territories). '

Ihe majority of lnuit live in Nunavut (30135),

followed by Nunavik (11800), Inuvialuit (3110), and Nunatsiavut (2285). Another 17690 lnuit

live outside of lnuit Nunangat, many in urban centres in southern Canada, including Ottawa,

Edmonton, and Montreal Traditional and Complementary Medicine Use

Among IndigenousCancer Patientsin Australia.

Canada, New Zealand, and the United Stales:A

Systematic Review

Integr Carreer Iher 2018:17(3): 568 581

Purpose: losystematically review the use of

traditional Indigenous and complementary medicines

among Indigenouscancer patients in Australia.

Canada. Newlealand.and the United States.

Methods:St odes on the use of traditional Indigenous

and complementary medicines among Indigenous

cancer patientsin Australia.Canada. New Zealand,

and the United States published between January

2000 and October 2017 wereeligible for inclusion.

Results:21articles based on 1Sstudieswere

included.Traditional Indigenousand compfcmeotary

medicines were used by between191to 57.7% of

Indigenous patients.Ibese modalities were most

often used in combination with conventional cancer

treatmentsto meetspiritual, emotional,and cultural

needs.These treatments bad multiple perceived

spiritual,emotional,and cultiral benefits.Traditional

Indigenousand comptementaiy medicine use

was influenced by a patient’s perceptions of their

healthcare practitioner's attitudes towardsthese

modalities.

Young and Growing Populations

•between 2006-2016 the Indigenous populations have increased by 42.5%, 4 times that of nonIndigenous Canadian population growth

•32.1 is the average age of the Indigenous population, about 8 yr younger than the non-lndigenous

Canadian population

•the aging Indigenous population is also growing, with anticipated doubling of >65 age group by 2036

Colonization and Healthcare

Colonizers have perpetrated specific acts throughout Canadian history that have greatly impacted the

physical, mental, emotional, and spiritual health of Indigenous peoples. Physicians should therefore

be aware of the historical (and current) underpinnings of Indigenous health disparities, and the

way in which health care professionals, including physicians, have acted as agents of the colonial

agenda historically, which are discussed here, and their responsibility to redress previously damaged

healthcare relationships (seeEthical, Legal, and Organizational Medicine, Resources in Indigenous

Health, ELOM29). Despite institutionalized abuse and assimilation, Indigenous people have survived

remarkable injustice and have built resilience through traditional knowledge and practices.

Residential Schools (1870s-1996)

The residentialschool era is well-known for itslasting and damaging effects on many generations

of Indigenous people.Many Indigenousstudentssuffered from poor nutrition, hygiene, and living

conditions, as well as physical,sexual,and psychological abuse from teachers and othersin power.

The intent of residential schools to assimilate Indigenous people also led to spiritual harmsthrough

significant loss of traditional language and culture.Residential schoolsurvivors report poorer general

and self-rated health as well asincreased rates of chronic and infectious diseases, mental distress,

depression,substance use, and suicide. Importantly, many of these outcomes extend to subsequent

generations(i.e.intergenerational trauma).

The term “residentialschoolsyndrome” has been proposed to better characterize the traditional

DSM-V definition of post-traumatic stress disorder with additional criteria speci

schoolsurvivors,such as tendency to misuse alcohol and drugs(often at a young age), loss of cultural

knowledge, violent or angry outbursts, and difficulty parenting. Treatment approaches must take into

account a holistic viewof all these criteria,rather than simply focusing on one aspect,like substance

use,which often perpetuates negative stereotypes.

In Canada,many Indigenous healing

practices include drumming,singing,

smudging,herbalteas, sweat lodges,

and other ceremonies.Healthcare

providers are encouraged to

research and explore these options

as an additional therapeutic toolfor

Indigenous patients requesting them.

Not all Indigenous patients will request

such treatments and so perhaps first ask

patients. “What do I need to know about

you as a person to give you the best care

possible?”

n

fic to residential i. J

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The Truth and Reconciliation Commission (TRC) (2015) is a document jointly created by the Canadian

government and residential school survivors that preserves in writing the truth of residentialschools

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and delineates recommendations for reconciliation. Many TRC recommendations pertain directly to

health and healthcare providers. Unfortunately,seven years later they remain recommendations and

have not become Calls to Action.

Nutrition Trials

Prom 1942 to 1952, nutritional scientists in conjunction with the Canadian government performed

unethical research on Indigenous people with tne aim of “studying the state of nutrition of the Indian.”

The lames Bay Survey is perhaps the most well

-known of these studies conducted on the Attawapiskat

and Rupert's House Cree First Nations, though many were conducted on residential school children

as well. One of the lead physician-scientists was Dr. Frederick iisdall (inventor of Pablum),former

president of the Canadian Paediatric Society and paediatrician at the Hospital for Sick Children in

Toronto, Ontario.Some unethical and arguably criminal acts committed by researchers were:

•lack of informed consent from parents or children

•Indigenous children were kept malnourished over a two-year period to establish a baseline

•one group of children received a flour mix not yet approved for sale that caused them to develop

anemia, contributing to greater morbidity and mortality in this group with no therapeutic

intervention

•in an effort to control as many factors as possible, dental care was denied to observe the progression of

dental cavities and gingivitis in the setting of malnutrition

Impact of Sustained Caloric Restriction on Residential School Survivors and Other

Generations

•sustained caloric restriction can cause height stunting, induce physiological changes to prioritize fat

over lean mass, and higher risk of developing type 2 diabetes

•stunting negatively impacts neurological, psychological,and immune systems

•due to sustained starvation, “the child’

s physiology is essentially ‘programmed’ by hunger to continue

the cycle of worsening effects, with their bodies displaying a rapid tendency for fat-mass accumulation

when nutritional resources become available”

•other generations are at risk of having a higher BM1 and developing obesity

Tuberculosis, Tuberculosis Sanatoriums, and “Indian Hospitals”

kuropean colonizers brought tuberculosis (TB) to Indigenous populations as early as the 1700s.

genous communities, particularly the Inuit, already had risk factors predisposing the spread of

TB. For example, there was malnutrition from food scarcity and overcrowding on federally mandated

reserves after forced relocation from traditional territories. From 1930-1940, death rates from TB

in Inuit populations were roughly 700 per 100000, among the highest ever recorded in a human

population. For comparison,TB was the tenth leading cause of death globally in 2016 at a crude death

rate of 17 per 100000, while ischemic heart disease was the first at 126 per 100000. This led the Canadian

government to forcibly relocate many Indigenous people to TB sanatoriums and “Indian hospitals,"

often hundreds of kilometres away.The average length ofstay at these institutions was 2.5 yr and many

patients never returned home.

hull

The TB health crisis persists today;in 2016, the average annual incidence rate of T

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B among the Inuit in

Canada was roughly 296 times higher than Canadian-born non-lndigenous people.In March 2018, the

national representational organization for Inuit people in Canada, called Inuit Tapiriit Kanatami(1TK),

and the Government of Canada committed to reduce TB rates across Inuit communities by 50% by 2025

and to eliminate TB by 2030 in a project called the Inuit Tuberculosis klimination Framework.

It is worth noting that “Indian hospitals” were initially welcomed by many First Nations who were under

the impression that reasonable healthcare was part of treaty terms. In reality, “Indian hospitals"were

crowded, underfunded, and poorly staffed,serving to segregate sick Indigenous people from the rest

of the population. They were also the site of the cycle of apprehension, coercive sterilization, chemical

and physical restraints, and scientific experimentation, all of which inflicted significant morbidity

and mortality. When the Canadian government began closing these hospitals in the 1960s, Indigenous

people continued to fight for their right to healthcare, which was finally recognized in the Indian Health

Policy of 1979.

Coerced Sterilizations

Throughout the twentieth century, eugenics programs existed across the country. In the 1920s-1930s,

both Alberta and British Columbia legalized eugenic policies in the Sexual Sterilization Acts which

were not repealed until the 1970s.To limit reproduction of ”unfit’’ people in the eyes of the government,

Indigenous women were disproportionately targeted. This is referred to as forced or coerced sterilization

and, according to various accounts by Indigenous women across the country, involved any number of

the fallowing:

•tubal ligations being performed without consent

•being falsely told that a procedure is reversible

•being pressured into signing consent forms while actively in labour or on operating tables

•being given an ultimatum to undergo a tubal ligation or risk child apprehension

It is important to note that many sterilizations also occurred outside legislation, in federally run “Indian

hospitals," and some have been documented as recently as 2018.At least 100 Indigenous women have

come forward with accounts of coerced sterilization by physicians and nurses,spanning from the 1970s

until 2018.

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Sixties Scoop and Indigenous Child Welfare

The “Sixties Scoop” (Johnson, 1983) (1951-1980s) refers to the government-mandated practice of

removing Indigenous children from their families without consent for placement in foster care or

adoption. As residential schoolsstarted to close, many children were transitioned to child welfare

facilities as the state deemed Indigenous parents unfit to care for their children - a legacy that persists

today. Similar to the Indian Residential School system,the goal was to assimilate Indigenous children

into a non-lndigenousfamily, rather than to directly provide child welfare to Indigenous communities.

Though Indigenous bands have increasingly been allowed to provide their own child welfare.Indigenous

children are still overrepresented in foster care.In 2016, Indigenous youth ages 0 to 4 made up about

half of all foster children in private households,despite being only 8% of total youth in this age group

in Canada. Youth with a history in government care may be at greater risk forsubstance misuse,street

involvement, and incarceration.

To this day, Indigenous children are disproportionately represented in the child welfare system and are

often apprehended for reasons directly related to the routine conditions of poverty.The apprehensions

that continue today echo the practices of the Sixties Scoop and residential school eras;the displacement

of Indigenous children separatesthem from their language and culture and hindersthe ability of

Indigenousfamilies to build resilience.Importantly,many Indigenous mothers and families avoid

accessing healthcare servicesfor fear of their children being apprehended.

Indigenous Approaches to Health and Wellness

• it isimportant to recognize the significant diversity amongst Indigenous nationsin the land now

known as Canada. Even within the same nation or language group,there will be variability in

practices. Despite this diversity,there are some ideas that recur across many nations

• restoring balance in the four realms ofspiritual,emotional, mental,and physical health of a person

acting as an individual, as well as a member of a family, community,and nation

ideas represented by the medicine wheel of First Nations peoples,the Learning Blanket of Inuit

peoples, and the Metis tree model all share a worldview based on holistic lifelong learning and

wellness

Indigenous medicines may take many forms (song,dance,smudge,ceremonies, plant medicines,

etc.)

practiced by experts who have decades of apprenticeship

while allopathic medicine often focuses on treating illness (like HTN or DM),Indigenous

medicine may understand the cause of a condition and the approach to healing in a different way

than a biomedical guideline

Indigenous medicine may focus on quality'oflife and not just cure

• cultural humility

cultural humility is a respectful, person-centered way of bringing curiosity and compassion

when a patient is willing to come forsupport

it takes courage to be humble enough to admit that we do not know what we do not know

Indigenous medicine is thousands of years old and eludes randomized controlled trials

Traditional Medicine is unlikely to interfere with Western Therapies

Latin root of “curiosity" is “cura,” which means “to care.

” Caring aboutsomeone’

s healing and

their beliefs about what may help them heal is a powerful act of witnessing and honouring.

Beginning with the belief that a person has wisdom about themselvesthat no one else does

and that we can be supporters of their healing, if they consent, can be a way to honour the

inherent wholeness of a person seeking care.This is especially true of Indigenous patientsfor

whom regaining self-determination is tantamount to regaining their wellness.

before assuming that an Indigenous person is interested in using traditional medicine, it is

important to begin with questions and curiosity'

.Dr.Chantal Perrotspeaks about the Patient

Dignity Questionnaire which advises healthcare workers to first ask patients, “What do I need to

know about you as a person to give you the best care possible?”

National Indigenous Health Organization (N1HO) offers 8 guidelines on practicing culturally

safe health care for Indigenous patientsincluding the need to allow Indigenous patientsto access

ceremony,song, and prayer;the need for information and for family support;guidelinesfor the

appropriate disposal of body parts and for handling death

Disease Prevention

Natural History of Disease

• course of a disease from onset to resolution

1. pathological onset

2. presymptomatic stage:from onset to first appearance ofsymptoms/signs

3. clinical manifestation of disease:may regressspontaneously, be subject to remissions and

relapses, or progress to death

Surveillance

• the continuous,systematic collection, analysis, and interpretation of health-related data needed for

the planning, implementation, and evaluation of public health practice

Sources:Public health surveillance (Internet].World HealthOrganization.AvailableIromhttpsi

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wwn.who.int

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topics/public health survedlance/ea

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PHll) Public Health and Preventive Medicine Toronto Notes 2023

• types ofsurveillance

• passive surveillance: reporting of disease data by all institutions that see patients, relying solely

on the cooperation of healthcare providers (laboratories, hospitals, health facilities, and private

practitioners)

most common, least expensive, but difficult to ensure completeness and timeliness of data

active surveillance: regular visits to health facilities for reviewing medical records to identify

suspected cases of disease under surveillance,or active testing of a population for the presence of

a disease

resource-intensive, used when a disease is targeted for eradication where every possible case

must be investigated, or for outbreak investigations

sentinel surveillance:selective reporting of disease data from a limited network of carefully

selected reporting sites with a high probability of seeing cases in question

well-designed system can be used to signal trends, identify outbreaks, and monitor the

burden of disease in a community in a timely and cost-effective manner compared to other

kinds of surveillance

may not be as effective in identifying rare diseases, or diseases that occur outside the

catchment area of sentinel sites

Sources:World HealthOiganuation. Public Health Surveillance. Accessed horn: hllps://www.who.lnl/immunli <ilion/monilormg surveillance/burden/ vpd/

surveillance lype passivcieni; htlpsri/www.who.inl/lmmuiiixalion/monitoring surveillanceiburdcn/vpd /survcillance type/achvefen/: hitps: .WAY who.

int/immuniiationfmonitoring surveillance) burden,1

vpdisurveillance lypci'senlinel/en/

Passive Prevention

Measures that operate without the

person’s active involvement (e.g.airbags

in cars) are more effective than active

prevention,measures that a person must

do on their own (e.g. wearing a seatbelt)

Example of Primary Prevention

HPV 9-Valent Vaccine and Its Efficacy in

the Prevention of Cervical Cancer

• This is a nonavalent HPV vaccine

coveting strains 6.11, 16.18. 31.33.

45.52,and 58

• The efficacy of this vaccine was

studied in 4 randomized,doubleblind. placebo-controlled trials on

females between 11 and 26 yt and

was found to prevent nearly100%of

precancerous cervical changes for up

Disease Prevention Strategies to 4 yr after vaccination

• measures aimed at preventing the occurrence, interrupting through early detection and treatment, or

slowing the progression of disease/mitigating the sequelae

Table 3. Levels of Disease Prevention Does Evidence Support Supervised

Injection Sites?

Can Fam Physician 2017:63(11):866

• Clinical question:Do supervised

injection sites (SISs) reduce mortality,

hospitalizations,ambulance calls,or

disease transmission?

• Bottom line: The best evidence

from cohort and modelling studies

suggests that SISs are associated

with lower overdose mortality

(88 fewer overdose deaths per

100000 person-years (PYs)),67%

fewer ambulance calls for treating

overdoses, and a decrease in HIV

infections.Effects on hospitalizations

are unknown

Level of Prevention Goal Examples

Primordial Preventing the development of risk factors Education that begins in childhood about behaviour thatcan

harm health

Programs that encourage physical activity

Immunization programs (e.g. measles, diphtheria, pertussis,

tetanus, polio,see Paediatrics, P5)

Smoking cessation

Seatbelt use

See f andmark Public Health andPreventive Medicine Idols.

PH32for more information on VAXICOl. which detailsthe

impact of influenza vaccination ol nursing home staff on

mortality of residents

Mammography

Routine Pap smears

FIT (vs.FOBI vs. colonoscopy)

Treatment and rehabilitation of disease to DM monitoring with HbAlc, eye exams,foot exams

prevent progression,permanent disability, and Medication to manage chronic conditions

future disease

Primary Protect health and prevent disease onset

Reducing exposure to risk factors

Secondary Early detection of (subdinical) disease to

minimize morbidity and mortality

Tertiary

Smoking Cessation:Ifaping Compared with

Traditional Nicotine Replacement Therapies:a

Systematic Review and Meta -analysis

BMJ Open 2021:11:e444222

Pooled resultsfrom six randomized control*

d