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Purpose: The COVID-19 pandemic led to major service disruptions in the healthcare sector, especially regarding sexual and reproductive health services. However, the impact of the pandemic on Canadian adolescents is relatively unknown. This study aimed to investigate the impacts of the COVID-19 pandemic and associated public health measures on the sexual and reproductive health (SRH) of adolescents in Alberta, Canada. Methods: A qualitative study using an interpretive description (ID) approach and community-based participatory research principles was conducted to capture the subjective experience and perceptions of adolescents and service providers. With the collaboration of the Adolescent Advisory Group and community partners, 18 adolescents and 15 service providers were recruited for the study through purposive sampling. Findings from the qualitative interviews were analyzed using thematic analysis. Results: Three major themes emerged from the analysis: (1) COVID-19 SRH experience, (2) barriers to SRH, and (3) adolescent SRH strategies. Our findings highlight numerous barriers and challenges that prevented adolescents from accessing SRH education, products, and services. Conclusion: The COVID-19 pandemic had a profound impact on the SRH and the well-being of adolescents. Our study reflects the need for diverse SRH strategies to maintain continued access to SRH resources during disruptive events, such as the pandemic. Plain language summary: Access to sexual and reproductive health (SRH) services is a basic human right. All individuals require access to appropriate SRH services to maintain their optimal sexual and reproductive health. Adolescents require special guidance, support, and youth-friendly services in matters of SRH as they enter puberty and explore their sexual identity. However, during the COVID-19 pandemic, many health and SRH services were suspended. Access to SRH products and services became difficult due to public health restrictions, which has possible negative consequences for adolescents' SRH. The experiences of adolescents during the COVID-19 pandemic regarding their SRH are not reported in Alberta, Canada. Therefore, we explored the impacts of these public health restrictions on adolescents' SRH. We performed qualitative interviews with adolescents and SRH service providers to know their perspectives on how the pandemic influenced the SRH of adolescents. This paper provides insights into the barriers faced by adolescents while accessing SRH services during the pandemic, as well as their perceptions of digital strategies, such as mobile applications, and other recommendations for supporting SRH education and services. Based on the study findings, an adolescent-friendly mobile application will be developed to provide a virtual platform connecting adolescents to SRH educational resources, services, and support. [ABSTRACT FROM AUTHOR]

Background: Virtual care quickly became of crucial importance to health systems around the world during the COVID-19 pandemic. Despite the potential of virtual care to enhance access for some communities, the scale and pace at which services were virtualized did not leave many organizations with sufficient time and resources to ensure optimal and equitable delivery of care for everyone. The objective of this paper is to outline the experiences of health care organizations rapidly implementing virtual care during the first wave of the COVID-19 pandemic and examine whether and how health equity was considered. Methods: We used an exploratory, multiple case study approach involving four health and social service organizations providing virtual care services to structurally marginalized communities in the province of Ontario, Canada. We conducted semi-structured qualitative interviews with providers, managers, and patients to understand the challenges experienced by organizations and the strategies put in place to support health equity during the rapid virtualization of care. Thirty-eight interviews were thematically analyzed using rapid analytic techniques. Results: Organizations experienced challenges related to infrastructure availability, digital health literacy, culturally appropriate approaches, capacity for health equity, and virtual care suitability. Strategies to support health equity included the provision of blended models of care, creation of volunteer and staff support teams, participation in community engagement and outreach, and securement of infrastructure for clients. We put our findings into the context of an existing framework conceptualizing access to health care and expand on what this means for equitable access to virtual care for structurally marginalized communities. Conclusion: This paper highlights the need to pay greater attention to the role of health equity in virtual care delivery and situate that conversation around existing inequitable structures in the health care system that are perpetuated when delivering care virtually. An equitable and sustainable approach to virtual care delivery will require applying an intersectionality lens on the strategies and solutions needed to address existing inequities in the system. [ABSTRACT FROM AUTHOR]

Background: The Rural Surgical Obstetrical Networks (RSON) project was developed in response to the persistent attrition of rural maternity services across Canada over the past two decades. While other research has demonstrated the adverse health and psychosocial consequences of losing local maternity services, this paper explores the impact of a program designed to increase the sustainability of rural services themselves, through the funding of four "pillars": increased scope and volume, clinical coaching, continuous quality improvement (CQI) and remote presence technology. Methods: We conducted in-depth, qualitative research interviews with rural health care providers and administrators in eight rural communities across British Columbia to understand the impact of the RSON program on maternity services. Researchers used thematic analysis to generate common themes across the dataset and interpret findings. Findings: Participants articulated six themes regarding the sustainability of maternity care as actualized through the RSON project: safety and quality through quality improvement opportunities, improved access to care through increased surgical volume and OR backup, optimized team function through innovative models of care, improved infrastructure, local innovation surrounding workforce shortages, and locally tailored funding models. Conclusion: Rural maternity sites benefited from the funding offered through the RSON pillars, as demonstrated by larger volumes of local deliveries, nearly unanimous positive accounts of the interventions by health care providers, and evidence of staffing stability during the study time frame. As such, the interventions provided through the Rural Surgical Obstetrical Networks project as well as study findings on the common themes of sustainable maternity care should be considered when planning core rural health services funding schemes. [ABSTRACT FROM AUTHOR]

Background: The integration of Primary Care (PC) into broader health systems has been a goal in jurisdictions around the world. Efforts to achieve integration at the meso-level have drawn particular attention, but there are few actionable recommendations for how to enact a 'pro-integration culture' amongst government and PC governance bodies. This paper describes pragmatic integration activity undertaken by meso-level participants in Alberta, Canada, and suggests ways this activity may be generalizable to other health systems. Methods: 11 semi-structured interviews with nine key informants from meso-level organizations were selected from a larger qualitative study examining healthcare policy development and implementation during the COVID-19 pandemic. Selected interviews focused on participants' experiences and efforts to 'do' integration as they responded to Alberta's first wave of the Omicron variant in September 2021. An interpretive descriptive approach was used to identify repeating cycles in the integration context, and pragmatic integration activities. Results: As Omicron arrived in Alberta, integration and relations between meso-level PC and central health system participants were tense, but efforts to improve the situation were successfully made. In this context of cycling relationships, staffing changes made in reaction to exogenous shocks and political pressures were clear influences on integration. However, participants also engaged in specific behaviours that advanced a pro-integration culture. They did so by: signaling value through staffing and resource choices; speaking and enacting personal and group commitments to collaboration; persevering; and practicing bi-directional communication through formal and informal channels. Conclusions: Achieving PC integration involves not just the reactive work of responding to exogenous factors, but also the proactive work of enacting cultural, relationship, and communication behaviors. These behaviors may support integration regardless of the shocks, staff turnover, and relational freeze-thaw cycles experienced by any health system. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic has been pervasive in its impact on all aspects of Canadian society. Along with its pervasiveness, the disease provided unprecedented complexity to the Canadian healthcare infrastructure, eliciting varying responses from the afflicted healthcare systems in Canada. However, insights into the various parameters and complexities endured by Canadian rural physicians and rural healthcare institutions during the pandemic have been scarce. Objective: This paper explores the conditions and complexity of living and working of Rural Family Physicians (RFPs) in rural healthcare in Canada during the pandemic. Methods: Community-based participatory research was utilized as a collaborative and partnership approach, equitably engaged community members in all aspects of research, ranging from designing the research question to analyzing data. Participants of this study include RFPs with at least one year of experience working in rural Canada. Data were collected through telephone interviews and analyzed according to the six-phase guide for the data's inductive thematic analysis. Data collection halted upon saturation. Results: Five significant compiled categories reflect the lived experiences of Rural Family Physicians. 1- virtual care as a challenge or forward progress; 2- canceling in-person visits and interrupting the routine; 3- shortage of health care providers and supporting staff; 4-ongoing coping process with the pandemic guidelines; 5-COVID-19 combat fatigue. Discussion: The inception of COVID-19 has significantly impacted rural physicians across several interconnected issues. This study illuminates the lesser-known effects of the COVID-19 pandemic, which heavily impacts rural healthcare. [ABSTRACT FROM AUTHOR]

Objective: In the past few years, increasing numbers of Indigenous doula collectives have been forming across Canada. Indigenous doulas provide continuous, culturally appropriate support to Indigenous women during pregnancy, birth, and the post-partum period. This support is critical to counter systemic medical racism and socioeconomic barriers that Indigenous families disproportionately face. This paper analyzes interviews with members of five Indigenous doula collectives to demonstrate their shared challenges, strategies, and missions. Methods: Qualitative interviews were conducted with members of five Indigenous doula collectives across Canada in 2020. Interviews were transcribed and returned to participants for their approval. Approved transcripts were then coded by all members of the research team to ascertain the dominant themes emerging across the interviews. Results: Two prominent themes emerged in the interviews. The first theme is "Indigenous doulas responding to community needs." Participants indicated that responding to community needs involves harm reduction and trauma-informed care, supporting cultural aspects of birthing and family, and helping clients navigate socioeconomic barriers. The second theme is "Indigenous doulas building connections with mothers." Participants' comments on providing care to mothers emphasize the importance of advocacy in healthcare systems, boosting their clients' confidence and skills, and being the "right" doula for their clients. These two inter-related themes stem from Indigenous doulas' efforts to counter dynamics in healthcare and social services that can be harmful to Indigenous families, while also integrating cultural teachings and practices. Conclusion: This paper illustrates that Indigenous doula care responds to a wide range of issues that affect Indigenous women's experiences of pregnancy, birth, and the post-partum period. Through building strong, trusting, and non-judgemental connections with mothers and responding to community needs, Indigenous doulas play a critical role in countering medical racism in hospital settings and advancing the resurgence of Indigenous birthing sovereignty. [ABSTRACT FROM AUTHOR]

Background: COVID-19 has significant impact on long-term care (LTC) residents and staff. The purpose of this paper is to report the data gathered during a COVID-19 outbreak in a Canadian LTC home regarding staff experiences, challenges, and needs, to offer lessons learned and implications. Methods: A total of 30 staff from multiple disciplines participated in the study, including nurses, care workers, recreational staff, and a unit clerk. Focus groups (n = 20) and one-on-one interviews (n = 10) were conducted as part of a larger participatory action research (PAR) study in a Canadian LTC home. All data collection was conducted virtually via Zoom, and thematic analysis was performed to identify themes. Results: Four main themes were identified: We are Proud, We Felt Anxious, We Grew Closer to Residents and Staff Members, and The Vaccines Help. Conclusions: This research details the resilience that characterizes staff in LTC, while highlighting the emotional toll of the pandemic, particularly during an outbreak. LTC staff in this study found innovative ways to connect and support residents and this resulted in stronger connections and relationships. Leadership and organizational support are pivotal for supporting team resilience to manage crisis and adapt positively in times of COVID-19 pandemic, especially during the period of outbreak. [ABSTRACT FROM AUTHOR]

Background: Intolerable suffering is a common eligibility requirement for persons requesting assisted death, and although suffering has received philosophic attention for millennia, only recently has it been the focus of empirical inquiry. Robust theoretical knowledge about suffering is critically important as modern healthcare provides persons with different options at end-of-life to relieve suffering. The purpose of this paper is to present findings specific to the understanding and application of suffering in the context of MAID from nurses' perspectives. Methods: A longitudinal qualitative descriptive study using semi-structured telephone interviews. Inductive analysis was used to construct a thematic account. The study received ethical approval and all participants provided written consent. Results: Fifty nurses and nurse practitioners from across Canada were interviewed. Participants described the suffering of dying and provided insights into the difficulties of treating existential suffering and the iatrogenic suffering patients experienced from long contact with the healthcare system. They shared perceptions of the suffering that leads to a request for MAID that included the unknown of dying, a desire for predictability, and the loss of dignity. Eliciting the suffering story was an essential part of nursing practice. Knowledge of the story allowed participants to find the balance between believing that suffering is whatever the persons says it is, while making sure that the MAID procedure was for the right person, for the right reason, at the right time. Participants perceived that the MAID process itself caused suffering that resulted from the complexity of decision-making, the chances of being deemed ineligible, and the heighted work of the tasks of dying. Conclusions: Healthcare providers involved in MAID must be critically reflective about the suffering histories they bring to the clinical encounter, particularly iatrogenic suffering. Further, eliciting the suffering stories of persons requesting MAID requires a high degree of skill; those involved in the assessment process must have the time and competency to do this important role well. The nature of suffering that patients and family encounter as they enter the contemplation, assessment, and provision of MAID requires further research to understand it better and develop best practices. [ABSTRACT FROM AUTHOR]

Background: Even as healthcare providers and systems were settling into the processes required for Medical Assistance in Dying (MAID) under Bill C-14, new legislation was introduced (Bill C-7) that extended assisted death to persons whose natural death is not reasonably foreseeable. The purpose of this paper is to describe the experiences of nurses and nurse practitioners with the implementation and ongoing development of this transition.Methods: This qualitative longitudinal descriptive study gathered data through semi-structured telephone interviews with nurses from across Canada; cross sectional data from 2020 to 2021 is reported here. The study received ethical approval and all participants provided written consent.Findings: Participants included nurses (n = 34) and nurse practitioners (n = 16) with significant experience with MAID. Participants described how MAID had transitioned from a new, secretive, and anxiety-producing procedure to one that was increasingly visible and normalized, although this normalization did not necessarily mitigate the emotional impact. MAID was becoming more accessible, and participants were learning to trust the process. However, the work was becoming increasingly complex, labour intensive, and often poorly remunerated. Although many participants described a degree of integration between MAID and palliative care services, there remained ongoing tensions around equitable access to both. Participants described an evolving gestalt of determining persons' eligibility for MAID that required a high degree of clinical judgement. Deeming someone ineligible was intensely stressful for all involved and so participants had learned to be resourceful in avoiding this possibility. The required 10-day waiting period was difficult emotionally, particularly if persons worried about losing capacity to give final consent. The implementation of C-7 was perceived to be particularly challenging due to the nature of the population that would seek MAID and the resultant complexity of trying to address the origins of their suffering within a resource-strapped system.Conclusions: Significant social and system calibration must occur to accommodate assisted death as an end-of-life option. The transition to offering MAID for those whose natural death is not reasonably foreseeable will require intensive navigation of a sometimes siloed and inaccessible system. High quality MAID care should be both relational and dialogical and those who provide such care require expert communication skills and knowledge of the healthcare system. [ABSTRACT FROM AUTHOR]

Background: Increasing numbers of primary care practitioners in refugee resettlement countries are providing care to refugees. Access to trained interpreters is a priority for these practitioners, but there are many barriers to the implementation of interpreted consultations in routine care. There is a lack of international, theoretically informed research. The purpose of this paper is to understand barriers to interpreter use in primary care consultations in four resettlement countries using Normalisation Process Theory. Method: We conducted a cross-sectional online survey with networks of primary care practitioners (PCPs) who care for refugees in Australia, Canada, Ireland and the US (n = 314). We analysed qualitative data from the survey about barriers to interpreter use (n = 178). We completed an inductive thematic analysis, iteratively developed a Normalisation Process Theory (NPT)-informed coding frame and then mapped the emergent findings onto the theory's construct about enacting interpreted consultations. Results: In all four countries, the use of an interpreter presented communication and interaction challenges between providers and patients, which can impede the goals of primary care consultations. Primary care practitioners did not always have confidence in interpreted consultations and described poor professional practice by some interpreters. There was variation across countries, and inconsistency within countries, in the availability of trained interpreters and funding sources. Conclusion: There are shared and differential barriers to implementation of interpreted consultations in a consistent and sustained way in the four countries studied. These findings can be used to inform country-specific and international level policies and interventions focusing on improving skills and resources for interpreted consultations to improve implementation of interpreted primary care consultations. [ABSTRACT FROM AUTHOR]

Background: Primary care, and its transformation into Primary Health Care (PHC), has become an area of intense policy interest around the world. As part of this trend Alberta, Canada, has implemented Primary Care Networks (PCNs). These are decentralized organizations, mandated with supporting the delivery of PHC, funded through capitation, and operating as partnerships between the province's healthcare administration system and family physicians. This paper provides an implementation history of the PCNs, giving a detailed account of how people, time, and culture have interacted to implement bottom up, incremental change in a predominantly Fee-For-Service (FFS) environment. Methods: Our implementation history is built out of an analysis of policy documents and qualitative interviews. We conducted an interpretive analysis of relevant policy documents (n = 20) published since the first PCN was established. We then grounded 12 semi-structured interviews in that initial policy analysis. These interviews explored 11 key stakeholders' perceptions of PHC transformation in Alberta generally, and the formation and evolution of the PCNs specifically. The data from the policy review and the interviews were coded inductively, with participants checking our emerging analyses. Results: Over time, the PCNs have shifted from an initial Frontier Era that emphasized local solutions to local problems and featured few rules, to a present Era of Accountability that features central demands for standardized measures, governance, and co-planning with other elements of the health system. Across both eras, the PCNs have been first and foremost instruments and supporters of family physician authority and autonomy. A core group of people emerged to create the PCNs and, over time, to develop a long-term Quality Improvement (QI) vision and governance plan for them as organizations. The continuing willingness of both these groups to work at understanding and aligning one another's cultures to achieve the transformation towards PHC has been central to the PCNs' survival and success. Conclusions: Generalizable lessons from the implementation history of this emerging policy experiment include: The need for flexibility within a broad commitment to improving quality. The importance of time for individuals and organizations to learn about: quality improvement; one another's cultures; and how best to support the transformation of a system while delivering care locally. [ABSTRACT FROM AUTHOR]

Background: Indigenous young people are currently highly overrepresented in the HIV epidemic in Canada, especially in the Prairie Provinces, such as Manitoba. Understanding HIV-vulnerability in Indigenous peoples must begin with understanding that social determinants are intersectional and linked to the historical legacy of European colonization. In this paper findings that detail the influence of the intersectional social determinants on Indigenous people who become infected with HIV in their youth are presented. Methods: The qualitative research design of phenomenology was used as it afforded the opportunity to understand Indigenous young people from their frames of reference and experiences of reality, resulting in a phenomenological understanding of their perspectives and experiences of the early years of living with HIV. A total of 21 Indigenous young people took part open-ended interviews. Results: The stories that the Indigenous young people shared revealed their deeply interconnected social worlds, and how social determinants including abuse, trauma, being part of the child welfare system, and housing and food security were connected throughout various stages of their lives. Such stages included childhood, adolescence and young adulthood (the time of HIV infection), and later adulthood for older participants with the social determinants having multiple influences on their health trajectories. Conclusions: The findings highlight the need for policies and programs that are broadly focused, addressing multiple social determinants together. Overall, there needs to be more emphasis on the multiple social determinants in the life situations of all Indigenous youth. Reducing the health and social disparities in Indigenous youth is key to reducing the number of young Indigenous people diagnosed with HIV. The findings also shed light on the importance of listening to young Indigenous people who have experienced HIV diagnosis and life following diagnosis. [ABSTRACT FROM AUTHOR]

Background: Lone parents and their children experience higher than average levels of adverse health and social outcomes, much of which are explained by high rates of poverty. Many high income countries have attempted to address high poverty rates by introducing employment requirements for lone parents in receipt of welfare benefits. However, there is evidence that employment may not reduce poverty or improve the health of lone parents and their children.Methods: We conducted a systematic review of qualitative studies reporting lone parents' accounts of participation in welfare to work (WtW), to identify explanations and possible mechanisms for the impacts of WtW on health and wellbeing. Twenty one bibliographic databases were searched. Two reviewers independently screened references and assessed study quality. Studies from any high income country that met the criteria of focussing on lone parents, mandatory WtW interventions, and health or wellbeing were included. Thematic synthesis was used to investigate analytic themes between studies.Results: Screening of the 4703 identified papers and quality assessment resulted in the inclusion of 16 qualitative studies of WtW in five high income countries, USA, Canada, UK, Australia, and New Zealand, covering a variety of welfare regimes. Our synthesis found that WtW requirements often conflicted with child care responsibilities. Available employment was often poorly paid and precarious. Adverse health impacts, such as increased stress, fatigue, and depression were commonly reported, though employment and appropriate training was linked to increased self-worth for some. WtW appeared to influence health through the pathways of conflict and control, analytical themes which emerged during synthesis. WtW reduced control over the nature of employment and care of children. Access to social support allowed some lone parents to manage the conflict associated with employment, and to increase control over their circumstances, with potentially beneficial health impacts.Conclusion: WtW can result in increased conflict and reduced control, which may lead to negative impacts on mental health. Availability of social support may mediate the negative health impacts of WtW. [ABSTRACT FROM AUTHOR]

Background: Peer influence, peer selection, and health risk awareness are factors in smoking among youth. Despite the numerous studies on the social context, social network, and how youth define themselves and their smoking status in relation to tobacco use, qualitative knowledge about the role of smoking within peer relationships from youth themselves is only emerging. In this paper, qualitative findings describing Canadian youth's perspectives and experiences of smoking within the context of peer relationships are presented.Methods: To examine youth's perceptions, a qualitative research study design was used. Seventy-five Canadian youth aged 11-19 years participated in open-ended interviews, focus groups, and photovoice methods. Data analysis involved several levels of analysis consistent with qualitative research.Results: Youth who smoked were perceived by non-smoking peers as less popular and less socially accepted as represented by the theme: The coolness (not so cool) factor. Non-smoking youth felt that peers who smoked strained relationships and forced them to set boundaries and negotiate friendships as denoted by the theme: Negotiating friendships: Being influenced, but also influencing. Finally, in the theme of Making sense of peers who smoke, youth struggled to understand peers who continued to smoke and why they would start in the first place.Conclusions: As reinforced in this study, Canadian youth increasingly view smoking as unhealthy and uncool. Moreover, youth report resisting peer influence to smoke and in fact, are now influencing their friends who smoke to quit. The self-empowerment stories of non-smoker youth reinforces the idea that the social meaning of smoking with peers is continuing to change from one where youth accepted and participated in the smoking behaviors of their peers, to an environment where youth's perceptions of personal health is paramount. Findings from this study could be used to guide health promotion and smoking prevention programs and campaigns for youth. [ABSTRACT FROM AUTHOR]

Background: Stanford's Chronic Disease Self-Management Program (CDSMP) stands out as having a large evidence-base and being broadly disseminated across various countries. To date, neither evidence nor practice exists of its systematic adaptation into a German-speaking context. The objective of this paper is to describe the systematic German adaptation and implementation process of the CDSMP (2010-2014), report the language-specific adaptation of Franco-Canadian CDSMP for the French-speaking part of Switzerland and report findings from the initial evaluation process.Methods: Multiple research methods were integrated to explore the perspective of workshop attendees, combining a longitudinal quantitative survey with self-report questionnaires, qualitative focus groups, and interviews. The evaluation process was conducted in for both the German and French adapted versions to gain insights into participants' experiences in the program and to evaluate its impact. Perceived self-efficacy was measured using the German version of the Self-Efficacy for Managing Chronic Disease 6-Item Scale (SES6G).Results: Two hundred seventy eight people attending 35 workshops in Switzerland and Austria participated in the study. The study participants were receptive to the program content, peer-led approach and found principal methods useful, yet the structured approach did not address all their needs or expectations. Both short and long-term impact on self-efficacy were observed following the workshop participation (albeit with a minor decrease at 6-months). Participants reported positive impacts on aspects of coping and self-care, but limited effects on healthcare service utilization.Conclusions: Our findings suggest that the process for cross-border adaptation was effective, and that the CDSMP can successfully be implemented in diverse healthcare and community settings. The adapted CDSMP can be considered an asset for supporting self-management in both German-and French-speaking central European countries. It could have meaningful, wide-ranging implications for chronic illness care and primary prevention and potentially tertiary prevention of chronic disease. Further investigations are needed to tailor the program for better access to vulnerable and disadvantaged groups who might benefit the most, in terms of facilitating their health literacy in chronic illness. [ABSTRACT FROM AUTHOR]

Introduction: Consumption of substances is a highly controversial behaviour, with those who do so commonly viewed as deviants, even criminals, or else as out of control addicts. In other work we showed that the use of substances by women who are pregnant or have recently become parents was mainly viewed by health and social care providers as morally wrong. Problematic substance use was framed through the narrow lens of gendered responsibilisation, resulting in women being seen primarily as foetal incubators and primary caregivers of infants. Methods: In this follow-up paper we examine descriptive and qualitative data from a convenience sample of biological mothers and fathers (N= 34) recruited as part of a larger mixed methods study of the development and early implementation of an integrated primary maternity care program. We present a description of the participants' backgrounds, family circumstances, health status, and perception of drug-related stigma. This is succeeded by a thematic analysis of their personal views on substance use during both pregnancy and the transition to parenthood. Results: Our results show that while many mothers and fathers hold abstinence as the ideal during pregnancy and early parenting, they simultaneously recognize the autonomy of women to judge substance use risk for themselves. Participants also call attention to social structural factors that increase/decrease harms associated with such substance use, and present an embodied knowledge of substance use based on their tacit knowledge of wellness and what causes harm. Conclusions: While these two main discourses brought forward by parents concerning the ideal of abstinence and the autonomy of women are not always reconcilable and are partially a reflection of the dissonance between dominant moral codes regarding motherhood and the lived experiences of people who use substances, service providers who are attuned to these competing discourses are likely to be more effective in their delivery of health and social services for vulnerable families. More holistic and nuanced perspectives of health, substance use, and parenting may generate ethical decision-making practice frameworks that guide providers in meeting and supporting the efforts of mothers and fathers to achieve well-being within their own definitions of problematic substance use. [ABSTRACT FROM AUTHOR]

Background: Primary care reform has been on the political agenda in Canada and many industrialized countries for several decades; it is widely seen as the foundation for broader health system transformation. Federal investments in primary care, including major cash transfers to provinces and territories as part of a 10-year health care funding agreement in 2004, triggered waves of primary care reform across Canada. Nevertheless, Commonwealth Fund surveys show, Canada continues to lag behind other industrialized nations with respect to timely access to care, electronic medical record use and audit and feedback for quality improvement in primary care. This paper evaluates the pace and direction of primary care reform as well as the extent of resulting change in the organization and delivery of primary care in Ontario, Canada's most populous province. Methods: Qualitative and quantitative methods were used for this study. A literature review was conducted to analyze the core dimensions of primary care reform, the history of reform in Ontario, and the extent to which different dimensions are integrated into Ontario's models. Quantitative data on the number of family physicians/general practitioners and patients enrolled in these models was examined over a 10-year period to determine the degree of change that has taken place in the organization and delivery of primary care in Ontario. Results: There are 11 core reform dimensions that individually and collectively shift from conventional primary care toward the more expansive vision of primary health care. Assessment of Ontario's models against these core dimensions demonstrate that there has been little substantive change in the organization and delivery of primary care over 10 years in Ontario. Conclusions: Primary care reform is a multi-dimensional construct with different reform models bundling core dimensions in different ways. This understanding is important to move beyond the rhetoric of "reform" and to critically assess the pace and direction of change in primary care in Ontario and in other jurisdictions. The conceptual framework developed in this paper can assist decision-makers, academics and health care providers in all jurisdictions in evaluating the pace of change in the primary care sector, as well as other sectors. [ABSTRACT FROM AUTHOR]

Background: African, Caribbean and other Black (ACB) people are a priority group for HIV prevention in Canada, but little is known about the epidemiology of HIV risk in this population. This paper helps fill the knowledge gap by: presenting service providers' and ACB people's perceptions about HIV risk in ACB populations; describing the distribution of HIV risk behaviours among ACB people according to markers of social status and position; and comparing results from these two analyses. Methods: The Black, African and Caribbean Canadian Health (BLACCH) Study is a mixed methods study that used semi-structured interviews and a cross-sectional quantitative questionnaire to collect information about HIV and health from 188 ACB people in London, Ontario, Canada. Qualitative content analysis was used to identify interview themes, and weighted bivariate statistical analyses were performed on the quantitative data. Behaviours related to HIV risk were stratified by sex, poverty status, immigration experience and employment status Results: Community members perceived that they were at low risk for HIV and mainly focused on sexual risks. They called for more information about HIV in Canada and culturally appropriate HIV services. Service providers cited marital infidelity and cultural and religious attitudes about condoms as barriers to women protecting themselves. They mentioned cultural norms, beliefs about masculinity and underrepresentation of heterosexual ACB men at AIDS service organizations as barriers to men protecting themselves. There were few statistically significant differences in risk behaviours reported by men and women. Those living in poverty were more likely to abstain from sex (p = 0.006) and use condoms (p = 0.027) in the past year. Those living in Canada longer reported higher prevalences of forced sex (p < 0.001), mixing alcohol or drugs with sex (p = 0.001) and past STI diagnoses (p = 0.032). Stable employment was associated with higher prevalences of not using condoms in the past year (p = 0.005) and past STI diagnoses (p = 0.018). Conclusions: The results show that perceptions about ACB people's HIV risk differ from actual risk, and those with higher social standing might be at greater risk. Furthermore, the social determinants of health are important factors in the epidemiology of HIV among ACB people. [ABSTRACT FROM AUTHOR]

Background: Evidence of variations in red blood cell transfusion practices have been reported in a wide range of clinical settings. Parallel studies in Canada and the United Kingdom were designed to explore transfusion behaviour in intensive care physicians. The aim of this paper is three-fold: first, to explore beliefs that influence Canadian intensive care physicians' transfusion behaviour; second, to systematically select relevant theories and models using the Theoretical Domains Framework (TDF) to inform a future predictive study; and third, to compare its results with the UK study. Methods: Ten intensive care unit (ICU) physicians throughout Canada were interviewed. Physicians' responses were coded into theoretical domains, and specific beliefs were generated for each response. Theoretical domains relevant to behaviour change were identified, and specific constructs from the relevant domains were used to select psychological theories. The results from Canada and the United Kingdom were compared. Results: Seven theoretical domains populated by 31 specific beliefs were identified as relevant to the target behaviour. The domains Beliefs about capabilities (confident to not transfuse if patients' clinical condition is stable), Beliefs about consequences (positive beliefs of reducing infection and saving resources and negative beliefs about risking patients' clinical outcome and potentially more work), Social influences (transfusion decision is influenced by team members and patients' relatives), and Behavioural regulation (wide range of approaches to encourage restrictive transfusion) that were identified in the UK study were also relevant in the Canadian context. Three additional domains, Knowledge (it requires more evidence to support restrictive transfusion), Social/professional role and identity (conflicting beliefs about not adhering to guidelines, referring to evidence, believing restrictive transfusion as professional standard, and believing that guideline is important for other professionals), and Motivation and goals (opposing beliefs about the importance of restrictive transfusion and compatibility with other goals), were also identified in this study. Similar to the UK study, the Theory of Planned Behaviour, Social Cognitive Theory, Operant Learning Theory, Action Planning, and Knowledge-Attitude-Behaviour model were identified as potentially relevant theories and models for further study. Personal project analysis was added to the Canadian study to explore the Motivation and goals domain in further detail. Conclusions: A wide range of beliefs was identified by the Canadian ICU physicians as likely to influence their transfusion behaviour. We were able to demonstrate similar though not identical results in a cross-country comparison. Designing targeted behaviour-change interventions based on unique beliefs identified by physicians from two countries are more likely to encourage restrictive transfusion in ICU physicians in respective countries. This needs to be tested in future prospective clinical trials. [ABSTRACT FROM AUTHOR]

Introduction: International evidence shows that enhancement of primary health care (PHC) services for disadvantaged populations is essential to reducing health and health care inequities. However, little is known about how to enhance equity at the organizational level within the PHC sector. Drawing on research conducted at two PHC Centres in Canada whose explicit mandates are to provide services to marginalized populations, the purpose of this paper is to discuss (a) the key dimensions of equity-oriented services to guide PHC organizations, and (b) strategies for operationalizing equity-oriented PHC services, particularly for marginalized populations. Methods: The PHC Centres are located in two cities within urban neighborhoods recognized as among the poorest in Canada. Using a mixed methods ethnographic design, data were collected through intensive immersion in the Centres, and included: (a) in-depth interviews with a total of 114 participants (73 patients; 41 staff), (b) over 900 hours of participant observation, and (c) an analysis of key organizational documents, which shed light on the policy and funding environments. Results: Through our analysis, we identified four key dimensions of equity-oriented PHC services: inequity-responsive care; trauma- and violence-informed care; contextually-tailored care; and culturally-competent care. The operationalization of these key dimensions are identified as 10 strategies that intersect to optimize the effectiveness of PHC services, particularly through improvements in the quality of care, an improved 'fit' between people's needs and services, enhanced trust and engagement by patients, and a shift from crisis-oriented care to continuity of care. Using illustrative examples from the data, these strategies are discussed to illuminate their relevance at three inter-related levels: organizational, clinical programming, and patient-provider interactions. Conclusions: These evidence- and theoretically-informed key dimensions and strategies provide direction for PHC organizations aiming to redress the increasing levels of health and health care inequities across population groups. The findings provide a framework for conceptualizing and operationalizing the essential elements of equity-oriented PHC services when working with marginalized populations, and will have broad application to a wide range of settings, contexts and jurisdictions. Future research is needed to link these strategies to quantifiable process and outcome measures, and to test their impact in diverse PHC settings. [ABSTRACT FROM AUTHOR]

Background: Despite the recommended guidelines on addressing diet for the management and prevention of obesity in primary care, the literature highlights that their implementation has been suboptimal. In this paper, we provide an in-depth understanding of current nutrition-related weight management practices of primary care providers (PCPs) working in relatively new multidisciplinary health care settings in Ontario. Methods: Three types of multidisciplinary primary care settings were included (2 Family Health Teams, 3 Community Health Centres and 1 Nurse Practitioner-Led Clinic). Participants (n = 20) included in this study were nurse practitioners (n = 13) and family physicians (n = 7) supporting care for adult patients (18 years or older). In-depth interviews were transcribed, coded and the content was analyzed using an integrated approach. Results: Our analysis showed that most PCPs used anthropometric measures such as weight for screening patients who would benefit from nutrition counselling with a dietitian. The topic of nutrition was generally brought up either during physical examinations, when patients were diagnosed with a chronic disease, or when blood markers were out of normal range. Participants also mentioned that physical examinations are no longer occurring annually, with most PCPs offering episodic care. All participants reported utilizing dietetic referrals, noting the enablers for providing the referral, which included access to an on-site dietitian. Nonetheless, dietetic referrals were mostly used when patients had an obesity-related co-morbidity. Participants mentioned that healthy eating advice was reinforced during follow-up visits with patients only when there was enough time to do so. Electronic Health Records (EHRs) were utilized to facilitate message reinforcement by PCPs, who perceived EHRs to be helpful for viewing what was discussed in the session with the dietitian. Conclusions: PCPs mostly used objective measures to screen for patients who would benefit from nutrition counselling rather than diet assessment, which undermines the importance of dietary intake and overemphasizes weight. With physical examinations occurring less frequently, there will be additional missed opportunities for addressing nutrition-related concerns. The presence of a dietitian on site allowed for PCPs to refer patients to nutrition counselling. Having sufficient time during medical visits and EHRs seemed to facilitate message reinforcement by PCPs in follow-up visits with patients. [ABSTRACT FROM AUTHOR]

Background: Indigenous peoples in developed countries have reduced life expectancies, particularly from chronic diseases. The lack of access to and take up of palliative care services of Indigenous peoples is an ongoing concern. Objectives: To examine and learn from published studies on provision of culturally safe palliative care service delivery to Indigenous people in Australia, New Zealand (NZ), Canada and the United States of America (USA); and to compare Indigenous peoples' preferences, needs, opportunities and barriers to palliative care. Methods: A comprehensive search of multiple databases was undertaken. Articles were included if they were published in English from 2000 onwards and related to palliative care service delivery for Indigenous populations; papers could use quantitative or qualitative approaches. Common themes were identified using thematic synthesis. Studies were evaluated using Daly's hierarchy of evidence-for-practice in qualitative research. Results: Of 522 articles screened, 39 were eligible for inclusion. Despite diversity in Indigenous peoples' experiences across countries, some commonalities were noted in the preferences for palliative care of Indigenous people: to die close to or at home; involvement of family; and the integration of cultural practices. Barriers identified included inaccessibility, affordability, lack of awareness of services, perceptions of palliative care, and inappropriate services. Identified models attempted to address these gaps by adopting the following strategies: community engagement and ownership; flexibility in approach; continuing education and training; a whole-of-service approach; and local partnerships among multiple agencies. Better engagement with Indigenous clients, an increase in number of palliative care patients, improved outcomes, and understanding about palliative care by patients and their families were identified as positive achievements. Conclusions: The results provide a comprehensive overview of identified effective practices with regards to palliative care delivered to Indigenous populations to guide future program developments in this field. Further research is required to explore the palliative care needs and experiences of Indigenous people living in urban areas. [ABSTRACT FROM AUTHOR]