The DEPICT model for participatory qualitative health promotion research analysis piloted in Canada, Zambia and South Africa

Will they always be living the Sisyphus punishment? The triple whammy for racialized women: a qualitative investigation of primary care researchers in Canada

Background

Existing literature overlooks the role of gender and race on research productivity, particularly in the context of primary care research. This study examines how gender and race influence the research productivity of primary care researchers in Canada, addressing a gap in existing literature.

Methods

Qualitative, descriptive methods were used, involving 60-min interviews with 23 Canadian primary care researchers. 13 participants were female (57%) and 10 participants (43%) were male. Fourteen participants were White (non-racialized; 61%), 8 were racialized (35%) and 1 did not comment on race (4%). Reflexive thematic analysis captured participant perceptions of factors influencing research productivity, including individual, professional, institutional, and systemic aspects.

Findings

Systemic bias and institutional culture, including racism, sexism, and unconscious biases against racialized women, emerge as key barriers to research productivity. The parenting life stage further compounds these biases. Barriers include lack of representation in faculty roles, toxic work environments, research productivity metrics, and exclusion by colleagues. Participants indicated that institutional reforms and systemic interventions are needed to foster a diverse, equitable, and inclusive environment. Strategies include recruiting equity-focused leaders, increasing representation of racialized female faculty, diversity training, mentorship programs, providing meaningful support, flexible work arrangements, and protected research time. Sponsors can offer more targeted grants for female and racialized researchers. Adjusting metrics for gender, race, parenthood, and collaborative metrics is proposed to enhance diversity and inclusion among researchers.

Interpretation

This study underscores the importance of addressing systemic bias at institutional and systemic levels to create a fair and supportive environment for primary care researchers. A multitude of strategies are needed including increasing representation of racialized female faculty, creating supportive and psychologically safe work environments, and public reporting of data on faculty composition for accreditation and funding decisions. Together, these strategies can alleviate the triple whammy and free these researchers from the Sisyphus Punishment - the absurdity of being asked to climb a hill while pushing a boulder with no hope of reaching the top.

Funding

College of Family Physicians of Canada.

Habituation for professional learning: a qualitative study of physiotherapy students' experiences working with anatomy cadavers

INTRODUCTION

Cadaveric dissection shapes the ways in which healthcare students understand the human body and the attitudes, identities and behaviors they exhibit as health professionals. There is however a paucity of related research with physiotherapy (PT) students.

PURPOSE

The purpose of this interpretivist study was to investigate PT students' conceptions of the human body in relation to experiences with human cadavers in anatomy education.

METHODS

Ten semi-structured interviews were conducted with PT students along with four optional written reflections completed. Data was thematically analyzed.

RESULTS

Students engaged in a continuous process of habituation involving oscillation between "humanization" and "dehumanization" of cadavers in the anatomy lab. We describe the contextual mediators that shaped the process, the multi-sensory and emotional experience of the students, and the "interruptions" that contributed to the variability in their conceptions over time and contexts. Students ultimately habituated toward dehumanization which had multiple effects on learning and professionalization.

CONCLUSION

Study findings highlight the complexity of PT students' experiences and learning within the cadaver lab outside of the formal goals of anatomy education. We discuss the implications for anatomy curricula, including the potential advantages of incorporating a biopsychosocial approach.

Recovery-oriented practice in a hospital mental health service

As part of mental health reform in Australia, new policies were introduced to support recovery-oriented practice; however, little has changed in hospital settings focused on managing risk and remediating acute symptoms. Previous studies have indicated that patients' experiences of personal recovery, during a hospital admission, may not mirror that of people living in the community, with patients being more likely to experience disconnection, hopelessness and disempowerment. Using a Participatory Health Research approach, eight mental health professionals, a patient advocate and an external researcher formed a research partnership to answer the question: How can staff enhance recovery-oriented practice in a hospital-based mental health service? The COREQ checklist was used for reporting the methods, analysis and findings. The methods comprised patient focus groups (n = 16 participants), interviews with managers (n = 7) and an online survey for staff (n = 17). Researchers analysed the feedback from the consultations using inductive thematic analysis, identifying two themes: relational recovery and recovery interventions. The findings indicate that relational recovery is key to recovery during a hospital admission and interventions that increase connectedness or reduce the impact of symptoms enhance personal recovery.

Developing and Retaining Homecare Nurses Through Employer-Based Tuition Assistance Programs: A Mixed Methods Study

PURPOSE

This study describes how an employer-based tuition-assistance program for homecare workers at one Canadian homecare organization enabled nursing career advancement and retention.

DESIGN

A convergent parallel mixed-methods design.

METHODS

We reviewed existing administrative data and concurrently conducted semi-structured interviews. Descriptive statistics were used on quantitative data and qualitative data was analyzed using thematic analysis. A joint data display was developed to integrate findings from both quantitative and qualitative data together.

FINDINGS

Tuition assistance reduced financial barriers to career advancement; 83% of recipients remained with their employer for at least 1-year post-studies but only 29% experienced career advancement. Psychosocial supports, career navigation and coaching to ease the licensing and role transition processes were identified as opportunities to support learners.

CONCLUSION

Employer-based tuition assistance programs are impactful in helping to develop skilled employees. Practical enhancements to further support career transitions may maximize retention to address urgent homecare staffing challenges.

CLINICAL EVIDENCE

Employer-based tuition assistance can be a useful strategy to support nursing career growth and staff retention.

Family expectations and demand for home-based videogaming therapy in children with cerebral palsy in Costa Rica: a mixed methods study

PURPOSE

To understand the expectations and demand for a movement-tracking videogame (Bootle Blast) for home-based, upper limb (UL) rehabilitation among Costa Rican children with cerebral palsy (CP).

METHODS

Data were collected via telephone screening (demand) and child-parent dyads Zoom interviews (expectations). Descriptive statistics and data transformation were used to report on demand success criteria (i.e., recruitment rate, having an appropriate screen and space to play, setting a weekly play time goal (PTG) ≥45 min, identifying one UL therapy goal). The DEPICT model for collaborative qualitative analysis was used in the thematic analysis of interview data.

RESULTS

Fifteen dyads participated (1.6 ± 1 recruited/month). All had a flat-screen TV in a suitable location to play, were able to set a UL therapy goal, and established PTGs ranging from 45-120 min per week. Identified themes were: 1) Socio-cultural factors heighten demand, 2) Feelings of hope prevail for the intervention, and 3) Collaborative goal setting supports realistic expectations for Bootle Blast.

CONCLUSIONS

Dyads had positive and realistic expectations about implementing the proposed videogaming intervention. This study provides insights on tailoring a family-centered, therapy gaming intervention to improve access to motor rehabilitation for children with CP in rural/remote settings and low-middle income countries.

Desiring support on a winding road with challenging intersections: Social and professional support for sexual minority forced migrant men

AIM

To explore experiences of social and health professional support among sexual minority forced migrant men.

DESIGN

Exploratory qualitative study.

METHODS

Individual semi-structured interviews were conducted in 2023 with 15 participants recruited through convenience, purposive and snowball sampling. Interviews were audio recorded, transcribed and analysed with systematic text condensation in a collaborative process between researchers and experts by lived experience.

RESULTS

The first category was 'desiring support along a road with challenging intersections'. Participants encountered a harsh reality and dangers in the host country. They sought social connections and communicated with others whilst in a social labyrinth within a new and reserved society. Although social support was desired and highly appreciated, the process involved a spectrum of both belonging and exclusion. The second category was 'navigating uncharted waters when seeking affirming health services'. A range of barriers to health services were encountered in a complex health system. Participants emphasized the importance of safe and affirming spaces that accommodate the vulnerability of disclosure.

CONCLUSION

Ensuring respectful and affirming support for sexual minority forced migrants is essential. Barriers in accessing health services need to be addressed, including informing about rights and ensuring safety.

IMPLICATION FOR THE PROFESSIONAL AND PATIENT CARE

Nurses and other health professionals can consider social support as a potentially valuable resource for health promotion. However, there is a need for more research investigating its mental health effects.

IMPACT

The intersectional disadvantages and discrimination encountered by sexual minority forced migrants call attention to the need for further advancements in inclusion health and affirming care.

REPORTING METHOD

This study adhered to the Consolidated Criteria for Reporting Qualitative Research.

PATIENT OR PUBLIC CONTRIBUTION

Three sexual minority forced migrants were members of the research team. They were involved in the data collection, analysis and reporting in close collaboration with researchers.

A Call to Disrupt Heteronormativity and Cisnormativity in Physical Therapy: Perspectives of 2SLGBTQIPA+ Participants on Future Directions for PT Curricula

Purpose

To explore the perspectives of individuals with self-reported expertise and/or lived experiences regarding aspects of 2SLGBTQIPA+ health that should be included in pre-licensure physical therapy (PT) curricula across Canada, including how, when, and by whom this content should be delivered.

Method

We conducted a critical qualitative, cross-sectional study with semi-structured virtual interviews. We analyzed participants' perspectives thematically using the DEPICT method.

Results

Thirteen participants across Canada with a variety of gender identities and sexual orientations were interviewed. Participants described how transformative change on 2SLGBTQIPA+ issues in PT requires an approach that is based on interrupting heteronormativity and cisnormativity in PT curricula. Participants explained how this could be achieved by (1) emphasizing both historical inequities and present-day considerations for safe and inclusive practice, (2) introducing the content early and integrating it throughout the programme using a variety of large- and small-group sessions, and (3) including 2SLGBTQIPA+ individuals in content delivery and creation.

Conclusions

This study brings attention to the need for the PT profession to understand how the pervasive social structures of heteronormativity and cisnormativity shape education and practice, and offer strategies for disrupting complicity with these systems of inequality.

Centering healthcare workers in digital health design: Usability and acceptability of two-way texting to improve retention in antiretroviral therapy in a public HIV clinic in Lilongwe, Malawi

New initiates on antiretroviral therapy (ART) are at high risk of treatment discontinuation, putting their health at risk. In low- and middle-income countries, like Malawi, appropriate digital health applications (apps) must fit into local clinic, connectivity and resource constraints. We describe the human centered design (HCD) and development process of an open-source, hybrid, two-way texting (2wT) system to improve ART retention. We detail the critical role of diverse healthcare workers (HCWs) in the HCD process to inform app usability, create buy-in, and ensure appropriate optimization for the local context. We optimized 2wT usability and acceptability over three HCD phases: 1) informal feedback sessions with diverse 2wT stakeholders, 2) a small pilot, and 3) key informant interviews. Phase one included four sessions with diverse HCWs, including "expert ART clients", clinical, technical, supervisory, and evaluation teams to inform 2wT design. In phase 2, a small pilot with 50 participating ART clients aimed to inform implementation improvement. Phase three included interviews with ten HCWs to deepen understanding of 2wT acceptability and usability, documenting strengths and weaknesses to inform optimization. Multi-phase feedback sessions with HCWs helped refine 2wT language and message timing for both weekly and tailored client-specific visit reminders. The pilot led to improvements in educational materials to guide client responses and ease interaction with HCWs. In interviews, the HCWs appreciated the HCD co-creation process, suggested ways to increase access for low-literacy clients or those without consistent phone access, and felt integrating 2wT with other eHealth platforms would improve scalability. Inclusion of HCWs across phases of HCD design, adaption, and optimization increased 2wT usability and acceptability among HCWs in this setting. Engaging HCWs into 2wT co-ownership from inception appears successful in co-creation of an app that will meet HCW needs, and therefore, enhance support for 2wT clients to attend visits and remain in care.

What factors are associated with the research productivity of primary care researchers in Canada? A qualitative study

BACKGROUND

Research evidence to inform primary care policy and practice is essential for building high-performing primary care systems. Nevertheless, research output relating to primary care remains low worldwide. This study describes the factors associated with the research productivity of primary care researchers.

METHODS

A qualitative, descriptive key informant study approach was used to conduct semi-structured interviews with twenty-three primary care researchers across Canada. Qualitative data were analyzed using reflexive thematic analysis.

RESULTS

Twenty-three primary care researchers participated in the study. An interplay of personal (psychological characteristics, gender, race, parenthood, education, spousal occupation, and support), professional (mentorship before appointment, national collaborations, type of research, career length), institutional (leadership, culture, resources, protected time, mentorship, type), and system (funding, systematic bias, environment, international collaborations, research data infrastructure) factors were perceived to be associated with research productivity. Research institutes and mentors facilitated collaborations, and mentors and type of research enabled funding success. Jurisdictions with fewer primary care researchers had more national collaborations but fewer funding opportunities. The combination of institutional, professional, and system factors were barriers to the research productivity of female and/or racialized researchers.

CONCLUSIONS

This study illuminates the intersecting and multifaceted influences on the research productivity of primary care researchers. By exploring individual, professional, institutional, and systemic factors, we underscore the pivotal role of diverse elements in shaping RP. Understanding these intricate influencers is imperative for tailored, evidence-based interventions and policies at the level of academic institutions and funding agencies to optimize resources, promote fair evaluation metrics, and cultivate inclusive environments conducive to diverse research pursuits within the PC discipline in Canada.

Continuing Professional Development in Response to COVID-19: Knowledge Mobilization for Occupational Therapy and Physiotherapy via a Curated Web Site

Purpose

Once the COVID-19 pandemic was declared, clinicians were redeployed to prepare for increased hospitalizations. This disruption necessitated rapid continuing professional development (CPD) resources for health care providers. This mixed-method study explored the experiences of occupational therapists and physiotherapists who accessed a CPD Web site that provided educational resources related to the pandemic to refresh their clinical knowledge and skills.

Methods

Faculty from the Michener Institute of Education at the University Health Network and University of Toronto along with 60 collaborators created a Web site to support the need for rapid CPD. An occupational therapist and physiotherapist advisory group informed the evolving design of the occupational therapy and physiotherapy content.

Results

In the occupational therapy profession 535 users created an account between April and November 2020 (236 practicing, 283 students, and 16 did not specify) and in the physiotherapy profession 829 created an account (532 practicing, 278 students and 19 did not specify). Each user viewed an average of 53 Web pages. Three themes emerged: (1)To prepare for practice changes, clinicians value a single repository of information; (2) Web site features can either facilitate or hinder access to the needed information; and (3) Participants described diverse learning needs.

Conclusions

The Web site design features assisted participants in preparing for redeployment and patient care. Features to encourage self-directed learning, such as the grouping of relevant topics and self-check quizzes, can enhance the user experience.

What is 'disability'? Exploring the conceptions of internationally educated learners in a Canadian physical therapy bridging program

BACKGROUND

Physiotherapists' understanding of disability has direct relevance for their practices and work with disabled people.

PURPOSE

To explore how physiotherapists from diverse backgrounds, cultures and social locations conceptualize disability. Understanding their conceptualizations will provide insight to determine future directions regarding disability education, in healthcare education, to optimize the quality of care and life for individuals with disabilities.

METHODS

Six internationally educated physiotherapists enrolled in a Canadian physical therapy bridging program were interviewed and data were analyzed for themes.

RESULTS

Participants' conceptualizations of disability were complex and a dynamic process that reflected what was 'thinkable' in relation to experience, such as with social location and in personal, professional and educational domains. This primary theme was reflected in three subthemes: 1) Professional PT acculturation shaped disability conceptualization in particular ways; 2) Medical model as the dominant way of thinking; and 3) Social model thinking was more feasible in resource rich contexts.

CONCLUSION

These results reinforce the benefits of a wide exposure to different ways of conceptualizing and addressing disability within PT education to counter the dominance of the medical model and reinforce the importance of advocacy and allyship with disabled people.

Raising awareness of anti-fat stigma in healthcare through lived experience education: a continuing professional development pilot study

BACKGROUND

Anti-fat attitudes and weight-based discrimination are prevalent in healthcare settings and among healthcare practitioners and clinical trainees, and can result in immense harm to patients. There is increasing recognition that anti-fat bias in healthcare is a critical issue that must be addressed, but there is a dearth of evidence demonstrating sustained attitude and behavioural change among clinicians, illustrating a need for more innovative educational approaches and rigorous evaluation. We describe the co-design and delivery of a narrative-based continuing professional development curriculum aimed at raising awareness of weight-based bias and stigma.

METHODS

Our research team of lived experience educators, clinicians and researchers collaboratively developed a series of seven podcast episodes comprised of narrative descriptions of lived experiences with and impacts of weight bias, stigma and discrimination in healthcare settings, as well as a post-podcast workshop to facilitate reflection and discussion between participants. The curriculum was piloted among 20 clinicians practicing at a large urban hospital in Mississauga, Canada. We explored feasibility, acceptability and learning impact by analyzing responses to questionnaires completed following each podcast episode and responses shared during the workshops and follow-up feedback sessions.

RESULTS

We observed high acceptability and feasibility of the curriculum. Participants experienced the podcast as a practical and convenient learning format and the workshop as a valuable opportunity to collectively debrief and reflect. The learning impact of the curriculum was strong; participants described a range of emotions elicited by the podcasts, engaged in self-reflection, and expressed a desire to modify clinical approaches. Barriers to the application of learnings identified by participants include pervasiveness of the use of body mass index (BMI) as an indicator of risk and a criterion for referral; discomfort with difficult conversations; prevalent biomedical understandings about the association between weight and health; and clinicians' defensiveness.

CONCLUSION

This pilot study yielded promising findings and demonstrated potential impact on weight bias and stigma among healthcare providers. Necessary next steps include conducting larger scale, rigorous evaluations of the curriculum among broader populations, both health professions trainees and current healthcare providers.

Understanding transitions in care for persons with limb loss: a qualitative study exploring health care providers' perspectives

PURPOSE

To explore health care providers' (HCP) experiences related to transitions in care from inpatient rehabilitation to the community for patients with limb loss.

MATERIALS AND METHODS

A qualitative study was conducted using semi-structured interviews. Participants were eligible if they were HCPs currently working in amputation rehabilitation at a rehabilitation hospital in Ontario, Canada, with at least 1-year experience in this setting, and could speak and understand English. Data were analyzed thematically using the six-step process of the DEPICT model dynamic reading, engaged codebook development, participatory coding, inclusive reviewing and summarizing of categories, collaborative analyzing and translating.

RESULTS

Fourteen HCPs from a variety of health care professions participated in this study. Five key themes describe participants' perspectives on the factors impacting patients' transition in care following limb loss. Specifically, participants emphasized patient preparedness, HCP follow-up, finances and funding, patient self-management skills, and psychosocial support as factors that could influence the transition in care.

CONCLUSION

This study identified challenges to transitions in care for people with limb loss. Future research is needed to evaluate solutions to address these challenges in transitions in care.

Sustaining a Workforce: Reflections on Work from Home and Community Care Nurses Transitioning out of the COVID-19 Pandemic

Introduction

The COVID-19 pandemic has had an unprecedented impact on nurses' well-being and desire to practice; however, the experience of Canadian home and community care nurses remains less well understood. As the health human resources crisis in this sector persists, understanding these nurses' experiences may be vital in creating more effective retention strategies.

Objective

The aim of this study was to explore how the COVID-19 pandemic shaped the working experiences, motivations, and attitudes of home and community care nurses in the Greater Toronto Area.

Methods

Using an exploratory, descriptive, qualitative approach, 16 home and community care nurses participated in semistructured interviews. Data were analyzed using collaborative thematic analysis. Participants shared their reflections on work by detailing their experiences prepandemic, during crisis, transitioning out of crisis, and regarding pandemic recovery.

Results

During the COVID-19 pandemic inadequate staffing resources during and beyond the crisis period disrupted many desirable facets of work for home and community care nurses such as stable, balanced, and flexible work conditions, and exacerbated the unfavorable aspects such as isolation and inconsistent support. Many nurses were reevaluating their careers: for some, this meant stronger professional attachment and for others, it meant intentions to leave. Improved sector preparedness, wages, and workplace support were identified as strategies to sustain this workforce beyond the pandemic.

Conclusion

Home care organizations must consider ways to address the root cause of concerns expressed by nurses who wish to practice in a supportive environment that is sufficiently staffed and sensitive to workload expectations.

"I would love for there not to be so many hoops … ": recommendations to improve abortion service access and experiences made by Indigenous women and 2SLGTBQIA+ people in Canada

Acknowledging the barriers in accessing sexual and reproductive health services that disproportionately impact Indigenous women and 2SLGTBQIA+ people, coupled with the lack of knowledge surrounding Indigenous peoples' experiences with abortion, we present qualitative findings from a pilot study investigating Indigenous experiences of accessing abortion services in Canada. We focus on findings related to participant recommendations for improving safety and accessibility of abortion services made by and for Indigenous people in Canada. Informed by an Indigenous Advisory Committee consisting of front-line service providers working in the area of abortion service access and/ or support across Canada, the research team applied an Indigenous methodology to engage with 15 Indigenous people across Canada utilising a conversational interview method, between September and November 2021. With representation from nine provinces and territories across Canada, participants identified with Anishinaabe, Cree, Dene, Haudenosaunee, Inuit, Métis and/ or Mi'kmaq Nations. Five cross-cutting recommendations emerged, including: (1) location, comfort, and having autonomy to choose where the abortion takes place; (2) holistic post-abortion supports; (3) accessibility, availability, and awareness of non-biased and non-judgemental information; (4) companionship, advocacy, and logistical help before and during the abortion from a support person; and (5) cultural safety and the incorporation of local practices and knowledges. Recommendations demonstrate that Indigenous people who have experienced an abortion carry practical solutions for removing barriers and improving access to abortion services in the Canadian context.

What are effective vaccine distribution approaches for equity-deserving and high-risk populations during COVID-19? Exploring best practices and recommendations in Canada: protocol for a mixed-methods multiple case codesign study

INTRODUCTION

The WHO has stated that vaccine hesitancy is a serious threat to overcoming COVID-19. Vaccine hesitancy among underserved and at-risk communities is an ongoing challenge in Canada. Public confidence in vaccine safety and effectiveness and the principles of equity need to be considered in vaccine distribution. In Canada, governments of each province or territory manage their own healthcare system, providing an opportunity to compare and contrast distribution strategies. The overarching objective of this study is to identify effective vaccine distribution approaches and advance knowledge on how to design and implement various strategies to meet the different needs of underserved communities.

METHODS AND ANALYSIS

Multiple case studies in seven Canadian provinces will be conducted using a mixed-methods design. The study will be informed by Experience-Based CoDesign techniques and theoretically guided by the Socio-Ecological Model and the Vaccine Hesitancy Matrix frameworks. Phase 1 will involve a policy document review to systematically explore the vaccine distribution strategy over time in each jurisdiction. This will inform the second phase, which will involve (2a) semistructured, in-depth interviews with policymakers, public health officials, researchers, providers, groups representing patients, researchers and stakeholders and (2b) an analysis of population-based administrative health data of vaccine administration. Integration of qualitative and quantitative data will inform the identification of effective vaccine distribution approaches for various populations. Informed by this evidence, phase 3 of the study will involve conducting focus groups with multiple stakeholders to codesign recommendations for the design and implementation of effective vaccine delivery strategies for equity-deserving and at-risk populations.

ETHICS AND DISSEMINATION

This study is approved by the University of Toronto's Health Sciences Research Ethics Board (#42643), University of British Columbia Behavioural Research Ethics Board (#H22-01750-A002), Research Ethics Board of the Nova Scotia Health Authority (#48272), Newfoundland and Labrador Health Research Ethics Board (#2022.126), Conjoint Health Research Ethics Board, University of Calgary (REB22-0207), and University of Manitoba Health Research Board (H2022-239). The outcome of this study will be to produce a series of recommendations for implementing future vaccine distribution approaches from the perspective of various stakeholders, including equity-deserving and at-risk populations.

Youth Perspectives on Menthol Sales Restrictions in Minneapolis and Duluth, Minnesota

Although menthol cigarettes are a starter product for youth, menthol was exempted from the 2009 Tobacco Control Act, which banned all other characterizing flavors. Minneapolis and Duluth, Minnesota, implemented menthol tobacco sales restrictions in 2018 to advance health equity for youth, African American, lesbian, gay, bisexual, trans, and queer (LGBTQ), and other communities adversely affected by menthol. This evaluation assesses the policy impact on youth access to menthol tobacco, exposure to menthol advertising, and tobacco use. A core group of youth aged 14 to 17 years (n = 30) was recruited from Minneapolis and Duluth to gather data through photo voice and peer interviews 2 months before and after policy implementation. This evaluation shares the results of focus groups with these core youth where they reflected on what they observed in the community and heard from peers. The core youth identified and categorized emergent themes using the evaluation questions. Following the focus groups, the evaluation staff used these preliminary themes and coded remaining transcripts. The core youth had mixed reactions to the impact of policies on access and use because many tobacco users in their age group obtain tobacco informally through peers, family members, and online. They observed decreases in retail advertising of menthol cigarettes, although many felt e-cigarettes and online advertising were more significant issues for their age group. Findings show a need for increased education and more comprehensive policy approaches, including addressing use of flavored e-cigarettes, online tobacco sales, and informal access, making youth access to tobacco more difficult.

Power and poverty: A participatory study on the complexities of HIV and intimate partner violence in an informal urban settlement in Nairobi, Kenya

People in informal urban settlements in Kenya face multiple inequalities, yet researchers investigate issues such as HIV or intimate partner violence (IPV) in isolation, targeting single populations and focusing on individual behaviour, without involving informal settlement dwellers. We formed a study team of researchers (n = 4) and lay investigators (n = 11) from an informal settlement in Nairobi, Kenya to understand the power dynamics in the informal urban settlement that influence vulnerability to IPV and HIV among women and men from key populations in this context. We facilitated participatory workshops with 56 women and 32 men from different marginalised groups and interviewed 10 key informants. We used a participatory data analysis approach. Our findings suggest the IPV and HIV nexus is rooted in the daily struggle for cash and survival in the informal urban settlement where lucrative livelihoods are scarce and a few gatekeepers regulate access to opportunities. Power is gendered and used to exercise control over people and resources. Common coping strategies applied to mitigate against the effects of poverty and powerlessness amplify vulnerabilities to HIV and IPV. These complex power relations create and sustain an environment conducive to IPV and HIV. Prevention interventions thus need to address underlying structural drivers, uphold human rights, create safe environments, and promote participation to maximise and sustain the positive effects of biomedical, behavioural, and empowerment strategies.

'By identifying myself as Métis, I didn't feel safe…': Experiences of navigating racism and discrimination among Métis women, Two-Spirit and gender diverse community members in Victoria, Canada

OBJECTIVE

Racism acts as a major barrier to accessing health services for Indigenous communities in Canada, often leading to delayed, avoided or lack of treatment altogether. The Métis population is uniquely positioned in urban settings, as they experience discrimination from both Indigenous and mainstream health and social services due to Canada's long colonial history that is ongoing. Yet, Métis are often left out of discussions regarding racism and health service access. This study explores the experiences of racism and health service access among Métis peoples in Victoria, British Columbia.

METHODS

We allied a conversational interview method to explore and understand experiences of self-identifying Métis women, Two-Spirit and gender diverse people (n = 24) who access health and social services in Victoria. Data analysis followed Flicker and Nixon's six-stage DEPICT model.

RESULTS

In this paper, we share the experiences of racism and discrimination of those who accessed health and social services in Victoria, British Columbia Such experiences include passing as White, experiencing racism following Métis identity disclosure and witnessing racism. Passing as White was viewed as a protective factor against discrimination as well as harming participants' sense of identity. Experiences of racism took the form of discriminatory comments, harassment and mistreatment, which influenced the willingness of disclosing Métis identity. Witnessing racism occurred in participants, personal and professional lives, negatively impacting them in indirect ways. Each experience of racism had a negative influence on participants' wellbeing and shaped their experience of accessing health and social services.

CONCLUSIONS

Métis people confront racism and discrimination when attempting to access health and social services through first-hand experiences, witnessing and/or avoidance. While this study contributes to the all too often unacknowledged voices of Métis in Canada, there is a continued need for Métis-specific research to accurately inform policy and practice.

"You Have to Be Careful About Every Detail" How the COVID-19 Pandemic Shaped the Experiences of Canadian Personal Support Workers Working in Home Care

OBJECTIVES

Personal support workers (PSWs) are an essential but vulnerable workforce supporting the home care sector in Canada. Given the impact COVID-19 has had on healthcare workers globally, understanding how PSWs have been impacted is vital.

METHODS

We conducted a qualitative descriptive study to understand the working experiences of PSWs over the COVID-19 pandemic. Nineteen semistructured interviews were conducted, and analysis was guided by the collaborative DEPICT framework.

RESULTS

Personal support workers are motivated by an intrinsic duty to work and their longstanding client relationships despite feeling vulnerable to transmission and infection. They experienced co-occurring occupational stressors and worsening work conditions, which impacted their overall well-being.

CONCLUSIONS

Pandemic conditions have contributed to increased occupational stress among PSWs. Employers must implement proactive strategies that promote and protect the well-being of their workforce while advocating for sector improvements.

Exploring the Experiences and Impacts of Research Role-Emerging Placements in Physiotherapy

Purpose

Research role-emerging placements (RREPs) have been integrated into placement offerings in Canadian physiotherapy programmes. The purpose of the present study is to describe the experiences and impacts of RREPs completed by graduates of Canadian physiotherapy programmes.

Methods

Participants were recruited by purposive sampling and completed semi-structured interviews to explore their RREP experiences. Themes were identified using thematic analysis and collaboratively analyzed using the DEPICT model.

Results

Eleven participants who completed RREPs during their Canadian physiotherapy programmes (three men, eight women; aged 26.9 [SD 2.7] years) took part in this study. The participants expressed the RREP was a valuable experience. Four themes emerged from the data: (1) Motivators for selecting an RREP included interest in research or a medical injury, (2) The RREP experience involved benefits and challenges, (3) Impacts of completing an RREP, and (4) RREP participant suggestions.

Conclusions

RREPs are valuable placement opportunities for learners in Canadian physiotherapy programmes facilitating the development of essential competencies in a non-traditional setting. RREPs could be considered as a placement opportunity for other allied health programmes, as the skills gained are beneficial for all health care professionals.

"And if my goal is never to leave Casey House?": The significance of place attachment for patients at a specialty HIV hospital in Toronto, Canada

The current healthcare context prioritizes shorter hospital stays and fewer readmissions. However, these measures may not fully capture care experiences for people living with HIV, especially those experiencing medical, psychosocial, and economic complexity. As part of a larger study, we conducted seven focus groups with people living with HIV (n = 52), who were current/former patients at a Toronto-based specialty hospital, examining their desires/needs for hospital programs. Using a novel place attachment lens, we conducted a thematic analysis focusing on the emotional bond between person (patient) and place (hospital). Our findings show that participants wanted an ongoing connection to hospital to fulfill their need(s) for control, security, restoration and belonging. Indeed, continual attachment to hospital may be beneficial for patients with complex care needs. Our research has implications for care engagement and retention frameworks.

A qualitative study exploring access barriers to abortion services among Indigenous Peoples in Canada

OBJECTIVE

This paper reports on findings from our exploratory qualitative study that aims to advance knowledge around access to and experiences with abortion services among Indigenous Peoples in Canada.

STUDY DESIGN

We applied an Indigenous methodology to engage with 15 Indigenous Peoples across Canada utilizing a conversational interview method. Our study was informed by an Indigenous Advisory Committee consisting of front-line service providers working in the area of abortion service access and/ or support across Canada.

RESULTS

We conducted conversations from September and November 2021. Participants identified with Métis, Cree, Dene, Inuit, Haudenosaunee, Anishinaabe, and Mi'kmaq nations, across nine provinces and territories. Participants spoke to six themes encompassing challenges and potential solutions around abortion access experiences among Indigenous Peoples in Canada. These included (1) logistical barriers, (2) poor treatment, (3) stigma, (4) impacts of colonialism on attitudes towards abortion, (5) traditional knowledge, and (6) follow-up care and support.

CONCLUSIONS

Our study demonstrates that Indigenous Peoples experience abortion access barriers that are different than non-Indigenous Canadians, and that these barriers are closely linked to colonialism.

IMPLICATIONS

Indigenous knowledges and practices that honor reproductive choice that pre-dates settler colonialism, must be brought forward into today to enhance the quality of abortion care.

Provider perspectives on patient-centredness: participatory formative research and rapid analysis methods to inform the design and implementation of a facility-based HIV care improvement intervention in Zambia

INTRODUCTION

Implementation of patient-centred care (PCC) practices in HIV treatment depends on healthcare workers' (HCWs) perceptions of the acceptability, appropriateness and feasibility of such practices (e.g. use of intentional, metric-driven activities to improve patient experiences).

METHODS

We applied rapid, rigorous formative research methods to refine a PCC intervention for future trial. In 2018, we conducted focus group discussions (FGDs) with 46 HCWs purposefully selected from two pilot sites. We elicited HCW perceptions of HIV service delivery, HCW motivation and perceived value of patient experience measures intended to improve PCC. FGDs utilized participatory methods to understand HCW responses to patient-reported care engagement challenges and Scholl's PCC Framework principles (e.g. seeing a patient as a unique person), enablers (e.g. care coordination) and activities (e.g. patient involvement). Our rapid analysis used analytic memos, thematic analysis, research team debriefs and HCW feedback to inform time-sensitive trial implementation.

RESULTS

While HCWs nearly universally identified with and supported principles of PCC in both facilities, they raised practical barriers given the practice environment. HCWs described motivation to help patients, attached value to seeing positive health outcomes and the importance of teamwork. However, HCWs reported challenges with enablers needed to deliver PCC. HCWs cited a work culture characterized by differential power dynamics between cadres and departments restricting HCW autonomy and resource access. Barriers included inflexibility in accommodating individual patient needs due to high patient volumes, limited human resources, laboratory capacity, infrastructure and skills translating patient perspectives into practice. HCW motivation was negatively influenced by encounters with "difficult patients," and feeling "unappreciated" by management, resulting in cognitive dissonance between HCW beliefs and behaviours. However, the enactment of PCC values also occurred. Results suggested that PCC interventions should reduce practice barriers, highlighting the value of mentors who could help HCWs dynamically engage with health system constraints, to facilitate PCC.

CONCLUSIONS

While HCWs perceived PCC principles as acceptable, they did not think it universally appropriate or feasible given the practice environment. Participatory and rapid methods provided timely insight that PCC interventions must provide clear and effective systems enabling PCC activities by measuring and mitigating relational and organizational constraints amenable to change such as inter-cadre coordination.

Community reinforcement approach (CRA) supported with structured recreation therapy: Experiences of people living with HIV in a pilot substance use treatment program at a specialty hospital

INTRODUCTION

Community reinforcement approach (CRA) is a behavioral intervention that has demonstrated favorable treatment outcomes for individuals with substance use disorders across studies. CRA focuses on abstinence; however, abstinence is not a desired goal among all people who use substances. Previous research has called for harm reduction-oriented treatment programs, especially within hospital settings. We examined the feasibility of a pilot CRA program, "Exploring My Substance Use" (EMSU), that integrates a harm-reduction perspective with structured recreation therapy at a specialty HIV hospital in Toronto, Canada.

METHODS

The 12-week EMSU program was delivered alongside a feasibility study that ran for 24 weeks (including an additional 12 weeks after program completion). We recruited hospital in/outpatients with moderate to severe substance use disorder to participate in the program and study. The EMSU program combined weekly substance use groups with weekly recreation therapy sessions. We collected data at five timepoints throughout the study; this article focuses on qualitative data from the final (24-week) interviews, which examine participants' experiences of the program-an under-researched element in CRA literature. We conducted thematic analysis in NVivo12 and descriptive statistics in SPSSv28.

RESULTS

Of the n = 12 participants enrolled in the EMSU program, six completed the 12-week intervention. All participants completed the 24-week study interview. The average age of participants was 41.5 years; eight identified as cis-male; most identified as white, experienced food insecurity, and were unstably housed. All participants valued the program, including opportunities to learn new skills and examine function(s) of their substance use, and would enroll if it were offered again. Participants discussed the benefits of leisure activities introduced through recreation therapy, which fostered social connections and provided inspiration/confidence to try new activities. Participants cited a lack of support for those experiencing health/personal challenges and overly strict program attendance rules. To improve the program, participants suggested more tactile activities and incorporating incentives.

CONCLUSIONS

Our findings support the feasibility of a CRA-based program with an integrated harm reduction and a recreation therapy component within an outpatient setting. Future programs should consider building in more flexibility and increased supports for clients dealing with complexities as well as consider COVID-19 related contingencies.

Co-designing a Sexual Health App With Immigrant Adolescents: Protocol for a Qualitative Community-Based Participatory Action Research Study

BACKGROUND

Canada is one of the world's most ethnically diverse countries, with over 7 million individuals out of a population of 38 million being born in a foreign country. Immigrant adolescents (aged 10 to 19 years) make up a substantial proportion of newcomers to Canada. Religious and cultural practices can influence adolescents' sexual attitudes and behaviors, as well as the uptake of sexual and reproductive health (SRH) services among this population. Adolescence is a time to establish lifelong healthy behaviors. Research indicates an alarming gap in adolescents' SRH knowledge, yet there is limited research on the SRH needs of immigrant adolescents in Canada.

OBJECTIVE

The purpose of this study is to actively engage with immigrant adolescents to develop, implement, and evaluate a mobile health (mHealth) intervention (ie, mobile app). The interactive mobile app will aim to deliver accurate and evidence-based SRH information to adolescents.

METHODS

We will use community-based participatory action research to guide our study. This research project will be conducted in 4 stages based on user-centered co-design principles. In Stage 1 (Empathize), we will recruit and convene 3 adolescent advisory groups in Edmonton, Toronto, and Vancouver. Members will be engaged as coresearchers and receive training in qualitative and quantitative methodologies, sexual health, and the social determinants of health. In Stage 2 (Define and Ideate), we will explore SRH information and service needs through focus group discussions with immigrant adolescents. In Stage 3 (Prototype), we will collaborate with mobile developers to build and iteratively design the app with support from the adolescent advisory groups. Finally, in Stage 4 (Test), we will return to focus group settings to share the app prototype, gather feedback on usability, and refine and release the app.

RESULTS

Recruitment and data collection will be completed by February 2023, and mobile app development will begin in March 2023. The mHealth app will be our core output and is expected to be released in the spring of 2024.

CONCLUSIONS

Our study will advance the limited knowledge base on SRH and the information needs of immigrant adolescents in Canada as well as the science underpinning participatory action research methods with immigrant adolescents. This study will address gaps by exploring SRH priorities, health information needs, and innovative strategies to improve the SRH of immigrant adolescents. Engaging adolescents throughout the study will increase their involvement in SRH care decision-making, expand efficiencies in SRH care utilization, and ultimately improve adolescents' SRH outcomes. The app we develop will be transferable to all adolescent groups, is scalable in international contexts, and simultaneously leverages significant economies of scale.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/45389.

Centering healthcare workers in developing digital health interventions: usability and acceptability of a two-way texting retention intervention in a public HIV clinic in Lilongwe, Malawi

Background

New initiates on antiretroviral therapy (ART) are at high risk of treatment discontinuation, putting their health at risk. In low-resource settings, like Malawi, appropriate digital health applications must fit into local connectivity and resource constraints. Target users' perspectives are critical for app usability, buy-in and optimization. We describe the formative stages of the design of a two-way text-based (2wT) system of tailored reminders and adherence messages for new ART initiates and share results from key informant interviews with HCWs focused on app usability and acceptability.

Methods

Using a co-creation approach with clients, clinical, technical and evaluation teams and over app development, we held four informal user feedback sessions, a small pilot with 50 clients, and ten key informant (KIIs) to deepen our understanding of healthcare workers (HCWs) needs, acceptability and usability.

Results

Formative research informed the design of interactive client-to-HCW communication, refining of the language and timing of weekly text blast motivational messages and tailored client-specific visit reminders. Informal feedback from HCW stakeholders also informed educational materials to enhance 2wT client understanding of how to report transfers, request visit date changes and ask questions related to their visits. In KII, HCWs noted their appreciation for the co-creation process, believing that the participatory HCD process and responsive design team enabled the development of a highly acceptable and usable 2wT digital tool. HCWs also suggested future improvements to promote inclusion of clients of varying literacy levels and economic backgrounds as well as integrating with other health platforms to improve uptake of 2wT.

Conclusions

Inclusion of HCWs increased perceptions of app usability and acceptability among HCWs. HCWs believe that 2wT will improve on-time ART visit attendance and provide valuable early retention in care support. The co-creation approach appears successful in designing an app that will meet HCW needs and, therefore, support client adherence to visits.

Voices of women in homelessness during the outbreak of the COVID-19 pandemic: a co-created qualitative study

BACKGROUND

Women in homelessness face extreme health- and social inequities. It could be postulated that during societal crises, they become even more vulnerable. Thus, the aim was to explore experiences related to the COVID-19 pandemic among women in homelessness.

METHODS

Ten interviews were conducted with women in homelessness, in Stockholm, Sweden, using researcher-driven photo elicitation. The data analysis was guided by the DEPICT model for collaborative data analysis and a qualitative content analysis was performed. A collaborative reference group of women with lived experience of homelessness contributed to the research process through designing the data collection, performing the data analysis, and providing feedback during report writing.

RESULTS

For women in homelessness, the COVID-19 pandemic was adding insult to injury, as it significantly affected everyday life and permeated most aspects of existence, leading to diminished interactions with others and reduced societal support. Thus, in an already dire situation, the virus amplified health- and social issues to another level. The women strived to find their balance on the shifting sands of guidelines and restrictions due to the pandemic. Adhering to the new social distancing rules and guidelines in line with the rest of society, was simply impossible when experiencing homelessness. However, for some women the pandemic was nothing but a storm in a teacup. The harsh reality continued irrespectively, living one day at a time and prioritizing provision for basic human needs.

CONCLUSIONS

The COVID-19 pandemic and homelessness can be viewed as two intersecting crises. However, the women's aggregated experiences were greater than the sum of experiencing homelessness and meeting the threat of the virus. Gender, exposure to violence, poverty, social isolation, and substance use were additional factors that further marginalized the women during the pandemic. To rebuild a better and more sustainable post-pandemic future for all, global commitment to ending homelessness is crucial. In addition, addressing social determinants of health must be the number one health intervention.

“They’re all struggling as well”: social and economic barriers and facilitators to self-managing chronic illness among marginalized people who use drugs

Purpose

Self-management is recommended for addressing chronic conditions, and self-management programmes improve health behaviours and outcomes. However, social and economic factors have been neglected in self-management research, despite their relevance for marginalized groups. Thus, we aimed to explore barriers and facilitators that influence self-management among socioeconomically marginalized people who use drugs (PWUD).

Methods

Using community-based participatory methods, we developed a qualitative interview guide and conducted peer-led recruitment. Participants were admitted into the study after self-identifying as using non-prescribed drugs, having a chronic health issue, and experiencing socioeconomic marginalization. Data were analysed using reflexive thematic analysis, taking a relational autonomy lens.

Results

Participants highlighted substantial barriers to managing their health issues, mostly stemming from their social and economic environments, such as unstable housing, low income, lack of supportive social networks, and negative healthcare experiences. Participants also described how their ability to self-manage their chronic conditions benefited from specific aspects of social interactions, including close relationships, community connectedness, and engaging in peer support.

Conclusions

Our findings suggest that structural interventions are needed to support self-management among marginalized PWUD, especially stable housing. Self-management supports for PWUD would benefit from including a range of low-barrier community-based options, peer work opportunities, and advocacy for needs.

"Make sure I hear snoring": Adolescent girls, trans, and non-binary youth using sound for sexual wellbeing boundary-making at home during COVID-19

To understand how COVID-19's stay-at-home orders impacted youths' sexual and social development, we conducted five virtual focus groups (n = 34) with adolescent girls', trans', and non-binary youths' aged 16-19 between April-June 2021 in the GTA. We queried experiences of home, privacy, and sexual wellbeing during Canada's third wave. Auto-generated zoom transcripts were coded using an inductive framework with NVivo. Field notes and team discussions on the coded data informed the analysis. This paper explores how sexual wellbeing during the pandemic is practiced in relation to, dependent upon, and negotiated at home. Using intersectionality theory and embodiment theory, this research analyzes how youth's diverse identities shape their understandings and experiences of sexual wellbeing. We found youth needed spaces where they were not only unseen, but importantly, unheard. We argue sound as an important piece of boundary-work that reveals the way youth construct space during precarious times. Youth primarily negotiated sonic privacy through (a) sound-proofing, (b) sound warnings and (c) "silent reassurance", a term we coined to describe the precursor of silence from other household members in order for youth to feel safe enough to practice sexual wellbeing. We found that white youth cited the bedroom as the best space for sexual wellbeing practices, but BIPOC youth felt the bedroom was only their best available option and still found they had to negotiate privacy. Attending to intersectionality theory, we expand on McRobbie and Garber's (1976) bedroom culture concept and widen Hernes' (2004) concept of physical, social and mental boundary-work to include sound as a fourth type, which straddles among them. This research shows how privacy, gender and sexual identities were negotiated at home in times of extreme uncertainty, highlighting how implications of home as a 'place' during the pandemic, constructs sexual wellbeing. Mapping how and where youth practice embodied sexual wellbeing exposes the ways that private and public understandings of identity relate to sexuality and geographies of home. We understand the home as a complex space that can not only determine sexual wellbeing, but where health promoting boundaries can be negotiated. We conclude with suggestions for supporting adolescent sexual wellbeing, inside and outside the home, during and after COVID-19.

Philanthropic donor perspectives about providing harm reduction services for people living with HIV/AIDS in a hospital setting

BACKGROUND

Hospital-based harm reduction services are needed to reduce drug-related harms, facilitate retention in care, and increase medical treatment adherence for people who use drugs. Philanthropic donor support plays a key role in delivering such innovative services which might fall outside current funding streams. However, little is known about how the principles, implementation, and practice of harm reduction services, which are often highly stigmatized, may impact donor behaviours. We explored this issue within Casey House, a speciality hospital in Toronto, Canada.

METHODS

Our mixed methods study utilized an explanatory sequential design. A convenience sample of n = 106 philanthropic individual donors, recruited via email, completed an anonymous web-based survey, between July and October 2020, which assessed their knowledge of harm reduction services and the potential impact of implementing new hospital-based harm reduction services on donors' future support. Following this, we conducted semi-structured qualitative interviews with n = 12 of the donors who completed a survey and volunteered to be interviewed. Interviews examined donors' perspectives about harm reduction and their hopes/concerns for such programming at Casey House. Data were analysed using descriptive statistics and participatory-based thematic analysis.

RESULTS

Survey data show a high level of support for hospital-based harm reduction services, with participants reporting that they "strongly agree/agree" with providing harm reduction equipment (85%), supervised consumption services (82%), and prescription opioid treatment (76%) at Casey House. A majority of participants (66%) claimed that implementing new harm reduction services at the hospital would not impact their future donation, while 6% said they would be less inclined to donate. Interview participants were supportive of harm reduction services at Casey House, recognizing the benefits of providing such services for hospital clients and the wider community. However, some spoke of the potential impact that implementing hospital-based harm reduction services may have on "other" donors who might be opposed. Although some believed harm reduction services should be fully funded by the government, most saw a role for donors in supporting such services.

CONCLUSIONS

Our findings show support of hospital-based harm reduction services among philanthropic donors and provide insight into how donor support may be affected when such services are introduced.

Evaluating the validity of a functional electrical stimulation clinical decision making tool: A qualitative study

INTRODUCTION

Following central nervous system damage, the recovery of motor function is a priority. For some neurological populations, functional electrical stimulation (FES) is recommended in best practice guidelines for neurorehabilitation. However, limited resources exist to guide FES application, despite clinicians reporting that a lack of FES knowledge prevents use in clinical practice. The FES Clinical Decision Making Tool was developed to assist clinicians with FES application and translation into clinical practice. The purpose of this study was to evaluate the content validity of the Tool from the perspectives of Canadian physical and occupational therapists using FES in neurorehabilitation.

METHODS

Thirteen participants (twelve women, one man), aged 40.5 ± 10.3 years, participated in individual semi-structured interviews to explore their clinical decision making experiences when applying FES and to evaluate the content validity (i.e., appropriateness, comprehensibility, and comprehensiveness) of the Tool. Interviews were analyzed using a qualitative conventional content analysis following the DEPICT model.

RESULTS

Three themes were identified. 1) Clinician context influences FES usage. Participants' experiences with FES use varied and application was influenced by treatment goals. 2) Parameter selection in clinical practice. Participants identified decision-making strategies and the challenges of parameter selection. 3) With modifications, the Tool is a valid resource to inform FES applications. Participants discussed its strengths, limitations, and suggested changes. While the Tool is useful, a more extensive resource (e.g., appendix) for the Tool is warranted.

DISCUSSION

A revised Tool was created to improve its comprehensiveness and comprehensibility. Thus, the Tool is a valid resource for applying FES in neurorehabilitation.

Participatory peer research exploring the experience of learning during Covid-19 for allied health and healthcare science students

INTRODUCTION

The teaching and learning experience of allied health and healthcare science students has altered because of the Covid-19 pandemic. Limited research has explored the experience on the future healthcare workforce using participatory research design. The aim of this study was to explore the impact of a global pandemic on the clinical and academic experiences of healthcare student using a co-production approach with student peer researchers.

METHODS

A participatory research approach adopting online focus groups facilitated by students trained as peer researchers was adopted. First, second and final year students from occupational therapy, physiotherapy, podiatry, healthcare science, diagnostic radiography and imaging, radiotherapy and oncology, and speech and language therapy were recruited to six focus groups. Data generated through focus groups were analysed thematically using the DEPICT model to support a partnership approach.

RESULTS

Twenty-three participants took part in six focus groups. The themes identified were: rapid changes to learning; living alongside Covid-19 and psychological impact. Students preferred blended learning approaches when available, as reduced peer interaction, studying and sleeping in the same space, and technology fatigue decreased motivation.

CONCLUSION

Due to rapid changes in learning and the stress, anxiety and isolation created by the pandemic, managing study, personal life and placement resulted in a gap in confidence in clinical skills development for students. Students took their professional identity seriously, engaged in behaviours to reduce transmission of Covid-19 and employed a range of coping strategies to protect wellbeing. A challenge with the move to online delivery was the absence of informal peer learning and students indicated that moving forward they would value a hybrid approach to delivery. Higher Education should capitalise on innovative learning experiences developed during the pandemic however it is important to research the impact this has on student skill acquisition and learning experience.

Reflections on health among women in homelessness: A qualitative study

WHAT IS KNOWN ON THE SUBJECT?: Previous research reports that people in homelessness have poor physical and mental health and are excluded from society with risk for loneliness and social exclusion. Women in homelessness face particularly vulnerable circumstances with significant risks of harm. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Feelings of having a home is a basis for meeting physical, psychosocial, and existential needs related to health. Being involved in authentic relationships and caring for others gives women in homelessness a sense of worth. To be accepted by others and feeling like an equal was important for experiences of preserved dignity. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses need to recognize and support women in homelessness for their capacity to heal and to experience health. To regard women in homelessness as active health-seekers, instead of passive victims, can improve women's experiences of care provided by mental health professionals. Nurses can promote health by regarding women as resourceful and active, despite the fact that they live in homelessness.

ABSTRACT

INTRODUCTION: Mental health issues are common among women in homelessness, alongside undertreated chronic physical conditions leading to serious and unnecessary complications. Even though homelessness and risks of impaired health have been researched, broader perspectives of health are absent.

AIM

To describe reflections on health among women with experiences of homelessness.

METHOD

We conducted 13 interviews with women in homelessness using researcher-driven photograph elicitation. Together with an advisory board of women with lived experience of homelessness, researchers were guided by the DEPICT model for collaborative data analysis and performed a thematic analysis.

FINDINGS

Women with experiences of homelessness emphasized three main resources for achieving health and well-being: feelings of having a home, being involved in authentic relationships and experiences of preserved dignity.

IMPLICATION FOR PRACTICE

Healthcare needs to integrate the perceived resources for health and well-being when caring for women in homelessness. It is imperative since women will return to the healthcare setting only if they feel safe and secure, and only if dignity is preserved or restored. The results promote utilization of an integrative nursing approach; understanding that the health of women in homelessness is inseparable from their environment and social determinants for health, such as housing and social integration.

"We can hardly even do it nowadays. So, what's going to happen in 5 years from now, 10 years from now?" The health and community care and support needs and preferences of older people living with HIV in Ontario, Canada: a qualitative study

Introduction

The population of people living with HIV (PLWH) is ageing consequent to effective treatment and a steady stream of new diagnoses among older adults. PLWH experience a greater burden of age‐related comorbidities and poorer social determinants of health compared to their HIV‐negative peers, yet comprehensive requisites for care and support as PLWH age remain poorly understood. Preferences And Needs for Ageing Care among HIV‐positive Elderly people in Ontario, Canada (PANACHE ON), explored the health and community care and social support needs and preferences of a diverse group of older PLWH (age 60+) and described life course experiences among older PLWH that shape these needs and preferences and whether they are met.

Methods

PANACHE ON was a qualitative community‐based participatory research study. In‐person focus groups using a semi‐structured interview guide were co‐facilitated by pairs of trained older PLWH from July to October 2019. Purposive sampling bolstered the inclusion of communities disproportionately affected by HIV in Ontario. Descriptive analysis was used to summarize demographic data; participatory data analysis was conducted by a subset of the research team, with transcripts double‐coded and analysed using NVIVO 12 Plus.

Results

A total of 73 PLWH participated, 66% identified as men. The mean age was 64 years (range 55–77) and median time living with HIV was 23 years (range 2–37). The current and anticipated needs of older PLWH, many of which were only partially met, included necessities such as food and housing, mobility and sensory aids, in‐home support, social and emotional support, transportation and information. Three experiences—trauma, stigma and uncertainty—intersected in the lives of many of our participants, shaping their needs for care and support, and impacting the ease with which these needs were met.

Conclusions

Unmet health and social needs and limited control over the availability and accessibility of ageing‐related care and support due to resource constraints or reduced capacity for self‐advocacy results in anxiety about the future among older PLWH, despite their well‐developed coping strategies and experience navigating systems of care. These study findings will inform the development of the first national needs assessment of older PLWH in Canada.

Depressive symptoms among people living with HIV in permanent supportive housing: Findings from a community-based participatory study in Vancouver, Canada

Permanent supportive housing (PSH) is an intervention addressing housing needs among marginally housed individuals. Little is known about whether and how PSH influences depressive symptoms among people living with HIV (PLHIV). This article shares results from a community-based study that, in 2016-2017, interviewed 24 residents of a PSH facility designated for PLHIV in Vancouver, Canada. The themes of taking control; social connectedness; conviviality; and relationships and supports described how the PSH environment affected depressive symptoms among the residents.

Acceptability and feasibility of community-based provision of urine pregnancy tests to support linkages to reproductive health services in Western Kenya: a qualitative analysis

BACKGROUND

The majority of women living in rural Kenya access antenatal care (ANC) late in pregnancy, and approximately 20% have an unmet need for family planning (FP). This study aimed to determine whether training community health volunteers (CHVs) to deliver urine pregnancy testing (UPT), post-test counselling, and referral to care was an acceptable and feasible intervention to support timely initiation of ANC and uptake of FP.

METHODS

We applied community-based participatory methods to design and implement the pilot intervention between July 2018 and May 2019. We conducted qualitative content analysis of 12 pre-intervention focus group discussions (FGDs) with women, men, and CHVs, and of 4 post-intervention FGDs with CHVs, each with 7-9 participants per FGD group. Using a pragmatic approach, we conducted inductive line-by-line coding to generate themes and subthemes describing factors that positively or negatively contributed to the intervention's acceptability and feasibility, in terms of participants' views and the intervention aims.

RESULTS

We found that CHV-delivered point of care UPT, post-test counselling, and referral to care was an acceptable and feasible intervention to increase uptake of ANC, FP, and other reproductive healthcare services. Factors that contributed to acceptability were: (1) CHV-delivery made UPT more accessible; (2) UPT and counselling supported women and men to build knowledge and make informed choices, although not necessarily for women with unwanted pregnancies interested in abortion; (3) CHVs were generally trusted to provide counselling, and alternative counselling providers were available according to participant preference. A factor that enhanced the feasibility of CHV delivering UPT and counselling was CHV's access to appropriate supplies (e.g. carrying bags). However, factors that detracted from the feasibility of women actually accessing referral services after UPT and counselling included (1) downstream barriers like cost of travel, and (2) some male community members' negative attitudes toward FP. Finally, improved financial, educational, and professional supports for CHVs would be needed to make the intervention acceptable and feasible in the long-term.

CONCLUSION

Training CHVs in rural western Kenya to deliver UPT, post-test counselling, and referral to care was acceptable and feasible to men, women, and CHVs in this context, and may promote early initiation of ANC and uptake of FP. Additional qualitative work is needed to explore implementation challenges, including issues related to unwanted pregnancies and abortion, the financial burden of volunteerism on CHVs, and educational and professional supports for CHVs.

Physiotherapists' Perspectives on Professional Practice Leadership Models: Key Features to Enhance Physiotherapy Practice

Purpose: The purpose of this study was to explore professional practice leadership models (PPLMs) within the Toronto Academic Health Science Network (TAHSN) by outlining the PPLMs currently in use, identifying elements of the PPLMs from physiotherapists' perspectives, and determining key features of PPLMs that enhance physiotherapy (PT) practice. Methods: In this qualitative, cross-sectional study, we used focus groups to explore physiotherapists' knowledge about their facility's PPLM, physiotherapists' role within the PPLM, the impact of professional practice leaders on PT practice, the impact of the PPLM on physiotherapists' job satisfaction, and the elements of an ideal PPLM. We coded transcripts using qualitative software and followed an inductive data analysis approach to develop themes. Results:We conducted eight focus groups with physiotherapists from six TAHSN facilities (four organizations). Five key features of PPLMs emerged from participants' perspectives: support network, organizational structure, professional development opportunities, influence of the leader in professional practice, and balance of workloads and accountabilities. Each key feature encompassed a group of interrelated elements - that is, components of the PPLMs that influenced PT practice. Conclusions: Our study is the first to explore elements and key features of the PPLMs used in TAHSN facilities as they relate to PT. We provide five recommendations to enhance PPLMs with respect to the PT profession.

Staying safe: how young women who trade sex in Toronto navigate risk and harm reduction

Celling Sex was a community-based participatory research project that used a strengths-based approach to explore the agentic harm reduction practices employed by young women who trade sex and learn about their experience accessing health and social services. Fifteen racially diverse young women participated in interviews. They described how they tried to stay safe and advice for others. Each participant also individually made a brief digital video (cellphilm) to tell their story. Participants were invited to a private screening at which cellphilms were screened and common themes identified. The interviews and cellphilms were subsequently coded according to these themes. Participants identified a number of trading risks including: physical risks (unwanted pregnancy, STIs, and violence), social risks (racism and fetishisation), and mental health risks. To mitigate these concerns, participants detailed the harm reduction strategies they used which included use of technology, screening measures, boundary setting, and actively incorporating sexual health protections. Young women who trade sex are keenly aware of the risks inherent in transactional relationships and proactively negotiate and navigate harm reduction strategies in the context of deep systemic barriers. Further intervention may be necessary for them to actualise these strategies and access important forms of health and social support.

Innovative participatory bilingual data analysis with Latinx/@ immigrants: Language, power, and transformation

OBJECTIVE

The insights of Latinx/@ immigrants are essential to developing interventions that better address complex multilevel phenomena impacting mental health. Despite important advances in methods that genuinely embody participatory research practices, attention to collaborative data collection, analysis, and dissemination are limited. Our aim is to describe the development and implementation of research practices to address these gaps through an emphasis on and understanding of the centrality of language in collaborative research processes.

METHOD

Guided from the outset by community-based participatory research principles, our community-academic research partnership recognized the importance of developing and intentionally studying our collaborative processes. As part of an ethnographic interview study with 24 Latinx/@ immigrants, a community-university research team developed innovative methods, including practices related to research team meetings, data collection, analysis, and dissemination, which we documented through ongoing discussion and reflection.

RESULTS

The resulting participatory research processes were grounded in a theoretical framework of praxis and language and included six innovative and iterative stages: (a) Establishing the research team, (b) planning the interview process/data collection, (c) developing the data analysis methodology, (d) interpreting findings to adapt the intervention, (e) integrating results of the participatory process into the analysis, and (f) data analysis for dissemination.

CONCLUSIONS

A focus on praxis and language revealed how the language of research structures' power, meaning, feeling, collaboration, analysis, and transformation. We also found that bilingual participatory analytic processes have important implications with respect to achieving genuine inclusion in rigorous research that moves toward equity for Latinx/@ immigrants and other populations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Navigating the Grey Zone of Physiotherapy Assistant Autonomy in Home Care: Perspectives of Physiotherapists and Physiotherapy Assistants

Purpose: To explore perspectives and experiences regarding the autonomy of physiotherapist assistants (PTAs) among physiotherapists and PTAs providing home care services in Ontario since the introduction of PTAs into home care rehabilitation teams. Method: For this qualitative study, we conducted semi-structured interviews with 10 physiotherapists and 5 PTAs working in home care. We analyzed interview transcripts using the DEPICT model. Results: Participants described navigating a grey zone characterized by a lack of clarity about acceptable levels of PTA autonomy. Four interrelating factors shaped the extent to which PTAs practiced with autonomy: system influences (number of physiotherapy visits, professional guidelines), patient complexity (status, comorbidities), perceived PTA competence (skills, training), and the physiotherapist–PTA relationship (trust, communication). Conclusions: New practice models in home care have impacted the role of both physiotherapists and PTAs. Home care agencies should facilitate emerging professional relationships and address autonomy-related challenges, such as trust and competence, to promote high-quality client-centred care.

Considerations for developing and implementing an online community-based exercise intervention with adults living with HIV: a qualitative study

OBJECTIVES

To describe the need for, and utility of, online community-based exercise (CBE) interventions with adults living with HIV and identify factors to consider in developing and implementing an online CBE intervention with adults living with HIV.

DESIGN

Qualitative descriptive study using web-based semistructured interviews.

PARTICIPANTS

We recruited adults representing at least one of five stakeholder groups with experience in CBE and/or HIV: (1) adults living with HIV, (2) rehabilitation professionals, (3) fitness personnel, (4) educators with eLearning experience and (5) representatives from HIV community-based organisations (CBOs).

DATA COLLECTION

We asked participants to describe their experiences with online CBE, need and utility for online CBE and factors in developing and implementing online CBE interventions. We analysed data using a group-based thematic analytical approach.

RESULTS

Among the 11 participants, most had experience working with adults living with HIV (73%) or with telehealth/rehabilitation/coaching in HIV or other chronic conditions (91%). Participants (eight women; two men; one non-binary; median age: 49 years), identified the need and utility for online CBE interventions to increase accessibility and continuity of care with adults living with HIV. Six factors to consider in developing and implementing online CBE included: (1) person-specific considerations (episodic nature of HIV, stigma, HIV disclosure), (2) accessibility of programme (physical space to exercise, reliable internet, access to devices, digital literacy), (3) programme delivery and technology (live vs prerecorded online classes, multiple online platforms for delivery, physical activity tracking, troubleshooting technology), (4) attributes of programme personnel (working with CBOs, relatable instructors, diverse staff), (5) programme content and design (tailored exercise classes, educational sessions) and (6) building community (shared experiences, peer support, social opportunities).

CONCLUSIONS

There is a need and utility for online CBE in the context of HIV. Considerations for development and implementation span individual, structural and technical, and community dimensions. Results can inform the future development and implementation of online CBE with adults living with HIV and other chronic episodic conditions.

Long COVID and episodic disability: advancing the conceptualisation, measurement and knowledge of episodic disability among people living with Long COVID - protocol for a mixed-methods study

INTRODUCTION

As the prevalence of Long COVID increases, there is a critical need for a comprehensive assessment of disability. Our aims are to: (1) characterise disability experiences among people living with Long COVID in Canada, UK, USA and Ireland; and (2) develop a patient-reported outcome measure to assess the presence, severity and episodic nature of disability with Long COVID.

METHODS AND ANALYSIS

In phase 1, we will conduct semistructured interviews with adults living with Long COVID to explore experiences of disability (dimensions, uncertainty, trajectories, influencing contextual factors) and establish an episodic disability (ED) framework in the context of Long COVID (n~10 each country). Using the conceptual framework, we will establish the Long COVID Episodic Disability Questionnaire (EDQ). In phase 2, we will examine the validity (construct, structural) and reliability (internal consistency, test-retest) of the EDQ for use in Long COVID. We will electronically administer the EDQ and four health status criterion measures with adults living with Long COVID, and readminister the EDQ 1 week later (n~170 each country). We will use Rasch analysis to refine the EDQ, and confirm structural and cross-cultural validity. We will calculate Cronbach's alphas (internal consistency reliability), and intraclass correlation coefficients (test-retest reliability), and examine correlations for hypotheses theorising relationships between EDQ and criterion measure scores (construct validity). Using phase 2 data, we will characterise the profile of disability using structural equation modelling techniques to examine relationships between dimensions of disability and the influence of intrinsic and extrinsic contextual factors. This research involves an academic-clinical-community partnership building on foundational work in ED measurement, Long COVID and rehabilitation.

ETHICS AND DISSEMINATION

This study was approved by the University of Toronto Research Ethics Board. Knowledge translation will occur with community collaborators in the form of presentations and publications in open access peer-reviewed journals and presentations.

Thinking rhizomatically and becoming successful with disabled students in the accommodations assemblage: Using storytelling as method

The number of disabled students enrolled in higher education institutions is increasing. Yet in disciplines such as nursing, where placements are an important part of student success, students' lived experiences, though an important and necessary aspect of promoting equity, diversity, and inclusion, has been ignored. In this paper, we respond to such issues by creating and utilizing a novel storytelling method that harnesses the antiessentialist philosophy of Deleuze and Guattari. Storytelling empowers students to both describe their experiences and inform institutions on how to better serve them, and we use concepts from Deleuze and Guattari to provide a framework for thinking about students and their pathways toward success as multiple. As we show, applying storytelling as a method through this lens offers an expansion of strategies to put students first and, therefore, promote equity at the administrative, research, educational, and practical levels. We describe how thinking rhizomatically opens new avenues of insight, allowing for the creation of institutional assemblages based on a diverse array of students' needs, enabling them to become successful in their own ways.

Exploring Audience Engagement and Critical Narrative Intervention With the Celling Sex Film

Young women who trade sex experience high rates of stigma that exacerbate existing health inequities. The products of participatory visual methodologies show promising potential for challenging stigma. In total, 15 young women who trade sex created individual brief videos to share their experiences. Following a participatory analysis, the videos were edited into one composite movie to highlight key messages. Eight facilitated screenings (cohosted by participant filmmakers and research team members) were organized with diverse community and health organizations. Audiences were led through a series of interactive writing, drawing, viewing, and discussion activities. Sessions were audio recorded, transcribed verbatim, and inductively analyzed to assess the impacts of the film on audiences. Audience reactions were categorized into four overarching themes to describe main impacts: consciousness raising, commitments to practice and organizational change, effectiveness of the approach, and limitations. Audience responses demonstrated that facilitated screenings can challenge harmful stereotypes and help viewers consider pathways to enact positive change in their personal and professional lives. However, changing deep-rooted patterns of stigma takes time, dedication, and accountability.

Visualizing DEPICT: A Multistep Model for Participatory Analysis in Photovoice Research for Social Change

As a critical narrative intervention, photovoice invites community members to use photography to identify, document, and discuss issues in their communities. The method is often employed with projects that have a social change mandate. Photovoice may help participants express issues that are difficult to articulate, create tangible and meaningful research products for communities, and increase feelings of ownership. Despite being hailed as a promising participatory method, models for how to integrate diverse stakeholders feasibly, collaboratively, and rigorously into the analytic process are rare. The DEPICT model, originally developed to collaboratively analyze textual data, enhances rigor by including multiple stakeholders in the analysis process. We share lessons learned from Picturing Participation, a photovoice project exploring engagement in the HIV sector, to describe how we adapted DEPICT to collaboratively analyze participant-generated images and narratives across multiple sites. We highlight the following stages: dynamic reading, engaged codebook development, participatory coding, inclusive reviewing and summarizing of categories, and collaborative analysis and translation, and we discuss how participatory analysis is compatible with creative, interactive dissemination outputs such as exhibitions, presentations, and workshops. The benefits of Visualizing DEPICT include feelings of increased ownership by community researchers and participants, enhanced rigor, and sophisticated knowledge translation approaches that honor multiple forms of knowing and community leadership. The potential challenges include navigating team capacity and resources, transparency and confidentiality, power dynamics, data overload, and streamlining "messy" analytic processes without losing complexity or involvement. Throughout, we offer recommendations for designing participatory visual analysis processes that are connected to critical narrative intervention and social change aims.

Experiences engaging in a group-based physiotherapist-led exercise programme for adults living with HIV and complex multimorbidity: a qualitative study

OBJECTIVE

To explore experiences participating in a group-based physiotherapist (PT)-led exercise programme among people living with HIV and complex multimorbidity.

DESIGN

We conducted a qualitative descriptive study using semistructured interviews.

RECRUITMENT AND SETTING

We recruited community-dwelling adults living with HIV who engaged in a group-based PT-led exercise programme within an HIV-specialty hospital in Toronto, Canada. Interviews were conducted in-person or by telephone.

PARTICIPANTS

Eight men and two women with a median age of 58 years and median of six concurrent conditions in addition to HIV, who had attended ≥2 classes of the exercise programme.

DATA COLLECTION

Interviews explored (1) reasons for engaging in the programme, (2) experiences with exercise prior to and after joining the programme, (3) facilitators and barriers to engagement and (4) perceived impacts of participation on health and disability. We administered the HIV Disability Questionnaire and a demographic questionnaire.

RESULTS

Experiences spanned perspectives prior to, during and after the PT-led exercise programme. Reasons for engaging in the programme included addressing health-related goals. Participants identified accessibility, the flexible schedule, interprofessional staff and the HIV-specific, group-based environment as facilitators to engagement. Participants reported high attendance rates, but identified episodic health challenges and overcrowded space as potential barriers to attending exercise classes. Perceived impacts on health and disability outcomes included improved physical, mental, social and cognitive health, and activities of daily living. Anticipated or actual experiences transitioning to independent exercise included facilitators (supportive programme leaders) and barriers (challenges motivatiing self to exercise alone).

CONCLUSIONS

Features of the programme that facilitated engagement included the interprofessional, group-based environment that offered tailored exercise in an HIV-specific facility, whereby participants perceived benefits in domains of health and disability. However, challenges transitioning to independent exercise remain. Group-based PT-led exercise programmes may facilitate engagement in exercise among adults living with HIV and complex multimorbidity.

Understanding disability in healthcare: exploring the perceptions of parents of young people with autism spectrum disorder

Purpose: How autism spectrum disorder (ASD) is understood (i.e., as a medical problem or natural human variation) has profound implications for how healthcare services are designed and delivered. As the recipients of these services, children and families are highly invested in these debates, yet little research has sought to investigate their views. The purpose of this study was to explore parents' conceptualizations of ASD in relation to disability, and how they align with, or diverge from, conceptualizations they encounter within healthcare.Materials and methods: Nine semi-structured qualitative interviews were conducted with parents of children with ASD and thematically analyzed.Results: The accounts suggested that participants integrated multiple and sometimes contradictory conceptualizations of disability that reflected both "medical" and "social" models and sources of disablement. While the participants often advocated for acceptance and inclusion of their child, the label of "neurodiversity" was commonly rejected due to the concern for potential loss of funding for services.Conclusions: Study findings highlight the relationship between how parents conceptualize ASD and their experiences accessing supportive services within current delivery structures. Implications for ASD service providers emphasize accommodating parents' unique and evolving values and priorities for healthcare and their relation to current service systems.Implications for RehabilitationParents conceptualizations of ASD both inform and are influenced by their experiences of accessing supportive services.This study highlights that parents' perspectives are fluid, context-dependent, and do not exclusively represent a single model or perspective of disability.To meet family needs, service providers including healthcare professionals must recognize parents' unique understandings of their child's ASD and appreciate how healthcare shapes these perceptions.

Quilted cellphilm method: A participatory visual health research method for working with marginalised and stigmatised communities

The use of participatory visual methods and integration of cellphone technology is expanding in global public health research. Cellphilm method capitalises on these trends by inviting participants to use mobile devices to create short videos about health topics. This paper presents the quilted cellphilm method, which supports the participation of stigmatised populations to engage in research. We present the method with reference to the Celling Sex project, which worked with young women who have transactional sex experience. Four key steps in our unique model are discussed: (a) individual cellphilm-making; (b) participatory analysis; (c) creating a composite video; (d) publicly screening the work. We consider how working individually with participants in the cellphilm-making process built trust. We unpack how offering participants opportunities to engage in either group or one-on-one activities promoted participation in collaborative analysis. We outline how creating a composite video of the cellphilms and organising screenings facilitated knowledge translation and exchange. Overall, the quilted cellphilm method created a supportive community for vulnerable participants to generate products that challenged social stigma. Increased reliance on mobile media, especially during the COVID-19 pandemic, makes the quilted cellphilm method an opportune, exciting and accessible approach for participatory public health research.

"Stripped of dignity" - Women in homelessness and their perspectives of healthcare services: A qualitative study

BACKGROUND

A much more substantial European evidence base on the accessibility of healthcare services among women experiencing homelessness across healthcare systems in Europe is warranted.

OBJECTIVE

To give voice to women with experiences of homelessness, and to explore their perspectives of healthcare services in an EU country with universal healthcare.

DESIGN

The study is part of a research program striving to promote equal healthcare through co-production with women in homelessness. An advisory board of women with lived experience of homelessness was established and a qualitative, interpretive and exploratory design was employed.

PARTICIPANTS

26 women with experience of homelessness were interviewed. Their median age was 46 years (range 42) and 70% were roofless/houseless.

METHODS

Data were analyzed with content analysis. Co-production and joint analyses were conducted by researchers and three women with experience of homelessness, using the DEPICT model for collaborative analysis.

RESULTS

The analysis resulted in one overall theme: Visiting healthcare from the outskirts of society, comprising three sub-themes: Demand for a life in order - Exclusion in action; Unwell, unsafe and a woman - Multifaceted needs challenge healthcare; and Abuse versus humanity - power of healthcare encounters to raise or reduce. Women's experiences of care encounters were disparate, with prevalent control, mistrust and stigma, yet healthcare professionals that demonstrated respect for the woman's human dignity was described both as life-altering and lifesaving.

CONCLUSIONS

Women in homelessness live on the outskirts of society and have multiple experiences of exclusion and loss of dignity within healthcare services. The multifaceted care needs challenge healthcare, leading to women feeling alienated, invisible, disconnected and worthless. We urge registered nurses to take actions for inclusion health, i.e. focusing health efforts of people experiencing extreme health inequities. We can lead the way by speaking up and confronting discriminating behaviors, protecting and restoring human dignity in caring relationships, and framing healthcare services for all citizens. Tweetable abstract: Women in homelessness have multiple experiences of exclusion and loss of dignity within healthcare services. Nurses must frame healthcare to include all citizens.