In this article, we discuss findings from an ethnographic study in which we explored experiences of access to primary care services from the perspective of Aboriginal people seeking care at an emergency department (ED) located in a large Canadian city. Data were collected over 20 months of immersion in the ED, and included participant observation and in-depth interviews with 44 patients triaged as stable and nonurgent, most of whom were living in poverty and residing in the inner city. Three themes in the findings are discussed: (a) anticipating providers' assumptions; (b) seeking help for chronic pain; and (c) use of the ED as a reflection of social suffering. Implications of these findings are discussed in relation to the role of the ED as well as the broader primary care sector in responding to the needs of patients affected by poverty, racialization, and other forms of disadvantage.
In this study, a series of focus groups were conducted to gain an understanding of the nature of stress among Canadian Aboriginal women and men living with diabetes. Specifically, attention was given to the meanings Aboriginal peoples with diabetes attach to their lived experiences of stress, and the major sources or causes of stress in their lives. The key common themes identified are concerned not only with health-related issues (i.e. physical stress of managing diabetes, psychological stress of managing diabetes, fears about the future, suffering the complications of diabetes, and financial aspects of living with diabetes), but also with marginal economic conditions (e.g. poverty, unemployment); trauma and violence (e.g. abuse, murder, suicide, missing children, bereavement); and cultural, historical, and political aspects linked to the identity of being Aboriginal (e.g. 'deep-rooted racism', identity problems). These themes are, in fact, acknowledged not as mutually exclusive, but as intertwined. Furthermore, the findings suggest that it is important to give attention to diversity in the Aboriginal population. Specifically, Métis-specific stressors, as well as female-specific stressors, were identified. An understanding of stress experienced by Aboriginal women and men with diabetes has important implications for policy and programme planning to help eliminate or reduce at-risk stress factors, prevent stress-related illnesses, and enhance their health and life quality.
The practice of integrating western and traditional indigenous medicine is fast becoming an accepted and more widely used approach in health care systems throughout the world. However, debates about intercultural health approaches have raised significant concerns. This paper reports findings of five case studies on intercultural health in Chile, Colombia, Ecuador, Guatemala, and Suriname. It presents summary information on each case study, comparatively analyzes the initiatives following four main analytical themes, and examines the case studies against a series of the best practice criteria.
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Diabetes is associated with increased fracture rates but the effect size, time course and modifying factors are poorly understood. This study was undertaken to assess the effect of diabetes on fracture rates and possible interactions with age, duration of diabetes and comorbidity. A retrospective, population-based matched cohort study (1984-2004) was performed using the Population Health Information System (POPULIS) for the Province of Manitoba, Canada. The study cohort consisted of 82,094 diabetic adults and 236,682 non-diabetic matched controls. Diabetes was subclassified as long term, short term, and newly diagnosed. Number of ambulatory diagnostic groups (ADGs) was an index of comorbidity. Poisson regression was used to study counts of combined hip, wrist and spine (osteoporotic) fractures (5691 with diabetes and 16,457 without diabetes) and hip fractures (1901 with diabetes and 5224 without diabetes). Independent effects of longer duration of diabetes (p-for-trend
Centre for Aboriginal Health Research, Suite 715 Buhler Research Centre, Department of Community Health Sciences, The University of Manitoba, 715 McDermot Avenue, Winnipeg, MB R3E 3P4. firstname.lastname@example.org
Can J Public Health. 2005 Jan-Feb;96 Suppl 1:S9-12
This paper describes the emergence of a formal partnership between Manitoba First Nations and researchers in the Department of Community Health Sciences at the University of Manitoba. This partnership reflects two decades of a working relationship in Manitoba involving university researchers and First Nations communities, as well as new and innovative approaches to developing organizations, training initiatives and projects that strengthen First Nations principles of governance. The emerging trust that has developed between the Manitoba First Nations and the University has made it possible to extend this partnership into building further research capacity and evidence-based decision-making among First Nations. Discussions between the Assembly of Manitoba Chiefs and the Northern Health Research Unit resulted in the development of a Manitoba First Nations Centre for Aboriginal Health Research. Its mission is to initiate, coordinate and support research activities designed to assist First Nations and Aboriginal communities and organizations in their efforts to promote healing, wellness and improved health services in their communities. Much of the health research described in this journal was facilitated through this partnership, which demonstrated the value of partnerships and new funding opportunities to better address the health information needs of First Nations communities, particularly at a time when Aboriginal communities were highly skeptical of the value of academic research.
International evidence shows that enhancement of primary health care (PHC) services for disadvantaged populations is essential to reducing health and health care inequities. However, little is known about how to enhance equity at the organizational level within the PHC sector. Drawing on research conducted at two PHC Centres in Canada whose explicit mandates are to provide services to marginalized populations, the purpose of this paper is to discuss (a) the key dimensions of equity-oriented services to guide PHC organizations, and (b) strategies for operationalizing equity-oriented PHC services, particularly for marginalized populations.
The PHC Centres are located in two cities within urban neighborhoods recognized as among the poorest in Canada. Using a mixed methods ethnographic design, data were collected through intensive immersion in the Centres, and included: (a) in-depth interviews with a total of 114 participants (73 patients; 41 staff), (b) over 900 hours of participant observation, and (c) an analysis of key organizational documents, which shed light on the policy and funding environments.
Through our analysis, we identified four key dimensions of equity-oriented PHC services: inequity-responsive care; trauma- and violence-informed care; contextually-tailored care; and culturally-competent care. The operationalization of these key dimensions are identified as 10 strategies that intersect to optimize the effectiveness of PHC services, particularly through improvements in the quality of care, an improved 'fit' between people's needs and services, enhanced trust and engagement by patients, and a shift from crisis-oriented care to continuity of care. Using illustrative examples from the data, these strategies are discussed to illuminate their relevance at three inter-related levels: organizational, clinical programming, and patient-provider interactions.
These evidence- and theoretically-informed key dimensions and strategies provide direction for PHC organizations aiming to redress the increasing levels of health and health care inequities across population groups. The findings provide a framework for conceptualizing and operationalizing the essential elements of equity-oriented PHC services when working with marginalized populations, and will have broad application to a wide range of settings, contexts and jurisdictions. Future research is needed to link these strategies to quantifiable process and outcome measures, and to test their impact in diverse PHC settings.
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Faculty of Physical Education and Recreation Studies, Health, Leisure and Human Performance Research Institute, 102 Frank Kennedy Centre, University of Manitoba, Winnipeg, Manitoba, R3T 2N2, Canada. email@example.com
Many Aboriginal peoples are widely exposed to stress in their lives. This exposure to stress appears linked not only to their contemporary and immediate life circumstances (e.g., marginal economic and at-risk living conditions) but also to their historical, cultural, and political contexts. Recently, diabetes has become prevalent in many Aboriginal communities worldwide. The purpose of the present study was to gain a better understanding of the ways in which Aboriginal peoples with diabetes cope with stress. The study used a series of focus groups among First Nations and Metis women and men with diabetes in Winnipeg, Manitoba, Canada. Based on our cross-thematic analyses of the data, three overarching themes were identified: (1) individual and collective strengths of Aboriginal peoples with diabetes must be recognized and utilized to facilitate healing from or coping with the experience of stress and trauma; (2) healing must be accomplished holistically by maintaining balance or harmony among mind, body, and spirit; and (3) effective ways of coping with stress and healing from trauma potentially promote positive transformations for Aboriginal peoples and communities at both individual and collective levels. Also, sub-themes of stress-coping and healing that underlie and further describe the above three overarching themes emerged from the data. These include: (a) interdependence/connectedness, (b) spirituality/transcendence, (c) enculturation/facilitation of Aboriginal cultural identity, (d) self-control/self-determination/self-expression, and (e) the role of leisure as a means of coping with stress and healing from trauma. Accordingly, our deeper analyses resulted in the development of an emergent model of stress-coping and healing among Aboriginal peoples with diabetes, which is presented as a dynamic system in which the three overarching themes are embedded in the five specific themes of coping/healing. This evidence-based emergent model appears to provide some important insights into health policy and program planning for Aboriginal peoples with diabetes and their communities.
The present study describes the trajectory of the energy gap (energy imbalance) in the Canadian population from 1976 to 2003, its temporal relationship to adult obesity, and estimates the relative contribution of energy availability and expenditure to the energy gap. It also assesses which foods contributed the most to changes in available energy over the study period.
Annual estimates of the energy gap were derived by subtracting population-adjusted per capita daily estimated energy requirements (derived from Dietary Reference Intakes) from per capita daily estimated energy available (obtained from food balance sheets). Food balance sheets were used to assess which foods contributed to changes in energy availability. Adult obesity rates were derived from six national surveys. The relationship to the energy gap was assessed through regression analysis.
Between 1976 and 2003, per capita daily estimated energy availability increased by 18 % (1744 kJ), and increased energy availability was the major driver of the increased energy gap. Salad oils, wheat flour, soft drinks and shortening accounted for the majority of the net increase in energy availability. Adult obesity was significantly correlated with the energy gap over the study period.
The widening energy gap is being driven primarily by increased energy availability. The food commodities driving the widening energy gap are major ingredients in many energy-dense convenience foods, which are being consumed with increasing frequency in Canada. Policies to address population obesity must have a strong nutritional focus with the objective of decreasing energy consumption at the population level.
A semistructured measure was developed from early descriptive work by Lipowski to elicit the meaning of breast cancer using eight preset categories: challenge, enemy, punishment, weakness, relief, strategy, irreparable loss, and value. This measure was applied in two studies: a cross-sectional survey of 1012 Canadian women at various points after diagnosis and a follow-up study 3 years later of 205 women from the previous study who were close to the time of diagnosis at the first testing. The majority of the 1012 women chose "challenge" (57.4%) or "value" (27.6%) to describe the meaning of breast cancer, whereas fewer chose the more negative "enemy" (7.8%) or "irreparable loss" (3.9%). At the 3-year follow-up assessment, 78.9% of the women who had indicated positive meaning by their choices of "challenge" or "value" did so again. Verbal descriptions provided by the women were congruent with those reported in previous qualitative studies of meaning in breast cancer with respect to the two most prevalent categories: challenge and value. At follow-up assessment, women who ascribed a negative meaning of illness with choices such as "enemy," "loss," or "punishment" had significantly higher levels of depression and anxiety and poorer quality of life than women who indicated a more positive meaning. The meaning-of-illness measure provides an approach that can be applied in large surveys to detect women who ascribe less positive meaning to the breast cancer experience, women who may be difficult to identify in the context of small, qualitative studies.
The paper presents a model of plausible mechanisms linking social capital to suicide risk factors among First Nations youth, informed by a study that explored the concept of social capital in First Nations communities, and by a study on mental health services in First Nations communities in Manitoba. The model incorporates several components of social capital. The plausible impact of social capital on protective and risk factors of suicide among youth is explored.