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Objective: While everyone—including front-line clinicians—should strive to prevent the maltreatment and other severe stresses experienced by many children and adults in everyday life, psychiatrists and other health professionals also need to consider how best to support, throughout the lifespan, those people affected by severe adversity. The first step in achieving this is a clear understanding of the definitions and concepts in the rapidly growing study of resilience. Our paper reviews the definitions of resilience and the range of factors understood as contributing to it, and considers some of the implications for clinical care and public health. Method: This narrative review took a major Canadian report published in 2006 as its starting point. The databases, MEDLINE and PsycINFO, were searched for new relevant citations from 2006 up to July 2010 to identify key papers considering the definitions of resilience and related concepts. Results: Definitions have evolved over time but fundamentally resilience is understood as referring to positive adaptation, or the ability to maintain or regain mental health, despite experiencing adversity. The personal, biological, and environmental or systemic sources of resilience and their interaction are considered. An interactive model of resilience illustrates the factors that enhance or reduce homeostasis or resilience. Conclusions: The 2 key concepts for clinical and public health work are: the dynamic nature of resilience throughout the lifespan; and the interaction of resilience in different ways with major domains of life function, including intimate relationships and attachments.

In the 2021 census, 100,815 people in Canada aged 15 and older identified as transgender or non-binary. Globally, transgender people are disproportionately burdened by several Sexually Transmitted and Blood-Borne Infections (STBBIs) but limited data are available in Canada. Transgender and non-binary people are recognised as key populations in the STBBI Action Plan 2024–2030. We conducted a scoping review of the evidence relating to STBBI prevalence; risk exposures; and use of STBBI testing, treatment and prevention services among transgender and non-binary people in Canada. We searched six databases for articles published between January 1, 2013 and September 1, 2023 and conducted a grey literature search of information published on provincial and territorial public health department websites and websites of eight relevant community organisations. 26 of 934 screened records were included, of which five were provincial surveillance reports from Ontario and Quebec. It is difficult to quantify the prevalence of any STBBI among transgender and non-binary people in Canada. Most provinces and territories, and the federal government, do not publish disaggregated STBBI prevalence data for these populations. Peer-reviewed literature provides HIV prevalence data for several subgroups of the transgender population in some parts of Canada but, in general, these studies were not designed to produce valid prevalence estimates. Transgender people may be less sexually active than other population groups, though this may vary between subgroups of the transgender population. Transgender people face many barriers to accessing healthcare, testing and treatment for STBBIs, while almost no research has been conducted on STBBIs in non-binary people. It is not possible to make specific recommendations for public policy based on the evidence as it currently exists. More public health surveillance and research, conducted in collaboration with transgender and non-binary communities across Canada, would help to better understand the burden of STBBIs in these populations nationally.

Chronic hepatitis C virus (HCV) infection in patients with stage 4–5 chronic kidney disease increases the risk of death and renal graft failure, yet patients with hepatitis C and chronic kidney disease have few treatment options. This study assesses an all-oral, ribavirin-free regimen in patients with HCV genotype 1 infection and stage 4–5 chronic kidney disease. In this phase 3 randomised study of safety and observational study of efficacy, patients with HCV genotype 1 infection and chronic kidney disease (stage 4–5 with or without haemodialysis dependence) were randomly assigned to receive grazoprevir (100 mg, NS3/4A protease inhibitor) and elbasvir (50 mg, NS5A inhibitor; immediate treatment group) or placebo (deferred treatment group) once daily for 12 weeks. Randomisation was done centrally with an interactive voice response system. An additional cohort of patients who were not randomised received the same regimen open-label and underwent intensive pharmacokinetic sampling. The primary efficacy outcome was a non-randomised comparison of sustained virological response at 12 weeks (SVR12) after the end of therapy for the combined immediate treatment group and the pharmacokinetic population with a historical control. The primary safety outcome was a randomised comparison between the immediate treatment group and the deferred treatment group. After 4 weeks of follow-up (study week 16), unmasking occurred and patients in the deferred treatment group received grazoprevir and elbasvir. The primary efficacy hypothesis was tested at a two-sided significance level (type I error) of 0·05 using an exact test for a binomial proportion. Safety event rates were compared between immediate treatment and deferred treatment groups using the stratified Miettinen and Nurminen method with baseline dialysis status as the strata. The study is registered at ClinicalTrials.gov, number NCT02092350. 224 patients were randomly assigned to the immediate treatment group with grazoprevir and elbasvir (n=111) or the deferred treatment group (n=113), and 11 were assigned to the intensive pharmacokinetic population. Overall, 179 (76%) were haemodialysis-dependent, 122 (52%) had HCV genotype 1a infection, 189 (80%) were HCV treatment-naive, 14 (6%) were cirrhotic, and 108 (46%) were African American. Of the 122 patients receiving grazoprevir and elbasvir, six were excluded from the primary efficacy analysis for non-virological reasons (death, lost-to-follow-up [n=2], non-compliance, patient withdrawal, and withdrawal by physician for violent behaviour). No patients in the combined immediate treatment group and intensive pharmacokinetic population and five (4%) in the deferred treatment group discontinued because of an adverse event. Most common adverse events were headache, nausea, and fatigue, occurring at similar frequencies in patients receiving active and placebo drugs. SVR12 in the combined immediate treatment group and intensive pharmacokinetic population was 99% (95% CI 95·3–100·0; 115/116), with one relapse 12 weeks after end of treatment when compared with a historical control of 45%, based on meta-analyses of interferon-based regimens used in clinical trials of patients infected with HCV who are on haemodialysis. Once-daily grazoprevir and elbasvir for 12 weeks had a low rate of adverse events and was effective in patients infected with HCV genotype 1 and stage 4–5 chronic kidney disease. Merck Sharp & Dohme Corp.

Background The health care sector has a significant role to play in fostering equity in the context of widening global social and health inequities. The purpose of this paper is to illustrate the process and impacts of implementing an organizational-level health equity intervention aimed at enhancing capacity to provide equity-oriented health care. Methods The theoretically-informed and evidence-based intervention known as ‘EQUIP’ included educational components for staff, and the integration of three key dimensions of equity-oriented care: cultural safety, trauma- and violence-informed care, and tailoring to context. The intervention was implemented at four Canadian primary health care clinics committed to serving marginalized populations including people living in poverty, those facing homelessness, and people living with high levels of trauma, including Indigenous peoples, recent immigrants and refugees. A mixed methods design was used to examine the impacts of the intervention on the clinics’ organizational processes and priorities, and on staff. Results Engagement with the EQUIP intervention prompted increased awareness and confidence related to equity-oriented health care among staff. Importantly, the EQUIP intervention surfaced tensions that mirrored those in the wider community, including those related to racism, the impacts of violence and trauma, and substance use issues. Surfacing these tensions was disruptive but led to focused organizational strategies, for example: working to address structural and interpersonal racism; improving waiting room environments; and changing organizational policies and practices to support harm reduction. The impact of the intervention was enhanced by involving staff from all job categories, developing narratives about the socio-historical context of the communities and populations served, and feeding data back to the clinics about key health issues in the patient population (e.g., levels of depression, trauma symptoms, and chronic pain). However, in line with critiques of complex interventions, EQUIP may not have been maximally disruptive. Organizational characteristics (e.g., funding and leadership) and characteristics of intervention delivery (e.g., timeframe and who delivered the intervention components) shaped the process and impact. Conclusions This analysis suggests that organizations should anticipate and plan for various types of disruptions, while maximizing opportunities for ownership of the intervention by those within the organization. Our findings further suggest that equity-oriented interventions be paced for intense delivery over a relatively short time frame, be evaluated, particularly with data that can be made available on an ongoing basis, and explicitly include a harm reduction lens.

Context: Significant attention has been directed toward addressing health inequities at the population health and systems levels, yet little progress has been made in identifying approaches to reduce health inequities through clinical care, particularly in a primary health care context. Although the provision of equity-oriented health care (EOHC) is widely assumed to lead to improvements in patients' health outcomes, little empirical evidence supports this claim. To remedy this, we tested whether more EOHC predicts more positive patient health outcomes and identified selected mediators of this relationship. Methods: Our analysis uses longitudinal data from 395 patients recruited from 4 primary health care clinics serving people living in marginalizing conditions. The participants completed 4 structured interviews composed of self-report measures and survey questions over a 2-year period. Using path analysis techniques, we tested a hypothesized model of the process through which patients' perceptions of EOHC led to improvements in self-reported health outcomes (quality of life, chronic pain disability, and posttraumatic stress [PTSD] and depressive symptoms), including particular covariates of health outcomes (age, gender, financial strain, experiences of discrimination). Findings: Over a 24-month period, higher levels of EOHC predicted greater patient comfort and confidence in the health care patients received, leading to increased confidence to prevent and manage their health problems, which, in turn, improved health outcomes (depressive symptoms, PTSD symptoms, chronic pain, and quality of life). In addition, financial strain and experiences of discrimination had significant negative effects on all health outcomes. Conclusions: This study is among the first to demonstrate empirically that providing more EOHC predicts better patient health outcomes over time. At a policy level, this research supports investments in equity-focused organizational and provider-level processes in primary health care as a means of improving patients' health, particularly for those living in marginalizing conditions. Whether these results are robust in different patient groups and across a broader range of health care contexts requires further study.

Racial health inequities are explained by inequities in access to medicaladvice and treatment, and the physiological effects of inequities in material conditions and everyday life; however, Canadian evidence on racial health inequities is limited. This review describes promising practices in population survey methods and approaches that can strengthen sampling, measurement and monitoring of racial health inequities and determinants of health for population subgroups within Canada-particularly Black Canadians. We employed three steps to identify promising practices in Canada's peer countries and their applicability to the Canadian context. First, we conducted a scan of websites based on prior knowledge of population-level health surveys and datasets. Second, we conducted a review of publications from 2010 to 2020 to identify any missed surveys and datasets. Third, we conducted a targeted review of Canadian population-level health surveys and data sources to identify challenges to and opportunities for implementing these promising practices. We identified 20 relevant surveys and data sources from the US, the UK, Australia and New Zealand. In several of Canada's peer countries, information on arealevel racial or ethnic concentration of residents is used to conduct targeted sampling strategies, increasing the non-White sample. Our search of the available Canadian datasets found that Canadian health surveys and administrative sources do not routinely incorporate these strategies. Canada could improve the measurement and monitoring of racial health inequities by applying enhanced sampling practices to collect racial data in surveys and improving procedures for administrative and other routinely collected data sources. There are also novel predictive methods being used to improve sampling of non-White groups, though further investigation of these methods is required.

Background Sexual and gender minority populations experience elevated risks for suicidality. This study aimed to assess prevalence and disparities in non-fatal suicidality and potential protective factors related to social support and health care access among sexual and gender minority youth and adults and their heterosexual and cisgender counterparts in Canada. The second objective was to examine changes in the prevalence of suicidal ideation and protective factors during the COVID-19 pandemic. Methods Pooled data from the 2015, 2016 and 2019 Canadian Community Health Surveys were used to estimate pre-pandemic prevalence of suicidal ideation, plans and attempts, and protective factors. The study also estimated changes in the prevalence of recent suicidal ideation and protective factors in fall 2020, compared with the same period pre-pandemic. Results The prevalence of suicidality was higher among the sexual minority populations compared with the heterosexual population, and the prevalence was highest among the bisexual population, regardless of sex or age group. The pre-pandemic prevalence of recent suicidal ideation was 14.0% for the bisexual population, 5.2% for the gay/lesbian population, and 2.4% for the heterosexual population. The prevalence of lifetime suicide attempts was 16.6%, 8.6%, and 2.8% respectively. More than 40% of sexual minority populations aged 15–44 years had lifetime suicidal ideation; 64.3% and 36.5% of the gender minority population had lifetime suicidal ideation and suicide attempts. Sexual and gender minority populations had a lower prevalence of protective factors related to social support and health care access. The prevalence of recent suicidal ideation among sexual and gender minority populations increased in fall 2020, and they tended to experience longer wait times for immediate care needed. Conclusions Sexual and gender minority populations had a higher prevalence of suicidality and less social support and health care access compared to the heterosexual and cisgender populations. The pandemic was associated with increased suicidal ideation and limited access to care for these groups. Public health interventions that target modifiable protective factors may help decrease suicidality and reduce health disparities. Highlights • This study provides population-based pre-pandemic estimates of the prevalence of non-fatal suicidality (suicidal ideation, plans, and attempts) among sexual and gender minority populations in Canada using pooled data from the 2015, 2016, and 2019 Canadian Community Health Survey. • Sexual and gender minority populations had a higher prevalence of suicidal ideation, plans, and attempts, compared with heterosexual and cisgender populations, regardless of sex or age group. Among sexual minority populations the bisexual population had the highest prevalence of suicidality. • More than 40% of sexual minority populations aged 15 to 44 years had lifetime suicidal ideation; two thirds and one third of the gender minority population had lifetime suicidal ideation and suicide attempts, respectively. • Sexual minority populations had a lower prevalence of social support and health care access; the presence of social support and health care access was related to lower prevalence of recent suicidal ideation. • The onset of the COVID-19 pandemic was associated with increased recent suicidal ideation among the sexual and gender minority populations, especially for males, adolescents, and young adults.

Science-based conservation of riverine fishes can be best targeted with specific information about spatial-ecological controls on the community, including anthropogenic stressors. Because anthropogenic stressors can originate at multiple spatial scales, we investigated the influence of natural and anthropogenic variables summarized within the reach, valley, and catchment on fish community composition along four river mainstems in Ontario, Canada. We used Redundancy Analyses (RDA) to explore models with multi- and single-scale variables on fish community composition. We used partial RDAs to differentiate the relative effects of variable types in multiscale models and to determine if spatial variables explained additional variation in fish community composition. Catchment variables accounted for the majority of explained variation in fish community composition in three of the four rivers, but instream habitat variables accounted for considerable variability in fish community composition in the two rivers that are highly fragmented by dams or naturally occurring rapids. Natural and human-derived fragmentation in rivers may reduce the influence of catchment controls, disrupt longitudinal gradients, and increase the influence of local instream habitat. Environmental variables that explained fish distribution had longitudinal or patchy spatial pattern within rivers, but spatial variables representing impediments to fish dispersal and proximity to receiving waterbodies failed to explain additional variation in fish community composition.

Sexual and gender minorities (SGM) experience a number of health inequities. That social determinants of health drive these inequities is well-documented, but there is little evidence on the number and types of interventions across Canada that address these determinants for these populations. We conducted an environmental scan of programs in Canada that target SGM, and classified the programs based on their level of intervention (individual/interpersonal, institutional and structural). We found that few programs target women, mid-life adults, Indigenous people or ethnoracial minorities, recent immigrants and refugees, and minority language speakers, and few interventions operate at a structural level.