Family and community resilience: a Photovoice study.

BACKGROUND: Adverse childhood experiences (ACEs), in combination with adverse community environments, can result in traumatic stress reactions, increasing a person's risk for chronic physical and mental health conditions. Family resilience refers to the ability of families to withstand and rebound from adversity; it involves coping with disruptions as well as positive growth in the face of sudden or challenging life events, trauma, or adversities. This study aimed to identify factors contributing to family and community resilience from the perspective of families who self-identified as having a history of adversity and being resilient during the COVID-19 pandemic. METHODS: This study used Photovoice, a visual participatory research method which asks participants to take photographs to illustrate their responses to a research question. Participants consisted of a maximum variation sample of families who demonstrated family level resilience in the context of the pair of ACEs during the COVID-19 pandemic. Family members were asked to collect approximately five images or videos that illustrated the facilitators and barriers to well-being for their family in their community. Semi-structured in-depth interviews were conducted using the SHOWeD framework to allow participants to share and elucidate the meaning of their photos. Using thematic analysis, two researchers then independently completed line-by-line coding of interview transcripts before collaborating to develop consensus regarding key themes and interpretations. RESULTS: Nine families were enrolled in the study. We identified five main themes that enhanced family resilience: (1) social support networks; (2) factors fostering children's development; (3) access and connection to nature; (4) having a space of one's own; and (5) access to social services and community resources. CONCLUSIONS: In the context of additional stresses related to the COVID-19 pandemic, resilient behaviours and strategies for families were identified. The creation or development of networks of intra- and inter-community bonds; the promotion of accessible parenting, housing, and other social services; and the conservation and expansion of natural environments may support resilience and health.

Experiences of pregnant Venezuelan migrants/refugees in Brazil, Ecuador and Peru: a qualitative analysis.

BACKGROUND: It is estimated that since 2014, approximately 7.3 million Venezuelan migrants/refugees have left the country. Although both male and female migrants/refugees are vulnerable, female migrants/refugees are more likely to face discrimination, emotional, physical, and sexual violence. Currently there is a lack of literature that explores the experiences of pregnant Venezuelan migrants/refugees. Our aim is to better understand the experience of this vulnerable population to inform programming. METHODS: In the parent study, Spryng.io's sensemaking tool was used to gain insight into the gendered migration experiences of Venezuelan women/girls. A total of 9339 micronarratives were collected from 9116 unique participants in Peru, Ecuador and Brazil from January to April 2022. For the purpose of this analysis, two independent reviewers screened 817 micronarratives which were identified by the participant as being about someone who was pregnant, ultimately including 231 as part of the thematic analysis. This was an exploratory study and an open thematic analysis of the narratives was performed. RESULTS: The mean age and standard deviation of our population was 25.77 ± 6.73. The majority of women in the sample already had at least 1 child (62%), were married at the time of migration (53%) and identified as low socio-economic status (59%). The qualitative analysis revealed the following main themes among pregnant Venezuelan migrants/refugees: xenophobia in the forms of racial slurs and hostile treatment from health-care workers while accessing pregnancy care; sexual, physical, and verbal violence experienced during migration; lack of shelter, resources and financial support; and travelling with the hopes of a better future. CONCLUSION: Pregnant Venezuelan migrants/refugees are a vulnerable population that encounter complex gender-based and societal issues that are rarely sufficiently reported. The findings of this study can inform governments, non-governmental organizations, and international organizations to improve support systems for pregnant migrants/refugees. Based on the results of our study we recommend addressing xenophobia in health-care centres and the lack of shelter and food in host countries at various levels, creating support spaces for pregnant women who experience trauma or violence, and connecting women with reliable employment opportunities and maternal healthcare.

Emergency department care experiences among people who use substances: a qualitative study.

BACKGROUND: People who use substances (PWUS) encounter significant barriers to accessing care for their complex health needs. As a result, emergency departments (EDs) often become the first point of healthcare access for many PWUS and are a crucial setting for the study of health inequities. This study aimed to understand the ED healthcare experiences of PWUS with the intent of informing ways of improving the delivery of equitable care. METHODS: This qualitative study was part of a larger cross-sectional, mixed-methods study that examined ED experiences among diverse underserved and equity-deserving groups (EDGs) within Kingston, Ontario, Canada. Participants shared and self-interpreted a story about a memorable ED or UCC visit within the preceding 24 months. Data from participants who self-identified as having substance use experiences was analyzed through inductive thematic analysis. RESULTS: Of the 1973 unique participants who completed the survey, 246 participants self-identified as PWUS and were included in the analysis. Most participants were < 45 years of age (61%), male (53%), and white/European (57%). 45% identified as a person with a disability and 39% frequently struggled to make ends meet. Themes were determined at the patient, provider, and system levels. PATIENT: history of substance use and experience of intersectionality negatively influenced participants' anticipation and perception of care. Provider: negative experiences were linked to assumption making, feelings of stigma and discrimination, and negative perceptions of provider care. Whereas positive experiences were linked to positive perceptions of provider care. System: timeliness of care and the perception of inadequate mental health resources negatively impacted participants' care experience. Overall, these themes shaped participants' trust of ED staff, their desire to seek care, and their perception of the care quality received. CONCLUSIONS: PWUS face significant challenges when seeking care in the ED. Given that EDs are a main site of healthcare utilization, there is an urgent need to better support staff in the ED to improve care experiences among PWUS. Based on the findings, three recommendations are proposed: (1) Integration of an equity-oriented approach into the ED, (2) Widespread training on substance use, and (3) Investment in expert resources and services to support PWUS.

Impacts of the COVID-19 pandemic on life and learning experiences of indigenous and non-Indigenous university and college students in Ontario, Canada: a qualitative study.

BACKGROUND: The years people spend attending university or college are often filled with transition and life change. Younger students often move into their adult identity by working through challenges and encountering new social experiences. These transitions and stresses have been impacted significantly by the COVID-19 pandemic, which has led to dramatic change in the post-secondary experience, particularly in the pandemic's early months when colleges and universities were closed to in person teaching. The goal of this study was to identify how COVID-19 has specifically impacted the postsecondary student population in Kingston, Ontario, Canada. METHODS: The Cost of COVID is a mixed methods study exploring the social and emotional impacts of the COVID-19 pandemic, with a focus on families, youth, and urban Indigenous People. The present analysis was completed using a subset of qualitative data including Spryng.io micronarrative stories from students in college and university, as well as in-depth interviews from service providers providing services to students. A double-coded phenomenological approach was used to collect and analyze data to explore and identify themes expressed by postsecondary students and service providers who worked with postsecondary students. RESULTS: Twenty-six micronarratives and seven in-depth interviews were identified that were specifically relevant to the post-secondary student experience. From this data, five prominent themes arose. Impacts of the COVID-19 pandemic on the use of technology was important to the post secondary experience. The pandemic has substantial educational impact on students, in what they chose to learn, how it was taught, and experiences to which they were exposed. Health and wellbeing, physical, psychological and emotional, were impacted. Significant impacts were felt on family, community, and connectedness aspects. Finally, the pandemic had important financial impacts on students which affected their learning and their experience of the pandemic. Impacts did differ for Indigenous students, with many of the traditional cultural supports and benefits of spaces of higher education no longer being available. CONCLUSION: Our study highlights important impacts of the pandemic on students of higher education that may have significant individual and societal implications going forward. Both postsecondary institutions and society at large need to attend to these impacts, in order to preserve the wellbeing of graduates, the Canadian labor market, and to ensure that the pandemic does not further exacerbate existing inequalities in post-secondary education in Canada.

Emergency department care experiences among members of equity-deserving groups: quantitative results from a cross-sectional mixed methods study.

BACKGROUND: Emergency departments (EDs) serve an integral role in healthcare, particularly for vulnerable populations. However, marginalized groups often report negative ED experiences, including stigmatizing attitudes and behaviours. We engaged with historically marginalized patients to better understand their ED care experiences. METHOD: Participants were invited to complete an anonymous mixed-methods survey about a previous ED experience. We analysed quantitative data including controls and equity-deserving groups (EDGs) - those who self-identified as: (a) Indigenous; (b) having a disability; (c) experiencing mental health issues; (d) a person who uses substances; (e) a sexual and gender minority; (f) a visible minority; (g) experiencing violence; and/or (h) facing homelessness - to identify differences in their perspectives. Differences between EDGs and controls were calculated with chi squared tests, geometric means with confidence ellipses, and the Kruskal-Wallis H test. RESULTS: We collected a total of 2114 surveys from 1973 unique participants, 949 controls and 994 who identified as equity-deserving. Members of EDGs were more likely to attribute negative feelings to their ED experience (p < 0.001), to indicate that their identity impacted the care received (p < 0.001), and that they felt disrespected and/or judged while in the ED (p < 0.001). Members of EDGs were also more likely to indicate that they had little control over healthcare decisions (p < 0.001) and that it was more important to be treated with kindness/respect than to receive the best possible care (p < 0.001). CONCLUSION: Members of EDGs were more likely to report negative ED care experiences. Equity-deserving individuals felt judged and disrespected by ED staff and felt disempowered to make decisions about their care. Next steps will include contextualizing findings using participants' qualitative data and identifying how to improve ED care experiences among EDGs to make it more inclusive and better able to meet their healthcare needs.

Cost of COVID-19: Using life course theory as a lens to understand the consequences of the pandemic.

Context: The COVID-19 pandemic and associated countermeasures have had broad implications across society which will have implications for physical and mental health for years to come. Understanding these experiences through the lens of life course constructs may help communities, service providers including family doctors, and governments to recognize and respond more effectively to the lasting impacts. Objective: To use life course theory to explore the impacts of the COVID-19 pandemic and associated countermeasures on child and family mental, social, and emotional well-being. Study Design: Qualitative study including anonymous micro-narrative collection using Spryng.io software (n=210); in-depth interviews with health and social service providers (n=30). Directed content analysis was used to examine the experiences of the COVID-19 pandemic as they relate to key constructs in life course theory. Setting: Kingston, Frontenac, Lennox and Addington counties in South-Eastern Ontario (pop. 210,000). Population Studied: Participants were recruited to the micronarrative collection through convenience sampling using the online data collection tool, as well as through intentional sampling targeting Indigenous people and people experiencing socio economic deprivation and homelessness. Participants for the in-depth interviews were intentionally recruited as key informants from local health and social service organizations. Results: All of the key constructs of life course theory were relevant when applied to our findings. Our data identified meaningful impacts on life course trajectory components including transitions, turning points, and social pathways, as well as using the principles of agency, life span development, linked lives, timing, and time and place. Conclusions: Our data illustrate the pervasive impact of the COVID-19 pandemic on all aspects of the life course. While service providers and policy makers are attuned to the acute crises currently unfolding, the long term impacts of life course disruption will play out over years, or potentially over the entire lifespan of this cohort. Responses to the pandemic cannot limit themselves to crisis management in the next 12-18 months, but will need to integrate an understanding of life course theory to support long term healing of individuals and communities.

Exploring the impact of COVID-19 on substance use patterns and service access of street involved individuals in Kingston, Ontario: a qualitative study.

This study aims to understand the experiences of street-involved individuals during the COVID-19 pandemic regarding substance use patterns and service access. With the collision of the COVID-19 pandemic and Canadian opioid epidemic came an increase in opioid related overdoses and increased barriers in accessing essential services since March 2020. Semi-structured interviews were conducted in June and July 2021, with 30 street-involved individuals in Kingston, Ontario. Analysis followed a phenomenological approach to qualitative research. Themes were coded by two independent researchers using NVIVO12. COVID-19 had detrimental effects on the lives of street-involved folks who use substances. Increased substance use to combat feelings of isolation and hopelessness related to loss of income and housing was commonly described. Increased fentanyl usage was considered the major contributor to the rise in overdoses over the pandemic. Restrictions on public access to businesses and services disproportionately impacted individuals with limited means. Harm reduction services and mental health support were considered extremely important throughout the pandemic. The coinciding COVID-19 pandemic and opioid epidemic place street-involved individuals who use substances in a uniquely dangerous position. As such, it is imperative that public policy decision-makers consider the differential needs of street-involved community members to provide safe, relevant, and compassionate solutions in future public health emergencies.

Food worry and mental health outcomes during the COVID-19 pandemic.

BACKGROUND: There is limited and inconsistent literature examining the relationship between food worry and mental health in the context of the COVID-19 pandemic. This study examined the association between food worry and mental health among community dwelling Canadian adults during the COVID-19 pandemic. METHODS: Adults age 16 years and older completed an anonymous online questionnaire between April 1, 2020 and November 30 2020. Measures of pre-pandemic and current food worry, depression (PHQ-2), anxiety (GAD-2), and sociodemographic variables were included. Multivariable logistic regression models were used to determine the association between food worry and symptoms of depression and anxiety. RESULTS: In total, 1605 participants were included in analyses. Worry about affording food was reported by 320 (14.78%) participants. In models adjusting for sociodemographic covariates, compared with people without food worry, participants who had food worry were 2.07 times more likely to report anxiety symptoms (aOR 2.07, 95% CI: 1.43 - 2.98, p < .001) and were 1.9 times more likely to report depressive symptoms (aOR 1.89, 95% CI: 1.39-2.57, p < .0001). Lower income, lower education, and pre-existing mental health conditions were significant predictors of symptoms of depression. Female gender, younger age, lower education, lower income, and pre-existing mental health condition were significant predictors of anxiety symptoms. CONCLUSION: Our study highlights the relationship between food worry and poor mental health. Policy supports such as improved income supports, clinical implications such as screening for food worry in primary care, referral to emergency food programs and support with meal planning may help mitigate mental health symptoms during the current pandemic, during future societal recovery from this pandemic and during future pandemics.

Experience of emergency department use among persons with a history of adverse childhood experiences.

BACKGROUND: Adverse childhood experiences (ACEs) are associated with increased morbidity and mortality, lower levels of distress tolerance, and greater emotional dysregulation, as well as with increased healthcare utilization. All these factors may lead to an increased use of emergency department (ED) services. Understanding the experience of ED utilization among a group of ED users with high ACE scores, as well as their experiences as viewed through the lens of a trauma and violence informed care (TVIC) framework, could be important to their provision of care. METHODS: This is the qualitative portion of a larger mixed methods study. Twenty-five ED users with high ACE scores completed in depth interviews. Thematic analysis of the interview transcripts was undertaken and directed content analysis was used to examine the transcripts against a TVIC framework. RESULTS: The majority of participants experienced excellent care although challenges to this experience were faced by many in the areas of registration and triage. Some participants did identify negative experiences of care and stigma when presenting with mental health conditions and pain crises, as did participants who perceived that they were considered "different" (dressed differently, living in poverty, young parents, etc.). Participants were thoughtful about their reasons for seeking ED care including lack of timely access to their family doctor, perceived urgency of their condition, or needs that fell outside the scope of primary care. Participants' experiences mapped onto a TVIC framework such that their needs and experiences could be framed using a TVIC lens. CONCLUSIONS: While the ED care experience was excellent for most participants, even those with a trauma history, there existed a subset of vulnerable patients for whom the principles of TVIC were not met, and for whom implementation of trauma informed care might have a positive impact on the overall experience of care. Recommendations include training around TVIC for ED leadership, staff and physicians, improved access to semi-urgent primary care, ED patient care plans integrating TVIC principles, and improved support for triage nurses and registration personnel.

Experience of healthcare among the homeless and vulnerably housed a qualitative study: opportunities for equity-oriented health care.

BACKGROUND: People experiencing homelessness are often marginalized and are known to face barriers to accessing acceptable and respectful healthcare services. This study examines the experience of accessing hospital-based services of persons experiencing homelessness or vulnerable housing in southeastern Ontario and considers the potential of Equity-Oriented Health Care (EOHC) as an approach to improving care. METHODS: Focus groups and in-depth interviews with people with lived experience of homelessness (n=31), as well as in-depth interviews of health and social service provider key informants (n=10) were combined with qualitative data from a survey of health and social service providers (n=136). Interview transcripts and written survey responses were analyzed using directed content analysis to examine experiences of people with lived experience of homelessness within the healthcare system. RESULTS: Healthcare services were experienced as stigmatizing and shaming particularly for patients with concurrent substance use. These negative experiences could lead to avoidance or abandonment of care. Despite supposed universality, participants felt that the healthcare system was not accountable to them or to other equity-seeking populations. Participants identified a system that was inflexible, designed for a perceived middle-class population, and that failed to take into account the needs and realities of equity-seeking groups. Finally, participants did identify positive healthcare interactions, highlighting the importance of care delivered with dignity, trust, and compassion. CONCLUSIONS: The experiences of healthcare services among the homeless and vulnerably housed do not meet the standards of universally accessible patient-centered care. EOHC could provide a framework for changes to the healthcare system, creating a system that is more trauma-informed, equity-enhancing, and accessible to people experiencing homelessness, thus limiting identified barriers and negative experiences of care.

Exploratory study of "real world" implementation of a clinical poverty tool in diverse family medicine and pediatric care settings.

BACKGROUND: Poverty is associated with increased morbidity related to multiple child and adult health conditions and increased risk of premature death. Despite robust evidence linking income and health, and some recommendations for universal screening, poverty screening is not routinely conducted in clinical care. METHODS: We conducted an exploratory study of implementing universal poverty screening and intervention in family medicine and a range of pediatric care settings (primary through tertiary). After attending a training session, health care providers (HCPs) were instructed to perform universal screening using a clinical poverty tool with the question "Do you ever have difficulty making ends meet at the end of the month?" for the three-month implementation period. HCPs tracked the number of patients screened and a convenience sample of their patients were surveyed regarding the acceptability of being screened for poverty in a healthcare setting. HCPs participated in semi-structured focus groups to explore barriers to and facilitators of universal implementation of the tool. RESULTS: Twenty-two HCPs (10 pediatricians, 9 family physicians, 3 nurse practitioners) participated and 150 patients completed surveys. Eighteen HCPs participated in focus groups. Despite the self-described motivation of the HCPs, screening rates were low (9% according to self-reported numbers). The majority of patients either supported (72%) or were neutral (22%) about the appropriateness of HCPs screening for and intervening on poverty. HCPs viewed poverty as relevant to clinical care but identified time constraints, physician discomfort, lack of expertise and habitual factors as barriers to implementation of universal screening. CONCLUSIONS: Poverty screening is important and acceptable to clinicians and patients. However, multiple barriers need to be addressed to allow for successful implementation of poverty screening and intervention in health care settings.

Creating a locally driven research agenda for the ethnic minorities of Eastern Myanmar.

BACKGROUND: Research funding and production is inequitably distributed internationally, with emphasis placed on the priorities of funders and international partners. Research capacity development, along with agenda-setting for research priorities can create agency and self-sufficiency and should be inclusive of all relevant stakeholders. Myanmar is a fragile state, where decades of conflict have created a weakened healthcare system and health research sector. The population of Eastern Myanmar have long had their healthcare needs met by community-based organisations and ethnic health organisations operating within Eastern Myanmar and the adjoining Thai-Myanmar border. Despite a transition to civilian rule, the current context does not allow for a truly participatory health research capacity development and agenda-setting exercise between the health leaders of Eastern Myanmar and the government in Yangon. In this context, and with a desire to enhance the capacity, legitimacy and agency of their organisations, the health leaders of Eastern Myanmar are seeking to develop their own health research capacity and to take control of their own research agenda. METHODS: Approximately 60 participants from 15 organisations attended a 3-day forum with the goals of (1) developing research capacity and interest through a research conference and methods workshop; (2) using a nominal group technique (NGT) to develop a locally driven research agenda; and (3) supporting the development of local research projects through ongoing funding and mentorship. RESULTS: Participants were actively engaged in the workshops and NGT. Participants identified a broad range of health issues as priorities and were able to develop consensus around a list of 15 top priorities for the populations they serve. Despite availability of ongoing support, participants did not pursue the opportunity to engage in their own research projects emerging from this forum. CONCLUSIONS: The NGT was an effective way to achieve engagement and consensus around research priorities between a group of healthcare providers, researchers and policy-makers from a variety of ethnic groups. More active involvement of senior leadership must happen before the energy harnessed at such a forum can be implemented in ongoing research capacity development.

Trans individuals' experiences in primary care.

OBJECTIVE: To explore past experiences and describe the expectations of members of the trans community regarding the delivery of primary care by their family physicians. DESIGN: Qualitative phenomenologic approach. SETTING: Kingston, Ont, which has a population of approximately 123 000. PARTICIPANTS: A convenience sample of 11 individuals older than 18 years of age who self-identified as trans was recruited through community agencies and family medicine clinics. METHODS: Semistructured interviews were recorded and transcribed verbatim, and thematic analysis of transcripts was carried out by 2 independent researchers using NVivo. MAIN FINDINGS: Eleven interviews took place between September and November 2016; 4 individuals identified as trans men, 6 as trans women, and 1 as gender nonconforming. Themes identified included perceived physician knowledge of trans identities, patient self-advocacy, discrimination, positive spaces, and expectations of ideal care. The expected role of the family physician for trans patients includes hormone assessment and prescription and referrals for gender-affirming surgeries. CONCLUSION: The trans community has several physical and mental health needs that are not being met by the current health care system. Family physicians need to be empowered to provide services such as hormone initiation and gender-affirming surgery referrals. Although other specialists might have a role for some patients, most trans people expect care to be delivered by family physicians whenever possible.

Primary care experiences of women with a history of childhood trauma and chronic disease: Trauma-informed care approach.

OBJECTIVE: To understand the primary care experiences of women who have a history of childhood trauma and chronic disease. DESIGN: Qualitative study using in-depth interviews with directed content analysis. SETTING: Family health team in Kingston, Ont. PARTICIPANTS: Twenty-six women. METHODS: Letters of invitation were sent to eligible participants followed by a telephone survey. Women with an adverse childhood experience (ACE) score of 4 or higher and with 2 or more chronic conditions were invited to participate in a one-on-one interview. MAIN FINDINGS: Participants were frequent users of health care services. Most had not been asked about ACEs by their family physicians. Most participants believed that their history of ACEs was important to their health and that providers should ask about childhood experiences. When participants discussed their primary care experiences, the following 6 common themes evolved: the importance of continuity of care; challenges with family medicine residents; provider awareness of abuse history; distress due to triggering events; characteristics of clinic staff and space; and engagement in care plans and choice. These discussions revealed that participants' primary care experiences were not always informed by the principles of trauma-informed care. CONCLUSION: Understanding the effect of ACEs on women's health is important. Incorporating a trauma-informed approach can be beneficial and enhance the experience of patients. Physicians should learn to ask patients about their childhood experiences, as it is important to their health care.

Developing consensus for postgraduate global health electives: definitions, pre-departure training and post-return debriefing.

BACKGROUND: Global health (GH) electives are on the rise, but with little consensus on the need or content of pre-departure training (PDT) or post-return debriefing (PRD) for electives in postgraduate medical education. METHODS: Using a 2-iteration Delphi process to encourage discussion and consensus, participants from 14 medical schools across Canada provided input to promote more uniform policy towards defining GH electives, when PDT and PRD should be mandatory and what curriculum should be included. RESULTS: There is consensus that PDT and PRD should be mandatory for international electives. Respondents felt that PDT should include a broad range of topics including objectives, travel safety, personal health, logistics, ethics of GH, scope of practice/supervision, and cultural awareness. PRD should include elective evaluation, lessons learned, knowledge translation, review of health and safety, and issues of reintegration. The format of PDT and PRD needs to be individualized to each institution to fit within the limitations of faculty who can serve as facilitators. Global health educators agreed on the importance of mandatory PDT and PRD for remote Canadian aboriginal electives, but did not feel that they could make recommendations without additional input of aboriginal scholars. CONCLUSIONS: All residency programs that send residents on international electives should work towards instituting quality, mandatory PDT and PRD. PDT and PRD should be recognized by universities as having academic merit and by program directors as core resident learning activities. Curriculum and objectives could be arranged around CanMEDS competencies, a physician competency framework that emphasizes qualities beyond medical expert such as professionalism, health advocate, and collaborator.

Barriers to primary care among immigrants and refugees in Peterborough, Ontario: a qualitative study of provider perspectives.

BACKGROUND: Canada's immigrants and refugees have often settled in large Canadian cities, but this is changing with rising costs of living and rural settlement initiatives. However, little consideration is made regarding systemic changes needed to accommodate this distribution, particularly in healthcare in medium-sized cities or smaller communities. For most Canadians, primary care is an entry point into the healthcare system but immigrants and refugees face unique barriers to accessing care compared to the general Canadian population. This project aimed to better understand the barriers to accessing primary care among newcomers in Peterborough, Ontario from the perspective of newcomer service providers. METHODOLOGY: Participants were recruited from community organizations identified by the local settlement agency, the New Canadians Centre, as having regular interactions with newcomer clients including clinics, not-for-profit organizations, and volunteer groups. Four focus groups were completed, each with three participants (n=12). A coding grid was deductively developed to guide thematic analysis by adapting Levesque et al.'s conceptual framework defining access to healthcare with five specific dimensions: approachability, acceptability, availability and accommodation, affordability, and appropriateness. RESULTS: Participants identified lack of awareness of the healthcare system, stigma, competing priorities, and direct costs as some of the barriers for newcomers. Participants highlighted barriers unique to Peterborough including proximity to services, social isolation, and a shortage of family physicians. The results also highlighted strengths in the community such as its maternal-child health programming. CONCLUSION: The results provide a glimpse of the challenges to accessing primary care among newcomers in medium-sized communities and identify opportunities to prepare for changing settlement patterns.

Engaging people with lived experiences on community advisory boards in community-based participatory research: a scoping review protocol.

INTRODUCTION: Community-based participatory research (CBPR) is a collaborative research approach that equally engages researchers and community stakeholders throughout all steps of the research process to facilitate social change and increase research relevance. Community advisory boards (CABs) are a CBPR tool in which individuals with lived experience and community organisations are integrated into the research process and ensure the work aligns with community priorities. We seek to (1) explore the best practices for the recruitment and engagement of people with lived experiences on CABs and (2) identify the scope of literature on minimising power dynamics between organisations and community members with lived experience who work on CABs together. METHODS AND ANALYSIS: This scoping review will follow the Arksey and O'Malley methodological framework, informed by Levac et al, and will be reported using a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram. Detailed and robust search strategies have been developed for Embase, Medline and PsychINFO. Grey literature references and reference lists of included articles published between 1 January 1990 and 30 March 2023 will be considered. Two reviewers will independently screen references in two successive stages of title/abstract and full-text screening. Conflicts will be decided by consensus or a third reviewer. Thematic analysis will be applied in three phases: open coding, axial coding and abstraction. Extracted data will be recorded and presented in a tabular format and/or graphical summaries, with a descriptive overview discussing how the research findings relate to the research questions. At this time, a preliminary search of peer-reviewed and grey literature has been conducted. Search results for peer-reviewed literature have been uploaded to Covidence for review and appraisal for relevance. ETHICS AND DISSEMINATION: Formal ethics approval is not required for this review. Review findings will inform ongoing and future CBPR community advisory board dynamics. REGISTRATION: The protocol has been registered prospectively on the Open Science Framework (https://doi.org/10.17605/OSF.IO/QF5D3).

Parental perceptions, attitudes, and beliefs regarding vaccination of children aged 0-5 years: A qualitative study of hill-tribe communities, Thailand.

The widespread availability and use of vaccines have tremendously reduced morbidity and deaths related to infectious diseases globally. However, in hill-tribe communities in Northern Thailand, vaccination rates remain low, and there is limited literature on parental perceptions, attitudes, and beliefs about vaccination for children under five years of age. We conducted a qualitative study employing semi-structured interviews to understand parents' perceptions, attitudes, and beliefs about vaccinations. A purposive sample was used to recruit participants. Data were analyzed using thematic analysis. 74 hill-tribe parents (14 Akha, 11 Hmong, 12 Lahu, 13 Lisu, 12 Karen, and 12 Yao) were interviewed. Four themes emerged from the interviews: 1) traditional beliefs, and practices 2) traumatic experiences, 3) lack of information and effective communication, and 4) trust and support from the community. Findings highlight that it is crucial to build trust by providing knowledge, appropriate information, and advice about vaccinations in order to improve vaccine coverage in children under five years of age in the hill-tribe context.