Birth and postnatal outcomes among infants of immigrant parents of different admission categories and parents born in Canada: a population-based retrospective study

BACKGROUND

Most studies of disparities in birth and postnatal outcomes by parental birthplace combine all immigrants into a single group. We sought to evaluate heterogeneity among immigrants in Canada by comparing birth and postnatal outcomes across different immigration categories.

METHODS

We conducted a population-based retrospective study using Statistics Canada data on live births and stillbirths (1993-2017) and infant deaths (1993-2018), linked to parental immigration data (1960-2017). We classified birthing parents as born in Canada, economic-class immigrants, family-class immigrants, or refugees, and evaluated differences in preterm births, small-for-gestational-age (SGA) and large-for-gestational-age (LGA) births, stillbirths, and infant deaths among singleton births by group.

RESULTS

Among 7 980 650 births, 1 715 050 (21.5%) were to immigrants, including 632 760 (36.9%) in the economic class, 853 540 (49.8%) in the family class, and 228 740 (13.4%) refugees. Compared with infants of Canadian-born birthing parents, infants of each of the 3 immigrant groups had higher risk of preterm birth, SGA birth, and stillbirth, but lower risk of LGA birth and neonatal death. Compared with infants of economic-class immigrants, infants of refugees had higher risk of early preterm birth (0.9% v. 0.8%, adjusted risk ratio [RR] 1.08, 95% confidence interval [CI] 1.01-1.15) and LGA birth (9.2% v. 7.5%, adjusted RR 1.12, 95% CI 1.10-1.15), but lower risk of SGA birth (10.2% v. 11.0%, adjusted RR 0.92, 95% CI 0.90-0.94), while infants of family-class immigrants had higher risk of SGA birth (12.2% v. 11.0%, adjusted RR 1.01, 95% CI 1.00-1.02). Risk of stillbirth, neonatal death, and overall infant death did not differ significantly among immigrant groups.

INTERPRETATION

Heterogeneity exists in outcomes of infants born to immigrants to Canada across immigration categories. These results highlight the importance of disaggregating immigrant populations in studies of health disparities.

Sex and gender differences in healthcare utilisation trajectories: a cohort study among Quebec workers living with chronic pain

OBJECTIVES

Chronic pain (CP) is a poorly recognised and frequently inadequately treated condition affecting one in five adults. Reflecting on sociodemographic disparities as barriers to CP care in Canada was recently established as a federal priority. The objective of this study was to assess sex and gender differences in healthcare utilisation trajectories among workers living with CP.

DESIGN

Retrospective cohort study.

PARTICIPANTS

This study was conducted using the TorSaDE Cohort which links the 2007-2016 Canadian Community Health Surveys and Quebec administrative databases (longitudinal claims). Among 2955 workers living with CP, the annual number of healthcare contacts was computed during the 3 years after survey completion.

OUTCOME

Group-based trajectory modelling was used to identify subgroups of individuals with similar patterns of healthcare utilisation over time (healthcare utilisation trajectories).

RESULTS

Across the study population, three distinct 3-year healthcare utilisation trajectories were found: (1) low healthcare users (59.9%), (2) moderate healthcare users (33.6%) and (3) heavy healthcare users (6.4%). Sex and gender differences were found in the number of distinct trajectories and the stability of the number of healthcare contacts over time. Multivariable analysis revealed that independent of other sociodemographic characteristics and severity of health condition, sex-but not gender-was associated with the heavy healthcare utilisation longitudinal trajectory (with females showing a greater likelihood; OR 2.6, 95% CI 1.6 to 4.1).

CONCLUSIONS

Our results underline the importance of assessing sex-based disparities in help-seeking behaviours, access to healthcare and resource utilisation among persons living with CP.

Service provider perspectives on how COVID-19 and pandemic restrictions have affected intimate partner and sexual violence survivors in Canada: a qualitative study

Background

The COVID-19 pandemic may increase risk of intimate partner and sexual violence and make relevant services less accessible. This study explored the perspectives of intimate partner and sexual violence workers across Canada on how the COVID-19 pandemic has affected the survivors with whom they work.

Methods

Using a qualitative descriptive design, we interviewed 17 management and frontline staff of organizations supporting survivors of intimate partner and sexual violence across Canada. Results: We identified 4 themes that describe the impacts of COVID-19 on intimate partner and sexual violence survivors, from the perspective of service providers: (1) No escape; (2) Isolation; (3) Tough decisions; and (4) Heightened vulnerability. These narrative findings are presented first, followed by an analysis within a social determinants of health framework. Interpreting our findings against such a framework revealed a complex interplay of social determinants, notably social support, access to services, and poverty, that produced several challenges for intimate partner and sexual violence survivors during COVID-19.

Conclusion

According to service providers, intimate partner and sexual violence survivors in Canada faced several challenges during the pandemic, including reduced ability to escape their situations, increased isolation, increasingly complex decisions, and heightened vulnerability. Our findings demonstrate the critical need to adopt a broader, more holistic approach in tackling  intimate partner and sexual violence by also addressing socioeconomic issues such as poverty and marginalization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01683-4.

Challenges, coping responses and supportive interventions for international and migrant students in academic nursing programs in major host countries: a scoping review with a gender lens

Background

International and migrant students face specific challenges which may impact their mental health, well-being and academic outcomes, and these may be gendered experiences. The purpose of this scoping review was to map the literature on the challenges, coping responses and supportive interventions for international and migrant students in academic nursing programs in major host countries, with a gender lens.

Methods

We searched 10 databases to identify literature reporting on the challenges, coping responses and/or supportive interventions for international and migrant nursing students in college or university programs in Canada, the United-States, Australia, New Zealand or a European country. We included peer-reviewed research (any design), discussion papers and literature reviews. English, French and Spanish publications were considered and no time restrictions were applied. Drawing from existing frameworks, we critically assessed each paper and extracted information with a gender lens.

Results

One hundred fourteen publications were included. Overall the literature mostly focused on international students, and among migrants, migration history/status and length of time in country were not considered with regards to challenges, coping or interventions. Females and males, respectively, were included in 69 and 59% of studies with student participants, while those students who identify as other genders/sexual orientations were not named or identified in any of the research. Several papers suggest that foreign-born nursing students face challenges associated with different cultural roles, norms and expectations for men and women. Other challenges included perceived discrimination due to wearing a hijab and being a ‘foreign-born male nurse’, and in general nursing being viewed as a feminine, low-status profession. Only two strategies, accessing support from family and other student mothers, used by women to cope with challenges, were identified. Supportive interventions considering gender were limited; these included matching students with support services' personnel by sex, involving male family members in admission and orientation processes, and using patient simulation as a method to prepare students for care-provision of patients of the opposite-sex.

Conclusion

Future work in nursing higher education, especially regarding supportive interventions, needs to address the intersections of gender, gender identity/sexual orientation and foreign-born status, and also consider the complexity of migrant students’ contexts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00678-0.

COVID-19, promotion and provision of palliative care: reaching out, accounting for linguistic diversity

The combined forces of economic globalization and international migration have resulted in specific challenges to palliative care systems. The COVID-19 pandemic has and is still greatly affecting elder populations as well as those across the age continuum living with long-standing chronic conditions or with pre-existing diverse unmet needs. While health promotion and palliative care may appear to be conceptually opposing fields, we argue that palliative care can and should fit under the umbrella of the health promotion continuum. This commentary seeks to discuss the importance of linguistic literacy and communication imperatives in the context of access to palliative care, given the broad, diversified and sensitive scope of care. While the pandemic has demonstrated that the public health responses of migrant host societies are deeply intertwined with policies as well as local rules and constraints, the promotion and provision of safe, timely and appropriate palliative care can be achieved through a sensitive assessment of differential contexts of diversity. The pandemic has painfully illustrated the need for a strong, respectful and equitable working partnership within the professions as well as with the civic society in order for the palliative needs of those exposed to a sustained risk not to be forgotten.

Télésanté en contexte de pandémie et de déconfinement : pratiques infirmières innovantes et partenariats pour des communautés équitables, sécuritaires et durables

La télésanté connait un essor fulgurant en ce contexte de pandémie. Or, en cette période d’insécurité mondiale, la santé préventive reprend ses droits. En période de déconfinement, la discipline et la cohésion sociale peuvent se relâcher. Cette enquête sociale vise à décrire un programme d'intervention à distance, réalisé en partenariat avec des locataires de logement communautaire, des infirmières et des étudiantes pour soutenir la littératie en santé au temps de la COVID-19. Le Programme de déconfinement en toute sécurité vise à renforcer les mesures préventives et de soutien avec des groupes en contexte de vulnérabilités économiques et sociales à l’aide de la télésanté. Les infirmières ont développé des pratiques cliniques et psychosociales et renforcé la littératie en santé, soutenant les mesures de santé publique post-COVID-19, surveillant l’éclosion de nouveaux foyers et apaisant les souffrances issues du confinement. À l’aide de cibles de performance des systèmes de santé et d’une perspective de justice sociale, nous avons documenté les défis, les leviers et les menaces à l’usage des pratiques à distance en prévention. Vecteur d’une approche intégrée, la télésanté préventive peut cibler simultanément, la lutte contre les maladies non transmissibles et transmissibles et les inégalités. La pandémie de COVID-19 renvoie à un nouvel équilibre des enjeux qui exige un accompagnement et des pratiques de santé communautaire engagées et critiques.

Where Sexual Orientation Has No Name: Sexual Orientation Missing Data in the Canadian Community Health Survey (2005-2014)

This study used data from the Canadian Community Health Survey (CCHS) (2005-2014) to analyze the relationships between sexual orientation item nonresponse and interview language, conversation language, migration status (migrant-non-migrant), cultural background, sex, age, education level, and marital status in a cross-sectional sample over 18 (n = 351,713 participants). Item nonresponse rates oscillated between 0.87% in 2007 and 1.4% in 2014. Individuals who self-declared as belonging to cultural groups such as Chinese, South Asian, South East Asian, Arab, Indigenous and Other had higher nonresponse odds compared to people who self-identified as Whites. The results showed significant higher nonresponse odds among immigrants. Women had higher nonresponse rates. The likelihood of non-answer increased with age and decreased with education. French interviews, interviews in other languages and speaking both English and French produced less nonresponse. Contrary to common beliefs, sexual orientation questions are not too controversial. Sexual orientation nonresponse is low and stable over time suggesting that research participants are willing to answer sexual orientation questions. These findings highlight that immigrants and people who self-declare as belonging to different cultural groups may interpret the sexual orientation questions differently.

Where boys don't dance, but women still thrive: using a development approach as a means of reconciling the right to health with the legitimization of cultural practices

Human rights language has become a common method of internationally denouncing violent, discriminatory or otherwise harmful practices, notably by framing them as reprehensible violations of those fundamental rights we obtain by virtue of being human. While often effective, such women’s rights discourse becomes delicate when used to challenge practices, which are of important cultural significance to the communities in which they are practiced. This paper analyses human rights language to challenge the gender disparity in access to health care and in overall health outcomes in certain countries where such disparities are influenced by important cultural values and practices. This paper will provide selected examples of machismo and marianismo discourses in certain Latin American countries on the one hand and of female genital cutting/excision (FGC/E) in practicing countries, both of which exposed to women’s rights language, notably for causing violations of women’s right to health. In essence, a reflective exercise is provided here with the argument that framing such discourses and practices as women’s rights violations. Calling for their abandonment have shown that it may not only be ineffective nor at times appropriate, it also risks delegitimizing associated discourses, norms and practices thereby enhancing criticisms of the women’s rights movement rather than adopting its principles. A sensitive community-based collaborative approach aimed at understanding and building cultural discourses to one, which promotes women’s capabilities and health, is proposed as a more effective means at bridging cultural and gender gaps.

Developing the culture of ethics in population health intervention research in Canada

Population health intervention research (PHIR) is a particular field of health research that aims to generate knowledge that contributes to the sustainable improvement of population health by enabling the implementation of cross-sectoral solutions adapted to social realities. Despite the ethical issues that necessarily raise its social agenda, the ethics of PHIR is still not very formalized. Unresolved ethical challenges may limit its focus on health equity. This contribution aims to highlight some of these issues and calls on researchers to develop a culture of ethics in PHIR. Three complementary ways are proposed: to build an ethical concept specific to this field, to promote a shared space for critical reflection on PHIR ethics, and to develop the ethical competence in PHIR for which a preliminary framework is proposed.

Conducting gender-based analysis of existing databases when self-reported gender data are unavailable: the GENDER Index in a working population

OBJECTIVES

Growing attention has been given to considering sex and gender in health research. However, this remains a challenge in the context of retrospective studies where self-reported gender measures are often unavailable. This study aimed to create and validate a composite gender index using data from the Canadian Community Health Survey (CCHS).

METHODS

According to scientific literature and expert opinion, the GENDER Index was built using several variables available in the CCHS and deemed to be gender-related (e.g., occupation, receiving child support, number of working hours). Among workers aged 18-50 years who had no missing data for our variables of interest (n = 29,470 participants), propensity scores were derived from a logistic regression model that included gender-related variables as covariates and where biological sex served as the dependent variable. Construct validity of propensity scores (GENDER Index scores) were then examined.

RESULTS

When looking at the distribution of the GENDER Index scores in males and females, they appeared related but partly independent. Differences in the proportion of females appeared between groups categorized according to the GENDER Index scores tertiles (p < 0.0001). Construct validity was also examined through associations between the GENDER Index scores and gender-related variables identified a priori such as choosing/avoiding certain foods because of weight concerns (p < 0.0001), caring for children as the most important thing contributing to stress (p = 0.0309), and ability to handle unexpected/difficult problems (p = 0.0375).

CONCLUSION

The GENDER Index could be useful to enhance the capacity of researchers using CCHS data to conduct gender-based analysis among populations of workers.

Canada's universal health-care system: achieving its potential

Access to health care based on need rather than ability to pay was the founding principle of the Canadian health-care system. Medicare was born in one province in 1947. It spread across the country through federal cost sharing, and eventually was harmonised through standards in a federal law, the Canada Health Act of 1984. The health-care system is less a true national system than a decentralised collection of provincial and territorial insurance plans covering a narrow basket of services, which are free at the point of care. Administration and service delivery are highly decentralised, although coverage is portable across the country. In the setting of geographical and population diversity, long waits for elective care demand the capacity and commitment to scale up effective and sustainable models of care delivery across the country. Profound health inequities experienced by Indigenous populations and some vulnerable groups also require coordinated action on the social determinants of health if these inequities are to be effectively addressed. Achievement of the high aspirations of Medicare's founders requires a renewal of the tripartite social contract between governments, health-care providers, and the public. Expansion of the publicly funded basket of services and coordinated effort to reduce variation in outcomes will hinge on more engaged roles for the federal government and the physician community than have existed in previous decades. Public engagement in system stewardship will also be crucial to achieve a high-quality system grounded in both evidence and the Canadian values of equity and solidarity.

Health and legal literacy for migrants: twinned strands woven in the cloth of social justice and the human right to health care

Background

Based on an analysis of published literature, this paper provides an over-view of the challenges associated with delivering on the right to access quality health care for international migrants to industrialized countries, and asks which group of professionals is best equipped to provide services that increase health and legal literacy. Both rights and challenges are approached from a social justice perspective with the aim of identifying opportunities to promote greater health equity. That is, to go beyond the legal dictates enshrined in principles of equality, and target as an ethical imperative a situation where all migrants receive the particular assistance they need to overcome the barriers that inhibit their equitable access to health care. This assistance is especially important for migrant groups that are further disadvantaged by differing cultural constructions of gender. Viewing the topic from this perspective makes evident a gap in both research literature and policy. The review has found that while health literacy is debated and enshrined as a policy objective, and consideration is given to improving legal literacy as a means of challenging social injustice in developing nations, however, no discussion has been identified that considers assisting migrants to gain legal literacy as a step toward achieving not only health literacy and improved health outcomes, but critical participation as members of their adoptive society.

Conclusion

Increasing migrant health literacy, amalgamated with legal literacy, aids migrants to better access their human right to appropriate care, which in turn demonstrably assists in increasing social engagement, citizenship and productivity. However what is not evident in the literature, is which bureaucratic or societal group holds responsibility for assisting migrants to develop critical citizenship literacy skills. This paper proposes that a debate is required to determine both who is best placed to provide services that increase health and legal literacy, and how they should be resourced, trained and equipped.

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.

Women's Political Participation in Rural India

This paper explores selected underlying themes related to rural Gujarati women's political participation. An analysis of this data subset provides an understanding of how gender operates in rural Gujarat with respect to women's social mobility as mediated by dimensions such as age, education, socio-economic status and household dynamics. Through qualitative inquiry and a gender-based analysis, this paper reveals the discrepancies between female and male perceptions concerning persistently low levels of female political participation, and in turn informs future directives working towards women's empowerment and gender parity.

Health-related quality of life and tuberculosis: a longitudinal cohort study

BACKGROUND

Active tuberculosis (TB) disease can impose substantial morbidity, while treatment for latent TB infection (LTBI) has frequent side effects. We compared health-related quality of life (HRQOL) between persons diagnosed and treated for TB disease, persons treated for LTBI, and persons screened but not treated for TB disease or LTBI, over one year following diagnosis/initial assessment.

METHODS

Participants were recruited at two hospitals in Montreal (2008-2011), and completed the Short Form-36 version 2 (SF-36) at baseline, and at 1, 2, 4, 6, 9, and 12 months thereafter. Eight domain scores and physical and mental component summary (PCS and MCS, respectively) scores were calculated from responses. Linear mixed models were used to compare mean scores at each evaluation and changes in scores over consecutive evaluations, among participants treated for TB disease and those treated for LTBI, each compared to the control group.

RESULTS

Of the 263 participants, 48 were treated for TB disease, 105 for LTBI, and 110 were control participants. Fifty-four percent were women, mean age was 35 years, and 90% were foreign-born. Participants treated for TB disease reported significantly worse mean scores at baseline compared to control participants (mean PCS scores: 50.0 vs. 50.7; mean MCS scores: 46.4 vs. 51.1), with improvement in mean MCS scores throughout the study period. Scores reported by participants treated for LTBI and control participants were comparable throughout the study.

CONCLUSION

TB disease is associated with decrements in HRQOL as measured by the SF-36. This is most pronounced during the weeks after diagnosis and treatment initiation, but is no longer evident after two months.

The impact of tuberculosis on health utility: a longitudinal cohort study

PURPOSE

To estimate health utility derived from the Short Form-36 (SF-36) questionnaire and Standard Gamble instrument for persons diagnosed and treated for tuberculosis (TB) disease, those diagnosed and treated for latent TB infection (LTBI), and those screened but not treated for TB disease or LTBI over the year following their diagnosis/initial assessment.

METHODS

Participants were recruited at two Montreal hospitals (2008-2011) and completed the SF-36 and Standard Gamble at baseline and at follow-up visits 1, 2, 4, 6, 9, and 12 months thereafter. SF-6D health utility scores were derived from SF-36 responses. Linear mixed models were used to compare mean health utility at each evaluation and changes in health utility between participants treated for TB disease, those treated for LTBI, and those in the control group.

RESULTS

Of the 263 participants, 48 were treated for TB disease, 105 for LTBI, and 110 were control participants. Fifty-four percent were women, mean age was 35 years, and 90% were foreign-born. Participants treated for TB disease reported worse health utility compared with control participants at the baseline visit (mean SF-6D: 0.69 vs. 0.81; mean Standard Gamble: 0.64 vs. 0.96). They reported successive improvement at months 1 and 2 that was then sustained throughout follow-up. Health utility reported by participants treated for LTBI and control participants was comparable throughout the study.

CONCLUSION

Treatment for TB disease had a substantial negative impact on health utility, particularly during the first 2 months of treatment. However, treatment for LTBI did not have a substantial impact.

Does a change in health research funding policy related to the integration of sex and gender have an impact?

We analyzed the impact of a requirement introduced in December 2010 that all applicants to the Canadian Institutes of Health Research indicate whether their research designs accounted for sex or gender. We aimed to inform research policy by understanding the extent to which applicants across health research disciplines accounted for sex and gender. We conducted a descriptive statistical analysis to identify trends in application data from three research funding competitions (December 2010, June 2011, and December 2011) (N = 1459). We also conducted a qualitative thematic analysis of applicants' responses. Here we show that the proportion of applicants responding affirmatively to the questions on sex and gender increased over time (48% in December 2011, compared to 26% in December 2010). Biomedical researchers were least likely to report accounting for sex and gender. Analysis by discipline-specific peer review panel showed variation in the likelihood that a given panel will fund grants with a stated focus on sex or gender. These findings suggest that mandatory questions are one way of encouraging the uptake of sex and gender in health research, yet there remain persistent disparities across disciplines. These disparities represent opportunities for policy intervention by health research funders.

Female Genital Cutting (FGC) and the ethics of care: community engagement and cultural sensitivity at the interface of migration experiences

BACKGROUND

Female Genital Cutting (FGC) anchored in a complex socio-cultural context becomes significant at the interface of access of health and social services in host countries. The practice of FGC at times, understood as a form of gender-based violence, may result in unjustifiable consequences among girls and women; yet, these practices are culturally engrained traditions with complex meanings calling for ethically and culturally sensitive health and social service provision. Intents and meanings of FGC practice need to be well understood before before any policies that criminalize and condemn are derived and implemented. FGC is addressed as a global public health issue with complex legal and ethical dimensions which impacts ability to access services, far beyond gender sensitivity. The ethics of terminology are addressed, building on the sustained controversial debate in regards to the delicate issue of conceptualization. An overview of international policies is provided, identifying the current trend of condemnation of FGC practices. Socio-cultural and ethical challenges are discussed in light of selected findings from a community-based research project. The illustrative examples provided focus on Western countries, with a specific emphasis on Canada.

DISCUSSION

The examples provided converge with the literature confirming the utmost necessity to engage with the FGC practicing communities allowing for ethically sensitive strategies, reduction of harm in relation to systems of care, and prevention of the risk of systematic gendered stigmatization. A culturally competent, gender and ethically sensitive approach is argued for to ensure the provision of quality ethical care for migrant families in host countries. We argue that socio-cultural determinants such as ethnicity, migration, sex and gender need to be accounted for as integral to the social construction of FGC.

SUMMARY

Working partnerships between the public health sector and community based organisations with a true involvement of women and men from practicing communities will allow for more sensitive and congruent clinical guidelines. In order to honour the fundamental principles and values of medical ethics, such as compassion, beneficence, non-malfeasance, respect, and justice and accountability, socio-cultural interactions at the interface of health and migration will continue to require proper attention. It entails a commitment to recognise the intrinsic value and dignity of girls' and women's context.

Cancer incidence among Canadian immigrants, 1980-1998: results from a national cohort study

Canadian immigrants have lower overall cancer risk than the Canadian-born population. Less is known about risks for immigrant subgroups and site-specific cancers. Linked administrative data sets were used to compare cancer incidence between subgroups of immigrants to Canada and the general Canadian population. The study involved 128,962 refugees and 241,010 non-refugees. Standardized incidence ratios (SIRs) were calculated for all-site and site-specific cancers by immigration categories and regions of birth. Relative to the general Canadian population, incidence of all-site cancer was lower among immigrants overall, by sex and refugee status (non-refugee SIRs 0.25: men, 0.24: women; refugee SIRs 0.31: both). Significantly higher SIRs resulted for liver, nasopharyngeal and cervical cancers, including liver cancer among South-East Asian and North-East Asian immigrants, and nasopharyngeal cancer among North-East Asian non-refugees. Hypothesized explanations for variation in cancer incidence include earlier viral infection in the country of origin.

Des services à domicile culturellement sensibles : perspective des intervenants et des proches-aidantes originaires d’Haïti en tant que cas traceur

In Canada, the care provided by families occurs in an increasingly multiethnic context. Against this backdrop, the present qualitative study aims to explore the needs/expectations and solutions not only of (female) natural caregivers of an elderly relative hailing from Haiti (presented in terms of tracking cases) but also of remunerated home care providers - all with a view to developing a culturally sensitive service offering. As such, this study works from a conceptual framework centring on the negotiation of a common area of agreement between the stakeholders involved (i.e., natural caregivers and home care providers). To this end, focus groups and individual interviews were conducted among 15 caregivers and 37 home care providers. The three recurrent themes emerging from the data analysis concern, in context, the needs/expectations and solutions surrounding the experience of service use, barriers to use, and the relationships between natural caregivers and home care providers. The statements of both groups evidenced a consistency of views and have thus provided a basis for developing some recommendations acceptable to all stakeholders from the perspective of making culturally-based adjustments to the service offering.

Ethical considerations in cross-linguistic nursing

This article reviews empirical evidence and ethical norms in cross-linguistic nursing. Empirical evidence highlights that linguistic barriers between nurses and patients can perpetuate discrimination and compromise nursing care. There are significant organizational and relational challenges involved in ensuring adequate use of interpreters by nurses. Some evidence suggests that linguistic barriers are particularly problematic for nurses when compared with physicians. A comparative analysis of nursing ethical norms for cross-linguistic nursing was conducted using the codes of ethics of the American Nurses Association, the Canadian Nurses Association, and the International Council of Nurses. Five principal ethical norms for cross-linguistic nursing were identified: (1) respect for the patient as a unique person; (2) respect for the patient's right to self-determination; (3) respect for patient privacy and confidentiality; (4) responsibility for one's own competence, judgment, and action; and (5) responsibility to promote action better to meet the needs of patients, families, and groups.

Disparities in mortality patterns among Canadian immigrants and refugees, 1980-1998: results of a national cohort study

This study examines mortality patterns among Canadian immigrants, including both refugees and non-refugees, 1980-1998. Records of a stratified random sample of Canadian immigrants landing between 1980-1990 (N = 369,936) were probabilistically linked to mortality data (1980-1998). Mortality rates among immigrants were compared to those of the general Canadian population, stratifying by age, sex, immigration category, region of birth and time in Canada. Multivariate analysis examined mortality risks for various immigrant subgroups. Although immigrants presented lower all-cause mortality than the general Canadian population (SMR between 0.34 and 0.58), some cause-specific mortality rates were elevated among immigrants, including mortality from stroke, diabetes, infectious diseases (AIDS and hepatitis among certain subgroups), and certain cancers (liver and nasopharynx). Mortality rates differed by region of birth, and were higher among refugees than other immigrants. These results support the need to consider the heterogeneity of immigrant populations and vulnerable subgroups when developing targeted interventions.

Midwives in Morocco: Seeking Recognition as Skilled Partners in Women-Centred Maternity Care

Around the world, midwives are increasingly being called upon to provide skilled care for pregnant women and newborns. In Morocco, there is a persistent lack of professional recognition of midwifery, which is consistent with widespread gender inequality and women's low status. Midwifery training in Morocco has evolved since the 1960s into a three-year undergraduate programme. Despite this, there is currently a shortfall of midwives to attend the large number of births in Morocco. Midwives have only partially replaced traditional birth attendants, especially in rural areas. Maternal mortality remains high. However, several recent government policies reflect increased attention to women's needs, e.g. since February 2006, midwives may be eligible for reimbursement should a medical doctor be unavailable. Since 1990, the Moroccan Midwives Association has been actively encouraging midwifery curriculum review, improvements in training and the professional status of midwifery. Partnerships with international midwifery associations have revealed challenges encountered elsewhere and helped us to establish specific strategies for promoting the professional recognition, autonomy and visibility of midwifery in Morocco. In a cultural context such as Morocco's, a disciplinary link between midwives and the medical community seems crucial. However, only with recognition of midwives as competent, skilled and valued partners can midwifery practice in Morocco progressively evolve into women-centred maternity care.

[Migration, ethics and public health in Quebec]

This article analyses the ethical issues of migration in relation to public health in Quebec. There are two objectives: to describe the progression of analysis of the migration phenomenon in public health over the last thirty years and to state the ethical debate it raises. The progression of analysis of the migration phenomenon has been characterised by various approaches: intercultural, acculturation, transcultural, and migratory journey. Although these approaches have contributed to the development of knowledge about the reality of immigration, they have also, in spite of themselves, generated stigmatisation, discrimination and the proliferation of prejudices. Generally, findings that have emerged when migration is taken into account indicate an imbalance of power. For some, to focus on the phenomenon of migration promotes the power imbalance while for others, to disregard it masks the issue.

The cultural context of gender, identity: female genital, excision and infibulation

Our goal is to explore the practices of female genital excision and infibulation as they relate to gender identity and the acculturation process in Canada. We examined relevant research on these issues and share the results of a nationwide project conducted in 1997-1999 among 162 Canadian immigrants from regions in Africa where practices of excision and infibulation are still in effect. Our discussion of gender identity is inextricably linked to notions about the ways in which girls, women, and virginity are socially constructed. The complexity of the acculturation process along with the integration within a host society is highlighted and the conflicting identities available to women are brought to the fore.

[A research partnership in a multiethnic setting]

The objective of this paper is to describe a research partnership endeavour with five community organizations focusing their work on facilitating the integration of immigrant populations in the Montreal area. Survey data were collected in order to obtain a sociodemographic picture of recent immigrant women (n = 254), their knowledge of Info-Santé CLSC services and their use of those services. Focus group discussions were also carried out to explore the needs of these women with regards to the various services offered by Info-Santé CLSC (n = 44). Among these women, some had previously used the services and others not. The community organizations were the main crafters of this research partnership across the various stages from its inception to evaluation. The success factors of such a partnership are discussed according to human, professional and organizational dimensions.

Focus groups in rural Gujarat, India: a modified approach

Focus groups have become increasingly popular in health research. However, their feasibility depends on the context of such research. Through discussion of focus groups they conducted in rural India, the authors argue that successful focus groups in rural contexts must be culturally sensitive, with a research team that goes beyond the mere technicalities of collecting data. A culturally competent focus group can result when the research team has geographic, political, economic, and sociocultural knowledge related to the research area and its population. With extensive local collaboration, foreign researchers are better able to conduct data collection respectfully. The authors provide recommendations for future studies toward increasing the cultural appropriateness of focus groups in areas such as rural India.

[Intercultural communication in the clinical context: a question of partnership]

This article is intended to promote reflection on the intercultural competence of nurses and other health professionals. It discusses the different types of interpretation used to communicate with patients who do not speak English or French, legal and ethical consequences, and impact on health-care quality. The authors offer recommendations for both research and clinical nursing, as well as the health-care system in general, and highlight the challenges faced by nurses in a pluralist society. The literature review reveals an inherent complexity in the use of diverse types of interpreters. Finally, the authors argue that the intricacy of the cross-cultural communication trio is intensified by a lack of adequate preparation of nurses and other health professionals and interpreters regarding cross-cultural communication.

[New immigrant women and health]

The Canadian health care system serves an increasingly ethnically diverse clientele, especially in major urban centres. Sustained inflows of immigrants demand that social and health care services partially revise their mission to help these newcomers maintain their health following arrival in Canada, since their health generally tends to deteriorate over time. This poses a special challenge for women who have immigrated recently, because their health is often jeopardized by vulnerability linked to their socioeconomic status. Responding in a culturally appropriate way to each person's needs entails a choice of health promotion and disease prevention strategies. While this choice is based on specific definitions of the concepts, it also must reflect immigrant women's perceptions of what constitutes promotion, prevention and health. The purpose of this study was to develop a profile of their perceptions and use of preventive social and health care services. Our respondents reported that health is the absence of psychological and physical problems and that health promotion is associated primarily with a good diet, physical exercise, control of stress, and continuing to lead an active life (work, education). They believe that disease prevention lies primarily in overcoming financial problems and gaining access to a healthy diet and medical care. These views are similar to North American concepts. Research could confirm the similarities and differences between immigrant women and host populations. Nursing interventions would support culturally appropriate comprehensive action that addresses the individual, family, community and social aspects.

[The interpreter in an intercultural clinical milieu]

The public's diversified language profile means that nursing practice must adjust to provide the same quality of care to all clients, no matter what language they speak. To improve quality and quantity of information exchanged in the nurse-client-interpreter triangle, the authors have investigated the type of information likely to be filtered and studied the various factors underlying the interpreter's choice to filter information. The authors also analyzed the values interpreters assign to information and the factors that form the background for filtering, including mistrust. The authors suggest adequately preparing interpreters; using interpreters' expertise; and developing an appropriate training program for intercultural interpreters to enable them to better function within health care institutions.

[Health promotion for immigrant women in Quebec]

Over the past fifteen years, the Canadian population has undergone increasing cultural diversification. Many researchers have investigated the role of culture with respect to social and health services. Most studies confirm the fact that increased cultural diversification related to immigration challenges the public health system in many ways. Certain groups, such as economically challenged immigrant women, may pose even greater problems to the health system. While these individuals are in relatively good health upon arrival to Canada, there is a need to ensure that adequate health promotion as well as disease prevention strategies are instituted. It is important to examine the concepts of health promotion and disease prevention through a cultural perspective. Little research has been done in this area. Concepts of promotion and prevention as they are understood by immigrants may not always coincide with North American or European definitions. Therefore, it is essential to consider life conditions that surround potential health promotion and prevention behaviors of immigrants. Empowerment, economic integration and acculturation are among the many factors that need to be taken into account when studying immigrants' health promotion behavior. Here, we present a critical analysis of current knowledge in this field. This is followed by research recommendations aimed at facilitating the development of health promotion and prevention strategies that are appropriate to the needs of Canadian, and more specifically of immigrant women in Québec.

Impact of immigration on tuberculosis infection among Canadian-born schoolchildren and young adults in Montreal

We conducted a cross-sectional tuberculin survey among non-BCG-vaccinated Canadian-born schoolchildren in grades 6 and 10, health professional students, and young adult workers, to estimate the association of tuberculin reactions with indices of contact with tuberculosis. Participants underwent simultaneous tuberculin testing with PPD-T (standard) and PPD-B (from M. intracellulare). Exposure was estimated from questionnaire responses, group, aggregate census, and tuberculosis incidence data. Of 3,710 participants, 88 (2.4%) had positive tuberculin reactions, i.e., of 10+ mm. Positive tuberculin reactions were rarely associated with larger reactions to PPD-B, but were associated with older age (adjusted odds ratio for each 5 years: 1.5 [95% confidence interval, 1.3, 1.8]), household contact (4.2 [1.4, 12.7]), and population group (health professional versus all others: 0.6 [0.3, 1.0]). Estimated annual risk of infection declined by 3% per year. Tuberculin reactions were not associated with any indices of contact in school, work or neighborhood settings with foreign-born from tuberculosis endemic areas, nor with tuberculosis in Canadian-born. There was no evidence of transmission of tuberculosis from affected high risk sub-groups in Montreal to the general population working or attending school.

Transcultural nursing and a care management partnership project

This paper aims to illustrate how Leininger's Theory of Culture Care Diversity and Universality has influenced the research process of a study that emerged from a care management partnership between Canadian nursing teachers and Tunisian nurses. The purpose of the study was to investigate the meanings of care as viewed by university hospital-based Tunisian nurses. The qualitative analysis of data gathered through observation-participation and interviews highlights recurrent patterns and reveals three major professional care themes. For Tunisian nurses care means to secure the patient's cooperation towards the medical regimen within established rules in the hospital; to contribute to curing the patient by using current technology as well as by maintaining their technical skills and improving their medical knowledge; to take charge of the patient to assist the physician in treating disease. This study showed that Tunisian nurses emphasize curing rather than widely shared community values such as interdependence, intercommunication, understanding, presence and responsibility for others. Discussion of the study's findings draws upon the perspective provided by Freire's Oppressed Group Theory. In order to promote cultural congruence within the Care Management Partnership Project in Tunisia, the three predicted modes of care within Leininger's theory guide the decisions and actions for future nursing research and partnership activities.

Utilization of health services among rural women in Gujarat, India

This study examined the effects of four sets of factors on use of curative health services among rural women living in Gujarat, India. The sets of factors analyzed were as follows: (1) the demographic characteristics of the women; (2) the characteristics of the household in which they lived; (3) the characteristics of the environment in which they lived; and (4) the price and convenience of care. The study focused on rural married women aged 17-45 who had at least one child. Nested multiple logistic regressions were computed on cross-sectional data to assess the simultaneous influences of the independent variables on (1) reports of episodes of illness (2) use of curative services among rural women who reported an illness and (3) use of a specific service. Four types of service were examined as outcomes of interest, namely, private doctors, Aga Khan Health Services centres, government health centres, and traditional healers. Other things being equal, women's education, income, family structure and kinship affiliation were significant predictors of use of service. Women seemed to be more sensitive to travel time to the health service and its associated costs (purdah restrictions, transportation and time costs) than to the direct costs of service. Factors such as women's occupation and sanitation facilities, while associated with use of service in the expected direction, were not significant predictors of use of service. Implications for health planning are offered, including initiatives to implement health promotion and disease prevention programs in addition to increasing access to the existing health services. Avenues for future studies are suggested, particularly in regard to decision-making processes affecting the health-seeking behavior of rural women. It is recommended that such policies and studies should consider the cultural environment in addition to the existing pluralistic health system.