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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

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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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... 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. ...
Article
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Background Including content on Indigenous health in medical school curricula has become a widely-acknowledged prerequisite to reducing the health disparities experienced by Indigenous peoples in Canada. However, little is known about what levels of awareness and interest medical students have about Indigenous peoples when they enter medical school. Additionally, it is unclear whether current Indigenous health curricula ultimately improve students’ beliefs and behaviours. Methods A total of 129 students completed a 43-item questionnaire that was sent to three cohorts of first-year medical students (in 2013, 2014, 2015) at one undergraduate medical school in Canada. This survey included items to evaluate students’ sociopolitical attitudes towards Indigenous people, knowledge of colonization and its links to Indigenous health inequities, knowledge of Indigenous health inequities, and self-rated educational preparedness to work with Indigenous patients. The survey also assessed students’ perceived importance of learning about Indigenous peoples in medical school, and their interest in working in an Indigenous community, which were examined as outcomes. Using principal component analysis, survey items were grouped into five independent factors and outcomes were modelled using staged multivariate regression analyses. Results Generally, students reported strong interest in Indigenous health but did not believe themselves adequately educated or prepared to work in an Indigenous community. When controlling for age and gender, the strongest predictors of perceived importance of learning about Indigenous health were positive sociopolitical attitudes about Indigenous peoples and knowledge about colonization and its links to Indigenous health inequities. Significant predictors for interest in working in an Indigenous community were positive sociopolitical attitudes about Indigenous peoples. Knowledge about Indigenous health inequities was negatively associated with interest in working in an Indigenous community. Conclusions Students’ positive sociopolitical attitudes about Indigenous peoples is the strongest predictor of both perceived importance of learning about Indigenous health and interest in working in Indigenous communities. In addition to teaching students about the links between colonization, health inequities and other knowledge-based concepts, medical educators must consider the importance of attitude change in designing Indigenous health curricula and include opportunities for experiential learning to shape students’ future behaviours and ultimately improve physician relationships with Indigenous patients. Electronic supplementary material The online version of this article (10.1186/s12909-018-1401-1) contains supplementary material, which is available to authorized users.
... 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]. ...
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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].
... 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. ...
Article
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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 .
... 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 ...
... 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. ...
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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.
... 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]. ...
Article
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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.
... 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). ...
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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.
... It is important to consider what a commitment to reconciliation means for APHAs in Canada who continue to experience barriers to stable housing and are more likely than non-Indigenous peoples living with HIV to experience housing-related discrimination (Monette et al., 2011). Moreover, it is essential to consider in what way funding can be optimized to meet the housing and health needs of APHAs. ...
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Stable Homes, Strong Families (SHSF) is a community-based research project that sought to investigate the connection between HIV, housing and Indigenous cultures and identify strategies to ensure culturally appropriate housing programs and policies for Indigenous peoples living with and affected by HIV. The impetus for this research stems from a body of knowledge that recognizes the inextricable link between housing and health, as well as growing momentum in Canada to reimagine the relationship between Indigenous and non-Indigenous peoples through decolonizing approaches and reconciliation. This paper outlines a number of solution-focused social policy recommendations that emerged from SHSF research findings to Indigenize the creation and management of housing for Indigenous peoples living with and affected by HIV. Recommendations include creating spaces for ceremonial practices and cultural traditions; integrating processes for community engagement and consultation; breaking down silos that exist between health, housing, and urban development stakeholders; and providing wrap around support services from an Indigenous perspective. In advocating for these recommendations, we aim to stimulate a dialog regarding how, and by whom, housing policies and practices can be developed, implemented, and mandated to best support Indigenous peoples living with and affected by HIV and AIDS across Canada and around the world.
... 9 Thus, structural and social inequities result in multiple and numerous health disparities. Those who experience structural vulnerability have higher rates of death across the spectrum of causes 10 and premature chronic morbidity at an earlier age, including diabetes, 11 cardiovascular disease, 12 many cancers, 13 HIV/AIDS, and hepatitis C. 14,15 These disparities are often coupled with high rates of serious and debilitating mental illness or substance use placing people at even greater risk of poor health outcomes. 16 Although these populations have a heightened need for care, they face unique challenges in accessing services. ...
Article
Background Considerable gains are being made in data-driven efforts to advance quality improvement in health care. However, organizations providing hospice-oriented palliative care for structurally vulnerable persons with terminal illnesses may not have the enabling data infrastructure or framework to derive such benefits. Methods We conducted a pilot cross-sectional qualitative study involving a convenience sample of hospice organizations across North America providing palliative care services for structurally vulnerable patients. Through semistructured interviews, we surveyed organizations on the types of data collected, the information systems used, and the challenges they faced. Results We contacted 13 organizations across North America and interviewed 9. All organizations served structurally vulnerable populations, including the homeless and vulnerably housed, socially isolated, and HIV-positive patients. Common examples of collected data included the number of referrals, the number of admissions, length of stay, and diagnosis. More than half of the organizations (n = 5) used an electronic medical record, although none of the record systems were specifically designed for palliative care. All (n = 9) the organizations used the built-in reporting capacity of their information management systems and more than half (n = 6) augmented this capacity with chart reviews. Discussion A number of themes emerged from our discussions. Present data collection is heterogeneous, and storage of these data is highly fragmented within and across organizations. Funding appeared to be a key enabler of more robust data collection and use. Future work should address these gaps and examine opportunities for innovative ways of analysis and reporting to improve care for structurally vulnerable populations.
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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.