In spite of the system: A qualitatively-driven mixed methods analysis of the mental health services experiences of LGBTQ people living in poverty in Ontario, Canada

Lesbian, gay, bisexual, trans, and/or queer (LGBTQ) people face barriers to accessing mental health care; however, we know little about service experiences of low income LGBTQ people. In this qualitatively-driven mixed methods study, over 700 women and/or trans people completed an internet survey, of whom 12 LGBTQ individuals living in poverty participated in interviews. Low income LGBTQ respondents saw more mental health professionals and had more unmet need for care than all other LGBTQ/income groups. Narrative analysis illustrated the work required to take care of oneself in the context of extreme financial constraints. These findings highlight the mechanisms through which inadequate public sector mental health services can serve to reproduce and sustain both poverty and health inequities.

Depression and discrimination in the lives of women, transgender and gender liminal people in Ontario, Canada

This article uses an intersectionality lens to explore how experiences of race, gender, sexuality, class and their intersections are associated with depression and unmet need for mental healthcare in a population of 704 women and transgender/gender liminal people from Ontario, Canada. A survey collecting demographic information, information about mental health and use of mental healthcare services, and data for the Everyday Discrimination Scale and the PHQ-9 Questionnaire for Depression was completed by 704 people via Internet or pen-and-paper between June 2011 and June 2012. Bivariate and regression analyses were conducted to assess group differences in depression and discrimination experiences, and predictors of depression and unmet need for mental healthcare services. Analyses revealed that race, gender, class and sexuality all corresponded to significant differences in exposure to discrimination, experiences of depression and unmet needs for mental healthcare. Use of interaction terms to model intersecting identities and exclusion contributed to explained variance in both outcome variables. Everyday discrimination was the strongest predictor of both depression and unmet need for mental healthcare. The results suggest lower income and intersections of race with other marginalised identities are associated with more depression and unmet need for mental healthcare; however, discrimination is the factor that contributes the most to those vulnerabilities. Future research can build on intersectionality theory by foregrounding the role of structural inequities and discrimination in promoting poor mental health and barriers to healthcare.

Mental health service use by recent immigrants from different world regions and by non-immigrants in Ontario, Canada: a cross-sectional study

Background

Given that immigration has been linked to a variety of mental health stressors, understanding use of mental health services by immigrant groups is particularly important. However, very little research on immigrants’ use of mental health service in the host country considers source country. Newcomers from different source countries may have distinct experiences that influence service need and use after arrival. This population study examined rates of use of primary care and of specialty services for non-psychotic mental health disorders by immigrants to Ontario Canada during their first five years after arrival. Service use by recent immigrants in broad source region groups representing all world regions was compared to use by age-matched Canadian-born or long term immigrants (called long term residents).

Method

This matched population-based cross-sectional study assessed likelihood of any use and counts of visits for each of primary care, psychiatric care and hospital care (emergency department visits or inpatient admissions) for non-psychotic mental health disorders from 1993–2012. Adult immigrants living in urban Ontario (n = 912,114) were categorized based on their nine world regions of origin. Sex-stratified conditional logistic regression models and negative binomial models were used to compare service use by immigrant region groups to their age-matched long term residents.

Results

Immigrant were more or less likely to access primary mental health care compared to age-matched long term residents, depending on their world region of origin. Regarding specialty mental health care (psychiatry and hospital care), immigrants from all regions used less than long term residents. Across the three mental health services, estimates of use by immigrant region groups compared to long term residents were among the lowest for newcomers from East Asian and Pacific (range: 0.16–0.82) and among the highest for persons from Middle East and North Africa (range: 0.56–1.23).

Conclusion

This population-based study showed lower use of mental health services by recent immigrants than long-term immigrants or native born individuals, with variation in immigrants’ use linked to world region of origin and type of mental health care. Variation across source region groups underscores the importance of identifying underlying individual characteristics that affect service use to make services more responsive to newcomers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0995-9) contains supplementary material, which is available to authorized users.

Rates of Anomalous Bupropion Prescriptions in Ontario, Canada

PURPOSE

Reports of bupropion misuse have increased since it was first reported in 2002. The purpose of this study was to explore trends in bupropion prescribing suggestive of misuse or diversion in Ontario, Canada.

METHODS

A serial cross-sectional study was conducted of Ontarians aged younger than 65 years who received prescriptions under Ontario's public drug program from April 1, 2000, to March 31, 2013. We determined the number of potentially inappropriate prescriptions in each quarter, defined as early refills dispensed within 50% of the duration of the preceding prescription, as well as potentially duplicitous prescriptions, defined as similarly early refills originating from a different prescriber and different pharmacy. We replicated these analyses for citalopram and sertraline, antidepressants not known to be prone to abuse.

RESULTS

We identified 1,780,802 prescriptions for bupropion, 3,402,462 for citalopram, and 1,775,285 for sertraline. Rates of early refills for bupropion declined during the study from 4.8% to 3.1%. In the final quarter, rates of early refills for bupropion were more common than for citalopram (3.1% vs 2.2%) (P <.001) but not for sertraline (3.1% vs 2.9%) (P =.16). Potentially duplicitous prescriptions for bupropion increased dramatically, from <0.05% of all prescriptions in early 2000 to 0.47% in early 2013 and by the final quarter were more common than both citalopram (0.11%) and sertraline (0.12%) (P <.001).

CONCLUSIONS

Although no marked differences were seen for early refills of bupropion relative to its comparators, potentially duplicitous prescriptions have increased dramatically in Ontario, suggesting growing misuse of the drug.

Can naloxone prescription and overdose training for opioid users work in family practice? Perspectives of family physicians

OBJECTIVE

To explore family physicians' attitudes toward prescribing naloxone to at-risk opioid users, as well as to determine the opportunities and challenges for expanding naloxone access to patients in family practice settings.

DESIGN

One-hour focus group session and SWOT (strengths, weaknesses, opportunities, and threats) analysis.

SETTING

Workshop held at the 2012 Family Medicine Forum in Toronto, Ont.

PARTICIPANTS

Seventeen conference attendees from 3 Canadian cities who practised in various family practice settings and who agreed to participate in the workshop.

METHODS

The workshop included an overview of information about naloxone distribution and overdose education programs, followed by group discussion in smaller focus groups. Participants were instructed to focus their discussion on the question, "Could this [overdose education and naloxone prescription] work in your practice?" and to record notes using a standardized discussion guide based on a SWOT analysis. Two investigators reviewed the forms, extracting themes using an open coding process.

MAIN FINDINGS

Some participants believed that naloxone could be used safely among family practice patients, that the intervention fit well with their clinical practice settings, and that its use in family practice could enhance engagement with at-risk individuals and create an opportunity to educate patients, providers, and the public about overdose. Participants also indicated that the current guidelines and support systems for prescribing or administering naloxone were inadequate, that medicolegal uncertainties existed for those who prescribed or administered naloxone, and that high-quality evidence about the intervention's effectiveness in family practice was lacking.

CONCLUSION

Family physicians believe that overdose education and naloxone prescription might provide patients at risk of opioid overdose in their practices with broad access to a potentially lifesaving intervention. However, they explain that there are key barriers currently limiting widespread implementation of naloxone use in family practice settings.

Perceived Satisfaction With Mental Health Services in the Lesbian, Gay, Bisexual, Transgender, and Transsexual Communities in Ontario, Canada: An Internet-Based Survey

This study compared mental health service experiences of lesbian, gay, or bisexual (LGB), transidentified, and cisgender (nontrans) heterosexual people in Ontario. An Internet-based survey, derived from the Canadian community health survey—Mental health and well-being—Cycle 1.2 (Statistics Canada, 2003), was completed by 326 individuals (194 LGB, 71 trans-identified, 61 cisgender heterosexual). Hierarchical logistic regression models were used to examine group differences. All three groups reported high levels of satisfaction and positive experiences with the provider seen most often in the past 12 months. However, substantial proportions of LGB and trans-identified people reported unmet need for mental health services.

Examining the relationship between neighbourhood deprivation and mental health service use of immigrants in Ontario, Canada: a cross-sectional study

OBJECTIVE

While newcomers are often disproportionately concentrated in disadvantaged areas, little attention is given to the effects of immigrants' postimmigration context on their mental health and care use. Intersectionality theory suggests that understanding the full impact of disadvantage requires considering the effects of interacting factors. This study assessed the inter-relationship between recent immigration status, living in deprived areas and service use for non-psychotic mental health disorders.

STUDY DESIGN

Matched population-based cross-sectional study.

SETTING

Ontario, Canada, where healthcare use data for 1999-2012 were linked to immigration data and area-based material deprivation scores.

PARTICIPANTS

Immigrants in urban Ontario, and their age-matched and sex-matched long-term residents (a group of Canadian-born or long-term immigrants, n=501,417 pairs).

PRIMARY AND SECONDARY OUTCOME MEASURES

For immigrants and matched long-term residents, contact with primary care, psychiatric care and hospital care (emergency department visits or inpatient admissions) for non-psychotic mental health disorders was followed for 5 years and examined using conditional logistic regression models. Intersectionality was investigated by including a material deprivation quintile by immigrant status (immigrant vs long-term resident) interaction.

RESULTS

Recent immigrants in urban Ontario were more likely than long-term residents to live in most deprived quintiles (immigrants--males: 22.8%, females: 22.3%; long-term residents--both sexes: 13.1%, p<0.001). Living in more deprived circumstances was associated with greater use of mental health services, but increases were smaller for immigrants than for long-term residents. Immigrants used less mental health services than long-term residents.

CONCLUSIONS

This study adds to existing research by suggesting that immigrant status and deprivation have a combined effect on recent immigrants' care use for non-psychotic mental health disorders. In settings where immigrants are over-represented in deprived areas, policymakers focused on increasing immigrants' access of mental health services should broadly address the influence of structural and cultural factors beyond the disadvantage.

Use of mental health care for nonpsychotic conditions by immigrants in different admission classes and by refugees in Ontario, Canada

BACKGROUND

Most Canadian newcomers are admitted in the economic, family, or refugee class, each of which has its own selection criteria and experiences. Evidence has shown various risks for mental health disorders across admission classes, but the respective service-use patterns for people in these classes are unknown. In this study, we compared service use for nonpsychotic mental health disorders by newcomers in various admission classes with that of long-term residents (i.e., Canadian-born persons or immigrants before 1985) in urban Ontario.

METHODS

In this population-based matched cross-sectional study, we linked health service databases to the Ontario portion of the Citizenship and Immigration Canada database. Outcomes were mental health visits to primary care physicians, mental health visits to psychiatrists, and emergency department visits or hospital admissions. We measured service use for recent immigrants (those who arrived in Ontario between 2002 and 2007; n = 359 673). We compared service use by immigrants in each admission class during the first 5 years in Canada with use by age- and sex-matched long-term residents. We measured likelihood of access to each service and intensity of use of each service using conditional logistic regression and negative binomial models.

RESULTS

Economic and family class newcomers were less likely than long-term residents to use primary mental health care. The use of primary mental health care by female refugees did not differ from that of matched long-term residents, but use of such care by male refugees was higher (odds ratio 1.14, 95% confidence interval 1.09-1.19). Immigrants in all admission classes were less likely to use psychiatric services and hospital services for mental health care. Exceptions were men in the economic and family classes, whose intensity of hospital visits was similar to that of matched long-term residents.

INTERPRETATION

Immigrants in all admission classes generally used less care for nonpsychotic disorders than longterm residents, although male refugees used more primary care. Future research should examine how mental health needs align with service use, particularly for more vulnerable groups such as refugees.

Primary care reform and service use by people with serious mental illness in Ontario

PURPOSE

To examine service use by adults with serious mental illness (SMI) rostered in new primary care models: enhanced fee-for-service (FFS), blended-capitation (CAP) and team-based capitation (TBC) models with and without mental health workers (MHW) in Ontario.

METHODS

This cross-sectional study used administrative health service databases to compare use of mental health and general health services among persons with SMI enrolled in new models (n = 125,233).

RESULTS

Relative to persons rostered in enhanced FFS, those in CAP and TBC had fewer mental health primary care visits (adjusted rate ratios and 95% confidence limits: CAP: 0.77 [0.74, 0.81]; TBC with MHW: 0.72 [0.68, 0.76]; TBC with no MHW: 0.81 [0.72, 0.93]). Compared to patients in enhanced FFS, those in TBC models also had more mental health hospital admissions (TBC with MHW: 1.12 [1.05, 1.20]; TBC with no MHW: 1.22 [1.05, 1.41]). Patterns of use of general services were similar.

CONCLUSION

Further attention to financial incentives in capitation that influence care of persons with SMI is necessary to determine if they are aligned with aims of primary care reform.

Inclusion of persons with mental illness in patient-centred medical homes: cross-sectional findings from Ontario, Canada

BACKGROUND

In Ontario, Canada, the patient-centred medical home is a model of primary care delivery that includes 3 model types of interest for this study: enhanced fee-for-service, blended capitation, and team-based blended capitation. All 3 models involve rostering of patients and have similar practice requirements but differ in method of physician reimbursement, with the blended capitation models incorporating adjustments for age and sex, but not case mix, of rostered patients. We evaluated the extent to which persons with mental illness were included in physicians' total practices (as rostered and non-rostered patients) and were included on physicians' rosters across types of medical homes in Ontario.

METHODS

Using population-based administrative data, we considered 3 groups of patients: those with psychotic or bipolar diagnoses, those with other mental health diagnoses, and those with no mental health diagnoses. We modelled the prevalence of mental health diagnoses and the proportion of patients with such diagnoses who were rostered across the 3 medical home model types, controlling for demographic characteristics and case mix.

RESULTS

Compared with enhanced fee-for-service practices, and relative to patients without mental illness, the proportions of patients with psychosis or bipolar disorders were not different in blended capitation and team-based blended capitation practices (rate ratio [RR] 0.91, 95% confidence interval [CI] 0.82-1.01; RR 1.06, 95% CI 0.96-1.17, respectively). However, there were fewer patients with other mental illnesses (RR 0.94, 95% CI 0.90-0.99; RR 0.89, 95% CI 0.85-0.94, respectively). Compared with expected proportions, practices based on both capitation models were significantly less likely than enhanced fee-for-service practices to roster patients with psychosis or bipolar disorders (for blended capitation, RR 0.92, 95% CI 0.90-0.93; for team-based capitation, RR 0.92, 95% CI 0.88-0.93) and also patients with other mental illnesses (for blended capitation, RR 0.94, 95% CI 0.92-0.95; for team-based capitation, RR 0.93, 95% CI 0.92-0.94).

INTERPRETATION

Persons with mental illness were under-represented in the rosters of Ontario's capitation-based medical homes. These findings suggest a need to direct attention to the incentive structure for including patients with mental illness.

Rural residence and risk for perinatal depression: a Canadian pilot study

Few studies have examined whether rural residence is associated with increased or decreased risk for postpartum depression (PPD). To address this research gap, this pilot study examined rates of depressive symptoms and perceived social support among women living in rural (population <10,000), semi-rural (population 10,000-20,000), and urban (downtown Toronto, population approximately 2.5 million) areas. Women were consecutively recruited at 25-35 weeks gestation from midwifery clinics and hospital-based prenatal care practices in two catchment areas and asked to complete a demographic questionnaire including postal code. On the basis of their responses, rural, semi-rural, and urban mothers were contacted by telephone at 36 weeks gestation (baseline) and 6-8 weeks postpartum (primary outcome). During each assessment, participants completed standardized measures of social connectedness, mental health, and health service utilization, including the Edinburgh Postnatal Depression Scale (EPDS) and the Medical Outcome Study Social Support Scale. A total of 87 participants [N = 23 rural (R), N = 23 semi-rural (SR), N = 41 urban (U)] were recruited into the study. There were no statistically significant differences between groups in mean EPDS scores during pregnancy (U = 7.1, SR = 5.3, R = 5.3, p = 0.15) or at 6 weeks postpartum (U = 5.3, SR = 4.4, R = 4.2, p = 0.43). The proportion of women with EPDS scores >12 similarly did not differ between groups. There were few statistically significant differences between groups on indicators of social connectedness; however, urban women reported significantly lower scores on measures of social network diversity and social capital than either the semi-rural or rural groups. This pilot study is limited by its small sample size; however, our data do not support the hypothesis that there are clinically important differences in risk for PPD associated with rural residence. Further studies examining potential relationships between indicators of social connectedness and perinatal mental health may be warranted.

Men's sexual orientation and health in Canada

OBJECTIVES

Previous large-scale population studies have reported that gay and bisexual men may be at increased risk for health disparities. This study was conducted to determine whether health status and health risk behaviours of Canadian men vary based on sexual orientation identity.

METHODS

Utilizing the Canadian Community Health Survey data (Cycle 2.1, 2003; n = 49,901), we conducted multivariable logistic regression to assess the independent effects of sexual orientation on health status and health risk behaviours. For all multivariate models, we calculated odds ratios, p-values, standard errors, and 95% confidence intervals (CIs) using the bootstrap re-sampling procedure recommended by Statistics Canada.

RESULTS

When compared to heterosexual men, gay and bisexual men did not report more respiratory conditions; had lower rates of obesity and overweight BMI; and reported more mood/anxiety disorders, and a history of lifetime suicidality. Gay and bisexual men did not report higher rates of daily smoking or risky drinking, however, gay men reported an almost six-fold increase in STD diagnoses when compared to heterosexual men.

CONCLUSION

This study represents the largest-known population-based data analysis on health risks and behaviours among men of varying sexual orientations. These findings raise important concerns regarding the impact of sexual orientation on mental and sexual health. Limitations of this data set, including those associated with measurement of sexual orientation, are discussed. Further research is required to understand the mechanisms that influence these health resiliencies and disparities.

Challenges and mental health experiences of lesbian and bisexual women who are trying to conceive

To date, there is little evidence to inform social work practice with lesbian and bisexual women who are trying to conceive (TTC). The authors report a preliminary examination of the mental health experiences of lesbian and bisexual women who are TTC, through a comparison with lesbian and bisexual women in the postpartum period (PP). Thirty-three lesbian and bisexual women (TTC, n = 15; PP, n = 18) completed standardized questionnaires assessing symptoms of depression and anxiety as well as relationship satisfaction and perceived social support. Qualitative interviews were also conducted to further investigate the experience of TTC. No significant differences were found between groups on any of the dependent variables. Analysis of qualitative data highlighted the challenges for lesbian and bisexual women who are TTC, particularly in terms of difficulty conceiving, lack of support during the conception process, and heterosexism in the fertility system. Women perceived these challenges to conception as having emotional consequences. The findings from this study begin to elucidate the unique context of TTC for lesbian and bisexual women, and they highlight the importance of culturally competent social work practice with this population.

The gatekeeper system and disparities in use of psychiatric care by neighbourhood education level: results of a nine-year cohort study in toronto

BACKGROUND

In Ontario, psychiatric care is fully covered by provincial health insurance without co-payments or deductibles. The provincial fee schedule supports a "gatekeeper" system for psychiatric care by paying psychiatrists more for consultations with patients who have a physician referral. In this context, we sought to explore socio-economic differences in patterns of mental health service delivery.

METHOD

We employed a retrospective cohort design using administrative and census data from 1995 to 2004. Subjects were 1,448,820 adults in Toronto with no physician mental healthcare in the previous three years. We determined time-dependent differences by sex and neighbourhood education quintile for the time to first mental health visit, time to the first mental health visit with a family physician or general practitioner (FP/GP), referral time from the FP/GP to a psychiatrist and the time to the first mental health visit with a psychiatrist.

RESULTS

Relative to the lowest neighbourhood education group, individuals in the highest neighbourhood education groups were less likely, and took longer, to have a first visit to a FP/GP, but once seen were more likely, and took less time, to be referred to a psychiatrist. The highest education group was more than twice as likely to see a psychiatrist without a FP/GP referral and took less time to do so than the lowest education group.

CONCLUSIONS/DISCUSSION

THE PATTERNS OF CARE WE FOUND SUGGEST THREE MAJOR CONCLUSIONS: (1) that a significant portion of psychiatric service users in our setting bypass the gatekeeper function of the FP/GP; (2) that social inequities are particularly marked when the gatekeeper role of the FP/GP is bypassed; and (3) that even within the gatekeeper system there is evidence of inequity in referral patterns and referral times. New models of mental healthcare delivery or adjustment of the current model may be needed to redress these disparities.

Correlates of mental health service use among lesbian, gay, and bisexual mothers and prospective mothers

Lesbian, gay, and bisexual women undertake parenting in a social context that may be associated with unique risk factors for perinatal depression. This cross-sectional study aimed to describe the mental health services used by women in the perinatal period and to identify potential correlates of mental health service use. Sixty-four women who were currently trying to conceive, pregnant, or the parent of a child less than one year of age were included. One-third of women reported some mental health service use within the past year; 30.6% of women reported a perceived unmet need for mental health services in the past year, with 40% of these women citing financial barriers as the reason for their unmet need. Women who were trying to get pregnant or who were less "out" were most likely to have had recent mental health service use. Women who had conceived by having sex with a man or who reported more than three episodes of discrimination were most likely to report unmet needs for mental health services. Providers may benefit from additional knowledge about the LBG social context that is relevant to perinatal health, and from identifying a strong referral network of skilled and affordable counsellors.

Education level, income level and mental health services use in Canada: associations and policy implications

BACKGROUND

Investigations of socio-economic gradients in mental health services use in Canada have used different measures of socio-economic status and have shown conflicting results. We explored the relationships between education level, income level and mental health services use among people with a mental illness using data from the Canadian Community Health Survey: Cycle 1.2.

METHODS

We included adults who met the criteria for an anxiety or depressive disorder in the past 12 months (n=3,101). We calculated the likelihood of seeking mental healthcare from a psychiatrist, psychologist, family physician or social worker over a period of 12 months by education level.

RESULTS

For each additional level of education, individuals were 15% more likely to see a psychiatrist, 12% more likely to see a family doctor, 16% more likely to see a psychologist and 16% more likely to see a social worker.

DISCUSSION/CONCLUSION

We found marked inequity in mental health services use by education level that was consistent across service types. Programs aiming to deliver targeted services to consumers who have not completed high school should be developed and evaluated.

Regular health care use by lesbians: a path analysis of predictive factors

BACKGROUND

Lesbians have more health risks than other women but access preventive medical care less frequently.

OBJECTIVE

To test the influence of (i) provider inquiry about sexual orientation, (ii) perceived provider gay-positivity and (iii) patient disclosure of sexual orientation on regular health care use in a sample of Canadian lesbians.

METHODS

A path analysis using community survey data from 489 lesbian respondents.

RESULTS

78.5% [95% confidence interval (CI): 74.7-82.0] of women reported regular health service use; 75.8% (95% CI: 72.2-79.8) of women had disclosed their sexual orientation to their provider; and 24.4% (95% CI: 20.6-28.2) of women had been asked about their sexual orientation by their provider. Of those women whose physicians had inquired about their sexual orientation, 100% (95% CI: 97.5-100.0) had disclosed. In the final path analysis, perceived provider gay-positivity and level of patient outness predicted disclosure, which, along with health status predicted regular health care use. All paths were significant at P < 0.05.

CONCLUSIONS

Provider-related factors including perceived gay-positivity and inquiry about sexual orientation are strongly associated with disclosure of sexual orientation. Disclosure is associated with regular health care use. Minor changes to practice could improve access to health services for lesbians.

The Sero-Prevalence of Antibodies to Trypanosoma cruzi in Latin American Refugees and Immigrants to Canada

BACKGROUND

Chagas' disease is caused by infection with the protozoan agent Trypanosoma cruzi. An estimated sixteen to eighteen million people are infected in Latin America. Outside of endemic regions, Chagas' disease may be transmitted through the transfusion of infected blood components, congenital infection and organ transplantation. We sought to determine the sero-prevalence of antibodies to T. cruzi in a community sample of Latin American refugees and immigrants to Canada.

METHODS

This was a sero-prevalence study in Latin American refugees and immigrants living in Canada. Eligible subjects were born in South America, Central America or in Mexico. Participants were recruited from a variety of community settings, as well as from medical clinics. Serum was tested by enzyme-linked immunoassay for antibodies to T. cruzi.

RESULTS

A total of 102 participants were enrolled. One sample tested positive for antibodies for T. cruzi. The seroprevalence in our sample was 1.0% (95% CI: 0.2%- 5.3%).

INTERPRETATION

We found a low sero-prevalence of Chagas' disease in a community sample of Latin American immigrants and refugees. Physicians who treat Latin American immigrants should consider the risk profile and clinical status of the individual in their decision to screen for Chagas' disease.

Lesbian and bisexual women's recommendations for improving the provision of assisted reproductive technology services

Qualitative focus groups were conducted with lesbian and bisexual women who were themselves or whose partners were in the process of trying to conceive (n = 6); who were biological parents of young children (n = 7); and who were nonbiological parents of young children or whose partners were currently pregnant (n = 10) to explore their donor insemination service needs and to provide recommendations for improved or additional services. The 10 recommendations generated by participants included providing cues that the service is lesbian and bisexual positive; offering lesbian- and bisexual-specific infertility support; providing opportunities for women to make informed choices about use of interventions consistent with their known or presumed fertility; and offering accessible services to known sperm donors, including gay men.

Service Use and Gaps in Services for Lesbian and Bisexual Women During Donor Insemination, Pregnancy, and the Postpartum Period

OBJECTIVE

Increasing numbers of lesbian and bisexual women are choosing to have children. This qualitative study investigated the degree to which a sample of Canadian lesbian and bisexual women were satisfied with the health and social services that they received during the process of trying to conceive, during pregnancy, and during the early postpartum weeks and months.

METHODS

Three focus groups were conducted: (1) women who were themselves, or whose partners were, in the process of trying to conceive (n = 6); (2) biological parents of young children (n = 7); and (3) women who were non-biological parents of young children or whose partners were currently pregnant (n = 10). Participants were asked to discuss their positive and negative experiences with health and social services during their efforts to conceive and through the perinatal period.

RESULTS

Participants were very satisfied with the care they received from midwives, doulas, and public health nurses. Services directed specifically to lesbian, gay, and bisexual parents were also perceived to be important sources of information and support. Many participants perceived fertility services to be unsupportive or unable to address their different health care needs.

CONCLUSION

Participants expressed satisfaction with pregnancy-related services provided by non-physicians and dissatisfaction with services provided by physicians and fertility clinics. There is a strong desire for fertility services specific to lesbian and bisexual women, but even minor changes to existing services could improve the satisfaction of lesbian and bisexual patients.

Counseling lesbian patients about getting pregnant

OBJECTIVE

To describe an approach to counseling lesbian patients about getting pregnant.

SOURCES OF INFORMATION

Information in this paper is based on evidence from randomized controlled trials (level I evidence), non-randomized trials (level II evidence), expert opinion (level III evidence), and government regulations.

MAIN MESSAGE

We review 5 steps that comprise an approach to counseling lesbian patients about getting pregnant safely and efficiently. These steps are preconception care (including counseling, testing, and immunization); donor choice (including explaining the risks and benefits of choosing between a known or anonymous donor and the difference between fresh and frozen semen); donor testing (including Health Canada's requirements for semen processing and recommendations for testing before home insemination); ordering the semen (including information about sperm banks and the need for "Canadian compliant" semen); and the insemination process (including techniques for monitoring ovulation and various methods of insemination).

CONCLUSION

Primary care physicians can help lesbians achieve pregnancy by providing education, testing, referrals, and insemination services.

Inequity in mental health care under Canadian universal health coverage

OBJECTIVE

Previous research has produced conflicting evidence about socioeconomic disparities in mental health care under universal health coverage in Canada. This study sought to determine equity in the delivery of ambulatory services from psychiatrists and family physicians for mental health problems in this setting.

METHODS

Outpatient billing claims and neighborhood socioeconomic status were examined with cross-sectional analysis. The study area consisted of the central southern portion of the city of Toronto, Ontario, including the city's downtown core. This urban setting is an economically and culturally diverse area. A total of 1,221 homogeneous enumeration areas (local neighborhoods) were surveyed, and data were examined for the 746,141 residents of these areas who had had a health visit in 2000. Rates of mental health visits to family physicians and psychiatrists were compared across socioeconomic quintiles. Socioeconomic status was determined according to educational attainment in the enumeration area.

RESULTS

Claimants from neighborhoods with the highest socioeconomic status were 1.6 times as likely as those from neighborhoods with the lowest socioeconomic status to use psychiatric care. Among persons who received care from a psychiatrist, claimants from neighborhoods with the highest socioeconomic status had significantly more psychiatric claims than those from neighborhoods with the lowest socioeconomic status. No significant gradients were found for either sex for any use of mental health care provided by family physicians. Among females, service users from the highest socioeconomic areas had more mental health visits to family physicians than those from the lowest socioeconomic areas.

CONCLUSIONS

Marked socioeconomic disparities were found in the use of care from a psychiatrist. Unlimited coverage of physician-provided mental health care is insufficient to fairly distribute services to those most in need.

Measuring the Effect of a Large Reduction in Welfare Payments on Mental Health Service Use in Welfare-Dependent Neighborhoods

BACKGROUND

Major social policy changes were implemented in Canada in the last decade with few efforts to examine their potential health effects.

OBJECTIVES

We sought to determine the impact of a large reduction in welfare benefits on use of ambulatory physician mental health services in areas with high levels of welfare dependency relative to areas with low levels of welfare dependency.

METHODS

The setting was Toronto, Canada. Data sources included census, provincial health insurance, and municipal welfare data. We used generalized estimating equations to compare ambulatory mental health service rates by neighborhood level of welfare dependency before and after a 21.6% reduction in welfare payments.

RESULTS

There were no long-term relative differences by welfare dependency in mental health service use before compared with after the policy change. There was a very small short-term increase in mental health visits to generalists in the 6 months after the policy change. We demonstrated a marked gradient in psychiatric service use with low welfare dependency areas having significantly higher rates of use than high welfare dependency areas.

CONCLUSIONS

We demonstrated a mismatch between known levels of need for care and levels of psychiatric use. We conclude that where use of services is not tightly linked to need for services, utilization data may be unsuitable for evaluating programs or policies. Social policy changes with potential health effects should have integrated evaluations planned at the time of policy implementation.

Using administrative data to measure ambulatory mental health service provision in primary care

OBJECTIVE

We sought to determine the accuracy of administrative data for identifying mental health service provision in primary care.

STUDY DESIGN

This was a chart abstraction study measuring agreement between billing data and clinical data on the binary variable "mental health visit." Data were collected from the charts and billing records of 5 academic family practice clinics in Toronto, Ontario (1999 to 2000). Billing claims (n = 952) were selected from the billings for all visits by a stratified random sampling technique. A blinded data abstractor reviewed the clinical charts and assigned diagnostic codes for each patient visit associated with the selected claims. Any visit with at least 1 abstracted mental health diagnostic code was defined as a mental health visit. The test characteristics of 4 administrative measures of mental health service provision, based on different combinations of billing codes, were calculated.

RESULTS

The accuracy of the administrative data was 86.8% when compared with clinical data. The sensitivity of the 4 administrative measures ranged from 22.3% to 80.7%. The specificity ranged from 97.0% to 99.5%.

CONCLUSIONS

This is the first study to establish the performance of administrative data in measuring mental health service provision in a primary care setting. In our setting, broadly defined administrative measures of mental health have excellent specificity and adequate sensitivity for exploring and understanding mental health service utilization.

Geographic methods for understanding and responding to disparities in mammography use in Toronto, Canada

OBJECTIVE

To use spatial and epidemiologic analyses to understand disparities in mammography use and to formulate interventions to increase its uptake in low-income, high-recent immigration areas in Toronto, Canada.

DESIGN

We compared mammography rates in four income-immigration census tract groups. Data were obtained from the 1996 Canadian census and 2000 physician billing claims. Risk ratios, linear regression, multilayer maps, and spatial analysis were used to examine utilization by area for women age 45 to 64 years.

SETTING

Residential population of inner city Toronto, Canada, with a 1996 population of 780,000.

PARTICIPANTS

Women age 45 to 64 residing in Toronto's inner city in the year 2000.

MEASUREMENTS AND MAIN RESULTS

Among 113,762 women age 45 to 64, 27,435 (24%) had received a mammogram during 2000 and 91,542 (80%) had seen a physician. Only 21% of women had a mammogram in the least advantaged group (low income--high immigration), compared with 27% in the most advantaged group (high income--low immigration) (risk ratio, 0.79; 95% confidence interval, 0.75 to 0.84). Multilayer maps demonstrated a low income-high immigration band running through Toronto's inner city and low mammography rates within that band. There was substantial geographic clustering of study variables.

CONCLUSIONS

We found marked variation in mammography rates by area, with the lowest rates associated with low income and high immigration. Spatial patterns identified areas with low mammography and low physician visit rates appropriate for outreach and public education interventions. We also identified areas with low mammography and high physician visit rates appropriate for interventions targeted at physicians.

Are claims of equivalency in digestive diseases trials supported by the evidence?

BACKGROUND & AIMS

Traditionally, randomized controlled trials (RCTs) have attempted to show the superiority of one intervention over another. However, when effective treatment already exists, it is sometimes more useful to prove that an intervention is equivalent, or at least not inferior, to the standard of care. Our aim was to determine whether claims of equivalency in digestive diseases trials are supported by the evidence.

METHODS

Medline was searched for RCTs published between 1989 and 2002 using the MeSH headings "exp therapeutic equivalency" and "exp digestive diseases" and the text words "equivalence," "equal," "equals," or "equivalent," yielding 902 articles. Of these, 73 articles met the inclusion criteria. These articles were evaluated using previously published criteria for equivalency.

RESULTS

Of the included articles, 33% stated an a priori research aim of equivalency, 92% reported differences of <20% between "equal" interventions, 34% set an equivalency boundary and tested it appropriately, and 19% performed a sample size calculation for equivalency. Overall, 12% of the reviewed articles met all 5 criteria. Fifty-two percent of our sample inappropriately used a failed superiority test (i.e., a P value > 0.05) as statistical "proof" of equivalency. Nonsurgical trials and those published between 1996 and 2002 were more likely to meet criteria than were surgical trials (P = 0.07) or trials published before 1996 (P = 0.003).

CONCLUSIONS

Claims of equivalency between interventions in digestive diseases trials tend to be poorly supported by the evidence. Erroneous claims of equivalency are potentially dangerous and may lead to substandard patient care.

Socioeconomic misclassification in Ontario's Health Care Registry

BACKGROUND

Addresses in some provincial health care registries are not systematically updated. If individuals are attributed to the wrong location, this can lead to errors in health care planning and research. Our purpose was to investigate the accuracy of socioeconomic classification based on addresses in Ontario's provincial health care registry.

METHODS

The study setting was Toronto's inner city, an area with a population of 799,595 in 1996. We ordered enumeration areas by 1996 mean household income and divided them into five roughly equal income groups by population. We then assigned an income quintile to each individual using both the address from Ontario's provincial heath care registry and that from hospital discharge abstracts. We compared these two sets of income quintiles and also used them to generate quintile-specific rates of medical hospital admissions in the year 2000.

RESULTS

Provincial registry and hospital-based addresses agreed on the exact enumeration area for 78.1% of individuals and for income quintile for 84.8% of individuals. Disagreement by more than one income quintile occurred for 7.4% of individuals. The two methods of assigning income quintiles yielded income-specific medical hospitalization rates and rate ratios that agreed within 1%.

INTERPRETATION

Although address inaccuracy was found in Ontario's health care registry, serious socioeconomic misclassification occurred at a relatively low rate and did not appear to introduce significant bias in the calculation of hospital rates by socioeconomic group. Updating of addresses at regular intervals is highly desirable and would result in improved accuracy of provincial health care registries.

The impact of policy changes on the health of recent immigrants and refugees in the inner city. A qualitative study of service providers' perspectives

BACKGROUND

Dramatic changes to health and social policy have taken place in Ontario over the last five years with few attempts to measure their impact on health outcomes. This study explored service providers' opinions about the impact of four major policy changes on the health of recent immigrant and refugee communities in Toronto's inner city.

METHODS

Semi-structured key informant interviews.

RESULTS

Reductions in funding for welfare, hospitals and community agencies were seen to have had major effects on the health of newcomers. Emergent themes included erosion of the social determinants of health, reduced access to health care, increased need for advocacy, deterioration in mental health, and an increase in wife abuse.

CONCLUSIONS

Several areas were identified where policy changes were perceived to have had a negative impact on the health of recent immigrants and refugees. This study provides insights for policy-makers, inner-city planners and researchers conducting population-based studies of immigrant health.

The impact of policy changes on the health of recent immigrants and refugees in the inner city. A qualitative study of service providers' perspectives

BACKGROUND

Dramatic changes to health and social policy have taken place in Ontario over the last five years with few attempts to measure their impact on health outcomes. This study explored service providers' opinions about the impact of four major policy changes on the health of recent immigrant and refugee communities in Toronto's inner city.

METHODS

Semi-structured key informant interviews.

RESULTS

Reductions in funding for welfare, hospitals and community agencies were seen to have had major effects on the health of newcomers. Emergent themes included erosion of the social determinants of health, reduced access to health care, increased need for advocacy, deterioration in mental health, and an increase in wife abuse.

CONCLUSIONS

Several areas were identified where policy changes were perceived to have had a negative impact on the health of recent immigrants and refugees. This study provides insights for policy-makers, inner-city planners and researchers conducting population-based studies of immigrant health.