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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: 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]

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]

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]

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]

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]

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]

Abstract: Contributing to health geography scholarship on the topic, the objective of this paper is to reveal Canadian medical tourists' perspectives regarding their choices to seek knee replacement or hip replacement or resurfacing (KRHRR) at medical tourism facilities abroad rather than domestically. We address this objective by examining the ‘talk strategies’ used by these patients in discussing their choices and the ways in which such talk is co-constructed by others. Fourteen interviews were conducted with Canadians aged 42–77 who had gone abroad for KRHRR. Three types of talk strategies emerged through thematic analysis of their narratives: motivation, justification, and normalization talk. Motivation talk referenced participants' desires to maintain or resume physical activity, employment, and participation in daily life. Justification talk emerged when participants described how limitations in the domestic system drove them abroad. Finally, being a medical tourist was talked about as being normal on several bases. Among other findings, the use of these three talk strategies in patients' narratives surrounding medical tourism for KRHRR offers new insight into the language-health-place interconnection. Specifically, they reveal the complex ways in which medical tourists use talk strategies to assert the soundness of their choice to shift the site of their own medical care on a global scale while also anticipating, if not even guarding against, criticism of what ultimately is their own patient mobility. These talk strategies provide valuable insight into why international patients are opting to engage in the spatially explicit practice of medical tourism and who and what are informing their choices. [Copyright &y& Elsevier]

Abstract: Despite the significant literature as well as energy devoted to ethical review of research involving human subjects, little attention has been given to understanding the experiences of those who volunteer as human subjects. Why and how do they decide to participate in research? Is research participation viewed as a form of social responsibility or as a way of obtaining individual benefits? What if anything do research subjects feel they are owed for participation? And what do they feel that they owe the researcher? Drawing on in-depth individual interviews conducted in 2006 and 2007 with 41 subjects who participated in a variety of types of health research in Canada, this paper focuses on subject perspectives on responsibility in research. Highlighting the range of ways that subjects describe their involvement in research and commitments to being a ‘good’ subject, we present a typology of narratives that sheds new light on the diverse meanings of research participation. These narratives are not mutually exclusive or prescriptive but are presented as ideal types typifying a set of circumstances and values. As such, they collectively illuminate a range of motivations expressed by human subjects as well as potential sources of vulnerability. The typology adds a new dimension to the literature in this area and has significant implications for researchers seeking more human-subject centred approaches to research recruitment and retention, as well as research ethics boards trying to better anticipate the perspectives of prospective participants. [Copyright &y& Elsevier]

Abstract: Urbanization among Indigenous peoples is growing globally. This has implications for the assertion of Indigenous rights in urban areas, as rights are largely tied to land bases that generally lie outside of urban areas. Through their impacts on the broader social determinants of health, the links between Indigenous rights and urbanization may be related to health. Focusing on a Canadian example, this study explores relationships between Indigenous rights and urbanization, and the ways in which they are implicated in the health of urban Indigenous peoples living in Toronto, Canada. In-depth interviews focused on conceptions of and access to Aboriginal rights in the city, and perceived links with health, were conduced with 36 Aboriginal people who had moved to Toronto from a rural/reserve area. Participants conceived of Aboriginal rights largely as the rights to specific services/benefits and to respect for Aboriginal cultures/identities. There was a widespread perception among participants that these rights are not respected in Canada, and that this is heightened when living in an urban area. Disrespect for Aboriginal rights was perceived to negatively impact health by way of social determinants of health (e.g., psychosocial health impacts of discrimination experienced in Toronto). The paper discusses the results in the context of policy implications and future areas of research. [Copyright &y& Elsevier]

Abstract: This paper addresses the gap in health services and policy research about the implications of everyday weather for health care work. Building on previous research on the weather-related challenges of caregiving in homes and communities, it examines the experiences of ‘seasonal bad weather’ for health care workers in long-term care institutions. It features a hermeneutic phenomenology analysis of six transcripts from interviews with nurses and personal support workers from a qualitative study of institutional long-term care work in rural Canada. Focussing on van Manen's existential themes of lived experience (body, relations, space, time), the analysis reveals important contradictions between the lived experiences of health care workers coping with bad weather and long-term care policies and practices that mitigate weather-related risk and vulnerability. The findings contribute to the growing concern for rural health issues particularly the neglected experiences of rural health providers and, in doing so, offer insight into the recent call for greater attention to the geographies of health care work. [Copyright &y& Elsevier]

Abstract: An interesting question concerns how large-scale (mental) health services policy initiatives come into being, and the role of evidence within the decision-making process behind their origins. This paper illustrates the process by which motivation to address homelessness, in the context of the upcoming 2010 Vancouver Olympics, was leveraged into a pan-Canadian project including sites in Vancouver, Winnipeg, Toronto, Montreal and Moncton, New Brunswick. The aim of the initiative was to implement and evaluate an intervention, Housing First, to provide housing and support to previously homeless people with mental illness. This qualitative case study was conducted between December 2009 and December 2010, employing grounded theory, and drawing on archival documents and interviews with 19 key informants involved in the conception of the project. Overall, the findings affirm that policy-making does not follow a rational, linear process of knowledge translation/exchange (KTE) and implementation, whereby evidence-based “products” are brought forward to address objectively determined needs and then “placed into decision-making events” (Lomas, 2007, p. 130). Instead, evidence-based policy making should be understood within the much more complex context of “policy entrepreneurship” (Kingdon, 2003; Mintrom & Norman, 2009) which entails taking advantage of windows of opportunity, and helping to bring together the “streams” of problems, politics, and policy ideas (Kingdon, 2003). [Copyright &y& Elsevier]

Abstract: Attempts to evaluate public consultations, participatory technology assessment, and deliberative democracy have typically considered impacts on either policy or participants. The determination of impacts on policy institutions has been limited due to the challenges of tracing effects through the policy process, or penetrating bureaucratic walls. This paper presents findings from a retrospective study exploring the institutional lessons learned from a 2001 Canadian national public consultation on xenotransplantation. The consultation was conducted through an arm’s-length process and involved the use of citizen juries in six regional sites. We conducted in-depth interviews of regulatory and policy actors who were engaged in early policy discussions and the consultation process. We reviewed evaluations of this process, both internal and external, which gave us richer insights into what institutional actors saw as the impacts of this consultative experience on their policy environment. Participants in our research identified a broader shift toward openness in policy culture which they linked specifically to the innovative consultation process employed for xenotransplantation. We argue that beyond input into policy decisions, a consultation may have an impact in terms of its contribution to overall shifts in institutional culture (related to institutional learning), such as an “opening” of technological decision processes to a broader range of actors, knowledge, and values. [Copyright &y& Elsevier]