(1) To describe sexually transmitted and blood-borne (STBB) co-infection events in Nova Scotia from 2019 to 2023. (2) To compare the demographics and risk factors of individuals presenting with a single STBB Infection (STBBI) vs an STBB co-infection event over the same period. We conducted a population-based descriptive study of residents in Nova Scotia diagnosed with an STBBI between January 2019 and December 2023. Data were pulled from Panorama, Nova Scotia Public Health’s information management system. Nova Scotia Surveillance Guidelines were used to define confirmed cases of each included STBBI (human immunodeficiency (HIV), hepatitis B (HBV), and hepatitis C (HCV) viruses, chlamydia, gonorrhea, and syphilis). We defined a co-infection event as infection by at least two separate STBBI pathogens within a 90-day period. We summarized demographic characteristics of individuals who experienced co-infection events and used the chi-square goodness-of-fit test to determine whether there was a significant difference in risk factor distribution compared to those who had a single STBBI (non-co-infection events). There were 320 STBB co-infection events from 2019 to 2023, with the reported rate of 6.7 co-infections per 100,000 population in 2019 and 10.7 co-infections per 100,000 population in 2023. A chlamydia-gonorrhea co-infection event was the most prevalent STBB co-infection in Nova Scotia, representing 72
Gaps between epidemiological evidence and public policy remain a persistent challenge in public health. Despite increasing data availability, and public awareness, evidence often fails to translate into timely or equitable policy action. In this Commentary, we argue that epidemiologists must come together to support the integrity of evidence-informed public health policy making. As an example, we describe the International Network for Epidemiology in Policy (INEP). INEP was established in 2006 to address these gaps by promoting the more ethical and effective use of epidemiological evidence in policy making. Comprising 25 member organizations, including the Canadian Society for Epidemiology and Biostatistics, INEP provides an international forum to support the bridge between science and policy. Highlighted is the Toolkit on the Misuse of Epidemiological Methods which provides a framework for recognizing and countering misinformation used to cast doubt and confuse the public and policy makers. Also highlighted is the statement on Including Children's Voices in Policy as an example of INEP's advocacy for equitable, evidence-informed, decision-making. Finally, we call for expanded engagement of Canadian epidemiologists and biostatisticians in global networks like INEP, which are essential for bridging science and policy, strengthening public trust, and ensuring epidemiologic evidence informs public health action.
In 2020, the Canadian Partnership Against Cancer commissioned the Urban Public Health Network to lead a multi-phased project to identify the inequalities and barriers to HPV vaccination for school-aged children across Canada. In Phase One, the UPHN team collaborated with public health and community partners across Canada to identify barriers to vaccination at a sub-jurisdictional and sub-populational level using a multiple methods approach. In Phase Two, UPHN is working with existing and new partners to achieve system-level outcomes through developing and testing innovative education and program delivery strategies to increase HPV immunization in school-based programs, using findings from Phase One. A Plan, Do, Study, Act (PDSA) framework, a core component of the Quality Improvement (QI) Model for Improvement, to implement quality improvement programs has been foundational in the development of and approach to these projects. In this commentary, we suggest that a PDSA framework offers an effective stepwise strategy to promote continuous learning, evaluation, and refinement of innovative practices, particularly in complex systems.
Violence and intentional self-harm are major contributors to morbidity and mortality in Canada. Newcomers may face unique vulnerabilities shaped by pre-migration trauma, settlement stressors, and structural barriers, yet population-based evidence on intentional injuries among immigrants in Alberta remains limited. The objective of the current study was to identify associations between immigrant status, and immigrant admission type, and intentional injuries experienced by Albertans. We conducted a longitudinal retrospective cohort study of Albertans using the 2016 data from census records linked to emergency department (ED) data from 2016 to 2023. Outcomes were ED visits for intentional injuries, defined using International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada (ICD-10-CA) codes for assault and self-harm. The primary exposure was immigrant status (recent immigrant vs. non-immigrant), and the secondary exposure was immigration by admission category (compared to long-term immigrants). Cox proportional hazards models were used to evaluate the association between immigrant status, immigration admission type, and intentional injury outcomes. Our baseline sample was representative of over 300,000 immigrants and 2.4 million non-immigrants living in Alberta in 2016. Injury rates were highest among non-immigrant (237.57 per 100,000 person-months) populations (vs. 168.73 per 100,000 person-months). Immigrant status was associated with a lower hazard of intentional injury compared with non-immigrants (HR 0.71, 95
Cervical cancer is highly preventable and treatable but continues to affect thousands in Canada each year. Inspired by the World Health Organization's global elimination goal, Canada has committed to eliminating cervical cancer by 2040. The Action Plan for the Elimination of Cervical Cancer in Canada, 2020-2030 outlines key strategies to increase human papillomavirus (HPV) vaccination, implement HPV primary screening, and improve follow-up care. It also prioritizes equity by embedding First Nations-, Inuit-, and Métis-specific actions and addressing systemic barriers faced by equity-denied populations. Provinces and territories have made progress, but more needs to be done to improve vaccination and screening rates. Recent advances, such as reduced HPV dosing schedules and HPV self-screening, offer promising opportunities to accelerate progress. Achieving elimination will require coordinated action to improve access, foster culturally safe care, and enhance data collection to identify and address inequities. This commentary highlights the need for intensified efforts and shared accountability to ensure all people in Canada benefit from cervical cancer prevention and care. With bold and inclusive action, Canada can become one of the first countries in the world to eliminate cervical cancer.
Indigenous epidemiology has emerged as a critical intervention to address health inequities and the exclusion of Indigenous Peoples from population health research. While advances in Indigenous data sovereignty and community-led surveillance have strengthened ethical accountability, less attention has been given to the epistemic conditions that shape how Indigenous knowledge systems are evaluated, constrained, and authorized within epidemiological research. This article examines how routine methodological, governance, and interpretive practices constrain Indigenous epistemologies in public health research and introduces the Theory of Epistemic Containment. The analysis draws on a longitudinal, reflexive, meta-methodological study of institutional texts produced over 15 years (2011–2026), including peer-review reports, grant-adjudication feedback, research ethics correspondence, editorial decisions, and committee and governance deliberations. The study treats methodological negotiations as empirical evidence of how scientific authority is produced and contested. The findings reveal recurring patterns of epistemic containment, including differential standards of methodological scrutiny, the relegation of Indigenous governance to ethical or contextual domains, the separation of Indigenous governance from epistemic authority, and asymmetrical authorization of causal claims and policy relevance. Quantitative epidemiological methods are routinely treated as neutral and self-authorizing, whereas Indigenous methodologies and governance systems are subjected to heightened justification, limitation, and restraint. This article advances the Theory of Epistemic Containment as a framework for understanding epistemic racism in Indigenous epidemiology. It argues that transforming population health research requires moving beyond methodological inclusion towards methodological accountability, recognizing Indigenous governance as an epistemically authoritative foundation for knowledge production, public health decision-making, and Indigenous self-determination.
In the summer of 2021, the Canadian province of British Columbia (B.C.) experienced an unprecedented extreme heat event, which resulted in 619 heat-related deaths across the province (Henderson et al., 2022). This evaluation aims to assess the sensitivity and specificity of a surveillance algorithm to identify heat illness-related emergency department (ED) visits during this period, as well as to explore the impact of adjusting the case definition to enhance algorithm performance. A chart review of ED visits across a regional health authority in B.C. during the 2021 period of extreme heat was conducted. This was considered the most accurate information to which the algorithm was compared. Sensitivity and specificity were calculated for the original algorithm, as well as for an expanded algorithm including heat-related illnesses and the following additional diagnoses: syncope, altered level of consciousness, acute kidney injury, acute renal failure, and general weakness. The original algorithm focusing on explicitly recorded heat illnesses has a sensitivity of 59
The objective of this workshop was to collaboratively co-create concrete, practical teaching resources that embed equity, diversity, and inclusion (EDI) concepts into epidemiology and biostatistics teaching in Canada. The 3-h interactive session developed four examples of the inclusion of EDI considerations in epidemiology and biostatistics teaching based on commonly used textbooks. Participants, in small breakout groups, critically reviewed examples from two common textbooks (Modern Epidemiology and Fundamentals of Biostatistics). Groups of four participants selected two examples each from a list of core concepts (e.g., confounding, regression). The groups then integrated EDI considerations into the core examples from the textbooks by addressing focus areas like sex and gender or race and ethnicity, and presented their revised materials. Two groups of four participants selected two topics each. Group 1 selected regression and missing data, while group 2 selected interaction/effect measure modification and hypothesis testing and two-way ANOVA. For a regression model example from Modern Epidemiology, participants recommended changing “pregnant women” to “pregnant person” for gender inclusivity and reframed “normal” to highlight social and structural determinants. In a missing data example, they replaced ageist and judgment-laden terminology (“elderly,” “unwilling”) with “older adults” and “unable.” Group 2 discussed the importance of including biological plausibility and measurement considerations when using sex, defined as male/female, as an effect measure modification in potential analyses. This workshop and concomitant paper demonstrate the need for integrating EDI into epidemiology and biostatistics teaching. It also provides concrete examples of how this can be done using common textbooks. Integrating EDI into the curriculum not only improves student understanding of EDI, but can also strengthen understanding of, and interest in, epidemiology and biostatistics.
In the context of widening health and social inequalities and increasingly complex public policy issues, the well-being policy paradigm offers an opportunity for public health to collaborate with non-health sectors to address social and structural determinants of health. The Quality of Life Framework for Canada (“the Framework”) is the Canadian federal government’s foray into well-being policy and can be considered a Health in All Policies (HIAP) initiative. This case study examines the Framework’s development alongside the HIAP model, identifying barriers and facilitators for effective multisectoral action. This work was developed as an applied policy case study. Semi-structured interviews were conducted with 18 representatives across 11 federal departments. A qualitative matrix approach and thematic analysis were used to identify success factors, barriers, and opportunities for improvement. The World Health Organization’s (WHO) Four Pillars Model for HIAP was used to guide analysis using the HIAP pillars (governance and accountability; leadership at all levels; ways of working; and resources, financing, and capabilities). Multisectoral action was critical to the success of the Framework’s development. Key facilitators included the establishment of interdepartmental governance, a formalized and transparent mandate, and committed leadership. Findings indicated strong alignment with and adoption of HIAP approaches. The findings from this case study illustrate how well-being policy initiatives can be leveraged to advance collaboration for public health equity and determinants of health. Lessons learned are relevant to the work of public health practitioners as well as those working in non-health sectors, including policy-makers and decision-makers, particularly in a government context.
This study presents the first province-wide spatial analysis of shelter accessibility for survivors of domestic violence in Ontario, Canada. Using travel time calculations from dissemination area (DA) centroids to the nearest crisis and second-stage shelters, we quantify geographic disparities in access across urban, suburban, rural, and remote communities. Shelter data were compiled from ShelterSafe and public databases, and rurality was classified using Statistics Canada’s Index of Remoteness. Results reveal stark gradients in accessibility: average travel time to second-stage housing in remote areas exceeds 247 min, compared to 26.6 min in urban centres. Crisis shelters, while more numerous per capita, remain significantly less accessible in rural regions. Regression models indicate that shelter type, remoteness, and service features (i.e., pet accommodation, childcare, accessibility) predict travel time, with second-stage shelters and those offering more service options often situated farther away. These findings underscore how structural and spatial inequities shape survivors’ ability to seek safety and support. Policy recommendations include revising housing eligibility timelines, investing in rural second-stage infrastructure, and using geospatial tools to identify service deserts.
Canadian population-based data show that sexually diverse youth face greater mental health challenges than their heterosexual peers. However, nuances within sexual diversity—particularly among mostly heterosexual persons—are overlooked, and psychotic-like experiences remain underexplored. We examined the mental health of sexually diverse young adults from Quebec, spanning indicators from well-being to psychotic-like experiences. Data were drawn from 1324 youth from the Quebec Longitudinal Study of Child Development—a representative cohort born in 1997/98 and followed up until age 23. Participants self-reported their sexual orientation and mental health across nine indicators: suicidality, depression, anxiety, binge drinking, cannabis, other drug use, psychotic-like experiences, well-being, and help-seeking. Standardized mean differences (SMD) assessed group differences, stratified by assigned sex at birth and sexual orientation. A total of 324 (24.47
In New Brunswick (NB), the Healthy Families, Healthy Babies (HFHB) public health program provides targeted perinatal services to first-time families at higher risk of poor outcomes. Research question: Does participation in the targeted HFHB prenatal program have a positive impact on select pregnancy and birth outcomes? Population-based administrative datasets were linked to develop a matched retrospective cohort study of all first-time births in NB between April 1, 2012, and March 31, 2020, using propensity scores (PS) and nearest neighbour to select a matched group of nonparticipants. Multivariable regression models provided PS-adjusted risk difference estimates while accounting for remaining imbalanced confounding variables. A cohort of 20,832 births was established, among which 2000 were HFHB prenatal program participants. Overall results do not demonstrate a consistent positive impact of participation on the pregnancy (anemia, gestational diabetes) and birth (preterm birth, poor APGAR score, large for gestational age (GA), small for GA) outcomes examined. Program participation had a small but consistent impact on reduced risk of gestational hypertension (RD −1.3
To explore how two major public health crises—the 2016 Fort McMurray wildfire and the COVID-19 pandemic—affected emergency care (EC) utilization among First Nations residents of the Regional Municipality of Wood Buffalo, Alberta, and to inform First Nations–led health system planning and response. We conducted a co-designed repeated cross-sectional study using interrupted time series analysis of administrative data. Monthly EC visit counts were modeled overall and for mental health and behavioural diagnoses (MBD). Two separate interrupted time series analyses were conducted, each with a single interruption point: the May 2016 wildfire (analytic window May 2014–April 2018) and April 2020 onset of COVID-19 (analytic window April 2017–March 2023). Segmented regression models (Poisson or negative binomial) estimated level and post-event slope changes stratified by age, sex, and location. The wildfire was associated with geographic displacement of care. Province-wide, EC visits showed immediate level changes (+ 21.0
High educational attainment is generally associated with better health outcomes. Yet, studies in the United States show diminished returns to education, such that the health benefits conferred from high educational attainment are weaker for Black Americans. Little is known about whether the diminished returns phenomenon also shapes the health of Black Canadians. To address this gap, this study investigated whether there is an education gradient among Black and White Canadians, such that higher educational attainment is associated with better health, and whether Black Canadians experience diminished health returns. Data from Canadian adults aged 25–64 (Black: N = 200, White: N = 8200) who responded to the 2018 cycle of the Longitudinal and International Study of Adults were analyzed cross-sectionally. Logistic regression models estimated the associations between educational attainment and good self-rated health. An interaction term tested variation in the education-health gradient by race. All models were adjusted for age, sex, and nativity. Fully adjusted models show the odds of reporting good self-rated health generally increased across levels of education. Findings also show that although statistically significant support for the diminishing returns hypothesis was fleeting, this likely reflects insufficient sample size, thus speaking to the need for better Canadian data. Our findings confirm that educational advancement generally confers health benefits for Black and White Canadians. Additional research with larger samples is needed, however, to better understand the systemic mechanisms which may preclude racialized populations from fully reaping the health benefits of education.
Advocates of a public health approach to psychoactive substances need actionable evidence. In several countries, multidisciplinary groups have used multi-criteria decision analysis (MCDA) to generate harm scores and rankings for commonly used psychoactive substances; however, these did not fully reflect substances’ prevalence of use. Public health policy decisions around psychoactive substances should be informed by population-level outcomes, which are driven by use prevalence. Led by a policy practitioner, a multidisciplinary group from across Canada conducted a MCDA of harms caused by 16 commonly used psychoactive substances. To make the analysis more relevant to public health policy, we adapted it to account for not only the severity of harms associated with a substance, but also prevalence of use. This adaptation was applied across harm criteria. Adapting MCDA this way allowed for the generation of harm scores that represent total population-level harm caused by each substance rather than individual-level harm. As a result, they provide clear evidence of the relative population-level harm caused by different substances. This evidence can inform prioritization of public health efforts and be used by policy practitioners advocating for a public health approach to substances. Adapting MCDA to reflect population-level outcomes is a practical innovation for public health policy and practice. Prevalence-adjusted MCDA produces evidence that is well aligned with how public health policy decisions are made and evaluated, and may be applicable to other public health issues characterized by multiple data sources and competing policy objectives.
This study explored the knowledge, awareness, and lived experiences of Indigenous youth ice hockey players across Canada with respect to concussion. Using a community-engaged approach grounded in Two-Eyed Seeing, we examined how intersections of culture, sport, and healthcare shape concussion education, disclosure, and recovery. Sport-related concussions (SRCs) are a significant health concern in Canada, with Indigenous youth disproportionately affected by injuries due to systemic inequities in healthcare access, culturally relevant education, and historical mistrust of medical institutions. Despite the high prevalence of concussions in ice hockey, limited research has examined Indigenous athletes’ perspectives on concussion knowledge, reporting, and recovery. We explored these issues among 48 Indigenous hockey players aged 15–24 from across Canada. Participants completed an online questionnaire that included both open-ended and closed-ended items, addressing concussion awareness, education, and recovery experiences. Thematic analysis revealed that while athletes generally recognized concussion symptoms, many delayed or avoided reporting injuries due to stigma and fear of being sidelined. Access to concussion education varied, with urban athletes more likely to have encountered formal resources, such as the Concussion Awareness Training Tool (CATT), while others relied on informal knowledge from peers, coaches, or family. Recovery experiences for many participants highlighted the importance of traditional healing methods, including smudging, sweat lodges, and Elder guidance, which were valued, but often absent in formal care pathways. In centring Indigenous voices, this work contributes to growing efforts to support Indigenous self-determination in concussion recovery through holistic and community-based approaches within sport and healthcare systems.
Canadian public health organizations across multiple provinces. The intervention is a funding initiative by the Canadian Partnership Against Cancer and the Urban Public Health Network to improve Human papillomavirus immunization by enabling exploration activities by local organizations to leverage data-driven surveillance and community engagement. These activities included quantitative analysis of immunization data linked to sociodemographic indicators and qualitative engagement involving interviews, focus groups, and participatory surveillance with providers and community members. The objective of this multi-site intervention is to demonstrate the value of utilizing mixed forms of surveillance data to improve public health practice using principles of “learning systems.” Mixed-methods surveillance identified geographic and demographic gaps, barriers with regard to HPV immunization coverage including language, trust, and systemic inequities. Exploration activities revealed significant disparities in HPV immunization coverage across regions and populations. Barriers included language and literacy challenges, mistrust of health systems, systemic racism, and logistical issues such as consent processes. Case examples from Vancouver Coastal Health, Saskatchewan Health Authority, Métis Nation BC, and others demonstrated how tailored strategies emerged from these insights. Quantitative findings highlighted sociodemographic predictors of under-immunization, while qualitative data underscored cultural and contextual factors influencing vaccine uptake. This multi-site, multi-method approach provided actionable intelligence for local public health organizations to adapt HPV immunization programs. Lessons learned include the need for flexible funding models and capacity-building for epidemiological analysis. The COVID-19 pandemic significantly influenced implementation timelines and resource allocation, underscoring the importance of resilience in public health systems. Limitations include variability in data infrastructure and challenges in harmonizing approaches across jurisdictions.
This commentary elucidates the Canadian Institutes of Health Research (CIHR) Institute of Population and Public Health’s (IPPH) bolstering of public health systems and services research (PHSSR), by way of its current strategic plan and the launch of two new funding opportunities. The investments advance IPPH’s commitment to strengthening the field of PHSSR, address national calls to bolster PHSSR in Canada, and scaffold on past IPPH investments. PHSSR has potential to inform public health practice and policy, while being responsive to real-world public health priorities and agendas. Our commentary focuses on Strengthening Equitable and Resilient Public Health Systems (STEPS) as an innovative funding program with impactful design elements, including an emphasis on health equity, systems research, knowledge mobilization, and the inter-dependent roles of the public and community sectors at the core of Canadian public health systems. We propose a theory of change on the value-add of PHSSR in driving systems change and in advancing resilient, high-performing, and equitable public health systems. This commentary contributes to the literature by highlighting the promise of PHSSR in Canada, describing STEPS as the first major Canadian funding program on PHSSR, and proposing a theory of change to drive systems change and impact.
