Browsing by Author "Aghajafari, Fariba"
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Item Open Access An exploration of COVID-19 vaccination models for newcomer refugees and immigrants in Calgary, Canada(2024-03-12) Aghajafari, Fariba; Wall, Laurent; Weightman, Amanda M.; Ness, Alyssa; Lake, Deidre; Anupindi, Krishna; Moorthi, Gayatri; Kuk, Bryan; Santana, Maria; Coakley, AnnaleeAbstract Background The World Health Organization stresses the need for tailored COVID-19 models of vaccination to meet the needs of diverse populations and ultimately reach high rates of vaccination. However, little evidence exists on how COVID-19 models of vaccination operated in the novel context of the pandemic, how vulnerable populations, such as refugees, experience COVID-19 vaccination systems in high-income countries, and what lessons may be learned from vaccination efforts with vulnerable populations. To address this gap, this study explored COVID-19 vaccine delivery models available to newcomer refugees and immigrants, and refugee experiences across different COVID-19 vaccine delivery models in Calgary, Canada, and surrounding area in 2021 and 2022, to understand the barriers, strengths, and strategies of models to support access to COVID-19 vaccination for newcomer refugees and immigrants. Methods Researchers conducted structured interviews with Government Assisted Refugees (n = 39), and semi-structured interviews with Privately Sponsored Refugees (n = 6), private refugee sponsors (n = 3), and stakeholders involved in vaccination systems (n = 13) in 2022. Thematic analysis was conducted to draw out themes related to barriers, strengths, and strategies of vaccine delivery models and the intersections with patient experiences. Results Newcomer refugee and immigrant focused vaccination models and strategies were explored. They demonstrated how partnerships between organizations, multi-pronged approaches, and culturally responsive services were crucial to navigate ongoing and emergent factors, such as vaccine hesitancy, mandates, and other determinants of under-vaccination. Many vaccination models presented through interviews were not specific to refugees and included immigrants, temporary residents, ethnocultural community members, and other vulnerable populations in their design. Conclusions Increasing COVID-19 vaccine uptake for newcomer refugees and immigrants, is complex and requires trust, ongoing information provision, and local partnerships to address ongoing and emerging factors. Three key policy implications were drawn. First, findings demonstrated the need for flexible funding to offer outreach, translation, cultural interpretation, and to meet the basic needs of patients prior to engaging in vaccinations. Second, the research showed that embedding culturally responsive strategies within services ensures community needs are met. Finally, collaborating with partners that reflect the diverse needs of communities is crucial for the success of any health efforts serving newcomers.Item Open Access Assessing the Experiences of Immigrants Receiving Primary Care during COVID-19: A mixed-methods study(2022-01) Bajgain, Bishnu; Santana, Maria J.; Aghajafari, Fariba; Jackson, JeanetteBackground: The entire healthcare system, including primary healthcare (PHC) services, has been disrupted since the onset of the COVID-19 pandemic. As the crisis threatens all citizens significantly, further barriers to accessing care exist for those who are most vulnerable, experience marginalization, and have pre-existing challenges. We aimed to explore immigrants’ lived experiences in accessing and receiving PHC services during the pandemic. Methods: A multiphase mixed-methods study using a sequential explanatory design was employed. The first study includes a systematic review that synthesizes the evidence on the experiences that immigrant patients have receiving PHC. Study two provides insights from a recently employed “COVID-19 Experiences and Impacts Survey” data and compares the experiences of Albertans that were born in and outside Canada. Descriptive statistics and multivariable logistic regression were performed, using STATA. The third study is a qualitative inquiry that aims to gain a deeper understanding of the newcomers’ (living in Canada ≤5 years) and providers’ experiences in PHC during the pandemic. A thematic analysis was applied, using NVivo software. Results: The literature review revealed four major concerns affecting healthcare experiences of immigrant patients: 1) cultural and linguistic difference; 2) socioeconomic challenges; 3) health system factors; and 4) patient-provider relationship. The quantitative analysis of survey data (N=10,175) showed Canadian-born respondents were more likely to report worsening mental health during the pandemic, as well as higher levels of perceived stress, anxiety, or depression compared to non-Canadian-born survey respondents. In addition, Canadian-born respondents were more likely to prefer virtual healthcare compared to those respondents born outside Canada. Both cohorts reported that delayed care during the pandemic negatively impacted their health, and similar percentages in each cohort reported hesitancy getting the COVID-19 Vaccine. The qualitative inquiry included 23 interviews (15 newcomers, 8 providers) and revealed three aspects driving newcomers’ and healthcare providers’ experiences: overall experiences (doctor-patient relationship, care coordination, expectation on care), virtual care experience (accessibility, communication), challenges in accessing and receiving healthcare (language/cultural difference, care accessibility, health system literacy, competing priorities). Conclusion: This thesis presents a comprehensive exploration and description of immigrants’ lived experiences in accessing and receiving PHC during the pandemic. Immigrants reported many challenges in accessing and receiving PHC, and these challenges have been increased since the COVID-19 pandemic. The results of this thesis yielded six recommendations that can inform PHC quality improvement initiatives and PHC policy.Item Open Access Both Mother and Infant Require a Vitamin D Supplement to Ensure That Infants' Vitamin D Status Meets Current Guidelines(MDPI, 2018-03-29) Aghajafari, FaribaWe examined the association between maternal vitamin D intake during breastfeeding with their infants' vitamin D status in infants who did or did not receive vitamin D supplements to determine whether infant supplementation was sufficient. Using plasma from a subset of breastfed infants in the APrON (Alberta Pregnant Outcomes and Nutrition) cohort, vitamin D status was measured by liquid chromatography-tandem mass spectrometry. Maternal and infants' dietary data were obtained from APrON's dietary questionnaires. The median maternal vitamin D intake was 665 International Units (IU)/day, while 25% reported intakes below the recommended 400 IU/day. Of the 224 infants in the cohort, 72% were exclusively breastfed, and 90% were receiving vitamin D supplements. Infants' median 25(OH)D was 96.0 nmol/L (interquartile ranges (IQR) 77.6-116.2), and 25% had 25(OH)D < 75 nmol/L. An adjusted linear regression model showed that, with a 100 IU increase in maternal vitamin D intake, infants' 25(OH)D increased by 0.9 nmol/L controlling for race, season, mid-pregnancy maternal 25(OH)D, birthweight, and whether the infant received daily vitamin D supplement (β = 0.008, 95% confidence interval (CI) 0.002, 0.13). These results suggest that, to ensure infant optimal vitamin D status, not only do infants require a supplement, but women also need to meet current recommended vitamin D intake during breastfeeding.Item Open Access Co-designing person-centred quality indicator implementation for primary care in Alberta: a consensus study(2022-11-08) Manalili, Kimberly; Scott, Catherine M.; Hemmelgarn, Brenda; O’Beirne, Maeve; Bailey, Allan L.; Haener, Michel K.; Banerjee, Cyrene; Peters, Sue P.; Chiodo, Mirella; Aghajafari, Fariba; Santana, Maria J.Abstract Background We aimed to contribute to developing practical guidance for implementing person-centred quality indicators (PC-QIs) for primary care in Alberta, Canada. As a first step in this process, we conducted stakeholder-guided prioritization of PC-QIs and implementation strategies. Stakeholder engagement is necessary to ensure PC-QI implementation is adapted to the context and local needs. Methods We used an adapted nominal group technique (NGT) consensus process. Panelists were presented with 26 PC-QIs, and implementation strategies. Both PC-QIs and strategies were identified from our extensive previous engagement of patients, caregivers, healthcare providers, and quality improvement leaders. The NGT objectives were to: 1. Prioritize PC-QIs and implementation strategies; and 2. Facilitate the participation of diverse primary care stakeholders in Alberta, including patients, healthcare providers, and quality improvement staff. Panelists participated in three rounds of activities. In the first, panelists individually ranked and commented on the PC-QIs and strategies. The summarized results were discussed in the second-round face-to-face group meeting. For the last round, panelists provided their final individual rankings, informed by the group discussion. Finally, we conducted an evaluation of the consensus process from the panelists’ perspectives. Results Eleven primary care providers, patient partners, and quality improvement staff from across Alberta participated. The panelists prioritized the following PC-QIs: ‘Patient and caregiver involvement in decisions about their care and treatment’; ‘Trusting relationship with healthcare provider’; ‘Health information technology to support person-centred care’; ‘Co-designing care in partnership with communities’; and ‘Overall experience’. Implementation strategies prioritized included: ‘Develop partnerships’; ‘Obtain quality improvement resources’; ‘Needs assessment (stakeholders are engaged about their needs/priorities for person-centred measurement)’; ‘Align measurement efforts’; and ‘Engage champions’. Our evaluation suggests that panelists felt that the process was valuable for planning the implementation and obtaining feedback, that their input was valued, and that most would continue to collaborate with other stakeholders to implement the PC-QIs. Conclusions Our study demonstrates the value of co-design and participatory approaches for engaging stakeholders in adapting PC-QI implementation for the primary care context in Alberta, Canada. Collaboration with stakeholders can promote buy-in for ongoing engagement and ensure implementation will lead to meaningful improvements that matter to patients and providers.Item Open Access Determining the Association between Continuity of Primary Care and Acute Care Use among Adult Patients with Chronic Kidney Disease in Alberta(2021-06-22) Chong, Christy C.E.; Ronksley, Paul; Elliott, Meghan; Campbell, David; Aghajafari, FaribaBackground: Acute care use is high among individuals with chronic kidney disease (CKD). It is unclear how relational continuity of primary care influences downstream acute care use. Aim: To determine if poor relational continuity of primary care is associated with higher rates of all-cause and potentially preventable acute care use among adults with CKD. This project had two objectives:1) To describe the relational continuity of primary care received among adults with CKD in Alberta over a 2-year period and,2) To determine if poor relational continuity of care is associated with higher rates of all-cause and CKD-related ACSC hospitalization and ED visits among adults with CKD.Design and Setting: A population-based retrospective cohort study of adults with stages 3 and 4 CKD and at least three visits to a primary care provider between April 1, 2011 to March 31, 2014 in Alberta, Canada.Method: Relational continuity was calculated using the Usual Provider Continuity index and descriptive statistics were used to summarize patient and acute care encounter characteristics. Adjusted rates (per 1,000 person-years) and incidence rate ratios for all-cause and CKD-related ambulatory care-sensitive condition (ACSC) hospitalizations and emergency department (ED) visits were estimated using negative binomial regression modelling. Results: Among 86,475 individuals with CKD, 51.3%, 30.0%, and 18.7% of patients had high, moderate, and poor continuity of primary care, respectively. There were 77,988 all-cause hospitalizations, 204,615 all-cause ED visits, 6,489 (8.3% of all hospitalizations) CKD-related ACSC hospitalizations, and 8,461 (4.1% of all ED visits) CKD-related ACSC ED visits during a median follow-up of 2.3 years. Rates of all-cause hospitalization and ED use increased with poorer continuity of primary care in a stepwise fashion across CKD stages. Poor continuity of primary care was also associated with higher rates of CKD-related ACSC hospitalization and ED visits, particularly among individuals with stage 3 CKD. Conclusion: Poor continuity of care is associated with increased acute care use and targeted strategies are needed to strengthen patient-provider relationships within primary care among those with CKD.Item Open Access Evaluating effectiveness of small group literacy instruction for Undergraduate Medical Education students using a pre-post survey study design(Wiley, 2015-06) McClurg, Caitlin; Powelson, Susan; Lang, Eddy; Aghajafari, Fariba; Edworthy, SteveThe purpose of our study was to determine if librarian-led small group information literacy instruction, closely integrated with course content and faculty participation, but without a hands on component, was an effective means to convey evidence based information literacy skills including clinical question formation, resource selection and online searching confidence. Five 15 minute evidence based information literacy sessions were delivered by three librarians to 12 practicing physician-led small groups of 15 students. Students were asked to complete an online survey before and after the lecture and seminar series. Data analysis was through simple descriptive statistics, reporting proportions for question responses. Instruction in a small group environment without a mandatory hands on component had a positive impact on student’s evidence based information literacy skills. Students were more likely to consult a librarian, and had increased confidence in their abilities to search and find relevant information.Item Open Access Patient-Reported Outcome Measures to Inform Measurement-based Care for Youth Living with Mental Health Concerns: A mixed method study(2024-03-19) Thapa Bajgain, Kalpana; Santana, Maria; Zwicker, Jennifer; Aghajafari, Fariba; Tang, KarenMeasurement-based care (MBC) describes the process of routinely using outcome measurement to guide treatment decisions supporting Patient-centered Care (PCC). Patient-reported Outcome Measures (PROMs) play a vital role in MBC supporting the delivery of PCC. Despite the evidence on the benefits of using PROMs in clinical care, some barriers hinder the selection of the PROMs, such as the different age groups for youth and poor consensus on which measurements are best practices and most appropriate for this population. This mixed-methods, multi-phased study addresses some of these gaps by focusing on identifying, selecting, and prioritizing the PROMs to be implemented in the clinical care of youth with depression and/or anxiety to inform the MBC program at the Summit Center. The first phase of this thesis work includes three stages: 1) a systematic review to identify, evaluate, and synthesize the global evidence on the use of PROMs in youth mental health clinical care 2) In the second stage, we create and combine a database of PROMs from different sources. In the third step, we selected the top 10 PROMs to prioritize in Phase 2. The selected top 10 PROMs were: Beck Depression Inventory (BDI), Child Behavioral Checklist (CBC), Child Health Questionnaire (CHQ), KIDSCREEN 10, Pediatric Quality of Life Inventory (PedsQL), Revised Children's Anxiety and Depression Scale (RCAD 25), Spence Children’s Anxiety Scale (SCAC), Screen for Child Anxiety Related Disorder (SCARED), Strength and Difficulties Questionnaires (SDQ), and The Young Person’s Core (YP-CORE). Then, in Phase 2, we conducted the Nominal Group Technique (NGT) with youth living with depression and anxiety and their family caregivers to prioritize these top 10 PROMs. The top PROMs ranked by youth were RCAD 25, BDI, YP-CORE, SCAS, SCARED, CBCL, PedsQl, SDQ, KIDSCREEN 10, and CHQ, while families/caregivers top-ranked RCAD 25, SCARED, YP-CORE, KIDSCREEN 10, SCAS, CBCL, PedsQl, SDQ, BDI, and CHQ. In summary, the findings of this study informed the MBC program at the Summit Center and presented an excellent opportunity to leverage the findings of this study to support the scale-up implementation of PROMs in the clinical care for youth living with mental health in Alberta.Item Open Access Patient-reported outcome measures used to improve youth mental health services: a systematic review(2023-02-14) Thapa Bajgain, Kalpana; Amarbayan, Mungunzul; Wittevrongel, Krystle; McCabe, Erin; Naqvi, Syeda F.; Tang, Karen; Aghajafari, Fariba; Zwicker, Jennifer D.; Santana, MariaAbstract Background Patient-reported outcome measures (PROMs) are standardized and validated self-administered questionnaires that assess whether healthcare interventions and practices improve patients’ health and quality of life. PROMs are commonly implemented in children and youth mental health services, as they increasingly emphasize patient-centered care. The objective of this study was to identify and describe the PROMs that are currently in use with children and youth living with mental health conditions (MHCs). Methods Three databases (MEDLINE, EMBASE, and PsycINFO) were systematically searched that used PROMs with children and youth < 18 years of age living with at least one diagnosed MHC. All methods were noted according to Preferred Reporting Items for Systematic reviews and Meta-Analysis. Four independent reviewers extracted data, which included study characteristics (country, year), setting, the type of MHC under investigation, how the PROMs were used, type of respondent, number of items, domain descriptors, and the psychometric properties. Results Of the 5004 articles returned by the electronic search, 34 full-texts were included in this review. This review identified both generic and disease-specific PROMs, and of the 28 measures identified, 13 were generic, two were generic preference-based, and 13 were disease-specific. Conclusion This review shows there is a diverse array of PROMs used in children and youth living with MHCs. Integrating PROMs into the routine clinical care of youth living with MHCs could improve the mental health of youth. Further research on how relevant these PROMs are children and youth with mental health conditions will help establish more uniformity in the use of PROMs for this population.Item Open Access Prioritizing Patient Reported Outcome Measures (PROMs) to use in the clinical care of youth living with mental health concerns: a nominal group technique study(2024-02-21) Bajgain, Kalpana Thapa; Mendoza, Justino; Naqvi, Farwa; Aghajafari, Fariba; Tang, Karen; Zwicker, Jennifer; Santana, Maria-JoseAbstract Background In the past few decades, particularly in the mental health setting, there has been growing interest in using Patient Reported Outcome Measures (PROMs) to assess the efficacy of the treatments in healthcare systems. Despite recent initiatives for global harmonization, there remains a lack of consensus on which PROMs are best practice and appropriate. Engagement of the service users, such as patients and family members/caregivers, is vital at this stage to ensure the selected PROMs are feasible, relevant, and acceptable to them. This study aimed to prioritize PROMs by youth and family/caregiver based on feasibility, relevance, and overall importance to be used in the clinical care of youth living with anxiety and/or depression. Methods Ten validated and widely used PROMs were presented to the patients and family/caregivers. Nominal group techniques were employed to prioritize the PROMs based on feasibility, relevance, and overall importance. Results For patients and families/caregivers, the PROMs, Revised Child Anxiety and Depression Scale (RCAD 25), and The Young Person’s Core (YP-CORE) were the highest priorities. Both felt that RCAD 25 was comprehensive, short, easy, and quick to complete, whereas regarding YP-CORE, patients and family/caregivers thought it was also short and relevant. Due to some specific concerns, the Strength and Difficulties Questionnaire and Child Health Questionnaire were the lowest prioritized by patients and family/caregivers. Conclusion It is of utmost importance that patient’s and family/caregivers’ voices or opinions are considered while selecting and implementing PROMs in mental health settings. Our study provides practical recommendations around measures best suited to achieve this.Item Open Access The primary care COVID-19 integrated pathway: a rapid response to health and social impacts of COVID-19(2022-12-20) Aghajafari, Fariba; Hansen, Brian; McBrien, Kerry; Leslie, Myles; Chiew, Alexandra; Ward, Rick; Li, Bing; Hu, JiaAbstract Background The first wave of COVID-19 in Calgary, Alberta accelerated the integration of primary care with the province’s centrally managed health system. This integration aimed to deliver wraparound in-community patient care through two interventions that combined to create the COVID-19 Integrated Pathway (CIP). The CIP’s interventions were: 1) a data sharing platform that ensured COVID-19 test results were directly available to family physicians (FPs), and 2) a clinical algorithm that supported FPs in delivering in-community follow up to improve patient outcomes. We describe the CIP function and its capacity to facilitate FP follow-up with COVID-19 patients and evaluate its impact on Emergency Department (ED) visits and hospitalization. Method We generated descriptive statistics by analyzing data from a Calgary Zone hub clinic called the Calgary COVID-19 Care Clinic (C4), provincially maintained records of hospitalization, ED visits, and physician claims. Results Between Apr. 16 and Sep. 27, 2020, 7289 patients were referred by the Calgary Public Health team to the C4 clinic. Of those, 48.6% were female, the median age was 37.4 y. 97% of patients had at least one visit with a healthcare professional, where follow-up was conducted using the CIP’s algorithm. 5.1% of patients visited an ED and 1.9% were hospitalized within 30 days of diagnosis. 75% of patients had a median of 4 visits with their FP. Discussion Our data suggest that information exchange between Primary Care (PC) and central systems facilitates primary care-based management of patients with COVID-19 in the community and has potential to reduce acute care visits.Item Open Access Vaccination Navigation, Access, and Hesitancy Among Refugees in Calgary, AB: A Scoping Review Protocol(2022-08-07) Aghajafari, Fariba; Ness, Alyssa; McClurg, Caitlin; Wall, Laurent; Pooladi-Darvish, ArshyaBackground: The COVID-19 vaccines provide between 80—95% protection against the disease and to reach herd immunity, between 70-83% of the population needs to be vaccinated. Access, as well as hesitancy, to vaccine can affect reaching this target. Refugees and new immigrants are at higher risk of being infected with COVID-191,3, and they may have inequitable access to vaccine. To overcome the inequity to access vaccine and addressing hesitancy in refugees and new immigrants, various outreach programs have been implemented globally 2,3,4,5,6. Objectives: The aim of this scoping review is to explore the model of delivery of Covid-19 vaccination and other common infectious disease vaccinations in newcomers and refugee populations. Method: Articles will be included if they were published in the year 2000 or later, focused on vaccine or immunization delivery, programs, initiatives, or policies among refugees, immigrants, migrants, asylum seekers or newcomers; or addressed vaccine hesitancy; and occurred during epidemic or endemic times. Study designs included in this scoping review will be randomized controlled trials or observational studies. MEDLINE, Ovid Healthstar, OVID Embase, OVID Medline, Web of Science, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Science Direct, Academic Search Complete, Google Scholar, Social Work Abstracts, and JSTOR databases were searched using controlled vocabulary terms and keywords for the following concepts: Covid-19 and major immunizations generally administered on a schedule, vaccines OR immunizations, refugees, asylum seekers, newcomers and immigrants. Grey literature was searched using Google’s site search feature for relevant news articles or social media, as well as non-government organization (NGO) and intergovernmental organization (IGO) websites for information specific to those organizations. Articles from academic databases will be exported to COVIDENCE followed by two rounds of screening, including the initial title/abstract review, followed by full text screening. Conflicts will be resolved by the Primary Investigator. Grey Literature will be collected in an excel spreadsheet and included to inform the background and discussion.Item Open Access Vitamin D Deficiency and Antenatal and Postpartum Depression: A Systematic Review(MDPI, 2018-04-12) Aghajafari, Fariba; Letourneau, Nicole Lyn; Mahinpey, Newsha; Cosic, Nela; Giesbrecht, G. F.Vitamin D has been implicated in antenatal depression (AD) and postpartum depression (PPD) in many studies; however, results have been inconsistent due to the complexity of this association. We searched the MEDLINE, Embase, PsycINFO, and Maternity and Infant Care databases for literature addressing associations between vitamin D and AD and PPD. Two independent authors reviewed titles and abstracts of the search results and selected studies for full review. Data were extracted, and a quality rating was done using the Newcastle–Ottawa Scale (NOS) on the selected studies. A total of 239 studies were identified; 14 were included in the review. The quality assessment of the included studies ranged from moderate to high. Of the studies on PPD, five of nine (55%) showed a significant association between vitamin D and PPD. Five of seven (71%) studies on AD showed a significant association with vitamin D status. As the included studies used different effect estimates and statistical analyses to report the association, it was not possible to transform the existing data into one single effect measure to employ meta-analytic techniques. While results of this systematic review vary, they indicate a significant association between vitamin D status and AD and PD.Item Open Access Vitamin D during Pregnancy(2016) Aghajafari, Fariba; Ross, Susan; O'Beirne, Maeve; Field, Catherine; Eliasziw, Misha; Dewey, DeborahVitamin D plays an important role in promoting healthy pregnancy and fetal development. There is a lack of knowledge on (1) the effect of vitamin D deficiency/ insufficiency on pregnancy and neonatal outcomes, (2) the association between maternal plasma vitamin D concentration and dietary intake, and (3) the prevalence of vitamin D deficiency/ insufficiency during pregnancy and the contribution of vitamin D metabolites to estimate vitamin D. This dissertation attempts to address these knowledge gaps about vitamin D during pregnancy. In a systematic review and meta-analysis of observational studies, low maternal 25(OH)D concentrations were found to be associated with higher risks of gestational diabetes (pooled OR 1.49, 95% CI: 1.18 to 1.89), preeclampsia (pooled OR 1.79, 95% CI: 1.25 to 2.58), small for gestational age (SGA) (pooled OR 1.85, 95% CI: 1.52 to 2.26) and lower birth weight (weighted mean difference: -130.92 g (95% CI: -186.69 to -75.14). However, that quality of individual studies was not always optimal due to inconsistent reporting on confounding factors. The two studies in this work involved pregnant women from a large Alberta cohort study to measure vitamin D. 3-epi-25(OH)D3 was found in all of the pregnant women’s blood in mid-pregnancy, at the time of delivery and in cord blood. When the 3-epimer was included in the estimation of status, the prevalence of vitamin D <75 nmol/L was significantly lower (P<0.005). A significant relationship between maternal reported dietary vitamin D intake and plasma 25(OH)D and 3-epi-25(OH)D3 concentration were identified. Consuming the Recommended Dietary Allowance (RDA) (600 IU/ day) was found to be insufficient to achieve vitamin D <75 nmol/L in half of participants. This research highlighted the potentially important association between maternal vitamin D status and pregnancy health and the variability that can arise in study results when different measures of vitamin D status are used. In addition, it extends the literature suggesting that current RDA may not be adequate to ensure that Canadian pregnant women achieving vitamin D status. Furthermore, this research showed that the method employed to measure vitamin D in pregnant women and cord blood can influence the estimates of status.