Prevalence of Current PTSD Symptoms Among a Sample of Black Individuals Aged 15 to 40 in Canada: The Major Role of Everyday Racial Discrimination,Racial Microaggresions,and Internalized Racism

Abstract

French

Objective

Most Black individuals in Canada report having experienced racial discrimination. Although previous studies have shown that there is a strong relationship between racial discrimination and posttraumatic stress disorder (PTSD), no studies in Canada have documented this association among Black individuals. The present study documents (1) the prevalence of PTSD among Black individuals using data from the Black Communities Mental Health project and (2) risk factors associated with PTSD, including racial microaggressions, everyday racial discrimination, and internalized racism.

Method

A total of 860 participants (75.6% of women) aged 15 to 40 years old (M = 24.96, SD = 6.29) completed questionnaires assessing PTSD, experience of traumatic events, racial microaggressions, everyday racial discrimination, and internalized racism.

Results

Findings showed that 95.1% of participants reported exposure to at least one traumatic event during their lifetime. In total, 67.11% of participants reported probable PTSD with no significant difference between men and women (68.2% and 67.8%, χ² = 0.132, p = 0.72). Participants born in Canada were more likely to experience significant PTSD symptoms, compared to those born abroad (70.92% and 53.14%, χ² = 19.69, p < 0.001). A multivariable linear regression model of PTSD symptoms was computed using sociodemographic variables and exposure to traumatic events as independent variables, which explained 25.9% of the variance. In addition to these variables, a second model included racial microaggressions, everyday racial microaggressions, and internalized racism, which explained 51.8% of the variance. The model showed that traumatic events (b = 0.6; p = 0.02), racial microaggressions (b = 0.5; p < 0.001), everyday discrimination (b = 0.2; p = 0.03) and internalized racism (b = 0.5; p < 0.001) were positively associated with PTSD symptoms.

Conclusions

This article highlights the detrimental consequences of racial discrimination against Black people in Canada. Prevention and mental health programs aimed at mitigating its consequences on the lives of Black people and other racialized populations must be implemented.

Keywords

PTSD racial discrimination Black individuals Canada

Introduction

The experience of different forms of trauma is common.^1–3 Whereas the majority of those exposed to various traumas can access resources, coping strategies, and resiliency mechanisms, some develop varying degrees of posttraumatic stress disorder (PTSD) symptoms.⁴ Indeed, PTSD is one of the most prevalent mental health problems. The prevalence varies according to the type of traumatic events experienced, ranging from 15% to 75% for technological disasters⁵ and between 20% and 30% for victims of natural disasters.^3,6 In Canada, the lifetime prevalence of PTSD is 9.2%, while 75.9% of people report having experienced at least one traumatic event.² However, studies in Canada have rarely explored racial and ethnic differences related to PTSD. One study of 221 Indigenous individuals showed a lifetime prevalence of PTSD of 55.2%.⁷ To date, no published studies have examined the prevalence of PTSD among Black people in Canada.⁸ The few studies that have included Black individuals in their samples did not conduct analyses to document the prevalence and factors related to PTSD in Black communities.^1,2 Yet studies in the United States (US) have shown that Black individuals are at higher risk of experiencing traumatic events and developing symptoms of PTSD, both among civilians and veterans.⁹

Studies in the US have also shown that racial discrimination is a significant risk factor in the exposure of Black people to traumatic events.⁹ Racial discrimination has also been shown to be a predictor of PTSD in Black people in the US.⁹ In Canada, a study of post-secondary Indigenous students found that racially motivated housing discrimination frequencies predicted symptoms of PTSD.¹⁰ Another study also found that everyday discrimination experienced by Indigenous people was associated with higher PTSD scores.¹¹ Studies have shown that various forms of racial discrimination such as everyday racial discrimination, racial microaggressions, and internalized racism (often overlooked), can play a vital role in the development of mental health problems.^11–15 These forms of discrimination are associated with increased mental health problems, including PTSD. However, despite the known association between racial discrimination and PTSD and the fact that Black people in Canada are more likely to be targeted by various forms of racial discrimination,^16,17 no studies have been conducted to either document the prevalence and factors associated with PTSD or to document the association between racial discrimination and PTSD in Black individuals. Based on this observation, this study aims to: (1) document the prevalence of PTSD among Black individuals using data from the Black Communities Mental Health (BCoMHeal) project¹⁶ and (2) examine risk factors associated with PTSD, including microaggressions, everyday racial discrimination, and internalized racism.

Methods

Participants and Procedures

The sample was composed of 860 individuals (75.6% women) between the ages of 15 and 40 years (M = 24.96 years, SD = 6.29). Of the entire sample, 79.1% were born in Canada, 64.82% were <25 years old, 66.43% were employed, and 33.57% unemployed. In addition, 4.86% reported not having formal education, 14.69% have completed secondary school, 56.75% attended university, 16.47% completed a post-secondary degree and 7.23% have a university degree. Regarding marital status, 53.18% of the participants were single, 29.38% were married, 4.92% were separated, and 2.53% were in another type of romantic relationship. The inclusion criteria were as follows: (1) self-identifying as a Black person; (2) residing in Canada; (3) aged 15 to 40; and (4) ability to understand written English or French. The data used for this study were taken from the BCoMHeal project.¹⁶

Participants were recruited using four different methods. The first method of recruitment was by using the University of Ottawa's Integrated System for Participation in Research (ISPR). The ISPR program anonymously matches undergraduate students enrolled in the introductory psychology course to various ongoing research studies, allowing them to voluntarily complete studies for up to four course credits, and additionally gain experience as a research participant. The second method used was digital recruitment posters. Posters were displayed on the numerous social media platforms of the research laboratory with paid advertisements to maximize reach. The third recruitment strategy involved placing posters in different religious institutions (e.g., Mosques) and universities. The fourth method used was community organizations that work directly with Black people in Canada. These organizations circulated recruitment materials through their networks and social media platforms. Participants were given a link to the Qualtrics™ (Provo, USA) online survey to complete the questions, and consent was obtained prior to completing the survey. Participants in the ISPR were given a course credit, and others were given a $15 e-gift card. The Research Ethics Board of the University of Ottawa and Université du Québec en Outaouais both authorized this study.

Measures

Sociodemographic Characteristics

Sociodemographic information (e.g., gender, age category, education level, marital status, employment status, and place of birth) was assessed using this questionnaire. The detailed sociodemographic characteristics of the sample can be found in previous publications.^18,19

Traumatic Events

Exposure to traumatic events (e.g., natural disasters, sexual abuse, death of a loved one, etc.) was assessed using the Traumatizing Life Events Questionnaire-Short Form (TLEQ-SF). The TLEQ-SF contains 9 items on a Yes or No scale. It has been tested among college students, veterans, and women who have experienced abuse. This questionnaire is widely used and demonstrates robust psychometric properties, such as reliability and validity.^20,21 Cronbach alpha in our sample was 0.90.

Posttraumatic Stress Disorder

Symptoms of posttraumatic stress disorder (PTSD) were assessed using the PTSD checklist for DSM-5 (PCL-5). This scale consisted of a self-report questionnaire with 20-item evaluating the symptom criteria of PTSD found in the DSM-5 (e.g., “In the past month, how much were you been bothered by repeated, disturbing, and unwanted memories of the stressful experience?”). The items in this measure were rated using a 5-point scale: from (0) Not at all to (4) Extremely. The PCL-5 has strong internal consistency (α = 0.94), test–retest reliability (r = 0.82), and convergent (r = 0.74 to 0.85) and discriminant (r = 0.31 to 0.60) validity.²² The 20-item scores are summed ranging from 0 to 80 with higher scores indicating more severe symptoms of PTSD. The cut-off score for probable PTSD is 33. The Cronbach alpha of the sample is 0.97.

Racial Microaggressions

The Inventory of Microaggressions Against Black Individuals (IMABI) was used to investigate experiences of racial microaggressions directed towards Black people.²³ The IMABI is a 14-item scale that assessed how frequently individuals have experienced common microassaults and microinsults. The items are scored on a 5-point scale from (1) This has never happened to me to (5) This event happened, and I was extremely upset. The Cronbach's alpha of our sample was 0.86.

Everyday Discrimination

Experiences of racial discrimination were evaluated using the Everyday Discrimination Scale (EDS).²⁴ We used the 5-item version to assess the pervasiveness of experiences of racial discrimination a person faces daily by asking whether specific statements apply to them or not (e.g., You receive poorer service than other people at restaurants or stores). Individuals are also asked to report the perceived cause of racial discrimination they face. The items were rated on a 6-point scale: from (1) almost every day to (6) never. The EDS has a good internal consistency and is widely used among Black communities.^24,25 The higher the summary score, the greater the frequency of perceived discrimination. The Cronbach's alpha in the present sample is 0.90.

Internalized Racism

Participants’ agreement with statements about their ethnic or racial group was assessed by The Internalized Racism scale.²⁶ This scale consisted of 12 items evaluating views on intelligence, pride, laziness, and other factors among the racial/ethnic groups (e.g., “Black people are violent,” etc.). The items were rated on a 4-point scale (very true (1), to true (2), not true (3), and not true at all (4)). This scale is widely used and has good internal consistency.²⁶ A higher summary score indicates higher levels of internalized racism. The Cronbach's alpha in the present sample is 0.78.

Statistical Analyses

All the analyses were conducted using the Statistical Package for the Social Sciences (SPSS), version 28 (IBM Corp., Armonk, USA). The percentage of missing data on the variables included in this research was between 2% and 13.1%. Multiple imputations were performed to account for missing data and optimize statistical power using the fully conditional specification in SPSS. First, the prevalence of traumatic events was computed. The prevalence of probable PTSD was calculated according to gender, age category, education level, employment status, place of birth, and different levels of racial microaggressions, internalized racism, and everyday discrimination. When a significant difference was observed, adjusted residuals were also reported to compare the observed to the expected count and potentially identify the categories that may be of possible influence. To better capture the progression of PTSD symptoms in relation to the progression of experiences of everyday racial discrimination, racial microaggressions, and internalized racism, their scores were classified into four categories with values below the 25th percentile, between the 25th and 50th percentile, between 50th and 75th percentile, and values beyond the 75th percentile according to past studies.^14,18,19

Linear regression was performed to investigate the association between symptoms of PTSD and traumatic events, racial microaggressions, and everyday discrimination. The model was estimated in two steps: the first model was computed by including sociodemographic characteristics (gender, age category, education level, employment status, and place of birth), and traumatic events. The second model was computed using the above-mentioned factors and the following: racial microaggressions, everyday discrimination, and internalized racism. The second model was computed to evaluate if these three factors related to racial discrimination would explain additional variance. Continuous variables were used for age, traumatic events, racial microaggressions, everyday discrimination, and internalized racism in the regression models. The homogeneity of variance was verified using the scatterplot of standardized predicted values versus the standardized residuals; and the normality of the residuals with the Shapiro–Wilk test and examination of skewness and kurtosis values. Skewness values between −1 and +1 and kurtosis values between −2 and +2 were considered satisfactory.^27,28

Results

A total of 95.1% of the sample reported exposure to at least one traumatic event during their lifetime. Compared to men, women reported a higher prevalence of exposure to at least one trauma (97.2% vs. 89.3, χ² = 21.94, p < 0.001). Most of these individuals reported exposure to multiple events with a mean of 5.41 (SD = 3.06). Women reported a significantly higher mean number of experiences of traumatic exposures (6.13 events; SD = 3.04), compared to men (3.38 events; SD = 2.04) (p < 0.001, t = 15.13).

Symptoms of PTSD frequencies are presented in Table 1 including only those who reported having experienced at least one traumatic event. A total of 67.1% of the sample was categorized as having met the threshold for probable PTSD. Although no statistically significant difference was observed between genders, 68.2% and 67.8% for men and women (χ² = 0.132, p = 0.72), respectively, and for employment (χ² = 1.24, p = 0.27), a significant difference was observed for age group (χ² = 5.35, p = 0.02), and place of birth (χ² = 19.69, p < 0.001). Furthermore, significant differences were also observed among levels of education (χ² = 38.38, p < 0.001), with a negative adjusted residual for “None” (−4.8) and university level (−2.8) denoting there were fewer people with probable PTSD than expected relative to the sample size in these two categories; inversely, a larger proportion than expected was observed for the “Incomplete post-secondary” level with a positive adjusted residual (3.5). Lastly, for marital status, results also showed a significant difference (χ² = 9.71, p = 0.02) along with a negative adjusted residual for “Single” (−2.9) while a positive value was noted among those who identified as “Married” (2.6).

Table 1.

Prevalence of Symptoms of PTSD.

	Symptoms of PTSD (N = 818)
Sociodemographic characteristics	Men	Women	Total	Chi-square	P-value
Total	68.16	66.77	67.11	0.132	0.717
Age
Less than 25 years	68.82	61.96	64.22	5.35	0.021
25 years and more	64.52	72.96	72.09
Education
No formal education	33.33	32.00	32.50	38.38	<0.001
High school	71.43	56.10	61.29
Incomplete post-secondary	70.00	72.37	72.07
Post-secondary	75.00	71.43	73.39
University	56.25	48.89	50.82
Marital status
Single	68.87	58.78	62.47	9.71	0.021
Married	66.67	72.50	72.29
Separated	66.67	85.00	75.61
Other	64.71	60.00	62.50
Employment
No	70.73	68.83	69.68	1.24	0.265
Yes	64.10	66.09	65.80
Place of birth
Born abroad	61.90	48.21	53.14	19.69	<0.001
Born in Canada	71.01	70.89	70.92
Traumatic events
1 – 2	53.85	54.26	54.11	22.51	<0.001
3 – 5	69.75	59.15	63.60
6 and more	86.67	73.54	74.55
Internalized racism
Low	25.00	37.42	34.42	232.74	<0.001
Mid	65.45	50.63	54.42
High	82.43	79.49	80.63
Very high	100.00	96.41	97.07
Racial microagressions
Low	50.00	46.11	47.28	69.82	<0.001
Mid	76.67	82.74	82.03
High	69.39	68.32	68.67
Very high	88.00	64.23	71.10
Everyday racial discrimination
Low	32.00	41.91	39.25	88.74	<0.001
Mid	81.43	70.45	74.26
High	77.61	65.35	70.24
very high	85.71	79.03	79.39

Participants who reported experiencing high levels of traumatic events (6 or more events) showed higher prevalence of PTSD (74.6%) compared to those in the mid (63.6%) and low (54.1%) categories, (χ² = 22.51, p < 0.001). Additionally, the total of people in the high levels of traumatic events category with experiences of probable PTSD was more than that expected (adjusted residual of 4.3).

Statistically significant differences were also observed among the various categories of internalized racism and racial discrimination, namely racial microaggression and everyday discrimination. For internalized racism, a greater prevalence of PTSD was noted across the high level (80.63%) and very high level (97.07%) categories (χ² = 232.74, p < .001). A larger than expected proportion was observed in the two upper categories with positive adjusted values of 11.6 and 4.5, respectively, for very high and high, while the opposite was noted for mid (−4.6) and low (−11.8). Considering both racial microaggression and everyday discrimination, those in the mid (82% and 74.3%, respectively) and very high (71.1% and 79.4%) categories reported greater symptoms of PTSD (χ² = 69.82, p < 0.001 and χ² = 88.74, p < 0.001). A greater than expected frequency was also observed in the mid category with adjusted residual values of 6.1 and 2.5, respectively, for racial microaggression and everyday discrimination. Also, a positive adjusted residual value was noted in the very high category of everyday discrimination (5.1).

The linear regression, summarized in Table 2, was carried out to assess the relationship between symptoms of PTSD and racial discrimination (microaggression, everyday discrimination, and internalized racism) controlling for traumatic events experienced, and sociodemographic characteristics. The first model that included sociodemographic characteristics and traumatic events showed a significant general effect with F(12, 537) = 15.61, p < 0.001 and explained 25.9% of the variance. Results showed experiences of a larger number of traumatic events (b = 1.6; p < 0.001) were associated with an increase in symptoms of PTSD. Furthermore, place of birth (b = 3; p = 0.01), employment (b = −3.9; p < 0.001), and education, those who did not hold a high school diploma or certificate (b = −4.5; p = 0.02), were also statistically significant.

Table 2.

Results of Multivariable Linear Regression Analyses Predicting Symptoms of PTSD among Black Canadians.

	Model 1: F(12, 537) = 15.61, p < 0.001; R² = 25.9%				Model 2: F(15, 534) = 38.24, p < 0.001; R² = 51.8%
	b	P-value	95% CI		b	P-value	95% CI
Age	−0.046	0.592	−0.217	0.124	−0.022	0.778	−0.181	0.136
Gender	0.636	0.546	−1.430	2.701	1.550	0.111	−0.361	3.462
Place of birth	2.978	0.009	0.741	5.214	0.297	0.763	−1.644	2.238
Employment	−3.874	<0.001	−5.871	−1.878	−0.071	0.935	−1.790	1.647
Education
No formal education	−4.546	0.016	−8.232	−0.861	−1.354	0.399	−4.516	1.808
High school	−0.064	0.961	−2.647	2.518	0.100	0.927	−2.058	2.258
Post-secondary	2.154	0.097	−0.393	4.702	0.823	0.478	−1.467	3.114
University	−1.665	0.310	−4.887	1.556	−0.696	0.606	−3.348	1.956
Marital status
Married	−0.970	0.546	−4.138	2.198	−1.116	0.412	−3.798	1.565
Separated	1.091	0.546	−2.458	4.640	1.272	0.434	−1.937	4.481
Other	2.142	0.454	−3.660	7.944	1.518	0.531	−3.412	6.448
Traumatic events	1.636	<0.001	1.169	2.103	0.558	0.019	0.094	1.022
Racial microaggressions	—				0.522	<0.001	0.438	0.606
Everyday discrimination	—				0.174	0.026	0.021	0.327
Internalized racism	—				0.467	<0.001	0.290	0.644

Reference categories are the following: Sex: male; Education level: incomplete post-secondary; Marital status: single; Place of birth: born in Canada

In a second multivariate regression model, racial microaggression, everyday discrimination, and internalized racism were added to the previous factors. The second model was also significant (F(15, 534) = 38.24, p < 0.001) and explained 51.8% of the variance. Contrary to the previous model, no significant effect was observed among sociodemographic factors. Yet, the number of traumatic events (b = 0.6; p = 0.02), racial microaggressions (b = 0.5; p < 0.001), everyday discrimination (b = 0.2; p = 0.03), and internalized racism (b = 0.5; p < 0.001) were positively associated with symptoms of PTSD.

Discussion

The first objective of this study was ostensibly to document the prevalence of PTSD symptoms among Black individuals aged 15–40 years in Canada. We were struck by our finding that nearly all participants (95.1%) reported experiencing at least one traumatic event meeting criterion A of the DSM-5 definition of PTSD (i.e., exposure to a traumatic event), which is a prerequisite for diagnosing PTSD.²⁹ This result is a markedly high frequency when compared to an oft-cited Canadian study, which found that 75.9% of Canadians reported at least one lifetime exposure traumatic event (73.4% in women and 78.5% in men).^2,30 Furthermore, studies in the US have largely shown a lower prevalence of traumatic exposure among Black people compared to what was observed in our sample of Canadians.^31,32 A study conducted among a sample of 34,075 Americans, 19% of whom were Black, found that 76.37% of them had been exposed to at least one traumatic event.³¹ Only one study of youth in custody indicated a prevalence of 94% among Black men and 86% among Black women.³³ The high prevalence rate among Black people in Canada warrants further study to identify the specific types of traumas experienced by Black people in Canada, the associated risk and protective factors, and their impact on the health of Black people.

The present study also showed that two-thirds of the participants experience probable PTSD (67.11%). This finding appears to be very high compared to previous Canadian studies. The most recent study conducted on the general population showed a prevalence of lifetime PTSD of 9.2% and current PTSD of 2.4%.² However, studies of specific populations with a known risk have shown varying prevalence rates. A study of migrants, some of whom had been detained upon arrival in Canada and some of whom were not, with 50% and 65.1%, respectively, from sub-Saharan Africa, reported a PTSD prevalence of 37.7% and 18.2%.³⁴ These rates are still low compared to the results of the present study. However, a study of urban Indigenous women in Canada showed an even higher prevalence than the present study (83.2%).³⁵ Studies conducted among Black people in the US have rarely yielded similar studies. One study of 2,310 college students found a prevalence of PTSD of 34.4%.³⁶ Another study of 806 African Americans found the prevalence of individuals with PTSD to be 26.05%,³⁷ while a study of 9,554 veterans found that Black veterans (n = 1,027) were more likely to experience PTSD symptoms, with a prevalence of 36.3%.³⁸ Even studies of incarcerated Black individuals have found a significantly lower prevalence of PTSD.³⁹

The results presented here show that experiences of traumatic life events predicted PTSD symptoms, which corroborates the results of many studies conducted in the general population and disaster-specific populations.³ More importantly, regardless the form of racial discrimination examined all predicted PTSD symptoms. Several conclusions can be posited from these results. First, the addition of the three variables, namely microaggressions, everyday racial discrimination, and internalized racism, accounted for twice as much variance in the model that is from 25.9% to 51.8% (very high compared to what is often observed in the literature). Second, all three variables (everyday racial discrimination, racial microaggressions, and internalized racism) predicted PTSD scores. Although there are no equivalent studies in Canada to compare these results to, research with Indigenous people has also shown that everyday racial discrimination and housing-related racial discrimination are associated with increased PTSD scores.^10,11 In the US, the association between racial microaggressions, everyday racial discrimination and PTSD has been established by several studies.¹⁵ One study found that different forms of racial microaggressions predicted symptoms of PTSD.¹⁵ Other studies have shown that everyday racial discrimination predicts PTSD in those exposed to trauma.^37,40,41 However, although the association between internalized racism and mental health problems is known to exist, we could not identify any studies that explored it as a predictor of PTSD symptoms. Thus, this study paves the way for further longitudinal studies to explore the association between internalized racism and PTSD.

Limitations

Despite the importance of this study, it has some limitations. First, Canadian general population studies of PTSD are relatively out of date^2,42 and were conducted using earlier versions of the DSM. This has limited the possibilities for comparison with the general population. Similarly, the lack of PTSD studies on Black communities in Canada and other racialized communities limited the possibilities for comparison. Second, we used self-reported questionnaires. Although this allows for easier access to a large sample, it remains a limitation because the validity of the diagnosis based on self-reported PTSD symptoms is limited. Third, the cross-sectional design of this study does not allow for factors to be assessed as true predictors, but only as correlates. Longitudinal studies are needed to assess the order of appearance of the variables and the causal aspects. Fourth, the use of a convenience sample precludes the generalization of the results of this study. This is especially true because our sample includes a disproportionately lower number of men. Although this is often observed in online studies and Black men (and men in general) are particularly reluctant to participate in research, efforts should be made in future studies to recruit a larger number of men.^43,44

Implications and Conclusions

Despite these limitations, this study is an important contribution to the scientific literature. First, it explores for the first time the prevalence of PTSD among Black people in Canada and shows a very high prevalence that deserves to be studied more in-depth. Further study is especially important because the overwhelming majority of Black people in Canada report having experienced at least one traumatic event. These traumas need to be explored further to understand their nature (e.g., humans, natural disasters, etc.). Second, this study reveals that different forms of racial discrimination predict PTSD scores among Black people in Canada. By accounting for twice the proportion of variance explained, these variables show that they play an important role in the development of PTSD symptoms. These findings should prompt clinicians to systematically investigate the experience of racial trauma in Black individuals who seek care in their offices with symptoms of PTSD. Given the discrete and pernicious nature of internalized racism, clinicians should continually assess this construct in Black individuals. They should seek to gain a comprehensive understanding of this poorly understood issue that is often confused with self-esteem and impacts different spheres of racialized people's lives.^14,45 Researchers should also focus on the association between internalized racism and PTSD, exploring other possible mediating and moderating links.

This article highlights the relationship between racial discrimination and PTSD symptoms among Black people in Canadian society. Preventing these consequences begins with preventing racism itself. However, realistically, our societies will still face racism in the coming years. For this reason, this study shows the need for prevention and mental health programs aimed at mitigating its consequences to the lives of Black people and other racialized populations. Advocacy is also an important aspect of (1) the implementation of mental healthcare that responds to the real needs of Black people; (2) the training of mental health professionals with tools and provisions to address issues related to racial trauma; (3) a better consideration of racial issues in health research in Canada; and (4) the reduction and eventual elimination of racism in healthcare services and society. Researchers, psychiatrists, psychologists, and other mental health professionals have a role to play at every level in reducing and eliminating disparities and moving towards a just and egalitarian society.

Footnotes

Acknowledgments

Our thanks are extended to Pari-Gole Noorishad and Saba Hajizadeh for project coordination.

Authors’ Contribution

JMC contributed to conceptualization, investigation, methodology, software, formal analysis, and writing—original draft. RDD contributed to writing—original draft—review & editing. WPD contributed to writing—original draft—review & editing. CSK contributed to methodology, data curation, review & editing, validation, and visualization. MG contributed to methodology, software, formal analysis, and writing—original draft.

Availability of Data

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy and ethical restrictions.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Public Health Agency of Canada (grant number 1920-HQ-000053).

ORCID iD

Jude Mary Cénat

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