Health disparities in Canada today: some evidence and a theoretical framework

Factors Associated with the Uptake of HIV Testing in Canada: Evidence from a Nationally Representative Study

In this study, we explore the factors associated with the uptake of HIV testing at the national level in Canada. Using the 2015-16 Canadian Community Health Survey and applying logistic regression analysis, we examine the associations between HIV testing and factors identified by the Andersen's behavioral model of healthcare utilization. We find that a range of predisposing, enabling, and need factors are significantly associated with HIV testing. For example, compared to the oldest respondents (i.e. 55-64), their younger counterparts (i.e. 45-54, 35-44, and 25-34) are more likely to have been tested for HIV. Compared to those in Atlantic Canada, respondents in Quebec (OR = 1.96, p < .001), Ontario (OR = 1.44, p < .001), Prairies (OR = 1.37, p < .001), British Columbia (OR = 1.99, p < .001), and the Territories (OR = 2.22, p < .001) are all more likely to have been tested for HIV. Based on these findings, we provide several important suggestions for policymakers and future research.

Traditional activities and general and mental health of adult Indigenous peoples living off-reserve in Canada

Introduction

We examined associations between traditional Indigenous activities and self-perceived general and mental health in adult Indigenous persons living off-reserve in Canada using the 2012 and 2017 Aboriginal Peoples Surveys (APS), the two most recent datasets. We utilized four traditional Indigenous activities including hunting, making clothes or footwear, making arts or crafts, and gathering wild plants to investigate these self-reported data.

Methods

Data from 9,430 and 12,598 respondents from the 2012 and 2017 APS, respectively, who responded to 15 questions concerning traditional activities were assessed using multivariable logistic regression to produce odds ratios (OR) and 95% confidence intervals (CI). Covariates included age, sex, education-level, income-level, Indigenous identity, residential school connection, ability to speak an Indigenous language, smoking status, and alcohol consumption frequency.

Results

Using the 2012 APS, clothes-making was associated with poor self-reported general (OR = 1.50, 95%CI: 1.12-1.99) and mental (OR = 1.59, 95%CI: 1.14-2.21) health. Hunting was associated with good mental health (OR = 0.71 95%CI: 0.56-0.93). Similarly, 2017 analyses found clothes-making associated with poor general health (OR = 1.25, 95%CI: 1.01-1.54), and hunting associated with good general (OR = 0.76, 95%CI: 0.64-0.89) and mental (OR = 0.69, 95%CI: 0.58-0.81) health. Artmaking was associated with poor general (OR = 1.37, 95%CI: 1.17-1.60) and mental (OR = 1.85, 95%CI: 1.58-2.17) health.

Conclusion

Hunting had protective relationships with mental and general health, which may reflect benefits of participation or engagement of healthier individuals in this activity. Clothes-making and artmaking were associated with poor general and poor mental health, possibly representing reverse causation as these activities are often undertaken therapeutically. These findings have implications for future research, programs and policies concerning Indigenous health.

The methods of improving cultural sensitivity of depression scales for use among global indigenous populations: a systematic scoping review

Cultural adaptation of psychometric measures has become a process aimed at increasing acceptance, reliability, and validity among specific Indigenous populations. We present a systematic scoping review to: (1) identify the depression scales that have been culturally adapted for use among Indigenous populations worldwide, (2) globally report on the methods used in the cultural adaptation of those scales, and (3) describe the main features of those cultural adaptation methods. We included articles published from inception to April 2021, including 3 levels of search terms: Psychometrics, Indigenous, and Depression. The search was carried out in the Ovid Medline, PubMed, Embase, Global Health, PsycINFO, and CINAHL databases, following PRISMA guidelines. We identified 34 reports on processes of cultural adaptation that met the criteria. The scales were adapted for use among Indigenous populations from Africa, Australia, Asia, North America, and Latin America. The most common scales that underwent adaptation were the Patient Health Questionnaire (PHQ-9), the Center for Epidemiologic Studies Depression Scale (CES-D), and the Edinburgh Postnatal Depression Scale (EPDS). Methods of adaptation involved a revision of the measures' cultural appropriateness, standard/transcultural translation, revision of the administration process, and inclusion of visual supports. Culturally safe administration of scales was reported in some studies. To come to a consensus on most appropriate methods of improving cultural safety of psychometric measurement, most studies utilized qualitative methods or mixed methods to understand the specific community's needs. Revision of linguistic equivalence and cultural relevance of content, culturally safe administration procedures, qualitative methods, and participatory research were key features of developing safe culturally adapted measures for depressive symptoms among Indigenous populations. While for comparability, uniform scales would be ideal as mental health evaluations, an understanding of the cultural impact of measurements and local depression expressions would benefit the process of developing culturally sensitive psychometric scales. PROSPERO registration ID: CRD42023391439.

Critically examining health complexity experienced by urban Indigenous peoples in Canada by exploring the factors that allow health complexity to persist: a qualitative study of Indigenous patients in Calgary, Alberta

OBJECTIVES

This study aims to identify and critically examine the components of health complexity, and explore the factors that allow it to exist, among urban Indigenous peoples in Canada.

DESIGN

Qualitative exploration with relational conversations.

SETTING

Calgary, Alberta, Canada.

PARTICIPANTS

A total of nine urban Indigenous patients were recruited from a multidisciplinary primary healthcare clinic that serves First Nations, Métis and Inuit peoples. Recruitment and data collection took place between September and November 2021.

RESULTS

Thematic analysis revealed three main themes, namely: sources of health complexity, psychological responses to adversity, and resilience, strengths, and protective factors. Key sources of health complexity arose from material resource disparities and adverse interpersonal interactions within the healthcare environment, which manifest into psychological distress while strengths and resilience emerged as protective factors.

CONCLUSION

The healthcare system remains inapt to address complexity among urban Indigenous peoples in Canada. Healthcare violence experienced by Indigenous peoples only further perpetuates health complexity. Future clinical tools to collect information about health complexity among urban Indigenous patients should include questions about the factors defined in this study.

Physical pain among Indigenous Peoples in Canada: a scoping review

PURPOSE

Pain is a multifaceted experience shaped by various factors including context of pain, previous life events, and ongoing ethnocultural circumstances. Moreover, the definition of pain is inconsistent across cultures. Western medicine views physical pain (e.g., associated with a bone fracture) and nonphysical mental pain (e.g., depression) as two distinct conditions. Indigenous perspectives are often more wholistic, encompassing mental, spiritual, emotional, and physical hurt. The subjective nature of pain invites ample opportunity for discrimination in both its assessment and management. As such, it is important to consider Indigenous perspectives of pain in research and clinical practice. To investigate which aspects of Indigenous pain knowledge are currently considered by Western research, we conducted a scoping review of the literature on pain in Indigenous Peoples of Canada.

SOURCE

In June 2021, we searched nine databases and downloaded 8,220 papers after removal of duplicates. Two independent reviewers screened abstracts and full-text articles.

PRINCIPLE FINDINGS

Seventy-seven papers were included in the analysis. Using grounded theory, five themes emerged: pain measures/scales (n = 7), interventions (n = 13), pharmaceuticals (n = 17), pain expression/experiences (n = 45), and pain conditions (n = 70).

CONCLUSION

This scoping review shows that there is a paucity of research on pain measurement in Indigenous Peoples of Canada. This finding is concerning in light of numerous studies reporting that Indigenous Peoples experience their pain as ignored, minimized, or disbelieved. Furthermore, a clear disconnect emerged between pain expression in Indigenous Peoples and assessment in medical professionals. We hope that this scoping review will serve to translate current knowledge to other non-Indigenous academics and to initiate meaningful collaboration with Indigenous partners. Future research led by Indigenous academics and community partners is critically needed to better address pain needs in Canada.

Demographic trends of patients undergoing ophthalmic surgery in Ontario, Canada: a population-based study

OBJECTIVE

In this study, we investigated the demographic trends of patients undergoing ophthalmic surgeries based on geographic region, priority level, and sex.

METHODS AND ANALYSIS

This population-based retrospective cohort study used the Ontario Health Wait Times Information System (WTIS) database from 2010 to 2021. The WTIS contains non-emergent surgical case volume and wait time data for 14 different regions, three priority levels (high, medium and low) and six ophthalmic subspecialty procedures.

RESULTS

Over the study period, on average 83 783 women and 65 555 men underwent ophthalmic surgery annually in Ontario. Overall, women waited an aggregate mean of 4.9 days longer than men to undergo surgery, and this disparity persisted across all geographic and priority stratifications. The average age at the time of surgery has been increasing slowly at a rate of 0.02 years/year (95% CI 0.00 to 0.05), with women being 0.6 years older than men overall.

CONCLUSION

These findings indicate that women have consistently longer wait times than men. The results of this study may be a sign of systemic sex-based differences that could be affecting women who need to be further explored for health equity.

A national-level examination of First Nations peoples’ mental health data: Predicting mental well-being from social determinants of health using the 2017 Aboriginal Peoples Survey

Introduction

A history of colonization and assimilation have resulted in social, economic, and political disparities for Indigenous people in Canada. Decades of discriminatory policies (e.g., the Indian Act, the Residential School System) have led to numerous health and mental health inequities, which have been intergenerationally maintained. Four main social determinants of health (i.e., income, education, employment, and housing) disproportionately influence the health of Indigenous peoples. These four social determinants have also been used within the Community Well-Being (CWB) index, which assesses the socio-economic wellbeing of a community. This study sought to extend previous research by assessing how specific indicators of CWB predict self-reported mental wellbeing within First Nations populations across Canada in a national dataset with more recent data.

Methods

This study utilized the 2017 Aboriginal Peoples Survey, which includes data on the social and economic conditions of First Nations people living off reserve aged 15 years and over.

Results

Results from a factorial ANOVA indicated that perceptions of income security, housing satisfaction, higher education, and employment are associated with increased self-reported mental health among First Nations individuals living off-reserve.

Discussion

These results support the idea that individual mental health interventions on their own are not enough; instead, broader social interventions aimed at addressing inequities in various social determinants of health (e.g., housing first initiatives) are needed to better support individual wellbeing.

How can pediatric surgeons address racism and become actively anti-racist?

BACKGROUND/PURPOSE

This is an article submitted on behalf of the Canadian Association of Pediatric Surgeons. We assert that Pediatric Surgeons must work to dismantle systemic racism. Pediatric Surgeons have expertise in both common and rare surgical diseases affecting patients ranging from premature neonates to adolescents. Thus, our professional obligation is to transform our health and social systems to prevent the harms of racism to our patients.

METHODS

Specific to the Canadian context, we describe a brief history, the ongoing impact on individuals and communities, and the harmful effect on the surgical community and trainees. Finally, we developed a series of practical recommendations to help surgeons become actively anti-racist.

RESULTS

Four primary recommendations are made: (1) Increasing and supporting anti-racism education; (2) Changing individual behaviours to combat racism; (3) Developing strategies for organizational change; and (4) Committing to diversity in leadership.

CONCLUSION

As surgeons, we are actors of change, and we can take meaningful steps to combat racism in our health systems.

LEVEL OF EVIDENCE

V.

A guiding framework for needs assessment evaluations to embed digital platforms in partnership with Indigenous communities

INTRODUCTION

In community-based research projects, needs assessments are one of the first steps to identify community priorities. Access-related issues often pose significant barriers to participation in research and evaluation for rural and remote communities, particularly Indigenous communities, which also have a complex relationship with academia due to a history of exploitation. To bridge this gap, work with Indigenous communities requires consistent and meaningful engagement. The prominence of digital devices (i.e., smartphones) offers an unparalleled opportunity for ethical and equitable engagement between researchers and communities across jurisdictions, particularly in remote communities.

METHODS

This paper presents a framework to guide needs assessments which embed digital platforms in partnership with Indigenous communities. Guided by this framework, a qualitative needs assessment was conducted with a subarctic Métis community in Saskatchewan, Canada. This project is governed by an Advisory Council comprised of Knowledge Keepers, Elders, and youth in the community. An environmental scan of relevant programs, three key informant interviews, and two focus groups (n = 4 in each) were conducted to systematically identify community priorities.

RESULTS

Through discussions with the community, four priorities were identified: (1) the Coronavirus pandemic, (2) climate change impacts on the environment, (3) mental health and wellbeing, and (4) food security and sovereignty. Given the timing of the needs assessment, the community identified the Coronavirus pandemic as a key priority requiring digital initiatives.

CONCLUSION

Recommendations for community-based needs assessments to conceptualize and implement digital infrastructure are put forward, with an emphasis on self-governance and data sovereignty.

Preventable mortality among sexual minority Canadians

Background

Epidemiologic studies point to multiple health inequities among sexual minority people, but few studies have examined mortality. Some causes of death are more preventable than others, and access to prevention is theorized to follow patterns of access to social and material resources. The objective of this study is to compare estimates of preventable mortality between sexual minority (SM)-i.e., bisexual, lesbian, gay-and heterosexual adults in Canada.

Methods

A population-based retrospective cohort with 442,260 (unweighted N) Canadian adults, ages 18-59 years, was drawn from the Canadian Community Health Survey/Canadian Mortality Database linked database (2003-2017). The Rutstein preventability rating index was used to classify cause-specific mortality (low/high). Longitudinal analyses were conducted using Cox proportional hazards models.

Results

SM respondents had higher hazard of all-cause mortality (unadjusted hazard ratio [uHR] 1.28, 95% CI 1.06, 1.55). The uHR increased when the outcome was limited to highly-preventable causes of mortality (uHR 1.43, 95% CI 1.14, 1.80). The uHR further increased in sensitivity analyses using higher thresholds of the Rutstein index. SM respondents had higher hazard of cause-specific mortality for heart disease (uHR 1.53, 95% CI 1.03, 2.29), accidents (uHR 1.97, 95% CI 1.01, 3.86), HIV (uHR 75.69, 95% CI 18.77, 305.20), and suicide (uHR 2.22, 95% CI 0.93, 5.30) but not for cancer (uHR 0.86, 95% CI 0.60, 1.25). The adjusted HR (aHR) for highly-preventable mortality was not attenuated by adjustment for confounders (aHR 1.57, 95% CI 1.20, 2.05) but was reduced by adjustment for hypothesized mediators relating to access to social and material resources (marital status, children, income, education; aHR 1.11, 95% CI 0.78, 1.58).

Conclusions

Preventable mortality was elevated for SM Canadians compared to heterosexuals. Early and broad access to sexual minority-affirming primary and preventive healthcare should be expanded.

Canada First Nations Strengths in Community-Based Primary Healthcare

INTRODUCTION

First Nation (FN) peoples and communities in Canada are still grappling with the effects of colonization. Health and social inequities result in higher disease burden and significant disparities in healthcare access and responsiveness. For resilience, survival, and self-determination, FN are looking inwards for strengths. This paper reports on the cultural, community, and family strengths that have supported FN communities in developing community-based primary healthcare (CBPHC) strategies to support health and wellbeing.

METHODS

The study was a partnership between university-based researchers; The First Nations Health and Social Secretariat of Manitoba; and eight First Nation communities in Manitoba. Community-based participatory research methods were used to engage the participating communities. One hundred and eighty-three in-depth, semi-structured key informant interviews were completed between 2014 and 2016 with key members of the First Nation communities, i.e., community-based health providers and users of primary healthcare services, representing all age and genders. Data-collection and analysis were conducted following iterative grounded theory analysis.

RESULTS

Community-based healthcare models based on local strengths support easier access and shorter wait times for care and compassionate care delivery. Resources such as homecare and medical transportation are helpful. Community cooperation, youth power, responsive leadership, and economic development as well as a strong cultural and spiritual base are key strengths supporting health and social wellbeing.

CONCLUSIONS

Locally led, self-determined care adds strength in FN communities, and is poised to create long-lasting primary healthcare transformation.

Enhancing health and wellness by, for and with Indigenous youth in Canada: a scoping review

BACKGROUND

Indigenous youth in Canada face profound health inequities which are shaped by the rippling effects of intergenerational trauma, caused by the historical and contemporary colonial policies that reinforce negative stereotypes regarding them. Moreover, wellness promotion strategies for these youth are replete with individualistic Western concepts that excludes avenues for them to access holistic practices grounded in their culture. Our scoping review explored strategies, approaches, and ways health and wellness can be enhanced by, for, and with Indigenous youth in Canada by identifying barriers/roadblocks and facilitators/strengths to enhancing wellness among Indigenous youth in Canada.

METHODS

We applied a systematic approach to searching and critically reviewing peer-reviewed literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews [PRISMA-ScR] as a reporting guideline. Our search strategy focused on specific keywords and MeSH terms for three major areas: Indigenous youth, health, and Canada. We used these keywords, to systematically search the following electronic databases published in English between January 01, 2017, to May 22, 2021: Medline [Ovid], PubMed, ERIC, Web of Science, Scopus, and iportal. We also used hand-searching and snowballing methods to identify relevant articles. Data collected were analysed for contents and themes.

RESULTS

From an initial 1695 articles collated, 20 articles met inclusion criteria for this review. Key facilitators/strengths to enhancing health and wellness by, for, and with Indigenous youth that emerged from our review included: promoting culturally appropriate interventions to engage Indigenous youth; using strength-based approaches; reliance on the wisdom of community Elders; taking responsibility; and providing access to wellness supports. Key barriers/roadblocks included: lack of community support for wellness promotion activities among Indigenous youth; structural/organizational issues within Indigenous communities; discrimination and social exclusion; cultural illiteracy among youth; cultural discordance with mainstream health systems and services; and addictions and risky behaviours.

CONCLUSION

This scoping review extracted 20 relevant articles about ways to engage Indigenous youth in health and wellness enhancement. Our findings demonstrate the importance of promoting health by, and with Indigenous youth, by engaging them in activities reflexive of their cultural norms, rather than imposing control measures that are incompatible with their value systems.

Mind the Gap: What Factors Determine the Worse Health Status of Indigenous Women Relative to Men Living Off-Reserve in Canada?

BACKGROUND

Indigenous populations have the poorest health outcomes in Canada. In addition, some studies report notable gender health gaps among Indigenous populations of Canada, with greater disadvantages for Indigenous women. To date, the driving factors behind the health gaps between Indigenous women and men are poorly understood.

METHOD

Using the four available Aboriginal People Surveys (APS) (2001, 2006, 2012, and 2017), we measure gender gaps in good general health (GGH) (i.e. good/very good/excellent self-rated health) among Indigenous adults (age 18 and above) living off-reserve in Canada. We apply the Oaxaca-Blinder (OB) decomposition method to identify the relative contribution of health endowments and the return to these endowments to the gender health gaps among Indigenous peoples.

RESULTS

Indigenous men are found to have a higher rate of GGH than their female counterparts. The gender health gap among Indigenous people has somewhat widened over the period 2001 to 2017. The widening of the gender health gap was observed in all four Indigenous identity groups, viz. registered First Nations, non-registered First Nations, Métis, and Inuit. The OB decomposition suggests that differences in endowments such as employment status and income between men and women explain between 30 to 60% of the gender health gap among Indigenous populations in Canada over the study period.

CONCLUSION

The social determinants of health appear to be the main factor explaining the gender health gap within the Indigenous peoples living in Canada. Policies improving employment opportunities and income among Indigenous women may potentially reduce the gender health gap within Indigenous population in Canada.

Shapeshifters, systems thinking and settler colonial logic: Expanding the framework of analysis of Indigenous health equity

Despite increased attention in the health care field to the disparate health outcomes of Indigenous peoples, inequities persist. Analytical frameworks with the capacity to account for integrated systems analysis of power and domination are underrepresented yet vital to affecting change. Narratives represent Indigenous approaches to systems thinking, yet are often excluded from the literature on theorizing health systems. Recent theorizing in systems thinking provides a conceptual toolkit to interrogate health systems in a way that emphasizes ongoing histories of settler colonialism that underpin determinants of vulnerability, risks and poor health outcomes. Walby's (2007) approach to complexity theory provides an opportunity to re-orient the way health system researchers and practitioneers approach systems of domination in the context of Indigenous peoples' health, including viewing settler colonialism as a shapeshifter who abounds within the possibility of their environment and is a master of time and space. We explore the concepts of attunement and restraint in complexity theory and complex adaptive systems to better understand the movements of shapeshifters. Further, we demonstrate an application of Walby's framework to a narrative, using the highly publicized story of Brian Sinclair, an Indigenous man who died in a Winnipeg Emergency department. Noting how this approach accounts for settler colonial logics in health care system performance, we establish linkages between Walby's articulation of complexity and the fields of Indigenous and Settler Colonial Studies, anchoring this discussion in Indigenous ontology through the metaphor of shapeshifting. By focusing on the systems level, we elucidate the plethora of individual experiences as outcomes of settler colonialism played out within highly complex, adaptive social systems.

Before the door: Comparing factors affecting symptom onset to first medical contact for STEMI patients between a high and low-middle income country

Background

Early reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) has been associated with preservation of left ventricular function and decrease in mortality. Symptom onset to first medical contact (FMC) time consumes the majority of total ischemic time, and remains one of the main reasons that patients do not receive timely care. With FMC to reperfusion time being effectively reduced in many parts of the world, the focus is now shifting to reducing symptom onset to FMC times.

Methods

This mixed-methods observational study was designed to elucidate factors affecting symptom onset to FMC time at a regional cardiac center in a low-middle income country (LMIC) and a high-income country (HIC). A review of the Aswan Heart Center and Hamilton General Hospital STEMI registry in Egypt and Canada was conducted, and retrospective semi-structured questionnaires carried out for a convenience sample of 158 patients.

Results

Gender, symptom type and severity were none-modifiable factors found between early and late presenters. Modifiable factors found were actions of bystanders, actions of patients, transportation method and time. Emotional factors also showed differences between the two groups.

Conclusion

While some concepts are generalizable, contextual differences in demographics, risk factors, access and knowledge are identified. These factors can be used to inform tailored knowledge translation strategies to help reduce symptom onset to FMC in both LMIC and HIC.

Survey Research on Health Inequalities: Exploring the Availability of Indicators of Multiple Forms of Capital in Canadian Datasets

Objective: Much of the extensive quantitative research linking socio-economic position (SEP) and health utilizes three common indicators: income, occupation and education. Existing survey data may enable researchers to include indicators of additional forms of capital in their analyses, permitting more nuanced consideration of the relationship between SEP and health. Our objective was to identify the breadth of survey questions related to economic, cultural, and social capital available through Statistics Canada surveys, and the extent to which those surveys also include health measures. Methods: We compiled a list of all population-based Statistics Canada surveys, and developed a broad list of potential indicators of forms of capital. We systematically searched the surveys for those indicators and health measures, analyzing their co-occurrence. Results: Traditional SEP indicators were present in 73% of surveys containing health measures, while additional indicators of social and cultural capital were available in 57%. Conclusion: Existing national survey data represent an under-exploited opportunity for research examining the relationship between various forms of capital and health in Canada. Future empirical explorations of these data could enrich our theoretical understanding of health inequities.

Counting the Dead: COVID-19 and Mortality in Quebec and British Columbia During the First Wave

The first wave of the COVID-19 pandemic has led to excess mortality across the globe, and Canada has been no exception. Nonetheless, the pandemic experience has been very different across provinces, and the objective of this paper is to investigate these differences focusing on two extreme cases. We contrast the mortality experience of British Columbia with that of Québec to understand how large differences in mortality during the first wave of the pandemic emerged across these two provinces. We find that most of the differences can be found in excess mortality in institutions (nursing homes) and that travel restrictions, differences in how deaths are recorded, differences in the seasonality of the flu, or differences in how the pandemic spread across different economic segments of the population are unlikely explain these large differences. We document that the reported death toll from COVID-19 is about 30% larger than excess mortality in Quebec due to lower mortality from other causes of death, in particular malignant tumors, heart disease, and respiratory problems. We do not find evidence of an income gradient (measured by postal code level income) in relative excess death for the first wave.

Exploring Theatre of the Oppressed and Forum Theatre as pedagogies in nursing education

BACKGROUND

Concepts such as racism, oppression and social justice are critical curricular inclusions in nursing education. However, traditional approaches to nursing education often fail to produce the desired reflection and change amongst students. There is an urgent need to develop nursing educators that can step outside the rigidity of the curricular status quo and engage students with pedagogies that support critical reflection, analysis and action. Participatory, experiential and interactive theatrical methods rooted in critical pedagogy, such as Theatre of the Oppressed (TO) and Forum Theatre (FT) may prove more effective at engendering reflection, analysis and action.

OBJECTIVES

The study explores health care providers' (including nurses, nurse educators and allied health professionals) and nursing students' experiences, reflections and usefulness of TO and FT as nursing pedagogies.

DESIGN

Influenced by Freire's Pedagogy of the Oppressed and Boal's Theatre of the Oppressed, this study was conducted on a Western Canadian university campus. Two groups participated: one that included health care providers (HCP) (n = 8) and the second that included an audience of nursing educators and students (n = 7). HCPs participated in a two-day TO workshop, while nursing students participated as audience members in the FT performance. The data were drawn from sharing circles and group discussions and were analyzed using thematic analysis.

RESULTS

The findings from HCPs revealed that TO represents an opportunity for reflection and growth; strengthening relationships; and practicing vulnerability. Given that students only participated as audience members, they described practical applications for using TO and FT as pedagogies in nursing education including in simulation and in theory-based courses.

CONCLUSION

This study demonstrates that TO and FT can play an important role in supporting HCPs' development as critical educators through embodied and reflective practice and that nursing students endorse the application of TO and FT in a broad range of learning contexts.

Associations of health status and diabetes among First Nations Peoples living on-reserve in Canada

OBJECTIVE

Our objective is to describe self-reported health status, prevalence of diabetes and obesity and their associations in participants from the First Nations Food, Nutrition and Environment Study (FNFNES) in order to identify possible correlates of health in First Nations adults.

METHODS

FNFNES is a participatory study with First Nations Peoples living on reserve lands south of the 60th parallel. Health and diabetes were self-reported, and prevalence of obesity was evaluated. Socio-demographic and lifestyle factors and traditional food (TF) activities were investigated for associations with health parameters.

RESULTS

High prevalence rates of overweight/obesity (78-91%) and diabetes (19% age-standardized prevalence) were found. Smoking rates were high and physical activity was low. In multivariable analyses, obesity was associated with region, income source, age, gender, smoking and self-reported health; diabetes and lesser self-reported health were associated with obesity and lower education. Diabetes was strongly associated with lesser self-reported health and weakly associated with being a smoker.

CONCLUSION

We have identified possible correlates of health in this population that can help to better understand the underlying concerns and identify solutions for First Nations and their partners. We urge governments and First Nations to address the systemic problems identified with a holistic ecosystem approach that takes into consideration the financial and physical access to food, particularly TF, and the facilitation of improved health behaviour. New mechanisms co-developed with First Nations leadership should focus on supporting sustainable, culturally safe and healthy lifestyles and closing the gaps in nutrition and food insecurity.

The First Nations Food, Nutrition and Environment Study (2008-2018)-rationale, design, methods and lessons learned

OBJECTIVE

To describe the rationale, the participatory nature of the methodology, and the lessons learned during the First Nations Food, Nutrition and Environment Study (FNFNES), a community-based participatory research project implemented in eight Assembly of First Nations regions, which includes the entirety of Canada south of the 60th parallel.

METHODS

FNFNES respected the First Nations principles of Ownership, Control, Access and Possession (OCAP®) ( https://fnigc.ca/ocap ). A random sampling strategy based on an ecosystem framework comprising 11 ecozones was adopted to collect representative nutritional and environmental health results for all First Nations adults living on-reserve south of the 60th parallel. Data collection occurred during the fall months from 2008 to 2016. Respective First Nations were involved in the planning and implementation of data collection for the five principal components: household interviews, tap water sampling for metals, surface water sampling for pharmaceuticals, hair sampling for mercury, and traditional food sampling for contaminants.

RESULTS

A total of 6487 adults from 92 First Nations participated in the Study (participation rate 78%). A higher percentage of females (66%) participated than males (34%). The average age of males and females was similar (44 and 45 years, respectively). This study offers a novel body of coherent and regionally representative evidence on the human dimension of the ongoing environmental degradation affecting First Nations.

CONCLUSION

FNFNES serves as a good example of participatory research. We encourage public health professionals to develop policy and programs building on the participatory dimension of the research as well as on its results. The information collected by the FNFNES is also important for community empowerment, environmental stewardship and the general promotion of good health by and for First Nations peoples in Canada.

Black Resilience: A Strategic Asset for Engaging Heterosexual Black Canadian Men in Community Responses to HIV

Black people's disproportionate burden of HIV in Canada has raised questions about whether they are sufficiently resilient to HIV, and how to promote resilience. In this paper, we critically examine the issue of resilience among heterosexual Black men in four large Canadian cities (Ottawa, Toronto, London, and Windsor). In 2016, a team of researchers engaged self-identified heterosexual Black men in critical reflection on HIV-related resilience and vulnerability, with the goal of identifying pathways to strengthen their involvement in community responses to HIV. In total, 56 men participated in in-depth interviews and 154 participated in 21 focus groups. The team also organized six focus groups (N = 41) with policymakers, service providers, and community leaders. All four cities participated in a multi-stage iterative process to identify the thematic content of the data. Three overarching sources of resilience emerged from our critical interpretive analysis: (1) bonding with other men, (2) strong commitment to family and community, and (3) demonstrating self-confidence and self-determination. These sources of resilience illustrate the value of love as a driving force for collective action on social justice, support for family and community, and self-determination. These expressions of love support heterosexual Black men to resist or negotiate the structural challenges and gendered ideologies that make them vulnerable to HIV. Based on our analysis, we propose the concept of Black resilience that transcends merely bouncing back from or accommodating to adversity; instead, we understand Black resilience as a predisposition that motivates strategic resistance to systemic disadvantage that undermines Black people's health and wellbeing.

"I went in there, had a bit of an issue with those folks": everyday challenges of heterosexual African, Caribbean and black (ACB) men in accessing HIV/AIDS services in London, Ontario

BACKGROUND

In Canada, heterosexual African, Caribbean, and Black (ACB) men's heightened risk of HIV infection has been linked to behavioral characteristics, including practices of hegemonic masculinity that discourage the use of HIV preventive services. However, this framing is bereft of the role of structural factors that may be contributing to new HIV infections. This paper examined the underlying factors limiting access to health services among heterosexual ACB men in London, Ontario Canada.

METHODS

A convenient sampling technique was used to recruit thirty-seven (n = 37) self-identified heterosexual ACB men and service providers. Four focus groups (FG) were conducted; three with ACB participants of similar age category (i.e., 16-24; 25-38; 39+), and one with service providers. The FGs focused on the barriers to using health services and interrogated the ease of access to HIV intervention programs by ACB men respectively. Recurring themes from the FGs were probed further using in-depth interviews (n = 13). FGs and in-depth interviews complemented each other in reducing uneven power dynamics, fact checking, and allowing for detail discussion of the topic under study. Data analyses were done in NVivo using a mixed inductive-deductive thematic analyses approach.

RESULTS

Most ACB men lacked information on HIV and were unaware of their increased risk of infection. Contrary to the notion that behavioral characteristics keep ACB men away from health services, we found that most ACB men were unaware of the availability of these services. Those that had some knowledge about the services reported that they were not appropriately tailored to their needs. In addition, stereotypes and stigma about the etiology of HIV among Blacks, and systemic neglect served as significant barriers to ACB men's use of services.

CONCLUSION

The findings suggest that, to enhance preventive health service use among heterosexual ACB men, there is the need to remove structural barriers. Engaging ACB men in the design and implementation of policies may be useful at improving access to HIV information, testing, and treatment services. Increased information dissemination to ACB men would create awareness of the availability of HIV services. Finally, service providers should be conscious of ACB men's concern about experiences of discrimination and racism at service centers.

Explaining the gaps in psychological distress and suicidal behaviours between non-Indigenous and Indigenous adults living off-reserve in Canada: a cross-sectional study

BACKGROUND

Indigenous people are disproportionately affected by mental health issues in Canada. We investigated factors underlying the difference in psychological distress and suicidal behaviours between non-Indigenous and Indigenous populations living off-reserve in Canada.

METHODS

We conducted a cross-sectional study using data from the 2012 Canadian Community Health Survey - Mental Health. Respondents were aged 18 years and older. We measured the variation in psychological distress (10-item Kessler Psychological Distress Scale scores, ranging from 10 [no distress] to 50 [severe distress]) and the prevalence of lifetime suicidal ideation and suicide plan between the Indigenous and non-Indigenous populations and explained these differences using the Blinder-Oaxaca approach.

RESULTS

The overall response rate for the survey was 68.9%, comprising 18 300 respondents (933 Indigenous and 17 367 non-Indigenous adults). We found lower mean psychological distress scores among non-Indigenous people than among Indigenous people (15.1 v. 16.1, p < 0.001) and a lower prevalence of lifetime suicidal ideation (9.2% v. 16.8%, p < 0.001) and plan (2.3% v. 6.8%, p < 0.001). We found that if socioeconomic status among Indigenous people were made to be similar to that of the non-Indigenous population, the differences in mean psychological distress scores and prevalence of lifetime suicidal ideation and suicide plan would have been reduced by 25.7% (women 20.8%, men 36.9%), 10.2% (women 11.2%, men 11.9%) and 5.8% (women 7.8%, men 8.1%), respectively.

INTERPRETATION

Socioeconomic factors account for a considerable proportion of the variation in mental health outcomes between non-Indigenous and Indigenous populations in Canada. Improving socioeconomic status among Indigenous people through plans like income equalization may reduce the gap in mental health outcomes between the 2 populations in Canada.

Mining sick: Creatively unsettling normative narratives about industry, environment, extraction, and the health geographies of rural, remote, northern, and Indigenous communities in British Columbia

Rural, remote, northern, and Indigenous communities on Turtle Island are routinely-as Cree Elder Willie Ermine says-pathologized. Social science and health scholarship, including scholarship by geographers, often constructs Indigenous human and physical geographies as unhealthy, diseased, vulnerable, and undergoing extraction. These constructions are not inaccurate: peoples and places beyond urban metropoles on Turtle Island live with higher burdens of poor health; Indigenous peoples face systemic violence and racism in colonial landscapes; rural, remote, northern, and Indigenous geographies are sites of industrial incursions; and many rural and remote geographies remain challenging for diverse Indigenous peoples. What, however, are the consequences of imagining and constructing people and places as "sick"? Constructions of "sick" geographies fulfill and extend settler (often European white) colonial narratives about othered geographies. Rural, remote, northern, and Indigenous geographies are discursively "mined" for narratives of sickness. This mining upholds a sense of health and wellness in southern, urban, Euro-white-settler imaginations. Drawing from multi-year, relationship-based, cross-disciplinary qualitative community-informed experiences, and anchored in feminist, anti-colonial, and anti-racist methodologies that guided creative and humanities-informed stories, this paper concludes with different stories. It unsettles settler-colonial powers reliant on constructing narratives about sickness in others and consequently reframes conversations about Indigenous well-being and the environment.

"It's all interconnected… like a spider web": a qualitative study of the meanings of food and healthy eating in an Indigenous community

Canadian Indigenous populations are disproportionately affected by rising rates of diet-related chronic disease and have been experiencing rapid lifestyle changes affecting diet. In recognition of these issues, this study aimed to obtain greater understanding of attitudes and meanings around healthy eating in a semi-remote community in Eeyou Istchee. A qualitative study design used semi-structured interviews and observational field notes to explore local accounts of food and health. Two distinct versions of “healthy eating” were identified: one relating to traditional food and preparation methods; the other reflecting medicalised accounts of illness and diagnosed conditions. The latter links with “southern” modes of accessing and preparing food, demonstrating local capacity to adapt to the rapid changes in body, lifestyle and environment being experienced. New connections, associating non-native ways with traditional practices, are being formed where traditional ways of living on the land have been severed. These local accounts show how people are continually negotiating different constructs of “healthy eating.” These findings expand current understandings of the context of food and healthy eating in Eeyou Istchee, emphasising present-day and historical experiences of the land. Future research and diet-related health interventions must continue to acknowledge and incorporate local understandings of health to help address the broader socio-political factors that shape Indigenous lifestyles, environments and health.

Patient perspectives on a harm reduction-oriented addiction medicine consultation team implemented in a large acute care hospital

BACKGROUND

Addiction medicine consultation teams [AMCTs] are a promising strategy for improving hospital care for patients with substance use disorders. Yet very little research has examined AMCT implementation in acute care settings. To address this gap, we conducted a process evaluation of a novel harm reduction-oriented AMCT. Our specific aims included examining patients' perspectives on factors that facilitated or hindered AMCT delivery, and its impact on their hospital care and outcomes.

METHODS

The AMCT provided integrated addiction medicine, harm reduction services, and wraparound health and social supports for patients of a large, urban acute care hospital in Western Canada. We adopted a focused ethnographic design and recruited 21 patients into semi-structured interviews eliciting their views on the care they received from the team.

RESULTS

Participants highlighted the AMCT's harm reduction approach; reputation amongst peers; and specialized training as especially important intervention facilitators. Key barriers that constrained the impact of the team included unmet expectations; difficulty accessing follow-up care; and residual conflicts between the AMCT's harm reduction approach and the abstinence-only orientation of some hospital staff. For a few participants these conflicts led to negative experiences. Despite this, participants reported that the AMCT had positive impacts overall, including declines in substance use, enhanced mental and emotional wellbeing, and improved socio-economic circumstances.

CONCLUSIONS

A novel harm reduction-oriented AMCT led to better hospital experiences and perceived outcomes for patients. However, further efforts are needed to ensure adequate post-discharge follow-up, and a consistent approach to substance use disorder care amongst all hospital staff.

EQUIP Emergency: study protocol for an organizational intervention to promote equity in health care

Background

Social inequities are widening globally, contributing to growing health and health care inequities. Health inequities are unjust differences in health and well-being between and within groups of people caused by socially structured, and thus avoidable, marginalizing conditions such as poverty and systemic racism. In Canada, such conditions disproportionately affect Indigenous persons, racialized newcomers, those with mental health and substance use issues, and those experiencing interpersonal violence. Despite calls to enhance equity in health care to contribute to improving population health, few studies examine how to achieve equity at the point of care, and the impacts of doing so. Many people facing marginalizing conditions experience inadequate and inequitable treatment in emergency departments (EDs), which makes people less likely to access care, paradoxically resulting in reliance on EDs through delays to care and repeat visits, interfering with effective care delivery and increasing human and financial costs. EDs are key settings with potential for mitigating the impacts of structural conditions and barriers to care linked to health inequities.

Methods

EQUIP is an organizational intervention to promote equity. Building on promising research in primary health care, we are adapting EQUIP to emergency departments, and testing its impact at three geographically and demographically diverse EDs in one Canadian province. A mixed methods multisite design will examine changes in key outcomes including: a) a longitudinal analysis of change over time based on structured assessments of patients and staff, b) an interrupted time series design of administrative data (i.e., staff sick leave, patients who leave without care being completed), c) a process evaluation to assess how the intervention was implemented and the contextual features of the environment and process that are influential for successful implementation, and d) a cost-benefit analysis.

Discussion

This project will generate both process- and outcome-based evidence to improve the provision of equity-oriented health care in emergency departments, particularly targeting groups known to be at greatest risk for experiencing the negative impacts of health and health care inequities. The main deliverable is a health equity-enhancing framework, including implementable, measurable interventions, tested, refined and relevant to diverse EDs.

Trial registration

Clinical Trials.gov #NCT03369678 (registration date November 18, 2017).

Exposure to perfluoroalkyl substances (PFAS) and associations with thyroid parameters in First Nation children and youth from Quebec

BACKGROUND

Perfluoroalkyl substances (PFASs) are found in several consumer goods. Exposure to PFASs in children has been associated with alteration in thyroid hormones, which have critical roles in brain function.

OBJECTIVE

In 2015, 198 children and youth (3-19 y) were recruited as part of the pilot project Jeunes, Environnement et Santé/Youth, Environment and Health (JES!-YEH!), realized in collaboration with four First Nation communities in Quebec. We aimed to evaluate serum concentrations of PFASs in relation to concentrations of thyroid-stimulating hormone (TSH), free thyroxine (T4) and thyroglobulin while adjusting for relevant confounders.

METHODS

PFASs (PFOS, PFOA, PFHxS, PFNA), 2,2',4,4'-Tetrabromodiphenyl ether (PBDE-47) thyroid parameters (TSH, free T4, and thyroglobulin) were measured in serum samples of 186 participants. Iodine, creatinine, and cotinine were measured in urine samples. Serum levels of PFASs were compared to those measured in the general Canadian population and elsewhere. Multivariate regression analyses were performed to determine associations between PFASs and TSH, free T4 and thyroglobulin.

RESULTS

PFOS, PFOA and PFHxS serum concentrations were low. However, PFNA concentrations among participants aged 12 to 19 years old from Anishinabe communities were three times higher than those measured in the Canadian Health Measures Survey (2009-2011) for the same age group (Geometric Means: 3.01 μg/L and 0.71 μg/L, respectively) and were particularly higher in the Anishinabe participants aged 6 to 11 years old (GM: 9.44 μg/L). Few participants had levels of TSH, free T4, and thyroglobulin outside age-specific paediatric ranges. When adjusted for relevant covariates and other contaminants, PFNA serum concentrations were positively associated with free T4 levels (Adjusted β = 0.36; p = 0.0014), but not with TSH and thyroglobulin levels. No association was observed between the other PFAS and thyroid hormones parameters.

CONCLUSION

This pilot project reveals among the highest exposure to PFNA in children reported until today, and suggests effects of PFNA as an endocrine disruptor, highlighting the importance of investigating the sources and effects of disproportionate exposure to emerging contaminants in some indigenous communities and ban all PFAS at the international scale.

"You can't chain a dog to a porch": a multisite qualitative analysis of youth narratives of parental approaches to substance use

BACKGROUND

Reducing harms of youth substance use is a global priority, with parents identified as a key target for efforts to mitigate these harms. Much of the research informing parental responses to youth substance use are grounded in abstinence and critiqued as ineffective and unresponsive to youth contexts. Parental provision of substances, particularly alcohol, is a widely used approach, which some parents adopt in an attempt to minimize substance use harms; however, research indicates that this practice may actually increase harms. There is an absence of research exploring youth perspectives on parental approaches to substance use or the approaches youth find helpful in minimizing substance use-related harms.

METHODS

This paper draws on interviews with youth aged 13-18 (N = 89) conducted within the Researching Adolescent Distress and Resilience (RADAR) study in three communities in British Columbia, Canada. An ethnographic approach was used to explore youth perspectives on mental health and substance use within intersecting family, social, and community contexts. This analysis drew on interview data relating to youth perspectives on parental approaches to substance use. A multisite qualitative analysis (MSQA) was conducted to examine themes within each research site and between all three sites to understand how youth perceive and respond to parental approaches to substance use in different risk environment contexts.

RESULTS

Within each site, youths' experiences of and perspectives on substance use were shaped by their parents' approaches, which were in turn situated within local social, geographic, and economic community contexts. Youth descriptions of parental approaches varied by site, though across all sites, youth articulated that the most effective approaches were those that resonated with the realities of their lives. Zero-tolerance approaches were identified as unhelpful and unresponsive, while approaches that were aligned with harm reduction principles were viewed as relevant and supportive.

CONCLUSIONS

Youth perspectives illustrate that parental approaches to substance use that are grounded in harm reduction principles resonate with young people's actual experiences and can support the minimization of harms associated with substance use. Evidence-based guidance is needed that supports parents and young people in adopting more contextually responsive harm reduction approaches to youth substance use.

Educational Disparities in Adult Mortality Across U.S. States: How Do They Differ, and Have They Changed Since the Mid-1980s?

Adult mortality varies greatly by educational attainment. Explanations have focused on actions and choices made by individuals, neglecting contextual factors such as economic and policy environments. This study takes an important step toward explaining educational disparities in U.S. adult mortality and their growth since the mid-1980s by examining them across U.S. states. We analyzed data on adults aged 45-89 in the 1985-2011 National Health Interview Survey Linked Mortality File (721,448 adults; 225,592 deaths). We compared educational disparities in mortality in the early twenty-first century (1999-2011) with those of the late twentieth century (1985-1998) for 36 large-sample states, accounting for demographic covariates and birth state. We found that disparities vary considerably by state: in the early twenty-first century, the greater risk of death associated with lacking a high school credential, compared with having completed at least one year of college, ranged from 40 % in Arizona to 104 % in Maryland. The size of the disparities varies across states primarily because mortality associated with low education varies. Between the two periods, higher-educated adult mortality declined to similar levels across most states, but lower-educated adult mortality decreased, increased, or changed little, depending on the state. Consequently, educational disparities in mortality grew over time in many, but not all, states, with growth most common in the South and Midwest. The findings provide new insights into the troubling trends and disparities in U.S. adult mortality.

Educational Disparities in Adult Health: U.S. States as Institutional Actors on the Association

Despite numerous studies on educational disparities in U.S. adult health, explanations for the disparities and their growth over time remain incomplete. We argue that this knowledge gap partly reflects an individualist paradigm in U.S. studies of educational disparities in health. These studies have largely focused on proximal explanations (e.g., individual behaviors) to the neglect of contextual explanations (e.g., economic policies). We draw on contextual theories of health disparities to illustrate how U.S. states, as institutional actors, shape the importance of education for health. Using two nationally-representative datasets and seven health measures for adults aged 45-89, we show that the size of the educational gradient in health varies markedly across states. The size varies because of variation in the health of lower-educated adults. We use state excise taxes on cigarettes to illustrate one way that states shape educational disparities in health. Our findings underscore the necessity of contextualizing these disparities.

A Systematic Review and Meta-Analysis of Disparities in the Prevalence of Suicide Ideation and Attempt Among Bisexual Populations

Sexual minorities are at increased risk of suicide; however, it is unclear whether there are within-sexual minority differences in risk across specific sexual identities-notably between bisexual and lesbian/gay subgroups. We therefore conducted a systematic review and meta-analysis to quantify associations between bisexual identity and self-reported suicide ideation and attempt and the moderation of these associations by gender/sex, age, sampling strategy, and measurement of sexuality. Abstracts and full texts were independently screened by two reviewers, resulting in a total of 46 studies that met inclusion criteria and reported 12-month or lifetime prevalence estimates for suicide ideation or attempt. A consistent gradient was observed across all four outcomes, whereby bisexual respondents reported the highest proportion of suicide ideation or attempt, lesbian/gay respondents the next highest proportion, and heterosexual respondents the lowest proportion. Random-effects meta-analysis comparing bisexual individuals with lesbian/gay individuals yielded odds ratios (ORs) ranging between 1.22-1.52 across the four outcomes examined. Between-study variability in ORs was large. Thirty-one percent of heterogeneity was explained by sample type (e.g., probability vs. non-probability) and 17% by gender/sex. ORs were consistently larger for women (range: 1.48-1.95, all statistically significant at p < .05) than for men (range: 1.00-1.48, all p > .05), suggesting that gender/sex moderates the association between bisexual identity and suicide risk. Within-sexual minority differences in suicide risk may be attributed to structural and interpersonal experiences of monosexism, bisexual erasure and invisibility, or lack of bisexual-affirming social support, each of which may be experienced differently across gender/sex identities.

Predictors of medical student interest in Indigenous health learning and clinical practice: a Canadian case study

BACKGROUND

Including content on Indigenous health in medical school curricula has become a widely-acknowledged prerequisite to reducing the health disparities experienced by Indigenous peoples in Canada. However, little is known about what levels of awareness and interest medical students have about Indigenous peoples when they enter medical school. Additionally, it is unclear whether current Indigenous health curricula ultimately improve students' beliefs and behaviours.

METHODS

A total of 129 students completed a 43-item questionnaire that was sent to three cohorts of first-year medical students (in 2013, 2014, 2015) at one undergraduate medical school in Canada. This survey included items to evaluate students' sociopolitical attitudes towards Indigenous people, knowledge of colonization and its links to Indigenous health inequities, knowledge of Indigenous health inequities, and self-rated educational preparedness to work with Indigenous patients. The survey also assessed students' perceived importance of learning about Indigenous peoples in medical school, and their interest in working in an Indigenous community, which were examined as outcomes. Using principal component analysis, survey items were grouped into five independent factors and outcomes were modelled using staged multivariate regression analyses.

RESULTS

Generally, students reported strong interest in Indigenous health but did not believe themselves adequately educated or prepared to work in an Indigenous community. When controlling for age and gender, the strongest predictors of perceived importance of learning about Indigenous health were positive sociopolitical attitudes about Indigenous peoples and knowledge about colonization and its links to Indigenous health inequities. Significant predictors for interest in working in an Indigenous community were positive sociopolitical attitudes about Indigenous peoples. Knowledge about Indigenous health inequities was negatively associated with interest in working in an Indigenous community.

CONCLUSIONS

Students' positive sociopolitical attitudes about Indigenous peoples is the strongest predictor of both perceived importance of learning about Indigenous health and interest in working in Indigenous communities. In addition to teaching students about the links between colonization, health inequities and other knowledge-based concepts, medical educators must consider the importance of attitude change in designing Indigenous health curricula and include opportunities for experiential learning to shape students' future behaviours and ultimately improve physician relationships with Indigenous patients.

Priorities and challenges for a palliative approach to care for rural indigenous populations: A scoping review

We carried out a scoping review to identify key priorities and challenges relevant to rural Indigenous palliative care stated in existing literature. Our scoping review activities followed Arskey and O'Malley's principles for conducting a scoping review. We included peer-reviewed literature from MEDLINE, CINAHL and EMBASE that included a discussion of Indigenous populations, palliative care, and rural settings, and did not use date limits. The literature search was conducted in April 2016, and the retrieved literature was screened for relevance and appropriateness April 2016-March of 2017. In addition to the academic literature, a scan of the grey literature was conducted in March 2017. The retrieved grey literature was screened for relevance and reviewed by a team from a provincial health authority serving Indigenous peoples to ensure relevance in a rural BC setting. Once reviewed for relevance and appropriateness, we added four reports to supplement our analysis. Ultimately, 44 peer-reviewed articles and 4 pieces of grey literature met our inclusion criteria and were included in the review. Our analysis revealed several challenges and priorities relevant to rural Indigenous palliative care. Key challenges included: (i) environmental and contextual issues; (ii) institutional barriers; and (iii) interpersonal dynamics challenging client/clinician interactions. Priorities included: (i) family connections throughout the dying process; (ii) building local capacity for palliative care to provide more relevant and culturally appropriate care; and (iii) flexibility and multi-sectoral partnerships to address the complexity of day-to-day needs for patients/families. These findings point to several areas for change and action that can improve the relevance, access and comprehensiveness of palliative care programming for rural Indigenous communities in Canada and elsewhere. Taking into account of the diversity and unique strengths of each Indigenous community will be vital in developing sustainable and meaningful change.

Social determinants of self-reported health for Canada's indigenous peoples: a public health approach

OBJECTIVE

In Canada, indigenous peoples suffer from a multitude of health disparities. To better understand these disparities, this study aims to examine the social determinants of self-reported health for indigenous peoples in Canada.

STUDY DESIGN

This study uses data from Statistics Canada's Aboriginal Peoples Survey 2012.

METHODS

Multinomial logistic regression models were used to examine how selected social determinants of health are associated with self-reported health among off-reserve First Nations and Métis peoples in Canada.

RESULTS

Our analysis shows that being older, female, and living in urban settings were significantly associated with negative ratings of self-reported health status among the indigenous respondents. Additionally, we found that higher income and levels of education were strongly and significantly associated with positive ratings of self-reported health status. Compared with indigenous peoples with an education level of grade 8 or lower, respondents with higher education were 10 times (5.35-22.48) more likely to report 'excellent' and 'very good' health. Respondents who earned more than $40,000 annually were three times (2.17-4.72) more likely to report 'excellent' and 'very good' health compared with those who earned less than $20,000 annually. When interacted with income, we also found that volunteering in the community is associated with better self-reported health.

CONCLUSIONS

There are known protective determinants (income and education) and risk determinants (location of residence, gender, and age) which are associated with self-reported health status among off-reserve First Nations and Métis peoples. For indigenous-specific determinants, volunteering in the community appears to be associated with self-perceived health status. Thus, addressing these determinants will be necessary to achieve better health outcomes for indigenous peoples in Canada. Next steps include developing indigenous-specific social determinants of health indicators that adequately measure culture, connection, and community.

Index coronary angiography use in Manitoba, Canada: a population-level descriptive analysis of First Nations and non-First Nations recipients

OBJECTIVES

To investigate recipient characteristics and rates of index angiography among First Nations (FN) and non-FN populations in Manitoba, Canada.

SETTING

Population-based, secondary analysis of provincial administrative health data.

PARTICIPANTS

All adults 18 years or older who received an index angiogram between 2000/2001 and 2008/2009. PRIMARY AND SECONDARY OUTCOME MEASURES: (1) Descriptive statistics for age, sex, income quintile by rural and urban residency and Charlson Comorbidity Index for FN and non-FN recipients. (2) Annual index angiogram rates for FN and non-FN populations and among those rates of 'urgent' angiograms based on acute myocardial infarction (AMI)-related hospitalisations during the previous 7 days. (3) Proportions of people who did not receive an angiogram in the 20 years preceding an ischaemic heart disease (IHD) diagnosis or a cardiovascular death; stratified by age (<65 or ≥65 years old).

RESULTS

FN recipients were younger (56.3vs63.8 years; p<0.0001) and had higher Charlson Comorbidity scores (1.32vs0.78; p<0.001). During all years examined, index angiography rates were lower among FN people (2.67vs3.33 per 1000 population per year; p<0.001) with no notable temporal trends. Among the index angiogram recipients, a higher proportion was associated with an AMI-related hospitalisation in the FN group (28.8%vs25.0%; p<0.01) and in both groups rates significantly increased over time. FN people who died from cardiovascular disease or were older (65+years old) diagnosed with IHD were more likely to have received an angiogram in the preceding 20-30 years (17.8%vs12.5%; p<0.01 and 50.9%vs49.5%; p<0.03, respectively). FN people diagnosed with IHD who were under the age of 65 were less likely to have received an angiogram (47.8%vs53.1%; p<0.01) CONCLUSIONS: Index angiogram use differences are suggested between FN and non-FN populations, which may contribute to reported IHD disparities. Investigating factors driving these rates will determine any association between ethnicity and angiography services.

Racial discrimination and depression among on-reserve First Nations people in rural Saskatchewan

OBJECTIVES

To determine among rural-dwelling on-reserve Saskatchewan First Nations people whether racial discrimination is associated with depression, and in turn, if this relationship is moderated by gender.

METHODS

As a component of a community-based participatory research project, a cross-sectional, interviewer-administered survey of 874 adults living on 2 Cree First Nation reserves in rural north-central Saskatchewan was conducted during May-August in 2012 and 2013. Self-reported, health-provider diagnosis of depression was the dependent variable and experiences of interpersonal racial discrimination was the primary exposure. Chi-square and multiple logistic regression were the main analytic techniques. Generalized estimating equations were applied to account for clustering within households.

RESULTS

Overall, 64% of participants reported being treated unfairly in 1 or more situations because of their ethnicity; 38% indicated discrimination occurring in 3 or more situations. Nineteen percent reported a diagnosis of depression. Adjusted analyses indicated that compared to those with no experience of racial discrimination, those reporting 1-2 and 3 or more situations were 1.77 times (95% CI: 1.06-2.95) and 1.91 times (95% CI: 1.19-3.04) more likely to have diagnosed depression respectively. The relationship between racial discrimination and depression was not modified by gender, although women were 1.85 times (95% CI: 1.24-2.76) more likely to report depression than men.

CONCLUSION

Interpersonal racial discrimination was associated with depression among First Nations women and men in rural Saskatchewan. Research directed at identifying the most efficacious interventions, programs and policies to combat racism is required to advance the goal of health equity.

Gestational exposure to volatile organic compounds (VOCs) in Northeastern British Columbia, Canada: A pilot study

BACKGROUND

Northeastern British Columbia (Canada) is an area of intense hydraulic fracturing for unconventional natural gas exploitation. There have been multiple reports of air and water contamination by volatile organic compounds in the vicinity of gas wells. Although these chemicals are known developmental toxicants, no biomonitoring effort has been carried out in the region.

OBJECTIVE

To evaluate gestational exposure to benzene and toluene in the Peace River Valley, Northeastern British Columbia (Canada).

METHODS

Urine samples were collected over five consecutive days from 29 pregnant women. Metabolites of benzene (s-phenylmercapturic acid (S-PMA) and trans, trans-muconic acid (t,t-MA)) and toluene (s-benzylmercapturic acid (S-BMA)) were measured in pooled urine samples from each participant. Levels of benzene metabolites were compared to those from the general Canadian population and from a biomonitoring study of residents from an area of active gas exploitation in Pavillion, Wyoming (USA). Levels measured in participants from the two recruitment sites, and self-identifying as Indigenous or non-Indigenous, were also compared.

RESULTS

Whereas the median S-PMA level (0.18μg/g creatinine) in our study was similar to that in the general Canadian population, the median t,t-MA level (180μg/g creatinine) was approximately 3.5 times higher. Five women had t,t-MA levels above the biological exposure index® proposed by the American Conference of Governmental Industrial Hygienists. The median urinary S-BMA level in our pilot study was 7.00μg/g creatinine. Urinary metabolite levels were slightly higher in self-identifying Indigenous women, but this difference was only statistically significant for S-PMA.

DISCUSSION

Urinary t,t-MA levels, but not S-PMA levels, measured in our study are suggestive of a higher benzene exposure in participating pregnant women from the Peace River Valley than in the general Canadian population. Given the small sample size and limitations of t,t-MA measurements (e.g., non-specificity), more extensive monitoring is warranted.

Recent Suicide Attempts Across Multiple Social Identities Among Gay and Bisexual Men: An Intersectionality Analysis

This study draws from intersectionality to describe variations in recent suicide attempts (RSA) among gay and bisexual men (GBM) across sociodemographics. Using survey data, logistic regression modeling explored RSA in two analytical stages: (1) the individual effects of each sociodemographic were measured; (2) two-way interaction terms between sociodemographics were tested and added to the models created in stage A. In stage A, only education and income achieved significance. In stage B, the study found that (a) education and income interacted significantly such that the odds of RSA increased for those with a lower income and a lower education; (b) sexual orientation and partnership status interacted, resulting in decreased odds among bisexual men in heterosexual partnerships; and (c) income and education interacted with geography; the effects of these variables were significant only among urban men. These findings suggest that GBM are at unequal risk of RSA according to intersecting sociodemographics.

Type 2 Diabetes in Canadian Aboriginal Adolescents: Risk Factors and Prevalence

PURPOSE

To identify the risk factors and prevalence rates of prediabetes and type 2 diabetes among northern Canadian Aboriginal adolescents.

DESIGN AND METHODS

In this novel exploratory, quantitative study, 160 high school students (aged 13-21) from three northern, predominantly Canadian Aboriginal communities were screened for risk for prediabetes and type 2 diabetes including demographic data, family medical history, anthropometric measurements, blood pressure, and hemoglobin A1c (HbA1c). Descriptive and inferential statistics, in addition to chi-square analysis, were used to establish risk and prevalence rates for prediabetes and type 2 diabetes in Aboriginal adolescents.

RESULTS

At least half of the adolescents presented with multiple risk factors for type 2 diabetes. In this sample, 10% had an HbA1c>5.7%, 22.5% were overweight, 17.5% were obese, and 26.6% had prehypertension or hypertension.

CONCLUSIONS

Prediabetes and type 2 diabetes are emerging as serious health concerns for young Aboriginal Canadians. This is troubling because both result from modifiable risk factors. As this study is the first to examine the prevalence of prediabetes in Canadian Aboriginal adolescents in the last decade, the findings underscore the necessity for early screening of Aboriginal adolescents for both prediabetes and type 2 diabetes.

PRACTICE IMPLICATIONS

Recommendations toward positive health outcomes include the introduction of early age screening programs, followed by culturally relevant interventions, specific to the modifiable risk factors (overweight/obesity and hypertension), and developed in collaboration with the communities. Such approaches have the potential to prevent the progression of prediabetes to diabetes and reduce complications related to type 2 diabetes.

The rise and fall of dental therapy in Canada: a policy analysis and assessment of equity of access to oral health care for Inuit and First Nations communities

Background

Inequality between most Canadians and those from Inuit and First Nations communities, in terms of both access to oral health care services and related health outcomes, has been a long-standing problem. Efforts to close this equity gap led to the creation of dental therapy training programs. These programs were designed to produce graduates who would provide services in rural and northern communities. The closure of the last dental therapy program in late 2011 has ended the supply of dental therapists and governments do not appear to have any alternative solutions to the growing gap in access to oral health care services between most Canadians and those from Inuit and First Nations communities.

Methods

A policy analysis of the rise and fall of the dental therapy profession in Canada was conducted using historical and policy documents. The analysis is framed within Kingdon’s agenda-setting framework and considers why dental therapy was originally pursued as an option to ensure equitable access to oral health care for Inuit and First Nations communities and why this policy has now been abandoned with the closure of Canada’s last dental therapy training school.

Results

The closure of the last dental therapy program in Canada has the potential to further reduce access to dental care in some Inuit and First Nations communities. Overlaps between federal and provincial jurisdiction have contributed to the absence of a coordinated policy approach to address the equity gap in access to dental care which will exacerbate the inequalities in comparison to the general population. The analysis suggests that while a technically feasible policy solution is available there continues to be no politically acceptable solution and thus it remains unlikely that a window of opportunity for policy change will open any time soon.

Conclusion

In the absence of federal government leadership, the most viable option forward may be incremental policy change. Provincial governments could expand the scope of practice for dental hygienists in the hope that it may support enhanced access, consumer choice, and efficiency in the delivery of oral health care to Inuit and First Nations communities in Canada.

Increased mortality among Indigenous persons in a multisite cohort of people living with HIV in Canada

OBJECTIVE

Compare all-cause mortality between Indigenous participants and participants of other ethnicities living with HIV initiating combination antiretroviral therapy (cART) in an interprovincial multi-site cohort.

METHODS

The Canadian Observational Cohort is a collaboration of 8 cohorts of treatment-naïve persons with HIV initiating cART after January 1, 2000. Participants were followed from the cART initiation date until death or last viral load (VL) test date on or before December 31, 2012. Cox proportional hazard models were used to estimate the effect of ethnicity on time until death after adjusting for age, gender, injection drug use, being a man who has sex with men, hepatitis C, province of origin, baseline VL and CD4 count, year of cART initiation and class of antiretroviral medication.

RESULTS

The study sample consisted of 7080 participants (497 Indigenous, 2471 Caucasian, 787 African/Caribbean/Black (ACB), 629 other, and 2696 unknown ethnicity). Most Indigenous persons were from British Columbia (BC) (83%), with smaller numbers from Ontario (13%) and Québec (4%). During the study period, 714 (10%) participants died. The five-year survival probability was lower for Indigenous persons (0.77) than for Caucasian (0.94), ACB (0.98), other ethnicities (0.96) and unknown ethnicities (0.85) (p &lt; 0.0001). In an adjusted proportional hazard model for which missing data were imputed, Indigenous persons were more likely to die than Caucasian participants (hazard ratio = 2.69, p &lt; 0.0001).

CONCLUSION

The mortality rate for Indigenous persons was higher than for other ethnicities and is largely reflective of the BC population. Addressing treatment challenges and identifying HIV- and non-HIV-related causes for mortality among Indigenous persons is required to optimize their clinical management.

Taking stock of the social determinants of health: A scoping review

BACKGROUND

In recent decades, the social determinants of health (SDOH) has gained increasing prominence as a foundational concept for population and public health in academic literature and policy documents, internationally. However, alongside its widespread dissemination, and in light of multiple conceptual models, lists, and frameworks, some dilution and confusion is apparent. This scoping review represents an attempt to take stock of SDOH literature in the context of contemporary population and public health.

METHODS

We conducted a scoping review to synthesize and map SDOH literature, informed by the methods of Arksey and O'Malley (2005). We searched 5 academic and 3 grey literature databases for "social determinants of health" and "population health" or "public health" or "health promotion," published 2004-2014. We also conducted a search on "inequity" or "inequality" or "disparity" or "social gradient" and "Canad*" to ensure that we captured articles where this language was used to discuss the SDOH. We included articles that discussed SDOH in depth, either explicitly or in implicit but nuanced ways. We hand-searched reference lists to further identify relevant articles.

FINDINGS

Our synthesis of 108 articles showed wide variation by study setting, target audience, and geographic scope, with most articles published in an academic setting, by Canadian authors, for policy-maker audiences. SDOH were communicated by authors as a list, model, or story; each with strengths and weaknesses. Thematic analysis identified one theme: health equity as an overarching and binding concept to the SDOH. Health equity was understood in different ways with implications for action on the SDOH.

CONCLUSIONS

Among the vast SDOH literature, there is a need to identify and clearly articulate the essence and implications of the SDOH concept. We recommend that authors be intentional in their efforts to present and discuss SDOH to ensure that they speak to its foundational concept of health equity.

Inflammatory Arthritis Prevalence and Health Services Use in the First Nations and Non-First Nations Populations of Alberta, Canada

OBJECTIVE

To estimate prevalence of rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic disease (PsD), and crystal-related arthritis and health care use for inflammatory arthritis in First Nations and non-First Nations patients in Alberta, Canada.

METHODS

Population-based cohorts of adults with RA, AS, PsD, and crystal-related arthritis were defined, with First Nations determination by premium payer status, to estimate prevalence rates. Rates of outpatient primary care, specialist visits, and hospitalizations (all-cause, inflammatory-arthritis specific) were estimated.

RESULTS

RA affected 3 times as many First Nations residents compared to non-First Nations residents (standardized rate ratio [SRR] 3.2, 95% confidence interval [95% CI] 2.9-3.4). AS and PsD were more prevalent in First Nations (AS 0.6 per 100 residents; SRR 2.7, 95% CI 2.3-3.2 and PsD 0.3 per 100 residents; SRR 1.5, 95% CI 1.3-1.9), whereas crystal-related arthritis was less prevalent (SRR 0.7, 95% CI 0.6-0.7). First Nations patients were more likely to have primary care visits (SRR 1.7, 95% CI 1.6-1.8) and less likely to have specialist visits (SRR 0.6, 95% CI 0.6-0.7) for RA relative to non-First Nations individuals. In PsD and crystal-related arthritis, First Nations people had higher rates of cause-specific hospitalizations.

CONCLUSION

The estimated prevalence of RA, AS, and PsD was higher in the First Nations population, while crystal-related arthritis was less prevalent compared to the non-First Nations population. First Nations people were more likely to see primary care physicians and were less likely to see specialists for inflammatory arthritis care.