Intersecting Inequities in COVID-19 Vaccination: A Discourse Analysis of Information Use and Decision-Making Among Ethnically Diverse Parents in Canada.

BACKGROUND: Little is known about how intersecting social privilege and disadvantage contribute to inequities in COVID-19 information use and vaccine access. This study explored how social inequities intersect to shape access to and use of COVID-19 information and vaccines among parents in Canada. METHODS: We conducted semi-structured interviews on COVID-19 vaccination information use with ethnically diverse parents of children ages 11 to 18 years from April to August 2022. We purposefully invited parents from respondents to a national online survey to ensure representation across diverse intersecting social identities. Five researchers coded transcripts in NVivo using a discourse analysis approach informed by intersectionality. Our analysis focused on use of vaccine information and intersecting privileges and oppressions, including identifying with equity-denied group(s). RESULTS: Interview participants (N = 48) identified as ethnically diverse non-Indigenous (n = 40) and Indigenous (n = 8) Peoples from seven Canadian provinces. Racialized minority or Indigenous participants reflected on historical and contemporary events of racism from government and medical institutions as barriers to trust and access to COVID-19 information, vaccines, and the Canadian healthcare system. Participants with privileged social locations showed greater comfort in resisting public health measures. Despite the urgency to receive COVID-19 vaccines, information gaps and transportation barriers delayed vaccination among some participants living with chronic medical conditions. CONCLUSION: Historicization of colonialism and ongoing events of racism are a major barrier to trusting public health information. Fostering partnerships with trusted leaders and/or healthcare workers from racialized communities may help rebuild trust. Healthcare systems need to continuously implement strategies to restore trust with Indigenous and racialized populations.

Informing efforts beyond tailored promotional campaigns by understanding contextual factors shaping vaccine hesitancy among equity-deserving populations in Canada: an exploratory qualitative study.

BACKGROUND: Vaccine hesitancy exists on a continuum ranging between complete adherence and complete refusal due to doubts or concerns within a heterogeneous group of individuals. Despite widespread acknowledgement of the contextual factors influencing attitudes and beliefs shaping COVID-19 vaccine hesitancy, qualitative research with equity-deserving groups, accounting for unique lived experiences, remains a gap in the literature. We aim to identify and begin to understand and document the unique contextual factors shaping hesitancy by equity-deserving groups as it relates to relationships with government and health authorities. METHODS: Participants were recruited and interviewed between Aug-Dec 2021. Semi-structured interviews using a convergent interviewing technique were conducted with individuals from the general population, as well as individuals who identify as First Nations, Métis, or Inuit, members of the LGBT2SQ + community, low-income Canadians, Black Canadians, and newcomers. Interviews were audio recorded and transcribed by a team of researchers. Memos were written following interviews and used to complement the thematic analysis of the interview data. Themes are presented in the results section. RESULTS: The rationale for hesitancy among equity-deserving groups is consistent with literature documenting hesitancy in the general population. Contextual factors surrounding equity-deserving groups' attitudes and beliefs, however, are unique and relate to a history of oppression, discrimination, and genocide. We identified factors unique to subgroups; for example, religious or fatalistic beliefs among participant who identify as FNMI, fear associated with lack of testing and speed of vaccines' production among participants who identify as FNMI, Black, and LGBT2SQ + , distrust of the healthcare system for LGBT2SQ + and Black Canadians, and distrust of the government and opposition to vaccine mandates for participating who identify as LGBT2SQ + , low-income, FNMI, or Black Canadian. Newcomers stood out as very trusting of the government and accepting of COVID-19 vaccination. CONCLUSIONS: While our data on vaccine hesitancy largely mirror concerns reported in the vast body of literature citing rationale for COVID-19 hesitancy in high-income countries, the contextual factors identified in our work point to the need for wider systemic change. Our results may be used to support efforts, beyond tailored promotion campaigns, to support the confident acceptance of vaccines for COVID-19 and the acceptance of novel vaccines as future infectious diseases emerge.

Sober Curiosity: A Qualitative Study Exploring Women's Preparedness to Reduce Alcohol by Social Class.

BACKGROUND: Urgent action is required to identify socially acceptable alcohol reduction options for heavy-drinking midlife Australian women. This study represents innovation in public health research to explore how current trends in popular wellness culture toward 'sober curiosity' (i.e., an interest in what reducing alcohol consumption would or could be like) and normalising non-drinking could increase women's preparedness to reduce alcohol consumption. METHODS: Qualitative interviews were undertaken with 27 midlife Australian women (aged 45-64) living in Adelaide, Melbourne and Sydney in different social class groups (working, middle and affluent-class) to explore their perceptions of sober curiosity. RESULTS: Women were unequally distributed across social-classes and accordingly the social-class analysis considered proportionally the volume of data at particular codes. Regardless, social-class patterns in women's preparedness to reduce alcohol consumption were generated through data analysis. Affluent women's preparedness to reduce alcohol consumption stemmed from a desire for self-regulation and to retain control; middle-class women's preparedness to reduce alcohol was part of performing civility and respectability and working-class women's preparedness to reduce alcohol was highly challenging. Options are provided for alcohol reduction targeting the social contexts of consumption (the things that lead midlife women to feel prepared to reduce drinking) according to levels of disadvantage. CONCLUSION: Our findings reinstate the importance of recognising social class in public health disease prevention; validating that socially determined factors which shape daily living also shape health outcomes and this results in inequities for women in the lowest class positions to reduce alcohol and related risks.

Laws, Policies, and Collective Agreements Protecting Low-wage and Digital Platform Workers During the COVID-19 Pandemic.

In the context of the COVID-19 pandemic, this commentary describes and compares shifting employment and occupational health social protections of low-wage workers, including self-employed digital platform workers. Through a focus on eight advanced economy countries, this paper identifies how employment misclassification and definitions of employees were handled in law and policy. Debates about minimum wage and occupational health and safety standards as they relate to worker well-being are considered. Finally, we discuss promising changes introduced during the COVID-19 pandemic that protect the health of low-wage and self-employed workers. Overall, we describe an ongoing "haves" and a "have not" divide, with on the one extreme, traditional job arrangements with good work-and-health social protections and, on the other extreme, low-wage and self-employed digital platform workers who are mostly left out of schemes. However, during the pandemic small and often temporary gains occurred and are discussed.

Examining social class as it relates to heuristics women use to determine the trustworthiness of information regarding the link between alcohol and breast cancer risk.

BACKGROUND: High rates of alcohol consumption by midlife women, despite the documented risks associated with breast cancer, varies according to social class. However, we know little about how to develop equitable messaging regarding breast cancer prevention that takes into consideration class differences in the receipt and use of such information. OBJECTIVE: To explore the heuristics used by women with different (inequitable) life chances to determine the trustworthiness of information regarding alcohol as a modifiable risk factor for breast cancer risk. METHODS AND MATERIALS: Interviews were conducted with 50 midlife (aged 45-64) women living in South Australia, diversified by self-reported alcohol consumption and social class. Women were asked to describe where they sought health information, how they accessed information specific to breast cancer risk as it relates to alcohol, and how they determined whether (or not) such information was trustworthy. De-identified transcripts were analysed following a three-step progressive method with the aim of identifying how women of varying life chances determine the trustworthiness of alcohol and breast cancer risk information. Three heuristics were used by women: (1) consideration of whose interests are being served; (2) engagement with 'common sense'; and (3) evaluating the credibility of the message and messenger. Embedded within each heuristic are notable class-based distinctions. CONCLUSIONS: More equitable provision of cancer prevention messaging might consider how social class shapes the reception and acceptance of risk information. Class should be considered in the development and tailoring of messages as the trustworthiness of organizations behind public health messaging cannot be assumed.

'I have a healthy relationship with alcohol': Australian midlife women, alcohol consumption and social class.

Alcohol consumption by Australian women during midlife has been increasing. Health promotion efforts to reduce alcohol consumption in order to reduce alcohol-related disease risk compete with the social contexts and value of alcohol in women's lives. This paper draws on 50 qualitative interviews with midlife women (45-64 years of age) from different social classes living in South Australia in order to gain an understanding of how and why women might justify their relationships with alcohol. Social class shaped and characterized the different types of relationships with alcohol available to women, structuring their logic for consuming alcohol and their ability to consider reducing (or 'breaking up with') alcohol. We identified more agentic relationships with alcohol in the narratives of affluent women. We identified a tendency for less control over alcohol-related decisions in the narratives of women with less privileged life chances, suggesting greater challenges in changing drinking patterns. If classed differences are not attended to in health promotion efforts, this might mitigate the effectiveness of alcohol risk messaging to women.

Place of alcohol in the 'wellness toolkits' of midlife women in different social classes: A qualitative study in South Australia.

In this article, we explore how women in different social classes had differential access to resources and services to enhance their 'wellness'-resulting in classed roles in alcohol consumption. We analyse data from a qualitative study on alcohol by midlife women in South Australia and employ the analogy of a 'toolkit' in order to understand the structural patterning of 'wellness tools'. Bourdieu's relational model of class guides our exploration of women's inequitable opportunities for wellness. Higher social class women had 'choices' facilitated by bulging wellness toolkits, such as yoga, exercise and healthy eating regimens-alcohol consumption was not essential to promoting 'wellness' and did not have an important place in their toolkits. Middle-class women had less well-stocked toolkits and consumed alcohol in a 'compensation approach' with other wellness tools. Alcohol consumption received positive recognition and was a legitimised form of enjoyment, fun and socialising, which needed counterbalancing with healthy activities. Working-class women had sparse toolkits-other than alcohol-which was a tool for dealing with life's difficulties. Their focus was less on 'promoting wellness' and more on 'managing challenging circumstances'. Our social class-based analysis is nestled within the sociology of consumption and sociological critiques of the wellness industry.

Social Class and Changes in Australian Women's Affect and Alcohol Consumption During COVID-19.

Introduction: Before the pandemic, mid-life women in Australia were among the "heaviest" female alcohol consumers, giving rise to myriad preventable health risks. This paper uses an innovative model of social class within a sample of Australian women to describe changes in affective states and alcohol consumption patterns across two time points during COVID-19. Methods: Survey data were collected from Australian mid-life women (45-64 years) at two time points during COVID-19-May 2020 (N = 1,218) and July 2020 (N = 799). We used a multi-dimensional model for measuring social class across three domains-economic capital (income, property and assets), social capital (social contacts and occupational prestige of those known socially), and cultural capital (level of participation in various cultural activities). Latent class analysis allowed comparisons across social classes to changes in affective states and alcohol consumption patterns reported at the two time points using alcohol consumption patterns as measured by the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) and its component items. Results: Seven social classes were constructed, characterized by variations in access to capital. Affective states during COVID-19 differed according to social class. Comparing between the survey time points, feeling fearful/anxious was higher in those with high economic and cultural capital and moderate social capital ("emerging affluent"). Increased depression was most prominent in the class characterized by the highest volumes of all forms of capital ("established affluent"). The social class characterized by the least capital ("working class") reported increased prevalence of uncertainty, but less so for feeling fearful or anxious, or depressed. Women's alcohol consumption patterns changed across time during the pandemic. The "new middle" class-a group characterized by high social capital (but contacts with low prestige) and minimal economic capital-had increased AUDIT-C scores. Conclusion: Our data shows the pandemic impacted women's negative affective states, but not in uniform ways according to class. It may explain increases in alcohol consumption among women in the emerging affluent group who experienced increased feelings or fear and anxiety during the pandemic. This nuanced understanding of the vulnerabilities of sub-groups of women, in respect to negative affect and alcohol consumption can inform future pandemic policy responses designed to improve mental health and reduce the problematic use of alcohol. Designing pandemic responses segmented for specific audiences is also aided by our multi-dimensional analysis of social class, which uncovers intricate differences in affective states amongst sub-groups of mid-life women.

Implications for clients when nurses view weight as main cause of Type 2 diabetes in primary care.

Type 2 diabetes (T2D) is often seen as primarily caused by weight, and its amelioration associated with individual behaviour change, which has the potential for negative consequences for people living with the disease. The aims of this study were to explore how weight was framed by diabetes resource nurses and to determine the implications of that framing for nurse practice in a primary care setting in Australia. The research was a qualitative empirical case study using semistructured interviews with nurses focusing on meanings and interpretations. The findings were interpreted using a constructivist epistemology of both inductive and deductive inference. The study found that nurses viewed overweight and obesity as unhealthy and the primary causes of T2D, and that weight was frequently discussed in the health care encounter. Nurses emphasised individual responsibility through behaviour change to manage T2D, downplaying other known causes such as age and family history and important social inequalities. Studies show that nurses have negative attitudes towards overweight and obese patients. The implications of this research are that the nurses' views could potentially negatively affect clients' management of T2D, which has the potential for poor health outcomes.

Transforming primary care for older Canadians living with frailty: mixed methods study protocol for a complex primary care intervention.

INTRODUCTION: Older Canadians living with frailty are high users of healthcare services; however, the healthcare system is not well designed to meet the complex needs of many older adults. Older persons look to their primary care practitioners to assess their needs and coordinate their care. They may need care from a variety of providers and services, but often this care is not well coordinated. Older adults and their family caregivers are the experts in their own needs and preferences, but often do not have a chance to participate fully in treatment decisions or care planning. As a result, older adults may have health problems that are not properly assessed, managed or treated, resulting in poorer health outcomes and higher economic and social costs. We will be implementing enhanced primary healthcare approaches for older patients, including risk screening, patient engagement and shared decision making and care coordination. These interventions will be tailored to the needs and circumstances of the primary care study sites. In this article, we describe our study protocol for implementing and testing these approaches. METHODS AND ANALYSIS: Nine primary care sites in three Canadian provinces will participate in a multi-phase mixed methods study. In phase 1, baseline information will be collected through questionnaires and interviews with patients and healthcare providers (HCPs). In phase 2, HCPs and patients will be consulted to tailor the evidence-based interventions to site-specific needs and circumstances. In phase 3, sites will implement the tailored care model. Evaluation of the care model will include measures of patient and provider experience, a quality of life measure, qualitative interviews and economic evaluation. ETHICS AND DISSEMINATION: This study has received ethics clearance from the host academic institutions: University of Calgary (REB17-0617), University of Waterloo (ORE#22446) and Université Laval (#MP-13-2019-1500 and 2017-2018-12-MP). Results will be disseminated through traditional means, including peer-reviewed publications and conferences and through an extensive network of knowledge user partners. TRIAL REGISTRATION NUMBER: NCT03442426;Pre-results.

Evaluating the effects of shelter-in-place policies during the COVID-19 pandemic.

We estimate the effects of shelter-in-place (SIP) orders during the first wave of the COVID-19 pandemic. We do not find detectable effects of these policies on disease spread or deaths. We find small but measurable effects on mobility that dissipate over time. And we find small, delayed effects on unemployment. We conduct additional analyses that separately assess the effects of expanding versus withdrawing SIP orders and test whether there are spillover effects in other states. Our results are consistent with prior studies showing that SIP orders have accounted for a relatively small share of the mobility trends and economic disruptions associated with the pandemic. We reanalyze two prior studies purporting to show that SIP orders caused large reductions in disease prevalence, and show that those results are not reliable. Our results do not imply that social distancing behavior by individuals, as distinct from SIP policy, is ineffective.

Understanding Access to and Utilisation of Sexual Health Services by South Asian Immigrant Men in Western Countries: A Scoping Review.

South Asian communities comprise one of the fastest growing populations in Western countries. However, the sexual health of immigrant men in particular remains vastly understudied and little is known about how and if men access these services. Four multi-disciplinary electronic databases were searched to between 1998 and 2018. The search yielded 586 articles; 407 duplicate articles were removed, and 376 did not meet the inclusion criteria. A total of 10 articles were included in this review. Herein we report the factors shaping sexual health service access and use, namely: (1) cultural and psychological factors; (2) sexual health service accessibility; (3) personal beliefs and patterns in service use; (4) social perspectives and conflicting values on sexual health. We identify the gaps in research needed for policymakers, formal healthcare providers, and South Asian community stakeholders to develop effective and inclusive sexual health programs for South Asian men in Western countries.

Exploring the effect of risk and benefit information provision on vaccination decision-making.

In the era in which people are bombarded with misinformation about vaccination, research regarding the degree to which various types of risk or benefit information affect perceptions of vaccines and intentions to vaccinate is critical. The present research utilizes a robust methodology to quantify the extent to which risk and benefit information affects vaccination intentions. Our work demonstrates an inverse relationship between the perceived risks and benefits of a vaccine. By providing information about either risks or benefits of avaccine, our findings suggest that we can change one's perception of both the risks and benefits of thevaccine. Considering that the main cognitive barriers to vaccination are related to concerns about efficacy and safety, our results suggest thatvaccinemessages can be framed to address the audience's main concerns, whether it be about the low efficacy of thevaccineor its safety, knowing that both frames would carry similar outcomes.

Pursuing dignified food security through novel collaborative governance initiatives: Perceived benefits, tensions and lessons learned.

Food security governance is broadening and diversifying, resulting in organizations coming together in novel collaborative actions, despite little history of working together. Alternative food initiatives coexist alongside traditional charitable, emergency-based approaches. Tensions can arise between approaches and collaborating organizations due to differences in philosophy, priorities, constraints and practices. There is limited knowledge on how converging interests are interacting with one another within shifting landscapes of collaborative intervention, or the experiences of governance stakeholders involved. Through in-depth interviews this case-study examines the experiences of diverse stakeholders involved in a novel food security coalition and their perceived benefits, challenges, tensions and lessons learned. Benefits included greater communication, information sharing, understanding of diverse needs, more frequent and customized referrals, and the development of a community food centre that has increased access to affordable fresh produce in inclusive manners. Simultaneously changes in governance have produced turf wars and competition over resources. We reveal the importance of sensitivity when advocating for food system reforms to avoid 'villainizing' organizations that have been supporting those in need through charitable means, or further marginalizing populations who may perceive less access barriers when using food banks. Our findings suggest perceptions on what it means to provide 'dignified' food access vary according to unique needs and lived experiences, and one delivery model is likely inappropriate. Food banks and alternative food initiatives serve unique roles and efforts should be made to ensure they can co-exist and that those with lived experience play an influential role in changing food governance systems.

Factors affecting access and use of preventive and weight management care: A public health lens.

Obesity is an important risk factor for various chronic diseases. While people with obesity use the health system more and incur higher costs, they may forego using preventive care services (e.g., gynecological cancer screenings) due to issues of service use and service access. The aim of this paper was to use a public health lens to elucidate system level factors that affect healthcare access and utilization for preventive and weight management care by patients with obesity. Some elucidated factors include lack of access to a Primary Care Provider (PCP) and multidisciplinary healthcare settings, gender of the PCP, duration of medical visits and health professionals' attitudes about obesity. We highlight potential strategies for leaders to use when improving access and use of health services by patients with obesity in Canada and the need for future empirical studies in this research area.

The Social Basis of Vaccine Questioning and Refusal: A Qualitative Study Employing Bourdieu's Concepts of 'Capitals' and 'Habitus'.

This article is an in-depth analysis of the social nature of vaccine decision-making. It employs the sociological theory of Bourdieu and Ingram to consider how parents experience non-vaccination as a valued form of capital in specific communities, and how this can affect their decision-making. Drawing on research conducted in two Australian cities, our qualitative analysis of new interview data shows that parents experience disjuncture and tugs towards 'appropriate' forms of vaccination behavior in their social networks, as these link to broader behaviors around food, school choices and birth practices. We show how differences emerge between the two cities based on study designs, such that we are able to see some parents at the center of groups valorizing their decisions, whilst others feel marginalized within their communities for their decisions to vaccinate. We draw on the work of philosopher Mark Navin to consider how all parents join epistemic communities that reward compliance and conformity with the status quo and consider what this means for interventions that seek to influence the flow of pro-vaccine information through vaccine-critical social groups.

Timely access to inpatient rehabilitation after stroke: a qualitative study of perceived barriers and potential solutions in Ontario, Canada.

PURPOSE: Stroke units have been established as best practice care, in part because they offer timely initiation of rehabilitation. Experts in Ontario, Canada recommend that eligible patients be transferred to inpatient rehabilitation (on average) by day 5 after ischemic stroke and day 7 after a hemorrhagic stroke. This study explores perceived barriers to implementation of these recommendations and potential solutions. METHOD: Exploratory focus groups were held with stakeholders from five geographically diverse regions across Ontario between September 2011 and January 2012. Participants were asked to consider the recommendations, list perceived barriers and to collectively discuss potential solutions. Data analysis included coding of transcribed data, sorting material to identify themes and confronting themes with a formalized body of knowledge. RESULTS: Barriers identified by participants fell into three categories: patient-centered, clinician-focused and resource or system based, within these, specific challenges included managing patients' medical and emotional readiness for rehabilitation, timely completion of medical tests, staff comfort in discharging patients, dedicated transportation and funding-related concerns. CONCLUSIONS: The structure of Ontario's health care system presents challenges to early transfer of stroke patients to inpatient rehabilitation, yet the stakeholders consulted in this study felt that these could be addressed with proper planning, improved coordination and targeted investment. Implications for rehabilitation Stroke units are a well-established best practice in stroke care and timely access to rehabilitation is a key component of their effectiveness. Stroke experts in Ontario, Canada recommend transfer of suitable patients to inpatient rehabilitation on day 5 and day 7, on average, after ischemic and hemorrhagic stroke, respectively. Stakeholders report that meeting these targets may require some adjustments to local processes of care, many of which can be achieved with little to no financial investment.

Bariatric surgery revisions and private health insurance.

OBJECTIVE: To identify: 1. The percentage of bariatric procedures that are revisions; 2. What proportion of bariatric revision procedures in public hospitals are for patients whose primary weight loss procedure occurred in a private hospital; 3. The age, sex and level of socioeconomic disadvantage of patients needing revisions. METHODS: An analysis of patient level admission data from the Integrated South Australian Activity Collection (ISAAC) was performed. Data were collected on all revisions for weight loss related procedures at all South Australian public and private hospitals, between 2000-2015 using the ISAAC codes for revision procedures. RESULTS: 12,606 bariatric procedures occurred in hospitals; ∼27% of which represent a revision (n=3366). Of these revisions, ∼82% occurred in a private hospital (n=2771), and ∼18% occurred in a public hospital (n=595). Of the 595 revisions in a public hospital, 51% of patients had their original bariatric procedure performed in a private hospital. The majority of patients who had a revision procedure are female (≥82%) with a mean age of ∼45. Individuals from the lowest 2 IRSD quintiles were over-represented for public hospital revisions and primary bariatric procedures. CONCLUSION: Further investigation is needed to identify: 1. Why 27% of bariatric procedures are revisions; 2. Why at least 51% of revisions in public hospitals are on patients whose original primary bariatric procedure was done in a private hospital; 3. The impact that revision procedures in public hospitals, particularly for originally private weight loss procedures, is having on public hospital wait times; 4. The impact of socioeconomic disadvantage on weight loss procedure outcomes.

Vaccine Rejecting Parents' Engagement With Expert Systems That Inform Vaccination Programs.

In attempting to provide protection to individuals and communities, childhood immunization has benefits that far outweigh disease risks. However, some parents decide not to immunize their children with some or all vaccines for reasons including lack of trust in governments, health professionals, and vaccine manufacturers. This article employs a theoretical analysis of trust and distrust to explore how twenty-seven parents with a history of vaccine rejection in two Australian cities view the expert systems central to vaccination policy and practice. Our data show how perceptions of the profit motive generate distrust in the expert systems pertaining to vaccination. Our participants perceived that pharmaceutical companies had a pernicious influence over the systems driving vaccination: research, health professionals, and government. Accordingly, they saw vaccine recommendations in conflict with the interests of their child and "the system" underscored by malign intent, even if individual representatives of this system were not equally tainted. This perspective was common to parents who declined all vaccines and those who accepted some. We regard the differences between these parents-and indeed the differences between vaccine decliners and those whose Western medical epistemology informs reflexive trust-as arising from the internalization of countering views, which facilitates nuance.