A WISH to be Housed: Exploring the Winter Interim Solution to Homelessness (WISH) Temporary Accommodation Model in London, Canada

Temporary housing programs (THPs) aim to serve the homeless population. This article explores the impacts of a THP, the Winter Interim Solution to Homelessness (WISH) in London, Canada, which applied a barrier-free, harm reduction model. Adopting an intersectional lens and interpretive description methodology, we analyzed data collected from WISH residents, utilizing a thematic analytic approach. Identified themes included: (1) "(It's) kinda like a real home" (WISH is unlike other shelters); (2) "It's like a buddy system" (A sense of community was fostered); (3) "It's the same size as a jail cell" (Problems with infrastructure); (4) "To keep us on focus" (Un/supportive staff/volunteers); (5) "I'm not sure what I'm going to do after" (The dearth of permanent housing creates trauma); and (6) "Too much bloody money in too little hands" (Distrust of housing providers). Although WISH was helpful to some residents, the temporary nature of the program limited its long-term impact.

Community perspectives on addressing and responding to HIV-testing, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) among African, Caribbean and Black (ACB) people in Ontario, Canada

BACKGROUND

The African, Caribbean, and Black (ACB) population of Ontario, Canada is comprised of individuals with diverse ethnic, cultural and linguistic backgrounds and experiences; some of whom have resided in Canada for many generations, and others who have migrated in recent decades. Even though the ACB population represents less than 3.5% of the Canadian population, this group accounts for 21.7% of all new HIV infections. It is well-documented that ACB populations, compared to the general population, experience multi-level barriers to accessing appropriate and responsive HIV services. In this paper, we present qualitative findings on the ACB population's experiences with HIV-testing, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) and obtain their perspectives on how to improve access.

METHODS

We conducted twelve Focus Group Discussions (FGDs), within a two-day World Café event and used socio-ecological framework and community-based participatory research (CBPR) approaches to guide this work. We meaningfully engaged ACB community members in discussions to identify barriers and facilitators to HIV testing, PEP and PrEP and how these may be addressed. The FGDs were transcribed verbatim and thematic analysis guided data interpretation. Credibility of data was established through data validation strategies such as external audit and peer-debriefing.

RESULTS

Our analyses revealed multi-level barriers that explain why ACB community members do not access HIV testing, PEP and PrEP. Fear, health beliefs, stigma and lack of information, were among the most frequently cited individual- and community-level barriers to care. Health system barriers included lack of provider awareness, issues related to cultural sensitivity and confidentiality, cost, and racism in the health care system. Participants identified multi-level strategies to address the HIV needs including community-based educational, health system and innovative inter-sectoral strategies.

CONCLUSION

CBPR, co-led by community members, is an important strategy for identifying the multi-level individual, interpersonal, community, institutional and structural factors that increase HIV vulnerability in ACB communities, notably anti-Black systemic racism. Study findings suggest the need for targeted community-based strategies and strategies aimed at reducing health system barriers to testing and care.

Correction to: Strengthening the Collection and Use of Disaggregated Data to Understand and Monitor the Risk and Burden of COVID-19 Among Racialized Populations

[This corrects the article DOI: 10.1007/s42650-021-00050-2.].

Advancing Healthcare for COVID-19 by Strengthening Providers’ Capacity for Best Practices in African, Caribbean and Black Community Service Provision in Ontario: A Multisite Mixed-Method Study Protocol

BACKGROUND: The ongoing COVID-19 pandemic has emerged as an unprecedented challenge for public and private life, and healthcare systems worldwide. African, Caribbean, and Black communities (ACB) represent some of the most vulnerable populations in terms of their susceptibility to health hazards, difficulty receiving adequate health care and relatively lower chances of recovery. OBJECTIVES: The main aim of this study is to improve the health system’s response during and after the COVID-19 pandemic by developing evidence-based models to inform policy and collaborative best practices to mitigate its spread and ameliorate related health consequences in vulnerable communities. METHODS: This is a mixed-method, multisite study based in Ottawa and Toronto that will involve in-depth qualitative interviews and surveys using a structured questionnaire. Data will be analyzed using NVivo for qualitative interviews, Stata 16 and IBM SPSS version 26 for statistical analyses. DISCUSSION: The findings of this study gained from highly professional health practitioners will produce strong evidence on current gaps in knowledge and practice in the healthcare system’s capacity to meet the health needs of ACB population. The distinct insights and perspectives will be disseminated with policymakers and researchers at all levels which will facilitate strategic policy making with the goal of addressing the unique challenges for health

Difficulties accessing health care services during the COVID-19 pandemic in Canada: examining the intersectionality between immigrant status and visible minority status

BACKGROUND

Difficulties accessing health care services can result in delaying in seeking and obtaining treatment. Although these difficulties are disproportionately experienced among vulnerable groups, we know very little about how the intersectionality of realities experienced by immigrants and visible minorities can impact their access to health care services since the pandemic.

METHODS

Using Statistics Canada's Crowdsourcing Data: Impacts of COVID-19 on Canadians-Experiences of Discrimination, we combine two variables (i.e., immigrant status and visible minority status) to create a new variable called visible minority immigrant status. This multiplicative approach is commonly used in intersectionality research, which allows us to explore disadvantages experienced by minorities with multiplicative identities.

RESULTS

Main results show that, compared to white native-born, visible minority immigrants are less likely to report difficulties accessing non-emergency surgical care (OR = 0.55, p < 0.001), non-emergency diagnostic test (OR = 0.74, p < 0.01), dental care (OR = 0.71, p < 0.001), mental health care (OR = 0.77, p < 0.05), and making an appointment for rehabilitative care (OR = 0.56, p < 0.001) but more likely to report difficulties accessing emergency services/urgent care (OR = 1.46, p < 0.05).

CONCLUSION

We conclude that there is a dynamic interplay of factors operating at multiple levels to shape the impact of COVID-19 related needs to be addressed through changes in social policies, which can tackle unique struggles faced by visible minority immigrants.

Unpacking the health and social consequences of COVID-19 through a race, migration and gender lens

The ongoing COVID-19 pandemic has emerged as an unprecedented challenge for healthcare systems across the world. To date, there has been little application of a race, migration and gender lens to explore the long-term health and social consequences of COVID-19 in African, Caribbean and Black (ACB) communities in Canada, who have been disproportionately impacted by this pandemic. The evidence presented in this commentary suggests that recovery strategies need to adopt an intersectional lens taking into account race, migration and gender since ACB women and ACB immigrant women have been among the populations most impacted both personally and economically. To do so, there is an urgent need to incorporate variables capturing race, beyond "visible minority" status; gender, beyond looking at differences between women and men; and factors to help understand the complexities of migration trajectories (i.e., beyond the dichotomy of born in Canada versus not born in Canada categories) in Canadian datasets. We provide examples of policy and practice initiatives that will be urgently required to address the needs of these population groups as these race-based data become available.

Recognizing and Responding to the Commonly Misunderstood Reactions to Sexual Assault: Evaluation of an Online Curriculum

Background: Sexual assault remains a serious public health issue with significant impacts on the health and well-being of individual women. Many women's reactions and behaviors post sexual assault are not well understood by the general public, or more worrying, among professionals to whom women frequently turn to for help. An innovative and evidence-informed online curriculum was developed to educate health and social service providers about the range of possible psychological responses and associated behaviors post sexual assault and to better equip them in supporting survivors in their recovery. Methods: The curriculum was evaluated using pre- and post-training tests designed to measure changes in fact-based knowledge, self-assessed knowledge, and procedural knowledge, that is, perceived competency. Results: A total of 759 participants registered to complete the curriculum between July 2018 and July 2019 and 175 completed both the pre- and post-training surveys. Data analyses showed significant improvement in the mean number of correct answers to the fact-based knowledge, self-reflection, and procedural knowledge questions from pre- to post-training. The response to the training was also very positive. Conclusions: The online curriculum was effective in improving participants' knowledge about and response to women who, in the aftermath of a sexual assault, may exhibit reactions or behaviors that are commonly misunderstood.

Understanding Social Network and Support for Older Immigrants in Ontario, Canada: Protocol for a Mixed-Methods Study

Background

Older adults are the fastest growing age group worldwide and in Canada. Immigrants represent a significant proportion of older Canadians. Social isolation is common among older adults and has many negative consequences, including limited community and civic participation, increased income insecurity, and increased risk of elder abuse. Additional factors such as the social, cultural, and economic changes that accompany migration, language differences, racism, and ageism heighten older immigrants’ vulnerability to social isolation.

Objective

This mixed-methods sequential (qualitative-quantitative) study seeks to clarify older immigrants’ social needs, networks, and support and how these shape their capacity, resilience, and independence in aging well in Ontario.

Methods

Theoretically, our research is informed by an intersectionality perspective and an ecological model, allowing us to critically examine the complexity surrounding multiple dimensions of social identity (eg, gender and immigration) and how these interrelate at the micro (individual and family), meso (community), and macro (societal) levels in diverse geographical settings. Methodologically, the project is guided by a collaborative, community-based, mixed-methods approach to engaging a range of stakeholders in Toronto, Ottawa, Waterloo, and London in generating knowledge. The 4 settings were strategically chosen for their diversity in the level of urbanization, size of community, and the number of immigrants and immigrant-serving organizations. Interviews will be conducted in Arabic, Mandarin, and Spanish with older women, older men, family members, community leaders, and service providers. The study protocol has received ethics approval from the 4 participating universities.

Results

Quantitative and qualitative data collection is ongoing. The project is funded by the Social Sciences and Humanities Council of Canada.

Conclusions

Comparative analyses of qualitative and quantitative data within and across sites will provide insights about common and unique factors that contribute to the well-being of older immigrants in different regions of Ontario. Given the comprehensive approach to incorporating local knowledge and expert contributions from multilevel stakeholders, the empirical and theoretical findings will be highly relevant to our community partners, help facilitate practice change, and improve the well-being of older men and women in immigrant communities.

International Registered Report Identifier (IRRID)

DERR1-10.2196/12616

Provider- and patient-related determinants of diabetes self-management among recent immigrants: Implications for systemic change

OBJECTIVE

To examine provider- and patient-related factors associated with diabetes self-management among recent immigrants.

DESIGN

Demographic and experiential data were collected using an international survey instrument and adapted to the Canadian context. The final questionnaire was pretested and translated into 4 languages: Mandarin, Tamil, Bengali, and Urdu.

SETTING

Toronto, Ont.

PARTICIPANTS

A total of 130 recent immigrants with a self-reported diagnosis of type 2 diabetes mellitus who had resided in Canada for 10 years or less.

MAIN OUTCOME MEASURES

Diabetes self-management practices (based on a composite of 5 diabetes self-management practices, and participants achieved a score for each adopted practice); and the quality of the provider-patient interaction (measured with a 5-point Likert-type scale that consisted of questions addressing participants' perceptions of discrimination and equitable care).

RESULTS

A total of 130 participants in this study were recent immigrants to Canada from 4 countries of origin-Sri Lanka, Bangladesh, Pakistan, and China. Two factors were significant in predicting diabetes self-management among recent immigrants: financial barriers, specifically, not having enough money to manage diabetes expenses (P = .0233), and the quality of the provider-patient relationship (P = .0016). Participants who did not have enough money to manage diabetes were 9% less likely to engage in self-management practices; and participants who rated the quality of their interactions with providers as poor were 16% less likely to engage in self-management practices.

CONCLUSION

Financial barriers can undermine effective diabetes self-management among recent immigrants. Ensuring that patients feel comfortable and respected and that they are treated in culturally sensitive ways is also critical to good diabetes self-management.

Taking action on violence through research, policy, and practice

BACKGROUND

Violence is a critical public health problem associated with compromised health and social suffering that are preventable. The Centre for Global Health and Health Equity organized a forum in 2014 to identify: (1) priority issues related to violence affecting different population groups in Canada, and (2) strategies to take action on priority issues to reduce violence-related health inequities in Canada. In this paper, we present findings from the roundtable discussions held at the Forum, offer insights on the socio-political implications of these findings, and provide recommendations for action to reduce violence through research, policy and practice.

METHODS

Over 60 academic researchers, health and social service agency staff, community advocates and graduate students attended the daylong Forum, which included presentations on structural violence, community violence, gender-based violence, and violence against marginalized groups. Detailed notes taken at the roundtables were analyzed by the first author using a thematic analysis technique.

FINDINGS

The thematic analysis identified four thematic areas: 1) structural violence perpetuates interpersonal violence - the historical, social, political and economic marginalization that contributes to personal and community violence. 2) social norms of gender-based violence-the role of dominant social norms in perpetuating the practice of violence, especially towards women, children and older adults; 3) violence prevention and mitigation programs-the need for policy and programming to address violence at the individual/interpersonal, community, and societal levels; and 4) research gaps-the need for comprehensive research evidence made up of systematic reviews, community-based intervention and evaluation of implementation research to identify effective programming to address violence.

CONCLUSIONS

The proceedings from the Global Health and Health Equity Forum underscored the importance of recognizing violence as a public health issue that requires immediate and meaningful communal and structural investment to break its historic cycles. Based on our thematic analysis and literature review, four recommendations are offered: (1) Support and adopt policies to prevent or reduce structural violence; (2) Adopt multi-pronged strategies to transform dominant social norms associated with violence; (3) Establish standards and ensure adequate funding for violence prevention programs and services; and (4) Fund higher level ecological research on violence prevention and mitigation.

Contribution of HIV to Maternal Morbidity Among Refugee Women in Canada

OBJECTIVES

We compared severe maternal morbidity (SMM) and SMM subtypes, including HIV, of refugee women with those of nonrefugee immigrant and nonimmigrant women.

METHODS

We linked 1,154,421 Ontario hospital deliveries (2002-2011) to immigration records (1985-2010) to determine the incidence of an SMM composite indicator and its subtypes. We determined SMM incidence according to immigration periods, which were characterized by lifting restrictions for all HIV-positive immigrants (in 1991) and refugees who may place "excessive demand" on government services (in 2002).

RESULTS

Refugees had a higher risk of SMM (17.1 per 1000 deliveries) than did immigrants (12.1 per 1000) and nonimmigrants (12.4 per 1000). Among SMM subtypes, refugees had a much higher risk of HIV than did immigrants (risk ratio [RR] = 7.94; 95% confidence interval [CI] = 5.64, 11.18) and nonimmigrants (RR = 17.37; 95% CI = 12.83, 23.53). SMM disparities were greatest after the 2002 policy came into effect. After exclusion of HIV cases, SMM disparities disappeared.

CONCLUSIONS

An apparent higher risk of SMM among refugee women in Ontario, Canada is explained by their high prevalence of HIV, which increased over time parallel to admission policy changes favoring humanitarian protection.

Self-management, health service use and information seeking for diabetes care among Black Caribbean immigrants in Toronto

OBJECTIVE

The objective of this research was to explore self-management practices and the use of diabetes information and care among Black-Caribbean immigrants with type 2 diabetes.

METHOD

The study population included Black-Caribbean immigrants and Canadian-born participants between the ages of 35 to 64 years with type 2 diabetes. Study participants were recruited from community health centres (CHCs), diabetes education centres, hospital-based diabetes clinics, the Canadian Diabetes Association and immigrant-serving organizations. A structured questionnaire was used to collect demographics and information related to diabetes status, self-management practices and the use of diabetes information and care.

RESULTS

Interviews were conducted with 48 Black-Caribbean immigrants and 54 Canadian-born participants with type 2 diabetes. Black-Caribbean immigrants were significantly more likely than the Canadian-born group to engage in recommended diabetes self-management practices (i.e. reduced fat diet, reduced carbohydrate diet, non-smoking and regular physical activity) and receive regular A1C and eye screening by a health professional. Black-Caribbean immigrant participants were significantly more likely to report receiving diabetes information and care through a community health centre (CHC) and nurses and dieticians than their Canadian-born counterparts.

CONCLUSIONS

CHCs and allied health professionals play an important role in the management of diabetes in the Black-Caribbean immigrant community and may contribute to this group's favourable diabetes self-management profile and access to information and care. Additional research is necessary to confirm whether these findings are generalizable to the Black-Caribbean community in general (i.e. immigrant and non-immigrant) and to determine whether the use of CHCs and/or allied health professionals is associated with favourable outcomes in the Black-Caribbean immigrant community as well as others.

Tuberculosis and common mental disorders: international lessons for Canadian immigrant health

Tuberculosis is a pressing global health issue. Its association with other infections, illnesses, and social factors, including immigration, is well known, yet comparatively little research has examined the connections between tuberculosis and mental disorder, particularly among immigrants in Canada. The authors report on a scoping review conducted to better understand the synergies of tuberculosis, mental disorders, and underlying social conditions as they affect immigrants' health. They highlight the articles that focused on the co-occurrence of tuberculosis and depression/anxiety. After describing their approach and strategy, the authors present key thematic categories: prevalence, clinical presentation, and effects of stigma and poverty. Examining the research within the global context, they argue that migration contributes to these synergistic conditions. The review shows that Canadians stand to gain much by learning from low- and middle-income countries about what constitutes best evidence in approaching complex global health issues.

Self-management, health service use and information seeking for diabetes care among recent immigrants in Toronto

INTRODUCTION

Our objective was to explore self-management practices, health services use and information-seeking for type 2 diabetes care among adult men and women from four recent immigrant communities in Toronto.

METHODS

A structured questionnaire was adapted for the Canadian context and translated into 4 languages. A total of 184 participants with type 2 diabetes-130 recent immigrants and 54 Canadian-born-were recruited in both community and hospital settings.

RESULTS

Recent immigrants were significantly less likely than the Canadian-born group to perform regular blood glucose and foot checks and significantly more likely than the Canadian-born group to be non-smokers, participate in regular physical activity and reduce dietary fat. Recent immigrants were significantly less likely than the Canadian-born group to use a specialist, alternative provider and dietician and less likely to report using dieticians, nurses and diabetes organizations as sources of diabetes-related information. Important differences were observed by sex and country of origin.

CONCLUSION

Findings suggest that diabetes prevention and management strategies for recent immigrants must address linguistic, financial, informational and systemic barriers to information and care.

Towards a global interdisciplinary evidence-informed practice: intimate partner violence in the ethiopian context

Background. Intimate partner violence is a global health issue and is associated with a range of health problems for women. Nurses, as the largest health workforce globally, are well positioned to provide care for abused women. Objectives. This nursing-led interdisciplinary project was conducted to understand the current state of knowledge about intimate partner violence in Ethiopia and make recommendations for country-specific activities to improve response to intimate partner violence through practice changes, education, and research. Methods. The project involved two phases: review of relevant literature and an interdisciplinary stakeholder forum and a meeting with nurse educators. Findings. The literature review identified the pervasiveness and complexity of intimate partner violence and its sociocultural determinants in the Ethiopian context. Two significant themes emerged from the forum and the meeting: the value of bringing multiple disciplines together to address the complex issue of intimate partner violence and the need for health care professionals to better understand their roles and responsibilities in actively addressing intimate partner violence. Conclusions. Further research on the topic is needed, including studies of prevention and resilience and "best practices" for education and intervention. Interdisciplinary and international research networks can support local efforts to address and prevent intimate partner violence.

International research collaboration as social relation: an Ethiopian-Canadian example

International collaboration in nursing and other health disciplines is vital for addressing global health issues. While the results and processes of such collaborations have been reported, few publications have addressed their philosophical or theoretical underpinnings, particularly with respect to collaboration between those in low- and high-income countries. Piaget's notion of social relations of cooperation and constraint and Habermas's notion of "lifeworld" provide a theoretical lens through which to examine international collaboration as a construction of knowledge. This article is an exploration of these ideas as seen in the collective experience of Canadians and Ethiopians organizing an interdisciplinary forum on intimate partner violence in Ethiopia. The project is presented as a case study for reflecting on international collaboration as a manifestation of social relations. Such re-visioning of international collaboration may be useful for improving collaborative processes and their outcomes.

A meta-synthesis of post-migration changes in marital relationships in Canada

OBJECTIVES

Immigration to a new country constitutes a major life change and challenge that can directly and indirectly affect the health of individuals and families. A systematic review was conducted to identify post-migration changes and understand their impact on immigrants' marital relationships in Canada.

METHOD

Using Noblit and Hare's meta-ethnography steps and Paterson et al.'s meta-data method, we conducted a meta-synthesis of qualitative articles.

SYNTHESIS

Four journal articles and one book chapter met the inclusion criteria. Our synthesis of these studies identified three key themes reflecting the major post-migration changes experienced by couples: changes in gender and sexual relations, loss of social networks and support, and de-skilling and de-professionalization. The importance of communication emerged as a fourth theme that cut across the three key themes. These post-migration changes were common across nine ethnic communities, and affected the couple as a unit as well as individuals within this unit, both negatively and positively. The changes were associated with four outcomes: abuse, separation/divorce, staying with each other, and resilience. The synthesis also showed various pathways that link the post-migration changes and their outcomes.

CONCLUSION

Understanding post-migration changes, their outcomes, and the pathways that link them is useful in developing health promotion activities to promote couples' resilience as well as health interventions to reduce the negative impact of the changes on couples and individuals. These activities and interventions must be planned at micro, meso, and macro levels of society.

Somatic Symptoms in a Community Sample of Ethiopian Immigrants in Toronto, Canada

Objective:

This study examines the occurrence and correlates of somatization in a sample of adult Ethiopian immigrants and refugees residing n Toronto, Canada.

Methods:

A random sample of 342 adult (≥ 18 years of age) Ethiopian immigrants and refugees in Toronto completed structured face-to-face interviews. The Diagnostic Interview Schedule (DIS) Somatization Disorder Module was used to collect data on somatic symptoms. The Composite International Diagnostic Interview (CIDI) was used to assess major depression and generalized anxiety disorder.

Results:

Nearly two-thirds of the study participants reported having had at least one somatic symptom, and 5% reported experiencing medically unexplained symptoms in the 12 months preceding the interview. Individuals with major depression had significantly increased number of somatic symptoms compared to those without major depressive disorder. In a multivariate linear regression analysis, controlling for major depressive disorder, a higher level of somatization was associated with older age, pre-migration trauma, and post-migration stressful life events, and limited English proficiency.

Conclusion:

The findings of the study suggest that somatic symptoms are prevalent among individuals in cross-cultural transition and symptom level was associated with pre-migration trauma, post-migration stressors and mental disorder, particularly depressive disorder. The data also indicate a need for primary care physicians to routinely screen immigrant minority clients who present with somatic complaints for common and treatable psychiatric conditions, such as depression. In minority immigrant communities, somatic symptoms may reflect psychiatric problems.

“Violence Is an International Language”

Research on intimate partner violence (IPV) across populations is challenging because of the multiplicity of definitions and lack of clarity about the behaviors that constitute IPV. The purpose of this study was to examine the ways in which Sri Lankan Tamil women in Toronto understand, define, and experience IPV. Focus group interviews were conducted with women representing different ages and stages of life. Findings suggest that definitions of IPV were not culturally specific. Rather, the Tamil women defined IPV broadly and recognized different forms of coercive control. However, psychologically abusive behaviors were identified that held particular meanings for this community.

Gender and psychotropic medication use: the role of intimate partner violence

OBJECTIVE

Women are known to use more psychotropic medications than men which may be linked to women's greater exposure to intimate partner violence (IPV).

METHOD

The use of medications for sleep, depression and anxiety in adults in the 1999 Canadian General Social Survey was assessed. Rates of medication use by adults exposed to IPV (physical, sexual, emotional and financial) were compared to rates of those reporting no IPV.

RESULTS

More women (14.9%) than men (9.6%) reported use of psychotropic medications in the preceding month. Rates were significantly higher in both women and men who reported IPV. This link was still present after key sociodemographic and health predictors of medication use were held constant.

CONCLUSION

This random population based study provides the first data to support the idea that IPV may explain at least some of the increased psychotropic medication use by women. IPV should be included as a predictor variable in future studies investigating psychotropic medication use which itself can be added to the list of adverse health risks of IPV.

Gender and the smoking behaviour of Ethiopian immigrants in Toronto

The objective of this paper is to present descriptive data on gender and smoking among Ethiopian immigrants in Toronto, Canada. The study used a cross-sectional epidemiological survey design (N = 342). The main outcome measures identified subjects as current (regular or occasional) smokers, daily smokers and former smokers. Overall, 20.8% of the individuals in the sample were current smokers and 15.7% were daily smokers. Although smoking rates (current and daily) were significantly higher among males compared to females, nearly twice as many female as male daily smokers reported that they began smoking post-migration (60.0% vs. 30.2%). Furthermore, 80.0% of female compared to nearly 56% of male daily smokers reported that they were smoking more post-migration. A significantly higher proportion of males compared to females were former daily smokers (17.8% vs. 4.4%). These findings present a challenge for public health professionals in terms of preventing the adoption of smoking among Ethiopian females and facilitating smoking cessation among Ethiopian males. Correlates with current smoking suggested that smoking prevention and cessation programs in newcomer immigrant communities may benefit from incorporating social, economic and religious contexts of these newcomers' lives from a gender-specific perspective.

Who is most at risk for intimate partner violence? A Canadian population-based study

Whole population studies on intimate partner violence (IPV) have given contradictory information about prevalence and risk factors, especially concerning gender. The authors examined the 1999 Canadian General Social Survey data for gender patterns of physical, sexual, emotional, or financial IPV from a current or ex-partner. More women (8.6%) than men (7.0%, p = .001) reported partner physical abuse in general, physical IPV causing physical injury (p < .0001), sexual abuse (1.7% vs. 0.2%, p < .0001), and financial abuse (4.1% vs. 1.6%, p < .0001). There were no gender differences for partner emotional abuse. Significant risk factors after multivariate modeling for physical/sexual IPV were younger age, being divorced/separated or single, having children in the household, and poor self-rated physical health. These findings from a large, randomly generated data set further refine our understanding of the risk profile for IPV in the developed world.

Health service utilization by Ethiopian immigrants and refugees in Toronto

The purpose of this study was to examine the health service utilization patterns of Ethiopian immigrants and refugees in a random sample of 342 adults residing in Toronto. The results suggested that 85% of the study participants used one or more type of health services, most often from a family physician. However, only 12.5% of them with a mental disorder received services from formal healthcare providers, mainly family physicians. While the presence of somatic symptoms was significantly associated with increased use of healthcare (p < 0.05), having a mental disorder was associated with lower rate of health service use (p < 0.05). These findings suggest that family physicians could play important role in identifying and treating Ethiopian clients who present with somatic symptoms, as these symptoms may reflect mental health problems. Further research is necessary to determine the reasons for the low rates of mental health services use in this population.

Provision of pharmaceutical care to patients with limited English proficiency

PURPOSE

A study was conducted to evaluate the current practices of pharmacists in ambulatory care clinics in communicating with and providing pharmaceutical care to patients who have limited English proficiency.

METHODS

Semistructured surveys were used to gather data from 16 pharmacists and 8 physicians from 15 ambulatory care clinics in metropolitan Toronto. The survey examined pharmacists' knowledge about the linguistic services, policies, and guidelines in their ambulatory care practice settings; the strategies that pharmacists and physicians use to communicate with patients with limited English proficiency; the challenges pharmacists face when providing pharmaceutical care to those patients; the drug-related problems observed by pharmacists and physicians; and how pharmacists and physicians can collaborate to resolve medication issues for those patients.

RESULTS

Many pharmacists (69%) were unaware of existing institutional policies for communicating with patients with limited English proficiency. Language interpretation services in clinics were nonstandardized and did not always reflect practitioners' preferences. All aspects of pharmaceutical care were reported to be difficult to accomplish in patients with limited English proficiency. Pharmacists and physicians identified similar drug-related problems, with nonadherence being the most commonly observed drug-related problem. Strategies suggested by pharmacists and physicians to improve communication with patients involved proactively identifying language needs of patients before appointments, having translated medication information available and using trained language interpreters.

CONCLUSION

Pharmacists at 15 ambulatory care clinics reported difficulty communicating with and providing pharmaceutical care to patients with limited English proficiency. Strategies suggested by pharmacists and physicians to enhance communication with those patients may help improve the quality of pharmaceutical care delivered.

Mental health service utilization by Ethiopian immigrants and refugees in Toronto

The purpose of this study was to examine the mental health service utilization patterns of Ethiopians in Toronto. A cross-sectional epidemiological survey of 342 randomly selected adults was conducted, based on a conceptual model of healthcare utilization suggested by Anderson and Newman. The results suggested that 5% of the respondents sought mental health services from healthcare professionals and 8% consulted nonhealthcare professionals. Although Ethiopians' utilization rate of mental health services did not greatly differ from the rates of the general population of Ontario (6%), only a small proportion (12.5%) of Ethiopians with mental disorders used services from healthcare professionals, mostly family physicians. The data also suggested that Ethiopians were more likely to consult traditional healers than healthcare professionals for mental health problems (18.8% vs. 12.5%). In multivariate logistic regression analyses, while the number of somatic symptoms experienced was positively associated with increased mental healthcare utilization (OR = 1.515, p < 0.05), having a mental disorder was associated with decreased mental healthcare utilization (OR = 0.784, p < 0.01). Our findings have important implications for mental health services. On the one hand, the findings suggest that somatic symptoms could lead to increased use of mental health services, particularly family physicians' services. On the other hand, the data suggested that although the mental healthcare needs of Ethiopians are high, they use fewer mental health services from healthcare professionals. It would seem that family physicians could play important role in identifying and treating Ethiopian clients with somatic symptoms, as these symptoms may reflect mental disorder.

Help-Seeking Rates for Intimate Partner Violence (IPV) Among Canadian Immigrant Women

We examined rates of help seeking for intimate partner violence (IPV) among recent (0-9 years in Canada) and non-recent (10+ years in Canada) immigrant women. Data from a national, cross-sectional, telephone survey were used. Help-seeking variables included disclosure of IPV, reporting IPV to police, use of social services subsequent to IPV, and barriers to social service use. Recent immigrant women, compared with non-recent immigrant women, were significantly more likely to report IPV to police and less likely to use social services. Findings have important implications for prevention and detection of IPV in immigrant communities and in future research.

Adding Insult to Injury: Intimate Partner Violence Among Women and Men Reporting Activity Limitations

PURPOSE

Women with activity limitations (ALs) are at risk for Intimate partner violence (IPV). This study examined IPV in men versus women with ALs.

METHODS

Data from the Canadian 1999 General Social Survey compared physical, sexual, emotional, and financial IPV from a current/expartner in 5 years for men and women with ALs compared with those without ALs. Logistic regression examined sex differences in IPV among those with ALs, adjusting for sociodemographic factors.

RESULTS

Rates of physical (11.9% versus 7.8%; p < 0.0001), sexual (3.5% versus 1.4%; p < 0.0001), emotional (27.1% versus 17.7%; p < 0.0001), and financial (7.5% versus 3.4%; p < 0.0001) IPV were greater in women with compared with without ALs. A similar pattern was seen for men, with greater rates of physical (9.2% versus 6.6%; p = 0.006), emotional (22.6% versus 18.2%; p = 0.002), and financial (2.6% versus 1.4%; p = 0.005) IPV in men with ALs than men without ALs. Risk factors for IPV included younger age, being divorced/separated or single, and having lower income and poorer health. Women with ALs were more likely than men to experience any IPV (29.1% versus 24.9%) and more severe and more incidents of IPV. In multivariable analysis, women were no longer at greater risk for "any IPV" after adjusting for sociodemographic variables (odds ratio = 1.09; 95% confidence interval, 0.88-1.36).

CONCLUSION

This is the first study to document IPV rates in men with ALs. Women with ALs were more likely to be divorced/separated, living in poverty, and in poorer health than men with ALs. These factors accounted for sex differences in IPV rates.

The association between length of stay in Canada and intimate partner violence among immigrant women

OBJECTIVE

We examined the prevalence of intimate partner violence (IPV) among recent (0-9 years) and nonrecent (>/= 10 years) immigrant women in Canada to determine whether differences in IPV were associated with length of stay in Canada.

METHODS

We analyzed data from the 1999 General Social Survey, a national cross-sectional telephone survey. We used weighted logistic regression analysis to examine the effect of length of stay in Canada on IPV and controlled for socio-cultural and other factors associated with IPV.

RESULTS

The crude prevalence of IPV was similar among recent and nonrecent immigrant women. However, after adjustment, the risk for IPV was significantly lower among recent immigrant women compared with nonrecent immigrant women. Country of origin, age, marital status, and having an activity limitation (physical/mental disability or health problem) also were associated with a higher risk for IPV.

CONCLUSIONS

Our findings have important implications for both prevention and detection of IPV among immigrant women.

Intimate partner violence among Canadian women with activity limitations

OBJECTIVE

To determine the prevalence of intimate partner violence (IPV) in the previous five years among women reporting activity limitations (AL).

DESIGN AND SETTING

A community based, representative telephone survey of Canadians aged 15 and over. AL was assessed by the question: "Does a long term physical or mental condition or health problem reduce the amount or the kind of activity that you can do at home, at school, at work or in other activities?" Response categories were: often, sometimes, or never.

PARTICIPANTS

8771 women who had a current/former partner of whom 1483 reported AL.

MAIN RESULTS

IPV was reported more often for AL (often or sometimes) compared with no AL women (emotional abuse (27.1, 26.4 v 17.7%, p<0.0001), physical-severe (7.3, 6.7 v 3.6%, p<0.0001), sexual abuse (3.5, 3.6 v 1.4%, p<0.0001)), or any IPV (30.5, 27.8 v 19.6%, p<0.0001). Adjusting for age, marital status, education, income, employment, children in the household, Aboriginal or visible minority status, place of birth, urban or rural residence, region of Canada, time in current residence, and religious attendance, AL women had higher odds of IPV (adjusted odds ratio: AL often=2.12; 95% CI: 1.64, 2.74; AL sometimes: OR=1.64; 95% CI:1.40, 2.29).

CONCLUSION

These findings call for increased recognition of violence that occurs in the lives of women with AL. This community based study suggests that abuse among those reporting AL is high. Women with AL represent a high risk group to be targeted in terms of IPV prevention and intervention.

Psychological and physical sequelae of intimate partner violence among women with limitations in their activities of daily living

OBJECTIVE

To compare the psychological and physical sequelae of physical/sexual intimate partner violence in women with and without activity limitations.

METHODS

We analyzed data from the Canadian 1999 General Social Survey. We included women reporting intimate partner violence in the previous 5 years (n = 897).

RESULTS

As a result of the violence, women with activity limitations were significantly more likely to feel ashamed/guilty (21.7 vs. 14.5%), depression/anxiety (31.5 vs. 19.8%), fearful (43.0 vs. 33.0%), lowered self-esteem (35.2 vs. 21.1%), increased caution/awareness (20.3 vs. 10.9%), and problems relating to men (16.4 vs. 5.4%). Significantly more women with activity limitations reported physical injury from violence (57.0 vs. 36.6%) and having to take time off from everyday activities (42.1 vs. 30.3%). Women with activity limitations had higher medication use for sleeping problems (OR = 3.17, 95% CI = 1.36, 5.73), anxiety (OR = 3.29, 95% CI = 1.75, 6.19) and depression (OR = 2.63, 95% CI = 1.41, 4.90).

CONCLUSION

Results suggest an additive effect between intimate partner violence and activity limitations that adds disproportionately to the burden of health for women with activity limitations.

Changing Help-Seeking Rates for Intimate Partner Violence in Canada

The adverse physical and psychological sequelae of intimate partner violence (IPV) are well documented, as are government initiatives in Canada since the early 1990s to address the problem through public awareness campaigns and service enhancement programs. While these initiatives have been designed to encourage abused women to come forward, there has been little research examining changes over time in help-seeking rates among this group. To fill this void, we compared data from two large Canadian population-based, cross-sectional telephone surveys: the 1993 Violence Against Women Survey (1993-VAWS) and the 1999 General Social Survey (1999-GSS). Among women who reported physical and/or sexual violence by a current or previous partner, we examined differences in rates of disclosure of abuse, help-seeking by type of service, and barriers to service use. Abused women in the 1999-GSS were significantly more likely than those in the 1993-VAWS to have reported disclosing a violent incident(s) to a family member (66.4% v. 43.9%), friend or neighbor (67.4% v. 45.4%), doctor or nurse (31.9% v. 23.0%), and/or minister, priest, or cleric (11.5% v. 7.3%). The 1999-GSS cohort was also more likely to have presented to a shelter or transition house (11.0% v. 7.8%), a crisis center (17.3% v. 4.2%), a counselor or psychologist (39.1% v. 14.7%), a women's center (11.2% v. 3.4%), and/or a community or family center (15.4% v. 4.7%). Among those women who did not seek help, fewer in the 1999-GSS reported that they did not know of any services (6.4% v. 17.0%), or that services were not available (0.8% v. 14.5%). Although we found a demonstrable increase in the numbers of abused women seeking help, overall, rates of service utilization were still low as late as 1999, highlighting the importance of continued government commitment to funding IPV initiatives.

Post-migration changes in gender relations among Ethiopian couples living in Canada

The Ethiopian community ofToronto, Canada, has identified the prevention of marital conflict and partner abuse as a priority issue. Previous research and community discussions suggested that changes in gender relations following migration contribute to both marital conflict and partner abuse. The objective of this community-based pilot study was to explore post-migration changes in gender relations among Ethiopian couples in order to inform the development of violence-prevention strategies. Qualitative research methods and analyses were used. In-depth interviews and focus-group discussions were conducted with 8 couples who had been married in Ethiopia and migrated to Toronto. The findings indicate changes in gender relations following migration as well as concordant and discordant patterns of change. Change was found to be associated with factors such as age, number of years married, experience in a third country, and gender-role socialization. Implications for future research and nursing practice are discussed.

Determinants of depression among Ethiopian immigrants and refugees in Toronto

The purpose of this study was to determine the occurrence of and risk factors for depressive disorder in a random sample of 342 Ethiopian immigrants and refugees in Toronto. The Composite International Diagnostic Interview questionnaire was used to measure depression. The results suggested a lifetime prevalence of depression among Ethiopian immigrants and refugees of 9.8%, which was slightly higher than the lifetime prevalence rate in the Ontario population (7.3%). However, the rate among Ethiopian immigrants and refugees was approximately three times higher than the rate estimated for Southern Ethiopia (3.2%). The data confirmed the significance of known risk factors for depression in immigrants, including younger age, experiences of premigration trauma, refugee camp internment, and postmigration stressful events. The implication of the overall finding is that there is a need to develop mental health intervention programs, particularly for people who have experienced premigration trauma, refugee camp internment, and postmigration stresses.

Setting the stage: reviewing current knowledge on the health of Canadian immigrants: what is the evidence and where are the gaps?

The paper reviews current knowledge on the health of Canadian immigrants, examines evidence, and identifies research gaps. The information presented is derived from two recent literature reviews. Most literature suggests that Canadian immigrants, particularly recent arrivals, enjoy health advantages over long-term immigrants and the Canadian-born population in terms of overall health status and the prevalence of certain chronic diseases. Immigrants with infectious diseases may experience improvements in health over time. Patterns of immigrant mental health are less clear. More research is needed on specific health problems, how to address determinants of health, and the types of programs and services necessary to maintain immigrants in good health over time. Steps must be taken to strengthen existing databases and develop new ones.

Physician-related determinants of cervical cancer screening among Caribbean women in Toronto

BACKGROUND

Minority women in Canada are less likely to be screened for cervical cancer than their counterparts in the general population, despite the fact that the proportion of these women who consult a general practitioner about their health each year is similar to minority women. This study examined the physician and practice characteristics associated with Pap testing and perceived barriers to Pap testing of family physicians serving the Caribbean community of Toronto.

METHODS

A mail-back questionnaire was sent to Toronto family physicians practicing in neighborhoods with a high proportion of Caribbean Canadians.

RESULTS

Although 79.7% of the 64 participating physicians reported that they were 'very likely" to include Pap testing during an annual check-up, nearly half did not believe that the majority of Caribbean patients were actually screened. The amount of time a physician spent on patient education was significantly associated with his/her likelihood of screening. Male physicians who reported a high proportion of Caribbean female patients in their practices were significantly less likely to screen for cervical cancer than those who saw fewer Caribbean patients.

CONCLUSION

These findings suggest that an increased emphasis on patient education is important to increase screening practice and that physician gender may be of major importance to the Caribbean community.

Promotion of Healthy Eating: Among New Immigrant Women in Ontario

Little attention has been given to the dietary patterns of new immigrant women in Canada. Research suggests that before migration, many immigrants, especially those from non-Western countries, consume a healthy diet, but this changes on migration. This paper presents information from a recently completed literature review conducted for the Women's Health Council of the Ontario Ministry of Health and Long-Term Care. The paper includes a review of the major determinants of food choice and health promotion strategies appropriate to new immigrant women. Our findings suggest that nutrition intervention for new immigrant women must consider the social context of these women's lives, address cultural, linguistic, economic and informational barriers and consider how these change over time. Recommendations are also made on how to best promote healthy eating in this group.

A review of theory and health promotion strategies for new immigrant women

BACKGROUND

There has been little empirical research on the best ways to influence women's health behaviour, particularly among women who are recent immigrants to Canada.

METHODS

This paper presents information from a literature review conducted for the Ontario Women's Health Council on effective theoretical models and health promotion strategies for women.

FINDINGS

Health promotion activities for all women should address theoretical variables as well as the broader determinants of women's health. New immigrant women represent a diverse group who often face multiple cultural, linguistic and systemic barriers to adopting and maintaining healthy behaviour.

INTERPRETATION

Many theoretical constructs of potential importance to recent immigrant women have not been adequately researched. More research is also needed on the relevancy and the applicability of commonly used health promotion approaches for this group.

Poverty, family process, and the mental health of immigrant children in Canada

OBJECTIVES

This study examined the differential effects of poverty on the mental health of foreign-born children, Canadian-born children of immigrant parents, and children of non-immigrant parents.

METHODS

Secondary analysis of data from a national Canadian study of children between 4 and 11 years of age was conducted.

RESULTS

Compared with their receiving-society counterparts, foreign-born children were more than twice as likely to live in poor families, but they had lower levels of emotional and behavioral problems. The effect of poverty on children's mental health among long-term immigrant and receiving-society families was indirect and primarily mediated by single-parent status, ineffective parenting, parental depression, and family dysfunction. In comparison, the mental health effect of poverty among foreign-born children could not be explained by the disadvantages that poor families often suffer.

CONCLUSIONS

Poverty may represent a transient and inevitable part of the resettlement process for new immigrant families. For long-stay immigrant and receiving-society families, however, poverty probably is not part of an unfolding process; instead, it is the nadir of a cycle of disadvantage.

The role of physicians in mammography referral for older Caribbean women in Canada

BACKGROUND

Despite the fact that the proportion of immigrant and minority women who consult a general practitioner about their health is similar to that of their Canadian-born counterparts, studies suggest that they are less likely to be screened for breast cancer. This study examines physician characteristics associated with mammography referral and perceived barriers to mammography among family physicians serving the Caribbean community of Toronto.

METHODS

The study consisted of a mail-back family physician survey.

RESULTS

Among the 64 physicians who responded to the survey, over half reported that they were "very likely" to refer women for mammography during a regular preventive check-up. Among physician variables, only the amount of time spent on patient education was significantly associated with the likelihood of referral. Regarding perceived barriers, for male physicians, patient refusal and intervention causing patient discomfort were significantly associated with referral. For female physicians, only forgetting to provide service was identified as a significant barrier to referral.

INTERPRETATION

An increased emphasis on patient education may help to increase screening referral among all physicians. Gender differences in perceived barriers to referral suggest that the gender of the physician is of major importance to the Caribbean community.

Rural physicians' perspectives on cervical and breast cancer screening: a gender-based analysis

Several studies highlight the role of physicians in determining cervical and breast cancer screening rates, and some urban studies report higher screening rates by female physicians. Rural women in North America remain underscreened for breast and cervical cancers. This survey was conducted to determine if there were significant gender differences in practices and perceptions of barriers to breast and cervical cancer screening among rural family physicians in Ontario, Canada. One hundred ninety-one family physicians (response rate 53.1%) who practiced in rural areas, small towns, or small cities completed a mail questionnaire. The physicians' mean age was 44.4 years (SD 9.9), and mean number of years in practice was 16.6 years (SD 10.3). Over 90% of physicians reported that they were very likely to conduct a Pap test and clinical breast examination (CBE) during a periodic health examination, and they had high levels of confidence and comfort in performing these procedures. Male (68%) and female (32%) physicians were similar in their likelihood to conduct screening, levels of confidence and comfort, and knowledge of breast and cervical cancer screening guidelines. However, the self-reported screening rates for Pap tests and CBE performed during last year were higher for female than male physicians (p < 0.01). Male physicians reported they were asked more frequently by patients for a referral to another physician to perform Pap tests and CBE (p < 0.001). Also, male physicians perceived patients' embarrassment as a stronger barrier to performing Pap tests (p < 0.05) and CBE (p < 0.01) than female physicians. No gender differences were observed in screening rates or related barriers to mammography referrals. These findings suggest that physicians' gender plays a role in sex-sensitive examination, such as Pap tests and CBE. There is a need to facilitate physician-patient interactions for sex-sensitive cancer screening examinations by health education initiatives targeting male physicians and women themselves. The feasibility of providing sex-sensitive cancer screening examinations by a same-sex health provider should also be explored.

Primary prevention of violence against women

The best mechanisms to prevent violence against women were reviewed in a critical appraisal conducted by the University Health Network Women's Health Program. Several promising primary interventions were identified. These included: educational and policy-related interventions to change social norms, early identification of abuse by health and other professionals, programs and strategies to empower women, safety and supportive resources for victims of abuse, and improved laws and access to the criminal justice system. The policy recommendations emerging from this analysis are presented.

Negative consequences of acculturation on health behaviour, social support and stress among pregnant Southeast Asian immigrant women in Montreal: an exploratory study

It is frequently assumed that migrant status constitutes a health risk because migration is inevitably associated with a period of significant adjustment and stress. This paper describes the role of acculturation in understanding the relationship between migration and low birthweight (LBW). Psychosocial and behavioural risk factors for LBW were explored using semi-structured interviews with 17 pregnant Southeast Asian women who represented different levels of acculturation. Findings suggested that acculturation had negative consequences for immigrant women. Higher levels of acculturation were associated with dieting during pregnancy, inadequate social support and stressful life experiences.

Refugees' time perspective and mental health

OBJECTIVE

The authors' goal was to investigate factors protective of the mental health of refugees, with a particular focus on time splitting and suppression of the past.

METHOD

Structured interviews covering premigration and postmigration stresses, personal and social resources, and mental health were given to 1,348 Southeast Asian refugees resettled in Vancouver, British Columbia, and to a comparison sample of 319 residents of Vancouver. Both groups of subjects also performed a task designed to measure orientation toward past, present, and future.

RESULTS

Compared with resident Canadians, refugees were more likely to exhibit an atomistic time perspective in which past, present, and future are split. Temporal atomism and avoidance of nostalgia were associated with a lower risk of depression than were other time perspectives.

CONCLUSIONS

Under conditions of extreme adversity, time splitting and suppression of the past may be adaptive strategies, mitigating the risk of depression.

The effect of acculturation on low birthweight in immigrant women

The interpretation of variations in perinatal morbidity by immigration status has been difficult. Of particular concern is the lack of attention to adaptive capacity. This study explores the effect of acculturation on term low birthweight (LBW) in five ethnic groups representing different immigration experiences. Using Quebec birth certificates (1979-1988), two birth cohorts were defined to control for the effects of repeat pregnancies. Bivariate and logistic regression analyses were used to examine the relationship between acculturation and term LBW. In both birth cohorts the more acculturated women experienced significantly higher rates of term LBW. The odds ratio for term LBW (1.6) was also significantly higher for the more acculturated group but this effect was only observed in the second birth cohort. These findings imply that in addition to other conventional factors, the level of acculturation of the mother should be assessed in perinatal risk identification systems.