'It doesn't happen any other way': relationship-building and reflexivity for equity-focused intersectoral practice (EquIP).

Intersectoral processes that bring together public institutions, civil society organizations and affected community members are essential to tackling complex health equity challenges. While conventional wisdom points to the importance of human relationships in fostering collaboration, there is a lack of practical guidance on how to do intersectoral work in ways that support authentic relationship-building and mitigate power differentials among people with diverse experiences and roles. This article presents the results of RentSafe EquIP, a community-based participatory research initiative conducted in Owen Sound, Canada, in the midst of a housing crisis. The research explored the potential utility of equity-focused intersectoral practice (EquIP), a novel approach that invests in human relationships and knowledge co-creation among professionals and affected members of the community. The three-phase EquIP methodology centred the grounded expertise of community members with lived/living experience of housing inadequacy to catalyze reflexive thinking by people in professional roles about the institutional gaps and barriers that prevent effective intersectoral response to housing-related inequities. The research demonstrated that EquIP can support agency professionals and community members to (i) engage in (re)problematization to redefine the problem statement to better include upstream drivers of inequity, (ii) support reflexivity among those in professional roles to identify institutional practices, policies and norms that perpetuate stigma and impede effective intersectoral response and (iii) spark individual and collective agency and commitment towards a more equity-focused intersectoral system. We conclude that the EquIP methodology is a promising approach for communities seeking to address persistent health equity and social justice challenges.

Implementing Indigenous Gender-Based Analysis in Research: Principles, Practices and Lessons Learned.

Numerous tools for addressing gender inequality in governmental policies, programs, and research have emerged across the globe. Unfortunately, such tools have largely failed to account for the impacts of colonialism on Indigenous Peoples' lives and lands. In Canada, Indigenous organizations have advanced gender-based analysis frameworks that are culturally-grounded and situate the understanding of gender identities, roles, and responsibilities within and across diverse Indigenous contexts. However, there is limited guidance on how to integrate Indigenous gender-based frameworks in the context of research. The authors of this paper are participants of a multi-site research program investigating intersectoral spaces of Indigenous-led renewable energy development within Canada. Through introspective methods, we reflected on the implementation of gender considerations into our research team's governance and research activities. We found three critical lessons: (1) embracing Two-Eyed Seeing or Etuaptmumk while making space for Indigenous leadership; (2) trusting the expertise that stems from the lived experiences and relationships of researchers and team members; and (3) shifting the emphasis from 'gender-based analysis' to 'gender-based relationality' in the implementation of gender-related research considerations. Our research findings provide a novel empirical example of the day-to-day principles and practices that may arise when implementing Indigenous gender-based analysis frameworks in the context of research.

Lessons from a rural housing crisis: grounded insights for intersectoral action on health inequities.

Local communities are struggling with persistent health inequities driven by income disparity, housing inadequacy, and other intersecting factors that constrain individual and community well-being. Increasingly, intersectoral approaches are recognized as essential to tackle such challenges, given their intersecting nature. This paper describes Equity-focused Intersectoral Practice (EquIP), a novel methodology that merges participatory research principles with the purposeful positioning of grounded expertise (lived experience) to shift the gaze of intersectoral actors towards the contextual factors that contribute to health inequities. The EquIP methodology creates uncommon spaces for intersectoral encounter that support critical reflexivity and relationship-building among institutional and community-based intersectoral actors. A case example of the EquIP methodology, implemented in a small, rural Canadian city in the context of a regional housing crisis, illustrates how investment in reflexivity and relational praxis among diverse intersectoral actors supports the identification of existing structures, beliefs, and practices within institutional settings that constrain effective intersectoral response to health inequities.

"You need to just provide health services:" navigating the politics of harm reduction in the twin housing and overdose crises in Vancouver, BC.

BACKGROUND: Since harm reduction's origins as a grassroots, activist movement, cooperation and compromise among people who use drugs, bureaucrats, politicians, and other actors have been critical to its advancement in Canada. Critics have argued, however, that the institutionalization of harm reduction practice within the context of a politically sensitive environment has eroded its radical potential. The overdose crisis in Vancouver's Downtown Eastside (DTES) community has led to innovative harm reduction organizing that has been replicated globally. In this paper, we explore how one such intervention, the Tenant Overdose Response Organizers (TORO) program, has supported a resurgence in tenant-led harm reduction organizing in Single Room Occupancy (SRO) buildings in the DTES. METHODS: We draw on 15 months of ethnographic fieldwork conducted between May 2017 and August 2018, over 100 hours of participant observation of TORO activities, and 15 semi-structured interviews with key stakeholders in the program. RESULTS: TORO's leaders attempted to mobilize harm reduction intervention towards collective action on SRO risk environments underlying drug-related harms, but their efforts were constrained by the necessity of meeting practical expectations of funders regarding health education and supply distribution. Navigating these constraints ultimately shaped the development of the TORO program, helping to secure its longevity but also limiting its ability to organize a coordinated harm reduction and tenants' rights response to the dual housing and overdose crises. CONCLUSION: Our examination of TORO demonstrates how the harm reduction movement continues to be shaped by conflict, cooperation, and compromise between the state and grassroots groups. Even as actors strive to work collaboratively, the unequal distribution of power inherent in this relationship may contribute to the reinscription of a depoliticized harm reduction approach. We discuss the potential role of the risk environment framework in lending political legitimacy to grassroots harm reduction initiatives.

"We have a roof over our head, but we have to eat too:" Exploring shifting foodscapes from homelessness into Housing First in Kingston, Ontario.

BACKGROUND: People facing extended periods of homelessness exhibit a remarkable degree of agency and resilience in procuring food. The literature on foodscapes considers the sociospatial contexts of food procurement, finding that what happens within and along the way to sites of food acquisition and consumption are important considerations in fully understanding and realizing food security. PURPOSE: This study explores the shift in foodscapes of people who are transitioning from homelessness into scattered-site independent housing via a municipal Housing First program and considers implications for health and wellbeing. METHODS: Our mixed-method approach included observational research at 11 local food providers and drop-in centres that provided context for semi-structured interviews with 10 Housing First clients in Kingston, Ontario between November 2016 and March 2017. RESULTS: The findings confirm that the provision of stable housing makes it possible for people to store, prepare, and consume food at home. An increased ability to have control over when, where, and what is eaten had a positive impact on people's sense of health and wellbeing. However, other effective markers of wellbeing were enacted along people's everyday routines and activities that had negative impacts. Interviewees remained heavily dependent on charitable food programs, including increased use of foodbanks. Others reported increasing detachment and social isolation from previously established food routines. Finally, the structured transition perpetuated a circuit of dependence and marginalization that fell short of contributing to improved food security as well as health and wellbeing. IMPLICATIONS: Understanding the relational geography of foodscape transitions is critical to the design of effective Housing First programs. Addressing the root causes of homelessness and poverty requires investments in comprehensive housing strategies including adequate social assistance and community supports that take a sociospatially holistic approach to wellbeing.

Naloxone urban legends and the opioid crisis: what is the role of public health?

As the overdose crisis in North America continues to deepen, public health leaders find themselves responding to sensational media stories, many of which carry forms and themes that mark them as urban legends.This article analyzes one set of media accounts - stories of misuse of naloxone, an opioid overdose antidote distributed to people who use drugs - through the lens of social science scholarship on urban legends. We suggest that these stories have met a public need to feel a sense of safety in uncertain times, but function to reinforce societal views of people who use drugs as undeserving of support and resources.Our field has a duty to speak out in favour of evidence-based programs that support the health of people who use drugs, but the optimal communication strategies are not always clear. Drawing attention to the functions and consequences of urban legends can help frame public health communication in a way that responds to needs without reinforcing prejudices, with application beyond naloxone to the other urban legends that continue to emerge in response to this crisis.

Towards equity-focused intersectoral practice (EquIP) in children's environmental health and housing: the transformational story of RentSafe.

SETTING: This paper chronicles the transformational process through which a national intersectoral collaboration, the Canadian Partnership for Children's Health and Environment (CPCHE), came to embrace a more upstream, equity-based focus in its mandate to advance children's environmental health. INTERVENTION: After 15 years of working within a conventional, evidence-informed approach to health promotion and policy advocacy, in 2010-2013, CPCHE had the opportunity to collaborate on the development of equity-focused knowledge translation (EqKT). EqKT is a relational approach to knowledge practices that challenges intersectoral actors to work to uncover biases and limitations within their own institutional paradigms and professional practices that constrain their capacity to address population health inequities. OUTCOME: The ensuing transformation towards equity-focused intersectoral practice led CPCHE to create an intersectoral initiative called RentSafe. Conceptually and operationally, RentSafe provides an intersectoral space within which the grounded expertise of people with experience of unhealthy and undignified housing provides a roadmap for public health and other practitioners to critically explore professional and institutional blind spots and barriers. With RentSafe as its watershed moment, CPCHE is shifting from a top-down "for whom" orientation to an authentically engaged "with whom" approach that seeks to work integrally with community partners to expose and challenge systemic roots of health inequity. IMPLICATIONS: The transformational story of CPCHE underscores the competencies needed for public health professionals to acknowledge the sources of our own biases and limitations as a necessary first step in equity-focused intersectoral practice (EquIP). It also affirms the value of working in partnership with those who experience the environmental health inequities that such efforts seek to address.

Vancouver Coastal Health's Second Generation Health Strategy: A need for a reboot?

In this commentary, we consider the motivations and implications of Vancouver Coastal Health's place-based population health strategy called the Downtown Eastside Second Generation Health Strategy (2GHS) in light of a broader historical view of shifting values in population and public health and structural health reforms in Canada over the past three decades. We argue that the tone and content of the 2GHS signals a shift towards a neoliberal clientelist model of health that treats people as patients and the DTES as a site of clinical encounter rather than as a community in its own right. In its clinical emphasis, the 2GHS fails to recognize the political dimension of health and well-being in the DTES, a community that faces compounding health risks associated with colonialism, gentrification, human displacement, the criminalization of poverty, sex work, and the street economy. Furthermore, we suggest that in its emphasis on allocating funding based on a rationalist model of health system access, the 2GHS undermines well-established insights and best practices from community-driven health initiatives. Our aim is to provide a provocation that will encourage public health policy-makers to embrace community-based leadership as well as the broader structural health determinants that are at the root of the current circumstances of people in the DTES and other marginalized communities in Canada.

Therapeutic landscapes of home: Exploring Indigenous peoples' experiences of a Housing First intervention in Winnipeg.

In this paper, we explore Indigenous perspectives of culture, place, and health among participants in a landmark Canadian Housing First initiative: At Home/Chez Soi (AHCS) project. Implemented from 2009 to 2013 in Winnipeg and four other Canadian cities, AHCS was a multi-city randomized control trial that sought to test the effectiveness of Housing First as a model for addressing chronic homelessness among people living with mental illnesses. As Winnipeg's homeless population is over 70% Indigenous, significant efforts were made to accommodate the culturally specific health, spiritual, and lifestyle preferences of the project's Indigenous participants. While a daunting challenge from an intervention perspective, Winnipeg's experience also provides a unique opportunity to examine how Indigenous participants' experiences can inform improved housing and mental health policy in Canada. In our study, conducted independently from, but with endorsement of the AHCS project, we utilized a case study approach to explore the experiences of the project's Indigenous participants. Data were collected by means of in-depth qualitative interviews with Indigenous participants (N = 14) and key informant project staff and investigators (N = 6). Our exploratory work demonstrates that despite relative satisfaction with the AHCS intervention, Indigenous peoples' sense of place in the city remains largely disconnected from their housing experiences. We found that structural factors, particularly the shortage of affordable housing and systemic erasure of Indigeneity from the urban sociocultural and political landscape, have adversely impacted Indigenous peoples' sense of place and home.

Health inequities experienced by Aboriginal children with respiratory conditions and their parents.

Asthma and allergies are common conditions among Aboriginal children and adolescents. The purpose of this study was to assess the health and health-care inequities experienced by affected children and by their parents. Aboriginal research assistants conducted individual interviews with 46 Aboriginal children and adolescents who had asthma and/or allergies (26 First Nations, 19 Métis, 1 Inuit) and 51 parents or guardians of these children and adolescents. Followup group interviews were conducted with 16 adolescents and 25 parents/ guardians. Participants reported inadequate educational resources, environmental vulnerability, social and cultural pressures, exclusion, isolation, stigma, blame, and major support deficits. They also described barriers to health-service access, inadequate health care, disrespectful treatment and discrimination by health-care providers, and deficient health insurance. These children, adolescents, and parents recommended the establishment of culturally appropriate support and education programs delivered by Aboriginal peers and health professionals.

Online support for children with asthma and allergies.

Children with asthma and allergies experience social isolation and gaps in social support particularly from peers. The objective of this pilot study was to design and test an accessible online support intervention for these children. Children (n = 27) aged 7 to 11 from across Canada participated. GoToMeeting was employed for the support group sessions and Club Penguin for social connections during and between support group meetings. Content included: strategies for coping with asthma and allergies, role playing and games to help children deal with difficult situations, fun and enjoyment, and presentations by positive role models. Participation in the online peer support intervention was high, 86.3% on average over the 8-week intervention. By sharing their experiences, listening to peers' experiences, and role playing, children were introduced to practical skills: problem solving, communicating, seeking support, and self-advocacy.

Right to a healthy city? Examining the relationship between urban space and health inequity by Aboriginal youth artist-activists in Winnipeg.

This paper explores the relationship between place and health inequity as experienced by Aboriginal youth living in Winnipeg, Canada. Between 2010 and 2011, a team of youth (N = 8) associated with a community-based Aboriginal youth arts program undertook a participatory community mapping process in order to link their personal health geographies to their right to the city. The results demonstrated several ways in which place, mobility, and boundaries affected their health experiences and, in turn, reflected their perceptions of health inequity. The study confirms that urban spaces can produce, and are produced by, highly racialized geographies that work to socially isolate, segregate, and immobilize Aboriginal youth while concomitantly increasing their exposure to higher risks to their health and well being.

Impacts of online peer support for children with asthma and allergies: It just helps you every time you can't breathe well".

Children with asthma and allergies experience social isolation and gaps in social support particularly from peers. The objective of this pilot study was to design and test an accessible online support intervention for these children. Support was delivered by peer mentors with asthma and allergies and a professional. Weekly support groups were conducted over 8 weeks using Go to Meeting and Club Penguin. Quantitative measures and a qualitative interview were administered. Significant increases in perceived support and support-seeking coping and trends in decreased loneliness emerged at post-test. Participants also reported increased self-confidence and satisfaction with the intervention.

Reconciling preferences and constraints in online peer support for youth with asthma and allergies.

In this article, we examine the opportunities and constraints of professionally mediated social networking in health promotion practice. Our analysis is based on the findings of a 12-week participatory study of a peer-led support intervention for youth with asthma and life-threatening allergies. The article begins with an overview of the preferences of youth, their parents, and young adults recruited as peer mentors for online features in the design of a customized support program. We then briefly explain the rationale behind our decision to design and host our intervention using a publicly available website called Ability Online in an effort to balance participants' preferences with important research obligations and safety requirements. Finally, we report on participants' level of satisfaction with the intervention as well as recommendations for health practitioners who wish to use social networking to enhance supports for youth with chronic health conditions.

Chronic disease prevention and the politics of scale: lessons from Canadian health reform.

The authors examine the politics of health-promotion dissemination in health policy using provincial cases from the Canadian Heart Health Initiative (CHHI)-Dissemination Phase, a nationwide chronic disease prevention initiative that took place between 1994 and 2005. Drawing on an analysis of health policy documents and key informant interviews from three provincial CHHI projects, the authors highlight the challenges to incorporate health-promotion strategies oriented toward collective approaches to health within variably "individual" oriented policy climates during a time of health reform. In doing this, the authors uncover a "politics of scale" where researchers developed very different strategies to advance chronic disease prevention within a contested political terrain. What emerged were strategies unique to provincial context. Understanding the politics of scale within health policy development provides insight into how health-promotion strategies should be shaped to achieve maximum effect.

Support needs and preferences of young adolescents with asthma and allergies: "just no one really seems to understand".

The objectives of this study were to identify support needs, support resources, and support barriers for young adolescents with asthma and allergies and to describe preferences for an accessible support intervention. Adolescents (N = 57) completed a survey questionnaire. Eight young adolescents, 10 parents, and 5 older adolescents participated in separate group interviews. Young adolescents' challenges included transition to self-care, balancing restrictions with safety, social isolation, and loneliness. Young teens recommended supportive networks facilitated by older adolescent peers and wanted to meet with other young adolescents living with asthma and allergies online and share information, advice, and encouragement with them.

Out of our inner city backyards: re-scaling urban environmental health inequity assessment.

In this paper, we report the results of a three-year research project (2008-2011) that aimed to identify urban environmental health inequities using a photography-mediated qualitative approach adapted for comparative neighbourhood-level assessment. The project took place in Vancouver, Toronto, and Winnipeg, Canada and involved a total of 49 inner city community researchers who compared environmental health conditions in numerous neighbourhoods across each city. Using the social determinants of health as a guiding framework, community researchers observed a wide range of differences in health-influencing private and public spaces, including sanitation services, housing, parks and gardens, art displays, and community services. The comparative process enabled community researchers to articulate in five distinct ways how such observable conditions represented system level inequities. The findings inform efforts to shift environmental health intervention from constricted action within derelict urban districts to more coordinated mobilization for health equity in the city.

Impact of online support for youth with asthma and allergies: pilot study.

Youth with asthma and allergies often feel isolated and different from their peers. The objective of this study was to test the impact of online social support for these youth. Three months of support was provided using weekly synchronous chat sessions. Online sessions were facilitated by trained peer mentors (older youth with asthma and/or allergies) and health professionals. Youth could also e-mail one another between chat sessions and post messages on an electronic community bulletin board. Twenty-eight adolescents across Canada participated. Social isolation and loneliness were significantly reduced. Youth reported gaining confidence and a sense of normality.

Online solutions to support needs and preferences of parents of children with asthma and allergies.

Many families of children with asthma and allergies experience support deficits and isolation. However, support interventions have not been designed to meet their needs. Consequently, parents' intervention preferences were elicited, and an online peer support group intervention was designed based on these preferences and piloted in the study described. In-depth interviews with 44 parents elicited preferences for support interventions for both children and parents. Many said they felt alone and wanted support from others in similar situations. Based on the parents' preferences for accessible online peer support groups, a pilot online intervention was designed and implemented. Parents received information and reassurance from other parents in peer support sessions. Parents appreciated the accessibility and anonymity of the online support group. This innovative online peer support intervention, informed by parents' preferences, could be adapted and tested in intervention trials and guide programs and practice for families affected by asthma, allergies, and other chronic conditions.

"I want to meet other kids like me": support needs of children with asthma and allergies.

CONTEXT: Asthma is the most common chronic illness of childhood and the leading cause of hospitalization in young children. Asthma negatively impacts physical health, psychosocial wellbeing, and quality of life for affected children but the psychosocial support needs of children with asthma and severe have not been studied from their point of view. OBJECTIVE: The objective of this study was to assess the support and education needs and preferred interventions of allergic children with asthma and/or severe allergies. METHODS: Qualitative constant comparative content analysis was used to identify major themes from semi-structured individual interviews with 20 children with asthma and allergies and 35 parents. FINDINGS: Children expressed frustration with the limitations imposed by asthma and allergies on their regular activities and normal lives. Parents believed that peer support--someone to whom their child could relate as a role model--could improve both their children's and their own coping. CONCLUSIONS: Parents and children preferred a combination of in-person meetings and Internet support to enhance the capacity of children, reduce children's anxiety, increase their self-care skills, and self-confidence. In addition they believed a support intervention was a stepping stone to developing a community of support for children with asthma, allergies, and anaphylaxis.