Our roles are not at ease: The work of engaging a youth advisory council in a mental health services delivery organization.

OBJECTIVES: There is growing policy impetus for including youth voices in health services research and health system reform. This article examines the perspectives of professionals in a mental healthcare organization charged with engaging young people as advisors in service transformation. METHODS: An institutional ethnography of a youth mental health services organization in Ontario, Canada, was conducted. Fieldwork consisted of twelve months of observation of meetings, interviews with youth advisors and adult service providers, with subsequent text analysis of engagement training and policy materials. The present article reports data from six adult professionals and related field observations. RESULTS: Service providers' efforts to engage youth were observed in three areas: a) supporting youth's development as advisors, b) retaining and deepening youth participation while waiting for organizational change and c) embedding relationships between youth and adults at various levels within the system of care. This work denotes existing tensions between the values and ideals of youth engagement and the everyday demands of services delivery. CONCLUSION: In this setting, a fundamental dimension of this work consisted of negotiating tensions between the policy enthusiasm for engagement and its realization in a health services context. In describing these contextual challenges, we outline implications for consideration by other youth mental health services. Engagement efforts that are authentic and sustained require resources and flexibility, and leadership commitment to instil service users' perspectives throughout multiple levels within the organization.

A critical narrative inquiry to understand the impacts of an overdose prevention site on the lives of site users.

BACKGROUND: Globally, communities are struggling to gain support for harm reduction strategies being implemented to address the impacts of substance use. A key part of this discussion is understanding and engaging with people who use drugs to help shape community harm reduction strategies. This study focused on how an overdose prevention site has influenced the lives of people who use drugs. METHODS: A critical narrative method was utilized, centred on photo-narratives. Twenty-seven individuals accessing an overdose prevention site were recruited to participate in preliminary interviews. Sixteen participants subsequently took photographs to describe the impact of the site and participated in a second round of interviews. Through independent coding and several rounds of team analysis, four themes were proposed to constitute a core narrative encompassing the diverse experiences of participants. RESULTS: A key message shared by participants was the sense that their lives have improved since accessing the site. The core narrative proposed is presented in a series of four themes or "chapters": Enduring, Accessing Safety, Connecting and Belonging, and Transforming. The chapters follow a series of transitions, revealing a journey that participants presented through their own eyes: one of moving from utter despair to hope, opportunity, and inclusion. Where at the outset participants were simply trying to survive the challenges of chaotic substance use, through the relationships and services provided at the site they moved towards small or large life transformations. CONCLUSIONS: This study contributes to an enhanced understanding of how caring relationships with staff at the overdose prevention site impacted site users' sense of self. We propose that caring relationships are an intervention in and of themselves, and that these relationships contribute to transformation that extends far beyond the public health outcomes of disease reduction. The caring relationships at the site can be a starting point for significant social changes. However, the micro-environment that existed within the site needs to extend beyond its walls for true transformative change to take place. The marginalization and stigmatization that people who use drugs experience outside these sites remains a constant barrier to achieving stability in their lives.

Ontario's Poverty Reduction Strategy: A Critical Discourse Analysis.

This article overviews the second phase of a two-phase study which examined experiences of health and social exclusion among mothers experiencing homelessness in Ontario, Canada. A critical discourse analysis was employed to analyze the policy document, Realizing Our Potential: Ontario's Poverty Reduction Strategy, 2014-2019. In nursing, analysis of policy is an emerging form of scholarship, one that draws attention to the macro levels influencing health and health promotion, such as the social determinants of health, and the policies that impact them. The clear neo-liberal underpinnings, within the strategy, with a focus on productivity and labor market participation leave little room for an understanding of poverty reduction from a human rights perspective. Further, gender-neutrality rendered the poverty experienced by women, and mothers, invisible. Notably, there were a lack of deadlines, target dates, and thorough action and evaluation plans. Such absence troubles whether poverty reduction is truly a priority for the government, and society as a whole.

Social Exclusion and Health: The Development of Nursing Knowledge.

The concept of social exclusion has been proposed as an important social determinant of health. However, use of the concept in health and health promotion research is in its infancy. In nursing discourse, in particular, exploration and application of the concept of social exclusion is minimal. The purpose of this article is to explore the relevance of the concept of social exclusion in the development of nursing knowledge. Current knowledge regarding social exclusion is examined and its use in health-related research is explored. To conclude, a conceptualization of social exclusion for the development of nursing knowledge is proposed.

Il a été proposé que le concept d'exclusion sociale soit considéré comme un important déterminant social de la santé. Cependant, le recours à ce concept dans la recherche en santé et en promotion de la santé en est encore à ses balbutiements. Dans le discours des sciences infirmières en particulier, l'étude et l'application du concept d'exclusion sociale sont toujours minimes. L'objectif du présent article est d'explorer la pertinence du concept d'exclusion sociale dans le développement du savoir en sciences infirmières. Les auteures y examinent les connaissances actuelles relatives à l'exclusion sociale et leur utilisation dans la recherche liée à la santé. L'article propose en conclusion une conceptualisation de l'exclusion sociale adaptée au développement des connaissances en sciences infirmières.

A Critical Discourse Analysis of Provincial Policies Impacting Shelter Service Delivery to Women Exposed to Violence.

Shelters for abused women function within a broad context that includes intersecting social structures, policies, and resources, which may constrain and limit the options available to abused women and tacitly reinforce the cycle of abuse. This feminist, qualitative study combined in-depth interviews and focus groups conducted with 37 staff and four executive directors from four shelters in Ontario, Canada, along with a critical discourse analysis of salient policy texts. Together, the interviews and critical discourse analysis formed an integrated analysis of the dialectic between policy as written and enacted. The study findings illuminate the complexity of the system and its impact on women, shelters, and the community and highlight how specific types of social policies and various social system subsystems and structures, and system configuration, shape the day to day reality of shelter service delivery and impact outcomes for abused women and their children. Collectively, these findings offer direction regarding where these policies could be improved and provide a basis for shelters, policy makers, advocates, and the community to strengthen current services and policies, potentially enhancing outcomes for women.

Laboring to mother in the context of past trauma: the transition to motherhood.

The occurrence of interpersonal trauma is a reality for many women, with effects that often persist long after the traumatic events end. The purpose of this feminist grounded theory study was to examine how past trauma shaped the lives of women as they became new mothers. We recruited a purposive sample of 32 women from two Canadian communities and conducted semistructured, dialogic interviews during the second trimester of pregnancy. We analyzed data using thematic content analytic methods, including open coding whereby we read transcripts line by line and applied codes to portions of text that illustrated concepts or themes. The substantive grounded theory, "laboring to mother in the context of past trauma," describes the exceedingly difficult emotional and cognitive work undertaken by pregnant women with histories of trauma as they anticipate becoming mothers. In this article, we present key components of the theory and offer recommendations for health and social service providers.

Strengths amidst vulnerabilities: the paradox of resistance in a mining-affected community in Guatemala.

The influence of large-scale mining on the psychosocial wellbeing and mental health of diverse Indigenous communities has attracted increased attention. In previous reports, we have discussed the influence of a gold mining operation on the health of a community in the Western highlands of Guatemala. Here, we discuss the community strengths, and acts of resistance of this community, that is, community processes that promoted mental health amidst this context. Using an anti-colonial narrative methodology that incorporated participatory action research principles, we developed a research design in collaboration with community leaders and participants. Data collection involved focus groups, individual interviews and photo-sharing with 54 men and women between the ages of 18 and 67. Data analysis was guided by iterative and ongoing conversations with participants and McCormack's narrative lenses. Study findings revealed key mechanisms and sources of resistance, including a shared cultural identity, a spiritual knowing and being, 'defending our rights, defending our territory,' and, speaking truth to power. These overlapping strengths were identified by participants as key protective factors in facing challenges and adversity. Yet ultimately, these same strengths were often the most eroded or endangered due the influence of large-scale mining operations in the region. These community strengths and acts of resistance reveal important priorities for promoting mental health and wellbeing for populations impacted by large-scale mining operations. Mental health practitioners must attend to both the strengths and parallel vulnerabilities that may be occasioned by large-scale projects of this nature.

Client-provider relationships in a community health clinic for people who are experiencing homelessness.

Recognizing the importance of health-promoting relationships in engaging people who are experiencing homelessness in care, most research on health clinics for homeless persons has involved some recognition of client-provider relationships. However, what has been lacking is the inclusion of a critical analysis of the policy context in which relationships are enacted. In this paper, we question how client-provider relationships are enacted within the culture of community care with people who are experiencing homelessness and how clinic-level and broader social and health policies shape relationships in this context. We explore these questions within a critical theoretical perspective utilizing a critical ethnographic methodology. Data were collected using multiple methods of document review, participant observation, in-depth interviews and focus groups. The participants include both clients at a community health clinic, and all clinic service providers. We explore how clients and providers characterized each other as 'good' or 'bad'. For providers, this served as a means by which they policed behaviours and enforced social norms. The means by which both providers' and clients' negotiated relationships are explored, but this is couched within both local and system-level policies. This study highlights the importance of healthcare providers and clients being involved in broader policy and systemic change.

Community health promotion with people who are experiencing homelessness.

Homelessness is an experience of being displaced. Once removed from their personal places, homeless people are barred access to healthy places in which to be. Health clinics for people who are experiencing homelessness offer an opportunity to create health-promoting places. In this study, we explore how place is experienced within a community health clinic for people who are experiencing homelessness. A critical ethnographic methodology was used. Results illustrate how clients and providers contested the space of the clinic. Discourses of safety, health promotion, and privacy were enacted, altered, and resisted in a constant practice of culture-making. Physical components of the space became conceptual components of how place and power in place were understood by clients and providers. Results point to the importance of conceptualizing service users as the key stakeholders in their care, considering how places may be more or less health promoting, and rethinking how safety is conceptualized.

Tensions in anti-colonial research: lessons learned by collaborating with a mining-affected indigenous community.

Community-based nurse researchers strive to develop collaborative partnerships that are meaningful to the health priorities of participants and relevant to their sociopolitical realities. Within the context of global inequity, intersecting forces of privilege and oppression inevitably shape the research process, resulting in tensions, contradictions, and challenges that must be addressed. This article has 3 purposes: to examine the political context of mining corporations, to describe common health threats and challenges faced by mining-affected communities, and to reflect on research with a mining-affected Indigenous community in Guatemala whose health and capacity for self-advocacy are impacted by a legacy of colonialism. Using an anti-colonial lens, the authors discuss 3 central tensions: community agency and community victimhood, common ground and distinct identities, and commitment to outcomes and awareness of limitations. They conclude by offering methodological suggestions for nurse researchers whose work is grounded in anti-colonial perspectives.

Structural and construct validity of the Quality of Life Scale among Canadian women with histories of intimate partner violence.

OBJECTIVES: To evaluate the structural and construct validity, and internal consistency of the Quality of Life Scale among Canadian women with histories of intimate partner violence. METHODS: Consistent with COSMIN Guidelines, a secondary analysis was conducted using data from a community sample of 250 adult (over 18 years) Canadian women with histories of partner violence and who participated in Wave 5 of the longitudinal Women's Health Effects Study. Data were collected 4 years after baseline using structured interviews that included the Quality of Life Scale and two mental symptom scales (Center for Epidemiological Depression Scale and Davidson Trauma Scale) used to assess construct validity of the Quality of Life Scale. RESULTS: Confirmatory factor analysis in MPLUS 8 with maximum likelihood estimation supported the hypothesized unidimensional structure of the 9-item Quality of Life Scale based on acceptable fit indices. Internal consistency, estimated using Cronbach's alpha and composite reliability, were .91 and .92, respectively, with item-total correlations ranging from .46 to .84. Inter-item correlation coefficients (range = .30-.79), suggesting that all items contribute to the total score. As hypothesized, the quality of life total score was negatively related to the total scores on both the Center for Epidemiologic Studies-Depression (r = -.739) and Davidson Trauma Scale (r = -.537), providing evidence of construct validity of the Quality of Life Scale. CONCLUSION: The Quality of Life Scale is a brief, reliable, valid, unidimensional self-report measure appropriate for use with women who have experienced partner violence. By addressing an important measurement gap, results of this study have potential to advance research on women's quality of life in the context of partner violence, including improving the evaluation of a growing body of advocacy and health interventions designed to support women's healing and well-being.

The health of women temporary agricultural workers in Canada: a critical review of the literature.

Among high-income countries such as Canada, there is growing dependency on "low skilled" temporary foreign workers in a variety of sectors. The purpose of this review is to critically synthesize and analyze the theoretical and empirical literature on gendered and temporary migration in the context of globalization and the health of temporary agricultural workers, particularly women in Canadian programs. While the social sciences literature contains well-developed conceptualizations of gendered migration, the research has focused on women in feminized occupations such as domestic work. Multidisciplinary searches produced only 11 research and review publications on the gendered constraints or health of temporary agricultural workers in Canada. Further investigation is needed to explore and integrate the strengths, resiliencies, and health-care needs of women migrant agricultural workers in Canada, as well as the barriers they face, within the intersecting and gendered forces of inequities at all levels: local, national, and global.

Perceptions of factors contributing to intimate partner violence among Sri Lankan Tamil immigrant women in Canada.

In this article we explore Sri Lankan Tamil immigrant women's views on factors contributing to intimate partner violence (IPV). We conducted eight focus groups with young, midlife, and senior women and women who experienced IPV. Three main themes emerged: postmigration sources of stress and conflict, patriarchal social norms that dictated gendered behavior, and individual male attributes and behaviors. Study participants recognized gender inequality and financial dependence as contributing factors and the role of women in promoting marital harmony. Findings suggest that pre- and postmigration factors need to be considered in the prevention of IPV in newcomer communities.

Taking a Stand to Remedy the Inadequacies of Action on Health Equity Exposed by COVID-19.

As we struggle with the impacts of a global pandemic, there is growing evidence of the inequitable impacts of this crisis. In this commentary, we argue that actions on health equity to date have been insufficient despite significant scholarship to guide both practice and policy. To move from talk to action on health equity, we propose the following five approaches: (1) reversing the erosion of publicly funded health systems; (2) creating broad economic means to support health; (3) moving health action upstream; (4) challenging ageist and/or ableist discourses; and (5) decolonizing approaches and enacting solidarity. Engaging in these actions will help close the gaps and address disparities made more evident during this global pandemic. The COVID-19 pandemic reinforces the need for us to move from discussion to action if we are to achieve health for all. Adopting a health equity lens is a means of both understanding and stimulating action to readdress the root causes of inequities and work toward a fairer, more just society.

Gaining ground, losing ground: the paradoxes of rural homelessness.

The study examined rural housing and homelessness issues and looked at similarities and differences between rural and urban areas. It involved a secondary analysis of focus group data collected in a 2001-06 Community University Research Alliance study of mental health and housing. The findings highlight concerns regarding the lack of services, which can precipitate a move from a rural to an urban community. Inadequate transportation services often posed a challenge to rural residents attempting to access services. Many participants preferred rural living but felt they had to choose between residing where they wanted to and having access to essential services. In some cases entire families were uprooted in pursuit of services. Once in an urban environment, rural participants had ongoing difficulty obtaining employment, housing, and services, which in turn led to disappointment in their new environment. The primary reason given for entering the shelter system was lack of alternatives and supports. Increased services need to be allocated to rural communities so that a health promotion and illness-prevention model of care can replace the current emphasis on crisis management.

A narrative study of refugee women who have experienced violence in the context of war.

Although women are rarely on the frontlines of battle, as in many other realms of contemporary life they bear a disproportionate burden of the consequences of war. Many have experienced torture firsthand or been witnesses to the torture or killing of family, friends, and loved ones. The use of rape and other forms of sexual torture has been well documented. For those who are forced to flee their homes and countries, separation from spouses, children, and other family members is common. Because of the sheer magnitude of global conflict, the number of refugees and displaced persons throughout the world has risen exponentially. It has been estimated that women constitute more than half of the world's refugee population. The purpose of this narrative study was to examine the experiences of refugee women who experienced violence in the context of war. Data analysis revealed 8 themes: lives forever changed, new notions of normality, a pervasive sense of fear, selves obscured, living among and between cultures, a woman's place in Canada, bearing heavy burdens--the centrality of children, and an uncaring system of care. Implications for research and practice, including limitations associated with individualized Western approaches, are discussed.

Uprooted and displaced: a critical narrative study of homeless, Aboriginal, and newcomer girls in Canada.

Uprooting and displacement are a common part of everyday life for millions of girls and young women throughout the world. While much of the discourse has centered on movement from one country to another, uprooting and displacement are also a reality for many within Canada. Notably, a growing population of homeless girls and Aboriginal girls also have experienced uprooting and dislocation from home, community, and in some cases, family. For many of these girls, multiple forms of individual and systemic violence are central features of their lives. The primary purpose of this critical narrative study is to examine how uprooting and displacement have shaped mental health among three groups: (1) newcomers to Canada (immigrant and refugee girls); (2) homeless girls; and (3) Aboriginal girls. In-depth narrative interviews were conducted with 19 girls in Southwestern Ontario. Narrative themes revealed that although there is much diversity within and between these groups, uprooting and displacement create social boundaries and profound experiences of disconnections in relationships. Barriers to re/establishing connections generate dangerous spaces within interlocking systems of oppression. However, in negotiating new spaces, there is the potential for the forming and re-forming of alliances where sources of support hold the promise of hope. It is within these spaces of hope and pathways of engagement where connections offer a renewed sense of belonging and well-being. The findings highlight the relevance of the construct of uprootedness in girls' lives, provide beginning directions for the design of gender-specific and culturally meaningful interventions, and comprise a substantial contribution to the growing body of research related to girls and young women.

Mothering Without a Home: Internalized Impacts of Social Exclusion.

Mothering while homeless poses significant barriers in achieving health and unique challenges while parenting without a home. The contextual processes shaping mothers' experiences of social exclusion and homelessness, and the internalized impacts on homeless mothers' lives, are reported on in this article. Critical narrative methodology was employed with 41 participants comprised of 26 mothers experiencing homelessness, and 15 service providers who provided care to mothers experiencing homelessness participated in this study. Two overarching themes were constructed: (1) internalized expectations and regulation and (2) pushing back from the margins: sources of resilience and resistance. Women showed a great deal of agency within the existing structures of exclusion; they worked, and at times fought, tirelessly for safety, housing, their children, and their human rights. They actively demonstrated their agency and resistance within the webs of exclusion they faced. In promoting health, nurses can best support mothers in many ways, such as by employing strengths-based nursing, challenging their own stigma and notions of 'good mothering', and by recognizing and challenging the often insurmountable barriers posed within the system for this population.

"Violence is an international language": Tamil women's perceptions of intimate partner violence.

Research on intimate partner violence (IPV) across populations is challenging because of the multiplicity of definitions and lack of clarity about the behaviors that constitute IPV. The purpose of this study was to examine the ways in which Sri Lankan Tamil women in Toronto understand, define, and experience IPV. Focus group interviews were conducted with women representing different ages and stages of life. Findings suggest that definitions of IPV were not culturally specific. Rather, the Tamil women defined IPV broadly and recognized different forms of coercive control. However, psychologically abusive behaviors were identified that held particular meanings for this community.