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Many scholars assert that Indigenous peoples across the globe suffer a disproportionate burden of mental illness. Research indicates that colonialism and its associated processes are important determinants of Indigenous peoples’ health internationally. In Canada, despite an abundance of health research documenting inequalities in morbidity and mortality rates for Indigenous peoples, relatively little research has focused on mental health. This paper provides a critical scoping review of the literature related to Indigenous mental health in Canada. We searched eleven databases and two Indigenous health-focused journals for research related to mental health, Indigenous peoples, and Canada, for the years 2006–2016. Over two hundred papers are included in the review and coded according to research theme, population group, and geography. Results demonstrate that the literature is overwhelmingly concerned with issues related to colonialism in mental health services and the prevalence and causes of mental illness among Indigenous peoples in Canada, but with several significant gaps. Mental health research related to Indigenous peoples in Canada overemphasizes suicide and problematic substance use; a more critical use of the concepts of colonialism and historical trauma is advised; and several population groups are underrepresented in research, including Métis peoples and urban or off-reserve Indigenous peoples. The findings are useful in an international context by providing a starting point for discussions, dialogue, and further study regarding mental health research for Indigenous peoples around the world. [ABSTRACT FROM AUTHOR]

People who use illegal drugs experience routine surveillance, including in healthcare and harm reduction settings. The MySafe Project - a safer supply pilot project that dispenses prescription opioids via a biometric vending machine - exists in the Canadian province of British Columbia. The machine scans a participant's palmprint and has a built-in camera that records every machine interaction. The aim of this paper is to understand participants' experiences of surveillance, privacy, and personal security when accessing this novel program. An integrative case study and grounded theory methodology was employed. Qualitative one-to-one interviews were conducted with 46 MySafe participants across three different program sites in Vancouver. We used a team-based approach to code interview transcripts and utilized directed and conventional content analyses for deductive and inductive analyses. While participants described negative experiences of surveillance in other public and harm reduction settings, they did not have concerns regarding cameras, collection of personal information, tracking, nor staff issues associated with MySafe. Similarly, while some participants had privacy concerns in other settings, very few privacy and confidentiality concerns were expressed regarding accessing the machine in front of others. Lastly, while some participants reported being targeted by others when accessing the machines, most participants described how cameras, staff, and machine locations helped ensure a sense of safety. Despite negative experiences of surveillance and privacy issues elsewhere, participants largely lacked concern regarding the MySafe program and machines. The machine-human interaction was characterized as different than some human-human interactions as the machine is completing tasks in a manner that is acceptable and comfortable to participants, leading to a social preference toward the machines in comparison to other surveilled means of accessing medications. These findings provide an opportunity to rethink how we conceptualize surveillance, medication access, and harm reduction programs targeting people who use drugs. • Studies demonstrate the negative effects of surveillance on people who use drugs in many healthcare settings. • Acquiring prescription opioids daily from a clinician is known to be stigmatizing. • Providing prescription opioids via biometric machines elicits a positive response despite surveillance mechanisms. • Counternarratives challenge assumptions about surveillance of people who use drugs. • Interacting with machines rather than humans may lead to more positive outcomes. [ABSTRACT FROM AUTHOR]

Census-based deprivation indices have been widely used in Aotearoa/New Zealand, Canada and UK to measure area-based socio-economic inequalities. This paper examines the indicators used in census-based area deprivation indices using a political ecology approach. We question whether the current indicators of deprivation derived from census data are meaningful for the all age groups and minority groups in the population, with a particular focus on deprivation indicators used in New Zealand, Canada and the United Kingdom. We comparatively reviewed methodological papers and reports that describe the indicators of deprivation in Aotearoa/New Zealand, Canada and the UK from 1975 to 2014. We consider the relationship between the notion of standards of living and measurements of deprivation and explore how hegemonic cultural constructs are implicit in measures of deprivation that privilege a Eurocentric, ageist and gender normative construction of statistics. We argue for more political ecological analyses to studying the relationship between social inequalities, geographies, health inequities and political economy to transform structures of oppression and inequality. This requires turning the analytical gaze on the wealthy and privileged instead of defaulting into deficit models to account for inequality. Studies of deprivation and inequality would benefit from understanding the processes and operations of power in the (re)production of socio-economic and health inequities to inform holistic strategies for social justice. [ABSTRACT FROM AUTHOR]

The use of visual methods is becoming increasingly common and accepted in health research. This paper explores the opportunities and constraints of using photo-based methods in the context of a community-based participatory research study on how to engage people living with HIV in conversations about a hospital's recently introduced harm reduction policy. Using a blended approach of photovoice and photo-elicited interviews, we provided participants (n = 16) with cameras and asked them to take a series of photos that “show how you feel about or have experienced harm reduction as a Casey House client.” We reflect on methodological insights from the study to think through the process of doing photo-based work on a stigmatized topic in a small hospital setting by foregrounding: 1) how the act of taking photos assisted participants in visualizing connections between space, harm reduction, and substance use; 2) expectations of participation and navigating daily health realities; and 3) issues of confidentiality, anonymity and stigma in clinical settings. These reflections provide a case study on the importance of critically examining the process of engaging with photo-based methods. We conclude the paper by re-thinking issues of context and photo-based methods. Rather than viewing context as a neutral backdrop to apply a method, context should be viewed as an active force in shaping what can or cannot be done or produced within the space. Photo-based methods may offer an effective community-engagement strategy but may require modification for use in a clinical setting when working on a stigmatized topic with individuals with complex health care needs. Given the potential of visual methods as a community engagement strategy, research teams are advised to understand the entire process as a data collection opportunity so that these methods can be further explored in a variety of contexts. [ABSTRACT FROM AUTHOR]

Infant mortality is a metric influenced by societal, political and medical advances. The way vital events are collected and reported are not always uniform. A lack of uniformity has disadvantaged some groups in society. In Canada, a multi-jurisdictional vital statistics system has truncated our ability to produce infant mortality rates for the Indigenous population. To understand how this evolved, this paper outlines the history of infant mortality, generally and internationally, and then documents the efforts to harmonize the collection and reporting of vital statistics (births and deaths) in Canada. Following this analysis is a historical review of vital event reporting for Canada's Indigenous population. A major finding of this paper is that racism, reframing, and jurisdictional posturing has limited our ability to accurately estimate live births and infant deaths for the Indigenous population. To improve Indigenous infant mortality estimation, Canada's governments need to transcend multijurisdictional challenges and fulfill international reporting obligations to Indigenous communities. [ABSTRACT FROM AUTHOR]

Abstract: The paper addresses a critically important area in Canadian immigration and health from both a social and a spatial perspective. It employs multilevel and contextual approaches to examine the social determinants of immigrant health as well as the place effects on self-reported health at a regional and neighborhood scale. The data come from the raw microdata file of the 2005–10 Canadian Community Health Survey (a random national health survey) and the publicly available Canadian Marginalization index based on the 2006 Census. Three populations are compared: Canadian-born, overall foreign-born, and Chinese immigrants. The results suggest various degrees of association between self-reported health, individual and lifestyle behavioral characteristics, and neighborhood material deprivation and ethnic concentration in census tracts. These factors contribute differently to the reported health of Chinese immigrants, Canada's largest recent immigrant group. A healthy immigrant effect is partially evident in the overall foreign-born population, but appears to be relatively weak in Chinese immigrants. For all groups, neighborhood deprivation moderately increases the likelihood of reporting poor health. Ethnic concentration negatively affects self-rated health, with the exception of the slight protective effect of Chinese-specific ethnic density in census tracts. The multilevel models reveal significant area inequalities across Census Metropolitan Areas/Census Agglomerations in risk of reporting unhealthy status, with greater magnitude in the foreign-born population. The vast regional variations in health among Chinese immigrants should be interpreted carefully due to the group's heavy concentration in large cities. The study contributes to the literature on ethnicity and health by systematically incorporating neighborhood contextual effects in modeling the social determinants of immigrant health status. It fills a gap in the literature on neighborhoods and health by focusing on ethnically disparate groups rather than on the general population. By revealing regional disparities in health, the paper adds a spatial perspective to the work on immigrant health. [Copyright &y& Elsevier]

Abstract: One of the core primary care reform initiatives seen across provinces in Canada is the introduction of inter-professional primary healthcare teams in which family physicians are encouraged to collaborate with other health professionals. Although a higher proportion of physicians are collaborating with various health professionals now compared to the previous decade, a substantial number of physicians still do not work in a collaborative setting. The objective of this paper is to examine the age, period and cohort effects of Canadian family physicians’ decisions to collaborate with seven types of health professionals: specialists, nurse practitioners, nurses, dieticians, physiotherapists, psychologists and occupational therapists. To this end, this paper employs a multivariate probit model consisting of seven equations and a cross-classified fixed-effects strategy to explain the collaborative decisions of family physicians. Utilizing three cross-sectional physician surveys from Canada over the 2001–2007 period, cohorts are defined over five-year intervals according to their year of graduation from medical school. We find that newer cohorts of physicians are more likely to collaborate with dieticians, physiotherapists, psychologists and occupational therapists; newer female cohorts are more likely to collaborate with nurses while newer male cohorts are less likely to collaborate with nurses but more likely to collaborate with specialists. Older physicians are more likely to collaborate with specialists, physiotherapists, psychologists, and occupational therapists; the age effect for nurses is U-shaped for male physicians while it is inverse U-shaped for females. Family physicians are collaborating more with all seven health professionals in 2004 and 2007 compared to 2001. Belonging to a group practice has a largely positive influence on collaborations; and being paid by a fee-for-service remuneration scheme exerts a negative influence on collaboration, ceteris paribus. The findings suggest that combining a non-fee-for-service remuneration arrangement with a group practice structure would facilitate effective collaboration. [Copyright &y& Elsevier]

Abstract Local public health authorities often lack the capacity to adapt to climate change, despite being on the 'front lines' of climate impacts. Upper-level governments are well positioned to create an enabling environment for adaptation and build local public health authorities' capacity, yet adaptation literature has not specified how upper-level governments can build local-level adaptive capacity. In this paper we examine how federal and regional governments can contribute to enabling and supporting public health adaptation to climate change at the local level in federal systems. We outline the local level's self-assessed adaptive capacity for public health adaptation in Canadian and German comparative case studies, in terms of funding, knowledge and skills, organizations, and prioritization, drawing upon 30 semi-structured interviews. Based on interviewees' recommendations and complemented by scientific literature, we develop a set of practical measures that could enable or support local-level public health adaptation. We find that adaptive capacity varies widely between local public health authorities, but most report having insufficient funding and staff for adaptation activities. We propose 10 specific measures upper-level governments can take to build local public health authorities' capacity for adaptation, under the interrelated target areas of: building financial capital; developing and disseminating usable knowledge; collaborating and coordinating for shared knowledge; and claiming leadership. Federal and regional governments have an important role to play in enabling local-level public health adaptation, and have many instruments available to them to fulfill that role. Selecting and implementing measures to enable local public health authorities' adaptive capacity will require tailoring to, and consideration, of the local context and needs. Highlights • Local public health authorities often lack capacity to adapt to climate change. • National and regional governments can play supportive or enabling role. • We propose 10 concrete measures to enable local public health adaptation. [ABSTRACT FROM AUTHOR]

Abstract: ‘Deliberative democracy’ is increasingly popular globally, as a means of securing public engagement with emerging health technologies and democratizing their governance. Architects of deliberative ‘mini-publics’ have tended, however, to privilege consensus within deliberation and the generation of ‘action commitments’ within a ‘decisional context’, despite widespread critique. Less attention has been paid to the phenomenon of persistent disagreement within constructed deliberative fora. This paper addresses this lacuna, performing a narrative analysis of four days of deliberation within one small group of demographically diverse public participants at the BC Biobank Deliberation (Vancouver, Canada, 2007). It reveals the value of listening to persistent deliberative disagreements. First, this paper argues that disagreements enable identification of deliberation and evaluation of its quality. Second, they generate insight into the deliberative process and the discursive means through which consensus can be achieved. Third, persistent deliberative disagreements can be creative of innovative governance solutions. In the case of the BC Biobank Deliberation, disagreements about compensation for biobank donors generated a range of suggestions for mediating between donor rights, corporate interests and societal needs – from tissue sample rentals to donor tax credits – suggestions that are unique to the existing academic and policy literature. Finally, this paper argues that practitioners should present persistent disagreements to public and policy audiences as an ‘output’ of deliberative democracy events. [Copyright &y& Elsevier]

Abstract: This paper reports on a qualitative study examining everyday practices of healthy living (HL). Forty-four semi-structured interviews were undertaken with Canadian and UK citizens, aged 45 – 70, in April–May 2010. The research sits within the now substantial literature concerned with how health information is mediated, both by people and technologies, and employed in the context of ‘good’ health citizenship. Throughout this work, notions of ‘choice’ and ‘empowerment’ have been interrogated, theoretically and empirically, to reveal both the knowledge/power relationships integral to ‘informing’ processes and the shifting relationship between information and care in contemporary health encounters. In this paper, we analyse how people make sense of what it means to live healthily and how they know if they are doing so by focussing on three ways in which study participants become informed about healthy living: through their engagement with universal HL messages, through their own information searches, and through their attempts to measure their ‘healthiness’. Following critique of the “logic of choice” in contemporary healthcare, we understand healthy living as a “situation of choice” where complex problems are framed as simple matters of choice and where information and technologies are understood as neutral aids to decision-making in support of ‘correct’ choices. Our analysis builds on and extends Mol’s work by exploring how participants negotiate between this “logic of choice” and her alternative “logic of care” in their accounts of everyday HL informing practices and how the two logics “interfere” with one another. These accounts show resistance to the logic of choice through ‘calls for care’ but they also show clearly how the disciplining logic of choice works to (re)present such calls for care as failed attempts at healthy living, undermining the very practices the logic of choice seeks to encourage. [Copyright &y& Elsevier]

Abstract: Social expectations surrounding sickness have undergone a transformation in Western welfare states. Emerging discourses about patients’ roles and responsibilities do not however always map neatly onto patients’ actions, experiences or desires. This paper emerges from a study in Ontario, Canada. Drawing on in-depth interviews with 5 women diagnosed with breast cancer we explore the activity and effort prompted for patients by the routine professional practice of outlining treatment options and encouraging patients to choose between them. We highlight research participants’ complex responses to their responsibility for treatment decisions: their accepting, deflecting and reframing and their active negotiation of responsibility with professionals. The literature on treatment decision making typically characterizes people who resist taking an active role as overwhelmed, misinformed about the nature of treatment decisions, or more generally lacking capacity to participate. In this paper we suggest that patients’ expressions of ambivalence about making treatment choices can be understood otherwise: as efforts to recast the identities and positions they and their physicians are assigned in the organization of cancer care. We also begin to map key features of this organization, particularly discourses of patient empowerment, and evidence-based medicine. [ABSTRACT FROM AUTHOR]

Abstract: In this paper we present a dialogue about the seemingly innocuous presence of environmental art in hospital settings as a way of furthering critical perspectives on the therapeutic landscapes concept and its application to medical spaces. We explicitly consider the potential utility of two perspectives, Foucaultian and Lacanian readings, for understanding the relationship between environmental art and the hospital waiting room. We use this paper as a vehicle to demonstrate how such theoretical perspectives can enhance critical scholarship on the therapeutic landscape concept, particularly as it is applied to settings such as health clinics and hospitals. A brief agenda for further critical engagements with the therapeutic nature of health care spaces is put forth in the conclusion. [Copyright &y& Elsevier]

This paper seeks to examine how immigrants in a multicultural society access and utilize culturally- and linguistically-diverse family physicians. It focuses on Mainland Chinese (MLC) immigrants – the most important source of immigrants to Canada since 1996 – in the Toronto Census Metropolitan Area (CMA), Canada. Specifically, the paper aims to explore the choice between Chinese-speaking and non-Chinese-speaking family physicians by MLC immigrants and to determine the underlying reasons for MLC immigrants use of ethnically- and linguistically-matched family physicians. A wide range of data are analyzed including survey and focus group data, physician data from the College of Physicians and Surgeons of Ontario (CPSO) and geo-referenced 2001 Canadian Census data. A mixed-method approach is employed combining quantitative analysis of survey data and Census data, spatial analysis of patient travel behaviour based on the survey and qualitative analysis based on focus groups. The paper reveals an overwhelming preference among MLC survey respondents for Chinese-speaking family physicians regardless of study areas and socioeconomic and demographic status. The focus groups suggest that language, culture and ethnicity are intertwined in a complex way to influence the choice of health care providers and health management strategies in the host society. The paper yields important policy implications for identifying health professional shortage areas for culturally-diverse populations, addressing issues related to foreign-trained physicians and enhancing primary care delivery relevant for immigrant populations. [Copyright &y& Elsevier]

This paper offers an expository discussion of an approach to qualitative health research we call immanent critique. The central analytic move of immanent critique, as we have practiced it, is to explore how claims that are internal to authoritative discourse are experienced by those who have been excluded from their formulation. This paper contributes to the discussion of the politics of qualitative research methods in an age of evidence. We do so by responding to a recent call to move beyond the micro-politics of the qualitative research encounter to consider the overall political effects of qualitative research. We argue that the political effects of research are partly enabled by mundane practices internal to the research process. We explore how this is so by considering one formulation of immanent critique—a qualitative study of the introduction of continuous quality improvement in Ontario hospitals. We emphasize how practices internal to our research—trade union collaboration, our orientation to authoritative claims, and procedures for generating and representing health care workers'' experiences—helped shape the political effects of our research. The latter include challenges to managerial claims about neo-liberal health reform and broadening the evidentiary terrain upon which interlocutors can participate in public debate about health care restructuring. [Copyright &y& Elsevier]

Abstract: The professional claims and struggles involved in the design of non-traditional health care places are rarely problematized in applied health research, perhaps because they tend to fade away once the new design is implemented. This paper offers insights into such professional tensions and their impact on health care delivery by examining the design of two dialysis service delivery models in Quebec, Canada. The satellite units were hosted in two small hospitals and staffed by recently trained nurses. The mobile unit was a bus fitted to accommodate five dialysis stations. It was staffed by experienced nurses and travelled back and forth between a university teaching hospital and two sites. In both projects, nephrologists supervised from a distance via a videoconferencing system. In this paper, we draw mainly from interviews with managers (mostly nurses) and physicians (n=18), and from on-site observations. Nephrologists, medical internists, and managers all supported the goal of providing “closer-to-patient” services. However, they held varying opinions on how to best materialize this goal. By comparing two models involving different clinical and spatial logics, we underscore the ways in which the design of non-traditional health care places opens up space for the re-negotiation of clinical norms. Instead of relatively straightforward conflicts between professions, we observed subtle but inexorable tensions within and beyond professional groups, who sought to measure up to “ideal standards” while acknowledging the contingencies of health care places. [Copyright &y& Elsevier]

Abstract: Mass media are very influential in shaping discourses about health but few studies have examined the extent to which newspaper coverage of such stories reflect issues embedded in health policy documents. We estimate the relative distribution of health stories using content analysis. Nine meta-topics are used to sort stories across a range of major influences shaping the health status of populations adapted from the document Toward a Healthy Future (Second Report on the Health of Canadians (1999)) (TAHF). A total of 4732 stories were analyzed from 13 Canadian daily newspapers (10 English, 3 French language) using a constructed week per quarter method. Stories were sampled from each chosen newspaper for the years 1993, 1995, 1997 and 2001. 72% (n=3405) of stories in this analysis were from English-language papers, 28% (n=1327) were from French-language papers. Topics related to health care (dealing either with issues of service provision and delivery or management and regulation) dominated newspaper stories, accounting for 65% of all stories. Physical environment topics accounted for about 13% of all stories, the socio-economic environment about 6% of stories, personal health practices about 5% of stories, and scientific advances in health research about 4% of stories. Other influences upon health identified in TAHF were rarely mentioned. The overall prominence of topics in newspapers is not consistent with the relative importance assigned to health influences in TAHF. Canadian newspapers rarely report on socio-economic influences frequently cited in the research literature (and reflected in TAHF) as being most influential in shaping population health outcomes. [Copyright &y& Elsevier]

Abstract: Changes in public policy have led to increasing numbers of children with disabilities and complex medical needs being cared for in the homes of Canadians. Little work, however, has explored the ethical implications of these policies. This paper focuses on some of the shortcomings of current policy and describes a developing method for policy analysis with an explicit focus on ethics that could be adopted in other nations. Three forms of analyses—descriptive, conceptual and normative—conducted on Canadian homecare policy documents describe various dimensions of Canadian homecare policy. The descriptive analysis demonstrated that the jurisdiction of homecare services is dispersed across numerous programs and ministries with no single structure for policy implementation and accountability. The needs of children and youth are rarely mentioned in home healthcare policies, but instead are addressed under broader social policies that are focused upon children and family. The conceptual analysis revealed four over-arching themes that represent the predominant elements of a value-structure that underlie homecare policy. They include: (1) home and community care as ideal; (2) the importance of independence and self-care of citizens; (3) family as primary care provider; and (4) citizenship as entitlement to rights and justice. Overall, these themes tend to reflect a neoliberal ideology that shifts the responsibility of care from the state to the individual and his/her family. A normative framework based on critical healthcare ethics is used in the paper to make recommendations to redress the current imbalance between state and family support. For example, including homecare services within the Canada Health Act (CHA) or the development of separate legislation consistent with the principles of the CHA would make it possible to ensure that the principles of universality, accessibility, portability and public administration, as opposed to principles that reinforce competitive individualism, direct the provision of homecare services in Canada. [Copyright &y& Elsevier]

Abstract: This paper addresses three questions: What is the extent of clinical guideline utilization by decision-makers in provincial health ministries, regional health authorities and hospitals in Canada? Are there differences between these work settings in regard to the extent of clinical guideline utilization? What are the determinants of clinical guidelines utilization in health ministries, regional health authorities and hospitals? Based on a survey of 899 decision-makers from Canadian provincial health ministries, regional health authorities and hospitals, the results indicate that there are large differences between work settings in regard to clinical guideline utilization. Not surprisingly, work settings like hospitals rely more intensively on clinical guidelines than the other work settings (health ministries or agencies and regional health authorities). The results of the regression models indicate that cognitive factors, social factors, technological factors, organizational factors and individual attributes significantly predict the utilization of clinical practice guidelines by decision-makers. However, the results of the regression models also indicate that some factors that predict clinical guideline utilization by decision-makers in hospitals do not predict clinical guidelines utilization by decision-makers working in ministries or in regional health authorities. Therefore, these results suggest that customized interventions would be appropriate in order to efficiently increase the utilization of clinical practice guidelines in different work settings. The paper concludes with suggestions for future research. [Copyright &y& Elsevier]

Industry and medicine share a complicated relationship that engenders a considerable degree of controversy. Although they share a relationship, industry and medicine have different perspectives toward their involvement with each other. Industry conceives of medicine as one aspect of the "drug pipeline", a larger set of relationships that is necessary for producing and marketing products. In contrast, select physicians refer to medicine's relationship with industry as "dancing with the porcupine", an inherently difficult and dangerous activity. This paper compares the "pipeline" and "porcupine" metaphors, and draws upon ethnographic data from fieldwork conducted among clinical neuroscientists at a Canadian medical school to further elucidate the perspectives of physicians toward industry and the nature of the physician-industry relationship. The paper argues that the physician-industry relationship is akin to a type of gift-exchange known as a total prestation, and that this form of total prestation is part of a strategy of capital reconversion. [ABSTRACT FROM AUTHOR]

This paper is concerned with events that were the subject of an inquest (The report of the Manitoba pediatric cardiac surgery inquest: an inquiry into twelve deaths at the Winnipeg Health Sciences Centre in 1994, Provincial Court of Manitoba, Winnipeg) into the deaths of 12 children who died while undergoing or shortly after having undergone cardiac surgery at the Winnipeg Health Sciences Centre, Man., Canada, during 1994. A notable finding of this inquest was that nurses involved with the pediatric cardiac surgery program were concerned about the competence of the surgeon and made sustained efforts throughout 1994 to have these concerns addressed. That the nurses’ concerns were not taken seriously is the central problem of this paper. The work of Foucault is used to set out a ground for thinking about this problem. In this case, knowledge practices, specifically those concerning who can claim status as a credible knower, produced limits for nurses. Such limits are neither good nor bad in themselves, but rather have effects with which we must be concerned. In this case, the limits produced by certain knowledge practices had the effect of rendering the nurses’ concerns irrelevant and this is significant in itself and also because it was an important part of how patient care was allowed to be compromised. [Copyright &y& Elsevier]

This paper combines multiple cross-sections of data drawn from the National Population Health Survey and Canadian Community Health Survey to confirm the existence of the ‘healthy immigrant effect’, specifically that immigrants are in relatively better health on arrival in Canada compared to native-born Canadians, and that immigrant health converges with years in Canada to native-born levels. The paper finds robust evidence that the healthy immigrant effect is present for the incidence of chronic conditions for both men and women, and results in relatively slow convergence to native-born levels. There is only weak evidence in terms of self-assessed health status. The inclusion of controls for region of origin and year of arrival does not account for the observed effects, although region of origin is an important determinants of immigrant health. The paper then considers some alternative explanations for the observed differences, and support is found for the idea that the healthy immigrant effect reflects convergence in physical health rather than convergence in screening and detection of existing health problems. [Copyright &y& Elsevier]

This paper compares the portrayal of breast, testicular and prostate cancer in mass print English language magazines in the United States and Canada from 1996 to 2001. It is a follow-up of three papers that examined each of these three diseases separately in high circulating magazines up to 1995. It includes both quantitative and qualitative analyses of magazine stories and notes the continuing dominance of a medical perspective regarding disease as well as the association of each type of cancer examined with stereotypically individualized yet feminine and masculine characteristics and pursuits. It notes the conflation of breast cancer, since the discovery of BRCA1 and BRCA2, with the family. To be a ‘feminine’ woman is to be vulnerable to breast cancer and to be a ‘masculine’ man is to be vulnerable to testicular cancer when young and prostate cancer when older. The association of disease not just with personhood but also with the specifics of stereotyped masculinity and femininity may construct a more intimate, more personal link between disease and identity. This close attachment of gender and disease may shore up and exacerbate a fear reaction. It may also serve to diminish the awareness of other, more prevalent, causes of death for men and women. The social control consequences of potentially exacerbated disease-specific fear are discussed. [Copyright &y& Elsevier]

This paper addresses the effects of chronic poverty on people with serious mental illness. More specifically, we are concerned with the extent to which welfare restructuring, by deepening the poverty facing people with serious mental illness, undermines the expressed intent of mental health policy to improve the quality of life (QOL) of this population. The province of Ontario in Canada forms the setting for the study. The paper first examines recent trends in mental health care and social assistance policy in Ontario. While income support is consistently recognized as a core element of mental health care, welfare restructuring has led to a significant decline in the real value of income supports received by people with serious mental illness. The paper then examines the implications of this trend for the QOL of residential care facility tenants in Hamilton, Ontario. Here, the case study is explicitly connected to QOL scholarship. In addition, the study is grounded in an analysis of the broader transformation of the welfare state in Ontario. Interview data suggest that tenants experience chronic poverty that has a deleterious impact on multiple life domains including basic needs, family, social relations, leisure and self-esteem. Implications for research and policy are discussed. [Copyright &y& Elsevier]

Difficult health care encounters often do not translate into expressions of dissatisfaction with care. This paper focuses on the ‘non-expression’ of dissatisfaction with care in the accounts of 12 people in Canada who provided care to a relative or friend who died of breast cancer.The analysis foregrounded in this paper began from the observation that as difficult health care experiences were elaborated, speakers located health professionals’ actions in relation to various situational factors, including the fact of a (cancer) death and conditions of constraint in the health system. Set alongside these two realities, expressions of dissatisfaction tended to be disarmed. Results of this study suggest that the cost of articulating dissatisfaction with care is high where the cared-for person has died, and the perceived value of focusing on difficult experiences is low. Further, respondents in this study took the specificity of the situation and the setting into account in formulating beliefs about the care outcomes for which health professionals could be held responsible. When conditions in the health system and the disease process of advanced cancer were positioned in talk as ‘ultimate limits’ on health professionals’ actions, perceived lapses in care were excused. [Copyright &y& Elsevier]

The paper examines levels and determinants of trust in a health care system and in key actors in the health policy community. Talcott Parsons theorizes that the sharing of common values is a necessary condition for interpersonal trust to exist; this paper tests that notion at the level of systemic (institutional) trust. The paper reports findings of a 1999 survey of 493 randomly selected residents of Calgary, Alberta, Canada. It uses multiple regression analysis to identify the determinants of three different types of trust—generalized systemic trust, fiduciary trust, and generalized trust in particular actors’ input to health system changes. Among the numerous independent variables, special attention is devoted to the degree of congruence or incongruence between the importance which respondents attach to one of the values enunciated in the Canada Health Act—namely, ‘accessibility’ (equal access to quality health care)—and the importance which respondents believe is attached to that value by the Regional Health Authority and by the Premier of the province. Both value importance and value congruence on equal accessibility are found to be important factors explaining variation in all three types of trust. In explaining levels of trust in the Premier on the issue of health care system reform, congruence on equal accessibility proved to be even more important than such factors as political partisanship, political cynicism, and personal experience as a patient in the health care system. Findings also suggest that there is an emotional component to systemic trust. [Copyright &y& Elsevier]

Healthcare professionals use the genre of case presentation to communicate among themselves the salient patient information during treatment and management. In case presentation, many uncertainties surface, regarding, e.g., the reliability of patient reports, the sensitivity of laboratory tests, and the boundaries of scientific knowledge. The management and portrayal of uncertainty is a critical aspect of professional discourse. This paper documents the rhetorical features of certainty and uncertainty in novice case presentations, considering their pragmatic and problematic implications for students’ professional socialization.This study was conducted during the third-year inpatient clerkship at a tertiary care, pediatric hospital in hospital in Canada. Data collection included: (1) non-participant observations of 19 student case presentations involving 11 student and 10 faculty participants, and (2) individual interviews with 11 students and 10 faculty participants. A grounded theory approach informed data collection and analysis.Five thematic categories emerged, two of which this paper considers in detail: “Thinking as a Student” and “Thinking as a Doctor”. Within these categories, the management and portrayal of uncertainty was a recurrent issue. Teachers modeled central features of a “professional rhetoric of uncertainty”, managing uncertainty of six origins: limits of individual knowledge, limits of evidence, limitless possibility, limits of patient''s/parent''s account, limits of professional agreement, and limits of scientific knowledge. By contrast, students demonstrated a “novice rhetoric of uncertainty”, represented by their focus on responding to personal knowledge deficits through the strategies of acknowledgement, argument, and deflection. Some students moved towards the professional rhetoric of uncertainty, suggesting not only advances in communication, but also shifts in attitude towards patients and colleagues, that were interpreted as indications that this rhetoric shapes professional identity and interactions. [Copyright &y& Elsevier]

Abstract While economic evaluations typically embrace health maximization as the maximization objective using quality-adjusted life years, there is increasing interest in the measurement of capability wellbeing and subjective wellbeing (SWB) for informing policy decisions. The objective of this study was to investigate the relationships between health-related quality of life (HRQoL), capability wellbeing and SWB. Data were used from 364 individuals living with spinal cord injury (SCI) who previously completed a web-based, cross-sectional survey (March–June 2013). Regression analyses were used to study the impacts of secondary health conditions on HRQoL, capability wellbeing and SWB; subsequently, a path analysis was used to assess direct and mediated pathways. HRQoL was measured using the EQ-5D-5L and the Assessment of Quality of Life 8-dimension (AQoL-8D) questionnaire; capability wellbeing was assessed using the ICEpop CAPability measure for Adults (ICECAP-A), and SWB was based on a single life satisfaction item (0–10 rating scale). Mean scores were 0.492, 0.573, 0.761 and 6.319 for EQ-5D-5L, AQoL-8D, ICECAP-A and SWB, respectively. Beta coefficients from the regression analyses indicated that secondary health conditions had the greatest negative impact on individuals' HRQoL (β AQoL-8D = −0.668, β EQ-5D-5L = −0.542), followed by SWB (β SWB = −0.481) and capability wellbeing (β ICECAP-A = −0.477). Capability wellbeing mediated the effect of secondary health conditions on HRQoL and SWB. The indirect effect of secondary health conditions on SWB through HRQoL was not statistically significant when using EQ-5D-5L; indirect effects were found when using AQoL-8D, one through HRQoL only and one through both capability wellbeing and HRQoL. This study highlights the different impacts of secondary health conditions on HRQoL, capability and SWB in the context of SCI. While the greatest impact was observed on individuals' HRQoL, our results provide further evidence that capability wellbeing (here, the ICECAP-A) adds complementary information about outcomes that could be used in economic evaluation. Highlights • Paper explores relationships between capability, subjective wellbeing (SWB) and HRQoL. • Clinical context of spinal cord injury and secondary health conditions (SHCs). • SHCs had the greatest negative impact on HRQoL (AQoL-8D and EQ-5D-5L). • ICECAP-A mediated the effect of SHCs on HRQoL (AQoL-8D and EQ-5D-5L) and SWB. • ICECAP-A provides complementary information to HRQoL instruments. [ABSTRACT FROM AUTHOR]

This paper examines whether low income and subjective financial strain are associated with mental health, as well as whether mastery weakens this association. We analyze three waves of a large sample of Canadians and utilize random and fixed effects regression strategies to assess bias introduced by unobserved time-stable confounders. In random effects models, both low income and subjective financial strain are associated with distress and anger. In fixed effects models that control for all time-stable confounders, the effect of low income is reduced to non-significance for both outcomes. The effect of subjective strain is also reduced in fixed effects models, but remained statistically significant. Sobel tests indicated that the effect of subjective strain on mental health is transmitted through mastery, but this indirect path is modest in magnitude. When interactions are tested, mastery weakens the association between subjective strain and distress, and this effect is robust to the influence of time-stable controls, but mastery does not buffer the subjective strain-anger relationship in either random or fixed-effects models. Finally, moving below the low income threshold increases anger for low mastery individuals, but seems to reduce anger when moving below the low income threshold is coupled with increases in mastery. Collectively, our findings demonstrate the importance of assessing the influence of unobserved time-stable confounders in stress research. Further, discrepancies in the moderating role of mastery reinforce calls for the assessment of multiple outcomes in mental health research. [ABSTRACT FROM AUTHOR]

Current literature confirms the negative consequences of contemporaneous economic insecurity for mental health, but ignores possible implications of repeated insecurity. This paper asks how much a person's history of economic insecurity matters for psychological distress by contrasting the implications of two models. Consistent with the health capital literature, the Healing model suggests psychological distress is a stock variable affected by shocks from life events, with past events having less impact than more recent shocks. Alternatively, the Breaking Point model considers that high levels of distress represent a distinct shift in life state, which occurs if the accumulation of past life stresses exceeds some critical value. Using five cycles of Canadian National Population Health Survey data (2000–2009), we model the impact of past economic insecurity shocks on current psychological distress in a way that can distinguish between these hypotheses. In our sample of 1775 males and 1883 females aged 25 to 64, we find a robust healing effect for one-time economic insecurity shocks. For males, only a recent one-time occurrence of economic insecurity is predictive of higher current psychological distress (0.19 standard deviations). Moreover, working age adults tend to recover from past accumulated experiences of economic insecurity if they were recently economically secure. However, consistent with the Breaking Point hypothesis, males experiencing three or four cycles of recent insecurity are estimated to have a level of current psychological distress that is 0.26–0.29 standard deviations higher than those who were employed and job secure throughout the same time period. We also find, consistent with other literature, distinct gender differences - for working age females, all economic insecurity variables are statistically insignificant at conventional levels. Our results suggest that although Canadians are resilient to one-time insecurity shocks, males most vulnerable to repeated bouts suffer from elevated levels of psychological distress. [ABSTRACT FROM AUTHOR]

There is some statistical evidence indicating that Somali refugees and immigrants have high rates of autism spectrum disorder (ASD). Somalis in North America call autism the “Western disease” because there is no word for autism in the Somali language and because many believe it does not exist in Somalia. In Toronto, Somali parents have forged an “epistemic community,” united around a coherent theory of the development of autism, its defining features, and most successful therapies. They work together with researchers to support the theory that gut bacteria is a causal factor for the development of autism. They argue that it is the diet and medical environment in North America (including the use of preservatives, genetically-modified processing, and antibiotics in both health care and food production) that explains the high rates of autism within the Somali diaspora. The paper argues that race and nationality have been underexplored in theories of embodied health movements. I argue that Somali parents' organizing pushes theories of health social movements in new directions, by suggesting that experiences of forced migration and racial exclusion, as well as non-Western cultural ontologies of health, are important for understanding embodied experiences of illness and the forging of “politicized collective illness identities” that challenge mainstream scientific understandings of autism. As such, Somalis' race and nationality play key roles in their pathways to group construction, in their embodied experiences of illness, and in their resources for mobilization. [ABSTRACT FROM AUTHOR]

This paper examines the feeling of lost control of the body that so many women experience through pregnancy and the postpartum period – why they feel it and how they interpret that feeling – and women's responses to the sense of lost control. For the 63 Canadian women we interviewed, the sense of lost control was related to the degree they felt their bodies changed and the number of physical problems they experienced while pregnant. Many women's references to “luck” as the cause of body changes and problems experienced underscored how little control they felt they had when they were pregnant. At the same time, women felt responsible for the well-being of their babies, and thus experienced guilt about their unruly bodies. Careful attention to diet helped some women, but not others, regain some sense of control; women with past experience of pregnancy who “gave in” to body change were more sanguine. In the postpartum period, body work (especially exercise) functioned to increase women's sense of control, but a variety of motives led them to do this work. [ABSTRACT FROM AUTHOR]

Injury is the leading cause of death for Canadians aged 1 to 44, occurring disproportionately across regions and communities. In the Inuit territory of Nunavut, for instance, unintentional injury rates are over three times the Canadian average. In this paper, we develop a framework for assessing vulnerability to injury and use it to identify and characterize the determinants of injuries on the land in Nunavut. We specifically examine unintentional injuries on the land (outside of hamlets) because of the importance of land-based activities to Inuit culture, health, and well-being. Semi-structured interviews (n = 45) were conducted in three communities that have varying rates of search and rescue (SAR), complemented by an analysis of SAR case data for the territory. We found that risk of land-based injuries is affected by socioeconomic status, Inuit traditional knowledge, community organizations, and territorial and national policies. Notably, by moving beyond common conceptualizations of unintentional injury, we are able to better assess root causes of unintentional injury and outline paths for prevention. [ABSTRACT FROM AUTHOR]

The act of problem formation is integral to the policymaking process. Moreover, the process by which certain situations, experiences or events are rendered problematic hinges upon the places, spaces and networks through which the issue is made visible and intelligible to policy makers and decision makers. In this paper, we explore these epistemic geographies by unpacking one such example – the Mental Health Commission of Canada’s At Home/Chez Soi study – a federally funded, $110 million field trial of the Housing First (HF) model. HF prioritizes rapid rehousing of the chronically homeless, followed by separate support and treatment services. The model has become widespread in Canada since 2005, based in large part on understandings of its cost-effectiveness. In this article, we utilize At Home/Chez Soi as an illustrative case for examining how ‘chronic homelessness’ is translated into a discourse of costs and benefits, and given an accounting value, through a series of translations. This problematization advances a particular logic – what we refer to as ‘bedspace’. [ABSTRACT FROM AUTHOR]

Rationale Living with a chronic illness poses many challenges, especially during the adolescent stage of development. Few studies have explored young people’s experiences of talking about their illness and how they go about deciding if and when they should tell others about their condition. Objective Our study sought the perspectives of Canadian children and adolescents living with inflammatory bowel disease (IBD) to determine how they go about deciding if and when to tell others about their illness. Methods Twenty-five participants with IBD, ranging in age from 10 to 17 years old, were interviewed about their experiences. Results Our participants highlighted that they generally preferred to conceal their illness. However, when they did disclose, they drew on a diverse range of contextual factors such as their knowledge of the illness as well as the severity of their illness, to make the decision. They also highlighted that one of the main challenges they experience is dealing with negative reactions to the news of their illness. This paper presents a decision-making model describing how children decide whether to disclose or conceal their IBD. Conclusion Our study illustrates that for children and adolescents, managing others’ knowledge about their illness has important implications for illness identity management. We argue that knowledge of how children with IBD make disclosure decisions is an important part of understanding the social experience of having IBD, and in creating environments that allow them to adapt to life with IBD. Our study clearly highlights the need for specific programs to be implemented to normalize IBD and to create supportive environments for children and adolescents diagnosed with IBD. [ABSTRACT FROM AUTHOR]

Prior research suggests that racial inequalities in health vary in magnitude across societies. This paper uses the largest nationally representative samples available to compare racial inequalities in health in the United States and Canada. Data were obtained from ten waves of the National Health Interview Survey (n = 162,271,885) and the Canadian Community Health Survey (n = 19,906,131) from 2000 to 2010. We estimated crude and adjusted odds ratios, and risk differences across racial groups for a range of health outcomes in each country. Patterns of racial health inequalities differed across the United States and Canada. After adjusting for covariates, black-white and Hispanic-white inequalities were relatively larger in the United States, while aboriginal-white inequalities were larger in Canada. In both countries, socioeconomic factors did not explain inequalities across racial groups to the same extent. In conclusion, while racial inequalities in health exist in both the United States and Canada, the magnitudes of these inequalities as well as the racial groups affected by them, differ considerably across the two countries. This suggests that the relationship between race and health varies as a function of the societal context in which it operates. [ABSTRACT FROM AUTHOR]

Bisexuality is consistently associated with poor mental health outcomes. In population-based data, this is partially explained by income differences between bisexual people and lesbian, gay, and/or heterosexual individuals. However, the interrelationships between bisexuality, poverty, and mental health are poorly understood. In this paper, we examine the relationships between these variables using a mixed methods study of 302 adult bisexuals from Ontario, Canada. Participants were recruited using respondent-driven sampling to complete an internet-based survey including measures of psychological distress and minority stress. A subset of participants completed a semi-structured qualitative interview to contextualize their mental health experiences. Using information regarding household income, number of individuals supported by the income and geographic location, participants were categorized as living below or above the Canadian Low Income Cut Off (LICO). Accounting for the networked nature of the sample, participants living below the LICO had significantly higher mean scores for depression and posttraumatic stress disorder symptoms and reported significantly more perceived discrimination compared to individuals living above the LICO. Grounded theory analysis of the qualitative interviews suggested four pathways through which bisexuality and poverty may intersect to impact mental health: through early life experiences linked to bisexuality or poverty that impacted future financial stability; through effects of bisexual identity on employment and earning potential; through the impact of class and sexual orientation discrimination on access to communities of support; and through lack of access to mental health services that could provide culturally competent care. These mixed methods data help us understand the income disparities associated with bisexual identity in population-based data, and suggest points of intervention to address their impact on bisexual mental health. [ABSTRACT FROM AUTHOR]

Drawing from a qualitative case study in rural British Columbia, Canada, this paper examines the discourse of kidney scarcity and its impact on renal care policies and practices. Our findings suggest that at different levels of care, there are different discourses and treatment foci. We have identified three distinct scarcity discourses at work. At the macro policy level, the scarcity of transplantable kidneys is the dominant discourse. At the meso health care institution level, we witnessed a discourse regarding the scarcity of health care and human resources . At the micro community level, there was a discourse of the scarcity of health and life-sustaining resources . For each form of scarcity, particular responses are encouraged. At the macro level, renal care and transplant organizations emphasize the benefits of kidney transplantation and procuring more donors. At the meso level, participants from the regional health care system increasingly encourage home hemodialysis and patient-led care. At the micro level, community health care professionals push for rural renal patients to attend dialysis and maintain their care plans. This work contributes to critical, interdisciplinary organ transfer discourse by contextualizing kidney scarcity. It reveals the tension between these discourses and the implications of pursuing kidney donations without addressing the conditions in which individuals experience kidney failure. [ABSTRACT FROM AUTHOR]

In this paper, we explore Indigenous perspectives of culture, place, and health among participants in a landmark Canadian Housing First initiative: At Home/Chez Soi (AHCS) project. Implemented from 2009 to 2013 in Winnipeg and four other Canadian cities, AHCS was a multi-city randomized control trial that sought to test the effectiveness of Housing First as a model for addressing chronic homelessness among people living with mental illnesses. As Winnipeg's homeless population is over 70% Indigenous, significant efforts were made to accommodate the culturally specific health, spiritual, and lifestyle preferences of the project's Indigenous participants. While a daunting challenge from an intervention perspective, Winnipeg's experience also provides a unique opportunity to examine how Indigenous participants' experiences can inform improved housing and mental health policy in Canada. In our study, conducted independently from, but with endorsement of the AHCS project, we utilized a case study approach to explore the experiences of the project's Indigenous participants. Data were collected by means of in-depth qualitative interviews with Indigenous participants (N = 14) and key informant project staff and investigators (N = 6). Our exploratory work demonstrates that despite relative satisfaction with the AHCS intervention, Indigenous peoples' sense of place in the city remains largely disconnected from their housing experiences. We found that structural factors, particularly the shortage of affordable housing and systemic erasure of Indigeneity from the urban sociocultural and political landscape, have adversely impacted Indigenous peoples' sense of place and home. [ABSTRACT FROM AUTHOR]

Given high levels of immigration into Canada and the associated requirement to understand the health needs of new arrivals, an extensive literature has developed over the past decade that has explored immigrant health issues, including the ‘healthy immigrant effect’. Surprisingly, however, issues of disability within the immigrant population have received much less attention. Using data from Statistics Canada, 2006a, 2006b Participation and Activity Limitation Survey (PALS), this paper examines disability and its covariates amongst immigrants relative to non-immigrants in Canada. Compared with their native-born counterparts, recent immigrant arrivals (within the past 10 years) were less likely to report disability and less likely to report a severe disability than the native-born. However, differences in the rates and covariates of disabilities between males and female immigrants were observed, which are partially explained by socioeconomic and sociodemographic effects. The conclusion explores potential reasons why differentials in disability rates are observed, and points to future research directions. [ABSTRACT FROM AUTHOR]

As health and social service professions increasingly emphasize commitments to equity, advocacy and social justice, non-traditional entrants to the professions increasingly bring much-needed diversity of social backgrounds and locations. Long the domain of elite social classes, the professions are not always welcoming cultures for those from lower social class backgrounds. This paper draws on notions of material, social and cultural capital, along with habitus , to examine the experiences of professionals with lower-class backgrounds, in educational programs and in their professions. The critical interpretive qualitative study draws on interviews with 27 professionals across Canada in medicine, nursing, social work and occupational therapy. While participants were clearly set apart from their colleagues by class origins, which posed distinct struggles, they also brought valuable assets to their work: enhanced connection and rapport with clients/patients, approachability, structural analysis and advocacy, plus nuanced re-envisioning of professional ethics to minimize power dichotomies. Rather than helping lower-class entrants adapt to the professions, it may be more beneficial to alter normative professional cultures to better suit these practitioners. • People from lower-class backgrounds may struggle in the professions. • The material, social and cultural capitals expected cast them as cultural outsiders. • They may more readily enact the social justice and equity aims of the professions. • We need transformational change to professional cultures of elitism and exclusion. [ABSTRACT FROM AUTHOR]

This paper contributes to the literature on Indigenous health, human dimensions of climate change, and place-based dimensions of health by examining the role of environment for Inuit health in the context of a changing climate. We investigated the relationship between one key element of the environment – sea ice – and diverse aspects of health in an Inuit community in northern Canada, drawing on population health and health geography approaches. We used a case study design and participatory and collaborative approach with the community of Nain in northern Labrador, Canada. Focus groups (n = 2), interviews (n = 22), and participant observation were conducted in 2010–11. We found that an appreciation of place was critical for understanding the full range of health influences of sea ice use for Inuit. Negative physical health impacts were reported on less frequently than positive health benefits of sea ice use, which were predominantly related to mental/emotional, spiritual, social, and cultural health. We found that sea ice means freedom for sea ice users, which we suggest influences individual and collective health through relationships between sea ice use, culture, knowledge, and autonomy. While sea ice users reported increases in negative physical health impacts such as injuries and stress related to changing environmental conditions, we suggest that less tangible climate change impacts related to losses of health benefits and disruptions to place meanings and place attachment may be even more significant. Our findings indicate that climate change is resulting in and compounding existing environmental dispossession for Inuit. They also demonstrate the necessity of considering place meanings, culture, and socio-historical context to assess the complexity of climate change impacts on Indigenous environmental health. [ABSTRACT FROM AUTHOR]

This paper examines the process of professional resocialization among internationally educated health care professionals (IEHPs) in Canada. Analyzing data from qualitative interviews with 179 internationally educated physicians, nurses, and midwives and 70 federal, provincial and regional stakeholders involved in integration of IEHPs, we examine (1) which aspects of professional work are modified in transition to a new health care system; (2) which aspects of professional practice are learned by IEHPs in the new health environment, and (3) how IEHPs maintain their professional identity in transition to a new health care system. In doing so, we compare the accounts of IEHPs with the policy stakeholders' positions and analyze the similarities and the differences across three health care professions (medicine, nursing, and midwifery). This enables us to explore the issue of professional resocialization from the analytical intersection of gender, professional dominance, and institutional/organizational lenses. [ABSTRACT FROM AUTHOR]

This paper explores social scientists' and humanities (SSH) scholars' integration within the academic medical research environment. Three questions guided our investigation: Do SSH scholars adapt to the medical research environment? How do they navigate their career within a culture that may be inconsistent with their own? What strategies do they use to gain legitimacy? The study builds on three concepts: decoupling, doxa, and epistemic habitus. Twenty-nine semi-structured interviews were conducted with SSH scholars working in 11 faculties of medicine across Canada. Participants were selected through purposeful and snowball sampling. The data were analyzed by thematic content analysis. For most of our participants, moving into medicine has been a challenging experience, as their research practices and views of academic excellence collided with those of medicine. In order to achieve some level of legitimacy more than half of our participants altered their research practices. This resulted in a dissonance between their internalized appreciation of academic excellence and their new, altered, research practices. Only six participants experienced no form of challenge or dissonance after moving into medicine, while three decided to break with their social science and humanities past and make the medical research community their new home. We conclude that the work environment for SSH scholars in faculties of medicine does not deliver on the promise of inclusiveness made by calls for interdisciplinarity in Canadian health research. [ABSTRACT FROM AUTHOR]

Policy-makers desire an optimal balance of financial incentives to improve productivity and encourage improved quality in primary care, while also avoiding issues of risk-selection inherent to capitation-based payment. In this paper we analyze risk-selection in capitation-based payment by using administrative data for patients ( n = 11,600,911) who were rostered (i.e., signed an enrollment form, or received a majority of care) with a primary care physician ( n = 8621) in Ontario, Canada in 2010/11. We analyze this data using a relative distribution approach and compare distributions of patient costs and morbidity across primary care payment models. Our results suggest a relationship between being in a capitation-based payment scheme and having low cost patients (and presumably healthy patients) compared to fee-for-service physicians. However, we do not have evidence that physicians in capitation-based models are reducing the care they provide to sick and high cost patients. These findings suggest there is a relationship between payment type and risk-selection, particularly for low-cost and healthy patients. [ABSTRACT FROM AUTHOR]

In this paper, we focus on the initial experiences of breastfeeding among mothers to examine the ways that infant-feeding is socially constructed in the hospital. Data comes from 51 in-depth interviews with 17 first-time mothers in Ontario, Canada. Analysis reveals 52 magnified moments that we categorize as Successful, Ultimately Successful and Unsuccessful. For mothers who describe Successful and Ultimately Successful moments, breastfeeding is understood as physiologically natural, and as something they must learn to do. Unsuccessful moments reveal that when health care providers interpret breastfeeding as not working, the breastfeeding discourse frequently shifts to one that incorporates formula as the means to achieve optimal infant health. In other words, in the hospital ‘breast is best’ holds true when breast ‘works’, otherwise mothers are often directed to give their babies formula. While formula appears to be compulsory in these moments, it is not typically understood as a “good or best” infant-feeding practice. For mothers in this situation, the shift from breast to formula is experienced as failures or evidence of inadequacy in their mothering. Paradoxically, our results suggest that formula may not, in and of itself, pose a threat to mothers' overall continued practice of breastfeeding. It appears that Successful and Ultimately Successful moments coincide with the current dominant ‘breast is best’ understanding. Unsuccessful moments, conversely, are insightful because they reveal when and how hospital practices disrupt mothers' understanding of their bodies and their role in providing the ‘best’ form of infant food. The implications for policy and practice are discussed. [ABSTRACT FROM AUTHOR]

The “general public” and specific “communities” are increasingly being integrated into scientific decision-making. This shift emphasizes “scientific citizenship” and collaboration between interdisciplinary scientists, lay people, and multi-sector stakeholders (universities, healthcare, and government). The objective of this paper is to problematize these developments through a theoretically informed reading of empirical data that describes the consequences of bringing together actors in the Canadian HIV community-based research (CBR) movement. Drawing on Foucauldian “governmentality” the complex inner workings of the impetus to conduct collaborative research are explored. The analysis offered surfaces the ways in which a formalized approach to CBR, as promoted through state funding mechanisms, determines the structure and limits of engagement while simultaneously reinforcing the need for finer grained knowledge about marginalized communities. Here, discourses about risk merge with notions of “scientific citizenship” to implicate both researchers and communities in a process of governance. [ABSTRACT FROM AUTHOR]

Non-invasive prenatal testing (NIPT) using cell-free DNA (cfDNA) offers numerous benefits to pregnant women and their families. It also raises ethical, legal and social concerns regarding, for instance, the possible effects of a routinization of prenatal genetic testing on free and informed decision-making by prospective parents, and the role of the state in governing its use. Technological advances are allowing cfDNA analyses to detect an increasing number of genetic risks and conditions in the fetus, potentially further exacerbating such concerns. From May 2015 to December 2016, we conducted a three-round Policy Delphi study (N R1 = 61, N R2 = 58, N R3 = 47; overall retention rate = 77.0%) to explore the social acceptability (SA) of current and potential future uses of NIPT in Canada according to participants with relevant professional, research or advocacy expertise. Participants came from four groups: healthcare professionals (N R3 = 14), social sciences and humanities researchers (N R3 = 13), patients/disability rights advocates (N R3 = 14), and cultural/religious communities advocates (N R3 = 6). This paper presents SA criteria and contextual contingencies relevant to the assessment of NIPT's SA according to the group. It also reports what uses (conditions or motives) participants thought should be banned, permitted, publicly funded, or promoted as a public health strategy. According to them, conditions resulting in severe pain or early death, as well as trisomies (13, 18, 21) and sex chromosome abnormalities, should be covered by Canadian public health insurance. However, there was wide agreement that direct-to-consumer NIPT should be legally banned, and that testing for fetal sex for non-medical reasons using NIPT should be either proscribed or discouraged. In addition to identifying areas of consensus, our results point to disagreement regarding, for instance, the required level of governance of whole-genome sequencing and testing for late onset conditions with low penetrance. This study also provides a model for exploring the SA of emerging technologies using the Policy Delphi method. • NIPT's social acceptability in Canada is explored using a three-round Delphi method. • Social acceptability is associated with 12 criteria of variable relevance. • Social acceptability depends on conditions tested, governance decisions and context. • Salient ethical tensions between reproductive autonomy and regulation are discussed. • A four-dimension model is proposed to explore social acceptability with experts. [ABSTRACT FROM AUTHOR]

Frameworks for understanding integrated care risk underemphasizing the complexities of the development of integrated care in a local context. The objectives of this article are to (1) present a novel strategy for conceptualizing integrated care as developing through a series of milestones at the organizational level, and (2) present a typology of milestones empirically generated through the analysis of four cases of integrated community-based primary health care (ICBPHC) in Canada and New Zealand. Our paper reports on an analysis of 4 specific organizational case studies within a large dataset generated for an international multiple case study project of exemplar models of ICBPHC. Drawing on earlier analyses of 359 qualitative interviews with patients, caregivers, health care providers, managers, and policymakers, in this article we present a detailed analysis of 28 interviews with managers and leaders of local models of integrated care. We generated a detailed timeline of the development of integrated care as expressed by each participant, and synthesized themes across timelines within each case to identify specific milestone events. We then synthesized across cases to generate the broader milestone categories to which each event belongs. We generated 5 milestone categories containing 12 more specific milestone events. The milestone categories include (1) strategic relational, (2) strategic process change, (3) internal structural, (4) inter-organizational structural, and (5) external milestones. We propose a comprehensive framework of developmental milestones for integrated care. Milestones represent a compelling strategy for conceptualizing the development of integrated care. Practically, policymakers and health care leaders can support the implementation of integrated care by examining the history and context of a given model of care and identifying strategies to achieve milestones that will accelerate integrated care. Further research should document additional milestone events and advance the development of dynamic frameworks for integrated care. • Developmental milestones accelerate or decelerate achievement of integrated care. • 5 categories of milestones are identified. • A comprehensive framework for milestones of integrated care is proposed. • Implementation strategies should be based on past milestones achieved. [ABSTRACT FROM AUTHOR]

Social supports have been shown to affect health in a variety of ways. This paper explores a hitherto ignored avenue linking social supports to health, namely through their influence on having a regular family doctor. We examine the role played by social supports in helping to explain why a significant portion of the Canadian population does not have a regular family doctor even though primary care is fully covered by the public insurer and when having a regular physician is associated with better care and with access to specialists. Five Canadian Community Health Surveys spanning 2001 to 2010 (n = 13,872 to n = 30,814) are employed, containing information on three measures of social support: sense of belonging to the local community, how often an individual has someone to confide in, and number of close friends and relatives. We find evidence of a positive link between social supports, especially sense of belonging, and having a regular doctor. Our results suggest that the benefits associated with policies geared towards community development and strengthening neighborhoods may also include facilitating access to primary-care physicians and, importantly, improving the matching of patients with regular family doctors. [ABSTRACT FROM AUTHOR]

Abstract: Clinical trials are often described as machine-like systems for generating specific information concerning drug safety and efficacy, and are understood as a component of the industrial drug development processes. This paper argues that contemporary clinical trials in oncology are not reducible to mere drug testing. Drawing on ethnographic fieldwork and interviews with researchers in the field of oncology from 2010 to 2013, we introduce a conceptual contrast between trials as testing machines and trials as clinical experimental systems to draw attention to the ways trials are increasingly being used to ask open-ended scientific questions. When viewed as testing machines, clinical trials are seen as a means to produce answers to straightforward questions and deviations from the protocol are seen as bugs in the system; but practitioners can also treat trials as clinical experimental systems to investigate as yet undefined problems and where heterogeneity becomes a means to produce novel biological or clinical insights. The rise of “biomarker-driven” clinical trials in oncology, which link measurable biological characteristics such as genetic mutations to clinical features such as a patient's response to a particular drug, exemplifies a trend towards more experimental styles of clinical work. These transformations are congruent with changes in the institutional structure of clinical research in oncology, including a movement towards more flexible, networked research arrangements, and towards using individual patients as model systems for asking biological questions. [Copyright &y& Elsevier]