Health

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Open Access
A Comparative Analysis Of Mental Health Reform: Canada, The United Kingdom, And Australia
(2024-11-07) Di Pierdomenico, Kaitlin Marie; Wiktorowicz, Mary E.
This dissertation explores the trajectories of mental health reform in Canada, the United Kingdom, and Australia, examining how each state’s political and institutional contexts within universal healthcare systems have influenced these trajectories. Despite being parliamentary democracies, these states exhibit significant variations in mental health governance due to differences in government control and levels of privatization. Using a historical institutionalism framework, the research examines how state-based institutional configurations impact the use and outcomes of mental health policy levers. The research investigates the relationship between healthcare governance and government structure, financing and service system designs, and professional regulation and payment. Drawing insights from Postpsychiatry and Mad activism, the research employs archival documentary analysis, policy analysis, and feedback from community service agencies to assess the effectiveness and reach of mental health reforms. It highlights the need for a moral transformation in global mental health, advocating for person-centered, recovery-oriented care that respects and integrates the social and structural determinants shaping health. The dissertation’s comparative analysis reveals the strategic use of policy levers and their impact on mental health policy trajectories and outcomes. Part One examines historical opportunities for change and identifies key policy levers. Part Two discusses the use of policy levers and mental health policy trajectories and outcomes. Part Three compares the use of policy levers across the states to highlight differences in the scale and pace of reforms. The analysis highlights a difference in the scale and pace of mental health policy reforms, with Australia and the UK implementing larger scale and faster paced changes compared to Canada’s more conservative approach. These differences are shaped by the state’s institutional frameworks and historical legacies that influence how mental healthcare is governed, financed, and delivered. The research highlights the imperative to shift from traditional biomedical models to more inclusive, human rights-focused mental health practices. This research improves understanding of the dynamic interplay between policy levers and mental health reforms in varied institutional contexts. It emphasizes that future policies be co-produced with policy communities, prioritizing community-based care and moving beyond traditional biomedical approaches to address broader social determinants of mental health. The research adds to the literature by offering an examination of the intersections between mental health policy, social justice, and institutional change.
Open Access
Farming in the Free Market: The Impact of the Dismantling of the Canadian Wheat Board on the Mental Health and Well-Being of Oil and Grain Seed Farmers in Saskatchewan
(2024-11-07) Zambo, Zsofia Magdolna; Raphael, Dennis
The Harper Government's dismantling of the Canadian Wheat Board’s (CWB) marketing monopoly in 2012 can be understood as part of a broader political project to liberalize Canada’s agriculture sector. While this policy shift has transformed Canada’s position within the global economic system, the impact it has had on small and mid-sized farmers in the grain sector is largely unknown, particularly with regards to mental health and well-being. The purpose of this research was to examine the social, political and economic impacts that removing the CWB has had on the lives of grain and oilseed farmers in Western Canada. This research’s methodology relies on both the ontological and epistemological assumptions of critical realism and employs a critical materialist political economy framework. A total of 29 semi-structured, open-ended interviews were included for this research study, including 17 Saskatchewan grain farmers and 12 individuals classified as relevant informants. This research found that the dissolution of the CWB had a tremendous impact on both farmers and their communities. The loss of the CWB likely exacerbated inequalities between farms, hastening the consolidation of farmland and contributing to rural depopulation. The issue of the CWB was also found to be highly divisive. A majority of farmers expressed either strong support or opposition to CWB, reflecting ideologically informed beliefs with regards to the benefits of collective marketing versus the marketing freedom respectively. For the most part, perceptions of farming post-CWB differed between these groups. Opponents of the CWB reported less overall stress with regards to grain marketing compared with CWB supporters. Perceptions of market competition, control, and transparency also varied with ideological views; CWB opponents generally believed they had greater control over their operations, faced adequate competition, and saw the current system as more transparent compared with CWB supporters. Farmers in both groups, however, identified corporate concentration and lack of adequate competition in the grain sector a major concern and source of stress. Given that the CWB remains highly divisive, solutions to improving farmer market power and thus reducing farmer stressors with regards to marketing may rest on reducing corporate power and concentration through legislation rather than reinstating a single desk marketing board, although that is an option that should be seriously considered as well.
Open Access
Don't let things you have done define you!: An anti-oppressive constructivist study of youth voices defining wellness
(2024-03-16) Christmas-Krumreich, Candice Marie; Khanlou, Nazilla
Problem Statement How health is defined and subsequently measured impacts programming. Who defines adaptive behaviour influences validation of youth mental health. Psychocentric discourses emphasize the “at-risk youth,” pathologizing individual behaviours and outcomes. Professionals devise definitions of youth wellness, rarely consulting with youth. Methods My study explored how youth from a small Canadian city define wellness within personal, relational, collective, and structural domains, to inform theory and practice around youth health strategies. Charmaz’s Constructivist Grounded Theory method was used. A critical, anti-oppressive theoretical approach identified power dynamics impacting youth wellness. Dialogical Action Theory framed pragmatic policy recommendations. Sampling was purposeful in locations where youth were present and snowballing used for recruitment. There were 16 youth aged 16 to 23 years with functional literacy of English, eligible to participate in semi-structured interviews (16) and two sets of focus groups (4). Results Youth self-identified by gender: six boys, six girls, and four gender diverse. Fifteen provided individual definitions of wellness; focus groups produced two co-created definitions. A holistic, ecologic model of meta-themes is a theoretical contribution to defining youth wellness. At the Personal Level, wellness was associated with competence, creativity, mindfulness, and self-care. At the Relational Level, wellness was promoted through positive friendships, empathetic kin, and non-judgemental “close” adults. Wellness at the Communal Level involved mental health supports, youth-friendly “safe spaces,” altruism, and social justice causes. These youth of the postmodern Information Age provided a wealth of practical advice around youth mental health, discrimination and stigma, safety, social media, substance use and homelessness. Policy recommendations include mediating wellness through early detection of languishing (e.g., depression, anxiety, and disordered eating); fostering empowerment through wellness literacy and youth voices in policy and program development; creating healing-centred engagement youth hubs; providing critical literacy skills to further social justice; and protecting the vulnerable and marginalized. Conclusion Of concern is the prevalence of stigma associated with mental health and substance use challenges and intergenerational trauma experienced by youth in this study. Youth wellness calls for whole-person restorative healing interventions, also extended to families and communities, given the collective nature of supports needed to foster healthy youth development.
Open Access
Exploring the Governance of Antimicrobial Stewardship and Deep Pandemic Prevention: From Siloed Approaches to Integrative Governance Models Informed by Urban Political Ecology
(2023-12-08) Aguiar, Raphael; Wiktorowicz, Mary E.
Governance of infectious disease prevention and antimicrobial resistance (AMR) share similar implementation challenges. Exploring the governance of antimicrobial stewardship and deep pandemic prevention that involves wildlife trade regulation as a source of zoonotic spillover may inform approaches to address AMR and other threats at the human-animal-environmental interface. This dissertation aims to explore governance models that adopt a One Health (OH) lens to address the governance of infectious disease prevention and AMR through (i) assessing the role of wildlife trade regulatory approaches in the prevention of zoonotic spillover and infection transmission, (ii) mobilizing an urban political ecology (UPE) lens to assess the under-exposed dimensions and interdependencies of AMR, and (iii) deploying a UPE lens to inform the analysis of peer-reviewed literature on implementation of OH-AMR governance approaches. To assess the role of wildlife trade regulatory approaches in the prevention of zoonotic spillover and infection transmission, a scoping review was conducted to identify and describe studies discussing different trade standards and regimes governing wildlife trade. To assess under-exposed urban dimensions of AMR and to inform AMR governance strategies, an interdisciplinary analysis was conducted to bridge the epistemic domains of UPE and OH. Lastly, a critical interpretive synthesis (CIS) of peer-reviewed literature was conducted through a UPE lens to clarify the extent to which OH-AMR governance responses institutionalize coordinated AMR-environmental approaches to address challenges and concerns. Governance of infectious diseases prevention in wildlife trade involves institutional and regulatory purviews concerning zoonotic spillover prevention characterized by fragmentation and lack of oversight by a single global coordination authority. The deployment of a UPE lens as a guide to practical politics of sustainability and human-nature relationships contributes to an understanding of how AMR and other systemic threats may be confronted in policy and practice. A UPE-informed analysis of literature discussing AMR governance arrangements reveals opportunities and limitations to simultaneously generate health and environmental gains for targeted populations. Mobilization of an OH approach that considers intersectoral linkages between wildlife trade and complex socioecological interactions that produce the interfaces where zoonotic spillover occurs may improve information sharing and intersectoral governance that contributes a better understanding of the role of global and national organizations in preventing zoonotic spillover and transmission. In an urbanized and interconnected world, a UPE lens illuminates the interconnections among urban life, AMR risks, other global health threats, and aligns with calls to rescale governance arrangements by better taking societal relations with nature into account. More research is needed to consider the feasibility and relevance of designing intersectoral OH-AMR approaches informed by the UPE of AMR.
Open Access
HPV Vaccine Access and Cervical Cancer Policymaking Process: A Comparative Governmental Priority Setting Study of Ghana, Rwanda, and Canada
(2023-12-08) Asempah, Eric; Wiktorowicz, Mary E.
Cervical cancer is a global health issue that claims over 600,000 lives yearly. While high-income countries (HICs) record lower incidence rates of cervical cancer, the opposite is true for underserved regions, such as sub-Saharan Africa (SSA), where a significant burden of global cervical cancer cases are reported. Over 70% of all cervical cancer is caused by high-risk (strain 16 and 18) human papillomavirus (HPV). Currently, prophylactic vaccines, Gardasil® and Gardasil9®, manufactured by Merck; Cervarix®, manufactured by GlaxoSmithKline (GSK); and Cecolin® manufactured by Xiamen Innovax Biotech Co, prevent HPV-related cervical cancer. However, most low- and middle-income countries (LMICs) national immunization programs do not include these vaccines. The thesis explores governmental priority settings and the policymaking imperatives for nationwide HPV vaccination in Canada, Rwanda, and Ghana. Ghana, a LMIC, has a cancer policy that covers cervical cancer; however, it lacks a specific policy governing the prevention and control of the disease. Rwanda (also a LMIC), on the other hand, was the first country in sub-Saharan Africa to implement a nationwide HPV vaccine program that aims to reduce and eventually eliminate cervical cancer case incidence and mortality. Canada, one of the first Organization for Economic Cooperation and Development (OECD) nations to implement province-wide HPV vaccination programs, provides instructive health policymaking propositions. Primary and secondary data were collected to develop country-specific case studies on the imperatives for the HPV vaccination program/policy in each country. A comparative analysis supports understanding the similarities and dissimilarities in policymaking and the environment within which the HPV vaccine and cervical cancer program were planned, formulated, and organized for implementation as a health intervention instrument. The results show different policy convergence and divergence nodes among the countries studied as governments look for solutions to public problems. Because governments have myriad competing public problems to address, selectively solving some problems and leaving others may depend on priorities and available resources. Prioritizing and deciding to act by implementing public HPV vaccination programs in HICs, such as Canada, and LMICs, such as Rwanda, and not acting due to resource constraints reveals that governments can leverage creative approaches to act on a public problem successfully with or without plentiful resources.
Open Access
Deeper Understanding: Addressing Methodological Constraints and Ethical Implications of Humanitarian Needs Assessments Using Natural Language Processing
(2023-08-04) Kreutzer, Tino; Orbinski, James
Humanitarian needs assessments (HNAs) are essential for prioritizing and informing the provision of humanitarian assistance. Data for HNAs are commonly collected using computer-assisted personal interviewing (CAPI) tools. However, the transcription and translation of qualitative interview responses during a humanitarian crisis is challenging to conduct rapidly and at scale. This has led to calls for deploying natural language processing (NLP), a type of artificial intelligence (AI), to enhance CAPI tools. Despite this, data on current methodological HNA practices and issues, as well as the risks to affected populations or organizations providing humanitarian assistance due to data processing, including AI use, are not well understood. This manuscript-based study employed a three-stage mixed-methods Design Science Research approach to inform the design and empirical evaluation of new features for KoboToolbox, a CAPI tool supported and used by humanitarian organizations, to systematically transcribe and translate answers to open-ended questions (OEQ) from HNA interviews. The first stage involved conducting interviews with international key informants (KIs) to explore current approaches to HNA and constraints related to different interview methods. Findings from interviews with 23 KIs from 13 countries revealed 47 themes. The second stage comprised a scoping review to map the range of ethical issues raised in academic literature concerning the processing of data from people affected by humanitarian crises. The scoping review identified 100 relevant studies after screening 8,387 papers, resulting in 22 themes. In the third stage, new KoboToolbox software features were designed and implemented based on a user-centered design approach, with usability testing conducted using observations and feedback from test users. Themes from stages 1 and 2 were used to inform the iterative design and software implementation process, which was validated through feedback from 14 test users from 10 countries. User testing demonstrated strong support for the applicability and usability of the new features, and the results were used to identify and address several usability issues in the software. The tool resulting from this research meets professional requirements and can now be readily deployed by humanitarian organizations worldwide to systematically transcribe, translate, and analyze answers to OEQs from HNA interviews.
Open Access
Exploring Engagement of Patients with Diabetes via mHealth Applications: A Mixed-Methods Study with Primary Care Providers
(2023-03-28) Prashad, Reshma Rajdai; Ahmad, Farah
Research Aims The use of mHealth diabetes self-management applications has emerged as a potential enabler for improving patient care. However, the uptake of such applications in vulnerable and marginalized patient populations remains unclear. This knowledge gap is concerning from a health equity perspective, especially when rates of diabetes are high among these populations. This study aims to examine how the understanding of health equity by primary care providers varies by practice type, as well as the barriers faced when attempting to use these applications. Methods Ecological systems theory and Weber’s conflict theory informed the review of the literature and interpretation of the results. I collected the data from August to October 2020. A convenience sampling approach was used for the survey and I conducted the interviews either by phone or on an online platform. Participants received the survey link through listservs and newsletters from the collaborating organizations, such as The Alliance for Healthier Communities, the Association of Family Health Teams of Ontario, and the Nurse Practitioner Association of Ontario. Forty-eight participants completed the survey, and fifteen participants completed the interview. Results Providers in Community Health Centres had a slightly higher understanding and application of health equity in their practice when compared to non-CHC settings. The hierarchical regression analysis did not explain the variance beyond the number of years in practice, education/training on the social aspects of health, professional status, and service to minorities/vulnerable patients. Even though the results did not support the hypothesis, the overall model explained 33% of the variance in the main outcome. Thus, this study shows that the factors collectively impacting the engagement of providers with diabetic patients included funding, training, and location of the practice. As a result, we can conclude that these factors influenced their application of a health equity lens to their daily work and recommendations for mHealth diabetes application utilization.
Open Access
Exploring Youths' Understanding of Intimate Relationships Through the Education Sector: An Institutional Ethnography
(2023-03-28) Rafiq, Anum; Ahmad, Farah
Adolescence is a vulnerable period for youth across the world. It is a period of new learnings with opportunities to understand and develop perspectives on health and well-being. With youth beginning to engage in intimate relationships at an earlier age in the 21st century, concentrating on the learning opportunity they have in school is paramount. The nature of what has been deemed important to teach in schools has changed throughout history, and focus has shifted from home/family skills to teaching youth how to be competitive in the job market. Amidst this emphasis, opportunities for them exist to learn about building healthy intimate relationships, one of the foundational elements of most people’s lives. Using an Institutional Ethnography (IE), I trace the lived experiences of youth in how they understand intimate relationships, and how their learning experience is organized through the high school Health and Physical Education (H&PE) course. I provide an empirical exploration of how the work of teachers and youth is socially organized by a biomedical, employment-related, and efficiency-based discourse. Through interviews with teachers and youth, I trace the control those ruling relations such as institutional expectations, performance reports, and timetabling enact over the experience of teachers and youth. My findings show how texts such as the H&PE curriculum, the Ontario College of Teachers (OCT) guidelines, Ministry of Education Performance Reports, and the timetable organize the day-to-day activities of teachers and students and reproduce different disjuncture for youth. This disjuncture includes some of their experiences being subordinated, difficulty relating to curriculum, and an experience of healthy living discussions being skimmed over across sites. My findings show that the experience of youth in learning about healthy intimate relationships is not akin to the espoused vision outlined in the H&PE (2015) curriculum policy. These findings have implications for policymakers, activists, and school administration alike, which call for an investigation into who is in power when it comes to youth’s learning needs, and a restructuring of existing institutional practices that allow for the flexibility required to broach the topic of healthy intimacy in a comprehensive manner.
Open Access
Tackling Health Inequalities through Public Policy Action: Insights from Canadian Policy Academics, Activists, and Advocates
(2022-12-14) Borras, Arnel Mercado; Raphael, Dennis
Despite numerous public policy proposals and interventions to address preventable health inequalities, that is, health inequities among and within countries, this societal problem persists. This research addresses how and why health inequities, especially class, race/ethnicity, and gender health inequities, persist in Canada and how to reduce such differences through public policy action. First, I performed a theoretical and critical realist review of existing literature focusing on pluralism, discursive institutionalism, and critical political economy approach to health and policy change. Then I conducted a thematic analysis of the interview data corpus gathered from 23 semi- structured interviews with leading and influential Canadian policy academics, activists, and advocates to address the research questions. Reflexivity also forms part of my methods. The main findings demonstrated that health inequities or the avoidable health inequalities in Canada are primarily caused by 1) the capitalist economic system; 2) the co-constitutives of capitalism, namely colonialism, racism, and sexism; and 3) maldistributive public policies. Health inequities are further sustained by 1) power, interest, and ideology trumping evidence-based research and policy ideas; 2) unequal wealth and power among competing interests and advocacy groups; 3) the dominance of the business and corporate sector in health politics and public policymaking processes; 4) neoliberal governing authorities; and 5) fragmented and weak labour unions, civil society groups, and social movements. Canada’s health inequities reduction efforts necessitate 1) pushing for redistributive public policies; 2) uniting and strengthening labour unions, civil society groups, and social movements; and 3) engaging in electoral politics. The core strategies to realize these health equity goals are the ensemble of information, education, advocacy, organization, and mobilization. Reducing health inequities in general and class, race/ethnicity, and gender health inequities, in particular, may involve struggling within and against capitalism and struggling for socialism. This study may provoke social actions toward emancipatory social change to achieve health justice.
Open Access
From the Standpoint of Policymakers: An Institutional Ethnography Inquiry into the Policymaking Process to Address Health Equity and Social Determinants of Health in Canada
(2022-12-14) Komakech, Morris Deno Copperfields; Raphael, Dennis
The health of a society’s population is determined by the way that society distributes its social and economic resources. This is because a high level of inequality and a wide gap in the socio-economic gradient corresponds with people’s experience of poor health. Despite available evidence of increasing socio-economic and health inequities in Canada, health equity (HE) considerations are not filtering through public policies, which may explain the skewing in the distribution of social determinants of health (SDH). Various governmental and non-state actors recognize these increasing social inequalities and have considered pursuing equity in public policies. Evidence shows that Canadian governments do not generally deliver on their pledges to implement HE-promoting policies. Inquiries about the incongruity between the stated institutional goal of pursuing HE in public policies and the persistent lack of it have pervaded public policy discourses. This study attempts to fill the knowledge gap in the public policy arena between the pluralist and institutionalist explanations of inequities to improve our understanding of “how” and “why” HE/SDH concepts are not filtering through into health policies. My original contribution to knowledge is an account of how policymakers’ work processes are drawn into and coordinated by a set of institutional relations of ruling. These institutional relations organize sequences of inter-related policymaking activities that link these activities to the work of others in producing or not producing policies with health equity outcomes. Using Institutional Ethnography as a method of inquiry, the study aims to highlight intrinsic institutional conceptual practices and explicate how “work” constituting policymaking is performed, influenced, and perceived in multiple institutional sites. Using mapping as an IE device, I map out institutional texts to illuminate the relations of ruling and social organization of policymaking as work. This study concludes that epistemologies rooted in hegemonic biomedical and neoliberal conceptual practices within the selected institutions dominate the ruling relations and the social organization of policymaking as work in these sites; and that, the gap between HE concepts and the government’s obligation to equity-driven health policy for actions on SDH demonstrates a lack of commitment to act in an increasingly market-oriented and politicized policymaking environment.
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.
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
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
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
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
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
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.