Search

Social medicine and health advocacy curricula are known to be uncommon in postgraduate medical education. As justice movements work to unveil the systemic barriers experienced by sexual and gender minority (SGM) populations, it is imperative that the emergency medicine (EM) community progress in its efforts to provide equitable, accessible, and competent care for these vulnerable groups. Given the paucity of literature on this subject in the context of EM in Canada, this commentary borrows evidence from other specialties across North America. Trainees across specialties and of all stages are caring for an increasing number of SGM patients. Lack of education at all levels of training is identified as a significant barrier to adequately caring for these populations, thereby precipitating significant health disparities. Cultural competency is often mistakenly attributed to a willingness to treat rather than the provision of quality care. However, positive attitudes do not necessarily correlate with trainee knowledge. Barriers to creating and implementing culturally competent curricula are plentiful, yet facilitating policies and resources are rare. While international bodies continuously publish position statements and calls to action, concrete change is seldom made. The scarcity of SGM curricula can be attributed to the universal absence of formal acknowledgment of SGM health as a required competency by accreditation boards and professional membership associations. This commentary synthesizes hand-picked literature in an attempt to inform healthcare professionals on their journey toward developing culturally competent postgraduate medical education. By thematically organizing evidence into a stepwise approach, the goal of this article is to borrow ideas across medical and surgical specialties to inform the creation of recommendations and make a case for an SGM curriculum for EM programs in Canada. [ABSTRACT FROM AUTHOR]

This article is based on an institutional ethnographic inquiry into the work of paramedics and the institutional setting that organizes and coordinates their work processes in a major City in Canada. Drawing on more than two hundred hours of observations and more than one hundred interviews with paramedics (average length of 18 minutes) and other emergency medical personnel, this article explores the standard and not so standard work of paramedics as they assess and care for their patients on the front lines of emergency health services. The multiplicity of interfacing social, demographic, locational, and situational factors that shape and organize the work of paramedics are analyzed. In doing so, this article provides insights into the complex work of an understudied yet ever-important profession in health care. [ABSTRACT FROM AUTHOR]

Objectives: Our primary objective was to estimate the association between loneliness and unmet healthcare needs and if the association changes when adjusted for demographic and health factors. Our secondary objective was to examine the associations by gender (men, women, gender diverse)., Design, Setting, Participants: Retrospective cross-sectional data from 44 423 community-dwelling Canadian Longitudinal Study on Aging participants aged 45 years and older were used., Primary Outcome Measure: Unmet healthcare needs are measured by asking respondents to indicate (yes, no) if there was a time when they needed healthcare in the last 12 months but did not receive it., Results: In our sample of 44 423 respondents, 8.5% (n=3755) reported having an unmet healthcare need in the previous 12 months. Lonely respondents had a higher percentage of unmet healthcare needs (14.4%, n=1474) compared with those who were not lonely (6.7%, n=2281). Gender diverse had the highest percentage reporting being lonely and having an unmet healthcare need (27.3%, n=3), followed by women (15.4%, n=887) and men (13.1%, n=583). In our logistic regression, lonely respondents had higher odds of having an unmet healthcare need in the previous 12 months than did not lonely (adjusted odd ratios (aOR) 1.80, 95% CI 1.64 to 1.97), adjusted for other covariates. In the gender-stratified analysis, loneliness was associated with a slightly greater likelihood of unmet healthcare needs in men (aOR 1.90, 95% CI 1.64 to 2.19) than in women (aOR 1.73, 95% CI 1.53 to 1.95). In the gender diverse, loneliness was also associated with increased likelihood of having an unmet healthcare need (aOR 1.38, 95% CI 0.23 to 8.29)., Conclusions: Loneliness was related to unmet healthcare needs in the previous 12 months, which may suggest that those without robust social connections experience challenges accessing health services. Gender-related differences in loneliness and unmet needs must be further examined in larger samples., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: This population-based observational study explores the associations between individual-level and neighbourhood-level indices of active living with inpatient mental healthcare use among adults with an underlying chronic cardiometabolic condition., Design and Setting: Data from the 2013-2014 Canadian Community Health Survey were linked longitudinally to hospital records from the 2013/2014‒2017/2018 Discharge Abstract Database and to a geocoded measure of active living environments (ALE). Relationships between individuals' leisure-time physical activity and neighbourhood ALE with risk of hospital admission for mental health disorders were assessed using multivariable Cox regressions., Participants: A national cohort was identified from the survey data of 24 960 respondents aged 35 years and above reporting having been diagnosed with diabetes, hypertension and/or heart disease., Outcome Measure: Potentially avoidable hospitalisation for a mood, anxiety or substance use disorder over a 5-year period., Results: More than half (52%) of adults aged 35 years and above with a cardiometabolic disease were physically inactive in their daily lives, and one-third (34%) resided in the least activity-friendly neighbourhoods. The rate of being hospitalised at least once for a comorbid mental disorder averaged 8.1 (95% CI: 7.0 to 9.3) per 1000 person-years of exposure. Individuals who were at least moderately active were half as likely to be hospitalised for a comorbid mental health problem compared with those who were inactive (HR: 0.50 (95% CI: 0.38 to 0.65)). No statistically discernible associations between neighbourhood ALE and hospitalisation risks were found after controlling for individuals' behaviours and characteristics, including in separate models stratified by age group and by sex., Conclusions: The evidence base to support prioritisation of interventions focusing on the built environment favouring mental health-promoting physical activity among higher-risk adults at the population level, independently of individual-level behaviours and characteristics, remains limited., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: People experiencing homelessness and mental illness face multiplebarriers to care. The goal of this study was to examine the association between health service use and indicators of need among individuals experiencinghomelessness and mental illness in Vancouver, Canada. We hypothesized that those with more severe mental illnesswould access greater levels of primary and specialist health services than those with less severe mental illness. Methods: Participants met criteria for homelessness and current mental disorder using standardized criteria (n = 497).Interviews assessed current health status and involvement with a variety of health services including specialist, general practice, and emergency services. The 80th percentile was used to differentiate ‘low health service use' and ‘high healthservice use'. Using multivariate logistic regression analysis, we analyzedassociations between predisposing, enabling and need-related factors with levels of primary and specialist health service use. Results: Twenty-one percent of participants had high primary care use, and 12% had high use of specialist services. Factors significantly (p ≤ 0.05) associated with high primary care use were: multiple physical illnesses [AOR 2.74 (1.12, 6.70]; poor general health [AOR 1.68 (1.01, 2.81)]; having a regular family physician [AOR 2.27 (1.27, 4.07)]; and negative social relationships [AOR 1.74 (1.01, 2.99)]. Conversely, having a more severe mental disorder (e.g. psychotic disorder) was significantly associated with lower odds of high service use [AOR 0.59 (0.35, 0.97)]. For specialist care, recent history of psychiatric hospitalization [AOR 2.53 (1.35, 4.75)] and major depressive episode [AOR 1.98 (1.11, 3.56)] were associated with high use, while having a blood borne infectious disease (i.e., HIV, HCV, HBV) was associated with lower odds of high service use. Conclusions: Contrary to our hypotheses, we found that individuals with greater assessed need, including more severe mental disorders, and blood-borne infectious diseases had significantly lower odds of being high health service users than those with lower assessed needs. Our findings reveal an important gap between levels of need and service involvement for individuals who are both homeless and mentally ill and have implications for health service reform in relation to the unmet and complex needs of a marginalized sub-population. (Trial registration: ISRCTN57595077 and ISRCTN66721740). [ABSTRACT FROM AUTHOR]

The article focuses on the health care in Canada which could benefit from its circumpolar neighbours in promoting health equity. It mentions that the Arctic Human Health Expert Group provides an international and policy-based forum that addresses the concern on human health and promotes the sharing of ideas for health improvement. It states that northern Canada needs a reorientation for circumpolar partnerships in building evidence-based policies and to distribute best practices in health care. INSET: KEY POINTS.

Abstract: This article identifies the extent to which demographic, socio-economic and geographic factors account for differences between Inuit and other Northern Canadian residents in health-related behaviours and health service use related to cancer incidence and diagnosis. The study population includes Inuit, Métis, First Nation and non-Aboriginal residents aged 21–65 who live in Nunavut, Northwest Territories, Labrador, Nunavik and Jamésie in northern Quebec, and the northern regions of Saskatchewan and Manitoba. Data are drawn from confidential versions of the 2000–2001 and 2004–2005 Canadian Community Health Surveys and the 2001 Aboriginal People''s Survey produced by Statistics Canada. Multivariate Logistic regression analysis is applied to a set of health-related behaviours including cigarette smoking, binge drinking and obesity, and a set of basic health service use measures including consultation with a physician, consultation with a nurse, Pap smear testing and mammography. We found that significantly higher smoking and binge drinking rates and lower rates of female cancer screening among Inuit are found not to be accounted for by differences in observable demographic and socio-economic characteristics, location of residence or distance from a hospital. As such we conclude that health-related behaviours leading to increased cancer risk and to a lower utilization of diagnostic cancer screening appear to be due to unobserved factors specific to Inuit and their unique social-cultural context. Policy interventions to address these problems may need to be targeted specifically to Inuit Canadians and should not be considered in isolation of their broader health, economic and social environment. [Copyright &y& Elsevier]

An article is presented that reports on the equity of health care in Canada. Canadian health equity can be advanced through improving social factors and determinants that cause disparities such as income, housing, education, and employment stability. The article also discusses health promotions and health indicators related to issues including infant mortality, life expectancy, injuries, and disease incidence. Information is provided on medical policy, insurance, demography, and population health as well.

Abstract: The paper reviews arguments that associations between small area socio-economic conditions and individual health are likely to vary according to the type of health condition considered. We comment on the importance of longitudinal research to examine how far area conditions predict later health outcomes, and also how far area variations in health may result from selective migration processes predicted by health status. Using data for 1996 and 2002, from the National Population Health Survey of Canada, linked to small area data on social and on material deprivation in the area of residence for 6950 survey respondents at the two time points, we report on analyses to address these questions. The area measures of material and social deprivation were previously developed by Pampalon and colleagues at the Institut National de Santé Publique de Québec and related to the dissemination area matching the informant''s postal code. The health outcomes considered were restriction of activity due to chronic conditions and psychological distress. Our findings suggest that individuals living in materially deprived areas in 2002 were more likely to be affected by health conditions resulting in restriction of activity. Prevalence of psychological distress was higher in areas with greater social deprivation in 2002. Most of these area differences were attenuated when adjustment was made for individual socio-demographic characteristics. Measures recorded in 1996 of individual characteristics and measures of deprivation for area of residence were used to predict change in health outcomes by 2002. Several individual factors (sex, age group, income, household composition) in 1996 were predictive of later health outcomes. After controlling for these individual characteristics the only significant association between health change and area deprivation was with development of restricted activity, which was more common among people who, in 1996, had lived in areas that ranked moderately high on material deprivation. We also report some evidence for selective migration effects, though these mainly seem to operate indirectly via socio-economic characteristics that predict both health outcomes and differential migration patterns. The clearest evidence on this point is for those in with psychological distress in 1996, who were particularly likely to move to an area which was more socially or materially deprived by 2002. This supports the idea that area differences in psychological distress are partly the result of selective migration effects. [Copyright &y& Elsevier]

Copyright of Contemporary Issues / Suvremene Teme is the property of Centar za Politoloska Istrazivanja and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

An expansive literature describes the links between social support and health. Though the bulk of this evidence emphasizes the health-enhancing effect of social support, certain aspects can have negative consequences for health (e.g., social obligations). In the Canadian context, the geographically small and socially interconnected nature of First Nation and Inuit communities provides a unique example through which to explore this relationship. Despite reportedly high levels of social support, many First Nation and Inuit communities endure broad social problems, thereby leading us to question the assumption that social support is primarily health protective. We draw from narrative analysis of interviews with 26 First Nation and Inuit Community Health Representatives to critically examine the health and social support relationship, and the social structures through which social support influences health. Findings indicate that there are health-enhancing and health-damaging properties of the health–social support relationship, and that the negative dimensions can significantly outweigh the positive ones. Social support operates at different structural levels, beginning with the individual and extending toward family and community. These social structures are important as they reinforce an individual's sense of belonging, however, these high-density networks can also exert conformity pressures and social obligations that promote health-damaging behaviours such as domestic violence and smoking. The poor material circumstances that characterize so many First Nation and Inuit communities add another layer of complexity as limited resources can trap individuals within the confines of their immediate social contexts. Research and policy interventions must pay close attention to the social context within which social support, health behaviours and material circumstances interact to influence health outcomes among First Nation and Inuit communities. [Copyright &y& Elsevier]

Cardiac disease is the number one killer of Canadian women. Therapy is highly time-dependent, yet treatment-seeking delay persists. The purpose of this grounded theory study was to explore how women seeking treatment for the symptoms of potential cardiac illness interpreted their symptoms, made decisions about seeking treatment, and understood experiences of care in the emergency department. Data were drawn from 100 hours of naturalistic observation, indepth interviews with 16 women who visited one of two urban emergency departments between June 2005 and June 2006, and three interviews with nurses. The basic social psychological process of maintaining integrity was identified, encompassing three distinct phases: "resisting disruption," "suspending agency," and "integrating experiences and knowledge." The findings suggest that in the face of a threat to life, women are first and foremost striving to maintain both the integrity of their sense of self and their ability to carry out role responsibilities. [ABSTRACT FROM AUTHOR]

Abstract: With increasingly fewer family physicians in many countries and students less interested in primary care careers, generalists are becoming an endangered species. This situation is a major health care resource management challenge. In a rapidly changing health care environment, family medicine is struggling for a clear identity—a matter which is crucial to health system restructuring because it affects the roles and functioning of other professions in the system. The objective of our study was to explore representations of roles and responsibilities of family physicians held by future family and specialist physicians and their clinical teachers in four Canadian medical school faculties of medicine, using both focus groups and individual interviews. In addition to family medicine, we targeted residency programs in general psychiatry, radiology and internal medicine—three areas that interface significantly between primary care and specialized medicine. In each faculty, respondents included the vice-dean of postgraduate studies; the director of each relevant program; educators in the program; residents in each specialty in their last year of training. Findings are centred around three major themes: (1) the definition of family medicine; (2) family medicine as an endangered species, and (3) the generation gap between young family physicians and their educators. The sustained physician–patient relationship is considered a core characteristic of family medicine that is much valued by patients and physicians—both generalists and specialists—as something to be preserved in any model of collaboration to be developed. Overall, two divergent directions emerge: preserving all the professions'' traditional functions while adapting to changing contexts, or concentrating on areas of expertise and moving towards creating “specialist” general practitioners, in response to a rapidly expanding scope of practice, and to the high value attributed to specialization by society and the professional system. [Copyright &y& Elsevier]

The study of integration of different medical practices in Western industrialized nations such as Canada has garnered intense scholarly attention. The aim of this article is to problematize the ongoing emphasis on a single, bio-scientific evidence base to assess the efficacy and safety standards of complementary/alternative medical (CAM) practices. Since mainstream health care practitioners as well as many integrative health care proponents in Canada emphasize the biomedical framework in defining evidence bases, I argue that this orientation creates three main paradoxes of CAM integration into mainstream health care: i) a hierarchy of value between the Western biomedical paradigm and other legitimate CAM epistemologies; ii) the biomedicalization of CAM practices, and iii) an integrative health care system that only considers bio-scientific evidence. Through preliminary ethnographic research with Traditional Chinese Medicine (TCM) practitioners in Ontario, Canada, I conclude that further collaborative research with practitioners of various medical traditions who integrate CAM into their regular practices is necessary to identify more encompassing types of evidence to evaluate the safety and efficacy of any therapeutic modality. Such a broader conceptual framework will facilitate a truly symmetrical and integrative health care system in which the contributions to health and wellness from different epistemologies meet diverse health care needs. [ABSTRACT FROM AUTHOR]

The article focuses on the issue regarding medical care of chronic disease in Canada. It is pointed out that the personal economic burden of chronic disease and illness is a serious challenge for Canadians in which public policy has strong focus emphasizing health system redesign. Moreover, it discusses the nature of conditions of chronic disease, chronic care model, variations of care strategies, principles of family medicine and framework for chronic care.

Elderly people from ethnic minority groups often experience different barriers in accessing health services. Earlier studies on access usually focused on types and frequency but failed to address the predictors of service barriers. This study examined access barriers to health services faced by older Chinese immigrants in Canada. Factor analysis results indicated that service barriers were related to administrative problems in delivery, cultural incompatibility, personal attitudes, and circumstantial challenges. Stepwise multiple regression showed that predictors of barriers include female gender, being single, being an immigrant from Hong Kong, shorter length of residency in Canada, less adequate financial status, not having someone to trust and confide in, stronger identification with Chinese health beliefs, and not self-identified as Canadian. Social work interventions should strengthen support and resources for the vulnerable groups identified in the findings. Service providers should adjust service delivery to better serve elderly immigrants who still maintain strong Chinese cultural values and beliefs. [ABSTRACT FROM AUTHOR]

Copyright of Recherches Sociographiques is the property of Recherches Sociographiques and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

This paper addresses cultural dimensions of end-of-life care in Canada and the USA. In both countries contemporary health care providers commonly encounter patients with quite variable understandings of what constitutes compassionate end-of-life care. Participation in particular ethnic and religious groups can have a significant effect upon how patients and their families communicate with health care providers, make decisions about treatment alternatives, engage in advance care planning, and frame moral deliberations. Much of the contemporary literature in the field of bioethics emphasizes the importance of truth telling, the principle of autonomy and the significance of patient choice, the value of advance care planning, and the right to have treatment withdrawn or withheld. However, a growing body of scholarship on the cultural dimensions of end-of-life care reveals a plurality of attitudes towards what constitutes appropriate forms of communication and decision making. While there are limits to the kind of social practices and moral claims that should be accommodated in liberal democracies, health care providers should take steps to ensure that they are providing culturally sensitive end-of-life care. [ABSTRACT FROM AUTHOR]

Explores the role of contextual influences in shaping community health-care decision-making processes in Ontario, Canada. Social and structural contexts of community participation; Promotion of community participation by institutional actions; Issue of hospital closure threats.

Objectives: In Canada, individuals experiencing homelessness (IEH) rely on public health and social services for healthcare, food and basic necessities. The COVID-19 pandemic has disproportionately affected marginalised populations, in part by impacting their access to such services. We performed a scoping review to identify from the published literature how access to services has changed for Canadian IEH during the pandemic., Data Sources: OVID Medline, Web of Science, Sociological Abstracts, CINAHL and OVID EmCare databases, and websites for the Salvation Army, Homeless Hub, Canadian Alliance to End Homelessness, Canadian Network for the Health and Housing of People Experiencing Homelessness and BC Centre for Disease Control., Study Design: We used the scoping review methodology developed by the Joanna Briggs Institute framework and defined access to healthcare and social services using the 10-component Levesque framework. Academic databases and grey literature searches were used, with the final searches for each taking place 24 May and 1 June 2021, respectively. Data were compiled into an Excel spreadsheet. Title and abstract screening and full-text review were completed by two independent reviewers (RG and MM). Data extraction was completed by MM and cross checked by RG., Results: In total, 17 academic and grey literature articles were included. Positive and negative changes in service access were reported in the literature. During the COVID-19 pandemic, access to social and healthcare resources was generally reduced for Canadian IEH. A new component of access, digital connectivity, was identified. Unexpectedly, coordination and collaboration of services improved, as did the number of outreach services., Conclusions: Positive changes to service access such as improved coordination of services should be scaled up. Further work should be done to improve access to digital technologies for IEH., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Behavioural activation (BA) is an effective treatment for depression; however, it is unclear if it can be used to manage pain., Objectives: To conduct a scoping review of primary research that reported using BA to support people living with chronic pain to understand how BA had been used in relation to pain. In addition, we wanted to understand whether there were any reported changes in that pain, and how and who delivered BA., Eligibility Criteria: Primary research published in English., Sources of Evidence: We searched seven databases MEDLINE, Ovid Embase, Ovid Emcare, PsycINFO, CINAHL, Scopus and Web of Science, for primary research. No initial date limit was used with the date the searches were conducted used as the end date limit (1 July 2021)., Charting Methods: A customised data extraction table was developed, piloted and used., Results: 551 papers were screened for inclusion, with 15 papers included in our review. Studies were conducted in North America and in Canada. These included three case studies, nine uncontrolled trials and three randomised controlled trials. Only two studies reported pain as the primary outcome. BA was applied across a range of pain related conditions. The dose of BA ranged from 3 to 16 sessions. Duration of treatment was 3 weeks to 12 months. Most studies reported reductions in pain following exposure to BA., Conclusion: BA has the potential to reduce pain. Caution needs to be exercised in the interpretation of these findings as a high risk of bias was observed in most studies. High-quality research is required to test if BA is an effective intervention for chronic pain., Competing Interests: Competing interests: GLM has received support from: Reality Health, ConnectHealth UK, Seqirus, Kaiser Permanente, Workers’ Compensation Boards in Australia, Europe and North America, AIA Australia, the International Olympic Committee, Port Adelaide Football Club, Arsenal Football Club, all for work related to pain and performance management. Professional and scientific bodies have reimbursed him for travel costs related to presentation of research on pain at scientific conferences and symposia. He has received speaker fees for lectures on pain and rehabilitation. He receives book royalties from NOIgroup publications, Dancing Giraffe Press & OPTP, for books on pain science, education and rehabilitation., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: To successfully combat COVID-19 vaccine hesitancy and increase uptake, research has demonstrated that interventions are most effective when tailored to meet local needs through active engagement and co-development with communities. This mixed-methods project uses a human-centred design (HCD) approach to understand local perspectives of COVID-19 vaccine hesitancy and develop strategies to enhance vaccine confidence for children and adolescents., Methods and Analysis: Project ECHO (Étude Communautaire sur l'Hésitation vaccinale contre la COVID-19) combines population-based surveys of parents and adolescents with community-based participatory action research to design and pilot strategies to enhance COVID-19 vaccine confidence in two underserved and ethnoculturally diverse neighbourhoods of Montreal, Canada. Two surveys conducted 6 months apart through primary and secondary schools are used to monitor vaccine acceptance and its social determinants among children and youth. Analyses of survey data include descriptive and inferential statistical approaches. Community-led design teams of parents and youth from the two participating neighbourhoods, supported by academic researchers, design thinking experts and community partners, use an HCD approach to: (1) gather data to understand COVID-19 vaccine decision-making among parents and youth in their community and frame a design challenge (inspiration phase); (2) develop an intervention to address the design challenge (ideation phase) and (3) pilot the intervention (implementation phase). Strategies to evaluate the community-led interventions will be co-developed during the implementation phase., Ethics and Dissemination: This study has been approved by the research ethics boards of the Sainte-Justine University Hospital Centre and the University of Montreal. Community design teams will be involved in the dissemination of findings and the design of knowledge translation initiatives that foster dialogue related to COVID-19 vaccination for children and adolescents among community, school and public health stakeholders. Findings will be disseminated through peer-reviewed publications, conference presentations, community forums, policy briefs, and social media content., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The CAEP 2021 2SLGBTQIA + i panel sought whether a gap exists within Canadian emergency medicine training pertaining to sexual and gender minority communities. This panel aimed to generate practical recommendations on improving emergency medicine education about sexual and gender minorities, thereby improving access to equitable healthcare., Methods: From August 2020 to June 2021, a panel of emergency medicine practitioners, residents, students, and community representatives met monthly via videoconference. A literature review was undertaken, and three mixed methods surveys were distributed to the CAEP member list, CAEP Resident Section, College of Family Physicians of Canada (CFPC) iii Emergency Medicine Members Interest Group, and to emergency medicine residency program directors and their residents. Informed by the review and surveys, recommendations were drafted and refined by panel members before presentation at the 2021 CAEP Academic Symposium. A plenary was presented to symposium attendees composed of national emergency medicine community members, which reported the survey results and literature review. All attendees were divided into small groups to develop an action plan for each recommendation., Conclusions: The panel outlines eight recommendations for closing the curricular gap. It identifies three perceived or real barriers to the inclusion of sexual and gender minority content in emergency medicine residency curricula. It acknowledges three enabling recommendations that are beyond the scope of individual emergency medicine programs or emergency departments (EDs), that if enacted would enable the implementation of the recommendations. Each recommendation is accompanied by two action items as a guide to implementation. Each of the three barriers is accompanied by two action items that offer specific solutions to overcome these obstacles. Each enabling recommendation suggests an action that would shift emergency medicine towards sociocultural competence nationally. These recommendations set the primary steps towards closing the educational gap., (© 2022. The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

Discusses whether or not the health care system of Canada, can serve as an appropriate model from which the U.S. can improve its own system. Basic outline of Canada's national health insurance system; Rationing of medical care; Availability of selected medical technologies; Concentration of finance in provincial ministries of health.

Objectives: Children from low-income households are at an increased risk of social, behavioural and physical health problems. Prior studies have generally relied on dichotomous outcome measures. However, inequities may exist along the range of outcome distribution. Our objective was to examine differences in distribution of three child health outcomes by income categories (high vs low): body mass index (BMI), behaviour difficulties and development., Design and Setting: This was a cross-sectional study using data from a primary care-based research network with sites in three Canadian cities, and 15 practices enrolling participants., Participants, Independent Variable and Outcomes: The independent variable was annual household income, dichotomised at the median income for Toronto (<$C80 000 or ≥$C80 000). Outcomes were: (1) growth (BMI z-score (zBMI) at 5 years, 1628 participants); (2) behaviour (Strengths and Difficulties Questionnaire (SDQ) at 3-5 years, 649 participants); (3) development (Infant Toddler Checklist (ITC) at 18 months, 1405 participants). We used distributional decomposition to compare distributions of these outcomes for each income group, and then to construct a counterfactual distribution that describes the hypothetical distribution of the low-income group with the predictor profile of the higher-income group., Results: We included data from 1628 (zBMI), 649 (SDQ) and 1405 (ITC) children. Children with lower family income had a higher risk distribution for all outcomes. For all outcomes, thecounterfactual distribution, which represented the distribution of children with lower-income who were assigned the predictor profile of the higher-income group, was more favourable than their observed distributions., Conclusion: Comparing the distributions of child health outcomes and understanding different risk profiles for children from higher-income and lower-income groups can offer a deeper understanding of inequities in child health outcomes. These methods may offer an approach that can be implemented in larger datasets to inform future interventions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Previous studies on depression in rural areas have yielded conflicting results. Features of rural areas may be conducive or detrimental to mental health. Our objective for this study was to determine if there are rural-urban disparities in depressive symptoms between those living in rural and urban areas of Canada., Design: We conducted a cross-sectional analysis of a prospective cohort study, which is as representative as possible of the Canadian population-the Tracking Cohort of the Canadian Longitudinal Study on Aging. For this cohort, data were collected from 2010 to 2014. Data were analysed and results were obtained in 2020., Participants: 21 241 adults aged 45-85., Measures: Rurality was grouped as urban (n=11 772); peri-urban (n=2637); mixed (n=2125; postal codes with both rural and urban areas); and rural (n=4707). Depressive symptoms were measured using the 10-item Center for Epidemiological Studies-Depression. We considered age, sex, education, marital status and disease states as potential confounding factors., Results: The adjusted beta coefficient was -0.24 (95% CI -0.42 to -0.07; p=0.01) for rural participants, -0.17 (95% CI -0.40 to 0.05; p=0.14) for peri-urban participants and -0.30 (95% CI -0.54 to -0.05; p=0.02) for participants in mixed regions, relative to urban regions. Risk factors associated with depressive symptoms were similar in rural and urban regions., Conclusions: The small differences in depressive symptoms among those living in rural and urban regions are unlikely to be relevant at a clinical or population level. The findings do suggest some possible approaches to reducing depressive symptoms in both rural and urban populations. Future research is needed in other settings and on change in depressive symptoms over time., Competing Interests: Competing interests: PDSJ reports receiving a Catalyst Grant (50240) from the Canadian Institutes of Health Research for the conduct of the study. The other authors declare that there is no conflict of interest., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

An essay is presented on the health care system in Canada. The author addresses the debate over the direction of the country's health care reform. They believe the Canadian medical care system needs to be reformed. They mention different societal issues related to health care reform. They emphasize the need for citizen engagement and greater resolve from the Canadian government to protect public values.

Objectives: People experiencing homelessness have a high prevalence and incidence of traumatic brain injury (TBI) due to violence. Little is known about the effectiveness of interventions to reduce TBI in this population. This study assessed the effect of Housing First (HF) on violence-related TBI in adults with experiences of homelessness and mental illness., Design: Pragmatic randomised trial., Participants: 381 participants in the Toronto site of the At Home/Chez randomised trial., Intervention: HF participants were provided with scattered-site housing using rent supplements and supports from assertive community treatment or intensive case management teams (n=218, 57.2%). Control participants had access to treatment as usual (TAU) in the community (n=163, 42.8%)., Main Outcome Measures: Primary outcomes were an incident physical violence-related TBI event and the number of physical violence-related TBI events during the follow-up period (January 2014 to March 2017). Interval-censored survival time regression and zero-inflated negative binomial regression were used to assess the effect of HF on primary outcomes., Results: Among study participants, 9.2% (n=35) had an incident physical violence-related TBI event, and the mean physical violence-related TBI events was 0.16 (SD ±0.6). Compared with TAU participants, HF participants did not have a significantly lower risk of an incident violence-related TBI event (adjusted HR : 0.58 (95% CI, 0.29 to 1.14)), but they had a significantly lower number of physical violence-related TBI events (unadjusted incidence rate ratio (IRR): 0.22 (95% CI, 0.06 to 0.78); adjusted IRR: 0.15 (95% CI, 0.05 to 0.48))., Conclusion: HF may be a useful intervention to reduce the burden of TBI due to physical violence among homeless individuals with mental illness., Trial Registration Number: ISRCTN42520374., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Community engagement practices in Indigenous health research are promoted as a means of decolonising research, but there is no comprehensive synthesis of approaches in the literature. Our aim was to assemble and qualitatively synthesise a comprehensive list of actionable recommendations to enhance community engagement practices with Indigenous peoples in Canada, the USA, Australia and New Zealand., Design: Integrative review of the literature in medical (Medline, Cumulative Index to Nursing and Allied Health Literature and Embase) and Google and WHO databases (search cut-off date 21 July 2020)., Article Selection: Studies that contained details regarding Indigenous community engagement frameworks, principles or practices in the field of health were included, with exclusion of non-English publications. Two reviewers independently screened the articles in duplicate and reviewed full-text articles., Analysis: Recommendations for community engagement approaches were extracted and thematically synthesised through content analysis., Results: A total of 63 studies were included in the review, with 1345 individual recommendations extracted. These were synthesised into a list of 37 recommendations for community engagement approaches in Indigenous health research, categorised by stage of research. In addition, activities applicable to all phases of research were identified: partnership and trust building and active reflection., Conclusions: We provide a comprehensive list of recommendations for Indigenous community engagement approaches in health research. A limitation of this review is that it may not address all aspects applicable to specific Indigenous community settings and contexts. We encourage anyone who does research with Indigenous communities to reflect on their practices, encouraging changes in research processes that are strengths based., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To evaluate sex-specific and age-specific associations of active living environments (ALEs) with premature cardiometabolic mortality., Design: Population-based retrospective cohort study., Setting: Residential neighbourhoods (1000-metre circular buffers from the centroids of dissemination areas) across Canada for which the Canadian ALE Measure was derived, based on intersection density, points of interest and dwelling density., Participants: 249 420 survey respondents from an individual-level record linkage between the Canadian Community Health Survey (2000-2010) and the Canadian Mortality Database until 2011, comprised of older women (65-85 years), older men (65-81 years), middle-aged women (45-64 years) and middle-aged men (45-64 years)., Primary Outcome Measures: Premature cardiometabolic mortality and average daily energy expenditure attributable to walking. Multivariable proportional hazards regression models were adjusted for age, educational attainment, dissemination area-level median income, smoking status, obesity, the presence of chronic conditions, season of survey response and survey cycle., Results: Survey respondents contributed a total of 1 451 913 person-years. Greater walking was observed in more favourable ALEs. Walking was associated with lower cardiometabolic death in all groups except for middle-aged men. Favourable ALEs conferred a 22% reduction in death from cardiometabolic causes (HR 0.78, 95% CI 0.63 to 0.97) for older women., Conclusions: On average, people walk more in favourable ALEs, regardless of sex and age. With the exception of middle-aged men, walking is associated with lower premature cardiometabolic death. Older women living in neighbourhoods that favour active living live longer., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To examine the relationship between developmental health and neighbourhood socioeconomic status (SES) in kindergarten children with disabilities., Design: Cross-sectional study using population-level database of children's developmental health at school entry (2002-2014)., Setting: 12 of 13 Canadian provinces/territories., Measures: Taxfiler and Census data between 2005 and 2006, respectively, were aggregated according to custom-created neighbourhood boundaries and used to create an index of neighbourhood-level SES. Developmental health outcomes were measured for 29 520 children with disabilities using the Early Development Instrument (EDI), a teacher-completed measure of developmental health across five domains., Analysis: Hierarchical generalised linear models were used to test the association between neighbourhood-level SES and developmental health., Results: All EDI domains were positively correlated with the neighbourhood-level SES index. The strongest association was observed for the language and cognitive development domain (β (SE): 0.29 (0.02)) and the weakest association was observed for the emotional maturity domain (β (SE): 0.12 (0.01))., Conclusions: The magnitude of differences observed in EDI scores across neighbourhoods at the 5th and 95th percentiles are similar to the effects of more established predictors of development, such as sex. The association of SES with developmental outcomes in this population may present a potential opportunity for policy interventions to improve immediate and long-term outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: HIV-associated neurocognitive disorder (HAND) may affect 30%-50% of people ageing with HIV. HAND may increase stress and anxiety, and impede coping. Psychosocial group therapy may ameliorate HAND's symptoms, yet the ideal intervention is unclear. This protocol outlines a pilot randomised controlled trial (RCT)-designed using community-based participatory research-to pilot cognitive remediation group therapy (CRGT) against an active comparator., Methods and Analysis: This is a pilot, parallel design, two-arm RCT that will recruit participants diagnosed with the mild neurocognitive disorder form of HAND from a neurobehavioural research unit at a tertiary care hospital in Toronto, Canada. Eligibility criteria include age ≥40 years, known HIV status for 5+ years, English fluency, able to consent and able to attend 8 weeks of group therapy. Eligible participants will be randomised to one of two treatment arms, each consisting of eight-session group interventions delivered once weekly at 3 hours per session. Arm 1 (novel) is CRGT, combining mindfulness-based stress reduction with brain training activities. Arm 2 (active control) is mutual aid group therapy. The primary outcomes are feasibility, measured by proportions of recruitment and completion, and acceptability, determined by a satisfaction questionnaire. The secondary outcome is intervention fidelity, where content analysis will be used to assess facilitator session reports. A between-group analysis will be conducted on exploratory outcomes of stress, anxiety, coping and use of intervention activities that will be collected at three time points., Ethics and Dissemination: Ethical approval was obtained from the Research Ethics Boards of St. Michael's Hospital and the University of Toronto. Findings will be disseminated through peer-reviewed publications, conference presentations and community reporting. This study could provide insight into design (eg, recruitment, measures) and intervention considerations (eg, structure, content) for a larger trial to lessen the burden of cognitive decline among people ageing with HIV., Trial Registration Number: NCT03483740; Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To pilot a peer-based intervention for people living with HIV who used substances, had challenges with antiretroviral adherence and would be discharged from hospital to community., Study Design: A community-based, quasi-experimental pilot intervention study designed to assess feasibility, acceptability and connection to a community-based HIV organisation., Setting: This study was conducted in Toronto, Canada, at Casey House (CH; hospital for people living with HIV) in collaboration with the AIDS Committee of Toronto (ACT; community-based HIV organisation)., Participants: People living with HIV who were CH inpatient between 1 April 2017 and 31 March 2018, struggled with antiretroviral adherence, actively used substances and would be discharged to community were eligible. Forty people met criteria, 19 were approached by an inpatient nurse and 17 consented. Average age was 48.8 years (SD=11.4), 58.8% were male and participants averaged 7.8 physical and mental health comorbidities (SD=3.1)., Intervention: Titled 'The ART of Conversation', the three-pronged personalised intervention was developed through input from CH clients and ACT volunteers, all living with HIV. Intervention components were (a) predischarge goal-setting (adherence, substance use and self-identified goal) with the study nurse; (b) predischarge meeting with an HIV+ peer volunteer (PV) and (c) nine postdischarge phone calls between PV and participant, once per day for 3 days, then once per week for 6 weeks., Primary Outcomes: Feasibility was measured through proportion of eligible participants recruited and PV availability. Acceptability was assessed through participant interviews at three times (preintervention, post-intervention and 6 weeks follow-up) and through PV call logs. Client records determined connection to ACT within the study timeframe., Results: Twelve participants completed the intervention and nine connected with ACT. Predischarge goal-setting and PV meeting were both feasible and acceptable. Postdischarge phone calls were a challenge as half of completers missed at least one call., Conclusions: Although predischarge goal-setting and PV meeting were feasible, methods to maintain connection following discharge require further investigation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The article discusses significance of major determinants of health other than the healthcare system. It states findings of the report "Health Care in Canada: What Makes Us Sick?" by Canadian Medical Association, which inferred that most major determinants of health lie outside the health system, and mentions that according to a policy study, factors like behavior, social circumstance, and physical environment, have more prominent role in health than the medical care system.

Introduction: Older adults are the fastest growing age group in Canada. Elder abuse has significant individual and societal implications, so it is critical to address. While interest in this topic is increasing, little is known about the risk factors for elder abuse in immigrant communities in Canada, or about culturally relevant strategies to address these risk factors., Methods and Analysis: This mixed-methods study is guided by the intersectionality and ecological frameworks. We will include two long-term (ie, established) and two recent immigrant communities from East Asian and South Asian communities in the Greater Toronto Area: Chinese, Korean, Punjabi and Tamil. Through structured group interviews, we will first identify factors that contribute to elder abuse within and across each of the immigrant communities and then explore culturally relevant strategies to address those risk factors. Group interviews will be conducted separately with five stakeholder groups in each of the four languages: older women, older men, family members, community leaders and service providers. Quantitative and qualitative data will be analysed at the level of the particular interview groups, subgroups and communities, and will be integrated across communities to identify common and unique risk factors and strategies to address elder abuse., Ethics and Dissemination: The study protocol has received ethics approval from the two universities associated with the research team. Given the comprehensive approach to incorporate local knowledge and expert contributions from multi-level stakeholders, the empirical and theoretical findings will facilitate practice change and improve the well-being of older men and women in immigrant communities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Immigrants are thought to be healthier than their native-born counterparts, but less is known about the health of refugees or forced migrants. Previous studies often equate refugee status with immigration status or country of birth (COB) and none have compared refugee to non-refugee immigrants from the same COB. Herein, we examined whether: (1) a refugee mother experiences greater odds of adverse maternal and perinatal health outcomes compared with a similar non-refugee mother from the same COB and (2) refugee and non-refugee immigrants differ from Canadian-born mothers for maternal and perinatal outcomes., Design: This is a retrospective population-based database study. We implemented two cohort designs: (1) 1:1 matching of refugees to non-refugee immigrants on COB, year and age at arrival (±5 years) and (2) an unmatched design using all data., Setting and Participants: Refugee immigrant mothers (n=34 233), non-refugee immigrant mothers (n=243 439) and Canadian-born mothers (n=615 394) eligible for universal healthcare insurance who had a hospital birth in Ontario, Canada, between 2002 and 2014., Primary Outcomes: Numerous adverse maternal and perinatal health outcomes., Results: Refugees differed from non-refugee immigrants most notably for HIV, with respective rates of 0.39% and 0.20% and an adjusted OR (AOR) of 1.82 (95% CI 1.19 to 2.79). Other elevated outcomes included caesarean section (AOR 1.04, 95% CI 1.00 to 1.08) and moderate preterm birth (AOR 1.08, 95% CI 0.99 to 1.17). For the majority of outcomes, refugee and non-refugee immigrants experienced similar AORs when compared with Canadian-born mothers., Conclusions: Refugee status was associated with a few adverse maternal and perinatal health outcomes, but the associations were not strong except for HIV. The definition of refugee status used herein may not sensitively identify refugees at highest risk. Future research would benefit from further refining refugee status based on migration experiences., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: To determine the feasibility of a Community-Based Participatory Tobacco Dependence Strategy (PROMPT) in the inner city population of Ottawa (Canada)., Design: A feasibility mixed methods prospective cohort study following principles of community-based participatory action research., Intervention: Recruited 80 people whouse drugs, followed them for 6 months while providing access to counselling, nicotine replacement therapy and peer-support in a community setting., Setting: Community research office in downtown Ottawa, adjacent to low-income housing, shelter services and street-based drug consumption., Primary Outcome: Retention rate at 6-month follow-up., Secondary Outcome: Biochemically validated 7-day point prevalence smoking abstinence at 26 weeks, self-reported abstinence in the past 7 days with exhaled carbon monoxide ≤10 ppm., Results: The average age of participants was 43.8 years. The 6-month follow-up rate was 42.5%. The mean number of smoking years reported was 27.3 years. The participants were 70% male, 33.7% reported less than a high-school education, 21% identified as indigenous and 43.8% reported an income between US$1000 and US$1999 per month. The baseline mean daily cigarette use was 20.5 and 9.3 cigarettes at study end, with mean reduction of 11.2 cigarettes at 6 months (P=0.0001). There was a considerable reduction in self-reported illicit substance use (18.8%), including a reduction in the opioids heroin (6.3%), fentanyl (2.6%) and Oxycontin (3.8%). The study findings also reveal psycho-socioeconomic benefits such as improved health, return to work and greater community engagement., Conclusions: The PROMPT project describes socioeconomic variables associated with tobacco and polysubstance use. A programme focused on tobacco dependence, easily accessible in the community and led by community peers with lived experience is feasible to implement and has the potential to support positive life changes. PROMPT's patient engagement model is an effective harm-reduction strategy for the growing opioid use crisis and can improve the health outcomes of marginalised at-risk populations worldwide., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Determines the copies of ethics applications that are required by university faculties of medicine in Canada. Evaluation of the Web sites of each university in Canada that had a faculty of medicine or equivalent courses; Correlations between the number of copies required by a research ethics board and the longitude of the location of the faculty of medicine.