Research Pillar: Population Health

A program of research on criminalization of sexuality, HIV and incarceration among marginalized women

Marginalized women (trans inclusive) living with and affected by HIV are disproportionately criminalized. This research will establish an empirical evidence base that documents the lived-experiences of criminalization and incarceration among sex workers and women living with HIV. The ultimate goal is to inform evidence-based law reform and interventions to redress over criminalization and negative effects of incarceration.

The objectives of this research program are to:

  1. Document how evolving laws and policy frameworks governing sexuality (criminalization of sex work; criminalization of HIV non-disclosure) impact HIV care trajectories, sexual health and social inequities among sex workers and women living with HIV.
  2. Describe and monitor the impacts of incarceration on HIV care trajectories and social outcomes among women living with HIV.
  3. Identify and pilot novel structural and community-based interventions to mitigate the impact of incarceration on HIV care trajectories and social outcomes among women living with HIV.
  4. Develop a research and training platform for innovative community-based participatory research approaches to inform program and policy interventions.

A causal inference framework for analyzing large administrative healthcare databases with a focus on multiple sclerosis

Provincial health authorities routinely collect patient information on a massive scale, but health researchers face the challenge of exploring cause-and-effect relationships using these non-randomized population-based data sources. Machine learning methods are increasingly used to analyze these large datasets, although they do not inherently take causal structures (i.e., how the variables affect each other) into consideration and may lead to less-than-optimal or even erroneous conclusions.

Health researchers urgently need new big-data analytic methods that are geared towards extracting causal explanations rather than merely increasing prediction accuracy. This project will develop innovative biostatistical methodologies that will better equip health researchers to infer causation from big-data sources.

As a motivating problem, with a bias reduction goal in mind, Dr. Karim will investigate potential benefits of disease-modifying drugs in multiple sclerosis patients 50 years of age or older. Ultimately, this methodological development will enable health researchers to convert information into actionable knowledge for other common, chronic conditions, leading to cost-effective medical decision making and improving the health of Canadians.

Mental health trajectories of immigrant and refugee children: An ecological population-based approach

Canada’s immigrant and refugee population is growing rapidly, representing over 20% of the population. Despite the significance for Canadian society, little is known about mental health and risk factors among immigrant and refugee children and youth. Such knowledge is, however, critical to understand how we can support them in adapting to Canada, and enhance their well-being. This project aims to create actionable evidence that health professionals, educators, and decision-makers can use to implement initiatives that can support the mental health of immigrant and refugee children and youth.

This research will:

  1. Use statistical analyses of multiple databases, linked at a population-level across 10 school districts of BC, to examine how child, family, school, and community factors relate to immigrant and refugee children’s mental health outcomes, and how these children and youth are using health services in BC.
  2. Ask immigrant and refugee youth about their perspectives on factors related to their mental health and access/barriers to mental health services, via interview focus groups in school and mental health clinic settings.

This is the first study in BC to combine province-wide data with children’s own perspectives to identify which factors may need to be addressed and what future prevention and intervention efforts are needed to support long-term health outcomes for immigrant/refugee children and youth in Canada.

End of Award Update – June 2023

Most significant outputs

This project allowed us to study and identify population-level diagnostic prevalence of mental health disorders across immigrant, refugee, and non-immigrant children and youth in British Columbia (BC). In this research, we found notable differences in the diagnostic prevalence rates of conduct disorder, attention-deficit/hyperactivity disorder (ADHD), and mood/anxiety disorders across immigrant, refugee, and non-immigrant children and youth, as well as across factors such as sex, age, and immigrant/refugee generation status.

This project also allowed us to delve more deeply into the factors that might impact the emotional health of refugee children. This research identified that specific factors associated with refugee children’s perceptions of their social context (e.g. a supportive school climate, support from adults at school) were associated with better emotional health.

 

Impact

To our knowledge, our research is the first to provide population-level mental disorder prevalence estimates that compare immigrant, refugee, and non-immigrant groups in BC. This provides important information to our understanding of the mental health status of immigrant and refugee children and youth in BC.

 

Potential Influence

We hope that this work will be the impetus for additional research examining the unique mental health patterns and needs of diverse child and youth sub-populations that tend to be underrepresented in mental health research. Understanding the unique needs of Canada’s diverse sub-populations is particularly important for health service planning and informing health policies.

 

Next Steps

With the support of a Tier 2 Canada Research Chair and funding from the Canadian Institutes of Health Research and Social Sciences and Humanities Research Council of Canada, we are continuing our work to deepen our understanding of the developmental trajectories and unique mental health needs of diverse children and youth in BC.

The real-world effectiveness of hepatitis C virus (HCV) treatment on decompensated cirrhosis and hospitalizations

Between 230,000 to 450,000 Canadians are infected with hepatitis C virus (HCV). Most of these people were infected decades ago and remained untreated due to the severe side effects and low effectiveness of interferon-based treatment regimens. Therefore, HCV associated liver related morbidity and mortality are now on the rise, with substantial impact on health care utilization. 

Recently, highly effective interferon-free direct acting antiviral (DAA) treatments have started to become available. However, data on real-world effectiveness of DAAs in terms of hospitalization, cirrhosis, decompensation, hepatocellular carcinoma  and mortality is not yet available. 

Dr. Darvishian will address crucial knowledge gaps in the HCV response to DAAs. Specifically, her research will:

  1. Assess the real-world effectiveness of DAA treatments on overall and liver disease-related hospitalizations and the number of hospital admissions.
  2. Assess the real-world effectiveness of DAA treatments in preventing decompensated cirrhosis.
  3. Assess the potential modifying effect of metformin and/or statin on effect of DAAs and their synergestic effects on hospitalizations and decompensated cirrhosis.

The results of this study will be critical for designing an optimal strategy for HCV care and DAA treatment and refining HCV treatment guidelines and strategies.
 

The role of material security in improving health for people who use illicit drugs

It is well known that an adequate and secure income promotes health. However, material security (e.g., housing, food, and service access) may operate distinctly from income security, particularly for people who use illicit drugs, whose ongoing need to acquire drugs may affect the degree to which income security translates into material security and subsequent health improvements. Nevertheless, material security and its relationship with health are not well understood, an important oversight in research among people who use illicit drugs (PWUD). 

Dr. van Draanen Earwaker will seek to fill this critical gap in the research by examining the role of material security in improving health for PWUD in British Columbia through a longitudinal mixed methods study. The results of her research will generate scientific knowledge about factors that enhance material security, the impact of material security on health, and what material security means to peer workers.

This information is of relevance to the PHS Community Services Society  and other social impact employers in British Colombia, as an increasing number of these social enterprises provide opportunities for reliable income as well as access to community support and resources for PWUD. This research will include an examination of how employment through these social enterprises and harm reduction services affect material security.

Dr. van Draanen Earwaker will work with knowledge users in community-based social enterprises, like PHS, to help spread successful employment models that address material security for highly socio-economically marginalized communities. Knowledge will be shared with the community, including feedback reports for community employers, and knowledge sharing sessions aimed at peer and social impact employers. Ultimately, this work will contribute to an evidence base for designing program and policy solutions to improve health outcomes for PWUD.

 

Can specialized sexual health clinics address unmet mental health needs of sexual minorities?

Gay, lesbian and bisexual (GLB) Canadians are at higher risk of depression, anxiety, drug and alcohol use problems and suicide attempts, but there are few places where these mental health needs can be met in a way that is mindful of the judgment GLB people may fear on the basis of their sexuality. Many sexual health clinics already serve as GLB-sensitive points of care for diagnosing and treating sexually transmitted infections, including HIV. These clinics and their nursing staff could be supported in routinely offering assessment, referral, and counseling for mental health concerns; however, the extent to which this is needed and desired has not yet been explored. Dr. Salway will use a combination of data sources and methods to characterize the potential for such interventions.

This study will answer three questions:

  1. What are the unmet mental health service needs of GLB clients of sexual health clinics?
  2. How can these needs potentially be met through the sexual health clinics?
  3. What is the appeal of new approaches to meeting mental health needs through sexual health clinics?

Dr. Salway will use a large, linked data set to estimate how many sexual health clinic clients currently access mental health-related services from other hospitals or clinics. Interviews will be conducted with nurses and clients, and a survey will be administered at three sexual health clinics in Vancouver that predominantly serve GLB populations. 

Dr. Salway’s research will be conducted in collaboration with nurses, clinic managers, and policy-makers to ensure that results are applied to existing services. Through these collaborations, findings will be translated into clinical guidelines, training programs for clinicians, and policy recommendations. Ultimately, this study will provide evidence for promising strategies that will not only improve health care for sexual health clinic clients, but also contribute to reductions in mental health disparities that continue to affect GLB Canadians today.
 

Early-life environmental exposures and development of childhood asthma

In Canada, a striking 13% of children (~500,000) have asthma. It is the leading cause of absenteeism from school, and accounts for more than 30% of Canadian health care billings for children. Asthma is also the leading cause of hospital admissions in both children and the general Canadian population. Given that asthma typically begins in childhood and lasts throughout life, the high prevalence, combined with significant related morbidity, make asthma the most common and burdensome chronic non-communicable disease affecting young Canadians.

Asthma is a complex disease dependent on the interactions of genetic predisposition with environmental factors including physical, microbial, and social environments. The Canadian Healthy Longitudinal Development (CHlLD), a cohort study funded by CIHR, has recruited over 3,500 pregnant mothers to collect such environmental and biological data from pregnancy up to age five in four Canadian cities: Vancouver, Edmonton, Toronto and Winnipeg. The proposed project will use biological and environmental data from the CHILD cohort and will focus on traffic-related air pollution and natural spaces. These two modifiable environmental exposures have been shown to be associated with asthma exacerbation.

The novelty of this research lies in the study of joint exposures and their interactions over time; their impact likely depends not only on individual genetic profiles, but also on the critical timing of exposure. Early life period, including in utero, is a critical influence on health in later life. Likewise, changes in gene function in relation to environmental influences provide evidence to explain how and why asthma and allergies exist and progress.

Dr. Sbihi’s research will examine how these changes, called epigenetic modifications, are affected by the early-life environmental exposures, including the body’s microbial milieu. By examining how the environmental exposures (traffic air pollutants, natural spaces, gut microbes) impact DNA methylation and consequently how these epigenetics modifications lead to asthma, we will be able to better understand the mechanisms of asthma development and subsequently provide better targeted prevention measures.

 

Addressing HIV/AIDS, sexual health, and substance use among gay and other men who have sex with men

New HIV diagnoses are 71 times higher among gay, bisexual and other men who have sex with men (GBM) than other men in Canada. Since 2010, BC has adopted Treatment as Prevention (TasP) as a policy to increase HIV testing and engage more HIV-positive individuals in effective treatment to reduce transmission at a population level. However, the number of new diagnoses among GBM in BC has remained largely unchanged. Further, surveillance shows an increase of HIV diagnoses among the youngest birth cohorts of GBM. HIV pre-exposure prophylaxis (PrEP) is a new preventive tool for HIV-negative GBM, but inaccurate information, sub-optimal adherence or risk-compensation could result in a false sense of security, paradoxically leading to increased HIV transmission. In addition to HIV, infectious syphilis is now epidemic among GBM in BC.

This research program will address the HIV and sexually transmitted infection (STI) epidemics among GBM in Metro Vancouver and BC. Dr. Lachowsky will measure HIV risk behaviour over time, determine how PrEP affects bacterial STI incidence, and analyze shifting attitudes about HIV, challenges with HIV prevention and treatment, and changes in sexual negotiation and practices. Results will directly inform population-specific, age-relevant public health policy, programming, and interventions to reduce the burden of HIV for GBM, especially young GBM.

Dr. Lachowsky will employ a bidirectional, integrated knowledge translation approach, with a Community Engagement Committee and key academic, public health, and community partners. An interactive Web 2.0 hub will allow for knowledge dissemination and generation with community and service providers, and will be complemented with more traditional presentations, workshops, and publications.This single research project is part of a larger program of research examining health disparities amongst GBM in BC and Canada using interdisciplinary, community-based approaches.

Improving substance use treatment trajectories for men who have sex with men

British Columbia is currently in the process of developing and implementing new evidence-based policies and clinical reforms to address problematic substance use, including new: (i) pharmacotherapy approaches (e.g., replacement therapies); (ii) clinical practice guidelines; and (iii) integrated service delivery models of care. While men who have sex with men (MSM) represent a key group with historically high levels of substance use disorder and subsequent social and health-related sequelae (e.g., increased rates of HIV and sexually transmitted and blood-borne infections), there remains a gap in our knowledge about how best to design and implement services for today's generations of various sub-groups of MSM who use drugs (e.g., MSM who are: young; Indigenous; economically deprived).

Dr. Knight's five-year population health research program will adapt health policy and service delivery practices to improve substance use treatment trajectories for key groups of MSM who use drugs and are at risk for severe health and/or social consequences (i.e., the criteria for substance use disorder, as defined under DSM-V criteria). The aim will be to identify the most efficacious and scalable combinations of strategies to adapt interventions that respond to MSM's individual needs and broader social and structural conditions. This approach to implementation science offers a way to go beyond describing the problem and to focus on building an evidence base for implementing and adapting context-sensitive and population-specific solutions into routine policy and practice.

With collaborators representing the BC Ministry of Health, Vancouver Coastal Health, BC Centre for Disease Control and YouthCO HIV/Hep C Society and the BC Centre for Excellence in HIV/AIDS, as well as through the engagement of the BC Centre on Substance Use's Community Advisory Board, Dr. Knight's findings will be used to inform the development of policies (including clinical and provincial guidelines) to effectively scale up and integrate services that have the capacity to improve substance use treatment trajectories for MSM. Contributions to new knowledge will include the identification of the individual, social and structural factors shaping MSM's ability to reduce problematic drug use and prevent severe health and social outcomes (e.g., HIV and/or Hep C). Study outputs will also be assessed at an annual Stakeholder Workshop in which recommendations will be developed and refined for clinical and provincial guidelines.

Improving the implementation and impact of evidence-based health promotion interventions in real world settings

Findings from health promotion research that could help Canadians live healthy lifestyles are often not applied in practice. This gap between health promotion research and health promotion practice is particularly concerning for people with spinal cord injury (SCI). Despite people with SCI's urgent need for interventions that respect their unique challenges and barriers to health behaviour change, there are very few health promotion interventions designed for people with SCI. To ensure health promotion research improves the health of all Canadians, there is an urgent need to improve the use of health promotion research in practice.

The aim of this five-year knowledge translation research program is to examine methods for improving the use of health promotion research in real-world practice. Given the lack of health promotion interventions for people with SCI, this research program will examine how we can improve the use of health promotion evidence to enhance the health of people living with SCI. 

Dr. Gainforth will examine how successful and unsuccessful practitioners apply health promotion techniques when promoting healthy behaviours to people with SCI and develop the first evidence-based guidelines, tools and interventions to improve knowledge translation partnerships between researchers and members of the SCI community. Lessons learned from practitioners will be used to develop and test tools and interventions to help other practitioners successfully promote healthy behaviours to people with SCI.

Ultimately, this research will develop best practices for building capacity among researchers and community members to conduct and share research in partnership. In turn, findings and the approach can support other research teams aiming to use partnerships to conduct and share research that enhances the health of marginalized groups.