Association of Material Deprivation Status, Access to Health Care Services, and Lifestyle With Screening and Prevention of Disease, Montreal, Canada, 2012.

INTRODUCTION: The objective of this study was to provide information on the effect of disparities in material deprivation, access to health care services, and lifestyle on the likelihood of undergoing screening for disease prevention. METHODS: We used data from a probability sample (N = 10,726) of the Montreal population aged 15 years or older and assessed 6 dependent variables (screening for breast cancer, cervical cancer, colon cancer, blood glucose, and high blood pressure and receipt of the seasonal influenza vaccination), and 3 independent variables (disparities in material deprivation, access to health care services, and personal lifestyle habits). We used logistic regression to analyze data and determine associations. RESULTS: Use of preventive health services increased as material deprivation declined, access to health care improved, and lifestyle habits became healthier. The combined effect of household income, an individual measure, and the material deprivation index (consisting of quintiles representing a range from the most privileged [quintile 1: best education, employment, and income] to the most deprived [quintile 5: least education, employment, and income) an ecological measure, showed that having a Papanicolaou test was significantly associated with high annual household income (≥$40,000) even if the woman resided in a deprived neighborhood (quintiles 4 and 5 of the material deprivation index) (odds ratio [OR], 1.38; 95% confidence interval (95% [CI], 1.04-1.84), whereas odds of having a mammogram or influenza vaccination were significantly associated with living in a privileged neighborhood (quintiles 1, 2, and 3 of the material deprivation index) even among people with a low annual household income (<$40,000) (mammogram: OR, 1.54; 95% CI, 1.00-2.38; influenza vaccination: OR, 1.31; 95% CI, 1.04-1.66). CONCLUSION: In addition to influencing lifestyle habits and access to health care services, disparities in material deprivation influence whether a person uses preventive health services. Public health professionals need to establish screening outreach programs in socioeconomically disadvantaged neighborhoods to enhance public participation in disease prevention programs and reduce disparities in health.

The impact of primary healthcare reform on equity of utilization of services in the province of Quebec: a 2003-2010 follow-up.

INTRODUCTION: In 2003, the Quebec government made important changes in its primary healthcare (PHC) system. This reform included the creation of new models of PHC, Family Medicine Groups (e.g. multidisciplinary health teams with extended opening hours and enrolment of patients) and Network Clinics (clinics providing access to investigation and specialist services). Considering that equity is one of the guiding principles of the Quebec health system, our objectives are to assess the impact of the PHC reform on equity by examining the association between socio-economic status (SES) and utilization of healthcare services between 2003 and 2010; and to determine how the organizational model of PHC facilities impacts utilization of services according to SES. METHODS: We held population surveys in 2005 (n = 9206) and 2010 (n = 9180) in the two most populated regions of Quebec province, relating to utilization and experience of care during the preceding two years, as well as organizational surveys of all PHC facilities. We performed multiple logistical regression analyses comparing levels of SES for different utilization variables, controlling for morbidity and perceived health; we repeated the analyses, this time including type of PHC facility (older vs newer models). RESULTS: Compared with the lowest SES, highest SES is associated with less emergency room visits (OR 0.80) and higher likelihood of at least one visit to a PHC facility (OR 2.17), but lower likelihood of frequent visits to PHC (OR 0.69), and higher affiliation to a family doctor (OR 2.04). Differences remained stable between the 2005 and 2010 samples except for likelihood of visit to PHC source which deteriorated for the lowest SES. Greater improvement in affiliation to family doctor was seen for the lowest SES in older models of PHC organizations, but a deterioration was seen for that same group in newer models. CONCLUSIONS: Differences favoring the rich in affiliation to family doctor and likelihood of visit to PHC facility likely represent inequities in access to PHC which remained stable or deteriorated after the reform. New models of PHC organizations do not appear to have improved equity. We believe that an equity-focused approach is needed in order to address persisting inequities.

The negative self-perceived health of migrants with precarious status in Montreal, Canada: A cross-sectional study.

BACKGROUND: Knowledge about the health impacts of the absence of health insurance for migrants with precarious status (MPS) in Canada is scarce. MPS refer to immigrants with authorized but temporary legal status (i.e. temporary foreign workers, visitors, international students) and/or unauthorized status (out of legal status, i.e. undocumented). This is the first large empirical study that examines the social determinants of self-perceived health of MPS who are uninsured and residing in Montreal. METHODS AND FINDINGS: Between June 2016 and September 2017, we performed a cross-sectional survey of uninsured migrants in Montreal, Quebec. Migrants without health insurance (18+) were sampled through venue-based recruitment, snowball strategy and media announcements. A questionnaire focusing on sociodemographic, socioeconomic and psychosocial characteristics, social determinants, health needs and access to health care, and health self-perception was administered to 806 individuals: 54.1% were recruited in urban spaces and 45.9% in a health clinic. 53.9% were categorized as having temporary legal status in Canada and 46% were without authorized status. Regions of birth were: Asia (5.2%), Caribbean (13.8%), Europe (7.3%), Latin America (35.8%), Middle East (21%), Sub-Saharan Africa (15.8%) and the United States (1.1%). The median age was 37 years (range:18-87). The proportion of respondents reporting negative (bad/fair) self-perception of health was 44.8%: 36.1% among migrants with authorized legal status and 54.4% among those with unauthorized status (statistically significant difference; p<0.001). Factors associated with negative self-perceived health were assessed using logistic regression. Those who were more likely to perceive their health as negative were those: with no diploma/primary/secondary education (age-adjusted odds ratio [AOR]: 2.49 [95% CI 1.53-4.07, p<0.001] or with a college diploma (AOR: 2.41 [95% CI 1.38-4.20, p = 0.002); whose family income met their needs not at all/a little (AOR: 6.22 [95% CI 1.62-23.85], p = 0.008) or met their needs fairly (AOR: 4.70 [95% CI 1.21-18.27], p = 0.025); with no one whom they could ask for money (AOR: 1.60 [95% CI 1.05-2.46], p = 0.03); with perception of racism (AOR: 1.58 [95% CI 1.01-2.48], p = 0.045); with a feeling of psychological distress (AOR: 2.17 [95% CI 1.36-3.45], p = 0.001); with unmet health care needs (AOR: 3.45 [95% CI 2.05-5.82], p<0.001); or with a health issue in the past 12 months (AOR: 3.44 [95% CI 1.79-6.61], p<0.001). Some variables that are associated with negative self-perceived health varied according to gender: region of birth, lower formal education, having a family income that does not meet needs perfectly /very well, insalubrious housing, not knowing someone who could be asked for money, and having ever received a medical diagnosis. CONCLUSIONS: In our study, almost half of immigrants without health insurance perceived their health as negative, much higher than reports of negative self-perceived health in previous Canadian studies (8.5% among recent immigrants, 19.8% among long-term immigrants, and 10.6% among Canadian-born). Our study also suggests a high rate of unmet health care needs among migrants with precarious status, a situation that is correlated with poor self-perceived health. There is a need to put social policies in place to secure access to resources, health care and social services for all migrants, with or without authorized status.

[Current pathologies among asylum seekers in Montreal: prevalence and associated risk factors]. / Pathologies courantes chez les demandeurs d'asile à Montréal: prévalence et facteurs de risque associés.

BACKGROUND: Canada received 22,873 asylum seekers in 2006. The screening of specific health problems in this population seems warranted. This study aims to estimate the prevalence of pathologies that were screened at the PRAIDA health service in Montreal, and to identify associations with certain risk factors. METHODS: A retrospective study was conducted on the files of patients who were screened between 2000 and 2004. Demographic and clinical information was compiled for computation of prevalence as well as multiple logistic regression analysis. RESULTS: Of the 289 files reviewed, 56.7% are for male and 43.3% for female patients, with a mean age of 34 years; 53% are Asians and 38% Africans. 59.4% of subjects received a psychiatric diagnosis (mainly depression and post-traumatic stress disorder). The paraclinical work-up showed: 20.3% anaemia, 9% eosinophilia, 29.7% HBcAb+, 5% HBsAg+, 1.5% hepatitis C (RNA+), 2.5% HIV+ and 45.9% TST+. 10.5% of stool samples contained a pathogen, and serologies for strongyloidiasis and schistosomiasis were positive in 17.3% and 3.9% of samples respectively. Significant associations included female gender with anaemia, African origin with rates of HBcAb and TST+, age with HBcAb and hepatitis C positivity, longer length of stay in Canada with eosinophilia and strongyloidiasis, shorter length of stay with HBcAb, and Asian origin with psychiatric disorders. CONCLUSIONS: This study suggests that the prevalence of screened pathologies as part of the PRAIDA health service work-up are high in this population and therefore warrant continuation of their screening until guidelines are constituted.

Health care access for refugees and immigrants with precarious status: public health and human right challenges.

Migration flux is being transformed by globalization, and the number of people with either undocumented or with a precarious status is growing in Canada. There are no epidemiological data on the health and social consequences of this situation, but clinicians working in primary care with migrants and refugees are increasingly worried about the associated morbidity. This commentary summarizes findings from a pilot study with health professionals in the Montreal area and suggests that the uninsured population predicament is a national problem. Although ethical and legal issues associated with data collection by clinicians, institutions and governments need to be examined, estimating the public health consequences and long-term cost associated with problems in access to health care due to migratory status should be a priority. Current regulations and administrative policies appear to be at odds with the principles of equal rights set out by the Canadian Charter of Rights and Freedoms and the UN Convention on the Rights of the Child. Beyond the commitment of individual clinicians, Canadian medical associations should take an advocacy role and scrutinize the ethical and medical implications of the present system.

Solidarity or financial sustainability: an analysis of the values of community-based health insurance subscribers and promoters in Senegal.

OBJECTIVES: Although community-based health insurance (CBHI) seemed promising to improve access to health care, its implementation has been slow and laborious. We hypothesize that the existing tension between the competing objectives of solidarity and financial sustainability that are pursued by CBHI may partly account for this. This paper aims to evaluate if there is a gap between CBHI subscribers' values and their promoters', and to determine which characteristics of subscribers and CBHIs are associated with their values. METHODS: A study of all Senegal CBHI organizations was undertaken in 2002. The analysis includes: 1) content of interviews with subscribers and promoters; and 2) multilevel logistical analysis of the links between characteristics of subscribers (n = 394) and organizations (n = 46) and composite indicators representing values (redistribution, solidarity when difficulties, solidarity between healthy and unhealthy). RESULTS: Promoters emphasize financial sustainability; subscribers are split between financial sustainability and solidarity. Men, polygamous families and individuals with a lower socio-professional status are twice as likely to be in favour of redistribution; subscribers who participate in decision-making and those who think their CBHI is facing difficulties are less in favour of solidarity. At CBHI level, although the variance was significant, none of the variables were retained. CONCLUSION: More attention should be given to reducing the gap between promoters' and subscribers' values, and to increasing member participation in the processes involved in implementing CBHI. This could help all actors involved to understand and improve determinants of enrolment in, and performance of CBHI, thus increasing access to health care for vulnerable populations in developing countries.

Does enrollment in multidisciplinary team-based primary care practice improve adherence to guideline-recommended processes of care? Quebec's Family Medicine Groups, 2002-2010.

BACKGROUND: We investigated whether multidisciplinary team-based primary care practice improves adherence to process of care guidelines, in the absence of financial incentives related to pay-for-performance. METHODS: We conducted a natural experiment including 135,119 patients, enrolled with a general practitioner (GP) in a multidisciplinary team Family Medicine Group (FMG) or non-FMG practice, using longitudinal data from Quebec's universal insurer over the relevant time period (2000-2010). All study subjects had diabetes, chronic obstructive pulmonary disease, or heart failure and were followed over a 7-year period, 2 years prior to enrollment and 5 years after. We constructed indicators on adherence to disease-specific guidelines and composite indicators across conditions. We evaluated the effect of FMGs using propensity score methods and Difference-in-Differences (DD) models. RESULTS: Rates of adherence to chronic disease guidelines increased for both FMG and non-FMG patients after enrollment, but not differentially so. Adherence to prescription-related guidelines improved less for FMG patients (DD [95% CI]=-2.83% [-4.08%, -1.58%]). We found no evidence of an FMG effect on adherence to consultation-related guidelines, (DD [95% CI]=-0.24% [-2.24%; 1.75%]). CONCLUSIONS: We found no evidence that FMGs increased adherence to the guidelines we evaluated. Future research is needed to assess why this reform did not improve performance on these quality-of-care indicators.