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Richard L, Golding H, Saskin R, Shariff SZ, Jenkinson JIR, Pridham KF, Snider C, Boozary A, Hwang SW. Trends in emergency department visits during cold weather seasons among patients experiencing homelessness in Ontario, Canada: a retrospective population-based cohort study. CAN J EMERG MED 2024; 26:339-348. [PMID: 38578567 DOI: 10.1007/s43678-024-00675-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/29/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE Recent anecdotal reports suggest increasing numbers of people experiencing homelessness are visiting emergency departments (EDs) during cold weather seasons due to inadequate shelter availability. We examined monthly ED visits among patients experiencing homelessness to determine whether there has been a significant increase in such visits in 2022/2023 compared to prior years. METHODS We used linked health administrative data to identify cohorts experiencing homelessness in Ontario between October and March of the 2018/2019 to 2022/2023 years. We analyzed the monthly rate of non-urgent ED visits as a proxy measure of visits plausibly attributable to avoidance of cold exposure, examining rates among patients experiencing homelessness compared to housed patients. We excluded visits for overdose or COVID-19. We assessed level and significance of change in the 2022/2023 year as compared to previous cold weather seasons using Poisson regression. RESULTS We identified a total of 21,588 non-urgent ED visits across the observation period among patients experiencing homelessness in Ontario. Non-urgent ED visits increased 27% (RR 1.24 [95% CI 1.14-1.34]) in 2022/2023 compared to previous cold weather seasons. In Toronto, such visits increased by 70% (RR 1.68 [95% CI 1.57-1.80]). Among housed patients, non-urgent ED visits did not change significantly during this time period. CONCLUSION Rates of ED visits plausibly attributable to avoidance of cold exposure by individuals experiencing homelessness increased significantly in Ontario in 2022/2023, most notably in Toronto. This increase in ED visits may be related to inadequate access to emergency shelter beds and warming services in the community.
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Affiliation(s)
- Lucie Richard
- MAP Centre for Urban Health Solutions, Toronto, ON, Canada.
| | | | | | | | | | | | - Carolyn Snider
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Unity Health Toronto, Toronto, ON, Canada
| | - Andrew Boozary
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Stephen W Hwang
- MAP Centre for Urban Health Solutions, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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Richard L, Golding H, Saskin R, Jenkinson JIR, Francombe Pridham K, Gogosis E, Snider C, Hwang SW. Cold-related injuries among patients experiencing homelessness in Toronto: a descriptive analysis of emergency department visits. CAN J EMERG MED 2023; 25:695-703. [PMID: 37405616 DOI: 10.1007/s43678-023-00546-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/16/2023] [Indexed: 07/06/2023]
Abstract
PURPOSE Homelessness increases the risk of cold-related injuries. We examined emergency department visits for cold-related injuries in Toronto over a 4-year period, comparing visits for patients identified as homeless to visits for patients not identified as homeless. METHODS This descriptive analysis of visits to emergency departments in Toronto between July 2018 and June 2022 used linked health administrative data. We measured emergency department visits with cold-related injury diagnoses among patients experiencing homelessness and those not identified as homeless. Rates were expressed as a number of visits for cold-related injury per 100,000 visits overall. Rate ratios were used to compare rates between homeless vs. not homeless groups. RESULTS We identified 333 visits for cold-related injuries among patients experiencing homelessness and 1126 visits among non-homeless patients. In each of the 4 years of observation, rate ratios ranged between 13.6 and 17.6 for cold-related injuries overall, 13.7 and 17.8 for hypothermia, and 10.3 and 18.3 for frostbite. Rates per 100,000 visits in the fourth year (July 2021 to June 2022) were significantly higher than in the pre-pandemic period. Male patients had higher rates, regardless of homelessness status; female patients experiencing homelessness had higher rate ratios than male patients experiencing homelessness. CONCLUSION Patients experiencing homelessness visiting the emergency department are much more likely to be seen for cold-related injuries than non-homeless patients. Additional efforts are needed to prevent cold-related exposure and consequent injury among people experiencing homelessness.
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Affiliation(s)
- Lucie Richard
- MAP Centre for Urban Health Solutions, Unity Health Toronto, 30 Bond St., Toronto, ON, Canada.
| | | | | | - Jesse I R Jenkinson
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, ON, Canada
| | | | - Evie Gogosis
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, ON, Canada
| | | | - Stephen W Hwang
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, ON, Canada
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Richard L, Nisenbaum R, Brown M, Liu M, Pedersen C, Jenkinson JIR, Mishra S, Baral S, Colwill K, Gingras AC, McGeer A, Hwang SW. Incidence of SARS-CoV-2 Infection Among People Experiencing Homelessness in Toronto, Canada. JAMA Netw Open 2023; 6:e232774. [PMID: 36912833 PMCID: PMC10011938 DOI: 10.1001/jamanetworkopen.2023.2774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
IMPORTANCE People experiencing homelessness are at high risk of SARS-CoV-2 infection. Incident infection rates have yet to be established in these communities and are needed to inform infection prevention guidance and related interventions. OBJECTIVE To quantify the SARS-CoV-2 incident infection rate among people experiencing homelessness in Toronto, Canada, in 2021 and 2022 and to assess factors associated with incident infection. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study was conducted among individuals aged 16 years and older who were randomly selected between June and September 2021 from 61 homeless shelters, temporary distancing hotels, and encampments in Toronto, Canada. EXPOSURES Self-reported housing characteristics, such as number sharing living space. MAIN OUTCOMES AND MEASURES Prevalence of prior SARS-CoV-2 infection in summer 2021, defined as self-reported or polymerase chain reaction (PCR)- or serology-confirmed evidence of infection at or before the baseline interview, and SARS-CoV-2 incident infection, defined as self-reported or PCR- or serology-confirmed infection among participants without history of infection at baseline. Factors associated with infection were assessed using modified Poisson regression with generalized estimating equations. RESULTS The 736 participants (415 of whom did not have SARS-CoV-2 infection at baseline and were included in the primary analysis) had a mean (SD) age of 46.1 (14.6) years; 486 (66.0%) self-identified as male. Of these, 224 (30.4% [95% CI, 27.4%-34.0%]) had a history of SARS-CoV-2 infection by summer 2021. Of the remaining 415 participants with follow-up, 124 experienced infection within 6 months, representing an incident infection rate of 29.9% (95% CI, 25.7%-34.4%), or 5.8% (95% CI, 4.8%-6.8%) per person-month. Report after onset of the SARS-CoV-2 Omicron variant was associated with incident infection, with an adjusted rate ratio (aRR) of 6.28 (95% CI, 3.94-9.99). Other factors associated with incident infection included recent immigration to Canada (aRR, 2.74 [95% CI, 1.64-4.58]) and alcohol consumption over the past interval (aRR, 1.67 [95% CI, 1.12-2.48]). Self-reported housing characteristics were not significantly associated with incident infection. CONCLUSIONS AND RELEVANCE In this longitudinal study of people experiencing homelessness in Toronto, SARS-CoV-2 incident infection rates were high in 2021 and 2022, particularly once the Omicron variant became dominant in the region. Increased focus on homelessness prevention is needed to more effectively and equitably protect these communities.
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Affiliation(s)
- Lucie Richard
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Rosane Nisenbaum
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Michael Brown
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Michael Liu
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
- Harvard Medical School, Boston, Massachusetts
| | - Cheryl Pedersen
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Jesse I. R. Jenkinson
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Sharmistha Mishra
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
- Division of Epidemiology and Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Stefan Baral
- Department of Epidemiology, John Hopkins University, Baltimore, Maryland
| | - Karen Colwill
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Anne-Claude Gingras
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Allison McGeer
- Department of Microbiology, Mount Sinai Hospital, Toronto, Toronto, Ontario, Canada
| | - Stephen W. Hwang
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of General Internal Medicine, University of Toronto, Toronto, Ontario, Canada
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Jenkinson JIR, Sniderman R, Gogosis E, Liu M, Nisenbaum R, Pedersen C, Spandier O, Tibebu T, Dyer A, Crichlow F, Richard L, Orkin A, Thulien N, Kiran T, Kayseas J, Hwang SW. Exploring COVID-19 vaccine uptake, confidence and hesitancy among people experiencing homelessness in Toronto, Canada: protocol for the Ku-gaa-gii pimitizi-win qualitative study. BMJ Open 2022; 12:e064225. [PMID: 35977770 PMCID: PMC9388714 DOI: 10.1136/bmjopen-2022-064225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION People experiencing homelessness are at high risk for COVID-19 and poor outcomes if infected. Vaccination offers protection against serious illness, and people experiencing homelessness have been prioritised in the vaccine roll-out in Toronto, Canada. Yet, current COVID-19 vaccination rates among people experiencing homelessness are lower than the general population. This study aims to characterise reasons for COVID-19 vaccine uptake and hesitancy among people experiencing homelessness, to identify strategies to overcome hesitancy and provide public health decision-makers with information to improve vaccine confidence and uptake in this priority population. METHODS AND ANALYSIS The Ku-gaa-gii pimitizi-win qualitative study (formerly the COVENANT study) will recruit up to 40 participants in Toronto who are identified as experiencing homelessness at the time of recruitment. Semistructured interviews with participants will explore general experiences during the COVID-19 pandemic (eg, loss of housing, social connectedness), perceptions of the COVID-19 vaccine, factors shaping vaccine uptake and strategies for supporting enablers, addressing challenges and building vaccine confidence. ETHICS AND DISSEMINATION Approval for this study was granted by Unity Health Toronto Research Ethics Board. Findings will be communicated to groups organising vaccination efforts in shelters, community groups and the City of Toronto to construct more targeted interventions that address reasons for vaccine hesitancy among people experiencing homelessness. Key outputs will include a community report, academic publications, presentations at conferences and a Town Hall that will bring together people with lived expertise of homelessness, shelter staff, leading scholars, community experts and public health partners.
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Affiliation(s)
- Jesse I R Jenkinson
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Ruby Sniderman
- Centre de recherche du Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Evie Gogosis
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Michael Liu
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
- Harvard Medical School, Boston, Massachusetts, USA
| | - Rosane Nisenbaum
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Cheryl Pedersen
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Olivia Spandier
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Tadios Tibebu
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Allison Dyer
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Frank Crichlow
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
- South Riverdale Community Health Centre, Toronto, Ontario, Canada
| | - Lucie Richard
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Aaron Orkin
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Inner City Health Associates, Toronto, Ontario, Canada
| | - Naomi Thulien
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Tara Kiran
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jolen Kayseas
- Department of Languages, Literature and Culture, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Stephen W Hwang
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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I R Jenkinson J, Strike C, Hwang SW, Di Ruggiero E. Legal, geographic and organizational contexts that shape knowledge sharing in the hospital discharge process for people experiencing homelessness in Toronto, Canada. Health Soc Care Community 2022; 30:e377-e387. [PMID: 33105525 DOI: 10.1111/hsc.13206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 09/28/2020] [Accepted: 10/01/2020] [Indexed: 06/11/2023]
Abstract
People experiencing homelessness use acute healthcare at higher rates than the general population, yet hospitals frequently discharge them to the streets or emergency shelters. Available literature on the hospital discharge process for people experiencing homelessness identifies knowledge sharing as an important and challenging part of the discharge process; however, it does little to explain what generates these challenges or what might support knowledge sharing. In this study, we explain under which contexts certain mechanisms are triggered to facilitate knowledge sharing between hospitals and shelters during the discharge process. Between September 2018 and April 2019, we interviewed 33 participants: hospital workers on general medicine wards across three hospitals; shelter workers; researchers, policy advisors or advocates working at the intersection of homelessness and healthcare in Toronto. We find that within the legal context of health information protection, the concept of "circle of care" has created barriers to knowledge sharing between hospitals and shelters by excluding shelter workers from discharge planning. We note, however, that the degree to which hospital workers have navigated these barriers and brought shelter workers into the discharge process varies across hospitals. We explore this variation and find that certain geographic and organisational contexts have activated the development of institutional- and individual-level relationships between hospitals and shelters or their workers, respectively. We suggest that these relationships generate increased trust and communication and have led to knowledge sharing between hospitals and shelters. These findings are applicable in most urban centres with hospitals and where people experiencing homelessness live. Understanding the role of context is imperative for developing appropriate and effective interventions to improve hospital discharge processes. The development and implementation of more effective discharge processes can contribute to improved post-discharge care and recovery for this patient population and contribute to addressing health equity.
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Affiliation(s)
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Stephen W Hwang
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Canada
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| | - Erica Di Ruggiero
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Jenkinson JIR, Strike C, Hwang SW, Di Ruggiero E. Nowhere to go: exploring the social and economic influences on discharging people experiencing homelessness to appropriate destinations in Toronto, Canada. Can J Public Health 2021; 112:992-1001. [PMID: 34448129 DOI: 10.17269/s41997-021-00561-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/02/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES A main component of discharging patients from hospital is identifying an appropriate destination to meet their post-hospitalization needs. In Canada, meeting this goal is challenged when discharging people experiencing homelessness, who are frequently discharged to the streets or shelters. This study aimed to understand why and how the ability of hospital workers to find appropriate discharge destinations for homeless patients is influenced by dynamic social and economic contexts. METHODS Guided by critical realism, we conducted semi-structured, in-depth interviews with 33 participants: hospital workers on general medicine wards at three urban hospitals; shelter workers; and researchers, policy advisors, and advocates working at the intersection of homelessness and healthcare. RESULTS Historical and contemporary social and economic contexts (e.g., shrinking financial resources) have triggered the adoption of efficiency and accountability measures in hospitals, and exclusion criteria and rules in shelters, both conceptualized as mechanisms in this article. Hospitals are pressured to move patients out as soon as they are medically stable, but they struggle to discharge patients to shelters: to prevent inappropriate discharges, shelters have adopted exclusion and eligibility rules and criteria. These mechanisms contribute to an explanation of why identifying an appropriate discharge destination for people experiencing homelessness is challenging. CONCLUSION Our results point to a systems gap in this discharge pathway where there is nowhere for people experiencing homelessness to go who no longer need acute care, but whose needs are too complex for shelters. Systemic changes are needed to better support hospital and shelter frontline workers to improve discharge processes.
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Affiliation(s)
- Jesse I R Jenkinson
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada. .,MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health, 30 Bond Street, Toronto, M5B 1W8, ON, Canada.
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Stephen W Hwang
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health, 30 Bond Street, Toronto, M5B 1W8, ON, Canada.,Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Erica Di Ruggiero
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Logie CH, Jenkinson JIR, Earnshaw V, Tharao W, Loutfy MR. A Structural Equation Model of HIV-Related Stigma, Racial Discrimination, Housing Insecurity and Wellbeing among African and Caribbean Black Women Living with HIV in Ontario, Canada. PLoS One 2016; 11:e0162826. [PMID: 27669510 PMCID: PMC5036880 DOI: 10.1371/journal.pone.0162826] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 08/29/2016] [Indexed: 01/15/2023] Open
Abstract
African and Caribbean Black women in Canada have new HIV infection rates 7 times higher than their white counterparts. This overrepresentation is situated in structural contexts of inequities that result in social, economic and health disparities among African and Caribbean Black populations. Economic insecurity is a distal driver of HIV vulnerability, reducing access to HIV testing, prevention and care. Less is known about how economic insecurity indicators, such as housing security, continue to influence the lives of women living with HIV following HIV-positive diagnoses. The aim of this study was to test a conceptual model of the pathways linking HIV-related stigma, racial discrimination, housing insecurity, and wellbeing (depression, social support, self-rated health). We implemented a cross-sectional survey with African and Caribbean Black women living with HIV in 5 Ontario cities, and included 157 participants with complete data in the analyses. We conducted structural equation modeling using maximum likelihood estimation to evaluate the hypothesized conceptual model. One-fifth (22.5%; n = 39) of participants reported housing insecurity. As hypothesized, racial discrimination had significant direct effects on: HIV-related stigma, depression and social support, and an indirect effect on self-rated health via HIV-related stigma. HIV-related stigma and housing insecurity had direct effects on depression and social support, and HIV-related stigma had a direct effect on self-rated health. The model fit the data well: χ2 (45, n = 154) = 54.28, p = 0.387; CFI = 0.997; TLI = 0.996; RMSEA = 0.016. Findings highlight the need to address housing insecurity and intersecting forms of stigma and discrimination among African and Caribbean Black women living with HIV. Understanding the complex relationships between housing insecurity, HIV-related stigma, racial discrimination, and wellbeing can inform multi-level interventions to reduce stigma and enhance health.
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Affiliation(s)
- Carmen H. Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
- Women’s College Research Institute, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
| | - Jesse I. R. Jenkinson
- Dalla Lana School of Public Health, Social and Behavioural Health Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Valerie Earnshaw
- Human Development and Family Studies, University of Delaware, Newark, Delaware, United States
| | - Wangari Tharao
- Women’s Health in Women’s Hands Community Health Centre, Toronto, Ontario, Canada
| | - Mona R. Loutfy
- Women’s College Research Institute, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
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