Did the design and planning of testing and contact tracing interventions for COVID-19 consider social inequalities in health? A multiple case study from Brazil, Canada, France & Mali.

The COVID-19 pandemic has led to an unprecedented global crisis. It has exposed and exacerbated weaknesses in public health systems worldwide, particularly with regards to reaching the most vulnerable populations, disproportionately impacted by the pandemic. The objective of our study was to examine whether and how social inequalities in health (SIH) were considered in the design and planning of public health responses to COVID-19 in jurisdictions of Brazil, Canada, France, and Mali. This article reports on a qualitative multiple case study of testing and contact tracing interventions in regions with high COVID-19 incidence in each country, namely: Manaus (Brazil), Montréal (Canada), Île-de-France (France), and Bamako (Mali). We conducted interviews with 108 key informants involved in these interventions in the four jurisdictions, focusing on the first and second waves of the pandemic. We analyzed our data thematically using a theoretical bricolage framework. Our analysis suggests that the lack of a common understanding of SIH among all actors involved and the sense of urgency brought by the pandemic eclipsed the prioritization of SIH in the initial responses. The pandemic increased intersectoral collaboration, but decision-making power was often unequal between Ministries of Health and other actors in each jurisdiction. Various adaptations to COVID-19 interventions were implemented to reach certain population groups, therefore improving the accessibility, availability, and acceptability of testing and contact tracing. Our study contributes to identifying lessons learned from the current pandemic, namely that the ways in which SIH are understood shape how interventions are planned; that having clear guidelines on how to integrate SIH into public health interventions could lead to more inclusive pandemic responses; that for intersectoral collaboration to be fruitful, there needs to be sufficient resources and equitable decision-making power between partners; and that interventions must be flexible to respond to emerging needs while considering long-standing structural inequalities.

Embedding anti-racism in Schools of Public Health: a pathway to accountability for progress towards equity.

The importance of seeing race as a socially constructed idea continues to produce unfair differences between humans and establishes power relations that lead to injustice and exposure to death. Since the racial justice movement in early 2020, there has been a heightened awareness of, and increased interest in, addressing historic racial disparities across Schools of Public Health (SPH) in Canada. Steps have been taken to recognize systemic racism and increase diversity through structural reforms to advance equity and inclusion; however, addressing racism demands collectively uprooting racist institutional designs still inherent in learning, teaching, research, service, and community engagement. This commentary highlights the need for sustained commitment to establishing longitudinal benchmarks for greater racial equity among students, staff, and faculty; revising curricula to include historic and contemporary narratives of colonialism and slavery; and providing community-engaged learning opportunities as instrumental to dismantle systemic drivers of racial health inequities locally and globally. We also advocate for intersectoral collaboration, mutual learning, and sharing of resources across SPH and partner agencies to accomplish a continual collective agenda for racial health equity and inclusion that is intersectional in Canada, while being held accountable to Indigenous and racialized communities.

RéSUMé: L'importance de voir la race comme une idée socialement construite continue de produire des différences inéquitables entre les gens et d'établir des relations de pouvoir qui mènent à l'injustice et à l'exposition à la mort. Depuis que le mouvement pour la justice raciale s'est enclenché au début de 2020, il existe une conscience aiguë des disparités raciales historiques entre les écoles de santé publique (ESP) du Canada et un intérêt accru pour le redressement de ces disparités. Des mesures ont été prises pour reconnaître le racisme systémique et accroître la diversité par des réformes structurelles visant à promouvoir l'équité et l'inclusion; cependant, pour aborder le racisme, il faut collectivement arracher les modèles institutionnels racistes qui font encore partie intégrante de l'apprentissage, de l'enseignement, de la recherche, des services et de la participation de la communauté. Dans notre commentaire, nous soulignons le besoin d'un engagement soutenu à établir des repères longitudinaux pour une plus grande équité raciale dans la population étudiante, au sein du personnel et dans le corps professoral, à revoir les programmes d'études pour y inclure les discours historiques et contemporains du colonialisme et de l'esclavage, et à offrir des possibilités d'enseignement faisant appel aux communautés, car elles contribueront à démanteler les moteurs systémiques des iniquités raciales en santé à l'échelle locale et mondiale. Nous promulguons aussi la collaboration intersectorielle, l'apprentissage mutuel et le partage des ressources entre les ESP et les organismes partenaires afin de concrétiser un plan d'action collective continue en faveur de l'équité raciale en santé et de l'inclusion ­ un plan qui sera intersectionnel au Canada et qui rendra des comptes aux communautés autochtones et racisées.

"It felt like building a plane while in flight": the consideration of social inequalities in the design and planning of a contact-tracing intervention for COVID-19 in Montreal, Quebec.

OBJECTIVE: In Canada and globally, the COVID-19 pandemic has increased social inequalities in health (SIH), furthering the vulnerability of certain groups and communities. Contact-tracing is a cornerstone intervention with COVID-19 prevention and control programs. The aim of this study was to describe whether and how SIH were considered during the design of the COVID-19 contact-tracing intervention in Montreal. METHODS: This study is part of the multi-country research program HoSPiCOVID, looking at the resilience of public health systems during the COVID-19 pandemic. A descriptive qualitative study was carried out in Montreal, based on a "bricolage" conceptual framework describing the consideration for SIH in intervention and policy design. Qualitative data were collected using semi-structured interviews with 16 public health practitioners, recruited using both purposive and snowball sampling. Data were analyzed thematically, both inductively and deductively. RESULTS: According to participants, SIH were not initially considered during the design of the contract-tracing intervention in Montreal. The participants were frustrated by the Minister of Health's initial resistance to integrating SIH into their public health response. However, adaptations were gradually made to better meet the needs of underserved populations. CONCLUSION: There is a need for a clear and common vision of SIH within the public health system. Decision-makers need to consider SIH prior to designing public health interventions in order for these not to further increase SIH in the future, especially in the face of a health crisis.

RéSUMé: OBJECTIF: Au Canada et dans le monde, la pandémie de COVID-19 a augmenté les inégalités sociales de santé (ISS), aggravant la vulnérabilité de certains groupes et communautés. Le suivi des contacts est une intervention fondamentale des programmes de prévention et de contrôle de la COVID-19. L'objectif de cette étude était de décrire si et comment les ISS ont été prises en compte lors de la conception de l'intervention de suivi des contacts pour la COVID-19 à Montréal. MéTHODES: Cette étude fait partie du programme de recherche multi-pays HoSPiCOVID, portant sur la résilience des systèmes de santé publique pendant la pandémie de COVID-19. Une étude qualitative descriptive a été menée à Montréal, sur la base d'un cadre conceptuel « bricolage ¼ décrivant la prise en compte des ISS dans la conception des interventions et des politiques. Des données qualitatives ont été recueillies au moyen d'entrevues semi-structurés avec 16 praticiens de la santé publique, recrutés par échantillonnage raisonné et en boule de neige. Les données ont été analysées de manière thématique, de façon inductive et déductive. RéSULTATS: Selon les participants, les ISS n'ont pas été initialement prises en compte lors de la conception de l'intervention de suivi des contacts à Montréal. Les professionnels de santé publique ont déploré le manque de volonté du Ministère de la Santé d'intégrer les ISS dans la réponse de santé publique. Toutefois, des adaptations ont été progressivement apportées pour mieux répondre aux besoins des populations vulnérables. CONCLUSION: Il est nécessaire d'avoir une vision claire et commune des ISS au sein du système de santé. Les décideurs doivent prendre en compte activement les ISS pour que celles-ci soient mieux conceptualisées, et que les interventions de santé publique n'aggravent pas les ISS, surtout en période de crise sanitaire.

Considering social inequalities in health in large-scale testing for COVID-19 in Montréal: a qualitative case study.

BACKGROUND: Evidence continues to demonstrate that certain marginalised populations are disproportionately affected by COVID-19. While many studies document the impacts of COVID-19 on social inequalities in health, none has examined how public health responses to the pandemic have unfolded to address these inequities in Canada. The purpose of our study was to assess how social inequalities in health were considered in the design and planning of large-scale COVID-19 testing programs in Montréal (Québec, Canada). METHODS: Part of the multicountry study HoSPiCOVID, this article reports on a qualitative case study of large-scale testing for COVID-19 in Montréal. We conducted semi-structured interviews with 19 stakeholders involved in planning large-scale testing or working with vulnerable populations during the pandemic. We developed interview guides and a codebook using existing literature on policy design and planning, and analysed data deductively and inductively using thematic analysis in NVivo. RESULTS: Our findings suggest that large-scale COVID-19 testing in Montréal did not initially consider social inequalities in health in its design and planning phases. Considering the sense of urgency brought by the pandemic, participants noted the challenges linked to the uptake of an intersectoral approach and of a unified vision of social inequalities in health. However, adaptations were gradually made to large-scale testing to improve its accessibility, acceptability, and availability. Actors from the community sector, among others, played an important role in supporting the health sector to address the needs of specific subgroups of the population. CONCLUSIONS: These findings contribute to the reflections on the lessons learned from COVID-19, highlighting that public health programs must tackle structural barriers to accessing healthcare services during health crises. This will be necessary to ensure that pandemic preparedness and response, including large-scale testing, do not further increase social inequalities in health.

Unmet healthcare needs among migrants without medical insurance in Montreal, Canada.

While access to healthcare for permanent residents in Canada is well known, this is not the case for migrants without healthcare coverage. This is the first large-scale study that examines the unmet healthcare needs of migrants without healthcare coverage in Montreal. 806 participants were recruited: 436 in the community and 370 at the NGO clinic. Proportions of individuals reporting unmet healthcare needs were similar (68.4% vs. 69.8%). The main reason invoked for these unmet needs was lacking money (80.6%). Situations of not working or studying, not having had enough food in the past 12 months, not having a medical prescription to get medication and having had a workplace injury were all significantly associated with higher odds of having unmet healthcare needs. Unmet healthcare needs were more frequent among migrants without healthcare coverage than among recent immigrants or the citizens with health healthcare coverage (69%, 26%, 16%). Canada must take measures to enable these individuals to have access to healthcare according to their needs in order to reduce the risk of worsening their health status, something that may have an impact on the healthcare system and population health. The Government of Quebec announced that all individuals without any healthcare coverage will have access to COVID-19 related health care. We hope that this right, the application of which is not yet obvious, can continue after the pandemic for all health care.

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.

What links can be made from narratives of migration and self-perceived health? A qualitative study with Haitian migrants settling in Quebec after the 2010 Haiti earthquake.

In January 2010, Haiti was hit by a terrible earthquake that pushed thousands of people to migrate. Many of them chose to settle in Quebec, Canada. Years after the earthquake, many Haitians continue to migrate to the Quebec province. Several studies however have shown that this population's socioeconomic status is lower than the provincial average. Given the potential multiple stressors that affect Haitian migrants in Quebec, there are concerns about their health status. Located at the intersection of international migration studies and global public health, this paper offers an in-depth qualitative investigation of Haitian migrants' representations of both their situation and self-perceived health in Montreal, Quebec. Our perspective on migrant health was inspired by the World Health Organisation's framework on the social determinants of health and recent studies in the field of migrant health. We collected and analysed qualitative data from 23 key informants (i.e., 12 women and 11 men, aged 21-76 years old) from diverse socioeconomic backgrounds. The analysis of the data from these people's narratives revealed the importance of structural determinants such as social position, and intermediate determinants such as living and working conditions. Our analysis also highlighted several interrelations between those determinants. Specifically, participants reported coping with issues related to migration status, income, occupation, language, challenging living and working conditions, and chronic stress. This study also shows that racism and social support each relate to both the structural and intermediate levels of the social determinants of health. The importance of social support brought by relatives, friends, as well as community-based organisations and religious practice, was underscored. Our findings were coherent with available literature looking at the determinants of health of racialized and migrant minorities in other high-income regions of the world. Our conclusive remarks featured reflections on three cross-cutting issues and their practical implications for policy and practices.

Barriers and recruitment strategies for precarious status migrants in Montreal, Canada.

BACKGROUND: Precarious status migrants are a group of persons who are vulnerable, heterogeneous, and often suspicious of research teams. They are underrepresented in population-based research projects, and strategies to recruit them are described exclusively in terms of a single cultural group. We analyzed the recruitment strategies implemented during a research project aimed at understanding precarious status migrants' health status and healthcare access in Montreal, Canada. The research sample consisted of 854 persons recruited from a variety of ethnocultural communities between June 2016 and September 2017. This article analyzes the strategies implemented by the research team to respond to the challenges of that recruitment, and assess the effectiveness of those strategies. Based on the results, we share the lessons learned with a view to increasing precarious status migrants' representation in research. METHOD: A mixed sequential design was used to combine qualitative data gathered from members of the research team at a reflexive workshop (n = 16) and in individual interviews (n = 15) with qualitative and quantitative data collected using the conceptual mapping method (n = 10). RESULTS: The research team encountered challenges in implementing the strategies, related to the identification of the target population, the establishment of community partnerships, and suspicion on the part of the individuals approached. The combination of a venue-based sampling method, a communications strategy, and the snowball sampling method was key to the recruitment. Linking people with resources that could help them was useful in obtaining their effective and non-instrumental participation in the study. Creating a diverse and multicultural team helped build trust with participants. However, the strategy of matching the ethnocultural identity of the interviewer with that of the respondent was not systematically effective. CONCLUSION: The interviewers' experience and their understanding of the issue are important factors to take into consideration in future research. More over, the development of a community resource guide tailored to the needs of participants should be major components of any research project targeting migrants. Finally, strategies should be implemented as the result of a continuous reflexive process among all members of the research team.

Mobiliser des représentations ethnoculturelles pour expliquer les disparités d'accès aux soins de santé au Burkina Faso.

OBJECTIVES: This study aims to describe how health professionals and managers put forward ethnocultural arguments to explain the partial failure of a maternal health policy and to discuss the potential impact of such ethnocultural representations on access to care. METHODS: This was a qualitative research socio-anthropologic in nature, making use of several methods of data collection, including in-depth interviews, informal discussions, non-participant observations conducted in health facilities, and a documentary analysis. In-depth interviews were conducted with 16 health professionals and 10 health district managers. Interviews were recorded and transcribed. The study took place in Djibo district, Burkina Faso. RESULTS: Ethnic identification, cultural practices related to childbirth (modesty, discretion, presence of women at the birth), the social status of women (low decision-making power), nomadism and social organization of population groups and their resistance to change are erected as "cultural barriers" to the maternal health policy. The widespread use of these representations by health professionals and managers contributes to the stereotyping and blaming of some social groups while hiding the structural factors that in fact have a greater influence on the use of maternal health services. CONCLUSION: This article highlights the danger of the excessive use of ethnocultural representations based on culturalistic ideology in public health policies in conveying stereotypes of certain groups. Thus, to understand the success or the failure of health policies, it remains important to consider the quality of contact between communities and the health system; structural factors, including the capacity of households to meet the expenses of health care; and distances between villages and health centres. These elements would contribute to a better understanding of the disparities uncovered with regard to the use of health services indicators.

Health inequalities in the Caribbean: increasing opportunities and resources.

Social inequalities in health are not a priority in the Caribbean region. However, a few studies suggested such disparities and indicators show important socioeconomic disparities between and within countries. There are indications that governments' investment in health and other social programs is insufficient in the region and that regional health institutions that guide national health policies and programs do not make the reduction of social inequalities a priority. Furthermore, the public health sector is generally weak and health services are mainly focusing on curative services. The author argues that there is a need to develop and to implement social policies that include equity and social justice as core values. In order to increase the focus on health inequalities in the region, there is also a need to strengthen the Public Health field that integrates Health Promotion strategies. It is also suggested that international, regional and national health sectors that include academic and research institutions, health-related journals and associations, and non-governmental organizations put health inequalities in the Caribbean on their agenda. Furthermore, there should be a fundamental switch from a biomedical perspective of health to a paradigm that considers health as the expression of political, social and economic circumstances.