Disruption as opportunity: Impacts of an organizational health equity intervention in primary care clinics

Primary healthcare practitioners' perspectives on trauma-informed primary care: a systematic review

BACKGROUND

Exposure to domestic and family violence is a pervasive form of complex trauma and a major global public health problem. At the frontline of the health system, primary healthcare practitioners are uniquely placed to support individuals with experiences of trauma, yet their views on trauma-informed primary care are not well understood. This systematic review of qualitative literature sought to explore primary healthcare practitioners' perspectives on trauma-informed primary care.

METHODS

Eight databases were searched up to July 2023. Studies were included if they consisted of empirical qualitative data, were conducted in general practice or equivalent generalist primary healthcare settings, and included the perspectives of primary healthcare practitioners where they could be distinguished from other participants in the analysis. Thematic synthesis was used for analysis.

RESULTS

13 papers met inclusion criteria, representing primary care settings from the United States, Canada, Australia, and Norway. Three key themes were developed: Changing the paradigm, Building trust, and Navigating the emotional load. Findings shed light on how primary healthcare practitioners perceive and strive to practise trauma-informed primary healthcare and the challenges of navigating complex, trauma-related work in the primary care environment.

CONCLUSIONS

This review supports the need for recognition of the value of primary care in supporting patients with histories of trauma and violence, the development of interventions to mitigate the emotional load worn by primary healthcare practitioners, and further work to develop a deep and consistent understanding of what trauma-informed primary care encompasses.

"… I carry their stories home …": experiences of nurses and midwives caring for perinatal adolescent mothers in primary health care settings in Rwanda

INTRODUCTION

Adolescent mothers require trauma- and violence-informed care during the perinatal period due to trauma histories and ongoing violence as a result of pregnancy. Nurses and midwives play a critical role in caring for adolescent mothers in primary healthcare settings in Rwanda in the perinatal period.

PURPOSE

To explore the experiences of nurses and midwives working with adolescent mothers in selected primary healthcare settings in Rwanda to inform the delivery of trauma- and violence- informed care.

METHODS

This study utilized an interpretive description qualitative approach and was conducted in eight primary healthcare settings in Rwanda. Twelve nurses and midwives working in perinatal services and four heads of health centers participated in in-depth individual interviews. Data were analyzed thematically.

RESULTS

The analysis revealed four main themes and 11 (sub-themes): (a) relational practice (being creative and flexible, "lending them our ears"); (b) individual challenges of providing care to adolescent mothers (lack of knowledge to provide care related to gender-based violence, and gendered experience); (c) factors contributing to workarounds (inflexible guidelines, lack of protocol and procedures, lack of nurses' and midwives' in service training, and the physical structure of the perinatal environment); and (d) vicarious trauma (living the feelings, "I carry their stories home," and hypervigilance in parenting).

CONCLUSION

Nurses and midwives find caring for adolescent mothers challenging due to their unique needs. These needs require them to be creative, adaptable, and attentive listeners to better understand their challenges. These practitioners face difficulties such as insufficient specific knowledge related to, for example, gender-based violence, inflexible guidelines, and a lack of protocols and training. Additionally, in the perinatal environment attention to the needs of practitioners in those settings is often lacking, and many nurses and midwives report experiencing vicarious trauma. Consequently, there is a pressing need for guidelines and protocols specifically tailored for the care of adolescent mothers. Ongoing trauma- and violence- informed care training and professional education should be provided to enhance the ability of nurses and midwives to care for adolescent mothers and prevent re-traumatization and mitigate vicarious trauma effectively.

Beyond individual factors: a critical ethnographic account of urban residential fire risks, experiences, and responses in single-room occupancy (SRO) housing

BACKGROUND

Burn injuries are a significant public health concern, closely linked to housing conditions and socioeconomic status. Residents in socioeconomically deprived neighbourhoods are at increased risk of exposure to hazards due to older and poorer housing conditions and limited access to fire protection measures. Individual behaviours such as substance use, smoking, and hoarding are often highlighted as primary causes of residential fires, overshadowing the broader socioeconomic and structural factors that also play a significant role in housing safety. This paper explores the correlation between inadequate housing conditions and heightened fire risks leading to burn injuries, focusing on the contextual factors shaping everyday urban fire risks, experiences, and responses of residents living in Single-Room Occupancy (SRO) housing in Vancouver's Downtown East Side (DTES) and staff working in the fire, health, housing (social and private), and non-profit sectors.

METHODS

As part of an ongoing ethnographic study, we partnered with the Vancouver Fire Rescue Services (VFRS) to conduct participant observations in private, non-profit, and government-owned SROs, modular homes, and a temporary shelter. This paper synthesizes insights from participant observations from the first author's self-reflexive journals, including informal conversations with approximately fifty-nine individuals such as SRO tenants, SRO managers/caretakers, health workers, burn survivors, municipal staff, not-for-profit staff, and firefighters.

RESULTS

Urgent housing-related issues contributing to inequitable everyday urban fire risks were identified, such as structural deficiencies in SRO buildings and systems, inadequate waste management and storage, and inequitable approaches to addressing hoarding. Additionally, disparities in access to information and the interaction between interpersonal and structural stigmas were significant factors, underscoring the pressing need for intervention.

CONCLUSION

Communities like DTES, facing precarious housing conditions, disadvantaged neighbourhoods, and complex health and social challenges, necessitate a comprehensive and holistic approach to fire prevention and safety. Recognizing the interplay between housing instability, mental and physical health issues, unregulated toxic drug supply, drug criminalization, and structural inequities allows practitioners from various sectors to develop contextually driven fire prevention strategies. This multifaceted approach transcends individual-level behaviour change and is crucial for addressing the complex issues contributing to fire risks in underserved communities.

"Breaking through the Brokenness": An Arts-Based Qualitative Exploration of Pregnant Women's Experience of Intimate Partner Violence while Receiving Trauma- and Violence-Informed Antenatal Care

Intimate partner violence (IPV) is a pervasive, worldwide public health concern. Risk of IPV may elevate during the perinatal period, increasing maternal and fetal health risks. Trauma- and violence-informed care shows promise among interventions addressing associated mental health sequelae. As a secondary analysis, the purpose of this study was to employ a qualitative arts-based exploration to better understand pregnant women's experiences of trauma and violence-informed perinatal care in the context of IPV. Using an arts-based qualitative methodology, different art forms were used to analyze, interpret, and report data, resulting in a layered exploration to represent phenomena. From this, four themes were reflected in four poetic pieces: Black Deep Corners, Triggering my Thoughts, Breaking through the Brokenness, and Now Perfectly Imperfect. Nine pieces of visual art were created reflecting these themes, creating a layered, embodied, artistic way to empathically explore and translate phenomena.

Telehealth Uptake Among Hispanic People During COVID-19: Retrospective Observational Study

Background

The Hispanic community represents a sizeable community that experiences inequities in the US health care system. As the system has moved toward digital health platforms, evaluating the potential impact on Hispanic communities is critical.

Objective

The study aimed to investigate demographic, socioeconomic, and behavioral factors contributing to low telehealth use in Hispanic communities.

Methods

We used a retrospective observation study design to examine the study objectives. The COVID-19 Research Database Consortium provided the Analytics IQ PeopleCore consumer data and Office Alley claims data. The study period was from March 2020 to April 2021. Multiple logistic regression was used to determine the odds of using telehealth services.

Results

We examined 3,478,287 unique Hispanic patients, 16.6% (577,396) of whom used telehealth. Results suggested that patients aged between 18 and 44 years were more likely to use telehealth (odds ratio [OR] 1.07, 95% CI 1.05-1.1; P<.001) than patients aged older than 65 years. Across all age groups, patients with high incomes were at least 20% more likely to use telehealth than patients with lower incomes (P<.001); patients who had a primary care physician (P=.01), exhibited high medical usage (P<.001), or were interested in exercise (P=.03) were more likely to use telehealth; patients who had unhealthy behaviors such as smoking and alcohol consumption were less likely to use telehealth (P<.001). Male patients were less likely than female patients to use telehealth among patients aged 65 years and older (OR 0.94, 95% CI 0.93-0.95; P<.001), while male patients aged between 18 and 44 years were more likely to use telehealth (OR 1.05, 95% CI 1.03-1.07; P<.001). Among patients younger than 65 years, full-time employment was positively associated with telehealth use (P<.001). Patients aged between 18 and 44 years with high school or less education were 2% less likely to use telehealth (OR 0.98, 95% CI 0.97-0.99; P=.005). Results also revealed a positive association with using WebMD (WebMD LLC) among patients aged older than 44 years (P<.001), while there was a negative association with electronic prescriptions among those who were aged between 18 and 44 years (P=.009) and aged between 45 and 64 years (P=.004).

Conclusions

This study demonstrates that telehealth use among Hispanic communities is dependent upon factors such as age, gender, education, socioeconomic status, current health care engagement, and health behaviors. To address these challenges, we advocate for interdisciplinary approaches that involve medical professionals, insurance providers, and community-based services actively engaging with Hispanic communities and promoting telehealth use. We propose the following recommendations: enhance access to health insurance, improve access to primary care providers, and allocate fiscal and educational resources to support telehealth use. As telehealth increasingly shapes health care delivery, it is vital for professionals to facilitate the use of all available avenues for accessing care.

Using a health equity lens to measure patient experiences of care in diverse health care settings

People who are structurally disadvantaged and marginalized often report poor health care experiences, such as inequitable treatment, due to intersecting forms of stigma and discrimination. There are many measures of patient experiences of care, however, few are designed to measure equity-oriented health care. In alignment with ongoing calls to integrate actions in support of health equity, we report on the development and testing of patient-reported experience measures that explicitly use a health equity and intersectional lens. Our analysis focuses on two different scales: the Equity-Oriented Health Care Scale-Ongoing, which was evaluated in primary health care settings where patients have an ongoing relationship with providers over time, and the Equity-Oriented Health Care Scale-Episodic, which was tested in an emergency department where care is provided on an episodic basis. Item Response Theory was used to develop and refine the scales. The psychometric properties of each scale were also evaluated. The Equity-Oriented Health Care Scale-Ongoing was first tested with a cohort of 567 patients. The Equity-Oriented Health Care Scale-Episodic was subsequently tested in an emergency department setting with 284 patients. Results of the Item Response Theory analysis for each scale yielded a brief index that captured the level of equity-oriented care when care is ongoing (12 items) or episodic (9 items). Both scales showed evidence of internal consistency and concurrent validity, based on a high correlation with quality of care. They are brief, easy-to-administer patient-reported experience measures that can support organizations to monitor quality of care. Their availability enhances the possibility of measuring equity-oriented health care in diverse contexts and can provide nuanced understandings of quality of care through an intersectional and equity lens.

Strategies and indicators to integrate health equity in health service and delivery systems in high-income countries: a scoping review

OBJECTIVE

The objective of this review was to describe how health service and delivery systems in high-income countries define and operationalize health equity. A secondary objective was to identify implementation strategies and indicators being used to integrate and measure health equity.

INTRODUCTION

To improve the health of populations, a population health and health equity approach is needed. To date, most work on health equity integration has focused on reducing health inequities within public health, health care delivery, or providers within a health system, but less is known about integration across the health service and delivery system.

INCLUSION CRITERIA

This review included academic and gray literature sources that described the definitions, frameworks, level of integration, strategies, and indicators that health service and delivery systems in high-income countries have used to describe, integrate, and/or measure health equity. Sources were excluded if they were not available in English (or a translation was not available), were published before 1986, focused on strategies that were not implemented, did not provide health equity indicators, or featured strategies that were implemented outside the health service or delivery systems (eg, community-based strategies).

METHODS

This review was conducted in accordance with the JBI methodology for scoping reviews. Titles and abstracts were screened for eligibility followed by a full-text review to determine inclusion. The information extracted from the included studies consisted of study design and key findings, such as health equity definitions, strategies, frameworks, level of integration, and indicators. Most data were quantitatively tabulated and presented according to 5 secondary review questions. Some findings (eg, definitions and indicators) were summarized using qualitative methods. Most findings were visually presented in charts and diagrams or presented in tabular format.

RESULTS

Following review of 16,297 titles and abstracts and 824 full-text sources, we included 122 sources (108 scholarly and 14 gray literature) in this scoping review. We found that health equity was inconsistently defined and operationalized. Only 17 sources included definitions of health equity, and we found that both indicators and strategies lacked adequate descriptions. The use of health equity frameworks was limited and, where present, there was little consistency or agreement in their use. We found that strategies were often specific to programs, services, or clinics, rather than broadly applied across health service and delivery systems.

CONCLUSIONS

Our findings suggest that strategies to advance health equity work are siloed within health service and delivery systems, and are not currently being implemented system-wide (ie, across all health settings). Healthy equity definitions and frameworks are varied in the included sources, and indicators for health equity are variable and inconsistently measured. Health equity integration needs to be prioritized within and across health service and delivery systems. There is also a need for system-wide strategies to promote health equity, alongside robust accountability mechanisms for measuring health equity. This is necessary to ensure that an integrated, whole-system approach can be consistently applied in health service and delivery systems internationally.

REVIEW REGISTRATION

DalSpace dalspace.library.dal.ca/handle/10222/80835.

Barriers to cancer treatment for people experiencing socioeconomic disadvantage in high-income countries: a scoping review

BACKGROUND

Despite advances in cancer research and treatment, the burden of cancer is not evenly distributed. People experiencing socioeconomic disadvantage have higher rates of cancer, later stage at diagnoses, and are dying of cancers that are preventable and screen-detectable. However, less is known about barriers to accessing cancer treatment.

METHODS

We conducted a scoping review of studies examining barriers to accessing cancer treatment for populations experiencing socioeconomic disadvantage in high-income countries, searched across four biomedical databases. Studies published in English between 2008 and 2021 in high-income countries, as defined by the World Bank, and reporting on barriers to cancer treatment were included.

RESULTS

A total of 20 studies were identified. Most (n = 16) reported data from the United States, and the remaining included publications were from Canada (n = 1), Ireland (n = 1), United Kingdom (n = 1), and a scoping review (n = 1). The majority of studies (n = 9) focused on barriers to breast cancer treatment. The most common barriers included: inadequate insurance and financial constraints (n = 16); unstable housing (n = 5); geographical distribution of services and transportation challenges (n = 4); limited resources for social care needs (n = 7); communication challenges (n = 9); system disintegration (n = 5); implicit bias (n = 4); advanced diagnosis and comorbidities (n = 8); psychosocial dimensions and contexts (n = 6); and limited social support networks (n = 3). The compounding effect of multiple barriers exacerbated poor access to cancer treatment, with relevance across many social locations.

CONCLUSION

This review highlights barriers to cancer treatment across multiple levels, and underscores the importance of identifying patients at risk for socioeconomic disadvantage to improve access to treatment and cancer outcomes. Findings provide an understanding of barriers that can inform future, equity-oriented policy, practice, and service innovation.

Improving access to general practice for and with people with severe and multiple disadvantage: a qualitative study

BACKGROUND

People with severe and multiple disadvantage (SMD) who experience combinations of homelessness, substance misuse, violence, abuse, and poor mental health have high health needs and poor access to primary care.

AIM

To improve access to general practice for people with SMD by facilitating collaborative service improvement meetings between healthcare staff, people with lived experience of SMD, and those who support them; participants were then interviewed about this work.

DESIGN AND SETTING

The Bridging Gaps group is a collaboration between healthcare staff, researchers, women with lived experience of SMD, and a charity that supports them in a UK city. A project was co-produced by the Bridging Gaps group to improve access to general practice for people with SMD, which was further developed with three inner-city general practices.

METHOD

Nine service improvement meetings were facilitated at three general practices, and six of these were formally observed. Nine practice staff and four women with lived experience of SMD were interviewed. Three women with lived experience of SMD and one staff member who supports them participated in a focus group. Data were analysed inductively and deductively using thematic analysis.

RESULTS

By providing time and funding opportunities to motivated general practice staff and involving participants with lived experience of SMD, service changes were made in an effort to improve access for people with SMD. These included prioritising patients on an inclusion patient list with more flexible access, providing continuity for patients via a care coordinator and micro-team of clinicians, and developing an information-sharing document. The process and outcomes improved connections within and between general practices, support organisations, and people with SMD.

CONCLUSION

The co-designed strategies described in this study could be adapted locally and evaluated in other areas. Investing in this focused way of working may improve accessibility to health care, health equity, and staff wellbeing.

Prevalence, correlates, and quality-of-life outcomes of major or persistent pain among women living with HIV in Metro Vancouver, Canada

While women living with HIV (WLWH) are twice as likely to report severe or undertreated chronic pain compared to men, little is known about pain among WLWH. Our goal was to characterize the correlates of pain as well as its impact on quality-of-life outcomes among women enrolled in the Sexual Health and HIV/AIDS Women's Longitudinal Needs Assessment (SHAWNA), an open longitudinal study of WLWH accessing care in Metro Vancouver, Canada. We conducted logistic regression analyses to identify associations between self-reported major or persistent pain with sociostructural and psychosocial correlates and with quality-of-life outcomes. Data are presented as adjusted odds ratios (aORs) with 95% confidence intervals. Among 335 participants, 77.3% reported pain at ≥ 1 study visit, with 46.3% experiencing any undiagnosed pain and 53.1% managing pain with criminalized drugs. In multivariable analysis, age (aOR 1.04[1.03-1.06] per year increase), food and housing insecurity (aOR 1.54[1.08-2.19]), depression diagnosis (aOR 1.34[1.03-1.75]), suicidality (aOR 1.71[1.21-2.42]), and non-daily, non-injection opioid use (aOR 1.53[1.07-2.17]) were associated with higher odds of pain. Daily non-injection opioid use (aOR 0.46[0.22-0.96]) and health services access (aOR 0.63[0.44-0.91]) were associated with lower odds of pain. In separate multivariable confounder models, pain was associated with reduced odds of good self-rated health (aOR 0.64[0.48-0.84] and increased odds of health interference with social activities (aOR 2.21[1.63-2.99]) and general function (aOR 3.24[2.54-4.13]). In conclusion, most WLWH in our study reported major or persistent pain. Pain was commonly undiagnosed and associated with lower quality of life. We identified structural and psychosocial factors associated with pain in WLWH, emphasizing the need for low-barrier, trauma-informed, and harm reduction-based interventions.

Fostering equitable change in health services: Using critical reflexivity to challenge dominant discourses in low back pain care in Australia

OBJECTIVES

Justice and equity-focused practices in health services play a critical but overlooked role in low back pain (LBP) care. Critical reflexivity - the ability to examine and challenge power relations, and broader social issues embedded in everyday life - can be a useful tool to foster practices that are more socially just. No research has yet explored this approach in back pain health services. This study sought to understand how clinicians construct LBP in relation to broader socio-cultural-political aspects of care and explore if those constructions changed when clinicians engaged with critically reflexive dialogues with researchers.

METHODS

Using critical discourse analysis methods, this qualitative study explored institutionalised patterns of knowledge in the construction of LBP care. We conducted 22 critically reflexive dialogues with 29 clinicians from two health services in Australia - a private physiotherapy clinic and a public multidisciplinary pain clinic.

RESULTS

Our analyses suggested that clinicians and services often constructed LBP care at an individual level. This dominant individualistic discourse constrained consideration of justice-oriented practices in the care of people with LBP. Through dialogues, discursive constructions of LBP care expanded to incorporate systems and health service workplace practices. This expansion fostered more equitable clinical and service practices - such as assisting patients to navigate health care systems, considering patients' socioeconomic circumstances when developing treatment plans, encouraging staff discussion of possible systemic changes to enhance justice, and fostering a more inclusive workplace culture. Although such expansions faced challenges, incorporating broader discourses enabled recommendations to address LBP care inequities.

CONCLUSIONS

Critical reflexivity can be a tool to foster greater social justice within health services. By expanding constructions of LBP care beyond individuals, critical reflexive dialogues can foster discussion and actions towards more equitable workplace cultures, services and systems.

Emergency department care experiences among people who use substances: a qualitative study

BACKGROUND

People who use substances (PWUS) encounter significant barriers to accessing care for their complex health needs. As a result, emergency departments (EDs) often become the first point of healthcare access for many PWUS and are a crucial setting for the study of health inequities. This study aimed to understand the ED healthcare experiences of PWUS with the intent of informing ways of improving the delivery of equitable care.

METHODS

This qualitative study was part of a larger cross-sectional, mixed-methods study that examined ED experiences among diverse underserved and equity-deserving groups (EDGs) within Kingston, Ontario, Canada. Participants shared and self-interpreted a story about a memorable ED or UCC visit within the preceding 24 months. Data from participants who self-identified as having substance use experiences was analyzed through inductive thematic analysis.

RESULTS

Of the 1973 unique participants who completed the survey, 246 participants self-identified as PWUS and were included in the analysis. Most participants were < 45 years of age (61%), male (53%), and white/European (57%). 45% identified as a person with a disability and 39% frequently struggled to make ends meet. Themes were determined at the patient, provider, and system levels.

PATIENT

history of substance use and experience of intersectionality negatively influenced participants' anticipation and perception of care. Provider: negative experiences were linked to assumption making, feelings of stigma and discrimination, and negative perceptions of provider care. Whereas positive experiences were linked to positive perceptions of provider care. System: timeliness of care and the perception of inadequate mental health resources negatively impacted participants' care experience. Overall, these themes shaped participants' trust of ED staff, their desire to seek care, and their perception of the care quality received.

CONCLUSIONS

PWUS face significant challenges when seeking care in the ED. Given that EDs are a main site of healthcare utilization, there is an urgent need to better support staff in the ED to improve care experiences among PWUS. Based on the findings, three recommendations are proposed: (1) Integration of an equity-oriented approach into the ED, (2) Widespread training on substance use, and (3) Investment in expert resources and services to support PWUS.

Towards a better understanding between non-Muslim primary care clinicians and Muslim patients: A literature review intended to reduce health care inequities in Muslim patients

Although Muslims are a growing population within many non-Muslim countries, there are insufficient Muslim clinicians to care for them. Studies have shown that non-Muslim clinicians have limited knowledge and understanding of Islamic practices affecting health, which may lead to disparities in the quality of healthcare delivery and outcomes when caring for Muslim patients. Muslims come from many different cultures and ethnicities and have variations in their beliefs and practices. This literature review provides some insights which may strengthen therapeutic bonds between non-Muslim clinicians and their Muslim patients resulting in improved holistic, patient-centered care in the areas of cancer screening, mental health, nutrition, and pharmacotherapy. Additionally, this review informs clinicians about the Islamic perspective on childbirth, end of life issues, travel for Islamic pilgrimage, and fasting during the month of Ramadan. Literature was sourced by a comprehensive search in PubMed, Scopus, and CINAHL along with hand screening of citations. Title and abstract screening followed by full-text screening excluded studies including less than 30% Muslim participants, protocols, or reporting results deemed irrelevant to primary care. 115 papers were selected for inclusion in the literature review. These were grouped into the themes of general spirituality, which were discussed in the Introduction, and Islam and health, Social etiquette, Cancer screening, Diet, Medications and their alternatives, Ramadan, Hajj, Mental health, Organ donation and transplants, and End of life. Summarizing the findings of the review, we conclude that health inequities affecting Muslim patients can be addressed at least in part by improved cultural competency in non-Muslim clinicians, as well as further research into this area.

Disparities in access to primary care are growing wider in Canada

Canadian provinces and territories have undertaken varied reforms to how primary care is funded, organized, and delivered, but equity impacts of reforms are unclear. We explore disparities in access to primary care by income, educational attainment, dwelling ownership, immigration, racialization, place of residence (metropolitan/non-metropolitan), and sex/gender, and how these have changed over time, using data from the Canadian Community Health Survey (2007/08 and 2015/16 or 2017/18). We observe disparities by income, educational attainment, dwelling ownership, recent immigration, immigration (regular place of care), racialization (regular place of care), and sex/gender. Disparities are persistent over time or increasing in the case of income and racialization (regular medical provider and consulted with a medical professional). Primary care policy decisions that do not explicitly consider existing inequities may continue to entrench them. Careful study of equity impacts of ongoing policy reforms is needed.

Review of current 2SLGBTQIA+ inequities in the Canadian health care system

Gender identity and sexual orientation are determinants of health that can contribute to health inequities. In the 2SLGBTQIA+ community, belonging to a sexual and/or gender minority group leads to a higher risk of negative health outcomes such as depression, anxiety, and cancer, as well as maladaptive behaviors leading to poorer health outcomes such as substance abuse and risky sexual behavior. Empirical evidence suggests that inequities in terms of accessibility to health care, quality of care, inclusivity, and satisfaction of care, are pervasive and entrenched in the health care system. A better understanding of the current Canadian health care context for individuals of the 2SLGBTQIA+ community is imperative to inform public policy and develop sensitive public health interventions to make meaningful headway in reducing inequity. Our search strategy was Canadian-centric and aimed at highlighting the current state of 2SLGBTQIA+ health inequities in Canada. Discrimination, patient care and access to care, education and training of health care professionals, and crucial changes at the systemic and infrastructure levels have been identified as main themes in the literature. Furthermore, we describe health care-related disparities in the 2SLGBTQIA+ community, and present available resources and guidelines that can guide healthcare providers in narrowing the gap in inequities. Herein, the lack of training for both clinical and non-clinical staff has been identified as the most critical issue influencing health care systems. Researchers, educators, and practitioners should invest in health care professional training and future research should evaluate the effectiveness of interventions on staff attitudinal changes toward the 2SLGBTQIA+ community and the impact on patient outcomes.

Physical pain among Indigenous Peoples in Canada: a scoping review

PURPOSE

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

SOURCE

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

PRINCIPLE FINDINGS

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

CONCLUSION

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

Indigenous Cultural Safety Trainings for Healthcare Professionals Working in Ontario, Canada: Context and Considerations for Healthcare Institutions

Background

Racism and discrimination are realities faced by Indigenous peoples navigating the healthcare system in Canada. Countless experiences of injustice, prejudice, and maltreatment calls for systemic action to redress professional practices of health care professionals and staff alike. Research points to Indigenous cultural safety training in healthcare systems to educate, train, and provide non-Indigenous trainees the necessary skills and knowledge to work with and alongside Indigenous peoples using cultural safe practices grounded in respect and empathy.

Objective

We aim to inform the development and delivery of Indigenous cultural safety training within and across healthcare settings in the Canadian context, through repository of Indigenous cultural safety training examples, toolkits, and evaluations.

Methods

An environmental scan of both gray (government and organization-issued) and academic literature is employed, following protocols developed by Shahid and Turin (2018).

Synthesis

Indigenous cultural safety training and toolkits are collected and described according to similar and distinct characteristics and highlighting promising Indigenous cultural safety training practices for adoption by healthcare institutions and personnel. Gaps of the analysis are described, providing direction for future research. Final recommendations based on overall findings including key areas for consideration in Indigenous cultural safety training development and delivery.

Conclusion

The findings uncover the potential of Indigenous cultural safety training to improve healthcare experiences of all Indigenous Peoples. With the information, healthcare institutions, professionals, researchers, and volunteers will be well equipped to support and promote their Indigenous cultural safety training development and delivery.

Barriers to cancer treatment and care for people experiencing structural vulnerability: a secondary analysis of ethnographic data

BACKGROUND

A key pillar of Canada's healthcare system is universal access, yet significant barriers to cancer services remain for people impacted by structural vulnerability (e.g., poverty, homelessness, racism). For this reason, cancer is diagnosed at a later stage, resulting in worse patient outcomes, a reduced quality of life, and at a higher cost to the healthcare system. Those who face significant barriers to access are under-represented in cancer control services Consequently, these inequities result in people dying from cancers that are highly treatable and preventable, however; little is known about their treatment and care course. The aim of this study was to explore barriers to accessing cancer treatment among people experiencing structural vulnerability within a Canadian context.

METHODS

We conducted a secondary analysis of ethnographic data informed by critical theoretical perspectives of equity and social justice. The original research draws from 30 months of repeated interviews (n = 147) and 300 h of observational fieldwork with people experiencing health and social inequities at the end-of-life, their support persons, and service providers.

RESULTS

Our analysis identified four themes presenting as 'modifiable' barriers to inequitable access to cancer treatment: (1) housing as a key determinant for cancer treatment (2) impact of lower health literacy (3) addressing social care needs is a pre-requisite for treatment (4) intersecting and compounding barriers reinforce exclusion from cancer care. These inter-related themes point to how people impacted by health and social inequities are at times 'dropped' out of the cancer system and therefore unable to access cancer treatment.

CONCLUSION

Findings make visible the contextual and structural factors contributing to inequitable access to cancer treatment within a publically funded healthcare system. Identifying people who experience structural vulnerability, and approaches to delivering cancer services that are explicitly equity-oriented are urgently needed.

Indigenous Cultural Safety Training for Applied Health, Social Work, and Education Professionals: A PRISMA Scoping Review

Anti-Indigenous racism is a widespread social problem in health and education systems in English-speaking colonized countries. Cultural safety training (CST) is often promoted as a key strategy to address this problem, yet little evidence exists on how CST is operationalized and evaluated in health and education systems. This scoping review sought to broadly synthesize the academic literature on how CST programs are developed, implemented, and evaluated in the applied health, social work and education fields in Canada, United States, Australia, and New Zealand. MEDLINE, EMBASE, CINAHL, ERIC, and ASSIA were searched for articles published between 1996 and 2020. The Joanna Briggs Institute's three-step search strategy and PRISMA extension for scoping reviews were adopted, with 134 articles included. CST programs have grown significantly in the health, social work, and education fields in the last three decades, and they vary significantly in their objectives, modalities, timelines, and how they are evaluated. The involvement of Indigenous peoples in CST programs is common, but their roles are rarely specified. Indigenous groups must be intentionally and meaningfully engaged throughout the entire duration of research and practice. Cultural safety and various related concepts should be careful considered and applied for the relevant context.

Implementing social interventions in primary care in Canada: A qualitative exploration of lessons learned from leaders in the field

PURPOSE

Primary health care providers and practices are increasingly instituting direct interventions into social determinants of health and health inequities, but experiences of the leaders in these initiatives remain largely unexamined.

METHODS

Sixteen semi-structured interviews with Canadian primary care leaders in developing and implementing social interventions were conducted to assess barriers, keys to success, and lessons learned from their work.

RESULTS

Participants focused on practical approaches to establishing and maintaining social intervention programs and our analysis pointed to six major themes. A deep understanding of community needs, through data and client stories, forms a foundation for program development. Improving access to care is essential to ensuring programs reach those most marginalized. Client care spaces must be made safe as a first step to engagement. Intervention programs are strengthened by the involvement of patients, community members, health team staff, and partner agencies in their design. The impact and sustainability of these programs is enhanced by implementation partnerships with community members, community organizations, health team members, and government. Health providers and teams are more likely to assimilate simple, practical tools into practice. Finally, institutional change is key to establishing successful programs.

CONCLUSION

Creativity, persistence, partnership, a deep understanding of community and individual social needs, and a willingness to overcome barriers underlie the implementation of successful social intervention programs in primary health care settings.

Social Suffering: Indigenous Peoples' Experiences of Accessing Mental Health and Substance Use Services

In this paper, we present findings from a qualitative study that explored Indigenous people's experiences of mental health and addictions care in the context of an inner-city area in Western Canada. Using an ethnographic design, a total of 39 clients accessing 5 community-based mental health care agencies were interviewed, including 18 in-depth individual interviews and 4 focus groups. Health care providers also were interviewed (n = 24). Data analysis identified four intersecting themes: normalization of social suffering; re-creation of trauma; the challenge of reconciling constrained lives with harm reduction; and mitigating suffering through relational practice. The results highlight the complexities of experiences of accessing systems of care for Indigenous people marginalized by poverty and other forms of social inequity, and the potential harms that arise from inattention to the intersecting social context(s) of peoples' lives. Service delivery that aims to address the mental health concerns of Indigenous people must be designed with awareness of, and responsiveness to, the impact of structural violence and social suffering on peoples' lived realities. A relational policy and policy lens is key to alleviate patterns of social suffering and counter the harms that are unwittingly created when social suffering is normalized.

The organizational health components for small-sized health-care organizations: A systematic review

BACKGROUND

Organizational health (OH) is an organizational aspect in which staff is encouraged to be clearly involved and participate in decision-making, problem solving, and collaborating to improve organizational climate and culture. Multilevel staff involvement facilitates strengthened relationships, open communication, trust, and organizational commitment. The purpose of this study was to find components of OH for small-sized health-care organizations.

METHODS

A systematic review across three key databases by using an extensive list of keywords components and interventions was conducted. This survey included studies that explored various OH elements, components and interventions.

RESULTS

It comprises 34 full-text studies from 221 received studies. Afterward, the OH elements were classified into three main categories (OH elements, organizational health literacy, and organizational health interventions). Then, according to the reviewed data, 23 dimensions were defined similarly for all groups of studies and relevant explanations related to them were reported.

CONCLUSION

The OH encompasses multiple dimensions. Empirical research is required for designing a questionnaire according to the final extracted components and measuring its validation in small-sized health organizations.

Health and healthcare equity within the Canadian cancer care sector: a rapid scoping review

BACKGROUND

Despite a publicly-funded healthcare system, alarming cancer-related health and healthcare inequities persist in Canada. However, it remains unclear how equity is being understood and taken up within the Canadian cancer context. Our objective was to identify how health and healthcare equity are being discussed as goals or aims within the cancer care sector in Canada.

METHODS

A rapid scoping review was conducted; five biomedical databases, 30 multidisciplinary websites, and Google were searched. We included English-language documents published between 2008 and 2021 that discussed health or healthcare equity in the Canadian cancer context.

RESULTS

Of 3860 identified documents, 83 were included for full-text analysis. The prevalence of published and grey equity-oriented literature has increased over time (2008-2014 [n = 20]; 2015-2021 [n = 62]). Only 25% of documents (n = 21) included a definition of health equity. Concepts such as inequity, inequality and disparity were frequently used interchangeably, resulting in conceptual muddling. Only 43% of documents (n = 36) included an explicit health equity goal. Although a suite of actions were described across the cancer control continuum to address equity goals, most were framed as recommendations rather than direct interventions.

CONCLUSION

Health and healthcare equity is a growing priority in the cancer care sector; however, conceptual clarity is needed to guide the development of robust equity goals, and the development of sustainable, measurable actions that redress inequities across the cancer control continuum. If we are to advance health and healthcare equity in the cancer care sector, a coordinated and integrated approach will be required to enact transformative and meaningful change.

The Presence 5 for Racial Justice Framework for anti-racist communication with Black patients

OBJECTIVE

To identify communication practices that clinicians can use to address racism faced by Black patients, build trusting relationships, and empower Black individuals in clinical care.

DATA SOURCES

Qualitative data (N = 112 participants, August 2020-March 2021) collected in partnership with clinics primarily serving Black patients in Leeds, AL; Memphis, TN; Oakland, CA; and Rochester, NY.

STUDY DESIGN

This multi-phased project was informed by human-centered design thinking and community-based participatory research principles. We mapped emergent communication and trust-building strategies to domains from the Presence 5 framework for fostering meaningful connection in clinical care.

DATA COLLECTION METHODS

Interviews and focus group discussions explored anti-racist communication and patient-clinician trust (n = 36 Black patients; n = 40 nonmedical professionals; and n = 24 clinicians of various races and ethnicities). The Presence 5 Virtual National Community Advisory Board guided analysis interpretation.

PRINCIPAL FINDINGS

The emergent Presence 5 for Racial Justice (P5RJ) practices include: (1) Prepare with intention by reflecting on identity, bias, and power dynamics; and creating structures to address bias and structural determinants of health; (2) Listen intently and completely without interruption and listen deeply for the potential impact of anti-Black racism on patient health and interactions with health care; (3) Agree on what matters most by having explicit conversations about patient goals, treatment comfort and consent, and referral planning; (4) Connect with the patient's story, acknowledging socioeconomic factors influencing patient health and focusing on positive efforts; (5) Explore emotional cues by noticing and naming patient emotions, and considering how experiences with racism might influence emotions.

CONCLUSION

P5RJ provides a framework with actionable communication practices to address pervasive racism experienced by Black patients. Effective implementation necessitates clinician self-reflection, personal commitment, and institutional support that offers time and resources to elicit a patient's story and to address patient needs.

Access Denied: Nurses' Perspectives of Access to Oncology Care Among Indigenous Peoples in Canada

Inequitable access to oncology care is a significant issue among Indigenous Peoples in Canada; however, the perspectives of oncology nurses have not been explored. Guided by an interpretive descriptive methodology, we explored nurses' perspectives on access to oncology care among Indigenous Peoples in Canada. Nurses described the health care system as "broken" and barriers to accessing oncology care as layered and compounding. Lack of culturally safe care was articulated as a significant issue impacting equitable access, while biomedical discourses were pervasive and competed with nurses' attempts at providing culturally safe and trauma- and violence-informed care by discounting the relational work of nurses.

Actions needed to promote health equity and the mental health of Canada's Black refugees

OBJECTIVES

The overall goal was to synthesize knowledge on actions that need to be taken to promote health equity and the mental health of Black refugees in Canada.

DESIGN

Group concept mapping systems were applied to generate and organize action-oriented statements related to the different social determinants of health. A total of 174 participants from the cities of Calgary and Edmonton with experience working with Black Canadians participated in four focus groups: (a) 2 focus groups that engaged 123 participants in brainstorming 84 statements guided by the following focus prompt: 'A specific action that would improve the mental health equity of Black refugees living in Canada is … ' and (b) 2 focus groups of 51 participants who sorted the generated statements and rated them by order of 'importance' and 'ideas seen in action.' Data was further computed and analysed by the research team and a select advisory group from the participants.

RESULTS

A 10-cluster map generated included the following clusters: (1) promoting cultural identity, (2) promoting ways of knowing, (3) addressing discrimination and racism, (4) addressing the criminalization of Black Canadians, (5) investing in employment for equity, (6) promoting equity in housing, (7) facilitating self-determination, (8) improving (public) services, (9) promoting appropriate and culturally relevant mental health services, and (10) working with and addressing faith and belief related issues. Clusters 4 and 9 ranked as the most important clusters in promoting health equity and the mental health of Black Canadians.

CONCLUSIONS

Addressing the criminalization of Black Canadians through a range of rehumanizing interventions at institutional levels will provide a platform from which they can participate and engage others in developing appropriate and culturally relevant mental health services.

EQUIP emergency: can interventions to reduce racism, discrimination and stigma in EDs improve outcomes?

Background

Despite a publicly funded system, health care in Canada has been shown to be deeply inequitable, particularly toward Indigenous people. Based on research identifying key dimensions of equity-oriented health care as being cultural safety, harm reduction and trauma- and violence-informed care, an intervention to promote equity at the organizational level was tested in primary health care, refined and adapted, and tested in Emergency Departments (EDs).

Methods

In partnership with clinical, community and Indigenous leaders in three diverse EDs in one Canadian province, we supported direct care staff to tailor and implement the intervention. Intervention activities varied in type and intensity at each site. Survey data were collected pre- and post-intervention from every consecutive patient over age 18 presenting to the EDs (n = 4771) with 3315 completing post-visit questions in 4 waves at two sites and 3 waves (due to pandemic constraints) at the third. Administrative data were collected for 12 months pre- and 12 months post-intervention.

Results

Throughout the study period, the participating EDs were dealing with a worsening epidemic of overdoses and deaths related to a toxic drug supply, and the COVID 19 pandemic curtailed both intervention activities and data collection. Despite these constraints, staff at two of the EDs mounted equity-oriented intervention strategies; the other site was experiencing continued, significant staff shortages and leadership changeover. Longitudinal analysis using multiple regression showed non-significant but encouraging trends in patient perceptions of quality of care and patient experiences of discrimination in the ED. Subgroup analysis showed that specific groups of patients experienced care in significantly different ways at each site. An interrupted time series of administrative data showed no significant change in staff sick time, but showed a significant decrease in the percentage of patients who left without care being completed at the site with the most robust intervention activities.

Conclusions

The trends in patient perceptions and the significant decrease in the percentage of patients who left without care being completed suggest potential for impact. Realization of this potential will depend on readiness, commitment and resources at the organizational and systems levels.

Trial registration

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

Toward equitable access to oncology care for Indigenous Peoples in Canada: Implications for nursing

As a result of overlapping social, economic, historical, and political influences, and intersecting experiences of racism, stigma and discrimination within healthcare, Indigenous Peoples in Canada experience inequitable access to healthcare and oncology care. The aim of this paper is to highlight some of the barriers contributing to inequitable access to oncology care, research examining oncology nurses' perspectives on these barriers and their roles in addressing barriers, and implications for nursing practice. Importantly, the role of nurses is not often considered in relation to healthcare access. By highlighting recent research evidence, I aim to open space to see the valuable work of oncology nurses, and to consider where and how we, as a profession, could better address inequities in access to oncology care for Indigenous Peoples.

Vers un accès équitable aux soins oncologiques pour les peuples autochtones du Canada : implications pour la pratique infirmière

Les peuples autochtones du Canada ne disposent pas d’un accès équitable aux soins de santé et aux soins oncologiques à cause de facteurs sociaux, économiques, historiques et politiques qui se recoupent tous les uns les autres, et auxquels s’ajoutent éventuellement le racisme, les préjugés et la discrimination qu’ils subissent dans le système de santé. Le but du présent article est de faire ressortir certains des obstacles empêchant un accès équitable aux soins oncologiques, de présenter les recherches portant sur ces mêmes obstacles vus selon la perspective des infirmières en oncologie et le rôle qu’elles jouent pour les abolir, et de décrire les implications pour la pratique infirmière. Plus important encore, la question de l’accès aux soins est rarement abordée sous l’angle du rôle des infirmières. Cet article se veut un espace pour souligner le précieux travail des infirmières en oncologie et pour examiner comment et où nous pourrions, comme profession, mieux combattre les inégalités d’accès aux soins oncologiques pour les peuples autochtones.

Impacts of racism on First Nations patients' emergency care: results of a thematic analysis of healthcare provider interviews in Alberta, Canada

Background

First Nations people experience racism in society and in the healthcare system. This study aimed to document emergency care providers’ perspectives on care of First Nations patients. First Nations research partner organizations co-led all aspects of the research.

Methods

Sixteen semi-structured interviews were conducted with Alberta emergency department (ED) physicians and nurses between November 2019 and March 2020.

Results

ED providers reported that First Nations patients are exposed to disrespect through tone and body language, experience overt racism, and may be neglected or not taken seriously. They described impacts of racist stereotypes on patient care, and strategies they took as individuals to address patient barriers to care. Recognized barriers to care included communication, resources, access to primary care and the ED environment itself.

Conclusions

Results may inform the content of anti-racist and anti-colonial pedagogy that is contextually tailored to ED providers, and inform wider systems efforts to counter racism against First Nations members and settler colonialism within healthcare.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08129-5.

Automating data collection methods in electronic health record systems: a Social Determinant of Health (SDOH) viewpoint

Social Determinant of Health (SDOH) data are important targets for research and innovation in Health Information Systems (HIS). The ways we envision SDOH in "smart" information systems will play a considerable role in shaping future population health landscapes. Current methods for data collection can capture wide ranges of SDOH factors, in standardised and non-standardised formats, from both primary and secondary sources. Advances in automating data linkage and text classification show particular promise for enhancing SDOH in HIS. One challenge is that social communication processes embedded in data collection are directly related to the inequalities that HIS attempt to measure and redress. To advance equity, it is imperative thatcare-providers, researchers, technicians, and administrators attend to power dynamics in HIS standards and practices. We recommend: 1. Investing in interdisciplinary and intersectoral knowledge generation and translation. 2. Developing novel methods for data discovery, linkage and analysis through participatory research. 3. Channelling information into upstream evidence-informed policy.

Racism in healthcare: a scoping review

BACKGROUND

Racism constitutes a barrier towards achieving equitable healthcare as documented in research showing unequal processes of delivering, accessing, and receiving healthcare across countries and healthcare indicators. This review summarizes studies examining how racism is discussed and produced in the process of delivering, accessing and receiving healthcare across various national contexts.

METHOD

The PRISMA guidelines for scoping reviews were followed and databases were searched for peer reviewed empirical articles in English across national contexts. No starting date limitation was applied for this review. The end date was December 1, 2020. The review scoped 213 articles. The results were summarized, coded and thematically categorized in regards to the aim.

RESULTS

The review yielded the following categories: healthcare users' experiences of racism in healthcare; healthcare staff's experiences of racism; healthcare staff's racial attitudes and beliefs; effects of racism in healthcare on various treatment choices; healthcare staff's reflections on racism in healthcare and; antiracist training in healthcare. Racialized minorities experience inadequate healthcare and being dismissed in healthcare interactions. Experiences of racism are associated with lack of trust and delay in seeking healthcare. Racialized minority healthcare staff experience racism in their workplace from healthcare users and colleagues and lack of organizational support in managing racism. Research on healthcare staff's racial attitudes and beliefs demonstrate a range of negative stereotypes regarding racialized minority healthcare users who are viewed as difficult. Research on implicit racial bias illustrates that healthcare staff exhibit racial bias in favor of majority group. Healthcare staff's racial bias may influence medical decisions negatively. Studies examining healthcare staff's reflections on racism and antiracist training show that healthcare staff tend to construct healthcare as impartial and that healthcare staff do not readily discuss racism in their workplace.

CONCLUSIONS

The USA dominates the research. It is imperative that research covers other geo-political contexts. Research on racism in healthcare is mainly descriptive, atheoretical, uses racial categories uncritically and tends to ignore racialization processes making it difficult to conceptualize racism. Sociological research on racism could inform research on racism as it theoretically explains racism's structural embeddedness, which could aid in tackling racism to provide good quality care.

Perspectives of structurally marginalised patients attending contextually tailored and integrated care practices in Canada: a focused ethnography study

OBJECTIVES

To better understand the experience of patients attending community-based primary healthcare practices (CBPHCPs) aimed at improving equity and access to primary care for underserved patients, which have been implemented locally in several countries, including Canada. There are currently little data on how, or to what extent, they mitigate patients' experience of social inequalities in care and improve their access to health. This study explored the impacts of the sociospatial characteristics of these practices on patients' care experience.

DESIGN AND METHODS

Qualitative, multisite, focused ethnographic study based on in-situ observations and interviews, incorporating inductive and deductive analysis, and using the concept of sense of place.

SETTING

Three CBPHCPs located in deprived urban areas in two provinces of Canada.

PARTICIPANTS

28 structurally marginalised persons (17 women) attending the clinics, ranging in age from 18 to 79 years, and 16 managers, clinicians and practitioners working in these clinics.

RESULTS

Data underscored the importance of clinic proximity and accessibility in facilitating patients' navigation of the health system. Patients appreciated the clinics' positive sociospatial characteristics. Non-judgmental environments and informal spaces fostered patients' empowerment and social interaction among themselves and with peer navigators and healthcare professionals. The experience of supportive continuity of care had a positive impact on patients' sense of well-being and, for many, a positive ripple effect and long-term impact on their social integration.

CONCLUSION

These results have important implications for policy given the current context, in which governments are challenged to support primary healthcare that addresses the social determinants of health to achieve greater equity. We conclude that scaling up contextually tailored care and deploying humanistic innovative organisational practices into mainstream care will help narrow the equity gap and reduce current prevalent social inequalities in the health system.

Culturally safe interventions in primary care for the management of chronic diseases of urban Indigenous People: a scoping review

Objectives

Chronic conditions represent an important source of major health issues among Indigenous People. The same applies to those, who live off-reserve and in urban areas. However, very few healthcare services are considered culturally safe, resulting in some avoidance of the public healthcare system. Our goal was to review the literature on culturally safe practices available to urban Indigenous People who suffer from chronic diseases.

Design

We conducted a scoping review to determine what culturally safe healthcare services are currently offered for the management of chronic conditions in urban Indigenous populations, to contribute to a tailored, holistic and safe space in mainstream healthcare systems.

Eligibility criteria

Peer-reviewed original research articles had to be published by 27 October 2020, in English or French.

Information source: In October 2020, we searched five academic databases (EBSCO, PsycArticles, SocINDEX, MEDLINE and PsycINFO) and also reviewed grey literature and the websites of organisations or governments. The data were extracted and collected in an EXCEL spreadsheet. Two reviewers independently screened 326 titles and abstracts, followed by an independent evaluation of 48 full text articles. A total of 19 studies were included in this scoping review, as well as 5 websites/documents from the grey literature.

Results

In total, 19 studies were included in our analysis. We found that Elders, family and the assistance of an interpreter are crucial elements to include to make urban Indigenous feel safe when they seek healthcare services. With this scoping review, we report interventions that are successful in terms of healthcare delivery for this population. Our findings provide insight on what services should be in place in mainstream healthcare settings to create a culturally safe experience for urban Indigenous People.

Conclusions

In recent years, there appears to be a growing awareness of the need to provide culturally safe health services. This scoping review identified multiple strategies to promote cultural safety in this context, as well as barriers and facilitators to their implementation. These elements, which have been extensively documented in the literature, should be included in the chronic diseases management interventions to be developed by urban and primary care settings.

Cultural Safety as an Outcome of a Dynamic Relational Process: The Experience of Inuit in a Mainstream Residential Addiction Rehabilitation Centre in Southern Canada

Few addiction treatment options are available in Arctic Canada, leading many Inuit to seek treatment programs in southern cities. We conducted a case study to understand what contributes to a culturally safe experience for Inuit in a mainstream addiction rehabilitation centre in Southern Canada. We carried out more than 700 hours of participant observation, in addition to semi-structured interviews and member-checking activities with 20 Inuit residents, 18 staff and four managers. Data were analysed using an inductive interpretative process. Throughout their journey in the program, Inuit navigated through contrasting situations and feelings that we grouped under six broad themes: having Inuit peers, having limitations imposed on one's ways of being and doing, facing ignorance and misperceptions, having conversations and dialogue, facing language barriers and being in a supportive and caring environment. This study highlights how cultural safety varies according to people, context and time, and relates to developing trustful relationships.

Connections and Biases in Health Equity and Culture Research: A Semantic Network Analysis

Health equity is a rather complex issue. Social context and economical disparities, are known to be determining factors. Cultural and educational constrains however, are also important contributors to the establishment and development of health inequities. As an important starting point for a comprehensive discussion, a detailed analysis of the literature corpus is thus desirable: we need to recognize what has been done, under what circumstances, even what possible sources of bias exist in our current discussion on this relevant issue. By finding these trends and biases we will be better equipped to modulate them and find avenues that may lead us to a more integrated view of health inequity, potentially enhancing our capabilities to intervene to ameliorate it. In this study, we characterized at a large scale, the social and cultural determinants most frequently reported in current global research of health inequity and the interrelationships among them in different populations under diverse contexts. We used a data/literature mining approach to the current literature followed by a semantic network analysis of the interrelationships discovered. The analyzed structured corpus consisted in circa 950 articles categorized by means of the Medical Subheadings (MeSH) content-descriptor from 2014 to 2021. Further analyses involved systematic searches in the LILACS and DOAJ databases, as additional sources. The use of data analytics techniques allowed us to find a number of non-trivial connections, pointed out to existing biases and under-represented issues and let us discuss what are the most relevant concepts that are (and are not) being discussed in the context of Health Equity and Culture.

Toward equity-oriented cancer care: a Strategy for Patient-Oriented Research (SPOR) protocol to promote equitable access to lung cancer screening

BACKGROUND

Screening for lung cancer with low dose CT can facilitate the detection of early-stage lung cancers that are amenable to treatment, reducing mortality related to lung cancer. Individuals are considered eligible for lung cancer screening if they meet specific high-risk criteria, such as age and smoking history. Population groups that are at highest risk of lung cancer, and therefore, the target of lung cancer screening interventions, are also the least likely to participate in lung cancer screening. This can lead to a widening of health inequities. Deliberate effort is needed to both reduce lung cancer risk (through upstream interventions that promote smoking cessation) as well as midstream interventions that promote equitable access to lung cancer screening.

METHODS

This protocol paper describes an equity-informed patient-oriented research study. Our study aims to promote equitable access to lung cancer screening by partnering with patients to co-design an e-learning module for healthcare providers. The learning module will describe the social context of lung cancer risk and promote access to lung cancer screening by increasing equity at the point of care. We have applied the Generative Co-Design Framework for Healthcare Innovation and detail our study processes in three phases and six steps: Pre-design (establishing a study governance structure); Co-design (identifying research priorities, gathering and interpreting data, co-developing module content); and Post-design (pilot testing the module and developing an implementation plan).

DISCUSSION

Patient engagement in research can promote the design and delivery of healthcare services that are accessible and acceptable to patients. This is particularly important for lung cancer screening as those at highest risk of developing lung cancer are also those who are least likely to participate in lung cancer screening. By detailing the steps of our participatory co-design journey, we are making visible the processes of our work so that they can be linked to future outcomes and related impact, and inform a wide range of patient co-led processes.

Effects of Race, Workplace Racism, and COVID Worry on the Emotional Well-Being of Hospital-Based Nurses: A Dual Pandemic

Persons of color in the US experience the worst COVID-related outcomes and account for the majority of COVID-19 cases and hospitalizations among healthcare workers. In a pandemic where minority populations and healthcare workers are among the hardest hit, nurses of color are undoubtedly taxed. Moreover, their workplace racism experiences represent a dual pandemic in that the effects of COVID-19 worries and workplace racism may synergize to the detriment of their emotional well-being. The purpose of this study was to examine the direct, indirect, and interactive effects of individual (race, COVID worry), interpersonal (workplace racial microaggressions), and institutional (racial climate) factors on hospital-based nurses' emotional well-being. A sample of 788 registered nurses who worked in New Jersey hospitals completed an electronic survey. Compared to White nurses, nonwhite nurses reported higher emotional distress, more negative racial climates, more racial microaggressions, and higher levels of COVID worry. Nurses' worry about getting sick from COVID and multiple racial microaggression experiences had the largest effects on the likelihood of high emotional distress. Racism variables and worry about COVID mediated indirect effects of nonwhite race on emotional distress. Racial microaggressions mediated an indirect effect of racial climate on this outcome. Nurses who were worried about getting sick from COVID and experienced multiple microaggressions and/or the most negative racial climates had severe emotional distress. There is a need for sustained investment in a racially diverse nursing workforce. Mitigating workplace racism in hospitals is crucial, particularly during public health crises that disproportionately threaten minority populations and healthcare workers.

Through An Equity Lens: Illuminating The Relationships Among Social Inequities, Stigma And Discrimination, And Patient Experiences of Emergency Health Care

People who experience the greatest social inequities often have poor experiences in emergency departments (EDs) so that they are deterred from seeking care, leave without care complete, receive inadequate care, and/or return repeatedly for unresolved problems. However, efforts to measure and monitor experiences of care rarely capture the experiences of people facing the greatest inequities, experiences of discrimination, or relationships among these variables. This analysis examined how patients' experiences, including self-reported ratings of care, experiences of discrimination, and repeat visits vary with social and economic circumstances. Every consecutive person presenting to three diverse EDs was invited if/when they were able to consent; 2424 provided demographic and contact information; and 1692 (70%) completed the survey. Latent class analysis (LCA) using sociodemographic variables: age, gender, financial strain, employment, housing stability, English as first language, born in Canada, and Indigenous identity, indicated a six-class solution. Classes differed significantly on having regular access to primary care, reasons for the visit, and acuity. Classes also differed on self-reported discrimination every day and during their ED visit, ratings of ED care, and number of ED visits within the past six months. ED care can be improved through attention to how intersecting forms of structural disadvantage and inequities affect patient experiences.

Equity-Oriented Healthcare: What It Is and Why We Need It in Oncology

Alarming differences exist in cancer outcomes for people most impacted by persistent and widening health and social inequities. People who are socially disadvantaged often have higher cancer-related mortality and are diagnosed with advanced cancers more often than other people. Such outcomes are linked to the compounding effects of stigma, discrimination, and other barriers, which create persistent inequities in access to care at all points in the cancer trajectory, preventing timely diagnosis and treatment, and further widening the health equity gap. In this commentary, we discuss how growing evidence suggests that people who are considered marginalized are not well-served by the cancer care sector and how the design and structure of services can often impose profound barriers to populations considered socially disadvantaged. We highlight equity-oriented healthcare as one strategy that can begin to address inequities in health outcomes and access to care by taking action to transform organizational cultures and approaches to the design and delivery of cancer services.

Trauma-informed Approaches to Substance Use Interventions with Indigenous Peoples: A Scoping Review

Indigenous Peoples experience disproportionately higher rates of problematic substance use. These problems are situated in a context of individual and intergenerational trauma from colonization, residential schools, and racist and discriminatory practices, policies, and services. Therefore, substance use interventions need to adopt a trauma-informed approach. We aimed to synthesize and report the current literature exploring the intersection of trauma and substance use interventions for Indigenous Peoples. Fourteen databases were searched using keywords for Indigenous Peoples, trauma, and substance use. Of the 1373 sources identified, 117 met inclusion criteria. Literature on trauma and substance use with Indigenous Peoples has increased in the last 5 years (2012-2016, n = 29; 2017-2021, n = 48), with most literature coming from the United States and Canada and focusing on historical or intergenerational trauma. Few articles focused on intersectional identities such as 2SLGBTQIA+ (n = 4), and none focused on veterans. There were limited sources (n = 25) that reported specific interventions at the intersection of trauma and substance use. These sources advocate for multi-faceted, trauma-informed, and culturally safe interventions for use with Indigenous Peoples. This scoping review illuminates gaps in the literature and highlights a need for research reporting on trauma-informed interventions for substance use with Indigenous Peoples.

Improving primary health care quality for refugees and asylum seekers: A systematic review of interventional approaches

Background

It has been widely acknowledged that refugees are at risk of poorer health outcomes, spanning mental health and general well‐being. A common point of access to health care for the migrant population is via the primary health care network in the country of resettlement. This review aims to synthesize the evidence of primary health care interventions to improve the quality of health care provided to refugees and asylum seekers.

Methods

A systematic review was undertaken, and 55 articles were included in the final review. The Preferred Reporting Items for Systematic Reviews was used to guide the reporting of the review, and articles were managed using a reference‐management software (Covidence). The findings were analysed using a narrative empirical synthesis. A quality assessment was conducted for all the studies included.

Results

The interventions within the broad primary care setting could be organized into four categories, that is, those that focused on developing the skills of individual refugees/asylum seekers and their families; skills of primary health care workers; system and/or service integration models and structures; and lastly, interventions enhancing communication services. Promoting effective health care delivery for refugees, asylum seekers and their families is a complex challenge faced by primary care professionals, the patients themselves and the communication between them.

Conclusion

This review highlights the innovative interventions in primary care promoting refugee health. Primary care interventions mostly focused on upskilling doctors, with a paucity of research exploring the involvement of other health care members. Further research can explore the involvement of interprofessional team members in providing effective refugee/migrant health.

Patient or Public Contribution

Patient and public involvement was explored in terms of interventions designed to improve health care delivery for the humanitarian migrant population, that is, specifically refugees and asylum seekers.

Indigenous peoples' positive experiences of culturally safe health care: a qualitative systematic review protocol

OBJECTIVE

The purpose of this systematic review is to explore what is known about Indigenous peoples' positive experiences with culturally safe health care.

INTRODUCTION

Research indicates that Indigenous people often experience stigma and discrimination from non-Indigenous health care providers when accessing health care services. One approach that has been put forward to address Indigenous health inequities is cultural safety. Studies have been conducted to identify what comprises culturally safe care for Indigenous people, however, many of these studies target the health care provider's perspective, rather than the perspective of the Indigenous person who is receiving the care.

INCLUSION CRITERIA

This review will consider studies that involve Indigenous peoples' positive experiences with culturally safe health care from any study setting. Studies that present relevant qualitative findings including descriptions, examples, or stories about how a health care provider enacted cultural safety from Indigenous perspectives will be considered.

METHODS

MEDLINE, CINAHL, Embase, PsycINFO, First Nations Periodical Index, the Native Health Database, the Indigenous Studies Portal, and the Arctic and Antarctic Regions Database will be searched for published studies. The search for unpublished studies will include Google and Google Scholar, ProQuest Dissertations and Theses, and OpenGrey. Databases will be searched from 1988 onward and only studies published in English will be included. The JBI systematic review guidelines will be followed. The JBI process of meta-aggregation will be used to identify categories and synthesize findings. The ConQual approach will be used to assess confidence in the review findings.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020173003.

Orienting child- and family-centered care toward equity

Child- and family-centered care (CFCC) is being increasingly adopted internationally as a fundamental philosophical approach to the design, delivery, and evaluation of children's services in diverse primary and acute health care contexts. CFCC has yet to be explored in the context of families and children whose health and health care is likely to be compromised by multifaceted social and structural factors, including racialization, material deprivation, and historically entrenched power imbalances. To date, an equity orientation for CFCC has not been examined or developed. This is a critical area of inquiry, given the increasing evidence that children in families who face such inequities have poor health outcomes. This article examines dominant discourses on CFCC in the context of families and children who are at greater risk of health inequities in wealthy countries, drawing on Canada as a useful example. It outlines an evidence-based approach to equity-oriented care that the authors contend has the potential to orient CFCC toward equity and provide greater clarity in the conceptualization, implementation, measurement, and evaluation of CFCC in ways that can benefit all families and children including those who have typically been excluded from research.