Employing Community-based Participatory Research Approaches to Improve Local Influenza Pandemic Preparedness in Remote and Isolated Canadian First Nations Communities
Charania, Nadia A.
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Background: Public health emergencies, such as influenza pandemics, continue to disproportionately impact Aboriginal Canadians (First Nations, Inuit, and Métis), especially those populations residing in geographically remote areas. Previous influenza pandemic plans reflected inadequacies with regards to addressing the pre-existing inequalities and special needs of Aboriginal Canadians during an influenza pandemic, and this may be attributed to their limited participation during preparedness efforts. Significant barriers hinder the ability of Aboriginal Canadians to effectively participate in preparedness efforts and there is a limited amount of information of how to operationalize their participation. By addressing the identified barriers to participation, community-based participatory research (CBPR) offers a promising framework and strategy to facilitate the effective participation of Aboriginal Canadians in influenza pandemic preparedness efforts. Objectives: The overall objective of this dissertation was to explore the use of CBPR approaches to engage community members in directing how to improve local influenza pandemic preparedness in remote and isolated Canadian First Nations communities. This dissertation consisted of five manuscripts grouped into three overarching studies; all of which employed a CBPR approach. The objectives for Study I were to qualitatively identify the needs and explore the potential of using a collaborative health informatics system (CHIS) to improve the delivery of health care services during an influenza pandemic response while also identifying any perceived barriers of implementing such a system. Study II used a qualitative questionnaire to examine the experiences, perceptions, and recommendations regarding implementing measures to mitigate the effects of an influenza pandemic. Study III was a cross-sectional survey conducted to gain an understanding of the bird harvesting practices and knowledge, risk perceptions, and attitudes regarding avian influenza among subsistence hunters and discussed related implications to future influenza pandemic plans. Methods: The initial needs assessment of Study I involved conducting semi-directed interviews with community-based health care professionals (n=9) residing in three remote and isolated Canadian First Nations communities to explore the use of the CHIS. The second needs assessment of Study I was conducted with one of the initial three study communities and involved semi-directed interviews and focus groups with community-based health care professionals (n=16). Questions were specifically developed to further explore issues that emerged from the initial needs assessment. Interviews were transcribed verbatim and open, axial, and selective coding were used to create the emerging concepts and categories. Study II involved conducting interviewer-administered questionnaires with community-based health care professionals (n=9) residing in three remote and isolated Canadian First Nations communities to explore the experiences, perceptions, and recommendations regarding forty-one mitigation measures. The collected qualitative data were transcribed verbatim and deductively analyzed following a template organizing approach. The cross-sectional survey of Study III was conducted with subsistence hunters (n=106) residing in a remote and isolated First Nations community. The survey employed twenty closed-ended questions related to bird harvesting practices, knowledge, risk perceptions, and attitudes about hunting influenza-infected birds. Two open-ended questions allowed for participants to describe their risk perceptions of avian influenza as well as any additional concerns. Simple descriptive statistics, cross-tabulations, and analysis of variance (ANOVA) were used to examine the distributions and relationships between variables. Written responses were transcribed verbatim and deductively analyzed following a template organizing approach. Results: For the initial needs assessment of Study I, the fifty-five emerging concepts were organized into five categories, including: general issues, potential benefits, potential uses, useful technical functions and suggested technical modifications, and concerns. Participants stated that the CHIS could improve the delivery of health care services by tracking and mapping the occurrence of disease outbreaks, along with facilitating communication and health information sharing between the involved health care organizations. Some concerns of the CHIS were noted, namely the concern of accessibility safeguards considering that confidential health information would be inputted, stored, and presented. For the second needs assessment of Study I, one hundred and thirty eight emerging concepts were organized into four overarching categories, including: level of intra- and inter-government agency communication and collaboration, health information sharing within and between government agencies, patient charting and reporting, and solutions. It was noted that having different jurisdictions responsible for providing health care services hindered the ability to share patient’s health information and provide quality health care. Participants stated that the CHIS could potentially be utilized to help manage a response by facilitating inter-agency communication, collaboration, and health information sharing. For Study II, participants reported that thirty mitigation measures were used during their response to the 2009 H1N1 influenza pandemic (A(H1N1)pdm09). Although participants reported that most measures were modified or altered when being implemented to address the unique characteristics of their communities. All of the mitigation measures implemented during A(H1N1)pdm09 were considered to be effective, along with three measures that were not used and one additional measure suggested by a participant. Measures were considered to be effective particularly if the measure aided in decreasing virus transmission, protecting their high-risk population, and increasing community awareness about influenza pandemics. Participants reported that lack of resources, minimal community awareness, overcrowding in homes, and inadequate health care infrastructure hindered the implementation of some mitigation measures. The list of community-informed recommended mitigation measures created from the collected data revealed many discrepancies when compared to national recommendations and existing literature. For Study III, the findings indicated that subsistence hunters partook in some practices while harvesting wild birds that could potentially expose them to avian influenza, although appropriate levels of compliance with some protective measures were reported. More than half of the respondents were generally aware of avian influenza, with fewer being aware of key signs and symptoms, and almost one third perceived a risk of becoming infected with avian influenza while harvesting birds. Participants aware of avian influenza were more likely to perceive a risk of being infected with avian influenza while harvesting birds. The results suggested that knowledge of avian influenza positively influenced the use of a recommended protective measure. Regarding attitudes about hunting influenza-infected birds, the results revealed that the percentage of hunters who would cease harvesting birds increased as avian influenza was detected in birds in more nearby geographic areas. Conclusions: Study I highlighted that the CHIS was viewed as being a useful and valuable tool to improve the delivery of health care, among other potential functions, during an influenza pandemic response. Study II highlighted the perceived barriers to implementing nationally recommended mitigation measures and supports the notion of recommending pandemic control strategies in remote and isolated Canadian First Nations communities that may not be supported in other communities. And Study III revealed a need for more education that is culturally-appropriate about avian influenza and precautions First Nations subsistence hunters can take to reduce the possibility of being exposed to avian influenza while harvesting wild birds. Moreover, the inclusion of First Nations subsistence hunters as an avian influenza risk group with associated special considerations in future influenza pandemic plans seems warranted. In general, the three overarching studies of this dissertation display the importance and value of employing CBPR approaches to engage locally impacted populations in improving influenza pandemic preparedness. The CBPR processes used and findings revealed throughout this dissertation can be used to inform future influenza pandemic preparedness efforts to improve the response capacity and health outcomes of Canadian First Nations residing in remote and isolated communities during the next influenza pandemic.