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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 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]

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]

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]

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 presents results of a research priority setting process focused on trans women living with and affected by HIV across Canada. It features data from semi-structured interviews and focus groups conducted with a diverse group of 76 trans women in five urban centers across the country on how they have navigated health and social service programming within their geographic context. The results focus on the structure and types of services. Respondents offered simple, yet creative ways to address barriers to vital services based on their individual and collective experiences. Notably, participants stressed the need for 1) trans-friendly and trans-specific services, 2) integrated health services, and aid in navigating complex, overlapping systems, and 3) comprehensive community-based services. They also suggest employing trans women as care coordinators or case managers in order to foster more trans-friendly environments and empower community members. We identify concrete ways to improve health and social services at the level of service delivery and program design, as well as recommendations for future participatory research. We close with an interrogation of trans people, and trans women living with and affected by HIV in particular, as 'hard to reach' populations. • Research with trans women yields richer insights if trans-identified experts lead. • Trans-friendly and trans-specific modes of service design and provision differ. • Integrated services are vital, but must address nuance of transgender women's needs. • Trans women are not hard to reach; rather, it is services that are hard to access. • Our trans-led community-based participatory approach can and should be reproduced. [ABSTRACT FROM AUTHOR]

Hospitals remain the most common location of death in a significant number of countries, and specialist palliative care is positioned as a crucial resource for improving hospital care for those nearing end of life. Little is known, however, about a substantive aspect of this work: how hospital palliative clinicians anticipate and organize a patient's dying trajectory. In this paper I draw from a larger original ethnographic research study of palliative specialists in two Canadian hospitals. Abductive analysis resulted in framing their work as affective labour, both reflecting and re-creating a larger affective economy shaping the affective states of everyone involved in the provision and uptake of care. I articulate six analytically ideal outcomes of clinicians' affective labour that organize end of life, including: 1) proactive co-authorship of disease trajectory; 2) mutual acknowledgement of a dying trajectory; 3) naturalizing direction and outcome of care, 4) ensuring a minimum of social disruption, 5) identification as compassionate and efficient care providers, and 6) increased specialist knowledge and interventions. In so doing, clinicians' practices become understandable as labour to meet a diversity of – at times conflicting – individual, organizational, and societal mandates that necessarily include, but extend well beyond, the patient and her immediate social network. This is the first study to consider hospital palliative care as an affective economy, and presents a theoretically innovative and empirically grounded model to advance new ways of conceptualizing hospital palliative care. I conclude by considering how this model, and the unique insights it affords, can inform the future development of end of life care in hospital settings. • Hospital palliative care is shaped by diverse health system priorities. • Clinicians use affective labour to meet patient, family member, and system needs. • Hospital palliative care can be understood and modeled as an "affective economy". • Negotiation and ambivalence are constitutive features of hospital palliative care. [ABSTRACT FROM AUTHOR]

Abstract: Innovation systems (IS) and science policy scholarship predominantly focus on linkages between universities and industry, and the commercial translation of academic discoveries. Overlooked in such analyses are important connections between universities and academic hospitals, and the non-commercial aspects of translational science. The two types of institutions tend to be collapsed into a single entity—‘the university’—and relational flows are lost. Yet the distinctions and flows between the two are crucial elements of translational science and the biomedical innovation system. This paper explores what has been called the ‘hidden research system’ that connects hospitals, universities, and their resources, with the clinical and scientific actors who make the linkages possible. Then, using a novel conceptual model of translational science, we examine the individual interactions and dynamics involved in a particular example of the biomedical innovation system at work: the diagnosis of IRAK-4 deficiency, a rare immunological disorder, and the translational flows that result. Contra to conventional IS analyses, we are able to point to the strong role of public-sector institutions, and the weak role of the private-sector, in the translational processes described here. Our research was conducted within a Canadian network of scientists and clinician–scientists studying the pathogenomics of immunological disorders and innate immunity. [Copyright &y& Elsevier]

Abstract: Since the 1970s, governments in many high-income countries have implemented a series of reforms in their health care systems to improve efficiency and effectiveness. Many of these reforms have been of a market-oriented character, involving the deregulation of key services, the creation of competitive markets, and the privatization of health and social care. Some scholars have argued that these “neoliberal” reforms have unseated the historical structural embeddedness of medicine, and in some cases even resulted in the proletarianisation of physicians. Other scholars have challenged this view, maintaining that medical hegemony continues to shape health care provision in most high-income countries. In this paper we examine how policy reforms may have altered medical dominance over maternity care in two comparatively similar countries – Canada and Australia. Our findings indicate that neoliberal reforms in these two countries have not substantially changed the historically hegemonic role medicine has played in maternity care provision. We discuss the implications of this outcome for the increased medicalisation of human reproduction. [Copyright &y& Elsevier]

Although ethnicity data are collected in most countries at the population level, it has become more common to collect such data in healthcare settings, partially in response to growing health and social inequities worldwide. However, the implications of doing so have not been studied. This two-year study was designed to critically examine the implications of collecting ethnicity data in healthcare settings. Using a critical ethnographic approach, we interviewed 104 patients, community and healthcare leaders, and healthcare workers within diverse clinical contexts in a large city in Western Canada in 2006–2007. This paper presents an interpretive thematic analysis, using an ethical lens, of the harms and benefits associated with the process of data collection in a clinical context. While most leaders and healthcare workers and some patients envisioned potential benefits associated with having ethnicity data, these benefits were seen as largely contingent upon action being taken to ameliorate inequities. Overwhelmingly, however, leaders from ethno-cultural communities and patients of diverse identities anticipated potential harm arising both from having ethnicity data and the process of collection. The analysis illustrates that in today's sociopolitical context, collecting ethnicity data in clinical contexts may engender considerable harm, particularly for racialized, vulnerable patients. If ethnicity data are currently collected at the population level, evidence of benefit is required before proceeding to collect these data at the point of care. [Copyright &y& Elsevier]

The Nisga’a Nation of Northwestern British Columbia have been pioneers in the area of obtaining administrative control over health services. This would seem to mark the end of medical colonialism for this First Nation. But the author argues that health program devolution, in this case, was part of a longer tradition of incorporating aspects of non-Native medicine in a way that supported Nisga’a social structure. Nevertheless, the author argues that health program devolution is part of the process of decolonization since it has supported the traditional social structure, enhanced community self-esteem and provided an opportunity for the locus of control to shift from the medical profession and the federal government to Nisga’a people. This paper sets the development of Nisga’a-centered health care in a historical context that sees the Nisga’a exerting a resistive will in the context of medical colonialism in twentieth century British Columbia. [Copyright &y& Elsevier]

This paper presents conclusions drawn from a comparative analysis of three qualitative case studies of participation processes at the regional level in Quebec''s healthcare system in Canada. Our objective is twofold: primarily, to draw on our observations to elaborate and discuss a sociological framework for the analysis of public participation; and secondarily, to use our data to criticise many pervasive but questionable preconceptions in the scientific literature on public participation. The framework used applies the social theory of P. Bourdieu in conjunction with the representation framework of H.F. Pitkin to demonstrate how any form of participation will imply some implicit or explicit delegation. The significance of the analysis is its focus on the social operations implied in these acts of delegation and in the use of the concept of symbolic struggles to understand the conflicts arising when the intrinsic legitimacy of the public is appropriated. [Copyright &y& Elsevier]

Given the framework of the 1984 Canada Health Act, the health status of immigrants should be similar to average levels within whole of Canada. Yet, assuming equality of health status between immigrant and non-immigrants, or between immigrant groups is likely an unrealistic and simplistic assumption, given unseen barriers affecting accessibility, the restructuring of the Canadian health care system, and problems with the provision of health care resources to the immigrant population. Using the National Population Health Survey, this paper focuses upon the health status of the immigrant population relative to that of non-immigrants within Canada, with reference to diagnosed conditions, self-assessed health, and the Health Utilities Index Mark 3. Findings indicate that, with the exception of the most recent arrivals, immigrants experience worse health status across most dimensions relative to non-immigrants. Multivariate analysis reveals that age, income adequacy, gender, and home ownership are dimensions upon which health status differs between the two groups. [Copyright &y& Elsevier]