Substance use care innovations during COVID-19: barriers and facilitators to the provision of safer supply at a toronto COVID-19 isolation and recovery site

BACKGROUND

Early in the COVID-19 pandemic, there was an urgent need to establish isolation spaces for people experiencing homelessness who were exposed to or had COVID-19. In response, community agencies and the City of Toronto opened COVID-19 isolation and recovery sites (CIRS) in March 2020. We sought to examine the provision of comprehensive substance use services offered to clients on-site to facilitate isolation, particularly the uptake of safer supply prescribing (prescription of pharmaceutical opioids and/or stimulants) as part of a spectrum of comprehensive harm reduction and addiction treatment interventions.

METHODS

We conducted in-depth, semi-structured interviews with 25 clients and 25 staff (including peer, harm reduction, nursing and medical team members) from the CIRS in April-July 2021. Iterative and thematic analytic methods were used to identify key themes that emerged in the interview discussions.

RESULTS

At the time of implementation of the CIRS, the provision of a safer supply of opioids and stimulants was a novel and somewhat controversial practice. Prescribed safer supply was integrated to address the high risk of overdose among clients needing to isolate due to COVID-19. The impact of responding to on-site overdoses and presence of harm reduction and peer teams helped clinical staff overcome hesitation to prescribing safer supply. Site-specific clinical guidance and substance use specialist consults were crucial tools in building capacity to provide safer supply. Staff members had varied perspectives on what constitutes 'evidence-based' practice in a rapidly changing, crisis situation.

CONCLUSION

The urgency involved in intervening during a crisis enabled the adoption of prescribed safer supply, meeting the needs of people who use substances and assisting them to complete isolation periods, while also expanding what constitutes acceptable goals in the care of people who use drugs to include harm reduction approaches.

The multiple makings of a supervised consumption service in a hospital setting

BACKGROUND

Whereas supervised consumption services (SCSs) are common in many community settings, they are seldomly found in acute care hospitals. As hospitals present unique circumstances that can shape the impacts of an SCS, careful consideration of local implementation contexts and practices is required. We explored the pre-implementation stage of an SCS, to examine how an SCS is made and made differently in relation to the material-discursive context of the hospital.

METHODS

We conducted 11 focus groups with 83 staff and clinicians at an inner-city hospital in Toronto, Canada. Data analysis followed principles of grounded theory and was informed by an 'evidence making interventions' framework.

RESULTS

While most participants indicated they would support the establishment of an SCS at the hospital, multiple enactments of an SCS emerged. An SCS was enacted: as a means to reduce drug-related risks for all people who use drugs, as an opportunity to intervene on patients' drug use, as a means to centralize drug use, and as a transformative intervention for the hospital. In our findings, harm reduction, abstinence, security, and risk mitigation goals existed closely together, yielding overlaying realities.

CONCLUSION

Our findings revealed various enactments of an SCS, some of which are likely to negatively affect people who use drugs and service access. As more hospitals consider the implementation of an SCS, understanding how an SCS is made in practice will be key to building a service that focuses on the needs of people who use drugs.

Exploring the Lived Experience of Self-Management Practices of Indigenous Men, Women, and Two Spirited Individuals Living with Type 2 Diabetes in Canada, the USA, Australia, and New Zealand: A Scoping Review

BACKGROUND

Indigenous men, women and two-spirted individuals have been significantly impacted by type 2 diabetes mellitus (T2DM) and its complications. It is believed that T2DM in Indigenous Peoples is a direct result of colonization and the introduction of changes to traditional Indigenous ways of knowing, being and living.

OBJECTIVES

The broader question will guide the aim of this scoping review: What is currently known about the lived experience of self-managing diabetes in Indigenous men, women and 2S individuals living with T2DM in Canada, USA, Australia and New Zealand? Specific objectives of this scoping review include 1) to explore the lived experience of self-management practices of Indigenous men, women, and two spirited individuals living with T2DM and 2) to describe how self-management experiences, differ from physical, emotional, mental, and spiritual perspectives.

METHODS

A total of six databases were searched and included Ovid Medline, Embase, PsychINFO, CINAHL, Cochrane, and the Native Health Database. An example of keywords searched included self-management, Indigenous, Type 2 Diabetes Mellitus. A total of 37 articles were included in the synthesis of results and the four quadrants of the Medicine Wheel were used to organize and interpret data.

RESULTS

The use of culture within self-management practices was important for Indigenous Peoples. Demographic data was collected for many of the studies including sex and gender characteristics, however only a small number of studies discussed the influence of sex and gender on outcomes.

CONCLUSIONS

Results inform future Indigenous diabetes education and health care service delivery and future research.

Mental health and cultural continuity among an urban Indigenous population in Toronto, Canada

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.

"They have their security, we have our community": Mutual support among people experiencing homelessness in encampments in Toronto during the COVID-19 pandemic

Unaffordable housing is a growing crisis in Canada, exacerbated by the COVID-19 pandemic, yet perspectives of people living outdoors in encampments have primarily gone unheard. We conducted qualitative interviews with encampment residents to explore how mutual support occurred within the social context of encampments. We found that mutually supportive interactions helped residents meet basic survival needs, as well as health and social needs, and reduced common health and safety risks related to homelessness. The homelessness sector should acknowledge that encampment residents form their own positive communities, and ensure policies and services do not isolate people from these beneficial social connections.

Using Concept Mapping to Define Indigenous Housing First in Hamilton, Ontario

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.

Findings From a Process Evaluation of an Indigenous Holistic Housing Support and Mental Health Case Management Program in Downtown Toronto

While urban Indigenous populations in Canada are increasing and represent many diverse and culturally vibrant communities, disparities between Indigenous and non-Indigenous people’s experiences of the social determinants of health are significant. The Mino Kaanjigoowin (MK) program at Na-Me-Res (Native Men’s Residence) in Toronto, Ontario, Canada, supports Indigenous men who are experiencing homelessness or are precariously housed and who have complex health and social needs. Using a community-partnered approach that aligns with wise practices for conducting Indigenous health research, a mixed-methods process evaluation of the MK program was conducted in 2017‒2018 by the Well Living House in partnership with Na-Me-Res. Thematic analysis of qualitative data gathered through two focus groups with community members who access the MK program (n = 9) and key informant interviews with staff (n = 11) was carried out using a decolonizing lens. Results indicate that the MK program provides a unique healing model that is grounded in trust, honour, and respect. Strengths of the program include a harm reduction framework, meeting basic needs, and person-centred care. The program could be enhanced through increased human resource capacity and improved infrastructure, including a separate space for MK staff and activities. The evaluation findings demonstrate how the MK program provides specialized and culturally safe services as a best- practice model to meet the complex health and social needs of urban Indigenous people.

Meeting Indigenous youth where they are at: knowing and doing with 2SLGBTTQQIA and gender non-conforming Indigenous youth: a qualitative case study

Background

Research carried out in partnership with Indigenous youth at The Native Youth Sexual Health Network (NYSHN) demonstrates that Indigenous youth can (and do) develop and implement public health interventions amongst their peers and within their communities, when supported by non-youth allies and mentors.

Methods

Together, NYSHN and Well Living House researchers co-designed a qualitative case study to demonstrate and document how Indigenous youth can and do practice their own form of public health implementation research (PHIR) in the realm of mental health promotion for 2SLGBTTQQIA and Gender Non-Conforming Indigenous youth. Academic and Indigenous youth researchers were: participant observers; conducted a focus group; and designed and implemented an online survey with Indigenous youth project participants. Governance, intellectual property, financial terms and respective academic and NYSHN roles and responsibilities were negotiated using a customized community research agreement. The data were thematically analyzed using a critical decolonizing lens that recognizes the historic and ongoing marginalization of Indigenous peoples while also highlighting the unique and diverse strengths of Indigenous communities’ knowledge and practice in maintaining their health and wellbeing.

Results

Analysis revealed how colonialism and intergenerational trauma have impacted Indigenous youth identity and the value of self-determination as it relates to their identity, their relationships, health and wellbeing. We also learned how knowing and doing about and for Indigenous youth needs to be youth determined – ‘nothing about us, without us’ -- yet also supported by allies. Finally, our analysis shares some promising practices in knowing and doing for and with Indigenous youth.

Conclusions

This study provides a reminder of the need to centre Indigenous youth throughout PHIR in order to realize sustainable benefit from research, services and programming. It emphasizes the need to recognize Indigenous youth as leaders and partners in these initiatives, support their efforts to self-determine, compensate them as partners, and prioritize Indigenous youth-determined frameworks and accountability mechanisms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09863-3.

Conceptualising cultural safety at an Indigenous-focused midwifery practice in Toronto, Canada: qualitative interviews with Indigenous and non-Indigenous clients

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.

Unweighted regression models perform better than weighted regression techniques for respondent-driven sampling data: results from a simulation study

Background

It is unclear whether weighted or unweighted regression is preferred in the analysis of data derived from respondent driven sampling. Our objective was to evaluate the validity of various regression models, with and without weights and with various controls for clustering in the estimation of the risk of group membership from data collected using respondent-driven sampling (RDS).

Methods

Twelve networked populations, with varying levels of homophily and prevalence, based on a known distribution of a continuous predictor were simulated using 1000 RDS samples from each population. Weighted and unweighted binomial and Poisson general linear models, with and without various clustering controls and standard error adjustments were modelled for each sample and evaluated with respect to validity, bias and coverage rate. Population prevalence was also estimated.

Results

In the regression analysis, the unweighted log-link (Poisson) models maintained the nominal type-I error rate across all populations. Bias was substantial and type-I error rates unacceptably high for weighted binomial regression. Coverage rates for the estimation of prevalence were highest using RDS-weighted logistic regression, except at low prevalence (10%) where unweighted models are recommended.

Conclusions

Caution is warranted when undertaking regression analysis of RDS data. Even when reported degree is accurate, low reported degree can unduly influence regression estimates. Unweighted Poisson regression is therefore recommended.

Unmet health needs and discrimination by healthcare providers among an Indigenous population in Toronto, Canada

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.

"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

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.

Our health counts: population-based measures of urban Inuit health determinants, health status, and health care access

Objective

Health determinants and outcomes are not well described for the growing population of Inuit living in southern urban areas of Canada despite known and striking health disparities for Inuit living in the north. The objective of this study was to work in partnership with Tungasuvvingat Inuit (TI) to develop population prevalence estimates for key indicators of health, including health determinants, health status outcomes, and health services access for Inuit in Ottawa, Canada.

Methods

We employed community-based respondent driven sampling (RDS) and a comprehensive health assessment survey to collect primary data regarding health determinants, status, and service access. We then linked with datasets held by the Institute for Clinical Evaluative Sciences (ICES), including hospitalization, emergency room, and health screening records. Adjusted population-based prevalence estimates and rates were calculated using custom RDS software.

Results

We recruited 341 Inuit adults living in Ottawa. The number of Inuit living, working or accessing health and social services in the City of Ottawa was estimated to be 3361 (95% CI 2309–4959). This population experiences high rates of poverty, unemployment, household crowding, and food insecurity. Prevalence of hypertension (25%; 95% CI 18.1–33.9), chronic obstructive pulmonary disease (6.7%; 95% CI 3.1–10.6), cancer (6.8%; 95% CI 2.7–11.9), and rates of emergency room access were elevated for Inuit in Ottawa compared to the general population. Access to health services was rated fair or poor by 43%. Multiple barriers to health care access were identified.

Conclusions

Urban Inuit experience a heavy burden of adverse health determinants and poor health status outcomes. According to urban Inuit in Ottawa, health services available to Inuit at the time of the study were inadequate.

Our Health Counts Toronto: using respondent-driven sampling to unmask census undercounts of an urban indigenous population in Toronto, Canada

OBJECTIVES

To provide evidence of the magnitude of census undercounts of 'hard-to-reach' subpopulations and to improve estimation of the size of the urban indigenous population in Toronto, Canada, using respondent-driven sampling (RDS).

DESIGN

Respondent-driven sampling.

SETTING

The study took place in the urban indigenous community in Toronto, Canada. Three locations within the city were used to recruit study participants.

PARTICIPANTS

908 adult participants (15+) who self-identified as indigenous (First Nation, Inuit or Métis) and lived in the city of Toronto. Study participants were generally young with over 60% of indigenous adults under the age of 45 years. Household income was low with approximately two-thirds of the sample living in households which earned less than $C20 000 last year.

PRIMARY AND SECONDARY OUTCOME MEASURES

We collected baseline data on demographic characteristics, including indigenous identity, age, gender, income, household type and household size. Our primary outcome asked: 'Did you complete the 2011 Census Canada questionnaire?'

RESULTS

Using RDS and our large-scale survey of the urban indigenous population in Toronto, Canada, we have shown that the most recent Canadian census underestimated the size of the indigenous population in Toronto by a factor of 2 to 4. Specifically, under conservative assumptions, there are approximately 55 000 (95% CI 45 000 to 73 000) indigenous people living in Toronto, at least double the current estimate of 19 270.

CONCLUSIONS

Our indigenous enumeration methods, including RDS and census completion information will have broad impacts across governmental and health policy, potentially improving healthcare access for this community. These novel applications of RDS may be relevant for the enumeration of other 'hard-to-reach' populations, such as illegal immigrants or homeless individuals in Canada and beyond.

Substance Use and Related Harms among Aboriginal People in Canada: A Comprehensive Review

BACKGROUND

There is evidence of increasing trends in substance use and related harms among Aboriginal populations in Canada. This paper provides a review of data on alcohol, tobacco, and illicit drug use and related harms.

METHODS

A comprehensive review of public data, journal publications, and grey literature published between 2000 and 2014 were reviewed if data included: people who self-identify as Aboriginal and who live in Canada; drug use; and morbidity and mortality related to drug use. Data were structured by major substance categories and compared with non-Aboriginal sample data where possible.

RESULTS

Over 100 documents were reviewed and revealed a disproportionate burden of substance use and harms, particularly among Aboriginal youth. Significant gaps in data exist, specifically, for urban populations.

CONCLUSION

This review reinforces concerns of many Aboriginal communities and organizations in Canada as well as highlights where prevention, programming, and policy efforts might be most effective.

Effective knowledge translation approaches and practices in Indigenous health research: a systematic review protocol

BACKGROUND

Effective knowledge translation (KT) is critical to implementing program and policy changes that require shared understandings of knowledge systems, assumptions, and practices. Within mainstream research institutions and funding agencies, systemic and insidious inequities, privileges, and power relationships inhibit Indigenous peoples' control, input, and benefits over research. This systematic review will examine literature on KT initiatives in Indigenous health research to help identify wise and promising Indigenous KT practices and language in Canada and abroad.

METHODS

Indexed databases including Aboriginal Health Abstract Database, Bibliography of Native North Americans, CINAHL, Circumpolar Health Bibliographic Database, Dissertation Abstracts, First Nations Periodical Index, Medline, National Indigenous Studies Portal, ProQuest Conference Papers Index, PsycInfo, Social Services Abstracts, Social Work Abstracts, and Web of Science will be searched. A comprehensive list of non-indexed and grey literature sources will also be searched. For inclusion, documents must be published in English; linked to Indigenous health and wellbeing; focused on Indigenous people; document KT goals, activities, and rationale; and include an evaluation of their KT strategy. Identified quantitative, qualitative, and mixed methods' studies that meet the inclusion criteria will then be appraised using a quality appraisal tool for research with Indigenous people. Studies that score 6 or higher on the quality appraisal tool will be included for analysis.

DISCUSSION

This unique systematic review involves robust Indigenous community engagement strategies throughout the life of the project, starting with the development of the review protocol. The review is being guided by senior Indigenous researchers who will purposefully include literature sources characterized by Indigenous authorship, community engagement, and representation; screen and appraise sources that meet Indigenous health research principles; and discuss the project with the Indigenous Elders to further explore the hazards, wisdom, and processes of sharing knowledge in research contexts. The overall aim of this review is to provide the evidence and basis for recommendations on wise practices for KT terminology and research that improves Indigenous health and wellbeing and/or access to services, programs, or policies that will lead to improved health and wellbeing.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016049787 .

Prescription opioid prescribing, use/misuse, harms and treatment among Aboriginal people in Canada: a narrative review of available data and indicators

INTRODUCTION

Prescription opioid (PO) misuse and related harms are high in Canada, and a major public health challenge. In Canada, 1.4 million individuals (4.3% of the total population) self-identify as Aboriginal, among whom substance use and related harms are elevated. While there are reports of PO use and associated problems among Aboriginal groups, no comprehensive data review currently exists.

METHODS

A review of available data sources (ie journal publications, public reports and 'grey' literature) was conducted following principles of a scoping review. Information and data were identified, extracted, and organized into major indicator categories: PO prescribing/dispensing, use/abuse, morbidity/mortality harms and treatment, and narratively reported.

RESULTS

Data suggest that PO dispensing, use and misuse levels among Aboriginal populations are high and/or rising in select settings when compared to the general Canadian population. High levels of PO-related dependence and pregnancy harms exist (mainly in Northern Ontario); there is some indication of elevated opioid mortality among Aboriginals. Vast discrepancies in availability and access to interventions exist; some recent pilot studies suggest improved care.

CONCLUSIONS

Data regarding PO use and harms among Aboriginal people are limited, even though elevated problem levels are indicated; improved monitoring, and more effective yet culturally and contextually appropriate interventions for this acute problem are needed.

Back to the basics: Identifying and addressing underlying challenges in achieving high quality and relevant health statistics for indigenous populations in Canada

Canada is known internationally for excellence in both the quality and public policy relevance of its health and social statistics. There is a double standard however with respect to the relevance and quality of statistics for Indigenous populations in Canada. Indigenous specific health and social statistics gathering is informed by unique ethical, rights-based, policy and practice imperatives regarding the need for Indigenous participation and leadership in Indigenous data processes throughout the spectrum of indicator development, data collection, management, analysis and use. We demonstrate how current Indigenous data quality challenges including misclassification errors and non-response bias systematically contribute to a significant underestimate of inequities in health determinants, health status, and health care access between Indigenous and non-Indigenous people in Canada. The major quality challenge underlying these errors and biases is the lack of Indigenous specific identifiers that are consistent and relevant in major health and social data sources. The recent removal of an Indigenous identity question from the Canadian census has resulted in further deterioration of an already suboptimal system. A revision of core health data sources to include relevant, consistent, and inclusive Indigenous self-identification is urgently required. These changes need to be carried out in partnership with Indigenous peoples and their representative and governing organizations.

Effective strategies to reduce commercial tobacco use in Indigenous communities globally: A systematic review

Background

All over the world, Indigenous populations have remarkably high rates of commercial tobacco use compared to non-Indigenous groups. The high rates of commercial tobacco use in Indigenous populations have led to a variety of health issues and lower life expectancy than the general population. The objectives of this systematic review were to investigate changes in the initiation, consumption and quit rates of commercial tobacco use as well as changes in knowledge, prevalence, community interest, and smoke-free environments in Indigenous populations. We also aimed to understand which interventions had broad reach, what the common elements that supported positive change were and how Aboriginal self-determination was reflected in program implementation.

Methods

We undertook a systematic review of peer-reviewed publications and grey literature selected from seven databases and 43 electronic sources. We included studies between 1994 and 2015 if they addressed an intervention (including provision of a health service or program, education or training programs) aimed to reduce the use of commercial tobacco use in Indigenous communities globally. Systematic cross-regional canvassing of informants in Canada and internationally with knowledge of Indigenous health and/or tobacco control provided further leads about commercial tobacco reduction interventions. We extracted data on program characteristics, study design and learnings including successes and challenges.

Results

In the process of this review, we investigated 73 commercial tobacco control interventions in Indigenous communities globally. These interventions incorporated a myriad of activities to reduce, cease or protect Indigenous peoples from the harms of commercial tobacco use. Interventions were successful in producing positive changes in initiation, consumption and quit rates. Interventions also facilitated increases in the number of smoke-free environments, greater understandings of the harms of commercial tobacco use and a growing community interest in addressing the high rates of commercial tobacco use. Interventions were unable to produce any measured change in prevalence rates.

Conclusions

The extent of this research in Indigenous communities globally suggests a growing prioritization and readiness to address the high rates of commercial tobacco use through the use of both comprehensive and tailored interventions. A comprehensive approach that uses multiple activities, the centring of Aboriginal leadership, long term community investments, and the provision of culturally appropriate health materials and activities appear to have an important influence in producing desired change.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2645-x) contains supplementary material, which is available to authorized users.

Mental health and substance use in an urban First Nations population in Hamilton, Ontario

OBJECTIVES

Mental health and substance use have been identified as health priorities currently facing Indigenous peoples in Canada; however, accessible and culturally relevant population health data for this group are almost non-existent. The aim of the Our Health Counts study was to generate First Nations adult population health data in partnership with the De dwa da dehs ney>s Aboriginal Health Access Centre in Hamilton, Ontario.

METHODS

Analysis involved data gathered through respondent-driven sampling. Prevalence estimates and 95% confidence intervals were generated for diagnosis and treatment of a psychological disorder or mental illness, depression, anxiety, post-traumatic stress disorder (PTSD) and suicide, alcohol and substance use, and access to emotional support.

RESULTS

Of the 554 First Nations adults who participated in the Our Health Counts study in Hamilton, 42% had been told by a health care worker that they had a psychological and/or mental health disorder. High rates of depression (39%) and PTSD (34%), as well as suicide ideation (41%) and attempts (51%) were reported. Half of the sample reported marijuana use in the previous 12 months, and 19% reported the use of cocaine and opiates.

CONCLUSION

First Nations adults living in Hamilton experience a disproportionate burden of mental health and addictions. By working in partnership with urban Aboriginal organizations, it is possible to produce policy- and service-relevant data and address the current deficiency in appropriate mental health and substance use services for urban Aboriginal people.

Unmasking health determinants and health outcomes for urban First Nations using respondent-driven sampling

OBJECTIVE

Population-based health information on urban Aboriginal populations in Canada is limited due to challenges with the identification of Aboriginal persons in existing health data sets. The main objective of the Our Health Counts (OHC) project was to work in partnership with Aboriginal stakeholders to generate a culturally relevant, representative baseline health data set for three urban Aboriginal communities in Ontario, Canada.

DESIGN

Respondent-driven sampling (RDS).

SETTING

Hamilton, Ontario, Canada.

PARTICIPANTS

The OHC study, in partnership with the De dwa da dehs ney >s Aboriginal Health Access Centre (DAHC), recruited 554 First Nations adults living in Hamilton using RDS.

RESULTS

Among First Nations adults living in Hamilton, 78% earned less than $20 000 per year and 70% lived in the lowest income quartile neighbourhoods. Mobility and crowded living conditions were also highly prevalent. Common chronic diseases included arthritis, hypertension, diabetes and chronic obstructive pulmonary disease and rates of emergency room access were elevated.

CONCLUSIONS

RDS is an effective sampling method in urban Aboriginal contexts as it builds on existing social networks and successfully identified a population-based cohort. The findings illustrate striking disparities in health determinants and health outcomes between urban First Nations individuals and the general population which have important implications for health services delivery, programming and policy development.

Intraurban mobility and its potential impact on the spread of blood-borne infections among drug injectors in Tijuana, Mexico

We explored intraurban mobility of Tijuana, Mexico, injection drug users (IDUs). In 2005, 222 IDUs underwent behavioral surveys and infectious disease testing. Participants resided in 58 neighborhoods, but regularly injected in 30. From logistic regression, "mobile" IDUs (injecting ≥3 km from their residence) were more likely to cross the Mexico/U.S. border, share needles, and get arrested for carrying syringes-but less likely to identify hepatitis as an injection risk. Mobile participants lived in neighborhoods with less drug activity, treatment centers, or migrants, but higher marriage and home ownership rates. Mobile IDUs should be targeted for outreach and further investigation. The study's limitations are noted.

Community-based services for homeless adults experiencing concurrent mental health and substance use disorders: a realist approach to synthesizing evidence

Consultations with community-based service providers in Toronto identified a lack of strong research evidence about successful community-based interventions that address the needs of homeless clients experiencing concurrent mental health and substance use disorders. We undertook a collaborative research effort between academic-based and community-based partners to conduct a systematic evidence synthesis drawing heavily from Pawson's realist review methodology to focus on both whether programs are successful and why and how they lead to improved outcomes. We examined scholarly and nonscholarly literature to explore program approaches and program elements that lead to improvements in mental health and substance use disorders among homeless individuals with concurrent disorders (CD). Information related to program contexts, elements, and successes and failures were extracted and further supplemented by key informant interviews and author communication regarding reviewed published studies. From the ten programs that we reviewed, we identified six important and promising program strategies that reduce mental health and, to a far lesser degree, substance use problems: client choice in treatment decision-making, positive interpersonal relationships between client and provider, assertive community treatment approaches, providing supportive housing, providing supports for instrumental needs, and nonrestrictive program approaches. These promising program strategies function, in part, by promoting and supporting autonomy among homeless adults experiencing CD. Our realist informed review is a useful methodology for synthesizing complex programming information on community-based interventions.

"No party hat, no party": successful condom use in sex work in Mexico and the Dominican Republic

Sex workers and their clients are particularly vulnerable to HIV/STI transmission. Most research on condom use has focused on barriers preventing use; less is known about attitudes, motivations and strategies employed by those who feel positively about condoms and who use them successfully. For this qualitative study, we conducted focus group discussions with sex workers (14), both female and transvestite, in Ciudad Juarez, Mexico, and female sex workers (17) and male clients (11) in Santo Domingo, Dominican Republic, who identified themselves as successful condom users in a condom use questionnaire. Discussions explored definitions of successful condom use, motivations and strategies for condom use and messages for future condom promotion. Sex workers defined successful condom use as being in agreement with their clients and partners about using condoms, protecting themselves from disease and unwanted pregnancy, and feeling good about using condoms. Condoms were seen to be hygienic, offer protection and provide a sense of security and peace of mind. Specific strategies included always having condoms on hand, stressing the positive aspects of condoms and eroticising condom use. Future educational messages should emphasise condom use to protect loved ones, increase security and pleasure during sex, and demonstrate respect for both sex workers, clients and partners.

Fentanyl use among street drug users in Toronto, Canada: behavioural dynamics and public health implications

Prescription opioids (POs) are playing an increasingly central role in street drug use and related harms in North America. One distinct PO substance of interest is Fentanyl (Duragesic), a potent opioid analgesic designed for transdermal time-release application. Studies from Europe and North America have documented the sizeable overdose and mortality burden associated with the non-medical use of this drug. This study explores practices and risk dynamics associated with Fentanyl abuse, also considering public health implications. Semi-structured interviews were conducted with 25 regular street-entrenched illicit PO users in Toronto, Canada, a sub-sample of which were recent Fentanyl users. Results showed that while relatively rare on the illicit PO market in Toronto, Fentanyl is a highly desired, sought after and relatively expensive PO drug among street users. In addition, the new 'matrix' patch technology implemented for Fentanyl since 2005 is a limited safeguard against abuse as simple extraction methods are utilized by street users. Finally, distinct risk behaviours relevant for public health emerge due to the high black market costs of Fentanyl and the extraction techniques applied, potentially facilitating high risks for infectious disease (e.g., HCV, HIV) transmission and/or overdose. Consequently, prevalence and practices of Fentanyl use by street users require closer monitoring, targeted interventions and further research regarding risks and outcomes.

Injecting drug users' experiences of policing practices in two Mexican-U.S. border cities: public health perspectives

BACKGROUND

Previous research has identified the impact of law enforcement practices on the behaviours and health of injection drug users (IDUs). We undertook a qualitative study of IDUs' experiences of policing practices in two Mexican cities on the U.S. border.

METHODS

In 2004, two teams of Mexican interviewers conducted in-depth interviews with IDUs residing in Tijuana and Ciudad Juarez (Cd. Juarez), Mexico, who had injected drugs at least once in the prior month. Topics included types of drug used, injection settings, access to sterile needles and experiences with police. Field notes and transcribed interviews were analysed to identify emergent themes.

RESULTS

Amongst the 43 participants, most reported that it is common for IDUs to be arrested and detained for 36h for carrying sterile or used syringes. Most reported that they or someone they knew had been beaten by police. Interviews suggested five key themes relating to police influence on the risk environment: (1) impact of policing practices on accessibility of sterile syringes, (2) influence of police on choice of places to inject drugs (e.g., shooting galleries), (3) police violence, (4) police corruption and (5) perceived changes in policing practices.

CONCLUSION

Findings suggest that some behaviour of police officers in Tijuana and Cd. Juarez is inconsistent with legal norms and may be negatively influencing the risk of acquiring blood-borne infections amongst IDUs. Implementing a comprehensive and successful HIV prevention programme amongst IDUs requires interventions to influence the knowledge, attitudes and practices of law enforcement officers.

Treatment for hepatitis C virus and cannabis use in illicit drug user patients: implications and questions

Illicit drug users are the primary risk group for HCV transmission, and will form the largest HCV treatment population for years to come. Sylvestre et al.'s study suggests that cannabis use may benefit treatment retention and outcomes in illicit drug users undergoing HCV treatment. In fact, there is substantial evidence that cannabis use may help address key challenges faced by drug users in HCV treatment (e.g., nausea, depression), especially when such treatment occurs in the context of methadone maintenance treatment which may amplify these consequences. While further research is required on the biological and clinical aspects of the benefits of cannabis use for HCV treatment, and the effectiveness of cannabis use for HCV treatment needs to be explored in larger study populations, we advocate that in the interim existing barriers to cannabis use are removed for drug users undergoing HCV treatment until the conclusive empirical basis for evidence-based guidance is available.

"Vivo para consumirla y la consumo para vivir" ["I live to inject and inject to live"]: high-risk injection behaviors in Tijuana, Mexico

Injection drug use is a growing problem on the US-Mexico border, where Tijuana is situated. We studied the context of injection drug use among injection drug users (IDUs) in Tijuana to help guide future research and interventions. Guided in-depth interviews were conducted with 10 male and 10 female current IDUs in Tijuana. Topics included types of drug used, injection settings, access to sterile needles, and environmental influences. Interviews were taped, transcribed verbatim, and translated. Content analysis was conducted to identify themes. Of the 20 IDUs, median age and age at first injection were 30 and 18. Most reported injecting at least daily: heroin ("carga", "chiva", "negra"), methamphetamine ("crico", "cri-cri"), or both drugs combined. In sharp contrast to Western US cities, almost all regularly attended shooting galleries ("yongos" or "picaderos") because of the difficulties obtaining syringes and police oppression. Almost all shared needles/paraphernalia ["cuete" (syringe), "cacharros" (cookers), cotton from sweaters/socks (filters)]. Some reported obtaining syringes from the United States. Key themes included (1) pharmacies refusing to sell or charging higher prices to IDUs, (2) ample availability of used/rented syringes from "picaderos" (e.g., charging approximately 5 pesos or "10 drops" of drug), and (3) poor HIV/AIDS knowledge, such as beliefs that exposing syringes to air "kills germs." This qualitative study suggests that IDUs in Tijuana are at high risk of HIV and other blood-borne infections. Interventions are urgently needed to expand access to sterile injection equipment and offset the potential for a widespread HIV epidemic.

Technical aspects of performing lymphoscintigraphy: optimization of methods used to obtain images

Sentinel node detection is an important part of the clinical management of newly diagnosed melanoma. Now there is a similar or even greater enthusiasm for sentinel node evaluation in patients with breast carcinoma. However, controversies exist regarding the dose, volume, and route of administration. Even the role of lymphoscintigraphy itself, in contrast to using only a hand-held gamma probe during surgery for sentinel node detection, is being debated. Nevertheless, many centers and surgeons find that lymphoscintigraphy images are valuable in the treatment of patients and they use lymphoscintigraphy as a guide during surgery and to confirm the results obtained with the hand-held probe. Centers just beginning to use lymphoscintigraphy may find the images especially useful. Given this fact, the authors wanted to define the practical and technical aspects of performing lymphoscintigraphy in patients with breast cancer and examined various methods for the optimization of the technique of image acquisition. The suggested technique is generally free of the controversies noted above and applies to most patients. It includes various maneuvers that aim to improve the rate of sentinel node visualization using the gamma camera and the accuracy of node detection. The recommendations presented here should prove useful for both those experienced and for those centers just beginning to use the technique of lymphoscintigraphy.

Role of exposure databases in risk management

Despite the development of numerous national exposure-related databases, exposure assessment remains a weak link in the chain of risk assessment and risk-management activities. Most databases include measures of environmental releases or concentrations of pollutants in specific media, but do not include actual measures of exposure. If accurate estimates of exposure experienced by populations or individuals are absent, it is impossible to judge the effectiveness of risk-management strategies. The Risk Management Work Group evaluation identified the following needs: refinement of measurements of total exposure experienced by individuals, improved characterization of the distribution of exposures in the population, longitudinal monitoring of exposure trends, and improved information about the public health implications of exposure. Recommendations are presented with the hope that the utility of existing databases will be improved and that future initiatives will be developed that meet the needs of risk management.