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Background: Improving equity and early access to palliative care for underserved populations in Canada is a priority. Little is known regarding access to palliative and end-of-life care in the Black population. Methods: We undertook a scoping review using the framework by Arksey and O'Malley to identify knowledge, access gaps, and experiences of palliative and end-of-life care among Blacks living with life-limiting illnesses in Canada. Primary studies, discussion papers, books, and reports were considered eligible. We followed a comprehensive search strategy developed by an information scientist. Searches were performed in the following bibliographic databases: Medline, EMBASE, PsycINFO via OVID, CINAHL via EBSCOhost, Scopus and Cochrane Library via Wiley. The search strategy was derived from three main concepts: (1) Black people; (2) Canada and Canadian provinces; (3) Palliative, hospice, or end-of-life care. No publication date or language limits were applied. Titles and abstracts were screened for eligibility by one reviewer and full text by two independent reviewers. Results: The search yielded 233 articles. Nineteen articles were selected for full-text review, and 7 articles met the inclusion criteria. These studies were published between 2010 and 2021, and conducted in the provinces of Ontario and Nova Scotia only. Studies used both quantitative and qualitative methods and included cancer decedents, next of kin, family caregivers and religious leaders. Sample sizes in various studies ranged from 6 − 2,606 participants. Included studies reported a general lack of understanding about palliative and end-of-life care, positive and negative experiences, and limited access to palliative and end-of-life care for Blacks, across all care settings. Conclusion: Findings suggest limited knowledge of palliative care and inequities in access to palliative and end-of-life care for Blacks living with life-limiting illnesses in 2 Canadian provinces. There is an urgent need for research to inform tailored and culturally acceptable strategies to improve understanding and access to palliative care and end-of-life care among Blacks in Canada. [ABSTRACT FROM AUTHOR]

Background: Indigenous populations in Canada and the United States (US) have maintained reciprocal relationships with nature, grounded in respect for and stewardship of the environment; however, disconnection from traditional food systems has generated a plethora of physical and mental health challenges for communities. Indigenous food sovereignty including control of lands were found to be factors contributing to these concerns. Therefore, our aim was to conduct a scoping review of the peer-reviewed literature to describe Indigenous disconnection from Indigenous food systems (IFS) in Canada and the US. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-SR) and Joanna Briggs Institute guidelines, we searched MEDLINE, SCOPUS, International Bibliography of the Social Sciences, Sociological Abstracts, and Bibliography of Native North Americans. Data was extracted from 41 studies and a narrative review completed based on study themes. Results: The overarching theme identified in the included studies was the impact of colonization on IFS. Four sub-themes emerged as causes for Indigenous disconnection from traditional food systems, including: climate change; capitalism; legal change; and socio-cultural change. These sub-themes highlight the multiple ways in which colonization has impacted Indigenous food systems in Canada and the US and important areas for transformation. Conclusions: Efforts to reconnect Indigenous knowledge and values systems with future food systems are essential for planetary health and sustainable development. Traditional knowledge sharing must foreground authentic Indigenous inclusion within policymaking. Highlights: • The main theme identified amongst the SR literature was the lasting impacts of colonization on Indigenous food systems in Canada and the US, which is described through four key areas: climate change; capitalism; legal changes; and socio-cultural changes. • Less than 20% of included papers report author positionality, with only 7% of included papers reporting Indigenous authorship, emphasizing an opportunity for more reporting and Indigenous engagement in the future. • Loss of cultural knowledge and practices was highlighted by many articles reviewed. • Revitalisation of IFS must include authentic Indigenous engagement, support Indigenous knowledge frameworks, community sharing networks, education programs and co-management. [ABSTRACT FROM AUTHOR]

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]

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: In Canada, there has been a significant increase in the training of Indigenous doulas, who provide continuous, culturally appropriate support to Indigenous birthing people during pregnancy, birth, and the postpartum period. The purpose of our project was to interview Indigenous doulas across Canada in order to document how they worked through the logistics of providing doula care and to discern their main challenges and innovations.Population/setting: Our paper analyzes interviews conducted with members of five Indigenous doula collectives across Canada, from the provinces of British Columbia, Manitoba, Ontario, Quebec and Nova Scotia.Methods: Semi-structured interviews were conducted with members of the five Indigenous doula collectives across Canada in 2020 as part of the project, "She Walks With Me: Supporting Urban Indigenous Expectant Mothers Through Culturally Based Doulas." Interview transcripts were approved by participants and subsequently coded by the entire research team to identify key themes.Results: Our paper examines two themes that emerged in interviews: the main challenges Indigenous doulas describe confronting when working within western systems, and how they navigate and overcome these obstacles. Specifically, interview participants described tensions with the biomedical approach to maternal healthcare and conflicts with the practice of Indigenous infant apprehension. In response to these challenges, Indigenous doulas are working to develop Indigenous-specific doula training curricula, engaging in collective problem-solving, and advocating for the reformation of a grant program in order to fund more Indigenous doulas.Conclusions: Both the biomedical model of maternal healthcare and the crisis of Indigenous infant apprehension renders Canadian hospitals unsafe and uncomfortable spaces for many Indigenous birthing people and their families. Indigenous doulas are continually navigating these challenges and creatively and concertedly working towards the revitalization of Indigenous birthing care. Indigenous doula care is critical to counter systemic, colonial barriers and issues that disproportionately impact Indigenous families, as well as recentering birth as the foundation of Indigenous sovereignty and community health. [ABSTRACT FROM AUTHOR]

Background: In Canada, there has been a significant increase in the training of Indigenous doulas, who provide continuous, culturally appropriate support to Indigenous birthing people during pregnancy, birth, and the postpartum period. The purpose of our project was to interview Indigenous doulas across Canada in order to document how they worked through the logistics of providing doula care and to discern their main challenges and innovations. Population/setting: Our paper analyzes interviews conducted with members of five Indigenous doula collectives across Canada, from the provinces of British Columbia, Manitoba, Ontario, Quebec and Nova Scotia. Methods: Semi-structured interviews were conducted with members of the five Indigenous doula collectives across Canada in 2020 as part of the project, "She Walks With Me: Supporting Urban Indigenous Expectant Mothers Through Culturally Based Doulas." Interview transcripts were approved by participants and subsequently coded by the entire research team to identify key themes. Results: Our paper examines two themes that emerged in interviews: the main challenges Indigenous doulas describe confronting when working within western systems, and how they navigate and overcome these obstacles. Specifically, interview participants described tensions with the biomedical approach to maternal healthcare and conflicts with the practice of Indigenous infant apprehension. In response to these challenges, Indigenous doulas are working to develop Indigenous-specific doula training curricula, engaging in collective problem-solving, and advocating for the reformation of a grant program in order to fund more Indigenous doulas. Conclusions: Both the biomedical model of maternal healthcare and the crisis of Indigenous infant apprehension renders Canadian hospitals unsafe and uncomfortable spaces for many Indigenous birthing people and their families. Indigenous doulas are continually navigating these challenges and creatively and concertedly working towards the revitalization of Indigenous birthing care. Indigenous doula care is critical to counter systemic, colonial barriers and issues that disproportionately impact Indigenous families, as well as recentering birth as the foundation of Indigenous sovereignty and community health. [ABSTRACT FROM AUTHOR]

Background: Sex and gender impacts health outcomes and disease risk throughout life. The health of women and members of the Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer or Questioning (2S/LGBTQ +) community is often compromised as they experience delays in diagnosis. Distinct knowledge gaps in the health of these populations have prompted funding agencies to mandate incorporation of sex and gender into research. Sex- and gender-informed research perspectives and methodology increases rigor, promotes discovery, and expands the relevance of health research. Thus, the Canadian Institutes of Health Research (CIHR) implemented a sex and gender-based analysis (SGBA) framework recommending the inclusion of SGBA in project proposals in 2010 and then mandating the incorporation of SGBA into grant proposals in 2019. To examine whether this mandate resulted in increased mention of sex or gender in funded research abstracts, we searched the publicly available database of grant abstracts funded by CIHR to analyze the percentage of abstracts that mentioned sex or gender of the population to be studied in the funded research. To better understand broader health equity issues we also examined whether the funded grant abstracts mentioned either female-specific health research or research within the 2S/LGBTQ + community. Results: We categorized a total of 8,964 Project and Operating grant abstracts awarded from 2009 to 2020 based on their study of female-specific or a 2S/LGBTQ + populations or their mention of sex or gender. Overall, under 3% of grant abstracts funded by CIHR explicitly mentioned sex and/or gender, as 1.94% of grant abstracts mentioned sex, and 0.66% mentioned gender. As one of the goals of SGBA is to inform on health equity and understudied populations with respect to SGBA, we also found that 5.92% of grant abstracts mentioned female-specific outcomes, and 0.35% of grant abstracts focused on the 2S/LGBTQ + community. Conclusions: Although there was an increased number of funded grants with abstracts that mentioned sex and 2S/LGBTQ + health across time, these increases were less than 2% between 2009 and 2020. The percentage of funded grants with abstracts mentioning female-specific health or gender differences did not change significantly over time. The percentage of funding dollars allocated to grants in which the abstracts mentioned sex or gender also did not change substantially from 2009 to 2020, with grant abstracts mentioning sex or female-specific research increasing by 1.26% and 3.47%, respectively, funding allocated to research mentioning gender decreasing by 0.49% and no change for 2S/LGBTQ +-specific health. Our findings suggest more work needs to be done to ensure the public can evaluate what populations will be examined with the funded research with respect to sex and gender to advance awareness and health equity in research. Highlights: The percentage of funded grants in which the abstracts mentioned sex or gender in health research remained largely unchanged from 2009 to 2020 with the largest increase of 1.57% for those mentioning sex. Total funding amounts for grants that mentioned sex or gender in the abstract stagnated or declined from 2009 to 2020. The percentage of funded grants in which the abstracts focusing on female-specific health did not change across 2009–2020, but the percentage of funding dollars increased by 3.47%. The percentage of grants in which the abstracts mentioned 2S/LGBTQ +-specific health more than tripled across 2009–2020 but remained less than 1% of all funded grants. Plain language summary: This paper examined the publicly available database of grant abstracts funded by the Canadian Institute of Health Research (CIHR) from 2009 to 2020 to determine the percentage of abstracts that mentioned sex or gender of the population to be studied. To better understand broader health equity issues we also examined whether the funded grant abstracts mentioned either female-specific health research or research within the 2S/LGBTQ + community. Although there was an increased number of funded grants with abstracts that mentioned sex and 2S/LGBTQ + health across time, these increases were less than 2% between 2009 and 2020. The percentage of funded grants with abstracts mentioning female-specific health or gender differences did not change significantly over time. The percentage of CIHR funding dollars allocated to grants in which the abstracts mentioned sex or female-specific research increased by 1.26% and 3.47%, respectively. However, funding allocated to research mentioning gender decreased by 0.49% and there was no significant change in funding amounts for 2S/LGBTQ +-specific health across time. We outline several recommendations for funding agencies to improve access to information especially on sex, gender and broader health equity populations to ensure the public can evaluate what populations will be examined within the funded research. Our findings suggest that to advance greater health equity in research, different strategies need to be employed to improve researcher utilization of sex and gender-based analysis as well as to advance health equity with respect to 2S/LGBTQ and women's health questions in research. [ABSTRACT FROM AUTHOR]

Background: The World Health Organization adopted the Global Strategy on Human Resources for Health Workforce 2030 in May 2016. It sets specific milestones for improving health workforce planning in member countries, such as developing a health workforce registry by 2020 and ensuring workforce self-sufficiency by halving dependency on foreign-trained health professionals. Canada falls short in achieving these milestones due to the absence of such a registry and a poor understanding of immigrants in the health workforce, particularly nursing and healthcare support occupations. This paper provides a multiscale (Canada, Ontario, and Ontario's Local Health Integration Networks) overview of immigrant participation in nursing and health care support occupations, discusses associated enumeration challenges, and the implications for health workforce planning focusing on immigrants.Methods: Descriptive data analysis was performed on Canadian Institute for Health Information dataset for 2010 to 2020, and 2016 Canadian Census and other relevant data sources.Results: The distribution of nurses in Canada, Ontario, and Ontario's Local Health Integration Networks reveal a growth in Nurse Practitioners and Registered/Licensed Practical Nurses, and contraction in the share of Registered Nurses. Immigrant entry into the profession was primarily through the practical nurse cadre. Mid-sized communities registered the highest growth in the share of internationally educated nurses. Data also pointed towards the underutilization of immigrants in regulated nursing and health occupations.Conclusion: Immigrants comprise an important share of Canada's nursing and health care support workforce. Immigrant pathways for entering nursing occupations are complex and difficult to accurately enumerate. This paper recommends the creation of an integrated health workforce dataset, including information about immigrant health workers, for both effective national workforce planning and for assessing Canada's role in global health workforce distribution and utilization. [ABSTRACT FROM AUTHOR]

Background: The increased scrutiny on public health brought upon by the ongoing COVID-19 pandemic provides a strong impetus for a renewal of public health systems. This paper seeks to understand priorities of public health decision-makers for reforms to public health financing, organization, interventions, and workforce. Methods: We used an online 3-round real-time Delphi method of reaching consensus on priorities for public health systems reform. Participants were recruited among individuals holding senior roles in Canadian public health institutions, ministries of health and regional health authorities. In Round 1, participants were asked to rate 9 propositions related to public health financing, organization, workforce, and interventions. Participants were also asked to contribute up to three further ideas in relation to these topics in open-ended format. In Rounds 2 and 3, participants re-appraised their ratings in the view of the group's ratings in the previous round. Results: Eighty-six public health senior decision-makers from various public health organizations across Canada were invited to participate. Of these, 25/86 completed Round 1 (29% response rate), 19/25 completed Round 2 (76% retention rate) and 18/19 completed Round 3 (95% retention rate). Consensus (defined as more than 70% of importance rating) was achieved for 6 out of 9 propositions at the end of the third round. In only one case, the consensus was that the proposition was not important. Proposition rated consensually important relate to targeted public health budget, time frame for spending this budget, and the specialization of public health structures. Both interventions related and not related to the COVID-19 pandemic were judged important. Open-ended comments further highlighted priorities for renewal in public health governance and public health information management systems. Conclusion: Consensus emerged rapidly among Canadian public health decision-makers on prioritizing public health budget and time frame for spending. Ensuring that public health services beyond COVID-19 and communicable disease are maintained and enhanced is also of central importance. Future research shall explore potential trade-offs between these priorities. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to (1) explore evidence provided by Canadian health and social care (HASC) academic programs in meeting their profession-specific interprofessional education (IPE)-relevant accreditation standards; (2) share successes, exemplars, and challenges experienced by HASC academic programs in meeting their IPE-relevant accreditation standards; and (3) articulate the impacts of IPE-relevant accreditation standards on enabling interprofessional learning to the global HASC academic community. Methods: Profession-specific (bilingual, if requested) surveys were developed and emailed to the Deans/Academic Program Directors of eligible academic programs with a request to forward to the individual who oversees IPE accreditation. Responses were collated collectively and by profession. Open-ended responses associated with our first objective were deductively categorized to align with the five Accreditation of Interprofessional Health Education (AIPHE) standards domains. Responses to our additional questions associated with our second and third objectives were inductively categorized into themes. Results/discussion: Of the 270 HASC academic programs surveyed, 30% (n = 24) partially or completely responded to our questions. Of the 106 IPE-relevant standards where evidence was provided, 62% (n = 66) focused on the Educational Program, 88% of which (n = 58) were either met or partially met, and 47% (n = 31) of which focused on practice-based IPE. Respondents cited various exemplars and challenges in meeting IPE-relevant standards. Conclusions: The overall sentiment was that IPE accreditation was a significant driver of the IPE curriculum and its continuous improvement. The array of exemplars described in this paper may be of relevance in advancing IPE implementation and accreditation across Canada and perhaps, more importantly, in countries where these processes are yet emerging. [ABSTRACT FROM AUTHOR]

Background: With the recent shift in focus to addressing HIV risk within relationships and couple-based interventions to prevent HIV transmission, successful recruitment of individuals involved in HIV-serodiscordant relationships is crucial. This paper evaluates methods used by the Positive Plus One (PP1) study to recruit and collect data on a diverse national sample of dyads and individuals involved in current or past HIV-serodiscordant relationships, discusses the strengths and limitations of the recruitment approach, and makes recommendations to inform the interpretation of study results and the design of future studies.Methods: PP1 used a multi-pronged approach to recruit adults involved in a current or past HIV-serodiscordant relationship in Canada from 2016 to 2018 to complete a survey and an interview. Upon survey completion, index (first recruited) partners were invited to recruit their primary current HIV-serodiscordant partner. We investigated participant enrollment by recruitment source, participant-, relationship-, and dyad-level sociodemographic characteristics, missing data, and correlates of participation for individuals recruited by their partners.Results: We recruited 613 participants (355 HIV-positive; 258 HIV-negative) across 10 Canadian provinces, including 153 complete dyads and 307 individuals who participated alone, and representing 460 HIV-serodiscordant relationships. Among those in current relationships, HIV-positive participants were more likely than HIV-negative participants to learn of the study through an ASO staff member (36% v. 20%, p < 0.001), ASO listserv/newsletter (12% v. 5%, p = 0.007), or physician/staff at a clinic (20% v. 11%, p = 0.006). HIV-negative participants involved in current relationships were more likely than HIV-positive participants to learn of the study through their partner (46% v. 8%, p < 0.001). Seventy-eight percent of index participants invited their primary HIV-serodiscordant partner to participate, and 40% were successful. Successful recruitment of primary partners was associated with longer relationship duration, higher relationship satisfaction, and a virally suppressed HIV-positive partner.Conclusions: Our findings provide important new information on and support the use of a multi-pronged approach to recruit HIV-positive and HIV-negative individuals involved in HIV-serodiscordant relationships in Canada. More creative strategies are needed to help index partners recruit their partner in relationships with lower satisfaction and shorter duration and further minimize the risk of "happy couple" bias. [ABSTRACT FROM AUTHOR]

Background: Homelessness is becoming an international public health issue in most developed countries, including Canada. Homelessness is regarded as both political and socioeconomic problems warranting broad and consistent result-oriented approaches.Methods: This paper represents the qualitative findings of a project that explored risk factors associated with family homelessness and strategies that could mitigate and prevent homelessness among families using a focused ethnographic study guided by the principles of participatory action research (PAR). The sample includes 36 family members residing at a family shelter who participated in focus groups over two years (between April 2016 and December 2017). Most of the participants were single-parent women.Results: The analysis yielded five major themes including, life challenges, lack of understanding of the system, existing power differentials, escaping from hardship, and a theme of proposed solutions for reducing family homelessness in the community.Conclusion: The findings illustrated the complex nature of family homelessness in Ontario; that the interaction of multiple systems can put families at risk of homelessness. Findings from this study underscore the need for urgent housing protocols aimed at educating homeless families on how to navigate and understand the system, enhance their conflict resolution skills, and develop strategies beyond relocation to help them to cope with difficulties with housing. [ABSTRACT FROM AUTHOR]

Background: Graphic Health Warnings (GHWs) on cigarette packages were first introduced in Canada in 2001 and will become mandatory in the US as of January 2022. While previous studies have evaluated the impacts of GHWs, the data used in these studies have several shortcomings. The objective of this paper was to investigate the likely impact of such warnings in the US based upon the experience of Canada using hitherto unexplored monthly cigarette sales data, and to explore if alternative approaches involving risk-reduced products might be more successful in reducing smoking. Methods: We used quasi-experimental segmented regression and difference-in-differences analyses. Data on monthly sales (i.e., shipments) of cigarettes from Canadian manufacturers to Canadian retailers during 1995–2005 were obtained from Statistics Canada. Results: We found that GHWs did not have a significant impact on the sales of cigarettes in Canada. We propose an alternative type of graphical health messaging that actively combines information on how to quit with the legally required messaging. The novelty of the proposal is that it is incentive compatible for the supply side of the market and if adopted in several states, the measure could be tested by using a suitable treatment–control design. Conclusions: Our findings imply that we should not expect any notable decline in sales or consumption as a result of implementation of GHWs in the US. The main impact of GHWs will be to add to the anti-smoking culture that has grown steadily over several decades, and this may impact smoking in the longer term. [ABSTRACT FROM AUTHOR]

Background: Ongoing legal and social discrimination, and stigmatization of people with lived experience of drug use (PWLE) continues to contribute to overdose-related deaths in Canada. The involvement of PWLE working in harm reduction services has proven effective in decreasing drug-related harms among PWLE; however, there exist unintended negative impacts. PWLE working in harm reduction services risk overextending themselves beyond employment parameters (e.g., emotional labor) with few systems in place (e.g., employment advocacy) for support. While meaningful participation of PWLE in harm reduction programs is critical to addressing the overdose crisis, their labor in Canada's overdose response commands further investigation and recognition. This paper examines some of the benefits and negative aspects of working in harm reduction among PWLE. Methods: Fifty qualitative surveys were completed by PWLE working in harm reduction services from across Canada at the National 2018 Stimulus conference held in Edmonton, Alberta. The surveys focused on the benefits and negatives of 'peer' employment and recommendations for organizational transformation through short answer written sections. Surveys were analyzed thematically using NVivo, informed by critical perspectives on substance use, with attention to key re-occurring themes on employment equity. Results: While participants described multiple benefits of working in harm reduction services, such as the valuing of their expertise by fellow 'peers,' growing skill sets, countering stigma, and preventing overdose deaths, issues of workplace equity were significantly identified. Stigma, tokenism, workplace discrimination, including power and pay inequities, as well as lack of worker compensation and benefits were identified as key factors persisting in the everyday experiences of participants. Conclusion: Continued exposure to stigma, workplace discrimination, and/or power imbalances, combined with the impact of high stakes employment (e.g., dealing with overdose deaths), can have significant consequences for PWLE working in harm reduction, including burn out. Policy recommendations include large-scale structural changes that address inequities of hierarchical 'peer' employment for PWLE, including increased leadership roles for diverse PWLE, pay equity and benefits, unionization, as well as more supportive working environments attentive to the intersecting social-structural factors (poverty, criminalization, racism, gendered violence) impacting the everyday lives of PWLE working in harm reduction. [ABSTRACT FROM AUTHOR]

Background: Climate change is a defining issue and grand challenge for the health sector in North America. Synthesizing evidence on climate change impacts, climate-health adaptation, and climate-health mitigation is crucial for health practitioners and decision-makers to effectively understand, prepare for, and respond to climate change impacts on human health. This protocol paper outlines our process to systematically conduct a literature review to investigate the climate-health evidence base in North America. Methods: A search string will be used to search CINAHL®, Web of Science™, Scopus®, Embase® via Ovid, and MEDLINE® via Ovid aggregator databases. Articles will be screened using inclusion/exclusion criteria by two independent reviewers. First, the inclusion/exclusion criteria will be applied to article titles and abstracts, and then to the full articles. Included articles will be analyzed using quantitative and qualitative methods. Discussion: This protocol describes review methods that will be used to systematically and transparently create a database of articles published in academic journals that examine climate-health in North America. [ABSTRACT FROM AUTHOR]

Background: In Ontario, Canada, Indigenous communities experience some of the province's worst drinking water, with issues ranging from deteriorating water quality to regulatory problems and lack of support. When water is known, or suspected, to be unsafe for human consumption, communities are placed under a Drinking Water Advisory. Between 2004 and 2013, approximately 70% of all on-reserve communities in Ontario were under at least one Drinking Water Advisory. Despite the widespread impact of Drinking Water Advisories on health and wellbeing, little is known about First Nation individuals' perceptions and experiences living with a Drinking Water Advisory. This study presents information shared by members of a community who have lived with Boil Water Advisories on and off for many years, and a long-term Boil Water Advisory since 2017. The goal of this paper is to unpack and explore the Boil Water Advisories from the perspective of community members and provide considerations for current and future Boil Water Advisory management. Methods: Methodological choices were driven by the principles of community-based participatory research. Two data collection methodologies were employed: hard copy surveys and interviews. Results: Forty-four individuals (19.5%) completed a survey. Eight Elders and 16 key informants participated in 20 interviews. Respondents expressed varying degrees of uncertainty regarding protective actions to take while under a Boil Water Advisory. Further, 79% of men but only 46% of women indicated they always adhere to the Boil Water Advisory. Knowledge gaps that could lead to risky behaviours were also identified. Finally, Boil Water Advisories were demonstrated to have physical, financial, and time impacts on the majority of respondents. Conclusions: A direct outcome was the identification of a critical need to reinforce best practices for health protection through community education and outreach. More broadly, Chief and Council were able to use the findings to successfully advocate for improved drinking water for the community. Additionally, benefits of participatory research and community ownership include enhanced local research capacity, and increased awareness of, and desire for, research to inform decisions. [ABSTRACT FROM AUTHOR]

Background: Over the last three decades, there has been worldwide recognition of peer support contributions to improve mental healthcare provision. However, in the current literature, little attention has been paid to exploring perspectives of peer supporters on their involvement in mental health services provision. The purpose of the present study was to examine peer supporters' perspectives on the implementation of a transitional discharge model (TDM), an intervention for the community integration of people with mental illness. Methods: This paper represents ethnographic qualitative data collected as part of a study that used mixed methods to evaluate the implementation of TDM across nine hospitals from the Province of Ontario, in Canada. The study involved a sample of 66 peer supporters, who were recruited from participating Consumer/Survivor Initiative Organizations and Peer Support Programs. The study collected data using two sets of focus groups, which were held at 6 months and 1-year post implementation. Data analysis used an ethnography model of qualitative analysis. Results: Peer supporters expressed that their involvement in mental healthcare enhanced clients' autonomy and hope about their recovery, as well as established a safety net and reduced hospital readmissions. Peer supporters articulated that they assumed several roles to facilitate clients' transition from hospital to the community. These roles included: assisting clients in building their capacity and developing healthy routines; attending regular on-ward and community meetings; accompanying clients to their appointments; and working with clients to set goals for their recovery. The study showed hindrances to effective implementation of peer support programs, such as a lack of understanding and appreciation of peer supporter roles, lack of careful allocation of peer supporters to clients, and an absence of appropriate protocols for ensuring the safety and supervision of the peer supporters. Conclusions: Results of the TDM implementation demonstrated that involving peer supporters in mental healthcare delivery may benefit clients by enhancing autonomy and hope about their recovery, as well as establishing a safety net and reducing hospital readmissions. Results from the study have the potential to inform healthcare professionals and managers of strategies for developing effective peer support programs. [ABSTRACT FROM AUTHOR]

Background: Evidence suggests that stigma against people with mental illness remains high. This demands innovative approaches to reduce stigma. One innovative stigma reduction method is participatory video (PV), whereby marginalized people come together to script, film and produce bottom-up educational videos about shared issues. These videos are then shown to target groups. This paper has two objectives (i) to examine the feasibility of using participatory video with people with severe mental illness (SMI); and (ii) to assess viewer impressions of the resultant videos and subsequent subjective impact. Methods: We conducted a participatory action research study with three workgroups of people with severe mental illness situated in different Canadian cities, who set out to create and disseminate locally-grounded mental-health themed videos. This involved process and outcome evaluation to assess feasibility and impact. Specifically, we (i) observed fidelity to a co-designed action-plan in all three workgroups; (ii) distributed brief purpose-built questionnaires to viewers at organized screenings to assess preliminary impact; and (iii) conducted focus groups with viewers to elicit further impressions of the videos and subsequent subjective impact. Results: The three workgroups achieved high-fidelity to the action-plan. They successfully produced a total of 26 videos, over double the targeted number, during an 18-month period. Likewise, the workgroups organized 49 screenings at a range of venues attended by 1542 people, again exceeding the action-plan targets. Results from the viewer questionnaires (N = 1104, response rate 72%) indicated that viewers reported that their understandings had improved after watching the videos. Four themes emerged from six viewer focus groups (N = 30), with participants frequently noting that videos were (i) educational and informative; (ii) real and relatable; (iii) attention-grabbing; and (iv) change-inducing. Conclusions: To our knowledge, this study is the first large-scale multi-site project examining the feasibility and impact of a participatory video program for people with severe mental illness. The results indicate that participatory video is a feasible method in this population and gives preliminary evidence that resultant videos can reduce viewer stigma. Thus, participatory video should be considered a promising practice in the ongoing effort to reduce mental illness stigma. [ABSTRACT FROM AUTHOR]

Background: With massive investment in health-related research, above and beyond investments in the management and delivery of healthcare and public health services, there has been increasing focus on the impact of health research to explore and explain the consequences of these investments and inform strategic planning. Relevance is reflected by increased attention to the usability and impact of health research, with research funders increasingly engaging in relevance assessment as an input to decision processes. Yet, it is unclear whether relevance is a synonym for or predictor of impact, a necessary condition or stage in achieving it, or a distinct aim of the research enterprise. The main aim of this paper is to improve our understanding of research relevance, with specific objectives to (1) unpack research relevance from both theoretical and practical perspectives, and (2) outline key considerations for its assessment.Approach: Our approach involved the scholarly strategy of review and reflection. We prepared a draft paper based on an exploratory review of literature from various fields, and gained from detailed and insightful analysis and critique at a roundtable discussion with a group of key health research stakeholders. We also solicited review and feedback from a small sample of expert reviewers.Conclusions: Research relevance seems increasingly important in justifying research investments and guiding strategic research planning. However, consideration of relevance has been largely tacit in the health research community, often depending on unexplained interpretations of value, fit and potential for impact. While research relevance seems a necessary condition for impact - a process or component of efforts to make rigorous research usable - ultimately, relevance stands apart from research impact. Careful and explicit consideration of research relevance is vital to gauge the overall value and impact of a wide range of individual and collective research efforts and investments. To improve understanding, this paper outlines four key considerations, including how research relevance assessments (1) orientate to, capture and compare research versus non-research sources, (2) consider both instrumental versus non-instrumental uses of research, (3) accommodate dynamic temporal-shifting perspectives on research, and (4) align with an intersubjective understanding of relevance. [ABSTRACT FROM AUTHOR]

Background: Chronic cerebrospinal venous insufficiency (CCSVI) treatment is an unproven intervention aimed at relieving some of the symptoms of multiple sclerosis (MS). Despite limited evidence of the efficacy and safety of this intervention, Canadians diagnosed with MS have been traveling abroad to access this procedure as it is not available domestically outside of limited clinical trials. This paper discusses the experiences of Canadians with MS seeking CCSVI treatment abroad. Methods: This paper presents a secondary analysis of 15 interviews with participants who had gone abroad for CCSVI treatment. Interviews were conducted over the phone between October 2012 and December 2012. All interviews were digitally recorded and transcribed verbatim. Transcripts were hand coded for: 1) why CCSVI treatment was sought and where it was obtained; 2) the role of having hope for a cure in seeking CCSVI; 3) the impact of MS on everyday life; and 4) the role other people played in the decision to go abroad. Results: The authors identified loss of faith, hope, and trust as themes emerging from the transcripts. The participants experienced a loss of faith with the Canadian health system and especially the neurologists who were responsible for their care and the classification of MS as a neurological disease. Access to CCSVI treatment abroad generated hope in these participants, but they were cautious in their expectations, focusing on symptom management rather than a cure. Trust in their caregivers abroad was generated through the recommendations of other MS sufferers and the credentials of their caregivers abroad. Conclusions: By deciding to seek an unproven intervention abroad, these individuals took on responsibility for their care from the Canadian health system. While evidence of the efficacy of CCSVI treatment is limited, the participants felt that they were making a rational care decision, focusing on the empowerment and renewed hope generated by seeking this intervention. Health professionals and policy makers globally should consider the causes of loss of faith in their domestic care systems and balance the benefits of empowerment and renewed hope against concerns that unproven interventions may create new health risks. [ABSTRACT FROM AUTHOR]

Background: Purposefully building stronger collaborations between primary care (PC) and public health (PH) is one approach to strengthening primary health care. The purpose of this paper is to report: 1) what systemic factors influence collaborations between PC and PH; and 2) how systemic factors interact and could influence collaboration.Methods: This interpretive descriptive study used purposive and snowball sampling to recruit and conduct interviews with PC and PH key informants in British Columbia (n = 20), Ontario (n = 19), and Nova Scotia (n = 21), Canada. Other participants (n = 14) were knowledgeable about collaborations and were located in various Canadian provinces or working at a national level. Data were organized into codes and thematic analysis was completed using NVivo. The frequency of "sources" (individual transcripts), "references" (quotes), and matrix queries were used to identify potential relationships between factors.Results: We conducted a total of 70 in-depth interviews with 74 participants working in either PC (n = 33) or PH (n = 32), both PC and PH (n = 7), or neither sector (n = 2). Participant roles included direct service providers (n = 17), senior program managers (n = 14), executive officers (n = 11), and middle managers (n = 10). Seven systemic factors for collaboration were identified: 1) health service structures that promote collaboration; 2) funding models and financial incentives supporting collaboration; 3) governmental and regulatory policies and mandates for collaboration; 4) power relations; 5) harmonized information and communication infrastructure; 6) targeted professional education; and 7) formal systems leaders as collaborative champions.Conclusions: Most themes were discussed with equal frequency between PC and PH. An assessment of the system level context (i.e., provincial and regional organization and funding of PC and PH, history of government in successful implementation of health care reform, etc) along with these seven system level factors could assist other jurisdictions in moving towards increased PC and PH collaboration. There was some variation in the importance of the themes across provinces. British Columbia participants more frequently discussed system structures that could promote collaboration, power relations, harmonized information and communication structures, formal systems leaders as collaboration champions and targeted professional education. Ontario participants most frequently discussed governmental and regulatory policies and mandates for collaboration. [ABSTRACT FROM AUTHOR]

Background: When seeking care at international hospitals and clinics, medical tourists are often accompanied by family members, friends, or other caregivers. Such caregiver-companions assume a variety of roles and responsibilities and typically offer physical assistance, provide emotional support, and aid in decision-making and record keeping as medical tourists navigate unfamiliar environments. While traveling abroad, medical tourists' caregiver-companions can find themselves confronted with challenging communication barriers, financial pressures, emotional strain, and unsafe environments.Methods: To better understand what actions and activities medical tourists' informal caregivers can undertake to protect their health and safety, 20 interviews were conducted with Canadians who had experienced accompanying a medical tourist to an international health care facility for surgery. Interview transcripts were subsequently used to identify inductive and deductive themes central to the advice research participants offered to prospective caregiver-companions.Results: Advice offered to future caregiver-companions spanned the following actions and activities to protect health and safety: become an informed health care consumer; assess and avoid exposure to identifiable risks; anticipate the care needs of medical tourists and thereby attempt to guard against caregiver burden; become familiar with important logistics related to travel and anticipated recovery timelines; and take practical measures to protect one's own health.Conclusion: Given that a key feature of public health is to use research findings to develop interventions and policies intended to promote health and reduce risks to individuals and populations, the paper draws upon major points of advice offered by study participants to take the first steps toward the development of an informational intervention designed specifically for the health and safety needs of medical tourists' caregiver companions. While additional research is required to finalize the content and form of such an intervention, this study provides insight into what practical advice former caregiver-companions state should be shared with individuals considering assuming these roles and responsibilities in the future. In addition, this research draws attention to the importance of ensuring that such an intervention is web-based and readily accessible by prospective caregiver-companions. [ABSTRACT FROM AUTHOR]

Background: Global trends in migration accompanied with recent changes to the immigrant selection process may have influenced the demographic and human capital characteristics of internationally educated nurses (IENs) in Canada and in turn the assistance required to facilitate their workforce integration. This study aimed to describe the demographic and human capital profile of IENs in Canada, to explore recent changes to the profile, and to identify predictors of IENs' workforce integration.Methods: A cross-sectional, descriptive, correlational survey design was used. Eligible IENs were immigrants, registered and employed as regulated nurses in Canada. Data were collected in 2014 via online and paper questionnaires. Descriptive statistics were used to examine the data by year of immigration. Logistic regression modeling was employed to identify predictors of IENs' workforce integration measured as passing the licensure exam to acquire professional recertification and securing employment.Results: The sample consisted of 2280 IENs, representative of all Canadian provincial jurisdictions. Since changes to the immigrant selection process in 2002, the IEN population in Canada has become more racially diverse with greater numbers emigrating from developing countries. Recent arrivals (after 2002) had high levels of human capital (knowledge, professional experience, language proficiency). Some, but not all, benefited from the formal and informal assistance available to facilitate their workforce integration. Professional experience and help studying significantly predicted if IENs passed the licensure exam on their first attempt. Bridging program participation and assistance from social networks in Canada were significant predictors if IENs had difficulty securing employment.Conclusions: Nurses will continue to migrate from a wide variety of countries throughout the world that have dissimilar nursing education and health systems. Thus, IENs are not a homogenous group, and a "one size fits all" model may not be effective for facilitating their professional recertification and employment in the destination country. Canada, as well as other countries, could consider using a case management approach to develop and tailor education and forms of assistance to meet the individual needs of IENs. Using technology to reach IENs who have not yet immigrated or have settled outside of urban centers are other potential strategies that may facilitate their timely entrance into the destination countries' nursing workforce. [ABSTRACT FROM AUTHOR]

Access to community-based primary health care (hereafter, 'primary care') is a priority in many countries. Health care systems have emphasized policies that help the community 'get the right service in the right place at the right time'. However, little is known about organizational interventions in primary care that are aimed to improve access for populations in situations of vulnerability (e.g., socioeconomically disadvantaged) and how successful they are. The purpose of this scoping review was to map the existing evidence on organizational interventions that improve access to primary care services for vulnerable populations. Scoping review followed an iterative process. Eligibility criteria: organizational interventions in Organisation for Economic Cooperation and Development (OECD) countries; aiming to improve access to primary care for vulnerable populations; all study designs; published from 2000 in English or French; reporting at least one outcome (avoidable hospitalization, emergency department admission, or unmet health care needs). Sources: Main bibliographic databases (Medline, Embase, CINAHL) and team members' personal files. Study selection: One researcher selected relevant abstracts and full text papers. Theory-driven synthesis: The researcher classified included studies using (i) the 'Patient Centered Access to Healthcare' conceptual framework (dimensions and outcomes of access to primary care), and (ii) the classification of interventions of the Cochrane Effective Practice and Organization of Care. Using pattern analysis, interventions were mapped in accordance with the presence/absence of 'dimension-outcome' patterns. Out of 8,694 records (title/abstract), 39 studies with varying designs were included. The analysis revealed the following pattern. Results of 10 studies on interventions classified as 'Formal integration of services' suggested that these interventions were associated with three dimensions of access (approachability, availability and affordability) and reduction of hospitalizations (four/four studies), emergency department admissions (six/six studies), and unmet healthcare needs (five/six studies). These 10 studies included seven non-randomized studies, one randomized controlled trial, one quantitative descriptive study, and one mixed methods study. Our results suggest the limited breadth of research in this area, and that it will be feasible to conduct a full systematic review of studies on the effectiveness of the formal integration of services to improve access to primary care services for vulnerable populations. [ABSTRACT FROM AUTHOR]

Background: Structural violence shapes the health of Indigenous peoples globally, and is deeply embedded in history, individual and institutional racism, and inequitable social policies and practices. Many Indigenous communities have flourished, however, the impact of colonialism continues to have profound health effects for Indigenous peoples in Canada and internationally. Despite increasing evidence of health status inequities affecting Indigenous populations, health services often fail to address health and social inequities as routine aspects of health care delivery. In this paper, we discuss an evidence-based framework and specific strategies for promoting health care equity for Indigenous populations. Methods: Using an ethnographic design and mixed methods, this study was conducted at two Urban Aboriginal Health Centres located in two inner cities in Canada, which serve a combined patient population of 5,500. Data collection included in-depth interviews with a total of 114 patients and staff (n = 73 patients; n = 41 staff), and over 900 h of participant observation focused on staff members' interactions and patterns of relating with patients. Results: Four key dimensions of equity-oriented health services are foundational to supporting the health and well-being of Indigenous peoples: inequity-responsive care, culturally safe care, trauma- and violence-informed care, and contextually tailored care. Partnerships with Indigenous leaders, agencies, and communities are required to operationalize and tailor these key dimensions to local contexts. We discuss 10 strategies that intersect to optimize effectiveness of health care services for Indigenous peoples, and provide examples of how they can be implemented in a variety of health care settings. Conclusions: While the key dimensions of equity-oriented care and 10 strategies may be most optimally operationalized in the context of interdisciplinary teamwork, they also serve as health equity guidelines for organizations and providers working in various settings, including individual primary care practices. These strategies provide a basis for organizational-level interventions to promote the provision of more equitable, responsive, and respectful PHC services for Indigenous populations. Given the similarities in colonizing processes and Indigenous peoples' experiences of such processes in many countries, these strategies have international applicability. [ABSTRACT FROM AUTHOR]

Background: The worldwide rise in common mental disorders (CMDs) is posing challenges in the provision of and access to care, particularly for immigrant, refugee and racialized groups from low-income backgrounds. eHealth tools, such as the Interactive Computer-Assisted Client Assessment Survey (iCCAS) may reduce some barriers to access. iCCAS is a tablet-based, touch-screen self-assessment completed by clients while waiting to see their family physician (FP) or nurse practitioner (NP). In an academic-community initiative, iCCAS was made available in English and Spanish at a Community Health Centre in Toronto through a mixed-method trial. Methods: This paper reports the perspectives of clients in the iCCAS group (n = 74) collected through an exit survey, and the perspectives of 9 providers (four FP and five NP) gathered through qualitative interviews. Client acceptance of the tool was assessed for cognitive and technical dimensions of their experience. They rated twelve items for perceived Benefits and Barriers and four questions for the technical quality. Results: Most clients reported that the iCCAS completion time was acceptable (94.5 %), the touch-screen was easy to use (97.3 %), and the instructions (93.2 %) and questions (94.6 %) were clear. Clients endorsed the tool's Benefits, but were unsure about Barriers to information privacy and provider interaction (mean 4.1, 2.6 and 2.8, respectively on a five-point scale). Qualitative analysis of the provider interviews identified five themes: challenges in Assessing Mental Health Services, such as case complexity, time, language and stigma; the Tool's Benefits, including non-intrusive prompting of clients to discuss mental health, and facilitation of providers' assessment and care plans; the Tool's Integration into everyday practice; Challenges for Use (e.g. time); and Promoting Integration Effectively, centered on the timing of screening, setting readiness, language diversity, and technological advances. Conclusions: Participant clients and providers perceived iCCAS as an easy and useful tool for mental health assessments at the Community Health Centre and similar settings. The findings are anticipated to inform further work in this area. [ABSTRACT FROM AUTHOR]

Background: Currently, there is a dearth of baseline data on the health of lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations in the province of Nova Scotia, Canada. Historically, LGBTQ health research has tended to focus on individual-level health risks associated with poor health outcomes among these populations, which has served to obscure the ways in which they maintain their own health and wellness across the life course. As such, there is an urgent need to shift the focus of LGBTQ health research towards strengths-based perspectives that explore the complex and resilient ways in which LGBTQ populations promote their health. Methods: This paper discusses the findings of our recent scoping review as well as the qualitative data to emerge from community consultations aimed at developing strengths-based approaches to understanding and advancing LGBTQ pathways to health across Nova Scotia. Results: Our scoping review findings demonstrated the lack of strengths-based research on LGBTQ health in Nova Scotia. Specifically, the studies examined in our scoping review identified a number of health-promoting factors and a wide variety of measurement tools, some of which may prove useful for future strengths-based health research with LGBTQ populations. In addition, our community consultations revealed that many participants had negative experiences with health care systems and services in Nova Scotia. However, participants also shared a number of factors that contribute to LGBTQ health and suggestions for how LGBTQ pathways to health in Nova Scotia can be improved. Conclusions: There is an urgent need to conduct research on the health needs, lived experiences, and outcomes of LGBTQ populations in Nova Scotia to address gaps in our knowledge of their unique health needs. In moving forward, it is important that future health research take an intersectional, strengths-based perspective in an effort to highlight the factors that promote LGBTQ health and wellness across the life course, while taking into account the social determinants of health. [ABSTRACT FROM AUTHOR]

Background: Accessing cancer treatment requires First Nation peoples living in rural and remote communities to either commute to care, or to relocate to an urban centre for the length or part of the treatment. While Canadians living in rural and remote communities must often make difficult decisions following a cancer diagnosis, such decisions are further complicated by the unique policy and socio-historical contexts affecting many First Nation peoples in Canada. These contexts often intersect with negative healthcare experiences which can be related to jurisdictional confusion encountered when seeking care. Given the rising incidence of cancer within First Nation populations, there is a growing potential for negative health outcomes.Methods: The analysis presented in this paper focuses on the experience of First Nation peoples' access to cancer care in the province of Manitoba. We analyzed policy documents and government websites; interviewed individuals who have experienced relocation (N = 5), family members (N = 8), healthcare providers and administrators (N = 15).Results: Although the healthcare providers (social workers, physicians, nurses, patient navigators, and administrators) we interviewed wanted to assist patients and their families, the focus of care remained informed by patients' clinical reality, without recognition of the context which impacts and constrains access to cancer care services. Contrasting and converging narratives identify barriers to early diagnosis, poor coordination of care across jurisdictions and logistic complexities that result in fatigue and undermine adherence. Providers and decision-makers who were aware of this broader context were not empowered to address system's limitations.Conclusions: We argue that a whole system's approach is required in order to address these limitations. [ABSTRACT FROM AUTHOR]

Retrenchment of government services has occurred across a wide range of sectors and regions. Care services, in particular, have been clawed away in the wake of fiscal policies of cost containment and neoliberal policies centred on individual responsibility and market autonomy. Such policies have included the deinstitutionalisation of care from hospitals and clinics, and early discharge from hospital, both of which are predicated on the notion that care can be provided informally within families and communities. In this paper we examine the post-birth "care crisis" that new mothers face in one region of Canada. Method: The data are drawn from a larger study of social determinants of pregnant and new mothers' health in Victoria, Canada. Mixed methods interviews were conducted among a purposive sample of women at three points in time. This paper reports data on sample characteristics, length of stay in hospital and health service gaps. This data is contextualised via a more in-depth analysis of qualitative responses from Wave 2 (4-6 weeks postpartum). Results: Out results show a significant portion of participants desired services that were not publically available to them during the post-birth period. Among those who reported a gap in care, the two most common barriers were: cost and unavailability of home care supports. Participants' open-ended responses revealed many positive features of the public health care system but also gaps in services, and economic barriers to receiving the care they wanted. The implications of these findings are discussed in relation to recent neoliberal reforms. Discussion & conclusions: While Canada may be praised for its public provision of maternity care, mothers' reports of gaps in care during the early postpartum period and increasing use of private doulas is a worrying trend. To the extent that individual mothers or families rely on the market for care provision, issues of equity and quality of care are pivotal. This paper concludes with suggestions for further research on the impact of recent changes in post-birth care on new fathers and on inequities in pre and post-birth care in less-resourced regions of the world. [ABSTRACT FROM AUTHOR]

Background: Over the last decade, Canada has been one of the top destination countries for internationally educated health professionals (IEHPs). After arrival, many struggle to professionally recertify and secure employment in their field. Considerable funding has been allocated to the development of new policies and programs to facilitate IEHPs' professional integration. Literature about the professional integration process and the available policies and programs is abundant, not synthesized and dispersed among a wide range of health professions and the academic and grey literature. This, in combination with the sustained policy relevance, contributed to the timeliness and necessity for conducting this scoping review.Methods: We used an updated version of Arskey and O'Malley's six-stage scoping review framework to summarize the amount, types, sources and distribution of the literature. Findings were summarized numerically and thematically. The themes included pre-immigration activities and programs, early arrival activities and programs, professional recertification and workplace integration.Results: Four hundred and seven published sources from 2000-2012 were retained for data charting and extraction. Most focused on international medical graduates or internationally educated nurses. IEHPs from the allied health professions were underrepresented. Methodologically, about one quarter of the papers are empirical studies with the next largest category being reports from professional certification bodies and educational institutions. The overarching concern is with workplace integration, professional recognition and bridging programs. Nursing dominates the literature about pre-immigration activities and programs whereas the literature about early arrival activities and programs, professional recertification and workplace integration is dominated by medicine. Although the literature does contain some information for IEHPs in the allied health professions, the thematic analysis did not identify a clear trend. A notable increase in the number of publications was present.Conclusions: The literature about IEHPs' professional integration in Canada is abundant. This reflects the sustained policy relevance of the recruitment, recognition and professional integration for IEHPs in Canada. This demonstrates that Canada provides an excellent case for this review from which the findings may have international significance. Nevertheless, little information is available about the effectiveness of the policies and programs available to facilitate IEHP integration, an area that requires further consideration. [ABSTRACT FROM AUTHOR]

Background: The Loggerhead Shrike, Eastern subspecies (Lanius ludovicianus ssp.) (LOSH) is a predatory songbird native to Eastern North America. It is estimated that there are fewer than 55 breeding pairs of this subspecies in North America. Captive breeding plays a critical role in preventing the extirpation of this subspecies from its Canadian range. Unfortunately, high numbers of unexplained deaths among young birds in the captive breeding population threatened the success of this program. This paper describes fledgling mortality in the captive breeding population, and seeks to identify factors associated with fledgling survival and, ultimately, to identify steps to mitigate fledgling mortality. Results: Over the study period (2006-2011) at two breeding sites, 696 LOSH were fledged. Among these, 68 % (n = 474) were released, 10 % (n = 69) were retained in the captive breeding population, and 22 % (n = 155) died. Fledgling survival declined from 99 % in 2006 to 44 % in 2011. The odds of survival were significantly lower for fledglings that were part of a second clutch. As the number of fledglings in a clutch increased, the odds of surviving increased significantly. As the breeding female aged from one to four years of age, there was a marked increase in the odds of a fledgling surviving, which then subsequently declined as females aged further. Conclusions: Based on our analyses, clutch number (first or second), number of fledglings in the brood, and age of breeding females were significant predictors of fledgling survival. Long-term breeding management decisions will have to balance the need to increase the number of individuals and breeding pairs in the wild by releasing large numbers of young, against the need to maintain a genetically viable captive population, until the wild population is large enough to be self-sustaining. [ABSTRACT FROM AUTHOR]

Background: During the first wave of the H1N1 influenza pandemic in 2009, Aboriginal populations in Canada experienced disproportionate rates of infection, particularly in the province of Manitoba. To protect those thought to be most at-risk, health authorities in Manitoba listed all Aboriginal people, including Metis, among those able to receive priority access to the novel vaccine when it first became available. Currently, no studies exist that have investigated the attitudes, influences, and vaccine behaviors among Aboriginal communities in Canada. This paper is the first to systematically connect vaccine behavior with the attitudes and beliefs that influenced Metis study participants' H1N1 vaccine decision-making. Methods: Researchers held focus groups (n = 17) with Metis participants in urban, rural, and remote locations of Manitoba following the conclusion of the H1N1 pandemic. Participants were asked about their vaccination decisions and about the factors that influenced their decisions. Following data collection, responses were coded into the broad categories of a social-ecological model, nuanced by categories stemming from earlier research. Responses were then quantified to show the most influential factors in positively or negatively affecting the vaccine decision. Results: Media reporting, the influence of peer groups, and prioritization all had positive and negative influential effects on decision making. Whether vaccinated or not, the most negatively influential factors cited by participants were a lack of knowledge about the vaccine and the pandemic as well as concerns about vaccine safety. Risk of contracting H1N1 influenza was the biggest factor in positively influencing a vaccine decision, which in many cases trumped any co-existing negative influencers. Conclusions: Metis experiences of colonialism in Canada deeply affected their perceptions of the vaccine and pandemic, a context that health systems need to take into account when planning response activities in the future. Participants felt under-informed about most aspects of the vaccine and the pandemic, and many vaccine related misconceptions and fears existed. Recommendations include leveraging doctor-patient interactions as a site for sharing vaccine-related knowledge, as well as targeted, culturally-appropriate, and empowering public information strategies to supply reliable vaccine and pandemic information to potentially at-risk Aboriginal populations. [ABSTRACT FROM AUTHOR]

Background: Survey research indicates that a surprising number of 12 to 14 year olds in North America engage in some form of paid work, and work-related injuries for this age group are reported at rates similar to older teens. Parents exhibit significant involvement in many aspects of their teens’ work and may influence perceptions of work safety, yet few studies have explored this phenomenon from a qualitative perspective with parents of working 12 to 14 year olds. Methods: This paper focuses on parental perceptions and understandings of work safety based on focus groups conducted with urban Canadian parents of young teens who work for pay. Parents discussed the types of job held by their 12 to 14 year olds, the perceived costs and benefits to working at this age, and their understanding of risk and supervision on the job. A grounded theory approach was used to thematically analyze the focus group transcripts. Results: Parents in this study held favourable attitudes towards their 12 to 14 year olds’ working. Parents linked pro-social moral values and skills such as responsibility, work ethic, time management, and financial literacy with their young teen’s employment experience. Risks and drawbacks were generally downplayed or discounted. Perceptions of workplace safety were mitigated by themes of trust, familiarity, sense of being in control and having discretion over their 12 to 14 year olds’ work situation. Further, parental supervision and monitoring fell along a continuum, from full parental responsibility for monitoring to complete trust and delegation of supervision to the workplace. Conclusions: The findings suggest that positive parental attitudes towards working overshadow occupational health and safety concerns. Parents may discount potential hazards based on the presence of certain mitigating factors. [ABSTRACT FROM AUTHOR]

Canadian reports have recommended that health as a human right must be Canada's overarching global commitment and that the primacy of human rights should be prioritized over other elements of international law including international trade and investment law as it applies to access to pharmaceuticals. This paper uses a series of case reports to examine Canada's commitment to this goal. Specifically it examines cases where improved access has been in conflict with increased intellectual property rights. The 6 cases are: Canada's position when 39 pharmaceutical companies took South Africa to court in 1998 over its legislation to allow parallel importation of patented medicines and to regulate the price of medications; the stance that Canada took in the negotiations around the Doha Declaration in 2001; the passage of Canada's Access to Medicines Regime in 2004 and subsequent attempts to amend the legislation in 2011 and 2012; Canada's involvement in the final declaration at the United Nations High-Level meeting on non-communicable diseases in 2012; Canada's views about the terms in the Anti-Counterfeiting Trade Agreement as expressed in 2009; and Canada's 2013 position on the extension of the exemption for least developed countries from having to comply with the terms of the Trade Related Aspects of Intellectual Property Rights Agreement. In the first case Canada was neutral but in the remaining 5 cases Canada prioritized intellectual property rights over access. This position is consistent with how Canada has acted around domestic issues involving intellectual property rights for pharmaceutical products. Canada has supported strengthened rights despite the fact that their touted benefits have not been realized either domestically or in developing countries. As a result Canada has failed in its humanitarian duty to protect the human right to health in the form of safe and low cost medicines for the people in developing countries. [ABSTRACT FROM AUTHOR]

Background: Resource allocation is a key challenge for healthcare decision makers. While several case studies of organizational practice exist, there have been few large-scale cross-organization comparisons.Methods: Between January and April 2011, we conducted an on-line survey of senior decision makers within regional health authorities (and closely equivalent organizations) across all Canadian provinces and territories. We received returns from 92 individual managers, from 60 out of 89 organizations in total. The survey inquired about structures, process features, and behaviours related to organization-wide resource allocation decisions. We focus here on three main aspects: type of process, perceived fairness, and overall rating.Results: About one-half of respondents indicated that their organization used a formal process for resource allocation, while the others reported that political or historical factors were predominant. Seventy percent (70%) of respondents self-reported that their resource allocation process was fair and just over one-half assessed their process as 'good' or 'very good'. This paper explores these findings in greater detail and assesses them in context of the larger literature.Conclusion: Data from this large-scale cross-jurisdictional survey helps to illustrate common challenges and areas of positive performance among Canada's health system leadership teams. [ABSTRACT FROM AUTHOR]

Background: Despite strong academic recognition of the SDOH both in Canada and internationally, acknowledgement and uptake of the SDOH in health policy and public consciousness have remained weak. This paper aims to discern reasons for limited action on the SDOH by examining the perceptions of the SDOH held by two groups more and less affiliated with public health in Canada. We conducted formal consultation with group members on their interpretation of the SDOH and their thoughts on the nature and basis of differences between those more and less aligned with the SDOH as a basis for action. Thematic analysis was used to evaluate the views of the two groups. Findings: Group 1 (community/public health workers) felt overwhelmed when confronted with questions regarding action on the SDOH within the context of their professional lives. They suggested an expanded list of health determinants that included factors such as voluntarism and happiness, transcending traditional notions of “root causes.” Furthermore, they did not articulate value-based reasons why others would oppose the SDOH; rather, in line with their professional roles, they adopted a value-neutral and pragmatic approach to working to improve health. Group 2 (child and youth advocacy organization members) seemed rooted in the 1986 Ottawa Charter for Health Promotion framework, with their recommendations aligned with strategies such as building healthy public policy and reorienting health services. Neither group made reference to issues of social justice or inequity when they made suggestions for improving health. Conclusions: We found that two groups with different affiliations to formal public health could discuss the SDOH without acknowledging the inequitable distribution of power and resources that lies at its root. We also found that those working in public health had difficulty moving beyond individual actions that they or their clients could take to improve health. For a group more focused on advocacy than direct service provision, the Ottawa Charter framework seemed more easily suited to their recommendations for action than suggesting actions that would address the SDOH. Our findings indicate that there remains work to be done in terms of translating the SDOH concept into action in Canada. [ABSTRACT FROM AUTHOR]

Background: Evidence suggests that immigrant women having different ethnocultural backgrounds than those dominant in the host country have difficulty during their access to and reception of maternity care services, but little knowledge exists on how factors such as ethnic group and cultural beliefs intersect and influence health care access and outcomes. Amongst immigrant populations in Canada, refugee women are one of the most vulnerable groups and pregnant women with immediate needs for health care services may be at higher risk of health problems. This paper describes findings from the qualitative dimension of a mixed-methodological study. Methods: A focused ethnographic approach was conducted in 2010 with Sudanese women living in an urban Canadian city. Focus group interviews were conducted to map out the experiences of these women in maternity care, particularly with respect to the challenges faced when attempting to use health care services. Results: Twelve women (mean age 36.6 yrs) having experience using maternity services in Canada within the past two years participated. The findings revealed that there are many beliefs that impact upon behaviours and perceptions during the perinatal period. Traditionally, the women mostly avoid anything that they believe could harm themselves or their babies. Pregnancy and delivery were strongly believed to be natural events without need for special attention or intervention. Furthermore, the sub-Saharan culture supports the dominance of the family by males and the ideology of patriarchy. Pregnancy and birth are events reflecting a certain empowerment for women, and the women tend to exert control in ways that may or may not be respected by their husbands. Individual choices are often made to foster self and outward-perceptions of managing one's affairs with strength. Conclusion: In today's multicultural society there is a strong need to avert misunderstandings, and perhaps harm, through facilitating cultural awareness and competency of care rather than misinterpretations of resistance to care. [ABSTRACT FROM AUTHOR]

Background: Climate change has been described as the biggest global health threat of the 21st century. Typically framed as an environmental issue, some suggest this view has contributed to public ambivalence and hence a lack of public engagement. The lack of understanding of climate change as a significant environmental health risk on the part of the lay public represents a significant barrier to behaviour change. We therefore need to think about reframing the impact of climate change from an environmental to a health issue. This paper builds on calls for increased understanding of the public's views of human health risks associated with climate change, focusing on facilitators and barriers to behaviour change. Methods: Semi-structured in-depth interviews (n = 22) with residents of the Golden Horseshoe region of Southern Ontario were conducted between August 2010 and January 2011. Topics included individual and community health, climate change, and facilitators and barriers to behaviour change. Results: Few participants recognized the role of the environment in the context of either individual and community health. When asked about health concerns specific to their community, however, environmental issues were mentioned frequently. Health effects as possible impacts of global environmental change were mentioned by 77% of participants when prompted, but this link was not described in great detail or within the context of impacting their communities or themselves. Participants were willing to act in environmentally friendly ways, and possible incentives to undertake behaviour change such as decreasing cost were described. Health co-benefits were not identified as incentives to engaging in mitigative or adaptive behaviours. Conclusions: The results support recent calls for reframing the impact of climate change from an environmental to a public health issue in order to increase public engagement in adaptive and mitigative behaviour change. While previous research has touched on public awareness of the human health risks of climate change, we have further explored the attitude-action link through the examination of facilitators and barriers to behaviour change. [ABSTRACT FROM AUTHOR]

Introduction: Canadian research on racial health inequalities that foregrounds socially constructed racial identities and social factors which can explain consequent racial health inequalities is rare. This paper adopts a social typology of salient racial identities in contemporary Canada, empirically documents consequent racial inequalities in hypertension in an original survey dataset from Toronto and Vancouver, Canada, and then attempts to explain the inequalities in hypertension with information on socioeconomic status, perceived experiences with institutionalized and interpersonal discrimination, and psychosocial stress. Methods: Telephone interviews were conducted in 2009 with 706 randomly selected adults living in the City of Toronto and 838 randomly selected adults living in the Vancouver Census Metropolitan Area. Bivariate analyses and logistic regression modeling were used to examine relationships between racial identity, hypertension, socio-demographic factors, socioeconomic status, perceived discrimination and psychosocial stress. Results: The Black Canadians in the sample were the most likely to report major and routine discriminatory experiences and were the least educated and the poorest. Black respondents were significantly more likely than Asian, South Asian and White respondents to report hypertension controlling for age, immigrant status and city of residence. Of the explanatory factors examined in this study, only educational attainment explained some of the relative risk of hypertension for Black respondents. Most of the risk remained unexplained in the models. Conclusions: Consistent with previous Canadian research, socioeconomic status explained a small portion of the relatively high risk of hypertension documented for the Black respondents. Perceived experiences of discrimination both major and routine and self-reported psychosocial stress did not explain these racial inequalities in hypertension. Conducting subgroup analyses by gender, discerning between real and perceived experiences of discrimination and considering potentially moderating factors such as coping strategy and internalization of racial stereotypes are important issues to address in future Canadian racial inequalities research of this kind. [ABSTRACT FROM AUTHOR]

Background: Many Canadian adolescents and young adults with mental health problems face delayed detection, long waiting lists, poorly accessible services, care of inconsistent quality and abrupt or absent inter-service transitions. To address these issues, ACCESS Open Minds, a multi-stakeholder network, is implementing and systematically evaluating a transformation of mental health services for youth aged 11 to 25 at 14 sites across Canada. The transformation plan has five key foci: early identification, rapid access, appropriate care, the elimination of age-based transitions between services, and the engagement of youth and families. Methods: The ACCESS Open Minds Research Protocol has multiple components including a minimum evaluation protocol and a stepped-wedge cluster randomized trial, that are detailed in this paper. Additional components include qualitative methods and cost-effectiveness analyses. The services transformation is being evaluated at all sites via a minimum evaluation protocol. Six sites are participating in the stepped-wedge trial whereby the intervention (a service transformation along the key foci) was rolled out in three waves, each commencing six months apart. Two sites, one high-population and one low-population, were randomly assigned to each of the three waves, i.e., randomization was stratified by population size. Our primary hypotheses pertain to increased referral numbers, and reduced wait times to initial assessment and to the commencement of appropriate care. Secondary hypotheses pertain to simplified pathways to care; improved clinical, functional and subjective outcomes; and increased satisfaction among youth and families. Quantitative measures addressing these hypotheses are being used to determine the effectiveness of the intervention. Discussion: Data from our overall research strategy will help test the effectiveness of the ACCESS Open Minds transformation, refine it further, and inform its scale-up. The process by which our research strategy was developed has implications for the practice of research itself in that it highlights the need to actively engage all stakeholder groups and address unique considerations in designing evaluations of complex healthcare interventions in multiple, diverse contexts. Our approach will generate both concrete evidence and nuanced insights, including about the challenges of conducting research in real-world settings. More such innovative approaches are needed to advance youth mental health services research. Trial registration number: Clinicaltrials.gov, ISRCTN23349893 (Retrospectively registered: 16/02/2017). [ABSTRACT FROM AUTHOR]

Background: Interest in value-based healthcare, generally defined as providing better care at lower cost, has grown worldwide, and learning health systems (LHSs) have been proposed as a key strategy for improving value in healthcare. LHSs are emerging around the world and aim to leverage advancements in science, technology and practice to improve health system performance at lower cost. However, there remains much uncertainty around the implementation of LHSs and the distinctive features of these systems. This paper presents a conceptual framework that has been developed in Canada to support the implementation of value-creating LHSs.Methods: The framework was developed by an interdisciplinary team at the Institut national d'excellence en santé et en services sociaux (INESSS). It was informed by a scoping review of the scientific and grey literature on LHSs, regular team discussions over a 14-month period, and consultations with Canadian and international experts.Results: The framework describes four elements that characterise LHSs, namely (1) core values, (2) pillars and accelerators, (3) processes and (4) outcomes. LHSs embody certain core values, including an emphasis on participatory leadership, inclusiveness, scientific rigour and person-centredness. In addition, values such as equity and solidarity should also guide LHSs and are particularly relevant in countries like Canada. LHS pillars are the infrastructure and resources supporting the LHS, whereas accelerators are those specific structures that enable more rapid learning and improvement. For LHSs to create value, such infrastructures must not only exist within the ecosystem but also be connected and aligned with the LHSs' strategic goals. These pillars support the execution, routinisation and acceleration of learning cycles, which are the fundamental processes of LHSs. The main outcome sought by executing learning cycles is the creation of value, which we define as the striking of a more optimal balance of impacts on patient and provider experience, population health and health system costs.Conclusions: Our framework illustrates how the distinctive structures, processes and outcomes of LHSs tie together with the aim of optimising health system performance and delivering greater value in health systems. [ABSTRACT FROM AUTHOR]

Background: Canadians have long been proud of their universal health insurance system, which publicly funds the cost of physician visits and hospitalizations at the point of care. Prescription drugs however, have been subject to a patchwork of public and private coverage which is frequently inefficient and creates access barriers to necessary medicine for many Canadians. Methods: A narrative review was undertaken to understand the important economic, policy and political considerations regarding implementation of universal prescription drug access in Canada (pan-Canadian pharmacare). PubMed, SCOPUS and google scholar were searched for relevant citations. Citation trails were followed for additional information sources. Published books, public reports, press releases, policy papers, government webpages and other forms of gray literature were collected from iterative internet searches to provide a complete view of the current state on this topic. Main findings: Regarding health economics, all five of the reviewed pharmacare simulation models have shown reductions in annual prescription drug expenditure. However, differing policy and cost assumptions have resulted in a wide range of cost-saving estimates between models. In terms of policy, a single-payer, 'first-dollar' coverage model, using a minimum national formulary, is the model most frequently advocated by the academic community, healthcare professions and many public and patient groups. In contrast, a multi-payer, catastrophic 'last-dollar' coverage model, more similar to the current "patchwork" state of public and private coverage, is preferred by industry drug manufacturers and private health insurance companies. Primary concerns from the detractors of universal, single-payer, 'first-dollar' coverage are the financing required for its implementation and the access barriers that may be created for certain patient populations that are not majorly present in the current public-private payer mix. Conclusion: Canada patiently awaits to see how the issue of prescription drug coverage will be resolved through the work of the Advisory Council on the Implementation of National Pharmacare. The overarching and ongoing discourse on policy and program implementation may be construed as a political debate informed by divergent public and private interests. [ABSTRACT FROM AUTHOR]

Background: Medical tourism is a practice where patients travel internationally to purchase medical services. Medical tourists travel abroad for reasons including costly care, long wait times for care, and limited availability of desired procedures stemming from legal and/or regulatory restrictions. This paper examines bariatric (weight loss) surgery obtained abroad by Canadians through the lens of 'circumvention tourism' - typically applied to cases of circumvention of legal barriers but here applied to regulatory circumvention. Despite bariatric surgery being available domestically through public funding, many Canadians travel abroad to obtain these surgeries in order to circumvent barriers restricting access to this care. Little, however, is known about why these barriers push some patients to obtain these surgeries abroad and the effects of this circumvention.Methods: Semi-structured phone interviews were conducted with 20 former Canadian bariatric tourists between February and May of 2016. Interview questions probed patients' motivations for seeking care abroad, as well as experiences with attempting to obtain care domestically and internationally. Interviews were digitally recorded, transcribed verbatim, and then thematically analyzed.Results: Three key barriers to access were identified: (1) structural barriers resulting in limited locally available options; (2) strict body mass index cut-off points to qualify for publicly-funded surgery; and (3) the extended wait-time and level of commitment required of the mandatory pre-operative program in Canada. It was not uncommon for participants to experience a combination, if not all, of these barriers.Conclusions: Collectively, these barriers restricting domestic access to bariatric care in Canada may leave Canadian patients with a sense that their health care system is not adequately addressing their specific health care needs. In circumventing these barriers, patients may feel empowered in their health care opportunities; however, significant concerns are raised when patients bypass protections built into the health system. Given the practical limitations of a publicly funded health care system, these barriers to care are likely to persist. Health professionals and policy makers in Canada should consider these barriers in the future when examining the implications medical tourism for bariatric surgery holds for Canadians. [ABSTRACT FROM AUTHOR]