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Pathways to Professions (P2P) is a 13-week experiential education program run by the New Brunswick Institute for Research, Data and Training (NB-IRDT) in partnership with the Government of New Brunswick’s Future GNB program. P2P provides university students with the opportunity to participate in New Brunswick-relevant research.
This year, the program hosted two health-related research streams composed of undergraduate students studying at or having recently graduated from the University of New Brunswick. VitalSignsNB, led by NB-IRDT Research Scientist Dr. Chris Folkins with support from Research Assistant Madeleine Gorman-Asal, included Communications Coordinator Olivia Hamilton and Student Researchers Kay Mills, Vanessa Dairo-Singerr, and Sof Mehlitz.
The P2P+ team was co-led by Dr. Folkins and NB-IRDT Senior Data Analyst Chandy Somayaji. Additionally, the team contained Student Data Analysts Rebecca Foster, Clark Brewster, Emily Thomson, and Kelsi Evans. New this year, the P2P+ stream offered a more advanced research experience for returning P2P students, allowing them to participate in hands-on data analysis in the Statistics Canada Research Data Centre on the UNB Fredericton campus.
Introduction
The New Brunswick healthcare system faces many challenges. Even before the beginning of the COVID-19 pandemic, New Brunswickers have been familiar with headlines about long family doctor waitlists and extensive emergency room wait times (New Brunswick Health Council [NBHC], 2018; Department of Health, 2018). Sufficient access to physician care and continuity of care are long-standing challenges that burden our most vulnerable populations.
The pandemic also introduced new challenges. Uncertainty surrounded many elements of life, including job security, lockdowns, and updates on the virus itself. These stressors, paired with social isolation, were likely contributors to the worsened mental health and increased substance use observed during the pandemic (Chen et al., 2021; Panchal et al., 2020; Roberts et al., 2021).
In a world still grappling with the effects of COVID-19, accessible and adequate healthcare has become more critical than ever. Data-informed decisions can lead to a more resilient and accessible healthcare system and promote healthier futures for all New Brunswickers. Providing evidence to support informed decision-making was the overarching goal for the eight P2P students, who conducted two research projects in the summer of 2022 focused on health and the healthcare system in New Brunswick.
The VitalSignsNB team used administrative data to examine how access to and continuity of physician care are associated with health- and health service utilization-related outcomes among New Brunswickers with chronic conditions.
The P2P+ research team investigated the COVID-19 pandemic’s effect on New Brunswickers’ mental health and substance use behaviours using Statistics Canada survey data accessed through the secure facilities at the Statistics Canada Research Data Centre.
Both projects can potentially inform health policy and service delivery that may promote improved health and well-being in New Brunswick.
VitalSignsNB: Health Outcomes Associated with Low Access to and Low Continuity of Physician Care
As per the New Brunswick Primary Health Survey, 70,000 New Brunswickers were without a family doctor in 2020 (NBHC, 2021). However, having a family doctor on paper does not guarantee quality healthcare access. Only 51% of those with a family physician can get an appointment when needed, which has worsened since 2011 (NBHC, 2021). There is an apparent discrepancy between the number of family doctors per capita and the reality of care received. Our research aims to explore the actual state of access to physician care in New Brunswick and examine how deficits in access may affect health outcomes.
Our Study
Access to routine physician care is essential in preventing, diagnosing, and treating chronic conditions. Those with chronic conditions are likely at a greater risk of negative health outcomes due to poor access. These issues are particularly relevant in New Brunswick, which has the highest prevalence of chronic conditions among the Canadian provinces (Health Council of Canada, 2014). For these reasons, our study focused on New Brunswickers with chronic conditions.
Data from the Canadian Chronic Disease Surveillance System (CCDSS) was used to identify a study population of individuals with one or more chronic conditions. Using NB Physician Billing data and criteria previously established in the literature (Glazier et al., 2008), study participants were classified as having either high or low access to care based on their frequency of physician encounters. Continuity of care is defined as routinely seeing the same provider. This is an essential indicator of the quality of care, as patient-reported outcomes improve with increased continuity (Health Quality Council of Alberta, 2016). To study the continuity of care, we classified our high-access population as having low or high continuity using the Usual Provider of Care (UPC) Index. Various sociodemographic characteristics characterized low and high access and continuity groups. Several health and health service-related outcomes were then compared between these groups using multivariate regression to explore the potential relationships between access, continuity, and quantifiable health.
Results
We found that 6.9% (23,465) of New Brunswickers with chronic conditions were classified as having low access to care. Continuity of care, measured only among the high access group, was classified as low in 25.7% (79,470) of individuals evaluated. In other words, of the New Brunswickers with chronic conditions who were able to see a healthcare provider regularly, 25.7% saw their most frequently visited provider in less than half of their encounters.
Characteristics Associated with Low Access to Care:
New Brunswickers who were male, aged 20-64 (vs 65+), had English as their preferred language (vs French), or were living in a rural area (vs urban), were more likely to have low access to care. The likelihood of low access to care varied according to the type of chronic condition affecting the individual. Strikingly, those with dementia were over 17 times more likely to be classified in the low-access group than those without dementia.
Preventive Care, Screening and Chronic Disease Management:
The low access and low continuity groups were less likely to receive preventive care, as evidenced by a decreased likelihood of influenza and pneumonia immunization among seniors in these groups, compared to their high access and continuity counterparts. Additionally, the incidence of immunization among seniors with respiratory conditions differed according to the level of access to care. Respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD) can lead to more severe consequences from the flu and pneumonia (Centers for Disease Control and Prevention [CDC], 2021). Immunization against these illnesses among those with respiratory conditions is of particular importance. A higher incidence of influenza and pneumonia immunization was observed among those with asthma or COPD in the high-access group compared to those without respiratory conditions. However, immunization was not more frequent among those with respiratory conditions in the low-access group. This suggests that low-access individuals with respiratory conditions may be at an increased risk of infectious disease complications due to lack of immunization compared to their high-access counterparts.
Lower incidences of preventive screening and chronic disease monitoring were also noted in the low-access group. Mammogram screening was about half as likely among those with low access to care. Further, people with diabetes with low access to care were less likely to receive HbA1c blood tests for glucose monitoring.
Low Access, Hospital-Associated Mortality and Length of Stay:
Those with low access had a higher risk of death during hospitalization and the year following hospital discharge than those with high access. Additionally, heart failure, Parkinson’s disease, and being 65 years of age or older were associated with increased incidence of in-hospital mortality in both low and high-access groups. However, the disparity in mortality was much greater in the low-access group. This suggests that low access may carry greater risk for older New Brunswickers and those with certain health conditions. The average length of hospital stays was also longer among seniors, particularly in the low-access group.
Low Continuity and Increased Hospitalizations:
Low continuity of care was associated with an increased incidence of hospital admission, as well as an increased incidence of readmission within 30 days after discharge.
Discussion
Low access was associated with decreased preventative care, screening and chronic disease monitoring and higher hospital-associated mortality. Low continuity was associated with decreased preventative care and increased hospitalizations and readmissions. Seniors and individuals with respiratory conditions, heart failure, and Parkinson’s disease were identified as potentially being at increased risk of negative health outcomes associated with low access to care.
VitalSignsNB’s study described the prevalence of low access to and continuity of physician care in NB, characterized the affected populations, and identified health outcomes associated with deficits in access and continuity. These findings may inform further research, policy, and practice initiatives to understand and overcome barriers to accessible and effective healthcare. In this manner, our work may improve health and wellness in New Brunswick and elsewhere.
As this was a retrospective study, the data analyzed came from a pre-pandemic world. While access to care and continuity of care continue to be critical to New Brunswickers’ well-being, the pandemic’s new reality presents its own unique challenges.
P2P+: Mental Health Outcomes and Substance Use Habits During the COVID-19 Pandemic in New Brunswick
The ongoing COVID-19 pandemic has presented significant challenges in people’s lives. It has required individuals to adapt to an unfamiliar way of living involving isolation and limited social interaction. Since COVID-19 arrived in Canada in 2020, there has been extreme uncertainty regarding many fundamental aspects of life, including job security and access to essential services. These new stressors introduced by the pandemic can potentially impact mental health and negatively promote unhealthy coping mechanisms. Indeed, several Canadian and international studies have noted worsened mental health outcomes and increased substance use associated with the pandemic (Chen et al., 2021; Panchal et al., 2020; Roberts et al., 2021), although few studies have examined the mental health impacts of the pandemic in New Brunswick. Understanding the impacts of the COVID-19 pandemic on New Brunswickers’ mental health is crucial to inform planning and policy development for the delivery of support and services during and after the pandemic.
The P2P+ study examined changes in mental health and substance use behaviours associated with the COVID-19 pandemic among New Brunswick residents aged 19 and older using the results of two population-based cross-sectional surveys conducted by Statistics Canada at time points before and during the pandemic: The Canadian Community Health Survey (CCHS) and the Survey on COVID-19 and Mental Health (SCMH). The surveys include questions concerning sociodemographic characteristics, mental and physical health, substance use, habitual behaviours, and, in the SCMH exclusively, COVID-19 pandemic-related questions. A comparison of survey data from during and before the pandemic provided insight into how New Brunswickers’ mental health and substance use behaviours may have changed due to the pandemic.
The mental health and substance use outcomes investigated included depression, anxiety, self-rated mental health, alcohol consumption, and cannabis use. The prevalence of outcomes was evaluated at time points before and during the pandemic in the NB population and by various sociodemographic, behavioural, and pandemic-specific characteristics. These same characteristics were included as covariates in multivariate regression models to identify characteristics associated with worsening mental health and increased substance use during the pandemic.
Results
Depression
The overall prevalence of depression increased from 6% before the pandemic to 21% during the pandemic, with a sharper increase observed among those aged 65+ (compared to younger individuals) and among those who live alone (compared to those who do not). We also noted that several pandemic-related experiences were associated with an increased likelihood of depression during the pandemic. Depression during the pandemic was more likely among people who reported the following (compared to those who did not): difficulty meeting financial obligations or essential needs due to the pandemic, feelings of loneliness or isolation, emotional distress, physical health problems due to the pandemic, and increased personal consumption of alcohol during the pandemic due to stress or loneliness.
Anxiety
We observed a slight increase in the overall prevalence of anxiety during the pandemic, although this increase was not statistically significant in our models adjusted for covariates. As with depression, however, several pandemic-related experiences were associated with an increased likelihood of anxiety during the pandemic. These included the same experiences related to depression during the pandemic and, additionally, loss of jobs or income due to the pandemic.
Self-Rated Mental Health
Worse self-rated general mental health during the pandemic (compared to before) was reported by 35% of survey respondents. It was more likely among those who also reported experiencing emotional distress or feelings of loneliness or isolation due to the pandemic, as well as those who increased their alcohol or cannabis use during the pandemic and those receiving professional help for mental or physical health issues.
Alcohol Consumption
Increased alcohol consumption during the pandemic was reported by 14% of respondents. Further, the likelihood of consuming alcohol once a week or more increased by 30%, and the likelihood of binge drinking once a week or more doubled compared to before the pandemic. Increased alcohol consumption during the pandemic was more likely to be reported among those who experienced emotional distress or had relationship problems due to the pandemic.
Cannabis Use
Increased cannabis use during the pandemic was reported by 6% of respondents. Additionally, the likelihood of using cannabis once a week or more increased by 70% during the pandemic. Increased cannabis use during the pandemic was more likely to be reported among those younger (age 19-39) and those who experienced emotional distress or relationship problems due to the pandemic.
Discussion
Our results suggest that the COVID-19 pandemic in New Brunswick was associated with an increased likelihood of depression, lower self-rated mental health, and increased use of alcohol and cannabis. Furthermore, we identified specific characteristics and experiences associated with worse mental health and increased substance use during the pandemic. As we recover from the pandemic and prepare to face similar challenges in the future, these findings may help us begin to understand how to leverage our best resources to support those most in need.
Conclusion
Pathways to Professions student research addressed two important challenges facing healthcare in New Brunswick: access to care and recovery from the COVID-19 pandemic. The results from both the VitalSignsNB and P2P+ research teams may contribute to evidence-informed decision-making aimed at improving health and healthcare delivery in New Brunswick.
The VitalSignsNB project was supported by the Department of Health and the Department of Social Development of the Province of New Brunswick under a contract with the New Brunswick Institute for Research, Data and Training at the University of New Brunswick. The results and conclusions are those of the authors, and no official endorsement by the Government of New Brunswick was intended or should be inferred. The researchers would like to thank the New Brunswick Innovation Foundation (NBIF) for the support and funding provided for this project.
The P2P+ project was supported by funds to the Canadian Research Data Centre Network (CRDCN) from the Social Sciences and Humanities Research Council (SSHRC), the Canadian Institute for Health Research (CIHR), the Canadian Foundation for Innovation (CFI), and Statistics Canada. Although the research and analysis are based on data from Statistics Canada, the opinions expressed do not represent the views of Statistics Canada. The researchers would like to thank Mitacs and the New Brunswick Health Research Foundation (NBHRF) for the support and funding provided for this project.
Authors
References:
Centers for Disease Control and Prevention. (2021). Lung disease including asthma and adult vaccination. https://www.cdc.gov/vaccines/adults/rec-vac/health-conditions/lung-disease.html
Chen, P. J., Pusica, Y., Sohaei, D., Prassas, I., & Diamandis, E.P. (2021). An overview of mental health during the COVID-19 pandemic. Diagnosis, 8(4): 403-412.
Department of Health. (2018, September). Health Annual Report 2017–2018. Government of New Brunswick. https://www2.gnb.ca/content/dam/gnb/Departments/h-s/pdf/en/Publications/AnnualReport_2017-2018.pdf
Glazier, R.H., Moineddin, R., Agha, M. M., Zagorski, B., Hall, R., Manuel, D. G., Sibley, L. M., & Kopp, A. (2008). The impact of not having a primary care physician among people with chronic conditions. ICES. https://www.ices.on.ca/flip-publication/the-impact-of-not-having-a-primary-care-physician-chronic-conditions/files/assets/basic-html/index.html#1
Health Quality Council of Alberta. (2016, April). Improving continuity of care: Key opportunities and a status report on recommendations from the 2013 continuity of patient care study. Calgary, AB: Quality Council of Alberta. https://hqca.ca/wp-content/uploads/2021/12/Continuity_of_Care_2016_FINAL.pdf
New Brunswick Health Council. (2018, August 29). One in five New Brunswickers on wait list went more than two years without finding family doctor. https://nbhc.ca/health-in-the-news/one-five-new-brunswickers-wait-list-went-more-two-years-without-finding-family
New Brunswick Health Council. (2021, November 30). In search of a better access to primary care services in New Brunswick. https://nbhc.ca/news/search-better-access-primary-care-services-new-brunswick
Panchal, N., Kamal, R., Orgera, K., Cox, C., Garfield, R., Hamel, L., & Chidambaram, P. (2020). The implications of COVID-19 for mental health and substance use. Kaiser Family Foundation. https://abtcounseling.com/wp-content/uploads/2020/09/The-Implications-of-COVID-19-for-Mental-Health-and-Substance-Use-_-KFF.pdf
Roberts, A., Rogers, J., Mason, R., Siriwardena, A. N., Hogue, T., Whitley, G. A., & Law, G.R. (2021) Alcohol and other substance use during the COVID-19 pandemic: A systematic review. Drug and Alcohol Dependence, 229(Pt A): 109150.
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