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A growing body of evidence points to persistent health inequities within racialized minority communities, and the effects of racial discrimination on health outcomes and health care experiences. While much work has considered how anti-Black racism operates at the interpersonal and institutional levels, limited attention has focused on internalized racism and its consequences for health care. This study explores patients' attitudes towards anti-Black racism in a Canadian health care system, with a particular focus on internalized racism in primary health care. This qualitative study employed purposive maximal variation and snowball sampling to recruit and interview self-identified Black persons aged 18 years and older who: (1) lived in Montréal during the COVID-19 pandemic, (2) could speak English or French, and (3) were registered with the Québec health insurance program. Adopting a phenomenological approach, in-depth interviews took place from October 2021 to July 2022. Following transcription, data were analyzed thematically. Thirty-two participants were interviewed spanning an age range from 22 years to 79 years (mean: 42 years). Fifty-nine percent of the sample identified as women, 38% identified as men, and 3% identified as non-binary. Diversity was also reflected in terms of immigration experience, financial situation, and educational attainment. We identified three major themes that describe mechanisms through which internalized racism may manifest in health care to impact experiences: (1) the internalization of anti-Black racism by Black providers and patients, (2) the expression of anti-Black prejudice and discrimination by non-Black racialized minority providers, and (3) an insensitivity towards racial discrimination. Our study suggests that multiple levels of racism, including internalized racism, must be addressed in efforts to promote health and health care equity among racialized minority groups, and particularly within Black communities. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Direct measures of health care affordability from the user perspective are needed to monitor equitable access to publicly funded health care in Canada. The objective of our study was to develop a survey-based measure of health care affordability applicable to the Canadian context. METHODS: We developed items after focus group exploration of access and cost barriers in the health care trajectory. We administered an initial instrument by telephone to a randomly-selected sample of 750 respondents in metropolitan, rural, and remote settings in Quebec. After analysis we developed a new, self-administered version eliciting the frequency of problem access due to five affordability dimensions. This version was mailed to a subset of participants. We conducted exploratory and confirmatory factor analysis. We used ordinal logistic regression modelling to examine how individual items and the subscale score predicted indicators of difficult access. We looked for effect modification by income categories. RESULTS: The five items load on a single construct with good internal consistency (a = 0.77). The overall score, 0 to 5, reflects the sum of problems with health care affordability due to direct and indirect costs. The item and subscale scores are sensitive to income status, with affordability problems more prevalent among low-income than high-income respondents. Each unit increase in the subscale score predicts increased likelihood of unmet needs (OR = 1.54), emergency room use (OR = 1.41), and delay-related health problem aggravation (OR = 1.80). DISCUSSION: This subscale reliably and validly measures cost barriers to medically necessary services in Canada, and can potentially be applied in other settings with publicly funded health systems. It can be used to monitor and compare health care equity. KEY WORDS: Primary health care; accessibility of health services; Canada; health care disparities; outcome and process assessment (health care) Can J Public Health 2015;106(2):e66-e71 doi: 10.17269/CJPH.106.4562 OBJECTIF: La mesure directe de l'accessibilite economique des soins de sante du point de vue de i'utiiisateur est necessaire pour surveiller I'equite d'acces aux soins de sante finance pubiiquement. Notre objectif est de developper une mesure d'accessibilite financiere des soins de sante applicable au contexte canadien. METHODES: Les items potentiels ont ete developpes a partir de resultats de groupes de discussion explorant les obstacles et facilitateurs de l'acces durant le processus de consommation des soins. La version initiale de l'instrument a ete administree par telephone a un echantillon de 750 repondants selectionne au hasard dans des regions metropolitaines, rurales et eloignees du Quebec. Apres analyse, une nouvelle version auto-administree a ete envoyee a un sous-ensemble de participants. L'echelle mesure la frequence de problemes d'acces selon cinq dimensions d'accessibilite economique. Nous avons effectue des analyses factorielles exploratoires et confirmatoires. Des modeles de regression logistique ordinale ont ete utilises pour examiner la capacite predictive de chaque item et du score de la sous-echelle en terme de difficultes d'acces. Nous avons teste pour la modification de l'effet par categorie de revenu. RESULTATS: Les cinq items de la sous-echelle se regroupent sur un seul facteur qui demontre une bonne coherence interne ([alpha] = 0, 77). Le score global, de 0 a 5, reflete la somme des problemes d'accessibilite economique des soins de sante en raison des couts directs et indirects. Le score est sensible au statut economique des repondants, les problemes d'accessibilite economique etant plus repandus chez les repondants ayant un faible revenu. Un accroissement du score de la sous-echelle predit une propension accrue a declarer des besoins non combles (RC = 1, 54), l'utilisation de soins d'urgence (RC = 1, 41), et une aggravation de problemes de sante due a des delais d'acces (RC = 1, 80). DISCUSSION: Cette sous-echelle mesure de maniere fiable et valide des obstacles economiques aux services medicalement necessaires dans le systeme de sante canadien. Elle pourrait potentiellement etre appliquee dans d'autres pays ayant des soins de sante finances par l'Etat. Il peut etre utilise pour surveiller et comparer l'equite des soins de sante. MOTS CLES: soins de sante primaires; accessibilite aux services de sante; Canada; disparites en soins de sante; evaluation des processus et resultats (soins de sante), The accessibility principle enshrined in the 1984 Canada Health Act (1) guaranteeing public coverage for 'medically necessary services' states that services should be provided uniformly, unimpeded either directly or indirectly [...]