Racial/Ethnic Disparities in Psychiatric Traits and Diagnoses within a Community-based Sample of Children and Youth: Disparités raciales/ethniques dans les traits et diagnostics psychiatriques au sein d'un échantillon communautaire d'enfants et de jeunes

OBJECTIVE

Racial/ethnic disparities in the prevalence of psychiatric disorders have been reported, but have not accounted for the prevalence of the traits that underlie these disorders. Examining rates of diagnoses in relation to traits may yield a clearer understanding of the degree to which racial/ethnic minority youth in Canada differ in their access to care. We sought to examine differences in self/parent-reported rates of diagnoses for obsessive-compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD) and anxiety disorders after adjusting for differences in trait levels between youth from three racial/ethnic groups: White, South Asian and East Asian.

METHOD

We collected parent or self-reported ratings of OCD, ADHD and anxiety traits and diagnoses for 6- to 17-year-olds from a Canadian general population sample (Spit for Science). We examined racial/ethnic differences in trait levels and the odds of reporting a diagnosis using mixed-effects linear models and logistic regression models.

RESULTS

East Asian (N = 1301) and South Asian (N = 730) youth reported significantly higher levels of OCD and anxiety traits than White youth (N = 6896). East Asian and South Asian youth had significantly lower odds of reporting a diagnosis for OCD (odds ratio [OR]East Asian = 0.08 [0.02, 0.41]; ORSouth Asian = 0.05 [0.00, 0.81]), ADHD (OREast Asian = 0.27 [0.16, 0.45]; ORSouth Asian = 0.09 [0.03, 0.30]) and anxiety (OREast Asian = 0.21 [0.11, 0.39]; ORSouth Asian = 0.12 [0.05, 0.32]) than White youth after accounting for psychiatric trait levels.

CONCLUSIONS

These results suggest a discrepancy between trait levels of OCD, ADHD and anxiety and rates of diagnoses for East Asian and South Asian youth. This discrepancy may be due to increased barriers for ethnically diverse youth to access mental health care. Efforts to understand and mitigate these barriers in Canada are needed.

[Programme d'été sur le vieillissement de l'Institut du vieillissement des Instituts de Recherche en Santé du Canada : trois pistes de réflexion de participants du Québec]

Chaque année, les Instituts de recherche en santé du Canada (IRSC) subventionnent le Programme d'été sur le vieillissement (PEV). Cette année, la semaine de formation qui rassemblait des étudiants canadiens de tous les cycles supérieurs avait pour thème la recherche multidisciplinaire au quatrième âge. Cette note de recherche présente trois éléments de réflexion de deux participants de l'édition 2023 du PEV : 1) les enjeux liés au vieillissement sont des occasions de transformer les paradigmes de la recherche; 2) la recherche collaborative doit être sociétale, et s'étendre au-delà du cercle restreint des milieux universitaires; 3) les critères d'équité, de diversité et d'inclusion intégrés aux projets de recherche doivent se refléter au sein des organisations qui mènent la recherche.

Predictors of Tri-council Funding Among Nutrition Researchers in Canada

Purpose: Barriers in research for women and dietitians have been documented. We sought to describe tri-council funding awarded within the nutrition discipline according to institution type, academic rank, gender, dietitian status, and primary research methods used.Methods: Using an online search methodology, faculty members with research appointments were identified from nutrition departments offering accredited dietetic programs and/or at Canada's collective of research-intensive universities known as U15. All data regarding faculty members, their institutions, and funding were collected through publicly available websites and Scopus. Tri-council funding associated with the nominated principal investigator, from a 5-year period, 2013-2014 to 2017-2018, was extracted. Binary logistic regression was used to test for predictors of receiving any tri-council operating funds within the 5-year period.Results: Faculty members (n = 237) from 21 institutions were identified for inclusion. Those from U15 institutions, at the full professor rank, nondietitians, men, and those who engaged in primarily quantitative research methods (vs. qualitative or mixed-methods) were significantly more likely to hold any tri-council funding during the eligible period. Dietitians (n = 76) were significantly less likely to hold tri-council funding, independent of institution, rank, gender, and primary research methods utilized.Conclusions: The apparent under-funding of academic dietitians from federal tri-council sources requires exploration.

At the feet of storytellers: Implications for practicing early relational health conversations

A family- and culturally-centered approach to conversations about early relational health (ERH) can open up opportunities for universal family engagement. The appraisal of family-baby relational health is more trustworthy and useful when there is attunement to family voice and facilitator bias. Early Relational Health Conversations (ERH-C) is a model for ERH promotion and intervention. This model has eight components: preparing and entering the ERH-C space, accessing strength and knowledge in a healing-centered space, pausing and co-creating, storytelling, witnessing, mutual reflection, affirming, and claiming their relationship narrative, and mutual insight. It is a paradigm shift in working with African American families and possibly other historically marginalized families who are also impacted by structural racism. The eight components are explained, and examples are given from the perspective of an Africentric worldview. The importance of cultural humility, attuning to and honoring family culture is emphasized. Insights for implementation in primary care and other settings are provided. Healing-centered engagement practices embedded in ERH-C have the potential to move ERH work into the social justice arena. The ERH-C is a family reflection model. Ideas for future directions for ERH-C are discussed.

At the feet of storytellers: Equity in early relational health conversations

Early Relational Health (ERH) focuses attention on family-baby relationships during the first 1000 days of life. Positive ERH enhances child health and development and family wellbeing. Universal, early identification of RH and vulnerability could add value to care. How to screen, when, where, and with whom is the question. Tools and models for screening are practitioner-centered. Bias can affect family engagement and outcomes. This may be problematic for African American families. Authors present findings of a discourse analysis and phenomenological study of experiences of African American families' and HealthySteps Specialists' (HSS) of color with screening ERH in Washington, D.C., USA (N = 13). Findings indicate relevance, acceptance and utility may be influenced by positionality, cultural context, issues of equity, and engagement in mutual reflection. A family-centered approach that opened space for non-dominant knowledge about ERH made positive differences in engagement and utility for families and practioners alike. Health and vulnerability were detected reliably using this approach. Outcomes include new theories about ERH-focused visits with African American families and infants, and a new model for centering ERH in pediatric practice, entitled Early Relational Health Conversations. ERH-C is a family reflection model, not necessarily dyadic. It may have value for other populations. Future directions in ERH-C research are suggested.

Are professors of human nutrition faculty at Canadian universities representative with respect to common social constructs of gender and race?

Attributes such as sex and race/ethnicity are associated with inequities in representation. The objective of this study was to assess representation of 2 social constructs, gender and race, of professors of human nutrition in Canada. Using information publicly available October 2021, individuals with the title of assistant, associate, or full professor were identified on websites of 20 Canadian universities offering undergraduate and/or graduate degrees in human nutrition. Individuals were subjectively stratified to social constructs, i.e., white, racialized, or Indigenous, based on photographs, ethnic origin of a surname, and regional and ethnic origin disclosures on university websites, LinkedIn, social media, etc. Gender was assigned based on publicly available photographs and self-disclosed pronouns (when available). Of the 190 individuals, 80% were white, 16.4% were racialized, and 2.6% were Indigenous peoples. The majority (65.3%) were women. In a subset with established doctoral thesis dates and dates of hire at their current institution (n = 153), racialized and Indigenous professors, especially assistant and associate, had earned their doctorate and been hired more recently than their white peers. This study is limited because only individuals with professorial titles were included and the assignment of social constructs for race and gender was subjective. Nevertheless, it establishes an understanding of the proportions of professors of human nutrition who are white, racialized, Indigenous, women, and men. Novelty: Canadian universities strive to be equitable, diverse, and inclusive. One hundred and ninety professors of human nutrition were stratified using social constructs for race and gender. Findings: 65% Women, 80% white, 16.4% racialized, and 2.6% Indigenous.

[The importance of ensuring long-lasting public-private cooperation]

The health crisis has led to real cooperation between the public and private health sector, for the benefit of the patients. This cooperation must not be restricted to certain circumstances but form a permanent part of a care provision regulated by equity, trust, transparency and recognition of the missions accomplished by healthcare workers.

Targeting subsidised inpatient services to the poor in a setting with limited state capacity: proxy means testing in Myanmar's hospital equity fund scheme

OBJECTIVES

Many low- and middle-income countries (LMICs) provide subsidised access to health services for the poor. Proxy means tests (PMTs) for income are typically employed to identify eligible beneficiaries for subsidised services but often result in significant mistargeting of benefits. We assessed the PMT approach used in Myanmar's hospital equity fund (HEF).

METHODS

We analysed inclusion/exclusion errors by comparing household eligibility under the PMT used for HEF with household consumption (the gold standard proxy for income in LMICs). We assessed receipt of benefits post-hospitalisation against HEF eligibility rules and household income. Focus groups/interviews were conducted to understand administrative factors that influence targeting. We modelled (linear regression) predictors of household consumption to improve PMT accuracy.

RESULTS

We found large targeting errors (86% of households in the bottom consumption quartile would be excluded and 15% of households in the top consumption quartile deemed eligible). HEF scores for PMT held little explanatory power for household income: 93% of individuals meeting the HEF eligibility criteria did not receive benefits post-hospitalisation, while 23% of ineligible individuals received programme support. Re-weighting PMT indicators on electricity access, land ownership and livestock ownership, and assigning weights to home-ownership, households with elderly/disabled members and household head education levels could significantly improve targeting accuracy. Poor programme awareness and uneven adherence to official eligibility determination procedures among staff likely affected targeting.

CONCLUSIONS

Re-weighting PMT indicators and increasing training and communication about qualification procedures could improve allocation of limited funds, though accurate targeting may continue to be challenging in contexts of low state capacity.

Bottlenecks in the provision of antenatal care: rural settled and mobile pastoralist communities in Chad

OBJECTIVE

To assess antenatal care (ANC) coverage and analyse constraining factors for service delivery to rural settled and mobile populations in two districts in Chad.

METHOD

Data from cross-sectional household and health facility surveys in the two Chadian rural health districts were analysed. First, contact coverage of ANC services in the study area was estimated from household data as the proportion of women who visited health facilities to obtain ANC during their last pregnancy. Second, bottlenecks in the provision of this service were explored by calibrating a multiplicative model of ANC contact coverage to household and health facility data. The model allowed quantification of the magnitude by which coverage decreased as it progressed through the health system. Sensitivity analysis was applied to account for uncertainty around the estimated coverage factors.

RESULTS

Direct estimates revealed that ANC contact coverage decreased as the number of required visits increased: 79% of rural settled mothers and 46% of mobile pastoralist mothers visited a health facility to obtain ANC at least once (ANC 1). Among mobile pastoralists, only 20% of pregnant women attended ANC at least three times compared to 63% of rural settled women. Availability, accessibility, affordability and acceptability contributed to reductions in service coverage in both populations. For mobile pastoralists, acceptability was clearly the most important factor. ANC 1 contact coverage resulting from the model is 50% for rural settled and 30% for mobile pastoralists.

CONCLUSION

Antenatal care coverage was low in rural districts of Chad, particularly for mobile pastoralists. Acceptability largely explained the prevailing difference between the two population groups.

[Justice and access to care]

Evoking justice in the field of care can be paradoxical considering the natural inequalities inherent to health. This article reflects on whether the use of the term justice in relation to access to care refers to equality or equity.

Éthique de la recherche en santé mondiale : la relation Nord-Sud, quel partenariat pour quelle justice sociale ?

La recherche en santé mondiale s'inscrit dans une volonté de mobiliser des connaissances au service d'interventions et de politiques publiques pour l'atteinte équitable du bien-être commun, notamment en matière de santé. Elle joue un rôle primordial en ce sens, en favorisant l'implication des communautés et leur autonomisation et de nombreuses lignes directrices supportent un tel partenariat. Néanmoins, certains enjeux éthiques sont liés au financement de la recherche, aux environnements de recherche, à la priorisation des problématiques de recherche, aux mécanismes d'évaluation éthique posent souvent un problème de justice sociale au niveau de la redistribution des ressources et de la reconnaissance des différences culturelles. Comment alors déterminer quelle est la façon « idéale » d'agir en tenant compte de la globalité des individus et du pluralisme culturel des sociétés pour « bien faire », pour satisfaire l'exigence de l'équité? Une réflexion et une démarche éthique demeurent essentielles, ainsi qu'un dialogue entre les chercheurs du Nord et du Sud, et leurs autres partenaires que sont les décideurs, les responsables locaux et les communautés. Un tel dialogue, établi dans un continuum du développement de projets de recherche à leur pérennité, peut grandement contribuer à limiter les problèmes de justice sociale et à viser un développement plus égalitaire des savoirs scientifiques. Plusieurs chercheurs se sont déjà engagés dans cette voie, et leurs initiatives devraient être encouragées pour mettre les nouveaux savoirs au service des populations.

Determining the effective coverage of maternal and child health services in Kenya, using demographic and health survey data sets: tracking progress towards universal health coverage

OBJECTIVES

Effective coverage (EC) is a measure of health systems' performance that combines need, use and quality indicators. This study aimed to assess the extent to which the Kenyan health system provides effective and equitable maternal and child health services, as a means of tracking the country's progress towards universal health coverage.

METHODS AND RESULTS

The Demographic Health Surveys (2003, 2008-2009 and 2014) and Service Provision Assessment surveys (2004, 2010) were the main sources of data. Indicators of need, use and quality for eight maternal and child health interventions were aggregated across interventions and economic quintiles to compute EC. EC has increased from 26.7% in 2003 to 50.9% in 2014, but remains low for the majority of interventions. There is a reduction in economic inequalities in EC with the highest to lowest wealth quintile ratio decreasing from 2.41 in 2003 to 1.65 in 2014, but maternal health services remain highly inequitable.

CONCLUSIONS

Effective coverage of key maternal and child health services remains low, indicating that individuals are not receiving the maximum possible health gain from existing health services. There is an urgent need to focus on the quality and reach of maternal and child health services in Kenya to achieve the goals of universal health coverage.

Rotavirus vaccines contribute towards universal health coverage in a mixed public-private healthcare system

OBJECTIVES

To evaluate rotavirus vaccination in Malaysia from the household's perspective. The extended cost-effectiveness analysis (ECEA) framework quantifies the broader value of universal vaccination starting with non-health benefits such as financial risk protection and equity. These dimensions better enable decision-makers to evaluate policy on the public finance of health programmes.

METHODS

The incidence, health service utilisation and household expenditure related to rotavirus gastroenteritis according to national income quintiles were obtained from local data sources. Multiple birth cohorts were distributed into income quintiles and followed from birth over the first five years of life in a multicohort, static model.

RESULTS

We found that the rich pay more out of pocket (OOP) than the poor, as the rich use more expensive private care. OOP payments among the poorest although small are high as a proportion of household income. Rotavirus vaccination results in substantial reduction in rotavirus episodes and expenditure and provides financial risk protection to all income groups. Poverty reduction benefits are concentrated amongst the poorest two income quintiles.

CONCLUSION

We propose that universal vaccination complements health financing reforms in strengthening Universal Health Coverage (UHC). ECEA provides an important tool to understand the implications of vaccination for UHC, beyond traditional considerations of economic efficiency.

Income Inequities in Health Care Utilization among Adults Aged 50 and Older

Equitable access to and utilization of health services is a primary goal for many health care systems, particularly in countries with universal publicly funded systems. Despite concerns regarding potentially adverse implications of the 1990s' health care policy and other reforms, whether and how income inequalities in service utilization changed remains unclear. This study addressed the impact of income on physician and hospital utilization from 1992-2002 among adults aged 50 and older in British Columbia. Those with lower incomes were found less likely to access general practitioner and specialist services but more likely to access hospital services. Income-related disparities in physician care increased over time; hospital care declined. Volume of GP and hospital care was inversely associated with income; these differences increased regarding GP services only. Findings of declines in hospital-care access, accompanied by increasing income-related disparities in physician-services access, show that inequities are increasing within Canada's health care system.

Efforts to reduce the disparity between permanent residents and temporary migrants: Stop TB experiences in Shanghai, China

OBJECTIVE

Eight of 17 districts of Shanghai have offered transportation and living allowances subsidies to patients with tuberculosis (TB) among the migrant population. The study aimed to assess the impact of the subsidising initiative on the treatment success rate (TSR) and identify the social determinants of treatment outcomes.

METHODS

The participants included 7072 residents and 5703 migrants who were registered in the TB Information Management System with smear-positive pulmonary TB from January 2006 to December 2010. The Cochran-Armitage test was employed to test the trends of TSR and logistic regressions to identify the factors associated with treatment outcome.

RESULTS

Without subsidies, migrant TB cases had lower odds of successful treatment [OR = 0.20 (95% CI 0.18-0.23)] than resident cases. Subsidisation was associated with a 65% increased odds ratio of success [1.65 (1.40-1.95)] among migrant cases. The TSR has stabilised at 87% for both permanent residents and temporary migrants since 2009. Living in districts with a population density ≥20,000/km(2) was associated with a low odds ratio [0.42 (0.26-0.68)] among resident cases, whereas among migrant cases those living in districts out of central downtown had a higher odds ratio of treatment success [peripheral downtown: 1.73 (1.36-2.20), suburban: 1.69 (1.16-2.46)]. The TB cases in districts with 2.0-2.9 TB specialists/100 cases had a higher odds ratio [2.99 (1.91-4.69)] of successful treatment than cases from districts with fewer specialists.

CONCLUSIONS

Besides free medical services, transport and living allowance subsidies to migrant patients with TB improved the treatment outcome significantly.

Trends in health facility deliveries and caesarean sections by wealth quintile in Morocco between 1987 and 2012

OBJECTIVES

To examine trends in the utilisation of facility-based delivery care and caesareans in Morocco between 1987 and 2012, particularly among the poor, and to assess whether uptake increased at the time of introduction of policies or programmes aimed at improving access to intrapartum care.

METHODS

Using data from nationally representative household surveys and routine statistics, our analysis focused on whether women delivered within a facility, and whether the delivery was by caesarean; analyses were stratified by relative wealth quintile and public/private sector where possible. A segmented Poisson regression model was used to assess whether trends changed at key events.

RESULTS

Uptake of facility-based deliveries and caesareans in Morocco has risen considerably over the past two decades, particularly among the poor. The rate of increase in facility deliveries was much faster in the poorest quintile (annual increase RR: 1.09; 95% CI: 1.07-1.11) than the richest quintile (annual increase RR: 1.01; 95% CI: 1.02-1.02). A similar pattern was observed for caesareans (annual increase among poorest RR: 1.13; 95% CI: 1.07-1.19 vs. annual increase among richest RR: 1.08; 95% CI: 1.06-1.10). We found no significant acceleration in trend coinciding with any of the events investigated.

CONCLUSIONS

Morocco's success in improving uptake of facility deliveries and caesareans is likely to be the result of the synergistic effects of comprehensive demand and supply-side strategies, including a major investment in human resources and free delivery care. Equity still needs to be improved; however, the overall trend is positive.

Participation in medical research as a resource-seeking strategy in socio-economically vulnerable communities: call for research and action

The freedom to consent to participate in medical research is a complex subject, particularly in socio-economically vulnerable communities, where numerous factors may limit the efficacy of the informed consent process. Informal consultation among members of the Switching the Poles Clinical Research Network coming from various sub-Saharan African countries, that is Burkina Faso, The Gambia, Rwanda, Ethiopia, the Democratic Republic of Congo (DRC) and Benin, seems to support the hypothesis that in socio-economical vulnerable communities with inadequate access to health care, the decision to participate in research is often taken irrespectively of the contents of the informed consent interview, and it is largely driven by the opportunity to access free or better quality care and other indirect benefits. Populations' vulnerability due to poverty and/or social exclusion should obviously not lead to exclusion from medical research, which is most often crucially needed to address their health problems. Nonetheless, to reduce the possibility of exploitation, there is the need to further investigate the complex links between socio-economical vulnerability, access to health care and individual freedom to decide on participation in medical research. This needs bringing together clinical researchers, social scientists and bioethicists in transdisciplinary collaborative research efforts that require the collective input from researchers, research sponsors and funders.

[The involvement of vulnerable people in participatory research in primary care: a literature review]

Malgré un vif intérêt pour la participation des patients à la gestion et à la prestation des soins de santé primaires, il n’existe aucune revue de la littérature sur le rôle des personnes vulnérables dans les projets de recherche participative menés dans le domaine des soins primaires. Une revue de la littérature de type narrative a été menée afin de combler cette lacune. L’objectif principal de cette revue a été d’évaluer le rôle des personnes vulnérables au sein de projets de recherche participative. Notre revue a recensé 26 articles et analysé 33 projets de recherche ou d’intervention en soins primaires. Elle révèle de nombreux écueils concernant l’implication des personnes vulnérables. Ces personnes ont joué un rôle varié, mais surtout modeste ou limité au sein des différents projets. Leur implication a surtout eu lieu à l’étape de la collecte des données. Peu de projets ont permis aux personnes vulnérables de prendre part à l’analyse des données ou à la diffusion des connaissances. Les tensions entre les chercheurs et les personnes vulnérables et la tendance à intégrer des acteurs organisés au sein des projets ont contribué à affaiblir le degré de participation des personnes vulnérables, et ce, à diverses étapes du processus de recherche et du développement d’intervention. Malgré tout, plusieurs retombées positives ont été identifiées, tant pour la communauté et les personnes vulnérables que pour les chercheurs. Entre autres, les projets ont permis aux chercheurs non universitaires d’acquérir de nouvelles compétences. De plus, certains projets ont favorisé la mise en place de nouveaux modèles de prestations de soins. Enfin, différents mécanismes permettant de rehausser la réciprocité entre les chercheurs et les personnes vulnérables sont proposés comme solutions pour réduire les inégalités et les tensions et, ultimement, favoriser l’implication des personnes vulnérables.

[Matrones and the reduction of maternal morality, a contribution to the debate]

Résumé

Avec le présupposé que la biomédecine était capable de prévenir la majorité des morts maternelles, l’une des recommandations formulées en 1987 par l’Initiative Maternité Sans Risque était de former des matrones. Ces formations réalisées durant trois décennies sont souvent décrites comme étant un échec. Néanmoins, elles n’ont guère pris en compte l’hétérogénéité des statuts sociaux et pratiques des matrones, ni remis en question certaines méthodes pédagogiques essentiellement didactiques et souvent inappropriées. Ainsi, le débat relatif à la pertinence de ces formations est loin d’être clos. Dans cette perspective, l’ouvrage collectif L’art des matrones revisité. Naissances contemporaines en question dirigé par Pascale Hancart Petitet (2011) rassemble neuf contributions d’auteur(e)s dont l’objectif n’est nullement de remettre en cause les effets bénéfiques de la biomédicalisation de l’accouchement mais de montrer, comment, et pourquoi, se construisent les pratiques des matrones et les discours dont elles sont l’objet actuellement.