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Canada’s child and youth health charter

https://policybase.cma.ca/en/permalink/policy10327
Last Reviewed
2018-03-03
Date
2007-05-29
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Last Reviewed
2018-03-03
Date
2007-05-29
Topics
Population health/ health equity/ public health
Text
CHILD AND YOUTH HEALTH IN CANADA THEIR CHARTER — OUR CHALLENGE “There can be no keener revelation of a society’s soul than the way it treats its children.” Nelson Mandela “One generation plants the trees; another gets the shade.” Chinese Proverb Children and youth have always been a priority for the doctors of Canada — the Child and Youth Health Initiative of the Canadian Medical Association, the Canadian Paediatric Society and the College of Family Physicians of Canada is evidence of that. We three organizations joined together in November 2006 to launch the Child and Youth Health Initiative. In September 2004, Canada’s first ministers committed to “improving the health status of Canadians through a collaborative process.” This led to an agreement on health goals for Canada. The first of them is “Our children reach their full potential, growing up happy, healthy, confident and secure.” At the international level, the United Nations Convention on the Rights of the Child sets out the wider rights of all children and young people, including the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. We now owe it to our children and youth to develop tangible health goals and targets. From the outset of the partnership, we were acutely aware that only a broad societal coalition could achieve the overarching goal of excellence in child and youth health in Canada. Making the health of children and youth a national priority requires a coalition of child and youth health champions, including governments, parents, health providers, businesses, schools, teachers and communities. To start that process, we created Canada’s Child and Youth Health Charter. An action framework was then developed called Canada’s Child and Youth Health Challenge because a charter alone will not deliver on the vision of the children and youth of Canada being among the healthiest in the world. Together, we believe they will help to build a coalition of child and youth health champions because they give the people who can make a difference in children and youth health a rallying point. The credibility and success of the Charter and the Challenge require broad, inclusive consultation and a commitment to child and youth health from society at large. The Child and Youth Health Summit, held April 25-26, 2007, was about consultation and commitment to making a difference to the health and well-being of children and youth. This document contains Canada’s Child and Youth Health Charter, which was one of the focuses of the summit. Canada’s Child and Youth Health Challenge and Canada’s Child and Youth Health Declaration, are the other components of our commitment and promise to take action for the children of Canada. These documents can be found at www.ourchildren.ca. Canada’s Child and Youth Health Charter In 2005, Canada’s federal, provincial and territorial governments created pan-Canadian health goals. The first of them is “Canada is a country where: Our children reach their full potential, growing up happy, healthy, confident and secure.” To reach their potential, children and youth need to grow up in a place where they can thrive — spiritually, emotionally, mentally, physically and intellectually — and get high-quality health care when they need it. That place must have three fundamental elements: a safe and secure environment; good health and development; and a full range of health resources available to all. Children and youth of distinct populations in Canada, including First Nations, Inuit and Métis, must be offered equal opportunities as other Canadian children and youth through culturally relevant resources. Canada must become: 1. A place with a safe and secure environment: a) Clean water, air and soil; b) Protection from injury, exploitation and discrimination; and c) Healthy family, homes and communities. 2. A place where children and youth can have good health and development: a) Prenatal and maternal care for the best possible health at birth; b) Nutrition for proper growth, development and long-term health; c) Early learning opportunities and high-quality care, at home and in the community; d) Opportunities and encouragement for physical activity; e) High-quality primary and secondary education; f) Affordable and available post-secondary education; and g) A commitment to social well-being and mental health. 3. A place where a full range of health resources is available: a) Basic health care including immunization, drugs and dental health; b) Mental health care and early help programs for children and youth; c) Timely access to specialty diagnostic and health services; d) Measurement and tracking the health of children and youth; e) Research that focuses on the needs of children and youth; and f) Uninterrupted care as youth move to adult health services and between acute, chronic and community care, as well as between jurisdictions. NOTES 1. The principles of this charter apply to all children and youth in Canada regardless of race, ethnicity, creed, language, gender, physical ability, mental ability, cultural history, or life experience. 2. Principles enshrined in all the goal statements include: a. Universality: The charter applies equally to all children and youth residing in Canada and covers all children and youth from 0-18 years of age. b. Without financial burden: All children and youth in Canada should have access to required health care, health services and drugs regardless of ability to pay. c. Barrier-free access: All children and youth, regardless of ability or circumstance should have appropriate access to optimal health care and health services. d. Measurement and monitoring: Appropriate resources will be available for adequate ongoing collection of data on issues that affect child and youth health and development. e. Safe and secure communities: Communities in Canada must create an environment for children and youth to grow that is safe and secure. 3. The purpose of this charter is to facilitate development of specific goals, objectives, actions and advocacy that will measurably improve child and youth health throughout Canada. 4. Success will be identified as simple, measurable, achievable, and timely goals and objectives for each of the 16 statements in this charter. 5. The initial draft of this charter has been developed by Canada’s physicians focusing on what they can best do to improve child and youth health; however, the support and participation of all individuals and groups interested in child and youth health is encouraged and desired. 6. The primary audience for actions and advocacy arising from this charter will be governments, agencies or individuals who, by virtue of legislation, regulation or policy have the ability to effect change for children and youth. 7. This charter is not a legal document; it represents a commitment by champions of child and youth health in Canada to the health and well-being of all children and youth in Canada. Charter Endorsers The following organizations have endorsed the Child and Youth Health Charter, as of October 9, 2007. Association of Canadian Academic Healthcare Organizations Boys and Girls Clubs of Canada Breakfast for Learning Canadian Association of Paediatric Health Centres Canadian Child and Youth Health Coalition Canadian Healthcare Association Canadian Institute of Child Health Canadian Medical Association Canadian Paediatric Society Canadian Pharmacists Association Canadian Psychological Association Centre of Excellence for Early Childhood Development Centre for Science in the Public Interest College of Family Physicians of Canada Landon Pearson Resource Centre for the Study of Childhood and Children's Rights Muttart Foundation National Alliance for Children and Youth National Anti-Poverty Organization Newfoundland and Labrador Medical Association Paediatric Chairs of Canada Safe Kids Canada, The National Injury Prevention Program of The Hospital for Sick Children Silken's ActiveKids Movement and Silken and Company Productions The Royal College of Physicians and Surgeons of Canada
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Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience

https://policybase.cma.ca/en/permalink/policy14165
Date
2019-10-17
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Date
2019-10-17
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
Homeless and vulnerably housed populations are heterogeneous and continue to grow in numbers in urban and rural settings as forces of urbanization collide with gentrification and austerity policies.2 Collectively, they face dangerous living conditions and marginalization within health care systems.3 However, providers can improve the health of people who are homeless or vulnerably housed, most powerfully by following evidence-based initial steps, and working with communities and adopting anti-oppressive practices.1,4,5 Broadly speaking, “homelessness” encompasses all individuals without stable, permanent and acceptable housing, or lacking the immediate prospect, means and ability of acquiring it.6 Under such conditions, individuals and families face intersecting social, mental and physical health risks that significantly increase morbidity and mortality.7,8 For example, people who are homeless and vulnerably housed experience a significantly higher prevalence of trauma, mental health conditions and substance use disorders than the general population.7,9 Canadian research reports that people who experience homelessness face life expectancies as low as 42 years for men and 52 years for women.7 A generation ago, homeless Canadians were largely middleaged, single men in large urban settings.10 Today, the epidemiology has shifted to include higher proportions of women, youth, Indigenous people (Box 1), immigrants, older adults and people from rural communities.13,14 For example, family homelessness (and therefore homelessness among dependent children and youth) is a substantial, yet hidden, part of the crisis.15 In 2014, of the estimated 235 000 homeless people in Canada, 27.3% were women, 18.7% were youth, 6% were recent immigrants or migrants, and a growing number were veterans and seniors.10 Practice navigators, peer-support workers and primary care providers are well placed to identify social causes of poor health and provide orientation to patient medical homes.16,17 A patient’s medical home is “a family practice defined by its patients as the place they feel most comfortable presenting and discussing their personal and family health and medical concerns.”18 Medical care is “readily accessible, centred on the patients’ needs, provided throughout every stage of life, and seamlessly integrated with other services in the health care system and the community” (https://patientsmedicalhome.ca). Primary care providers are also well positioned to mobilize health promotion, disease prevention, diagnosis and treatment, and rehabilitation services.19 GUIDELINE VULNERABLE POPULATIONS CPD Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience Kevin Pottie MD MClSc, Claire E. Kendall MD PhD, Tim Aubry PhD, Olivia Magwood MPH, Anne Andermann MD DPhil, Ginetta Salvalaggio MD MSc, David Ponka MDCM MSc, Gary Bloch MD, Vanessa Brcic MD, Eric Agbata MPH MSc, Kednapa Thavorn PhD, Terry Hannigan, Andrew Bond MD, Susan Crouse MD, Ritika Goel MD, Esther Shoemaker PhD, Jean Zhuo Jing Wang BHSc, Sebastian Mott MSW, Harneel Kaur BHSc, Christine Mathew MSc, Syeda Shanza Hashmi BA, Ammar Saad, Thomas Piggott MD, Neil Arya MD, Nicole Kozloff MD, Michaela Beder MD, Dale Guenter MD MPH, Wendy Muckle BScN MHA, Stephen Hwang MD, Vicky Stergiopoulos MD, Peter Tugwell MD n Cite as: CMAJ 2020 March 9;192:E240-54. doi: 10.1503/cmaj.190777 CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/190777-guide See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.200199 KEY POINTS
Clinical assessment and care of homeless and vulnerably housed populations should include tailoring approaches to a person’s gender, age, Indigenous heritage, ethnicity and history of trauma; and advocacy for comprehensive primary health care.
As initial steps in the care of homeless and vulnerably housed populations, permanent supportive housing is strongly recommended, and income assistance is also recommended.
Case-management interventions, with access to psychiatric support, are recommended as an initial step to support primary care and to address existing mental health, substance use and other morbidities.
Harm-reduction interventions, such as supervised consumption facilities, and access to pharmacologic agents for opioid use disorder, such as opioid agonist treatment, are recommended for people who use substances. GUIDELINE CMAJ
MARCH 9, 2020
VOLUME 192
ISSUE 10 E241 However, the social and health resources available to homeless and vulnerably housed people may vary based on geographic setting, municipal resources, housing coordination, and patients’ mental health and substance use–related care needs. In addition, many physical and mental health disorders remain undiagnosed or inconsistently treated because of missed opportunities for care, patient mistrust of the health care system or limited access to health services.3 Homeless and vulnerably housed people can benefit from timely and effective health, addiction and social interventions. Our guideline provides initial steps for practice, policy and future research, and is intended to build collaboration among clinicians, public health providers and allied health providers. Values such as trauma-informed and patient-centred care, and dignity are needed to foster trust and develop sustainable therapeutic relationships with homeless and vulnerably housed people.20,21 Scope The purpose of this clinical practice guideline is to inform providers and community organizations of the initial priority steps and effective interventions for homeless and vulnerably housed people. The guideline addresses upstream social and health needs (i.e., housing), as well as downstream health-related consequences of inadequate housing. The target audiences are health providers, policymakers, public health practitioners and researchers. Our guideline does not aim to address all conditions associated with homelessness, nor does it aim to discuss in depth the many etiologies of homelessness, such as childhood trauma, the housing market, or the root causes of low social assistance rates and economic inequality. Rather, this guideline aims to reframe providers’ approach toward upstream interventions that can prevent, treat and work toward ending the morbidity and mortality associated with homelessness. A parallel set of Indigenous-specific clinical guidelines is currently being developed by an independent, Indigenous-led team.22 This process recognizes the distinct rights of Indigenous Peoples, including the right to develop and strengthen their own economies, social and political institutions; the direct links between historic and ongoing colonial policies and Indigenous homelessness; and the need for Indigenous leadership and participation in research that is about Indigenous Peoples. Recommendations The steering committee and guideline panel members developed and approved recommendations to improve social and health outcomes for homeless and vulnerably housed people. The order of these recommendations highlights priority steps for homeless health care. We list a summary of the recommendations in Table 1 and we present our list of good practice statements in Table 2. These good practice statements are based on indirect evidence and support the delivery of the recommendations. The methods used to develop the recommendations are described later in this document. A summary of how to use this guideline is available in Box 2. Permanent supportive housing
Identify homelessness or housing vulnerability and willingness to consider housing interventions.
Ensure access of homeless or vulnerably housed individuals to local housing coordinator or case manager (i.e., call 211 or via a social worker) for immediate link to permanent supportive housing and/or coordinated access system (moderate certainty, strong recommendation). Evidence summary Our systematic review (Tim Aubry, University of Ottawa, Ottawa, Ont.: unpublished data, 2020) identified 14 trials on permanent supportive housing (PSH).30–43 Several trials across Canada and the United States showed that PSH initiatives house participants more rapidly compared with usual services (73 v. 220 d; adjusted absolute difference 146.4, 95% confidence interval [CI] 118.0 to 174.9);30 increase the number of people who maintain stable housing at 2 years (pooled odds ratio [OR] 3.58, 95% CI 2.36 to 5.43);30,40 and significantly increase the percentage of days spent stably housed.41 No trials showed a significant improvement in mental health symptoms compared with standard care.30,31,33,34,41,42 Two studies found that the mental health of PSH participants did not improve as much as that of usual care participants (e.g., mean difference –0.49, 95% CI –0.85 to –0.12).30,31 The At Home/Chez Soi trial showed small improvements in quality of life for high-needs (adjusted standardized mean difference 0.15, 95% CI 0.04 to 0.24)30 and moderate-needs (mean difference 4.37, 95% CI 1.60 to 7.14) homeless participants in patients receiving PSH.41 Youth receiving PSH saw larger improvements in their quality of life during the first 6 months (mean difference 9.30, 95% CI 1.35 to 17.24), which diminished over time (mean difference 7.29, 95% CI –1.61 to 16.18).44 No trials showed a significant improvement in substance use compared with standard care.30,33,41–43 Most trials reported no effect of PSH on acute care outcomes (e.g., number of emergency department visits and percentage of participants admitted to hospital).30,41 However, 2 trials suggest that PSH participants had lower rates of hospital admission (rate reductions of 29%, 95% CI 10 to 44) and time in hospital (e.g., mean difference –31, 95% CI –48 to –14).34,38,45 One trial found no effect of PSH on job tenure, hours of work per week or hourly wage compared with standard care.46 Participants receiving PSH may have increased odds of employment, but this depends on the severity of participant needs.46 One trial found no effect on income outcomes.46 Box 1: Indigenous homelessness Indigenous homelessness is a term used to describe First Nations, Métis and Inuit individuals, families or communities who lack stable, permanent and appropriate housing, or the immediate prospects, means or ability to acquire such housing. However, this term must be interpreted through an Indigenous lens to understand the factors contributing to this condition. These factors include individuals, families and communities isolated from their relationships to land, water, place, family, kin, each other, animals, cultures, languages and identities as well as the legacy of colonialism and genocide.11 It is estimated that urban Indigenous people are 8 times more likely to experience homelessness than the general population.11,12 GUIDELINE E242 CMAJ
ISSUE 10 The certainty of the evidence was rated moderate, because blinding of participants and personnel was not feasible in any of the trials we examined as a result of the nature of the intervention. Furthermore, several trials did not employ allocation concealment or blinding of outcome-assessment procedures, which could introduce high risks of detection and performance biases. Income assistance
Identify income insecurity.
Assist individuals with income insecurity to identify incomesupport resources and access income (low certainty, conditional recommendation). Evidence summary We identified 10 trials on income-assistance interventions, including rental assistance,47–56 financial empowerment,47 social enterprise interventions,48 individual placement and support,48,54 and compensated work therapy.52 Our systematic review showed the benefit that income-assistance interventions have on housing stability (Gary Bloch, University of Toronto, Toronto, Ont., and Vanessa Brcic, University of British Columbia, Vancouver, BC: unpublished data, 2020). Rental assistance increased the likelihood of being stably housed (OR 4.60, 95% CI 3.10 to 6.83).56 Rental assistance combined with case management increased the number of days in stable housing per 90-day period compared with case management alone (mean Table 1: Summary of evidence-based recommendations Recommendations and clinical considerations Grade rating* Recommendation 1: A homeless or vulnerably housed person Moderate certainty
Ensure access for homeless or vulnerably housed individuals to local housing coordinator or case manager (i.e., call 211 or via a social worker) for immediate link to permanent supportive housing and coordinated access system. Clinical considerations: Many jurisdictions will provide alternative housing services for specific marginalized populations, for example, Indigenous people, women and families, youth, those who identify as LGBTQ2+, those with disabilities, refugees and migrants. Strong recommendation Recommendation 2: A homeless or vulnerably housed person with experience of poverty, income instability or living in a low-income household Low certainty
Assist individuals with income insecurity to identify income-support resources and access income. Clinical considerations: Consult poverty screening tools when needed (e.g., https://cep.health/clinical-products /poverty-a-clinical-tool-for-primary-care-providers). Conditional recommendation Recommendation 3: A homeless or vulnerably housed person with multiple comorbid or complex health needs (including mental illness and/or substance use) Low certainty
Identify history of severe mental illness, such as psychotic or mood and anxiety disorders, associated with substantial disability, substance use, or multiple/complex health needs.
Ensure access to local community mental health programs, psychiatric services for assessment, and linkage to intensive case management, assertive community treatment or critical time intervention where available. Clinical considerations: Call 211 or consult primary care providers, social workers or case managers familiar with local access points and less intensive community mental health programs. Conditional recommendation Recommendation 4: A homeless or vulnerably housed person currently using opioids Very low certainty
Identify opioid use disorder.
Ensure access within primary care or via an addiction specialist to opioid agonist therapy (OAT), potentially in collaboration with a public health or community health centre for linkage to pharmacologic interventions. Clinical considerations: Encourage all patients taking opioid medication to have a naloxone kit. Though barriers to prescribing methadone and buprenorphine remain, be aware of new regulations that aim to facilitate OAT access and options in your jurisdiction, in particular for buprenorphine. Conditional recommendation Recommendation 5: A homeless or vulnerably housed person with substance use disorder Very low certainty
Identify, during history or physical examination, problematic substance use, including alcohol or other drugs.
Identify the most appropriate approach, or refer to local addiction and harm-reduction/prevention services (e.g., supervised consumption facilities, managed alcohol programs) via appropriate local resources such as public health or community health centre or local community services centre. Clinical considerations: In case of active opioid use disorder, facilitate patient access to OAT. Patients should be made aware of supervised consumption facility locations (Appendix 1, available at www.cmaj.ca/lookup/suppl/ doi:10.1503/cmaj.190777/-/DC1). Conditional recommendation Note: LGBTQ2+ = lesbian, gay, bisexual, transgender, questioning and two-spirited. *See Box 2 for definitions. †211 is a special abbreviated telephone number reserved in Canada and the United States as an easy-to-remember 3-digit telephone number meant to provide information and referrals to health, human and social service organizations. GUIDELINE CMAJ
ISSUE 10 E243 difference 8.58, p < 0.004).55 Compensated work therapy was found to reduce the odds of homelessness (OR 0.1, 95% CI 0.1 to 0.3).52 No income interventions showed an effect on mental health outcomes.47,52,55,56 The impact of these interventions on substance use outcomes were mixed. Provision of housing vouchers did not affect substance use over 3 years;55 however, compensated work therapy showed immediate reductions in drug (reduction: –44.7%, standard error [SE] 12.8%; p = 0.001) and alcohol use problems (–45.4%, SE 9.4%; p = 0.001), as well as the number of substance use–related physical symptoms (–64.4%, SE 8.0%; p = 0.001).52 These differences, however, tended to decline with time. No significant effects were found on overall quality-of-life, finances, health and social relations scores. Provision of housing vouchers resulted in higher family-relations score and satisfaction, and quality of housing compared with standard care.55 One trial reported that rental assistance was associated with reduced emergency department visits and time spent in hospital, but this reduction was not significantly different than in the comparator group.56 Individual placement and support was found to improve employment rates only when there was high fidelity to the model (OR 2.42, 95% CI 1.13 to 5.16).54 Financial-empowerment education and provision of housing vouchers had no effect on employment outcomes.47,55 Financial-empowerment education and individual placement and support had no effect on hourly wages.47,54 Provision of housing vouchers had no effect on monthly income.55 The certainty of the evidence was rated low because several trials introduced high risk of detection and performance bias. Furthermore, 1 trial reported low consent rates of 47% and a 1:4 sampling ratio that further limited statistical power.52 As well, participants in the control group wanting to enter income-assistance programs after completing the study had incentives to underreport symptoms, which introduced high risk for measurement bias. Case management
Identify history of severe mental illness, such as psychotic or mood and anxiety disorders, associated with substantial disability, substance use disorders, or multiple or complex health needs.
Ensure access to local community mental health programs, psychiatric services for assessment and linkage to intensive case management, assertive community treatment or critical time intervention where available (low certainty, conditional recommendation). Evidence summary Our systematic review examined the effectiveness of standard case management, as well as specific intensive casemanagement interventions, such as assertive community treatment, intensive case management and critical time intervention among homeless and vulnerably housed populations and corresponding level of need (David Ponka, University of Ottawa, Ottawa, Ont.: unpublished data, 2020). We included a total of 56 citations, of which 10 trials reported on standard case management,51,57–65 8 trials on assertive community treatment,66–73 16 trials on intensive case management74–89 and 5 trials on critical time intervention.90–94 Box 2: How to use and understand this GRADE guideline (www.gradeworkinggroup.org) This guideline supplies providers with evidence for decisions concerning interventions to improve health and social outcomes for people who are homeless or vulnerably housed. This guideline is not meant to replace clinical judgment. Statements about clinical considerations, values and preferences are integral parts of the recommendations meant to facilitate interpretation and implementation of the guideline. Recommendations in this guideline are categorized according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system as strong or conditional recommendations. Strong recommendations indicate that all or almost all fully informed patients would choose the recommended course of action, and indicate to clinicians that the recommendation is appropriate for all or almost all individuals. Strong recommendations represent candidates for quality-of-care criteria or performance indicators. Conditional recommendations indicate that most informed patients would choose the suggested course of action, but an appreciable minority would not. With conditional recommendations, clinicians should recognize that different choices will be appropriate for individual patients, and they should help patients arrive at a decision consistent with their values and preferences. Conditional recommendations should not be used as a basis for standards of practice (other than to mandate shared decision-making). Good practice statements represent common-sense practice, are supported by indirect evidence and are associated with assumed large net benefit. Clinical considerations provide practical suggestions to support implementation of the GRADE recommendation. GRADE certainty ratings High: further research is very unlikely to change our confidence in the estimate of effect. Moderate: further research is likely to have an important impact on the confidence in the estimate of effect and may change the estimate. Low: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low: any estimate of the effect is very uncertain. Table 2: Good practice statements to support delivery of care Good practice statement Indirect evidence (reference) 1. Homeless and vulnerably housed populations should receive trauma-informed and personcentred care. 23–26 2. Homeless and vulnerably housed populations should be linked to comprehensive primary care to facilitate the management of multiple health and social needs. 27 3. Providers should collaborate with public health and community organizations to ensure programs are accessible and resources appropriate to meet local patient needs. 28,29 GUIDELINE E244 CMAJ
ISSUE 10 Of 10 trials on standard case management, 10 evaluated housing stability. Only 3 reported significant decreases in homelessness,57,62,63 an effect that diminished over time in 1 trial of a time-limited residential case management in which participants in all groups accessed substantial levels of services.57 A program tailored to women reduced the odds of depression at 3 months (OR 0.38, 95% CI 0.14 to 0.99), but did not show improvements in the women’s overall mental health status (mean difference 4.50, 95% CI –0.98 to 9.98).64 One trial reported higher levels of hostility (p < 0.001) and depression symptoms (p < 0.05) among female participants receiving nurse-led standard case management compared with those receiving standard care.60 Few studies reported on substance use, quality of life, employment or income outcomes. Findings of assertive community treatment on housingstability, quality-of-life and hospital-admission outcomes are mixed. Two trials found that participants receiving the treatment reported fewer days homeless (p < 0.01)71 and more days in community housing (p = 0.006),70 whereas 2 trials reported no effect on episodes of homelessness or number of days homeless.66,73 Further, these interventions showed an added benefit in reducing the number of participants admitted to hospital (mean difference –8.6, p < 0.05) and with visits to the emergency department (mean difference –1.2, p = 0.009).67 Most trials of assertive community treatment reported no significant differences in mental health outcomes, including psychiatric symptoms, substance use, or income-related outcomes between the treatment and control groups. Intensive case management reduced the number of days homeless (pooled standardized mean difference –0.22, 95% CI –0.40 to –0.03), but not the number of days spent in stable housing.78,80,89 In most studies, there was no major improvement in psychological symptoms between the treatment and control groups. However, 1 trial reported significantly greater reductions in anxiety, depression and thought disturbances after 24 months (mean difference change from baseline –0.32, p = 0.007), as well as improved life satisfaction (mean difference 1.23, p = 0.001) using intensive case management.86 One trial reported no significant difference in quality of life.83 Findings on substance use were mixed. Six of the 10 trials reported that intensive case management was associated with improvements in substance use behaviours.74,78,82,84,87,88 Participants receiving intensive case management reported fewer visits to the emergency department (mean difference 19%, p < 0.05) but did not have shorter hospital stays compared with control groups.85 Intensive case management had no effect on the number of days of employment, or on income received from employment; however, income received by participants through public assistance increased (e.g., mean difference 89, 95% CI 8 to 170).78,85 Critical time intervention was beneficial in reducing the number of homeless nights (mean difference –591, p < 0.001) and the odds of homelessness (OR 0.23, 95% CI 0.06 to 0.90) during the final 18 weeks of follow-up.91 Participants receiving the treatment were rehoused sooner than those receiving standard care,95 but did not spend more days rehoused.90 Adults receiving critical time intervention showed significant improvements in psychological symptoms (mean difference –0.14, 95% CI –0.29 to 0.01).90 However, findings for children’s mental health were mixed: children aged 1.5–5 years showed improvements in internalizing (ß coefficient –3.65, 95% CI –5.61 to –1.68) and externalizing behaviours (ß coefficient –3.12, 95% CI –5.37 to –0.86), whereas changes for children aged 6–10 years and 11–16 years were not significant.93 There were no significant effects of critical time intervention on substance-use,90 quality-of-life90,92 or income-related outcomes.96 Two trials reported mixed findings on hospital admission outcomes; in 1 study, allocation to critical time intervention was associated with reduced odds of hospital admission (OR 0.11, 95% CI 0.01 to 0.96) and total number of nights in hospital (p < 0.05) in the final 18 weeks of the trial.97 However, another study reported a greater total number of nights in hospital for the treatment group compared with usual care (1171 v. 912).98 The certainty of the evidence was rated low because several trials introduced high risk of detection and performance bias. Opioid agonist therapy
Ensure access to opioid agonist therapy in primary care or by referral to an addiction specialist, potentially in collaboration with public health or community health centre for linkage to pharmacologic interventions (low certainty, conditional recommendation). Evidence summary We conducted a review of systematic reviews on pharmalogic interventions for opioid use disorder.99 Twenty-four reviews, which included 352 unique primary studies, reported on pharmacologic interventions for opioid use disorder among general populations.100–123 We expanded our inclusion criteria to general populations, aware that most studies among “general populations” had a large representation of homeless populations in their samples. We did not identify any substantial reason to believe that the mechanisms of action of our interventions of interest would differ between homeless populations who use substances and the general population of people who use substances. Reviews on pharmacologic interventions reported on the use of methadone, buprenorphine, diacetylmorphine (heroin), levo-a-acetylmethadol, slow-release oral morphine and hydromorphone for treatment of opioid use disorder. We found pooled all-cause mortality rates of 36.1 and 11.3 per 1000 person years for participants out of and in methadone maintenance therapy, respectively (rate ratio 3.20, 95% CI 2.65 to 3.86), and mortality rates of 9.5 per 1000 person years for those not receiving buprenorphine maintenance therapy compared with 4.3 per 1000 person years among those receiving the therapy (rate ratio 2.20, 95% CI 1.34 to 3.61).116 Overdose-specific mortality rates were similarly affected, with pooled overdose mortality rates of 12.7 and 2.6 per 1000 person years for participants out of and in methadone maintenance therapy, and rates of 4.6 and 1.4 per 1000 person years out of and in buprenorphine maintenance therapy.116 Compared with nonpharmacologic approaches, methadone maintenance therapy had no significant GUIDELINE CMAJ
ISSUE 10 E245 effect on mortality (relative risk 0.48, 95% CI 0.10 to 2.39).110 With respect to morbidity, pharmacologic interventions for opioid use disorder reduced the risk of hepatitis C virus (HCV) acquisition (risk ratio 0.50, 95% CI 0.40 to 0.63)112 and HIV infection.103 Adverse events were reported for all agents.100,109,119,122 Treatment with methadone and buprenorphine was associated with reduced illicit opioid use (standardized mean difference –1.17, 95% CI –1.85 to –0.49).109 Availability of buprenorphine treatment expanded access to treatment for patients unlikely to enrol in methadone clinics and facilitated earlier access for recent initiates to opioid use.117 The relative superiority of one pharmacologic agent over another on retention outcomes remains unclear; however, use of methadone was found to show better benefits than nonpharmacologic interventions for retention (risk ratio 4.44, 95% CI 3.26 to 6.04).110 The certainty of evidence ranged from very low to moderate, primarily because of inconsistency, high risk of bias and evidence from nonrandomized studies. Harm-reduction interventions
Identify problematic substance use, including alcohol or other drugs.
Identify the most appropriate approach or refer to local addiction and harm reduction/prevention services (e.g., supervised consumption facilities, managed alcohol programs) via appropriate local resources, such as public health or community health centre or les centres locaux de services communautaires (low certainty, conditional recommendation). Evidence summary We conducted a review of systematic reviews on supervised consumption facilities and managed alcohol programs.99 Two systematic reviews, which included 90 unique observational studies and 1 qualitative meta-synthesis reported on supervised consumption facilities.124–126 For managed alcohol programs, 1 Cochrane review had no included studies,127 and 2 greyliterature reviews reported on 51 studies.128,129 Establishment of supervised consumption facilities was associated with a 35% decrease in the number of fatal opioid overdoses within 500 m of the facility (from 253.8 to 165.1 deaths per 100 000 person years, p = 0.048), compared with 9% in the rest of the city (Vancouver).124 There were 336 reported opioid overdose reversals in 90 different individuals within the Vancouver facility over a 4-year period (2004–2008).125 Similar protective effects were reported in Australia and Germany. Observational studies conducted in Vancouver and Sydney showed that regular use of supervised consumption facilities was associated with decreased syringe sharing (adjusted OR 0.30, 95% CI 0.11 to 0.82), syringe reuse (adjusted OR 2.04, 95% CI 1.38 to 3.01) and public-space injection (adjusted OR 2.79, 95% CI 1.93 to 3.87).125 These facilities mediated access to ancillary services (e.g., food and shelter) and fostered access to broader health support.125,126 Attendance at supervised consumption facilities was associated with an increase in referrals to an addiction treatment centre and initiation of methadone maintenance therapy (adjusted hazard ratio 1.57, 95% CI 1.02 to 2.40).125 Evidence on supervised consumption facilities was rated very low to low, as all available evidence originated from nonrandomized studies. There was a lack of high-quality evidence for managed alcohol programs. Few studies reported on deaths among clients of these programs.128 The effects of managed alcohol programs on hepatic function are mixed, with some studies reporting improvement in hepatic laboratory markers over time, and others showing increases in alcohol-related hepatic damage;129 however, this may have occurred regardless of entry into such a program. This evidence suggested that managed alcohol programs result in stabilized alcohol consumption and can facilitate engagement with medical and social services.128 Clients experienced significantly fewer social, health, safety and legal harms related to alcohol consumption.129 Individuals participating in these programs had fewer hospital admissions and a 93% reduction in emergency service contacts.128 The programs also promoted improved or stabilized mental health128 and medication adherence.129 Cost effectiveness and resource implications Permanent supportive housing We found 19 studies assessing the cost and net cost of housing interventions.30,41,45,130–145 In some studies, permanent supportive housing interventions were associated with increased cost to the payers, and the costs of the interventions were only partially offset by savings in medical and social services as a result of the intervention.30,41,131–134,142 Six studies showed that these interventions saved payers money.135,137,139,141,144,145 Four of these studies, however, employed a pre–post design.135,139,141,145 Moreover, 1 cost-utility analysis of PSH suggested that the provision of housing services was associated with increased costs and increased quality-adjusted life years, with an incremental cost-effectiveness ratio of US$62 493 per quality-adjusted life year.136 Compared with usual care, PSH was found to be more costly to society (net cost Can$7868, 95% CI $4409 to $11 405).138 Income assistance Two studies55,146 focused on the cost effectiveness of incomeassistance interventions. Rental assistance with clients receiving case-management intervention had greater annual costs compared with usual care or groups receiving only case management.55 For each additional day housed, clients who received income assistance incurred additional costs of US$58 (95% CI $4 to $111) from the perspective of the payer, US$50 (95% CI –$17 to $117) from the perspective of the health care system and US$45 (95% CI –$19 to $108) from the societal perspective. The benefit gained from temporary financial assistance was found to outweigh its costs with a net savings of US$20 548.146 Case management Twelve publications provided evidence on cost and costeffectiveness of case-management interventions.44,55,67,69,73,75,88,96,147–150 Findings of these studies were mixed; the total cost incurred by clients of standard case management was higher than that of clients receiving usual or standard care61,88 and assertive GUIDELINE E246 CMAJ
ISSUE 10 community treatment,67,147 but lower compared with a US clinical case-management program that included housing vouchers and intensive case management.55 Cost-effectiveness studies using a societal perspective showed that standard case management was not cost effective compared with assertive community treatment for people with serious mental disorders or those with a concurrent substance-use disorder, as it was more expensive.67 For intensive case management, the cost of supporting housing with this program could be partially offset by reductions in the use of emergency shelters and temporary residences.41 Intensive case management is more likely to be cost effective when all costs and benefits to society are considered.41 A pre–post study showed that providing this program to high-need users of emergency departments resulted in a net hospital cost savings of US$132 726.150 Assertive community treatment interventions were associated with lower costs compared with usual care.66,67,73,148,149 We identified only 1 study on the cost effectiveness of critical time intervention that reported comparable costs (US$52 574 v. US$51 749) of the treatment compared with the usual services provided to men with severe mental illness.96 Interventions for substance use We identified 2 systematic reviews that reported findings from 6 studies in Vancouver on the cost effectiveness of supervised consumption facilities;124,125 5 of these 6 studies found the facilities to be cost effective. After consideration of facility operating costs, supervised consumption facilities saved up to Can$6 million from averted overdose deaths and incident HIV cases. Similarly, Can$1.8 million was saved annually from the prevention of incident HCV infection. Clinical considerations Providers can, in partnership with directly affected communities, employ a range of navigation and advocacy tools to address the root causes of homelessness, which include poverty caused by inadequate access to social assistance, precarious work, insufficient access to quality child care, social norms that allow the propagation of violence in homes and communities, inadequate supports for patients and families living with disabilities or going through life transitions, and insufficient and poor-quality housing stock.151 In addition, providers should tailor their approach to the patient’s needs and demographics, taking into account access to services, personal preferences and other illnesses.152 Providers should also recognize the social and human value of accepting homeless and vulnerably housed people into their clinical practices. The following sections provide additional evidence for underserved and marginalized populations. Women A scoping review of the literature on interventions for homeless women (Christine Mathew, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020) yielded 4 systematic reviews153–156 and 9 randomized controlled trials (RCTs)36,60,92,95,157–161 that focused specifically on homeless and vulnerably housed women. Findings showed that PSH was effective in reducing the risk of intimate partner violence and improving psychological symptoms.158 For women with children experiencing homelessness, priority access to permanent housing subsidies can reduce child separations and foster care placements, allowing women to maintain the integrity of their family unit.158 As well, Housing First programs for families, critical time interventions during times of crisis, and therapeutic communities are associated with lower levels of psychological distress, increased self-esteem and improved quality of life for women and their families.92,155 A gender-based analysis highlighted the importance of safety, service accessibility and empowerment among homeless women. We suggest that providers focus on patient safety, empowerment among women who have faced genderbased violence, and improve access to resources, including income, child care and other social support services. Youth A systematic review on youth-specific interventions reported findings from 4 systematic reviews and 18 RCTs.162 Permanent supportive housing improved housing stability. As well, individual cognitive behavioural therapy has been shown to result in significant improvements in depression scores, and family-based therapies are also promising, resulting in reductions in youth substance use through restoring the family dynamic. Findings on motivational interviewing, skill building and case-management interventions were inconsistent, with some trials showing a positive impact and others not identifying significant benefits. Refugee and migrant populations A qualitative systematic review on homeless migrants (Harneel Kaur, University of Ottawa, Ottawa, Ont.: unpublished data, 2020) identified 17 qualitative articles that focused on the experiences of homeless migrants.163–179 Findings indicated that discrimination, limited language proficiency and severed social networks negatively affected homeless migrants’ sense of belonging and access to social services, such as housing. However, employment opportunities provided a sense of independence and improved social integration. Methods Composition of participating groups In preparation for the guideline, we formed the Homeless Health Research Network (https://methods.cochrane.org/equity/ projects/homeless-health-guidelines), composed of clinicians, academics, and governmental and nongovernmental stakeholders. The Homeless Health Guideline Steering Committee (K.P. [chair], C.K., T.A., A.A., G.S., G.B., D.P., E.A., V.B., V.S. and P.T.) was assembled to coordinate guideline development. Expert representation was sought from eastern and western Canada, Ontario, Quebec and the Prairie provinces for membership on the steering committee. In addition, 5 people with lived experience of homelessness (herein referred to as “community scholars”180) were recruited to participate in the guideline-development activities. A management committee (K.P., C.K. and P.T.) oversaw the participating groups and monitored competing interests. The steering committee decided to develop a single guideline publication informed by a series of 8 systematic reviews. The GUIDELINE CMAJ
ISSUE 10 E247 steering committee assembled expert working groups to operationalize each review. Each working group consisted of clinical topic experts and community scholars who were responsible for providing contextual expertise. The steering committee also assembled a technical team, which provided technical expertise in the conduct and presentation of systematic reviews and meta-analyses. Finally, the steering committee assembled the guideline panel, which had the responsibility to provide external review of the evidence and drafted recommendations. The panel was composed of 17 individuals, including physicians, primary care providers, internists, psychiatrists, public health professionals, people with lived experience of homelessness, medical students and medical residents. Panel members had no financial or intellectual conflicts of interest. A full membership list of the individual teams’ composition is available in Appendix 2, available at www.cmaj.ca/lookup/ suppl/doi:10.1503/cmaj.190777/-/DC1. Selection of priority topics We used a 3-step modified Delphi consensus method (Esther Shoemaker, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020) to select priority health conditions for marginalized populations experiencing homelessness or vulnerable housing. Briefly, between May and June 2017, we developed and conducted a survey (in French and English), in which we asked 84 expert providers and 76 people with lived homelessness experience to rank and prioritize an initial list of needs and populations. We specifically asked participants, while answering the Delphi survey, to keep in mind 3 priority-setting criteria when considering the unique challenges of implementing health care for homeless or vulnerably housed people: value added (i.e., the opportunity for a unique and relevant contribution), reduction of unfair and preventable health inequities, and decrease in burden of illness (i.e., the number of people who may have a disease or condition).181 The initial top 4 priority needs identified were as follows: facilitating access to housing, providing mental health and addiction care, delivering care coordination and case management, and facilitating access to adequate income. The priority marginalized populations identified included Indigenous people; women and families; youth; people with acquired brain injury, or intellectual or physical disabilities; and refugees and other migrants (Esther Shoemaker, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020). Each working group then scoped the literature using Google Scholar and PubMed to determine a list of interventions and terms relating to each of the priority-need categories. Each working group came to consensus on the final list of interventions to be included (Table 3). Guideline development We followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for the development of this clinical guideline, including the identification of clinical questions, systematic reviews of the best available evidence, Table 3: Descriptions of priority-need interventions Intervention Description Permanent supportive housing
Long-term housing in the community with no set preconditions for access. Housing may be paired with the provision of individualized supportive services that are tailored to participants’ needs and choices, including assertive community treatment and intensive case management.
This guideline groups the Housing First model (a homeless assistance approach that prioritizes providing housing) with permanent supportive housing. Income assistance
Benefits and programs that improve socioeconomic status. This may include assistance that directly increases income and programs that help with cost reduction of basic living necessities.
This guideline also groups employment programs (e.g., individual placement and support, and compensated work therapy) in this category. Case management
Standard case management allows for the provision of an array of social, health care and other services with the goal of helping the client maintain good health and social relationships.
Intensive case management offers the support of a case manager who brokers access to an array of services. Case-management support can be available for up to 12 hours per day, 7 days a week, and each case manager often has a caseload of 15–20 service users.
Assertive community treatment offers team-based care to individuals with severe and persistent mental illness by a multidisciplinary group of health care workers in the community. This team should be available 24 hours per day, 7 days per week.
Critical time intervention supports continuity of care for service users during times of transition. Case management is administered by a critical time intervention worker and is a time-limited service, usually lasting 6–9 months. Pharmacologic interventions for substance use disorder
Pharmacologic interventions for opioid use disorder, including methadone, buprenorphine, diacetylmorphine, levo-a-acetylmethadol and naltrexone.
Pharmacologic agents for reversal of opioid overdose: opioid antagonist administered intravenously or intranasally (e.g., naloxone). Harm reduction for substance use disorders
Supervised consumption facilities: facilities (stand-alone, co-located or pop-up) where people who use substances can consume preobtained substances under supervision.
Managed alcohol programs: shelter, medical assistance, social services and the provision of regulated alcohol to support residents with severe alcohol use disorder. GUIDELINE E248 CMAJ
ISSUE 10 assessment of the certainty of the evidence and development of recommendations.182 We conducted a series of systematic reviews to answer the following clinical question: Should PSH, income assistance, case management, pharmacologic agents for opioid use, and/or harm-reduction interventions be considered for people with lived experience of homelessness? Systematic reviews for each intervention were driven by a logic model. A detailed description of the methods used to compile evidence summaries for each recommendation, including search terms, can be found in Appendix 3, available at www.cmaj.ca/ lookup/suppl/doi:10.1503/cmaj.190777/-/DC1. We sought evidence on questions considering population, interventions and comparisons according to published a priori protocols.183–186 We used relevant terms and structured search strategies in 9 bibliographic databases for RCTs and quasi-experimental studies. The technical team reviewed titles, abstracts and full texts of identified citations, selected evidence for inclusion and compiled evidence reviews, including cost-effectiveness and resource-use data, for consideration by the guideline panel. The technical team collected and synthesized data on the following a priori outcomes: housing stability, mental health, quality of life, substance use, hospital admission, employment and income. Where possible, we conducted meta-analyses with random effects and assessed certainty of evidence using the GRADE approach. Where pooling of results was not appropriate, we synthesized results narratively. In addition to the intervention and cost-effectiveness reviews, the technical team conducted 3 systematic reviews to collect contextual and population-specific evidence for the populations prioritized through our Delphi process (women, youth, refugees and migrants) (Christine Mathew, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020; Harneel Kaur, University of Ottawa, Ottawa, Ont.: unpublished data, 2020).162 Additionally, we conducted 1 qualitative literature review to capture patient values and preferences, focused on the experiences of people who are homeless in engaging with our selected interventions.20 Drafting of recommendations The steering committee hosted a 2-day knowledge-sharing event, termed the “Homeless Health Summit,” on Nov. 25–26, 2018. Attendees included expert working group members, community scholars, technical team members, and other governmental and nongovernmental stakeholders. Findings from all intervention reviews were presented and discussed according to the GRADE Evidence to Decision framework.187 After the meeting, the steering committee drafted GRADE recommendations (Box 2) through an iterative consensus process. All steering-committee members participated in multiple rounds of review and revision of the drafted clinical recommendations. Guideline panel review We used the GRADE Evidence to Decision framework to facilitate the development of recommendations187–189 (Appendix 4, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.190777/-/DC1). We used GRADEpro and the Panel Voice software to obtain input from the guideline panel.190 Panellists provided input on the wording and strength of the draft recommendations. They also provided considerations for clinical implementation. We required endorsement of recommendations by 60% of panel members for acceptance of a recommendation. After review by the guideline panel, the steering committee reviewed the final recommendations before sign-off. Good practice statements We developed a limited number of good practice statements to support the delivery of the initial evidence-based recommendations. A good practice statement characteristically represents situations in which a large and compelling body of indirect evidence strongly supports the net benefit of the recommended action, which is necessary for health care practice.191–193 Guideline-development groups consider making good practice statements when they have high confidence that indirect evidence supports net benefit, there is a clear and explicit rationale connecting the indirect evidence, and it would be an onerous and unproductive exercise and thus a poor use of the group’s limited resources to collect this evidence. The steering committee came to a consensus on 3 good practice statements based on indirect evidence. Identification of implementation considerations We completed a mixed-methods study to identify determinants of implementation across Canada for the guideline (Olivia Magwood, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020). Briefly, the study included a survey of 88 stakeholders and semistructured interviews with people with lived experience of homelessness. The GRADE Feasibility, Acceptability, Cost (affordability) and Equity (FACE) survey collected data on guideline priority, feasibility, acceptability, cost, equity and intent to implement. We used a framework analysis and a series of meetings (Ottawa, Ont., Jan. 13, 2020; Hamilton, Ont., Aug. 16, 2019; Gatineau, Que., July 18, 2019) with relevant stakeholders in the field of homeless health to analyze our implementation data. Management of competing interests Competing interests were assessed using a detailed form adapted from the International Committee of Medical Journal Editors Uniform Disclosure Form for Potential Conflicts of Interest194 and the Elsevier sample coauthor agreement form for a scientific project, contingencies and communication.195 These forms were collected at the start of the guideline activities for the steering committee, guideline panel and community scholars. All authors submitted an updated form in June 2019 and before publication. The management committee iteratively reviewed these statements and interviewed participants for any clarifications and concerns. A priori, the management committee had agreed that major competing interests would lead to dismissal. There were no competing interests declared. Implementation Our mixed-methods study (Olivia Magwood, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020) looking at guideline priority, feasibility, acceptability, cost, equity and intent to implement, identified the following concerns regarding implementation of this guideline. GUIDELINE CMAJ
ISSUE 10 E249 Stakeholders highlighted the importance of increasing primary care providers’ knowledge of the process of applying to PSH programs and informing their patients about the resources available in the community. The major concerns regarding feasibility arose around the limited availability of existing services, such as housing, as well as administrative and human resources concerns. For example, not all primary care providers work in a team-based comprehensive care model and have access to a social worker or care coordinator who can help link the patient to existing services. Furthermore, wait lists for PSH are frequently long. Despite this, all stakeholders agreed that access to PSH was a priority and is a feasible recommendation. Allied health practitioners and physicians do not always agree with their new role in this area. Some feedback suggested pushback from family physicians who have limited time with patients and less experience exploring social determinants of health, such as housing or income. The initial steps outlined in this guideline would come at an opportunity cost for them. Stigma attached to the condition of homelessness was recognized as an important barrier to care for homeless populations. Many stakeholders recognized that successful implementation of these recommendations may require moderate costs to increase the housing supply, income supports and human resources. However, supervised consumption facilities, with their range of benefits, were perceived as cost-saving. Many interventions have the potential to increase health equity, if available and accessible in a local context. Many stakeholders highlighted opportunities to increase knowledge of the initial steps and advocate on a systematic level to increase availability of services. Suggested performance measures We developed a set of performance measures to accompany this guidleline for consideration by providers and policy-makers:
The proportion of adults who are assessed for homelessness or vulnerable housing over 1 year.
The proportion of eligible adults who are considered for income assistance over 1 year.
The proportion of eligible adults using opioids who are offered opioid agonist therapy over 1 year. Updates The Homeless Health Research Network will be responsible for updating this guideline every 5 years. Other guidelines This guideline complements other published guidelines. This current guideline aims to support the upcoming Indigenousspecific guidelines that recognize the importance of Indigenous leadership and methodology that will recognize distinct underlying causes of Indigenous homelessness (Jesse Thistle, York University, Toronto, Ont.: personal communication, 2020). The World Health Organization has developed guidelines to promote healthy housing standards to save lives, prevent disease and increase quality of life.196 Other guidelines specific to opioid use disorder exist,197,198 including 1 for “treatment-refractory” patients.199 In the United Kingdom, the National Institute for Health Care and Excellence has published guidelines for outpatient treatment of schizophrenia and has published multimorbidity guidelines (www.nice.org.uk/guidance). The National Health Care for the Homeless Council in the US has adapted best practices to support front-line workers caring for homeless populations.200 How is this guideline different? This guideline distills initial steps and evidence-based approaches, to both homeless and vulnerably housed people, with the assistance of patients and other stakeholders. It also introduces a new clinical lens with upstream interventions that provide a social and health foundation for community integration. Its initial steps support the vision of the Centre for Homelessness Impact in the UK, which envisions a society where the experience of homelessness, in instances where it cannot be prevented, is only ever rare, brief and nonrecurrent.201 Finally, we hope that our stakeholder engagement inspires and equips future students, health providers and the public health community to implement the initial step recommendations. Gaps in knowledge Evidence-based policy initiatives will need to address the accelerating health and economic disparities between homeless and general housed populations. As primary care expands its medical home models,27 there will be a research opportunity for more traumainformed care202 to support the evidence-based interventions in this guideline. Indeed, clinical research can refine how providers use the initial steps protocol: housing, income, case management and addiction. With improved living conditions, care coordination and continuity of care, research and practice can shift to treatable conditions, such as HIV and HCV infection, substance use disorder, mental illness and tuberculosis.203 Medical educators will also need to develop new training tools to support the delivery of interventions. Curricula and training that support the delivery of interventions, such as traumainformed and patient-centred care, will also be needed.12 Many of the recommended interventions in this guideline rely on collaboration of community providers, housing coordinators and case management. Interdisciplinary primary care research and maintenance of linkages to primary care will benefit from new homeless health clinic networks. Monitoring transitions in care and housing availability will be an important research goal for Canada’s National Housing Strategy and the associated Reaching Home program. Conclusion Homelessness has become a health emergency. Initial steps in addressing this crisis proposed in this guideline include strongly recommending PSH as an urgent intervention. The guideline also recognizes the trauma, disability, mental illness and stigma GUIDELINE E250 CMAJ
ISSUE 10 facing people with lived homelessness experience and thus recommends initial steps of income assistance, intensive case management for mental illness, and harm-reduction and addictiontreatment interventions, including access to opioid agonist therapy and supervised consumption facilities. The successful implementation of this guideline will depend on a focus on the initial recommendations, trust, patient safety and an ongoing collaboration between primary health care, mental health providers, public health, people with lived experience and broader community organizations, including those beyond the health care field. References 1. Frankish CJ, Hwang SW, Quantz D. Homelessness and health in Canada: research lessons and priorities. Can J Public Health 2005;96(Suppl 2):S23-9. 2. 31 days of promoting a better urban future: Report 2018. Nairobi (Kenya): UN Habitat, United Nations Human Settlement Programme; 2018. 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ISSUE 10 195. Primack RB, Cigliano JA, Parsons ECM, et al. Coauthors gone bad; how to avoid publishing conflict and a proposed agreement for co-author teams [editorial]. Biol Conserv 2014;176:277-80. 196. WHO housing and health guidelines. Geneva: World Health Organization; 2018. 197. Korownyk C, Perry D, Ton J, et al. Managing opioid use disorder in primary care: PEER simplified guideline. Can Fam Physician 2019;65:321-30. 198. Bruneau J, Ahamad K, Goyer M-È, et al.; CIHR Canadian Research Initiative in Substance Misuse. Management of opioid use disorders: a national clinical practice guideline. CMAJ 2018;190:E247-57. 199. Fairbairn N, Ross J, Trew M, et al. Injectable opioid agonist treatment for opioid use disorder: a national clinical guideline. CMAJ 2019;191:E1049-56. 200. Montauk SL. The homeless in America: adapting your practice. Am Fam Physician 2006;74:1132-8. 201. Teixeira L, Russell D, Hobbs T. The SHARE framework: a smarter way to end homelessness. London (UK): Centre for Homelessness Impact; 2018; Available: www. homelesshub.ca/resource/share-framework-smarter-way-end-homelessness (accessed 2019 Dec. 12). 202. Purkey E, Patel R, Phillips SP. Trauma-informed care: better care for everyone. Can Fam Physician 2018;64:170-2. 203. Homelessness & health: What’s the connection [fact sheet]. Nashville (TN): National Health Care for the Homeless Council; 2011. Available: https://nhchc.org/wp-content /uploads/2019/08/Hln_health_factsheet_Jan10-1.pdf (accessed 2019 June 1). Competing interests: Gary Bloch is a founding member, former board member and currently a clinician with Inner City Health Associates (ICHA), a group of physicians working with individuals experiencing homelessness in Toronto, which provided funding for the development of this guideline. He did not receive payment for work on the guideline and did not participate in any ICHA board decision-making relevant to this project. Ritika Goel, Michaela Beder and Stephen Hwang also receive payment for clinical services from ICHA, and did not receive payment for any aspect of the submitted work. No other competing interests were declared. This article has been peer reviewed. Affiliations: C.T. Lamont Primary Health Care Research Centre (Pottie, d Wendy Muckle led the Homeless Health Summit. Esther Shoemaker led the Delphi consensus. Olivia Magwood led the reviews on lived experiences and substance use, Tim Aubry led the review on housing, Gary Bloch and Vanessa Brcic led the review on income, David Ponka and Eric Agbata led the review on case management, Jean Zhuo Jing Wang and Sebastian Mott led the homeless youth review, Harneel Kaur led the homeless migrant review, Christine Mathew and Anne Andermann led the homeless women review, Syeda Shanza Hashmi and Ammar Saad led medical student engagement and competency review, Thomas Piggott co-led the GRADE Assessment with Olivia Magwood and Kevin Pottie, Michaela Beder and Nicole Kozloff contributed substantially to the substance use review, and Neil Arya and Stephen Hwang provided critical policy information. All of the named authors engaged in the writing and review, gave final approval of the version of the guideline to be published, and agreed to be accountable for all aspects of the work. Funding: This guideline was supported by a peer-reviewed grant from the Inner City Health Associates, and supplemental project grants from the Public Health Agency of Canada, Employment Social Development Canada, Canadian Medical Association and Champlain Local Integrated Health Network. Personnel from collaborating agencies provided nonbinding feedback during the preparation of systematic reviews and the guideline. The funders had no role in the design or conduct of the study; collection, analysis and interpretation of the data; or preparation, review or final approval of the guideline. Final decisions regarding the protocol and issues that arose during the guideline-development process were solely the responsibility of the guideline steering committee. Acknowledgements: The authors thank everyone who participated in the development of this guideline, including community scholars, technical team leads, guideline panel members and working group members. Endorsements: Canadian Medical Association, Canadian Public Health Association, Canadian Federation of Medical Students, The College of Family Physicians of Canada, Public Health Physicians of Canada, Canadian Association of Emergency Physicians, The Canadian Alliance to End Homelessness, Canadian Nurses Association Disclaimer: The views expressed herein do not necessarily represent the views of the funding agencies. Correspondence to: Kevin Pottie, kpottie@uottawa.ca
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The Lancet Countdown on Health and Climate Change - Policy brief for Canada

https://policybase.cma.ca/en/permalink/policy14257
Date
2019-11-01
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Date
2019-11-01
Topics
Population health/ health equity/ public health
Text
The Lancet Countdown on Health and Climate Change Policy brief for Canada 1 Finding: Exposure to wildfires is increasing in Canada, with more than half of the 448,444 Canadians evacuated due to wildfires between 1980 and 2017 displaced in the last decade. Recommendation: Incorporate lessons learned from recent severe wildfire seasons into a strengthened pan-Canadian emergency response approach that anticipates increasing impacts as the climate continues to change. Finding: The percentage of fossil fuels powering transport in Canada remains high, though electricity and biofuels are gaining ground. Fine particulate air pollution generated by transportation killed 1063 Canadians in 2015, resulting in a loss of economic welfare for Canadians valued at approximately $8 billion dollars. Recommendation: Develop provincial and territorial legislation requiring automakers to gradually increase the annual percentage of new light-duty vehicles sold that are zero emissions, working toward a target of 100% by 2040. Finding: Canada has the third-highest per capita greenhouse gas emissions from healthcare in the world, with healthcare accounting for approximately 4% of the country’s total emissions. Recommendation: Establish a sustainable healthcare initiative that assembles experts from research, education, clinical practice, and policy to support Canada’s healthcare sector in reducing greenhouse gas emissions and preventing pollution-related deaths, consistent with healthcare’s mandate to ‘do no harm’ and the timelines and goals of the Paris Agreement, charting a course for zero-emissions healthcare by 2050. Finding: The health of Canadians is at risk due to multiple and varied risks of climate change, including those described in this policy brief (see Figure 1). An ongoing, coordinated, consistent and pan-Canadian effort to track, report, and create healthy change is required. Recommendation: Integrate health considerations into climate-related policymaking across sectors, including in Canada’s updated 2020 Nationally Determined Contribution Commitments under the United Nations Framework Convention on Climate Change (UNFCCC) process, and increase ambition to ensure Canada commits to doing its fair share in achieving the goals of the Paris Agreement. Introduction Climate change is the biggest global health threat of the 21st century,1 and tackling it could be our greatest health opportunity.2 “The health of a child born today will be impacted by climate change at every stage in their life. Without significant intervention, this new era will come to define the health of an entire generation.”3 However, another path is possible: a world that meets the ambition of the Paris Agreement and proactively adapts to protect health from the climate impacts we cannot now avoid. This year’s briefing presents key findings and recommendations toward this path. Key messages and recommendations Health and climate change in Canada Imagine an infant born today in Canada. This child enters a country warming at double the global rate, with the average temperature in Canada having increased 1.7oC between 1948-2016.4 The North is warming even faster: areas in the Northwest Territories’ Mackenzie Delta are now 3oC warmer than in 1948.5 Climate-related impacts on health and health systems are already being felt,6 with examples outlined in Figure 1. By the time the child is in their twenties, in all feasible emissions scenarios, Canada will have warmed by at least 1.5oC as compared to a 1986-2005 reference period.4 Two scenarios are possible for the remainder of the child’s life. If GHG emissions continue to rise at the current rate (a situation referred to by the Intergovernmental Panel on Climate Change (IPCC) as the “high emissions scenario,” or ‘RCP8.5’) temperature increases in Canada will continue after 2050, reaching 6oC relative to 1986-2005 by the time the child is in their child’s sixties.4 Globally, this degree of warming places populations at a greater risk of wildfires, extreme heat, poor air quality, and weather-related disasters. It will also lead to changes in vector-borne disease, as well as undernutrition, conflict, and migration. These impacts and others negatively impact mental health,3 including via ecological anxiety and grief.8 Climate change will not impact everyone equally, and can widen existing disparities in health outcomes between and within populations, with Indigenous populations, people in low-resource settings,28 and future generations29 disproportionately affected.30 This degree of warming has the potential to disrupt core public health infrastructure and overwhelm health services.2 Alternatively, if global emissions peak soon and quickly fall to net zero, consistent with the IPCC’s low-emissions scenario, (RCP 2.6), temperatures will remain steady from 2040 onwards.4 Measures needed to accomplish this, such as increasing clean energy, improving Figure 1: Examples of impacts of Climate Change on Health and Health Systems in Canada Indicators of climate-related health impacts and adaptation This year’s policy brief presents information on three key indicators of climate-related health impacts and adaptive responses. Additional recommendations can also be found in the 2017 and 2018 policy briefs.6,24 Wildfires Lancet Countdown data indicates that the number of daily population wildfire exposure events increased from an average of 35,300 in 2001-2004 to 54,100 in 2015-2018, not including those subjected to wildfire smoke. Canadian data supports increasing impacts: more than half of the 448,444 Canadians evacuated due to wildfires between 1980-2017 were displaced in the last decade.35 These exposures not only pose a threat to public health, but also result in major economic and social burdens. 2019 marks a crux point for humanity: choices and policies made in the lead up to the 2020 UNFCCC Nationally Determined Contribution submissions will determine whether the world follows the disastrous high-emissions scenario, or the safer low-emissions path. Children are taking to the streets to demand a livable world. It is the task of today’s political leaders and other adults to exert maximal effort within their spheres of influence in order to set a course for a healthy response to climate change. public transit, cycling and walking rates, and adhering to a plantrich diet in accordance with Canada’s new food guide, decrease emissions, and also improve health and decrease healthcare costs.30 Canada is not on track: in 2016, total Canadian GHG emissions were 704 Mt CO2e, an increase of more than 100 Mt since 1990.31 Policies and measures currently under development but not yet implemented are forecast to reduce national emissions to 592 Mt CO2e by 2030,32 79 Mt CO2e above Canada’s 2030 target of 513 MtCO2e 32—a goal which is itself too weak to represent a fair contribution by Canada to the emissions reductions necessary to meet the goals of the Paris Climate Change Agreement. The Earth as a whole is warming less quickly than Canada—but still far too fast. The IPCC and the World Health Organization have emphasized that keeping global surface temperature warming to 1.5oC is key to obtaining the best outcomes now possible for human health.33,34 To do so would require global net human-caused emissions to fall by about 45% from 2010 by 2030, reaching ‘net zero’ by 2050.34 Updated Nationally Determined Contributions to the Paris Agreement are due to be submitted by 2020: policymakers must integrate health considerations through proposed interventions. Figure 2: Number of Wildfire Evacuees in Canada 1980-2017.* Source: Wildland Fire Evacuation Database, Natural Resources Canada.35 (used with permission) *N.B. Reporting for 2017 only includes evacuations up to and including July In a mid-range GHG emissions scenario, wildfires in Canada are projected to rise 75% rise by the end of the 21st century,36 necessitating a strong adaptive response. Human health impacts of fire include death, trauma, and major burns,37 anxiety during wildfire periods,35,38 and post-traumatic stress disorder, anxiety and depression related to evacuations.39,40 Wildfire smoke also travels vast distances41 and increases asthma and chronic obstructive pulmonary disease exacerbations, with growing evidence of an association with all-cause mortality.41 Impacts on health systems can be severe: during the Fort McMurray fire hospital staff evacuated 103 patients in a matter of hours,10,42 and the 2017 British Columbia wildfires resulted in 700+ staff displaced, 880 patients evacuated, and 19 sites closed by the Interior Health Authority, at a cost of $2.7 million.12 Such devastating events also generate significant emissions, contributing to climate change, and helping to generate conditions conducive to future blazes.43 Much can be done to lessen the health impacts of wildfires. Qualitative data indicates that populations who are better-briefed on the local evacuation plan, as well as ways to lessen the risk of fire to their property, are not only more prepared but also less anxious.35,38 Building codes can be changed to help keep smoke out, primary care practitioners can ensure vulnerable patients receive at-home air filtration systems and respiratory medications prior to wildfire season,44 public health professionals can collaborate with municipal officials to maximize smoke forecast-informed outdoor and well-ventilated indoor recreation opportunities,38 and health personnel can help ensure evacuation plans are clearly communicated.45 Sustainable and healthy transport since 2000, they account for less than 4% of the energy used in transport (Figure 3). This rate of change is inconsistent with the emissions pathway required to keep today’s and future children safe. Support is therefore required for investments in public transit,47 and cycling infrastructure,48 creating win-wins for health by increasing physical activity levels and improving community cohesion, while reducing chronic disease, healthcare costs and GHG emissions.49,50 Zero emissions vehicles also reduce air pollution and are increasingly affordable: the up-front cost of electric vehicles is forecast to become competitive on an un-subsidized basis from 2024 onwards.51 British Columbia recently passed legislation requiring all new cars sold to be zero-emission by 2040.52 Other provinces would benefit from matching this ambition. Figure 3: Per Capita Fuel Consumption for Transport in Canada. Source: Lancet Countdown Transport-related pollution is harming the health of Canadians. Fine particulate matter (PM2.5) air pollution related to land-based transportation was responsible for approximately 1063 deaths in 2015 in Canada, resulting in a loss of economic welfare for Canadians valued at approximately $8 billion dollars.24 Additionally, Canada has the highest pediatric asthma rate amongst countries of comparable income level, with nitrogen dioxide (NO2) from traffic responsible for approximately 1 in 5 new cases of asthma in children.46 With transport responsible for 24% of national GHG emissions in 2017,31 decarbonizing this sector must be prioritized. Progress is entirely too slow: total fuel consumption for road transport per capita decreased 5.4% from 2013 to 2016. While per capita use of electricity and biofuels for transport increased by 600% Healthcare sector emissions Though Canadians are proud of the care they provide for one another with this country’s system of universal healthcare,53 Lancet Countdown analysis reveals an area which should give pause to all who endeavor to “do no harm”: Canada’s healthcare system has the world’s third highest emissions per capita. Previous analysis showed healthcare sector emissions to be responsible for 4.6% of the national total,54 as well as more than 200,000 tons of other pollutants, resulting in 23,000 disability-adjusted life years (DALYs) lost annually.54 Emissions from the health sector represent a strategic mitigation target in a single-payer healthcare system straining under the weight of an inexorably increasing burden of disease. While Canadian healthcare sector emissions are increasing, the world-leading Sustainable Development Unit in England reported an 18.5% decrease in National Health Service, public health and social care system emissions from 2007-2017 despite an increase in clinical activity.55 Despite healthcare being a provincial jurisdiction, there is a role for pan-Canadian sustainability initiatives to unite diverse experts spanning public health and the spectrum of clinical disciplines, economics, sustainability science and beyond. This demands health sector-wide education, consistent with existing efforts to increase environmental literacy for health professionals.56 1. Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet 2009;373(9676):1693-733. 2. Watts N, Amann M, Arnell N, et al. The 2018 report of The Lancet Countdown on health and climate change: shaping the health of nations for centuries to come. Lancet 2018; vol. 392: 2479–514. 3. Watts N, Amann M, Arnell N, et al. The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate. Lancet 2019; vol. 394: 1836–78. 4. Government of Canada. Canada’s Changing Climate Ottawa, Ontario,; 2019. 5. Government of the Northwest Territories. Climate Observations in the Northwest Territories (1957-2012) Inuvik * Norman Wells * Yellowknife * Fort Smith. 6. Howard C, Rose C, Hancock T. Lancet Countdown 2017 Report: Briefing for Canadian Policymakers. Lancet Countdown and Canadian Public Health Association; 2017 October 31st, 2017. 7. Rosol R, Powell-Hellyer S, Chan HM. Impacts of decline harvest of country food on nutrient intake among Inuit in Arctic Canada: impact of climate change and possible adaptation plan. Int J Circumpolar Health 2016;75(1):31127. 8. Cunsolo A, Ellis N. Ecological grief as a mental health response to climate change-related loss. Nature Climate Change 2018;8:275-81. 9. Yao J, Eyamie J, Henderson SB. Evaluation of a spatially resolved forest fire smoke model for population-based epidemiologic exposure assessment. J Expo Sci Environ Epidemiol 2016;26(3):233-40. 10. Hampshire G. Hospital heroes get patients to safety during Fort McMurray fire: 17 buses took 105 patients to safety in dramatic evacuation. CBC News. 2016. Available from: http://www.cbc.ca/news/canada/edmonton/hospital-heroesget- patients-to-safety-during-fort-mcmurray-fire-1.3574416. 11. Kirchmeier-Young M, Zwiers F, Gillett N, Cannon A. Attributing extreme fire risk in Western Canada to human emissions. Climatic Change 2017;144(2):365-79. 12. British Columbia Interior Health Authority. Wildfire Emergency Response 2017. 2018. 13. Kirchmeier-Young M, Gillett N, Zwieres F, Cannon A, Anslow F. Attribution of the Influence of Human-Induced Climate Change on an Extreme Fire Season. Earth’s Future: American Geophysical Union 2018. 14. Alberta Health. Impact of Wildfires on the Mental Health of Fort McMurray Residents: Neurotic Disorders, Daily Physician Visits within an Emergency Department 2015 vs. 2016. Alberta Health, Health Standards, Quality and Performance Division, Analytics and Performance Reporting Branch,; 2016. 15. Teufel B, Diro GT, What K, Mildrad SM, Jeong DI, Ganji A, et al. Investigation of the 2013 Alberta flood from weather and climate perspectives. Climate Dynamics 2017:2881-99. 16. Canadian Broadcasting Corporation. Alberta Flood 2013: The five people we lost. 2014. Available from: https://www.cbc.ca/calgary/features/albertaflood2013/ alberta-flood-deaths/. 17. United Nurses of Alberta. UNA Calgary office closed, many health facilities affected by southern Alberta flooding. 2013 June 21, 2013. 18. Yusa A, Berry P, J JC, Ogden N, Bonsal B, Stewart R, et al. Climate Change, Drought and Human Health in Canada. Int J Environ Res Public Health 2015;12(7):8359-412. 19. Smoyer-Tomic KE, Klaver JD, Soskolne CL, Spady DW. Health Consequences of Drought on the Canadian Prairies. EcoHealth 2004. 20. Government of Canada Agriculture and Agri-Food Canada. Impact of Climate Change on Canadian Agriculture. 2015 [Oct 22, 2017]; Available from: http:// www.agr.gc.ca/eng/science-and-innovation/agricultural-practices/agriculture- and-climate/future-outlook/impact-of-climate-change-on-canadian-agriculture/? id=1329321987305 21. Cryderman K. Drought in Western Canada is becoming an agricultural nightmare for farmers. 2018. Available from: https://www.theglobeandmail.com/ canada/alberta/article-drought-in-western-canada-is-becoming-an-agricultural- nightmare-for/. 22. Ziska LH, Makra L, Harry SK, Bruffaerts N, Hendrickx M, Coates F, et al. Temper-ature-related changes in airborne allergenic pollen abundance and seasonality across the northern hemisphere: a retrospective data analysis. Lancet Planet Health 2019;3(3):e124-e31. 23. Nelder MP, Wijayasri S, Russell CN, Johnson KO, Marchand-Austin A, Cronin K, et al. The continued rise of Lyme disease in Ontario, Canada: 2017. Canadian Communicable Disease Review 2018;44(10):231-6. 24. Howard C, Rose C, Rivers N. Lancet Countdown 2018 Report: Briefing for Canadian Policymakers. Canadian Medical Association, Canadian Public Health Association, The Lancet Countdown; 2018 November. 25. a. Regional Public Health Department of Montreal. Epidemiological Investigation Heat Wave Summer 2018 in Montréal - Summary. 2019. b. Vogel MM, Zscheischler J, Wartenburger R, et al. Concurrent 2018 hot extremes across Northern hemisphere due to human-induced climate change. Earth's Future, 2019; vol. 7, 692–703. https://doi.org/10.1029/ 2019EF001189 26. Fenech A. Yes, Mr. Premier, Your Province is Shrinking! 2014 [cited 2019 Sept 20, 2019]; Available from: http://projects.upei.ca/climate/2014/02/16/ yes-mr-premier-your-province-is-shrinking/ 27. Kelleya C, Mohtadib S, Canec M, Seagerc R, Kushnirc Y. Climate change in the Fertile Crescent and implications of the recent Syrian drought. Proceedings of the National Academy of Science 2015;112 no 11: 3241–6,. 28. Berry HL, Bowen K, Kjellstrom T. Climate change and mental health: a causal pathways framework. Int J Public Health 2010;55(2):123-32. 29. Walpole SC, Rasanathan K, Campbell-Lendrum D. Natural and unnatural synergies: climate change policy and health equity. Bull World Health Organ 2009;87(10):799-801. 30. Watts N, Adger WN, Agnolucci P, Blackstock J, Byass P, Cai W, et al. Health and climate change: policy responses to protect public health. Lancet 2015;386(10006):1861-914. 31. Government of Canada. Greenhouse Gas Emissions. 2018 [June 13, 2018.]; Available from: https://www.canada.ca/en/environment-climate-change/ services/environmental-indicators/greenhouse-gas-emissions.html 32. Environment and Climate Change Canada. Canadian Environmental Sustainability Indicators: Progress Towards Canada’s Greenhouse Gas Emissions Reduction Target. 2019 [Sept 3, 2019]; Available from: https://www.canada. ca/content/dam/eccc/documents/pdf/cesindicators/progress-towards-canada- greenhouse-gas-reduction-target/2019/progress-towards-ghg-emissions- target-en.pdf 33. Ebi K, Campbell-Lendrum D, Wyns A. The 1.5 Health Report--Synthesis on Health and Climate Science in the IPCC SR1.5. 2018 2018. 34. Intergovernmental Panel on Climate Change. Global Warming of 1.5C--Summary for Policymakers. 2018 October 8, 2018. 35. Christianson A. Wildland Fire Evacuations in Canada. Natural Resources Canada; 2017. 36. Wotton M, Nock C, Flannigan M. International Journal of Wildland Fire 2010;19(3):253-71. 37. Cameron PA, Mitra B, Fitzgerald M, Scheinkestel CD, Stripp A, Batey C, et al. Black Saturday: the immediate impact of the February 2009 bushfires in Victoria, Australia. Med J Aust 2009;191(1):11-6. 38. Dodd W, Scott P, Howard C, Scott C, Rose C, Cunsolo A, et al. Lived experience of a record wildfire season in the Northwest Territories, Canada. Can J Public Health 2018;109(3):327-37. 39. McDermott BM, Lee EM, Judd M, Gibbon P. Posttraumatic stress disorder and general psychopathology in children and adolescents following a wildfire disaster. Can J Psychiatry 2005;50(3):137-43. 40. Papanikolaou V, Adamis D, Mellon RC, Prodromitis G. Psychological distress following wildfires disaster in a rural part of Greece: a case-control population- based study. Int J Emerg Ment Health 2011;13(1):11-26. 41. Reid CE, Brauer M, Johnston FH, Jerrett M, Balmes JR, Elliott CT. Critical Review of Health Impacts of Wildfire Smoke Exposure. Environ Health Perspect 2016;124(9):1334-43. 42. Matear D. The Fort McMurray, Alberta wildfires: Emergency and recovery management of healthcare services. J Bus Contin Emer Plan 2017;11(2):128- 50. 43. Liu Y, Goodrick S, Heilman W. Wildland fire emissions, carbon, and climate: Wildfire–climate interactions. Forest Ecology and Management 2014;317:80- 96. 44. Barn PK, Elliott CT, Allen RW, Kosatsky T, Rideout K, Henderson SB. Portable air cleaners should be at the forefront of the public health response to landscape fire smoke. Environ Health 2016;15(1):116. 45. Maguet S. Public Health Responses to Wildfire Smoke Events. BC Center for Disease Control; 2018. 46. Achakulwisut P, Brauer M, Hystad P, Anenberg SC. Global, national, and urban burdens of paediatric asthma incidence attributable to ambient NO2 pollution: estimates from global datasets. Lancet Planet Health 2019;3(4):e166-e78. 47. Besser LM, Dannenberg AL. Walking to public transit: steps to help meet physical activity recommendations. Am J Prev Med 2005;29(4):273-80. 48. United Kingdom Department of Transport. Value for Money Assessment for Cycling Grants. 2014. 49. Woodcock J, Tainio M, Cheshire J, O’Brien O, Goodman A. Health effects of the London bicycle sharing system: health impact modelling study. BMJ 2014;348:g425. 50. Maizlish N, Woodcock J, Co S, Ostro B, Fanai A, Fairley D. Health cobenefits and transportation-related reductions in greenhouse gas emissions in the San Francisco Bay area. Am J Public Health 2013;103(4):703-9. 51. Willett W, Rockstrom J, Loken B, Springmann M, Lang T, Vermeulen S, et al. Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems. Lancet 2019. 52. Zussman R. Legislation introduced to require all new cars sold in B.C. to be zero-emission by 2040. Global News Online. 2019. Available from: https:// globalnews.ca/news/5152429/legislation-introduced-electric-cars/2019. 53. Thompson N. More Canadians take pride in symbols of the country’s present than its past: survey. 2019. 54. Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic- environmental-epidemiological analysis. PLoS Med 2018;15(7):e1002623. 55. National Health System Sustainable Development Unit. Reducing the use of natural resources in health and social care 2018 report. 2018. 56. Parkes M, Poland B, Allison A, Cole DC, Culbert I, Gislason MK, et al. In press-Preparing for the future of public health: Ecological determinants of health and the call for an eco-social approach to public health education. Canadian Journal of Public Health 2019. DOI: 10.17269/s41997-019-00263-8. References Organisations and acknowledgements The concept of this brief was developed by the Lancet Countdown on Health and Climate Change. This brief was written by Courtney Howard, MD; Chris Buse, PhD; Caren Rose, PhD; Andrea MacNeill, MD, MSc; and Margot Parkes, MBChB, MAS, PhD. Review was provided by Owen Adams, PhD; Ian Culbert; and Sandy Buchman, MD. Thanks to Sarah Henderson, PhD; Peter Barry, PhD; Brian Wiens, PhD; Robin Edger, LLB, LLM; Jeff Eyamie, and Ashlee Cunsolo, PhD for their assistance. Contributions and review on behalf of the Lancet Countdown were provided by Jess Beagley and Nick Watts, MBBS. THE LANCET COUNTDOWN The Lancet Countdown: Tracking Progress on Health and Climate Change is an international, multi-disciplinary collaboration that exists to monitor the links between public health and climate change. It brings together 35 academic institutions and UN agencies from every continent, drawing on the expertise of climate scientists, engineers, economists, political scientists, public health professionals, and doctors. Each year, the Lancet Countdown publishes an annual assessment of the state of climate change and human health, seeking to provide decision-makers with access to high-quality evidence-based policy guidance. For the full 2019 assessment, visit www.lancet countdown.org/2019-report . THE CANADIAN MEDICAL ASSOCIATION The Canadian Medical Association (CMA), formed in Quebec City in 1867, has led some of Canada’s most important health policy changes. As we look to the future, the CMA will focus on advocating for a healthy population and a vibrant profession. THE CANADIAN PUBLIC HEALTH ASSOCIATION The Canadian Public Health Association (CPHA) is a national, independent, non-governmental organization that advances public health education, research, policy and practice in Canada and around the world through the Canadian Journal of Public Health, position statements, discussion documents and other resources.
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Recommended guidelines for low-risk drinking

https://policybase.cma.ca/en/permalink/policy10143
Last Reviewed
2019-03-03
Date
2011-03-05
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Last Reviewed
2019-03-03
Date
2011-03-05
Topics
Population health/ health equity/ public health
Text
Note: These Guidelines are not intended to encourage people who choose to abstain for cultural, spiritual or other reasons to drink, nor are they intended to encourage people to commence drinking to achieve health benefits. People of low bodyweight or who are not accustomed to alcohol are advised to consume below these maximum limits. Guideline 1 Do not drink in these situations: When operating any kind of vehicle, tools or machinery; using medications or other drugs that interact with alcohol; engaging in sports or other potentially dangerous physical activities; working; making important decisions; if pregnant or planning to be pregnant; before breastfeeding; while responsible for the care or supervision of others; if suffering from serious physical illness, mental illness or alcohol dependence. Guideline 2 If you drink, reduce long- term health risks by staying within these average levels: Women Men 0–2 standard drinks* per day 0–3 standard drinks* per day No more than 10 standard drinks per week No more than 15 standard drinks per week Always have some non-drinking days per week to minimize tolerance and habit formation. Do not increase drinking to the upper limits as health benefits are greatest at up to one drink per day. Do not exceed the daily limits specified in Guideline 3. Guideline 3 If you drink, reduce short- term risks by choosing safe situations and restricting your alcohol intake: Risk of injury increases with each additional drink in many situations. For both health and safety reasons, it is important not to drink more than: Three standard drinks* in one day for a woman Four standard drinks* in one day for a man Drinking at these upper levels should only happen occasionally and always be consistent with the weekly limits specified in Guideline 2. It is especially important on these occasions to drink with meals and not on an empty stomach; to have no more than two standard drinks in any three-hour period; to alternate with caffeine-free, non-alcoholic drinks; and to avoid risky situations and activities. Individuals with reduced tolerance, whether due to low bodyweight, being under the age of 25 or over 65 years old, are advised to never exceed Guideline 2 upper levels. Guideline 4 When pregnant or planning to be pregnant: The safest option during pregnancy or when planning to become pregnant is to not drink alcohol at all. Alcohol in the mother's bloodstream can harm the developing fetus. While the risk from light consumption during pregnancy appears very low, there is no threshold of alcohol use in pregnancy that has been definitively proven to be safe. Guideline 5 Alcohol and young people: Alcohol can harm healthy physical and mental development of children and adolescents. Uptake of drinking by youth should be delayed at least until the late teens and be consistent with local legal drinking age laws. Once a decision to start drinking is made, drinking should occur in a safe environment, under parental guidance and at low levels (i.e., one or two standard drinks* once or twice per week). From legal drinking age to 24 years, it is recommended women never exceed two drinks per day and men never exceed three drinks in one day. 2 Approved by the CMA Board in March 2011 Last reviewed and approved by the CMA Board in March 2019. The above is excerpted from the report, Alcohol and Health in Canada: A Summary of Evidence and Guidelines for Low-Risk Drinking Available: https://www.ccsa.ca/sites/default/files/2019-04/2011-Summary-of-Evidence-and-Guidelines-for-Low-Risk%20Drinking-en.pdf (accessed 2019 March 01).
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