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Smylie J, Bourgeois C, Snyder M, Maddox R, McConkey S, Rotondi M, Prince C, Dokis B, Hardy M, Joseph S, Kilabuk A, Mattina JA, Cyr M, Blais G. Design and implementation of the Our Health Counts (OHC) methodology for First Nations, Inuit, and Metis (FNIM) health assessment and response in urban and related homelands. Can J Public Health 2024:10.17269/s41997-024-00867-9. [PMID: 38619750 DOI: 10.17269/s41997-024-00867-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 02/09/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVES Methods for enumeration and population-based health assessment for First Nations, Inuit, and Metis (FNIM) living in Canadian cities are underdeveloped, with resultant gaps in essential demographic, health, and health service access information. Our Health Counts (OHC) was designed to engage FNIM peoples in urban centres in "by community, for community" population health assessment and response. METHODS The OHC methodology was designed to advance Indigenous self-determination and FNIM data sovereignty in urban contexts through deliberate application of Indigenous principles and linked implementation strategies. Three interwoven principles (good relationships are foundational; research as gift exchange; and research as a vehicle for Indigenous community resurgence) provide the framework for linked implementation strategies which include actively building and maintaining relationships; meaningful Indigenous community guidance, leadership, and participation in all aspects of the project; transparent and equitable sharing of project resources and benefits; and technical innovations, including respondent-driven sampling, customized comprehensive health assessment surveys, and linkage to ICES data holdings to generate measures of health service use. RESULTS OHC has succeeded across six urban areas in Ontario to advance Indigenous data sovereignty and health assessment capacity; recruit and engage large population-representative cohorts of FNIM living in urban and related homelands; customize comprehensive health surveys and data linkages; generate previously unavailable population-based FNIM demographic, health, and social information; and translate results into enhanced policy, programming, and practice. CONCLUSION The OHC methodology has been demonstrated as effective, culturally relevant, and scalable across diverse Ontario cities.
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Affiliation(s)
- Janet Smylie
- Well Living House, Li Ka Shing Research Institute, Unity Health Toronto, Toronto, ON, Canada.
- Dalla Lana School of Public Health and Department of Family & Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | | | - Marcie Snyder
- Well Living House, Li Ka Shing Research Institute, Unity Health Toronto, Toronto, ON, Canada
| | - Raglan Maddox
- Well Living House, Li Ka Shing Research Institute, Unity Health Toronto, Toronto, ON, Canada
- National Centre for Epidemiology and Public Health, College of Health & Medicine, The Australian National University, Canberra, Australia
| | - Stephanie McConkey
- Well Living House, Li Ka Shing Research Institute, Unity Health Toronto, Toronto, ON, Canada
| | - Michael Rotondi
- School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | | | - Brian Dokis
- Southwest Ontario Aboriginal Health Access Centre, London, ON, Canada
| | - Michael Hardy
- Anishnawbe Mushkiki Aboriginal Health Access Centre, Thunder Bay, ON, Canada
| | - Serena Joseph
- Waasegiizhig Nanaandawe'iyewigamig Aboriginal Health Access Centre, Kenora, ON, Canada
| | | | - Jo-Ann Mattina
- De dwa da dehs nye>s Aboriginal Health Centre, Hamilton, ON, Canada
| | - Monica Cyr
- Aboriginal Health & Wellness Centre, Winnipeg, MB, Canada
| | - Genevieve Blais
- Well Living House, Li Ka Shing Research Institute, Unity Health Toronto, Toronto, ON, Canada
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Abstract
The authors present a model for pursuing equity in research on health and aging, in terms of: (a) community-driven research governance, with reference to examples inside and outside of the United States, (b) a focus on policy change, where policy is defined broadly in terms of all legislative and regulatory change, and (c) equity-focused research practices, at the level of measurement, analysis, and study design. The model is visualized as a "threefold path" that researchers may walk, to achieve changes within our field, and changes in how we interface with other fields, and communities.
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Affiliation(s)
- James Iveniuk
- The Bridge at NORC, National Opinion Research Center, Chicago, Illinois, USA
| | - Jocelyn Wilder
- The Bridge at NORC, National Opinion Research Center, Chicago, Illinois, USA
| | - Ellis Monk
- Department of Sociology, Harvard University, Cambridge, Massachusetts, USA
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Muir NM, Rotondi M, Brar R, Rotondi NK, Bourgeois C, Dokis B, Hardy M, Maddox R, Smylie J. Our Health Counts: Examining associations between colonialism and ever being incarcerated among First Nations, Inuit, and Métis people in London, Thunder Bay, and Toronto, Canada. Can J Public Health 2023:10.17269/s41997-023-00838-6. [PMID: 38158518 DOI: 10.17269/s41997-023-00838-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 11/06/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES Indigenous peoples have a disproportionately high prevalence of incarceration in the Canadian justice system. However, there is limited Indigenous-driven research examining colonialism and the justice system, specifically associations between racism, externally imposed family disruptions, and history of ever being incarcerated. Therefore, this study examined the association between the proportion of previous incarceration and family disruption, experiences of racism, and victimization for Indigenous adults in London, Thunder Bay, and Toronto, Ontario, Canada. The three communities expressed that they did not want comparison between the communities; rather, they wanted analysis of their community to understand where more supports were needed. METHODS Indigenous community partners used respondent-driven sampling (RDS) to collect data from First Nations, Inuit, and Métis (FNIM) peoples in London, Thunder Bay, and Toronto. Prevalence estimates, 95% confidence intervals, and relative risk were reported using unweighted Poisson models and RDS-adjusted proportions. RESULTS Proportions of ever being incarcerated ranged from 43.0% in London to 54.0% in Toronto and 72.0% in Thunder Bay. In all three cities, history of child protection involvement and experiencing racism was associated with an approximate 25.0% increase in risk for previous incarceration. In Toronto and London, victimization was associated with increased risk for incarceration. CONCLUSION This research highlights disproportionately high prevalence of ever being incarcerated among FNIM living in three Ontario cities. Experiencing racism, family disruption, and victimization are associated with incarceration. Decreasing the rates of family disruption, experiences of racism, and victimization should inform future policy and services to reduce the disproportionately high prevalence of incarceration for FNIM people living in urban settings.
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Affiliation(s)
| | | | - Raman Brar
- Well Living House, Li Ka Shing Knowledge Institute, Unity Health Toronto, St. Michael's Hospital, Toronto, ON, Canada
| | | | | | - Brian Dokis
- Southwest Ontario Aboriginal Health Access Centre (SOAHAC), London, ON, Canada
| | | | - Raglan Maddox
- Research School of Population Health, Australian National University, Canberra, Australia
| | - Janet Smylie
- Well Living House, Li Ka Shing Knowledge Institute, Unity Health Toronto, St. Michael's Hospital, Toronto, ON, Canada
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Gartner DR, Maples C, Nash M, Howard-Bobiwash H. Misracialization of Indigenous people in population health and mortality studies: a scoping review to establish promising practices. Epidemiol Rev 2023; 45:63-81. [PMID: 37022309 DOI: 10.1093/epirev/mxad001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 02/27/2023] [Accepted: 04/03/2023] [Indexed: 04/07/2023] Open
Abstract
Indigenous people are often misracialized as other racial or ethnic identities in population health research. This misclassification leads to underestimation of Indigenous-specific mortality and health metrics, and subsequently, inadequate resource allocation. In recognition of this problem, investigators around the world have devised analytic methods to address racial misclassification of Indigenous people. We carried out a scoping review based on searches in PubMed, Web of Science, and the Native Health Database for empirical studies published after 2000 that include Indigenous-specific estimates of health or mortality and that take analytic steps to rectify racial misclassification of Indigenous people. We then considered the weaknesses and strengths of implemented analytic approaches, with a focus on methods used in the US context. To do this, we extracted information from 97 articles and compared the analytic approaches used. The most common approach to address Indigenous misclassification is to use data linkage; other methods include geographic restriction to areas where misclassification is less common, exclusion of some subgroups, imputation, aggregation, and electronic health record abstraction. We identified 4 primary limitations of these approaches: (1) combining data sources that use inconsistent processes and/or sources of race and ethnicity information; (2) conflating race, ethnicity, and nationality; (3) applying insufficient algorithms to bridge, impute, or link race and ethnicity information; and (4) assuming the hyperlocality of Indigenous people. Although there is no perfect solution to the issue of Indigenous misclassification in population-based studies, a review of this literature provided information on promising practices to consider.
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Affiliation(s)
- Danielle R Gartner
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI 48824, United States
| | - Ceco Maples
- Department of Anthropology, College of Social Science, Michigan State University, East Lansing, MI 48824, United States
| | - Madeline Nash
- Department of Sociology, College of Social Science, Michigan State University, East Lansing, MI 48824, United States
| | - Heather Howard-Bobiwash
- Department of Anthropology, College of Social Science, Michigan State University, East Lansing, MI 48824, United States
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Daneshmand R, Acharya S, Zelek B, Cotterill M, Wood B. Changes in Children and Youth's Mental Health Presentations during COVID-19: A Study of Primary Care Practices in Northern Ontario, Canada. Int J Environ Res Public Health 2023; 20:6588. [PMID: 37623173 PMCID: PMC10454016 DOI: 10.3390/ijerph20166588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/27/2023] [Accepted: 08/11/2023] [Indexed: 08/26/2023]
Abstract
Recent research suggests that children and youth are at increased risk of anxiety and depression due to the indirect effects of the COVID-19 pandemic. In Canada, children and youths may face additional hurdles in accessing mental health services in rural areas due to socioeconomic disadvantages and healthcare provider shortages worsened by the pandemic. Our study aimed to assess changes in primary healthcare utilization related to depression and anxiety among children and youth aged 10-25 years in Northern Ontario, Canada. We analyzed de-identified electronic medical record data to assess primary healthcare visits and prescriptions for depression and anxiety among children and youth aged 10-25 years. We used provider billing data and reasons for visits and antidepressant/antianxiety prescriptions compared with 21 months pre-pandemic (1 June 2018 to 28 February 2020) and 21 months during the pandemic (1 April 2020 to 31 December 2021). Our interrupted time series analysis showed an average increase in visits by 2.52 per 10,000 person-months and in prescriptions by 6.69 per 10,000 person-months across all ages and sexes. Females aged 10 to 14 years were found to have the greatest relative change in visits across all age-sex groups. The greatest relative increases in antianxiety and antidepression prescriptions occurred among females and males aged 10 to 14 years, respectively. These findings indicate that there were increased anxiety and depression presentations in primary healthcare among children and youths living in northern and rural settings during the COVID-19 pandemic. The increased primary healthcare presentations of anxiety and depression by children and youths suggest that additional mental health resources should be allocated to northern rural primary healthcare to support the increased demand. Adequate mental health professionals, accessible services, and clinical recommendations tailored to northern rural populations and care settings are crucial.
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Affiliation(s)
- Roya Daneshmand
- Thunder Bay Regional Health Research Institute, Thunder Bay, ON P7B 6V4, Canada
- Section of Family Medicine, Northern Ontario School of Medicine (NOSM) University, Thunder Bay, ON P7B 5E1, Canada; (S.A.); (B.Z.); (M.C.)
| | - Shreedhar Acharya
- Section of Family Medicine, Northern Ontario School of Medicine (NOSM) University, Thunder Bay, ON P7B 5E1, Canada; (S.A.); (B.Z.); (M.C.)
| | - Barbara Zelek
- Section of Family Medicine, Northern Ontario School of Medicine (NOSM) University, Thunder Bay, ON P7B 5E1, Canada; (S.A.); (B.Z.); (M.C.)
| | - Michael Cotterill
- Section of Family Medicine, Northern Ontario School of Medicine (NOSM) University, Thunder Bay, ON P7B 5E1, Canada; (S.A.); (B.Z.); (M.C.)
| | - Brianne Wood
- Thunder Bay Regional Health Research Institute, Thunder Bay, ON P7B 6V4, Canada
- Section of Family Medicine, Northern Ontario School of Medicine (NOSM) University, Thunder Bay, ON P7B 5E1, Canada; (S.A.); (B.Z.); (M.C.)
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Graham S, Muir NM, Formsma JW, Smylie J. First Nations, Inuit and Métis Peoples Living in Urban Areas of Canada and Their Access to Healthcare: A Systematic Review. Int J Environ Res Public Health 2023; 20:5956. [PMID: 37297560 PMCID: PMC10252616 DOI: 10.3390/ijerph20115956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/12/2023] [Accepted: 05/17/2023] [Indexed: 06/12/2023]
Abstract
In Canada, approximately 52% of First Nations, Inuit and Métis (Indigenous) peoples live in urban areas. Although urban areas have some of the best health services in the world, little is known about the barriers or facilitators Indigenous peoples face when accessing these services. This review aims to fill these gaps in knowledge. Embase, Medline and Web of Science were searched from 1 January 1981 to 30 April 2020. A total of 41 studies identified barriers or facilitators of health service access for Indigenous peoples in urban areas. Barriers included difficult communication with health professionals, medication issues, dismissal by healthcare staff, wait times, mistrust and avoidance of healthcare, racial discrimination, poverty and transportation issues. Facilitators included access to culture, traditional healing, Indigenous-led health services and cultural safety. Policies and programs that remove barriers and implement the facilitators could improve health service access for Indigenous peoples living in urban and related homelands in Canada.
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Affiliation(s)
- Simon Graham
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC 3010, Australia
| | - Nicole M. Muir
- Psychology Department, York University, Toronto, ON M3J 1P3, Canada
| | | | - Janet Smylie
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
- Well Living House, and Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada
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Firestone M, McConkey S, Beaudoin E, Bourgeois C, Smylie J. Mental health and cultural continuity among an urban Indigenous population in Toronto, Canada. Can J Public Health 2022:10.17269/s41997-022-00709-6. [PMID: 36525204 DOI: 10.17269/s41997-022-00709-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 10/05/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Mental health and psychiatric disorders significantly affect individuals on personal and social levels. Indigenous populations in Canada have disproportionately high rates of mental health diagnoses. Our Health Counts (OHC) Toronto assessed mental health, racism, family disruption, and cultural continuity among urban Indigenous people. The objectives of this study were to understand (1) the demographics and characteristics of Indigenous adults with a diagnosed psychological/mental health disorder and (2) potential associations of psychological/mental health diagnoses with experiences of colonization and cultural continuity among Indigenous adults in Toronto. METHODS Using community-based participatory research methods, Indigenous adults in Toronto were recruited by respondent-driven sampling (RDS) to complete a comprehensive health assessment survey. RDS-II weights were applied to calculate population-based estimates, and adjusted odds ratios with 95% confidence intervals were produced using logistic regression, controlling for age and gender. RESULTS Among Indigenous adults, nearly half (45%) reported receiving a mental health diagnosis. Participants reported lifetime anxiety disorders (53%), major depression (51%), and high rates of suicide ideation (78%). Of Indigenous adults with a diagnosed mental health disorder, 72.7% reported participating in ceremony. Attending residential schools (OR: 7.82) and experiencing discrimination (OR: 2.69) were associated with having a mental health disorder. CONCLUSION OHC Toronto responded to the gaps in health assessment data for urban Indigenous people. Despite historic and ongoing trauma, Indigenous people have maintained cultural practices and a strong sense of identity. Efforts aimed at supporting Indigenous well-being must respond to the roots of trauma, racism, and existing Indigenous community knowledge and strengths.
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Affiliation(s)
- Michelle Firestone
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, ON, Canada.
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
| | - Stephanie McConkey
- Well Living House, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Emily Beaudoin
- Well Living House, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | | | - Janet Smylie
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Well Living House, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
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Firestone M, Zewge-Abubaker N, Salmon C, McKnight C, Hwang SW. Using Concept Mapping to Define Indigenous Housing First in Hamilton, Ontario. Int J Environ Res Public Health 2022; 19:12374. [PMID: 36231673 PMCID: PMC9566522 DOI: 10.3390/ijerph191912374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/08/2022] [Accepted: 09/16/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The lasting impact of colonization contributes to the disproportionate rates of homelessness experienced by Indigenous people in Canada. METHODS This study used participatory mixed methods to evaluate an urban, Indigenous-led Housing First program in Ontario to fill knowledge gaps on wise practices addressing the unique dimensions of Indigenous homelessness. Using concept mapping, staff perspectives were engaged to generate 65 unique statements describing program delivery and their interrelationships using a six-cluster map. RESULTS 'Team's Professional Skills' and 'Spiritual Practices' rated high in importance (mean = 4.75 and 4.73, respectively), and feasibility (mean = 4.31 and 4.33, respectively). While fairly important, 'Partnerships and Agency Supports' was ranked least feasible (mean = 3.89). On average, clusters rated higher in importance than feasibility. CONCLUSION Concept mapping draws from local knowledge, elicits strong engagement, and captured the holistic and client-centred approach of an Indigenous Housing First Model.
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Affiliation(s)
- Michelle Firestone
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond St., Toronto, ON M5B1W8, Canada
| | - Nishan Zewge-Abubaker
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond St., Toronto, ON M5B1W8, Canada
| | - Christina Salmon
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond St., Toronto, ON M5B1W8, Canada
| | - Constance McKnight
- De dwa da dehs nye>s Aboriginal Health Centre, 678 Main St E, Hamilton, ON L8M 1K2, Canada
| | - Stephen W. Hwang
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond St., Toronto, ON M5B1W8, Canada
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Jubinville D, Smylie J, Wolfe S, Bourgeois C, Berry NS, Rotondi M, O'Brien K, Venners S. Relationships to land as a determinant of wellness for Indigenous women, two-spirit, trans, and gender diverse people of reproductive age in Toronto, Canada. Can J Public Health 2022:10.17269/s41997-022-00678-w. [PMID: 36042155 DOI: 10.17269/s41997-022-00678-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 07/13/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Disparities in Indigenous reproductive health reflect Canada's historic and ongoing colonial relationship with Indigenous peoples, which includes persistent inequities in health and social services. Reproductive justice scholars and activists advocate for intersectional approaches to enhancing Indigenous health equity that recognize land as a central determinant of wellness. The purpose of this study is to examine the association between relationships to land and wellness in a study of urban Indigenous women, two-spirit, trans, and gender diverse people of reproductive age in Canada's largest city, Toronto. METHODS Data were obtained from the cross-sectional Our Health Counts (OHC) Toronto study, which employed respondent-driven sampling methods (n = 323) and a community-directed comprehensive health assessment survey. In an exploratory analysis, we took an Indigenous reproductive justice theoretical approach to multivariable logistic regression. RESULTS After adjusting for covariates, there was a statistically significant positive association between relationships to the land and wellness that was estimated with good precision (OR 3.7, 95% CI 2.5-5.3). CONCLUSION Our findings indicate that among urban Indigenous women, two-spirit, trans, and gender diverse people of reproductive age there is a positive association between feeling strong in their relationships to land and feeling balanced in the four domains of health (physical, spiritual, mental, and emotional). The community-based, community-directed design of OHC Toronto was congruent with a reproductive justice approach to research. Reproductive justice theories are adaptable to quantitative research on Indigenous reproductive health and can yield novel insights for supporting Indigenous wellness.
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Affiliation(s)
- Danette Jubinville
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.
- Ekw'í7tl Indigenous Doula Collective, Vancouver, British Columbia, Canada.
| | - Janet Smylie
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sara Wolfe
- Seventh Generation Midwives Toronto, Toronto, Ontario, Canada
| | | | - Nicole S Berry
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Michael Rotondi
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
| | - Kristen O'Brien
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Scott Venners
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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Avery L, Maddox R, Abtan R, Wong O, Rotondi NK, McConkey S, Bourgeois C, McKnight C, Wolfe S, Flicker S, Macpherson A, Smylie J, Rotondi M. Modelling prevalent cardiovascular disease in an urban Indigenous population. Can J Public Health 2022:10.17269/s41997-022-00669-x. [PMID: 35945472 DOI: 10.17269/s41997-022-00669-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/28/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Studies have highlighted the inequities between the Indigenous and non-Indigenous populations with respect to the burden of cardiovascular disease and prevalence of predisposing risks resulting from historical and ongoing impacts of colonization. The objective of this study was to investigate factors associated with cardiovascular disease (CVD) within and specific to the Indigenous peoples living in Toronto, Ontario, and to evaluate the reliability and validity of the resulting model in a similar population. METHODS The Our Health Counts Toronto study measured the baseline health of Indigenous community members living in Toronto, Canada, using respondent-driven sampling. An iterative approach, valuing information from the literature, clinical insight and Indigenous lived experiences, as well as statistical measures was used to evaluate candidate predictors of CVD (self-reported experience of discrimination, ethnic identity, health conditions, income, education, age, gender and body size) prior to multivariable modelling. The resulting model was then validated using a distinct, geographically similar sample of Indigenous people living in Hamilton, Ontario, Canada. RESULTS The multivariable model of risk factors associated with prevalent CVD included age, diabetes, hypertension, body mass index and exposure to discrimination. The combined presence of diabetes and hypertension was associated with a greater risk of CVD relative to those with either condition and was the strongest predictor of CVD. Those who reported previous experiences of discrimination were also more likely to have CVD. Further study is needed to determine the effect of body size on risk of CVD in the urban Indigenous population. The final model had good discriminative ability and adequate calibration when applied to the Hamilton sample. CONCLUSION Our modelling identified hypertension, diabetes and exposure to discrimination as factors associated with cardiovascular disease. Discrimination is a modifiable exposure that must be addressed to improve cardiovascular health among Indigenous populations.
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Affiliation(s)
- Lisa Avery
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
| | - Raglan Maddox
- Well Living House, Li Ka Shing Knowledge Institute, Unity Health Toronto - St. Michaels Hospital, Toronto, ON, Canada
- Aboriginal and Torres Strait Islander Health Group, National Centre for Epidemiology and Public Health, Research School of Population Health, The Australian National University, Canberra, Australia
| | - Robert Abtan
- School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | - Octavia Wong
- School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | - Nooshin Khobzi Rotondi
- Well Living House, Li Ka Shing Knowledge Institute, Unity Health Toronto - St. Michaels Hospital, Toronto, ON, Canada
- Ontario Tech University, Oshawa, ON, Canada
| | - Stephanie McConkey
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Well Living House, Li Ka Shing Knowledge Institute, Unity Health Toronto - St. Michaels Hospital, Toronto, ON, Canada
| | - Cheryllee Bourgeois
- Seventh Generation Midwives Toronto, Toronto, ON, Canada
- Metropolitan University, Toronto, ON, Canada
| | | | - Sara Wolfe
- Seventh Generation Midwives Toronto, Toronto, ON, Canada
| | - Sarah Flicker
- School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | - Alison Macpherson
- School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | - Janet Smylie
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Well Living House, Li Ka Shing Knowledge Institute, Unity Health Toronto - St. Michaels Hospital, Toronto, ON, Canada
| | - Michael Rotondi
- School of Kinesiology and Health Science, York University, Toronto, ON, Canada
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Smylie J, McConkey S, Rachlis B, Avery L, Mecredy G, Brar R, Bourgeois C, Dokis B, Vandevenne S, Rotondi MA. Uncovering SARS-COV-2 vaccine uptake and COVID-19 impacts among First Nations, Inuit and Métis Peoples living in Toronto and London, Ontario. CMAJ 2022; 194:E1018-E1026. [PMID: 35918087 PMCID: PMC9481260 DOI: 10.1503/cmaj.212147] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2022] [Indexed: 11/14/2022] Open
Abstract
Background: First Nations, Inuit and Métis Peoples across geographies are at higher risk of SARS-CoV-2 infection and COVID-19 because of high rates of chronic disease, inadequate housing and barriers to accessing health services. Most Indigenous Peoples in Canada live in cities, where SARS-CoV-2 infection is concentrated. To address gaps in SARS-CoV-2 information for these urban populations, we partnered with Indigenous agencies and sought to generate rates of SARS-CoV-2 testing and vaccination, and incidence of infection for First Nations, Inuit and Métis living in 2 Ontario cities. Methods: We drew on existing cohorts of First Nations, Inuit and Métis adults in Toronto (n = 723) and London (n = 364), Ontario, who were recruited using respondent-driven sampling. We linked to ICES SARS-CoV-2 databases and prospectively monitored rates of SARS-CoV-2 testing, diagnosis and vaccination for First Nations, Inuit and Métis, and comparator city and Ontario populations. Results: We found that SARS-CoV-2 testing rates among First Nations, Inuit and Métis were higher in Toronto (54.7%, 95% confidence interval [CI] 48.1% to 61.3%) and similar in London (44.5%, 95% CI 36.0% to 53.1%) compared with local and provincial rates. We determined that cumulative incidence of SARS-CoV-2 infection was not significantly different among First Nations, Inuit and Métis in Toronto (7364/100 000, 95% CI 2882 to 11 847) or London (7707/100 000, 95% CI 2215 to 13 200) compared with city rates. We found that rates of vaccination among First Nations, Inuit and Métis in Toronto (58.2%, 95% CI 51.4% to 64.9%) and London (61.5%, 95% CI 52.9% to 70.0%) were lower than the rates for the 2 cities and Ontario. Interpretation: Although Ontario government policies prioritized Indigenous populations for SARS-CoV-2 vaccination, vaccine uptake was lower than in the general population for First Nations, Inuit and Métis Peoples in Toronto and London. Ongoing access to culturally safe testing and vaccinations is urgently required to avoid disproportionate hospital admisson and mortality related to COVID-19 in these communities.
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Affiliation(s)
- Janet Smylie
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont.
| | - Stephanie McConkey
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont
| | - Beth Rachlis
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont
| | - Lisa Avery
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont
| | - Graham Mecredy
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont
| | - Raman Brar
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont
| | - Cheryllee Bourgeois
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont
| | - Brian Dokis
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont
| | - Stephanie Vandevenne
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont
| | - Michael A Rotondi
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont
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Clark W, Lavoie JG, Mcdonnell L, Nickel N, Anawak J, Brown L, Clark G, Evaluardjuk-Palmer M, Ford F, Dutton R, Wong S, Sanguins J, Katz A. Trends in Inuit health services utilisation in Manitoba: findings from the Qanuinngitsiarutiksait study. Int J Circumpolar Health 2022; 81:2073069. [PMID: 35543481 PMCID: PMC9103522 DOI: 10.1080/22423982.2022.2073069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
There is a notable lack of research related to trends in Inuit accessing health services throughout the land known as Canada. Given Nunavut’s reliance on specialised services provided in the Northwest Territories, Alberta, Manitoba, and Ontario, this gap is particularly problematic, making it more difficult for Nunangat to proactively plan new programs for emerging needs, and for provinces to respond to those needs. The Qanuinngitsiarutiksait study aimed to address this gap by developing detailed profiles of Inuit accessing health services in Manitoba. We used administrative data routinely collected by Manitoba agencies, to support the development of Inuit-centric services. It was conducted in partnership with the Manitoba Inuit Association, and Inuit Elders from Nunavut Canada and Manitoba. We focused on two interrelated cohorts: Kivallirmiut (Inuit from the Kivalliq region of Nunavut) who come to Winnipeg to access specialised services; and Manitobamiut (Inuit already living in Manitoba). Findings show that health services are primarily accessed in Winnipeg. Half of health services accessed by Kivallirmiut are for in-patient care at facilities with the Winnipeg Regional Health Authority. The other half are for advanced out-patient care including specialist consults. For Kivallirmiut, hospitalisation for pregnancy and birth are the most prevalent reasons for hospitalisation, followed by diseases of the respiratory system. Noteworthy, rates of hospitalisation for conditions treatable in primary healthcare for Kivallirmiut are considerably lower than those for Manitobans living in the northern part of the province (where comparable constraints exist). For Inuit adults, rates of hospitalisation for these conditions are comparable to those of Manitobans living in small communities. Inuit living in Manitoba are most often hospitalised for mental health reasons, although other reasons are nearly as prevalent. Our results support the need for more Inuit-centric health programming in Winnipeg.
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Affiliation(s)
- Wayne Clark
- Indigenous Health Initiatives, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Josée G Lavoie
- Director of Ongomiizwin Research, Professor, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Leah Mcdonnell
- Ongomiizwin Research, University of Manitoba, Winnipeg, Canada
| | - Nathan Nickel
- Director of Ongomiizwin Research, Professor, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | | | | | | | | | | | | | - Sabrina Wong
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - Julianne Sanguins
- Health & Wellness Department, Manitoba Métis Federation, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Alan Katz
- Department of Family Medicine, University of Manitoba, Winnipeg, Canada
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Hayward A, Wodtke L, Craft A, Robin T, Smylie J, McConkey S, Nychuk A, Healy C, Star L, Cidro J. Addressing the need for indigenous and decolonized quantitative research methods in Canada. SSM Popul Health 2021; 15:100899. [PMID: 34584930 PMCID: PMC8455856 DOI: 10.1016/j.ssmph.2021.100899] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 08/13/2021] [Accepted: 08/15/2021] [Indexed: 12/01/2022] Open
Abstract
Though qualitative methods are often an appropriate Indigenous methodology and have dominated the literature on Indigenous research methods, they are not the only methods available for health research. There is a need for decolonizing and Indigenizing quantitative research methods, particularly in the discipline of epidemiology, to better address the public health needs of Indigenous populations who continue to face health inequities because of colonial systems, as well as inaccurate and incomplete data collection about themselves. For the last two decades, researchers in colonized countries have been calling for a specifically Indigenous approach to epidemiology that recognizes the limits of Western epidemiological methods, incorporates more Indigenous research methodologies and community-based participatory research methods, builds capacity by training more Indigenous epidemiologists, and supports Indigenous self-determination. Indigenous epidemiology can include a variety of approaches, including: shifting standards, such as age standardization, according to Indigenous populations to give appropriate weight to their experiences; carefully setting recruitment targets and using appropriate recruitment methods to fulfill statistical standards for stratification; acting as a bridge between Indigenous and Western technoscientific perspectives; developing culturally appropriate data collection tools; and developing distinct epidemiological methods based on Indigenous knowledge systems. This paper explores how decolonization and Indigenization of epidemiology has been operationalized in recent Canadian studies and projects, including the First Nations Regional Longitudinal Health Survey and how this decolonization and Indigenization might be augmented with the capacity-building of the future Our Health Counts Applied Indigenous Epidemiology, Health Information, and Health Services and Program Evaluation Training and Mentorship Program in Canada.
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Key Words
- CBPR, community-based participatory research
- CIHR, Canadian Institutes of Health Research
- Capacity-building
- Community-based participatory research
- Decolonized
- Epidemiology
- FNIGC, First Nations Information Governance Centre
- FNIM, First Nations Inuit and Métis
- ISC, Indigenous Services of Canada
- Indigenous research methods
- NEIHR, Network Environments for Indigenous Health Research
- OHC-NET, Our Health Counts Applied Indigenous Epidemiology, Health Information and Health Services and Program Evaluation Training and Mentorship Program
- PAHO, Pan American Health Organization
- Quantitative methods
- RHS, The First Nations Regional Longitudinal Health Survey
- TEC, Tribal Epidemiology Centers
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Affiliation(s)
- Ashley Hayward
- University of Winnipeg, 515 Portage Avenue, Winnipeg, Manitoba, R3B 2E9, Canada
| | - Larissa Wodtke
- University of Winnipeg, 515 Portage Avenue, Winnipeg, Manitoba, R3B 2E9, Canada
| | - Aimée Craft
- University of Ottawa, 57 Louis Pasteur Street, Ottawa, Ontario, K1N 6N5, Canada
| | - Tabitha Robin
- University of Manitoba, 66 Chancellors Circle, Winnipeg, Manitoba, R3T 2N2, Canada
| | - Janet Smylie
- Centre for Urban Health Solutions (C-UHS), St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
| | - Stephanie McConkey
- Centre for Urban Health Solutions (C-UHS), St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
| | - Alexandra Nychuk
- University of Winnipeg, 515 Portage Avenue, Winnipeg, Manitoba, R3B 2E9, Canada
| | - Chyloe Healy
- Blackfoot Confederacy, 820 59th Ave S.E., Unit 100, Calgary, AB, T2H 2G5, Canada
| | - Leona Star
- First Nations Health and Social Secretariat of Manitoba, 74-360 Kernaghan Avenue, Winnipeg, Manitoba, R2C 5G1, Canada
| | - Jaime Cidro
- University of Winnipeg, 515 Portage Avenue, Winnipeg, Manitoba, R3B 2E9, Canada
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Smylie J, O'Brien K, Beaudoin E, Daoud N, Bourgeois C, George EH, Bebee K, Ryan C. Long-distance travel for birthing among Indigenous and non-Indigenous pregnant people in Canada. CMAJ 2021; 193:E948-E955. [PMID: 34155046 PMCID: PMC8248471 DOI: 10.1503/cmaj.201903] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND: For Indigenous Peoples in Canada, birthing on or near traditional territories in the presence of family and community is of foundational cultural and social importance. We aimed to evaluate the association between Indigenous identity and distance travelled for birth in Canada. METHODS: We obtained data from the Maternity Experiences Survey, a national population-based sample of new Canadian people aged 15 years or older who gave birth (defined as mothers) and were interviewed in 2006–2007. We compared Indigenous with non-Indigenous Canadian-born mothers and adjusted for geographic and sociodemographic factors and medical complications of pregnancy using multivariable logistic regression. We categorized the primary outcome, distance travelled for birth, as 0 to 49, 50 to 199 or 200 km or more. RESULTS: We included 3100 mothers living in rural or small urban areas, weighted to represent 31 100 (1800 Indigenous and 29 300 non-Indigenous Canadian-born mothers). We found that travelling 200 km or more for birth was more common among Indigenous compared with non-Indigenous mothers (9.8% v. 2.0%, odds ratio [OR] 5.45, 95% confidence interval [CI] 3.52–8.48). In adjusted analyses, the association between Indigenous identity and travelling more than 200 km for birth was even stronger (adjusted OR 16.44, 95% CI 8.07–33.50) in rural regions; however, this was not observed in small urban regions (adjusted OR 1.04, 95% CI 0.37–2.91). INTERPRETATION: Indigenous people in Canada experience striking inequities in access to birth close to home compared with non-Indigenous people, primarily in rural areas and independently of medical complications of pregnancy. This suggests inequities are rooted in the geographic distribution of and proximal access to birthing facilities and providers for Indigenous people.
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Affiliation(s)
- Janet Smylie
- Well Living House (Smylie), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie), University of Toronto; Ontario HIV Treatment Network (O'Brien); Midwifery Education Program (Bourgeois), Ryerson University; Seventh Generations Midwives Toronto (Bourgeois), Toronto, Ont.; Department of Public Health (Daoud), Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel; National Aboriginal Council of Midwives (Harney George, Bebee), BC; Native Women's Association of Canada (Ryan), Ont.; Bridlewood Medical Centre (Beaudoin), Kanata, Ont.
| | - Kristen O'Brien
- Well Living House (Smylie), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie), University of Toronto; Ontario HIV Treatment Network (O'Brien); Midwifery Education Program (Bourgeois), Ryerson University; Seventh Generations Midwives Toronto (Bourgeois), Toronto, Ont.; Department of Public Health (Daoud), Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel; National Aboriginal Council of Midwives (Harney George, Bebee), BC; Native Women's Association of Canada (Ryan), Ont.; Bridlewood Medical Centre (Beaudoin), Kanata, Ont
| | - Emily Beaudoin
- Well Living House (Smylie), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie), University of Toronto; Ontario HIV Treatment Network (O'Brien); Midwifery Education Program (Bourgeois), Ryerson University; Seventh Generations Midwives Toronto (Bourgeois), Toronto, Ont.; Department of Public Health (Daoud), Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel; National Aboriginal Council of Midwives (Harney George, Bebee), BC; Native Women's Association of Canada (Ryan), Ont.; Bridlewood Medical Centre (Beaudoin), Kanata, Ont
| | - Nihaya Daoud
- Well Living House (Smylie), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie), University of Toronto; Ontario HIV Treatment Network (O'Brien); Midwifery Education Program (Bourgeois), Ryerson University; Seventh Generations Midwives Toronto (Bourgeois), Toronto, Ont.; Department of Public Health (Daoud), Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel; National Aboriginal Council of Midwives (Harney George, Bebee), BC; Native Women's Association of Canada (Ryan), Ont.; Bridlewood Medical Centre (Beaudoin), Kanata, Ont
| | - Cheryllee Bourgeois
- Well Living House (Smylie), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie), University of Toronto; Ontario HIV Treatment Network (O'Brien); Midwifery Education Program (Bourgeois), Ryerson University; Seventh Generations Midwives Toronto (Bourgeois), Toronto, Ont.; Department of Public Health (Daoud), Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel; National Aboriginal Council of Midwives (Harney George, Bebee), BC; Native Women's Association of Canada (Ryan), Ont.; Bridlewood Medical Centre (Beaudoin), Kanata, Ont
| | - Evelyn Harney George
- Well Living House (Smylie), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie), University of Toronto; Ontario HIV Treatment Network (O'Brien); Midwifery Education Program (Bourgeois), Ryerson University; Seventh Generations Midwives Toronto (Bourgeois), Toronto, Ont.; Department of Public Health (Daoud), Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel; National Aboriginal Council of Midwives (Harney George, Bebee), BC; Native Women's Association of Canada (Ryan), Ont.; Bridlewood Medical Centre (Beaudoin), Kanata, Ont
| | - Kerry Bebee
- Well Living House (Smylie), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie), University of Toronto; Ontario HIV Treatment Network (O'Brien); Midwifery Education Program (Bourgeois), Ryerson University; Seventh Generations Midwives Toronto (Bourgeois), Toronto, Ont.; Department of Public Health (Daoud), Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel; National Aboriginal Council of Midwives (Harney George, Bebee), BC; Native Women's Association of Canada (Ryan), Ont.; Bridlewood Medical Centre (Beaudoin), Kanata, Ont
| | - Chaneesa Ryan
- Well Living House (Smylie), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie), University of Toronto; Ontario HIV Treatment Network (O'Brien); Midwifery Education Program (Bourgeois), Ryerson University; Seventh Generations Midwives Toronto (Bourgeois), Toronto, Ont.; Department of Public Health (Daoud), Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel; National Aboriginal Council of Midwives (Harney George, Bebee), BC; Native Women's Association of Canada (Ryan), Ont.; Bridlewood Medical Centre (Beaudoin), Kanata, Ont
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Nelson SE, Rosenberg MW. Age-Friendly Cities and Older Indigenous People: An Exploratory Study in Prince George, Canada. Can J Aging 2021;:1-10. [PMID: 33988115 DOI: 10.1017/S071498082100009X] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Cities around the world are responding to aging populations and equity concerns for older people by developing age-friendly communities plans, following the World Health Organization's guidelines. Such plans, however, often fail to account for the wide diversity of older people in cities, with the result that some older people, including Indigenous older people, do not see their needs reflected in age-friendly planning and policies. This article reports on a study involving 10 older First Nations and Métis women in the city of Prince George, Canada, comparing the expressed needs of these women with two age-friendly action plans: that of the city of Prince George, and that of the Northern Health Authority. Four main categories were raised in a group discussion and interview with these women at the Prince George Native Friendship Centre: availability of health care services, accessibility and affordability of programs and services, special roles of Indigenous Elders, and experiences of racism and discrimination. There are many areas of synergy between the needs expressed by the women and the two action plans; however, certain key areas are missing from the action plans; in particular, specific strategies for attending to the needs of Indigenous and other older populations who often feel marginalized in health care and in age-friendly planning.
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Howard-Bobiwash HA, Joe JR, Lobo S. Concrete Lessons: Policies and Practices Affecting the Impact of COVID-19 for Urban Indigenous Communities in the United States and Canada. Front Sociol 2021; 6:612029. [PMID: 33969048 PMCID: PMC8102815 DOI: 10.3389/fsoc.2021.612029] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/02/2021] [Indexed: 05/12/2023]
Abstract
Throughout the Americas, most Indigenous people move through urban areas and make their homes in cities. Yet, the specific issues and concerns facing Indigenous people in cities, and the positive protective factors their vibrant urban communities generate are often overlooked and poorly understood. This has been particularly so under COVID-19 pandemic conditions. In the spring of 2020, the United Nations High Commissioner Special Rapporteur on the Rights of Indigenous Peoples called for information on the impacts of COVID-19 for Indigenous peoples. We took that opportunity to provide a response focused on urban Indigenous communities in the United States and Canada. Here, we expand on that response and Indigenous and human rights lens to review policies and practices impacting the experience of COVID-19 for urban Indigenous communities. Our analysis integrates a discussion of historical and ongoing settler colonialism, and the strengths of Indigenous community-building, as these shape the urban Indigenous experience with COVID-19. Mindful of the United Nations Declaration on the Rights of Indigenous Peoples, we highlight the perspectives of Indigenous organizations which are the lifeline of urban Indigenous communities, focusing on challenges that miscounting poses to data collection and information sharing, and the exacerbation of intersectional discrimination and human rights infringements specific to the urban context. We include Indigenous critiques of the implications of structural oppressions exposed by COVID-19, and the resulting recommendations which have emerged from Indigenous urban adaptations to lockdown isolation, the provision of safety, and delivery of services grounded in Indigenous initiatives and traditional practices.
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Affiliation(s)
- Heather A. Howard-Bobiwash
- Department of Anthropology, Michigan State University, East Lansing, MI, United States
- Centre for Indigenous Studies, University of Toronto, Toronto, ON, Canada
- *Correspondence: Heather A. Howard-Bobiwash,
| | - Jennie R. Joe
- Department of Family and Community Medicine, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Susan Lobo
- American Indian Studies, University of Arizona, Tucson, AZ, United States
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Churchill ME, Smylie JK, Wolfe SH, Bourgeois C, Moeller H, Firestone M. Conceptualising cultural safety at an Indigenous-focused midwifery practice in Toronto, Canada: qualitative interviews with Indigenous and non-Indigenous clients. BMJ Open 2020; 10:e038168. [PMID: 32994245 PMCID: PMC7526316 DOI: 10.1136/bmjopen-2020-038168] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Cultural safety is an Indigenous concept that can improve how healthcare services are delivered to both Indigenous and non-Indigenous peoples in Canada. This study explored how Indigenous and non-Indigenous clients at an urban, Indigenous-focused midwifery practice in Toronto, Canada (Seventh Generation Midwives Toronto, SGMT) conceptualised and experienced culturally safe care. DESIGN AND SETTING Interviews were conducted with former clients of SGMT as a part of a larger evaluation of the practice. Participants were purposefully recruited. Interviews were transcribed and analysed thematically using an iterative, consensus-based approach and a critical, naturalistic, and decolonising lens. PARTICIPANTS Saturation was reached after 20 interviews (n=9 Indigenous participants, n=11 non-Indigenous participants). RESULTS Three domains of cultural safety emerged. Each domain included several themes: Relationships and Communication (respect and support for choices; personalised and continuous relationships with midwives; and being different from past experiences); Sharing Knowledge and Practice (feeling informed about the basics of pregnancy, birth, and the postpartum period; and having access to Indigenous knowledge and protocols), and Culturally Safe Spaces (feeling at home in practice; and having relationships interconnected with the physical space). While some ideas were shared across groups, the distinctions between the Indigenous and non-Indigenous participants were prominent. CONCLUSION The Indigenous participants conceptualised cultural safety in ways that highlight the survival and resurgence of Indigenous values, understandings, and approaches in cities like Toronto, and affirm the need for Indigenous midwives. The non-Indigenous participants conceptualised cultural safety with both congruence, illuminating Black-Indigenous community solidarities in cultural safety, and divergence, demonstrating the potential of Indigenous spaces and Indigenous-focused midwifery care to also benefit midwifery clients of white European descent. We hope that the positive impacts documented here motivate evaluators and healthcare providers to work towards a future where 'cultural safety' becomes a standard of care.
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Affiliation(s)
- Mackenzie E Churchill
- Well Living House, MAP Centre for Urban Health Solutions (C-UHS), St Michael's Hospital, Toronto, Ontario, Canada
| | - Janet K Smylie
- Well Living House, MAP Centre for Urban Health Solutions (C-UHS), St Michael's Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sara H Wolfe
- Seventh Generation Midwives Toronto (SGMT), Toronto, Ontario, Canada
| | | | - Helle Moeller
- Department of Health Sciences, Lakehead University, Thunder Bay, Ontario, Canada
| | - Michelle Firestone
- MAP Centre for Urban Health Solutions (C-UHS), St. Michael's Hospital, Toronto, Ontario, Canada
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Nguyen NH, Subhan FB, Williams K, Chan CB. Barriers and Mitigating Strategies to Healthcare Access in Indigenous Communities of Canada: A Narrative Review. Healthcare (Basel) 2020; 8:healthcare8020112. [PMID: 32357396 PMCID: PMC7349010 DOI: 10.3390/healthcare8020112] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 11/16/2022] Open
Abstract
The objective of this review is to document contemporary barriers to accessing healthcare faced by Indigenous people of Canada and approaches taken to mitigate these concerns. A narrative review of the literature was conducted. Barriers to healthcare access and mitigating strategies were aligned into three categories: proximal, intermediate, and distal barriers. Proximal barriers include geography, education attainment, and negative bias among healthcare professionals resulting in a lack of or inadequate immediate care in Indigenous communities. Intermediate barriers comprise of employment and income inequities and health education systems that are not accessible to Indigenous people. Distal barriers include colonialism, racism and social exclusion, resulting in limited involvement of Indigenous people in policy making and planning to address community healthcare needs. Several mitigation strategies initiated across Canada to address the inequitable health concerns include allocation of financial support for infrastructure development in Indigenous communities, increases in Indigenous education and employment, development of culturally sensitive education and medical systems and involvement of Indigenous communities and elders in the policy-making system. Indigenous people in Canada face systemic/policy barriers to equitable healthcare access. Addressing these barriers by strengthening services and building capacity within communities while integrating input from Indigenous communities is essential to improve accessibility.
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Affiliation(s)
- Nam Hoang Nguyen
- Department of Agriculture, Food and Nutritional Sciences, University of Alberta, Edmonton, AB T6G 2E1, Canada
| | - Fatheema B. Subhan
- School of Public Health, University of Alberta, Edmonton, AB T6G 1K4, Canada
| | - Kienan Williams
- Population, Public and Indigenous Health Strategic Clinical Network, Alberta Health Services, Calgary, AB T2W 1S7, Canada
| | - Catherine B. Chan
- Department of Agriculture, Food and Nutritional Sciences, University of Alberta, Edmonton, AB T6G 2E1, Canada
- Department of Physiology, University of Alberta, Edmonton, AB T6G 2H7, Canada
- Diabetes, Obesity and Nutrition Strategic Clinical Network, Alberta Health Services, Edmonton, AB, T2W 1S7, Canada
- Correspondence: ; Tel.: +01-780-492-9939
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Monchalin R, Smylie J, Nowgesic E. "I Guess I Shouldn't Come Back Here": Racism and Discrimination as a Barrier to Accessing Health and Social Services for Urban Métis Women in Toronto, Canada. J Racial Ethn Health Disparities 2019; 7:251-261. [PMID: 31664676 DOI: 10.1007/s40615-019-00653-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/08/2019] [Accepted: 10/10/2019] [Indexed: 11/29/2022]
Abstract
Racism serves as a major barrier in access to health and social services, leading to absent, delayed, and/or avoidance of treatment. Métis Peoples experience barriers to accessing both Indigenous-specific and mainstream services yet are often left out of discourses surrounding racism and service access. Racism and discrimination experienced by Métis people is rooted within a deep history of assimilative and racist colonial policies. The objective of this research was to create space for the all too often unacknowledged voices of Métis Peoples by engaging with the traditional community health experts, Métis women. This research aimed to learn from Métis women's experiences to build an understanding on steps toward filling the health service gap. Nested within a longitudinal cohort study, this research employed a conversational method with urban Métis women in Toronto, Canada. In this paper, we share the experiences of racism and discrimination faced by urban Métis women when accessing and working within health and social services. Métis women (n = 11) experience racial discrimination such as witnessing, absorbing, and facing racism in mainstream service settings, while experiencing lateral violence and discrimination in Indigenous-specific services. This research highlights the need for reframing conversations around race, identity, health services, and the urban Métis community.
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Affiliation(s)
- Renée Monchalin
- Faculty of Human and Social Development, School of Public Health and Social Policy, University of Victoria, Victoria, BC, V8P 5C2, Canada. .,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
| | - Janet Smylie
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Well Living House, Centre for Urban Health Solutions (CUHS) in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Earl Nowgesic
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
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21
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Kitching GT, Firestone M, Schei B, Wolfe S, Bourgeois C, O'Campo P, Rotondi M, Nisenbaum R, Maddox R, Smylie J. Unmet health needs and discrimination by healthcare providers among an Indigenous population in Toronto, Canada. Can J Public Health 2019; 111:40-49. [PMID: 31435849 PMCID: PMC7046890 DOI: 10.17269/s41997-019-00242-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 06/26/2019] [Indexed: 11/22/2022]
Abstract
Objectives Inequalities between Indigenous and non-Indigenous peoples in Canada persist. Despite the growth of Indigenous populations in urban settings, information on their health is scarce. The objective of this study is to assess the association between experience of discrimination by healthcare providers and having unmet health needs within the Indigenous population of Toronto. Methods The Our Health Counts Toronto (OHCT) database was generated using respondent-driven sampling (RDS) to recruit 917 self-identified Indigenous adults within Toronto for a comprehensive health assessment survey. This cross-sectional study draws on information from 836 OHCT participants with responses to all study variables. Odds ratios and 95% confidence intervals were estimated to examine the relationship between lifetime experience of discrimination by a healthcare provider and having an unmet health need in the 12 months prior to the study. Stratified analysis was conducted to understand how information on access to primary care and socio-demographic factors influenced this relationship. Results The RDS-adjusted prevalence of discrimination by a healthcare provider was 28.5% (95% CI 20.4–36.5) and of unmet health needs was 27.3% (95% CI 19.1–35.5). Discrimination by a healthcare provider was positively associated with unmet health needs (OR 3.1, 95% CI 1.3–7.3). Conclusion This analysis provides new evidence linking discrimination in healthcare settings to disparities in healthcare access among urban Indigenous people, reinforcing existing recommendations regarding Indigenous cultural safety training for healthcare providers. Our study further demonstrates Our Health Counts methodologies, which employ robust community partnerships and RDS to address gaps in health information for urban Indigenous populations.
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Affiliation(s)
- George Tjensvoll Kitching
- Department of Public Health and General Practice, NTNU, Trondheim, Norway. .,Schulich School of Medicine and Dentistry, Western University, Clinical Skills Building, London, Ontario, N6A 5C1, Canada.
| | - Michelle Firestone
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Berit Schei
- Department of Public Health and General Practice, NTNU, Trondheim, Norway
| | - Sara Wolfe
- Seventh Generation Midwives Toronto, Toronto, Ontario, Canada
| | | | - Patricia O'Campo
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Michael Rotondi
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
| | - Rosane Nisenbaum
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Raglan Maddox
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Faculty of Health, University of Canberra, Canberra, ACT, Australia
| | - Janet Smylie
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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McLaren L, Braitstein P, Buckeridge D, Contandriopoulos D, Creatore MI, Faulkner G, Hammond D, Hoffman SJ, Kestens Y, Leatherdale S, McGavock J, Norman WV, Nykiforuk C, Ridde V, Smylie J. Why public health matters today and tomorrow: the role of applied public health research. Can J Public Health 2019; 110:317-322. [PMID: 30887457 PMCID: PMC6964435 DOI: 10.17269/s41997-019-00196-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 02/12/2019] [Indexed: 11/20/2022]
Abstract
Public health is critical to a healthy, fair, and sustainable society.
Realizing this vision requires imagining a public health community that can maintain
its foundational core while adapting and responding to contemporary imperatives such
as entrenched inequities and ecological degradation. In this commentary, we reflect
on what tomorrow’s public health might look like, from the point of view of our
collective experiences as researchers in Canada who are part of an Applied Public
Health Chairs program designed to support “innovative population health research
that improves health equity for citizens in Canada and around the world.” We view
applied public health research as sitting at the intersection of core principles for
population and public health: namely sustainability, equity, and effectiveness. We
further identify three attributes of a robust applied public health research
community that we argue are necessary to permit contribution to those principles:
researcher autonomy, sustained intersectoral research capacity, and a critical
perspective on the research-practice-policy interface. Our intention is to catalyze
further discussion and debate about why and how public health matters today and
tomorrow, and the role of applied public health research therein.
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Affiliation(s)
| | | | | | | | - Maria I Creatore
- CIHR Institute of Population & Public Health and University of Toronto, Toronto, Canada
| | - Guy Faulkner
- University of British Columbia, Vancouver, Canada
| | | | - Steven J Hoffman
- CIHR Institute of Population & Public Health and York University, Toronto, Canada
| | | | | | - Jonathan McGavock
- University of Manitoba and the Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | | | | | - Valéry Ridde
- IRD (French Institute For Research on Sustainable Development), CEPED (IRD-Université Paris Descartes), ERL INSERM SAGESUD, Université Paris Sorbonne Cités, Paris, France.,University of Montreal Public Health Research Institute (IRSPUM), Montreal, Canada
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Firestone M, Syrette J, Jourdain T, Recollet V, Smylie J. "I feel safe just coming here because there are other Native brothers and sisters": findings from a community-based evaluation of the Niiwin Wendaanimak Four Winds Wellness Program. Can J Public Health 2019; 110:404-413. [PMID: 30868415 DOI: 10.17269/s41997-019-00192-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 01/30/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Urban Indigenous populations in Canada are steadily growing and represent diverse and culturally vibrant communities. Disparities between Indigenous and non-Indigenous peoples' experiences of the social determinants of health are a growing concern. Under the guidance of the West End Aboriginal Advisory Council (WEAAC), Parkdale Queen West Community Health Centre (PQWCHC) launched the Niiwin Wendaanimak Four Winds Wellness Program that seeks to enhance health and community services for homeless and at-risk Indigenous populations in Toronto. OBJECTIVES A process evaluation was carried out to (1) assess the collaborative service delivery model; (2) identify service gaps and issues for homeless and at-risk Indigenous populations; and (3) develop recommendations for how non-Indigenous organizations can provide culturally responsive services for Indigenous populations. METHODS In consultation with the WEAAC, a thematic analysis of qualitative data collected from 2 focus groups with community members who access the Niiwin Wendaanimak program and 17 key informant interviews with staff and peers was conducted. RESULTS The Niiwin Wendaanimak program bridges teachings of inclusivity and the practice of harm reduction to create a non-judgemental space where community members' dignity and autonomy is respected. Strengths of the program include Indigenous leadership and access to activities that promote wellness and community building. CONCLUSIONS As a non-Indigenous service provider, PQWCHC is meeting the needs of homeless and at-risk Indigenous populations in Toronto. Program strengths, system gaps, and challenges including policy recommendations were identified.
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Affiliation(s)
- Michelle Firestone
- Well Living House, Centre for Urban Health Solutions (C-UHS), St. Michael's Hospital, 209 Victoria St, Toronto, ON, M5B1T8, Canada. .,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
| | - Jessica Syrette
- Well Living House, Centre for Urban Health Solutions (C-UHS), St. Michael's Hospital, 209 Victoria St, Toronto, ON, M5B1T8, Canada
| | - Tessa Jourdain
- Well Living House, Centre for Urban Health Solutions (C-UHS), St. Michael's Hospital, 209 Victoria St, Toronto, ON, M5B1T8, Canada
| | - Vivian Recollet
- Parkdale Queen West Central Toronto Community Health Centre, 168 Bathurst Street, Toronto, ON, M5V 2R4, Canada
| | - Janet Smylie
- Well Living House, Centre for Urban Health Solutions (C-UHS), St. Michael's Hospital, 209 Victoria St, Toronto, ON, M5B1T8, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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