Health

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Open Access
Querying Everyday Scarcity: A Feminist Political Economy Analysis of Kidney Dialysis and Transplantation in Rural British Columbia
(2015-08-28) Brassolotto, Julia Marina; Daly, Tamara J.
This thesis uses a feminist political economy perspective to analyze the findings from a qualitative case study regarding kidney dialysis and transplantation in rural and remote British Columbia. This case study was conducted in order to investigate the concept of "scarcity," which is very common in organ transfer discourse. Critical ethnography and document analysis were used to examine the ways in which scarcity manifests in policy, practice, and everyday life. The main areas of focus include: the systemic context for the practices; the intersection of social location and geographic isolation; the intersection of gender, work and health; the implications of work in the local resource industry for renal health and renal replacement options; the role of unpaid care work provided by family members; and the implications of shifting care from institutions to families and individuals – particularly in a rural and remote context. Broadly, I argue that the scarcity of transplantable organs remains the dominant public discourse, that this discourse informs policies and practices, and that, despite these trends, lived experiences of scarcity at this site of study have more to do with the scarcity of human and health care resources, particular services, and health and life-sustaining resources for patients.
Open Access
Medical Education and Financial Conflict of Interest Relationships with the Pharmaceutical Industry in Canada: An Analysis of Four Areas of Medical Education
(2016-11-25) Shnier, Adrienne Rebecca; Lexchin, Joel. R.
Financial conflict of interest (FCOI) relationships in medicine have been found to expose medical education in medical schools, medical journals, and continuing medical education (CME) hosted by professional medical associations (PMAs) to vulnerability to corporate bias. Institutional policy analysis concerning FCOI relationships and industry involvement in medical education in Canada is limited. Therefore, informed by neoliberal corporate bias theory and Mertonian norms of science, this dissertation contributes analyses of conflict of interest policies, disclosures, and opportunities for drug company involvement in the production and dissemination of medical knowledge. In a publication-based dissertation format, the first manuscript provides an evaluation of conflict of interest policies at the 17 medical schools in Canada. The second manuscript provides an analysis of the culture of corporate science, informed by neoliberal ideology, through an examination of the extensive and pervasive roles of the drug promotion industry in clinical trial research, interpretation, writing, and publishing in medical journals. The third manuscript offers an evaluation of policies concerning FCOI relationships and industry involvement in CME development and programming adopted by 60 professional medical associations in Canada. The fourth and final manuscript comprises an quantitative analysis of FCOI relationship disclosures in Canadian clinical practice guidelines. In general, these evaluative efforts found that the policy environment concerning industry involvement in various types of medical education in Canada is permissive and FCOI relationships are common among guideline authors. Positioned within the context of neoliberal corporate bias theory and Mertonian norms of science, these findings of general policy permissiveness indicate an alignment of goals between the pharmaceutical industry and medical education institutions. The necessity for increased transparency in terms of industrys roles in not only conducting, analyzing, interpreting, and publishing pharmaceutical research, but also data sharing is supported by existing literature on financial conflict of interest relationships with the pharmaceutical industry. Furthermore, the strengthening and enforcement of policies on industry involvement and FCOI relationships in these areas of medical education would help to ensure that medical education in the publics interest is achieved.
Open Access
Understanding the Impact of Safety Climate, Teamwork Climate, and Mindful Organizing on Safety Outcomes at a Large Community Hospital - A Mixed-Methods Study
(2018-03-01) Zaheer, Shahram Ahmad; Ginsburg, Liane R.
Aim: The current study examined the impact of staff perceptions of safety climate (i.e., senior and supervisory leadership support for safety), teamwork climate, and mindful organizing on three self-reported measures of safety outcomes (i.e., overall perceptions of patient safety, overall patient safety grade, and turnover intention) at a large community hospital in Southern Ontario. Methods: Survey and interview data were collected from nurses, allied health professionals, and unit clerks working on one of four units: ICU, general medicine, adult mental health, or the ED. In total, 183/247 eligible clinical staff returned a completed survey (response rate = 74%); 4-6 semi-structured interviews were conducted on each unit. Results: Hierarchical regression analyses showed teamwork climate was significantly associated with all three studys predictor variables while senior leadership was significantly associated with overall perceptions of patient safety and overall patient safety grade. Non-significant associations were found between supervisory leadership, mindful organizing and the three outcome variables. The qualitative findings corroborated the survey results while also providing important insights into why certain statistical relationships were found to be non-significant e.g., interviewees perceived the safety specific responsibilities of frontline supervisors much more broadly compared to the narrower conceptualization of the construct in the survey. In addition, the qualitative findings helped expand the characteristics of the studys key concepts e.g., interviewees highlighted the prevalent negative impact of unit and profession boundaries on teamwork climate. Practice Implications: Healthcare organizations should recruit into leadership roles and retain individuals who prioritize safety and possess adequate relational competencies. Furthermore, it is important to provide on-site workshops on topics (e.g., conflict and stress management) that can strengthen working relationships across professional and unit boundaries. The frontline clinicians would also benefit from on-site clinical training and presence of adequate staffing levels so they can provide high quality patient care. Conclusions: There is increasing empirical evidence regarding the importance of context-specific factors for patient and staff safety, however, certain literature gaps still remain e.g., an over-reliance on non-theory driven quantitative research. The current study has addressed some of these gaps, together with adding to our understanding of how context influences safety.
Open Access
Three Decades of Epidemic Black Gun Homicide Victimization in Toronto: Analyzing Causes and Consequences of a Criminological Approach
(2018-08-27) Khenti, Akwatu Alleyne; Raphael, Dennis
This dissertation analyzes Black gun violence and homicide victimization in Toronto from a health equity and critical race perspective rather than prevailing criminological theories. Young Black men in Toronto are estimated to be five times more likely to become victims of homicidal violence (Gartner & Thompson, 2004). Utilizing a publication-based dissertation format, the first manuscript (Chapter 2) highlights a declining public safety of young Black men over three decades and questions why this phenomenon is not regarded as a public health crisis. It identifies some key public health considerationsrelated to violence prevention, early intervention, and treatment. The theoretical framework (Chapter 3) contextualizes core assumptions of criminological theories with striking inequities across key social determinants of health, significant intersectionalities, and persistent patterns of systemic racism. The second manuscript (Chapter 4) applies a Critical Race Theoretical (CRT) framework to the available literature. CRT highlights the ongoing relevance of systemic racism to the current framing of Black gun-violence by the media, education, and criminal justice system. The third manuscript (Chapter 5) explores potential pathways from experiencing structural violence to the increased risk of homicide victimization. The implementation of the politically motivated War on Drugs compounds risks and vulnerabilities associated with the key determinants of socioeconomic status -- especially because of over-policing and excessive incarceration. The fourth manuscript (Chapter 6) argues that the War on Drugs (WOD) approach has strengthened systemic anti-Black racism across key sectors of society. The fifth manuscript (Chapter 7) analyzes an 11-year period (2004-2014) and finds Black homicide rates to be highest in neighbourhoods with intersecting socioeconomic disadvantage and a high proportion of Black residents. However, neighbourhoods of less socioeconomic disadvantage with smaller proportions of Black residents also have some of the highest Black homicide rates -- probably due to racial stigmatization. The sixth and final manuscript (Chapter 8) describes dominant public stigmatizations, as well as health promotion potential in Afrocentric resiliency building. The chapter elucidates how public racial stigmatization drives and sustains Black homicide victimization (BHV) through self-stigmatization. Afrocentrism provides an alternative narrative with which to counter dominant deficit narratives and engender agency in individuals and communities.
Open Access
Intersectoral Action for Health: Challenges, Opportunities, and Future Directions in the WHO European Region
(2018-08-27) Mikkonen, Juha Pekka; Raphael, Dennis
Human health is shaped by public policy decisions made not only by the health sector, but numerous other sectors and actors that influence peoples social, economic, and cultural conditions. Therefore, national health ministries cannot solve the root causes of many health problems without also engaging non-health sectors to implement health-promoting public policies. For over three decades, the World Health Organization (WHO) has actively endorsed the concept of intersectoral action for health as a key approach to address the most pressing health challenges at the national and international levels. At the international level, the need to engage non-health sectors in health promotion activities has been repeated in nine outcome documents of the global health promotion conferences organized by WHO between 1986 and 2016. However, calls to promote health through greater intersectoral action have not led to wide-scale and systematic implementation by national governments and jurisdictions. The challenges and opportunities to intersectoral action for health are rarely identified in a systematic way in the existing research literature. To address the current gap in knowledge, this dissertation was based on three key research questions: (1) How do the expert informants within the WHO Regional Office for Europe understand the concepts of intersectoral action for health and governance for health?, (2) What do the academic literature and key informants identify as the challenges and barriers to intersectoral action for health?, and (3) Which factors facilitate the implementation of the intersectoral action for health and what are the opportunities to promote health through such action in the future? The methods of this study included an in-depth review of literature and primary data collection that involved 28 semi-structured interviews with WHO Programme Managers, Unit Leaders, Directors, and Technical Officers working at the WHO Regional Office for Europe in Copenhagen. A thematic analysis of the key informant interviews focused on the challenges and opportunities to intersectoral action for health. The aim of this analysis is to shed light on the factors that are relevant to the policy process and dynamics of intersectoral policymaking. The findings of this study draw on the perspectives that the informants had gained by working with many of the 53 countries that comprise the WHO European region. The analysis involved a computer-assisted coding process with NVivo software and led to ten thematic challenges/barriers and to ten thematic opportunities/facilitators. Overall, this dissertation increases understanding of the political, technical, institutional, and managerial barriers to intersectoral action for health. In addition, it presents a systematic analysis of the factors that can facilitate intersectoral action for health and considers the future of intersectoral approaches in health promotion. Based on the empirical findings, the concluding section includes eighteen recommendations for strategies to overcome the challenges and barriers to the implementation of intersectoral action for health in the future. These recommendations include various strategies such as ensuring high-level political support and a mandate for intersectoral action, mapping out co-benefits among sectoral partners, establishing permanent intersectoral mechanisms, ensuring adequate resources for implementation and monitoring, and increasing the capacity of the health sector to work with non-health sectors.
Open Access
The Selection Process of the Mexican National Essential Medicines List (NEML): A Grounded Theory Approach
(2018-11-21) Lopez, Mirna Romero; Lexchin, Joel R.
One of the biggest challenges that low- and middle-income governments like Mexico have in ensuring equitable access to medicines is to maximize the quantity of drugs they are able to procure with their limited resources. This maximization can be achieved by purchasing, at the lowest possible prices, those drugs that are essential for treating the most prevalent diseases in their population. The first step in addressing this challenge is to have a National Essential Medicines List (NEML) that allows for a rational selection of Essential Medicines (EM). However, considering that the 70% of pharmaceuticals on the world market are duplicative or non-essential, equitable access to EM will also depend on the knowledge and technical capability that governments have to select drugs that meet the safety, efficacy, cost, and quality standards that satisfy the priority health needs of their population. Even though Mexico has a NEML, up until now, there have not been studies that describe how the government selects this list. All that is known is described in the regulation that standardizes the selection process of this list. My grounded theory study allowed me to interview 12 out of the 31 government officials who participate in the selection of the NEML, and also of a group of 5 people familiar with the process to better understand how the NEML is selected. Through these interviews, I learned about unknown aspects of the process that helped me to formulate a theory about how the process functions in reality. This theory suggests that the government selects its NEML in a very political environment, surrounded by many contradictions that cannot be easily uncovered because power controls, via domination, the discursive consciousness of the government officials who select the list and the Mexican population. Discursive consciousness involves the knowledge which actors are able to express on the level of discourse. Even though it is expected that the Mexican government bases the selection of its NEML on rational decisions, my study concludes that the foundation upon which the selection of this list is being made is not rationality, but rather the reflection of many political and economic interests.
Open Access
Psycho-Social Contributions to Higher Type 2 Diabetes Mellitus Prevalence among South Asian Immigrants Living in Canada
(2018-11-21) Kabir, Syeda Farahnaaz; Raphael, Dennis
This thesis studies psycho-social aspects of the experiences of South Asian immigrants (SAI) in Canada and how these may be related to the elevated presence of type 2 diabetes mellitus (T2DM) in this group. It does so by examining the way in which variables such as education and income levels, the gap between education and income levels, and psycho-social variables related to stress, predict the presence of T2DM in this group as compared to two other social groups: Chinese Immigrants (CI) and Canadian born whites (CBW). The results of this research support the hypotheses laid out for this dissertation that exposure to education/income gap increases risk for T2DM, and that SAI have higher risk for T2DM compared to CI and CBW.
Open Access
The Epidemiology of Community-Acquired Clostridium Difficile in the Niagara Region, Ontario, Canada, Between September 2011 and December 2013
(2018-11-21) Salaripour, Maryam; Ginsburg, Liane R
Clostridium difficile infections (CDIs) have historically been associated with exposure to healthcare settings. In recent years, however, the incidence of community-acquired Clostridium difficile infections (CA-CDI), along with the number of patients requiring hospitalization for it, has been increasing. This research uses a framework grounded in Complex Adaptive Systems (CAS) to reveal new and different epidemiological findings on CA-CDI to indicate novel health equity leverage points. It explores the epidemiology and established risk factors associated with CA-CDI in the Niagara Region, Ontario, and compares them with those of healthcare-associated CDI (HA-CDI) in the same area. The first manuscript evaluates the literature on existing evidence of risk factors for CA-CDI by applying The Joanna Briggs Institute (JBI) Reviewers Manual 2015, Methodology for JBI Scoping Reviews. The review identifies that CA-CDI is seen more often than HA-CDI in younger and female populations. Exposure to antimicrobials is common but not as common as in HA-CDI cases. The scoping review establishes the need for further epidemiological studies on CA-CDI. The second manuscript provides a nonparametric descriptive analysis, comparing CA-CDI and HA-CDI cases in Niagara Health System (NHS) hospitals, based on a retrospective case series design. Hospitalized CA-CDI patients have a lower median age and less exposure to antimicrobials and other medications. Gender proportions are similarly distributed between the two groups. The emerging recommendation is that CA-CDI must be considered as a potential diagnosis in patients admitted to hospital with diarrhea, even in the absence of conventional CDI risk factors. The third and final manuscript evaluates the spatial and genotype features of CA-CDI and HA-CDI. It finds that geographical clustering, temporal patterns, and genotypic features are unique in each category. These studies point to the need for a better understanding of transmission routes between communities and healthcare settings; further research is required to establish community CA-CDI risk factors. Together, these evaluations establish that we must develop a systems approach to explore health problems and respond effectively at a population level. The research and policy environment must be strengthened by modifying current practices, setting priorities, and providing funding for empirical studies and equitable health policies.
Open Access
Policy in Motion: LGBTQ+ Health from the Fringes to Mainstream?
(2019-07-02) McKenzie, Cameron Stephen; Mulé, Nick J.
This manuscript-based dissertation examines the perceptions and experiences of selected community-based LGBTQ+ health organizations in the Greater Toronto and Hamilton Area of Ontario as they navigate the current neoliberal policy environment. It also examines how well these organizations understand and implement the social determinants of health (SDH) framework in their communities within that environment. As such, the SDHs structural approach to health equity, augmented by an emergent Queer Liberation Theory, forms the theoretical foundation of this analysis. For historical context, I conducted a content analysis of The Body Politics coverage of the HIV/AIDS crisis from 1981 to 1987 to examine the impact of HIV/AIDS on the movement. I also conducted semi-structured interviews with people who were active with the publication during that period for their reflections on how the movement has developed. To understand the place of LGBTQ+ health in the existing policy environment, I collaborated with colleagues to analyze how LGBTQ+ health is represented on the Ontario Ministry of Health and Long-term Cares and the Ontario Local Health Integration Networks websites. We conducted comparative snapshot content analyses in 2009 and 2017. To contextualize the comparative content analysis, we conducted semi-structured interviews with bureaucrats to see how well stated policies and commitments to health equity matched with real policy initiatives. With these insights, I conducted semi-structured interviews with staff of community-based LGBTQ+ health organizations to understand their perceptions and experiences of the policy environment and of the SDH approach more broadly. Findings indicate that LBGTQ+ health equity is a very small part of the policy discussion and remains very much on the fringes of health care policy and programming in any practical sense. LGBTQ+ organizations have a good understanding of equity issues and the SDH approach but must operate in survival mode. The theoretical contribution of this work is to point out the inadequacy of the SDH frameworks understanding of LGBTQ+ health equity and to articulate three pillars in the development of Queer Liberation Theory (anti-assimilationism, solidarity across movements, and political economy) in the hope of improving the SDH framework and moving forward equitable approaches to LGBTQ+ health in a challenging policy environment.
Open Access
How Do the Attitudes and Beliefs Towards Mental Health- Seeking Behaviour Differ Between Racialized and Non-Racialized Students in a University Environment?
(2020-05-11) Lal, Rodrick Jaswant; Reaume, Geoffrey
The purpose of this research study was to explore the perceptions of racialized and non-racialized students at York Universitys Keele campus towards seeking help for mental health problems. A convenience sample consisting of 491 students participated in the cross-sectional survey. The majority (n = 413, 84.1%) were identified as Canadian racialized, mainly Asian, South Asian, Caribbean, Middle Eastern and African students. The remainder (n = 78, 15.9%) were Canadian non-racialized, (English, French, Italian and Portuguese) students identifying with dominant Canadian culture. Most of the students (n = 77.4%) were female. All of the participants completed the Attitudes Toward Seeking Professional Help Scale; Beliefs About Psychological Services Scale; Vancouver Index of Acculturation; Race-Related Events Scale; Centre for Epidemiological Studies Depression Scale, and the Beck Anxiety Inventory. Attitudes and intentions toward seeking help were more negative among the racialized students. A higher level of stigma was also a predictor of negative attitudes and lower intentions towards seeking mental health counseling amongst the racialized group. Stigmatization among the racialized and non-racialized male students was higher than among the female students. The older racialized students tended to have higher positive scores for attitudes toward seeking help than younger students. Attitudes toward seeking help were more positive among the students who lived with their families. Previous mental diagnosis was also a significant predictor of attitudes toward seeking help. Very few racialized and non-racialized students used the counselling services or the online information system at York university to obtain information on mental health issues. The findings of this research study advocate university governance, healthcare professionals, and counsellors need to improve their services to address the specific needs and concerns of racialized students. Future research should focus on how findings can be translated into practice by designing culturally adaptive treatment modalities, including electronic media, that focus on resolving mental health problems among racialized and non-racialized students.
Open Access
Theorizing Precarization and Racialization as Social Determinants of Health: A Case Study Investigating Work in Long-Term Residential Care
(2020-05-11) Syed, Iffath Unissa; da Silveira Gorman, Rachel
This thesis uses anti-racist and feminist political economy of health perspectives that intersect with immigrant status, in order to analyze the findings from a single-case study investigating the social determinants of health and work precarization in a residential long-term care (LTC) facility in Toronto, Ontario. Throughout this dissertation, I use mixed methods case study to investigate social, political, and economic implications in the lives of health care workers. Observation, interview, and survey methods were utilized to investigate workers health in relation to the precarization of work. Specifically, I used the concept of precarization as a lens to track the ways in which work relations impact the other social determinants of health. The main areas of focus include the intersections of gender, work, and occupational health with race, immigrant status, and culture; the ways in which precarization affects employees in this specific health care sector; the implications of precarization in the health and wellbeing of workers and their families; the role of (un)paid care work and social support provided by family members; and the exercise of strength, resilience, resistance, agency, and coping strategies. Broadly, I will argue that precarization in LTC is an increasingly experienced phenomenon, and that various levels of precarization are experienced by particular workers who are women, racialized persons, and immigrants. This study contributes to our understanding of racialization as a social determinant of health, and analyzes the health impacts of workplace inequality through the lens of precarization. The study makes the case for closer attention to racism and precarity both on and as social determinants of health.
Open Access
Mental Health and Psychosocial Calls in the Prehospital Setting in Ontario: A Qualitative Case Study
(2020-05-11) Ford-Jones, Polly Christine; Daly, Tamara J.
Paramedics have seldom been included in discussions of mental health care and yet play a significant role in the chain of mental health care for many. This thesis explores the nature of paramedic work and the mental health and psychosocial calls encountered by paramedics in the community. This project is a case study of mental health and psychosocial calls in paramedicine in Ontario and was designed to explore the care provided by paramedics on mental health and psychosocial calls, the training and resources for these calls, and the experiences of paramedics in managing these calls. Using both a feminist political economy and social determinants of health approach, this thesis explores questions around care provision on the front lines, but also beyond into community mental health services and to the social determinants of health impacting an individuals need for care from paramedic services. I conducted interviews with front-line paramedics, paramedic services management, paramedic educators and Base Hospital physicians/managers; observation in three paramedic services including urban, rural/suburban and rural with varying degrees of engagement on the issue of mental health in paramedicine; and document analyses of the standards guiding paramedic practice in this area. This thesis reframes issues of mental health calls in paramedicine from an issue of misuse of emergency services, to one which accounts for the contexts creating distress as well as existing constraints for work and care. Findings from this study support enhanced training and education for paramedics, specific mental health related programming for paramedic services, as well as the importance of working conditions for both care providers and care recipients. I argue that there must be a balance between efforts placed on establishing appropriate supports for managing mental health and psychosocial calls as well as addressing necessary training and education in this area, while simultaneously ensuring sufficient focus remains at the level of prevention at the broader social, political, and economic determinants of physical and mental health.
Open Access
Kakuma's Shadows: Everyday Violence in the Lives and Livelihoods of Young People Living at the Turkana-Kakuma Refugee Camp Nexus
(2020-05-11) Bishop, Danielle Elizabeth; Giles, Wenona
This dissertation is an ethnographic case study of how everyday violence impacts the lives of refugee and host community young people living in and around Kakuma refugee camp in Turkana County, northwestern Kenya. By engaging with scholarship on structural violence theory and the social determinants of health, this study demonstrates how structural and political exclusions intersect with age, gender and ethnicity to produce insecurity for both refugee and local host young people, and for young mothers in particular. It also demonstrates the complex forms of exploitation that refugee and host young people experience in their efforts to protect themselves against violence in their everyday lives, and how they use their bodies to mitigate the resource, rights and protection deficits that shape their life worlds. Fourteen months of qualitative fieldwork in Kakuma and its environs revealed that informal labour, intermarriages, practices of relocation and, sometimes, rape itself, have become multidimensional strategies used by both refugees and hosts to overcome the rights and protection deficits they face and to access the basic needs the humanitarian regime and the nation state have failed to provide. I argue that these complex forms of exploitation and coping are forced by a continuum of systemic neglect and entrenched refugee-host co-dependency and co-survival. They also rest outside the purview of normative humanitarian policy and practice at global and national levels; they operate in the background of, and are unconsidered within child protection policies, host inclusion policies, and current institutionalized vulnerability categories. As a result, they are normalized, persist unabated, go beyond mere survival, and are not temporary. Yet, they result in only temporary safety nets. In the long term, these strategies lead to increased discrimination, lowered social capital, a lack of access to supportive resources, and further destitution for both refugees and hosts. I conclude that these are the shadows Kakuma casts. Because the shadows are symptomatic of power and of policy deficits, young refugees and hosts are systematically denied the right to dignity, health, education and well-being, the impacts of which are overlooked with grave consequences to human rights.
Open Access
Patient Perspectives on Health Seeking Behavior: Understanding Lived Experiences of Poverty and Lung Cancer Screening
(2020-08-11) Sayani, Ambreen Ahmed; Raphael, Dennis
In Canada, lung cancer is one of the most commonly diagnosed cancers and is responsible for a quarter of all cancer-related deaths. The use of low-dose CT (LDCT) to detect early-stage lung cancers that are amenable to treatment is a recent health innovation that can potentially lower mortality due to lung cancer. Screening with LDCT is currently being piloted as a provincially run program by Cancer Care Ontario. There are, however, health equity concerns for people living with low income. On one hand, they are more likely to smoke and have a higher risk of lung cancer. On the other hand, they are less likely to participate in preventative healthcare such as cancer screening. Using a theoretical thematic analysis informed by the morphogenetic approach, this study sought to contextualize the lived experiences of poverty and the choice to participate in cancer screening for individuals identified at high-risk of developing lung cancer. By placing lay knowledge of those with lived experiences as the pivot of my analyses, I demonstrate how living and working conditions shape a trajectory of social disadvantage over the life course which underpins lifestyle choices such as smoking and an elevated health risk of developing lung cancer, as well as the need and ability to seek care. Three themes: pathways of disadvantage, lung cancer risk and early detection, and safe spaces of care illuminate how choice is contextual to the availability of material resources such as income and housing, and how choice is influenced by having access to spaces of care that are free of judgement and personal bias. My findings have practical implications for the implementation of a provincially run lung cancer screening program to minimize inequities in lung cancer through cancer screening.
Open Access
Aging Interdependently: A Critical Ethnographic Study of Successful Aging and the Oldest Old
(2020-11-13) Naidoo, Vishaya; Raphael, Dennis
In both Canadian policies and scholarly research, there is a tendency to presume that the perspective and service needs of all older people (aged 65+ years) are similar. Yet, less is known about the unique circumstance of the oldest old (aged 85+ years): a cohort with a diverse spectrum of experiences distinct from their younger older adult counterparts. This study explores the accounts of a group of community-living adults among the oldest old utilizing the services of an older adult recreational centre located in urban Ontario to understand successful aging in the very late life years. Prominent intersectional identity locations in this phase of life, specifically gender and disability status, are examined in light of essential support needs and the policy goals of Active Living and aging in place. Using qualitative approaches of critical ethnography and case study, semi-structured interviews were conducted with nine women and nine men (aged 85+ years), four staff members from the older adult centre, and one respondent family member. A combination of participant data, observations, and document analysis, together with a conceptual framework comprised of feminist political economy, life course theory, and intersectionality inform the final analysis of this work. Findings reveal that despite a deeply entrenched neoliberal doctrine of sustained independence, successful aging in the oldest old is influenced by prominent social determinants of health (SDOH) and best delivered through an interdependence model of support that includes both formal government services and informal networks of care. This involves strengthened welfare state programs in several service areas, including income supports, transportation mechanisms, personal care, home care, caregiver supports, disability supports, gender-specific provisions, and increased social connections. Broadly, this study concludes that an interpretation of late later life that is unconstrained by the limitations of neoliberalism and individualism is an important first step in cultivating equity for the oldest old.
Open Access
Caregiver Experiences with Publicly Funded and Privately Financed Home Care in Ontario
(2020-11-13) Yakerson, Alla; Morrow, Marina
Home care is an integral aspect of Ontarios health care system. Services provided to individuals may allow them to live with independence within the comfort of their own residence. Over the last decade the demand for home care has risen substantially due to a number of factors including: the growing population, the rising share of individuals over the age of 65, the increasing rates of complex and chronic conditions, trends to faster hospital discharge, and advances in treatments/technologies. Simultaneously, the rise in neoliberalism has led to the restructuring of financing and delivery of health care through market-based models. While ostensibly an attempt to reduce public spending, it is more likely a result of an ideological shift away from state-provided care towards market-oriented service provision. In light of this, in the home care area, the state has been able to reduce its financial obligations by enabling privatization in the sector. The significance of policy change in the home care system and the decisions regarding the balance of the public/private scheme, therefore, have had serious implication for the experiences of those who provide the care the unpaid Informal Family Caregivers (IFC). At present, public funding and provision of care have not kept up with the demand for services, thereby, encouraging individuals to turn to the private market if they find inadequacies in the delivery of publicly funded local home care services (McGregor, 2001). In light of this, the purpose of this study is to examine the lived experiences of IFC who seek services for their relatives from the public home care system as well as from the private marketplace. In doing so, the goal is to understand the circumstances and challenges faced by these caregivers in accessing care in each of these two systems and obtaining respite from their duties. This knowledge is fundamental to the health care system which seeks to prevent the institutionalization of individuals as well as to minimize health care costs associated with the physical and psychological outcomes of caregiving which may differ in quality. This study is influenced by the work of FP economists to explain inequities in health as stemming in part from the unequal division of labour in society by which women must both gain paid employment and carry out household work (cleaning, cooking, laundry, gardening, taking care of children and the elderly etc.). FPE further draws on the Social Determinants of Health (SDOH) concept, which considers how the organization, and distribution of resources such as income and health services interact with the social location of gender to impact health outcomes. The qualitative research approach of descriptive phenomenology is employed to convey and understand the lived experiences of IFC with both the publicly funded and privately financed home care systems in and around the Greater Toronto Area. Quantitative analysis is further used to complement the voices of the participants. By illuminating micro-level individual experiences in relation to broader political and economic context, the development of new theories can take place and lead to further investigations pertaining to the phenomenon of interest. By generating knowledge and creating awareness, the ultimate goal is to influence policies of care and service provision to address issues concerning equity and health.
Open Access
Youth Substance Use: A Critical Analysis of Tensions Between Federal Policy Discourse and Frontline Service Provision in Ontario
(2021-07-06) Ali, Farihah; Chaufan, Claudia
Substance use ranging from experimentation to problematic use and addiction is most common among youth and young adults. Evidence shows that the earlier in life individuals begin to use substances, the higher the risk for substance misuse. Adolescence and young adulthood are life stages when behaviours and habits become established. They are also periods of social and developmental change as youth navigate through challenges and transition through social roles. In order to respond to substance use issues in Ontario, the substance use service provider arena is guided by federal policies and offers a range of services from both public and private domains, intended to support youth experiencing substance use issues. My dissertation had three objectives: 1) to assess the experience of frontline service providers to shed light on their perspectives on challenges faced by youth who use substances; 2) to critically evaluate representations of substance use among youth in a federal substance use strategy document that informs provincial level practice; and 3) to assess the policy implications of the tensions between dominant representations of substance use in policy documents and the lived experience of frontline service workers in the field of substance use for policy, practice and equity. To achieve these objectives, I conducted an online survey of Ontario service providers recruited from youth-oriented addiction substance use treatment organizations, I followed up with qualitative key informant interviews of a sub-sample of willing survey participants, and I assessed dominant representations of the problem of substance use using the critical policy approach of WPR (Bacchi, 1999), through an examination of the National Canadian Drugs and Substance Use Strategy (CDSS). My findings revealed significant tensions between theory and practice. While frontline providers expressed the need for harm-reduction, non-pharmacological and prevention initiatives for youth, the National Strategy downplayed this need, as well as the significance of the social determinants of health, while largely framing the behaviours of users of substance as falling under the jurisdiction of the criminal justice system. I offer policy recommendations on how to reduce the identified gaps between dominant representations and practice and propose strategies to encourage policy makers to develop youth-appropriate substance use reduction policies.
Open Access
A Mixed Methods Study of Immigrant and Canadian-Born Pakistani Youths Mental Health in Canada: Resilience, Identity and Self-Esteem
(2021-07-06) Khan, Attia; Khanlou, Nazilla
The mental health and wellbeing of immigrant minority youth in multicultural societies is shaped by a constellation of social factors which determine their health. Some of these factors include race, ethnicity, gender, religion, age, immigration status, social supports and socioeconomic status. Little is known about the mental health issues of immigrant and Canadian-born Pakistani youth in Canada. In order to fill this gap, this study was undertaken. Purpose: The goal of this study was to explore the perspectives of immigrant and Canadian-born Pakistani youth regarding their mental health and to measure their self-rated mental health, self-esteem, resilience and ethnic identity. Method: An embedded concurrent mixed methods study was utilized as per Creswell & Plano Clark (2017). The survey component was completed by 81 youth for the quantitative arm of the study. Individual interviews with 8 youth, 4 parents and 2 service providers were conducted for the qualitative arm. In addition, 3 focus groups with youth and 2 with parents were conducted. Results: Quantitative arm: There was a significant difference in household income by region of birth [X2 (4, n = 81) = 14.59, p = .006] and by generation status [X2 (8, n = 81) = 19.822, p = .011]. Health (Health Composite) was correlated with self-esteem (CSE) (r = 0.726, p < .001). Multiple regression found income was associated with Health Composite (Wald F =3.951, p = .047). Qualitative arm data analysis identified 13 themes, of these 11 related to factors influencing immigrant Pakistani youths mental health. Mixed methods analysis found 9 themes common to both arms: Resilience, mental health cases, mental health supports, dissatisfaction with treatment and supports, stigma, financial difficulties and impact on mental health, identity and acculturation issues, discrimination, justice, fairness and social exclusion. Findings showed that qualitative and quantitative (survey) data may lead to opposite results: race, identity and acculturation affected youths mental health positively (quantitative) and negatively (qualitative). Conclusion: Strategies to overcome mental health challenges in immigrant Pakistani youth should include family counselling, integrating faith-based counselling, destigmatizing Islam, guaranteed employment for newcomer families and non-discriminatory national policies that promote social and cultural inclusion.
Open Access
HEALTH SYSTEMS INTEGRATION AND TRANSFORMATION THROUGH CROSS-SECTORAL COLLABORATION
(2022-03-03) Liu, Grace Hoi Yiu; Tsasis, Peter
Statement of the problem Health system integration has been a challenge world-wide. There is no one best model to ensure successful integration. The aim of this research is to better understand "how to" build cross-sectoral collaboration for health systems integration and transformation. This study sheds light on understanding the patterns of communication and collaboration among the participants of six newly established teams or "Tables" in one of the Local Health Integration Networks in Ontario (Canada). This naturalistic inquiry study uses a combination of Complex Adaptive Systems and Relational Coordination theories as a theoretical lens to interpret the findings. Methods A mixed-methods approach has been used with Methodological Triangulation, which includes quantitative surveys (at baseline and follow-up), qualitative interviews and member checking. Results The survey response rate was 62% at Baseline (n=45) and 25% at Follow-up (n=22). Relational Coordination Index Scores was "moderate" with no significant differences between Baseline and Follow-up and no differences between the stakeholders or "Tables." From the twelve interviews, it was revealed that context matters at the local levels. "Rural Tables" with "moderate" Relational Coordination reported "inter-dependency" and the "Suburban Tables" with "weak" Relational Coordination reported "inter-organizational challenges." Discussion There is no one-size-fits-all model for health systems integration, and there is no formula for determining whether policy directives should be "bottom-up," "top-down" or "both." Based on this conundrum, it is recommended that leaders view health care as a Complex Adaptive System in order to allow the system to transform, change and to develop inter-dependencies, inter-organizational relationships and self-organizing capacities. Policymakers should take this into consideration in policy development and evaluation. New strategies are proposed and further research is needed to inform health systems change. Conclusion The findings characterized the process of intentional cross-sectoral collaboration using Complex Adaptive Systems and Relational Coordination theories to understand the patterns of communication and collaboration among the stakeholders and "Tables". A policy framework on "how to" build cross-sectoral collaboration for health systems integration and transformation has been developed, which adds a much-needed understanding on cross-sectoral collaboration.
Open Access
The Adaptation Experiences of Transnational Physiotherapists in Ontario, Canada: A Grounded Theory Approach
(2022-08-08) Andrion, Jeffrey John; Lum, Lillie L. Q.
In both research and policy, much attention has been given to further understand how inter-nationally educated professionals integrate in Canada. However, little attention has been given to the reintegration experiences of physiotherapists who were educated and trained internationally. Using the constructivist grounded theory (CrGT) method, the main study objective was to generate a theory to further explore these issues. Following the CrGT approach, transnational physiotherapists were invited to share their Canadian integration experiences. The participants’ reflections about their lived experiences, feelings, and thoughts led to the identification of the contextual elements (micro, meso, and macro) as the dominant themes of “Facilitators” and “Barriers”. Further analysis revealed that a specific set of structural barriers and facilitators point to the five integration stages and six adaptation identities. In this study, identity adaptation (IA) emerged as the core theory that explained the participants’ successes and challenges. The contributions of this study are the first to be reported in the physiotherapy-immigration discourse. These include identifying the various social structures and processes that impact the integration of the transnational physiotherapists. Some of these examples include the positive effect of social networks and the negative implications of the “Canadian experience” (CE) requirement. The results have implications for more successful professional integration at the education, policy, and practice levels.