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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]

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]

Abstract: In the past two decades, research on the sociology of diagnosis has attained considerable influence within medical sociology. Analyzing the process and factors that contribute to making a diagnosis amidst uncertainty and contestation, as well as the diagnostic encounter itself, are topics rich for sociological investigation. This paper provides a reformulation of the sociology of diagnosis by proposing the concept of ‘social diagnosis’ which helps us recognize the interplay between larger social structures and individual or community illness manifestations. By outlining a conceptual frame, exploring how social scientists, medical professionals and laypeople contribute to social diagnosis, and providing a case study of how the North American Mohawk Akwesasne reservation dealt with rising obesity prevalence to further illustrate the social diagnosis idea, we embark on developing a cohesive and updated framework for a sociology of diagnosis. This approach is useful not just for sociological research, but has direct implications for the fields of medicine and public health. Approaching diagnosis from this integrated perspective potentially provides a broader context for practitioners and researchers to understand extra-medical factors, which in turn has consequences for patient care and health outcomes. [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]

Abstract: Limited access to healthcare for vulnerable immigrant children in Europe and North America is increasingly worrisome as immigration policies harden. This paper analyzes the gap between States'' obligations under international human rights law and the disparate local implementations in diverse countries. Studies that are both multidisciplinary and incorporate micro and macro level indicators are needed to reveal discrepancies between entitlements and access. It is argued that the lack of available data on the magnitude of the problem and on its individual and public health consequences stems from the conflicting situation faced by health institutions required to simultaneously protect the best interest of each child and allocate limited resources. Collaboration in research is urgently needed to assist policy-makers and institutions make informed decisions. [Copyright &y& Elsevier]

Abstract: The geography of small areas has important implications for studying the contextual determinants of health because of potential errors when measuring ecologic exposures and estimating their effects on health. In this paper, we present an approach for designing homogeneous zones optimising the spatial distribution of an area-level exposure, active living potential (ALP), based on data collected in Montreal, Canada. The objectives are to (1) assess and compare variation in walking behaviours between these purposefully designed zones and between standard administrative units, census tracts; and (2) disentangle the relative influence of ALP and area-level socioeconomic conditions on walking using the alternative geographies. Zones were designed by statistically classifying smallest census areas (disseminations areas) into seven categories of exposure similar along three indicators of ALP: population density, land use mix, and geographic accessibility to services. Mapping of categories resulted in the delineation of zones characterised by one of seven levels of ALP. A sample of 2716 adults aged ≥45 years was geocoded and cross-classified in 270 zones and 112 census tracts. Individuals reported on minutes and motives of walking and provided socioeconomic information. Data were analysed using cross-classified multilevel models. Variation in utilitarian walking was larger across the purposefully defined zones than across census tracts. Total walking varied significantly between census tracts only. Greater ALP was associated with more utilitarian walking but with less recreational walking. Higher socioeconomic position in census tracts was positively associated with total, utilitarian, and recreational walking. The soundness of standard administrative units for measuring ecologic exposure and their associations with health should be considered prior to conducting analyses. The added value of different approaches for understanding how place relates to health remains to be established and should be the focus of further investigations. [Copyright &y& Elsevier]

This paper analyzes the community health of the Wikwemikong Unceded Indian Reserve (WUIR), Ontario, Canada. Results are reported from fieldwork including participant observation, key informant interviewing and self-reported data measuring health status, risk behaviour, place of residence, self-identity, and personal history extracted from 350 interviews conducted during a community-wide needs assessment. The research aimed to create a health plan for the community; however, subsequent analysis of the needs assessment results indicates that internal diversity exists in health status and needs between the seven villages that comprise WUIR. The analysis suggests variation in health status and risk-taking behaviour among community members may be related to varying colonial histories among the villages. The implications of intra-community variation in health status in First Nations are discussed in relation to influential health policy theories such as the determinants of health and health transfer policy in Canada. [Copyright &y& Elsevier]

Abstract: This paper uses a comparative case study of Canada and the USA to argue that, in order to fully understand the associations between population health and the socioeconomic environment we must begin to place importance on the dynamic aspect of these factors—examining them as they evolve over time. In particular, for institutional and policy shifts that often unfold over decades, population health must attend to these big, slow moving processes by adopting a historical perspective to the knowledge base. We compare Canada and the USA on basic health outcomes and a range of determinants of health for which routine data have been collected for all or most of the period between 1950 and the present. During the analysis that follows, we are able to establish that, at the level of society (i) greater economic well being and spending on health care does not yield better health outcomes, that (ii) public provision and income redistribution trump economic success where population health is concerned, and (iii) that the gradual development of public provision represents the buildup of social infrastructure that has long-lasting effects on health status. Our case study shows what can be gleaned from a comparative perspective and a long-term view. The long view allows us to detect the gradual divergence in health status between these two societies and to trace potential institutional causes that would otherwise go unnoticed. The perspective introduced here, and in particular the comparison of Canada and the USA, provides strong support for the use of cross-national comparative work, and a historical perspective on the investigation of societies that successfully support population health. [Copyright &y& Elsevier]

Abstract: This paper contributes to the current debates surrounding private delivery of health care services by addressing the distinctive challenges, constraints and opportunities facing for-profit and non-profit providers of long-term care in rural and small town settings. It focuses on the empirical case of Ontario, Canada where extensive restructuring of long-term care, under the rubric of managed competition, has been underway since the mid-1990s. In-depth interviews with 72 representatives from local governments, public health institutions and authorities, for-profit and non-profit organisations, and community groups during July 2003 to December 2003 form the platform for a qualitative analysis of the implications of managed competition as it relates to the provision of long-term care in the countryside. The results suggest that the introduction and implementation of managed competition has accentuated the problems of service provision in rural communities, and that the long-standing issues of caregiving in rural situations transcend the differences, perceived or otherwise, between for-profit and non-profit provision. Understanding the implications of market-oriented long-term care restructuring initiatives for providers, and their clients, in rural situations requires a re-focussing of research beyond the for- versus non-profit dichotomy. [Copyright &y& Elsevier]

In this paper, we examine the challenges of defining the boundaries of outreach work using the example of needle exchange programs. In particular, we examine the multiple and inter-related factors that extend needle exchange outreach work beyond its official mandate. Using semi-structured interviews, 59 workers at 15 programs in Ontario, Canada were asked questions about operational policies and routines. An iterative and inductive analytic process was used. Over time, most outreach workers develop a well-defined sense of the activities they consider to be consistent with a harm reduction approach and the types of conduct that are considered to be acceptable and professional. Workers conceptualize their roles to encompass education and support but are reluctant to impose a rigid definition of their roles. A pragmatic and humble stance combined with strong beliefs in social justice encourages workers to find informal solutions to meet client needs that extend beyond the program mandate. As a result, doing ‘extra’ is the norm. These extra efforts are informal, but often regular, expansions of the service complement. Construction of flexible boundaries provides opportunities to meet many client needs and unexpected situations; however, going the extra-mile strains resources. A minority of workers blur the boundaries between private and professional lives. Further, a variety of personal, social and socio-political forces encourage outreach workers to continually redefine the boundaries of their roles and service complements. [Copyright &y& Elsevier]

The socio-political context of modern environmental health disasters tends to be defined as being outside the scope of official public health and epidemiological investigations into the causes of such disasters. On the other hand, popular accounts of these disasters tend to focus exclusively on the role of particular individuals and/or political actors, while minimizing the role of ecological factors. It is argued that an exclusive focus on either set of causal factors gives an incomplete or distorted picture of the origins of an environmental health disaster. In this paper, a socio-ecological analysis is developed to demonstrate how the largest outbreak of waterborne E. coli O157:H7 in Canadian history was the emergent product of a complex interplay and intertwining of social and ecological processes. The socio-ecological autopsy approach that is developed here traces the social and ecological chain of events that ultimately led to the outbreak and demonstrates, in particular, the need for investigative analysis to focus on the socio-ecological “incubation” of an environmental health disaster. Drawing from both the social sciences (particularly, the sociology of disasters and organizational sociology), and from the ecological sciences (particularly disease ecology), the analysis developed here responds to the call for the application of a more transdisciplinary approach to the study of contemporary environmental health problems. [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]

While much is known about the impact of law and public policy, we know considerably less about their antecedents. Theories of policy adoption suggest that a variety of policy inputs help to shape legislative change. This research considers the enactment of municipal smoking bylaws in Canada between 1970 and 1995. The emergence of second-hand smoke (SHS) has been offered as a viable explanation for the increased enactment of local smoking restrictions. A number of indicators confirm the rising public health concern around SHS. Using Health Canada data on municipal smoking bylaw enactment in Canada, this paper employs an event history analysis to trace the role of four indicators of the increased recognition of SHS as a public health concern—scientific research, parliamentary debate, print media, and health advocacy. Findings indicate that the print media and health advocacy play the strongest role in explaining the increase in the adoption of municipal smoking bylaws in Canada. Results lend support to the quantitative study of the policy adoption process and to theories of policy making that consider multiple influences on policy adoption. [Copyright &y& Elsevier]

Community public health interventions based on citizen and community participation are increasingly discussed as promising avenues for the reduction of health inequalities and the promotion of social justice. However, very few authors have provided explicit principles and guidelines for planning and implementing such interventions, especially when they are linked with research. Traditional approaches to public health programming emphasise expert knowledge, advanced detailed planning, and the separation of research from intervention. Despite the usefulness of these approaches for evaluating targeted narrow-focused interventions, they may not be appropriate in community health promotion, especially in Aboriginal communities. Using the experience of the Kahnawake Schools Diabetes Prevention Project, in Canada, this paper elaborates four principles as basic components for an implementation model of community programmes. The principles are: (1) the integration of community people and researchers as equal partners in every phase of the project, (2) the structural and functional integration of the intervention and evaluation research components, (3) having a flexible agenda responsive to demands from the broader environment, and (4) the creation of a project that represents learning opportunities for all those involved. The emerging implementation model for community interventions, as exemplified by this project, is one that conceives a programme as a dynamic social space, the contours and vision of which are defined through an ongoing negotiation process. [Copyright &y& Elsevier]