Impact of Language Barriers on Outcomes and Experience of COVID-19 Patients Hospitalized in Quebec, Canada, During the First Wave of the Pandemic.

Language barriers (LB) contribute to coronavirus disease 2019 (COVID-19) health inequities. People with LB were more likely to be SARS-CoV-2 positive despite lower testing and had higher rates of hospitalization. Data on hospital outcomes among immigrants with LB, however, are limited. We aimed to investigate the clinical outcomes of hospitalized COVID-19 cases by LB, immigration status, ethnicity, and access to COVID-19 health information and services prior to admission. Adults with laboratory-confirmed community-acquired COVID-19 hospitalized from March 1 to June 30, 2020, at four tertiary-care hospitals in Montréal, Quebec, Canada were included. Demographics, comorbidities, immigration status, country of birth, ethnicity, presence of LB, and hospital outcomes (ICU admission and death) were obtained through a chart review. Additional socio-economic and access to care questions were obtained through a phone survey. A Fine-Gray competing risk subdistribution hazards model was used to estimate the risk of ICU admission and in-hospital death by immigrant status, region of birth and LB Among 1093 patients, 622 (56.9%) were immigrants and 101 (16.2%) of them had a LB. One third (36%) of immigrants with LB did not have access to an interpreter during hospitalization. Admission to ICU and in-hospital mortality were not significantly different between groups. Prior to admission, one third (14/41) of immigrants with LB had difficulties accessing COVID-19 information in their mother tongue and one third (9/27) of non-white immigrants with a LB had difficulties accessing COVID-19 services. Immigrants with LB were inequitably affected by the first wave of the pandemic in Quebec, Canada. In our study, a large proportion had difficulties accessing information and services related to COVID-19 prior to admission, which may have increased SARS-CoV-2 exposure and hospitalizations. After hospitalization, a large proportion did not have access to interpreters. Providing medical information and care in the language of preference of increasing diverse populations in Canada is important for promoting health equity.

Safe enough? Rethinking the concept of cultural safety in healthcare and training.

Refining the cultural safety concept to include an acknowledgement of both the discomfort inherent in training and care and the time needed to overcome multiple layers of oppression may partially buffer the feelings of failure or fraud that often arise from unrealistic expectations regarding equity, diversity and inclusion policies.

Vaccination of children in marginalized neighbourhoods: Equity and diversity challenges with COVID-19 vaccination campaigns.

The coronavirus disease 2019 (COVID-19) pandemic has exacerbated social inequities along ethnic, racial and socio-economic lines, with significant harmful consequences for children. Building on the lessons learned from community-based initiatives, this commentary proposes a reflection around equity, diversity, and inclusion challenges embedded in child vaccination campaigns during an emergency context. We argue that building equitable and inclusive practices around marginalized communities' child vaccination is a multifaceted challenge. Beyond good intentions-wanting to protect children-the risks and benefits associated with highlighting diversity in each intervention need to be carefully considered, especially when it comes to a contested/polarizing procedure such as vaccination with a novel type of vaccine. Often, a one-size-fits-all approach negates and perpetuates structural inequities. In other cases, highlighting diversity and inequities may inadvertently increase stigma and discrimination, and further harm or infantilize targeted communities. By providing multiple perspectives, a transdisciplinary approach can support decision-making in a crisis context.

Ethno-cultural disparities in mental health during the COVID-19 pandemic: a cross-sectional study on the impact of exposure to the virus and COVID-19-related discrimination and stigma on mental health across ethno-cultural groups in Quebec (Canada).

BACKGROUND: Although social and structural inequalities associated with COVID-19 have been documented since the start of the pandemic, few studies have explored the association between pandemic-specific risk factors and the mental health of minority populations. AIMS: We investigated the association of exposure to the virus, COVID-19-related discrimination and stigma with mental health during the COVID-19 pandemic, in a culturally diverse sample of adults in Quebec (Canada). METHOD: A total of 3273 residents of the province of Quebec (49% aged 18-39 years, 57% women, 51% belonging to a minority ethno-cultural group) completed an online survey. We used linear and ordinal logistic regression to identify the relationship between COVID-19 experiences and mental health, and the moderating role of ethno-cultural identity. RESULTS: Mental health varied significantly based on socioeconomic status and ethno-cultural group, with those with lower incomes and Arab participants reporting higher psychological distress. Exposure to the virus, COVID-19-related discrimination, and stigma were associated with poorer mental health. Associations with mental health varied across ethno-cultural groups, with exposed and discriminated Black participants reporting higher mental distress. CONCLUSIONS: Findings indicate sociocultural inequalities in mental health related to COVID-19 in the Canadian context. COVID-19-related risk factors, including exposure, discrimination and stigma, jeopardise mental health. This burden is most noteworthy for the Black community. There is an urgent need for public health authorities and health professionals to advocate against the discrimination of racialised minorities, and ensure that mental health services are accessible and culturally sensitive during and in the aftermath of the pandemic.

A repeated cross-sectional study of sympathy for violent radicalization in Canadian college students.

The upsurge in violent radicalization is associated with a global increase in social inequalities and conflicts related to different markers of identity. To date, literature on the factors associated with legitimizing violence toward others is cross-sectional and does not provide information on the possible change of this phenomenon over time. Such information is necessary to design primary prevention programs that are adapted to and address a rapidly evolving social context. We use a repeated cross-sectional study design to explore the association between sociodemographic characteristics and scores on the Sympathy for Violent Radicalization Scale (SVR) in Quebec (Canada) college students at 2 times points. Results from an online survey completed by students of 6 colleges in 2015 (n = 854) and 2017 (n = 702) indicate that although overall scores on the SVR scale remained stable, there were changes in the association between age, identity, and the outcome at the two time points. Specifically, scores on the SVR were significantly higher among younger students in 2017 than in 2015. In addition, in 2017 we observed a relationship between collective identity and SVR that was not present in 2015. These results align with other recent studies in Canada and the U.S. documenting the emergence of new forms of youth politicized bullying associated with race, ethnicity, and religion. A close monitoring of the phenomenon is warranted to both better understand the impact of populist policies on the increase in hate incidents and crimes and develop programs to address these forms of violence from a public health perspective. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Mental Health of Refugee Children and Youth: Epidemiology, Interventions, and Future Directions.

The number of refugee youth worldwide receives international attention and is a top priority in both academic and political agendas. This article adopts a critical eye in summarizing current epidemiological knowledge of refugee youth mental health as well as interventions aimed to prevent or reduce mental health problems among children and adolescents in both high- and low-to-middle-income countries. We highlight current challenges and limitations of extant literature and present potential opportunities and recommendations in refugee child psychiatric epidemiology and mental health services research for moving forward. In light of the mounting xenophobic sentiments we are presently witnessing across societies, we argue that, as a first step, all epidemiological and intervention research should advocate for social justice to guarantee the safety of and respect for the basic human rights of all refugee populations during their journey and resettlement. A constructive dialogue between scholars and policy makers is warranted.

Exploring the discrimination-radicalization nexus: empirical evidence from youth and young adults in Belgium.

OBJECTIVES: Violence committed by extremists has serious violent and non-violent public health consequences. Researchers have hypothesized an association between experiencing discrimination and support for radicalization. This study examines the relationship between perceived discrimination and support for violent extremism among youth and young adults in Belgium. METHODS: A total of 2037 young adults between the ages of 16 and 30 participated in the study. We used multivariate linear regression to determine the association between sociodemographic characteristics, experiences of perceived discrimination, and scores on the Radical Intention Scale (RIS). RESULTS: Sex, religion, generation status, and language were associated with experiencing discrimination. Sex and language were associated with scores on the RIS. Discrimination based on language and political views was independently associated with scores on the RIS. Discrimination experienced during interactions with the police/justice system was also associated with RIS scores. CONCLUSIONS: Public health primary prevention programs and policies that target the relationship between discrimination and sympathy for violent radicalization need to be situated on micro- to macro-levels. Of primary importance is the development of partnerships between stakeholders in public health, legal, political, and educational sectors to develop strategies to diminish discrimination and promote positive civic engagement among youth.

Mental health needs and services for migrants: an overview for primary care providers.

BACKGROUND: The objective of this article is to present an overview of the burden, spectrum of diseases and risk factors for mental illness among subgroups of migrants, namely, immigrants, refugees and individuals with precarious legal status. This expert review summarises some of the implications for primary care services in migrant receiving countries in the global North. METHODS: A broad literature review was conducted on the epidemiology of mental health disorders in migrants and the available evidence on mental health services for this population focusing on key issues for primary care practitioners in high-income countries. RESULTS: Although most migrants are resilient, migration is associated with an over-representation of mental disorder in specific subpopulations. There is a general consensus that stress-related disorders are more prevalent among refugee populations of all ages compared to the general population. Relative to refugees, migrants with precarious legal status may be at even higher risk of depression and anxiety disorders. Persistence and severity of psychiatric disorders among migrant populations can be attributed to a combination of factors including severity of trauma exposures during the migration process. Exposure to stressors after resettlement, such as poverty and limited social support, also impacts mental illness. Services for migrants are affected by restricted accessibility and should address cultural and linguistic barriers to and issues in the larger social environment that impact psychosocial functioning. CONCLUSION: There is substantial burden of mental illness among some migrant populations. Primary care providers seeking to assist individuals need to be cognizant of language barriers to and challenges of working with interpreters as well as sensitive to cultural and social contexts within the diagnosis and service delivery process. In addition, best practices in screening migrants and providing intervention services for mental disorders need to be sensitive to where individuals and families are in the resettlement trajectory.

Canadian response to need for transformation of youth mental health services: ACCESS Open Minds (Esprits ouverts).

AIM: Youth mental health is of paramount significance to society globally. Given early onset of mental disorders and the inadequate access to appropriate services, a meaningful service transformation, based on globally recognized principles, is necessary. The aim of this paper is to describe a national Canadian project designed to achieve transformation of mental health services and to evaluate the impact of such transformation on individual and system related outcomes. METHOD: We describe a model for transformation of services for youth with mental health and substance abuse problems across 14 geographically, linguistically and culturally diverse sites, including large and small urban, rural, First Nations and Inuit communities as well as homeless youth and a post-secondary educational setting. The principles guiding service transformation and objectives are identical across all sites but the method to achieve them varies depending on prevailing resources, culture, geography and the population to be served and how each community can best utilize the extra resources for transformation. RESULTS: Each site is engaged in community mapping of services followed by training, active stakeholder engagement with youth and families, early case identification initiatives, providing rapid access (within 72 hours) to an assessment of the presenting problems, facilitating connection to an appropriate service within 30 days (if required) with no transition based on age within the 11 to 25 age group and a structured evaluation to track outcomes over the period of the study. CONCLUSIONS: Service transformation that is likely to achieve substantial change involves very detailed and carefully orchestrated processes guided by a set of values, principles, clear objectives, training and evaluation. The evidence gathered from this project can form the basis for scaling up youth mental health services in Canada across a variety of environments.

Addressing Mental Health Needs of Refugees.

Throughout history, refugees have alternatively been seen as entitled victims of adversity or as threats or abusers of host countries scarce resources. Within the present globalized context, ambivalent public perceptions of refugees are shattering the protective nature of the post migratory environment in refugee receiving countries. This raises new challenges for refugees' mental health and calls for systemic responses to address both pre-migratory trauma and losses and post migratory adversities. Recent evidence on the effectiveness of mental health treatment for refugees confirms the utility of trauma-focused psychotherapy and the limits of psychopharmacology for stress related disorders in this group. Training of mental health professionals may improve the quality of care for refugees by deconstructing prevalent prejudices about them and promoting empathic understanding. Mental health professionals may also advocate by providing information about social determinants refugee mental health to policy makers and promoting psychosocial interventions and protective social policies.

Challenges related to migration and child attachment: A pilot study with South Asian immigrant mother-child dyads.

This pilot study examined psychological, social and cultural risk factors for child insecure attachment in a sample of South Asian immigrant families experiencing high migration stress in Montreal, Canada. Thirty-three participants were recruited through a local Health and Social Service organization. Maternal anxiety and depression, social support, and national and religious sense of belonging were assessed. Child attachment behaviors were coded from a 15 min free play period. Results indicated that maternal depressive symptoms were related to lower child attachment security scores. Lower support from friends was related to greater child ambivalent attachment behaviors. A higher sense of belonging to the country of origin was related to greater child disorganized attachment behaviors. These findings suggest that migration stresses, which include maternal depression, lack of social support and the sense of belonging, are associated with child attachment, and these variables should be considered in the design of appropriate interventions.

Determinants of Child Attachment in the Years Postpartum in a High-Risk Sample of Immigrant Women.

Our goal was to examine maternal mental health and associated stresses in a sample of high-risk immigrant mothers, and its association with child insecure attachment in the years following childbirth. Mothers and their child (Mage = 37 months) were recruited through a Health and Social Service organization in the Parc-Extension neighborhood in Montreal, Quebec. Mothers completed the Hopkins Symptoms Checklist (HSCL-25), the Multidimensional Scale of Perceived Social Support (MPSS) and a sociodemographic questionnaire that included questions on premature delivery and birth weight. Attachment behaviors were coded out of a videotaped free play sequence using the Preschool and Early School-Age Attachment Rating Scales (PARS). Analysis revealed high levels of clinical anxiety and depression, low social support and low attachment security. Significant mean differences and associations were found between anxiety, depression, social support, preterm delivery and child attachment. These results underscore the importance of screening for anxiety and depression early in the postnatal years, in order to prevent associated consequences such as child insecure attachment. Results also highlight the importance of building positive social networks, especially with immigrant populations.

Ethnographic case study of a community day center for asylum seekers as early stage mental health intervention.

Clinical guidelines in refugee mental health increasingly advocate phased approaches to intervention that foreground the provision of pragmatic and social support in contexts of ongoing instability. However, the impact of such interventions has rarely been explored from the perspective of refugees themselves. We conducted ethnographic research on the experiences and perceptions of users of an intervention embodying this approach: a community Day Center for asylum seekers in Montreal. Data comprising 15 interviews and field notes from 50 participant observation visits were analyzed using an established theoretical framework to identify mechanisms supporting self-perceived wellbeing among users in the domains of safety, social networks, justice, identity/roles, and existential meaning. Results shed light on how this nonspecific buffering intervention responds to the threats and pressures asylum seekers themselves identify as most salient in the immediate postflight context. These findings are discussed in relation to emerging theoretical frameworks in refugee mental health that emphasize agency, justice, and the role of local ecologies. We conclude that the Day Center shows significant promise as an innovative early stage mental health intervention for precarious status migrants and merits further research and evaluation. (PsycINFO Database Record

The gap between entitlement and access to healthcare: An analysis of "candidacy" in the help-seeking trajectories of asylum seekers in Montreal.

In 2012 the Canadian government made significant cuts to its historically strong federal refugee health coverage plan. While this policy had negligible effects on the level of coverage provided to asylum seekers in Quebec, there is evidence that this group nonetheless experienced reduced healthcare access during the period of polarized national debate that ensued. This study engaged the "candidacy" model of healthcare access to illuminate factors contributing to the observed gap between entitlement and access. Twenty-five semi-structured interviews were conducted with asylum seekers in Montreal to elicit narrative accounts of difficulties encountered in the pursuit of healthcare. Thematic content analysis in conjunction with a holistic examination of help-seeking trajectories revealed several important barriers to obtaining care, including widespread confusion and misinformation about refugee health coverage, cumbersome administrative procedures specific to asylum seekers, and long wait times. Feelings of marginalization and insecurity associated with precarious migratory status appeared to amplify the effects of these barriers to care such that even a minor access difficulty could have dramatic effects on future help-seeking and access outcomes. Demonstrating awareness of public discourses interrogating their deservingness of health coverage, participants often interpreted access difficulties as evidence of health professionals' unwillingness to serve them. Such interpretations conspired with fears associated with the asylum claim process to suppress self-advocacy, further help-seeking, and at times even information-seeking. This finding is particularly significant in that it suggests a mechanism through which hostile public representations of forced migrants-increasingly prevalent in Western host countries-can themselves endanger the physical, psychological, and social health of highly disadvantaged populations, even in the presence of strong entitlement policies. We close with reflections on how theoretical models of healthcare access might be adjusted to better accommodate the unique experiences of precarious status migrants.

Knowledge of Healthcare Coverage for Refugee Claimants: Results from a Survey of Health Service Providers in Montreal.

Following changes to the Interim Federal Health (IFH) program in Canada in 2012, this study investigates health service providers' knowledge of the healthcare coverage for refugee claimants living in Quebec. An online questionnaire was completed by 1,772 staff and physicians from five hospitals and two primary care centres in Montreal. Low levels of knowledge and significant associations between knowledge and occupational group, age, and contact with refugees were documented. Social workers, respondents aged 40-49 years, and those who reported previous contact with refugee claimants seeking healthcare were significantly more likely to have 2 or more correct responses. Rapid and multiple changes to the complex IFH policy have generated a high level of confusion among healthcare providers. Simplification of the system and a knowledge transfer strategy aimed at improving healthcare delivery for IFH patients are urgently needed, proposing easy avenues to access rapidly updated information and emphasizing ethical and clinical issues.