Dalla Lana School of Public Health

1 Supporting Excellence in Interdisciplinary Research

I’m excited that DLSPH is creating new structures to enable truly interdisciplinary and cross-disciplinary research. This is helping me to collaborate with the wide range of experts I need to help bring precision public health into practice.

The research engine at DLSPH is continuing to move at high speed, with increased research support for faculty and funding opportunities and successes that include but go beyond COVID-19, which is the prominent research concern of the year globally and is addressed elsewhere in this report.

In addition to creating seed funding for COVID-19 research in March, DLSPH set aside seed funding for non-COVID-19 research to preserve the richness of the School’s research portfolio through prioritization of non-COVID-19 research proposals.

The Office of Research continues to explore additional sources of funding. For example, DLSPH has provided $8,000 in seed funding for a grant to associate professor Aviv Shachak entitled Physician Burnout and Use of Mobile Information and Communication Technology, which will explore questions such as how and in what ways physicians engage with MICT for clinical and administrative work-related purposes outside of working hours.

DLSPH Office of Research

DLSPH faculty members have been very successful in obtaining funding for DLSPH-led studies, which has, in turn, led to an expansion of the support the research office can provide.

The increased funding, said Professor France Gagnon, Associate Dean – Research, has brought two new Canada Research Chairs (CRCs) to our school: a CIHR Tier 2 position, which was advertised in the fall of 2020, and a Tier 1 CRC, which will be advertised early in 2021. In addition, the influx of the number of research grants and grant funds has made it necessary to add a new research funding officer, Sarah Namer, to the staff. Namer came on board during the 2020-21 academic year and will support interdisciplinary research at DLSPH, as well as faculty award nominations. She works closely with Caroline Godbout, the research development officer, to support our researchers in their grant and award applications.

SSHRC Success

DLSPH researchers are claiming an increasing presence in social science research, with a tripling of funds from the Social Sciences and Humanities Research Council (SSHRC) in the past few years.

“We are very excited about the success of our principal investigators in the social sciences,” said Lee Vernich, DLSPH’s Director of Research. “Their success with SSHRC funding in recent years is particularly remarkable: our researchers have received more funding in the first three months of 2020 than in 2019.”

Five DLSPH researchers – associate professor Erica Di Ruggiero and assistant professors Meena Andiappan, Arif Jetha, Amaya Perez-Brumer and Jay Shaw — claimed success in the January 2020 Insight Development Competition, reflecting a strategy by the School to provide comprehensive research support to all faculty members. This resulted in increased participation by our School’s social science researchers in these competitions, allowing DLSPH to take advantage of SSHRC’s decision to fund health-related research.

Di Ruggiero will use the funds to study how political, social, cultural and economic factors are influencing Canada’s progress on implementing the UN’s 17 Sustainable Development Goals, while Jetha will study the unique challenges and opportunities for diverse groups of young people in the future of work. Andiappan is exploring the impact of workplace-required necessary evils — tasks in which a person must knowingly and intentionally cause emotional or physical harm to another human being in the service of achieving some perceived greater good — on unethical behaviour.

A number of these project are collaborative and/or interdisciplinary. Shaw, for example, is working with DLSPH colleagues Jennifer Gibson, director of the Joint Centre for Bioethics, and Alison Paprica of IHPME to explore the values that may be overlooked — such as equity and informed consent — when integrating Artificial Intelligence (AI) technologies into health care.

Meanwhile, Perez-Brumer will study the experiences of Venezuelan transgender women relocating to Peru, along with a multinational collaborator at U of T, the Universidad Peruana Cayetano Heredia and Féminas (a Peruvian transgender activist organization).

In addition, assistant professor Angela Mashford-Pringle, associate director of the Waakebiness-Bryce Institute for Indigenous Health, is immersed in the research funded by her 2019 SSHRC Insight grant that actually began in spring 2020. The project, entitled Kijibashik: Turn It Around―Indigenous Women’s Stories on Motherhood and Incarceration, is being conducted in partnership with Jerry Flores, an assistant professor of sociology at U of T

Interdisciplinary Research Areas

The DLSPH interdisciplinary research areas are new initiatives to foster collaboration across the School, the University, and beyond, on research and education efforts aligned with DLSPH research priority themes. With an injection of funding and planning support, the goal is to create new teams that are positioned for discovery and prepared to pursue the “big questions.” Their work will be used to help train the next generation of public health and health system leaders.

This past year, DLSPH invested in two teams to build the first interdisciplinary clusters over the subsequent three years:

The Data Science research cluster, led by associate professor Laura Rosella, is providing leadership in AI and emerging informatics and analytics technologies to improve population health and health systems performance. With 25 members from across nine divisions, the interdisciplinary team is leading important debates, training, and providing support for high impact data science research projects in population health. Its seed funding program for novel data science population health projects leveraged new priority funding from the Edwin S.H. Leong Centre for Healthy Children. In January, the cluster will hold the first of its public Conversations in AI and Health, a series that seeks to foster critical thought and debate regarding data science in the context of public health and health systems.

The Interdisciplinary cluster in Global Public Health and Health Systems Improvement through Implementation Science is co-led by associate professors Erica Di Ruggiero and Xiaolin Wei. It engages faculty and students from across the School, the University, affiliated hospitals and research centres, as well as faculty based abroad (currently including Kenya, the Philippines and Israel).

The team is building capacity in implementation science within and beyond DLSPH. Two new postdoctoral fellows have been engaged to develop projects that address different implementation science priorities, and more than 20 graduate students, in teams drawn from across DLSPH divisions and institutes, has launched group projects, co-mentored by cluster faculty members.

In a partnership with the WHO’s Special Programme for Research and Training in Tropical Diseases, the team will be piloting an international training program in Operational Research, involving expert facilitators with learners from Canada and low-and middle-income countries to develop actionable health systems research projects.

A third emerging research cluster, still in the formative stages, will focus on integrated care, in support of the DLSPH goal of “Building sustainable and equitable health systems through integration and engagement at the organizational, local and jurisdictional level,” and will draw inspiration from WHO reports on person-centred integrated care. Two inaugural meetings are scheduled for January 2021.

Professor Walter Wodchis will lead this initiative; the group’s vision is to achieve a person-centred sustainable, equitable, and integrated learning health system, drawing upon the expertise of DLSPH faculty and experts from across the university in five specific areas:

1. Community-oriented care systems;
2. Intersection between medical and social care;
3. Organisational learning and innovation culture;
4. Financing, economics and payment; and
5. Digital health.

7 IHPME

I’m looking forward to continuing to work with such a multidisciplinary and innovative group of researchers and to help propel the Institute forward as we make our mark globally.

The Institute of Health Policy, Management and Evaluation (IHPME) integrates application of cutting-edge theory and methods to better understanding of health and health systems questions. The Institute’s exceptional faculty and student scholars engage with health care professionals and policy makers across health and social care to enhance the sustainability, performance, and equity of health systems with the goal of advancing population health. The work of the Institute has been particularly noteworthy and central to the public health-care system during the 2019–2020 academic year.

New Leadership

There is much to report about IHPME’s achievements during the ever-changing landscape of this past academic year, not the least of which was the appointment of a new director, Professor Audrey LaPorte. Laporte began her five-year term in January 2020.

Professor Laporte is an internationally recognized scholar with expertise in dynamic microeconomic theory, applied labour economics and econometrics. She has been a faculty member of the Institute since 2001, recently serving as the Program Director for the Health Services Research Program and as the Institute’s Interim Director since June of 2019.

“I’m looking forward to continuing to work with such a multidisciplinary and innovative group of researchers as Director, and to help propel the Institute forward as we make our mark globally,” Laporte says.

Professor Laporte received another honour this year when she was named President-Elect by the International Health Economics Association, one of the world’s largest and most prestigious health economics associations. She is one of only a few women to undertake this role, as well as the first Canadian.

“To me it shows that insights from the Canadian policy environment are contributing to a broader international discussion and is a reflection of the high-quality analysis being done in a multi-disciplinary environment such as IHPME,” said Laporte.

New faculty members continued to enhance the roster of talented public health professionals who teach and conduct research at IHPME. Meena Andiappan, who teaches organizational behavior in the Health Services Research program, joined IHPME from Montpellier Business School in France. Andiappan’s research has centered around ethical behavior, including ethical leadership and change mechanisms.

Andiappan expressed her pleasure at joining IHPME, saying, “The Institute is so interdisciplinary, bringing together people from different types of educational backgrounds, and I find that the best research often comes from this kind of collaboration—where each person shares and leverages their expertise to shed new light on challenging questions.”

Kerry Kuluski, a status Associate Professor at IHPME, has taken on a new challenge as the Dr. Mathias Gysler Research Chair in Patient & Family Centered Care and Scientist at Trillium Health Partners Institute for Better Health. Kuluski will focus on creating a measurement strategy to capture the things that matter to patients and families in their care. Closely connected to that is optimizing care experiences, particularly as patients and caregivers transition from one area of care to another, while also considering the needs of providers and decision makers.

“The Institute for Better Health is a known innovator, unafraid to test out new models of care,” said Kuluski. “They also stand behind a learning health system approach, and it’s what sets them apart. Having researchers work closely on the front line to understand what is needed, and trying new things as they go, is part of the constant learning cycle.”

She joins IHPME Professors Robert Reid and Walter Wodchis, who are also faculty at the Institute for Better Health. Reid is the Institute’s Chief Scientist and the Hazel McCallion Research Chair in Learning Health Systems. Wodchis is the Research Chair in Implementation and Evaluation Science.

Professor Julia O’Sullivan joined IHPME in June 2020. A former dean of education at U of T, Western University and Lakehead University, O’Sullivan’s research and development work are focused on children underserved in schools, especially their inherent right to be taught literacy skills.

Partnerships

The collaborative endeavours undertaken by IHPME faculty members demonstrated the DLSPH commitment to one of the goals of the School’s 2019–2024 Academic Plan: Creating a global presence through collaborative research and education in health system strengthening with a focused set of strong partners.

For example, the North American Observatory on Health Systems and Policies (NAO), under the leadership of Professor Greg Marchildon and associate professor Sara Allin, partnered with WHO to reliably track and document the policy interventions by federal, provincial and territorial governments in response to the COVID-19 pandemic and to make that information publicly available. The NAO team has created a detailed policy timeline that outlines the timing and severity of policy and public health interventions to mitigate the impact of COVID-19.

“By creating a credible, open resource that captures the timing, intensity and range of measures taken across Canada, we’re providing indispensable support to decision-makers across the globe who are navigating COVID-19 policies,” said Allin, who is Director of the NAO .

Meanwhile, Professor Vivek Goel and Julie Zarb, an assistant professor in IHPME’s teaching stream, led the secretariat for a platform that brings together more than 2,500 researchers from across the country to provide the federal government with the best evidence to inform COVID-19 policy-making. As Goel takes up his new role as President of the University of Waterloo, IHPME Professor Peter Jüni will transition into the leadership of the CANCOVID initiative.

“COVID-19 is sparking new demands on health system leaders and the surge of need is bigger than traditional communications can carry,” says Zarb.

Professor Fiona Miller, IHPME’s chair in health management strategies, formed a partnership with the Centre for Sustainable Healthcare (CSH) in the United Kingdom and launched the Centre for Sustainable Health Systems with a vision of creating “health systems characterized by practices and policies that are environmentally, socially, and financially sustainable, allowing us to address the health and care needs of today without compromising our ability to address those needs tomorrow.”

“Once you see sustainability as a dimension of quality, it shifts thinking among health system professionals and encourages mobilization. I wanted to infuse that energy into what already exists here at IHPME, which is this constant drive to improve our health system,” said Miller. “As a Centre, our goal is to work in collaboration with a growing number of clinician leaders, healthcare managers and health researchers who are concerned about these issues, and through partnerships with organizations in the health sector, to encourage and support sustainable health system change, through education, research, and service-oriented action.”

NON-COVID-19 RESEARCH (Read about COVID-19 research)

Although many health-care researchers directed their energies toward pandemic-related research this past year, there were other significant papers published by IHPME faculty, students and alumni.

Cost of Adverse Events

Researchers from the Institute of Health Policy, Management and Evaluation, used a data tool developed by the Canadian Institute for Health Information (CIHI), and the Canadian Patient Safety Institute (CPSI), to estimate, for the first time, the impact of hospital harm on Ontario’s health system, and the striking result is a cost upwards of $1 billion and close to 408,000 additional hospital days.

“Experiencing harm in hospital can extend your stay, which is well-established, but what is novel about our study is that we show that its impact extends to post-discharge health services utilization and estimate the total health system impact of that harm on our resources,” said Lauren Tessier, lead author of the study and a PhD student at IHPME.

Tessier and her fellow researchers measured the occurrence of hospital harm within patient-centered episodes or PCEs, a methodology that was only recently developed by IHPME associate professor Sara Guilcher, who is also a co-author on this study. The research was published in the Canadian Medical Association Journal.

Free Medication and Adverse Health Outcomes

Nav Persaud, an associate professor at IHPME and a clinician-scientist at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, led a study that found that distributing essential medicines at no charge to patients resulted in a 44 per cent increase in people taking their medications.

“It is sad that in a high-income country like Canada, millions of Canadians cannot afford their prescribed medications—including life-saving medicines such as insulin,” said Persaud. “We hope that our findings help inform public policy changes. This is no longer a question of whether free distribution of medicines can improve health outcomes. It is a question of whether governments will act.”

Immigration and Health

A study led by IHPME graduate Ghazal Fazli, who earned her PhD at U of T, found that immigrants to Canada have a 40% higher risk of developing prediabetes compared to long-term residents. The study, published in BMC Medicine, also found that young adults of South Asian descent develop prediabetes 15 years earlier than those of Western European descent.

“This is a significant finding because our current guidelines recommend screening all adults for type 2 diabetes at age 40. Yet there is evidence that those of South Asian descent are at a much greater risk at of developing prediabetes much younger age,” said Fazli. “Theoretically if we identify someone’s risk earlier, we can provide them with an opportunity to adopt lifestyle changes. This could decrease their risk of developing type 2 diabetes by nearly 60% according to randomized trials, but if we don’t identify them early, they enter the system too late and at a greater cost to the health system.”

Student Research

IPHME’s students are the future of our public health care system and will contribute to policy and practise, not only in Canada, but across the globe. We are proud of all of our students, but we specially commend those students and graduates who earned awards and external recognition this past year, as well as those whose initiatives made a real contribution to public health.

A Case for Revising Cancer Screening Guidelines

Jill Furzer and Lauren Tessier, PhD students at the Institute of Health Policy, Management and Evaluation, led a study showing that early mammographic and MRI screening for female survivors of Hodgkin’s lymphoma (HL) is a costly strategy that provides very limited additional benefits in preventing cancer compared to having an MRI alone.

Furzer and Tessier found that screening with both an MRI and mammogram at age 30 is on average more expensive and less effective than screening using MRI only. They also found that at age 25, adding an MRI to mammography screening also added significant costs without a meaningful change on life expectancy or quality of life for the survivor.

“Mammograms are not as sensitive as MRI in their ability to look for new tumors, especially in women under age 50, and there is often a low compliance rate in this population of women,” said Tessier. “Our findings show that the guidelines should be more specific to an individual’s specific risk profile and that survivors of pediatric HL would likely benefit from starting screening earlier than age 30.”

Seeing Barriers Clearly

Afua Oteng Asare, a PhD student at the Institute of Health Policy, Management and Evaluation, has been analyzing the cost-effectiveness of the Ministry of Health and Long-term Care’s recent child vision protocol. As part of Ontario’s public health standards, health units are now required to provide vision screening in all kindergarten classrooms.

It is a concern that requires attention, noted Asare, because vision screening is key to diagnosing two very common and major conditions that often begin in childhood: refractive errors which include short-sightedness (myopia), long-sightedness (hyperopia), and blurred vision near and far (astigmatism).

Asare has been interested in examining barriers to vision care access since she first began her clinical practice as an optometrist in Ghana. She saw that most patients coming to have their eyes examined were of a higher socio-economic status and began to question how it might be possible to make vision care accessible to everyone.

Improving Sleep

Stuart Douglas, an Emergency Physician and Intensivist and recent graduate of the Master’s in Quality Improvement and Patient Safety (QIPS), at IHPME has developed a quality improvement initiative at Kingston Health Sciences Centre that promotes better sleep for patients in the ICU.

“After admission to the ICU patients are often at risk of developing post ICU syndrome, which comes with a constellation of functional limitations that can last a lifetime,” said Douglas.

Some of these limitations for patients are physical, involving decreased work capacity and muscle fatigue, while other symptoms are neuro cognitive and can include a range of psychiatric issues. Improving sleep may mitigate the risk of developing these issues.

Douglas’ project earned him the Harry and Rose Perlstein Award, presented to a student whose research has the potential to improve health care services for patients in long-term and acute care settings

Venturing into the World of Podcasting

Matthew Goulbourne and Sarah Sawaya, of the Master’s in Health Administration program, launched a podcast about emerging health leaders called Built to Lead. The show is based on leadership concepts shared at Vernissage Health, a dialogue series that pairs IHPME graduate students with established health-care leaders.

The pair wrapped up a successful, six-episode inaugural season, the theme of which is “Leadership: From Self-doubt to Confidence.” They capped the season with a live webinar on Oct. 1, 2020 featuring Matt Anderson, CEO of Ontario Health, and Camille Orridge, former CEO of the Toronto Central LHIN and a senior Fellow at Wellesley Institute.

Sawaya notes they had to wear many hats: technician, producer, host, editor and marketer. She found interviewing guests particularly rewarding. “I think we both improved our communication skills a lot. If you listen from the first episode to the last episode, you can see the difference. I use those skills every day at work. It was one of the only things I’ve done where I can see the direct one-to-one value,” she says.

The podcast can be found on all major streaming platforms.

Leading a COVID-19 Effort

As the pandemic unfolded, students in IHPME’s System Leadership and Innovation (SLI) program stepped up and demonstrated – no real surprise – leadership with initiatives that provided public information and assistance.

A team of SLI students, including Ushma Purohit, Daniel Lee, Monisha Persaud and Geoffrey Sem, developed the COVID19 Central website, an online hub of news and resources that simplifies access to information for the general public as well as for health-care providers. A separate team, that also included Purohit, launched a site called COVID19Ask. This website provides well-researched and expert-verified answers to the most frequently asked questions regarding COVID-19. The information on the site is reviewed by a team of infectious disease experts, physicians and epidemiologists.

Lee is one of 270 students taking part in the Student-Senior Isolation Prevention Partnership (SSIPP), an ongoing initiative that pairs students with socially isolated older adults in the community to provide weekly phone check-ins to promote social connection and improve health literacy of COVID-19. The volunteers are also teaching seniors to use technology, assisting with grocery delivery, and developing a FAQ for seniors regarding COVID-19 and relevant community resources.

And, during March Break, he recruited more than 500 student volunteers from medicine, public health, nursing, social work, and other health faculties to support health professionals with these day-to-day tasks. Lee co-led a steering committee that matched student volunteers with health-care professionals on a one-on-one basis.

“I think all of us were seeing our preceptors and instructors going to the front lines and we want to help out as much as we can,” said Lee, a second-year SLI and U of T Medicine student.

Notable Student and Alumni Awards

• Eleven IHPME students received Vanier Canada Graduate Scholarships in 2020. The scholarships are among the most prestigious and competitive graduate awards. Vanier scholars are recognized for their academic excellence, research potential, and leadership and receive $50,000 of guaranteed funding support for three years during their doctoral studies. IHPME’s 2020 awardees are Federico Angriman, Danielle Baribeau, Doug Cheung, Karen Chung, Erik Friesen, Victoria Haldane, Ayah Nayfeh, Jill Macklin, Hala Muaddi, Chris Noel and Sahr Wali.
• Four IHPME students were among the master’s degree students across the country to receive Vector Scholarships in AI. Michael De Wit, Rachelle Perron, An-Qi Shen and Jamie Wang were nominated by program director Julia Zarb for their vision and drive in their efforts to support AI development across Canada and within the health system. The Vector Scholarship in AI recognizes promising AI talent and supports recruitment of top students to AI-related master’s programs in Ontario.
• Marnie Howe, a graduate of IHPME’s MSc in Health Administration program, was selected as U of T’s annual recipient of the Robert Wood Johnson Award, given to six Canadians who have made promising contributions to health services management and plan to continue working in the field. As a physician, Howe has made it her goal to advocate for palliative care supports for patients at their most vulnerable. She worked as the home care lead physician for the Temmy Latner Centre for Palliative Care based out of Sinai Health System, before assuming her current role as the physician lead for special projects within Medical Affairs at Sinai Health Systems, thanks in part to her practicum placement during MHSc program.
• Fahima Dossa’s timely research has earned her the prestigious Royal Society of Canada Alice Wilson Award, named in honour of the first woman elected to the Royal Society in 1931 and given to three women researchers from across Canada. The award recognizes Dossa’s outstanding academic achievement and her continued work as a postdoctoral researcher on issues facing women’s health care. During her PhD studies, the IHPME graduate in health systems research sought to understand the health care decisions that women make, specifically those who undergo genetic testing for the BRCA1 and BRCA2 mutations, to determine their risk of breast and ovarian cancer.

In Memoriam: Dr. Peggy Leatt

IHPME also experienced loss this year with the death of Peggy Leatt, former chair of the Institute of Health Policy, Management and Evaluation. Recruited by the University of Toronto in 1980, she served as chair of IHPME from 1988–98. Leatt was a respected educator and a leader in the field of health management. She was the first woman to chair the Board of the Association of University Programs in Health Administration (AUPHA) and the first Canadian to chair the Board of the Accrediting Commission on Education for Health Services Administration Commission (now CAHME)—two international leadership roles in improving health care education.