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Inequalities in Determinants of Health Among Aboriginal and Caucasian Persons Living With HIV/AIDS in Ontario: Results From the Positive Spaces, Healthy Places Study

DOI:10.1007/bf03404900
Authors:
Laverne E Monette
Laverne E Monette
Laverne E Monette
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Sean B Rourke at St. Michael's Hospital
Sean B Rourke
Katherine Gibson
Katherine Gibson
Katherine Gibson
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Tsegaye Bekele at Ontario Hiv Treatment Network
Tsegaye Bekele
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Abstract

Aboriginal Canadians (i.e., First Nations, Inuit and Métis) are disproportionately affected by HIV/AIDS, and experience greater social and economic marginalization and poorer housing conditions. This study sought to understand the differences in the determinants of health and housing-related characteristics between samples of Aboriginal and Caucasian adults living with HIV/AIDS in Ontario. We analyzed baseline demographic, socio-economic, health, and housing-related data from 521 individuals (79 Aboriginal and 442 Caucasian) living with HIV/AIDS and enrolled in the Positive Spaces, Healthy Places study. We compared the characteristics of Aboriginal and Caucasian participants to identify determinants of health and housing-related characteristics independently associated with Aboriginal ethnicity. Compared to Caucausian participants living with HIV, Aboriginal participants were more likely to be younger, female or transgender women, less educated, unemployed, and homeless or unstably housed. They were also more likely to have low incomes and to have experienced housing-related discrimination. In a multivariate model, gender, income, and experiences of homelessness were independently associated with Aboriginal ethnicity. Aboriginal individuals living with HIV/AIDS in our sample are coping with significantly worse social and economic conditions and are more likely to experience challenging housing situations than a comparison group of Caucasian individuals living with HIV/AIDS. To develop effective care, treatment and support strategies for Aboriginal peoples with HIV, it is critical to address and improve their socio-economic and housing conditions.
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... This is particularly true when evaluation teams focus on overcoming challenges to data collection collectively, while retaining the communities' voice and equity [39][40][41][42][43][44]46]. Finally, intersectional approaches to research facilitate an unpacking of stigmatic, health-based and cultural cross-overs between Indigeneity and other experiences of health-or socially-based marginalisation [211,387,428,453,473]. ...
... Transgender women are at a high risk of HIV acquisition compared to other Aboriginal subpopulations [428]. ...
... Despite some Aboriginal women undergoing HIV testing more on average compared to Aboriginal men [195], Aboriginal WLWH also make a significant proportion of P/WLWH [352,428,534,535], and experience some of the highest rates of mortality and ill health [186,536]. They are at significant risk of treatment attrition or aversion [418], particularly when they are also PWUD [452]. ...
An evidence review from Australia, Aotearoa/New Zealand and Canada for the WA Aboriginal Sexual Health and Blood-borne Viruses Strategy
Research
Full-text available
  • Jan 2019
This review was commissioned by the Department of Health WA as part of the development process for the fourth WA Aboriginal sexual health and blood-borne virus (SHBBV) strategy (2019–2023). This strategy aims to prevent and reduce rates of infection in Australian communities.This review has followed the structure of the third strategy, analysing the data through each domain: prevention and education; testing and diagnosis; disease management and clinical care; workforce development; enabling environments, and; research, evaluation, and surveillance. The review aims to provide a broad overview of evidence on the way SHBBV health promotion, care, and research are negotiated with Aboriginal populations across three countries: Aotearoa/ New Zealand, Australia, and Canada. The data were collected through a scoping review of academic and grey literature (2005-2018), and further developed with the guidance of an advisory group. Culturally appropriate reviews can provide inroads to more constructive policy-making and research practices in health [45, 46]. Reviews can help to address the gaps in inclusive practice guidelines that are evident in current Australian Aboriginal health strategies, in part due to significant knowledge gaps [47]. In particular, reviews which utilise ‘decolonising methodologies’ (such as stakeholder consultation and the expansion of what can be considered ‘valid’ knowledge) can include research that is informed by the needs of communities, as well as the data collected through standard literature searches [48]. Decolonisation, the positioning of Aboriginal-led frameworks at the fore of service delivery, is a crucial aspect of positive and constructive health care, promotion, and research for Aboriginal people [49-51]. It involves directly engaging affected communities, keeping Aboriginal voices amplified and considered throughout institutional processes, practicing reflexivity and immersion, and ensuring that any research or health care/promotion outcomes are addressed with an Aboriginal lens in mind [51-53].
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... In Canada and around the world, Indigenous peoples experience significant health inequities compared to non-Indigenous peoples. [1][2][3] These persistent inequities are consequences of settler-colonialism, perpetuated by settler 1 social systems and institutions that actively efface and misrepresent Indigenous realities and lifeways. [1,4,5] Indigenous peoples' health has been, and continues to be, harmed by individual, structural, and institutional racism that is perpetuated by health care systems and individual providers. ...
... [1][2][3] These persistent inequities are consequences of settler-colonialism, perpetuated by settler 1 social systems and institutions that actively efface and misrepresent Indigenous realities and lifeways. [1,4,5] Indigenous peoples' health has been, and continues to be, harmed by individual, structural, and institutional racism that is perpetuated by health care systems and individual providers. [3,[6][7][8] To help address these health inequities, it has been generally acknowledged that cultural safety programming must be embedded in the education of health care professionals. ...
... This study had two dependent variables of interest that were chosen based on input from the IAC and because of their relevance to the intended attitudinal and behavioural outcomes of cultural safety training. [27][28][29] First, 'Perceived importance of Indigenous content in curricula' was assessed using the following four items: [1] It is valuable for physicians to be educated on Indigenous social issues, [2] It is valuable for physicians to be educated on Indigenous health issues, [3] Conventional (Western) physicians should be aware of traditional medicine(s) that their patients may be using, and [4] The clinical curriculum should incorporate a rotation in an Indigenous community. These items were amalgamated to represent this overarching construct on the basis of principal component analysis (PCA), which identified primary loading of these four items onto the same factor, with minimal cross-loadings. ...
Predictors of medical student interest in Indigenous health learning and clinical practice: A Canadian case study
Article
Full-text available
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... For example, 11.3% of all new HIV infections are among indigenous people despite the fact that they make up less than 5% of the national population [9]. Further, a study of those living with HIV in Ontario found that people living with HIV were more likely to be female or trans women, younger, have lower educational attainment, unemployed, homeless or unstably housed, and experienced housing-related discrimination [10]. Te overrepresentation of indigenous women among those living with HIV is compounded by their increased likelihood to experience stressful life events. ...
... Given the connection between stress, mental health, and HIV progression [10,20] and the related outcomes among indigenous women, this research seeks to understand how a stress-reducing intervention can be implemented in community settings. As a part of the broader Indigenous Women's Stress Study (IWSS), this research examined the feasibility and utility of a culturally inclusive intervention aimed at reducing stress levels and improving the overall wellbeing of indigenous women in Ontario, including but not limited to those living with HIV. ...
Evaluating Facilitators’ Experience Delivering a Stress-Reducing Intervention for Indigenous Women with and without HIV
Article
Full-text available
Indigenous women encounter increased stressful life experiences such as socioeconomic insecurities as well as inequities in health services and outcomes. These stress inequities, which stem from the historical and ongoing effects of settler colonialism, also worsen health outcomes for those women living with HIV. As a part of a broader research project on the impacts of stress-reducing interventions for indigenous women, this study examines the experiences of the women who facilitated the intervention. This research was conducted to evaluate the impacts of a biweekly stress-reducing intervention conducted in Thunder Bay, Ontario. The facilitators of the intervention participated in a focus group in 2019 where they detailed the reach, effectiveness, adoption, and implementation of the intervention. The results suggest that effective stress-reducing interventions should strive to be accessible and inclusive and that doing so can increase program engagement with the service organization hosting the intervention. Further, the results highlight the strengths and challenges of the intervention, including how it helped foster leadership skills and increased indigenous cultural learning among facilitators. These findings demonstrate the strength of community-led interventions and subsequent opportunities for facilitators to grow as leaders. Further, the study highlights how this style of intervention can also encourage participants to engage in other health and wellbeing programs offered by the community partner hosting the intervention. These findings suggest that interventions aimed at reducing stress among indigenous women facing socioeconomic insecurities, including those living with HIV, are both feasible and beneficial for participants, facilitators, and the nonprofit service organizations delivering them.
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... The use of ambulance services for those who are homeless and mentally ill is indicative of the lack of essential supports to sustain wellness. Consistent with research with non-homeless samples, we found that Indigenous participants were more likely than non-Indigenous people to report positive status for HIV, hepatitis C or hepatitis B Virus. 39 40 Marshall et al examined HIV prevalence among street-involved youth and found that Indigenous ethnicity was a correlate of HIV infection and that hepatitis C coinfection was less common among Indigenous participants. 39 Indigenous people also face disparities in HIV outcomes and treatment, as they are likely to be diagnosed and initiate treatment later than non-Indigenous patients. ...
... Indigenous people have been noted to suffer higher mortality even after receiving antiretroviral treatment, suggesting that social determinants may need to be addressed in order to realise the expected effectiveness of medical treatment. 40 Interventions must consider the intergenerational context of Indigenous homelessness, and promote the health of children through investments in families and communities. This analysis has strengths and limitations. ...
Indigenous and non-Indigenous people experiencing homelessness and mental illness in two Canadian cities: A retrospective analysis and implications for culturally informed action
Article
Full-text available
  • Apr 2019
Objectives Indigenous people in Canada are not only over-represented among the homeless population but their pathways to homelessness may differ from those of non-Indigenous people. This study investigated the history and current status of Indigenous and non-Indigenous people experiencing homelessness and mental illness. We hypothesised that compared with non-Indigenous people, those who are Indigenous would demonstrate histories of displacement earlier in life, higher rates of trauma and self-medication with alcohol and other substances. Design and setting Retrospective data were collected from a sample recruited through referral from diverse social and health agencies in Winnipeg and Vancouver. Participants Eligibility included being 19 years or older, current mental disorder and homelessness. Measures Data were collected via interviews, using questionnaires, on sociodemographics (eg, age, ethnicity, education), mental illness, substance use, physical health, service use and quality of life. Univariate and multivariable models were used to model the association between Indigenous ethnicity and dependent variables. Results A total of 1010 people met the inclusion criteria, of whom 439 self-identified as Indigenous. In adjusted models, Indigenous ethnicity was independently associated with being homeless at a younger age, having a lifetime duration of homelessness longer than 3 years, post-traumatic stress disorder, less severe mental disorder, alcohol dependence, more severe substance use in the past month and infectious disease. Indigenous participants were also nearly twice as likely as others (47% vs 25%) to have children younger than 18 years. Conclusions Among Canadians who are homeless and mentally ill, those who are Indigenous have distinct histories and current needs that are consistent with the legacy of colonisation. Responses to Indigenous homelessness must be developed within the context of reconciliation between Indigenous and non-Indigenous Canadians, addressing trauma, substance use and family separations. Trial registration number ISRCTN42520374 , ISRCTN57595077 , ISRCTN66721740 .
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... 9 Although behavior, especially high-risk sexual behavior, is the final pathway to HIV/AIDS, it is closely linked to various SDHs. [11][12][13][14][15][16][17][18][19][20][21][22] For example, one study found that young African American women from economically disadvantaged neighborhoods who reported a lack of food at home, homelessness, and low perceived education and employment prospects had 2.2 to 4.7 times higher odds than those without these risk factors for reporting multiple sex partners, risky sex partners (including older men and partners involved in gangs), substance use before sex, and exchange sex (ie, trading sex for goods and services). 23 Other evidence indicates that poverty and other structural factors create a risk environment that is conducive to HIV transmission and suboptimal engagement in HIV care among low-income African American people living with HIV. ...
... A final recommendation, given the high risk of HIV/ AIDS among MSM, is to develop and evaluate more SDH interventions for men and boys. A 2017 study of the biggest concerns of young adults (aged [18][19][20][21][22][23][24] in racial/ethnic minority groups who are at risk for HIV, including MSM, revealed ...
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... This conclusion requires intense further research. High, or low, rate of participation of women in society can be linked, indirectly or directly, to other factors studied earlier, such as friendly neighborhood [9,12,17] psycho-social environment [9,15], social support [22,27], marital status [23,31], or even culture [8,16]. The second interesting determinant was the percentage of the working-age population. ...
Does “Rural” Always Mean the Same? Macrosocial Determinants of Rural Populations’ Health in Poland
Article
Full-text available
Rural areas, as well as urban ones, are not homogeneous in terms of social and economic conditions. Those surrounding large urban centers (suburban rural areas) act different roles than those located in remote areas. This study aims to measure the level of inequalities in social determinants of health (SDH) between two categories of rural areas. We pose the following research hypotheses: (hypothesis H1) rural areas in Poland are relatively homogenous in the context of SDH and (hypothesis H2) SDH affects life expectancies of rural residents. Based on data covering all rural territories, we found that rural areas in Poland are homogenous in SDH. We also find important determinants of health rooted in a demographic structure—the feminization index and a ratio of the working-age population. On the other hand, we cannot confirm the influence of commonly used SDH-GDP and unemployment rate.
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... Death, dying, and access to care for structurally vulnerable populations Impacted by forces of oppression, such as racism, colonialism, sexism, and/or classism, structurally vulnerable populations experience disproportionate rates of negative health outcomes, including, a heightened risk of poorer mental health, problematic substance use, as well as premature chronic morbidity and earlier death expectancy when compared to the average population [19][20][21][22][23][24]. Such negative health outcomes are the manifestation of various structural and systemic processes that produce violence, trauma, and harm [25,26]. ...
“Just too busy living in the moment and surviving”: barriers to accessing health care for structurally vulnerable populations at end-of-life
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Full-text available
Background Despite access to quality care at the end-of-life (EOL) being considered a human right, it is not equitable, with many facing significant barriers. Most research examines access to EOL care for homogenous ‘normative’ populations, and as a result, the experiences of those with differing social positioning remain unheard. For example, populations experiencing structural vulnerability, who are situated along the lower rungs of social hierarchies of power (e.g., poor, homeless) will have unique EOL care needs and face unique barriers when accessing care. However, little research examines these barriers for people experiencing life-limiting illnesses and structural vulnerabilities. The purpose of this study was to identify barriers to accessing care among structurally vulnerable people at EOL. Methods Ethnography informed by the critical theoretical perspectives of equity and social justice was employed. This research drew on 30 months of ethnographic data collection (i.e., observations, interviews) with structurally vulnerable people, their support persons, and service providers. Three hundred hours of observation were conducted in homes, shelters, transitional housing units, community-based service centres, on the street, and at health care appointments. The constant comparative method was used with data collection and analysis occurring concurrently. Results Five significant barriers to accessing care at EOL were identified, namely: (1) The survival imperative; (2) The normalization of dying; (3) The problem of identification; (4) Professional risk and safety management; and (5) The cracks of a ‘silo-ed’ care system. Together, findings unveil inequities in accessing care at EOL and emphasize how those who do not fit the ‘normative’ palliative-patient population type, for whom palliative care programs and policies are currently built, face significant access barriers. Conclusions Findings contribute a nuanced understanding of the needs of and barriers experienced by those who are both structurally vulnerable and facing a life-limiting illness. Such insights make visible gaps in service provision and provide information for service providers, and policy decision-makers alike, on ways to enhance the equitable provision of EOL care for all populations.
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... The history of residential schools continues to echo in poverty, limited access to education and fair employment, alcoholrelated stigma (Egan, 2014), lack of access to health care and education, unsafe sexual behaviour, and use of contaminated injecting equipment (McCall & Lauridsen-Hoegh, 2014). Thus, social and economic conditions, which are significantly worse for Aboriginal individuals (Monette et al., 2011), shape the risk of acquiring HIV (Cain et al., 2013). ...
Partner-seeking experiences of single heterosexual people living with HIV in a Western Canadian city
Thesis
Full-text available
  • Jan 2016
This narrative research study aimed to answer the question: What is the experience of heterosexual people living with HIV in terms of partner-seeking in a Western Canadian city? Ten participants shared their experiences in semi-structured interviews. Relationship challenges were the major stressor of living with the illness. Feeling desperate about finding a partner and incorporating a new identity as a person living with HIV, some participants turned to celibacy. Other findings included lack of understanding of harm reduction strategies and favoring as partners people who also lived with HIV because of the shared knowledge, the absence of the need to disclose, and perceptions of greater self-stigma in a serodiscordant relationship. Recommendations for AIDS service organizations (e.g., discussions of healthy relationships, sexuality, self-esteem) and health care professionals (e.g., incorporating family planning and harm reduction strategies in discussions with patients) are suggested. Limitations and directions for future research are also discussed.
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Experiences of HIV among global Indigenous populations through the lens of the UN Declaration on the Rights of Indigenous Peoples
Article
  • Jul 2023
Since its introduction in 2007, the UN Declaration on the Rights of Indigenous Peoples (UNDRIP) has been adopted by 144 countries worldwide. In a ten-point statement released in 2017, Indigenous leaders in the HIV and AIDS community established a list of truths and actions to be used for advocacy to end AIDS among Indigenous Peoples through self-determination, justice, and human rights. 15 years after the UNDRIP and 5 years after the 10-point statement, this Review asks where we are in terms of upholding the UNDRIP and the International Indigenous HIV and AIDS Community statement in relation to HIV and AIDS, and what is needed to better uphold and respond to these directives. HIV in Indigenous populations continues to intersect with multiple forms of oppression, racism, and discrimination, which are yet to be eliminated from laws, policies, and practices. Eradicating white supremacy and Indigenous-specific racism across all health systems is a bare minimum requirement to uphold Indigenous rights within health care, and must be accompanied by support for Indigenous, self-determined, culturally tailored, and community-specific health and wellness services.
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Providing Data-Driven Equitable Palliative and End-of-Life Care for Structurally Vulnerable Populations: A Pilot Survey of Information Management Strategies
Article
  • Aug 2019
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Article
Full-text available
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The CES-D Scale: A Self-Report Depression Scale for Research in the General Population
Article
The CES-D scale is a short self-report scale designed to measure depressive symptomatology in the general population. The items of the scale are symptoms associated with depression which have been used in previously validated longer scales. The new scale was tested in household interview surveys and in psychiatric settings. It was found to have very high internal consistency and adequate test- retest repeatability. Validity was established by pat terns of correlations with other self-report measures, by correlations with clinical ratings of depression, and by relationships with other variables which support its construct validity. Reliability, validity, and factor structure were similar across a wide variety of demographic characteristics in the general population samples tested. The scale should be a useful tool for epidemiologic studies of de pression.
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Socioeconomic status, access to triple therapy, and survival from HIV-disease since 1996
Article
  • Nov 2002
In the era before highly active antiretroviral therapy (HAART), socioeconomic status was associated with survival from HIV disease. We have explored socioeconomic status, access to triple therapy (HAART), and mortality in the context of a universal healthcare system. We evaluated 1408 individuals who initiated double or triple therapy between 1 August 1996 and 31 December 1999, and were followed until 31 March 2000. Cumulative HIV-related mortality rates were estimated using Kaplan-Meier methods and Cox proportional hazards regression. In the overall Cox model, we found that adherence [risk ratio (RR) 0.83; per 10% increase], CD4 cell count (RR 1.53; per 100 cell decrease), and lower socioeconomic status (RR 2.19; high versus low), were associated with HIV-related mortality. However, socioeconomic status was not significant among patients prescribed triple therapy in a stratified analysis, or in a sub-analysis restricted to patients prescribed HAART in the initial regimen. When we investigated if inequitable access to HAART by socio-economic status could explain the discrepancy, we found that persons in the lower socio-economic strata were less likely to be prescribed triple therapy even after adjustment for clinical characteristics. In a universal healthcare system, socioeconomic status was strongly associated with HIV-related mortality. When we investigated possible explanations for this association, we found that individuals of lower socioeconomic status were less likely to receive triple therapy after adjustment for clinical characteristics. Our findings highlight the need for the monitoring of therapeutic guidelines to ensure equitable access, as treatment strategies are updated.
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