Experiences of Intergenerational Trauma in Second-Generation Refugees: Healing Through Occupation

BACKGROUND.

Trauma experienced in one generation can affect the health and well-being of subsequent generations, such as impairing life skills, personal contentment, behaviour patterns and sense of self. This phenomenon has predominantly been explored with descendants of European refugees and is not fully understood from an occupational perspective.

PURPOSE.

This research explores how intergenerational trauma manifests in the occupational lives of second-generation Ilankai Tamil and Vietnamese refugees.

METHODS.

Using qualitative narrative inquiry, 12 adult children of Tamil and Vietnamese refugees residing in the Greater Toronto Area participated in semi-structured interviews. Narratives were thematically analysed.

FINDINGS.

Findings illustrate how sociohistorical, cultural and familial contexts influence the way second-generation refugees view what they can and should do. Many healing responses to intergenerational trauma include occupations focused on communal care.

IMPLICATIONS.

Findings from this study reveal the unique struggles and needs of two understudied populations and the possibilities for healing through occupation.

Comparison of adverse perinatal outcomes between Asians and Caucasians: a population-based retrospective cohort study in Ontario

BACKGROUND

Racial disparities in adverse perinatal outcomes have been studied in other countries, but little has been done for the Canadian population. In this study, we sought to examine the disparities in adverse perinatal outcomes between Asians and Caucasians in Ontario, Canada.

METHODS

We conducted a population-based retrospective cohort study that included all Asian and Caucasian women who attended a prenatal screening and resulted in a singleton birth in an Ontario hospital (April 1st, 2015-March 31st, 2017). Generalized estimating equation models were used to estimate the independent adjusted relative risks and adjusted risk difference of adverse perinatal outcomes for Asians compared with Caucasians.

RESULTS

Among 237,293 eligible women, 31% were Asian and 69% were Caucasian. Asians were at an increased risk of gestational diabetes mellitus, placental previa, early preterm birth (< 32 weeks), preterm birth, emergency cesarean section, 3rd and 4th degree perineal tears, low birth weight (< 2500 g, < 1500 g), small-for-gestational-age (<10th percentile, <3rd percentile), neonatal intensive care unit admission, and hyperbilirubinemia requiring treatment, but had lower risks of preeclampsia, macrosomia (birth weight > 4000 g), large-for-gestational-age neonates, 5-min Apgar score < 7, and arterial cord pH ≤7.1, as compared with Caucasians. No difference in risk of elective cesarean section was observed between Asians and Caucasians.

CONCLUSION

There are significant differences in several adverse perinatal outcomes between Asians and Caucasians. These differences should be taken into consideration for clinical practices due to the large Asian population in Canada.

The effect of race/ethnicity on obesity traits in first year university students from Canada: The GENEiUS study

Background

Little is known about the impact of race/ethnicity on weight change at university. The objective of this study is to determine if ethnicity has an impact on obesity traits in a multiethnic cohort of first-year students at McMaster University in Ontario, Canada.

Methods

183 first year students from the three most represented ethnic groups (South Asian, East Asian, and white-Caucasian) in our study sample were followed longitudinally with data collected early in the academic year and towards the end of the year. Obesity parameters including body weight, body mass index (BMI), waist and hip circumference, and waist hip ratio (WHR) were analyzed. The Wilcoxon signed-rank test was used for pairwise comparison of traits from the beginning to the end of the year in the absence of adjustments. Linear regression was used with covariate adjustments to investigate the effect of ethnicity on obesity traits.

Results

A significant increase in weight by 1.49 kg (95%CI: 1.13–1.85) was observed over the academic year in the overall analyzed sample. This was accompanied by significant gains in BMI, waist and hip circumferences, and WHR. Ethnicity stratified analysis indicated significant increase in all investigated obesity traits in East Asians and all traits, but WHR, in South Asians. White-Caucasians only displayed significant increases in weight and BMI. Body weight and hip circumference were significantly lower in East Asians compared to white-Caucasians at baseline. However, East Asians displayed a significantly larger increase in mean BMI and weight compared to white-Caucasians after first-year. South Asians displayed larger waist circumference at baseline compared to East Asians and larger WHR compared to white-Caucasians.

Conclusion

Our findings demonstrate that ethnicity has an impact on obesity traits in first-year university students. Universities should take ethnicity into account while implementing effective obesity prevention programs to promote healthy and active lifestyles for students.

Health service utilization in immigrants with multiple sclerosis

Background

Access to neurology specialty care can influence outcomes in individuals with multiple sclerosis (MS), but may vary based on patient sociodemographic characteristics, including immigration status.

Objective

To compare health services utilization in the year of MS diagnosis, one year before diagnosis and two years after diagnosis in immigrants versus long-term residents in Ontario, Canada.

Methods

We identified incident cases of MS among adults aged 20–65 years by applying a validated algorithm to health administrative data in Ontario, Canada, a region with universal health insurance and comprehensive coverage. We separately assessed hospitalizations, emergency department (ED) visits, outpatient neurology visits, other outpatient specialty visits, and primary care visits. We compared rates of health service use in immigrants versus long-term residents using negative binomial regression models with generalized estimating equations adjusted for age, sex, socioeconomic status, urban/rural residence, MS diagnosis calendar year, and comorbidity burden.

Results

From 2003 to 2014, there were 13,028 incident MS cases in Ontario, of whom 1,070 (8.2%) were immigrants. As compared to long-term residents, rates of hospitalization were similar (Adjusted rate ratio (ARR) 0.86; 95% CI: 0.73–1.01) in immigrants the year before MS diagnosis, but outpatient neurology visits (ARR 0.93; 95% CI: 0.87–0.99) were slightly less frequent. However, immigrants had higher rates of hospitalization during the diagnosis year (ARR 1.20, 95% CI: 1.04–1.39), and had greater use of outpatient neurology (ARR 1.17, 95% CI: 1.12–1.23) but fewer ED visits (ARR 0.86; 95% CI: 0.78–0.96). In the first post-diagnosis year, immigrants continued to have greater numbers of outpatient neurology visits (ARR 1.16; 95% CI: 1.10–1.23), but had fewer hospitalizations (ARR 0.79; 95% CI: 0.67–0.94).

Conclusions

Overall, our findings were reassuring concerning health services access for immigrants with MS in Ontario, a publicly funded health care system. However, immigrants were more likely to be hospitalized despite greater use of outpatient neurology care in the year of MS diagnosis. Reasons for this may include more severe disease presentation or lack of social support among immigrants and warrant further investigation.

Prevalence, incidence and outcomes of diabetes in Ontario First Nations children: a longitudinal population-based cohort study

BACKGROUND

First Nations people are known to have a higher risk of childhood-onset type 2 diabetes, yet population-level data about diabetes in First Nations children are unavailable. In a partnership between Chiefs of Ontario and academic researchers, we describe the epidemiologic features and outcomes of diabetes in First Nations children in Ontario.

METHODS

We created annual cohorts from 1995/96 to 2014/15 using data from the Registered Persons Database linked with the federal Indian Register. We used the Ontario Diabetes Database to identify children with all types of diabetes and calculated the prevalence and incidence for First Nations children and other children in Ontario. We describe glycemic control in First Nations children and other children in 2014.

RESULTS

In 2014/15, there were 254 First Nations children and 10 144 other children with diagnosed diabetes in Ontario. From 1995/96 to 2014/15, the prevalence increased from 0.17 to 0.57 per 100 children, and the annual incidence increased from 37 to 94 per 100 000 per year among First Nations children. In 2014/15, the prevalence of diabetes was 0.62/100 among First Nations girls and 0.36/100 among other girls. The mean glycosylated hemoglobin level among First Nations children was 9.1% (standard deviation 2.7%) and for other children, 8.5% (standard deviation 2.1%).

INTERPRETATION

First Nations children have substantially higher rates of diabetes than non-Aboriginal children in Ontario; this is likely driven by an increased incidence of type 2 diabetes and increased risk for diabetes among First Nations girls. There is an urgent need for strategies to address modifiable factors associated with the risk of diabetes, improve access to culturally sensitive diabetes care and improve outcomes for First Nations children.

Diabetes during pregnancy and perinatal outcomes among First Nations women in Ontario, 2002/03-2014/15: a population-based cohort study

BACKGROUND

In Canada, increasing numbers of women, especially First Nations women, are affected by diabetes during pregnancy, which is a major risk factor for adverse maternal and neonatal outcomes. The aim of this study was to examine temporal trends in pregnancy outcomes and use of health care services in a population-based cohort of First Nations women compared to other women in Ontario according to diabetes status during pregnancy.

METHODS

Using health administrative databases, we created annual cohorts of pregnant women from 2002/03 to 2014/15 and identified those with preexisting diabetes and gestational diabetes. We used the Indian Register to identify First Nations women. We estimated rates of adverse maternal and infant outcomes, and measures of use of health care services in each population.

RESULTS

There were 1 671 337 deliveries among 1 065 950 women during the study period; of these deliveries, 31 417 (1.9%) were in First Nations women, and 1 639 920 (98.1%) were in other women. First Nations women had a higher prevalence of preexisting diabetes and gestational diabetes than other women in Ontario. First Nations women with preexisting diabetes had higher rates of preeclampsia (3.2%-5.6%), labour induction (33.4%-42.9%) and cesarean delivery (47.8%-53.7%) than other women in Ontario, as did First Nations women with gestational diabetes (3.2%-4.7%, 38.5%-46.9% and 41.4%-43.4%, respectively). The rate of preterm birth was similar between First Nations women and other women in Ontario. Although First Nations women had a higher rate of babies who were large for gestational age than other women, regardless of diabetes status, obstructed labour rates were similar for the 2 cohorts. Almost all First Nations women, regardless of diabetes status, were seen by a primary care provider during their pregnancy, but rates of use of specialty care were lower for First Nations women than for other women. Fifteen percent of all pregnant women with preexisting diabetes visited an ophthalmologist during their pregnancy.

INTERPRETATION

Our results confirm disparities in maternal and neonatal outcomes between First Nations women and other women in Ontario. Access to primary care for pregnant women seemed adequate, but access to specialized care, especially for women with preexisting diabetes, needs to improve.

Ethnic differences in acute heart failure outcomes in Ontario

BACKGROUND

Previous studies have identified ethnic differences in outcomes after episodes of acute heart failure in natives of Asia as compared to those of Europe. Whether these ethnic differences in outcomes would still exist, years after migration to a different geographical and cultural setting remain unclear. We investigated the one-year mortality after an episode of acute heart failure admission in Ontario residents of South Asian and Chinese descent as compared to the General Population.

METHODS

We conducted a population-based, retrospective cohort study of adult Ontarions who were hospitalized for AHF between April 1, 2010 and March 31, 2016. Ethnicity was categorized using validated surname-based algorithms. The primary outcome was all-cause one-year mortality. Mortality rates were calculated using the Kaplan-Meier method. The relative hazard of death was assessed using a multivariable Cox proportional hazard model.

RESULTS

Of 82,125 patients, 1287 (1.6%) were Chinese, 1662 (2.0%) were South Asians, and the remaining 79,176 (96.4%) were of the General Population. The risk of mortality was markedly lower amongst South Asians (adjusted HR 0.81, 95% CI [0.73-0.89]) relative to the General Population. There was no statistically significant difference in the risk of mortality between Chinese and the General Population (adjusted HR 1.00 [0.91-1.10]). In addition, guideline-directed medical therapies were associated with similar survival benefit in patients of all three ethnic origins.

CONCLUSIONS

We found a lower risk of one-year mortality after acute heart failure hospitalization amongst South Asians compared to Chinese and the General Population, and similar benefit of medical therapy in all three groups. Further studies are needed to explore the etiologies of these ethnic disparities to truly improve outcomes at the population level.

Mental Health Consultation Among Ontario's Immigrant Populations

To determine the prevalence rates and characteristics of past-year mental health consultation for Ontario's adult (18 + years old) immigrant populations. The Canadian Community Health Survey (CCHS) 2012 was used to calculate the prevalence rates of past-year mental health consultation by service provider type. Characteristics associated with mental health consultation were determined by carrying out multivariable logistic regression analysis on merged CCHS 2008-2012 data. Adult immigrant populations in Ontario (n = 3995) had lower estimated prevalence rates of past-year mental health consultation across all service provider types compared to Canadian-born populations (n = 14,644). Amongst those who reported past-year mental health consultation, 57.89% of Ontario immigrants contacted their primary care physician, which was significantly higher than the proportion who consulted their family doctor from Canadian-born populations (45.31%). The factors of gender, age, racial/ethnic background, education level, working status, food insecurity status, self-perceived health status, smoking status, alcohol drinking status, years since immigration, and age at time of immigration were significantly associated with past-year mental health consultation for immigrant populations. Ontario's adult immigrant populations most commonly consult their family doctor for mental health care. Potential exists for expanding the mental health care role of primary care physicians as well as efforts to increase accessibility of specialized mental health services. Integrated, coordinated care where primary care physicians, specialized mental health professionals, social workers, and community educators, etc. working together in a sort of "one-stop-shop" may be the most effective way to mitigate gaps in the mental health care system. In order to effectively tailor mental health policy, programming, and promotion to suit the needs of immigrant populations initiatives that focus on the connection between physical and mental health and migration variables such as length of stay in Canada, years since immigration, and other important migration variables (beyond the scope of the CCHS which require further study) need to be developed. Examination of the social determinants of mental health is critical to understand how we can best serve the mental health needs of Ontario's immigrant populations.

Blood cadmium concentrations and environmental exposure sources in newcomer South and East Asian women in the Greater Toronto Area, Canada

BACKGROUND

Immigrant women are often identified as being particularly vulnerable to environmental exposures and health effects. The availability of biomonitoring data on newcomers is limited, thus, presenting a challenge to public health practitioners in the identification of priorities for intervention.

OBJECTIVES

In fulfillment of data needs, the purpose of this study was to characterize blood concentrations of cadmium (Cd) among newcomer women of reproductive age (19-45 years of age) living in the Greater Toronto Area (GTA), Canada and to assess potential sources of environmental exposures.

METHODS

A community-based model, engaging peer researchers from the communities of interest, was used for recruitment and follow-up purposes. Blood samples were taken from a total of 211 newcomer women from South and East Asia, representing primary, regional origins of immigrants to the GTA, and environmental exposure sources were assessed via telephone survey. Metal concentrations were measured in blood samples (diluted with 0.5% (v/v) ammonium hydroxide and 0.1% (v/v) octylphenol ethoxylate) using a quadrupole ICP-MS. Survey questions addressed a wide range of environmental exposure sources, including dietary and smoking patterns and use of nutritional supplements, herbal products and cosmetics.

RESULTS

A geometric mean (GM) blood Cd concentration of 0.39µg/L (SD:±2.07µg/L) was determined for study participants (min/max: <0.045µg/L (LOD)/2.36µg/L). Several variables including low educational attainment (Relative Ratio (RR) (adjusted)=1.50; 95% CI 1.17-1.91), milk consumption (RR (adjusted)=0.86; 95% CI 0.76-0.97), and use of zinc supplements (RR (adjusted)=0.76; 95% CI 0.64-0.95) were observed to be significantly associated with blood Cd concentrations in the adjusted regression model. The variable domains socioeconomic status (R²_adj=0.11) and country of origin (R²_adj=0.236) were the strongest predictors of blood Cd.

CONCLUSION

Blood Cd concentrations fell below those generally considered to be of human health concern. However, negative health effects cannot be entirely excluded, especially for those that fall in the upper percentile range of the distribution, given the mounting evidence for negative health outcomes at low environmental exposure concentrations.

Healing the Spirit: Exploring Sexualized Trauma and Recovery among Indigenous Men in Toronto

Colonial policies in Canada have led to social disruption and intergenerational trauma across Indigenous nations, contributing to high rates of sexualized violence within many communities. While mental health and social science discourse has identified the harmful impacts of violence against Indigenous women in Canada, there continues to be a lack of focus on the unique mental health needs of Indigenous men in this regard. This article reviews the results of a nationally funded research study which looked at the mental health and healing needs of Indigenous men in Toronto who have experienced sexualized trauma. This study followed Indigenous protocols for research and was conducted in partnership with Anishnawbe Health Toronto, a culture-based community health center. The methodology utilized a narrative inquiry and interviewed six community men about their recovery journeys and ten community healers and counselors about recovery through a gendered lens. The results explore the discourses that contribute to the social construction of masculinity(ies) and the impacts of these social norms on help-seeking behaviors. These results inform culturally appropriate and gender-relevant mental health service provision for Indigenous male clients recovering from sexualized trauma.

Mining in subarctic Canada: airborne PM2.5 metal concentrations in two remote First Nations communities

Airborne particulate matter arising from upwind mining activities is a concern for First Nations communities in the western James Bay region of Ontario, Canada. Aerosol chemical components were collected in 2011 from two communities in northern Ontario. The chemical and mass concentration data of particulate matter collected during this study shows a significant difference in PM2.5 in Attawapiskat compared to Fort Albany. Elemental profiles indicate enhanced levels of some tracers thought to arise from mining activities, such as, K, Ni, and crustal materials. Both communities are remote and isolated from urban and industrial pollution sources, however, Attawapiskat First Nation has significantly enhanced levels of particulate matter, and it is likely that some of this arises from upwind mining activities.

A systematic review of the effectiveness of school-based obesity prevention programmes for First Nations, Inuit and Métis youth in Canada

First Nations, Inuit and Métis (FNIM) youth are disproportionately affected by obesity and represent known a high-risk group in Canada. School-based prevention programmes may have the potential to effectively influence obesity-related health behaviours (i.e. healthy eating and physical activity) among this population. We conducted a systematic review of nine electronic databases (2003-2014) to identify studies that describe school-based programmes that have been developed to improve obesity-related health behaviours and outcomes among FNIM youth in Canada. The objectives of this review were to identify and evaluate the effectiveness of these programmes and assess the strength of the methodologies used to evaluate them. Fifteen studies, representing seven distinct interventions, met our inclusion criteria. The majority of these programmes did not result in significant improvements in outcomes related to obesity, healthy eating, or physical activity among FNIM youth. The studies varied in design rigour and use of evaluation activities. The lack of literature on effective school-based programmes for FNIM youth in Canada that target obesity-related outcomes highlights a priority area for future intervention development, evaluation and dissemination within the peer-reviewed literature. Further research is needed on interventions involving Métis and Inuit youth, secondary school-aged FNIM youth and FNIM youth living in urban settings.

Lesbians in the city: mobilities and relational geographies

This article examines contemporary lesbians' (and queer women's) urban geographies, drawing from empirical research on Toronto, Canada and Sydney, Australia. Our argument is grounded in research highlighting lesbians' distinctive urban experiences: lesbians have both participated in gay villages and gay male spaces and, importantly, carved out their own urban places, including commercial and residential concentrations. In this article we use new mobilities scholarship to delineate historical and contemporary relational geographies materializing since World War II, which continue to rewrite lesbians' and queer women's inhabitation and experiences of urban landscapes in Toronto and Sydney.

The MaBwana Black men's study: community and belonging in the lives of African, Caribbean and other Black gay men in Toronto

In Canada, there is a paucity of research aimed at understanding Black gay men and the antecedents to risk factors for HIV. This study is an attempt to move beyond risk factor analysis and explore the role of sexual and ethnic communities in the lives of these men. The study utilized a community-based research and critical race theory approach. Semi-structured interviews were conducted with eight key informants to augment our understanding of Black gay men and to facilitate recruitment of participants. In-depth interviews were done with 24 Black gay men. Our data showed that the construction of community for Black gay men is challenged by their social and cultural environment. However, these men use their resilience to navigate gay social networks. Black gay men expressed a sense of abjuration from both gay and Black communities because of homophobia and racism. It is essential for health and social programmers to understand how Black gay men interact with Black and gay communities and the complexities of their interactions in creating outreach educational, preventive and support services.

HIV, gender, race, sexual orientation, and sex work: a qualitative study of intersectional stigma experienced by HIV-positive women in Ontario, Canada

BACKGROUND

HIV infection rates are increasing among marginalized women in Ontario, Canada. HIV-related stigma, a principal factor contributing to the global HIV epidemic, interacts with structural inequities such as racism, sexism, and homophobia. The study objective was to explore experiences of stigma and coping strategies among HIV-positive women in Ontario, Canada.

METHODS AND FINDINGS

We conducted a community-based qualitative investigation using focus groups to understand experiences of stigma and discrimination and coping methods among HIV-positive women from marginalized communities. We conducted 15 focus groups with HIV-positive women in five cities across Ontario, Canada. Data were analyzed using thematic analysis to enhance understanding of the lived experiences of diverse HIV-positive women. Focus group participants (n = 104; mean age = 38 years; 69% ethnic minority; 23% lesbian/bisexual; 22% transgender) described stigma/discrimination and coping across micro (intra/interpersonal), meso (social/community), and macro (organizational/political) realms. Participants across focus groups attributed experiences of stigma and discrimination to: HIV-related stigma, sexism and gender discrimination, racism, homophobia and transphobia, and involvement in sex work. Coping strategies included resilience (micro), social networks and support groups (meso), and challenging stigma (macro).

CONCLUSIONS

HIV-positive women described interdependent and mutually constitutive relationships between marginalized social identities and inequities such as HIV-related stigma, sexism, racism, and homo/transphobia. These overlapping, multilevel forms of stigma and discrimination are representative of an intersectional model of stigma and discrimination. The present findings also suggest that micro, meso, and macro level factors simultaneously present barriers to health and well being--as well as opportunities for coping--in HIV-positive women's lives. Understanding the deleterious effects of stigma and discrimination on HIV risk, mental health, and access to care among HIV-positive women can inform health care provision, stigma reduction interventions, and public health policy.

Delivering away from home: the perinatal experiences of First Nations women in northwestern Ontario

INTRODUCTION

Our objective was to understand the perinatal knowledge and experiences of First Nations women from northwestern Ontario who travel away from their remote communities to give birth.

METHODS

A systematic review of MEDLINE, HealthSTAR, HAPI, Embase, AMED, PsycINFO and CINAHL was undertaken using Medical Subject Headings and keywords focusing on Canadian Aboriginal (First Nations, Metis and Inuit) prenatal education and care, and maternal health literacy. This qualitative study using semistructured interviews was conducted in a rural hospital and prenatal clinic that serves First Nations women. Thirteen women from remote communities who had travelled to Sioux Lookout, Ont., to give birth participated in the study.

RESULTS

We identified 5 other qualitative studies that explored the birthing experiences of Aboriginal women. The studies documented a negative experience for women who travelled to access intrapartum maternity care. While in Sioux Lookout to give birth, our participants also experienced loneliness and missed their families. They were open to the idea of a culturally appropriate doula program and visits in hospital by First Nations elders, but they were less interested in access to tele-visitation with family members back in their communities. We found that our participants received most of their prenatal information from family members.

CONCLUSION

First Nations women who travel away from home to give birth often travel great cultural and geographic distances. Hospital-based maternity care programs for these women need to achieve a balance of clinical and cultural safety. Programs should be developed to lessen some of the negative consequences these women experience.

Accuracy of the Broselow tape in estimating the weight of First Nations children

INTRODUCTION

During resuscitation, the Broselow tape (BT) is the standard method of estimating pediatric weight based on body length. The First Nations population has a higher prevalence of obesity and experiences more injury than the non-First Nations population. The prevalence of obesity has raised the concern that the BT may not accurately estimate weight in this population. The purpose of this study was to validate the BT in 8 First Nations communities.

METHODS

We performed a search of the electronic medical records of 2 community health centres that serve 8 local First Nations communities. We searched for the most recent clinic visit during which height and weight had been recorded in the records of patients less than 10 years of age with a postal code indicating residence in a First Nations community. The patients' actual weight was compared with their BT weight estimates using the Bland-Altman method. The Spearman coefficient of rank and percentage error was also calculated.

RESULTS

A total of 243 children were included in the study (119 girls, 124 boys). The mean age was 33.3 months (95% confidence interval [CI] 29.7 to 36.9), mean height was 91.8 cm (95% CI 89.0 to 94.6), mean weight was 16.2 kg (95% CI 15.0 to 17.3)and mean BT weight was 14.0 kg (95% CI 13.1 to 14.8). The Bland-Altman percent difference was 11.9% (95% CI -17.3% to 41.1%). The Spearman coefficient of rank correlation was 0.963 (p < 0.001). The BT had a percentage error greater than 10% error 51.8% of the time, with 49.4% being underestimations.

CONCLUSION

The BT was often not accurate at estimating the weight of children in 8 First Nations communities; it underestimated their weight almost half of the time.

"Mr. Burk is most interested in their welfare": J.G. Burk's campaign to help the Anishinabeg of northwestern Ontario, 1923-53

Although there is a small but growing body of literature on Euro-Canadians who acted "with good intentions" towards the First Nations (Haig-Brown and Nock 2006), precious little has been written about those within the ranks of the Department of Indian Affairs who acted benevolently towards the Aboriginal peoples. James Gerry Burk, Indian agent for the Anishinabeg of the western Lake Superior region for three decades (1923-53), was one such individual. He chose to ignore the department's prevailing racist ideology in favour of nurturing the incipient desire for industry and enterprise that he saw first-hand among the Aboriginal constituents of his agency. In the process, he was compelled to overcome numerous obstacles that Indian Affairs placed in his way. As a result, Burk's career stands as a glowing testament to the indomitable spirit of one departmental official's commitment to assisting the Aboriginal peoples.

Comparative efficiency assessment of primary care service delivery models using data envelopment analysis

This paper compares the relative productive efficiencies of four models of primary care service delivery using the data envelopment analysis method on 130 primary care practices in Ontario, Canada. A quality-controlled measure of output and two input scenarios are employed: one with full-time-equivalent labour inputs and the other with total expenditures. Regression analysis controls for the mix of patients in the practice population. Overall, we find that community health centres fare the worst when it comes to relative efficiency scores.

The role of the Toronto Girls' Home, 1863-1910

It has been suggested that the role of Ontario children's homes, who had for half a century been helping disadvantaged children, changed significantly and immediately under the 'Children's Protection Act of 1893'. However, the records of the girls admitted to Toronto Girls' Home from 1863 to 1910 suggest that this was not the case, for this home at least. For most of their history, their core clientele was the children of poor respectable parents dealing with a crisis or who could not both work and care for their children. Thus, although prior to 1893 they did also care for a significant number of neglected children, and after 1893 fewer such children were admitted, the Home continued for more than 20 years to help families as they always had, providing a form of family support for which the child protection system was not designed.

Framing the new midwifery: media narratives in Ontario and Quebec during the 1980s and 1990s

After long periods of activism and policy debate, Ontario and Quebec were the first two provinces to integrate midwifery into their health-care services. Despite its success and growing popularity in the post-legislative era, midwifery was a highly contentious policy issue, with debates emerging at every level of policy development. In this essay, the authors explore how these debates played out in media. Specifically, the authors suggest that the frames produced by newspapers during this period served to align midwifery with broader provincial socio-political discourses, which in turn legitimized state intervention in the area of reproductive health. At the same time, however, the authors demonstrate that where Ontario media representations muted differences between midwives and physicians, representations in Quebec emphasized them. Thus, the authors show that in very different ways, media representations of midwifery in Ontario and Quebec both established a discursive context in which the state had to "act on" midwifery and midwives, and also challenged the potential of midwifery to transform women's birth experiences.

First Nations women's knowledge of menopause: experiences and perspectives

OBJECTIVE

To understand and describe the menopause experiences and perspectives of First Nations women residing in northwestern Ontario.

DESIGN

Phenomenologic approach using in-depth qualitative interviews.

SETTING

Sioux Lookout, Ont, and 4 surrounding First Nations communities.

PARTICIPANTS

Eighteen perimenopausal and postmenopausal First Nations women, recruited by convenience and snowball sampling techniques.

METHODS

Semistructured interviews were audiotaped and transcribed. Themes emerged through a crystallization and immersion analytical approach. Triangulation of methods was used to ensure reliability of findings.

MAIN FINDINGS

This study confirms the hypothesis that menopause is generally not discussed by First Nations women, particularly with their health care providers. The generational knowledge gained by the women in this study suggests that a variety of experiences and symptoms typical of menopause from a medical perspective might not be conceptually linked to menopause by First Nations women. The interview process and initial consultation with translators revealed that there is no uniform word in Ojibway or Oji-Cree for menopause. A common phrase is "that time when periods stop," which can be used by caregivers as a starting point for discussion. Participants' interest in the topic and their desire for more information might imply that they would welcome the topic being raised by health care providers.

CONCLUSION

This study speaks to the importance of understanding the different influences on a woman's menopause experience. Patient communication regarding menopause might be enhanced by providing women with an opportunity or option to discuss the topic with their health care providers. Caregivers should also be cautious of attaching preconceived ideas to the meaning and importance of the menopause experience.

Alberta's and Ontario's liquor boards: why such divergent outcomes?

The provinces of Alberta and Ontario have chosen very different methods to distribute alcoholic beverages: Alberta privatized the Alberta Liquor Control Board (ALCB) in 1993 and established a private market to sell beverage alcohol, while Ontario, in stark contrast, opted to retain and expand the Liquor Control Board of Ontario (LCBO). This article examines the reasons for the divergent policy choices made by Ralph Klein and Mike Harris' Conservative governments in each province. The article draws on John Kingdon's “multiple streams decision-making model,” to examine the mindsets of the key decision-makers, as well as “historical institutionalism,” to organize the pertinent structural, historical and institutional variables that shaped the milieu in which decision-makers acted. Unique, province-specific political cultures, histories, institutional configurations (including the relative influence of a number of powerful actors), as well as the fact that the two liquor control boards were on opposing trajectories towards their ultimate fates, help to explain the different decisions made by each government. Endogenous preference construction in this sector, furthermore, implies that each system is able to satisfy all relevant stakeholders, including consumers.

Contemporary treatments for psychological trauma from the perspective of peacekeepers

The purpose of this hermeneutic phenomenological study was to examine contemporary treatment approaches for psychological trauma from the perspective ofpeacekeepers. Data were collected via audiotaped interviews with 10 contemporary peacekeepers who had been deployed to Somalia, Rwanda, or the formerYugoslavia. The participants were asked to describe their experience with various treatments for psychological trauma. Narratives from the transcribed interviews were reviewed with the participants and their comments solicited for rigour and verification of meaning. A thematic analysis of the text, conducted to examine the ways in which contemporary treatment approaches help peacekeepers to heal from trauma, revealed 3 themes: medications as helping the most, understanding what is going on, and self-healing as a journey of discovery. The embodied nature of healing from trauma among contemporary peacekeepers should not be overlooked. Studies on the efficacy of different treatment modalities for psychological trauma, including mind-body complementary therapies, are needed.

Linking traditional knowledge and environmental practice in Ontario

Beginning in the late 1980s with the release of Our Common Future by the World Commission on Environment and Development, followed by the development of international accords such as the 1992 Convention on Biological Diversity, international pressure to resolve Indigenous rights issues has been steadily mounting. Successive Canadian governments have been striving increasingly to recognize and incorporate Aboriginal traditional knowledge into resource management planning. Following more than a decade of such efforts, the question of how to achieve such incorporation appropriately remains inadequately answered. This essay contributes to the resolution of this issue by first clarifying some key differences between Aboriginal and non-Aboriginal definitions of "traditional knowledge." Then, three Ontario case studies are briefly described that highlight the most and least successful aspects of previous undertakings. Among the lessons learned are the need to value traditional knowledge on a par with Western science while recognizing the particular capabilities of each system, and the requirement that Aboriginal peoples and their knowledge participate on a mutually respectful basis.

Cigarette smoking and cardiovascular risk factors among Aboriginal Canadian youths

BACKGROUND

Aboriginal populations in North America are exhibiting an increased prevalence of cardiovascular disease and associated traditional and nontraditional cardiovascular risk factors, trends believed to be due to the influence of Western lifestyle habits. Because these influences are present at an early age, we sought to study the patterns of one such habit, cigarette smoking, among Aboriginal Canadian youths and to assess the associated accrual of cardiovascular risk factors at an early age.

METHODS

Patterns of cigarette smoking were assessed in a population-based, cross-sectional study involving 236 youths aged 10-19 (mean 14.9) years in the Oji-Cree community of Sandy lake, in northwestern Ontario. Participants underwent clinical and metabolic evaluation with assessment of cardiovascular risk factors.

RESULTS

The prevalence of cigarette smoking among the study participants was considerably higher than age-specific national averages, with fully 50% of the participants overall and 82% of the adolescent participants (aged 15-19) being current smokers. Compared with their peers, children smoking 6 or more cigarettes per day had an enhanced cardiovascular risk profile consisting of a higher mean systolic blood pressure (111 v. 107.5 mm Hg, p = 0.036), a higher mean plasma homocysteine level (8.7 v. 7.6 micromol/L, p = 0.008) and a lower mean serum folate level (4.5 v. 5.4 mmol/L, p = 0.007), after adjustment for age, sex and body mass index. In separate multiple linear regression analyses, current cigarette exposure (number of cigarettes smoked per day) emerged as an independent determinant of both systolic blood pressure and plasma homocysteine level.

INTERPRETATION

In this Aboriginal community with remarkably high rates of cigarette smoking among its youth, an independent dose-response relation was found between current smoking exposure and both traditional (systolic blood pressure) and nontraditional (homocysteine level) cardiovascular risk factors. The association of cigarette smoking with an enhanced cardiovascular risk profile at an early age may be a factor contributing to the high prevalence of cardiovascular disease in this Aboriginal population.

Hypoadiponectinaemia in South Asian women during pregnancy: evidence of ethnic variation in adiponectin concentration

AIMS

People of South Asian descent face an increased risk of Type 2 diabetes mellitus (DM) and coronary artery disease (CAD) compared with other ethnic groups. One candidate factor underlying this risk may be adiponectin, as circulating levels of this adipocyte-derived protein are reduced in both Type 2 DM and CAD. In a recent study, we assessed the relationship between adiponectin and gestational diabetes (GDM), a potential model of early events in the natural history of Type 2 DM. Here, we report the impact of ethnicity on plasma adiponectin concentration in that study.

METHODS

A cross-sectional study was performed in 180 women undergoing oral glucose tolerance testing in late second or early third trimester to investigate the relationship between adiponectin and glucose tolerance in pregnancy. Based on self-reported ethnicity, participants were stratified into three groups: (i) Caucasian (n = 116), (ii) South Asian (n = 31), and (iii) Asian (n = 28).

RESULTS

Median adiponectin concentration was much lower in the South Asian group (9.7 micro g/ml) than in Caucasians (15.8 micro g/ml) or Asians (16.1 micro g/ml) (overall P < 0.0001). With adjustment for age, prepregnancy body mass index, weight gain in pregnancy, previous history of GDM, family history of DM, fasting insulin and glucose intolerance, mean adiponectin remained significantly lower among South Asians compared with either Caucasians (P < 0.0001) or Asians (P = 0.0034).

CONCLUSIONS

Women of South Asian descent exhibit significantly reduced plasma concentrations of adiponectin in pregnancy compared with Caucasian and Asian counterparts. This observation raises the possibility of hypoadiponectinaemia as a potential factor contributing to the increased risk of diabetes and cardiovascular disease in South Asians.

Diabetes-associated autoantibodies in aboriginal children

Type-2 diabetes is increasing in aboriginal children and adolescents and must be distinguished from type-1 diabetes in this population. The absence of diabetes-associated autoantibodies supports the clinical impression of type-2 diabetes in the affected members of this population.

Understanding individual differences in word recognition skills of ESL children

This paper focuses on the extent to which the development of ESL (English as a Second Language) word recognition skills mimics similar trajectories in same-aged EL1 (English as a First Language) children, and the extent to which phonological processing skills and rapid naming can be used to predict word recognition performance in ESL children. Two cohorts of Grade 1 ESL and EL1 primary-level children were followed for two consecutive years. Results indicated that vocabulary knowledge, a measure of language proficiency, and nonverbal intelligence were not significant predictors of word recognition in either group. Yet, by considering individual differences in phonological awareness and rapid naming, it was possible to predict substantial amounts of variance on word recognition performance six months and one year later in both language groups. Commonality analyses indicated that phonological awareness and rapid naming contributed unique variance to word recognition performance. Moreover, the profiles of not at-risk children in the EL1 and ESL groups were similar on all but the oral language measure, where EL1 children had the advantage. In addition, EL1 and ESL profiles of children who had word-recognition difficulty were similar, with low performance on rapid naming and phonological awareness. Results indicate that these measures are reliable indicators of potential reading disability among ESL children.

Prevalence of gestational diabetes mellitus among Swampy Cree women in Moose Factory, James Bay

BACKGROUND

Although high rates of gestational diabetes mellitus have been documented in native populations, few studies have examined rates of the disease among native Indians in Canada. The authors conducted a study to estimate the prevalence of gestational diabetes among Swampy Cree women, to identify factors predictive of the occurrence of gestational diabetes, and to identify delivery and infant outcomes related to the presence of the disease.

METHODS

Information on Swampy Cree women who gave birth at Weeneebayko Hospital, Moose Factory, James Bay, Ont., between 1987 and 1995 was obtained from medical charts. Patients with and without gestational diabetes were compared. Logistic regression analysis was used to identify independent predictors of gestational diabetes. Delivery and infant outcomes that occurred secondary to gestational diabetes were also identified by means of logistic regression.

RESULTS

A total of 1401 deliveries occurred at Weeneebayko Hospital over the study period, of which 1298 were included in the study. Gestational diabetes was diagnosed in 110 (8.5% [95% confidence interval (CI) 6.9%-9.9%]) of the 1298 pregnancies. Factors predictive of gestational diabetes were age 35 years or more (relative risk [RR] 4.1, 95% CI 1.5-11.7), a history of gestational diabetes in a previous pregnancy (RR 6.4, 95% CI 3.5-11.7), diastolic blood pressure of 80 mm Hg or higher at the first prenatal visit (RR 1.7, 95% CI 1.1-2.8), weight greater than 80 kg at the first prenatal visit (RR 4.9, 95% CI 1.8-12.9) and having a first-degree relative with diabetes (RR 3.0, 95% CI 1.4-6.1). The only delivery outcome independently associated with the presence of gestational diabetes was an increased likelihood of needing assisted delivery (forceps or vacuum extraction) (RR 2.8, 95% CI 1.1-7.0). Shoulder dystocia was indirectly associated with gestational diabetes owing to increased infant birth weight. Infant outcomes associated with the presence of gestational diabetes were birth weight greater than 4500 g (RR 2.4, 95% CI 1.4-3.8), hyperbilirubinemia (RR 2.9, 95% CI 1.4-6.1), hypoglycemia (RR 7.3, 95% CI 3.7-14.4) and hypocalcemia (RR 8.9, 95% CI 2.3-33.7).

INTERPRETATION

Gestational diabetes occurred in a significant minority of Swampy Cree women and was associated with a number of adverse outcomes.

Canadians' use of U.S. medical services

To explore the extent of cross-border care seeking among Canadians, we analyzed the growth and distribution of Ontario Health Insurance Plan expenditures for medical care services provided in the United States to Ontario residents from 1987 to 1995. Although total out-of-province spending is low relative to in-province spending, there is evidence of cross-border care seeking for cardiovascular and orthopedic procedures, mental health services, and cancer treatments. However, combined with a preliminary investigation of cross-border patient care seeking using nonpublic funding sources, these analyses do not support the perception of widespread cross-border medical care seeking by Ontario residents.

Intention to relocate to the United States

OBJECTIVES

To gain insight into family medicine residents' attitudes toward relocating to the United States and to examine factors influencing their decisions.

DESIGN

Cross-sectional mailed survey.

SETTING

University of Toronto family medicine program.

PARTICIPANTS

First- and second-year residents in the academic year 1995 to 1996. A 74.6% response rate (144 of 193 residents) was achieved.

MAIN OUTCOME MEASURES

Intention to relocate to the United States. Degree of importance of 11 motivational factors in residents' decisions to relocate.

RESULTS

In this survey, 48% of residents reported they intended to relocate to the United States, but only 17% recalled expecting to relocate before Ontario's introduction of geographic billing restriction legislation. Geographic billing restriction was the motivational factor most residents (86.8%) considered very important in their decision-making process. The two factors potentially predicting US relocation were finance and climate.

CONCLUSIONS

Many factors influence family medicine residents' intention to relocate to the United States. Geographic billing restriction was the most significant motivational factor, and its introduction has likely precipitated a marked shift in residents' attitudes favouring US relocation.

Substance abuse treatment for Ontario residents in the United States

In Canada, individuals experiencing problems related to their alcohol and drug use receive treatment and rehabilitative care through services provided primarily through the publicly funded health and social service system. During the past decade, however, an increasing number of Canadians have received treatment for substance abuse at facilities located in the United States, with most of the cost for this treatment borne by the various provincial health insurance plans. This paper provides a comprehensive analysis of the Ontario experience of treatment for substance abuse in the United States. First, the policy and planning context for the use of American treatment programs by Ontario residents and the rationale for recent changes to the reimbursement guidelines for such out-of-country treatment is reviewed. Secondly, the major trends in utilization of American programs over the past decade will be described and comparisons drawn to trends in the development of Ontario's own treatment system. This information has been used to help guide the development of treatment services in Ontario. In addition, the data serve as a baseline to measure the impact of various policy and program initiatives recently introduced in Ontario to reduce the utilization of treatment resources based in the United States.

Ontario's move to limit out-of-province health care spending pays off in big way

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Increased prevalence of hereditary metabolic diseases among native Indians in Manitoba and northwestern Ontario

OBJECTIVE

To compare the prevalence of hereditary metabolic diseases in the native and non-native populations of Manitoba and northwestern Ontario.

DESIGN

Retrospective analysis.

SETTING

Children's Hospital, Winnipeg.

PATIENTS

Patients were selected by three methods: laboratory tests designed to screen patients suspected of having a metabolic disease, laboratory investigation of newborn infants with abnormalities detected through screening, and investigation of near relatives of probands with disease.

RESULTS

A total of 138 patients with organic acid, amino acid and carbohydrate disorders were seen from 1960 to 1990. Of these, 49 (36%) were native Indians (Algonkian linguistic group). This was in sharp contrast to the proportion of native Indians in the total study population (5.8%). Congenital lactic acidosis due to pyruvate carboxylase deficiency (13 patients), glutaric aciduria type I (14 patients) and primary hyperoxaluria type II (8 patients) were the most common disorders detected. Other rare disorders included glutaric aciduria type II (one patient), 2-hydroxyglutaric aciduria (one patient) and sarcosinemia (one patient). Underreporting, especially of glutaric aciduria type I and hyperoxaluria type II, was likely in the native population.

CONCLUSIONS

Hereditary metabolic diseases are greatly overrepresented in the native population of Manitoba and northwestern Ontario. We recommend that native children who present with illnesses involving disturbances of acid-base balance or with neurologic, renal or liver disease of unknown cause by investigated for a possible metabolic disorder.