Research R acial and ethnic disparities in the use of health services and in health outcomes have been extensively studied and well documented in the United States and the United Kingdom. Studies from both countries reveal that black, Hispanic and Asian people are less likely to access health care and experience more barriers than people who are not visibly members of ethnic minorities -that is, white people.1-7 The factors underlying ethnic disparities in health service usage are complex and could include such variables as health insurance coverage, physicians' attitudes toward minority patients, language, poverty, transportation, education, familiarity with the health care delivery system, and the degree and kind of family support. 3,6-17The evidence from the United States and the United Kingdom cannot automatically be generalized to Canada, and there is a need for rigorous study of Canadian ethnic populations and their use of health services. The first reason is that much of the US and UK literature on this topic is broadly categorized into "black" and "Hispanic" populations. The United States, the United Kingdom and Canada have different racial and ethnic population compositions because of historical factors. The legacy of slavery in the United States and of colonization in the United Kingdom have led to a higher proportion of persons identified as black. In contrast, Canada has many Asian people in its ethnic make-up, because in recent years a large proportion of immigrants to Canada have come from Asia (59%), with a small proportion from Central and South America and the Caribbean (11%) and Africa (8%).18 At present, the 3 largest visible minority groups in Canada are Chinese (mainly from Hong Kong, Taiwan and mainland China), South Asian (from Asian India, Pakistan, Bangladesh and Sri Lanka) and black people.The second reason is that culture, health status and sociodemographic characteristics even in the same racial or ethnic population may differ between Canada and the United States or the United Kingdom. In recent years, Canada has selected immigrants with high education, strong technical skills and correspondingly favourable health status, with only a relatively small number of immigrants arriving as refugees; US and UK ethnic minorities may differ in those respects. The third reason is that the Canadian health system differs fundamentally from the US health system, and somewhat from the parallel public and private systems of the United Kingdom. Interpretation: : Use of health services in Canada varies considerably by ethnicity according to type of service. Although there is no evidence that members of visible minorities use general physician and specialist services less often than white people, their utilization of hospital and cancer screening services is significantly less. CMAJ 2006;174(6):787-91 Abstract

BackgroundIntegrated Management of Childhood Illness (IMCI) was developed by the World Health Organization (WHO) and the United Nations International Children’s Fund (UNICEF) and aims at reducing childhood morbidity and mortality in resource-limited settings including Tanzania. It was introduced in 1996 and has been scaled up in all districts in the country. The purpose of this study was to identify factors influencing the implementation of IMCI in the health facilities in Mwanza, Tanzania since reports indicates that the guidelines are not full adhered to by the healthcare workers.MethodsA cross-sectional study design was used and a sample size of 95 healthcare workers drawn from health centers and dispensaries within Mwanza city were interviewed using self-administered questionnaires. Structured interview was also used to get views from the city IMCI focal person and the 2 facilitators. Data were analyzed using SPSS and presented using figures and tables.ResultsOnly 51% of healthcare workers interviewed had been trained. 69% of trained Healthcare workers expressed understanding of the IMCI approach. Most of the respondents (77%) had a positive attitude that IMCI approach was a better approach in managing common childhood illnesses especially with the reality of resource constraint in the health facilities. The main challenges identified in the implementation of IMCI are low initial training coverage among health care workers, lack of essential drugs and supplies, lack of onsite mentoring and lack of refresher courses and regular supportive supervision. Supporting the healthcare workers through training, onsite mentoring, supportive supervision and strengthening the healthcare system through increasing access to essential medicines, vaccines, strengthening supply chain management, increasing healthcare financing, improving leadership & management were the major interventions that could assist in IMCI implementation.ConclusionsThe healthcare workers can implement better IMCI through the collaboration of supervisors, IMCI focal person, Council Health Management Teams (CHMT) and other stakeholders interested in child health. However, significant barriers impede a sustainable IMCI implementation. Recommendations have been made related to supportive supervision and HealthCare system strengthening among others.

French speakers residing in predominantly English-speaking communities have been linked to difficulties accessing health care. This study examined health care access experiences of immigrants and non-immigrants who self-identify as Francophone or French speakers in a mainly English speaking province of Canada. We used semi-structured interviews to gather opinions of recent users of physician and hospital services (N = 26). Language barriers and difficulties finding family doctors were experienced by both French speaking immigrants and non-immigrants alike. This was exacerbated by a general preference for health services in French and less interest in using language interpreters during a medical consultation. Some participants experienced emotional distress, were discontent with care received, often delayed seeking care due to language barriers. Recent immigrants identified lack of insurance coverage for drugs, transportation difficulties and limited knowledge of the healthcare system as major detractors to achieving health. This study provided the groundwork for future research on health issues of official language minorities in Canada.

Background:A link exists between breastfeeding difficulties and postpartum depression, and evidence shows that some breastfeeding promotion initiatives may increase maternal stress and contribute to risk of the condition. We conducted a prospective cohort study to determine whether breastfeeding difficulties affect the risk of postpartum depression and whether breastfeeding support modifies the relationship between breastfeeding difficulties and postpartum depression. Methods:Between June and October 2010, we recruited 442 women who intended to breastfeed from all maternity hospitals in Calgary within 72 hours of giving birth to full-term, singleton infants. We administered questionnaires at birth and 6 weeks and 6 months postpartum, measuring breastfeeding difficulties, exposure to breastfeeding supports and postpartum depression. We used qualitative inquiry to measure breastfeeding support experiences. Postpartum depression was defined as a score of 10 or greater on the Edinburgh Postnatal Depression Scale or a self-reported diagnosis of depression in the first 6 months postpartum.Results: A total of 386 women (87.3%) reported moderate to severe breastfeeding difficulties and 437 (98.9%) received some form of breastfeeding advice, help or support. Among women with breastfeeding difficulties, those who did not report a negative breastfeeding support experience were at decreased risk of postpartum depression (risk ratio 0.36). In the final regression model a negative breastfeeding support experience was a significant effect modifier of the relationship between breastfeeding difficulties and postpartum depression.Interpretation: The quality of breastfeeding support is important not only for breastfeeding promotion but also for maternal mental health. Educating front-line caregivers to ensure that support experiences of breastfeeding women are positive can reduce the risk of postpartum depression. Abstract Research CMAJ OPEN E104CMAJ OPEN, 4(1)