Search

Background: Indigenous children living in high income countries have a consistently high prevalence of mental health problems. We aimed to identify psychosocial risk and protective factors for mental health in this setting. Methods: A systematic review of studies published between 1996 and 2016 that quantitatively evaluated the association between psychosocial variables and mental health among Indigenous children living in high income countries was conducted. Psychosocial variables were grouped into commonly occurring domains. Individual studies were judged to provide evidence for an association between a domain and either good mental health, poor mental health, or a negligible or inconsistent association. The overall quality of evidence across all studies for each domain was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) guidelines. Results: Forty-seven papers were eligible (mainland US 30 [64%], Canada 8 [17%], Australia 7 [15%], Hawaii 4 [9%]), including 58,218 participants aged 4-20 years. Most papers were cross-sectional (39, 83%) and measured negative mental health outcomes (41, 87%). Children's negative cohesion with their families and the presence of adverse events appeared the most reliable predictors of increased negative mental health outcomes. Children's substance use, experiences of discrimination, comorbid internalising symptoms, and negative parental behaviour also provided evidence of associations with negative mental health outcomes. Positive family and peer relationships, high self-esteem and optimism were associated with increased positive mental health outcomes. Conclusions: Quantitative research investigating Indigenous children's mental health is largely cross-sectional and focused upon negative outcomes. Indigenous children living in high income countries share many of the same risk and protective factors associated with mental health. The evidence linking children's familial environment, psychological traits, substance use and experiences of discrimination with mental health outcomes highlights key targets for more concerted efforts to develop initiatives to improve the mental health of Indigenous children. [ABSTRACT FROM AUTHOR]

Background: Virtual care quickly became of crucial importance to health systems around the world during the COVID-19 pandemic. Despite the potential of virtual care to enhance access for some communities, the scale and pace at which services were virtualized did not leave many organizations with sufficient time and resources to ensure optimal and equitable delivery of care for everyone. The objective of this paper is to outline the experiences of health care organizations rapidly implementing virtual care during the first wave of the COVID-19 pandemic and examine whether and how health equity was considered. Methods: We used an exploratory, multiple case study approach involving four health and social service organizations providing virtual care services to structurally marginalized communities in the province of Ontario, Canada. We conducted semi-structured qualitative interviews with providers, managers, and patients to understand the challenges experienced by organizations and the strategies put in place to support health equity during the rapid virtualization of care. Thirty-eight interviews were thematically analyzed using rapid analytic techniques. Results: Organizations experienced challenges related to infrastructure availability, digital health literacy, culturally appropriate approaches, capacity for health equity, and virtual care suitability. Strategies to support health equity included the provision of blended models of care, creation of volunteer and staff support teams, participation in community engagement and outreach, and securement of infrastructure for clients. We put our findings into the context of an existing framework conceptualizing access to health care and expand on what this means for equitable access to virtual care for structurally marginalized communities. Conclusion: This paper highlights the need to pay greater attention to the role of health equity in virtual care delivery and situate that conversation around existing inequitable structures in the health care system that are perpetuated when delivering care virtually. An equitable and sustainable approach to virtual care delivery will require applying an intersectionality lens on the strategies and solutions needed to address existing inequities in the system. [ABSTRACT FROM AUTHOR]

Background: Inequitable access to primary health care (PHC) remains a problem for most western countries. Failure to scale up effective interventions has been due, in part, to a failure to share the logic and essential elements of successful programs. The aim of this paper is to describe what we learned about improving access to PHC for vulnerable groups across multiple sites through use of a common theory-based program logic model and a common evaluation approach. This was the IMPACT initiative. Methods: IMPACT's evaluation used a mixed methods design with longitudinal (pre and post) analysis of six interventions. The analysis for this paper included four of the six sites that met study criteria. These sites were located in Canada (Alberta, Quebec and Ontario) and Australia (New South Wales). Using the overarching logic model, unexpected findings were reviewed, and alternative explanations were considered to understand how the mechanisms of each intervention may have contributed to results. Results: Each site addressed their local access problem with different strategies and from different starting points. All sites observed changes in patient abilities to access PHC and provider access capabilities. The combination of intended and observed consequences for consumers and providers was different at each site, but all sites achieved change in both consumer ability and provider capability, even in interventions where there was no activity targeting provider behaviors. Discussion: The model helped to identify, explore and synthesize intended and unintended consequences of four interventions that appeared to have more differences than similarities. Similar outcomes for different interventions and multiple impacts of each intervention on abilities were observed, implying complex causal pathways. Conclusions: All the interventions were a low-cost incremental attempt to address unmet health care needs of vulnerable populations. Change is possible; sustaining change may be more challenging. Access to PHC requires attention to both patient abilities and provider characteristics. The logic model proved to be a valuable heuristic tool for defining the objectives of the interventions, evaluating their impacts, and learning from the comparison of 'cases'. [ABSTRACT FROM AUTHOR]

Objective: In the past few years, increasing numbers of Indigenous doula collectives have been forming across Canada. Indigenous doulas provide continuous, culturally appropriate support to Indigenous women during pregnancy, birth, and the post-partum period. This support is critical to counter systemic medical racism and socioeconomic barriers that Indigenous families disproportionately face. This paper analyzes interviews with members of five Indigenous doula collectives to demonstrate their shared challenges, strategies, and missions. Methods: Qualitative interviews were conducted with members of five Indigenous doula collectives across Canada in 2020. Interviews were transcribed and returned to participants for their approval. Approved transcripts were then coded by all members of the research team to ascertain the dominant themes emerging across the interviews. Results: Two prominent themes emerged in the interviews. The first theme is "Indigenous doulas responding to community needs." Participants indicated that responding to community needs involves harm reduction and trauma-informed care, supporting cultural aspects of birthing and family, and helping clients navigate socioeconomic barriers. The second theme is "Indigenous doulas building connections with mothers." Participants' comments on providing care to mothers emphasize the importance of advocacy in healthcare systems, boosting their clients' confidence and skills, and being the "right" doula for their clients. These two inter-related themes stem from Indigenous doulas' efforts to counter dynamics in healthcare and social services that can be harmful to Indigenous families, while also integrating cultural teachings and practices. Conclusion: This paper illustrates that Indigenous doula care responds to a wide range of issues that affect Indigenous women's experiences of pregnancy, birth, and the post-partum period. Through building strong, trusting, and non-judgemental connections with mothers and responding to community needs, Indigenous doulas play a critical role in countering medical racism in hospital settings and advancing the resurgence of Indigenous birthing sovereignty. [ABSTRACT FROM AUTHOR]

Introduction: Healthcare organisations serve clients from diverse Indigenous and other ethnic and racial groups on a daily basis, and require appropriate client-centred systems and services for provision of optimal healthcare. Despite advocacy for systems-level approaches to cultural competence, the primary focus in the literature remains on competency strategies aimed at health promotion initiatives, workforce development and student education. This paper aims to bridge the gap in available evidence about systems approaches to cultural competence by systematically mapping key concepts, types of evidence, and gaps in research. Methods: A literature search was completed as part of a larger systematic search of evaluations and measures of cultural competence interventions in health care in Canada, the United States, Australia and New Zealand. Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched from 2002 to 2015. Overall, 109 studies were found, with 15 evaluating systems-level interventions or describing measurements. Thematic analysis was used to identify key implementation principles, intervention strategies and outcomes reported. Results: Twelve intervention and three measurement studies met our inclusion criteria. Key principles for implementing systems approaches were: user engagement, organisational readiness, and delivery across multiple sites. Two key types of intervention strategies to embed cultural competence within health systems were: audit and quality improvement approaches and service-level policies or strategies. Outcomes were found for organisational systems, the client/practitioner encounter, health, and at national policy level. Discussion and implications: We could not determine the overall effectiveness of systems-level interventions to reform health systems because interventions were context-specific, there were too few comparative studies and studies did not use the same outcome measures. However, examined together, the intervention and measurement principles, strategies and outcomes provide a preliminary framework for implementation and evaluation of systems-level interventions to improve cultural competence. Identified gaps in the literature included a need for cost and effectiveness studies of systems approaches and explication of the effects of cultural competence on client experience. Further research is needed to explore the extent to which cultural competence improves health outcomes and reduces ethnic and racially-based healthcare disparities. [ABSTRACT FROM AUTHOR]

Intersectionality is a widely adopted theoretical orientation in the field of women and gender studies. Intersectionality comes from the work of black feminist scholars and activists. Intersectionality argues identities such as gender, race, sexuality, and other markers of difference intersect and reflect large social structures of oppression and privilege, such as sexism, racism, and heteronormativity. The reach of intersectionality now extends to the fields of public health and knowledge translation. Knowledge translation (KT) is a field of study and practice that aims to synthesize and evaluate research into an evidence base and move that evidence into health care practice. There have been increasing calls to bring gender and other social issues into the field of KT. Yet, as scholars outline, there are few guidelines for incorporating the principles of intersectionality into empirical research. An interdisciplinary, team-based, national health research project in Canada aimed to bring an intersectional lens to the field of knowledge translation. This paper reports on key moments and resulting tensions we experienced through the project, which reflect debates in intersectionality: discomfort with social justice, disciplinary divides, and tokenism. We consider how our project advances intersectionality practice and suggests recommendations for using intersectionality in health research contexts. We argue that while we encountered many challenges, our process and the resulting co-created tools can serve as a valuable starting point and example of how intersectionality can transform fields and practices. [ABSTRACT FROM AUTHOR]

Introduction: Even in countries with universal healthcare systems, excess mortality rates due to physical chronic diseases in patients also suffering from serious mental illness like schizophrenia is such that their life expectancy could be lessened by up to 20 years. The possible explanations for this disparity include: unhealthy habits (i.e. smoking; lack of exercise); side-effects of psychotropic medication; delays in the detection or initial presentation leading to a more advanced disease at diagnosis; and inequity of access to services. The main objective of this paper is to explore the feasibility and acceptability of patient partnership for developing an interactive guide to improve access to primary care providers for chronic diseases management and health promotion among patients with severe mental illnesses. Methods: A participatory action research design was used to engage patients with mental illness as full research partners for a strategy for patient-oriented research in primary care for persons with schizophrenia who also have chronic physical illnesses. This strategy was also developed in partnership with a health and social services centre responsible for the health of the population of a territory with about 100,000 inhabitants in East-end Montreal, Canada. A new interactive guide was developed by patient research partners and used by 146 participating patients with serious mental illness who live on this territory, for them to be better prepared for their medical appointment with a General Practitioner by becoming more aware of their own physical condition. Results: Patient research partners produced a series of 33 short videos depicting signs and symptoms of common chronic diseases and risk factors for the leading causes of mortality and study participants were able to complete the corresponding 33-item questionnaire on an electronic touch screen tablet. What proved to be most relevant in terms of interactivity was the dynamic that has developed among the study participants during the small group learning sessions, a training technique designed for healthcare professionals that was adapted for this project for, and with patient partners. Conclusion: This research has shown the feasibility and acceptability of patient partnership and patient-oriented research approaches to the R&D process of a new medical tool and intervention for patients with serious mental illness, and its acceptability for addressing inequity of this disadvantaged population in terms of access to primary care providers. [ABSTRACT FROM AUTHOR]

Introduction In the field of health, numerous frameworks have emerged that advance understandings of the differential impacts of health policies to produce inclusive and socially just health outcomes. In this paper, we present the development of an important contribution to these efforts -- an Intersectionality-Based Policy Analysis (IBPA) Framework. Methods Developed over the course of two years in consultation with key stakeholders and drawing on best and promising practices of other equity-informed approaches, this participatory and iterative IBPA Framework provides guidance and direction for researchers, civil society, public health professionals and policy actors seeking to address the challenges of health inequities across diverse populations. Importantly, we present the application of the IBPA Framework in seven priority health-related policy case studies. Results The analysis of each case study is focused on explaining how IBPA: 1) provides an innovative structure for critical policy analysis; 2) captures the different dimensions of policy contexts including history, politics, everyday lived experiences, diverse knowledges and intersecting social locations; and 3) generates transformative insights, knowledge, policy solutions and actions that cannot be gleaned from other equity-focused policy frameworks. Conclusion The aim of this paper is to inspire a range of policy actors to recognize the potential of IBPA to foreground the complex contexts of health and social problems, and ultimately to transform how policy analysis is undertaken. [ABSTRACT FROM AUTHOR]

Health inequalities amplified by the COVID-19 pandemic have disproportionately affected racialized and equity-deserving communities across Canada. In the Municipality of Peel, existing data, while limited, illustrates that individuals from racialized and equity-deserving communities continue to suffer, receive delayed care, and die prematurely. In response to these troubling statistics, grassroots community advocacy has called on health systems leaders in Peel to work with community and non-profit organizations to address the critical data and infrastructure gaps that hinder addressing the social determinants of health in the region. To support these advocacy efforts, we used a community-based participatory research approach to understand how we might build a data collection ecosystem across sectors, alongside community residents and service providers, to accurately capture the data about the social determinants of health. This approach involved developing a community engagement council, defining the problem with the community, mapping what data is actively collected and what is excluded, and understanding experiences of sociodemographic data collection from community members and service providers. Guided by community voices, our study focused on sociodemographic data collection in the primary care context and identified which service providers use and collect these data, how data are used in their work, the facilitators and barriers to data use and collection. Additionally, we gained insight into how sociodemographic data collection could be respectful, safe, and properly governed from the perspectives of community members. From this study, we identify a set of eight recommendations for sociodemographic data collection and highlight limitations. This foundational community-based work will inform future research in establishing data governance in partnership with diverse and equity-deserving communities. [ABSTRACT FROM AUTHOR]

Background: There is a growing interest in employing community wellness worker models in Indigenous populations to address inequities in healthcare access and outcomes, concerns about shortage in health and mental health human resources, and escalating burden of chronic and complex diseases driving significant increase in health services demand and costs. A thorough review of Indigenous community wellness worker models has yet to be conducted. This rapid review sought to outline the characteristics of a community wellness worker model in Indigenous contexts across the globe, detailing factors shaping implementation challenges and success. Methods: A rapid review of the international peer-reviewed and grey literature of OVID Medline, Global Index Medicus, Google, and Google Scholar was conducted from January to June 2022 for Indigenous community wellness/mental health worker models and comparative models. Articles were screened and assessed for eligibility. From eligible articles, data pertaining to study design and sample; description of the program, service, or intervention; model development and implementation; terminology used to describe workers; training features; job roles; funding considerations; facilitators and barriers to success; key findings; outcomes measured; and models or frameworks utilized were extracted. Data were synthesized by descriptive and pattern coding. Results: Twenty academic and eight grey literature articles were examined. Our findings resulted in four overarching and interconnected themes: (1) worker roles and responsibilities; (2) worker training, education, and experience; (3) decolonized approaches; and (4) structural supports. Conclusion: Community wellness worker models present a promising means to begin to address the disproportionately elevated demand for mental wellness support in Indigenous communities worldwide. This model of care acts as a critical link between Indigenous communities and mainstream health and social service providers and workers fulfill distinctive roles in delivering heightened mental wellness supports to community members by leveraging strong ties to community and knowledge of Indigenous culture. They employ innovative structural solutions to bolster their efficacy and cultivate positive outcomes for service delivery and mental wellness. Barriers to the success of community wellness worker models endure, including power imbalances, lack of role clarity, lack of recognition, mental wellness needs of workers and Indigenous communities, and more. [ABSTRACT FROM AUTHOR]

Background: Racism in the healthcare system has become a burgeoning focus in health policy-making and research. Existing research has shown both interpersonal and structural forms of racism limiting access to quality healthcare for racialised healthcare users. Nevertheless, little is known about the specifics of racism in the inpatient sector, specifically hospitals and rehabilitation facilities. The aim of this scoping review is therefore to map the evidence on racial discrimination experienced by people receiving treatment in inpatient settings (hospitals and rehabilitation facilities) or their caregivers in high-income countries, focusing specifically on whether intersectional axes of discrimination have been taken into account when describing these experiences. Methods: Based on the conceptual framework developed by Arksey and O'Malley, this scoping review surveyed existing research on racism and racial discrimination in inpatient care in high-income countries published between 2013 and 2023. The software Rayyan was used to support the screening process while MAXQDA was used for thematic coding. Results: Forty-seven articles were included in this review. Specifics of the inpatient sector included different hospitalisation, admission and referral rates within and across hospitals; the threat of racial discrimination from other healthcare users; and the spatial segregation of healthcare users according to ethnic, religious or racialised criteria. While most articles described some interactions between race and other social categories in the sample composition, the framework of intersectionality was rarely considered explicitly during analysis. Discussion: While the USA continue to predominate in discussions, other high-income countries including Canada, Australia and the UK also examine racism in their own healthcare systems. Absent from the literature are studies from a wider range of European countries as well as of racialised and disadvantaged groups other than refugees or recent immigrants. Research in this area would also benefit from an engagement with approaches to intersectionality in public health to produce a more nuanced understanding of the interactions of racism with other axes of discrimination. As inpatient care exhibits a range of specific structures, future research and policy-making ought to consider these specifics to develop targeted interventions, including training for non-clinical staff and robust, transparent and accessible complaint procedures. [ABSTRACT FROM AUTHOR]

Women's health research strives to make change. It seeks to produce knowledge that promotes action on the variety of factors that affect women's lives and their health. As part of this general movement, important strides have been made to raise awareness of the health effects of sex and gender. The resultant base of knowledge has been used to inform health research, policy, and practice. Increasingly, however, the need to pay better attention to the inequities among women that are caused by racism, colonialism, ethnocentrism, heterosexism, and able-bodism, is confronting feminist health researchers and activists. Researchers are seeking new conceptual frameworks that can transform the design of research to produce knowledge that captures how systems of discrimination or subordination overlap and "articulate" with one another. An emerging paradigm for women's health research is intersectionality. Intersectionality places an explicit focus on differences among groups and seeks to illuminate various interacting social factors that affect human lives, including social locations, health status, and quality of life. This paper will draw on recently emerging intersectionality research in the Canadian women's health context in order to explore the promises and practical challenges of the processes involved in applying an intersectionality paradigm. We begin with a brief overview of why the need for an intersectionality approach has emerged within the context of women's health research and introduce current thinking about how intersectionality can inform and transform health research more broadly. We then highlight novel Canadian research that is grappling with the challenges in addressing issues of difference and diversity. In the analysis of these examples, we focus on a largely uninvestigated aspect of intersectionality research - the challenges involved in the process of initiating and developing such projects and, in particular, the meaning and significance of social locations for researchers and participants who utilize an intersectionality approach. The examples highlighted in the paper represent important shifts in the health field, demonstrating the potential of intersectionality for examining the social context of women's lives, as well as developing methods which elucidate power, create new knowledge, and have the potential to inform appropriate action to bring about positive social change. [ABSTRACT FROM AUTHOR]

In this paper we argue the importance of including gender and sexually diverse populations in policy development towards a more inclusive form of health promotion. We emphasize the need to address the broad health and wellbeing issues and needs of LGBT people, rather than exclusively using an illness-based focus such as HIV/AIDS. We critically examine the limitations of population health, the social determinants of health (SDOH), and public health goals, in light of the lack of recognition of gender and sexually diverse individuals and communities. By first acknowledging the unique health and social care needs of LGBT people, then employing anti-oppressive, critical and intersectional analyses we offer recommendations for how to make population health perspectives, public health goals, and the design of public health promotion policy more inclusive of gender and sexual diversity. In health promotion research and practice, representation matters. It matters which populations are being targeted for health promotion interventions and for what purposes, and it matters which populations are being overlooked. In Canada, current health promotion policy is informed by population health and social determinants of health (SDOH) perspectives, as demonstrated by Public Health Goals for Canada. With Canada's multicultural makeup comes the challenge of ensuring that diverse populations are equitably and effectively recognized in public health and health promotion policy. [ABSTRACT FROM AUTHOR]

Background: The reduction of health inequalities is a focus of many national and international health organisations. The need for pragmatic evidence-based approaches has led to the development of a number of evidence-based equity initiatives. This paper describes a new program that focuses upon evidencebased tools, which are useful for policy initiatives that reduce inequities. Methods: This paper is based on a presentation that was given at the "Regional Consultation on Policy Tools: Equity in Population Health Reports," held in Toronto, Canada in June 2002. Results: Five assessment tools were presented. 1. A database of systematic reviews on the effects of educational, legal, social, and health interventions to reduce unfair inequalities is being established through the Cochrane and Campbell Collaborations. 2 Decision aids and shared decision making can be facilitated in disadvantaged groups by 'health coaches' to help people become better decision makers, negotiators, and navigators of the health system; a pilot study in Chile has provided proof of this concept. 3. The CIET Cycle: Combining adapted cluster survey techniques with qualitative methods, CIET's population based applications support evidence-based decision making at local and national levels. The CIET map generates maps directly from survey or routine institutional data, to be used as evidence-based decisions aids. Complex data can be displayed attractively, providing an important tool for studying and comparing health indicators among and between different populations. 4. The Ottawa Equity Gauge is applying the Global Equity Gauge Alliance framework to an industrialised country setting. 5 The Needs-Based Health Assessment Toolkit, established to assemble information on which clinical and health policy decisions can be based, is being expanded to ensure a focus on distribution and average health indicators. Conclusion: Evidence-based planning tools have much to offer the goal of equitable health development. [ABSTRACT FROM AUTHOR]

Background: Indigenous young people are currently highly overrepresented in the HIV epidemic in Canada, especially in the Prairie Provinces, such as Manitoba. Understanding HIV-vulnerability in Indigenous peoples must begin with understanding that social determinants are intersectional and linked to the historical legacy of European colonization. In this paper findings that detail the influence of the intersectional social determinants on Indigenous people who become infected with HIV in their youth are presented. Methods: The qualitative research design of phenomenology was used as it afforded the opportunity to understand Indigenous young people from their frames of reference and experiences of reality, resulting in a phenomenological understanding of their perspectives and experiences of the early years of living with HIV. A total of 21 Indigenous young people took part open-ended interviews. Results: The stories that the Indigenous young people shared revealed their deeply interconnected social worlds, and how social determinants including abuse, trauma, being part of the child welfare system, and housing and food security were connected throughout various stages of their lives. Such stages included childhood, adolescence and young adulthood (the time of HIV infection), and later adulthood for older participants with the social determinants having multiple influences on their health trajectories. Conclusions: The findings highlight the need for policies and programs that are broadly focused, addressing multiple social determinants together. Overall, there needs to be more emphasis on the multiple social determinants in the life situations of all Indigenous youth. Reducing the health and social disparities in Indigenous youth is key to reducing the number of young Indigenous people diagnosed with HIV. The findings also shed light on the importance of listening to young Indigenous people who have experienced HIV diagnosis and life following diagnosis. [ABSTRACT FROM AUTHOR]

Background: In this paper we examine the relationship between social capital and two mental health outcomes—self-rated mental health (SRMH) and heavy episodic drinking (HED)—among the Indigenous populations of Canada. We operationalize a unique definition of social capital from Indigenous specific sources that allows for an analysis of the importance of access to Indigenous networks and communities. We also examine gender variations in the relationship between social capital and the two outcomes, as there is a noticeable lack of research examining the influence of gender in the recent literature on the mental health of Indigenous populations in Canada. Methods: Using data from the 2012 cycle of the Aboriginal Peoples Survey, logistic regression models were estimated to assess if gender was a significant predictor of either SRMH or HED among the entire Indigenous sample. The sample was then stratified by gender and the relationship between two social capital variables—one general and one indigenous-specific—and each mental health outcome was assessed separately among male and female respondents. All analyses were also further stratified into specific Indigenous groups—First Nations, Métis, or Inuit—to account for the unique cultures, histories, and socioeconomic positions of the three populations. Results: Female respondents were more likely to report fair or poor SRMH in the total sample as well as the First Nations and Métis subsamples (OR = 1.48, CI = 1.14–1.91; OR = 1.63, CI = 1.12–2.36; OR = 1.44, CI = 1.01–2.05 respectively). However, female respondents were less likely than males to engage in weekly HED in all three of the same populations (OR = 0.43, CI = 0.35–0.54, all respondents; OR = 0.42, CI = 0.31–0.58, First nations; OR = 0.39, CI = 0.27–0.56, Métis). Social capital from sources specific to Indigenous communities was associated with lower odds of weekly HED, but only among Indigenous men. Meanwhile the strength of family ties was associated with lower odds of reporting fair/poor SRMH among both Indigenous men and women. However, these results vary in strength and significance among the different Indigenous populations of Canada. Conclusions: The results of this paper address a critical gap in the literature on gender differences in SRMH and HED among the Indigenous populations of Canada, and reveal gendered variations in the relationship between social capital and SRMH and HED. These findings support further investigation into the role that social capital and particularly Indigenous-specific forms of social capital may play as a determinant of health. This research could contribute to future mental health initiatives aimed at strengthening the social capital of Indigenous populations and promoting resilient Indigenous communities with strong social connections. [ABSTRACT FROM AUTHOR]

Introduction: Consumption of substances is a highly controversial behaviour, with those who do so commonly viewed as deviants, even criminals, or else as out of control addicts. In other work we showed that the use of substances by women who are pregnant or have recently become parents was mainly viewed by health and social care providers as morally wrong. Problematic substance use was framed through the narrow lens of gendered responsibilisation, resulting in women being seen primarily as foetal incubators and primary caregivers of infants. Methods: In this follow-up paper we examine descriptive and qualitative data from a convenience sample of biological mothers and fathers (N= 34) recruited as part of a larger mixed methods study of the development and early implementation of an integrated primary maternity care program. We present a description of the participants' backgrounds, family circumstances, health status, and perception of drug-related stigma. This is succeeded by a thematic analysis of their personal views on substance use during both pregnancy and the transition to parenthood. Results: Our results show that while many mothers and fathers hold abstinence as the ideal during pregnancy and early parenting, they simultaneously recognize the autonomy of women to judge substance use risk for themselves. Participants also call attention to social structural factors that increase/decrease harms associated with such substance use, and present an embodied knowledge of substance use based on their tacit knowledge of wellness and what causes harm. Conclusions: While these two main discourses brought forward by parents concerning the ideal of abstinence and the autonomy of women are not always reconcilable and are partially a reflection of the dissonance between dominant moral codes regarding motherhood and the lived experiences of people who use substances, service providers who are attuned to these competing discourses are likely to be more effective in their delivery of health and social services for vulnerable families. More holistic and nuanced perspectives of health, substance use, and parenting may generate ethical decision-making practice frameworks that guide providers in meeting and supporting the efforts of mothers and fathers to achieve well-being within their own definitions of problematic substance use. [ABSTRACT FROM AUTHOR]

Introduction: Accurate measurement of health inequities is indispensable to track progress or to identify needs for health equity policy interventions. A key empirical task is to measure the extent to which observed inequality in health -- a difference in health -- is inequitable. Empirically operationalizing definitions of health inequity has generated an important question not considered in the conceptual literature on health inequity. Empirical analysis can explain only a portion of observed health inequality. This paper demonstrates that the treatment of unexplained inequality is not only a methodological but ethical question and that the answer to the ethical question -- whether unexplained health inequality is unfair -- determines the appropriate standardization method for health inequity analysis and can lead to potentially divergent estimates of health inequity. Methods: We use the American sample of the 2002-03 Joint Canada/United States Survey of Health and measure health by the Health Utilities Index (HUI). We model variation in the observed HUI by demographic, socioeconomic, health behaviour, and health care variables using Ordinary Least Squares. We estimate unfair HUI by standardizing fairness, removing the fair component from the observed HUI. We consider health inequality due to factors amenable to policy intervention as unfair. We contrast estimates of inequity using two fairness-standardization methods: direct (considering unexplained inequality as ethically acceptable) and indirect (considering unexplained inequality as unfair). We use the Gini coefficient to quantify inequity. Results: Our analysis shows that about 75% of the variation in the observed HUI is unexplained by the model. The direct standardization results in a smaller inequity estimate (about 60% of health inequality is inequitable) than the indirect standardization (almost all inequality is inequitable). Conclusions: The choice of the fairness-standardization method is ethical and influences the empirical health inequity results considerably. More debate and analysis is necessary regarding which treatment of the unexplained inequality has the stronger foundation in equity considerations. [ABSTRACT FROM AUTHOR]

Introduction: International evidence shows that enhancement of primary health care (PHC) services for disadvantaged populations is essential to reducing health and health care inequities. However, little is known about how to enhance equity at the organizational level within the PHC sector. Drawing on research conducted at two PHC Centres in Canada whose explicit mandates are to provide services to marginalized populations, the purpose of this paper is to discuss (a) the key dimensions of equity-oriented services to guide PHC organizations, and (b) strategies for operationalizing equity-oriented PHC services, particularly for marginalized populations. Methods: The PHC Centres are located in two cities within urban neighborhoods recognized as among the poorest in Canada. Using a mixed methods ethnographic design, data were collected through intensive immersion in the Centres, and included: (a) in-depth interviews with a total of 114 participants (73 patients; 41 staff), (b) over 900 hours of participant observation, and (c) an analysis of key organizational documents, which shed light on the policy and funding environments. Results: Through our analysis, we identified four key dimensions of equity-oriented PHC services: inequity-responsive care; trauma- and violence-informed care; contextually-tailored care; and culturally-competent care. The operationalization of these key dimensions are identified as 10 strategies that intersect to optimize the effectiveness of PHC services, particularly through improvements in the quality of care, an improved 'fit' between people's needs and services, enhanced trust and engagement by patients, and a shift from crisis-oriented care to continuity of care. Using illustrative examples from the data, these strategies are discussed to illuminate their relevance at three inter-related levels: organizational, clinical programming, and patient-provider interactions. Conclusions: These evidence- and theoretically-informed key dimensions and strategies provide direction for PHC organizations aiming to redress the increasing levels of health and health care inequities across population groups. The findings provide a framework for conceptualizing and operationalizing the essential elements of equity-oriented PHC services when working with marginalized populations, and will have broad application to a wide range of settings, contexts and jurisdictions. Future research is needed to link these strategies to quantifiable process and outcome measures, and to test their impact in diverse PHC settings. [ABSTRACT FROM AUTHOR]

Background: Intersectionality theory, a way of understanding social inequalities by race, gender, class, and sexuality that emphasizes their mutually constitutive natures, possesses potential to uncover and explicate previously unknown health inequalities. In this paper, the intersectionality principles of "directionality," "simultaneity," "multiplicativity," and "multiple jeopardy" are applied to inequalities in self-rated health by race, gender, class, and sexual orientation in a Canadian sample. Methods: The Canadian Community Health Survey 2.1 (N = 90,310) provided nationally representative data that enabled binary logistic regression modeling on fair/poor self-rated health in two analytical stages. The additive stage involved regressing self-rated health on race, gender, class, and sexual orientation singly and then as a set. The intersectional stage involved consideration of two-way and three-way interaction terms between the inequality variables added to the full additive model created in the previous stage. Results: From an additive perspective, poor self-rated health outcomes were reported by respondents claiming Aboriginal, Asian, or South Asian affiliations, lower class respondents, and bisexual respondents. However, each axis of inequality interacted significantly with at least one other: multiple jeopardy pertained to poor homosexuals and to South Asian women who were at unexpectedly high risks of fair/poor self-rated health and mitigating effects were experienced by poor women and by poor Asian Canadians who were less likely than expected to report fair/ poor health. Conclusions: Although a variety of intersections between race, gender, class, and sexual orientation were associated with especially high risks of fair/poor self-rated health, they were not all consistent with the predictions of intersectionality theory. I conclude that an intersectionality theory well suited for explicating health inequalities in Canada should be capable of accommodating axis intersections of multiple kinds and qualities. [ABSTRACT FROM AUTHOR]

Background: Women are more likely to develop osteoarthritis (OA), and have greater OA pain and disability compared with men, but are less likely to receive guideline-recommended management, particularly racialized women. OA care of diverse women, and strategies to improve the quality of their OA care is understudied. The purpose of this study was to explore strategies to overcome barriers of access to OA care for diverse women. Methods: We conducted qualitative interviews with key informants and used content analysis to identify themes regarding what constitutes person-centred OA care, barriers of OA care, and strategies to support equitable timely access to person-centred OA care. Results: We interviewed 27 women who varied by ethno-cultural group (e.g. African or Caribbean Black, Chinese, Filipino, Indian, Pakistani, Caucasian), age, region of Canada, level of education, location of OA and years with OA; and 31 healthcare professionals who varied by profession (e.g. family physician, nurse practitioner, community pharmacist, physio- and occupational therapists, chiropractors, healthcare executives, policy-makers), career stage, region of Canada and type of organization. Participants within and across groups largely agreed on approaches for person-centred OA care across six domains: foster a healing relationship, exchange information, address emotions, manage uncertainty, share decisions and enable self-management. Participants identified 22 barriers of access and 18 strategies to overcome barriers at the patient- (e.g. educational sessions and materials that accommodate cultural norms offered in different languages and formats for persons affected by OA), healthcare professional- (e.g. medical and continuing education on OA and on providing OA care tailored to intersectional factors) and system- (e.g. public health campaigns to raise awareness of OA, and how to prevent and manage it; self-referral to and public funding for therapy, greater number and ethno-cultural diversity of healthcare professionals, healthcare policies that address the needs of diverse women, dedicated inter-professional OA clinics, and a national strategy to coordinate OA care) levels. Conclusions: This research contributes to a gap in knowledge of how to optimize OA care for disadvantaged groups including diverse women. Ongoing efforts are needed to examine how best to implement these strategies, which will require multi-sector collaboration and must engage diverse women. [ABSTRACT FROM AUTHOR]

Background: Vaccine hesitancy exists on a continuum ranging between complete adherence and complete refusal due to doubts or concerns within a heterogeneous group of individuals. Despite widespread acknowledgement of the contextual factors influencing attitudes and beliefs shaping COVID-19 vaccine hesitancy, qualitative research with equity-deserving groups, accounting for unique lived experiences, remains a gap in the literature. We aim to identify and begin to understand and document the unique contextual factors shaping hesitancy by equity-deserving groups as it relates to relationships with government and health authorities. Methods: Participants were recruited and interviewed between Aug-Dec 2021. Semi-structured interviews using a convergent interviewing technique were conducted with individuals from the general population, as well as individuals who identify as First Nations, Métis, or Inuit, members of the LGBT2SQ + community, low-income Canadians, Black Canadians, and newcomers. Interviews were audio recorded and transcribed by a team of researchers. Memos were written following interviews and used to complement the thematic analysis of the interview data. Themes are presented in the results section. Results: The rationale for hesitancy among equity-deserving groups is consistent with literature documenting hesitancy in the general population. Contextual factors surrounding equity-deserving groups' attitudes and beliefs, however, are unique and relate to a history of oppression, discrimination, and genocide. We identified factors unique to subgroups; for example, religious or fatalistic beliefs among participant who identify as FNMI, fear associated with lack of testing and speed of vaccines' production among participants who identify as FNMI, Black, and LGBT2SQ + , distrust of the healthcare system for LGBT2SQ + and Black Canadians, and distrust of the government and opposition to vaccine mandates for participating who identify as LGBT2SQ + , low-income, FNMI, or Black Canadian. Newcomers stood out as very trusting of the government and accepting of COVID-19 vaccination. Conclusions: While our data on vaccine hesitancy largely mirror concerns reported in the vast body of literature citing rationale for COVID-19 hesitancy in high-income countries, the contextual factors identified in our work point to the need for wider systemic change. Our results may be used to support efforts, beyond tailored promotion campaigns, to support the confident acceptance of vaccines for COVID-19 and the acceptance of novel vaccines as future infectious diseases emerge. [ABSTRACT FROM AUTHOR]

Objective: Epidemics impact individuals unevenly across race, gender, and sexuality. In addition to being more vulnerable to COVID-19 infection, evidence suggests racialized gender and sexual minorities experienced disproportionate levels of discrimination and stigma during the COVID-19 epidemic. Drawing on Critical Race Theory (CRT), we examined the experiences of gay, bisexual, queer, and other men who have sex with men (GBQM) of colour facing discrimination during COVID-19. Design: Engage-COVID-19 is a mixed methods study examining the impact of COVID-19 on GBQM living in Vancouver, Toronto, and Montréal, Canada. We conducted two rounds of qualitative interviews (November 2020 to February 2021, and June to October 2021) with 93 GBQM to explore the evolving impact of COVID-19 on their lives. Transcripts were coded using inductive thematic analysis. Data analysis was conducted using Nvivo software. Results: Fifty-nine participants identified as Black, Indigenous, and/or a Person of Colour (BIPOC). These GBQM of colour described multiple experiences of discrimination during COVID-19. Although participants did not report experiences of discrimination based on their sexual identity during COVID-19, we found that experiences of racism affected how they were treated within their sexual networks. Experiences of racism were most often reported by East Asian and Black GBQM. These participants faced racism in public and online spaces, primarily in the form of verbal harassment. Several participants were also harassed because they wore face masks. Verbal abuse against GBQM of colour was largely prompted by racist discourses related to COVID-19. Conclusion: Racism remains a pernicious threat to the well-being of GBQM of colour. CRT highlights the importance of assessing how sexualized and gendered discourses about race shape the experiences of GBQM of colour navigating multiple epidemics like COVID-19 and HIV. These pervasive discourses unevenly affect racial and sexual minorities across multiple epidemics, and negatively impact health outcomes for these populations. [ABSTRACT FROM AUTHOR]

Purpose: Socially disadvantaged patients may lack self-efficacy to navigate a complex health system making them vulnerable to healthcare inequity. We aimed to develop an Index of social vulnerability that predicts increased risk of negative healthcare events (e.g. emergency hospitalization), independent of chronic disease burden. The analysis illustrates the conceptual and practical steps leading to the development of a pragmatic Index of social vulnerability to limited healthcare self-efficacy. Methods: Using data from a 3-year cohort of 2507 adult primary care patients in Québec (Canada), we applied two complementary structural equation modelling approaches—Partial Least Squares Path Modelling (PLS-PM) and Multiple indicators and Multiple Causes (MIMIC) modelling—to identify a minimal set of social characteristics that could be summed into an Index related to limited healthcare self-efficacy. We then used logistic regression to determine if the Index predicted: hospital emergency department use; hospital admissions; unmet need for care, and others. We privileged parsimony over explanatory capacity in our analytic decisions to make the Index pragmatic for epidemiologic and clinical use. Results: The Individual Social Vulnerability Index is the weighted sum of five indicators: two indicators of social support; educational achievement; financial status; limited language proficiency. The Index predicts increased likelihood of all negative healthcare outcomes except unmet need, with a clear threshold at Index ≥ 2. The effect is independent of chronic disease burden. Conclusion: When social deficits outweigh social assets by two or more (Index ≥ 2), there is an increased risk of negative healthcare events beyond the risk attributable to poor health. The Index is a pragmatic tool to identify a minority of patients who will require additional support to receive equitable healthcare. [ABSTRACT FROM AUTHOR]

Background: Perceived health status indicates people's overall perception of their health, including both physical and psychological dimensions. The aim of this study was to examine the determinants of self-perceived health for Canadians aged 40 and older using data from the Canadian Community Health Survey (2010). Methods: Multiple logistic regression models were employed to identify factors associated with self-perceived health in two age groups: Adults aged 65+ and Adults aged 40-64. Results: We found that higher income was significantly associated with better health status while chronic conditions and stress were associated with worse health status. In the 40-64 and 65+ age groups, individuals in the highest income bracket were 4.65 and 1.94 times, respectively, more likely to report better health than individuals in the lowest income bracket. The difference in the level of income associated health inequities between the two age groups point to the need for understanding the reasons behind lower inequities among seniors and how much the social protections provided by the Canadian government to seniors contribute to lowering inequities. Conclusions: Though Canada has a national public health insurance system providing coverage to all Canadians, health inequities associated with income persist providing further evidence of the importance of the social determinants of health. Examining the extent of these inequities and what factors influence them helps direct policy attention. In addition to documenting inequities, this paper discusses policy options for reducing the identified inequities. [ABSTRACT FROM AUTHOR]

Objective: This study examined the dental care utilization and self-preserved dental health of Asian immigrants relative to non-immigrants in Canada. Factors associated with oral health-related disparities between Asian immigrants and other Canadians were further examined. Methods: We analyzed 37,935 Canadian residents aged 12 years and older in the Canadian Community Health Survey 2012–2014 microdata file. Factors (e.g., demographics, socioeconomic status, lifestyles, dental insurance coverage, and year of immigration) associated with disparities in dental health (e.g., self-perceived teeth health, dental symptoms during past one month, and teeth removed due to decay in past one year) and service utilization (e.g., visiting dentist within the last three years, visiting dentist more than once per year) between Asian immigrants and other Canadians were examined using multi-variable logistic regression models. Results: The frequency of dental care utilization was significantly lower in Asian immigrants than their non-immigrant counterparts. Asian immigrants had lower self-perceived dental health, were less likely to be aware of recent dental symptoms, and more likely to report tooth extractions due to tooth decay. Low education (OR = 0.42), male gender(OR = 1.51), low household income(OR = 1.60), non-diabetes(OR = 1.87), no dental insurance(OR = 0.24), short immigration length (OR = 1.75) may discourage Asian immigrants from dental care utilization. Additionally, a perceived lack of necessity to dentist-visiting was a crucial factor accounting for the disparities in dental care uptake between Asian immigrants and non-immigrants. Conclusion: Asian immigrants showed lower dental care utilization and oral health than native-born Canadians. [ABSTRACT FROM AUTHOR]

Background: Perceived financial security impacts physical, mental, and social health and overall wellbeing at community and population levels. Public health action on this dynamic is even more critical now that the COVID-19 pandemic has exacerbated financial strain and reduced financial wellbeing. Yet, public health literature on this topic is limited. Initiatives targeting financial strain and financial wellbeing and their deterministic effects on equity in health and living conditions are missing. Our research-practice collaborative project addresses this gap in knowledge and intervention through an action-oriented public health framework for initiatives targeting financial strain and wellbeing. Methods: The Framework was developed using a multi-step methodology that involved review of theoretical and empirical evidence alongside input from a panel of experts from Australia and Canada. In an integrated knowledge translation approach, academics (n = 14) and a diverse group of experts from government and non-profit sectors (n = 22) were engaged throughout the project via workshops, one-on-one dialogues, and questionnaires. Results: The validated Framework provides organizations and governments with guidance for the design, implementation, and assessment of diverse financial wellbeing- and financial strain-related initiatives. It presents 17 priority actionable areas (i.e., entry points for action) likely to have long-lasting, positive effects on people's financial circumstances, contributing to improved financial wellbeing and health. The 17 entry points relate to five domains: Government (All Levels), Organizational & Political Culture, Socioeconomic & Political Context, Social & Cultural Circumstances, and Life Circumstances. Conclusions: The Framework reveals the intersectionality of root causes and consequences of financial strain and poor financial wellbeing, while also reinforcing the need for tailored actions to promote socioeconomic and health equity for all people. The dynamic, systemic interplay of the entry points illustrated in the Framework suggest opportunities for multi-sectoral, collaborative action across government and organizations towards systems change and the prevention of unintended negative impacts of initiatives. [ABSTRACT FROM AUTHOR]

Background: A key pillar of Canada's healthcare system is universal access, yet significant barriers to cancer services remain for people impacted by structural vulnerability (e.g., poverty, homelessness, racism). For this reason, cancer is diagnosed at a later stage, resulting in worse patient outcomes, a reduced quality of life, and at a higher cost to the healthcare system. Those who face significant barriers to access are under-represented in cancer control services Consequently, these inequities result in people dying from cancers that are highly treatable and preventable, however; little is known about their treatment and care course. The aim of this study was to explore barriers to accessing cancer treatment among people experiencing structural vulnerability within a Canadian context. Methods: We conducted a secondary analysis of ethnographic data informed by critical theoretical perspectives of equity and social justice. The original research draws from 30 months of repeated interviews (n = 147) and 300 h of observational fieldwork with people experiencing health and social inequities at the end-of-life, their support persons, and service providers. Results: Our analysis identified four themes presenting as 'modifiable' barriers to inequitable access to cancer treatment: (1) housing as a key determinant for cancer treatment (2) impact of lower health literacy (3) addressing social care needs is a pre-requisite for treatment (4) intersecting and compounding barriers reinforce exclusion from cancer care. These inter-related themes point to how people impacted by health and social inequities are at times 'dropped' out of the cancer system and therefore unable to access cancer treatment. Conclusion: Findings make visible the contextual and structural factors contributing to inequitable access to cancer treatment within a publically funded healthcare system. Identifying people who experience structural vulnerability, and approaches to delivering cancer services that are explicitly equity-oriented are urgently needed. [ABSTRACT FROM AUTHOR]

Biomedical advances in healthcare and antiretroviral treatment or therapy (ART) have transformed HIV/AIDS from a death sentence to a manageable chronic disease. Studies demonstrate that people living with HIV who adhere to antiretroviral therapy can achieve viral suppression or undetectability, which is fundamental for optimizing health outcomes, decreasing HIV-related mortality and morbidity, and preventing HIV transmission. African, Caribbean, and Black (ACB) communities in Canada remain structurally disadvantaged and bear a disproportionate burden of HIV despite biomedical advancements in HIV treatment and prevention. This institutional ethnography orients to the concept of 'structural violence' to illuminate how inequities shape the daily experiences of ACB people living with HIV across the HIV care cascade. We conducted textual analysis and in-depth interviews with ACB people living with HIV (n = 20) and health professionals including healthcare providers, social workers, frontline workers, and health policy actors (n = 15). Study findings produce a cumulative understanding that biomedical HIV discourses and practices ignore structural violence embedded in Canada's social fabric, including legislation, policies and institutional practices that produce inequities and shape the social world of Black communities. Findings show that inequities in structural and social determinants of health such as food insecurity, financial and housing instability, homelessness, precarious immigration status, stigma, racial discrimination, anti-Black racism, criminalization of HIV non-disclosure, health systems barriers and privacy concerns intersect to constrain engagement and retention in HIV healthcare and ART adherence, contributing to the uncertainty of achieving and maintaining undetectability and violating their right to health. Biomedical discourses and practices, and inequities reduce Black people to a stigmatized, pathologized, and impoverished detectable viral underclass. Black people perceived as nonadherent to ART and maintain detectable viral loads are considered "bad" patients while privileged individuals who achieve undetectability are considered "good" patients. An effective response to ending HIV/AIDS requires implementing policies and institutional practices that address inequities in structural and social determinants of health among ACB people. [ABSTRACT FROM AUTHOR]

Background: Despite a publicly-funded healthcare system, alarming cancer-related health and healthcare inequities persist in Canada. However, it remains unclear how equity is being understood and taken up within the Canadian cancer context. Our objective was to identify how health and healthcare equity are being discussed as goals or aims within the cancer care sector in Canada. Methods: A rapid scoping review was conducted; five biomedical databases, 30 multidisciplinary websites, and Google were searched. We included English-language documents published between 2008 and 2021 that discussed health or healthcare equity in the Canadian cancer context. Results: Of 3860 identified documents, 83 were included for full-text analysis. The prevalence of published and grey equity-oriented literature has increased over time (2008-2014 [n = 20]; 2015-2021 [n = 62]). Only 25% of documents (n = 21) included a definition of health equity. Concepts such as inequity, inequality and disparity were frequently used interchangeably, resulting in conceptual muddling. Only 43% of documents (n = 36) included an explicit health equity goal. Although a suite of actions were described across the cancer control continuum to address equity goals, most were framed as recommendations rather than direct interventions. Conclusion: Health and healthcare equity is a growing priority in the cancer care sector; however, conceptual clarity is needed to guide the development of robust equity goals, and the development of sustainable, measurable actions that redress inequities across the cancer control continuum. If we are to advance health and healthcare equity in the cancer care sector, a coordinated and integrated approach will be required to enact transformative and meaningful change. [ABSTRACT FROM AUTHOR]

Background: Disentangling the impacts of sex and gender in understanding male and female differences is increasingly recognised as an important aspect for advancing research and addressing knowledge gaps in the field of work-health. However, achieving this goal in secondary data analyses where direct measures of gender have not been collected is challenging. This study outlines the development of a gender index, focused on gender roles and institutionalised gender, using secondary survey data from the Canadian Labour Force survey. Using this index we then examined the distribution of gender index scores among men and women, and changes in gender roles among male and female labour force participants between 1997 and 2014. Methods: We created our Labour Force Gender Index (LFGI) using information in four areas: responsibility for caring for children; occupation segregation; hours of work; and level of education. LFGI scores ranged from 0 to 10, with higher scores indicating more feminine gender roles. We examined correlations between each component in our measure and our total LFGI score. Using multivariable linear regression we examined change in LFGI score for male and female labour force participants between 1997 and 2014. Results: Although women had higher LFGI scores, indicating greater feminine gender roles, men and women were represented across the range of LFGI scores in both 1997 and 2014. Correlations indicated no redundancy between measures used to calculate LFGI scores. Between 1997 and 2014 LFGI scores increased marginally for men and decreased marginally for women. However, LFGI scores among women were still more than 1.5 points higher on average than for men in 2014. Conclusions: We have described and applied a method to create a measure of gender roles using survey data, where no direct measure of gender (masculinity/femininity) was available. This measure showed good variation among both men and women, and was responsive to change over time. The article concludes by outlining an approach to use this measure to examine the relative contribution of gender and sex on differences in health status (or other outcomes) between men and women. [ABSTRACT FROM AUTHOR]

Health equity in pharmaceutical research is concerned with creating equal opportunities for men and women to partake in clinical trials. Equitable representation is imperative for determining the safety, effectiveness, and tolerance of drugs for all consumers. Historically, women have been excluded from participating in clinical research leading to a lack of knowledge regarding drug effects and their consequences. This paper examines the changes made since the implementation of Canadian policies on the representation of women in clinical trials, the analysis of sex and gender, as well as the discourses that are prominent among researchers. A feminist ethics framework is used to examine the structures that endeavor to elucidate women's involvement in trials, as experienced under extensive patriarchal history. Scholarly literature and Canadian government policy documents are used to explore the development of clinical trials as pertaining to sex and gender. Findings suggest that women continue to be underrepresented or excluded from important research, highlighting ongoing ethical and justice concerns. Improvement recommendations for policies are outlined. [ABSTRACT FROM AUTHOR]

Background: Multisectoral approaches to health are collaborations between stakeholders across multiple sectors, usually formed to address issues that affect health but go beyond the purview of one particular sector. The significance of multisectoral partnerships to attain health equity has been widely acknowledged. However, the extent which equity can be attained depends upon the perceptions of various stakeholders. We examine how multisectoral partnerships promoting healthy eating and active living conceptualized and employed an equity lens in their work. Method: This study is part of a larger pan-Canadian mixed-method research and knowledge sharing program entitled MUSE (Multisectoral Urban Systems for health and Equity in Canadian cities). Data collected from both quantitative and qualitative sources for two sites of the MUSE project-Saskatoon and Toronto were analyzed. In the qualitative part, 30 semi-structured key informant interviews were conducted with key stakeholders from six different multisectoral partnerships based in Saskatoon and Toronto. Data were analyzed in an inductive way. In the quantitative part, a survey with 37 representatives of stakeholder organizations was carried out. Simple descriptive statistics (means and percentages) were used to observe the distribution of data and to complement the qualitative analysis. Results: Equity was not a central component in program design although participants addressing equity, did so by discussing accessibility. How much consideration was given to equity varied as a function of the type of partnership. Most participants emphasized geographical accessibility but a few mentioned financial accessibility. Collaborative leadership style facilitated a participatory decision-making process, and thereby upholding equity in the partnership decision-making process. Communication, networking, and negotiation skills were found to be core competencies of a leader that contributed in upholding equity in partnership dynamics. The study also showed some challenges to embed equity in partnership works, such as the lack of comprehensive understanding of population health and its equity tenet. Conclusions: Findings indicate that multisectoral partnerships aimed at promoting healthy eating and physical activity experience several challenges to attain equity within the partnership as well as in the partnership-based works aimed at reducing health equity in populations. Factors identified can support decision makers commit to and work to attaining equity within their partnerships as well as in the partnership-based work in the community and beyond. [ABSTRACT FROM AUTHOR]

Background: With migration occurring over a series of centuries, dating back to the 1600's, the circumstance regarding Black people in Canada is a complex account. A plethora of social issues and the failure to adequately acknowledge and reconcile historical issues, has resulted in health inequity, disparities and knowledge gaps, related to the Black population in Canada. In nursing, historical records indicate a legacy of discrimination that continues to impact Black nurses. The profession has begun reckoning with anti-Black racism and the residual effects. This scoping review sought to chart the existing evidence on Black nurses in the nursing profession in Canada. Methods: JBI methodology was used to search peer-reviewed evidence and unpublished gray literature. Sources were considered for inclusion based on criteria outlined in an a priori protocol focusing on: 1) Canada 2) Black nurses and 3) nursing practice. No restrictions were placed on date of publication and language was limited to English and French. All screening and extractions were completed by two independent reviewers. Results: The database search yielded 688 records. After removing duplicates, 600 titles and abstracts were screened for eligibility and 127 advanced to full-text screening. Eighty-two full-text articles were excluded, for a total of 44 sources meeting the inclusion criteria. Seven sources were identified through gray literature search. Subsequently, 31 sources underwent data extraction. Of the 31 sources, 18 are research (n = 18), six are commentaries (n = 6); one report (n = 1) and six are classified as announcements, memoranda or policy statements (n = 6). The review findings are categorized into five conceptual categories: racism (n = 12); historical situatedness (n = 2); leadership and career progression (n = 7); immigration (n = 4); and diversity in the workforce (n = 4). Conclusions: This review reveals the interconnectedness of the five conceptual categories. Racism was a prominent issue woven throughout the majority of the sources. Additionally, this review captures how racism is exacerbated by intersectional factors such as gender, class and nationality. The findings herein offer insight regarding anti-Black racism and discrimination in nursing as well as suggestions for future research including the use of diverse methodologies in different jurisdictions across the country. Lastly, the implications extend to the nursing workforce in relation to enhancing diversity and addressing the ongoing nursing shortage. [ABSTRACT FROM AUTHOR]

Background: The health care sector has a significant role to play in fostering equity in the context of widening global social and health inequities. The purpose of this paper is to illustrate the process and impacts of implementing an organizational-level health equity intervention aimed at enhancing capacity to provide equity-oriented health care. Methods: The theoretically-informed and evidence-based intervention known as 'EQUIP' included educational components for staff, and the integration of three key dimensions of equity-oriented care: cultural safety, trauma- and violence-informed care, and tailoring to context. The intervention was implemented at four Canadian primary health care clinics committed to serving marginalized populations including people living in poverty, those facing homelessness, and people living with high levels of trauma, including Indigenous peoples, recent immigrants and refugees. A mixed methods design was used to examine the impacts of the intervention on the clinics' organizational processes and priorities, and on staff. Results: Engagement with the EQUIP intervention prompted increased awareness and confidence related to equity-oriented health care among staff. Importantly, the EQUIP intervention surfaced tensions that mirrored those in the wider community, including those related to racism, the impacts of violence and trauma, and substance use issues. Surfacing these tensions was disruptive but led to focused organizational strategies, for example: working to address structural and interpersonal racism; improving waiting room environments; and changing organizational policies and practices to support harm reduction. The impact of the intervention was enhanced by involving staff from all job categories, developing narratives about the socio-historical context of the communities and populations served, and feeding data back to the clinics about key health issues in the patient population (e.g., levels of depression, trauma symptoms, and chronic pain). However, in line with critiques of complex interventions, EQUIP may not have been maximally disruptive. Organizational characteristics (e.g., funding and leadership) and characteristics of intervention delivery (e.g., timeframe and who delivered the intervention components) shaped the process and impact. Conclusions: This analysis suggests that organizations should anticipate and plan for various types of disruptions, while maximizing opportunities for ownership of the intervention by those within the organization. Our findings further suggest that equity-oriented interventions be paced for intense delivery over a relatively short time frame, be evaluated, particularly with data that can be made available on an ongoing basis, and explicitly include a harm reduction lens. [ABSTRACT FROM AUTHOR]

Background: In response to the Kosovo crisis, Canada received 5,500 Albanian Kosovar refugees in 1999 as part of the emergency humanitarian evacuation and settlement effort. This study attempts to describe the experiences of service providers at the international, national, and local levels, involved in the organization and delivery of health and settlement services in Canada for the Kosovar refugees. Methods: A qualitative case study design using key informant interviews was used. Nominated sampling was used to identify 17 individuals involved in the organization and delivery of health and settlement. Key themes were identified and recommendations made to provide a framework for the development of policy to guide response to future humanitarian emergencies. Results: Six themes emerged: (1) A sense of being overwhelmed, (2) A multitude of health issues, (3) critical challenges in providing health care, (4) access to health and settlement services, (5) overall successes and (6) need for a coordinated approach to migration health. Conclusions: For those involved, the experience was overwhelming but rewarding. Interviewees' major concerns were the need for a more comprehensive and coordinated approach to the flow of medical information and handling of specific health problems. [ABSTRACT FROM AUTHOR]

Background: Difficulties accessing health care services can result in delaying in seeking and obtaining treatment. Although these difficulties are disproportionately experienced among vulnerable groups, we know very little about how the intersectionality of realities experienced by immigrants and visible minorities can impact their access to health care services since the pandemic. Methods: Using Statistics Canada's Crowdsourcing Data: Impacts of COVID-19 on Canadians—Experiences of Discrimination, we combine two variables (i.e., immigrant status and visible minority status) to create a new variable called visible minority immigrant status. This multiplicative approach is commonly used in intersectionality research, which allows us to explore disadvantages experienced by minorities with multiplicative identities. Results: Main results show that, compared to white native-born, visible minority immigrants are less likely to report difficulties accessing non-emergency surgical care (OR = 0.55, p < 0.001), non-emergency diagnostic test (OR = 0.74, p < 0.01), dental care (OR = 0.71, p < 0.001), mental health care (OR = 0.77, p < 0.05), and making an appointment for rehabilitative care (OR = 0.56, p < 0.001) but more likely to report difficulties accessing emergency services/urgent care (OR = 1.46, p < 0.05). Conclusion: We conclude that there is a dynamic interplay of factors operating at multiple levels to shape the impact of COVID-19 related needs to be addressed through changes in social policies, which can tackle unique struggles faced by visible minority immigrants. [ABSTRACT FROM AUTHOR]

Background: Diabetes is a chronic medical condition which demands that patients engage in self-management to achieve optimal glycemic control and avoid severe complications. Individuals who have diabetes and are experiencing homelessness are more likely to have chronic hyperglycemia and adverse outcomes. Our objective was to collaborate with individuals experiencing homelessness and care providers to understand the barriers they face in managing diabetes, as a first step in identifying solutions for enhancing diabetes management in this population. Methods: We recruited individuals with lived experience of homelessness and diabetes (i.e. clients; n = 32) from Toronto and health and social care providers working in the areas of diabetes and/or homelessness (i.e. providers; n = 96) from across Canada. We used concept mapping, a participatory research method, to engage participants in brainstorming barriers to diabetes management, which were subsequently categorized into clusters, using the Concept Systems Global MAX software, and rated based on their perceived impact on diabetes management. The ratings were standardized for each participant group, and the average cluster ratings for the clients and providers were compared using t-tests. Results: The brainstorming identified 43 unique barriers to diabetes management. The clients' map featured 9 clusters of barriers: Challenges to getting healthy food, Inadequate income, Navigating services, Not having a place of your own, Relationships with professionals, Diabetes education, Emotional wellbeing, Competing priorities, and Weather-related issues. The providers' map had 7 clusters: Access to healthy food, Dietary choices in the context of homelessness, Limited finances, Lack of stable, private housing, Navigating the health and social sectors, Emotional distress and competing priorities, and Mental health and addictions. The highest-rated clusters were Challenges to getting healthy food (clients) and Mental health and addictions (providers). Challenges to getting healthy food was rated significantly higher by clients (p = 0.01) and Competing priorities was rated significantly higher by providers (p = 0.03). Conclusions: Experiencing homelessness poses numerous barriers to managing diabetes, the greatest of which according to clients, is challenges to getting healthy food. This study showed that the way clients and providers perceive these barriers differs considerably, which highlights the importance of including clients' insights when assessing needs and designing effective solutions. [ABSTRACT FROM AUTHOR]

Understanding how to create structural change by actively counteracting racialized ways of interacting with Indigenous peoples at an individual and organizational level within health care systems and health professions education is essential for creating a more inclusive, equitable, and healthier society. In health professions education, the primary means of teaching about health inequities has been to frame them as stemming from culturally or ethnically based issues. While attention to culturally specific practices can be valuable to health and healing in some contexts, education that solely focuses on Indigenous cultures risks perpetuating cultural stereotypes and othering, rather than focusing on how Eurocentric systems continue to exert oppressive effects on Indigenous peoples. We present an organizational transformation framework grounded in equitable partnerships from a comprehensive critical review of the literature on the integration of equity and social justice in undergraduate health professions education with a focus on Indigenous health. We did a thematic analysis of the results and discussions presented in the 26 selected articles to identify promising practices and challenges associated with the integration of equity and social justice in undergraduate health professions education. The framework resulting from this analysis is composed of three interrelated components: 1) adopt critical pedagogical approaches that promote Indigenous epistemologies; 2) partner with Indigenous students, educators and communities; 3) engage educators in critical pedagogical approaches and health equity issues. This framework could guide the development of contextually tailored interventions that contribute to decolonizing health professions education. [ABSTRACT FROM AUTHOR]

Background: Effective treatment has extended the life expectancy and reduced disability in people living with HIV (PLWH). However, previous research has found 45–65% of working-age PLWH were unemployed compared to 5–10% in the general public of North America and Europe. We examined the barriers to gaining employment among PLWH. Methods: Thirty-five in-depth interviews were conducted in person or over the phone with PLWH living in Toronto or Ottawa. This included PLWH who were unemployed but actively seeking employment, as well as PLWH who had successfully gained employment through an agency that specifically supported PLWH funded by the AIDS Committee of Toronto. Interviews were conducted between February 2019 and March 2020. All interviews were audio-recorded, transcribed and analyzed using thematic analysis. Results: The majority of participants were between the ages of 40–55 and identified as male. Participants shared many common barriers when describing their attempts to attain or maintain employment. Although varying in employment status at the time of the study, consistent barriers included experiencing HIV stigma in workplaces, challenges overcoming mental health illnesses, and difficulties in navigating social assistance and unemployment insurance programs when pursuing a return to work. Conclusions: PLWH face significant barriers when attempting to engage with employment opportunities. Health providers and organizations can do more to support campaigns to end HIV stigma, to support individuals in pursuing employment, and to advocate for policy change that supports reentry into the workforce for PLHA. [ABSTRACT FROM AUTHOR]

Background: Respiratory health conditions appear to be more common among First Nations people versus non-First Nations people in Canada. However, the prevalence of chronic obstructive pulmonary disease (COPD) and its associated risk factors in First Nations communities are unknown. This project aims to estimate the prevalence of COPD in several First Nations communities in British Columbia, Canada and to characterize respiratory symptoms, COPD risk factors, and healthcare utilization. Methods: This project is approved by both the University of British Columbia and Carrier Sekani Family Services Research Ethics Boards. We will randomly sample 220 adults, 30 years and older, from 11 participating First Nations. Each participant will complete pre- and post-bronchodilator spirometry tests and the adapted American Thoracic Society Epidemiological Questionnaire with items about smoking history, respiratory symptoms, co-morbidities, and exposures, in order to identify the presence of COPD and its associated individual, occupational, and community risk factors. Homes will be assessed for air quality measures including particulate matter, carbon monoxide and carbon dioxide, and humidity. Health care utilization will be abstracted from the electronic medical record. Discussion: This is the first project in Canada to estimate the prevalence of COPD in First Nations communities using a random-sampling approach to recruitment. Additionally, although this study will collect detailed information on smoking history, we will also characterize past and current risk factors beyond cigarette smoking. Finally, our methodology ensures that the benefits to the communities are realized during the study period. Individual results will be shared with individuals and health providers to facilitate care. Air quality results will be sent to each Nation's governing council to facilitate remediation where necessary. Trial registration: The study has been retrospectively registered at clinicaltrials.gov (NCT04105088). [ABSTRACT FROM AUTHOR]

Background: Public policy approaches to funding paediatric medicines in developed public health systems remain understudied. Current approaches to HTA present a variety of conceptual, methodological and practical problems in the context of child health. This study explores the technical and sociopolitical determinants of public funding decisions on paediatric drugs, through the analysis of interviews with stakeholders involved in or impacted by HTA for child health technologies at the provincial and national levels in Canada. Methods: We undertook in-depth interviews with a purposive sample (n = 22) of stakeholders involved with or affected by drug funding decisions for children at the provincial (Ontario) and national levels in Canada. Grounded theory methods were employed to guide data collection and analysis. Theory on 'technology-as-policy' and the sociopolitics of health technologies served as sensitizing concepts for inductive data coding and analysis. Emergent themes informed the development of conceptual and practical insights on social values and system dynamics related to child HTA, of relevance to public policymaking on the coverage of health technologies for children in Canada. Results: Participant reflection on the normative and systems dimensions of drug funding for children formed two broad categories: HTA paradigms and sociopolitical context. Our analysis revealed notable differences of context and substance related to child health technology production, evaluation and use. These differences spanned the major phases of HTA (from assembly to assessment to integration) and the surrounding sociopolitical milieu (from markets to governance to politics). Careful analysis of these differences sets in relief a number of substantive and procedural shortcomings of current HTA paradigms in respect of child health. Our findings suggest a need to rethink how HTA is structured and operationalized for child health technologies. Conclusions: Current approaches to health technology assessment are not well calibrated to the realities of child health and illness. Our study presents a nuanced and contextually grounded analysis of concepts instrumental to drug funding decisions for children. The insights generated are directly applicable to the Canadian and Ontario contexts, but also yield fundamental knowledge about HTA for children that are germane to drug policy in other health systems. [ABSTRACT FROM AUTHOR]

Self-identified race/ethnicity is largely used to identify, monitor, and examine racial/ethnic inequalities. A growing body of work underscores the need to consider multiple dimensions of race – the social construction of race as a function of appearance, societal interactions, institutional dynamics, stereotypes, and social norms. One such multidimensional measure is socially-assigned race, the perception of one's race by others, that may serve as the basis for differential or unfair treatment and subsequently lead to deleterious health outcomes. We conducted a scoping review to systematically appraise the socially-assigned race and health literature. A systematic search of the PubMed, Web of Science, 28 EBSCO databases and 24 Proquest databases up to September 2019 was conducted and supplemented by a manual search of reference lists and grey literature. Quantitative and qualitative studies that examined socially-assigned race and health or health-related outcomes were considered for inclusion. Eighteen articles were included in the narrative synthesis. Self-rated health and mental health were among the most frequent outcomes studied. The majority of studies were conducted in the United States, with fewer studies conducted in New Zealand, Canada, and Latin America. While most studies demonstrate a positive association between social assignment as a disadvantaged racial or ethnic group and poorer health, some studies did not document an association. We describe key conceptual and methodological considerations that should be prioritized in future studies examining socially-assigned race and health. Socially-assigned race can provide additional insight into observed differential health outcomes among racial/ethnic groups in racialized societies based upon their lived experiences. Studies incorporating socially-assigned race warrants further investigation and may be leveraged to examine nuanced patterns of racial health advantage and disadvantage. [ABSTRACT FROM AUTHOR]

Background: Household food insecurity is a potent marker of material deprivation with adverse health consequences. Studies have repeatedly found a strong, independent relationship between owning a home and lower vulnerability to food insecurity in Canada and elsewhere, but the reasons for this relationship are poorly understood. We aimed to examine the influence of housing asset, housing debt and housing expenditure on the relationship between homeownership status and food insecurity in Canada. Methods: Cross-sectional data on food insecurity, housing tenure and expenditures, home value, income and sociodemographic characteristics were derived from the 2010 Survey of Household Spending, a population-based survey. Multivariable logistic regression models were conducted to estimate odds ratios of food insecurity among households of all incomes (n = 10,815) and those with lower incomes (n = 5547). Results: Food insecurity prevalence was highest among market renters (28.5%), followed by homeowners with a mortgage (11.6%) and mortgage-free homeowners (4.3%). Homeowners with a mortgage (OR: 0.51, 95% CI: 0.39–0.68) and those without a mortgage (OR: 0.23, 95% CI: 0.16–0.35) had substantially lower adjusted odds of food insecurity than market renters, and accounting for the burden of housing cost had minimal impact on the association. Mortgage-free homeowners had lower adjusted odds ratios of food insecurity compared to homeowners with a mortgage, but differences in the burden of housing cost fully accounted for the association. When stratifying homeowners based on presence of mortgage and housing asset level, the adjusted odds ratios of food insecurity for market renters were not significant when compared to mortgage holders with low housing asset. Mortgage-free owners with higher housing asset were least vulnerable to food insecurity (adjusted OR: 0.18, 95% CI: 0.11–0.27). Conclusions: Substantial disparities in food insecurity exist between households with different homeownership status and housing asset level. Housing policies that support homeownership while ensuring affordable mortgages may be important to mitigate food insecurity, but policy actions are required to address renters' high vulnerability to food insecurity. [ABSTRACT FROM AUTHOR]

Background: In 2008, a revised set of public health standards was released in the province of Ontario, Canada. The updated Ontario Public Health Standards (OPHS) introduced a new policy mandate that required local public health units (PHUs) to identify "priority populations" for public health programs and services. The aim of this study was to understand how this Priority Populations Mandate (PPM) facilitated or hindered action on health equity or the social determinants of health through PHUs in Ontario. Methods: This study used two sets of qualitative data that were part of a larger study. The first set of data was 16 semi-structured key informant interviews with policymakers involved in developing the OPHS and public health practitioners. The second set of data was the qualitative component of a role-based survey sent out to all the 36 PHUs in Ontario. Thematic content analysis was conducted to iteratively develop themes to answer the research question. Results: We identified six factors that both facilitated and hindered action on health equity and social determinants of health action in the province resulting from the OPHS and PPM. These six factors were grouped into three categories or themes: OPHS policy attributes (1. introducing new terminology, 2. allowing flexibility in implementation and 3. ensuring evidence-informed decision-making), health sector context into which the PPM was introduced (4. different understandings of health equity and 5. variability in existing partnerships) and implementation by PHUs (6. requirement to address the PPM). Conclusions: Although the revised OPHS and the PPM facilitated action on health equity and the social determinants of health, on the whole, this objective could have been better met. The mandate within the OPHS could have been strengthened with respect to promoting action on health equity and the social determinants of health through more clearly defined terminology, conveying a guiding health equity vision and uniting different PHU approaches to addressing health equity. [ABSTRACT FROM AUTHOR]

Background: Social marginalization and criminalization create health and safety risks for sex workers and reduce their access to health promotion and prevention services compared to the general population. Community empowerment-based interventions that prioritize the engagement of sex workers show promising results. Peer-to-peer interventions, wherein sex workers act as educators of their colleagues, managers, clients and romantic partners, foster community mobilization and critical consciousness among sex workers and equip them to exercise agency in their work and personal lives. Methods: A pilot peer health education program was developed and implemented, with and for sex workers in one urban centre in Canada. To explore how the training program contributed to community empowerment and transformative learning among participants, the authors conducted qualitative interviews, asked participants to keep personal journals and to fill out feedback forms after each session. Thematic analysis was conducted on these three data sources, with emerging themes identified, organized and presented in the findings. Results: Five themes emerged from the analysis. Our findings show that the pilot program led to reduced internalized stigma and increased self-esteem in participants. Participants' critical consciousness increased concerning issues of diversity in cultural background, sexual orientation, work experiences and gender identity. Participants gained knowledge about how sex work stigma is enacted and perpetuated. They also became increasingly comfortable challenging negative judgments from others, including frontline service providers. Participants were encouraged to actively shape the training program, which fostered positive relationships and solidarity among them, as well as with colleagues in their social network and with the local sex worker organization housing the program. Resources were also mobilized within the sex worker community through skills building and knowledge acquisition. Conclusion: The peer education program proved successful in enhancing sex workers' community empowerment in one urban setting by increasing their knowledge about health issues, sharing information about and building confidence in accessing services, and expanding capacity to disseminate this knowledge to others. This 'proof of concept' built the foundation for a long-term initiative in this setting and has promise for other jurisdictions wishing to adapt similar programs. [ABSTRACT FROM AUTHOR]

Background: Inequality between most Canadians and those from Inuit and First Nations communities, in terms of both access to oral health care services and related health outcomes, has been a long-standing problem. Efforts to close this equity gap led to the creation of dental therapy training programs. These programs were designed to produce graduates who would provide services in rural and northern communities. The closure of the last dental therapy program in late 2011 has ended the supply of dental therapists and governments do not appear to have any alternative solutions to the growing gap in access to oral health care services between most Canadians and those from Inuit and First Nations communities. Methods: A policy analysis of the rise and fall of the dental therapy profession in Canada was conducted using historical and policy documents. The analysis is framed within Kingdon's agenda-setting framework and considers why dental therapy was originally pursued as an option to ensure equitable access to oral health care for Inuit and First Nations communities and why this policy has now been abandoned with the closure of Canada's last dental therapy training school. Results: The closure of the last dental therapy program in Canada has the potential to further reduce access to dental care in some Inuit and First Nations communities. Overlaps between federal and provincial jurisdiction have contributed to the absence of a coordinated policy approach to address the equity gap in access to dental care which will exacerbate the inequalities in comparison to the general population. The analysis suggests that while a technically feasible policy solution is available there continues to be no politically acceptable solution and thus it remains unlikely that a window of opportunity for policy change will open any time soon. Conclusion: In the absence of federal government leadership, the most viable option forward may be incremental policy change. Provincial governments could expand the scope of practice for dental hygienists in the hope that it may support enhanced access, consumer choice, and efficiency in the delivery of oral health care to Inuit and First Nations communities in Canada. [ABSTRACT FROM AUTHOR]

Background: One of the main arguments made in favor of community water fluoridation is that it is equitable in its impact on dental caries (i.e., helps to offset inequities in dental caries). Although an equitable effect of fluoridation has been demonstrated in cross-sectional studies, it has not been studied in the context of cessation of community water fluoridation (CWF). The objective of this study was to compare the socio-economic patterns of children's dental caries (tooth decay) in Calgary, Canada, in 2009/10 when CWF was in place, and in 2013/14, after it had been discontinued. Methods: We analyzed data from population-based samples of schoolchildren (grade 2) in 2009/10 and 2013/14. Data on dental caries (decayed, missing, and filled primary and permanent teeth) were gathered via open mouth exams conducted in schools by registered dental hygienists. We examined the association between dental caries and 1) presence/absence of dental insurance and 2) small area index of material deprivation, using Poisson (zero-inflated) and logistic regression, for both time points separately. For small-area material deprivation at each time point, we also computed the concentration index of inequality for each outcome variable. Results: Statistically significant inequities by dental insurance status and by small area material deprivation were more apparent in 2013/14 than in 2009/10. Conclusions: Results are consistent with increasing inequities in dental caries following cessation of CWF. However, further research is needed to 1) confirm the effects in a study that includes a comparison community, and 2) explore possible alternative reasons for the findings, including changes in treatment and preventive programming.. [ABSTRACT FROM AUTHOR]

Introduction: Immigrants are among the most vulnerable population groups in North America; they face multidimensional hurdles to obtain proper healthcare. Such barriers result in increased risk of developing acute and chronic conditions. Subsequently a great deal of burden is placed on the healthcare system. Community navigator programs are designed to provide culturally sensitive guidance to vulnerable populations in order to overcome barriers to accessing healthcare. Navigators are healthcare workers who support patients to obtain appropriate healthcare. This scoping review systematically searches and summarizes the literature on community navigators to help immigrant and ethnic minority groups in Canada and the United States overcome barriers to healthcare. Methods: We systematically searched electronic databases for primary articles and grey literature. Study selection was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Articles were selected based on four criteria: (1) the study population was comprised of immigrants or ethnic minorities living in Canada or the United States ; (2) study outcomes were related to chronic disease management or primary care access; (3) the study reported effects of community navigator intervention; (4) the study was published in English. Relevant information from the articles was extracted and reported in the review. Result: Only one study was found in the literature that focused on navigators for immigrants in Canada. In contrast, 29 articles were found that reported navigator intervention programs for immigrant minorities in the United States. In these studies navigators trained and guided members of several ethnic communities for chronic disease prevention and management, to undertake cancer screening as well as accessing primary healthcare. The studies reported substantial improvement in the immigrant and ethnic minority health outcomes in the United States. The single Canadian study also reported positive outcome of navigators among immigrant women. Conclusion: Navigator interventions have not been fully explored in Canada, where as, there have been many studies in the United States and these demonstrated significant improvements in immigrant health outcomes. With many immigrants arriving in Canada each year, community navigators may provide a solution to reduce the existing healthcare barriers and support better health outcomes for new comers. [ABSTRACT FROM AUTHOR]

Introduction: Prior cross-national studies of socioeconomic inequalities in obesity have only compared summary indices of inequality but not specific, policy-relevant dimensions of inequality: (a) shape of the socioeconomic gradient in obesity, (b) magnitude of differentials in obesity across socioeconomic levels and, (c) level of obesity at any given socioeconomic level. We use unique data on two highly comparable societies - U.S. and Canada - to contrast each of these inequality dimensions. Methods: Data came from the 2002/2003 Joint Canada/U.S. Survey of Health. We calculated adjusted prevalence ratios (APRs) for obesity (compared to normal weight) by income quintile and education group separately for both nations and, between Canadians and Americans in the same income or education group. Results: In the U.S., every socioeconomic group except the college educated had significant excess prevalence of obesity. By contrast in Canada, only those with less than high school were worse off, suggesting that the shape of the socioeconomic gradient differs in the two countries. U.S. differentials between socioeconomic levels were also larger than in Canada (e.g., PR quintile 1 compared to quintile 5 was 1.82 in the U.S. [95 % CI: 1.52-2.19] but 1.45 in Canada [95 % CI: 1.10-1.91]). At the lower end of the socioeconomic gradient, obesity was more prevalent in the U.S. than in Canada. Conclusions: Our results suggest there is variation between U.S. and Canada in different dimensions of socioeconomic inequalities in obesity. Future research should examine a broader set of nations and test whether specific policies or environmental exposures can explain these differences. [ABSTRACT FROM AUTHOR]